TRICARE Manuals - Display Chap 24 Sect 1 (Change 139, Jun 10, 2024) (2024)

TRICARE Operations Manual 6010.59-M, April 1, 2015

TRICARE Overseas Program (TOP)

Chapter 24

Section 1

Administration

Revision:C-127, August 21, 2023

1.0GENERAL

All TRICARE requirements regardingadministration shall apply to the TRICARE Overseas Program (TOP) unlessspecifically changed, waived, or superseded by this section; theTRICARE Policy Manual (TPM), Chapter12; or the TRICARE contract for health care support servicesoutside the 50 United States (U.S.) and the District of Columbia(hereinafter referred to as the “TOP contract”). See Chapter1 for additional instructions regarding administration.Specific health care support services required for the performanceof this contract are identified in this chapter, in the TPM, Chapter12, and the TOP contract.

2.0CONTRACT ADMINISTRATION ANDINSTRUCTIONS TO CONTRACTOR

2.1The provisionsof Chapter 1, Section 2 are applicable to theTOP. Additionally, the TOP contractor shall coordinate with theDefense Health Agency (DHA) Contracting Officer (CO), the appropriateDHA Contracting Officer Representative (COR), and the TRICARE OverseasProgram Office (TOPO) on any TOP policy or contractual issue thatrequires additional Government clarification or assistance to resolve.

2.2Theprovisions of Chapter 1, Section 2, paragraph 4.0 are supersededas described in paragraphs 2.2.1 through 2.2.6.

2.2.1A14 calendar day notice will be provided by the DHA Procurement ContractingOfficer (PCO) for all meetings hosted by DHA.

2.2.2The TOP contractor shall provideup to four contractor representatives at the Performance ReadinessValidation briefing at DHA.

2.2.3TheTOP contractor shall provide at least two contractor representativesfor transition briefings/meetings with each overseas Military TreatmentFacility (MTF) and TAO. All briefings/meetings must be completedno later than 60 calendar days prior to the start of health caredelivery (SHCD). These briefings/meetings shall be targeted towardscommand suite/key leaders and their staff and shall encompass allkey contract areas where collaboration between the contractor andthe MTF/TRICARE Area Office (TAO) will occur.

2.2.4The TOP contractor shall provideannual representation at two contractor conferences (senior managementlevel) at DHA. The contractor shall also provide up to four contractor representativesat up to four additional meetings at the direction of the CO percontract year.

2.2.5The TOPcontractor shall provide representation at semiannual TOP operationalmeetings to be held at DHA Aurora with TOPO, TAO, and service representation.

2.2.6TheTOP contractor shall provide two contractor representatives at upto 18 additional meetings/site visits at the direction of the COper option period.

3.0TRICARE PROCESSING STANDARDS

The provisions of Chapter 1, Section 3 regarding TRICARE processingstandards apply with following exceptions:

3.1The standard in Chapter 1, Section 3, paragraph 1.2.3 whichincreases referral accuracy percentages by 1% each Option Periodapplies through Option Period 5 of the TOP contract. The referralaccuracy percentages for Option Periods 6 and 7 shall be 99%.

3.2Chapter 1, Section 3, paragraph 1.2.5 doesnot apply to the TOP contract. Required reports are identified inSection F of the TOP contract.

3.3Chapter 1, Section 3, paragraph 1.3 does notapply to the TOP contract. Network adequacy requirements are detailedin Section C and Section H of the TOP contract.

Note:The standards for telephoneinquiries apply to all toll-free lines supporting TOP contract customerservice activities.

4.0MANAGEMENT

The provisions of Chapter 1, Section 4 are applicable to theTOP, except that the provisions of Chapter 1, Section 4, paragraph 2.3 regardingzip code files are only applicable to Puerto Rico.

5.0COMPLIANCE WITH FEDERAL STATUTES

See Chapter 1, Section 5 forinstructions regarding compliance with Federal statutes.

6.0LEGAL MATTERS

See Chapter 1, Section 6 forinstructions regarding legal matters.

7.0TRANSITIONS

The provisions of Chapter2 do not apply to the TOP contract.

7.1Transition-InPlan

The TOP contractor will delivera transition-in plan 10 days after contract award. In addition tothe transition-in plan, the contractor shall provide weekly statusreports throughout transition period or as directed by the Government.

