TRICARE Operations Manual 6010.59-M, April 1, 2015
Transitions
Chapter 2
Section 2
SystemsDevelopment
Revision:C-116, February 22, 2023
1.0Transition
1.1Upon reprocurementof a TRICARE contract, an incumbent contractor may succeed itselfor a new contractor may be awarded the contract. The Defense HealthAgency (DHA) will coordinate transition activities with the incumbent/newcontractor and Defense Finance and Accounting Service (DFAS)/U.S.Coast Guard (USCG)/Public Health System (PHS), during the transition-inperiod. When the contract is awarded to a new contractor, the followingactions will be taken by the outgoing and incoming contractors.
1.2The outgoing contractor shallstop all allotments by sending a “stop allotment notice” to DFAS afterthey receive the last payment under their contract. To stop allotments,the contractor shall ensure the notice is atDFAS by the sixth day of the preceding month, for example, to stopfor May 1st, the “stop allotment notice” has to be at DFAS by April6th.
1.3The incoming contractor shallsend an “allotment request” to DFAS no later than the sixth day ofthe month prior to the first payment being due. For example, tostart May 1st, the “start request” shall beat DFAS by April 6th.
2.0System Interface Meetings
2.1The incoming contractor shallschedule a systems interface meeting with the Government within30 days of the transition start date. The purpose of the meetingis to review requirements for the establishment of connectivitywith Government systems and applications.
2.2The incomingcontractor’s Facility Security Officer (FSO) shall attend a meetingwith DHA Personnel Security Branch (PSB) to review Personnel SecurityRequirements and the procedures for requesting background checksand Common Access Cards (CACs) in accordance with the TRICARE SystemsManual (TSM), Chapter 1, Section 1.1. The FSO shall undergothe required background check and obtain the necessary trustworthinesscertification (Automated Data Processing/Information Technology(ADP/IT)) prior to approving requests for the remaining staff inthe incoming contractor’s organization.
2.3UserAccess Requirements
The incomingcontractor shall ensure personnel complete appropriate backgroundand security checks in accordance with the TSM, Chapter1.
2.4ConnectivityRequirements
2.4.1The incoming contractor shallcollaborate with the Government to establish the required interfaceswith Government 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.
2.4.2Data Transmission Start Up
2.4.2.1The DHA will coordinate Businessto Business (B2B) Gateway and DFAS connectivity for all contractors.DHA will also coordinate integration testing of the connectivityand data transmission. DHA and the contractor will collaborate withDFAS/USCG/PHS on the development of a test plan and schedule.
2.4.2.2At the start-up planning meeting,each contractor on the telecommunication network shall provide toDHA the name, address, and telephone number of the person who willserve as a technical POC (update when a change occurs). The contractor shallalso provide a separate computer center (Help Desk) number to DHAthat the DHA computer operator can use for data transmission problem resolution.
2.5Systems Development
Approximately 60 days priorto the start of health care delivery (SHCD), the DHA (or its designees)will review the non-claims processing systems and the telecommunicationsinterconnections between these systems. The contractor shall conducta demonstration of the system(s) capabilities, so the Governmentcan determine whether the systems satisfy TRICARE contract requirements.This includes the telecommunications links between the contractor,DHA and Defense Enrollment Eligibility Reporting System (DEERS).The contractor shall effect any modifications required by DHA priorto SHCD.
2.6Claims Processing System andOperations
Duringthe period between the date of award and the SHCD, the incomingcontractor shall, pursuant to the Integrated Master Plan/IntegratedMaster Schedule (IMP/IMS), meet the following contractor file conversionsand testing requirements:
2.6.1ContractorFile Conversions and Testing
2.6.1.1The incoming contractor shallperform initial conversion and testing of all Automated Data Processing(ADP) files (e.g., provider files, claims history files, and beneficiaryhistory) no later than 30 days following receipt of the files fromthe outgoing contractor(s). The Government will conduct integrationtesting to validate the contractor’s internal interfaces to eachof the TRICARE Military Health Systems (MHS) Information Management/InformationTechnology (IM/IT). This testing will verify the contractor’s systemintegration, functionality, and implementation process. The incomingcontractor shall be responsible for the preparation and completionof Integration Testing 45 days prior to the SHCD.
2.6.1.2DHA 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. The contractor Testing Coordinatorsshall use a Government provided web application to report and trackissues and problems identified during integration testing.
