1.0 GRIEVANCE PROCESSING JURISDICTION
1.1 The contractor with processing
jurisdiction shall be responsible for processing all grievances
filed by or on behalf of the beneficiary.
1.2 The contractor
shall forward out-of-jurisdiction grievances to the contractor with
grievance processing jurisdiction within three business days of
receipt.
1.3 The contractor will notify
the beneficiary within three business days when a grievance is forwarded.
2.0 CONTRACTOR
RESPONSIBILITIES
The contractor
shall develop and implement a grievance process, separate and apart
from the appeal’s process.
2.1 The contractor’s grievance
process shall be fully operational by the start of health care delivery
(SHCD).
2.1.1 The grievance system shall
allow full opportunity for aggrieved parties to seek and obtain
an explanation or correction of any perceived failure of a network
provider, contractor, or subcontractor to furnish the level or quality
of care or service to which the beneficiary may believe he or she
is entitled.
2.1.2 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.
2.1.3 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 or timeliness of the service.
2.1.4 The contractor
shall forward the correspondence to the contractor’s appeals unit
for a reconsideration review if the written complaint reveals an
appealable issue.
2.2 The contractor
shall involve appropriate medical personnel, to include quality
assurance personnel, in any case where the grievance is related
to the quality of medical care or impacts on utilization review
activities.
2.3 The contractor shall conduct
an investigation and respond to all grievances, regardless if the
issue is a perceived or true contractor failure refer to
Chapter 1, Section 3 for performance standards.
2.4 The contractor
shall offer grievants the opportunity to request a second review
if they are dissatisfied with the initial response, for performance
standards refer to
Chapter 1, Section 3.
2.5 The contractor
shall provide the Government with a statistically valid random sample
of all grievances received along with the responses.
2.6 The contractor
shall provide the random sampling of grievances on a quarterly basis
utilizing the Government designated system. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
2.7 The contractor
shall maintain records for all grievances, including the correspondence,
results, review, investigation and the action(s) taken to resolve
any problems which are identified through the grievance, in accordance
with
Chapter 9.