TDP6 Program Operations.pdf

TDP6 Program Operations

1.0. ENROLLMENT. The contractor shall process all enrollment actions in accordance with

Section C.5.1.1.2 and TRICARE System Manual (TSM) Chapter 3, Section 4.2. Enrollment in the TDP is voluntary and shall be portable as members transfer between Active Duty, Selected

Reserve, Individual Ready Reserve (IRR) and National Guard (NG) status (see Section J, Attachment J-3, TDP Coverage Plans for the different enrollment plans and Attachment J-8, Reserve Component Categories). The effective date of coverage shall begin on the first day of the month following the month in which the contractor receives the enrollment application and the payment, equal to one month’s premium. If an application and premium payment are received after the 20th day of the month, enrollment will begin on the first day of the second month after the month in which the contractor received the application. This recurring principle is referred to as the “20th of the month rule.”

1.1. Types of Enrollment. Enrollment shall be on a single or family basis.

1.1.1. When there is an existing enrollment, family members will be automatically enrolled upon turning one year old. Existing types of enrollments will be modified by the Defense Enrollment

Eligibility Reporting System (DEERS) automatically (see TSM, Chapter 3, Section 4.2) when a family member is added or turns one year old. Once the family expands past single status the new child will be automatically enrolled at age one and the enrollees will be switched from the

Single plan to the Family plan. It also applies in the reverse when a member loses eligibility, going from Family to Single. The contractor shall correct the enrollment premiums when they receive notifications from DEERS when enrollment plans change from single to family or family to single. All eligible family members of a sponsor must be enrolled if any one of them is enrolled, with the following exceptions.

1.1.1.1. Children under the age of one may be excluded from enrollment if there is only one member of the family age one or older, allowing for a Single plan enrollment of the family member age one or older until any other family member reaches the age of one. DEERS will track the non-enrolled child of an enrolled member until age one, at which time DEERS will automatically enroll the child and any other children under age one changing the Single plan to a

Family plan enrollment. The contractor shall notify the sponsor of the associated premium rate change.

1.1.1.2. Partial Family Enrollments. When a sponsor has eligible family members residing in two or more locations, the sponsor may elect to enroll only those eligible family members residing in one location or the sponsor may elect to enroll eligible family members residing in multiple locations. The sponsor must identify those family members residing in separate locations to the contractor.

1.1.1.3. For active duty/AGR family members only, when a family member requires a hospital or special treatment environment (due to medical, physical handicap, or mental condition) for dental care otherwise covered by the TDP, the family member may be excluded from TDP enrollment and may continue to receive care from a military treatment facility. The sponsor must provide documentation such as a signed letter or memorandum from the provider or administrator, to the contractor attesting to this requirement for a hospital or special treatment environment. The sponsor must provide the documentation with the request for disenrollment, prior to receipt of the services.

1.1.1.4. A Selected Reserve, IRR, or NG sponsor may enroll just themselves or just their eligible family members, or both themselves and their family members. However, due to differences in the way premiums are paid for the sponsor and their family members a Selected Reserve, IRR, or

NG sponsor must enroll independently of their family members. As a result, there will be two

TDP policies under the same Social Security Number. This action is required due to the sponsor’s premium being partially subsidized by the Government, while the family member has a 100% enrollee paid premium.

1.2. TDP Survivor Benefit. Surviving family members are eligible to receive TDP benefits when:

• An active duty sponsor dies while on active duty for a period of more than 30 days, or

• A Ready Reserve sponsor [i.e., Selected Reserve or Individual Ready Reserve

(mobilization asset), as specified in 10 U.S.C. 10143 and 10144(b) respectively] dies.

The Reserve sponsor does not have to be on active duty for the family member to be eligible for survivor benefits.

The Government will pay for 100% of the TDP premium for survivors as follows:

1.2.1. Spouse. The surviving spouse is eligible to receive TDP survivor benefits for up to three years from the sponsor’s date of death.

1.2.2. Children. The TDP Survivor Benefit for children ends at the age of 21, or 23 if enrolled in a full-time course of study in a secondary school or in a full-time course of study in an institution of higher education (subject to TRICARE eligibility limitations).

1.2.3. Incapacitated Children. The TDP Survivor benefit for incapacitated children (subject to

TRICARE eligibility limitations) is the greater of:

• Three years from the sponsor’s date of death (not to exceed 21 years of age), or

• The date on which such dependent attains 21 years of age, or

• The date on which the dependent attains 23 years of age if enrolled in a full-time course of study in a secondary school or in a full-time course of study in an institution of higher education (subject to TRICARE eligibility limitations).

