J-3a Program Ops v2.docx

Attachment J-3a Program Operations

1.0 ELIGIBILITY.

1.1. Eligibility Determinations. The Uniformed Services are responsible for reporting an Active Duty Service Member’s (ADSM’s) eligibility status in the Defense Enrollment Eligibility Reporting System (DEERS). The contractor shall interface directly with DEERS through the Government provided on-line software to determine eligibility (see Section C.5.4 and the TRICARE Systems Manual (TSM) Chapter 3, Defense Enrollment Eligibility Reporting System). DEERS shall be the primary source for determining eligibility. The contractor shall contact the Dental Service Point of Contacts (DSPOCs), the applicable local Dental Treatment Facility (DTF), or use military orders to verify eligibility for those individuals who are indicated on DEERS as not eligible (e.g., not on active duty but who may have a Line of Duty determination entitling the member to dental care) (see Section J, Attachment J-10, Uniformed Services DTFs / Defense Medical Information System Identification [DMIS-ID] Continental United States [CONUS]/Outside Continental United States [OCONUS]). The categories for eligibility are as follows:

1.1.1. Active Duty Service Members. All ADSMs on continuous active duty orders for more than 30 days are eligible to receive dental coverage, subject to the requirements and limitations provided in the Active Duty Dental Program (ADDP). ADSMs with a duty location and residence greater than 50 miles from a CONUS DTF and/or enrolled in TRICARE Prime Remote (TPR) are automatically eligible for remote ADSM benefits (see paragraph 2.0 Remote ADSM Enrollment and Section J, Attachment J-5a, Instructions for Remote ADSM’s Dental Care). ADSMs that are stationed OCONUS must be enrolled in TRICARE Prime Remote in order to be eligible for remote ADSM benefits. ADSMs stationed OCONUS who are not enrolled in TPR, must contact the DHA Dental Program Section to receive remote ADSM dental benefits.

1.1.2. National Guard/Reserve Members. National Guard/Reserve members that serve on continuous active duty for more than 30 days are considered ADSMs. National Guard members are TRICARE eligible if on federally funded orders for more than 30 days. In addition, National Guard members moved directly from federal orders to state orders are eligible for TRICARE when performing State disaster response duty as if on active duty orders for more than 30 days [see TRICARE Policy Manual (TPM) Chapter 10, Section 10.1, TRICARE Coverage for Certain Members of the National Guard (NG)]. If the National Guard member is on state orders for other than State disaster response duty, they are not eligible for TRICARE under ADDP, but may enroll in the TRICARE Dental Program (TDP).

1.1.3. Transitional Assistance Medical Program (TAMP). Reserve component members discharged after more than 30 days on active duty in support of a contingency operation or a preplanned mission using TAMP are eligible and will be considered remote ADSMs. This care will run concurrently with the member’s TAMP coverage (see TPM Chapter 10, Section 5.1, Transitional Assistance Management Program).

1.1.4. Early Activation Members. Reserve Component (RC) members who are issued delayed-effective-date active duty orders for more than 30 days in support of a contingency operation or a preplanned mission, are eligible for ADDP as defined in TPM Chapter 10, Section 9.1, Early Eligibility Benefits for the Reserve Components (RCs) (see Section J, Attachment J-4, Procedures for Remote ADSM Categories ).

1.1.5. Line of Duty (LOD). LOD is for RC members who incur or aggravate an injury, illness or disease while serving on active duty for 30 days or less as defined in DoD Instruction 1241.2, Reserve Component Incapacitation System Management (see Section J, Attachment J-4, Procedures for Remote ADSM Categories).

1.1.6. Foreign Forces Members (FFMs). FFMs on temporary or permanent assignment in the CONUS geographic regions may be eligible to participate in ADDP pursuant to an approved agreement (e.g., reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), Partnership for Peace (PFP) SOFA) (see Section J, Attachment J-4, Procedures for Remote ADSM Categories).

1.1.7. Wounded Warrior. ADSMs that are being treated inpatient at a Veterans Affairs (VA) Hospital or ADSMs who are identified as a Wounded Warrior and are receiving inpatient/outpatient care at a VA Hospital are eligible for ADDP (see Section J, Attachment J-4, Procedures for Remote ADSM Categories).

2.0. REMOTE ADSM ENROLLMENT.

2.1. The contractor shall record all remote ADSMs’ enrollments, re-enrollments, disenrollments, and correct enrollment discrepancies on DEERS, as specified in the TSM, Chapter 3, Defense Enrollment Eligibility Reporting System. DEERS is the primary source for verifying eligibility and enrollment for a remote ADSM. The contractor shall interface directly with DEERS through the Government provided on-line software (see Section C.5.4). The contractor shall perform all enrollments/disenrollments using this web based system. Enrollment/disenrollment information input by the contractor will be applied to the DEERS database. DEERS will transmit enrollment transactions to the contractor who shall apply the enrollment DEERS information to the contractor’s system. Sensitive enrollment/eligibility information that is subject to the Privacy Act shall be maintained in the contractor’s owned and operated IT system during the period of contract performance.