7.2Transition Specifications Meeting

The incoming contractor shallattend a two to four day meeting with the outgoing contractor andDHA within 15 days following contractaward. This meeting is for the purpose of developing a schedulefor transition-in and transition-out activities. If the incomingcontractor is an incumbent, it shall attend a one to two day meetingwith DHA. DHA will notify the contractor as to the exact date ofthe meeting. Contractor representatives attending this meeting shallhave the experience, expertise, and authority to approve processesand establish project commitments on behalf of their organization.

7.3Interface Meetings

Within 30 daysfrom contract award, the incoming contractor shall arrange meetingswith Government and external agencies to establish all interfacesnecessary to meet the requirements of this contract. DHA representativesshall be included in these meetings.

8.0TRANSITION-IN REQUIREMENTS

8.1Systems Development

Approximately 80 daysprior to the initiation of health care delivery, the non-claimsprocessing systems and the telecommunications interconnections betweenthese systems shall be reviewed by the DHA or its designees, toinclude a demonstration by the contractor of the system(s) capabilities,to determine whether the systems satisfy the requirements of TRICAREas otherwise provided in the contract. This includes the telecommunicationslinks with DHA and Defense Enrollment Eligibility Reporting System (DEERS)and the Business-to-Business Gateway (B2B). The review will alsoconfirm that the hardware, software, and communications links requiredfor operating the automated TRICARE Duplicate Claims System (DCS)have been installed and are ready for DHA installation of the DCSapplication software (see the TRICARE Systems Manual (TSM), Chapter4). The contractor shall implement any modifications requiredby DHA prior to the initiation of services.

8.2Executionof Agreements with Contract Providers

8.2.1All contractprovider agreements shall be executed, and loaded to the contractor’ssystem, 80 days prior to the startof health care delivery, or at such other time as is mutually agreedbetween the contractor and DHA.

8.2.2The contractor shall reporton network adequacy on a monthly basis during the transition.

8.3See 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 Directorno later than 60 days prior to theSHCD.

8.4EnrollmentTransition

The contractorshall begin the enrollment process no later than (NLT) 60 daysprior to the scheduled SHCD, with actual enrollment processing tobegin 40 days prior to the SHCD, subject to DHA approval of systemsunder the contract.

8.4.1For enrollmentsin the region with an effective date prior to the SCHD (e.g., activeduty (AD) enrollment, mid-month enrollment; transfer-in), the incomingcontractor must effect an enrollment to begin on the SHCD once notifiedby the outgoing contractor of the new enrollment. (Defense ManpowerData Center (DMDC) may run a report at the end of the transitionperiod that reflects new additions.)

8.4.2When the outgoing contractorrequests deletion of current enrollments with an effective dateprior to the SHCD (e.g., transfers out; disenrollments for failureto pay fees; cancellations, etc.), the incoming contractor mustcancel the future enrollment segment and notify the outgoing contractor whenthis action has been completed.

8.4.3For all other enrollment actionswith an effective date prior to SHCD (e.g., Primary Care Manager(PCM) changes; Defense Medical Information System-IdentificationCode (DMIS-ID) changes; enrollment begin date changes; etc.), requestedby the outgoing contractor, the incoming contractor must cancelthe future enrollment segment and notify the outgoing contractorwhen this action has been completed. When notified by the outgoingcontractor that their change has been effected, the incoming contractormust reinstate the future enrollment segment.

8.4.4Once health care delivery begins,all enrollment actions will be accomplished by the incoming contractor.If the outgoing contractor requires a retroactive change, they mustsubmit their request to the incoming contractor who will performthe change and notify the outgoing contractor when it is complete.

8.5Transfer of Enrollment Files

8.5.1The incoming contractor shallobtain enrollment information from DEERS through an initial enrollmentload file. DMDC will provide the incoming contractor with an incrementalenrollment load file for each contract transition. The incomingcontractor shall process each enrollment load file within 24 hoursor less from receipt of the file.

Note:Each contract transition shallrequire a three-day freeze of enrollment and claim processing. Thisfreeze will occur beginning the first weekend that precedes the60 day window prior to the SHCD. The actual calendar dates willbe determined during the transition meeting.

8.5.2The incoming contractor shallsend enrollment renewal notices for all enrollees whose currentenrollment period expires on or after the SHCD. The incoming contractorshall send billing statements where the enrollment fee payment wouldbe due on or after the SHCD. The incoming contractor shall startsending billing notices and process renewals 45 days prior to theSHCD.

