2.0 TRICARE
Service Centers (TSC
s)
support2.1 Location,
Operations, And Staffing
2.1.1 TSCs are jointly staffed by Military
Treatment Facility (MTF) personnel
and TOP contractor personnel. TSCs in the MTFs are
operational, Monday - Friday (except holidays recognized
by the installation) during the administrative hours of the MTF.
2.1.2 The TOP
contractor shall provide Beneficiary Service Representatives (BSRs)
on a full-time basis at each location as designated in the contract.
BSRs shall be qualified to perform
the duties described
in paragraph 2.2.
2.1.3 The TOP contractor shall provide sufficient
BSR staffing to accomplish all work in a timely manner; however,
at least one full-time BSR will be assigned to each location regardless
of actual workload unless the Government has specifically authorized
part-time coverage. The TOP contractor shall advise the Government
of any locations where the workload does not justify full-time BSR coverage.
The TOP contractor shall implement appropriate business processes
to provide full-time TSC coverage if the assigned Customer Service
Representative(s) (CSR(s)) are unavailable due to planned or unplanned
absences (e.g., illness, leave, personal emergencies, etc.) for
more than two consecutive business days. Local processes for managing
short-term CSR absences (up to two consecutive business days) shall
be addressed in the Statement of Responsibilities (SOR).
2.1.4 BSRs shall have a fully operational,
on-line interface with the automated claims processing and enrollment
systems which support the functions of the TSC no later than 30
calendar days prior to the start of health care delivery (SHCD)
and shall maintain that interface through the life of the contract.
2.2
BSR Functions
at TSC
s2.2.1 The contractor
shall provide overseas TSCs with BSR support to provide all Military
Health System (MHS) beneficiaries with
the information
and services as specified below
.
• Provide TOP
Prime, TOP Prime Remote, and TOP Select enrollment information and perform
enrollments/disenrollments to include assisting MTFs/beneficiaries
with transferring enrollment to another region.
• Perform
Health Care Finder (HCF) functions upon beneficiary/MTF request.
• Provide
information on the Point of Service (POS) option;
• Provide
information on claims (including on-line access to
the claims processing system for information about the status of
a claim);
• Provide
assistance regarding claim problems when the TOP
contractor is responsible for processing the claim; and
• Provide
continuity-of-care services to all MHS beneficiaries
including, but not limited to, active duty personnel, dependents
of active duty personnel, retirees and their dependents, survivors,
Medicare-eligible beneficiaries and all other categories of individuals
eligible to receive MHS services.
• Perform
Primary Care Manager (PCM) changes and resolve PCM Information Transfer (PIT)
discrepancies.
• Perform
registrations in the Composite Health Care System (CHCS) (as required
to support TRICARE enrollments) and update patient information in
CHCS and Defense Enrollment Eligibility Reporting System (DEERS).
• Assist
beneficiaries with TRICARE benefit/coverage or claims questions
(BSRs shall have sufficient claims knowledge to handle routine questions
regarding claims and the ability to access and navigate the claims
system).
• Assist
beneficiaries with debt collection issues.
• Provide
TRICARE briefings as requested by the MTF.
• Distribute
TRICARE marketing materials.
• Assist
beneficiaries with utilizing Government messaging systems.
• Assist
beneficiaries in navigating procurement of Durable Medical Equipment
(DME).
Note: The
contractor shall confirm eligibility for care and enrollment status
of beneficiaries before making any arrangements for medical services.
2.2.2 TRICARE Program Information
The TOP contractor shall provide personal assistance
to all MHS beneficiaries seeking information about TRICARE Prime, TRICARE
Select, TRICARE
For Life (TFL), Civilian Health and Medical Program
of the Department of Veteran Affairs (CHAMPVA), TRICARE Mail Order
Pharmacy (TMOP), Global Nurse Advice Line (NAL), and the TRICARE
dental contracts. The TOP contractor shall ensure
that the TSCs are supplied with educational materials to
include enrollment and claims submission information.
Through the BSRs and call centers, the TOP contractor shall establish
mechanisms to advise beneficiaries of care options, including the
POS option, and services offered.
2.2.3 BSR Interface With MTFs
BSRs
shall act as the focal point for providing information, referral,
and assistance to beneficiaries seeking access to TRICARE services.
BSRs shall maintain day-to-day liaison with MTF staff to promote
MTF optimization and ensure effective performance of the access,
referral, information, and continuity of care functions.