For example, if a sponsor dies when an incapacitated child is 19 and is not in a full-time course of study in a secondary school or institution of higher education, the TDP Survivor benefit would end when the dependent attains 21 years of age. If the 19 year old meets the secondary or higher education requirements stated above, then the TDP Survivor benefit would end when the dependent attains 23 years of age.

1.2.4. Currently Enrolled. When death occurs, DEERS will automatically disenroll the enrolled family members from the current TDP plan and automatically reenroll the previously enrolled family members under the terms of the TDP Survivor Benefit and the Government will pay for 100% of the TDP premium. Normal cost-shares still apply. DEERS shall promptly notify the survivors of this enrollment and details of the survivor benefit. The enrollee’s contract year does not reset with the transfer from their previous plan to the TDP survivor benefit plan.

The enrollee’s annual maximums, orthodontic maximum, etc., do not start over, but continue for the duration of their contract year. Contractual lock-in and lock-out provisions are not applicable to the TDP survivor benefit.

1.2.5. Not Enrolled. When death of a sponsor in an active duty, Guard or Reserve status occurs, DEERS will automatically notify the surviving family members of their eligibility for enrollment in the TDP and provide guidance to contact the TDP contractor for enrollment if desired. The 20th of the month enrollment rule does not apply in this situation. The enrollee will be covered the first day of the month after the month in which they enroll.

1.2.6. DEERS Tracking. DEERS will track the three year TDP Survivor Benefit period for the surviving spouse and disenroll the spouse at the expiration of the three year period. Sixty days prior to disenrollment from the survivor plan, DEERS will notify the family members of coverage termination. DEERS will also notify the family members at the time of coverage termination.

1.3. Partial month re-enrollment provision for Selected Reserve, IRR, and NG members.

When previously enrolled Selected Reserve, IRR, and NG members are released from active duty, the members will be automatically re-enrolled into the TDP by DEERS with coverage being effective the day following the release from active duty date (See Section G.4 for processing of these premiums).

1.4. National Guard State Disaster Response Duty. National Guard members that serve on continuous active duty for more than 30 days are considered ADSMs. NG family members are eligible for the Active Duty Family Member dental premium (i.e. 70/30 for Junior Enlisted or

60/40 for all other ranks split premium) if the sponsor is on federally funded orders for more than

30 days. In addition, when NG members are moved directly from federal orders to state orders to perform State disaster response duty, the NG member retains ADSM status and the NG family members are eligible for the Active Duty Family Member dental premium as if the NG sponsor was on active duty orders for more than 30 days [see TPM Chapter 10, Section 10.1, TRICARE

Coverage for Certain Members of the National Guard (NG)]. If the NG member is on state orders for other than State disaster response duty, the NG member and their family members are responsible for 100% of their TDP premium (see Section J, Attachment J-3, TDP Coverage

Plans).

1.5. Lock-in and Lock-Out Periods. All new enrollees will incur a 12-month lock-in period.

There is a 12-month enrollment lock-out if the enrollee fails to pay premiums during the 12-month lock-in period or disenrolls for other than valid reasons as specified in 32 CFR

199.13(c)(3)(ii)(E). Following a valid disenrollment or after disenrolling subsequent to the expiration of the lock-out period, an eligible enrollee may re-enroll at any time, with another

12-month lock-in. The TDP enrollment lock-in and lock-out requirements shall take precedence over the contractor’s standard practice.

1.5.1. Voluntary Disenrollment. If voluntary disenrollment occurs prior to the end of the initial

12-month enrollment period, the contractor shall set the lockout manually in the Government furnished web-based enrollment system/application.

1.5.2. Involuntary Disenrollment. When an enrollee fails to pay enrollment premiums, the contractor shall disenroll the beneficiary with a reason code of “failure to pay fees”. Prior to processing a disenrollment with a reason of “non-payment of fees”, the contractor shall reconcile their premium payment system against the premium totals in DEERS. Once the contractor confirms that payment amounts match, the disenrollment can be entered in the Government furnished web-based enrollment system/application.

1.5.3. The contractor may cancel the lockout and disenrollment. A disenrollment cancellation removes the disenrollment event and reinstates the enrollment as if the disenrollment never occurred.

2.0. PREMIUM PAYMENTS. For each Ordering Period, all Single premium amounts shall be the same and all Family premium amounts shall be the same, irrespective of whether the member is Active Duty, Selected Reserve, IRR, survivor status, or geographic regions. The contractor shall accept payment of premiums as stated below (see Section G, and TSM, Chapter 1, Section

1.1).

