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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Overseas Program (TOP)
Chapter 24
Section 11
Communications and Customer Service (C&CS)
Revision:  C-83, January 20, 2021
1.0  GENERAL
1.1  All TRICARE requirements regarding C&CS shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (U.S.) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 11 for additional instructions.
1.2  The following paragraphs in Chapter 11, Section 2, do not apply to the TOP contract: paragraphs 1.3.2, 2.1, 2.2, and 3.0.
2.0  TRICARE Service Centers (TSCs) support
2.1  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.
2.1.5  BSR support in the TSC shall meet the standards in Chapter 1, Section 3, as applicable.
2.2  BSR Functions at TSCs
2.2.1  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.
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.
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 24 hours per day, seven days a week, 365 days a year. 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)).
Note:  Only the frequency requirements of Chapter 11, Section 2, paragraph 1.1 are superseded; all other requirements of the referenced paragraph apply to the TOP contractor.
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.
7.0  Grievances And Grievance Processing
The TOP contractor shall process all grievances related to contractor personnel or contractor actions. The contractor shall also process all grievances related to network or non-network purchased care sector providers or institutions.
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