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TRICARE Operations Manual 6010.59-M, April 1, 2015
Communications and Customer Service (C&CS)
Chapter 11
Section 4
Inquiry Services Department - General
Revision:  C-24, May 18, 2018
1.0  Inquiry Service Department Objectives
Contractors shall implement an inquiry processing service which ensures that all inquiries received from TRICARE beneficiaries, providers, and other interested parties are processed in a timely and consistent manner and that information delivered about the TRICARE program is accurate. The services department shall be able to assist in settling TRICARE claims and providing program information whether the inquiry is by telephone, letter, or electronic media. For inquiries regarding active duty claims, contractors shall follow the procedures as outlined in the Chapter 17.
2.0  Written Inquiries
The contractor shall process both routine and priority correspondence in accordance with the standards and requirements set forth in Chapter 1, Section 3. These standards apply to electronic and paper correspondence.
3.0  Telephones
The contractor shall provide trained personnel to answer all TRICARE inquiries in accordance with Chapter 1, Section 3, paragraph 3.4.
4.0  Training Of Service Representatives
All representatives must be knowledgeable with a high level of communication skills. Online access to claims history and all other necessary information shall be provided. Service representatives must be thoroughly trained in the areas outlined in Chapter 1. Special emphasis should be placed on medical terminology, program benefit policies for all TRICARE health plans and how the programs are applied in processing, Privacy Act and Freedom of Information Act (FOIA) requirements, contractor claims processing system capabilities, and training in the identification and reporting of potential fraud and abuse situations. All personnel shall receive communications training including how to listen for content, ensure customer courtesy and effectively manage time.
5.0  Online TRICARE Provider Search Tool
5.1  The contractor shall provide a regional online provider search tool on the contractor’s public web site for use by beneficiaries to search for and display TRICARE network and TRICARE authorized (non-network) providers (Professional, Ancillary, Facility, Allied Health, and Behavioral Health) information. A standard disclaimer shall be posted on the tool and outputs of the tool that non-network providers have accepted TRICARE patients in the past, but may not accept them routinely and to contact the provider to validate whether TRICARE beneficiaries are currently being accepted; if no telephone number is provided, consult their local telephone directory. The overseas contractor is exempt from providing an online directory of non-network providers (see Chapter 5, Section 1, paragraph 2.1.4, for network online directory).
5.2  The TRICARE network search tool shall allow the beneficiary, at a minimum, to search by provider name, provider organization (if applicable), provider type, provider specialty, and distance from their residence. The tool shall display, at a minimum, the provider’s name, provider organization (if applicable), specialty, office location, office phone number (if available), and distance from the beneficiary’s zip code. For network providers, the tool shall indicate whether the provider is accepting new patients.
5.3  For non-network providers, the search tool shall clearly indicate the provider is non-network. Also, for non-network providers, the listing shall be based on claims submissions for a rolling 14 month period not to include the latest two months of claims. The accuracy standard does not apply to the non-network provider search tool; however, the contractor shall ensure that the non-network provider search tool is refreshed no less than monthly. Upon request of the provider or organization, non-network provider information shall be removed within 30 days and not displayed in the future.
5.4  Contractors are responsible to immediately remove provider information if a provider has been excluded, suspended, or terminated from TRICARE (see Chapter 13, Section 5).
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