8.5.3Outstandingenrollment record discrepancies and issues reported to the DEERSSupport Office (DSO) by the outgoing contractor will be transferredto the incoming contractor for reconciliation. Records will be reconciledin accordance with TSM, Chapter 3.

8.6TRICARE Service Center (TSC)Phase-In

8.6.1The incomingcontractor shall utilize the existing TSCs. The outgoing contractorshall allow reasonable access to the incoming contractor throughoutthe transition period to become familiar with the communicationlines, equipment and office layout.

8.6.2The final schedule for accessto and occupancy of the TSCs will be determined at the TransitionSpecifications Meeting. The approved schedule must allow the outgoingcontractor to fulfill all contract requirements through the lastday of health care delivery, and must provide the incoming contractorsufficient access to the TSC to prepare for delivery of all requiredfunctions on the first day of their contract.

8.6.3All Contractor Customer Service,Education and Health Care Finder (HCF) Field Representatives andoverseas TSC representatives shall be fully trained and availablefor all duties no less than 80 calendar days prior to initiationof health care services.

Note:Overseas TSCs are managed bythe MTFs and are jointly staffed by MTF and TOP contractor personnel.The TOP contractor is responsible for providing on-site BeneficiaryService Representative (BSR) support in all TSC locations.

8.7Contractor File Conversionsand Testing

8.7.1The incomingcontractor shall perform initial conversion and testing of all AutomatedData Processing (ADP) files (e.g., provider files, pricing files,and beneficiary history) NLT 30 calendar days following receiptof the files from the outgoing contractor(s).

8.7.2Integration testing will beconducted to validate the contractor’s internal interfaces to each ofthe TRICARE Military Health Systems (MHSs). This testing will verifythe contractor’s system integration, functionality, and implementationprocess. The incoming contractor shall be responsible for the preparationand completion of Integration Testing 45 days prior to the SHCD.(See the TSM, Chapter 1, Section 1.1, paragraph 2.0.)

8.7.3Contractors shall provide certificationof compliance with the National Institute of Standards and Technology(NIST)-based Information Assurance (IA) program identified in theTSM, Chapter 1, Section 1.1, to fulfill all systemaccess requirements prior to connecting with the MHS and/or theinitiation of Integration Testing.

8.7.4DHA 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 Managers. The TestingCoordinator 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 availablefor use by contractor Test Coordinators to report and track issuesand problems identified during integration testing.

8.8Receipt of Outgoing Contractor’sWeekly Shipment of History Updates and Dual Operations

8.8.1Beginning with the 120th calendarday prior to the SHCD and continuing for 180 calendar days afterthe SHCD, the incoming contractor shall convert the weekly shipmentsof the beneficiary history updates from the outgoing contractor(s)within two working days following receipt. These files shall bevalidated by the incoming contractor before use. Tests for claimsand duplicate claims shall be performed within two workdays followingconversion. Following the SHCD, these files shall be loaded to historyand used for claims processing.

8.8.2During the 180 calendar daysafter the SHCD when both the incoming and outgoing contractors areprocessing claims, both contractors shall maintain close interfaceon history update exchanges and provider file information. Duringthe first 60 calendar days of dual operations, the contractors shallexchange beneficiary history updates with each contractor’s claimsprocessing cycle run. Thereafter, the exchange shall not be lessthan twice per week until the end of dual processing. The incomingcontractor shall assume total responsibility for the maintenanceof the TRICARE Encounter Provider Record (TEPRV) beginning withthe SHCD. The incoming contractor will coordinate and cooperatewith the outgoing contractor to ensure that the outgoing contractorcan continue to process claims accurately; conversely, the outgoingcontractor has responsibility to notify the incoming contractorof any changes in provider status that they become aware of throughtheir operations.

8.9Transition-InRequirements Related To Transitional Cases

8.9.1In notifying beneficiariesof the transition to another contractor, both the incoming and outgoingcontractors shall include instructions on how the beneficiary mayobtain assistance with transitional care. If the outgoing contractorsucceeds itself, costs related to each contract will be kept separatefor purposes of contract accountability.

