2.0 CONTRACT ADMINISTRATION AND
INSTRUCTIONS TO CONTRACTOR
2.1 The provisions
of
Chapter 1, Section 2 are applicable to the
TOP. Additionally, the TOP contractor shall coordinate with the
Defense Health Agency (DHA) Contracting Officer (CO), the appropriate
DHA Contracting Officer Representative (COR), and the TRICARE Overseas
Program Office (TOPO) on any TOP policy or contractual issue that
requires additional Government clarification or assistance to resolve.
2.2 The provisions
of
Chapter 1, Section 2, paragraph 4.0 are superseded
as described in
paragraphs 2.2.1 through
2.2.6.
2.2.1 The DHA CO will provide a 14
calendar day notice for all meetings hosted by DHA.
2.2.2 The TOP
contractor shall provide up to four contractor representatives at
the Performance Readiness Validation (PRV) briefing at DHA.
2.2.3 The TOP
contractor shall provide at least two contractor representatives
for transition briefings/meetings with each overseas Military Medical
Treatment Facility (MTF) and TRICARE Area Office (TAO). All briefings/meetings
shall be completed no later than 60 calendar days prior to the start
of health care delivery (SHCD). These briefings/meetings shall be
targeted towards command suite/key leaders and their staff and shall
encompass all key contract areas where collaboration between the
contractor and the MTF/TAO will occur.
2.2.4 The TOP
contractor shall provide annual representation at two contractor
conferences (senior management level) at DHA. The contractor shall
also provide up to four contractor representatives at up to four additional
meetings at the direction of the CO per contract year.
2.2.5 The TOP
contractor shall provide representation at semiannual TOP operational
meetings to be held at DHA-Aurora (DHA-A) with TOPO, TRICARE Area
Office (TAO) and service representation.
2.2.6 The TOP contractor shall provide
two contractor representatives at up to 18 additional meetings/site visits
at the direction of the CO per option period.
8.0 TRANSITION
IN REQUIREMENTS
8.1 Systems Development
Approximately 80 calendar days
prior to the initiation of health care delivery (HCD), the non-claims
processing systems and the telecommunications interconnections between
these systems shall be reviewed by the DHA or its designees, to
include a demonstration by the contractor of the system(s) capabilities,
to determine whether the systems satisfy the requirements of TRICARE
as otherwise provided in the contract. This includes the telecommunications
links with DHA and Defense Enrollment Eligibility Reporting System
(DEERS) and the Business-to-Business Gateway (B2B). The review will
also confirm that the hardware, software, and communications links required
for operating the automated TRICARE Duplicate Claims System (DCS)
have been installed and are ready for DHA installation of the DCS
application software (see TRICARE Systems Manual (TSM),
Chapter
4). The contractor shall implement any modifications required
by DHA prior to the initiation of services.
8.2 Execution
of Agreements with Contract Providers
8.2.1 All contract
provider agreements shall be executed, and loaded to the contractor’s
system, 80 calendar days prior to the SHCD, or at such other time
as is mutually agreed between the contractor and DHA.
8.2.2 The contractor
shall report on network adequacy on a monthly basis during the transition.
8.3 See
Section 15, for instructions regarding Statements
of Responsibilities (SORs). In addition to the SOR requirements
in these referenced paragraphs, the TOP contractor shall also execute
a SOR with each TAO
Executive Director no
later than 60 calendar days prior to the SHCD.
8.4 Enrollment
Transition
The contractor
shall begin the enrollment process no later than 60 calendar days
prior to the scheduled SHCD, with actual enrollment processing to
begin 40 calendar days prior to the SHCD, subject to DHA approval
of systems under the contract.
8.4.1 For enrollments
in the region with an effective date prior to the SCHD (e.g., active
duty (AD) enrollment, mid-month enrollment; transfer-in), the incoming
contractor shall effect an enrollment to begin on the SHCD once notified
by the outgoing contractor of the new enrollment. (DMDC may run
a report at the end of the transition period that reflects new additions.)
