1.0
Grievance
Processing Jurisdiction
The contractor
with claims processing jurisdiction for the beneficiary’s claim
is responsible for processing grievances filed by or in behalf of
the beneficiary. Should a grievance pertain to an issue that is
the responsibility of another contractor, the responsible contractor
will assist the claims processing contractor in resolving the issue.
2.0 Grievance
System
The contractor shall develop and
implement a grievance system, separate and apart from the appeal
process. The grievance system shall allow full opportunity for aggrieved
parties to seek and obtain an explanation for and/or correction
of any perceived failure of a network provider, contractor, or subcontractor
to furnish the level or quality of care and/or service to which
the beneficiary may believe he/she is entitled. Any TRICARE beneficiary,
sponsor, parent, guardian, or other representative who is aggrieved
by any failure or perceived failure of the contractor, subcontractor
or contracted providers to meet the obligations for timely, quality
care and service may file a grievance. All grievances must be submitted
in writing. The subjects of grievances may be, but are not limited
to, such issues as the refusal of a Primary Care Manager (PCM) to
provide services or to refer a beneficiary to a specialist, the
length of the waiting period to obtain an appointment, undue delays
at an office when an appointment has been made, poor quality of
care, or other factors which reflect upon the quality of the care
provided or the quality and/or timeliness of the service. If the
written complaint reveals an appealable issue, the correspondence
shall be forwarded to the contractor’s appeals unit for a reconsideration
review.
3.0 Contractor
Responsibilities
It is the contractor’s responsibility
to conduct an investigation and, if possible, resolve the aggrieved
party’s problem or concern. In this responsibility, the contractor
shall:
3.1 Ensure
that information for filing of grievances is readily available to
all Military Health System (MHS) beneficiaries within the service
area.
3.2 Maintain a system of receipt, identification,
and control which will enable accurate and timely handling. All
grievances shall be stamped with the actual date of receipt within
three workdays of receipt by the contractor. The date of receipt
shall be counted as the first day.
3.3 Investigate the grievance and document
the results within 60 calendar days of receipt of the grievance.
The contractor shall notify the Procuring Contracting Officer (PCO)
of all grievances for which reviews were not completed within 60
days of receipt.
3.4 Provide interim written responses by the
30th calendar day after receipt for all grievances not Processed
To Completion (PTC) by that date.
3.5 Take positive steps to resolve any
problem identified within 60 days of the problem identification.
If the problem cannot be resolved within that period of time, the
PCO or Contracting Officer’s Representative (COR) shall be informed
of the nature of the problem and the expected date of resolution.
If there is no resolution to the problem, the contractor shall acknowledge
receipt of the grievance and explain to the grievant why the problem
cannot be resolved.
3.6 Written notification of the results
of the review shall be submitted to the beneficiary within 60 days
of receipt. The letter will indicate who the grievant may contact
to obtain more information and provide an opportunity for the grievant,
if not satisfied with the resolution, to request a second review by
a different individual.
3.7 Ensure the involvement in the grievance
review process of appropriate medical personnel, including personnel
responsible for the contractor’s quality assurance program in any
case where the grievance is related to the quality of medical care
or impacts on utilization review activities.
3.8 Maintain records
for all grievances, including copies of the correspondence, the
results of the review/investigation and the action taken to resolve
any problems which are identified through the grievance.