Military Health System

1.1.1.1  The contractor shall submit an IMP/IMS 10 calendar days after award as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract, to allow Government oversight of transition progress. The contractor’s IMP shall demonstrate that the contract transition is structured to provide a balanced technical approach, to minimize and control risk, to accomplish up-front summary planning and commitment, and to provide a basis for subsequent detailed planning. The contractor shall ensure the IMP includes milestones and measurable indicators that can be used to evaluate the contractor’s satisfactory progress toward being fully capable to enable the start of service performance under this contract.

1.1.1.2  The contractor shall identify an individual responsible for transition management who will serve as the single point of contact for the Government for all transition activities. This individual will be the overall coordination point for the management of the IMP/IMS and coordinate and integrate interdependencies with the outgoing contractor and other entities associated with the transition of the contract.

1.1.3.1  Within 30 days from contract award, the incoming contractor shall arrange meetings with Government and external agencies to review requirements for the establishment of connectivity with Government systems, applications necessary to meet the requirements of this contract and coordination of operations. The contractor shall include the DHA Program Office representatives in these meetings.

1.1.3.2  The incoming contractor’s Facility Security Officer (FSO) shall attend a meeting with DHA Personnel Security Branch (PSB) to review Personnel security Requirements and the procedures for requesting background checks and Common Access Cards (CACs) in accordance with the TRICARE Systems Manual (TSM), Chapter 1, Section 1.1. The contractor shall ensure the FSO undergoes the required background check and obtains the necessary trustworthiness certification (Automated Data Processing/Information Technology (ADP/IT)) prior to approving requests for the remaining staff in the incoming contractor’s organization.

1.1.3.3  The contractor shall submit to DHA, within 15 days following the interface meetings, a revised IMP/IMS which incorporates the results of the Transition Specifications and interface meetings.

1.1.3.4  The contractor shall document interface meetings with formal minutes and submit them in accordance with the Incoming Weekly Status Reporting, CDRL located in Section J of the contract.

1.1.5.1  Within 60 calendar days of contract award, the incoming contractor shall meet with and establish an MOU with DHA Communications, in accordance with the CDRL. The Government will ensure the MOU includes, but is not limited to, the review and approval process for educational materials, the identification of desired educational materials required by either DHA or other DHA contractors, the process for requesting additional educational materials, and the ordering and bulk shipment of materials. The contractor shall agree to make the MOU effective within 30 days of the meeting. The contractor shall coordinate the content of the MOU with the CO and the Contracting Officers Representative (COR).

1.1.5.2  Within sixty calendar days prior to the start of services delivery, the incoming contractor shall have executed a MOU with the other TRICARE contractors (Managed Care Support, TRICARE Overseas, and Pharmacy). The contractor shall ensure the MOU includes, but is not limited to, provider file update coordination, beneficiary history transfers, customer service coordination and marketing/education coordination in accordance with the CDRL.

1.1.5.3  Within thirty calendar days prior to the start of services delivery, the incoming contractor shall execute a MOU with the TRICARE Claims Review Contractor for safe, secure, and positive electronic transmittal of claims processing documentation/information in accordance with the CDRL.

1.2.4.1  The DHA will coordinate Business to Business (B2B) Gateway for all contractors. DHA will also coordinate integration testing of the connectivity and data transmission.

1.2.4.2  At the start-up planning meeting, the incoming contractor on the telecommunication network shall provide DHA the name, address, and telephone number of the person who will serve as a technical Point of Contact (POC). The contractor shall also provide a separate computer center (Help Desk) number to DHA that the DHA computer operator can use for resolution of problems related to data transmissions.

1.2.5.1  DHA will conduct System Integration testing to validate the contractor’s internal interfaces to each of the TRICARE Military Health Systems (MHS) Information Management/Information Technology (IM/IT) systems and applications. The test will verify the contractor’s system integration, functionality, and implementation process.

1.2.5.2  The contractor shall coordinate DMDC data file conversion and testing activities with the Government and submit required documents (Test Plan/Scenarios) within the time frames established during the systems interface meetings but no later than (NLT) 30 days following the Systems Integration Interface Meeting.

1.2.5.3  The contractor shall prepare and complete Integration Testing 45 days prior to the start of services delivery.

1.2.5.4  DHA Test Managers will work with the contractor to plan, execute and evaluate the Integration Testing efforts. The contractor shall identify a primary and a back-up Testing Coordinator to work with the DHA Test Manager. The testing coordinator is responsible for contractor testing preparations, coordination of tests, identification of issues and their resolution, and verification of test results. The contractor Testing Coordinators shall use a Government provided web application to report and track issues and problems identified during integration testing.

