1.0 General
The contractor shall provide timely, accurate
answers to all TRICARE inquiries. Written inquiries include inquiries
submitted on paper and those submitted electronically. Written inquiries
received shall be sorted and categorized as defined in
paragraph 3.0.
For standards, refer to
Chapter 1, Section 3. On
all outgoing correspondence from the contractor to the beneficiary,
if the SSN is used it shall be limited to the last four digits.
1.1 Correspondence
Receipt And Control
The contractor shall
establish and maintain an automated control system for routine and priority
correspondence, appeals, and grievances which meets the requirements
of
Chapter 1, Section 3;
Chapters 11; and
12. The contractor shall capture and retain
needed data for input to workload and cycle time aging reports.
1.2 Availability
Of information
Information required for appropriate
responses to inquiries, must be retrievable from the contractor’s
internal records as specified in
Chapter 9, Section 1.
2.0 Control
Correspondence shall be controlled and stamped
with the actual date of receipt in the contractor’s custody. The
control system shall be automated unless the contractor receives
approval for another system which will produce comparable results.
When appropriate, the contractor must be able to associate incoming
correspondence with prior inquiries. All correspondence or other
documents received or generated in the services department shall
be filed in accordance with
Chapter 9, Section 1. If
correspondence is answered by telephone, a record of the conversation
shall be filed with the inquiry.
3.0
Categories
Of Correspondence
All incoming correspondence
shall be separated into the following categories for reporting purposes:
• Appeals.
• Grievances.
• Priority correspondence.
• Routine inquiries.
• Allowable charge
complaints.
4.0 Routine
Correspondence
4.1 Responses may be provided by telephone, form
letter, preprinted information, individual letter, or electronic
means, as appropriate. A copy of the response shall be filed with
the inquiry. The text of written responses shall be typed. On form
letters or preprinted information, the address may be neatly handwritten,
if the contractor chooses. In situations of potential fraud or abuse,
a referral to the contractor’s Program Integrity Unit shall be completed
and a copy of the referral filed with the correspondence. For beneficiary
and provider services standards, see
Chapter 1, Section 3.
4.2 The contractor
shall develop inquiries that do not contain enough information to
identify the specific concern, using the quickest and most cost
effective method for acquiring the information. After a reasonable
effort has been made to acquire the missing information, the contractor
shall notify the correspondent that a response is not possible without
the requested information. The contractor may then close the item
for reporting purposes.
4.3 Correspondence status inquiries,
such as “tracer” claims from providers or beneficiaries and provider
and beneficiary letters inquiring about the status of a claim, may
be closed without a written response if the claim was processed
within five calendar days prior to receipt of the inquiry. The day that
the determination was made that the inquiry may be closed without
a written response is the day the inquiry is to be closed for correspondence
cycle time purposes. Otherwise, “tracer” claims, usually submitted
by providers, are to be researched to determine whether the initial
claim was received. If the initial claim was received and processed
to completion, the contractor shall advise the provider of the date
processed and the amount of payment, if any, or reason for denial.
If the initial claim was not received, the contractor shall indicate
this on the claim and submit the claim for normal processing, advising
the provider of this action.
5.0 Priority
Correspondence
5.1 Priority written correspondence is correspondence
received from members of the U.S. Congress, the Office of the Assistant
Secretary of Defense (Health Affairs) (OASD(HA)); Defense Health Agency
(DHA); the Director, TRICARE Regional Offices (TROs) and such other
classes as may be designated as “priority” by the Contracting Officer
(CO). Inquiries from the Surgeons General, Flag Officers, and state
officials such as insurance commissioners are considered priority
correspondence.
5.2 The contractor shall forward
all Congressional inquiries involving Defense Enrollment Eligibility Reporting
System (DEERS) to the DEERS Research and Analysis Section, Defense
Manpower Data Center (DMDC)/DEERS, 400 Gigling Road, Seaside, California
93955-6771. The contractor shall include any claim information required
for that organization to respond to the inquiry. A notification
shall be sent to the Congressional office informing it that the
letter has been forwarded to the DMDC Support Office (DSO).
5.3 For priority
written inquiry standards, refer to
Chapter 1, Section 3.
The contractor shall forward copies of all Congressional correspondence
to DHA and include the contractor’s response.
6.0 Correspondence
Completion And Quality Control
6.1 A piece of correspondence
shall be considered answered when the contractor’s response to the individual
or office provides a detailed outline of all actions taken to resolve
the problem(s) and includes, as appropriate:
• An explanation of
the requirements leading to the benefit determination;
• A clear, complete
response to all stated or implied questions;
• When necessary to
understanding, copies of Explanation(s) of Benefits (EOB(s)), claim number(s)
of the original claim(s), and the claim number(s) of adjustment
claim(s) including sufficient details to establish an easily followed
audit trail;
• Other
documents for full explanation and clarity;
• Clear explanation
of any additional actions that require an action or reply by the
inquirer before the contractor can take final action on the matter;
and
• A
referral form to the contractor’s Program Integrity Unit if potential
fraud or abuse is identified. A copy of the referral shall be filed
with the correspondence.
6.2 When DHA
staff requests the contractor to provide claims processing information
required by DHA to answer an inquiry, the contractor need not provide
detailed explanations of TRICARE policy, but shall provide a regulatory
citation in support of the benefit determination, the date the claim
was first received, the date the EOB was mailed, and a detailed
explanation of any delay. The response shall be legible and clearly
stated. When requested, the contractor shall furnish DHA with copies
of all claims, supporting documents, previous correspondence relating
to the particular case, a recapitulation, and a narrative description
of the claims processing history for that claim (e.g., date received,
date completed, date paid, etc.). In the case of a TRICARE Prime
beneficiary, it may be necessary to provide information about special
coverage, pamphlets, enrollment information, or copies of all or
parts of a health care record.
6.3 The
contractor shall ensure the correspondence it prepares is accurate,
responsive, clear, timely and that its tone conveys concern and
a desire to be of service. To monitor correspondence, contractors shall
establish a quality control procedure to ensure its correspondence
reflects the elements previously listed. The findings of the quality
control review shall be incorporated into training programs to upgrade
the performance of all persons involved in correspondence preparation.
Contractors are free to tailor the program to meet their needs.
Service to the beneficiaries and providers, as reflected in the
quality and timeliness of correspondence, is a key management responsibility.
7.0 Required
Reports
The contractor shall have the capability
to provide data for the following management reports:
7.1 An open
correspondence reporting system which identifies priority correspondence
over 10 calendar days old and routine inquiries over 15 days old
for management follow-up action. This report shall include the sponsor’s
name and SSN, the patient’s name, the name of the correspondent,
the date of the correspondence, the date the correspondence was
received by the contractor, the current status of the correspondence,
the date of the latest interim response, and the anticipated or
final response date. This report is for contractor use only and
the contractor may use any reporting system it chooses, provided
there are adequate controls to meet timeliness standards.
7.2 Correspondence
statistics for prompt and accurate completion of the TRICARE Monthly Workload
and Cycle Time/Aging Reports.