2.2.. The contractor shall verify eligibility for the following types of remote ADSM dental coverage:

· ADSMs enrolled in TRICARE Prime Remote (TPR) (CONUS/OCONUS)

· ADSMs not eligible for TPR who live and work more than 50 miles from a DTF (CONUS)

· Early Eligibility members

· Reserve component members under TAMP

· LOD members

· Foreign Forces members stationed CONUS

· Wounded Warriors (Includes members in Warrior Transition Units (WTU) and those in Community Based Health Care Organizations (CBHCO))

· Automatic enrollment for NOAA ADSMs

· ADSMs stationed overseas requesting care while temporarily in the United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, or the Northern Mariana Islands

· Other ADSMs as dictated by the Government

2.2.1. Enrollment for Remote ADSMs Enrolled in TPR. Eligibility to enroll in medical TPR requires that the ADSM’s permanent duty location and residence be more than 50 miles from a CONUS Military Treatment Facility (MTF) or designated clinic, or assigned to a remote OCONUS location. DEERS will systematically enroll, disenroll, and maintain enrollments for ADSMs enrolled in TPR coverage plan based on the ADSM’s medical TPR enrollment.

2.2.2. Enrollment for ADSMs Not Eligible for TPR. An ADSM whose permanent duty location and/or residence is less than 50 miles from a MTF or designated clinic is not eligible to enroll in TPR. If the ADSM’s permanent duty location and residence is within 50 miles of an MTF but more than 50 miles from a DTF, he or she will not be automatically enrolled as a remote ADSM, but the contractor shall, upon request, manually enroll the member as a remote ADSM. This applies to both CONUS and OCONUS.

2.2.3. OCONUS ADSMs. OCONUS ADSMs that are not coded remote in DEERS are eligible for enrollment as a remote ADSM if the ADSM is requesting to receive dental care in the United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, or the Northern Mariana Islands. The contractor shall enroll the ADSM as a remote member in DEERS by entering the remote ADSM Health Care Delivery Program (HCDP) Plan Coverage Code. The ADSM will be eligible for benefits as a remote ADSM (see Section J, Attachments J-4, Procedures for Remote ADSM Categories and J-5a Instructions for Remote ADSM’s Dental Care). Any dental care will be reimbursed as CONUS.

2.2.3.1. OCONUS ADSMs that are coded as remote in DEERS are eligible to receive care in CONUS, either from a DTF or as a remote member. The ADSM will be eligible for benefits as a remote ADSM (see Section J, Attachments J-4, Procedures for Remote ADSM Categories and J-5a, Instructions for Remote ADSM’s Dental Care). Any dental care will be reimbursed as CONUS.

2.2.4. Automatic Enrollment as a Remote ADSM. All National Oceanic and Atmospheric Administration (NOAA) ADSMs will be eligible for remote ADSM enrollment. DEERS will systematically enroll, disenroll, and maintain enrollments as remote ADSMS for NOAA ADSMs.

2.2.5. Enrollment for Other Remote ADSMs. The contractor shall enroll, disenroll and maintain enrollments for ADSMs that the DHA Dental Program Section authorizes to be enrolled as remote ADSMs.

2.3. DEERS Remote Updates. The ADDP Contracting Officer’s Representative (COR) is responsible for notifying DEERS of any remote area updates.

2.4. Remote ADSM Coverage Cards. Defense Manpower Data Center (DMDC) prints and mails the remote ADSM coverage cards directly to the enrollee at the residential mailing address specified on the enrollment application after the receipt of the enrollment record. DMDC also provides written notification for new enrollments, plan type changes, disenrollments, and the replacement of the remote ADSM coverage card.

3.0. DENTAL BENEFIT. The contractor shall provide the dental care benefit as stated in Section J, Attachment J-2, Benefits, Exclusions and Limitations, and Section C.4.1.1. The Government will reimburse the contractor only for covered dental benefits, non-covered dental benefits specifically authorized by the DSPOCs, care referred by a DTF, and those dental benefits that require and have received preauthorization. This benefit does not have any premiums. OCONUS DTF-referred care is not authorized under this contract, with the exception of dental care in Bahrain and Souda Bay which shall be authorized by the OCONUS DSPOC (see Section J, Attachment J-3b, Program Operations for OCONUS).

4.0. REFERRALS AND AUTHORIZATIONS. The contractor shall establish a compliant mechanism by which referrals and authorizations will be electronically transmitted and tracked in accordance with Section J, Attachment J-3c, Program Operations for Data Systems.

4.1. Authorization is not required for emergency dental care (see Section J, Attachments J-2, Benefits, Exclusions and Limitations; J-4, Procedures for Remote ADSM Categories; and J-5a, Instructions for Remote ADSM’s Dental Care).

4.1.1. All authorizations are valid for 12 months from the authorization date. The contractor shall deny claims for care received more than 12 months after the authorization date. If an appeal of the denial is submitted the contractor shall follow the appeals process detailed in paragraph 13.0, Appeals and Grievances.

