TRICARE Manuals - Display Chap 20 Sect 2 (Change 139, Jun 10, 2024) (2024)

TRICARE Operations Manual 6010.59-M, April 1, 2015

TRICARE Medicare Eligible Program (TMEP)

Chapter 20

Section 2

TRICAREMedicare Eligible Program (TMEP) Transition

Revision:C-116, February 22, 2023

The transition requirementsin Chapter 2 shallnot apply to the TMEP contractor.

1.0Contractor Transition-in

1.1Management And Administration

1.1.1Integrated Master Plan (MP)/IntegratedMaster Schedule (IMS)

1.1.1.1The contractor shall submitan IMP/IMS 10 calendar days after award as identified by DD Form1423, Contract Data Requirements List (CDRL), located in SectionJ of the contract, to allow Government oversight of transition progress.The contractor’s IMP shall demonstrate that the contract transitionis structured to provide a balanced technical approach, to minimizeand control risk, to accomplish up-front summary planning and commitment,and to provide a basis for subsequent detailed planning. The contractorshall ensure the IMP includes milestones and measurable indicators thatcan be used to evaluate the contractor’s satisfactory progress towardbeing fully capable to enable the start of service performance underthis contract.

1.1.1.2The contractor shall identifyan individual responsible for transition management who will serveas the single point of contact for the Government for all transitionactivities. This individual will be the overall coordination pointfor the management of the IMP/IMS and coordinate and integrate interdependencieswith the outgoing contractor and other entities associated withthe transition of the contract.

1.1.2TransitionSpecifications Meeting

The contractorshall attend a two to four day meeting with the Defense Health Agency(DHA) within 15 days following contract award. This meeting is forthe purpose of developing a schedule for phase-in and phase-outactivities. DHA will notify the contractor(s) as to the exact dateand location of the meeting. The contractor shall ensure its representativeshave the experience, expertise, and authority to provide approvalsand establish project commitments on behalf of their organization.

1.1.3Interface Meetings

1.1.3.1Within 30 days from contractaward, the incoming contractor shall arrange meetings with Governmentand external agencies to review requirements for the establishmentof connectivity with Government systems, applications necessaryto meet the requirements of this contract and coordination of operations.The contractor shall include the DHA Program Office representativesin these meetings.

1.1.3.2The incoming contractor’s FacilitySecurity Officer (FSO) shall attend a meeting with DHA PersonnelSecurity Branch (PSB) to review Personnel security Requirementsand the procedures for requesting background checks and Common AccessCards (CACs) in accordance with the TRICARE Systems Manual (TSM), Chapter 1, Section 1.1. The contractor shallensure the FSO undergoes the required background check and obtainsthe necessary trustworthiness certification (Automated Data Processing/InformationTechnology (ADP/IT)) prior to approving requests for the remainingstaff in the incoming contractor’s organization.

1.1.3.3The contractor shall submitto DHA, within 15 days following the interface meetings, a revisedIMP/IMS which incorporates the results of the Transition Specificationsand interface meetings.

1.1.3.4The contractor shall documentinterface meetings with formal minutes and submit them in accordancewith the Incoming Weekly Status Reporting, CDRL located in SectionJ of the contract.

1.1.4Transition-In(Phase-In) Weekly Status Reporting

The incoming contractor shallsubmit a weekly status report of the transition schedule progress, identifyingschedule modifications and impacts to DHA beginning the 20th calendarday following “Notice of Award” by DHA through the 180th calendarday after the start of services delivery in accordance with theCDRL (or as directed by the Contracting Officer (CO) based on thestatus of the transition and other operation factors).

1.1.5Memorandum of Understanding(MOU) with TRICARE Contractors

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

1.1.5.2Within sixty calendar daysprior to the start of services delivery, the incoming contractor shallhave executed a MOU with the other TRICARE contractors (ManagedCare Support, TRICARE Overseas, and Pharmacy). The contractor shallensure the MOU includes, but is not limited to, provider file updatecoordination, beneficiary history transfers, customer service coordinationand marketing/education coordination in accordance with the CDRL.

1.1.5.3Within thirty calendar daysprior to the start of services delivery, the incoming contractor shallexecute a MOU with the TRICARE Claims Review Contractor for safe,secure, and positive electronic transmittal of claims processingdocumentation/information in accordance with the CDRL.