8.4.2 When the
outgoing contractor requests deletion of current enrollments with
an effective date prior to the SHCD (e.g., transfers out; disenrollments
for failure to pay fees; cancellations, etc.), the incoming contractor
shall cancel the future enrollment segment and notify the outgoing
contractor when this action has been completed.
8.4.3 For all
other enrollment actions with an effective date prior to SHCD (e.g.,
Primary Care Manager (PCM) changes; Defense Medical Information
System Identification Code (DMIS-ID) changes; enrollment begin date changes;
etc.), requested by the outgoing contractor, the incoming contractor
shall cancel the future enrollment segment and notify the outgoing
contractor when this action has been completed. When notified by
the outgoing contractor that their change has been effected, the
incoming contractor shall reinstate the future enrollment segment.
8.4.4 Once HCD
begins, all enrollment actions shall be accomplished by the incoming
contractor. If the outgoing contractor requires a retroactive change,
they shall submit their request to the incoming contractor who perform
the change and notify the outgoing contractor when it is complete.
8.5 Transfer
of Enrollment Files
8.5.1 The incoming contractor shall
obtain enrollment information from DEERS through an initial enrollment load
file. DMDC will provide the incoming contractor with an incremental
enrollment load file for each contract transition. The incoming
contractor shall process each enrollment load file within 24 hours
or less from receipt of the file.
Note: Each contract transition shall
require a three-day freeze of enrollment and claim processing. This
freeze will occur beginning the first weekend that precedes the
60 calendar day window prior to the SHCD. The actual calendar dates
will be determined during the transition meeting.
8.5.2 The incoming
contractor shall send enrollment renewal notices for all enrollees
whose current enrollment period expires on or after the SHCD. The
incoming contractor shall send billing statements where the enrollment
fee payment would be due on or after the SHCD. The incoming contractor
shall start sending billing notices and process renewals 45 calendar
days prior to the SHCD.
8.5.3 Outstanding enrollment record
discrepancies and issues reported to the DEERS Support Office (DSO) by
the outgoing contractor will be transferred to the incoming contractor
for reconciliation. Records will be reconciled in accordance with
the TSM,
Chapter 3.
8.6 TRICARE
Service Center (TSC) Phase-In
8.6.1 The incoming contractor shall
use the existing TSCs. The outgoing contractor shall allow reasonable access
to the incoming contractor throughout the transition period to become
familiar with the communication lines, equipment and office layout.
8.6.2 The final
schedule for access to and occupancy of the TSCs will be determined
at the Transition Specification (TRANSPEC) Meeting.
The approved schedule must allow the outgoing contractor to fulfill
all contract requirements through the last day of HCD, and must
provide the incoming contractor sufficient access to the TSC to prepare
for delivery of all required functions on the first day of their
contract.
8.6.3 All Contractor Customer Service,
Education and Health Care Finder (HCF) Field Representatives and overseas
TSC representatives shall be fully trained and available for all
duties no less than 80 calendar days prior to initiation of health
care services.
Note: Overseas TSCs are managed by
the MTFs and are jointly staffed by MTF and TOP contractor personnel. The
TOP contractor shall provide on-site Beneficiary Service Representative
(BSR) support in all TSC locations.
8.7 Contractor
File Conversions and Testing
8.7.1 The incoming contractor shall
perform initial conversion and testing of all Automated Data Processing (ADP)
files (e.g., provider files, pricing files, and beneficiary history)
no later than 30 calendar days following receipt of the files from
the outgoing contractor(s).
8.7.2 Integration
testing will be conducted to validate the contractor’s internal
interfaces to each of the TRICARE Military Health Systems (MHSs).
This testing will verify the contractor’s system integration, functionality, and
implementation process. The incoming contractor shall be responsible
for the preparation and completion of Integration Testing 45 calendar
days prior to the SHCD. (See the TSM,
Chapter 1, Section 1.1.)
8.7.3 The contractor
shall provide certification of compliance with the National Institute
of Standards and Technology (NIST)-based Information Assurance (IA)
program identified in TSM,
Chapter 1, Section 1.1 to fulfill all system
access requirements prior to connecting with the MHS and/or the
initiation of Integration Testing.
