2.0 TRICARE SERVICE CENTERS (TSC
s)
SUPPORT
2.1 Location, Operations, And Staffing
2.1.1 TSCs
are jointly staffed by Military Medical Treatment Facility (MTF)
personnel and TOP contractor personnel.The
TOP contractor shall provide staff at TSCs per the requirements
listed below and in the contract. TSCs in the MTFs are
operational Monday through 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.
The
TOP contractor shall ensure BSRs
shall
be are 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, The
TOP contractor shall assign at least one full-time BSR will
be assigned to each location regardless of actual
workload unless the Government has specifically
authorizes 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) (CSRs)
are unavailable due to planned or unplanned absences (e.g., illness, leave,
personal emergencies, etc.) for more than two consecutive business
days. The TOP contractor shall address local
processes for managing short-term CSR absences (up to two consecutive
business days) shall be addressed in the
Statement of Responsibilities (SOR) with the MTF.
2.1.4 The
TOP contractor shall ensure 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 The
TOP contractor shall maintain that interface through
the life of the contract.
2.1.5 The
TOP contractor shall ensure BSR support in the TSC
shall meet
s the
processing standards
in
Chapter 1, Section 3, as applicable.
2.2 BSR Functions At TSCs
2.2.1 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;
• Provider continuity-of-care
services to all MHS beneficiaries including, but not limited to,
active duty personnel, dependents of active duty personnel ADFMs,
retirees and their dependents family
members, 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 (the TOP contractor
shall ensure 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 using Government
messaging systems;
• Assist beneficiaries in navigating
procurement of procuring Durable
Medical Equipment (DME).
Note: The contractor shall confirm beneficiary 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 TPharm), Global MHS Nurse
Advice Line (NAL), TRICARE Medicare Eligible Program
(TMEP), Continued Healthcare Benefit Program (CHCBP), 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. The
TOP contractor shall ensure 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
The TOP contractor
shall ensure 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 Commanders’ Directors’ and
TRICARE Area Office (TAO) Director’s determinations for Primary
Care Manager (PCM) assignment, and following grievance and inquiry
procedures in accordance with this manual.
2.2.5 Claims
The TOP contractor
shall ensure 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 shall 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 ADFMs, retirees
and their dependents family
members, 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 BSR shall refer beneficiaries shall
be referred to the appropriate dental contractor
for additional information.
2.3 Creating And
Updating Department of Defense (DoD) Self-Service Logon (DS Logon)
AccountsDoD
affiliates and Department of Veterans Affairs/Veterans Health Administration
(DVA/VHA) affiliates qualify for a DS Logon account. A DS Logon
is a secure, self-service logon ID that allows DoD/DVA/VHA affiliates
to access certain websites using a single username and password.
DoD/DVA/VHA affiliates are DoD sponsors, spouses (regardless of
age), and dependents (18 and older), and retirees and veterans who
have an active affiliation in the DEERS, which includes Reserve
Component (RC) sponsors (including all subcomponents such as the
Selected Reserve, Retired Reserve, Individual Ready Reserve (IRR),
and Standby Reserve) along with their spouses, and dependents (18
and older). The DoD Self-Service Access Station (DS Access Station)
is an on-line web application developed by the DMDC for the purpose
of creating DS Logon account requests on behalf of DoD/DVA/VHA affiliates.
When a beneficiary inquiry concerns the DS Logon, the contractor
shall refer the caller to the DoD MyAccessCenter application help
section at https://myaccess.dmdc.osd.mil/.
2.3.1 DS Access StationUpon request by
DoD/DVA/VHA affiliates, BSRs located in TSCs shall use the DS Access
Station and perform In-Person Proofing (IPP) to generate requests
for DMDC to create and update DS Logon accounts following instructions
specified in the current version of the DS Logon - Access Station
User Guide. DS Access Station is currently available at https://www.dmdc.osd.mil/appj/dsaccessstation/.
The contractor shall request DS Access Station user authorization
for TSC personnel from DMDC through the contractor’s DEERS site
security manager. A copy of the current DS Logon - Access Station
User Guide will be provided upon request.
2.3.2 DS Logon Account
LevelsTwo
account levels of DS Logon access are available to DoD/DVA/VHA affiliates,
each with progressing security features and each with a different
user-authentication procedure:
2.3.2.1 Basic Account
(Level 1)This
is an entry level user account established online that only provides
limited view access to the user’s personal information that the
user has provided on-line. This level of account is provided to
individuals who have registered online at the eBenefits website
(http://www.ebenefits.va.gov)
without being in-person proofed. Many applications will not allow
access with a Basic (Level 1) Account.
