TRICARE Manuals - Display Chap 20 Sect 1 (Change 138, May 21, 2024)

TRICARE Medicare Eligible Program (TMEP)

Chapter 20

Section 1

Administration

Revision: C-108, May 18, 2022

All TRICARE requirements noted in Chapter 1 regarding administration shall apply to TMEP unless specifically changed, waived, or superseded by this section (as indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.

1.0 Organization of the Defense Health Agency (DHA)

Chapter 55, Title 10, of the United States Code (USC), provides that the Secretary of Defense and the Secretary of Health and Human Services (HHS) shall jointly prescribe regulations for the administration of TRICARE. Department of Defense Directive (DoDD) 5136.13 (The DHA Charter) established DHA as an agency under the policy guidance and direction of the Assistant Secretary of Defense (Health Affairs) (ASD(HA)).

2.0 Contract Administration and Instructions

2.1 The TMEP contractor shall comply with the requirements in Chapter 1, Section 2.

2.2 In addition to the requirements in Chapter 1, Section 2, paragraph 2.0, the TMEP contractor shall submit, in accordance with DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract, a quarterly report outlining the modifications and implementation dates.

2.3 The requirements in Chapter 1, Section 2, paragraph 4.0 are superseded by the following: Generally, the Contracting Officer (CO) will provide a 14 calendar day notice for all meetings hosted by DHA. The contractor shall provide up to four contractor representatives at up to four meetings at the direction of the CO per contract year.

3.0 TRICARE Processing Standards

3.1 The TMEP contractor shall comply with requirements in Chapter 1, Section 3, except for Chapter 1, Section 3, paragraphs 1.2 through 1.2.5, 1.3, 3.3, 3.4, and 4.1.

3.2 In addition to the requirements in Chapter 1, Section 3, paragraph 1.1, the TMEP contractor shall track and report preauthorizations for Skilled Nursing Facilities (SNF) separate from other preauthorizations noted in Chapter 7, Section 2 and TPM, Chapter 1, Section 7.1. The timeliness standards apply to the total volume of preauthorizations. See CDRL M010.

3.3 Telephone inquiry requirements:

The TMEP contractor shall meet service levels described below at all times daily, weekly, monthly, etc. The Government will not accept averages.

• Blockage rates shall not exceed 5%;

• 95% of all calls received shall be answered within two rings by the Interactive Voice Response (IVR);

• 90% of all calls shall not exceed 60 seconds of time in queue (waiting for an agent or the next IVR queue);

• 95% of all calls answered by an agent shall not exceed a 30 second “hold-time” during the call;

• 85% of all calls answered by an agent shall achieve resolution in one call;

• 100% of all calls answered by an agent not fully and completely resolved on the initial call shall be fully and completely resolved within 10 business days.

4.0 Management

4.1 The TMEP contractor shall comply with requirements in Chapter 1, Section 4, except for Chapter 1, Section 4, paragraph 2.3.

4.2 The reference to Cycle/Time/Aging Report in Chapter 1, Section 4, paragraphs 3.1 and 3.2 refer to the Management report in TMEP.

5.0 Compliance with Federal Statutes

The TMEP contractor shall comply with the requirements in Chapter 1, Section 5.

6.0 Legal Matters

The TMEP contractor shall comply with the requirements in Chapter 1, Section 6.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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