1.2.6.1  The contractor shall test its capability to create, send, and receive compliant transactions. The contractors shall provide written evidence (e.g., certification from a transaction testing service) of successful testing of their capabilities to create, send, and receive compliant transactions to the contracting offices NLT 60 days prior to the start of services delivery.

1.2.6.2  The incoming contractor shall test their capability to process standard transactions. The contractor shall ensure this testing is “cradle-to-grave” from receipt of the transactions, through processing, and completion of all associated functions including creating and transmitting associated response transitions. The contractor shall ensure its testing involves the receipt and processing of claims transaction and submission to and acceptance by the DHA of TRICARE Encounter Data (TED) records and the creation of contract compliant electronic Explanation of Benefits (EOB). The contractor shall complete “cradle-to-grave” testing NLT 30 days prior to the start of services delivery.

1.3.1.1  The incoming contractor shall ensure its customer service personnel are fully trained and knowledgeable about TMEP and the TRICARE program and are able to accurately answer customer inquiries at the start of services delivery.

1.3.1.2  Prior to the start of services delivery, the contractor shall ensure all incoming contractor customer service personnel attend training on military culture and life. The Government will provide the training materials.

1.3.1.3  The contractor shall demonstrate its successful implementation and operation of its Interactive Voice Recognition System to DHA approximately 60 calendar days prior to the start of services delivery.

1.3.2.1  The contractor shall prepare a mailing to all Congressional offices by the 45th calendar day prior to the start of services delivery according to the specifications of the official transition schedule. The contractor shall submit the proposed mailing to the CO and the COR for review, and to DHA Communications for approval NLT 90 calendar days prior to the start of services. The contractor shall ensure the mailing discusses any contractor unique processing requirements and any other needed information dictated by the official transition schedule.

1.3.2.2  The contractor shall mail an introductory letter to all beneficiary households, who had claims activity in the previous 12 months, NLT 45 days prior to the start of services delivery.

1.4.2.1  NLT 60 calendar days prior to the start of the service delivery, the incoming contractor shall establish and test a trading partner agreement with the Medicare Benefits Coordinator Recovery Contractor (BCRC) and have it in place at the start of services delivery to receive claims.

1.4.2.2  NLT 60 days prior to the start of services delivery, the contractor shall demonstrate to DHA successful receipt and testing of electronic claims batches from Medicare for TRICARE processing.

1.4.4.1  Beginning with the 120th calendar day prior to the start of services delivery and continuing after the start of services delivery until all pertinent claims received by the outgoing contractor have been processed, the incoming contractor shall convert the weekly shipment of the beneficiary history and deductible file updates from the outgoing contractor files within two business days following receipt. The contractor shall validate these files before use. The contractor shall perform tests for claims, update of catastrophic cap, and duplicate claims within two business days following conversion. The incoming contractor shall resolve issues with the outgoing contractor. The incoming contractor shall inform the DHA COR of all issues identified within two business days and provide the problem resolution. Following the start of services delivery, the incoming contractor shall load these files to history and use them for claims processing on the first processing cycle following the check for duplicate claims.

1.4.4.2  During the period after the start of services delivery when the incoming contractor and the outgoing contractor are processing claims, both contractors shall maintain close interface on history update exchanges and provider file maintenance. During the first 60 calendar days of dual operations, both contractors shall exchange beneficiary history updates with each contractor’s claims processing cycle run. Thereafter, both contractors shall ensure the exchange is not less than twice per week until the end of dual processing period.

1.4.6.2  The incoming contractor shall access the web-based DCS via the Patient Encounter Processing and Reporting (PEPR) Portal in accordance with the TSM, Chapter 4 and ensure the connection is tested and accessible.

1.4.6.3  The contractor shall participate in Government furnished DCS training and schedule training per the IMP/IMS.

1.4.6.4  The Government and incoming contractor shall determine together the date when the incoming contractor will assume full responsibility for resolving all existing potential duplicate claim sets from the outgoing contractor (including completing existing recoupments), and for all new potential duplicate claim sets, during transition meetings. The incoming contractor shall add the date to the transition plan/schedule.

1.4.6.5  During transition, the incoming contractor will ensure all DCS users complete the on-line DHA DCS training via Joint Knowledge Online (JKO) at https://jkodirect.jten.mil/Atlas2/page/login/Login.jsf. Training shall be completed between 120 days prior to the start of services delivery and not later than 60 days following the start of services delivery. The incoming contractor shall schedule training in accordance with the transition plan/schedule. The contractor shall meet all user access requirements prior to the initiation of training.

1.4.6.6  The incoming contractor shall begin using the DCS to resolve identified potential duplicate claim sets “owned” by the incoming contractor 120 days following the start of services delivery.

