2.0 TRICARE Service Centers (TSC
s)
support
2.1 Location, Operations, And Staffing
2.1.1 TSCs are jointly staffed by
Military Treatment Facility (MTF) personnel and TOP contractor personnel.
TSCs in the MTFs are operational, Monday - Friday (except holidays
recognized by the installation) during the administrative hours
of the MTF.
2.1.2 The TOP contractor shall provide
Beneficiary Service Representatives (BSRs) on a full-time basis
at each location as designated in the contract. BSRs shall be qualified
to perform the duties described in
paragraph 2.2.
2.1.3 The TOP contractor shall provide
sufficient BSR staffing to accomplish all work in a timely manner;
however, at least one full-time BSR will be assigned to each location
regardless of actual workload unless the Government has specifically
authorized part-time coverage. The TOP contractor shall advise the
Government of any locations where the workload does not justify
full-time BSR coverage. The TOP contractor shall implement appropriate
business processes to provide full-time TSC coverage if the assigned
Customer Service Representative(s) (CSR(s)) are unavailable due
to planned or unplanned absences (e.g., illness, leave, personal
emergencies, etc.) for more than two consecutive business days.
Local processes for managing short-term CSR absences (up to two
consecutive business days) shall be addressed in the Statement of
Responsibilities (SOR).
2.1.4 BSRs shall
have a fully operational, on-line interface with the automated claims
processing and enrollment systems which support the functions of
the TSC no later than 30 calendar days prior to the start of health
care delivery (SHCD) and shall maintain that interface through the
life of the contract.
2.2 BSR
Functions at TSC
s2.2.1 The contractor
shall provide overseas TSCs with BSR support to provide all Military
Health System (MHS) beneficiaries with the information and services
as specified below.
• Provide TOP Prime, TOP Prime
Remote, and TOP Select enrollment information and perform enrollments/disenrollments
to include assisting MTFs/beneficiaries with transferring enrollment
to another region.
• Perform Health Care Finder
(HCF) functions upon beneficiary/MTF request.
• Provide information on the
Point of Service (POS) option;
• Provide information on claims
(including on-line access to the claims processing system for information
about the status of a claim);
• Provide assistance regarding
claim problems when the TOP contractor is responsible for processing the
claim; and
• Provide continuity-of-care
services to all MHS beneficiaries including, but not limited to,
active duty personnel, dependents of active duty personnel, retirees
and their dependents, survivors, Medicare-eligible beneficiaries
and all other categories of individuals eligible to receive MHS services.
• Perform Primary Care Manager
(PCM) changes and resolve PCM Information Transfer (PIT) discrepancies.
• Perform registrations in the
Composite Health Care System (CHCS) (as required to support TRICARE enrollments)
and update patient information in CHCS and Defense Enrollment Eligibility
Reporting System (DEERS).
• Assist beneficiaries with TRICARE
benefit/coverage or claims questions (BSRs shall have sufficient claims
knowledge to handle routine questions regarding claims and the ability
to access and navigate the claims system).
• Assist beneficiaries with debt
collection issues.
• Provide TRICARE briefings as
requested by the MTF.
• Distribute TRICARE marketing
materials.
• Assist beneficiaries with utilizing
Government messaging systems.
• Assist beneficiaries in navigating
procurement of Durable Medical Equipment (DME).
Note: The contractor shall confirm
eligibility for care and enrollment status of beneficiaries before making
any arrangements for medical services.
2.2.2 TRICARE Program Information
The TOP contractor shall provide
personal assistance to all MHS beneficiaries seeking information about
TRICARE Prime, TRICARE Select, TRICARE For Life (TFL), Civilian
Health and Medical Program of the Department of Veteran Affairs
(CHAMPVA), TRICARE Mail Order Pharmacy (TMOP), Global Nurse Advice
Line (NAL), and the TRICARE dental contracts. The TOP contractor
shall ensure that the TSCs are supplied with educational materials
to include enrollment and claims submission information. Through the
BSRs and call centers, the TOP contractor shall establish mechanisms
to advise beneficiaries of care options, including the POS option,
and services offered.
2.2.3 BSR Interface With MTFs
BSRs shall act as the focal
point for providing information, referral, and assistance to beneficiaries seeking
access to TRICARE services. BSRs shall maintain day-to-day liaison
with MTF staff to promote MTF optimization and ensure effective
performance of the access, referral, information, and continuity of
care functions.
