1.1 Assistance To Beneficiaries
The contractor and the TRICARE
Quality Monitoring Contract (TQMC) contractor shall provide beneficiaries,
or other qualified persons requiring assistance (e.g., providers,
representatives), with information needed for proper filing of a
request for formal review or hearing. Such assistance shall include
advising of requirements for timely filing, the amounts in dispute
required for filing the request, the specific matter in dispute,
copies of the written determination notice(s) which is (are) being
appealed, and any additional documents or information which may have
a bearing on the matter in dispute.
1.2 Assistance
To DHA
1.2.1 The contractor and the TQMC
contractor shall provide, upon DHA request, the complete file(s)
covering the claim(s) and reconsideration(s) in dispute when DHA
receives a request for a formal review or hearing (See
Section 3 for requirements).
1.2.2 The contractor
shall have the capability to send and receive secure electronic
files to protect Personally Identifiable Information (PII) and Protected
Health Information (PHI).
1.2.3 The DHA
Office of General Counsel (OGC) will request the entire appeal file
by telephone, secure email, or facsimile.
1.2.4 The contractor
shall also provide copies of nonproprietary information extracted
from its agreements with network providers and non-network institutional
providers involved in the formal review or hearing case if requested
to do so by the DHA OGC.
1.2.5 The contractor shall copy the
entire file (making one-sided copies only) and mail it by overnight
mail to the DHA OGC or on the same day through secure electronic
transmission unless the contractor submits a request for extension
by telephone or email. In no event will the extension exceed five
business days after receipt of the request.
1.2.6 The contractor
shall, upon request, assist DHA in developing additional information
to fully develop facts in the case.
1.2.7 The contractor
and TQMC contractor shall provide and update DHA OGC with the Points
of Contact (POCs) responsible for coordination of appeal functions
to include names, email addresses, and telephone numbers.