8.7.4 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 Managers.
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.
8.8 Receipt
of Outgoing Contractor’s Weekly Shipment of History Updates and
Dual Operations
8.8.1 Beginning with the 120th calendar
day prior to the SHCD and continuing for 180 calendar days after the
SHCD, the incoming contractor shall convert the weekly shipments
of the beneficiary history updates from the outgoing contractor(s)
within two business days following receipt. The incoming contractor
shall validate these files before use. The contractor shall perform
tests for claims and duplicate claims within two business days following
conversion. Following the SHCD, the contractor shall load these
files to history and use them for claims processing.
8.8.2 During the
180 calendar days after the SHCD when both the incoming and outgoing
contractors are processing claims, both contractors shall maintain
close interface on history update exchanges and provider file information.
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. The
incoming contractor shall assume total responsibility for the maintenance
of the TRICARE Encounter Provider Record (TEPRV) beginning with
the SHCD. The incoming contractor shall coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
can continue to process claims accurately; conversely, the outgoing
contractor shall notify the incoming contractor of any changes in
provider status that they become aware of through their operations.
8.9 Transition-In
Requirements Related To Transitional Cases
In notifying beneficiaries of
the transition to another contractor, both the incoming and outgoing
contractors shall include instructions on how the beneficiary may
obtain assistance with transitional care. If the outgoing contractor succeeds
itself, costs related to each contract shall be kept separate for
purposes of contract accountability.
8.9.1 Non-Network
Inpatient Transitional Cases
These are beneficiaries who are
inpatients (occupying an inpatient bed) at 0001 hours on the first
day of any health care contract period in which the incoming contractor
begins HCD. In the case of Diagnosis Related Group (DRG) reimbursement,
the outgoing contractor shall pay through the first month of HCD
or the date of discharge, whichever occurs first. If the facility
is reimbursed on a per diem basis, the outgoing contractor shall
pay all the institutional charges accrued prior to 0001 hours on
the first day of HCD, under the incoming contractor. The incoming
contractor thereafter is responsible for payment.
8.9.2 Non-Network
Outpatient/Professional Transitional Cases
These are cases, such as obstetric
care, that are billed and payable under “Global” billing provisions
of Current Procedural Terminology, 4th edition (CPT-4), Health
Care Financing Administration (HCFA) Healthcare
Common Procedure Coding System (HCPCS), or local coding in use at
the time of contract transition, and where an Episode Of Care (EOC)
shall have commenced during the period of HCD of the outgoing contractor
and continues, uninterrupted, after the SHCD by the incoming contractor.
The outgoing contractor shall process claims for outpatient/professional
services related to transitional cases for services delivered prior
to 0001 hours on the first day of HCD. The incoming contractor shall
process claims for dates of service thereafter.
8.9.3 Network
Inpatient Care During Contract Transition
The status of network provider
changes (provider’s network agreement with the outgoing contractor
is terminated resulting in the provider’s loss of network status)
with the SHCD of the new contract. As a result, the contractor shall reimburse
claims for inpatient care in accordance with
paragraph 8.9.1 for non-network
transitional cases. Beneficiary copay is based on the date of admission;
therefore, TRICARE Prime beneficiaries who are inpatients as described
in
paragraph 8.9.1, shall continue to be subject
to TRICARE Prime network copayments and shall not be subject to
Point Of Service (POS) copayments.
8.9.4 Home
Health Care (HHC) During Contract Transition
HHC, for a 60 calendar day
EOC, initiated during the outgoing contractor’s HCD period and extending, uninterrupted,
into the HCD period of the incoming contractor are considered to
be transitional cases. Reimbursement for both the Request for Anticipated
Payment (RAP) and the final claim shall be the responsibility of
the outgoing contractor for the entire 60 calendar day episodes
covering the transition period from the outgoing to the incoming
contractor.