2.1. Active Duty Family members must pay monthly enrollment fees through an allotment from a Uniformed Services Finance Center. Selected Reserve, Individual Ready Reserve and National

Guard members, and their family members must pay enrollment fees through Electronic Funds

Transfer (EFT) from the enrollee’s designated financial institution (which may include a recurring credit or debit card charge). The contractor shall provide all necessary forms to complete EFTs and credit or debit card actions. The contractor shall be responsible for verifying the information necessary to initiate monthly allotments and EFTs.

2.2. TDP enrollees who elect the monthly fee payment option must pay the first month’s installment at the time the enrollment application is submitted to allow time for the allotment or

EFT to be established. The contractor shall accept payment of the first month’s installment by personal check, cashier’s check, traveler’s check, money order, or credit card.

2.3. Uniformed Services Finance Centers and DHA Interface. The contractor shall interface with the Uniformed Services Finance Centers through the MHS B2B Gateway as described in

TSM Chapter 1. The files transmitted between the contractor and the finance centers will be in accordance with the TDP Finance File Layouts and Communication Protocols. The Government shall render payment to the contractor on a monthly basis via Electronic Funds Transfer (EFT).

Information required by which to establish the EFT shall be submitted to the Uniformed Services

Finance Center, no later than seven months prior to the start work date of the contract. The contractor’s Uniformed Services Finance Center interfaces shall be ready to begin testing approximately 30 days after the Government’s acknowledgement of the contractor's Annual

System Security Plan and Associated Plans of Action for a Contractor’s Internal Unclassified

Information System (see Exhibit A, CDRL A050).

2.3.1. The contractor shall notify the Uniformed Services Finance Center when a payroll allotment or deduction is initiated, changed or terminated as a result of information received from the sponsor or DEERS.

2.4. Active Duty Family Member Enrollees. The enrollee's share of the premium will be collected through a Uniformed Services Finance Center, if sufficient funds are available at the time of collection (see TSM, Chapter 1, Section 1.1).

2.5. Selected Reserve, Individual Ready Reserve (IRR) and National Guard Enrollees.

Starting with initial enrollment, the contractor shall immediately direct bill for premiums due from Selected Reserve, IRR and National Guard members, and their family members. The contractor shall notify the enrollee that they must set up either an EFT from their bank account or a recurring credit card.

2.6. Partial-Month Premiums. Partial-month premiums will not be collected from the previously enrolled Selected Reserve and IRR members newly released from active duty, nor will the payment be made by the Government for the partial month coverage period. The last full month premium paid to the contractor for coverage during the month the member’s status changed to active duty will be deemed to apply to the partial month re-enrollment period. When the contractor receives the re-enrollment notification from DEERS, the contractor is required to notify the member of the premium payment amount that is owed and re-establish the premium collection process to be used to collect the member’s portion of the premium payment.

2.7. Contractor Direct Billing. If there are insufficient funds or no payroll account is available at the time of collection, the premium collection will migrate from the Uniformed Service

Finance Center payroll allotment or deduction to direct bill, EFT or recurring credit card after one month of no-deduct. The contractor shall allow a 90 day grace period before consideration for disenrollment. The contractor shall then disenroll the beneficiary for failure to pay premiums at the end of the 90-day period (i.e. 30-day no payroll deduction plus 60 days to direct bill). The contractor shall exercise discretion to allow re-enrollment of beneficiaries that were disenrolled for failure to pay premiums. The beneficiary will only have the option for EFT or recurring credit card payment should the contractor grant the re-enrollment request.

2.8. The only instance where a check may be used to pay premiums is for the initial enrollment, unless administrative issues arise in the processing of an automated method, in which case the contractor may, at their discretion, accept payment by check in order to preserve the beneficiary’s TDP enrollment status. The contractor shall not require beneficiaries to pay an administrative fee of any kind for use of a particular payment option offered by the contractor, but may assess the account holder a charge in the event there are insufficient funds to process a premium payment.

2.9. Enrollees shall not be required to pay more than one month's premium in a single payment, except for retroactive periods of enrollment. If the enrollee fails to pay premiums or disenrolls for an invalid reason, the Government will not pay any portion of the premium (Government or enrollee share) for the remaining months. If it is determined that an enrollee has been erroneously disenrolled, the contractor shall process retroactive enrollments and apply the correct premiums. Once an enrollee begins a payroll allotment through a Uniformed Service Finance

Center, the enrollee cannot stop it during the 12-month period, except for a valid disenrollment reason (see paragraph 1.5, Lock-in and Lock-Out Periods).

2.10. The contractor may retroactively enroll beneficiaries up to 18 months. All premiums must be retroactively collected for backdated enrollments.

2.11. If enrollment fees are overpaid at any point during an enrollment year, the contractor may credit the overpayment to any outstanding payments due. If the overpayment of enrollment fees is not applied to outstanding payments due, the contractor shall refund any overpayments of $1 or more to the enrollee.