2.2.4 Enrollment
BSRs and
contractor call center staff shall provide personal assistance to
eligible beneficiaries, electing to enroll or disenroll, and permanently
assigned active duty personnel enrolling in TRICARE Prime. The TOP
contractor shall provide assistance to all MHS beneficiaries, including
active duty, Medicare eligibles, and others, in understanding program
requirements, by answering questions, adhering to MTF Commanders’
and TAO Director’s determinations for PCM
assignment, and following grievance and inquiry procedures in accordance
with this manual.
2.2.5 Claims
BSRs in
the TSCs shall assist all TRICARE beneficiaries with all claims
issues when the TOP contractor is responsible for processing the
claim. When the TOP contractor is not responsible for processing
the claim, the BSR in the TSC shall
assist the beneficiary in identifying and contacting the organization
that is responsible for processing the claim. The
BSR will provide information (including on-line access to the claims
processing system for information about the status of a claim),
assist beneficiaries with claim problems when the TOP contractor
is responsible for processing the claim and provide continuity-of-care
services to all MHS beneficiaries including, but not limited to,
active duty personnel, dependents of active duty personnel, retirees
and their dependents, survivors, Medicare-eligible beneficiaries
and all other categories of individuals eligible to receive MHS
services.
2.2.6 TRICARE Dental Plans
BSRs in
the TSCs shall provide general information on eligibility for the
TRICARE Dental Plans. The beneficiaries
shall be referred to the appropriate dental contractor for additional information.
2.3 Creating
And Updating Department of Defense (DoD) Self-Service Logon (DS
Logon) Accounts
DoD affiliates and Department
of Veterans Affairs (DVA)/Veterans Health Administration (VHA) affiliates
qualify for a DS Logon account. A DS Logon is a secure, self-service
logon ID that allows DoD/DVA/VHA affiliates to access certain web
sites using a single username and password. DoD/DVA affiliates are
DoD sponsors, spouses (regardless of age), and dependents (18 and
older), and retirees and veterans who have an active affiliation
in the
DEER
S,
which includes Reserve Component (RC) sponsors (including all subcomponents
such as the Selected Reserve, Retired Reserve, Individual Ready Reserve
(IRR), and Standby Reserve) along with their spouses, and dependents
(18 and older). The DoD Self-Service Access Station (DS Access Station)
is an on-line web application developed by the Defense Manpower
Data Center (DMDC) for the purpose of creating DS Logon account
requests on behalf of DoD/DVA/VHA affiliates. When a beneficiary
inquiry concerns the DS Logon, the contractor shall refer the caller
to the DoD MyAccessCenter application help section at
https://myaccess.dmdc.osd.mil/.
2.3.1 DS Access
Station
Upon request by DoD/DVA/VHA affiliates,
BSRs
located in TSCs shall use the DS Access Station and
perform In-Person Proofing (IPP) to generate requests for DMDC to
create and update DS Logon accounts following instructions specified
in the current version of the DS Logon - Access Station User Guide.
DS Access Station is currently available at
https://www.dmdc.osd.mil/appj/dsaccessstation/.
The contractor shall request DS Access Station user authorization
for TSC personnel from DMDC through the contractor’s DEERS site
security manager. A copy of the current DS Logon - Access Station User
Guide will be provided upon request.
2.3.2 DS Logon Account Levels
Two account levels of DS Logon access are available
to DoD/DVA/VHA affiliates, each with progressing security features
and each with a different user-authentication procedure:
2.3.2.1 Basic Account
(Level 1)
This is an entry level user account
established online that only provides limited view access to the
user’s personal information that the user has provided on-line.
This level of account is provided to individuals who have registered
online at the eBenefits web site (
http://www.ebenefits.va.gov) without
being in-person proofed. Many applications will not allow access
with a Basic (Level 1) Account.
2.3.2.2 Premium Account (Level 2)
This account is given to a DoD/DVA/VHA affiliate
who has self-registered using their Common Access Card (CAC) or
Defense Financing and Accounting Service (DFAS)/myPay Login ID or who
has completed an IPP process with designated representatives such
as TSC personnel. To provide enhanced security to the user’s personal
information, access to most applications including TRICARE-related
applications require a Premium (Level 2) Account.
2.3.3 Generating
DS Logon Requests
2.3.3.1 Before generating a request for a Premium Account,
TSC personnel shall determine if the requestor has an existing Basic
Account. If they do, TSC personnel shall follow DS Logon user guide instructions
to generate a request to upgrade the Basic Account to a Premium
Account. Upon successful completion of an upgrade, the Premium Account
is immediately available for use.