8.10 Prior Authorizations and Referrals
The incoming contractor shall
honor outstanding prior authorizations and referrals issued by the
outgoing contractor, covering care through 60 calendar days after
the SHCD under the incoming contract, in accordance with the outgoing
contractors existing practices and protocols, within the scope of
the TRICARE program and applicable regulations or statutes. In the
case of Residential Treatment Care (RTC) care, both the incoming
and outgoing contractors shall authorize that part of the stay falling
within their areas of responsibility; however, the incoming contractor
shall use the authorization issued by the outgoing contractor as
the basis for continued stay. This transition period for prior authorizations
and referrals is extended to one year for obstetrical care or any
other condition for which a one-year authorization has been issued.
8.11 Case
Management (CM)
The incoming
contractor shall receive case files and documentation regarding
all beneficiaries under CM programs. The incoming contractor shall
ensure seamless continuity of services to those beneficiaries.
8.12 Program
Integrity
(PI)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 SHCD. The incoming contractor shall work with the
DHA Program Integrity PI Office (PI) to
ensure seamless continuity of oversight of these cases.
8.13 Health
Insurance Portability And Accountability Act of 1996 (HIPAA)
The incoming contractor, as
a covered entity under HIPAA, may honor an authorization or other
express legal document obtained from an individual permitting the
use and disclosure of protected health information prior to the
compliance date (HHS Privacy Regulation, §164.532).
8.14 Installation
And Operation Of The Duplicate Claims System (DCS)
The incoming contractor shall
have purchased, installed, configured, and connected the personal
computers and printers required to operate the DCS no later than
60 calendar days prior to the SHCD. See
Chapter
4, for hardware, software, printer, configuration and
communications requirements and contractor installation responsibilities. Approximately
30 to 45 calendar days prior to HCD, DHA will provide and install
the DCS application software on the incoming contractor designated
personal computers and provide on-site training for users of the
DCS in accordance with TSM,
Chapter 4.
Following the SHCD, 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 TSM,
Chapter
4 and the transition plan requirements.
8.15 The TOP
contractor shall prepare a mailing to the Resident Commissioners
of Puerto Rico and the Northern Mariana Islands, and the Congressional
representatives for American Samoa, Guam, and the US Virgin Islands
by the 45th calendar day prior to the SHCD according to the specifications
of the official transition schedule. The contractor shall submit
a proposed mailing to the DHA CO, DHA COR, and TOPO, for approval
no later than 90 calendar days prior to the SHCD. The mailing shall
discuss any unique processing requirements of the contractor and
any other needed information dictated by the official transition
schedule.
9.0 TRANSITION
OUT
9.1 TRANSPEC
Meeting
The outgoing
contractor shall attend a meeting with representatives of the incoming
contractor and DHA, within 15 calendar days following the effective
date of the contract. This meeting is for the purpose of developing
a schedule of transition-in/transition out activities. DHA will
notify the contractor(s) as to the exact date and location of the
meeting. The outgoing contractor shall provide a proposed transition-out
plan at the TRANSPEC Meeting.
9.2 Data
The outgoing contractor shall
provide to DHA (or, at the option of DHA, to a successor contractor)
such information as DHA shall require to facilitate transitions
from the contractor’s operations to operations under any successor contract.
The outgoing contractor shall provide all files in a non-proprietary
format and the contractor shall include such file specifications
and documentation as may be necessary for interpretation of these
files. Such information may include, but is not limited to, the
following:
• The data contained in the contractor’s
enrollment information system.
• The data contained in the contractor’s
claims processing systems.
• Information about the management
of the contract that is not considered, under applicable Federal
law, to be proprietary to the contractor.
• An automated indexing system
that can be used independently of the outgoing contractor’s data
system. (See
Chapter 9, Section 3, paragraph 2.8 for automated
indexing system requirements.)
9.3 Transition-Out
of the Contractor’s Claims Processing Operations
Upon notice of award to another
contractor, and during the procurement process leading to an effective
date of a new contract, the contractor shall undertake the following
transition-out activities regarding services as an outgoing contractor.
