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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Overseas Program (TOP)
Chapter 24
Section 10
Communications and Customer Service (C&CS)
Revision:  C-20, October 31, 2024
1.0  General
The TOP contractor shall apply all TRICARE requirements regarding C&CS unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (US) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 11 for additional instructions.
2.0  TRICARE SERVICE CENTERS (TSCs) 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, Active Duty Family Members (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) Executive 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.While authorizations are required for Active Duty Service Member (ADSM) private sector care, for administrative reasons, the contractor shall process and pay such claims without an authorization 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 2.4.1 as if there were an authorization on file.
3.0  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:
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, Chief, TOPO, /TAO Executive 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 TOP Prime Remote enrollees to ensure beneficiary access/receipt of urgent or emergent care in the 50 United States US and the District of Columbia. The contractor shall also assist beneficiaries residing or enrolled in the United States US 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 US 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)).
Note:  Only the frequency requirements of Chapter 11, Section 2, paragraph 1.1 are superseded; all other requirements of the referenced paragraph apply to the TOP contractor.
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 timelines.
5.4  The Government will ensure provider satisfaction with contractor-provided information by conducting random satisfaction surveys of select network providers.
6.0  GRIEVANCES AND GRIEVANCE PROCESSING
The TOP contractor shall process all grievances related to contractor personnel or contractor actions. The TOP contractor shall also process all grievances related to network or non-network private sector care providers or institutions.
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