1.1.6Guidelines, Desk Instructions,and Reference Materials

The incomingcontractor shall develop processing guidelines, desk instructions/user’smanuals and reference materials for internal use, at least 60 calendardays prior to the start of services delivery. The contractor shallmake these available for Government review. The contractor may useelectronic versions.

1.1.7BankAccounts

The contractorshall establish bank accounts in accordance with Section G, notlater than 60 calendar days prior to the start of services delivery.

1.2Systems Development And Testing

1.2.1User Access Requirements

The incoming contractor shallensure personnel complete appropriate background and security checks inaccordance with the TSM, Chapter 1.

1.2.2National Institute of Standardsand Technology (NIST) Compliance

The incoming contractor shallprovide certification of compliance with the National Instituteof Standards and Technology (NIST) Compliance based InformationAssurance (IA) program identified in TSM, Chapter 1, Section 1.1 to fulfill all systemaccess requirements prior to connecting with the MHS and/or theinitiation of Integration Testing.

1.2.3Connectivity Requirements

The incoming contractor shallcollaborate with the Government to establish the required interfaces withGovernment systems and applications. The contractor shall completethe submission of required forms (e.g., Business to Business Questionnaire,DD Form 2875, etc.) in accordance with the TSM, Chapter1.

1.2.4DataTransmissions Start Up

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

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

1.2.5File Conversions And Testing

During the period between thedate of award and start of services delivery, the incoming contractor shall,pursuant to the IMP/IMS, meet the following contractor file conversionsand testing requirements.

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

1.2.5.2The contractor shall coordinateDMDC data file conversion and testing activities with the Governmentand submit required documents (Test Plan/Scenarios) within the timeframes established during the systems interface meetings but nolater than (NLT) 30 days following the Systems Integration InterfaceMeeting.

1.2.5.3The contractor shall prepareand complete Integration Testing 45 days prior to the start of servicesdelivery.

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

1.2.6Transaction Testing

In the absence of the inclusionof testing requirements in updated Health Insurance Portabilityand Accountability Act (HIPAA) legislation, the contractor shallcomply with testing requirements in accordance with the CO direction.At a minimum, testing shall include the following:

1.2.6.1The contractor shall test itscapability to create, send, and receive compliant transactions. Thecontractors shall provide written evidence (e.g., certificationfrom a transaction testing service) of successful testing of theircapabilities to create, send, and receive compliant transactionsto the contracting offices NLT 60 days prior to the start of servicesdelivery.

Note:Where failures occur duringtesting, the contractor shall make necessary corrections and re-testuntil a successful outcome is achieved.

1.2.6.2The incoming contractor shalltest their capability to process standard transactions. The contractorshall ensure this testing is “cradle-to-grave” from receipt of thetransactions, through processing, and completion of all associatedfunctions including creating and transmitting associated responsetransitions. The contractor shall ensure its testing involves thereceipt and processing of claims transaction and submission to andacceptance by the DHA of TRICARE Encounter Data (TED) records andthe creation of contract compliant electronic Explanation of Benefits(EOB). The contractor shall complete “cradle-to-grave” testing NLT30 days prior to the start of services delivery.

1.2.7TED Testing

The incoming contractor shalldemonstrate the ability to successfully create and submit all TEDrecord types and TEPRVs NLT 30 days prior to the start of servicesdelivery. This includes, but is not limited to, adjustment, denialand cancellation records.

1.2.8Non-ClaimsSystems

Approximately60 calendar days prior to the initiation of services delivery underTMEP, DHA or its designees will review the non-claims processingsystems and the telecommunications interconnections between thesesystems. The contractor shall demonstrate that its system(s) capabilitiesand DHA will determine whether the systems satisfy the requirementsof TRICARE as otherwise provided in the contract. The contractordemonstration shall include the telecommunications links with DHAand DEERS. The contractor shall effect any modifications required byDHA prior to the initiation of services delivery under TMEP.

1.3Customer Service

1.3.1Call Center

1.3.1.1The incoming contractor shallensure its customer service personnel are fully trained and knowledgeableabout TMEP and the TRICARE program and are able to accurately answercustomer inquiries at the start of services delivery.

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

1.3.1.3The contractor shall demonstrateits successful implementation and operation of its Interactive VoiceRecognition System to DHA approximately 60 calendar days prior tothe start of services delivery.

