TRICARE Operations Manual 6010.59-M, April 1, 2015
Communications and Customer Service (C&CS)
Chapter 11
Section 6
TelephoneInquiries
Revision:C-86, March 26, 2021
1.0Telephone System
1.1The contractor shall providean incoming toll-free telephone inquiry system. Multiple telephonenumbers may be utilized for telephone inquiries; however, at leastone toll-free line must have the ability to seamlessly transfercalls (via a phone tree or other business process) to any telephoneinquiry location maintained by the contractor and its subcontractors.All telephones must be staffed and able to respond in a manner thatmeets performance standards throughout the entire period. A recordedmessage indicating normal business hours shall be used on the telephonelines after hours. Calls shall be handled in the order they arereceived. The contractor shall advertise the toll-free service usingall available media including the Explanation of Benefits (EOB),newsletters, telephone directories published by the contractor,military organizations, etc. and other appropriate sources.
1.2The telephone system must includea 24-hour, seven days a week, nationally accessible service, forall Military Health System (MHS) beneficiaries, including beneficiariestraveling in the contractor’s region, seeking information and/orassistance in locating a network provider, to include behavioral healthproviders willing to accept TRICARE. Callers seeking this informationmust have the ability to speak with live personnel. These personnelshall be able to enter authorizations for urgent care for beneficiariestraveling outside of their Prime Service Area (PSA).
2.0Responsiveness
Telephone inquiries shall beanswered according to the standards in Chapter 1, Section 3.Contractors may respond to telephone inquiries by letter if theycannot contact the caller by phone or if a complex explanation isrequired. The contractor staff shall be trained to respond in themost appropriate, accurate manner. Telephone inquiries reportinga potential fraud or abuse situation shall be documented and referredto the contractor’s Program Integrity Unit.
3.0Requirements
There should be no differentiationin the service provided whether the call originates locally or through thetoll-free lines. The contractor shall provide toll-free telephoneaccess to all TRICARE inquiries (active duty personnel, TRICAREbeneficiaries, dual-eligible beneficiaries, Director, TRICARE RegionalOffice (TRO), providers, Assistant Secretary of Defense (HealthAffairs) (ASD(HA)), Defense Health Agency (DHA), Beneficiary Counselingand Assistance Coordinators (BCACs), Debt Collection AssistanceOfficers (DCAOs), and Congressional offices). At a minimum, thetelephone system shall be fully staffed and service shall be continuousduring normal business hours which are defined as 8:00 a.m. through6:00 p.m. (except weekends and holidays) in all time zones withinthe region. Additionally, the call center shall bestaffed and operational with normal business hours on Federal Holidaysthat fall during open season (excluding Thanksgiving Holiday). Allcustomer service provided by telephone shall be without long distancecharges to the beneficiary. Telephone service is intended to assistthe public in securing answers to various TRICARE questions including,but not limited to:
3.1Generalprogram information.
3.2Specificinformation regarding claims in process and claims completed, includingexplanations of the methods and specific facts employed in makingreasonable charge and medical necessity determinations, and informationregarding types of medical services submitted (The contractor shall transferout-of-jurisdiction calls requiring the assistance of another contractor.The contractor shall answer program information and network provideravailability/assistance calls without regard to jurisdiction.).
3.3When the inquiry concerns questionsabout Defense Enrollment Eligibility Reporting System (DEERS) orDEERS eligibility, the contractor shall refer the caller to theDefense Manpower Data Center (DMDC) Beneficiary Telephone Center,6:00 a.m. to 3:30 p.m. Pacific Time, toll-free 1-800-538-9552, TTY/TDD1-866-363-2883. These numbers cannot be used by the contractor orother service provider; they are only for the beneficiary’s use.
3.4Additional information neededto have a claim processed.
3.5Informationabout review and appeal rights and the actions required by the beneficiaryor provider to use these rights.
