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Q -- TRICARE Quality Monitoring Contract (TQMC)

Notice Date
Notice Type
813920 — Professional Organizations
Contracting Office
Other Defense Agencies, Office of the Secretary of Defense, TRICARE Management Activity, 16401 East Centretech Parkway, Aurora, Colorado, 80011
ZIP Code
Solicitation Number
Archive Date
Point of Contact
Scott J Lamond, Phone: 303-676-3649
E-Mail Address
Small Business Set-Aside
Presolicitation Notice: The Solicitation Website http://www/tricare.mil/contracting/healthcare/solicitations under the solicitation category of Other Health Care/Support Services will only currently be available for vendor registration as a Potential Offeror and for notice as to when the formal Request for Proposal (RFP) will be available for download on or after January 8, 2010. Description The purpose of this contract is to assist Health Affairs, TRICARE Management Activity (TMA), the TRICARE Regional Offices (TRO), the Designated Provider Program Office (DPPO), the TRICARE Overseas (TAO) Europe, Pacific and Latin America/Canada Program Offices, the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) COR and the pharmacy and dental program offices, by providing the Government with an independent, impartial evaluation of the care provided to Military Health System (MHS) beneficiaries. The TRICARE Quality Monitoring Contractor (TQMC) shall review care provided by the Designated Providers (DP) under the Uniformed Services Family Health Plan (USFHP), the Managed Care Support Contracts (MCSCs) and the TDEFIC contractor. In addition, the TQMC will review records from other TRICARE contractors (e.g., TRICARE pharmacy and dental contractors) to satisfy requirements to validate the quality of care delivery under the TRICARE benefit. The TQMC is part of TRICARE's Quality and Utilization Review Peer Review Organization Program, in accordance with Code of Federal Regulations 32 CFR 199.15. The Objectives under this contract are: To provide an independent, impartial evaluation of the health care provided to the MHS beneficiaries. To evaluate "best value health care" as defined in the TRICARE Operations Manual. To measure, evaluate, and identify superior quality health care services and recommend means to transfer successes. To provide comprehensive and timely reviews that are consistent with all TRICARE requirements, to ensure receipt of appropriate levels of health care for all beneficiaries. DOCUMENTS Title 10, United States Code, Chapter 55 32 CFR 199 The TRICARE Program Manuals - August 1, 2002 Edition of the TRICARE Manuals are denoted below and relate to TQMC performance requirements and the interface in association with other T-Nex suite of contracts. Anywhere in the TRICARE Program Manuals - August 2002 Edition where it states National Quality Monitoring Contractor or the term NQMC it shall apply to the TQMC during related performance under this contract. MCSC North Region - Contract H94002-03-C-0011 - Health Net Federal Services, Inc. MCSC South Region - Contract H94002-03-C-0010 - Humana Military Healthcare Services MCSC West Region - Contract H94002-03-C-0009 - TriWest Healthcare Alliance Corporation TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) - Contract H94002-07-D-0001 - Wisconsin Physicians Service Insurance Corporation (WPS) Uniformed Services Family Health Plan (Designated Providers - DPs) Brighton Marine Health Center - Contract - H94002-09-C-0001 Christus Health Systems - Contract H94002-09-C-0002 John Hopkins Medical Service Corp. - Contract H94002-09-C-0003 Martin's Point Health Care Center - Contract H94002-09-C-0004 Pacific Medical Center - Contract H94002-09-C-0005 Saint Vincent Catholic Medical Centers of NY - Contract H94002-09-C-0006 TRICARE Operations Manual (TOM) 6010.51-M, dated August 1, 2002, through Change 90. TRICARE Policy Manual (TPM) 6010.54-M, dated August 1, 2002, through Change 101. TRICARE Reimbursement Manual (TRM) 6010.55-M, dated August 1, 2002, through Change 107. TRICARE Systems Manual (TSM) 7950.1-M, dated August 1, 2002, through Change 77. The TRICARE Program Manuals - February 1, 2008 Edition of the TRICARE Manuals are denoted below and relate to TQMC performance requirements and the interface in association with other T-3 suite of contracts: TRICARE Pharmacy - Contract H94002-08-C-0003 - Express Scripts Inc. Active Duty Dental Program - Contract H94002-08-C-0004 - United Concordia Companies, Inc. MCSC North Region - Contract H94002-09-C-0008 - Aetna Government Health Plan, LLC MCSC South Region - Contract H94002-09-C-0009 - United Health Military and Veterans Services MCSC West Region - Contract H94002-09-C-0007 - TriWest Healthcare Alliance Corporation TRICARE Overseas Program (TOP) - Contract H94002-10-D-0001 - International SOS Assistance, Inc. TRICARE Operations Manual (TOM) 6010.56-M, dated February 1, 2008, through Change 14. TRICARE Policy Manual (TPM) 6010.57-M, dated February 1, 2008, through Change 21. TRICARE Reimbursement Manual (TRM) 6010.58-M, dated February 1, 2008, through