TRICARE Dental Program 7/Third Party Administrator Industry Forum

Questions & Answers / Clarifications

This document contains responses from the government to industry questions regarding the Third Party Administrator (TPA) Post Industry 1:1. It clarifies various aspects of the upcoming TPA contract and its relationship with existing and future dental programs.

• Acquisition Approach: The government has not fully determined the acquisition approach but does not anticipate setting aside the requirements for small businesses. Any capable company can compete.
• NAICS Code: The relevant NAICS code is 524292 - Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds.
• Enrollment: The government has not yet determined how enrollment will be handled, but there will not be auto-enrollment. The TPA will not be developing enrollment applications. Enrollment and eligibility verification will occur in real-time with DEERS/milConnect, with potential batch reporting for other transactions.
• Data Transfer: The TPA will not be responsible for encounter data collection or input to the Military Data Repository (MDR). The TPA will be required to handle standard transactions such as HIPAA and X12.
• IT Security: DFARS clause 252.204-7012 and DFARS clause 252.204-7021 (CMMC) requirements apply. Cloud computing minimum security requirement is equivalent to FedRAMP Moderate, potentially FedRAMP High or above for system interfaces.
• Transition: The TPA RFP will be issued prior to the TDP-7 RFP. The TPA will transition in with the TDP-7 carriers over an expected 12-month period.
• Carrier Competition: All carriers will provide worldwide coverage (CONUS and OCONUS); no regions are planned.
• Provider Interaction: The TPA will not be responsible for anything related to dental providers.

This document provides crucial clarifications that bidders should consider when preparing their proposals. Key areas include the acquisition approach, security requirements, transition timelines, and the division of responsibilities between the TPA and carriers. Specific details regarding performance metrics, pricing, and enrollment processes will be further defined in the RFP.

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.