2.12. On a monthly basis, the contractor shall review all enrollment and fee reports provided by the Government to ensure enrollments and premium payments are accurate. The contractor shall also ensure all policy termination dates correspond with the paid through premium date reported in DEERS. The contractor shall report all discrepancies identified to the Contracting Officer for further coordination and reconciliation with DMDC (see Section J, Exhibit A, CDRL M070, Enrollment and Fee Reconciliation Analysis Report).

3.0 COST SHARES. CONUS and OCONUS enrollees are responsible for paying the cost-share amounts defined in Section J, Attachment J-4, Cost Shares.

4.0 BENEFIT MAXIMUMS. The contractor shall apply benefit maximums in accordance with Section J, Attachment J-2, Benefits, Exclusions and Limitations.

5.0 ACCESS TO DENTAL CARE PROVIDERS. The contractor shall establish provider networks in accordance with Section C.5.1.1.3. Enrollees shall not be restricted as to their choice of provider.

5.1. The contractor shall provide the Contracting Officer with written notification of any instances of provider network inadequacy relative to the access standards specified in C.5.1.1.3

(see Section J, Exhibit A, CDRL M020 Provider Network Access Report). Provider network inadequacy is defined as any failure to meet general and specialty provider access standards.

5.2. Non-compliant General Dentist Network Access Standard. When more than 25% percent or more than 200 enrollees in a specific five digit ZIP code area are unable to obtain a periodic or initial (nonemergency) dental examination appointment with a network provider within the access standards specified in C.5.1.1.3.a, then DHA will designate that area as non-compliant with the general dentist network access standard. Once so designated, the contractor shall reimburse the non-network providers selected by enrollees in that area (or a subset of the area or nearby ZIP codes in other five digit ZIP code areas as determined by DHA) at the level of the provider’s usual fees less applicable enrollee cost-shares. Enrollee cost-shares shall be based on the contractor’s fee schedule for that geographic area rather than the provider’s usual fees.

The contractor shall notify enrollees residing in a non-compliant area that they can use any provider and that their claims will be reimbursed as if they were receiving care from a network provider. DHA shall determine when such areas become compliant with the access standards.

When determined compliant, the contractor shall notify the enrollees by mail that network dentists are now available and normal reimbursements will take effect 30 calendar days from the date of the notification.

5.3. The contractor shall deploy Mobile Dental Units (MDUs), with DHA approval, in accordance with the standard stated in C.5.1.1.3.d. for areas of the country where there are 200 or more enrollees who do not have access to dental care because there are no practicing dentists within 50 driving miles of a beneficiary’s place of residence or because 200 or more enrollees reside in a non-compliant area (see paragraph 5.2 Non-compliant General Dentist Network

Access Standard). Mobile Dental Units are authorized once per year for the following locations:

• South Fairbanks, Alaska

• Fort Irwin, California

5.3.1. The TRICARE Dental Program Branch may identify no more than two additional locations per Ordering Period on an as needed basis. The Contracting Officer’s

Representative (COR) will notify the contractor 60 days prior to the date the MDU is required. If the need continues one year after utilization of the MDU, the location may be modified into the contract so that the contractor will offer the MDU at that location annually.

5.3.2. Compliance with the standard will be reported to the Government annually. To calculate the scheduling requirement of a minimum of 30% of TDP enrollees in each location per event, the total enrollment for each location 30 days prior to the scheduled event will be calculated using the following ZIP codes:

• South Fairbanks, AK: 99737 and 99731

• Fort Irwin, California 92310

5.3.3. If any of the locations listed above do not utilize the MDU, that annual service may be used at another location with prior approval from the Contracting Officer.

5.3.4. The MDUs shall be staffed by dentists, hygienists and certified dental assistants, to provide diagnostic, preventive, routine restorative and non-complicated oral surgery (simple extractions), as well as triage referrals of emergency needs. The contractor shall utilize online appointment technology to allow TDP enrollees to schedule appointments in each area where a mobile dental unit is deployed. TDP enrollees may also call the contractor’s toll-free customer service telephone number to schedule an appointment. The contractor’s Interactive Voice

Response (IVR) system shall provide a mobile scheduling option. Prior to each mobile unit event, the contractor shall post informational notices on the TDP website. The contractor shall also communicate information on upcoming mobile unit events via the TDP enrollee’s preferred method of communication (mail, email or website). For new enrollees in these areas, the contractor shall develop a targeted, specialized mailing (with DHA approval) to inform them of the mobile unit services and other pertinent information. Enrollees who utilize mobile dental unit services will also be provided with a hard copy or electronic version of treatment rendered, to include radiographs, periodontal charting, treatment notes, etc. Additionally, the contractor shall work with enrollees who utilize mobile services to coordinate any necessary follow-up and/or specialty care.

