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TRICARE Operations Manual 6010.62-M, April 2021
Administration
Chapter 1
Section 3
TRICARE Processing Standards
Revision:  C-5001, June 23, 2021
1.0  TIMELINESS AND QUALITY STANDARDS OF PERFORMANCE
1.1  The contractor shall provide or arrange for delivery of high-value, quality, timely health care services and timely and accurate processing of claims received into its custody, whether for network or non-network care.
1.2  The contractor shall provide courteous, accurate, and timely responses to inquiries from beneficiaries, providers and Defense Health Agency (DHA).
1.3  The contractor shall provide management reports which identify actual contractor performance in relation to contract standards. Details for reporting are identified in the DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
1.4  DHA has established standards of performance which will be monitored by DHA and other Government agencies to measure contractor performance. Minimum performance standards are listed below.
2.0  ENROLLMENT
2.1  The contractor shall process Primary Care Manager (PCM) change requests received from the Government furnished web-based self-service enrollment system/application within six calendar days of receiving the request.
2.2  The contractor shall modify the effective date to be the date the contractor received the request, or the date requested by the beneficiary up to 90 calendar days in the future.
2.3  The incoming contractor shall submit the transfer of enrollment to Defense Enrollment Eligibility Reporting System (DEERS) using the Government-furnished systems application, within four calendar days of receipt of a beneficiary request. For enrollment transfers rules refer to Chapter 6, Section 1 for effective date rules.
2.4  The contractor shall record enrollments using the Government-furnished web-based enrollment system/application within 10 business days of receipt.
2.5  The contractor shall provide the equipment needed to run the DEERS desktop enrollment application and shall meet technical specifications in the TRICARE Systems Manual (TSM), Chapter 3.
2.6  The contractor shall process all PCM change requests submitted by beneficiaries enrolled to a civilian network PCM via any means other than the Government-furnished web-based self-service enrollment system/application within three business days of receipt, with an effective date no later than the third business day.
2.7  The Markets/Military Medical Treatment Facilities (MTFs) may request PCM reassignment, including panel reassignments using telephone, email or other electronic submissions. The preferred method for panel reassignments is the batch staging application within PCM Panel Reassignment tool (PCMRA). Regardless of the submission method, the Market/MTF will provide sufficient information identifying both the PCMs and beneficiaries involved in a move to allow the contractor to reasonably accomplish the move.
2.8  The contractor shall process each Direct Care (DC) PCM reassignment, both individual and panel reassignment, within three business days of receiving all required information from the Market/MTF.
3.0  CUSTOMER SERVICE - BENEFICIARY AND PROVIDER SERVICES (BPS)
3.1  For all processing standards, the actual date of receipt shall be counted as the first day. The date the reply is mailed shall be counted as the processed to completion date.
3.2  The contractor shall comply with the following standards:
3.2.1  Telephone Inquiries
The following required levels of service shall be available at all times (e.g., daily, weekly, and monthly). Averages are not acceptable.
•  Blockage rates shall not exceed 5%.
•  The average speed of answer shall not exceed 20 seconds.
•  The call abandonment rate shall be less than 5%.
•  Total “on hold” time for 95% of all calls shall not exceed two minutes during the entire telephone call.
•  Eighty-five percent (85%) of all telephone caller inquiries shall achieve resolution in one call. (Includes calls transferred to an individual.)
•  Response accuracy 97% (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).
Note:  Average Speed of Answer (ASA). The average time the agent took to answer beneficiary’s calls. This time includes the time while the agent’s phone rings and the time waiting in queue; however, does not include the time spent navigating the Interactive Voice Response (IVR).
3.2.2  Routine Written Inquiries
3.2.2.1  The contractor shall stamp all routine written inquiries with the actual date of receipt within three business days of receipt in the contractor’s custody.
3.2.2.2  The contractor shall provide final responses to routine written inquiries as follows:
•  Eighty-five percent (85%) within 15 calendar days of receipt;
•  Ninety-seven percent (97%) within 30 calendar days of receipt; and
•  One hundred percent (100%) within 45 calendar days of receipt.
3.2.3  Priority Written Inquiries (Congressional, Assistant Secretary of Defense (Health Affairs) (ASD(HA)), and DHA)
3.2.3.1  All priority written inquiries shall be stamped with the actual date of receipt within one business days of receipt in the contractor’s custody.
3.2.3.2  The contractor shall provide final responses to priority written inquiries as follows:
•  Eighty-five percent (85%) within 10 calendar days of receipt.One hundred percent (100%) within 30 calendar days of receipt.
3.2.4  Grievances
3.2.4.1  The contractor stamp all written grievances with the actual date of receipt within one business day of receipt in the contractor’s custody.