8.9.2Non-NetworkInpatient Transitional Cases

These are beneficiaries whoare inpatients (occupying an inpatient bed) at 0001 hours on thefirst day of any health care contract period in which the incomingcontractor begins health care delivery. In the case of DiagnosisRelated Group (DRG) reimbursem*nt, the outgoing contractor shallpay through the first month of health care delivery or the dateof discharge, whichever occurs first. If the facility is reimbursedon a per diem basis, the outgoing contractor is responsible forpayment of all the institutional charges accrued prior to 0001 hourson the first day of health care delivery, under the incoming contractor.The incoming contractor thereafter is responsible for payment.

8.9.3Non-Network Outpatient/ProfessionalTransitional Cases

Theseare cases, such as obstetric care, that are billed and payable under“Global” billing provisions of Current Procedural Terminology, 4thedition (CPT-4), HCFA Common Procedure Coding System (HCPCS), orlocal coding in use at the time of contract transition, and wherean Episode Of Care (EOC) shall have commenced during the periodof health care delivery of the outgoing contractor and continues,uninterrupted, after the SHCD by the incoming contractor. Outpatient/professionalservices related to transitional cases are the responsibility ofthe outgoing contractor for services delivered prior to 0001 hourson the first day of health care delivery and of the incoming contractorthereafter.

8.9.4NetworkInpatient Care During Contract Transition

The status of network providerchanges (provider’s network agreement with the outgoing contractoris terminated resulting in the provider’s loss of network status)with the SHCD of the new contract. As a result, claims for inpatientcare shall be reimbursed in accordance with paragraph 8.9.2 for non-network transitionalcases. Beneficiary copay is based on the date of admission; therefore,Prime beneficiaries who are inpatients as described in paragraph 8.9.2,shall continue to be subject to Prime network copayments and shallnot be subject to Point Of Service (POS) copayments.

8.9.5Home Health Care (HHC) DuringContract Transition

HHC, fora 60-day EOC, initiated during the outgoing contractor’s healthcare delivery period and extending, uninterrupted, into the healthcare delivery period of the incoming contractor are considered tobe transitional cases. Reimbursem*nt for both the Request for AnticipatedPayment (RAP) and the final claim shall be the responsibility ofthe outgoing contractor for the entire 60-day episodes coveringthe transition period from the outgoing to the incoming contractor.

8.10Prior Authorizations and Referrals

The incoming contractor shallhonor outstanding prior authorizations and referrals issued by the outgoingcontractor, covering care through 60 days after the SHCD under theincoming contract, in accordance with the outgoing contractors existingpractices and protocols, within the scope of the TRICARE programand applicable regulations or statutes. In the case of ResidentialTreatment Care (RTC) care, both the incoming and outgoing contractorsare responsible for authorizing that part of the stay falling withintheir areas of responsibility; however, the incoming contractormay utilize the authorization issued by the outgoing contractoras the basis for continued stay. This transition period for priorauthorizations and referrals is extended to one year for obstetricalcare or any other condition for which a one-year authorization hasbeen issued.

8.11CaseManagement

The incomingcontractor shall receive case files and documentation regardingall beneficiaries under case management programs. The incoming contractorshall ensure seamless continuity of services to those beneficiaries.

8.12Program Integrity

The incoming contractor shallreceive case files and documentation regarding all open program integritycases from the outgoing contractor NLT 30 days from the SHCD. Theincoming contractor shall work with the DHA Program Integrity Office(PI) to ensure seamless continuity of oversight of these cases.

8.13Health Insurance PortabilityAnd 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).

8.14Installation And OperationOf The DCS

The incomingcontractor shall have purchased, installed, configured, and connectedthe personal computers and printers required to operate the DCSNLT 60 days prior to the start of the health care delivery. Seethe TSM, Chapter 4,for hardware, software, printer, configuration and communications requirementsand contractor installation responsibilities. Approximately 30-45days prior to health care delivery, DHA will provide and installthe DCS application software on the incoming contractor designatedpersonal computers and provide on-site training for users of theDCS in accordance with the TSM, Chapter4. Following the SHCD, the DCS will begin displaying identifiedpotential duplicate claim sets for which the incoming contractorhas responsibility for resolving. The incoming contractor shallbegin using the DCS to resolve potential duplicate claim sets inaccordance with TSM, Chapter 4 andthe transition plan requirements.

8.15The TOP contractor shall preparea mailing to the Resident Commissioners of Puerto Rico and the NorthernMariana Islands, and the Congressional representatives for AmericanSamoa, Guam, and the U.S. Virgin Islands by the 45th calendar dayprior to the SHCD according to the specifications of the officialtransition schedule. The proposed mailing shall be submitted tothe DHA CO, DHA COR, and TOPO, for approval no later than 90 calendardays prior to the SHCD. The mailing shall discuss any unique processingrequirements of the contractor and any other needed informationdictated by the official transition schedule.