Change 23. TRICARE Systems Manual (TSM) 7950.2-M, dated February 1, 2008, through Change 14. The TRICARE manuals and CFR are located at: http://manuals.tricare.osd.mil. TRICARE Operations Manual (TOM) 6010.56 M, dated February 2, 2008. TRICARE Policy Manual (TPM) 6010.57, dated February 2, 2008. TRICARE Reimbursement Manual (TRM) 6010.58, dated February 2, 2008. TRICARE Systems Manual (TSM) 7950.2, dated February 2, 2008. The TRICARE manuals and CFR are located at: http://manuals.tricare.osd.mil. TECHNICAL REQUIREMENTS INFORMATION - TECHNICAL REQUIREMENTS: General: The TQMC shall establish and maintain sufficient and appropriate management, staff, management support services, resources and facilities necessary to achieve and maintain compliance with the requirements of this contract. The TQMC shall have available to it the services of actively practicing, board certified, licensed doctors of medicine and osteopathy and dentists to assure adequate review of services provided by the various medical and dental specialties and subspecialties, as identified by the American Board of Medical Specialties, the Bureau of Osteopathic Specialists and the National Certifying Boards for Dental Specialties. Active participation means practicing, on a routine basis, a minimum of 20 hours per week. The TQMC shall have procedures for ensuring availability of actively practicing non-physician reviewers of all the provider types set forth in 32 CFR 199.6. Reviewers: The TQMC shall document its review and verification of the credentials, and maintain current and accurate records, for all reviewers under this contract. The TQMC shall conduct the credential verification process when the reviewer is first considered for employment or contract, or every three years, after the individual has assumed reviewer responsibilities. It shall be the TQMC's responsibility to ensure that all staff maintains the required qualifications and certifications while performing under this contract. Credentialing files shall be available for inspection and audit by representatives from the Government upon request. Quality Management: The TQMC shall establish and continuously operate an Internal Quality Management Program (IQMP) covering every aspect of the TQMC's operation to ensure control, accuracy, and timeliness. Records Security and Confidentiality: The TQMC shall operate a system of records in support of the Department of Defense (DoD) Military Health System which requires obtaining, maintaining, and using personal information strictly in accordance with controlling laws, regulations, DoD Policy, and contract requirements. Focused Studies: In general, the TQMC shall accomplish focused studies of TMA selected study issues that have a potential to significantly impact beneficiary health, functional status, and satisfaction. Additionally, focused studies may be related to specific individual providers, provider groups, or institutional providers. Health Care Technology Assessments: The assessments shall utilize published, refereed scientific literature and shall assess individual health care technologies, to include the full range of medical or surgical devices, services or procedures; behavioral health devices, services or procedures; dental health devices, services or procedures; or the use of pharmaceuticals for purposes other than that approved by the U.S. Food and Drug Administration. Health care technology assessments which include full in-depth assessments and short assessments on specific, focused health care topics. Short assessments are those which require less time to complete due to the lower availability of literature to review. Medical Necessity (Reconsideration) Reviews (Second Level Appeal): The TQMC shall conduct medical necessity (reconsideration) reviews and issue decisions consistent with Chapter 12 of the TOM for reviews conducted after the start of health care delivery. These reviews shall include medical necessity appeals from MCSCs, DPs, MTFs (including those from ADSMs), TDEFIC, TRICARE Overseas contractor, dental contractor and the Pharmacy contractor. For TRICARE Overseas components, the TQMC will consider the standard of care available in the outside the continental United States (OCONUS) location when providing medical necessity reconsideration and second level appeals. Internal/External Case Reviews for Appeals and Hearings: The TQMC shall conduct internal and external case reviews and additionally shall provide peer reviewers to serve as witnesses. Mental Health Facility Certification: The TQMC shall be responsible for determining whether Residential Treatment Centers (RTCs), Substance Use Disorder Rehabilitation Facilities (SUDRFs), and Psychiatric Partial Hospitalization Programs (PHPs) meet TRICARE requirements. INFORMATION - ORGANIZATONAL CONFLICT Of INTEREST (OCI) In accordance with FAR 9.505, Organization and Consultant Conflicts of Interest (OCI), TMA is notifying all interested offerors that "actual" and "potential" organizational conflicts of interests exist. This is to assist prospective offerors in