3.2.4.2  The contractor shall provide interim written response by the 30th calendar day after receipt for all grievances not processed to completion by that date. The interim response shall include an explanation for the delay and an estimated date of completion. Ninety-five percent (95%) of all grievances shall be processed to completion within 60 calendar days from the date of receipt.
3.2.5  Walk-In Inquiries (TRICARE Overseas Contract Only)
•  Ninety-five percent (95%) of walk-in inquiries shall be acknowledged and be assisted by a service representative within 15 minutes of entering the reception area.
•  Ninety-nine percent (99%) of walk-in inquiries shall be acknowledged and assisted by a service representative within 20 minutes of entering the reception area
4.0  NETWORK ADEQUACY
4.1  Starting in Option Period 1, the following percent of claims for TRICRE Prime enrollees region-wide in the contractor’s geographic area of responsibility (excluding TRICARE Prime Remote (TPR)/TRICARE Prime Remote for Active Duty Family Members (TPRADFM) enrollees) will be for care rendered by a network provider. This includes all claims for TRICARE Prime enrollees except Emergency Room (ER) claims, urgent care claims, Point-of-Service (POS) claims, or claims with Other Health Insurance (OHI).
•  Ninety percent (90%) Option Period 1.
•  Ninety-one percent (91%) Option Period 2.
•  Ninety-two percent (92%) Option Period 3.
•  Ninety-three percent (93%) Option Period 4.
•  Ninety-four percent (94%) Option Period 5.
•  Ninety-five percent (95%) Option Periods 6 through 8.
4.2  A minimum of 96% of referrals for TRICARE Prime enrollees who reside in TRICARE Prime Service Areas (PSAs) and TRICARE Prime enrollees who reside outside PSAs and have waived the travel-time access standards shall be to the Market/MTF or a civilian network provider. All referrals, except the following, will be included to determine compliance with the standard:
•  Referrals that are unknown to the contractor before the visit (specifically ER visits, retroactively authorized referrals).
•  Self-referrals and referrals of beneficiaries who use OHI as first payor.
•  Market/MTF directed referrals to non-network providers when network providers are available.
•  All other referrals are included without exception.
5.0  PREAUTHORIZATIONS/AUTHORIZATIONS AND REFERRALS
5.1  Preauthorizations/Authorizations
The contractor shall issue determinations on at least:
•  Ninety percent (90%) of all requests for preauthorization/authorization within two business days following receipt of the request and all required information.
•  One hundred percent (100%) of such requests within five business days following receipt of the request and all required information.
•  One hundred percent (100%) of all urgent authorizations, excluding those requiring peer review or factual determination, shall be processed within 24 hours. Exclusions shall be processed within two business days.
5.2  Referral Processing
5.2.1  The contractor shall issue a referral authorization or denial following the date of receipt of a request for a referral, on at least:
•  Ninety percent (90%) of all requests within one business day.
•  One hundred percent (100%) of all requests within two business days.
•  One hundred percent (100%) of all urgent referrals, excluding those requiring peer review or factual determination, shall be processed within one business day. Exclusions shall be processed within two business days.
5.2.2  The contractor shall achieve and continuously maintain a referral and authorization processing accuracy percentage of at least 95% during Option Period 1. Beginning with Option Period 2, this referral and authorization processing accuracy standard shall increase by 1% each Option Period until the standard reaches 99% during Option Period 5 and remain at 99% for the remainder of the contract, in addition to the referral timeliness standards identified in paragraph 5.2.1. The contractor shall complete a 100% audit of MTF Prime referrals and for Network Prime referrals the contractor shall random sample audit a statistically valid sample size at p = 0.5, at a 95% confidence level, with a margin of error of +-1 for each 12-month option period and provide monthly audit reports based on a minimum of 800 referrals per month. For purposes of evaluation, a referral and authorization shall be considered to be processed accurately when all of the following actions are correctly performed and correctly reflected on the referral and authorization.
5.2.2.1  Referrals to a network provider which do not result in an authorization (e.g., a referral which is returned to the Market/MTF for missing information) shall not be considered in calculating referral processing accuracy.
5.2.2.2  The contractor shall provide a monthly report to the Government of the number of returned referrals and a summary of the most common types of information missing. This feedback shall also be provided with the returned referral. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
5.2.2.3  The contractor shall report on 100% of all referrals processed to completion in regards to timeliness standards and accuracy. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
6.0  CLAIMS
6.1  Claims Processing Timeliness
Unless otherwise specified, the standards below apply to all claims.
6.2  Retained Claims
6.2.1  The contractor shall process 98% retained and adjustment claims accurately and to completion within 30 calendar days from the date of receipt.