9.0Transition-OUT

9.1Transition Specifications Meeting

The outgoing contractor shallattend a meeting with representatives of the incoming contractorand DHA, within 15 calendar days following the effective date ofthe contract. This meeting is for the purpose of developing a scheduleof transition-in/transition out activities. DHA will notify the contractor(s)as to the exact date and location of the meeting. The outgoing contractorshall provide a proposed transition-out plan at the Transition SpecificationsMeeting.

9.2Data

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. All files shall be provided in a non-proprietary formatand the contractor shall include such file specifications and documentationas may be necessary for interpretation of these files. Such informationmay include, but is not limited to, the following:

The data contained in the contractor’senrollment information system.

The data contained in the contractor’sclaims processing systems.

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

An automated indexing systemthat can be used independently of the outgoing contractor’s data system.(See Chapter 9, Section 3, paragraph 2.2.2 forAutomated Indexing System requirements.)

9.3Transition-Out Of The Contractor’sClaims Processing Operations

Upon notice of award to anothercontractor, and during the procurement process leading to an effectivedate of a new contract, the contractor shall undertake the followingtransition-out activities regarding services as an outgoing contractor.

9.3.1Transfer of Electronic FileSpecifications

The outgoingcontractor shall transfer to the incoming contractor by expressmail or similar overnight delivery service, NLT three calendar daysfollowing award announcement, electronic copies of the record layoutswith specifications, formats, and definitions of fields, and dataelements, access keys and sort orders, for the following:

The TEPRVs.

The TRICARE Encounter PricingFiles (TEPRCs).

The Enrolled Beneficiary andPCM Assignment Files.

Mental Health Provider Files- The outgoing contractor must assure that the incoming contractor hasbeen given accurate provider payment information on all mental healthproviders paid under the TRICARE inpatient mental health per diempayment system. This should include provider name; tax identificationnumber; address including zip code; high or low volume status; ifhigh volume, provide the date the provider became high volume; andthe current per diem rate along with the two prior year’s per diemamounts. The providers under the per diem payment system must be designatedby Medicare, or meet exemption criteria, as exempt from the inpatientmental health unit, the unit would be identified as the providerunder the TRICARE inpatient mental health per diem payment system.

9.3.2Transfer Of ADP Files (Electronic)

The outgoing contractor shallprepare in non-proprietary electronic format and transfer to the incomingcontractor or DHA, by the 15th calendar day following the TransitionSpecifications Meeting unless otherwise negotiated by the incomingand outgoing contractors, all specified ADP files, such as the Providerand Pricing files, in accordance with specifications in the officialtransition schedule and will continue to participate in preparationand testing of these files until they are fully readable by the incomingcontractor or DHA.

9.3.3OutgoingContractor Weekly Shipment Of History Updates

The outgoing contractor shalltransfer to the incoming contractor, in electronic format, all beneficiary historyand deductible transactions (occurring from the date of preparationfor shipment of the initial transfer of such history files) beginningthe 120th calendar day prior to the SHCD (until such a time that allprocessing is completed by the outgoing contractor) in accordancewith the specifications in the official transition schedule.

9.3.3.1During the 180 calendar daysafter the SHCD when both the incoming and outgoing contractors areprocessing claims, both contractors shall maintain close interfaceon history update exchanges and provider file information. Duringthe first 60 calendar days of dual operations, the contractors shallexchange beneficiary history updates with each contractor’s claimsprocessing cycle run. Thereafter, the exchange shall not be lessthan twice per week until the end of dual processing.

9.3.3.2The incoming contractor shallassume total responsibility for the maintenance of the TEPRV beginningwith the SHCD. The incoming contractor will coordinate and cooperatewith the outgoing contractor to ensure that the outgoing contractorcan continue to process claims accurately; conversely, the outgoingcontractor has the responsibility to notify the incoming contractorof any changes in provider status that they become aware of throughtheir operations.

