1.0 TELEPHONES
1.1 The contractor
shall adhere to telephone inquiries in accordance with
Chapter 11, Section 7, unless superseded in
this section or the contract.
1.2 The contractor
shall provide an incoming telephone inquiry system and those telephone
inquiries shall be answered according to standards contained in
the contract. The contractor may respond to telephone inquiries by
letter, if a written response provides better service. For example,
it may be difficult to reestablish telephone contact with the calling
party, a written response may provide the caller with needed documentation,
or a situation may call for a complex explanation which is clearer
if written. The contractor staff shall be trained to respond in
the most appropriate, accurate manner. The contractor shall document
and refer telephone inquiries reporting a potential fraud or abuse
situation shall be documented and referred to the contractor’s Program
Integrity Unit as received.
1.3 Telephone
requirements and standards apply to all telephone calls. The contractor
shall make telephone service available for all TRICARE inquiries
(active duty personnel, TRICARE beneficiaries, dual eligible beneficiaries, TRICARE
Health Plan (THP), providers, Defense Health Agency (DHA), Managed
Care Support Program Sections (MCSPS), Beneficiary Counseling and
Assistance Coordinators (BCACs), etc.). The phone number(s) shall
be published on the Explanation of Benefits/Explanation of Payment
(EOB/EOP) and otherwise be publicized. Telephone service is intended
to assist the public in securing answers to various TRICARE questions
including, but not limited to:
1.3.1 General TRICARE Pharmacy (TPharm)
Benefits Program information.
1.3.2 Specific
information regarding claims in process and claims completed, explanations
of the methods and specific facts employed in making medical necessity
determinations, and information regarding types of pharmaceuticals
covered.
1.3.3 Any additional information
to have a claim processed (including documentation that may be required for
completion of a medical necessity review or prior authorization).
1.3.4 Questions
about Defense Enrollment Eligibility Reporting System (DEERS) or
DEERS eligibility that cannot be answered by the contractor, shall
be referred to the DMDC Beneficiary Telephone Center, 6:00 am to
3:30 pm Pacific Time, toll free 1-800-538-9552, TTY/TDD 1-866-363-2883.
(These numbers are only for beneficiary use.)
1.3.5 Transferring
out-of-jurisdiction calls requiring the assistance of another contractor
in accordance with contract requirements.
1.4 The contractor
or telephone company with which the contractor does business shall
have telephone equipment that is programmed to measure and record
response time and ensure standards are always met. At a minimum,
the contractor shall ensure the equipment can:
1.4.1 Measure
Blockage Rate. Blockage rate is defined as the percentage of time
a caller receives a busy signal. The blockage rate shall be expressed
as a percentage, which is to be determined as follows: divide the number
of calls answered by the contractor by the number of calls reaching
and attempting to reach the contractor (shall be machine generated
figures).
1.4.2 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). Includes 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.
1.4.3 Provide
outgoing lines sufficient to allow call-backs. Additionally, the
contractor shall have automatic call distributors, and ARUs with
after-hours message recorders (if needed), an automated, interactive
24 hour call-handling system designed to ensure maximum access to
the toll-free lines. The contractor shall ensure the system provides
automated responses to requests for general pharmacy benefits program
information.
1.5 The contractor shall establish
a monitoring system to ensure quality of performance. This shall
include monitoring calls for accuracy, responsiveness, clarity,
and tone. The contractor shall submit telephone reports in accordance
with contract requirements.
2.0 AUDITS AND INSPECTIONS
2.1 Federal Acquisition Regulation
(FAR) 52.215-2, included in all TRICARE contracts, provides that
DHA, its related audit agencies, and the Comptroller General of
the United States (US) have the right to examine all supporting
documentation to permit evaluation of cost or pricing data submitted
by a contractor. This examination shall verify that cost or pricing
data submitted during negotiations, including changes and the preparation
of any fiscal report of settlement, are accurate, complete, and
current. This right continues for three years after final payment
to the contractor. The contractor’s facilities and applicable records
also shall be subject to inspection and audit by DHA.