1.3.2Mailings

1.3.2.1The contractor shall preparea mailing to all Congressional offices by the 45th calendar day priorto the start of services delivery according to the specificationsof the official transition schedule. The contractor shall submitthe proposed mailing to the CO and the COR for review, and to DHA Communicationsfor approval NLT 90 calendar days prior to the start of services.The contractor shall ensure the mailing discusses any contractorunique processing requirements and any other needed informationdictated by the official transition schedule.

1.3.2.2The contractor shall mail anintroductory letter to all beneficiary households, who had claimsactivity in the previous 12 months, NLT 45 days prior to the startof services delivery.

1.3.3Web-BasedServices And Applications

The contractorshall demonstrate successful implementation and operation of itsweb-based capabilities as described in the contract, approximately60 calendar days prior to the start of services delivery.

1.4Claims Processing

1.4.1Claims Processing And Operations

The incoming contractor shallprocess claims based on the claim date of receipt at the start ofservices delivery.

1.4.2MedicareCrossover Claims

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

1.4.2.2NLT 60 days prior to the startof services delivery, the contractor shall demonstrate to DHA successfulreceipt and testing of electronic claims batches from Medicare forTRICARE processing.

1.4.3ContractorFile Conversion And Testing

The incoming contractor shallcomplete initial conversion and testing of all Automated Data Processing (ADP)files (e.g., provider files, beneficiary history files, and claimhistory files) NLT 30 calendar days following receipt of the filesfrom the outgoing contractor.

1.4.4Receipt of Outgoing Contractor’sShipment of History Updates and Dual Operations

1.4.4.1Beginning with the 120th calendarday prior to the start of services delivery and continuing afterthe start of services delivery until all pertinent claims receivedby the outgoing contractor have been processed, the incoming contractorshall convert the weekly shipment of the beneficiary history anddeductible file updates from the outgoing contractor files withintwo business days following receipt. The contractor shall validatethese files before use. The contractor shall perform tests for claims, updateof catastrophic cap, and duplicate claims within two business daysfollowing conversion. The incoming contractor shall resolve issueswith the outgoing contractor. The incoming contractor shall informthe DHA COR of all issues identified within two business days andprovide the problem resolution. Following the start of servicesdelivery, the incoming contractor shall load these files to historyand use them for claims processing on the first processing cyclefollowing the check for duplicate claims.

1.4.4.2During the period after thestart of services delivery when the incoming contractor and the outgoingcontractor are processing claims, both contractors shall maintainclose interface on history update exchanges and provider file maintenance.During the first 60 calendar days of dual operations, both contractorsshall exchange beneficiary history updates with each contractor’sclaims processing cycle run. Thereafter, both contractors shallensure the exchange is not less than twice per week until the endof dual processing period.

1.4.5Prior Authorizations

The incoming contractor shallhonor outstanding prior authorization issued by the outgoing contractor,covering care through 60 days after the start of services deliveryunder the incoming contract, in accordance with the outgoing contractor’sexisting practices and protocols, within the scope of the TRICAREprogram and applicable regulations or statutes.

1.4.6Duplicate Claims System (DCS)

1.4.6.1Incoming and Outgoing ContractorRequirements

1.4.6.2The incoming contractor shallaccess the web-based DCS via the Patient Encounter Processing andReporting (PEPR) Portal in accordance with the TSM, Chapter4 and ensure the connection is tested and accessible.

1.4.6.3The contractor shall participatein Government furnished DCS training and schedule training per theIMP/IMS.

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

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

1.4.6.6The incoming contractor shallbegin using the DCS to resolve identified potential duplicate claimsets “owned” by the incoming contractor 120 days following the startof services delivery.

1.4.6.7The incoming contractor shallbegin processing potential duplicate claim sets transferred fromthe outgoing contractor 150 days following the start of servicesdelivery.

1.4.6.8The incoming contractor shallidentify at least one individual to serve as the DCS POC. The contractorDCS POCs shall be individuals who are, or will be, trained in theuse of the DCS, and who is able to perform the required researchand determine whether a particular claim is within their processingjurisdiction. The contractor shall provide the name(s), title(s),business address (es), and business telephone number(s) of theirDCS POCs to the CO, with courtesy copies to the Contracting OfficerRepresentative (COR) and to the DHA DCS Program Representative.The contractor shall provide the DCS POCs to the CO NLT two weeksprior to the implementation of the DCS.