4.2. CONUS DTF Referral and Authorizations. When ADSMs are assigned to units with DTF availability, the DTF is responsible for referring the ADSM to an available network provider and authorizing the care. The DTF shall contact the contractor when the ADSM cannot be referred to a network provider. The contractor shall assist the DTF in locating a network provider or a non-network provider. If a network provider is not available, then the contractor shall authorize use of a non-network provider in accordance with paragraph 8.0, Non-Network Providers. Each referral will include a request for treatment narrative summary. The contractor shall reimburse dental care as specified on the DTF referral/authorization unless alteration is authorized under Section J, Attachment J-6, Similar or Alternate Dental Procedure Codes Accepted for Referral/Authorization Claims. DTFs shall consult with the DSPOCs prior to referring out an ADSM for implants (see Section J, Attachment J-2, Benefits, Limitations and Exclusions, and Attachment J-3c, Program Operations for Data Systems).

4.2.1. Treatment Narrative Summaries and Radiographs. The contractor shall ensure that each referral includes a request to the provider for treatment narrative summaries. The contractor shall ensure that network providers will submit the treatment narrative summary and any radiographs completed for that session within 10 business days of treatment, into the contractor's referral and authorization system. The contractor shall instruct the network provider to include any duty limiting conditions for the ADSM in the treatment narrative summaries. The contractor shall inform network providers that the claim will be denied if the treatment narrative summary and any radiographs are not provided and that the ADSM will not be responsible for any charges related to the denied claim. The contractor shall instruct the providers to provide copies of the treatment narrative summary and any radiographs upon request at no additional charge. The contractor shall track the treatment narrative summary and radiograph requests and receipts in its referral and authorization tracking system, where they will be available for the referring DTF to view and/or download (see Section J, Attachment J-3c, Program Operations for Data Systems).

4.2.1.1. The contractor shall coordinate with the non-network providers to try and obtain any treatment narrative summaries and radiographs for authorized care. The contractor shall enter these documents into the referral and tracking system for authorized non-network care.

4.3. OCONUS Referral and Authorizations. The contractor shall refer to Section J, Attachment J-3b, Program Operations for OCONUS, for the OCONUS authorization requirements.

4.4. CONUS DTF Referred Orthodontics. Each Service Headquarters has one dentist Representative, with approval authority, who reviews their Service’s DTF referred orthodontics. Each DTF will electronically forward all DTF referred orthodontics to the Service’s Representative for approval/denial. The Service Representative electronically forwards the denied cases to the DTF and the approved cases to the contractor and the DTF.

4.5. DSPOC Referrals and Authorizations. DSPOC authorization is required for all care for which the remote ADSM cannot self-refer or for which the contractor cannot approve/deny (see Section J, Attachment J-5a, Instructions for Remote ADSM’s Dental Care). The contractor shall submit all authorization requests, all supporting documentation, diagnostic quality radiographs, and the patient’s case documents, in an electronic format to the DSPOC via the contractor’s referral and authorization tracking system (see Section J, Attachment J-3c, Program Operations for Data Systems). The contractor shall utilize Section J, Attachment J-9, Dental Service Points of Contacts (DSPOCS) Material Checklist, to determine what materials shall be submitted to the DSPOCS for the case review. The contractor shall utilize the DSPOC Review Codes listed in Section J, Attachment J-8, Dental Service Points of Contact (DSPOC) Review Codes, in conveying DSPOC approval/disapproval of authorization requests to the provider and/or ADSM.

4.6. Remote ADSM Self-Referrals. Remote ADSM’s can self-refer for all covered routine care except for care over $750 per procedure or appointment, or over a cumulative total of $1500 for treatment plans completed within a consecutive 12-month period. These dollar thresholds are based on the provider’s network fee allowance. In addition, other than the exceptions stated in Section J, Attachment J-5a, Instructions for Remote ADSM’s Dental Care, DSPOC authorization is required for all care on appointments where routine care under $750 may be combined with specialty care that is provided on the same date of service, even if a portion of it has been previously approved. Remote ADSMs residing CONUS can self-refer only to network providers except for emergency care. When a remote ADSM self refers to a non-network provider for non-emergency care and a network provider is available, the contractor shall follow the procedures for non-network provider reimbursement as specified in paragraph 8.0, Non-Network Providers.

4.7. Contractor Authorizations.

4.7.1. Dental care provided by non-network providers is not permitted unless authorized by the contractor, DSPOC, or DHA Dental Program Section. The contractor shall authorize use of a non-network provider as specified in paragraph 8.0, Non-Network Providers.

4.7.2. The contractor shall approve or deny authorization of payment for specialty procedures as specified in Section J, Attachment J-5a, Instructions for Remote ADSM’s Dental Care.

4.7.3. The contractor shall approve similar or alternate dental procedures as defined in Section J, Attachment J-6, Similar or Alternate Dental Procedure Codes Accepted for Referral/Authorization Claims.

4.8. Follow-up Dental Care. Follow-up dental care for authorized treatment shall be administered by the provider who performed the initial treatment. No additional authorization is required for follow-up visits. Emergency visits do not count as an initial authorized visit. Any required treatment after an emergency visit will require an authorization.

5.0. ACCESS TO DENTAL CARE PROVIDERS. The contractor shall establish provider networks in accordance with all of the performance standards stated in Section C.4.1.3.a and C.4.1.3.b.

5.1. Network Inadequacy. The contractor shall provide the Contracting Officer with written notification of any instances of provider network inadequacy relative to the access standards specified in Section C.4.1.3.a and C.4.1.3.b. (see Section J, Exhibit B, Contract Data Requirements List (CDRL) M050, Provider Network Access Report). Provider network inadequacy is defined as any failure to meet general and specialty provider access standards.

