1.0 General
The contractor shall establish
and maintain sufficient staffing and management support services
and commit all other resources and facilities necessary to achieve
and maintain compliance with all quantitative and qualitative standards
for claims processing timeliness, claims inventory levels, claims control,
and claims accuracy. The requirements below outline minimum requirements
of Defense Health Agency (DHA). Contractors are encouraged to develop
and employ the most effective management techniques available to
ensure economical and effective operation.
2.0 System Additions Or Enhancements
2.1 Implementation of Changes in
Program Requirements
The contractor
shall have the capacity, using either directly employed personnel
or contracted personnel, to maintain and operate all required systems
and to achieve timely implementation of changing program requirements.
2.2 Maintaining Current Status
of Diagnostic and Procedural Coding Systems (PCS)
Contractors are required to
use the current versions of the updated American Medical Association Physicians
Current Procedural Terminology, 4th Edition (CPT-4), and the International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) diagnostic coding system; and any special codes that
may be directed by DHA. Beginning with dates of service on or after
the mandated date, as directed by Health and Human Services (HHS)
for International Classification of Diseases, 10th Revision (ICD-10)
implementation, for outpatient facility and all non-facility services,
and for inpatient facility charges with discharge dates on or after
the mandated date, contractors will be required to replace the use
of ICD-9-CM diagnosis codes with the current version of the ICD-10-CM
and the International Classification of Diseases, 10th Revision,
Procedure Coding System (ICD-10-PCS) for inpatient hospital procedures.
The contractor is responsible for using the most current codes correctly.
That responsibility includes making any needed revisions required
by periodic CPT-4 and ICD-9-CM or ICD-10-CM and ICD-10-PCS updates
issued by the publishers. When updates occur, contractors will be
notified of the date the TRICARE Encounter Data (TED) editing system
will be accepting changes in the codes.
2.3
Zip
Code File
The contractor
shall maintain and update an electronic file of all zip codes using
a Government-furnished electronic zip code directory. The contractor
shall incorporate this electronic file in its claims processing
system to determine the validity of a beneficiary or provider zip
code. This directory will be provided by the Government no less
than four and no more than 12 times per calendar year. Updates to the
electronic zip code directory for the purposes of contract modifications,
directed policy actions, and expansion or termination of zip codes
by the U.S. Postal Service (USPS), shall be accomplished at no additional
cost to the Government.
2.4
Updating
And Maintaining TRICARE Reimbursement Systems
The contractor, at no additional
cost to the Government and as directed by DHA shall implement all policy
changes and clarifications to existing TRICARE reimbursement systems
affecting both the level of payment and the basic method of reimbursement
as they apply to current provider categories implemented at the
time of contract award. The TRICARE Reimbursement Manual (TRM) is
the source for instructions and guidance on all existing reimbursement
systems for current provider categories.
3.0 Management Controls
The contractor shall develop
and employ management procedures necessary to ensure control, accuracy,
and timeliness of transactions associated with operation of their
call center, TRICARE Service Center (TSC) functions (TRICARE overseas
contract only), enrollment, authorizations, provider referrals, claims
processing, beneficiary services, provider services, reconsiderations,
grievances, Automatic Data Processing (ADP), and financial functions.
These procedures include such elements as:
3.1 An automated claims aging report,
by status and location, for the purpose of identifying backlogs
or other problem areas delaying claims processing. At a minimum,
this report must be sorted to enable a count of the total number
of claims pending for a specified length of time, e.g., the time periods
specified in the Monthly Cycle Time/Aging Report.
3.2 An automated returned claims
report counting the number of claims returned by the time periods
specified in the Monthly Cycle Time/Aging Report.
3.3 Procedures to ensure confidentiality
of all beneficiary and provider information, to ensure that the
rights of the individual are protected in accordance with the provisions
of the Privacy Act and the HIPAA and Health and Human Services (HHS)
Privacy Regulation and prevent unauthorized use of DHA files.
3.4 A system to control adjustments
to processed claims which will document the actual date the need
for adjustment is identified, the reason for the adjustment and
the names of both the requesting and authorizing persons. The controls
shall also ensure the accurate and timely update of the beneficiary
history files, the timely and accurate submission of the TED data
and issuance of the proper notice to the beneficiaries and providers
affected by the adjustments.
3.5 A set
of processing guidelines, desk instructions/user’s manuals and reference
materials for internal use. These materials shall be maintained,
on a current basis, for the life of the contract. Desk instructions
shall be available to each employee in the immediate work area.