2.3.3.2 If a Premium
Account is created outright rather than being upgraded from a Basic
Account, the Premium Account will not be effective and available
for use until the requestor receives a letter in postal mail from
DMDC and follows the instructions in the letter before the specified
deadline to activate the Premium Account. If the requestor does
not have an existing Basic Account, TSC personnel shall inform the
requestor of the advantages of establishing a Basic Account and
provide the requestor with the procedures for obtaining a Basic
Account. If the requestor does not wish to create a Basic Account
first, TSC personnel shall proceed with the procedures for a new
DS Logon request.
2.3.4 DS Access Station Users and
Confidentiality
Only users authorized by
the DMDC may access the DS Access Station and perform IPP. Furthermore,
only authorized DS Access Station users may view any documents presented
for IPP or be informed in any way of information available in the
DS Access Station. Every authorized user must safeguard the confidentiality
of such information at all times to comply with the Privacy Act
of 1974. The contractor shall return all documents presented for
IPP to the requester and shall not retain any documents. The contractor
shall not make photocopies or any other images of documents presented for
IPP.
3.0 HEALTH
CARE FINDER (HCF) SERVICES
3.1 TOP HCF functions are performed
by
BSRs located in the TSCs or in contractor-operated
call center(s). The TOP contractor shall offer call center operations
to support HCF services via toll-free lines 24 hours per day, seven
days per week, 365 days per year.
Note: The contractor
shall offer claims assistance via toll-free lines seven days per
week, 365 days per year, between the hours of 2:00 AM and 7:00 PM
Central Standard Time (CST). These service hours for claims assistance
apply even if claims assistance is provided via the contractor’s
call center(s).
3.1.1 HCFs are responsible for facilitating access
to purchased care sector provider care (including, but not limited
to, primary care, specialty care, mental health care, ancillary
services, DME, and
pharmacy services), and for authorizing certain health care services.
Additionally, HCFs shall inform beneficiaries of access mechanisms,
referral procedures, and rules regarding use of network/non-network
providers. They shall also improve patient continuity of care by
establishing mechanisms to facilitate necessary consultations, follow-up
appointments and the sharing of medical records. TOP HCFs will serve
all MHS beneficiaries in the region, regardless of their enrollment
status. This includes dual-eligible beneficiaries and beneficiaries
residing or enrolled in the 50 U.S. and the District of Columbia
who may require assistance when accessing care in an overseas location.
3.1.2 For MTF
enrollees, the specialty care referral process includes a covered
benefit review; entering appropriate authorizations into the contractor’s
system; locating a qualified network or non-network purchased care
sector provider to provide the care on a cashless, claimless basis;
providing the beneficiary with a written care authorization and
the purchased care sector provider’s information; and assisting
the beneficiary with establishing an appointment with the purchased
care sector provider (upon beneficiary request).The contractor shall
also provide information to MTF personnel regarding the status of
specialty care referrals and shall work cooperatively with the MTF
to assist in obtaining consult results from purchased care sector
providers; however, the contractor is not responsible for tracking
receipt of consult results.
3.1.3 For TOP Prime Remote enrollees,
the specialty care referral process includes a medical necessity
review; a covered benefit review; entering appropriate authorizations
into the contractor’s system; locating a qualified network or non-network
purchased care sector provider to provide the care on a cashless,
claimless basis; providing the beneficiary with a written care authorization
and the purchased care sector provider’s information; and assisting
the beneficiary with establishing an appointment with the purchased
care sector provider (upon beneficiary request). This process is
also applicable to Service members who are on Temporary Additional
Duty/Temporary Duty (TAD/TDY), in an authorized leave status, or
deployed/deployed on liberty in a remote overseas location, and
to TRICARE Prime/TRICARE Prime Remote (TPR) enrollees who require
urgent specialty care while traveling outside the 50 U.S. and the
District of Columbia.
Note: This process
applies to all TOP Prime Remote enrollees, regardless of the status/location
of the referring provider or health unit.
3.1.4 Beneficiaries
enrolled to the Uniformed Services Family Health Plan (USFHP) and
the Continued Health Care Benefit Program (CHCBP) must follow the
requirements of those programs when obtaining overseas care.
