TRICARE Manuals - Display Chap 11 Sect 5 (Baseline, Dec 5, 2022)

Communications and Customer Service (C&CS)

Chapter 11

Section 5

Correspondence Control, Processing, And Appraisal

Revision:

1.0 GENERAL

1.1 The contractor shall provide timely, accurate answers to all TRICARE inquiries. Written inquiries include inquiries submitted on paper and electronically. The contractor shall follow reporting in accordance with DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

1.2 The contractor shall send beneficiary notifications regarding enrollment, eligibility and other benefit related communications as directed by the Government Designated Authority (GDA). The contractor shall follow reporting in accordance with DD Form 1423, CDRL, located in Section J of the applicable contract. All guidance regarding availability, completion and quality control of correspondence within this section applies to beneficiary notifications.

1.3 The contractor shall use the last four digits of the beneficiaries’ Social Security Number (SSN) on all outgoing correspondence from the contractor to the beneficiary, if the SSN is used.

1.4 Correspondence Receipt And Control

1.4.1 The contractor shall establish and maintain an automated control system for routine and priority correspondence, appeals, and grievances which meets the requirements of Chapter 1, Section 3, Chapters 11, and 12.

1.4.2 The contractor shall capture and retain needed data for input to workload and cycle-time aging reports.

1.5 Availability Of information

The contractor shall provide internal records related to correspondence to the Government within three business days of the initial request, or within 24 hours for an expedited request.

2.0 CONTROL

The contractor shall have an automated system capable of tracking, stamping (actual date of receipt), identifying related correspondence (including telephone inquiries) and sorting correspondence or other documents from priority correspondence in accordance with Chapter 9, Section 1. If correspondence is answered by telephone, a record of the conversation shall be filed with the inquiry.

3.0 ROUTINE CORRESPONDENCE

3.1 The contractor shall provide responses to inquiries in the most appropriate manner which includes telephone, preprinted information, individual letter or electronic means in accordance with Chapter 1, Section 3.

3.1.1 The contractor shall record and file a copy of the response along with the inquiry.

3.1.2 The contractor shall refer any potential fraud or abuse situations to the contractor’s Program Integrity (PI) Unit.

3.2 The contractor shall make every attempt to collect any missing information in responding to an inquiry.

3.2.1 The contractor shall notify the correspondent that a response is not possible without the requested information, after a reasonable effort has been made to acquire the missing information.

3.2.2 The contractor may then close the item for reporting purposes.

4.0 PRIORITY CORRESPONDENCE

4.1 The contractor shall forward all Congressional inquiries involving the Defense Enrollment Eligibility Reporting System (DEERS) and will include any claim information required to respond to the inquiry to the DEERS Research and Analysis Section, DMDC/DEERS, 400 Gigling Road, Seaside, California 93955-6771.

4.2 The contractor shall send a notification to the originating Congressional office in accordance with Chapter 1, Section 3 informing it that the letter has been forwarded to the DMDC Support Office (DSO).

4.3 The contractor shall forward copies of all Congressional correspondence and responses to the appropriate GDA on a monthly basis through a secure Government system.

5.0 CORRESPONDENCE COMPLETION AND QUALITY CONTROL

The contractor shall ensure that each response to every piece of correspondence includes a detailed outline of all actions taken to resolve the problem(s) and includes, as appropriate:

• An explanation of the requirements leading to the benefit determination;

• A clear, complete response to all stated or implied questions;

• When necessary to support the action taken, copies of Explanation(s) of Benefits (EOBs), claim number(s) of the original claim(s), and the claim number(s) of adjustment claim(s) including sufficient details to establish an easily followed audit trail;

• Other documents necessary for full explanation and clarity;

• Clear explanation of any additional actions that require an action or reply by the inquirer before the contractor can take final action on the matter; and

• A referral form to the contractor’s PI Unit if potential fraud or abuse is identified. A copy of the referral shall be filed with the correspondence.

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