1.4.6.7  The incoming contractor shall begin processing potential duplicate claim sets transferred from the outgoing contractor 150 days following the start of services delivery.

1.4.6.8  The incoming contractor shall identify at least one individual to serve as the DCS POC. The contractor DCS POCs shall be individuals who are, or will be, trained in the use of the DCS, and who is able to perform the required research and determine whether a particular claim is within their processing jurisdiction. The contractor shall provide the name(s), title(s), business address (es), and business telephone number(s) of their DCS POCs to the CO, with courtesy copies to the Contracting Officer Representative (COR) and to the DHA DCS Program Representative. The contractor shall provide the DCS POCs to the CO NLT two weeks prior to the implementation of the DCS.

1.4.6.9  DHA will provide each contractor with the list of all DCS POCs. Whenever a new contract is awarded, DHA will notify all contractors of the new contractor’s DCS POC. Once the initial listing is provided to the contractors, each contractor shall maintain the listing and keep DHA and the other contractors informed of any changes.

1.4.6.10  In accordance with the Financial Procedures in the Transition Plan, the contract, and the TRICARE Operations Manual (TOM), the outgoing contractor shall package and forward to the incoming contractor, refund checks received and offsets taken for recoupments associated with duplicate claims payments and recoupment files associated with in progress duplicate claim recoupment 120 days following the start of services delivery.

1.4.6.11  On the last day of the fourth month following the start of services delivery, or upon direction of the Government, the outgoing contractor shall cease researching Open claim sets and initiating new recoupments associated with duplicate claim payments. The outgoing contractor shall also cease entering refund data and linking adjustment date in the DCS for Pending and Validate claim sets.

1.4.6.12  The outgoing contractor shall move all Open DCS claim sets to Pending, Validate, or Closed status by the last day of TED record(s) submissions (as defined by the transition plan).

1.4.6.13  When the outgoing contractor has ceased entering refund and adjustment date on the DCS, the outgoing contractor may receive refunds and/or may submit TED record(s) adjustments for claims in Open and Pending sets. In this case, the incoming contractor shall resolve the set without knowing the amount of the refund received by the outgoing contractor.

1.4.6.14  If the actual recoupment amount was zero when the set was transferred from the outgoing contractor, the incoming contractor shall apply the adjustment to the set while leaving the actual recoupment amount as zero dollars. Resolution will result in a Validate status, and the incoming contractor shall explain that the outgoing contractor did not enter the actual recoupment amount.

1.4.6.15  Following the start of services delivery, the DCS will begin displaying identified potential duplicate claim sets that the incoming contractor shall resolve. The incoming contractor shall begin using the DCS to resolve potential duplicate claim sets in accordance with the TSM, Chapter 4 and the IMP/IMS requirements.

1.4.6.16  The incoming contractor shall assume full responsibility for resolving all existing potential duplicate claim sets from the outgoing contractor (including completing existing recoupments) and for all new potential duplicate claim sets as agreed upon during the transition meeting.

1.5.1.1  The contractor shall submit all deliverables to DHA via the E-Commerce Extranet unless otherwise directed by the CDRL. The contractor shall access the system via the Internet through a workstation browser and a static Internet Protocol (IP) address. The application is “thin client” meaning that the contractor does not need to install software on the client workstation and no software is downloaded into the browser. Java script and cookies need to be enabled in the browser to use the application. The application is best viewed at a resolution of 1024 x 768 pixels in an Internet Explorer (IE) browser (Version 8 and higher). Other browsers such as Firefox and Chrome are not supported. The contractor shall access the system using the Secure Socket Layer (SSL) protocol (https://) and the system is protected by individually assigned user name and password or CAC.

1.5.1.2  The contractor shall request access to the Extranet via the E-Commerce User Access Form-External which the Government will provide to the contractor. The Government grants users access to deliverables at the contract level. Deliverables submitted by one contractor are not accessible to any other contractor.

1.5.1.3  The contractor shall submit deliverables that provide data for measuring objective requirements. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract.

1.5.1.4  The incoming contractor shall schedule initial training on deliverable submission within 30 calendar days after award. The Government will provide additional training for new users throughout the contract upon contractor request. The Government will provide technical support during the business week. The Government will provide a POC for access and deliverable submission during initial training.

1.5.2.1  The incoming contractor shall receive case files and documentation regarding all open program integrity cases from the outgoing contractor NLT 30 days from the start of services delivery. The incoming contractor shall work with the DHA Program Integrity Office (PI) to ensure seamless continuity of oversight of these cases. This shall include any open leads under development, proactive action items, etc., and not limited to cases.

1.5.2.2  The incoming contractor shall develop and maintain standard operating procedures relevant to Chapter 13. The contractor shall provide one complete set of these materials to the Government on the first day of service delivery, as required by the corresponding CDRL, with updates provided as changes occur.