2.3.2.2 Premium Account
(Level 2)This
account is given to a DoD/DVA/VHA affiliate who has self-registered
using their Common Access Card (CAC) or Defense Financing and Accounting
Service (DFAS)/myPay Login ID or who has completed an IPP process
with designated representatives such as TSC personnel. To provide
enhanced security to the user’s personal information, access to
most applications including TRICARE-related applications require
a Premium (Level 2) Account.
2.3.3 Generating DS
Logon Requests2.3.3.1 Before
generating a request for a Premium Account, TSC personnel shall
determine if the requestor has an existing Basic Account. If they
do, TSC personnel shall follow DS Logon user guide instructions
to generate a request to upgrade the Basic Account to a Premium
Account. Upon successful completion of an upgrade, the Premium Account
is immediately available for use.
2.3.3.2 If a Premium
Account is created outright rather than being upgraded from a Basic
Account, the Premium Account will not be effective and available
for use until the requestor receives a letter in postal mail from DMDC
and follows the instructions in the letter before the specified
deadline to activate the Premium Account. If the requestor does
not have an existing Basic Account, TSC personnel shall inform the
requestor of the advantages of establishing a Basic Account and
provide the requestor with the procedures for obtaining a Basic
Account. If the requestor does not wish to create a Basic Account
first, TSC personnel shall proceed with the procedures for a new DS
Logon request.
2.3.4 DS Access Station
Users and Confidentiality2.3.4.1 Only users authorized
by the DMDC may access the DS Access Station and perform IPP. Furthermore, only
authorized DS Access Station users may view any documents presented
for IPP or be informed in any way of information available in the
DS Access Station. Every authorized user must safeguard the confidentiality
of such information at all times to comply with the Privacy Act
of 1974.
2.3.4.2 The
contractor shall return all documents presented for IPP to the requester
and shall not retain any documents. The contractor shall not make
photocopies or any other images of documents presented for IPP.
3.0 HCF SERVICES3.1 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.Note: The contractor shall offer claims
assistance via toll-free lines seven days per week, 365 days per
year, between the hours of 2:00 AM and 7:00 PM Central Standard
Time (CST). These service hours for claims assistance apply even
if claims assistance is provided via the contractor’s call center(s).
3.1.1 HCFs are responsible
for facilitating access to private sector care provider care (including,
but not limited to, primary care, specialty care, mental health
care, ancillary services, Durable Medical Equipment (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 US 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 private sector care
provider to provide the care on a cashless, claimless basis; providing
the beneficiary with a written care authorization and the private
sector care provider’s information; and assisting the beneficiary
with establishing an appointment with the private sector care 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 private sector care 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 private sector care provider to provide the
care on a cashless, claimless basis; providing the beneficiary with
a written care authorization and the private sector care provider’s
information; and assisting the beneficiary with establishing an
appointment with the private sector care 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 US 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.
2.3 The TOP HCF
is
responsible shall perform for
the following functions:
2.3.1 Referral Assistance for TOP
Beneficiaries
The TOP
contractor (working in concert with the MTF Commander 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 shall
also assist non-enrollees in finding network/non-network
private sector care 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 private sector care provider and to obtain authorization
for the care (see Sections 17 and 18 for additional information
on HCF referral assistance).
2.3.2 Referral Assistance for Beneficiaries
Enrolled or Residing in the 50 US 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 US
and the District of Columbia. These referrals will generally be
initiated by the beneficiary, a private sector care 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 US and the District of Columbia (to include emergency medical
evacuation per
Chapter 24, 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.
2.3.3 Authorizations
2.3.3.1 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 US and the
District of Columbia. The contractor shall also ensure that MTF-issued
authorizations are entered into all applicable contractor systems. The
TOP contractor shall ensure non-emergent specialty health
care received from a private sector care provider must
be is authorized if paying benefits are
to be paid as TOP Prime/TPR.
2.3.3.2 Care subject to a PCM referral/authorization
may receive a clinical review and authorization by the HCF or other
designee.
2.3.4 If an ADFM TOP Prime/TOP Prime
Remote enrollee receives care that was not authorized, the TOP contractor
shall cover the care may be covered under
the TOP POS option, with POS deductibles and cost-shares. The
TOP contractor shall apply POS provisions also
apply to TRICARE Prime/TPR enrollees who receive
routine care outside the 50 US and the District of Columbia without
obtaining prior authorization from the TOP contractor. The care
must also be otherwise coverable under TRICARE or the TOP
contractor shall deny the claim shall
be denied.
