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.
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).