1.4.6.9DHA will provide each contractorwith 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 contractorshall maintain the listing and keep DHA and the other contractorsinformed of any changes.

1.4.6.10In accordance with the FinancialProcedures in the Transition Plan, the contract, and the TRICAREOperations Manual (TOM), the outgoing contractor shall package andforward to the incoming contractor, refund checks received and offsetstaken for recoupments associated with duplicate claims paymentsand recoupment files associated with in progress duplicate claim recoupment120 days following the start of services delivery.

1.4.6.11On the last day of the fourthmonth following the start of services delivery, or upon directionof the Government, the outgoing contractor shall cease researchingOpen claim sets and initiating new recoupments associated with duplicateclaim payments. The outgoing contractor shall also cease enteringrefund data and linking adjustment date in the DCS for Pending andValidate claim sets.

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

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

1.4.6.14If the actual recoupment amountwas zero when the set was transferred from the outgoing contractor,the incoming contractor shall apply the adjustment to the set whileleaving the actual recoupment amount as zero dollars. Resolutionwill result in a Validate status, and the incoming contractor shallexplain that the outgoing contractor did not enter the actual recoupmentamount.

1.4.6.15Following the start of servicesdelivery, the DCS will begin displaying identified potential duplicateclaim sets that the incoming contractor shall resolve. The incomingcontractor shall begin using the DCS to resolve potential duplicateclaim sets in accordance with the TSM, Chapter4 and the IMP/IMS requirements.

1.4.6.16The incoming contractor shallassume full responsibility for resolving all existing potential duplicateclaim sets from the outgoing contractor (including completing existingrecoupments) and for all new potential duplicate claim sets as agreedupon during the transition meeting.

1.5Other Transition Requirements

1.5.1Performance Assessment ReportingSubmissions

1.5.1.1The contractor shall submitall deliverables to DHA via the E-Commerce Extranet unless otherwisedirected by the CDRL. The contractor shall access the system viathe Internet through a workstation browser and a static InternetProtocol (IP) address. The application is “thin client” meaning thatthe contractor does not need to install software on the client workstationand no software is downloaded into the browser. Java script andcookies need to be enabled in the browser to use the application.The application is best viewed at a resolution of 1024 x 768 pixelsin an Internet Explorer (IE) browser (Version 8 and higher). Otherbrowsers such as Firefox and Chrome are not supported. The contractorshall access the system using the Secure Socket Layer (SSL) protocol(https://) and the system is protected by individually assigneduser name and password or CAC.

1.5.1.2The contractor shall requestaccess to the Extranet via the E-Commerce User Access Form-Externalwhich the Government will provide to the contractor. The Governmentgrants users access to deliverables at the contract level. Deliverablessubmitted by one contractor are not accessible to any other contractor.

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

1.5.1.4The incoming contractor shallschedule initial training on deliverable submission within 30 calendardays after award. The Government will provide additional trainingfor new users throughout the contract upon contractor request. TheGovernment will provide technical support during the business week.The Government will provide a POC for access and deliverable submissionduring initial training.

1.5.2Program Integrity

1.5.2.1The incoming contractor shallreceive case files and documentation regarding all open programintegrity cases from the outgoing contractor NLT 30 days from thestart of services delivery. The incoming contractor shall work withthe DHA Program Integrity Office (PI) to ensure seamless continuityof oversight of these cases. This shall include any open leads underdevelopment, proactive action items, etc., and not limited to cases.

1.5.2.2The incoming contractor shalldevelop and maintain standard operating procedures relevant to Chapter13. The contractor shall provide one complete set of thesematerials to the Government on the first day of service delivery,as required by the corresponding CDRL, with updates provided aschanges occur.

1.5.3HealthInsurance Portability and Accountability Act of 1996 (HIPAA)

The incoming contractor, asa covered entity under HIPAA, may honor an authorization or otherexpress legal document obtained from an individual permitting theuse and disclosure of protected health information prior to thecompliance date (HHS Privacy Regulation, §164.532).

1.5.4Records Management

The incoming contractor’s RecordsManagement liaison shall attend the first available DHA provided recordsmanagement training following contract award in accordance with Chapter9.

