1.0 Correspondence
1.1 Priority
Correspondence
Priority written correspondence
is correspondence received from members of Congress, the Office
of the Assistant Secretary of Defense (Health Affairs) (OASD(HA)),
Defense Health Agency (DHA), Director, TRICARE Regional Offices
(TROs), and such other classes as may be designated as “priority”
by the Procuring Contracting Officer (PCO). Inquiries from the Surgeons
General, Flag Officers, and state officials, such as insurance commissioners,
are considered priority correspondence. 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,
CA 93955-6771, including any claim information required for them
to respond to the inquiry. A notification shall be sent to the Congressional
office informing them that the letter has been forwarded to the
DMDC Support Office (DSO).
1.2 Routine Correspondence
Responses may be provided by telephone, form
letter, preprinted information, e-mail, or individual letter. A
copy of the response shall be filed with the inquiry. The text of
written responses shall be typed. 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.
If correspondence is received that does not contain enough information
to identify the specific concern, the contractor should develop
the incomplete inquiry by using the quickest and most cost effective
method for acquiring the information. After a reasonable effort
has been made to acquire the missing information, notify the correspondent
that a response is not possible until receipt of the requested information.
The contractor may then close the correspondence for reporting purposes.
Correspondence inquiries requesting the status of a claim may be
closed without a response if the claim was processed within five
calendar days prior to receipt of the inquiry; otherwise, a response
is required.
1.3 Correspondence Completion
A piece of correspondence shall be considered
answered when the contractor’s response to the individual provides
a detailed outline of all actions taken to resolve the problem(s),
or answers the inquiry. This includes, as appropriate, an explanation
of the requirements leading to the benefit determination, and a
clear complete response to all stated or implied questions. If the
response states or implies that additional action will be taken
by the contractor, but that final or additional action requires
an action or reply by the inquirer, the contractor shall clearly
explain what is required.
1.4 When DHA staff requests the
contractor to provide claims processing information required for DHA
to respond to an inquiry, the contractor need not provide detailed
explanations of TRICARE policy, but rather shall provide information
regarding when the claim was received, when a prescription was dispensed,
the reason for any delays, when an Explanation of Benefits (EOB)
was mailed (if appropriate), and any other supporting information
necessary to answer the inquiry. If requested, the contractor shall
supply copies of all claims, supporting documents, and previous
correspondence relating to the particular inquiry, etc.
1.5 The contractor
shall ensure that correspondence is accurate, responsive, clear,
timely, and that its tone conveys concern and a desire to be of
service. To monitor correspondence, the contractor shall establish
a quality control procedure to ensure its correspondence reflects
these elements. Any findings of the quality control review shall
be incorporated into training programs to upgrade the performance
of all staff involved in correspondence preparation.
2.0 Telephones
2.1 The contractor
shall provide an incoming telephone inquiry system. Telephone inquiries
shall be answered according to standards contained in the contract.
The contractor may respond to telephone inquiries by letter, if
a written response provides better service. For example, it may
be difficult to reestablish telephone contact with the calling party,
a written response may provide the caller with needed documentation,
or a situation may call for a complex explanation which is clearer
if written. The contractor staff shall be trained to respond in
the most appropriate, accurate manner. Telephone inquiries reporting
a potential fraud or abuse situation shall be documented and referred
to the contractor’s Program Integrity Unit.
2.2 Telephone
requirements and standards apply to all telephone calls. The contractor
shall make telephone service available for all TRICARE inquiries
(active duty personnel, TRICARE beneficiaries, dual eligible beneficiaries,
Director, TROs, providers, DHA, Beneficiary Counseling and Assistance Coordinators
(BCACs), etc.). The phone number(s) shall be published on the EOB
and otherwise be publicized. Telephone service is intended to assist
the public in securing answers to various TRICARE questions including,
but not limited to:
• General TRICARE Pharmacy
(TPharm) Benefits Program information.
• Specific information
regarding claims in process and claims completed, explanations of
the methods and specific facts employed in making medical necessity
determinations, and information regarding types of pharmaceuticals
covered.
• Any
additional information to have a claim processed (including documentation
that may be required for completion of a medical necessity review
or prior authorization).
• Questions about DEERS
or DEERS eligibility that cannot be answered by the contractor, shall
be referred to the 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 are only for beneficiary use.)
• Transferring out-of-jurisdiction
calls requiring the assistance of another contractor in accordance
with contract requirements.
2.3 The contractor
or telephone company with which the contractor does business shall
have telephone equipment that is programmed to measure and record
response time and ensure standards are always met. At a minimum,
the equipment shall:
2.3.1 Measure Blockage Rate. Blockage rate is defined
as the percentage of time a caller receives a busy signal. The blockage
rate shall be expressed as a percentage, which is to be determined
as follows: divide the number of calls answered by the contractor
by the number of calls reaching and attempting to reach the contractor
(must be machine generated figures).
2.3.2 Measure the number of calls
received each month and the time elapsing between acknowledgement
and handling by a telephone representative or Automated Response
Unit (ARU). Includes 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.
