TRICARE Operations Manual 6010.62-M, April 2021
Transitions
Chapter 2
Section 2
SystemsDevelopment
Revision:
1.0CYBERSECURITY REQUIREMENTS
The incoming contractor shallcomplete and submit all required forms (e.g., System Security Plan(SSP)) in accordance with the TRICARE Systems Manual (TSM), Chapter1
2.0PERSONNEL SECURITY AND USERACCESS REQUIREMENTS
2.1The incoming contractor’s FacilitySecurity Officer (FSO) shall attend a meeting with the Defense Health Agency(DHA) Personnel Security Branch (PSB) within 30 calendar days aftercontract award to review Personnel Security requirements and proceduresfor requesting background checks and Common Access Cards (CACs)in accordance with the TSM, Chapter 1, Section 1.1.
2.2The incoming contractor shallensure personnel complete appropriate background and security checks inaccordance with TSM, Chapter 1, Section 1.1.
2.3The incomingcontractor shall obtain CACs from Real-Time Automated PersonnelIdentification System (RAPIDS) sites.
2.3.1The incomingcontractor shall build in the distance and appointment capacityfor obtaining CACs in accordance with Chapter2 transition requirements.
2.3.2The incomingcontractor shall use the RAPIDS locator website (https://idco.dmdc.osd.mil/idco/)for scheduling personnel who require CACs.
3.0CONNECTIVITY REQUIREMENTS
The incoming contractor shallcomplete and submit the required forms (e.g., Business to Business(B2B) Questionnaire, DD Form 2875, etc.) in accordance with TSM, Chapter1.
4.0SYSTEM INTERFACE MEETINGS
4.1The incoming contractor shallprovide to the Government Designated Authority (GDA) the name, address,and telephone number of the technical Points of Contact (POCs) atthe Transition Specifications (TRANSPEC) Meeting, and shall ensureparticipation by subject matter experts in all scheduled meetingsfor the understanding and clarification of systems implementationrequirements at the Interface Meetings listed below.
4.2The incoming contractor shallcommunicate, collaborate, and coordinate with the GDA no later than30 calendar days from contract award to schedule the following interfacemeetings:
•System Integration InterfaceMeeting (SIIM) to identify all Defense Enrollment Eligibility ReportingSystem (DEERS) systems interfaces and applications necessary tomeet the requirements of this contract and TSM, Chapter3.
•TRICARE Encounter Data (TED)Integration Interface Meeting (TIIM) to identify all TED systemsinterfaces and applications necessary to meet the requirements ofthis contract and TSM, Chapter 2.
•Military Health System (MHS)Genesis Interface Meeting to identify all MHS Genesis systems interfacesand applications necessary to meet the requirements of this contract, Chapter7, and TSM, Chapter 1.
•Referral Management SystemInterface Meeting to identify all referral systems interfaces andapplications necessary to meet the requirements of this contract, Chapter7, and TSM, Chapter 1.
•Uniformed Services Pay CentersInterface Meeting to identify all pay center systems interfacesand applications necessary to meet the requirements of this contractand TSM, Chapter 1.
•E-Commerce System InterfaceMeeting to identify all contract deliverable systems interfacesand applications necessary to meet the requirements of this contractand Chapter 7.
•DHA-Great Lakes (DHA-GL) [theSpecified Authorization Staff (SAS) for Army, Air Force, Navy, MarineCorps, Coast Guard, and National Guard TRICARE Prime Remote (TPR)enrollees] Interconnectivity meeting to identify all contract deliverable,systems interfaces, and applications necessary to meet the requirementsof this contract, Chapters 16, 17,and TSM, Chapter 1.
4.3The Government will collaboratewith the incoming contractor as to the exact date, length, and location ofall interface meeting(s), and will provide the meeting agenda priorto the meeting(s).
5.0UNIFORMED SERVICES PAY CENTERTRANSITIONS
5.1The GDA will coordinate andschedule with the incoming and outgoing contractors the transitionof beneficiary allotment payments from the outgoing to the incomingcontractor.
5.2The outgoing contractor shallstop all allotments by sending a “stop allotment notice” to theUniformed Services pay center(s) after the last payment under theircontract has been received. To stop allotments, the notice has tobe at the Uniformed Services pay center(s) by the sixth calendarday of the preceding month. For example, to stop for May 1st, the“stop allotment notice” has to be at the Uniformed Services paycenter(s) by April 6th.
5.3The outgoingcontractor shall communicate, collaborate, and coordinate the schedulewith the GDA no later than 90 calendar days following contract award.
5.4The incoming contractor shallsend an “allotment request” to the Uniformed Services pay center(s)no later than the sixth calendar day of the month prior to the firstpayment being due. For example, to start May 1st, the “start request”must be at the Uniformed Services pay center(s) by April 6th.
