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TRICARE Operations Manual 6010.59-M, April 1, 2015
Communications and Customer Service (C&CS)
Chapter 11
Section 8
Grievances And Grievance Processing
Revision:  C-24, May 18, 2018
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.
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