2.3.5 The TOP contractor
shall deny claims for Service member care that was not
referred and authorized shall be denied unless
it is retroactively authorized by the appropriate Uniformed
Service and Director, DHA. This includes obtaining an
approved waiver for any non-covered service. POS does not apply
to Service members.
3.0 CUSTOMER SERVICE RESPONSIBILITIES
TOP customer support shall
be provided to all Military Health System staff to include, but
not limited to, 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:
3.1 The TOP contractor shall secure
at a minimum one dedicated post office box for the
receipt of per overseas region to receive all
claims and correspondence from foreign locations per overseas region.
3.2 The TOP contractor shall identify
a specific individual and an alternate to assist the Director, TROs,
TOPO/TAO Directors, DHA, BCACs and stateside claims processing contractors
with the resolution of TOP issues. The TOP contractor
shall refer issues which cannot be successfully resolved shall
be referred to the TOP Contracting Officer’s Representative
(COR).
3.3 The TOP contractor shall identify
a specific individual and an alternate to assist DCAOs with the
resolution of resolving TOP
beneficiary debt collection issues.
3.4 The TOP contractor shall
be
responsible for establish
ing and
operating operate 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:
3.4.1 The TOP contractor shall provide
toll-free telephone service for claims assistance to beneficiaries
and providers 24 hours a day, seven days a week, 365 days a year. The
TOP contractor shall ensure these toll-free services shall
be are available from any
stateside or overseas location.
3.4.2 The TOP contractor shall have
the ability to translate claims submitted in a foreign language
and write written in
German, Italian, Japanese, Korean, Tagalog (Filipino), and Spanish,
or shall have the ability to obtain such translation or in writing.
3.4.3 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.
3.4.4 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).
3.4.5 The TOP contractor shall provide,
upon Government request, claims documentation of
claims for auditing purposes.
3.5 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 United States and the District
of Columbia. The contractor shall also assist beneficiaries residing
or enrolled in the United States 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 United States 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.
4.0 BENEFICIARY SERVICES
4.1 The TOP contractor shall achieve
the highest level of beneficiary satisfaction possible in the overseas environment. This
shall be accomplished by developing The
TOP contractor shall develop qualified private sector care
provider networks (complemented by non-network private sector care
providers as necessary), ensuring ensure timely
access to private sector care, providing provide TOP
information/education/training to beneficiaries and private sector
care providers, and processing claims
in a timely, accurate manner.
4.2 In addition to the beneficiary
education requirements outlined in
Chapter 11, Sections 1 and
2,
the TOP contractor shall
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.
4.3 The TOP contractor shall maintain
up-to-date lists of private sector care network providers, and shall make
this information available at all TOP TSCs and via
web-based access. The TOP contractor shall ensure web-based
network provider listings shall include
information regarding authorization requirements that are applicable to
TOP Prime and TOP Prime Remote enrollees.
4.4 The TOP contractor’s
beneficiary education activities and materials shall
include information for TOP Prime and Prime Remote
enrollees regarding care received in
the 50 US and the District of Columbia in its TOP Prime
and TOP Prime Remote beneficiary educational activities and materials. This
process The TOP contractor shall include
information regarding referrals/authorizations while stateside,
TOP POS policy, and the recommended process for accessing care while
stateside. The TOP contractor shall encourage TOP
Prime and TOP Prime Remote enrollees traveling stateside shall
be encouraged to utilize use MTF
care whenever possible. If MTF care is not available, the
TOP contractor shall encourage beneficiaries should
be encouraged to seek care from a network provider
before obtaining care from a non-network provider.
4.5 The
frequency of the requirement
in
Chapter 11, Section 2, paragraph 1.1, is superseded
for the TOP
contract. The TOP contractor
by
a requirement for shall provide 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)).
5.0 PROVIDER SERVICES
5.1 The TOP contractor shall ensure
that all private sector care 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.
5.2 The TOP contractor shall have
the responsibility for developing and
delivering TRICARE Program information
to private sector care providers. The contractor shall determine
the requirements for printed products and will shall 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.
5.3 The TOP contractor
shall ensure its provider education materials shall include
information regarding claims processing procedures, claims submission
deadlines, and normal claims processing time lines.
5.4 The Government shall will ensure
provider satisfaction with contractor-provided information by conducting
random satisfaction surveys of select network providers.