6.0 DENTAL READINESS CLASSIFICATION. Upon request, network providers shall complete the DD Form 2813 (Active Duty/Reserve/Guard/Civilian Forces Dental Examination

Form) provided at Attachment J-7a, at no additional cost to the enrollee. The contractor shall collect the Reserve Component Service Member’s dental readiness classification information from providers and shall report this information on the TDP Claims File Data Elements monthly data feed (see Section J Attachment J-10, MDR Data Elements Layout). The classification definitions are listed in Attachment J-7b, Department of Defense Oral Health and Readiness

Classification System. The contractor shall only report either Classification 1, 2, or 3;

Classification 4 is not used for this contract.

7.0 HOLD HARMLESS PROVISION. A network provider may not require payment from the enrollee for any excluded services that the enrollee received from the network provider, i.e., the enrollee will be held harmless except as follows:

7.1. If the enrollee did not inform the provider that he or she was a TRICARE enrollee, the provider may bill the enrollee for services provided.

7.2. If the care delivered exceeded the benefit frequency limitation, e.g., if a beneficiary receives three prophylaxes within a 12-month period and the benefit allows for coverage of two within a

12-month period, the beneficiary is responsible for the cost of the third prophylaxis, irrespective of whether or not the beneficiary was notified that the care would exceed the frequency limitation.

7.3. If the enrollee was informed that the services were excluded and he/she agreed in advance to pay for the services, the provider may bill the enrollee. An agreement to pay must be evidenced by written records and the enrollee’s signature. If the enrollee is a minor, then the agreement to pay must be signed by the sponsor, custodial parent or guardian. Written records include for example: 1) provider notes written prior to receipt of the services demonstrating that the enrollee was informed that the services were excluded and the enrollee agreed to pay for them and a signed acknowledgement by the enrollee; 2) a statement or letter written by the enrollee prior to receipt of the services, acknowledging that the services were excluded and agreeing to pay for them; 3) statements written by both the enrollee and provider following receipt of the services that the enrollee, prior to receipt of the services, agreed to pay for them, knowing that the services were excluded. General agreements to pay, such as those signed by the enrollee at the time of admission, are not evidence that the enrollee knew specific services were excluded.

7.4. The enrollee will be entitled to a full refund of any amount paid by the enrollee for the excluded services, including any cost-share amounts, provided the enrollee informed the network provider that he or she was a TRICARE enrollee, and did not agree in advance to pay for the services after having been informed that the services were excluded. In order to obtain a refund, the enrollee is not required to ask the provider to return the payments the enrollee has made for excluded services. Instead, the enrollee will be refunded by the contractor for any payments made by the enrollee or by another party on behalf of the enrollee (excluding an insurer or provider) for the excluded services. The enrollee, or other party making payment on behalf of the enrollee, must request a refund in writing from the contractor by the end of the sixth month following the month in which payment was made to the provider or by the end of the sixth month following the month in which DHA advised the enrollee that he or she was not liable for the excluded services. The time limit may be extended where good cause is shown. Good cause is defined as follows:

7.4.1. Administrative error, such as, misrepresentation or mistake, by an officer or employee of

DHA, if performing functions under TRICARE and acting within the scope of the officer's or employee's authority.

7.4.2. Mental incompetence of the enrollee or, in the case of a minor child, mental incompetence of his or her guardian, parent, or sponsor.

7.4.3. Adjudication delays by other health insurance, when not attributable to the enrollee.

8.0 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 OCONUS locality (e.g., state, country, territory, etc.) in which the services were rendered, including national and/or lower level requirements and

Canadian federal and/or provincial requirements, as appropriate. Claims for services rendered by providers who do not meet applicable licensure requirements shall be denied.

8.1. The contractor is responsible for determining the standard dental malpractice coverage required in the state (including state risk pools if applicable) for each network provider (both professional and institutional). In the absence of a state law requirement for dental malpractice insurance coverage, the contractor is responsible for determining the local community standard for dental malpractice coverage, and the contractor must maintain the documentation evidencing both the standard and compliance by network providers. In those cases where there are no state and/or community requirements, the contractor shall use its corporate/commercial network provider dental malpractice insurance requirements for dental malpractice insurance coverage.

8.2. Each network provider agreement must indicate the required coverage and the provider's compliance with the requirements.

8.3. Evidence documenting the required coverage of each network provider under the contract shall be provided to the Contracting Officer upon request. The Contracting Officer retains the authority to determine whether state 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.

8.4. The contractor shall comply with the liability and indemnification requirements stated in

Section H.2.