6.2.2  The contractor shall retain all claims that contain sufficient information to allow processing to completion and all claims for which missing information may be developed from in-house sources, including DEERS and contractor operated or maintained electronic, paper, or film files. A “retained claim” is defined as any claim retained (held in the contractor’s possession) for any reason.
Note:  The above does not prohibit a contractor from retaining a claim for external development.
6.3  Retained and Excluded Claims
The contractor shall process 100% of all claims (both retained and excluded, including adjustments) accurately and to completion within 90 calendar days from the date of receipt.
6.4  Duplicate Claims Resolution
6.4.1  The contractor shall utilize the automated TRICARE Duplicate Claims System (DCS) to resolve DHA identified potential duplicate claims payments.
6.4.2  The contractor shall move Open status potential duplicate claim sets to Pending, Validate, or Closed status on a first-in/first-out basis. To this end, contractor performance will be measured against the percentage of claim sets in Open status at the end of a month with load dates over 30 calendar days old. No more than 10% of the potential duplicate claim sets remaining in Open status at the end of a month shall have load dates over 30 calendar days old. For reporting requirements, see the DD Form 1423, CDRL, located in Section J of the applicable contract.
6.4.3  Contractor compliance with this standard shall be determined from the Performance Standard Report generated by the DCS (see the TSM, Chapter 4, Addendum B, Summary/Management Report entitled “Performance Standard,” for a description and example of the Performance Standard Report). The 10% standard becomes effective on the first calendar day of the seventh month following the start of health care delivery (SHCD). For reporting requirements, see the DD Form 1423, CDRL, located in Section J of the applicable contract.
6.5  Claims Processing Accuracy
6.5.1  Claim Payment Errors
Claim payment errors for the first two option periods, the extrapolated absolute error total shall not exceed 2% of the total paid amount of each universe. In all remaining option periods, the extrapolated absolute error total shall not exceed 1.75% of the total paid amount for each universe.
6.5.2  First Pass Auto-Adjudication
The contractor shall process claims with a first pass auto-adjudication rate of 80% of the total monthly claims volume in Option Period 1 of the contract and increase the percentage by at least 1% in each subsequent option year. Deferred claims include some claims that are excluded from the total monthly claims volumes. Details for reporting are identified in DD Form 1423, CDRL, located in Section J of the applicable contract. Deferred claims excluded from this requirement are defined as:
•  Claims requiring development for possible Third Party Liability (TPL) or OHI;
•  Claims requiring intervention by another TRICARE Prime contractor; and
•  Claims requiring Government intervention (i.e., claims held for pricing updates, claims held pending the issuance of a policy change or as a result of change orders, etc.).
6.5.3  Claims Reprocessing
The contractor shall not exceed 2% reprocessing rate of the total monthly claims volume processed for the first two option periods. In all remaining option periods, the contractor shall not exceed 1.75% reprocessing rate of the total monthly claims volume processed. Deferred claims include some claims that are excluded from the total monthly claims volumes. Details for reporting are identified in DD Form 1423, CDRL, located in Section J of the applicable contract. Deferred claims excluded from this requirement are defined as:
•  Claims requiring development for possible TPL or OHI;
•  Claims requiring intervention by another TRICARE Prime contractor; and
•  Claims requiring Government intervention (i.e., claims held for pricing updates, claims held pending the issuance of a policy change or as a result of change orders, etc.).
7.0  APPEALS
7.1  Expedited Preadmission or Preprocedure Reconsiderations
The contractor shall process to completion 100% of requests for expedited preadmission or preprocedure reconsiderations within three business days of the date of receipt by the contractor of the reconsideration request (unless the reconsideration is rescheduled at the written request of the appealing party). Expedited preadmission or preprocedure requests are those requests filed by the beneficiary within three calendar days after the beneficiary receipt of the initial denial determination.
7.2  Non-Expedited Medical Necessity Reconsiderations
The contractor shall meet the following processing standards for non-expedited medical necessity reconsiderations which begins from the date of receipt by the contractor until processed to completion:
•  Ninety-five percent (95%) within 30 calendar days.
•  One hundred percent (100%) within 60 calendar days
7.3  Non-Expedited Factual Reconsiderations
The contractor shall meet the following standards for non-expedited factual reconsiderations which begins from the date of receipt by the contractor until processed to completion:
•  Ninety-five percent (95%) within 30 calendar days of receipt.
•  One hundred percent (100%) within 60 calendar days from the date of receipt of the reconsideration request. The date of completion is considered to be the date the reconsideration determination is mailed to the appropriate parties.
7.4  Determinations Reversed by DHA Appeals and Hearings Process
The contractor shall process to completion 100% of contractor determinations reversed by the appeals process within 21 calendar days of receipt.
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