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TRICARE Operations Manual 6010.62-M, April 2021
Communications and Customer Service (C&CS)
Chapter 11
Section 8
Grievances And Grievance Processing
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.
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.
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