TRICARE Medicare Eligible Program Second Generation (TMEP2) Draft RFP

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

This Performance Work Statement (PWS) details the requirements for the TRICARE Medicare Eligible Program (TMEP) Contract. The primary objective is to provide claims processing and associated customer support services for beneficiaries eligible for both Medicare and TRICARE benefits within specified U.S. territories and possessions.

• Claims Processing: Timely and accurate processing of claims, including applying deductibles, copayments, coinsurance, and catastrophic cap calculations in accordance with TRICARE regulations and manuals. This includes coordinating benefits with other health insurance and processing preauthorization/authorization requirements.

• Customer Service: Providing comprehensive, accessible, and satisfactory customer services to beneficiaries and providers 24/7 via multiple channels, including a HIPAA-compliant Interactive Voice Response (IVR) unit and call center staff.

• Provider Reimbursement: Verifying TRICARE authorized providers and processing reimbursements, including managing Medicare crossover claims and utilizing Electronic Funds Transfer (EFT) for payments.

• Data Management: Utilizing the Defense Enrollment Eligibility Reporting System (DEERS) for beneficiary information and submitting TRICARE Encounter Data (TED) records.

• Management Functions: Providing experienced leadership, sufficient staffing, and management support, including a Quality Management (QM) and Quality Improvement (QI) program.

• Transition Activities: Ensuring operational readiness for Option Period 1 and managing transition-in and transition-out activities seamlessly.

• Claims processing must meet accuracy and timeliness standards outlined in the TRICARE Operations Manual (TOM) and TRICARE Systems Manual (TSM).

• Customer service must result in beneficiary and provider satisfaction, with specific standards detailed in TOM, Chapter 20.

• The Contractor must maintain a QM/QI program and conduct quarterly operational and assessment reviews.

• The contract covers claims processing and customer support for beneficiaries in the United States, Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Mariana Islands.

• Specific periods of performance are detailed within the contract, including Option Periods.

• Compliance with 32 Code of Federal Regulations (CFR) Part 199, TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), and TRICARE Operations Manual (TOM).

• Utilization of Government-furnished data, including DEERS files and TRICARE centralized provider files.

• Implementation of a personnel security program and adherence to Cybersecurity Maturity Model Certification (CMMC) Level 2 requirements.

• Entry into a Data Sharing Agreement (DSA) for data obtained from DoD systems.

• Provision of Government personnel with off-site electronic read-only access to contract data.

Other / Unclassified

This document, "TMEP2 Section H Draft Special Contract Requirements," outlines specific contractual requirements beyond standard clauses. It details:

• Integrated Process Teams (IPTs): Procedures for establishing and participating in IPTs for major contract or program changes, including timelines for personnel identification and meeting participation.
• Financial Liability: Contractor's responsibility for civilian health care services/supplies provided outside the contract scope when erroneously authorized.
• Freedom of Information Act (FOIA): Requirement to provide a FOIA releasable contract with explanations of FOIA exemptions.
• Performance Incentives: Details on monetary incentives for meeting specified performance levels, including general performance metrics and beneficiary satisfaction rates, with associated quarterly funding by option period.
• Performance Guarantees: A comprehensive set of performance guarantees (8 in total) covering areas such as telephone service blockage rates, total hold time, transfer accuracy, claims processing timeliness (30 and 90 days), TED edit accuracy, written correspondence accuracy, telephone response accuracy, priority correspondence timeliness, and claims processing accuracy. Each guarantee includes standards, definitions, and application details with associated monthly or quarterly performance guarantee amounts for different tiers.
• DHA Quarterly Claims Processing Accuracy Compliance Reviews: Outlines methodologies for reviewing TED records, including payment accuracy, denied payment accuracy, and occurrence review sampling. It details required contractor documentation, error determinations (payment, process, occurrence, documentation), and rebuttal procedures.
• Organizational Conflicts of Interest (OCI): Directs attention to FAR Subpart 9.5 and states that DHA has determined an actual or significant potential OCI exists or may be created. It outlines contractor responsibilities to avoid, neutralize, or mitigate conflicts, including notification requirements and potential consequences for breach.

This document is crucial for bidders as it defines specific performance expectations, potential financial liabilities, incentive opportunities, and strict compliance requirements. Understanding these detailed contract requirements, particularly the performance guarantees and claims processing standards, is essential for developing accurate proposals, estimating costs, and assessing the operational demands of the contract. The OCI section also highlights potential restrictions or considerations for bidders.

Form / Attachment / Pricing Sheet

This document appears to be a template or form intended for bidders to provide organizational information. It is structured with columns for Section, Subsection/Citation, Subject, Question/Comment, and Additional Info/Rationale, suggesting it may be used for bidders to ask questions or provide comments related to specific sections of a solicitation or other document.

• The form is organized into numbered rows, with columns for detailed input.
• It prompts for "Insert Organizations Name" at the top.
• The columns suggest a structured way to log questions, comments, or additional information pertaining to specific parts of a solicitation (Section C or H).

Bidders should use this form to formally submit any questions, comments, or requests for clarification regarding the solicitation documents. It provides a structured method for the government to receive and potentially address bidder inquiries, which may impact proposal preparation and understanding of requirements.