2.3.3 The contractor shall have telephone equipment
that provides outgoing lines sufficient to allow call-backs. Additionally,
the contractor shall have automatic call distributors, and ARUs
with after-hours message recorders (if needed), an automated, interactive
24 hour call-handling system designed to ensure maximum access to
the toll-free lines. The system shall provide automated responses
to requests for general pharmacy benefits program information.
2.3.4 The contractor
shall establish a monitoring system to ensure quality of performance.
This shall include monitoring calls for accuracy, responsiveness,
clarity, and tone. The contractor shall submit telephone reports
in accordance with contract requirements.
3.0 Audits
and Inspections
3.1 Federal Acquisition Regulation (FAR) 52.215-2,
included in all TRICARE contracts, provides that DHA, its related
audit agencies, and the Comptroller General of the United States
(U.S.) have the right to examine all supporting documentation to
permit evaluation of cost or pricing data submitted by a contractor.
This examination is to verify that cost or pricing data submitted
during negotiations, including changes and the preparation of any
fiscal report of settlement, are accurate, complete, and current.
This right continues for three years after final payment to the
contractor. The contractor’s facilities and applicable records also
shall be subject to inspection and audit by DHA.
3.2 All inspections
shall be conducted either at DHA or at the contractor’s facility.
Inspection, acceptance, and receipt of services provided by the
contractor shall be accomplished by the PCO or designee(s). Inspections
include, but are not limited to, DHA payment audits, performance
audits, Program Integrity audits coordinated with DHA, and contractor/DHA
quality assurance audits.
3.3 The contractor is required
to provide DHA with free access to all financial records, cost information,
systems documentation, program logic, operating manuals, procedures,
and other information and documentation gathered, used, and stored
as a part of the contractor’s TRICARE operations, including the
performance of its subcontractor(s). Subcontractors must provide
the same free access to DHA.
3.4 Proprietary information, if
so designated in the contract (including the technical proposal)
will not be released by DHA to unauthorized recipients. However,
DHA will not recognize, as proprietary, information records and
files which constitute essential data resources in the processing
of TPharm claims and the generation of TED records.
3.5 DHA reserves
the right to specify the format, media, and timing of the delivery
to, and access by DHA, of information and documentation. Access
to information and documentation also includes the right of DHA
inspection. This is to assure that the Government has full and free
use of TRICARE data, as well as supporting information and documentation
for program purposes. DHA will assure that restricted rights are
properly maintained.
3.6 Contract performance evaluations
by Government staff, including audit personnel under contract, will
be conducted periodically at the location(s) of the contractor’s
operations and/or subcontractor’s operations. These reviews will
include financial and operational analyses of all aspects of the
contractor’s performance under the terms of the contract. The contractor
shall make available all appropriate personnel, facilities, and
documentation required in the conduct of such reviews or investigations
by DHA or other authorized Government agency. Upon request of the
PCO, the contractor shall provide adequate office space (at a contractor
operated facility determined by the Government) for any long-term
on-site auditors. Evaluations may include desk audits and surveys
of contractor performance. The contractor will be furnished written
findings.
3.7 Claim reviews shall be performed by DHA (or
a DHA-designated entity) for claims processed under the TPharm Program
contract. Samples will be drawn on a semi-annual basis from TED
records which pass DHA edits. The contractor shall provide the required
supporting documentation for the sample claims in order for a complete
review of a claim record to be conducted.
4.0 EOB
4.1 The purpose
of the pharmacy EOB is to provide a consolidated listing of prescriptions
filled for the month. An EOB shall be provided to each beneficiary
obtaining pharmacy services through a retail pharmacy or the Mail
Order Pharmacy (MOP). If the beneficiary did not fill any prescriptions
during the time frame, no EOB is necessary.
4.2 The contractor
shall provide the toll free number to its beneficiary service center
on the EOB for beneficiaries to call for benefit questions or report
any questionable transactions that appear on their EOB.
4.3 The EOB
shall provide space for the Government to include a short informational
statement. A pharmacy EOB shall not be issued to pharmacies or health
care providers.
4.5 The contractor may use its
standard EOB design, but shall ensure that it includes the following items:
• Name
of the Pharmacy where each prescription was filled.
• Location of Pharmacy
(City and State).
• Drug Name, quantity,
days supply, and dosage form of each prescription filled.
• Product classification
(i.e., brand, generic, non-formulary).
• Date prescription
dispensed by pharmacy.
• Billed or Submitted
Amount.
• TRICARE
Allowed Amount.
• Total Paid by Other
Health Insurance (OHI).
• Cost-Share/Copayment.
• TRICARE Amount
Paid.
• Amount
Applied Towards Catastrophic Cap.
• Amount Applied
Towards Individual & Family Deductible.
• Potential cost
saving opportunities (e.g., generic vs brand, MOP vs retail).
5.0 Explanation
of Payment (EOP)
The purpose of the EOP is
to describe the action taken for each claim processed to a final determination
(paid or denied).
5.1 Beneficiaries receive EOPs
for Direct Member Reimbursements (DMRs). Beneficiaries do not receive
EOPs for retail point of sale claims, mail order claims, or Military
Treatment Facility (MTF) claims.
5.2 Pharmacies receive EOPs with
their scheduled payments for all claims processed to final determination
during the pay cycle. Any applicable offsets will be documented.