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TRICARE Operations Manual 6010.62-M, April 2021
Communications and Customer Service (C&CS)
Chapter dona11
Section 7
Telephone Inquiries
Revision:  
1.0  TELEPHONE SYSTEM
1.1  The contractor shall provide an incoming toll-free telephone inquiry system. Multiple telephone numbers may be utilized for telephone inquiries. At least one toll-free line must have the ability to seamlessly transfer calls (e.g., a phone tree or other business process) to any telephone inquiry location maintained by the contractor and its subcontractors.
1.2  The contractor shall staff telephones and respond in a manner that meets performance standards throughout the entire period.
1.3  The contractor shall provide a recorded message indicating normal business hours on the telephone lines after hours.
1.4  The contractor shall handle calls in the order they are received.
1.5  The contractor shall advertise the toll-free service using all available media (e.g., Explanation of Benefits (EOBs), newsletters, telephone directories published by the contractor, military organizations) and other appropriate sources.
1.6  The telephone system must include a 24-hour, seven days a week, nationally accessible service, for all Military Health System (MHS) beneficiaries, including beneficiaries traveling in the contractor’s area of responsibility, seeking information, assistance, or in locating a network provider, to include behavioral health providers willing to accept TRICARE. Callers seeking this information must have the ability to speak with live personnel. These personnel shall be able to enter authorizations for urgent care for beneficiaries traveling outside of their Prime Service Area (PSA).
2.0  RESPONSIVENESS
2.1  The contractor shall answer all telephone inquiries according to the standards in Chapter 1, Section 3.
2.2  The contractor may respond to telephone inquiries by letter if they cannot contact the caller by phone or if a complex explanation is required.
2.3  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.
3.0  REQUIREMENTS
3.1  There should be no differentiation in the service provided whether the call originates locally or through the toll-free lines.
3.2  The contractor shall provide toll-free telephone access to all TRICARE inquiries received from Active Duty Service Members (ADSMs), TRICARE beneficiaries, dual eligible beneficiaries, Government Designated Authority (GDA), providers, Assistant Secretary of Defense (Health Affairs) (ASD(HA)), Defense Health Agency (DHA), Beneficiary Counseling and Assistance Coordinators (BCACs), Debt Collection Assistance Officers (DCAOs), and Congressional offices).
3.2.1  The telephone system shall be fully staffed and service shall be continuous during normal business hours which are defined as 8:00 am through 6:00 pm (except weekends and holidays) in all time zones within the geographic area of responsibility.
3.2.1.1  The contractor shall operate its call center on Veteran’s Day to accommodate enrollment inquiries and transactions during TRICARE open enrollment season between November and December each year.
3.2.1.2  The contractor shall operate and staff its call center during normal business hours on Federal holidays that fall during open season (excluding Thanksgiving holiday).
3.2.1.3  The contractor shall provide customer service by telephone without long distance charges to the beneficiary. Telephone service is intended to assist the public in securing answers to various TRICARE questions including, but not limited to:
3.2.1.3.1  General program information.
3.2.1.3.2  Specific information regarding claims in process and claims completed, including explanations of the methods and specific facts employed in making reasonable charge and medical necessity determinations, and information regarding types of medical services submitted.
3.2.1.3.3  Transfer or provide the correct contact information for out-of-jurisdiction calls.
3.2.1.3.4  Answer program information and network provider information calls without regard to jurisdiction.
3.2.1.3.5  When the inquiry concerns questions about Defense Enrollment Eligibility Reporting System (DEERS) or DEERS eligibility, refer the caller to DMDC Beneficiary Telephone Center, 6:00 am to 3:30 pm Pacific Time, toll-free 1-800-538-9552, TTY/TDD 1-866-363-2883.
3.2.1.3.6  The contractor or other service providers shall not use the DMDC Beneficiary Telephone Center toll-free numbers; numbers are only for use by the beneficiaries.
