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TRICARE Operations Manual 6010.62-M, April 2021
Communications and Customer Service (C&CS)
Chapter 11
Section 7
TelephoneInquiries
Revision:
1.0TELEPHONE SYSTEM
1.1The contractor shall providean incoming toll-free telephone inquiry system. Multiple telephonenumbers may be utilized for telephone inquiries. At least one toll-freeline must have the ability to seamlessly transfer calls (e.g., aphone tree or other business process) to any telephone inquiry locationmaintained by the contractor and its subcontractors.
1.2The contractor shall stafftelephones and respond in a manner that meets performance standards throughoutthe entire period.
1.3The contractor shall providea recorded message indicating normal business hours on the telephone linesafter hours.
1.4The contractor shall handlecalls in the order they are received.
1.5The contractor shall advertisethe toll-free service using all available media (e.g., Explanationof Benefits (EOBs), newsletters, telephone directories publishedby the contractor, military organizations) and other appropriatesources.
1.6The 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 area of responsibility, seeking information,assistance, or in locating a network provider, to include behavioralhealth providers willing to accept TRICARE. Callers seeking thisinformation must have the ability to speak with live personnel.These personnel shall be able to enter authorizations for urgentcare for Active Duty Service Members (ADSMs) beneficiaries travelingoutside of their Prime Service Area (PSA).
2.0RESPONSIVENESS
2.1The contractor shall answerall telephone inquiries according to the standards in Chapter 1, Section 3.
2.2The contractor may respondto telephone inquiries by letter if they cannot contact the callerby phone or if a complex explanation is required.
2.3The contractorstaff shall be trained to respond in the most appropriate, accuratemanner. Telephone inquiries reporting a potential fraud or abusesituation shall be documented and referred to the contractor’s ProgramIntegrity Unit.
3.0REQUIREMENTS
3.1Thereshould be no differentiation in the service provided whether thecall originates locally or through the toll-free lines.
3.2The contractorshall provide toll-free telephone access to all TRICARE inquiriesreceived from ADSMs, TRICARE beneficiaries, dual eligible beneficiaries,Government Designated Authority (GDA), providers, Assistant Secretaryof Defense (Health Affairs) (ASD(HA)), Defense Health Agency (DHA),Beneficiary Counseling and Assistance Coordinators (BCACs), DebtCollection Assistance Officers (DCAOs), and Congressional offices).
3.2.1The telephonesystem shall be fully staffed and service shall be continuous duringnormal business hours which are defined as 8:00 am through 6:00pm (except weekends and holidays) in all time zones within the geographicarea of responsibility.
3.2.1.1The contractor shall operateits call center on Veteran’s Day to accommodate enrollment inquiries andtransactions during TRICARE open enrollment season between Novemberand December each year.
3.2.1.2The contractor shall operateand staff its call center during normal business hours on Federalholidays that fall during open season (excluding Thanksgiving holiday).
3.2.1.3The contractor shall providecustomer service by telephone without long distance charges to the beneficiary.Telephone service is intended to assist the public in securing answersto various TRICARE questions including, but not limited to:
3.2.1.3.1General program information.
3.2.1.3.2Specific information regardingclaims in process and claims completed, including explanations of themethods and specific facts employed in making reasonable chargeand medical necessity determinations, and information regardingtypes of medical services submitted.
3.2.1.3.3Transfer or provide the correctcontact information for out-of-jurisdiction calls.
3.2.1.3.4Answer program informationand network provider information calls without regard to jurisdiction.
3.2.1.3.5When the inquiry concerns questionsabout Defense Enrollment Eligibility Reporting System (DEERS) orDEERS eligibility, refer the caller to DMDC Beneficiary TelephoneCenter, 6:00 am to 3:30 pm Pacific Time, toll-free 1-800-538-9552,TTY/TDD 1-866-363-2883.
3.2.1.3.6The contractor or other serviceproviders shall not use the DMDC Beneficiary Telephone Center toll-freenumbers; numbers are only for use by the beneficiaries.
