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 applicable 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 IMP shall include 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 (POC) 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 calendar 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. DHA Program Office representatives shall be included 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 FSO shall undergo the required background check and obtain 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, with 15 calendar days following the interface meetings, a revised IMP/IMS which incorporates the results of the TRANSPEC and interface meetings. The final IMP/IMS may be incorporated into the TMEP contract at no cost to the Government.

1.1.3.4  The contractor shall document interface meetings with formal minutes and submit them in accordance with the Incoming Weekly Status Reporting, DD Form 1423, CDRL, located in Section J of the applicable 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 DD Form 1423, CDRL, located in Section J of the applicable contract. The MOU shall include, but not be 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 MOU shall be effective within 30 calendar days of the meeting. The content of the MOU shall be coordinated with the CO and the Contracting Officers Representative (COR).

1.1.5.2  Sixty (60) calendar days prior to the start of services delivery the incoming contractor shall have executed an MOU with the other TRICARE contractors (Managed Care Support Contract (MCSC), TRICARE Overseas Program (TOP), and TRICARE Pharmacy (TPharm)). The MOU shall include, but not be limited to, provider file update coordination, beneficiary history transfers, customer service coordination and marketing/education coordination in accordance with DD Form 1423, CDRL, located in Section J of the applicable contract.

1.1.5.3  Thirty (30) calendar days prior to the start of services delivery the incoming contractor shall have executed an MOU with the TRICARE Claims Review Contractor for safe, secure, and positive electronic transmittal of claims processing documentation/information in accordance with DD Form 1423, CDRL, located in Section J of the applicable contract.

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 POC. The contractor shall also provide a separate computer center (Help Desk) number to DHA with the DHA computer operator can use for resolution of problems related to data transmissions.

1.2.5.1  System Integration testing will be conducted to validate the contractor’s internal interfaces to each of the TRICARE Military Health Systems (MHS) Information Management/Information Technology (IM/IT). 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 30 calendar days following the Systems Integration Interface Meeting.

1.2.5.3  The contractor shall be responsible for the preparation and completion of Integration Testing 45 calendar 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. A web application will be available for use by contractor Test Coordinators to report and track issues and problems identified during integration testing.

1.2.6.1  Contractors shall test their capability to create, send, and receive compliant transactions. 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 no later than 60 calendar days prior to the start of services delivery.

1.2.6.2  The incoming contractor shall test their capability to process standard transactions. This testing shall be “cradle-to-grave” testing from receipt of the transactions, through processing, and completion of all associated functions including creating and transmitting associated response transitions. Testing involving the receipt and processing of claims transaction shall also include the submission to and acceptance by the DHA of TRICARE Encounter Data (TED) Provider (TEPRVs) records and the creation of contract compliant electronic Explanation of Benefits (EOB). It is expected that the contractors shall complete “cradle-to-grave” testing no later than 30 calendar days prior to the start of services delivery.

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

1.3.1.2  Prior to the start of services delivery, all incoming contractor customer service personnel shall attend training on military culture and life. This training will be provided by the Government.

1.3.1.3  The contractor shall demonstrate to DHA successful implementation and operation of its Interactive Voice Recognition System 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 proposed mailing shall be submitted to the Procurement Contracting Officer (PCO) and the COR for review, and DHA Communications for approval no later than 90 calendar days prior to the start of services. The mailing shall discuss any unique processing requirements of the contractor 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 no later than 45 calendar days prior to the start of services delivery.

1.4.2.1  No later than 60 calendar days prior to the start of the service delivery, the incoming contractor shall have an established and tested trading partner agreement with the Medicare Benefits Coordinator Recovery Contractor (BCRC) in place for receipt of at the start of services delivery TRICARE crossover claims.

1.4.2.2  No later than 60 calendar 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. These files shall be validated by the incoming contractor before use. Tests for claims, update of catastrophic cap, and duplicate claims shall be performed within two business days following conversion. Any issues identified by the incoming contractor shall be resolved with the outgoing contractor and the DHA COR shall be kept informed of all issues identified within two business days and the problem resolution. Following the start of services delivery, these files shall be loaded to history and used 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, the contractors shall exchange beneficiary history updates with each contractor’s claims processing cycle run. Thereafter, the exchange shall not be 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 has been tested and is accessible.

1.4.6.3  The incoming contractor shall ensure all users have fulfilled security and access requirements for the web-based DCS no later than 60 calendar days prior to the start of services delivery. This includes:

1.4.6.4  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, shall be determined during transition meetings and be established in the transition plan/schedule.