2.7Data
The outgoing contractor shallprovide to DHA (or, at the option of DHA, to a successor/incoming contractor)all DHA shall required information to facilitate transitions fromthe contractor’s operations to the incoming contractor’s operationsunder any successor contract. The outgoing contractor shall provideall files in a non-proprietary format; and the incoming contractorshall include such file specifications and documentation as necessaryfor file interpretation. Such information may include, but is notlimited 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.
2.8Transaction 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 ContractingOfficer (CO) direction. At a minimum, testing shall include the following:
2.8.1Contractors shall test theircapability to create, send, and receive compliant transactions. Contractorsshall provide written evidence (e.g., certification from a transactiontesting service) of successful testing of their capabilities tocreate, send, and receive compliant transactions to the CO no laterthan 60 days prior to the SHCD.
Note:Where failures occur duringtesting, the contractor shall make necessary corrections and re- testuntil they achieve a successful outcome.
2.8.2Contractors shall test theircapability to process standard transactions. This testing shallbe “cradle-to-grave” testing from receipt of the transactions, throughprocessing, and completion of all associated functions includingcreating and transmitting associated response transactions. Testing involvingthe receipt and processing of claims transactions shall also includethe submission to and acceptance by the DHA of TRICARE EncounterData (TED) records and the creation of contract compliant electronicExplanation Of Benefits (EOB). The contractor shall complete “cradle-to-grave” testingno later than 30 days prior to the SHCD.
2.9Phase-Out of the Contractor’sClaims Processing Operations
Upon notice of award to anothercontractor, the outgoing contractor shall undertake the following phase-outactivities regarding services as an outgoing contractor.
2.9.1Transfer of Electronic FileSpecifications
The outgoingcontractor shall provide to the incoming contractor, no later thanthree days following award announcement or upon direction of theCO, electronic copies of the record layouts with specifications,formats, and definitions of fields, and data elements, access keysand sort orders, for the following:
•Beneficiary History Files.
•Claims History Files.
•The TRICARE Encounter ProviderFiles (TEPRVs).
•The Enrolled Beneficiary andPrimary Care Manager (PCM) Assignment Files.
•Mental Health Provider Files:The outgoing contractor shall provide the incoming contractor with accurateprovider payment information on all mental health providers paidunder the TRICARE inpatient mental health per diem payment system.This shall include provider name; Tax Identification Number (TIN);address including ZIP code; high orlow volume status; if high volume, provide the date the providerbecame high volume; and the current per diem rate along with the twoprior year’s per diem amounts. The providers under the per diempayment system must be designated by Medicare, or meet exemptioncriteria, as exempt from the inpatient mental health unit. The unitwould be identified as the provider under the TRICARE inpatientmental health per diem payment system.
2.9.2Transfer Of ADP Files
By the 15th day following theTransitions Specifications Meeting, the outgoing contractor shallprepare in non-proprietary electronic format and transfer to theincoming contractor or DHA 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 shall continue to participate in preparationand testing of these files until they are fully readable by theincoming contractor or DHA.
2.9.3OutgoingContractor 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 and everyweek thereafter beginning the 120th day prior to the SHCD until sucha time that all processing is completed by the outgoing contractorin accordance with the specifications in the official transitionschedule.
3.0TED Records
3.1Theincoming contractor shall ensure the TED record(s) complieswith the TSM, Chapter 2 and thecontract.
3.2The incoming contractor shallensure the TEPRV complies with the TSM, Chapter2 and the contract.
3.3The incomingcontractor shall demonstrate the ability to successfully createand submit all TED record(s) typesand TEPRVs prior to SHCD. This includes, but is not limited to,adjustment, denial and cancellation records.
4.0DUPLICATE CLAIMS SYSTEM (DCS)
4.1Incoming And Outgoing ContractorRequirements
4.1.1The 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 has been tested and is accessible.
4.1.2The contractor shall participatein Government furnished DCS training. Training will be scheduledas part of the IMP/IMS.
4.1.3The Government and contractorshall determine the date when an incoming contractor will assumefull responsibility for resolving all existing potential duplicateclaim sets from the outgoing contractor (including completing existingrecoupments), and for all new potential duplicate claim sets, duringtransition meetings. The contractor shall add the date to the transitionplan/schedule.