6.0. PROVIDER REQUIREMENTS. Prior to the payment of any claim for dental services, the contractor shall ensure that the provider has complied with the licensure requirements established by 32 CFR 199.6 or the locality (e.g., state, country, territory, etc.) in which the services were rendered. The contractor shall also ensure that national and/or lower level requirements and Canadian federal and/or provincial requirements are complied with as appropriate. Claims for services rendered by providers who do not meet applicable licensure requirements shall be denied. Each network provider agreement shall indicate their compliance with licensure requirements. See Section J, Attachment J-3b, Program Operations for OCONUS, for TRICARE OCONUS Preferred Dentist (TOPD) requirements.

6.1. The contractor is responsible for determining the standard dental malpractice coverage required in the state, country, province, commonwealth/territory, etc., (including state, country, province, commonwealth/territory risk pools if applicable) for each professional and institutional network provider (see Section J, Attachment J-3b, Program Operations for OCONUS, for TOPDs). In the absence of any state, country, province, commonwealth/territory, etc., local law requirement for dental malpractice insurance coverage, the contractor is responsible for determining the local community standard for dental malpractice coverage. The contractor shall maintain the documentation evidencing both the standard and compliance by network providers. In those cases where there are no state, country, province, commonwealth/territory and/or community requirements, the contractor shall use its corporate/commercial network provider dental malpractice insurance requirements for dental malpractice insurance coverage. The contractor does not have to apply its corporate/commercial network provider dental malpractice insurance requirements to its TOPDs.

6.1.1. Each network provider agreement shall indicate the required coverage and the provider's compliance with these requirements.

6.1.2. Evidence documenting the required coverage of each network provider under contract shall be provided to the Defense Health Agency (DHA) Dental Program Section upon request. The DHA Dental Program Section retains the authority to determine whether state, country, province, commonwealth/territory and/or local requirements for dental malpractice coverage have been met by a network provider and whether the evidence documenting the required coverage complies with contract requirements.

6.3. The contractor shall comply with the liability and indemnification requirements stated in Section H.5.

6.4. The contractor shall provide a copy of their network provider agreement in accordance with CDRL M050 Provider Network Access Report.

7.0. NETWORK PROVIDERS

7.1. Network providers shall submit claims to the contractor for all authorized and/or covered dental care provided to eligible ADSMs (see Section J, Attachment J-2, Benefits, Exclusions and Limitations). ADSMs shall not be billed for any authorized and/or covered care, nor be liable for any co-payments or cost-shares. The Government will reimburse the contractor for authorized and/or covered dental care based on Section J, Exhibit A, Current Dental Terminology (CDT) Pricing List.

7.2. The contractor shall deny care not authorized by the DTF, DSPOC, or contractor, and care that does not meet the remote self-referred requirements. If the DTF, ADSM or provider appeals the initial denial, the contractor may approve the claim for payment one time, if it is for routine care. For all other care the contractor shall process the appeal in accordance with paragraph 13.0. The contractor shall inform the ADSM of the implications of seeking unauthorized care in that they may be held responsible for all costs. If the ADSM continues to seek unauthorized care, the contractor shall contact the DSPOC for a coverage determination. The DSPOC will direct the contractor to either pay for the service in full; or direct the ADSM to pay all charges.

7.3. If the contractor receives a request for payment of services for care that are not covered under Section J, Attachment J-2, Benefits, Exclusions and Limitations, the contractor shall contact the DSPOC for a coverage determination. The DSPOC will direct the contractor to either pay for the service in full or direct the ADSM to pay all charges.

7.4. Hold Harmless Provision. The contractor shall ensure that network providers and TOPDs hold harmless an ADSM if an ADSM elects to receive a non-covered dental service from a network provider or TOPD, the ADSM shall be informed by the provider in advance of receiving the service that the service is excluded from coverage and the ADSM nevertheless agrees to pay for the service. Such agreement to pay by the ADSM will constitute a waiver of the ADSM’s right to be held harmless from financial liability and will be evidenced in writing, either by written agreement or in clinical notes entered into the ADSM’s dental record contemporaneously with the time, date of agreement and the ADSM’s signature. The ADSM’s decision to receive such service, without written evidence of the ADSM’s agreement to pay notwithstanding exclusion from coverage, will not constitute a waiver of the ADSM’s right to be held harmless. The ADSM will not be held harmless from financial liability if the ADSM fails to advise the network provider or TOPD, in advance of receiving the service that he or she is an ADSM. Under “hold harmless,” the ADSM has no financial liability and therefore has no further appeal rights for care that is denied coverage. If the ADSM waives his or her right to be held harmless, the ADSM will be financially liable for the care received.

7.5. Dental Services Agreement. The contractor shall enter into a Dental Services Agreement with the Department of Veterans Affairs (VA) to refer ADSMs requiring dental services to participating VA dental clinics, on a “space available” basis, as authorized by Section 20 I of the Veterans Health Care Act of 1992, Public Law 102-585, 38 U.S.C. 8111. The VA furnishes the contractor with a current list of participating providers which the contractor will add to its participating provider network for the specific purpose of providing dental care under the provisions of the ADDP contract. For services rendered, the VA submits claims to the ADDP contractor for reimbursement, in accordance with the contractor's Maximum Allowable Charge (see Section J, Exhibit A, CDT Pricing Table).

