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.