2.2.4 Enrollment
BSRs and contractor call center
staff shall provide personal assistance to eligible beneficiaries,
electing to enroll or disenroll, and permanently assigned active
duty personnel enrolling in TRICARE Prime. The TOP contractor shall
provide assistance to all MHS beneficiaries, including active duty,
Medicare eligibles, and others, in understanding program requirements,
by answering questions, adhering to MTF Directors’ and TRICARE
Area Office (TAO) Executive Directors’ determinations
for PCM assignment, and following grievance and inquiry procedures
in accordance with this manual.
2.2.5 Claims
BSRs in the TSCs shall assist
all TRICARE beneficiaries with all claims issues when the TOP contractor
is responsible for processing the claim. When the TOP contractor
is not responsible for processing the claim, the BSR in the TSC
shall assist the beneficiary in identifying and contacting the organization
that is responsible for processing the claim. The BSR will provide
information (including on-line access to the claims processing system
for information about the status of a claim), assist beneficiaries
with claim problems when the TOP contractor is responsible for processing
the claim and provide continuity-of-care services to all MHS beneficiaries
including, but not limited to, active duty personnel, dependents of
active duty personnel, retirees and their dependents, survivors,
Medicare-eligible beneficiaries and all other categories of individuals
eligible to receive MHS services.
2.2.6 TRICARE Dental Plans
BSRs in the TSCs shall provide
general information on eligibility for the TRICARE Dental Plans.
The beneficiaries shall be referred to the appropriate dental contractor
for additional information.
3.0 HEALTH CARE FINDER (HCF) SERVICES
3.1 TOP HCF functions are performed
by BSRs located in the TSCs or in contractor-operated call center(s).
The TOP contractor shall offer call center operations to support
HCF services via toll-free lines 24 hours per day, seven days per
week, 365 days per year.
3.1.1 HCFs are
responsible for facilitating access to purchased care sector provider
care (including, but not limited to, primary care, specialty care,
mental health care, ancillary services, DME, and pharmacy services),
and for authorizing certain health care services. Additionally,
HCFs shall inform beneficiaries of access mechanisms, referral procedures,
and rules regarding use of network/non-network providers. They shall
also improve patient continuity of care by establishing mechanisms
to facilitate necessary consultations, follow-up appointments and
the sharing of medical records. TOP HCFs will serve all MHS beneficiaries
in the region, regardless of their enrollment status. This includes dual-eligible
beneficiaries and beneficiaries residing or enrolled in the 50 U.S.
and the District of Columbia who may require assistance when accessing
care in an overseas location.
3.1.2 For MTF
enrollees, the specialty care referral process includes a covered
benefit review; entering appropriate authorizations into the contractor’s
system; locating a qualified network or non-network purchased care
sector provider to provide the care on a cashless, claimless basis;
providing the beneficiary with a written care authorization and
the purchased care sector provider’s information; and assisting
the beneficiary with establishing an appointment with the purchased
care sector provider (upon beneficiary request).The contractor shall
also provide information to MTF personnel regarding the status of
specialty care referrals and shall work cooperatively with the MTF
to assist in obtaining consult results from purchased care sector
providers; however, the contractor is not responsible for tracking
receipt of consult results.
3.1.3 For TOP
Prime Remote enrollees, the specialty care referral process includes
a medical necessity review; a covered benefit review; entering appropriate
authorizations into the contractor’s system; locating a qualified
network or non-network purchased care sector provider to provide
the care on a cashless, claimless basis; providing the beneficiary
with a written care authorization and the purchased care sector
provider’s information; and assisting the beneficiary with establishing
an appointment with the purchased care sector provider (upon beneficiary
request). This process is also applicable to Service members who
are on Temporary Additional Duty/Temporary Duty (TAD/TDY), in an
authorized leave status, or deployed/deployed on liberty in a remote
overseas location, and to TRICARE Prime/TRICARE Prime Remote (TPR)
enrollees who require urgent specialty care while traveling outside
the 50 U.S. and the District of Columbia.
Note: This process applies to all
TOP Prime Remote enrollees, regardless of the status/location of the
referring provider or health unit.
3.1.4 Beneficiaries
enrolled to the Uniformed Services Family Health Plan (USFHP) and
the Continued Health Care Benefit Program (CHCBP) must follow the
requirements of those programs when obtaining overseas care.
3.2 The TOP HCF is responsible
for the following functions:
3.2.1 Referral
Assistance for TOP Beneficiaries
The TOP contractor (working in
concert with the MTF
Director) shall
ensure optimal use of MTFs and to foster coordination of all care
delivered in the civilian sector and care referred to and from the
MTF. The TOP HCF is the primary mechanism for achieving these objectives.