8.0. NON-NETWORK PROVIDERS.

8.1. The contractor shall instruct ADSMs to contact the contractor when an ADSM receives authorized care from a non-network provider who demands payment prior to the ADSM receiving care, so that the contractor can arrange reimbursement to the provider. When an ADSM has paid a non-network provider for an emergency situation or authorized care and seeks reimbursement, the contractor shall reimburse the ADSM. The contractor shall instruct the ADSM that if the ADSM elects to use a non-network provider for non-covered dental services, the ADSM waives his/her right to be held harmless for financial liability (see paragraph 7.4, Hold Harmless Provision).

8.2. The contractor shall deny unauthorized non-network provider claims for covered care (see Section J, Attachment J-2, Benefits, Exclusions and Limitations). If the DTF, ADSM or provider appeals the initial denial, the contractor may approve the claim for payment one time if the claim is for routine care. If the contractor approves the initial denial, the contractor shall process the claim for billed charges and the Government will pay the billed charges. The contractor shall inform the ADSM of the implications of utilizing a non-network provider without authorization. If the ADSM continues to use a non-network provider, the contractor shall contact the DSPOC for a coverage determination. The DSPOC will direct the contractor to either pay for the service in full; pay the network charge and direct the ADSM to pay the difference; or direct the ADSM to pay all charges. If the DSPOC authorizes care for services received from a non-network provider when a network provider was available, the Government will be responsible for paying the billed charges.

8.3. The DSPOC or the DHA Dental Program Section shall be the authorizing authority for the use of a non-network provider when a general dentist or specialty network provider is available within the network access standards stated in Section C.4.1.3a and C.4.1.3b, unless the treatment qualifies as emergency dental care and therefore does not require an authorization. The contractor shall process these claims for billed charges and the Government will pay the billed charges.

8.4. The contractor shall be the authorizing authority for the use of a non-network general dentist when a network general dentist is not available within the network access standards stated in Section C.4.1.3a. The contractor shall be responsible for the difference between the billed charges and what the Government would have paid if it were network charges. The Government is responsible only for the charges as shown in Section J, Exhibit A CDT Pricing Table for ADSMs.

8.5. The contractor shall be the authorizing authority for the use of a non-network specialty provider when a specialty network provider is not available within the network access standards stated in Section C.4.1.3b. The contractor shall be responsible for the difference between the billed charges and what the Government would have paid if it were network charges. The Government is responsible only for the charges as shown in Section J, Exhibit A CDT Pricing Table for ADSMs.

9.0. DENTAL READINESS CLASSIFICATION (DRC). The contractor shall collect the DRC information from either providers or ADSMs. The contractor shall report this information on the ADDP MDR Data Claims and Provider Files report (see Section J, Attachment J-12, MDR Data Elements Layout and Exhibit B, CDRL M040, MDR Data Claims and Provider Files). The classification definitions are listed in Section J, Attachment J-7b, Department of Defense Oral Health and Readiness Classification System. The contractor shall only report DRCs 1, 2, or 3. DRC 4 is not used for ADSMs. One dental classification will be reported for the claim, not a dental classification for each procedure. The contractor shall deny any claim that does not include the DRC until a DRC is provided to the contractor in hardcopy, electronic or telephonic format.

9.1 The contractor shall ensure that upon request, network providers will complete the DD Form 2813, Active Duty/Reserve/Guard/Civilian Forces Dental Examination Form (see Section J, Attachment J-7a) at no additional cost to the member.

10.0. COORDINATION OF BENEFITS. In accordance with 10 U.S.C. 1074, TRICARE is always primary payer for ADSMs.

10.1. Due to rapid changes in eligibility of Reserve Component members moving from Reserve status to Active Duty status, there may be occurrences of care erroneously paid or denied. When the Reserve Component member is enrolled in the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the care should have been paid under the ADDP contract or vice versa, the contractor shall coordinate with the FEDVIP contractor to correct the claim payment, per the Memorandum of Understanding (MOU) with the FEDVIP (see Section J, Exhibit B, CDRL R200 MOU with FEDVIP). In these cases, where the member received care under the FEDVIP, and the member was subsequently determined to be eligible under the ADDP, the contractor shall pay the claim in full without requiring DSPOC authorization, so long as the care received was a covered benefit under the ADDP. This payment process applies to paid claims and to claims denied under the FEDVIP due to being a non-covered benefit. In cases where the member had lost ADDP eligibility and reverted to FEDVIP coverage, the ADDP contractor shall recoup the claim payment from the payee and refund the Government. The ADSM will be notified to file a claim with their FEDVIP coverage.

11.0. CLAIMS PROCESSING. The contractor shall process dental care claims to completion (payment or denial), as defined in the TRICARE Operations Manual (TOM), Appendix A, “Processed to Completion”, and in accordance with the standards at Section C.4.1.7. The filing deadline for claims is one year from the date of service for CONUS claims and three years from date of service for OCONUS claims (see 10 U.S.C. 55 Section 1106). The contractor shall make payment based upon the assignment on the claim form indicated. If there is no indication on the form, payment will be made to the ADSM. If a non-network provider submits the claim and requests that the payment be made to the ADSM, then the contractor shall forward the payment to the ADSM.