9.3.4TransferOf Non-ADP Files

The outgoingcontractor shall transfer to the incoming contractor all non-ADPfiles (e.g., authorization files, clinic billing authorizations,and tapes/CDs, which identify Congressional and DHA completed correspondencefiles, appeals files, TRICARE medical utilization, and administrationfiles) in accordance with the specifications in the official transitionschedule. The hard copies of the Beneficiary History Files are tobe transferred to the incoming contractor or Federal Records Center(FRC). The contractor shall provide samples and descriptions ofthese files to the incoming contractor at the Transition SpecificationMeeting.

9.3.5Explanationof Benefits (EOB) Record Data Retention and Transmittal

If the contractor elects toretain the EOB data on a computer record, it must, in the eventof a transition to another contractor, provide either a full setof electronic records covering the current and two prior years,or, at the PCO’s discretion, provide the data and necessary programsto reproduce the EOB in acceptable form and transfer such data andprograms to the successor contractor or to DHA. DHA shall be thefinal authority in determining the form and/or acceptability ofthe data.

9.3.6OutgoingContractor Weekly Status Reporting

Until all inventories havebeen processed, the outgoing contractor shall submit a weekly statusreport of inventories and phase-out activities to DHA beginningthe 20th calendar day following the Specifications Meeting untilotherwise notified by the PCO to discontinue. This shall be donein accordance with specifications of the official transition schedule.

9.3.7Prior Authorizations and Referrals

The outgoing contractor shallprovide all prior authorizations and referrals that cover care spanningthe SHCD under the new contract or care that could potentially beginin the incoming contractor’s health care delivery period. The outgoingand incoming contractor shall mutually agree to the date and schedulefor transfer of this information.

9.3.8Case Management Files

NLT 60 days prior to the SHCDunder the new contract, the outgoing contractor shall provide the incomingcontractor with all files pertaining to beneficiaries covered undera Case Management program. Electronic files shall be provided undera non- proprietary format. The outgoing contractor shall cooperatewith the incoming contractor to ensure seamless continuity of careand services for all such beneficiaries.

9.3.9Requirements Related To TransitionalCases

The outgoingcontractor shall provide the incoming contractor with instructionsfor beneficiaries and providers on how the beneficiary may obtainassistance with transitional care.

9.3.10Program Integrity Files

NLT 30 days prior to the SHCDunder the new contract, the outgoing contractor shall provide the incomingcontractor with all fraud and abuse information it has collectedduring the tenure of the contract relevant to TRICARE providersand beneficiaries. For example, (not all inclusive) high dollar initialdraft fraud cases, post payment utilization and reviews that identifiedpotential fraud, established provider/beneficiary outlier watchlists, list of providers on prepayment review, copies of educational letters,regional fraud trend/outlier reports, Fraudline reports, and beneficiarycomplaints related to health care fraud. Electronic files shallbe provided under a non-proprietary format.

9.4Final Processing Of OutgoingContractor

The outgoingcontractor shall:

Process all claims receivedthrough the last date of the outgoing contractor’s healthcare delivery. Processingof these claims, including adjustments, shall be completed with180 days following the start of the incoming TOP contractor’s healthcaredelivery period.

All claims shall meet the samestandards as outlined in the current outgoing contract. Any residual claimreceived after SHCD shall be forwarded to the incoming contractorwithin 24 hours of receipt. Claims for the Philippines, that havebeen pended for development of missing/required documentation orpended for provider certification, shall be denied on the 179thday if information was not received or certification was not complete.Any residual information related to the Philippines claims receivedafter SHCD shall be forwarded to the incoming contractor with 24hours of receipt.

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.

9.4.1Correction 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 health care delivery.

9.4.2Transition-Out of the AutomatedTRICARE DCS

The outgoingcontractor shall phase-out the use of the automated TRICARE DCSin accordance with the TSM, Chapter 4 andtransition plan requirements.

9.4.3Transition-Out Of The Contractor’sProvider Network, TSCs, And MTF Agreements

9.4.3.1Upon notice of award to anothercontractor, the outgoing contractor shall provide full cooperationand support to the incoming contractor, to allow an orderly transition,without interruption, of all functions relating to the MTF interfaceand the establishment of a provider network by the incoming contractor.This shall include, but is not limited to, data relating to on-siteservice centers, equipment, telephones and all other functions havingan impact on the MTFs.

9.4.3.2Within 15 calendar days ofthe Transitions Specifications Meeting the outgoing contractor shalldraft and submit a revised plan for transition of the MTF interfaces.Resolution of differences identified through the coordination processmust be accomplished in collaboration with TOPO.