2.2 All inspections
will be conducted either at DHA or at the contractor’s facility.
Inspection, acceptance, and receipt of services provided by the
contractor shall be accomplished by the Contracting Officer (CO)
or designee(s). Inspections include, but are not limited to, DHA
payment audits, performance audits, Program Integrity audits coordinated
with DHA, and contractor/DHA quality assurance audits.
2.3 The contractor
is required to provide DHA with free access to all financial records,
cost information, systems documentation, program logic, operating
manuals, procedures, and other information and documentation gathered,
used, and stored as a part of the contractor’s TRICARE operations,
including the performance of its subcontractor(s). Subcontractors
shall provide the same free access to DHA.
2.4 DHA will
not release proprietary information, if so designated in the contract
(including the technical proposal) will not be released by DHA to
unauthorized recipients. However, DHA will not recognize, as proprietary, information
records and files which constitute essential data resources in the
processing of TPharm claims and the generation of TRICARE Encounter
Data (TED) records.
2.5 DHA reserves the right to specify
the format, media, and timing of the delivery to, and access by
DHA, of information and documentation. Access to information and
documentation also includes the right of DHA inspection. This is
to assure that the Government has full and free use of TRICARE data,
as well as supporting information and documentation for program
purposes. DHA will assure that restricted rights are properly maintained.
2.6 Contract
performance evaluations by Government staff, including audit personnel
under contract, will be conducted periodically at the location(s)
of the contractor’s operations and/or subcontractor’s operations.
These reviews will include financial and operational analyses of
all aspects of the contractor’s performance under the terms of the
contract. The contractor shall make available all appropriate personnel,
facilities, and documentation required in the conduct of such reviews
or investigations by DHA or other authorized Government agency.
Upon request of the PCO, the contractor shall provide adequate office
space (at a contractor operated facility determined by the Government)
for any long-term on-site auditors. Evaluations may include desk
audits and surveys of contractor performance. The contractor will
be furnished written findings.
3.0 EOB
3.1 The purpose
of the pharmacy EOB is to provide a consolidated listing of prescriptions
filled for the beneficiary.
3.2 The contractor
shall provide the toll free number to its beneficiary service center
on the EOB for beneficiaries to call for benefit questions or report
any questionable transactions that appear on their EOB.
3.3 The EOB
shall provide space for the Government to include a short informational
statement. A pharmacy EOB shall not be issued to pharmacies or health
care providers.
3.5 The contractor
may use its standard EOB design, but shall ensure that it includes
the following items:
• Name of the Pharmacy where
each prescription was filled.
• Location of Pharmacy (City
and State).
• Drug Name, strength, dosage
form, quantity, and days supply, of each prescription filled.
• Product classification (i.e.,
brand, generic, non-formulary).
• Date prescription dispensed
by pharmacy.
• Billed or Submitted Amount.
• TRICARE Allowed Amount.
• Total Paid by Other Health
Insurance (OHI), as applicable.
• Cost-Share/Copayment.
• TRICARE Amount Paid.
• Amount Applied Towards Catastrophic
Cap.
• Amount Applied Towards Individual
& Family Deductible.
• Potential cost saving opportunities
(e.g., generic vs brand, Mail Order Pharmacy (MOP) vs retail).
4.0 EOP
4.1 The purpose
of the pharmacy EOP is to describe the action taken for each claim
processed to a final determination (paid or denied).
4.2 The contractor
shall only provide EOPs to beneficiaries for Direct Member Reimbursements
(DMRs) only. The contractor shall not provide EOPs to beneficiaries
for retail point of sale claims, mail order claims, or Market/Military
Medical Treatment Facility (MTF) claims.
4.3 The contractor
shall provide EOPs to pharmacies with their scheduled payments for
all claims processed to final determination during the pay cycle.
The contractor shall document any applicable offsets.