1.0 GENERAL
The contractor shall establish
and maintain sufficient staffing and management support services
and commit other resources and facilities to achieve and maintain
compliance with all quantitative and qualitative standards of the contract.
2.0 SYSTEM
ADDITIONS OR ENHANCEMENTS
2.1 Implementation of Changes in
Program Requirements
The contractor
shall have the capacity and personnel to maintain and operate all
required systems, and to achieve timely implementation of changing
program requirements as directed by the Contracting Officer (CO).
2.2 Maintaining
Current Status of Diagnostic and Procedural Coding Systems (PCS)
2.2.1 The contractor
shall use the current versions of applicable coding systems, including,
but not limited to: Current Procedural Terminology (CPT), Healthcare
Common Procedural Coding System (HCPCS), International Classification
of Diseases, 10th Revision (ICD-10-Clinical Modification (CM) and
ICD-10-PCS).
2.2.2 The contractor shall use the
most current diagnostic and procedural codes correctly, which includes implementing
any revisions based on periodic updates issued by the publishers.
2.3 ZIP Code File
2.3.1 The contractor
shall maintain and update an electronic file of all ZIP codes using
a Government-furnished electronic ZIP code directory.
2.3.2 The contractor
shall incorporate this electronic file in its claims processing
system to determine the validity of a beneficiary or provider ZIP
code. The Government will provide this directory no less than four
and no more than 12 times per calendar year.
2.4 Updating
and Maintaining TRICARE Reimbursement Systems
The contractor shall implement
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 existing reimbursement
systems for current provider categories.
3.0 MANAGEMENT
CONTROLS
The contractor
shall develop and employ management procedures to ensure control,
accuracy, and timeliness of transactions associated with operation
of its 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
to comply with contract requirements and standards.
4.0 QUALITY
CONTROL
4.1 The contractor shall develop
and implement a quality control program consisting of supervisory
review of appeals, grievances, correspondence, and telephone responses.
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. For
reporting requirements, see DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract.
4.2 The contractor
shall develop and implement an end-of-processing quality review
program which assures accurate input and correct payments for authorized
services received from certified providers by eligible beneficiaries.
This shall begin by the end of the third month after the SHCD and
be carried out quarterly thereafter. For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3 The contractor
shall retain copies of the reviewed appeals, grievances, correspondence,
and related working documents, in separate files, for a period of
no less than four months following submission of contract deliverables.
Electronic file storage is an acceptable form of storage. All stored
files shall have a tamper-proof date attached for version control
purposes.
4.4 The contractor shall provide
all documentation to the Government within 10 calendar days of a Government
request.
5.0 REPORTING
5.1 The contractor
shall provide special programming reports to the Defense Health
Agency (DHA) on an “as needed” basis. The DHA CO or Contract Officer’s
Representative (COR) will not request a special programming report
more than 10 times per contract period. The CO or COR will tell
the contractor what information to include in the report. Examples
of these reports include claims history data (either limited or
complete) by provider, including one or more sub-identifiers; beneficiary;
specific diagnosis(es); specific procedure code(s); and/or geographic region
delineated by ZIP code(s).
5.2 The contractor shall submit
the reports by means of electronic medium or a disc as specified
by the CO or COR.
5.3 The contractor shall provide
the completed reports to the CO or COR within 60 calendar days of
the date on the written request from the PCO or COR.
5.4 The contractor
shall inform the CO or COR of the cost, if any.
5.5 The contractor
shall complete the special report within the time requested by DHA
unless a different delivery date is approved.
5.6 For reporting
requirements, see the DD Form 1423, CDRL, located in Section J of
the applicable contract.
6.0 STAFF TRAINING PROGRAM
6.1 The contractor shall develop
and implement formal initial and ongoing training program for both internal
contractor and subcontractor staff, including training on program
updates as they occur, to ensure a high quality of service to beneficiaries
and providers.
6.2 The contractor shall document
the personnel files of staff members who receive the training. The contractor
shall maintain centralized documentation of the training session
agendas, identity of attendees, actual dates and duration of training
sessions.
7.0 INTERNAL
FINANCIAL/ACCOUNTING AUDITS AND CONTROL PROGRAMS
7.1 The contractor
shall verify that its accounting data are correct, reliable and
comply with all Government accounting standards and requirements.
7.2 The contractor’s
corporate internal review staff shall conduct regular, routine and
ad-hoc reviews to ensure proper monitoring in the areas of finance,
financial accounting, internal controls, and special checks issued and
returned, and selected history maintenance transactions for possible
fraud or abuse.
8.0 BENEFICIARY
SURVEYS
8.1 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).
8.2 The contractor shall not conduct
written or telephonic beneficiary surveys without the approval of
the DHA.
8.3 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 geographic
area of responsibility.
8.4 The contractor shall work with
the Government Designated Authority (GDA) to define their ongoing
and special purpose requirements for survey data.
8.5 The contractor
may submit surveys, sampling plans, and cost estimates through the
GDA to the DHA Decision Support Division (DSD) for approval and
licensing if it has a special need for a survey.