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TRICARE Operations Manual 6010.59-M, April 1, 2015
Transitions
Chapter 2
Section 5
Critical Processes (CPs) - Customer Service
Revision:  C-26, May 30, 2018
1.0  CUSTOMER SERVICE
The contractor shall operate call centers that will provide accurate and timely responses to TRICARE customers in accordance with Chapter 1, Section 3.
1.1  The contractor shall begin validating call center capabilities no later than 120 days prior to the start of health care delivery (SHCD), and shall continue to validate call center capabilities until full operating capability is reached in accordance with paragraph 5.2. The contractor’s TRICARE call center capability shall be satisfactorily operational no later than 60 days prior to SHCD.
1.2  Training documents and response scripts shall be available for review at each of the contractor demonstration events.
1.3  Prior to the SHCD, all contractor customer service personnel shall attend training on military culture and life. This training will be provided by the Government.
2.0  Phase-In Requirements Related to the Health Care Finder (HCF) Function
The hiring and training of call center HCF function staff by the incoming contractor shall be completed prior to the SHCD for TRICARE Prime in each Prime Service Area (PSA). The provider/ beneficiary community shall be advised of the procedures for obtaining HCF assistance prior to the SHCD.
3.0  Public Notification Program-Provider And Congressional Mailing
The contractor shall prepare a mailing to all non-network TRICARE providers and Congressional offices within the region by the 45th calendar day prior to the SHCD according to the specifications of the official transition schedule. The proposed mailing shall be submitted to the Procuring Contracting Officer (PCO) and the TRICARE Regional Office (TRO), and the Defense Health Agency (DHA) Marketing and Education Committee (MEC) for approval no later than 90 calendar days prior to the start of each option period. The mailing shall discuss any unique processing requirements of the contractor and any other needed information dictated by the official transition schedule.
4.0  TRICARE Handbook
The contractor shall provide the TRICARE handbook to beneficiaries via e-mail or as a download from the contractor’s website. Only one printed (hardcopy) TRICARE Handbook shall be mailed, per household, when specifically requested by the beneficiary.
5.0  Performance Readiness Validation (PRV)/performance Readiness Assessment And Verification (PRAV)
During transition, the incoming contractor’s performance readiness status regarding customer service activities will be subject to PRV/PRAV reviews as described below.
5.1  Customer Service PRV
5.1.1  The contractor shall offer an automated telephone critique to 100% of toll-free service line callers who interact with a live customer service representative. No later than 120 days prior to SHCD, the contractor shall initiate validation of call center capabilities.
5.1.1.1  The validation shall assess the contractor’s ability to receive calls, document calls, provide correct answers, have supervisors ready to assist with difficult calls, and perform any handoffs to other contractors. The contractor shall provide the Government with a comprehensive briefing on the processes, test results, and findings of the 120 day validation. This briefing should summarize information that was reported to the Government via the Weekly Integrated Master Plan/Integrated Master Schedule (IMP/IMS) Status Report. Results shall be briefed as validated performance against desired performance levels and contract standards and/or requirements.
5.1.1.2  The validation shall measure the contractor’s ability to meet the following standards:
•  Blockage Rates less than 5%.
•  Call Abandonment Rates less than 5%.
•  Average Speed of Answer less than 45 seconds.
•  On hold Times less than 30 seconds 95% of the time.
•  Call resolution in first call 85% of the time.
•  Response accuracy 90% (Responses provided by Call Center staff shall be accurate and complete according to the terms of the contract and all applicable TRICARE programs and policies).
5.1.2  Sixty days prior to SHCD, the contractor shall validate its call center operational capabilities. The contractor shall test its ability to receive calls, document calls, provide correct answers, have supervisors ready to assist with difficult calls, and perform any handoffs to other contractor personnel with no problems. The validation will include accuracy and stress testing of all aspects its call center. The contractor shall test its capability against each of the standards referenced above and provide the results to the Government. The contractor shall provide the Government transition team with a comprehensive briefing on the processes, test results, and findings of the 60 Day validation. This briefing shall summarize the information that was reported to the Government via the Weekly IMP/IMS Status Report. Results shall be briefed as validated performance against desired performance levels and contract standards and/or requirements.
5.1.3  Sixty days prior to SHCD, the contractor shall validate its customer service staff is fully trained and knowledgeable about TRICARE and is able to utilize multiple means of contemporary communication media (e.g., electronic mail, web page, telephone texting process, smart phone applications and social media outlets) to accurately answer customer questions. The validation shall include a demonstration that the staff is full trained. The contractor shall provide the Government with access to training documents and response scripts. The validation shall include a demonstration of a fully functional customer service data exchange and interface with the claims processing system. The validation results shall be briefed to the Government 55 days prior to SHCD.
5.1.4  Thirty days prior to SHCD, the contractor shall repeat the validation process described in paragraph 5.1.3 and brief the results to the Government 25 days prior to SHCD.
5.2  Customer Service PRAV
5.2.1  The contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding customer service activities as described above. If, after review, the Government finds the contractor’s performance readiness for customer service to be deficient, the contractor must submit a detailed mitigation plan no later than 10 business days following the Government’s findings.
5.2.2  Specific PRAV activities, assessment techniques, and performance readiness thresholds will be identified by the Government during the Transition Specification Meeting.
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