6.0SYSTEMS DEVELOPEMENT
The GDA, no later than 60 calendardays prior to the start of health care delivery (SHCD), will testthe non-claims processing systems and the telecommunications interconnectionscapabilities, to determine whether the systems meet the requirementsof the Government and the contract.
6.1The incomingcontractor shall include a demonstration to the Government of itsnon-claims processing system(s), and the telecommunications interconnectionscapabilities.
6.2The incoming contractor shalleffect any modifications required by DHA no later than 30 calendardays prior to the SHCD.
7.0CLAIMS PROCESSING SYSTEM ANDOPERATIONS
7.1The 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 calendar days following receipt of thefiles from the outgoing contractor.
7.1.1The incomingcontractor shall conduct integration testing to validate implementationprocess, internal interfaces to each of the Government’s systems,integration, and functionality no later than 60 calendar days prior tothe SHCD.
7.1.2The incoming contractor shallidentify a primary and secondary Testing Coordinator that is responsible fortesting preparations, coordination of tests, identification of issuesand resolution, verification of test results, and shall communicate,collaborate, and coordinate integration testing with the GovernmentTest Managers.
7.2The Governmentwill instruct the incoming contractor on how issues will be reportedand tracked during integration testing at the interface meeting.
7.3The Government will coordinatewith the incoming contractor throughout transition to plan, execute, andevaluate the integration testing efforts.
8.0TRANSACTION TESTING
8.1The incoming contractor shall,follow Health Insurance Portability and Accountability Act (HIPAA)and Contracting Officer (CO) written direction in regards to transactiontesting. At a minimum, testing shall include the following:
•The incoming contractor shallconduct initial testing and compliance with all HIPAA mandated Transactions, CodeSets, and Identifiers (TCS&I) adopted by HIPAA Final Rule inthe Federal Register prior to the SHCD, except forthose TCS&I specifically stated by the DHA as not apply to useby the DHA.
•The incoming contractor shalltest their capability to create, send, and receive compliant transactionsand shall provide written evidence (e.g., certification from a transactiontesting service) of successful testing of their capabilities tocreate, send, and receive compliant transactions to the contractingoffices no later than 60 calendar days prior to the SHCD.
•The incoming contract shalltest its capability no later than 60 calendar days prior to theSHCD to comply with any TCS&I Final Rule(s) adopted in the FederalRegister prior to the SHCD but with required compliance date afterthe SHCD.
•The incoming contractor shallprovide written evidence (e.g., certification from a transactiontesting service) of successful testing of their compliance withthe requirements of the adopted Final Rule(s) to the contracting officesno later than 60 calendar days prior to the applicable mandatedimplementation date(s) of the Final Rule(s).
8.2The incoming contractor shallmake necessary corrections and re-test until a successful outcomeis achieved in the event transaction compliance failures occur duringtesting. Failure to certify HIPAA TCS&I compliance with HIPAAnamed and adopted TCS&I no later than 60 calendar days priorto the SHCD may result in delay of the SHCD.
8.3The incoming contractor shalltest their capability to process standard transactions. This testingshall be “cradle-to-grave” testing from receipt of the transactions,through processing, and completion of all associated functions includingcreating and transmitting associated response transactions. Testinginvolving the receipt and processing of claims transactions shallalso include the submission to and acceptance by the DHA of TEDrecords and the creation of contract compliant electronic ExplanationOf Benefits (EOB). The incoming contractor shall complete “cradle-to-grave”testing no later than 30 calendar days prior to the SHCD.
Note:The TRICARE Health Plan (THP)(including business associate contractors) may be selected for ano-notice HIPAA transactions compliance audit at any time, initiatedby the Centers for Medicare and Medicaid Services (CMS) throughthe HIPAA Compliance Review Program.
9.0TED RECORDS
9.1The incomingcontractor shall ensure the TED record complies with the TSM, Chapter2 and the contract no later than 30 calendar days priorto the SHCD.
9.2The incoming contractor shallensure the TRICARE Encounter Provider (TEPRV) record complies withthe TSM, Chapter 2 andthe contract no later than 30 calendar days prior to the SHCD.
9.3The incoming contractor mustdemonstrate the ability to successfully create and submit all TEDrecord types and TEPRVs no later than 30 calendar days prior tothe SHCD. This includes, but is not limited to, adjustment, denialand cancellation records.
10.0DUPLICATE CLAIMS SYSTEM (DCS)
10.1Incoming Contractor Requirements
10.1.1The incoming contractor shallutilize DCS for the identification of post-payment potential duplicate claimspayments via the Patient Encounter Processing and Reporting (PEPR)Portal in accordance with the TSM, Chapter4.
10.1.2The incoming contractor shallparticipate in Government furnished DCS training.
10.1.3The incoming contractor shallcomplete all user access requirements in accordance with the TSM, Chapter1 prior to the initiation of training.
10.1.4The Government will coordinatewith the incoming contractor for the scheduling of DCS trainingno later than 60 calendar days following the SHCD.