The referral services of the TOP HCF are primarily for ensuring
access to care for enrolled beneficiaries, but the TOP HCF is also
available to assist non-enrollees in finding network/non-network
purchased care sector providers. For TOP Prime/TOP Prime Remote
enrollees, the referral is generally initiated by the beneficiary’s
PCM. The PCM or beneficiary contacts the TOP HCF for assistance
in locating an appropriate purchased care sector provider and to
obtain authorization for the care (see
Sections 16 and
17 for additional information on HCF referral
assistance).
3.2.2 Referral
Assistance for Beneficiaries Enrolled or Residing in the 50 U.S.
and the District of Columbia
The TOP contractor shall provide
referral assistance for TRICARE Prime/TPR enrollees who require urgent
or emergent health care while traveling outside the 50 U.S. and
the District of Columbia. These referrals will generally be initiated
by the beneficiary, a purchased care sector provider, or an overseas MTF
provider. Emergency care never requires preauthorization; however,
ADFMs enrolled to TRICARE Prime/TPR may receive routine, urgent
and emergency health care services in locations outside the 50 U.S.
and the District of Columbia (to include emergency medical evacuation
per
Section 7) on a cashless, claimless basis
if the care is coordinated in advance with the TOP contractor. The
TOP contractor shall implement guarantee of payment or other business
processes to ensure that ADFMs enrolled to TRICARE Prime/TPR receive
routine, urgent or emergency medical services on a cashless, claimless
basis upon beneficiary request.
3.2.3 Authorizations
3.2.3.1 The TOP HCF will authorize
care for TPR enrollees; for Service members who are on TAD/TDY,
in an authorized leave status, or deployed, deployed on liberty
in a remote overseas location, and for TRICARE Prime/TPR enrollees
who require urgent or emergent health care while traveling outside the
50 U.S. and the District of Columbia. The contractor shall also
ensure that MTF-issued authorizations are entered into all applicable
contractor systems. Non-emergent specialty health care received
from a purchased care sector provider must be authorized if benefits
are to be paid as TOP Prime/TPR.
3.2.3.2 Care subject to a PCM referral/authorization
may receive a clinical review and authorization by the HCF or other
designee.
3.2.4 If an
ADFM TOP Prime/TOP Prime Remote enrollee receives care that was
not authorized, the care may be covered under the TOP POS option,
with POS deductibles and cost-shares. POS provisions also apply
to TRICARE Prime/TPR enrollees who receive routine care outside
the 50 U.S. and the District of Columbia without obtaining prior
authorization from the TOP contractor. The care must also be otherwise
coverable under TRICARE or the claim shall be denied.
3.2.5 While referrals
are required for ADSM private sector care, for administrative reasons,
the contractor shall process and pay such claims without a referral
for TRICARE covered services. The contractor will also pay for services,
supplies and equipment based on a DHA-approved Supplemental Health
Care Program (SHCP) waiver under Chapter 17, Section 3, paragraph 2.2.4 as
if there were a referral on file. POS does not apply
to Service members.
4.0 Customer Service Responsibilities
TOP customer support shall be
provided to all Military Health System staff to include, but not
limited to, TRICARE Overseas Program Office (TOPO),
TAOs, Beneficiary Counseling and Assistance Coordinators (BCACs)/Debt
Collection Assistance Officers (DCAOs), stateside TROs, stateside
contractors, stateside TRICARE beneficiaries traveling overseas,
and DHA staff. TOP contractor customer support service shall include
the following:
4.1 The TOP contractor shall secure
at a minimum one dedicated post office box for the receipt of all
claims and correspondence from foreign locations per overseas region.
4.2 The TOP contractor shall identify
a specific individual and an alternate to assist the Director, TROs, Chief, TOPO, TAO Executive Directors,
DHA, BCACs and stateside claims processing contractors with the
resolution of TOP issues. Issues which cannot be successfully resolved
shall be referred to the TOP Contracting Officer’s Representative
(COR).
4.3 The TOP contractor shall identify
a specific individual and an alternate to assist DCAOs with the resolution
of TOP beneficiary debt collection issues.
4.4 The TOP
contractor shall be responsible for establishing and operating a
dedicated TRICARE overseas claims/correspondence processing department
with a dedicated staff. This department and staff shall be under
the direction of a supervisor, who shall function as the contractor’s
POC for TRICARE overseas claims and related operational and support
services. The contractor’s department for TRICARE overseas claims
shall include at a minimum the following functions/requirements:
4.4.1 The TOP contractor shall provide
toll-free telephone service for claims assistance to beneficiaries
and providers 24 hours per day, seven days a week, 365 days a year.