9.4.3.3The outgoing contractor shallensure a HCF function continues through the last date of healthcare delivery under the current contract, unless otherwise negotiatedwith the incoming contractor during the Transition SpecificationsMeeting. The outgoing contractor shall also vacate the TSCs on the40th calendar day prior to the start of the health care deliveryand establish a centralized HCF function.

9.4.3.4The outgoing contractor shallcontinue to issue prior authorizations for care for which it is financiallyresponsible. However, authorization-related information shall beshared between the incoming and the outgoing contractors to precluderequiring a provider or beneficiary to duplicate the paperwork andother effort related to establishing prior authorizations. The outgoingcontractor may issue prior authorizations as late as midnight onthe day prior to the end of its health care delivery for inpatientstays that will continue as transitional cases. The two contractorsshall interface on the clinical issues of a case where both contractorswill, or can reasonably expect to have periods of liability forthe same EOC.

9.4.3.5The outgoing contractor shallmaintain toll-free lines and web-based customer service capabilities,accessible to the public during the first 90 calendar days of dualoperations in order to properly respond to inquiries related toclaims processed for services incurred during the period of theirrespective liability. Beneficiary inquiry lines will continue tobe staffed as defined in the contract.

9.5Transition-Out of EnrollmentActivities

9.5.1Priorto the SHCD under the successor contract, for all enrollment renewalsor payments in which the new enrollment period or period coveredby the premium payment will begin under the new contract, the outgoingcontractor shall amend renewal notices and billing statements (orinclude a stuffer/insert) to advise the enrollee to direct any enrollment-relatedcorrespondence and enrollment fee payments to the successor contractor.

9.5.2Any enrollment-related correspondenceand/or enrollment fee payments subsequently received by the outgoingcontractor shall be forwarded to the incoming contractor withinthree working days of receipt.

9.5.3The outgoing contractor shallterminate marketing and enrollment activity 40 calendar days priorto the start of the incoming contractor’s health care delivery.Any enrollment requests or applications received after the 40thcalendar day shall be transferred to the incoming contractor by overnightdelivery at the outgoing contractor’s expense.

9.5.4Throughout the enrollment dualprocessing period, the outgoing and incoming contractors shall coordinateenrollment files no less than weekly to ensure that new enrollmentsand enrollment renewals are accurately and timely reflected in theincoming contractor’s enrollment files and in DEERS.

9.6Cost Accounting

If the outgoing contractorsucceeds itself, costs related to each contract shall be kept separatefor purposes of contract accountability, according to the aboveguidelines.

9.7RecordsDisposition

The contractorshall include a records disposition plan as part of the transition-outplan submitted to DHA at the Transition Specifications Meeting.

9.8Provide Information

The contractor shall, uponreceipt of a written request from DHA, provide to potential offerorssuch items 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.

9.9Recoupment

9.9.1Installment Cases

The outgoing contractor shalltransfer all installment cases to DHA, Office of General Counsel(OGC), Claims Collection Section (CCS). A list of all installmentcases to be transferred, shall be provided by fax or encrypted emailto CCS before the cases are transferred.

9.9.2Cases Less Than 12 Months

The outgoing contractor shalltransfer cases greater or equal to $110 ($30 for pharmacy) and thatare less than 12 months old to the incoming contractor, who shallassume management of the cases. Cases received by the incoming contractorshall be managed until the debt is collected in full, or combined withany other under $600 active recoupment case against the same debtorto equal $600 or more and transferred to DHA, OGC, CCS. Cases thatdo not meet the criteria, shall be written off by the contractor.

9.10Transition Out of TED Activities

Transition-out activities relatedto TED shall be accomplished no later than 14 months after the startof health care delivery for the incoming contractor. At 180 daysafter the end of healthcare delivery the contractor shall not issueor reissue any checks/payments unless authorized by DHA, CRM. The contractoris required to keep all bank accounts associated with claims paymentsopen until all outstanding checks/payments have either cleared orstale date. If a payment stale dates, the contractor is requiredto cancel the associated TED data with DHA and notify the incomingcontractor. The contractor may cease TED data submissions when allTED reported checks/payments issued under this contract have clearedor stale date. The contractor may request (at no-cost to the government)an extension for TEDs processing after the 14 month period endsif more time is needed to complete stale date check processing.

- END -

TRICARE Manuals - Display Chap 24 Sect 1 (Change 139, Jun 10, 2024) (2024)

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