9.3.1 Transfer
of Electronic File Specifications
The outgoing contractor shall
transfer to the incoming contractor by express mail or similar overnight
delivery service, no later than three calendar days following award
announcement, electronic copies of the record layouts with specifications,
formats, and definitions of fields, and data elements, access keys
and sort orders, for the following:
9.3.1.1 The TRICARE Encounter
Provider Files (TEPRVs).
9.3.1.2 The TRICARE Encounter Pricing
Files (TEPRCs).
9.3.1.3 The Enrolled Beneficiary and
PCM Assignment Files.
9.3.1.4 Mental Health Provider Files.
The outgoing contractor shall assure that the incoming contractor
has been given accurate provider payment information on all mental
health providers paid under the TRICARE inpatient mental health
per diem payment system. This shall include provider name; tax identification
number; address including ZIP code; high or low volume status; if
high volume, provide the date the provider became high volume; and
the current per diem rate along with the two prior year’s per diem
amounts. The providers under the per diem payment system must be
designated by Medicare, or meet exemption criteria, as exempt from
the inpatient mental health unit, the unit would be identified as
the provider under the TRICARE inpatient mental health per diem
payment system.
9.3.2 Transfer of ADP Files (Electronic)
The outgoing contractor shall
prepare in non-proprietary electronic format and transfer to the
incoming contractor or DHA, by the 15th calendar day following the
TRANSPEC Meeting unless otherwise negotiated by the incoming and
outgoing contractors, all specified ADP files, such as the Provider
and Pricing files, in accordance with specifications in the official
transition schedule and will continue to participate in preparation
and testing of these files until they are fully readable by the
incoming contractor or DHA.
9.3.3 Outgoing
Contractor Weekly Shipment Of History Updates
The outgoing contractor shall
transfer to the incoming contractor, in electronic format, all beneficiary
history and deductible transactions (occurring from the date of
preparation for shipment of the initial transfer of such history files)
beginning the 120th calendar day prior to the SHCD (until such a
time that all processing is completed by the outgoing contractor)
in accordance with the specifications in the official transition
schedule.
9.3.3.1 During the 180 calendar days
after the SHCD when both the incoming and outgoing contractors are processing
claims, both contractors shall maintain close interface on history
update exchanges and provider file information. 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.
9.3.3.2 The incoming contractor shall
assume total responsibility for the maintenance of the TEPRV beginning
with the SHCD. The incoming contractor shall coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
shall continue to process claims accurately; conversely, the outgoing contractor shall notify
the incoming contractor of any changes in provider status that they
become aware of through their operations.
9.3.4 Transfer
Of Non-ADP Files
The outgoing
contractor shall transfer to the incoming contractor all non-ADP
files (e.g., authorization files, clinic billing authorizations,
and tapes/CDs, which identify Congressional and DHA completed correspondence
files, appeals files, TRICARE medical utilization, and administration
files) in accordance with the specifications in the official transition
schedule. The hard copies of the Beneficiary History Files are to
be transferred to the incoming contractor or Federal Records Center
(FRC). The contractor shall provide samples and descriptions of
these files to the incoming contractor at the TRANSPEC Meeting.
9.3.5 Explanation
of Benefits (EOB) Record Data Retention and Transmittal
If the contractor elects to retain
the EOB data on a computer record, it must, in the event of a transition
to another contractor, provide either a full set of electronic records
covering the current and two prior years, or, at the CO’s discretion,
provide the data and necessary programs to reproduce the EOB in
acceptable form and transfer such data and programs to the successor
contractor or to DHA. DHA shall be the final authority in determining
the form and/or acceptability of the data.
9.3.6 Outgoing
Contractor Weekly Status Reporting
Until all inventories have been
processed, the outgoing contractor shall submit a weekly status
report of inventories and phase-out activities to DHA beginning
the 20th calendar day following the Specifications Meeting until
otherwise notified by the PCO to discontinue. The contractor shall
do this in accordance with specifications of the official transition
schedule.
9.3.7 Prior Authorizations and Referrals
The outgoing contractor shall
provide all prior authorizations and referrals that cover care spanning
the SHCD under the new contract or care that could potentially begin
in the incoming contractor’s HCD period. The outgoing and incoming
contractor shall mutually agree to the date and schedule for transfer
of this information.