3.2.1.3.7  Information regarding review and appeal rights and the actions required by the beneficiary or provider to use these rights.
3.2.1.3.8  Information regarding and procedures for the TRICARE Program (e.g., enrollment, TRICARE plans available, Point of Service (POS) option, continuity of care, referral management, and provider directories).
3.2.1.3.9  Information regarding benefit authorization requirements and procedures for obtaining authorizations. Provisions must be included to allow the transfer of calls to the authorizing organization (within the contractor’s organization, to include subcontractor) without disconnecting the call.
3.2.2  The contractor shall verify eligibility for care and enrollment status of beneficiaries before making any arrangements for medical services.
3.3  The contractor can refer beneficiaries to the appropriate dental contractor for additional information for general information on eligibility for the TRICARE Dental Plans (Active Duty Dental Program (ADDP) and TRICARE Dental Plan (TDP)) and how to obtain dental plan information from the appropriate dental contractor. Retirees may be referred to the Office of Personnel Management (OPM) for retired dental benefits.
3.4  The contractor shall refer the caller to the DoD MyAccessCenter application help section at https://myaccess.dmdc.osd.mil/ when the inquiry concerns questions about a Department of Defense (DoD) Self-Service Logon (DS Logon). This web site provides information that will help the beneficiary determine the most efficient means for obtaining a DS Logon based on their affiliation and current status. A DS Logon is a secure, self-service logon that allows DoD and Department of Veterans Affairs/Veterans Health Administration (DVA/VHA) affiliates to access certain web sites using a single username and password.
3.5  Telephone Standards
3.6  Toll-Free Telephone Service
The contractor shall advertise the toll-free service using all available media (e.g., the EOB, newsletters, telephone directories published by the contractor, military organizations) and other appropriate sources.
3.7  Telephone Monitoring Equipment
The contractor shall utilize telephone equipment that is programmed to measure and record response times of incoming calls and determine whether DHA telephone standards are met. See Chapter 1, Section 3 for standards.
3.7.1  Measure Busy Signal Level
Busy signal level is defined as the percentage of time a caller receives a busy signal.
3.7.2  Measure Call Volumes And Handling Times
The contractor shall measure the number of calls received each month and the time elapsing between acknowledgments and handling by a telephone representative or Automated Response Unit (ARU).
3.7.3  Measures shall include 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.
4.0  REPORTS
4.1  The contractor shall report telephone activity via monthly management reports. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
4.2  The contractor may offer an automated telephone critique to 100% of toll-free service line callers who interact with a live customer service representative. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3  The contractor shall collect and report customer service and beneficiary support workload to include categorization of the reason and volume of beneficiary inquiries received by their call center, in accordance with Government-directed data collection requirements contained in the contract and as directed in Chapter 14. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
5.0  TELEPHONE APPRAISAL SYSTEM
5.1  The contractor shall provide real-time remote and on-site call monitoring capabilities to DHA Government staff identified by the applicable GDA and designated by the Contracting Officer (CO).
5.2  This requirement for remote call monitoring access does not apply to the TRICARE Overseas Program (TOP) contractor.
6.0  BENEFICIARY ENCOUNTER DOCUMENTATION ACCESS
6.1  The contractor shall provide the Government access to all information obtained during beneficiary encounters. This includes encounters through mail, emails, walk-ins, and telephone calls. Summaries of each encounter should be made available in the contractor’s on-line system.
6.2  The information will be available to select staff within the MHS, primarily those in a customer service capacity such as BCACs and DCAOs. Access to the information for staff outside the Market/Military Medical Treatment Facility (MTF) will be approved by a GDA and for staff at the Market/MTF, access will be approved by the Contract Liaison.
6.3  Quality reviews may be conducted when discrepancies in information provided by contractor staff to beneficiaries have been identified. Access to information will not include sensitive or behavioral health information. Information obtained from incoming correspondence and emails will be available upon request.
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