10.1.5The Government will establisha date when the incoming contractor will assume full responsibilityfor resolving all existing potential duplicate claim sets from theoutgoing contractor.
10.1.6The incoming contractor shallbegin using DCS to resolve identified potential duplicate claimsets “owned” by the outgoing contractor and pursue any existingrecoupments received from the outgoing contractor upon reassignmentby the Government to the incoming contractor.
10.1.6.1The incoming contractor shallapply the adjustment to the set without modifying the recoupment amountif the recoupment amount was zero when the set was transferred fromthe outgoing contractor.
10.1.6.2The incoming contractor shallapply the adjustment to the set while leaving the actual recoupment amountas zero dollars. Resolution will result in a Validate status,requiring an explanation by the incoming contractor that the outgoingcontractor did not enter the actual recoupment amount.
10.1.7The incoming contractor shallidentify at least one individual and one alternate (who are, orwill be, trained in the use of the DCS, and who are able to performthe required research and determine whether a particular claim iswithin their processing jurisdiction), to serve as the DCS POCsfor assigned DCS claim sets.
10.1.8The incoming contractor shallprovide the name(s), title(s), business address(es), and business telephonenumber(s) of their DCS POCs to the Government no later than 10 businessdays prior to implementation of DCS to production.
10.1.9The Government will provideeach contractor with the list of all DCS POCs. Whenever a new contractis awarded, the Government will notify all contractors of the newcontractor’s DCS POC.
10.1.10The incoming contractor shallmaintain and provide updated POC information to the Government no laterthan 14 calendar days following any change.
10.2Outgoing Contractor Requirements
10.2.1The outgoing contractor shallpackage and forward refund checks received and offsets taken for recoupmentsassociated with duplicate claims payments to the incoming contractorand provide recoupment files associated with in progress duplicateclaim recoupment within 120 calendar days following SHCD.
10.2.2The outgoing contractor shallcease researching Open claim sets and initiatingnew recoupments associated with duplicate claim payments upon reassignmentto the incoming contractor.
10.2.3The outgoing contractor shallcease entering refund data and linking adjustment data in the DCSfor Pending and Validate claimsets upon reassignment to the incoming contractor.
10.2.4The outgoing contractor shallmove all Open DCS claim sets to a Pending, Validate,or Closed status by the last day of TED submissionsin accordance with the contractor’s transition-out plan.
10.2.5The outgoing contractor shallstop entering refund and adjustment data on the DCS upon reassignmentto the incoming contractor. Refunds may be received and TED adjustmentsmay still be submitted for claims in Open and Pending sets.In this case, the incoming contractor may be required to resolvethe set without knowing the amount of the refund received by theoutgoing contractor.
10.2.6The outgoing contractor shallphase-out the use of the automated TRICARE DCS in accordance with TSM, Chapter4, Integrated Master Plan (IMP), and Integrated MasterSchedule (IMS) as identified by DD Form 1423, Contract Data RequirementsList (CDRL), located in Section J of the applicable contract.
11.0PERFORMANCE ASSESSMENT REPORTING
11.1Training
The incoming contractor shallschedule initial training on the submission of deliverables within30 calendar days after award. Additional training for new userswill be provided throughout the contract upon request.
11.2Technical Support
Technical support is providedduring the business week. A POC for access and deliverable submissionwill be provided during initial training.
12.0INTERCONNECTIVITY BETWEEN THECONTRACTOR AND DHA-GL (THE SAS FOR ARMY, AIR FORCE, NAVY, MARINECORPS, COAST GUARD, AND NATIONAL GUARD TPR ENROLLEES)
12.1The incoming contractor shallprovide access for entry and edit of referrals into existing systems supportingthis contract.
12.2The incomingcontractor shall propose one of the following access options:
12.2.1Government staff physicallylocated in Great Lakes, IL, accessing the contractor’s system;
12.2.2Contractor staff physicallylocated in Great Lakes, IL, accessing the contractor’s system; or
12.2.3Government personnel performinga backup role in the event contractor personnel are unavailable dueto annual or sick leave or another reason.
12.3The contractor shall ensurethe contractor’s system can be accessed over a secure connectionby Government employees who are teleworking using a Government furnishedlaptop.
12.4The incoming contractor shallcreate a standard management listing for all pending referrals requiring SASreview. The listing will be made available on-line to the SAS.
12.5The incoming contractor shallpropose the design for the listing to the SAS for approval 30 calendardays prior to the SHCD.
13.0DMDCTEST ENVIRONMENT
13.1The incoming contractor shallassume that an exclusive testing environment will not be availablefor development/testing of their internal processes and applications.All testing will occur in the DMDC customer test environment, whichis shared by all DMDC customers, including other DHA contractors.
13.2The incomingcontractor shall attend training provided by DMDC on DMDC maintainedapplications used by the incoming contractor.
13.3The incomingcontractor shall provide a list of attendees no later than 10 businessdays prior to DMDC training.
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