TRICARE Manuals - Display Chap 20 Sect 4 (Change 44, Mar 7, 2019)

TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)

Chapter 20

Section 4

Other TRICARE Dual Eligibles Contract Requirements

Revision:

1.0 Customer Service

1.1 Telephone Inquiries

The TRICARE Dual Eligible Fiscal Intermediary Contractor (TDEFIC) shall provide nationwide (to include Hawaii, Alaska, and Puerto Rico) toll-free telephone service that is fully staffed and provides continuous service during normal business hours. During normal business hours for the caller’s time zone, callers must be offered the option of speaking with a customer service representative. Telephone access outside of normal business hours for the caller’s time zone shall be by automated means, such as a provision for leaving messages and/or for obtaining information via an automated response mechanism. Responses shall be furnished within the time frames mandated under the TDEFIC.

1.2 Written Inquiries

The TDEFIC contractor shall respond promptly and meaningfully to all written inquiries, including inquiries received via e-mail. Responses must be furnished within the time frames mandated under the TDEFIC response standards in Section 3, paragraph 8.0.

1.3 Education Requirements

1.3.1 The education requirements of TRICARE beneficiaries and providers will be accomplished through a collaborative effort with Defense Health Agency (DHA) Communications. This collaboration will ensure information and education about the TRCARE for Life (TFL) Program policies, changes and/or addition to benefits are effectively provided. Educational activities include targeted beneficiary and provider education related to specific issues. Issues may be identified by the Government or the contractor.

1.3.2 The contractor shall submit an education plan that outlines how TRICARE beneficiaries and providers will be informed and educated on all aspects of the TFL Program. DHA and DHA Communications will review the plan and provide appropriate feedback for recommended changes.

1.3.3 Required Educational Materials

1.3.3.1 The Government will furnish all beneficiary educational materials which may include printed and electronic media. Materials developed by the Government and distributed in support of the TFL Program will be selected on the basis of recommendations by the contractor, the Program Manager, DHA leadership and others with interests and concerns about the information being provided to TRICARE/Medicare Dual Eligible beneficiaries and other stakeholders. DHA Communications and the DHA Program Office will review all recommendations and will prioritize products in accordance with funding availability. DHA Communications will have final approval authority. The contractor shall be responsible for the distribution of Government furnished materials to the TFL beneficiaries.

1.3.3.2 The contractor shall furnish claim forms, claim completion instructions, the TFL Handbook, Defense Enrollment Eligibility Reporting System (DEERS) information and other TFL educational materials upon request to beneficiaries, providers and Congressional offices. The contractor shall establish and maintain effective communications with all TRICARE/Medicare dual eligible beneficiaries.

2.0 Audits, Inspections And Reports

2.1 DHA requires the contractor to prepare and submit routine workload and management reports used to establish a uniform format for recording data on contractor operations and to provide historical data for continued evaluation of contractor performance. While the data contained in the reports are essential to DHA for purposes of program management, they are equally essential for a contractor’s management of the program. The contractor shall be accountable for assuring that reports contain accurate and complete data. The contractor shall prepare written procedures describing the source of the information as well as the specific steps followed in the collection and preparation of data for each report. In addition, the contractor shall establish a Quality Assurance (QA) program to assure a high degree of reporting accuracy. All reports must be supported with sufficient documentation and audit trails by the contractor for DHA on-site and desktop audit inspections. All plans, reports, etc., shall be titled as listed here. For reports where there is no data to report, the contractor shall submit a report indicating, no data.

2.2 The contractor shall follow the requirements for audits, inspections and reports as shown in Chapter 14, Sections 1 and 2.

3.0 Medicare Crossover Fees

Medicare crossover fees are paid to Medicare contractors by the DHA contractor. These fees cover the transmission of data on paid claims from the Medicare contractor to DHA contractors in order to facilitate DHA processing as second payer on the TFL claims. The contractor shall submit non-TRICARE Encounter Data (TED) vouchers covering these expenses to DHA on an as needed basis, generally once or twice a month.

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