11.1. Emergency Care Claims. If a contractor receives a request for payment of services from a network or non-network provider that qualifies as emergency dental care, the contractor shall pay the claim.

11.2. Non-covered Services. If the contractor receives a request for payment of services for care that are not covered under Section J, Attachment J-2, Benefits, Limitations and Exclusions, the contractor shall contact the DSPOC for a coverage determination. The DSPOC will direct the contractor to either pay for the service in full; or direct the ADSM to pay all charges.

12.0. DENTAL EXPLANATION OF BENEFITS (DEOBs). The contractor shall provide each ADSM and provider with a DEOB. The contractor shall ensure the DEOBs clearly describe the action taken on the claim or claims and provide information regarding appeal rights, to include the address and instructions for filing an appeal. The contractor shall ensure all DEOBs include a statement advising recipients to notify the contractor if the care identified on the DEOB was not actually received. Providers shall receive DEOBs at their service address for all care rendered even if the provider uses a Third Party Administrator. The contractor may mail drafts/checks separately to a provider billing address. The contractor shall provide a duplicate DEOB at an ADSM’s request, without charge to the ADSM, regardless of their status.

13.0. APPEALS AND GRIEVANCES. The contractor shall process appeals and grievances within the timeframes stated in Section C.4.1.8 and C.4.1.9.

13.1. Appeals. The contractor shall establish and maintain appeal procedures in support of ADSMs. The contractor shall utilize Section J, Attachment J-9, Dental Service Points of Contacts (DSPOCS) Material Checklist, to determine what materials shall be submitted to the DSPOCS for the appeal review.

13.1.1. If the DSPOC and/or contractor denies a request for reimbursement of service or written request for authorization, the contractor shall notify the dental provider, ADSM, and ADSM’s command in writing. The ADSM, ADSM’s command, dental provider or the ADSMs authorized representative, may appeal the denial as long as they comply with the provision herein for appealing the denial.

13.1.2. First Level. The contractor shall ensure that any appeal of a denial is in writing and received by email, fax or other delivery within 90 days of the ADSM, ADSM’s command, or dental provider receiving notice of the denial. If the request is not received within the 90 days, the contractor shall notify the requestor within the timeframe specified for non-priority correspondence standards listed at Section C.4.1.10.(6) of receiving the request that the appeal was not received timely and therefore denied. A copy will be provided to the DHA Dental Program Section. The contractor shall forward the appeal to the DSPOC, via the referral and authorization tracking system (see Section J Attachment J-3c, Program Operations for Data Systems) within 7 days of receipt. The DSPOC will issue a decision electronically to the contractor within 10 days of receipt, by either granting the appeal, denying the appeal or requesting additional information. The contractor shall notify the appealing party within 14 days of receipt of the DSPOC’s decision.

13.1.3. Second Level. In the event the DSPOC denies the appeal, then the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative may seek additional review of the DSPOC’s decision by submitting a written request to the contractor within 30 days of receipt of the denial. The contractor shall ensure that it was received within 30 days of the denial. If the request is not received within the 30 days, the contractor shall notify the requestor within the timeframe specified for non-priority correspondence standards listed at Section C.4.1.10.(6) of receiving the request that the appeal was not received timely and therefore denied. The contractor shall provide a copy to the DHA Dental Program Section. In order to obtain further review of the DSPOC’s decision, the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative submits to the contractor their written request for review of the DSPOC’s decision. The request for review shall include a copy of the DSPOC’s decision. The contractor shall electronically forward the request to the DSPOC within 7 days of receipt for a second and separate DSPOC review. Second level appeals are not reviewed by the DSPOC that conducted the first level appeal review. The DSPOC issues a decision electronically to the contractor, within 15 days of receipt, either affirming or reversing the initial DSPOC’s first level decision. The decision may overrule the previous decision in whole or in part. The contractor shall notify the appealing party within 14 days of receipt of the DSPOC’s decision. All second level decisions issued by the DSPOC on policy related appeals (i.e. not related to a clinical reason) are final and not subject to further appeal.

13.1.4. Final Level. In the event that the DSPOC affirms their first level decision, the ADSM, ADSM’s command, dental provider or the ADSM’s authorized representative may seek further review only if the appeal is based on a clinical needs or services that meet the requirement of dental care that is necessary to meet military dental readiness guidelines. The appeal must be submitted in writing to the contractor within 30 days of receipt of the second decision. The contractor shall ensure that it was received within 30 days of the denial. If the request is not received within the 30 days the contractor shall notify the requestor within the timeframe specified for non-priority correspondence standards listed at Section C.4.1.10.(6) of receiving the request that the appeal was not received timely and therefore denied. The contractor shall provide a copy to the DHA Dental Program Section. The written request shall include copies of the First and Second level decisions. The contractor shall electronically forward the request to the DSPOC within 7 days of receipt. The DSPOC electronically forwards the request to the Surgeon General or designee for the ADSM’s Branch of Service, with a copy to the DHA Dental Program Section, within 7 days. The Surgeon General or designee for the ADSM’s Branch of Service decision is final and not subject to further appeal. The contractor shall notify the appealing party within 14 days of receipt of the final decision.