1.5.5Recoupments/Overpayments

1.5.5.1The incoming contractor andDHA, Office of General Counsel (OGC), Claims Collection Section(CCS), shall receive the designated cases from the outgoing contractorNLT 30 days after the start of services delivery. The incoming contractorshall reflect the number of cases and the amount of the outstandingdebt received from the outgoing contractor on the next monthly AccountsReceivable Report following the date of transition. (The detailsfor content and submission of this report are contained in the CDRL).

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

1.5.5.3The incoming contractor shallcontinue to monitor and manage the VA overpayments in accordancewith Chapter 10, Section 4.

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

1.5.6Appeals And Hearings

1.5.6.1The incoming contractor shalldevelop and maintain appeals processing guidelines, desk instructions,and reference materials relevant to Chapter12 and Chapter 11, Section 8.The incoming contractor shall provide one complete set of thesematerials to the Government as required by the corresponding CDRL,with updates provided as changes occur.

1.5.6.2The incoming contractor shallassume responsibility for processing new reconsiderations receivedon and after the start of services delivery.

2.0Contractor Transition-Out

2.1Management And Administration

2.1.1Transition Specifications

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

2.1.1.2The outgoing contractor shallprovide a proposed phase-out plan at the Transition SpecificationsMeeting.

2.1.1.3The outgoing contractor shallidentify an individual responsible for transition management whowill serve as the single point of contact for the Government forall transition activities.

2.1.2Transition-Out (Phase-Out)Weekly Status Reporting

The outgoingcontractor shall submit a weekly status report of inventories andphase-out activities to DHA beginning the 20th calendar day followingthe Specifications Meeting until otherwise notified by the CO todiscontinue. The contractor shall comply with specifications ofthe official transition schedule.

2.1.3Provide Information

The outgoing contractor shall,upon receipt of written request from DHA, provide to potential offerers suchitems and data as required by DHA. This shall include non-proprietaryinformation, such as record formats and specifications, field descriptionsand data elements, claims and correspondence volumes, etc.

2.1.4Data

The outgoing contractor shallprovide to DHA (or, at the option of DHA, to a successor contractor)such information as DHA shall require to facilitate transitionsfrom the contractor’s operations to operations under any successorcontract. The outgoing contractor shall provide all files in a non-proprietaryformat and the contractor shall include such file specificationsand documentation as may be necessary for interpretation of thesefiles. Such information may include, but is not limited to, thefollowing:

The data contained in the contractor’sclaims processing system.

Information about the managementof the contract that is not considered, under applicable Federallaw, to be proprietary to the contractor.

2.2System Testing

2.2.1Common Access Cards (CACs)

The outgoing contractor shallensure retrieval of CACs as outlined in the TSM, Chapter 1, Section 1.1.

2.2.2Duplicate Claims System (DCS)

The outgoing contractor shallphase-out the use of the automated TRICARE DCS in accordance with TSM, Chapter4 and the IMP/IMS.

2.3Claims Processing

2.3.1Phase-Out of the Contractor’sClaims Processing Operations

Upon notice of award to anothercontractor, and during the procurement process leading to a contract award,the outgoing contractor shall undertake phase-out activities describedbelow.

2.3.2Transferof Electronic File Specifications

The outgoing contractor shallprovide to the incoming contractor, NLT three calendar days following awardannouncement or upon direction of the CO, electronic copies of therecord layouts with specifications, formats, and definitions offields, and data elements, access keys and sort orders, for the following:

Beneficiary History Files.

Claims History Files.

The TRICARE Encounter ProviderFiles (TEPRVs).

Mental Health Provider Files:The outgoing contractor give the incoming contractor accurate providerpayment information on all mental health providers paid under theTRICARE inpatient mental health per diem payment system. This shallinclude provider name; Tax Identification Number (TIN); addressincluding ZIP code; high or low volumestatus; if high volume, provide the date the provider became highvolume; and the current per diem rate along with the two prior year’sper diem amounts. The contractor shall ensure the providers underthe per diem payment system are designated by Medicare, or meetexemption criteria, as exempt from the inpatient mental health unit.

The unit is be identified asthe provider under the TRICARE inpatient mental health per diempayment system.

