1.0 Telephone
System
1.1 The contractor shall provide an incoming toll-free
telephone inquiry system. Multiple telephone numbers may be utilized
for telephone inquiries; however, at least one toll-free line must have
the ability to seamlessly transfer calls (via a phone tree or other
business process) to any telephone inquiry location maintained by
the contractor and its subcontractors. All telephones must be staffed
and able to respond in a manner that meets performance standards
throughout the entire period. A recorded message indicating normal
business hours shall be used on the telephone lines after hours.
Calls shall be handled in the order they are received. The contractor
shall advertise the toll-free service using all available media
including the Explanation of Benefits (EOB), newsletters, telephone
directories published by the contractor, military organizations,
etc. and other appropriate sources.
1.2 The telephone system must
include a 24-hour, seven days a week, nationally accessible service, for
all Military Health System (MHS) beneficiaries, including beneficiaries
traveling in the contractor’s region, seeking information and/or
assistance in locating a network provider, to include behavioral health
providers willing to accept TRICARE. Callers seeking this information
must have the ability to speak with live personnel. These personnel
shall be able to enter authorizations for urgent care for beneficiaries
traveling outside of their Prime Service Area (PSA).
1.3 The contractor
shall offer an automated telephone critique to 100% of toll-free
service line callers who interact with a live customer service representative. Details
for reporting are identified
by the DD Form 1423, Contract
Data Requirements List (CDRL), located in Section
J of the applicable contract.
3.0
Requirements
There should be no differentiation in the service
provided whether the call originates locally or through the toll-free
lines. The contractor shall provide toll-free telephone access to
all TRICARE inquiries (active duty personnel, TRICARE beneficiaries,
dual-eligible beneficiaries, Director, TRICARE Regional Office (TRO),
providers, Assistant Secretary of Defense (Health Affairs) (ASD(HA)),
Defense Health Agency (DHA), Beneficiary Counseling and Assistance
Coordinators (BCACs), Debt Collection Assistance Officers (DCAOs),
and Congressional offices). At a minimum, the telephone system shall
be fully staffed and service shall be continuous during normal business
hours which are defined as 8:00 a.m. through 6:00 p.m. (except weekends
and holidays) in all time zones within the region. All customer service
provided by telephone shall be without long distance charges to
the beneficiary. Telephone service is intended to assist the public
in securing answers to various TRICARE questions including, but not
limited to:
3.1 General program information.
3.2 Specific
information regarding claims in process and claims completed, including
explanations of the methods and specific facts employed in making
reasonable charge and medical necessity determinations, and information
regarding types of medical services submitted (The contractor shall transfer
out-of-jurisdiction calls requiring the assistance of another contractor.
The contractor shall answer program information and network provider
availability/assistance calls without regard to jurisdiction.).
3.3 When the
inquiry concerns questions about Defense Enrollment Eligibility
Reporting System (DEERS) or DEERS eligibility, the contractor shall
refer the caller to the Defense Manpower Data Center (DMDC) Beneficiary
Telephone Center, 6:00 a.m. to 3:30 p.m. Pacific Time, toll-free
1-800-538-9552, TTY/TDD 1-866-363-2883. These numbers cannot be
used by the contractor or other service provider; they are only
for the beneficiary’s use.
3.4 Additional information needed
to have a claim processed.
3.5 Information about review and
appeal rights and the actions required by the beneficiary or provider
to use these rights.
3.6 Information about and procedures
for the TRICARE Program, i.e., enrollment, TRICARE plans available,
Point of Service (POS) option, continuity of care, referral management,
and provider directories.
3.7 Information concerning benefit
authorization requirements and procedures for obtaining authorizations.
Provisions must be included to allow the transfer of calls to the
authorizing organization (within the contractor’s organization,
to include subcontractor) without disconnecting the call. The contractor
shall ensure eligibility for care and enrollment status of beneficiaries
before making any arrangements for medical services.
3.8 General
information on eligibility for the TRICARE Dental Plans (Active
Duty Dental Program (ADDP), TRICARE Dental Plan (TDP), and TRICARE
Retired Dental Plan (TRDP)) and how to obtain dental plan information
from the appropriate dental contractor. The beneficiaries shall
be referred to the appropriate dental contractor for additional
information.
3.9 When
the inquiry concerns questions about a Department of Defense (DoD)
Self-Service Logon (DS Logon), the contractor shall refer the caller
to the DoD MyAccessCenter application help section at
https://myaccess.dmdc.osd.mil/.
This web site provides information that will help the beneficiary determine
the most efficient means for obtaining a DS Logon based on their
affiliation and current status. A DS Logon is a secure, self-service
logon that allows DoD and Department of Veterans Affairs (VA) affiliates
to access certain web sites using a single username and password.
3.11 Toll-Free
Telephone Service
The contractor shall advertise
the toll-free service using all available media including the EOB, newsletters,
telephone directories published by the contractor, military organizations,
etc. and other appropriate sources.
3.12 Telephone Monitoring Equipment
The contractor shall utilize telephone equipment
that is programmed to measure and record response times of incoming
calls and determine whether DHA standards are met. See
Chapter 1, Section 3, paragraph 3.4 for standards.
3.12.1 Measure Busy
Signal Level
“Busy signal level” is defined
as the percentage of time a caller receives a busy signal.
3.12.2 Measure Call
Volumes And Handling Times
Contractors shall
measure the number of calls received each month and the time elapsing between
acknowledgment and handling by a telephone representative or Automated
Response Unit (ARU). Measures shall include all calls that are directly
answered by an individual or ARU (no waiting time). The on-hold
time period begins when the telephone call is acknowledged and does
not include the ring time.
7.0 Beneficiary
Encounter Documentation Access
The contractor
shall supply the government access to all information obtained during beneficiary
encounters. This includes encounters through emails, walk-ins, and
phone calls. Summaries of each encounter should be made available
in the contractor’s online system. The information will be available
to select staff within the MHS, primarily those in a customer service
capacity such as BCACs and DCAOs. Access to the information for
staff outside the Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) will be approved by a designated TRO representative
and for staff at the MTF/eMSM, access will be approved by the Contract
Liaison. Quality reviews may be conducted when discrepancies in
information provided by contractor staff to beneficiaries has been
identified. Access to information will not include sensitive or
behavioral health information. Information obtained from incoming
correspondence and emails will be available upon request.