9.3.8 CM Files
No later than 60 calendar days
prior to the SHCD under the new contract, the outgoing contractor
shall provide the incoming contractor with all files pertaining
to beneficiaries covered under a CM program. Electronic files shall
be provided under a non-proprietary format. The outgoing contractor
shall cooperate with the incoming contractor to ensure seamless
continuity of care and services for all such beneficiaries.
9.3.9 Requirements
Related To Transitional Cases
The outgoing contractor shall
provide the incoming contractor with instructions for beneficiaries
and providers on how the beneficiary may obtain assistance with
transitional care.
9.3.10 Program Integrity Files
No later than 30 calendar days
prior to the SHCD under the new contract, the outgoing contractor
shall provide the incoming contractor with all fraud and abuse information
it has collected during the tenure of the contract relevant to TRICARE
providers and beneficiaries. For example, (not all inclusive) high
dollar initial draft fraud cases, post payment utilization and reviews
that identified potential fraud, established provider/beneficiary
outlier watch lists, list of providers on prepayment review, copies
of educational letters, regional fraud trend/outlier reports, Fraud
line reports, and beneficiary complaints related to health care
fraud. Electronic files shall be provided under a non-proprietary
format.
9.4 Final Processing Of Outgoing
Contractor
The outgoing
contractor shall:
• Process all claims received
through the last date of the outgoing contractor’s HCD. Processing
of these claims, including adjustments, shall be completed with
180 calendar days following the start of the incoming TOP contractor’s
HCD period.
• Ensure all claims shall meet
the same standards as outlined in the current outgoing contract.
Any residual claim received after SHCD shall be forwarded to the
incoming contractor within 24 hours of receipt. Claims for the Philippines,
that have been pended for development of missing/required documentation
or pended for provider certification, shall be denied on the 179th
calendar day if information was not received or certification was
not complete. The outgoing contractor shall forward any residual
information related to the Philippines claims received after SHCD
to the incoming contractor with 24 hours of receipt.
• Be liable, after the termination
of services under this contract, for any payments to subcontractors
of the contractor arising from events that took place during the
period of this contract.
• Process all correspondence,
allowable charge complaints, and incoming telephonic inquiries which
pertain to claims or services processed or delivered under this
contract within the time frames established for response by the
standards of the contract.
• Complete all appeal and grievance
cases that pertain to claims or services processed or delivered
under this contract within the time frames established for response
by the standards of the contract.
9.4.1 Correction
of Edit Rejects
The outgoing
contractor shall retain sufficient resources to ensure correction
(and reprocessing through DHA) of all TRICARE Encounter Data (TED)
record edit errors no later than 210 calendar days following the
start of the incoming contractor’s HCD.
9.4.2 Transition-Out
of the Automated TRICARE DCS
The outgoing contractor shall
phase-out the use of the automated TRICARE DCS in accordance with
TSM,
Chapter 4 and
transition plan requirements
9.4.3 Transition-Out
Of The contractor’s Provider Network, TSCs, And MTF Agreements
9.4.3.1 Upon notice of award to another
contractor, the outgoing contractor shall provide full cooperation and
support to the incoming contractor, to allow an orderly transition,
without interruption, of all functions relating to the MTF interface
and the establishment of a provider network by the incoming contractor.
This shall include, but is not limited to, data relating to on-site
service centers, equipment, telephones and all other functions having an
impact on the MTFs.
9.4.3.2 Within 15 calendar days of
the Transitions Specifications Meeting, the outgoing contractor
shall draft and submit a revised plan for transition of the MTF
interfaces. Resolution of differences identified through the coordination
process must be accomplished in collaboration with TOPO.
9.4.3.3 The outgoing contractor shall
ensure a HCF function continues through the last date of HCD under the
current contract, unless otherwise negotiated with the incoming
contractor during the TRANSPEC Meeting. The outgoing contractor
shall also vacate the TSCs on the 40th calendar day prior to the
SHCD and establish a centralized HCF function.