9.0 CLAIMS PROCESSING. The contractor shall process dental care claims to completion

(payment or denial) in an accurate and timely manner, as defined in TOM, Appendix A, “Processed to Completion”, and in accordance with C.5.1.1.6. Payment will be made based upon the assignment on the claim form indicated. If there is no indication on the form, payment will be made to the beneficiary. If a non-network provider submits the claim and requests that the payment be made to the enrollee, then the contractor shall forward the payment to the enrollee.

9.1. TDP network providers shall file all claims on behalf of the enrollee and shall agree not to balance bill.

9.2. Enrollees utilizing non-network providers may be balance billed for the balance of the provider’s fee (see paragraph 5.2 for exceptions when using non-network providers).

9.3. Non-network Reimbursement. The contractor shall pay the claims generated in a network compliant area when CONUS enrollees use a non-network provider (minus the appropriate cost-share) at the lesser of (1) billed charges; or (2) the network maximum allowable charge for similar services in that same locality (region) or state. The requirement for reimbursement in a non-compliant area will remain the same (see paragraph 5.2).

9.4. Coordination of Benefits. The contractor shall follow coordination of benefits rules in accordance with general industry standards and guidance set forth by the National Association of

Insurance Commissioners. Where TRICARE is secondary payer, the contractor shall reimburse the enrollee (or provider as applicable) for the patient liability amount remaining following payment by the primary payer, up to the amount the TDP would have paid had the TDP been primary.

9.5. Beneficiary Under Age One. If the contractor is unable to select a patient from the family listing provided by DEERS, the contractor shall check the patient’s date of birth. If the date of birth is within 365 days of the date of the query (i.e., a patient less than one year old), the contractor shall release the claim for normal processing.

10.0 DENTAL EXPLANATION OF BENEFITS (DEOBs). The contractor shall provide each beneficiary and provider with a DEOB. The DEOB must 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 DEOB must also provide information on the annual maximum as well as sufficient information to allow a beneficiary to file a claim with a supplemental insurance carrier. All DEOBs shall 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. Drafts/checks may be mailed separately to a provider billing address.

The contractor shall provide a duplicate DEOB at a beneficiary’s request, without charge to the beneficiary, regardless of their status.

11.0 CUSTOMER SERVICE. The contractor shall provide comprehensive, readily accessible customer services that include multiple avenues of access (for example, e-mail, World Wide

Web, telephone, and facsimile) for TDP beneficiaries and providers.

11.1. The contractor’s customer service center shall be available to answer customer inquiries in accordance with contract standards stated in C.5.1.1.9, from 6:00 p.m. Sunday to 10:00 p.m.

Friday, Eastern Time (except holidays) and on Saturday from 9:00 am – 1:00 pm Eastern Time.

The contractor’s customer service center shall be able to communicate with non-English speaking customers.

11.2. Both CONUS and OCONUS callers shall be provided long distance telephone access at no cost to call for general information, assistance in locating a provider, status of claims, or other

TDP related issues. 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.

11.3. The contractor shall provide responses to written correspondence received either via hardcopy or electronic media. Priority correspondence is correspondence received from

Members of Congress, DoD leadership and/or DHA leadership.

11.4. Web Site. The contractor shall provide a Web site that will provide information which includes, at a minimum, an explanation of the TDP benefit, promote the advantages of receiving preventive dental care, a listing of network providers accepting new patients searchable by ZIP code, and contractor contact information. This contact information shall include phone numbers, mailing, and email address(es). The Web site shall also provide online access to the TDP Dental

Benefits Booklet, the TDP Benefits Brochure, an ADA approved Provider Claim Form for use by enrollees under the TDP, and a link to DHA’s main TRICARE Web site at http://www.TRICARE.mil. The Web site design and content shall be subject to review and approval by the TRICARE Dental Program Branch prior to activation.

11.5. Misdirected Communications. The contractor shall forward, within three working 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 three working days of receipt. Out-of-jurisdiction communications include correspondence, appeals, e-mails, faxes, and phone messages.

11.6. Enrollee Alerts and Reminders. The contractor shall provide multiple types of alerts and reminders for beneficiary convenience and education. The alerts and reminders as listed below shall be sent using text, phone, PKI-compliant secure email, or direct mail depending on the enrollee’s communication preference.

• Welcome Email/Text to welcome enrollees to the program and provide links to benefit booklet.

• Appointment reminders sent to enrollees at least 24 hours prior to their scheduled dental appointments.

• Personalized appointment scheduling alerts sent one month prior to service due date to remind enrollees of the need to schedule diagnostic/preventive services.

