TRICARE Manuals - Display Chap 2 Sect 5 (Baseline, Dec 5, 2022)

Transitions

Chapter 2

Section 5

Critical Processes (CPs) - Customer Service

Revision:

1.0 TRANSITION-IN GENERAL

The incoming contractor’s TRICARE call center shall be fully operational in accordance with Chapter 11, Section 7 and able to meet the standards in Chapter 1, Section 3 no later than 90 calendar days prior to the start of health care delivery (SHCD).

1.1 The incoming contractor shall include in its Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) the details and schedule of activities to begin customer service functions at the open enrollment period as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

1.2 The incoming contractor shall begin validating call center capabilities no later than 120 calendar days prior to SHCD, and continue to validate call center capabilities until full operating capability is reached in accordance with paragraph 5.1.1.1.

1.3 The incoming contractor shall ensure call center staffing meets the following milestones:

• Fifty percent (50%) onboard and trained at 90 calendar days prior to SHCD;

• Seventy-five percent (75%) onboard and trained at 60 calendar days prior to SHCD; and

• One hundred percent (100%) onboard and trained at 30 calendar days prior to SHCD.

1.4 The incoming contractor shall demonstrate that it has the correct number of call center staff onboard to manage high-call volumes at the SHCD.

1.5 The incoming contractor’s training documents and response scripts shall be available for the Government to review upon request.

1.6 The incoming contractor’s customer service personnel shall attend training on military culture and life prior to SHCD.

1.7 The Government will provide instructions to the incoming contractor on how to obtain military culture, training, and life at the Transition Specification (TRANSPEC) Meeting.

2.0 TRANSITION-OUT GENERAL

2.1 The outgoing contractor shall maintain toll-free lines and web-based customer service capabilities, accessible to the public during the first 180 calendar days of dual operations (dual operations begins when the incoming contractor receives the Enrollment Gold File from DMDC) in order to properly respond to inquiries related to claims processed for services incurred during the period of their respective liability.

2.2 The outgoing contractor shall continue to staff beneficiary inquiry lines as defined in the contract.

2.3 The outgoing contractor shall maintain adequate toll-free line coverage to ensure that the blockage rate does not exceed the blockage rate on the contractor’s most critical private or other government business access line.

3.0 PHASE-IN REQUIREMENTS RELATED TO THE HEALTH CARE FINDER (HCF) FUNCTION (OVERSEAS CONTRACT ONLY)

3.1 The incoming contractor shall complete the hiring and training of call center HCF function staff by prior to the SHCD for TRICARE Prime in each Prime Service Area (PSA).

3.2 The incoming contractor shall outline the duties of the HCF as well as provide the dedicated toll free number to access these services. The provider and/or beneficiary community shall be advised of the procedures for obtaining HCF assistance prior to SHCD.

3.3 The outgoing contractor shall ensure an HCF function continues through the last date of health care delivery under the current contract, unless otherwise negotiated with the incoming contractor during the TRANSPEC Meeting.

3.4 The outgoing contractor shall vacate the TRICARE Service Centers (TSCs) on the 40th calendar day prior to the SHCD and establish a centralized HCF function.

4.0 PUBLIC NOTIFICATION PROGRAM-PROVIDER AND CONGRESSIONAL MAILING

4.1 The incoming contractor shall deliver to the Government a proposed mailer for all non-network TRICARE providers and Congressional offices for its geographic area of responsibility no later than 90 calendar days prior to the SHCD. The mailing shall be in accordance with Chapter 11, Section 3 and discuss any unique processing requirements of the contractor.

4.2 The incoming contract shall send the accepted mailer by the Government to all non-network TRICARE providers and Congressional offices no later than 45 calendar days prior to the SHCD.

5.0 PERFORMANCE READINESS VALIDATION (PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)

During transition, the incoming contractor’s performance readiness status regarding customer service activities will be subject to PRV/PRAV reviews as described below.

5.1 Customer Service PRV

5.1.1 The incoming contractor shall conduct an initial validation of their ability to receive calls, document calls, provide correct answers, have supervisors ready to assist with difficult calls, and perform any handoffs to other contractors. The contractor’s initial validation shall be conducted no later than 120 calendar days prior to SHCD.

5.1.1.1 The incoming contractor shall validate in its initial PRV the ability to meet the following standards. If realistic volume isn’t available to test, the incoming contractor shall provide a detailed plan to meet the standards.

• Blockage rates less than 5%.

• The AVERAGE time elapsed between INITIATED telephone ringing and connection with Automated Response Unit (ARU) shall not exceed 20 seconds.

• On hold times less than two minutes 95% of the time.

• Call resolution in first call 85% of the time.

• Response accuracy 97% (responses provided by call center staff shall be accurate and complete according to the terms of the contract and all applicable TRICARE programs and policies).

• The incoming contractor shall provide a call center quality monitoring report for the PRV call center validation. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

5.1.1.2 The incoming contractor shall provide a risk mitigation plan to address potential system failure and projected call volumes including stress testing efforts. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

5.1.1.3 The incoming contractor shall provide the Government with a comprehensive briefing on their initial PRV processes, test results, and findings within 10 calendar days of PRV completion. This briefing should summarize information that was reported to the Government in its weekly IMP and IMS report. Results shall be briefed as validated performance against desired performance levels and contract standards and/or requirements.

5.1.2 The incoming contractor shall conduct a re-validation of its call center operational capabilities no later than 90 calendar days prior to SHCD. The contractor shall test its ability to receive calls, document calls, provide correct answers, have supervisors ready to assist with difficult calls, and perform any handoffs to other contractor personnel with no problems. The contractor shall test its capability against each of the standards referenced above and provide the results to the Government.

5.1.3 The incoming contractor shall provide the Government transition team with a comprehensive briefing on the processes, test results, and findings of the 90-day re-validation. This briefing shall summarize the information that was reported to the Government in its weekly IMP and IMS report. Results shall be briefed as validated performance against desired performance levels and contract standards and/or requirements.

5.1.4 The incoming contractor shall validate that its customer service staff is fully trained and knowledgeable about TRICARE and is able to accurately respond to telephone inquiries and written correspondence. The contractor shall conduct this validation no later than 90 calendar days prior to SHCD.

5.1.4.1 The incoming contractor shall include in its validation a demonstration that the staff is fully trained.

5.1.4.2 The incoming contractor shall include in its validation a demonstration of a fully functional customer service data exchange and interface with the claims processing system.

5.1.4.3 The validation results shall be briefed to the Government no later than 85 calendar days prior to SHCD.

5.1.5 The incoming contractor shall conduct a re-validation of its call center operational capabilities no later than 60 calendar days prior to SHCD. The contractor shall test its ability to receive calls, document calls, provide correct answers, have supervisors ready to assist with difficult calls, and perform any handoffs to other contractor personnel with no problems. The contractor shall test its capabilities against each of the standards referenced above and demonstrate the results to the Government at an onsite visit no later than 55 calendar days prior to the SHCD.

5.2 Customer Service PRAV

5.2.1 The incoming contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding customer service activities as described above. If, after review, the Government finds the contractor’s performance readiness for customer service to be deficient, the contractor must submit a detailed mitigation plan no later than 10 business days following the Government’s findings.

5.2.2 Specific PRAV activities, assessment techniques, and performance readiness thresholds will be identified by the Government during the TRANSPEC Meeting.

- END -

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.