9.4.3.4 The outgoing contractor shall
continue to issue prior authorizations for care for which it is
financially responsible. However, authorization-related information
shall be shared between the incoming and the outgoing contractors
to preclude requiring a provider or beneficiary to duplicate the
paperwork and other effort related to establishing prior authorizations.
The outgoing contractor may issue prior authorizations as late as
midnight on the day prior to the end of its HCD for inpatient stays
that will continue as transitional cases. The two contractors shall interface
on the clinical issues of a case where both contractors shall, or
can reasonably expect to have periods of liability for the same
EOC.
9.4.3.5 The outgoing contractor shall
maintain toll-free lines and web-based customer service capabilities, accessible
to the public during the first 90 calendar days of dual operations
in order to properly respond to inquiries related to claims processed
for services incurred during the period of their respective liability. The outgoing
contractor shall continue to staff beneficiary inquiry lines as
defined in the contract.
9.5 Transition-Out
of Enrollment Activities
9.5.1 Prior to the SHCD under the
successor contract, for all enrollment renewals or payments in which
the new enrollment period or period covered by the premium payment
will begin under the new contract, the outgoing contractor shall
amend renewal notices and billing statements (or include a stuffer/insert)
to advise the enrollee to direct any enrollment-related correspondence
and enrollment fee payments to the successor contractor.
9.5.2 The outgoing
contractor shall forward enrollment-related correspondence and/or
enrollment fee payments subsequently received by the outgoing contractor
to the incoming contractor within three business days of receipt.
9.5.3 The outgoing
contractor shall terminate marketing and enrollment activity 40
calendar days prior to the start of the incoming contractor’s HCD. The
outgoing contractor shall transfer enrollment requests or applications
received after the 40th calendar day to the incoming contractor
by overnight delivery at the outgoing contractor’s expense.
9.5.4 Throughout
the enrollment dual processing period, the outgoing and incoming
contractors shall coordinate enrollment files no less than weekly
to ensure that new enrollments and enrollment renewals are accurately
and timely reflected in the incoming contractor’s enrollment files
and in DEERS.
9.6 Cost Accounting
If the outgoing contractor succeeds
itself, the outgoing contractor shall keep costs related to each
contract separate for purposes of contract accountability, according
to the above guidelines.
9.7 Records
Disposition
The contractor
shall include a records disposition plan as part of the transition-out
plan submitted to DHA at the TRANSPEC Meeting.
9.8 Provide
Information
The contractor
shall, upon receipt of a written request from DHA, provide to potential offerers such
items and data as required by DHA. This shall include non-proprietary
information, such as record formats and specifications, field descriptions
and data elements, claims and correspondence volumes, etc.
9.9 Recoupment
9.9.1 Installment
Cases
The outgoing
contractor shall transfer all installment cases to DHA, Office of
General Counsel (OGC), Claims Collection Section (CCS). The outgoing
contractor shall provide a list of all installment cases to be transferred
by fax or encrypted email to CCS before transferring the cases.
9.9.2 Cases
Less Than 12 Months
The outgoing
contractor shall transfer cases greater or equal to $110 ($30 for
pharmacy) and that are less than 12 months old to the incoming contractor,
who shall assume management of the cases. 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,
CCS. The contractor shall write off cases that do not meet the criteria.
9.10 Transition
Out of TED Activities
The outgoing
contractor shall accomplish transition-out activities related to
TED no later than 14 months after the SHCD for the incoming contractor.
At 180 calendar days after the end of HCD, the contractor shall
not issue or reissue any checks/payments unless authorized by DHA,
CRM. The outgoing contractor shall keep all bank accounts associated
with claims payments open until all outstanding checks/payments
have either cleared or stale date. If a payment stale dates, the outgoing contractor shall cancel
the associated TED data with DHA and notify the incoming contractor.
The outgoing contractor may cease TED data submissions when all
TED reported checks/payments issued under this contract have cleared
or stale date. The outgoing contractor shall request (at no-cost
to the Government) an extension for TEDs processing after the 14
month period ends if more time is needed to complete stale date
check processing.