Military Health System

1.1  The contractor shall provide an incoming toll-free telephone inquiry system. Multiple telephone numbers may be utilized for telephone inquiries. At least one toll-free line must have the ability to seamlessly transfer calls (e.g., a phone tree or other business process) to any telephone inquiry location maintained by the contractor and its subcontractors.

1.2  The contractor shall staff telephones and respond in a manner that meets performance standards throughout the entire period.

1.3  The contractor shall provide a recorded message indicating normal business hours on the telephone lines after hours.

1.4  The contractor shall handle calls in the order they are received.

1.5  The contractor shall advertise the toll-free service using all available media (e.g., Explanation of Benefits (EOBs), newsletters, telephone directories published by the contractor, military organizations) and other appropriate sources.

1.6  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 area of responsibility, seeking information, assistance, or 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 Active Duty Service Members (ADSMs) beneficiaries traveling outside of their Prime Service Area (PSA).

2.1  The contractor shall answer all telephone inquiries according to the standards in Chapter 1, Section 3.

2.2  The contractor may respond to telephone inquiries by letter if they cannot contact the caller by phone or if a complex explanation is required.

2.3  The contractor staff shall be trained to respond in the most appropriate, accurate manner. Telephone inquiries reporting a potential fraud or abuse situation shall be documented and referred to the contractor’s Program Integrity Unit.

3.1  There should be no differentiation in the service provided whether the call originates locally or through the toll-free lines.

3.2  The contractor shall provide toll-free telephone access to all TRICARE inquiries received from ADSMs, TRICARE beneficiaries, dual eligible beneficiaries, Government Designated Authority (GDA), 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).

3.3  The contractor can refer beneficiaries to the appropriate dental contractor for additional information for general information on eligibility for the TRICARE Dental Plans (Active Duty Dental Program (ADDP) and TRICARE Dental Plan (TDP)) and how to obtain dental plan information from the appropriate dental contractor. Retirees may be referred to the Office of Personnel Management (OPM) for retired dental benefits.

3.4  The contractor shall refer the caller to the DoD MyAccessCenter application help section at https://myaccess.dmdc.osd.mil/ when the inquiry concerns questions about a Department of Defense (DoD) Self-Service Logon (DS Logon). 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/Veterans Health Administration (DVA/VHA) affiliates to access certain web sites using a single username and password.

4.1  The contractor shall report telephone activity via monthly management reports. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

4.2  The contractor may offer an automated telephone critique to 100% of toll-free service line callers who interact with a live customer service representative. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

4.3  The contractor shall collect and report customer service and beneficiary support workload to include categorization of the reason and volume of beneficiary inquiries received by their call center, in accordance with Government-directed data collection requirements contained in the contract and as directed in Chapter 14. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

5.1  The contractor shall provide real-time remote and on-site call monitoring capabilities to DHA Government staff identified by the applicable GDA and designated by the Contracting Officer (CO).

5.2  This requirement for remote call monitoring access does not apply to the TRICARE Overseas Program (TOP) contractor.

6.1  The contractor shall provide the Government access to all information obtained during beneficiary encounters. This includes encounters through mail, emails, walk-ins, and telephone calls. Summaries of each encounter should be made available in the contractor’s on-line system.

6.2  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 Market/Military Medical Treatment Facility (MTF) will be approved by a GDA and for staff at the Market/MTF, access will be approved by the Contract Liaison.

6.3  Quality reviews may be conducted when discrepancies in information provided by contractor staff to beneficiaries have 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.