2.3.3Transferof ADP Files

By the15th calendar day following the Transitions Specifications Meeting,the outgoing contractor shall prepare in non-proprietary electronicformat and transfer to the incoming contractor or DHA, unless otherwisenegotiated by the incoming and outgoing contractors, all specifiedADP files (e.g., provider certification and any pricing files, checkcopies, release of information documents, TPL files, etc.) in accordancewith specifications in the official transition schedule and shallcontinue to participate in preparation and testing of these filesuntil they are fully readable by the incoming contractor or DHA.

2.3.4Outgoing Contractor WeeklyShipment of History Updates

The outgoing contractor shalltransfer to the incoming contractor, in non-proprietary electronicformat, all beneficiary history and deductible transactions occurringfrom the date of preparation for shipment of the initial transferof such history files and every week thereafter beginning the 120thcalendar day prior to the start of services delivery until sucha time that all processing is completed by the outgoing contractorin accordance with the specifications in the official transitionschedule.

2.3.5PriorAuthorizations

The outgoingcontractor shall provide all prior authorizations that cover carespanning the start of services delivery under the new contract orcare that could potentially be in the incoming contractor’s servicesdelivery period. The outgoing and incoming contractor shall mutuallyagree to the date and schedule for transfer of this information.

2.3.6Transfer of Beneficiary Information

The outgoing contractor shallprovide a list of all TMEP special program (ECHO, ICMP-PEC, etc.)and LDT Demonstration beneficiaries to the incoming contractor.

2.3.7Transfer of Non-ADP Files

The outgoing contractor shalltransfer to the incoming contractor all non-Automated Data Processing (ADP)files (e.g., Congressional and DHA completed correspondence files,appeal files, TRICARE medical utilization, and administration files)in accordance with the specifications in the official transition scheduleand Chapter 9. Theoutgoing contractor shall transfer hard copies of the BeneficiaryHistory Files to the incoming contractor or Federal Records Center(FRC) as required by Chapter 9. The outgoingcontractor shall provide samples and descriptions of these filesto the incoming contractor at the Transition Specification Meeting.

2.3.8Final Processing of OutgoingContractor

The outgoingcontractor shall:

Process to completion all claims,to include adjustments, received during its period of services delivery.The contractor shall complete processing these claims within 180days following the start of the incoming contractor’s services delivery.The outgoing contractor shall meet all contract standards for theseclaims.

Be liable, after the terminationof services under this contract, for any payments to subcontractors ofthe contractor arising from events that took place during the periodof this contract.

Process all correspondence,allowable charge complaints, and incoming telephonic inquiries which pertainto claims or services processed or delivered under this contractwithin the time frames established for response by the standardsof the contract.

Complete all appeal and grievancecases that pertain to claims or services processed or delivered underthis contract within the time frames established for response bythe standards of the contract.

2.3.9Correction of Edit Rejects

The outgoing contractor shallretain sufficient resources to ensure correction (and reprocessing throughDHA) of all TED record edit errors NLT 210 calendar days followingthe start of the incoming contractor’s services delivery.

2.3.10Termination of Trading PartnerAgreement

The outgoingcontractor shall terminate their trading partner agreement withthe BCRC to ensure receipt of crossover claims concludes with theend of the period of performance.

2.4Other Outgoing Transition Requirements

2.4.1Program Integrity

The outgoing contractor shallprovide weekly updates, on the outgoing weekly status report, of programintegrity case files, including new cases initiated through theend of the outgoing contractor’s contract delivery period. Thisshall also include active leads and cases under development thathave not yet been forwarded to DHA PI. See Chapter9 for additional information on transferring electronic records.

2.4.2Records Management

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

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

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

2.4.3Transfer of Electronic Records

2.4.3.1During transition, the outgoingcontractor shall transfer all DHA electronic records not eligiblefor destruction along with their associated metadata to the incomingcontractor. DHA electronic records suitable for transfer shall beidentified through meetings between contractors, the DHA RecordsManagement Officer and the DHA Contracting Office. The outgoingcontractor shall develop a process for transferring the data tothe incoming contractor that ensures no metadata or their associatedrecord objects are lost in the transition process.

2.4.3.2The outgoing contractor shallensure documentation adequately identifies, services, and interpretselectronic records designated for storage by DHA and shall transferthe documentation with the records.

