1.0
Grievance
Processing Jurisdiction
The contractor
with claims processing jurisdiction for the beneficiary’s claim
is responsible for processing grievances filed by or in behalf of
the beneficiary. Should a grievance pertain to an issue that is
the responsibility of another contractor, the responsible contractor
will assist the claims processing contractor in resolving the issue.
2.0 Grievance
System
The contractor
shall develop and implement a grievance system, separate and apart
from the appeal process. The grievance system shall allow full opportunity
for aggrieved parties to seek and obtain an explanation for and/or
correction of any perceived failure of a network provider, contractor,
or subcontractor to furnish the level or quality of care and/or
service to which the beneficiary may believe he/she is entitled.
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. 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 and/or timeliness of the service.
If the written complaint reveals an appealable issue, the correspondence
shall be forwarded to the contractor’s appeals unit for a reconsideration
review.
3.0 Contractor Responsibilities
It is the contractor’s responsibility
to conduct an investigation and, if possible, resolve the aggrieved party’s
problem or concern. In this responsibility, the contractor shall:
3.1 Ensure that information for
filing of grievances is readily available to all Military Health
System (MHS) beneficiaries within the service area.
3.2 Maintain a system of receipt,
identification, and control which will enable accurate and timely handling.
All grievances shall be stamped with the actual date of receipt
within three workdays of receipt by the contractor. The date of
receipt shall be counted as the first day.
3.3 Investigate
the grievance and document the results within 60 calendar days of
receipt of the grievance. The contractor shall notify the Procuring
Contracting Officer (PCO) of all grievances for which reviews were
not completed within 60 days of receipt.
3.4 Provide
interim written responses by the 30th calendar day after receipt
for all grievances not Processed To Completion (PTC) by that date.
3.5 Take positive steps to resolve
any problem identified within 60 days of the problem identification.
If the problem cannot be resolved within that period of time, the
PCO or Contracting Officer’s Representative (COR) shall be informed
of the nature of the problem and the expected date of resolution.
If there is no resolution to the problem, the contractor shall acknowledge
receipt of the grievance and explain to the grievant why the problem
cannot be resolved.
3.6 Written
notification of the results of the review shall be submitted to
the beneficiary within 60 days of receipt. The letter will indicate
who the grievant may contact to obtain more information and provide
an opportunity for the grievant, if not satisfied with the resolution,
to request a second review by a different individual.
3.7 Ensure the involvement in the
grievance review process of appropriate medical personnel, including
personnel responsible for the contractor’s quality assurance program
in any case where the grievance is related to the quality of medical
care or impacts on utilization review activities.
3.8 Maintain records for all grievances,
including copies of the correspondence, the results of the review/investigation
and the action taken to resolve any problems which are identified
through the grievance.