TRICARE Dental Program 7/Third Party Administrator Industry Forum

Form / Attachment / Pricing Sheet

This document is a Draft Work Breakdown Structure (WBS) for a Third Party Administrator (TPA) supporting dental carrier services. It outlines the tasks and requirements for the TPA.

• Section 1.0: Provide Eligibility and Enrollment: Details the TPA's role as an intermediary for real-time beneficiary eligibility and enrollment, including interface with DEERS and enrollment file transmission.
• Section 2.0: Provide Premium Administration: Covers processing complex billing scenarios, managing premium streams, direct billing, and conducting monthly audits and reconciliations. It also includes extensive reporting requirements.
• Section 3.0: Provide Customer Service: Outlines requirements for customer service standards, beneficiary comparison tools, enrollment counseling, marketing materials, and call center operations. It also addresses support for dental carriers and service pay centers.
• Section 4.0: Systems Connectivity: Addresses requirements for secure, reliable, and tested systems interface and interoperability with DEERS and dental carriers, ensuring compliance with cybersecurity and HIPAA standards.
• Section 5.0: Transition In and Out Capability: Details requirements for managing the transition of services, including a transition plan, financial management approach, communications plan, and reporting.

This WBS provides a detailed breakdown of the expected services and responsibilities of a Third Party Administrator. Bidders can use this document to understand the scope of work, technical requirements, reporting obligations, and customer service expectations for this opportunity, which is crucial for developing a comprehensive proposal.

Statement of Work (SOW) / Performance Work Statement (PWS)

This Performance Work Statement (PWS) outlines the requirements for the TRICARE Dental Program Six Generation (TDP6) contract, a non-personal services contract to provide comprehensive dental care services worldwide to eligible TRICARE beneficiaries.

• Provide cost-effective, worldwide dental care services for eligible family members of Uniformed Service active duty personnel, Selected Reserve, Individual Ready Reserve (IRR), and National Guard, and their eligible family members.

• Establish and maintain a provider network in the 50 United States, District of Columbia, U.S. Virgin Islands, Guam, and Puerto Rico, as well as a list of TRICARE OCONUS Preferred Dentists (TOPDs).

• Manage program operations including eligibility verification, enrollment, premium collection, customer service, claims processing, and beneficiary/provider education.

• Comply with various directives, including the TRICARE Policy Manual, TRICARE Systems Manual, TRICARE Operations Manual, and HIPAA regulations.

• Network Access: Specific standards for general and specialty dental care provider access based on geographic area (Very Rural, Rural, Suburban, Urban) and driving miles.

• Timeliness: Standards for processing enrollment actions, claims, appeals, and grievances within specified business days.

• Quality: Acceptable Quality Levels (AQLs) for accurate enrollment entries, claim payments, and corrected claims.

• Customer Service: Metrics for telephone call answering times, resolution rates, and response times for written correspondence.

• Data Systems: 99.9% system availability for TDP data sets and dashboard.

• Period of Performance (PoP): Base Period/Transition-In: 12/01/2023 - 11/30/2024. Five Ordering Periods (OPs) from 12/01/2024 to 11/30/2029. A Residual Phase-Out period follows.

• Place of Performance: Contractor's facility or a remote environment, with specific requirements for CONUS and OCONUS operations.