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TRICARE Operations Manual 6010.59-M, April 1, 2015
Communications and Customer Service (C&CS)
Chapter 11
Section 6
Telephone Inquiries
Revision:  C-86, March 26, 2021
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; however, at least one toll-free line must have the ability to seamlessly transfer calls (via a phone tree or other business process) to any telephone inquiry location maintained by the contractor and its subcontractors. All telephones must be staffed and able to respond in a manner that meets performance standards throughout the entire period. A recorded message indicating normal business hours shall be used on the telephone lines after hours. Calls shall be handled in the order they are received. The contractor shall advertise the toll-free service using all available media including the Explanation of Benefits (EOB), newsletters, telephone directories published by the contractor, military organizations, etc. and other appropriate sources.
1.2  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 region, seeking information and/or assistance 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
Telephone inquiries shall be answered according to the standards in Chapter 1, Section 3. Contractors may respond to telephone inquiries by letter if they cannot contact the caller by phone or if a complex explanation is required. 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
There should be no differentiation in the service provided whether the call originates locally or through the toll-free lines. The contractor shall provide toll-free telephone access to all TRICARE inquiries (active duty personnel, TRICARE beneficiaries, dual-eligible beneficiaries, Director, TRICARE Regional Office (TRO), 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). At a minimum, the telephone system shall be fully staffed and service shall be continuous during normal business hours which are defined as 8:00 a.m. through 6:00 p.m. (except weekends and holidays) in all time zones within the region. Additionally, the call center shall be staffed and operational with normal business hours on Federal Holidays that fall during open season (excluding Thanksgiving Holiday). All customer service provided by telephone shall be 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:
3.1  General program information.
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 (The contractor shall transfer out-of-jurisdiction calls requiring the assistance of another contractor. The contractor shall answer program information and network provider availability/assistance calls without regard to jurisdiction.).
3.3  When the inquiry concerns questions about Defense Enrollment Eligibility Reporting System (DEERS) or DEERS eligibility, the contractor shall refer the caller to the Defense Manpower Data Center (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 cannot be used by the contractor or other service provider; they are only for the beneficiary’s use.
3.4  Additional information needed to have a claim processed.
3.5  Information about review and appeal rights and the actions required by the beneficiary or provider to use these rights.
3.6  Information about and procedures for the TRICARE Program, i.e., enrollment, TRICARE plans available, Point of Service (POS) option, continuity of care, referral management, and provider directories.
3.7  Information concerning 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. The contractor shall ensure eligibility for care and enrollment status of beneficiaries before making any arrangements for medical services.
3.8  General information on eligibility for the TRICARE Dental Plans (Active Duty Dental Program (ADDP), TRICARE Dental Plan (TDP), and TRICARE Retired Dental Plan (TRDP)) and how to obtain dental plan information from the appropriate dental contractor. The beneficiaries shall be referred to the appropriate dental contractor for additional information.
3.9  When the inquiry concerns questions about a Department of Defense (DoD) Self-Service Logon (DS Logon), the contractor shall refer the caller to the DoD MyAccessCenter application help section at https://myaccess.dmdc.osd.mil/. 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 (DVA)/Veterans Health Administration (VHA) affiliates to access certain web sites using a single username and password.
3.10  Telephone Standards
3.11  Toll-Free Telephone Service
The contractor shall advertise the toll-free service using all available media including the EOB, newsletters, telephone directories published by the contractor, military organizations, etc. and other appropriate sources.
3.12  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 standards are met. See Chapter 1, Section 3, paragraph 3.4 for standards.
3.12.1  Measure Busy Signal Level
“Busy signal level” is defined as the percentage of time a caller receives a busy signal.
3.12.2  Measure Call Volumes And Handling Times
Contractors shall measure the number of calls received each month and the time elapsing between acknowledgment and handling by a telephone representative or Automated Response Unit (ARU). 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
Telephone activity shall be reported via monthly management reports in accordance with contract requirements.
5.0  Telephone Appraisal System
The contractor shall provide real-time remote and on-site call monitoring capabilities to DHA Government staff identified by the applicable DHA office (the Director, TROs or other applicable Program Office for which this is a contractual requirement) and designated by the Contracting Officer (CO). This requirement for remote call monitoring access does not apply to the TRICARE Overseas Program (TOP) contractor.
6.0  Beneficiary Contact Data
The contractors 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.
7.0  Beneficiary Encounter Documentation Access
The contractor shall supply the government access to all information obtained during beneficiary encounters. This includes encounters through emails, walk-ins, and phone calls. Summaries of each encounter should be made available in the contractor’s online system. 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 Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) will be approved by a designated TRO representative and for staff at the MTF/eMSM, access will be approved by the Contract Liaison. Quality reviews may be conducted when discrepancies in information provided by contractor staff to beneficiaries has 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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