3.2 The TOP
HCF is responsible for the following functions:
3.2.1 Referral Assistance for TOP
Beneficiaries
The TOP contractor (working
in concert with the MTF Commander) shall ensure optimal use of MTFs
and to foster coordination of all care delivered in the civilian
sector and care referred to and from the MTF. The TOP HCF is the
primary mechanism for achieving these objectives. The referral services
of the TOP HCF are primarily
for ensuring access
to care for enrolled beneficiaries, but the TOP HCF is also available
to assist non-enrollees in finding network/non-network purchased
care sector providers. For TOP Prime/TOP Prime Remote enrollees,
the referral is generally initiated by the beneficiary’s PCM. The
PCM or beneficiary contacts the TOP HCF for assistance in locating
an appropriate purchased care sector provider and to obtain authorization
for the care (see
Sections 17 and
18 for additional
information on HCF referral assistance).
3.2.2 Referral
Assistance for Beneficiaries Enrolled or Residing in the 50 U.S.
and the District of Columbia
The TOP contractor
shall provide referral assistance for TRICARE Prime/TPR enrollees
who require urgent or emergent health care while traveling outside
the 50 U.S. and the District of Columbia. These referrals will generally
be initiated by the beneficiary, a purchased care sector provider,
or an overseas MTF provider. Emergency care never requires preauthorization;
however, ADFMs enrolled to TRICARE Prime/TPR may receive
routine, urgent
and emergency health care services in locations outside the 50 U.S.
and the District of Columbia (to include emergency medical evacuation
per
Section 7) on a cashless, claimless basis
if the care is coordinated in advance with the TOP contractor. The
TOP contractor shall implement guarantee of payment or other business
processes to ensure that ADFMs enrolled to TRICARE Prime/TPR
receive
routine, urgent
or emergency medical services on a cashless, claimless basis upon
beneficiary request.
3.2.3 Authorizations
3.2.3.1 The TOP
HCF will authorize care for TPR enrollees; for Service members who
are on TAD/TDY, in an authorized leave status, or deployed, deployed
on liberty in a remote overseas location, and for TRICARE Prime/TPR
enrollees who require urgent or emergent health care while traveling
outside the 50 U.S. and the District of Columbia. The contractor
shall also ensure that MTF-issued authorizations are entered into
all applicable contractor systems. Non-emergent specialty health
care received from a purchased care sector provider must be authorized
if benefits are to be paid as TOP Prime/TPR.
3.2.3.2 Care subject
to a PCM referral/authorization may
receive a clinical review and authorization by the HCF or other
designee.
3.2.4 If an ADFM TOP Prime/TOP Prime
Remote enrollee receives care that was not authorized, the care
may be covered under the TOP POS option, with POS deductibles and
cost-shares. POS provisions also apply to TRICARE Prime/TPR enrollees
who receive routine care outside the
50 U.S. and the District of Columbia without obtaining prior authorization
from the TOP contractor. The care must also be otherwise coverable
under TRICARE or the claim shall be denied.
3.2.5 Service
member care that was not referred and authorized shall be denied
unless it is retroactively authorized by the appropriate service
and Director, DHA. This included obtaining an approved waiver for
any non-covered service. POS does not apply to Service members.
4.0 Customer
Service Responsibilities
TOP customer support
shall be provided to all Military Health System staff
to include, but not limited to, TOPO, TAOs, Beneficiary
Counseling and Assistance Coordinators (BCACs)/Debt Collection Assistance
Officers (DCAOs), stateside TROs, stateside contractors, stateside
TRICARE beneficiaries traveling overseas, and DHA staff.
TOP contractor customer support service shall include the following:
4.1 The TOP
contractor shall secure at a minimum one dedicated post office box
for the receipt of all claims and correspondence from foreign locations
per overseas region.
4.2 The TOP contractor shall identify
a specific individual and an alternate to assist the Director, TROs,
TOPO/TAO Directors, DHA, BCACs and stateside claims processing contractors
with the resolution of TOP issues. Issues which cannot be successfully
resolved shall be referred to the TOP Contracting Officer’s Representative
(COR).
4.3 The TOP contractor shall identify a specific
individual and an alternate to assist DCAOs with the resolution
of TOP beneficiary debt collection issues.
4.4 The TOP contractor shall be
responsible for establishing and operating a dedicated TRICARE overseas
claims/correspondence processing department with a dedicated staff.
