1.0 General
The contractor shall provide timely,
accurate answers to all TRICARE inquiries. Written inquiries include
inquiries submitted on paper and those submitted electronically.
Written inquiries received shall be sorted and categorized as defined
in
paragraph 3.0.
For standards, refer to
Chapter 1, Section 3. On
all outgoing correspondence from the contractor to the beneficiary,
if the SSN is used it shall be limited to the last four digits.
1.1 Correspondence
Receipt And Control
The contractor shall establish and
maintain an automated control system for routine and priority correspondence,
appeals, and grievances which meets the requirements of
Chapter 1, Section 3;
Chapters 11; and
12. The contractor shall capture and retain
needed data for input to workload and cycle time aging reports.
1.2 Availability
Of information
Information required for appropriate responses
to inquiries, must be retrievable from the contractor’s internal
records as specified in
Chapter 9, Section 1.
2.0 Control
Correspondence shall be controlled
and stamped with the actual date of receipt in the contractor’s
custody. The control system shall be automated unless the contractor
receives approval for another system which will produce comparable
results. When appropriate, the contractor must be able to associate
incoming correspondence with prior inquiries. All correspondence
or other documents received or generated in the services department
shall be filed in accordance with
Chapter 9, Section 1. If
correspondence is answered by telephone, a record of the conversation
shall be filed with the inquiry.
3.0
Categories
Of Correspondence
All incoming correspondence shall
be separated into the following categories for reporting purposes:
• Appeals.
• Grievances.
• Priority correspondence.
• Routine inquiries.
• Allowable charge
complaints.
4.0 Routine Correspondence
4.1 Responses
may be provided by telephone, form letter, preprinted information,
individual letter, or electronic means, as appropriate. A copy of
the response shall be filed with the inquiry. The text of written
responses shall be typed. On form letters or preprinted information,
the address may be neatly handwritten, if the contractor chooses.
In situations of potential fraud or abuse, a referral to the contractor’s
Program Integrity Unit shall be completed and a copy of the referral
filed with the correspondence. For beneficiary and provider services
standards, see
Chapter 1, Section 3.
4.2 The contractor
shall develop inquiries that do not contain enough information to
identify the specific concern, using the quickest and most cost
effective method for acquiring the information. After a reasonable
effort has been made to acquire the missing information, the contractor
shall notify the correspondent that a response is not possible without
the requested information. The contractor may then close the item
for reporting purposes.
4.3 Correspondence status inquiries,
such as “tracer” claims from providers or beneficiaries and provider
and beneficiary letters inquiring about the status of a claim, may
be closed without a written response if the claim was processed
within five calendar days prior to receipt of the inquiry. The day that
the determination was made that the inquiry may be closed without
a written response is the day the inquiry is to be closed for correspondence
cycle time purposes. Otherwise, “tracer” claims, usually submitted
by providers, are to be researched to determine whether the initial
claim was received. If the initial claim was received and processed
to completion, the contractor shall advise the provider of the date
processed and the amount of payment, if any, or reason for denial.
If the initial claim was not received, the contractor shall indicate
this on the claim and submit the claim for normal processing, advising
the provider of this action.
5.0 Priority
Correspondence
5.1 Priority
written correspondence is correspondence received from members of
the U.S. Congress, the Office of the Assistant Secretary of Defense
(Health Affairs) (OASD(HA)); Defense Health Agency (DHA); the Director,
TRICARE Regional Offices (TROs) and such other classes as may be designated
as “priority” by the Contracting Officer (CO). Inquiries from the
Surgeons General, Flag Officers, and state officials such as insurance
commissioners are considered priority correspondence.
5.2 The contractor
shall forward all Congressional inquiries involving Defense Enrollment
Eligibility Reporting System (DEERS) to the DEERS Research and Analysis
Section, Defense Manpower Data Center (DMDC)/DEERS, 400 Gigling
Road, Seaside, California 93955-6771. The contractor shall include
any claim information required for that organization to respond
to the inquiry. A notification shall be sent to the Congressional
office informing it that the letter has been forwarded to the DMDC
Support Office (DSO).
5.3 For priority written inquiry standards,
refer to
Chapter 1, Section 3. The contractor shall
forward copies of all Congressional correspondence to DHA and include
the contractor’s response.
6.0 Correspondence
Completion And Quality Control
6.1 A piece of correspondence shall
be considered answered when the contractor’s response to the individual
or office provides a detailed outline of all actions taken to resolve
the problem(s) and includes, as appropriate:
• An explanation of the requirements leading
to the benefit determination;
• A clear, complete response to all stated
or implied questions;
• When necessary to understanding, copies
of Explanation(s) of Benefits (EOB(s)), claim number(s) of the original
claim(s), and the claim number(s) of adjustment claim(s) including sufficient
details to establish an easily followed audit trail;
• Other documents for full explanation and
clarity;
• Clear explanation
of any additional actions that require an action or reply by the
inquirer before the contractor can take final action on the matter;
and
• A referral
form to the contractor’s Program Integrity Unit if potential fraud
or abuse is identified. A copy of the referral shall be filed with
the correspondence.
6.2 When DHA staff requests the contractor
to provide claims processing information required by DHA to answer
an inquiry, the contractor need not provide detailed explanations
of TRICARE policy, but shall provide a regulatory citation in support
of the benefit determination, the date the claim was first received,
the date the EOB was mailed, and a detailed explanation of any delay.
The response shall be legible and clearly stated. When requested,
the contractor shall furnish DHA with copies of all claims, supporting
documents, previous correspondence relating to the particular case,
a recapitulation, and a narrative description of the claims processing
history for that claim (e.g., date received, date completed, date
paid, etc.). In the case of a TRICARE Prime beneficiary, it may
be necessary to provide information about special coverage, pamphlets,
enrollment information, or copies of all or parts of a health care record.
6.3 The
contractor shall ensure the correspondence it prepares is accurate,
responsive, clear, timely and that its tone conveys concern and
a desire to be of service. To monitor correspondence, contractors shall
establish a quality control procedure to ensure its correspondence
reflects the elements previously listed. The findings of the quality
control review shall be incorporated into training programs to upgrade
the performance of all persons involved in correspondence preparation.
Contractors are free to tailor the program to meet their needs.
Service to the beneficiaries and providers, as reflected in the
quality and timeliness of correspondence, is a key management responsibility.
7.0 Required
Reports
The contractor shall have the capability
to provide data for the following management reports:
7.1 An open
correspondence reporting system which identifies priority correspondence
over 10 calendar days old and routine inquiries over 15 days old
for management follow-up action. This report shall include the sponsor’s
name and SSN, the patient’s name, the name of the correspondent,
the date of the correspondence, the date the correspondence was
received by the contractor, the current status of the correspondence,
the date of the latest interim response, and the anticipated or
final response date. This report is for contractor use only and
the contractor may use any reporting system it chooses, provided
there are adequate controls to meet timeliness standards.
7.2 Correspondence
statistics for prompt and accurate completion of the TRICARE Monthly Workload
and Cycle Time/Aging Reports.