Reference material such as procedure codes, diagnostic codes, and
special processing guidelines, shall be available to each work station
with a need for frequent referral. Other reference materials shall
be provided in each unit with a reasonable need and in such quantity
as to ensure the ease of availability needed to facilitate work flow.
Electronic versions may be used.
4.0 Quality Control
4.1 The
contractor shall develop and implement an end-of-processing quality
control program which assures accurate input and correct payments
for authorized services received from certified providers by eligible
beneficiaries.
4.2 The
contractor shall have a quality control program consisting of supervisory
review of appeals, grievances, correspondence, and telephone responses.
This must begin by the end of the third month after the start of
health care delivery (SHCD) and be carried out monthly thereafter.
The review shall include a statistically valid sample or 30 records,
whichever is greater, of each of the following: appeals, grievances,
correspondence processed and telephonic responses completed. The
criteria for review shall be accuracy and completeness of the written
or telephonic response, clarity of the response, and timeliness
with reference to the quantitative standards for the processing
of appeals, grievances, and correspondence. Any lack of courtesy
or respect in the response shall also be noted. All findings shall
be documented, provided to DHA Contracting Officer’s Representative
(COR) staff, or authorized auditors, and used in a documented training
program.
4.3 The quality review program
will sample each quarter, a sufficient number of processed claims and
adjustments to ensure the required quality of adjudication and processing
and provide adequate management control. Claims in the sample shall
include all claim types and be selected randomly, or by other acceptable
statistical methods, in sufficient number to yield at least a 90%
confidence level with a precision of 2%. The sample will be drawn
at or near the end of each quarter from claims completed during
the review period. The contractor may draw the sample up to 15 calendar
days prior to the close of the quarter, but must include claims
completed in the period between the date the sample is drawn and
the close of the quarter in the next quarterly sample. The contractor
shall reflect the inclusive processing dates of the claims in the
sample in the report submitted to DHA. The sampling will begin by
the end of the first quarter of processing. Documentation of the
results shall be completed within 45 calendar days of the close
of each contract quarter.
4.4 The contractor
shall retain copies of the reviewed claims, appeals, grievances,
correspondence, and related working documents, in separate files,
for a period of no less than four months following submission of
audit results to the Procuring Contracting Officer (PCO). DHA staff
will review the results and will on a regular basis audit a selected
sampling of the audited/quality review documents. The review may
occur at the contractor’s site or at a location specified by DHA.
The contractor shall provide all documentation supporting this review
within 10 calendar days of a DHA request.
5.0
Staff
Training Program
The contractor
shall develop and implement a formal initial and ongoing staff training
program including training on program updates as they occur, to
ensure a high quality of service to beneficiaries and providers.
Such training shall include mandatory, documented training in Confidentiality
of Patient Records (42 United States Code (USC) [290dd-3]) requirements
(see
Section 5). The contractor shall not only
provide education on these requirements but must document the personnel
files of the staff members who receive the training. Centralized
documentation shall also be maintained of the training session agendas,
identity of attendees, actual dates and duration of training sessions,
etc. The contractor is also responsible for ensuring that subcontractor
staff is fully trained.
6.0 Internal Audits And Management
Control Programs
Using
its corporate internal review capability, the contractor is responsible
for verifying that accounting data are correct, reliable and comply
with all Government accounting standards and requirements. The contractor’s
corporate internal review staff must conduct regular, routine reviews
to ensure proper monitoring in the areas of finance, financial accounting,
internal controls, special checks issued and returned, and selected
history maintenance transactions for possible fraud or abuse.
7.0 Beneficiary Surveys
In accordance with Department
of Defense Instruction (DoDI) 1100.13, and Health Affairs Policy Memorandum
97-012, surveys of military members, retirees and their families
must be approved and licensed through issuance of a Report Control
Symbol (RCS). Contractors shall not conduct written or telephonic
beneficiary surveys without the approval of the DHA Decision Support
Division (DSD). DHA has an ongoing survey research and analysis
program which includes periodic population-based and encounter-based
surveys of DoD beneficiaries. The surveys address beneficiary information
seeking strategies and preferences, health status, use of care,
satisfaction with military and civilian care, and attitudes toward
TRICARE. The data are collected at the Prime Service Area (PSA)
level and can be aggregated to the regional level. Regional reports
containing PSA data are available through the Director, TRICARE
Regional Offices (TROs)/Program Office. Contractors shall work with
the Director, TROs/Program Offices to define both their ongoing
and special purpose requirements for survey data. Contractors with
special needs not met by an existing instrument may submit surveys,
sampling plans, and cost estimates through the Director, TROs/Program
Office to the DHA, DSD, for approval and licensing.