3.2.1.3.7Information regarding reviewand appeal rights and the actions required by the beneficiary or providerto use these rights.
3.2.1.3.8Information regarding and proceduresfor the TRICARE Program (e.g., enrollment, TRICARE plans available,Point of Service (POS) option, continuity of care, referral management,and provider directories).
3.2.1.3.9Information regarding 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.
3.2.2The contractorshall verify eligibility for care and enrollment status of beneficiariesbefore making any arrangements for medical services.
3.3The contractorcan refer beneficiaries to the appropriate dental contractor foradditional information for general information on eligibility forthe TRICARE Dental Plans (Active Duty Dental Program (ADDP) andTRICARE Dental Plan (TDP)) and how to obtain dental plan informationfrom the appropriate dental contractor. Retirees may be referredto the Office of Personnel Management (OPM) for retired dental benefits.
3.4The contractorshall refer the caller to the DoD MyAccessCenter application helpsection at https://myaccess.dmdc.osd.mil/ whenthe inquiry concerns questions about a Department of Defense (DoD)Self-Service Logon (DS Logon). This web site provides informationthat will help the beneficiary determine the most efficient meansfor obtaining a DS Logon based on their affiliation and currentstatus. A DS Logon is a secure, self-service logon that allows DoDand Department of Veterans Affairs/Veterans Health Administration(DVA/VHA) affiliates to access certain web sites using a singleusername and password.
3.5Telephone Standards
Refer to Chapter 1, Section 3.
3.6Toll-FreeTelephone Service
The contractorshall advertise the toll-free service using all available media(e.g., the EOB, newsletters, telephone directories published bythe contractor, military organizations) and other appropriate sources.
3.7TelephoneMonitoring Equipment
The contractorshall utilize telephone equipment that is programmed to measureand record response times of incoming calls and determine whetherDHA telephone standards are met. See Chapter 1, Section 3 forstandards.
3.7.1Measure Busy Signal Level
Busy signal level is definedas the percentage of time a caller receives a busy signal.
3.7.2MeasureCall Volumes And Handling Times
The contractor shall measurethe number of calls received each month and the time elapsing between acknowledgmentsand handling by a telephone representative or Automated ResponseUnit (ARU).
3.7.3Measures shall include allcalls that are directly answered by an individual or ARU (no waitingtime). The on-hold time period begins when the telephone call isacknowledged and does not include the ring time.
4.0REPORTS
4.1The contractorshall report telephone activity via monthly management reports.For reporting requirements, see DD Form 1423, Contract Data RequirementsList (CDRL), located in Section J of the applicable contract.
4.2The contractormay offer an automated telephone critique to 100% of toll-free serviceline callers who interact with a live customer service representative.For reporting requirements, see DD Form 1423, CDRL, located in SectionJ of the applicable contract.
4.3The contractorshall 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. For reportingrequirements, see DD Form 1423, CDRL, located in Section J of theapplicable contract.
5.0TELEPHONEAPPRAISAL SYSTEM
5.1The contractor shall providereal-time remote and on-site call monitoring capabilities to DHA Governmentstaff identified by the applicable GDA and designated by the ContractingOfficer (CO).
5.2This requirement for remotecall monitoring access does not apply to the TRICARE Overseas Program (TOP)contractor.
6.0BENEFICIARY ENCOUNTER DOCUMENTATIONACCESS
6.1The contractor shall providethe Government access to all information obtained during beneficiary encounters.This includes encounters through mail, emails, walk-ins, and telephonecalls. Summaries of each encounter should be made available in thecontractor’s on-line system.
6.2The informationwill be available to select staff within the MHS, primarily thosein a customer service capacity such as BCACs and DCAOs. Access tothe information for staff outside the Market/Military Medical TreatmentFacility (MTF) will be approved by a GDA and for staff at the Market/MTF,access will be approved by the Contract Liaison.
6.3Qualityreviews may be conducted when discrepancies in information providedby contractor staff to beneficiaries have been identified. Accessto information will not include sensitive or behavioral health information.Information obtained from incoming correspondence and emails willbe available upon request.
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