developing their own business strategies regarding TMA requirements, and in doing so, avoid, mitigate, and neutralize any actual and potential OCIs. The following is provided for the purpose of identifying, avoiding, and mitigating against OCIs of this solicitation/award process. It is the position of TMA's that the following companies have an actual conflict of interest and may not serve as a prime contractor, subcontractor, or in any advisory capacity to any offeror of this solicitation/contract: Lockheed-Martin, Axiom, Irving Burton Associates, Kennell and Associates, Lumetra, Ingenix, Altarum Institute and APPTIS. No offers will be accepted from a prime contractor, subcontractor, or any entity in an advisory capacity to any offeror, that has, or intends to also submit an offer for the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC), the North Region Managed Care Support Contract (MCSC), the South Region MCSC, the West Region MCSC, the TRICARE pharmacy contracts, TRICARE dental contracts and the TRICARE Overseas Program (TOP) Contract. The current contractors for these contracts are: North Region MCSC - Currently - Health Net Federal Services, Inc.; For T-3 MCSC - Aetna Government Health Plan, LLC South Region MCSC - Currently - Humana Military Healthcare Services; For T-3 MCSC - United Health Military and Veterans Services West Region MCSC - Currently - TriWest Healthcare Alliance Corporation; For eT-3 MCSC - TriWest Healthcare Alliance Corporation TRICARE Overseas Program (TOP) - International SOS Assistance, Inc. TRICARE Pharmacy - Express Scripts, Inc. TRICARE for Life - TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)-Wisconsin Physicians Service TRICARE Active Duty Dental Program - United Concordia Companies Incorporated TRICARE Retiree Dental Program - Delta Dental TRICARE Dental Program (Family & Selective Reserve Dental) - United Concordia Companies Incorporated Potential or actual Organizational Conflicts of Interests (OCIs) may exist with TMA contractors that currently perform logistical, program, operational, data management support for TMA Aurora CO, TMA Falls Church VA, and the Defense Manpower Data Center. Also, many of the Managed Care Support Contractors use various subcontractors including WPS, PGBA, Value Options, and EDS. It is incumbent that all offerors shall use sound business judgment and determine the significance of any conflict of interest. It is the position of TMA that by the nature of their contract with TMA and or entities that contract with TMA, the following contractors (including, but not limited to the following) may fall into the potential or actual OCI category: Wisconsin Physicians Services (WPS), Palmetto Government Benefits Administrators (PGBA), Electronic Data Systems (EDS), Meridian, Intellidyne L.L.C., CTA Inc., E.R. Williams, and Deloitte. In the event an offeror for this procurement intends to use any of these entities as a subcontractor or in any advisory capacity to this solicitation/contract, the offerors shall provide a mitigation plan to the Government that effectively demonstrates how the offeror shall mitigate any potential or actual OCI in its business arrangement for supporting this contract and any other TMA contract. The mitigation plan should be forwarded to the Contracting Officer as soon as possible but before proposals are due. Additionally, if the offeror through the exercise of sound business judgment identifies a potential or actual conflict of interest with other than or through, the aforementioned entities or arrangements, the offeror shall also submit a mitigation plan. OTHER GENERAL INFORMATION: The Solicitation will contain proposing services of a base period and 4 option periods. Each option period is 1 year in duration. The provision reference FAR 52.217-5, entitled Evaluation of Options, and the clauses reference FAR 52,217-8, entitled Option to Extend Services, and reference FAR 52.217-9, entitled Option to Extend the Term of the Contract will be contained in the RFP. All interested vendors shall be registered in the Central Contractor Registration (www.ccr.gov) before award can be made. The period of performance includes a base period and four one-year option periods. Source Selection procedures in accordance with FAR Part 15 will be used to determine the successful offeror. All responsible sources submitting a responsive proposal shall be considered by the agency. The solicitation will only be available through electronic media (download from the TRICARE website at http://www.tricare.mil/contracting/healthcare/solicitations/index.cfm. If you wish to receive information regarding the request for proposals during solicitation process, you must register as a Potential Offeror. Questions regarding the solicitation must be submitted using "E-Mail Questions to the Contracting Officer" option on the TRICARE website. POC: Scott Lamond, Contracting Officer, Phone: 303 676-3649, FAX 303 676-3987, email: scott.lamond@tma.osd.mil However, preference is by email.
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