1.5.5.1  The incoming contractor and DHA, Office of General Counsel (OGC), Claims Collection Section (CCS), shall receive the designated cases from the outgoing contractor NLT 30 days after the start of services delivery. The incoming contractor shall reflect the number of cases and the amount of the outstanding debt received from the outgoing contractor on the next monthly Accounts Receivable Report following the date of transition. (The details for content and submission of this report are contained in the CDRL).

1.5.5.2  The incoming contractor shall receive cases greater or equal to $110 and that are less than 12 months old. The incoming contractor shall manage these cases until the debt is collected in full, or combined with any other under $600 active recoupment case against the same debtor to equal $600 or more and transferred to DHA, OGC, and CCS.

1.5.5.3  The incoming contractor shall continue to monitor and manage the VA overpayments in accordance with Chapter 10, Section 4.

1.5.5.4  The incoming contractor shall receive court ordered restitution cases from the outgoing contractor. The incoming contractor shall continue to collect whatever payments are forthcoming and advise the probation officer when a payment is missed, in accordance with Chapter 10, Section 5.

1.5.6.1  The incoming contractor shall develop and maintain appeals processing guidelines, desk instructions, and reference materials relevant to Chapter 12 and Chapter 11, Section 8. The incoming contractor shall provide one complete set of these materials to the Government as required by the corresponding CDRL, with updates provided as changes occur.

1.5.6.2  The incoming contractor shall assume responsibility for processing new reconsiderations received on and after the start of services delivery.

2.1.1.1  The outgoing contractor shall attend a two to four day meeting as indicated in paragraph 1.1.2.

2.1.1.2  The outgoing contractor shall provide a proposed phase-out plan at the Transition Specifications Meeting.

2.1.1.3  The outgoing contractor shall identify an individual responsible for transition management who will serve as the single point of contact for the Government for all transition activities.

2.4.2.1  The outgoing contractor shall provide an automated indexing system that can be used independently of the contractor’s data system as outlined in Chapter 9, Section 3, in the event of a transition.

2.4.2.2  The outgoing contractor shall maintain a complete set of documentation to transfer to the incoming contractor in the event of a transition. The contractor shall ensure the documentation describes the metadata, how the files are formatted, and other information that will allow DHA or an incoming contractor to efficiently and effectively retrieve the records. If the outgoing contractor does not have an incoming contractor to transfer documentation to, see Chapter 9, Section 4, for additional guidance on records disposal, storage and transfer.

2.4.2.3  Upon direction from DHA, the outgoing contractor shall also be prepared to present the incoming contractor with standard claim images, in Tagged Imaged File Format (TIFF) or searchable Portable Document Format (PDF). Valid alternatives shall be submitted to DHA for review and consideration.

2.4.3.1  During transition, the outgoing contractor shall transfer all DHA electronic records not eligible for destruction along with their associated metadata to the incoming contractor. DHA electronic records suitable for transfer shall be identified through meetings between contractors, the DHA Records Management Officer and the DHA Contracting Office. The outgoing contractor shall develop a process for transferring the data to the incoming contractor that ensures no metadata or their associated record objects are lost in the transition process.

2.4.3.2  The outgoing contractor shall ensure documentation adequately identifies, services, and interprets electronic records designated for storage by DHA and shall transfer the documentation with the records.

2.4.5.1  The outgoing contractor shall comply with the requirements in Chapter 9, in final disposition of all files and documentation. The outgoing contractor shall include records disposition plan as part of the phase-out plan submitted to DHA at the Transition Specifications Meeting.

2.4.5.2  Once the transition of records and materials has been accomplished, the outgoing contractor shall destroy all copies to include backup data in accordance with 36 CFR Part 1226, “Implementing Disposition”. The contractor shall not dispose or destroy any copies or backup data prior to formal, written notification from the DHA Contracting Office or DHA Records Management Office. The contractor shall provide a formal record of destruction or certificate to the DHA CO and the DHA Records Management Officer documenting what was destroyed, the date(s) destroyed and by whom. The contractor shall include a records disposition plan as part of the phase-out plan submitted to DHA at the Transition Specifications Meeting.

2.4.5.3  In the event that the outgoing contractor does not have an incoming contractor to accept transfer of electronic records, refer to Chapter 9, Section 4, for additional guidance on records disposal, storage, and transfer.

2.4.6.1  The outgoing contractor shall send the designated cases NLT 30 days after the start of services delivery.

2.4.6.2  The outgoing contractor shall submit a credit adjustment to include all amounts recouped up to the point of transition. The outgoing contractor shall ensure its final Accounts Receivable Report reflects the number of cases and the amount of the outstanding debt transferred to the incoming contractor.