1.0 Telephone
System
1.1 The contractor shall provide an
incoming toll-free telephone inquiry system. Multiple telephone
numbers may be utilized for telephone inquiries; however, at least
one toll-free line must have the ability to seamlessly transfer
calls (via a phone tree or other business process) to any telephone
inquiry location maintained by the contractor and its subcontractors.
All telephones must be staffed and able to respond in a manner that
meets performance standards throughout the entire period. A recorded
message indicating normal business hours shall be used on the telephone
lines after hours. Calls shall be handled in the order they are
received. The contractor shall advertise the toll-free service using
all available media including the Explanation of Benefits (EOB),
newsletters, telephone directories published by the contractor,
military organizations, etc. and other appropriate sources.
1.2 The telephone
system must include a 24-hour, seven days a week, nationally accessible
service, for all Military Health System (MHS) beneficiaries, including
beneficiaries traveling in the contractor’s region, seeking information
and/or assistance in locating a network provider, to include behavioral health
providers willing to accept TRICARE. Callers seeking this information
must have the ability to speak with live personnel. These personnel
shall be able to enter authorizations for urgent care for beneficiaries
traveling outside of their Prime Service Area (PSA).
3.0
Requirements
There should be no differentiation
in the service provided whether the call originates locally or through
the toll-free lines. The contractor shall provide toll-free telephone
access to all TRICARE inquiries (active duty personnel, TRICARE
beneficiaries, dual-eligible beneficiaries, Director, TRICARE Regional
Office (TRO), providers, Assistant Secretary of Defense (Health
Affairs) (ASD(HA)), Defense Health Agency (DHA), Beneficiary Counseling
and Assistance Coordinators (BCACs), Debt Collection Assistance
Officers (DCAOs), and Congressional offices). At a minimum, the
telephone system shall be fully staffed and service shall be continuous
during normal business hours which are defined as 8:00 a.m. through
6:00 p.m. (except weekends and holidays) in all time zones within
the region. Additionally, the call center shall be
staffed and operational with normal business hours on Federal Holidays
that fall during open season (excluding Thanksgiving Holiday). All
customer service provided by telephone shall be without long distance
charges to the beneficiary. Telephone service is intended to assist
the public in securing answers to various TRICARE questions including,
but not limited to:
3.1 General program information.
3.2 Specific
information regarding claims in process and claims completed, including
explanations of the methods and specific facts employed in making
reasonable charge and medical necessity determinations, and information
regarding types of medical services submitted (The contractor shall transfer
out-of-jurisdiction calls requiring the assistance of another contractor.
The contractor shall answer program information and network provider
availability/assistance calls without regard to jurisdiction.).
3.3 When
the inquiry concerns questions about Defense Enrollment Eligibility
Reporting System (DEERS) or DEERS eligibility, the contractor shall
refer the caller to the Defense Manpower Data Center (DMDC) Beneficiary
Telephone Center, 6:00 a.m. to 3:30 p.m. Pacific Time, toll-free
1-800-538-9552, TTY/TDD 1-866-363-2883. These numbers cannot be
used by the contractor or other service provider; they are only
for the beneficiary’s use.
3.4 Additional information needed to have a
claim processed.
3.5 Information about review and appeal rights
and the actions required by the beneficiary or provider to use these
rights.
3.6 Information
about and procedures for the TRICARE Program, i.e., enrollment,
TRICARE plans available, Point of Service (POS) option, continuity
of care, referral management, and provider directories.
3.7 Information
concerning benefit authorization requirements and procedures for
obtaining authorizations. Provisions must be included to allow the
transfer of calls to the authorizing organization (within the contractor’s
organization, to include subcontractor) without disconnecting the
call. The contractor shall ensure eligibility for care and enrollment
status of beneficiaries before making any arrangements for medical
services.
3.8 General information on eligibility
for the TRICARE Dental Plans (Active Duty Dental Program (ADDP),
TRICARE Dental Plan (TDP), and TRICARE Retired Dental Plan (TRDP))
and how to obtain dental plan information from the appropriate dental
contractor. The beneficiaries shall be referred to the appropriate
dental contractor for additional information.
3.9 When
the inquiry concerns questions about a Department of Defense (DoD)
Self-Service Logon (DS Logon), the contractor shall refer the caller
to the DoD MyAccessCenter application help section at
https://myaccess.dmdc.osd.mil/.
This web site provides information that will help the beneficiary determine
the most efficient means for obtaining a DS Logon based on their
affiliation and current status. A DS Logon is a secure, self-service
logon that allows DoD and Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) affiliates to access certain web sites
using a single username and password.
3.11 Toll-Free
Telephone Service
The contractor shall advertise the
toll-free service using all available media including the EOB, newsletters,
telephone directories published by the contractor, military organizations,
etc. and other appropriate sources.
3.12 Telephone Monitoring Equipment
The contractor shall utilize telephone
equipment that is programmed to measure and record response times
of incoming calls and determine whether DHA standards are met. See
Chapter 1, Section 3, paragraph 3.4 for standards.
3.12.1 Measure Busy
Signal Level
“Busy signal level” is defined as the percentage
of time a caller receives a busy signal.
3.12.2 Measure Call
Volumes And Handling Times
Contractors
shall measure the number of calls received each month and the time
elapsing between acknowledgment and handling by a telephone representative
or Automated Response Unit (ARU). Measures shall include all calls
that are directly answered by an individual or ARU (no waiting time).
The on-hold time period begins when the telephone call is acknowledged
and does not include the ring time.
7.0 Beneficiary
Encounter Documentation Access
The contractor
shall supply the government access to all information obtained during beneficiary
encounters. This includes encounters through emails, walk-ins, and
phone calls. Summaries of each encounter should be made available
in the contractor’s online system. The information will be available
to select staff within the MHS, primarily those in a customer service
capacity such as BCACs and DCAOs. Access to the information for
staff outside the Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) will be approved by a designated TRO representative
and for staff at the MTF/eMSM, access will be approved by the Contract
Liaison. Quality reviews may be conducted when discrepancies in
information provided by contractor staff to beneficiaries has been
identified. Access to information will not include sensitive or
behavioral health information. Information obtained from incoming
correspondence and emails will be available upon request.