2.0 TRICARE
SERVICE CENTERS (TSC
s) SUPPORT
2.1 Location, Operations, And Staffing
2.1.1 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 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.
The TOP contractor shall assign at least one full-time BSR to each
location regardless of actual workload unless the Government 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) in the Statement of Responsibilities (SOR)
with the MTF.
2.1.4 The TOP
contractor shall ensure BSRs 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). 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 meets 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;
• Provide continuity-of-care
services to all MHS beneficiaries including, but not limited to,
active duty personnel, ADFMs, retirees and their 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 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 using
Government messaging systems;
• Assist beneficiaries in procuring
Durable Medical Equipment (DME).
Note: The contractor shall confirm
beneficiary eligibility for care and enrollment status 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 Pharmacy ( TPharm), 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 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 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) 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 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 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, ADFMs, retirees and their
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 to the appropriate dental contractor
for additional information.
2.3 The TOP HCF shall perform for
the following functions:
2.3.1 Referral
Assistance for TOP Beneficiaries
The TOP contractor (working
in concert with the MTF Director) shall ensure optimal use of MTFs
and 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 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
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
is authorized if paying benefits 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 under the
TOP POS option, with POS deductibles and cost-shares. The TOP contractor
shall apply POS provisions 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.
2.3.5 The TOP
contractor shall deny claims for Service member care that was not
referred and authorized 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
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 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 resolving
TOP beneficiary debt collection issues.
3.4 The TOP contractor shall establish
and 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 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 written in German, Italian, Japanese, Korean, Tagalog (Filipino),
and Spanish, or shall have the ability to obtain such translation
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
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.
The TOP contractor shall develop qualified private sector care provider
networks (complemented by non-network private sector care providers
as necessary), ensure timely access to private sector care, provide
TOP information/education/training to beneficiaries and private
sector care providers, and process 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 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 via web-based access. The TOP contractor shall ensure
web-based network provider listings include information regarding
authorization requirements that are applicable to TOP Prime and
TOP Prime Remote enrollees.
4.4 The TOP
contractor shall include information regarding care in the 50 US
and the District of Columbia in its TOP Prime and TOP Prime Remote
beneficiary educational activities and materials. 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 to use MTF care
whenever possible. If MTF care is not available, the TOP contractor shall
encourage beneficiaries 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 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 develop
and deliver TRICARE Program information to private sector care providers.
The contractor shall determine the requirements for printed products
and 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 include information regarding claims processing
procedures, claims submission deadlines, and normal claims processing
time lines.
5.4 The Government
will ensure provider satisfaction with contractor-provided information
by conducting random satisfaction surveys of select network providers.