3.6Informationabout and procedures for the TRICARE Program, i.e., enrollment,TRICARE plans available, Point of Service (POS) option, continuityof care, referral management, and provider directories.
3.7Information concerning benefitauthorization requirements and procedures for obtaining authorizations.Provisions must be included to allow the transfer of calls to theauthorizing organization (within the contractor’s organization,to include subcontractor) without disconnecting the call. The contractorshall ensure eligibility for care and enrollment status of beneficiariesbefore making any arrangements for medical services.
3.8General information on eligibilityfor the TRICARE Dental Plans (Active Duty Dental Program (ADDP),TRICARE Dental Plan (TDP), and TRICARE Retired Dental Plan (TRDP))and how to obtain dental plan information from the appropriate dentalcontractor. The beneficiaries shall be referred to the appropriatedental contractor for additional information.
3.9Whenthe inquiry concerns questions about a Department of Defense (DoD)Self-Service Logon (DS Logon), the contractor shall refer the callerto the DoD MyAccessCenter application help section at https://myaccess.dmdc.osd.mil/.This web site provides information that will help the beneficiary determinethe most efficient means for obtaining a DS Logon based on theiraffiliation and current status. A DS Logon is a secure, self-servicelogon that allows DoD and Department of Veterans Affairs (DVA)/VeteransHealth Administration (VHA) affiliates to access certain web sitesusing a single username and password.
3.10Telephone Standards
Refer to Chapter 1, Section 3, paragraph 3.4.
3.11Toll-Free Telephone Service
The contractor shall advertisethe toll-free service using all available media including the EOB, newsletters,telephone directories published by the contractor, military organizations,etc. and other appropriate sources.
3.12Telephone Monitoring Equipment
The contractor shall utilizetelephone equipment that is programmed to measure and record response timesof incoming calls and determine whether DHA standards are met. See Chapter 1, Section 3, paragraph 3.4 for standards.
3.12.1Measure Busy Signal Level
“Busy signal level” is definedas the percentage of time a caller receives a busy signal.
3.12.2Measure Call Volumes And HandlingTimes
Contractorsshall measure the number of calls received each month and the timeelapsing between acknowledgment and handling by a telephone representativeor Automated Response Unit (ARU). Measures shall include all callsthat are directly answered by an individual or ARU (no waiting time).The on-hold time period begins when the telephone call is acknowledgedand does not include the ring time.
4.0Reports
Telephone activity shall bereported via monthly management reports in accordance with contract requirements.
5.0Telephone Appraisal System
The contractor shall providereal-time remote and on-site call monitoring capabilities to DHA Governmentstaff identified by the applicable DHA office (the Director, TROsor other applicable Program Office for which this is a contractualrequirement) and designated by the Contracting Officer (CO). Thisrequirement for remote call monitoring access does not apply tothe TRICARE Overseas Program (TOP) contractor.
6.0BeneficiaryContact Data
The contractorsshall collect and report customer service and beneficiary supportworkload to include categorization of the reason and volume of beneficiaryinquiries received by their call center, in accordance with government-directeddata collection requirements contained in the contract and as directedin Chapter 14.
7.0BeneficiaryEncounter Documentation Access
The contractor shall supplythe government access to all information obtained during beneficiary encounters.This includes encounters through emails, walk-ins, and phone calls.Summaries of each encounter should be made available in the contractor’sonline system. The information will be available to select staffwithin the MHS, primarily those in a customer service capacity suchas BCACs and DCAOs. Access to the information for staff outsidethe Military Treatment Facility (MTF)/Enhanced Multi-Service Market(eMSM) will be approved by a designated TRO representative and forstaff at the MTF/eMSM, access will be approved by the Contract Liaison.Quality reviews may be conducted when discrepancies in informationprovided by contractor staff to beneficiaries has been identified.Access to information will not include sensitive or behavioral healthinformation. Information obtained from incoming correspondence andemails will be available upon request.
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