13.1.5. The contractor shall ensure that any appealable issue may only be appealed through the above process one time. Once a final decision is rendered, the issue may not be appealed again.

13.2. Grievances. The contractor is responsible for processing grievances filed by or on behalf of the ADSM.

13.2.1. The contractor shall develop and implement a grievance system, separate and apart from the appeal process. The grievance system shall allow full opportunity for aggrieved parties to seek and obtain an explanation for and/or correction of any perceived failure of a network provider, ADDP contractor, or subcontractor personnel to furnish the level or quality of care and/or service to which the ADSM may believe he/she is entitled. Grievances may be filed for or on behalf of the ADSM, by the ADSM, by the referring DTF, or by the DSPOC. All grievances must be submitted in writing. The subjects of grievances may be, but are not limited to, such issues as the refusal of a network provider to provide services or to refer an ADSM to a specialist, the length of the waiting period to obtain an appointment, undue delays at an office when an appointment has been made, poor quality of care, or other factors which reflect upon the quality of the care provided or the quality and/or timeliness of the service. If the written complaint reveals an appealable issue, the correspondence shall be forwarded to the contractor’s appeals unit for a reconsideration review.

13.2.2. Grievances may be mailed, faxed or delivered to the contractor. In addition to these methods of delivery the contractor shall offer on their Web site a fillable online grievance form that may be submitted through an online process. The Web application will include the ability to include supporting documentation.

13.2.3. It is the contractor’s responsibility to conduct an investigation and, if possible, resolve the aggrieved party’s problem or concern. In this responsibility, the contractor shall:

13.2.3.1 Ensure that information for filing of grievances is readily available to all ADSMs.

13.2.3.2. Maintain a system of receipt, identification, and control which will enable accurate and timely handling. All grievances shall be stamped upon receipt with the actual date of receipt.

13.2.3.3. Investigate the grievance and document the results in accordance with the standards stated in Section C.4.1.9. The contractor shall notify the COR of all grievances for which reviews were not completed within 60 days of receipt.

13.2.3.4. Provide interim written responses within 30 days after receipt for all grievances not Processed To Completion (PTC) by that date.

13.2.3.5. Take positive steps to resolve any problem identified within 60 days of the problem identification. If the problem cannot be resolved within that period of time, the COR shall be informed of the nature of the problem and the expected date of resolution. If there is no resolution to the problem, the contractor shall acknowledge receipt of the grievance and explain to the grievant why the problem cannot be resolved in accordance with the statutory requirements referenced in Section C.2.1.

13.2.3.6. Written notification of the results of the review shall be submitted to the grievant within 60 days of the original receipt of the grievance in accordance with the statutory requirements referenced in Section C.2.1. The letter will indicate who the grievant may contact to obtain more information and provide an opportunity for the grievant, if not satisfied with the resolution, to request a second review by a different individual.

13.2.3.7. Ensure the involvement in the grievance review process of appropriate dental personnel, including personnel responsible for the contractor’s quality assurance program in any case where the grievance is related to the quality of medical care or impacts on utilization review activities. The contractor shall ensure that no quality assurance information protected under Title 10 U.S.C., Chapter 55, Section 1102, or other applicable state or federal law, is divulged to the grievant or the individual filing on behalf of the grievant, to include the DTF commander.

13.2.3.8. Maintain records for all grievances, including copies of the correspondence, the results of the review/investigation and the action taken to resolve any problems which are identified through the grievance.

14.0. CUSTOMER SERVICE. The contractor shall provide comprehensive, readily accessible customer services that include multiple avenues of access (for example, e-mail, Website, telephone, and facsimile) for beneficiaries and providers.

14.1. The contractor’s customer service center shall be available to answer customer inquiries in accordance with contract standards stated in Section C.4.1.10, from 6:00 p.m. Sunday to 10:00 p.m. Friday, Eastern Time and on Saturday from 9:00 am – 1:00 pm Eastern Time, except for federal holidays. The contractor’s customer service center shall be able to communicate with non-English speaking customers.

14.2. Both CONUS and OCONUS callers shall be provided long distance telephone access at no cost to call Customer Service. If the contractor uses an Automated Response Unit to answer incoming telephone calls, the initial listing of menu choices shall offer the caller the opportunity to immediately speak with a Customer Service Representative.

14.3. The contractor shall provide assistance if the ADSM requests help in finding a provider, and/or scheduling an appointment. The contractor shall schedule appointments for the ADSM (CONUS/OCONUS) when requested by the ADSM or DTF, through the contractor’s website or via telephone with a customer service representative. For any appointment scheduled by the contractor, the contractor shall send to the ADSM electronic scheduling reminders, appointment reminders, and failed appointment notices. The contractor shall track ADSM appointments as specified in Section J, Attachment J-3c, Program Operations for Data Systems. Reminders/notices must be sent via Public Key Infrastructure (PKI) encrypted (i.e., Common Access Card (CAC) encrypted) or through the contractor’s proprietary secure email system. If the ADSM requests non-Protected Health Information (PHI)/Personally Identifiable Information (PII) be sent unencrypted to their military account or to their non-secure account (e.g. their personal email address), the contractor may comply with the ADSM’s request.