Toll-free services shall be available from any stateside or overseas
location.
4.4.2 The TOP contractor shall have
the ability to translate claims submitted in a foreign language
and write in German, Italian, Japanese, Korean, Tagalog (Filipino),
and Spanish, or shall have the ability to obtain such translation
or writing.
4.4.3 The TOP contractor shall provide
on-line read only access to their claims processing system to TOPO,
each TAO, and the DHA technical representative for TOP claims.
4.4.4 The TOP contractor shall provide
a secure, user-friendly Internet portal for receipt of customer
claims status inquiries and access to claims status information
(to include the ability to view and print Explanation of Benefits
(EOBs).
4.4.5 The TOP contractor shall provide,
upon Government request, documentation of claims for auditing purposes.
4.5 The TOP contractor shall assist
traveling TOP Prime and Prime Remote enrollees to ensure beneficiary
access/receipt of urgent or emergent care in the 50 U.S. and the
District of Columbia. The contractor shall also assist beneficiaries
residing or enrolled in the U.S. or the District of Columbia who require
urgent or emergent care while traveling overseas. ADFMs who are
enrolled to TRICARE Prime or TPR may receive emergency medical services
in locations outside the 50 U.S. and the District of Columbia (to
include emergency medical evacuation) on a cashless, claimless basis
if the care is coordinated in advance with the TOP contractor.
5.0 BENEFICIARY SERVICES
5.1 The TOP contractor shall achieve
the highest level of beneficiary satisfaction possible in the overseas
environment. This shall be accomplished by developing qualified
purchased care sector provider networks (complemented by non-network
purchased care sector providers as necessary), ensuring timely access
to purchased care sector care, providing TOP information/education/training
to beneficiaries and purchased care sector providers, and processing
claims in a timely, accurate manner.
5.2 In
addition to the beneficiary education requirements outlined in
Chapter 11, Sections 1 and
2, the
TOP contractor may be required to conduct beneficiary education/enrollment
activities for arriving/deploying units in accordance with the enrollment
protocols established in the SOR between the TOP contractor and
the MTFs.
5.3 The TOP contractor shall maintain
up-to-date lists of purchased care sector network providers, and
shall make this information available at all TOP TSCs and via web-based
access. Web-based network provider listings shall include information
regarding authorization requirements that are applicable to TOP
Prime and Prime Remote enrollees.
5.4 The TOP
contractor’s beneficiary education activities and materials shall
include information for TOP Prime and TOP Prime
Remote enrollees regarding care received in the 50 U.S. and the
District of Columbia. This process shall include information regarding
referrals/authorizations while stateside, TOP POS policy, and the
recommended process for accessing care while stateside. TOP Prime
and TOP Prime Remote enrollees traveling
stateside shall be encouraged to utilize MTF care whenever possible.
If MTF care is not available, beneficiaries should be encouraged
to seek care from a network provider before obtaining care from
a non-network provider.
5.5 The requirement
in
Chapter 11, Section 2, paragraph 1.1, is superseded
for the TOP contractor by a requirement for a total of nine three-day
TRICARE training courses per contract option period (two per option
period within the TRICARE Eurasia-Africa area; two within the TRICARE
Pacific area; two within the TRICARE Latin America/Canada (TLAC)
area; and three additional courses that may occur in any stateside
or overseas location at the direction of the Contracting Officer
(CO)).
6.0 PROVIDER SERVICES
6.1 The TOP contractor shall ensure
that all purchased care sector network providers and their support
staff have sufficient understanding of the applicable TRICARE program
requirements, policies, and procedures to allow them to carry out
the requirements of this contract in an efficient and effective manner
that promotes beneficiary satisfaction.
6.2 The TOP
contractor shall have the responsibility for developing and delivering
TRICARE Program information to purchased care sector providers.
The contractor shall determine the requirements for printed products
and will develop and deliver these products after obtaining approval
from the Government. The information in these products will generally
be determined by the contractor based on their understanding of
the needs of their network providers; however, the Government may
mandate the inclusion of certain topics or information.
6.3 Provider education materials
shall include information regarding claims processing procedures, claims
submission deadlines, and normal claims processing time lines.
6.4 The Government shall ensure
provider satisfaction with contractor-provided information by conducting
random satisfaction surveys of select network providers.