DHA RFI: TRICARE Claims Review Service (TCRS)

Notice ID: HT9402-21-RFI-0097

The Department of Defense (DOD) Defense Health Agency (DHA) seeks information about methods DHA may use to improve its health care claims processing compliance reviews to identify and report improper payments made by DHA TRICARE purchased care contractors to civilian healthcare providers and/or TRICARE beneficiaries.

To accomplish its goals, the DHA includes in the TRICARE Claims Review Service (TCRS) requirements support for the Improper Payment Program which initiates focused studies that result from contract claims processing compliance reviews; healthcare data analysis and/or mining; the implementation of a new health benefit; or at the request of other DHA entities. The ultimate goal is to develop contract requirements that achieve the maximum impact and value for our taxpayers. In particular, the DHA seeks comments regarding which approaches it should consider to assess various aspects of identifying improper payments and/or developing requirements for focused studies. The intent of the RFI-Source Sought is to gather information from industry about commercial best practices, benchmarks or other methods which DHA may use for upcoming contract requirements.

The TCRS contractor performs claims processing compliance reviews on a quarterly, semi-annual or annual basis depending on the DHA purchased care contractor’s contract requirements. Quarterly compliance reviews are conducted on the MCSCs, TDEFIC, TPharm, and TOP contracts, while compliance reviews are conducted semi-annually on the ADDP contract. Separate annual health care cost (AHCC) reviews are performed on each MCSC. These reviews are performed to support the accuracy of Target Health Care Costs and to identify unallowable underwritten health care costs under the terms of the MCSCs.

The TCRS contractor develops a process to validate the accuracy of claims payment based on claims processing documentation provided by the DHA TRICARE purchased care contractors. DHA provides statistically valid samples of TRICARE purchased care data records in the form of a list of TRICARE Encounter Data (TED) Internal Control Numbers (ICNs) listings to both the TCRS and DHA TRICARE purchased care contractors to initiate the compliance review process. The DHA TRICARE purchased care contractors have approximately 45 calendar days from the date of receiving the TED ICN listing to compile claims processing documentation which substantiates the adjudication and reimbursement of the healthcare claim being reviewed.

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