2.4.4Explanation of Benefits (EOB)Record Data Retention and Transmittal

If the outgoing contractorelects to retain the EOB data on a computer record, the contractorshall, in the event of a transition to another contractor, provideeither a full set of electronic records covering the current andtwo prior years, or, at the CO’s discretion, provide the data andnecessary programs to reproduce the EOB in acceptable form and transfersuch data and programs to the incoming contractor or to DHA. DHAwill be the final authority in determining the form and/or acceptabilityof the data. See Chapters 2 and 9 foradditional information on transitioning electronic EOBs.

2.4.5Records Disposition

2.4.5.1The outgoing contractor shallcomply with the requirements in Chapter9, in final disposition of all files and documentation.The outgoing contractor shall include records disposition plan aspart of the phase-out plan submitted to DHA at the Transition SpecificationsMeeting.

2.4.5.2Once the transition of recordsand materials has been accomplished, the outgoing contractor shalldestroy all copies to include backup data in accordance with 36CFR Part 1226, “Implementing Disposition”. The contractor shallnot dispose or destroy any copies or backup data prior to formal,written notification from the DHA Contracting Office or DHA RecordsManagement Office. The contractor shall provide a formal recordof destruction or certificate to the DHA CO and the DHA RecordsManagement Officer documenting what was destroyed, the date(s) destroyedand by whom. The contractor shall include a records dispositionplan as part of the phase-out plan submitted to DHA at the TransitionSpecifications Meeting.

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

2.4.6Recoupments/Overpayments

2.4.6.1The outgoing contractor shallsend the designated cases NLT 30 days after the start of servicesdelivery.

2.4.6.2The outgoing contractor shallsubmit a credit adjustment to include all amounts recouped up tothe point of transition. The outgoing contractor shall ensure itsfinal Accounts Receivable Report reflects the number of cases andthe amount of the outstanding debt transferred to the incoming contractor.

2.4.6.3Installment Cases

The outgoing contractor shalltransfer all installment cases to DHA, Office of General Counsel(OGC), CCS. The contractor shall provide a list of all installmentcases to be transferred by fax or encrypted email to CCS beforetransferring the cases.

2.4.6.4CasesLess Than 12 months

The outgoingcontractor shall transfer cases greater or equal to $110 ($30 forpharmacy) and that are less than 12 months old to the incoming contractor.The outgoing contractor shall write-off cases that do not meet thecriteria.

2.4.6.5CasesGreater Than 12 Months

2.4.6.5.1The outgoing contractor shallwrite off cases less than $600 that when combined with other casesdo not equal $600 or more, and reported on line A5 of the AccountsReceivable Summary Report (refer to the CDRL).

2.4.6.5.2The outgoing contractor shalltransfer cases greater or equal to $600 to DHA, OGC, CCS. The contractorshall provide a list of all transfer cases to CCS by fax or encryptedemail before the cases are transferred.

2.4.6.6Veterans Affairs (VA) Overpayments

The outgoing contractor shalltransfer identified VA Overpayment cases to the incoming contractorin accordance with the transition schedule.

2.4.7Third Party Recovery

The outgoing contractor shalltransfer, in accordance with the transition schedule, court ordered restitutioncases to the incoming contractor for continued collection.

2.4.8Appeals And Hearings

The outgoing contractor shallaccept requests for reconsideration, including requests by DHA to reopena case, received through the end of the outgoing contractor periodof performance.

2.4.8.1Assistanceto Incoming Contractor, TRICARE Quality Management Contract (TQMC), andDHA During Transition

Duringtransition, the outgoing contractor or the TQMC shall make available,upon request, individual cases completed during the transition periodand not yet transferred to the incoming contractor or TQMC. Theoutgoing contractor shall not mail the appeal file to the incomingcontractor, the TQMC, or DHA later than five business days afterreceipt of a telephonic, written or fax request from DHA or the incomingcontractor during a transition period.

2.4.8.2Appeal Case Files

Upon request from the incomingcontractor, the outgoing contractor shall transfer individual cases completedduring the transition period and not yet transferred to the incomingcontractor in accordance with Chapter12.

2.4.9CostAccounting

If theoutgoing contractor succeeds itself, the contractor shall keep costsrelated to each contract separate for purposes of contract accountability.

- END -

TRICARE Manuals - Display Chap 20 Sect 2 (Change 139, Jun 10, 2024) (2024)
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