4.1.4Duringtransition, the incoming contractor shallensure all DCS users complete the online DHA DCS training via JointKnowledge Online (JKO) at https://jkodirect.jten.mil/Atlas2/page/login/Login.jsf. Training shallbe completed between 120 days prior to the SHCD andnot later than 60 days following the SHCD. The incoming contractorshall schedule training inaccordance with the transition plan/schedule. The contractor shallmeet all user access requirements prior to the initiation of training.
4.1.5The incoming contractor shallbegin using the DCS to resolve identified potential duplicate claimsets “owned” by the incoming contractor 120 days following the SHCD.
4.1.6The incoming contractor shallbegin processing potential duplicate claim sets transferred fromthe outgoing contractor 150 days following the SHCD.
4.1.7For each regional contractfor which a contractor is responsible, the contractor shall identify atleast one individual to serve as the DCS Point of Contact (POC).Contractor DCS POCs shall be individuals who are, or will be, trainedin the use of the DCS, and who are 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 OfficerRepresentatives (CORs) and to the DHA DCS Program Representative.The contractor shall provide the DCS POCs to the CO no later thantwo weeks prior to implementation of the DCS.
4.1.8DHA 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.
4.1.9In accordance with the FinancialProcedures in the Transition Plan, the contract, and the TOM, theoutgoing contractor shall package and forward to the incoming contractor,refund checks received and offsets taken for recoupments associatedwith duplicate claims payments and recoupment files associated within progress duplicate claim recoupment 120 days following SHCD.
4.1.10On the last day of the fourthmonth following the start of SHCD, or upon direction of the Government,the outgoing contractor shall cease researching Open claimsets and initiating new recoupments associated with duplicate claimpayments. The outgoing contractor shall also cease entering refunddata and linking adjustment data in the DCS for Pending and Validate claimsets.
4.1.11The outgoing contractor shallmove all Open DCS claim sets to a Pending, Validate,or Closed status by the last day of TED record(s) submissions(as defined by the transition plan).
4.1.12When the outgoing contractorhas ceased entering refund and adjustment data on the DCS, refundsmay be received and/or TED record(s) adjustmentsmay still be submitted for claims in Open and Pending sets.In this case, the incoming contractor shall resolve the set withoutknowing the amount of the refund received by the outgoing contractor.
4.1.13If 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. Resolutionwould result in a Validate status, and the incoming contractorshall submit an explanation that the outgoing contractor did notenter the actual recoupment amount.
4.1.14Following the SHCD, the DCSwill begin displaying identified potential duplicate claim sets forwhich the incoming contractor shall resolve. The incoming contractorshall begin using the DCS to resolve potential duplicate claim setsin accordance with the TSM, Chapter 4 andthe IMP/IMS requirements.
4.1.15The 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 claims sets asagreed upon during the transition meeting.
4.2Phase-Out of the AutomatedTRICARE DCS
The outgoingcontractor shall phase-out the use of the automated TRICARE DCSin accordance with TSM, Chapter 4 andIMP/IMS.
5.0Performance Assessment Reporting
5.1Submission Requirements
The contractor shall submitreports and plans for transition in and transition out as identifiedby the DD Form 1423, Contract Data Requirements List (CDRL), locatedin Section J of the applicable contract.
5.2Training
The incoming contractor shallschedule initial training on deliverable submission within 30 daysafter award. The Government will provide additional training fornew users throughout the contract upon contractor request.
5.3Technical Support
The Government will provideperformance assessment reporting technical support during the business week.The Government will provide a POC for access and deliverable submissionduring initial training.
6.0Interconnectivity Between TheContractor And Defense Health Agency-Great Lakes (DHA-GL) [The SpecifiedAuthorization Staff (SAS) For Army, Air Force, Navy, Marine Corps,Space Force, Coast Guard, And National Guard TRICARE Prime Remote(TPR) Enrollees]
6.1The contractor shall provideaccess for referral entry and edit in existing systems supporting thiscontract. The contractor shall propose one of the following accessoptions:
•Government staff physicallylocated in Great Lakes, IL, accessing the contractor’s system; or
•Contractor staff physicallylocated in Great Lakes, IL, accessing the contractor’s system, and Governmentpersonnel performing a backup role in the event contractor personnelare unavailable due to annual or sick leave or another reason.
6.2The contractor shall createa standard management listing for all pending referrals requiring SASreview. The contractor shall make the listing available on-lineto the SAS. The contractor shall propose the listing design to theSAS for approval 30 days prior to the SHCD.
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