14.4. The contractor shall provide responses to written correspondence received either via hardcopy or electronic media. Priority correspondence is that correspondence received from Members of Congress, DoD leadership and/or DHA leadership (see Section C.4.1.10[5] and [6]).

14.5. The contractor shall send an unencrypted email to the ADSM’s military account or if requested, to a non-secure email account( see paragraph 14.3), which contains a link for the ADSM to participate in a patient satisfaction survey within seven business days of a claim being processed to completion. The survey will be administered by the Tri-Service Center for Oral Health Studies or other DoD approved agency. If this email is returned undeliverable the contractor does not have to follow-up on the delivery as they would such as appointment notices to the ADSM.

15.0. WEBSITE. The contractor shall provide a website with information including, at a minimum, contractor contact information, an explanation of the ADDP benefit, a network provider directory, and which promotes the advantages of receiving preventive dental care. The network provider directory shall include the provider’s name, specialty, gender, address, phone number, fax number, whether the provider is accepting new patients, and whether the provider performs amalgam restorations (CDT D2140, D2150, D2160, or D2161). The directory shall be searchable, at a minimum, by ZIP code, distance, address, and individual provider name. The website shall also provide online access to the ADDP dental benefits, the ADDP Handbook, the ADDP Benefits Brochure, an American Dental Association (ADA) approved Provider Claim Form for use by beneficiaries and providers, and a link to DHA’s main TRICARE website at http://www.TRICARE.mil. The website shall also allow beneficiaries to securely check the status of claims and view their Dental Explanations of Benefit. The website design and content shall be subject to review and approval by the DHA Dental Program Section and DHA Communications prior to activation.

16.0. MISDIRECTED COMMUNICATIONS. The contractor shall forward, within 3 business days of identification, all out-of-jurisdiction claims to the appropriate contractor (e.g., regional Managed Care Support Contractor or Retail Pharmacy Contractor). All out-of-jurisdiction correspondence received from the Government, private providers and the public shall be returned to the sender within 3 business days of receipt. Out-of-jurisdiction communications include correspondence, appeals, e-mails, faxes, and phone messages.

17.0. EDUCATION REQUIREMENTS. The education of ADDP beneficiaries, network providers, TOPDs, military commanders, and Military Dental Treatment Facilities (DTF) staff will be accomplished through a collaborative effort between the contractor, DHA Dental Program Section, DHA Communications, the Managed Care Support contractors (MCSCs), and other TRICARE contractors.

17.1. Education Plan. The contractor shall submit an annual education plan in accordance with this attachment and Section J, Exhibit B, CDRL AP010, ADSM, Provider and DTF Education Plan.

17.2. Interface Requirements. The contractor shall meet with and establish a Memorandum of Understanding (MOU) with DHA Communications as stated in this attachment and Section J, Exhibit B, CDRL R120, MOU with DHA Communications. The MOU will establish the review and approval process for annual education plans and identify the DHA process for obtaining education materials. The contractor shall ensure that all education materials are coordinated with the COR prior to approval and release for printing or posting to the DHA/Contractor website.

17.3. Material Formats. The contractor shall use the Government’s national suite of TRICARE educational materials pertaining to specific aspects of the TRICARE benefit and programs. The contractor shall use the Government’s mandatory formats to ensure “one look and feel” of all educational material. The contractor shall ensure educational materials cite the TRICARE website www.tricare.mil/dental. This website will direct the beneficiaries and providers to the correct dental site.

17.4. Monthly Meetings. The contractor shall participate in monthly TRICARE beneficiary and provider workgroup meetings comprised of other DHA program representatives and the DHA Communications Office. The contractor shall provide unique perspectives, ideas, and recommendations regarding the development and maintenance of TRICARE educational materials to the group. The contractor may attend these meetings via teleconference, video telecommunications, or in person. Meetings are typically in the Washington, D.C. area.

17.5. Education Strategy. The contractor’s education strategy may include a broad array of tools to include, but not limited to, printed mass communications materials, use of on line technology, advertisements in publications that target the eligible population, regular participation at conferences, seminars, trade fairs, family support association and council meetings, and military/reserve association meetings that are attended by eligible persons or Government representatives that train or support eligible persons, and presentations to Reserve Component units.

17.6. Provider Education. The contractor shall educate the network providers and TOPDs on the overall ADDP benefit. The contractor shall make the educational training available on line to the providers. The contractor shall ensure network providers and TOPDs are familiar with the following:

· referral and authorization requirements

· hold harmless requirements

· claim submittal process

· supporting documentation requirements to accompany claims and/or dental care authorization requests

· how to complete the DD From 2813, Active Duty/Reserve/Guard/Civilian Forces Dental Examination Form The contractor shall also ensure network providers and TOPDs are educated on Dental Readiness Classification (DRC) levels as described in Section J, Attachment J-7b, Department of Defense Oral Health and Readiness Classification System, and the procedures for bringing a DRC 3 level patient down to a DRC 2 level for readiness care. The contractor shall ensure that the network providers understand that the network reimbursement fees are set by the contractor and not by DoD.

17.7. Education Program Content. The contractor’s education program shall provide guidance for ADSMs using non-network providers and OCONUS providers, such as how they may contact the contractor for authorization to see a non-network provider, the hold harmless requirements, appointment…