1.0
Grievance
Processing Jurisdiction
The contractor with
claims processing jurisdiction for the beneficiary’s claim is responsible
for processing grievances filed by or in behalf of the beneficiary.
Should a grievance pertain to an issue that is the responsibility
of another contractor, the responsible contractor will assist the
claims processing contractor in resolving the issue.
2.0 Grievance
System
The contractor shall develop and implement
a grievance system, separate and apart from the appeal process.
The grievance system shall allow full opportunity for aggrieved
parties to seek and obtain an explanation for and/or correction
of any perceived failure of a network provider, contractor, or subcontractor
to furnish the level or quality of care and/or service to which
the beneficiary may believe he/she is entitled. Any TRICARE beneficiary,
sponsor, parent, guardian, or other representative who is aggrieved
by any failure or perceived failure of the contractor, subcontractor
or contracted providers to meet the obligations for timely, quality
care and service may file a grievance. All grievances must be submitted
in writing. The subjects of grievances may be, but are not limited
to, such issues as the refusal of a Primary Care Manager (PCM) to
provide services or to refer a beneficiary to a specialist, the
length of the waiting period to obtain an appointment, undue delays
at an office when an appointment has been made, poor quality of
care, or other factors which reflect upon the quality of the care
provided or the quality and/or timeliness of the service. If the
written complaint reveals an appealable issue, the correspondence
shall be forwarded to the contractor’s appeals unit for a reconsideration
review.
3.0 Contractor
Responsibilities
It is the contractor’s responsibility
to conduct an investigation and, if possible, resolve the aggrieved
party’s problem or concern. In this responsibility, the contractor
shall:
3.1 Ensure that information for filing of grievances
is readily available to all Military Health System (MHS) beneficiaries
within the service area.
3.2 Maintain a system of receipt,
identification, and control which will enable accurate and timely handling.
All grievances shall be stamped with the actual date of receipt
within three workdays of receipt by the contractor. The date of
receipt shall be counted as the first day.
3.3 Investigate the grievance
and document the results within 60 calendar days of receipt of the grievance.
The contractor shall notify the Procuring Contracting Officer (PCO)
of all grievances for which reviews were not completed within 60
days of receipt.
3.4 Provide interim written responses
by the 30th calendar day after receipt for all grievances not Processed
To Completion (PTC) by that date.
3.5 Take positive steps to resolve
any problem identified within 60 days of the problem identification.
If the problem cannot be resolved within that period of time, the
PCO or Contracting Officer’s Representative (COR) shall be informed
of the nature of the problem and the expected date of resolution.
If there is no resolution to the problem, the contractor shall acknowledge
receipt of the grievance and explain to the grievant why the problem
cannot be resolved.
3.6 Written notification of the
results of the review shall be submitted to the beneficiary within
60 days of receipt. The letter will indicate who the grievant may
contact to obtain more information and provide an opportunity for
the grievant, if not satisfied with the resolution, to request a
second review by a different individual.
3.7 Ensure the involvement in
the grievance review process of appropriate medical personnel, including
personnel responsible for the contractor’s quality assurance program
in any case where the grievance is related to the quality of medical
care or impacts on utilization review activities.
3.8 Maintain
records for all grievances, including copies of the correspondence,
the results of the review/investigation and the action taken to
resolve any problems which are identified through the grievance.