This department and staff shall be under the direction of a supervisor,
who shall function as the contractor’s POC for TRICARE overseas
claims and related operational and support services. The contractor’s
department for TRICARE overseas claims shall include at a minimum
the following functions/requirements:
4.4.1 The TOP contractor shall provide
toll-free telephone service for claims assistance to beneficiaries
and providers seven days a week, 365 days a year, between the hours
of 2:00 AM and 7:00 PM CST. Toll-free services shall be available
from any stateside or overseas location.
4.4.2 The TOP contractor shall have
the ability to translate claims submitted in a foreign language
and write in German, Italian, Japanese, Korean, Tagalog (Filipino),
and Spanish, or shall have the ability to obtain such translation
or writing.
4.4.3 The TOP contractor shall provide on-line read
only access to their claims processing system to TOPO,
each TAO, and the DHA
technical representative for TOP claims.
4.4.4 The TOP contractor shall provide
a secure, user-friendly Internet portal
for receipt of customer claims status inquiries and access to claims
status information (to include the ability to view and print Explanation
of Benefits (EOBs).
4.4.5 The TOP contractor shall provide,
upon Government request, documentation of claims for auditing purposes.
4.5 The TOP
contractor shall assist traveling TOP Prime and Prime Remote enrollees
to ensure beneficiary access/receipt of urgent or emergent care
in the 50 U.S. and the District of Columbia. The contractor shall
also assist beneficiaries residing or enrolled in the U.S. or the
District of Columbia who require urgent or emergent care while traveling
overseas. ADFMs who are enrolled to TRICARE Prime or TPR may receive
emergency medical services in locations outside the 50 U.S. and
the District of Columbia (to include emergency medical evacuation)
on a cashless, claimless basis if the care is coordinated in advance
with the TOP contractor.
5.0 BENEFICIARY
SERVICES
5.1 The TOP contractor shall achieve the highest
level of beneficiary satisfaction possible in the overseas environment.
This shall be accomplished by developing qualified purchased care
sector provider networks (complemented by non-network purchased
care sector providers as necessary), ensuring timely access to purchased
care sector care, providing TOP information/education/training to beneficiaries
and purchased care sector providers, and processing claims in a
timely, accurate manner.
5.2 In
addition to the beneficiary education requirements outlined in
Chapter 11, Sections 1 and
2, the
TOP contractor may be required to conduct beneficiary education/enrollment
activities for arriving/deploying units in accordance with the enrollment
protocols established in the
SOR between the
TOP contractor and the MTFs.
5.3 The TOP contractor shall maintain
up-to-date lists of purchased care sector network providers, and
shall make this information available at all TOP TSCs and via web-based
access. Web-based network provider listings shall include information
regarding authorization requirements that are applicable to TOP
Prime and Prime Remote enrollees.
5.4 The TOP contractor’s beneficiary
education activities and materials shall include information for TOP
Prime and Prime Remote enrollees regarding care received in the
50 U.S. and the District of Columbia. This process shall include
information regarding referrals/authorizations while stateside,
TOP POS policy, and the recommended process for accessing care while
stateside. TOP Prime and Prime Remote enrollees traveling stateside
shall be encouraged to utilize MTF care whenever possible. If MTF care
is not available, beneficiaries should be encouraged to seek care
from a network provider before obtaining care from a non-network
provider.
5.5 The requirement in
Chapter 11, Section 2, paragraph 1.1, is superseded
for the TOP contractor by a requirement for a total of nine three-day
TRICARE training courses per contract option period (two per option
period within the TRICARE Eurasia-Africa area; two within the TRICARE
Pacific area; two within the TRICARE Latin America/Canada (TLAC)
area; and three additional courses that may occur in any stateside
or overseas location at the direction of the Contracting Officer
(CO)).
6.0 PROVIDER
SERVICES
6.1 The TOP contractor shall ensure that all purchased
care sector network providers and their support staff have sufficient
understanding of the applicable TRICARE program requirements, policies, and
procedures to allow them to carry out the requirements of this contract
in an efficient and effective manner that promotes beneficiary satisfaction.
6.2 The TOP
contractor shall have the responsibility for developing and delivering
TRICARE Program information to purchased care sector providers.
The contractor shall determine the requirements for printed products
and will develop and deliver these products after obtaining approval
from the Government. The information in these products will generally
be determined by the contractor based on their understanding of
the needs of their network providers; however, the Government may
mandate the inclusion of certain topics or information.
6.3 Provider
education materials shall include information regarding claims processing
procedures, claims submission deadlines, and normal claims processing
time lines.
6.4 The Government shall ensure provider satisfaction
with contractor-provided information by conducting random satisfaction
surveys of select network providers.