THE PURPOSE IS TO PROVIDE CLAIMS PROCESSING AND RELATED SUPPORT SERVICES FOR PERSONS WITH DUAL TRICARE AND MEDICARE ELIGIBILITY IN SUPPORT OF THE DEPARTMENT OF DEFENSE'S TRICARE PROGRAM. THE ROLE OF THE CONTRACTOR IS TO ASSIST THE DEFENSE HEALTH PROGRAM IN OPERATING AN INTEGRATED HEALTH CARE DELIVERY SYSTEM BY PROVIDING CLAIMS ASSISTANCE, AND BY PROCESSING SPECIFIED TRICARE CLAIMS FOR PAYMENT. THE CLAIMS PROCESSING AND ASSOCIATED CUSTOMER SUPPORT SERVICES IS FOR CLAIMS SUBMITTED BY AND ON BEHALF OF MHS BENEFICIARIES WHO ARE ELIGIBLE FOR BOTH MEDICARE AND TRICARE BENEFITS, FOR SERVICES RECEIVED IN THE UNITED STATES, PUERTO RICO, GUAM, THE U.S. VIRGIN ISLANDS, AMERICAN SAMOA AND THE NORTHERN MARIANA ISLANDS. THE CONTRACTOR SHALL PROVIDE THE EXPERTISE OF MEDICAL AND MENTAL HEALTH CARE CLAIMS PROCESSING AND ITS SUPPORT SERVICES BY INCORPORATING AND OPERATING THE BEST PRACTICES OF THE PRIVATE SECTOR IN SUPPORT OF TRICARE. DELIVER ALL SERVICES IN A MANNER THAT SUPPORTS THE TRICARE FULLY INTEGRATED HEALTH CARE DELIVERY AND FINANCING SYSTEM FOR ALL MHS BENEFICIARIES. THE TRICARE DUAL ELIGIBLE FISCAL INTERMEDIARY CONTRACTOR (TDEFIC) SHALL ESTABLISH CUSTOMER SERVICE ACTIVITIES THAT SUPPORT THE CLAIMS PROCESSING FUNCTION AND OTHER ADMINISTRATIVE SERVICES TRADITIONALLY ASSOCIATED WITH CLAIMS PROCESSING AS DESCRIBED BELOW. OF CRITICAL IMPORTANCE IS THE CONTRACTOR'S SUCCESS IN COLLABORATING WITH AND REACHING AGREEMENTS WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) COORDINATION OF BENEFITS CONTRACTOR (COBC) TO TRANSFER MEDICARE PROCESSED CLAIMS TO THE CONTRACTOR ("CROSS-OVER CLAIMS") FOR SECONDARY PROCESSING (TRICARE OPERATIONS MANUAL, CHAPTER 22, SECTION 2). PROVIDER CERTIFICATION. ALL PROVIDERS WHO RECEIVE REIMBURSEMENT UNDER THIS CONTRACT SHALL BE TRICARE-AUTHORIZED PROVIDERS IN ACCORDANCE WITH THE CRITERIA SET FORTH IN 32 CFR 199.6. THE CONTRACTOR SHALL VERIFY ALL PROVIDERS' AUTHORIZED STATUS THROUGH THE TRICARE MANAGEMENT ACTIVITY CENTRALIZED TRICARE ENCOUNTER PROVIDER RECORDS (TEPRV) (TSM, CHAPTER 2) OR, IF NOT LISTED, SHALL OBTAIN AND MAINTAIN DOCUMENTARY EVIDENCE TO CERTIFY THAT THE PROVIDER MEETS THE CRITERIA SET FORTH IN 32 CFR 199.6 AND THE TRICARE POLICY MANUAL. EXCEPTIONS: THE CONTRACTOR IS NOT REQUIRED TO VERIFY THE PROVIDER'S AUTHORIZED STATUS IF TRICARE IS NOT THE PRIMARY PAYER AND MEDICARE HAS ACCEPTED THE CLAIM AS FROM AN AUTHORIZED PROVIDER. THE NATIONAL QUALITY MONITORING CONTRACTOR (NQMC) WILL CERTIFY ALL RESIDENTIAL TREATMENT CENTERS (RTCS), SUBSTANCE USE DISORDER REHABILITATION FACILITIES (SUDRFS) AND PSYCHIATRIC PARTIAL HOSPITALIZATION PROGRAMS (PHPS) AND THE TDEFIC CONTRACTOR SHALL ACCEPT SUCH CERTIFICATION AS VALID. THE CONTRACTOR SHALL SUBMIT INFORMATION ON ALL PROVIDERS AUTHORIZED BY THE CONTRACTOR, TO THE TRICARE MANAGEMENT ACTIVITY CENTRALIZED TEPRV SYSTEM IN ACCORDANCE WITH THE PROVISIONS OF THE TRICARE SYSTEMS MANUAL. THE CONTRACTOR SHALL ENSURE THAT CARE PROVIDED, INCLUDING MENTAL HEALTH CARE, IS MEDICALLY NECESSARY AND APPROPRIATE AND COMPLIES WITH THE TRICARE BENEFITS CONTAINED IN 32 CFR 199.4 AND 199.5. THE CONTRACTOR SHALL USE BEST BUSINESS PRACTICES CONSISTENT WITH TRICARE LAW, REGULATION AND POLICY IN REVIEWING AND APPROVING CARE AND ESTABLISHING MEDICAL MANAGEMENT PROGRAMS TO CARRY OUT THIS ACTIVITY TO THE EXTENT AUTHORIZED BY LAW. NOTWITHSTANDING THE CONTRACTOR'S AUTHORITY TO UTILIZE ITS BEST BUSINESS PRACTICES IN MANAGING, REVIEWING AND AUTHORIZING HEALTH CARE SERVICES, THE CONTRACTOR SHALL COMPLY WITH THE PROVISIONS OF 32 CFR 199.4 AND THE TRICARE POLICY MANUAL REGARDING REVIEW AND APPROVAL OF MENTAL HEALTH SERVICES. THE CONTRACTOR SHALL BE CONSIDERED A MULTI-FUNCTION PEER REVIEW ORGANIZATION (PRO) UNDER THIS CONTRACT AND SHALL FOLLOW ALL STANDARDS, RULES, AND PROCEDURES OF THE TRICARE PRO PROGRAM (32 CFR 199.15).