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.