• Tailored appointment scheduling alerts for enrollees with chronic medical conditions sent one month prior to service due date to remind enrollees of the need to schedule diagnostic/preventive service because their specific chronic conditions include a different benefit structure (e.g., diabetic enrollees receive additional preventive services).

http://www.tricare.mil/

11.7. Appointment Assistance. Enrollees may schedule an appointment online with providers who accept online appointments. Enrollees may also contact the contractor’s Customer Service

Representatives to request assistance with scheduling an appointment.

11.8. Special Needs Program. The contractor’s special needs program will clearly designate specially trained network providers who treat special needs patients in its online “Find a Dentist” application. The contractor shall provide tailored educational materials for all special needs enrollees, caregivers and network providers. In addition, the contractor shall also provide designated customer service representatives and regional liaisons for branch of service Special

Needs offices, installation Special Needs offices and Special Needs Coordinators at the Military

Treatment Facilities (MTFs).

12.0 EDUCATION REQUIREMENTS. The education of TDP beneficiaries, TDP providers, and Military Health System (MHS) staff will be accomplished through a collaborative effort between the DHA Communications, the Managed Care Support contractors (MCSCs), and other

TRICARE contractors. The contractor is responsible for providing the content of educational materials. The Government will furnish all printed educational materials. The TDP contractor will be responsible for the individual distribution of Government-furnished materials.

12.1. Education Plan. The contractor shall submit an annual education plan in accordance with

Section J, Attachment J-11, Transition-In and Exhibit A CDRL AP010, Beneficiary and Provider

Education Plan.

12.2. Interface Requirements. The contractor shall meet with and establish a Memorandum of

Understanding (MOU) with DHA Communications as stated in Section J, Attachment J-11, Transition-In and Exhibit A CDRL R110, 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.

12.3. 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 educational materials must cite the Web site www.tricare.mil/dental. This Web site will direct the beneficiary and provider to the correct dental site.

12.4. The contractor shall participate in monthly TRICARE beneficiary and provider workgroup meetings comprised of other DHA programs’ representatives and the TRICARE Beneficiary

Publications Office. The contractor shall provide unique perspectives, ideas, and recommendations regarding the development and maintenance of TRICARE educational materials to the group. Meetings may be attended via teleconference, video telecommunications, or in person, which is typically in the Washington, D.C. area.

12.5. Mass Communication Materials. The Government will print and provide the educational documents (i.e., TDP Benefits Brochure) to the contractor. Initial requests for desired education materials shall be submitted to DHA Communications during the development of the MOU after initial award of the dental contract. Requests for additional desired education http://www.tricare.mil/dental materials, not included in the annual submission of the Education Plan, shall be submitted to

DHA Communications in accordance with the established MOU. The contractor shall post all current versions of approved mass communications materials on its Web site. The contractor is responsible for the printing of any communication materials other than the TDP Benefits

Brochure. The contractor is responsible for distribution of these materials and any additional approved communication materials. The contractor shall not duplicate information that is already provided by DEERS (See TSM Chapter 3).

12.5.1. The contractor shall offer each household and provider a choice in the manner in which to receive communication materials. Methods of distributing materials shall include, but not limited to the beneficiary’s choice of either, (1) the TDP Web site where the beneficiary may read it or download a PDF version, or (2) U.S. mail. The contractor shall make every effort to reduce the mailing of hard copies.

12.5.2. The contractor shall issue two newsletters a year to enrollees. Content for one newsletter will be developed by DHA; content for the other will be developed by the contractor. The newsletters will provide updates related to benefits and coverage, and include information to assist beneficiaries in maximizing their TDP benefits. The newsletters shall also encourage a preventive approach to dental health. Additionally, the contractor shall issue two newsletters a year to providers. All newsletters will be issued in electronic format only.

12.5.3. After Ordering Period One, the contractor shall inform enrollees and dental providers 60 calendar days prior to the start of each Ordering Period, of any changes to the program for the next Ordering Period, including any premium changes.

12.6. TDP Benefits Booklet. DHA Communications shall coordinate with the contractor and the COR in developing and updating the comprehensive TDP Benefits Booklet. The TDP

Benefits Booklet shall contain the information prescribed in 32 CFR 199.13(e)(1) (iii) (A), and at a minimum it shall provide a link to Section J, Attachment J-2, Benefits, Exclusions and

Limitations of the TDP contract on the TDP website. The TDP Benefits Booklet shall clearly explain the operational procedures under the TDP to facilitate maximum use of program benefits by enrollees. The booklet shall also contain specific OCONUS dental benefits information, exceptions for Selected Reserve and IRR populations, and premium/cost-share information. The contractor shall make the TDP Benefits Booklet available on the TDP website no later than 30 calendar days prior to start of dental care delivery. The TDP Benefits Booklet will not be distributed in printed form.