1.4.6.5  During transition the Government will provide DCS training to the incoming contractor. Training may occur 120 calendar days prior to the start of services delivery, but no later than 60 calendar days following the start of services delivery. The incoming contractor shall coordinate training needs in accordance with the transition plan/schedule. All user access requirements shall be met 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 calendar 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 calendar days following the start of services delivery.

1.4.6.8  The incoming contractor is required to identify at least one individual to serve as the DCS POC. The contractor’s DCS POC must be an individual who is, 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 PCO, with courtesy copies to the COR and to the DHA DCS Program Representative. The DCS POCs shall be provided to the PCO no later than 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, it is the responsibility of each contractor to 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 calendar 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 a Pending, Validate, or Closed status by the last day of TED 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, refunds may be received and/or TED adjustments may still be submitted for claims in Open and Pending sets. In this case, the incoming contractor may be required to 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 may apply the adjustment to the set while leaving the actual recoupment amount as zero dollars. Resolution would result in a Validate status, requiring an explanation by the incoming contractor 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 for which the incoming contractor has responsibility for resolving. 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  All deliverables shall be submitted to DHA via the E-Commerce Extranet unless otherwise directed by the DD Form 1423, CDRL, located in Section J of the applicable contract. The system is accessed via the Internet through a workstation browser and requires a static Internet Protocol (IP) address. The application is “thin client” meaning that no software needs to be installed on the client workstation and no software is downloaded into the browser. Java script and cookies need to be enabled in the browser to utilize 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 system must be accessed using the Secure Socket Layer (SSL) protocol (https://) and is protected by individually assigned user name and password or CAC.

1.5.1.2  Access to the Extranet shall be requested using the E-Commerce User Access Form-External which will be provided by the Government. Access to deliverables is granted to users at the contract level and deliverables submitted by one contractor will not be accessible to any other contractor.

1.5.1.3  Deliverables that provide data for measuring objective requirements will require submission in Microsoft® Excel format with metric data reported in the same cell within the same worksheet for each reporting period. This may require an additional worksheet be added to the contractor’s deliverable. If required, the new report template will be provided by the Government prior to the start of the first reporting period.

1.5.1.4  The incoming contractor shall schedule initial training on the submission of deliverables within 30 calendar days after award. Additional training for new users will be provided throughout the contract upon request. Technical support is provided during the business week. A POC for access and deliverable submission will be provided 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 no later than 30 calendar 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. One complete set of these materials shall be provided to the Government on the first day of service delivery, as required by the corresponding DD Form 1423, CDRL, located in Section J of the applicable contract, 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 no later than 30 calendar 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 DD Form 1423, CDRL, located in Section J of the applicable contract).

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 will 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, CCS.

1.5.5.3  The incoming contractor shall continue to monitor and manage the VA overpayments in accordance with Chapter 10, Section 3.

1.5.5.4  The incoming contractor shall receive court ordered restitution cases from the outgoing. Incoming shall continue to collect whatever payments are forthcoming and advise the probation officer when a payment is missed, in accordance with Chapter 10, Section 4.

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 7. One complete set of these materials shall be provided to the Government as required by the corresponding DD1423, CDRL, located in Section J of the applicable contract, 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 TRANSPEC Meeting.

2.1.1.3  The outgoing contractor shall identify an individual responsible for transition management who will service as the single POC 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 be turned over to the incoming contractor in the event of a transition. The documentation shall describe 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, all DHA electronic records not eligible for destruction along with their associated metadata shall be transferred to the incoming contractor. DHA electronic records suitable for transfer shall be identified through meetings between contractors, the DHA Records Management Officer (RMO) and the DHA Contracting Office. The 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 documentation must adequately identify, service, and interpret electronic records designated for storage by DHA and the documentation must be transferred with the records.

2.4.5.1  The outgoing contractor shall comply with the provisions of 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 TRANSPEC 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. A formal record of destruction or certificate shall be provided to the DHA Contracting Office documenting what was destroyed, the date(s) destroyed and by whom. This certificate of destruction shall be provided to the DHA RMO. The contractor shall include a records disposition plan as part of the phase-out plan submitted to DHA at the TRANSPEC 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 and Chapter 2, Section 6, for additional guidance on records disposal, storage, and transfer.

2.4.6.1  The outgoing contractor shall send the designated cases no later than 30 calendar 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 final Accounts Receivable Report for the outgoing contractor shall reflect the number of cases and the amount of the outstanding debt transferred to the incoming contractor.