12.6.1. The contractor shall inform new enrollees/households within 15 calendar days of receipt of the new enrollee’s premium payment of how to access the TDP Benefits Booklet on the TDP website.

12.6.2. DHA Communications, through the TRICARE Dental Program Branch, shall publish an updated version of the TDP Benefits Booklet, with appropriate revisions due to program changes, not to exceed two updates over the life of the contract. Annual updates shall be published in a supplement. DHA Communications will coordinate proposed changes with the contractor and the COR and submit its final draft to the contractor and the COR for review no later than 90 days prior to the intended release date. Updated versions of the TDP Benefits Booklet and any supplements will be made available on the TDP website.

12.7. TDP Benefits Brochure. DHA Communications in coordination with the contractor and the TRICARE Dental Program Branch shall develop a TDP Benefits Brochure to be used as a supplement and/or quick reference guide to the Benefits Booklet. The TDP Benefits Brochure shall provide a condensed overview of the TDP benefit. The TDP Benefits Brochure should include summary information about eligibility, enrollment, premiums, cost shares, claim filing, and policy benefits and limitations. The contractor shall make available the TDP Benefits

Brochure to the new eligibles that are identified on a quarterly file received from Defense

Manpower Data Center (DMDC) (see paragraph 12.5.1).

12.8. Copyrighted Material. The contractor may claim any copyright interest in any education materials solely produced or developed by the contractor during contract performance, and will have commercial rights in that material. These materials may or may not be combined with or include information provided by the Government. The Government will have a royalty free right to use the material as well as any product with which it is delivered while performing this contract or any subsequent contracts, for any Government purpose.

13.0. DECLARATION OF A NATIONAL DISASTER AREA. When the President of the

U.S. declares an area of Continental United States (CONUS) or any U.S. territory with a provider network to be a "National Disaster Area" the contractor shall at the earliest practical moment, begin contacting all network providers in the affected area, by the most expeditious manner available, to determine the providers ability to continue to treat current TDP patients and/or accept new TDP patients. The contractor shall provide an initial report of their findings in accordance with see Section J, Exhibit A, CDRL R050, National Disaster Action Report. The contractor shall continue to monitor the status of network providers in the affected area that stated that they were unable to treat current and/or new TDP patients. The contractor shall provide updates to the CO as stated in Section J, Exhibit A, CDRL R050, National Disaster

Action Report. The contractor shall list a toll free telephone number on their Web site for disaster victims to call for assistance. The contractor shall update the list of network providers on their Web site to indicate which network providers are currently unable to treat current TDP patients and/or accept new TDP patients and when they anticipate that these providers will again be able to treat current TDP patients and/or accept new TDP patients, and finally, which providers will not be able to treat current TDP patients and/or accept new TDP patients for the foreseeable future or will not be returning as a network provider. The contractor shall assist disaster victims with finding another provider that will provide needed care and is in, or as near as possible, to the area where the disaster victim is currently located. This assistance shall include the contractor working with the new provider to either obtain or reconstruct required patient records at minimal or no cost to patient. The contractor shall assist disaster victims, who are in an ongoing orthodontic, prosthodontic or other restorative care program, find a new provider that can continue/complete that program; will negotiate with the new provider to minimize any additional cost to be borne by the patient that is a result of their having to change to a different provider due to conditions beyond their control; will take action to capture any funds the patient had paid the previous provider for treatment that had not yet been completed and transfer those funds to the new provider. In addition to providing assistance to locate a provider, if access is jeopardized, the contractor will send mobile dental units to these areas to temporarily treat TDP enrollees until impacted offices are able to begin treating patients again.

Mobile units will be staffed with general dentists and certified dental assistants. All general and emergency care services will be available until it is no longer needed. Furthermore, enrollees who utilize mobile dental unit services will be provided with a hard copy or electronic version of treatment rendered, to include radiographs, periodontal charting, treatment notes, etc. The contractor shall waive radiograph frequency limitations, should enrollee treatment records be lost or destroyed by the national disaster. To ensure continuity of care and any follow-up care, the contractor shall keep the established toll-free hotline open for at least 60 days after the mobile dental unit has left the area to assist enrollees with appointment making and records re-establishment if needed. The contractor shall temporarily allow an additional six months after the normal contractual deadline for enrollees, impacted by the disaster, to file Dental Care

Claims. Unless otherwise directed by the CO, the contractor shall hold all outgoing mail for patients living in the designated U.S. Postal Service ZIP codes for the Disaster Area until either the patients notify the contractor of their new/temporary address for receiving mail or the U.S.

Postal Service announces that mail delivery has once again started for the disaster impacted ZIP code areas.