Compliments Grievances and Appeals

<h2>COMPLIMENTS GRIEVANCES AND APPEALS</h2> <h4>{margintop=5;nomargin:}Compliments</h4> {fontweight=500:What Is A Compliment?} A compliment is described as any verbal or written expression of satisfaction or appreciation beyond the normal thank you for assistance. {fontweight=500:How Can I Compliment My Provider?} Beneficiaries can compliment services they have received from TOP Providers via email at: <a href="mailto:TOPGlobalQualityAssu@internationalsos.com" target="_blank">TOPGlobalQualityAssu@internationalsos.com</a> <h4>Grievances</h4> {fontweight=500:What Is A Grievance?} A grievance is a written complaint or concern about a non-appealable issue regarding a perceived failure by any member of the health care delivery team. Any TRICARE civilian or military provider, TRICARE beneficiary, sponsor, parent or guardian or other representative of an eligible beneficiary may file a grievance. International SOS as the TRICARE Overseas Program (TOP) Contractor is responsible for investigating and resolving all grievances. Grievances are generally resolved within 60 days of receipt. Following resolution, International SOS will notify the party submitting the grievance that the review is complete. Grievances may include such issues as: <ul> <li>The quality of health care or services (e.g., accessibility, appropriateness, level of care, continuity, timeliness of care)</li> <li>The demeanor or behavior of providers and their staffs</li> <li>The performance of any part of the health care delivery system</li> <li>Practices related to patient safety</li> </ul> {fontweight=500:How Can I File A Grievance?} The following information is required for International SOS to investigate and work toward resolving your emailed grievance: {marginleft=-2;marginright=5;fontsize=18:• } Contact Information, including:{margintop=-5;nomargin:} <ul> <li>Beneficiary’s name, address, and telephone number</li> <li>Individual or institutional provider contact details</li> </ul> {marginleft=-2;marginright=5;fontsize=18:• } Beneficiary’s date of birth{margintop=-30;nomargin:} {marginleft=-2;marginright=5;fontsize=18:• } A description of the issue or concern, including:{margintop=-10;nomargin:} <ul> <li>Date and time of the event</li> <li>Name of the provider(s) and/or person(s) involved</li> <li>Location of the event (address)</li> <li>The nature of the concern or complaint</li> <li>Details describing the event or issue</li> </ul> {fontweight=500:Note:} If you are not the involved beneficiary and the beneficiary is age 18 or younger, the adult beneficiary must complete the ‘Authorization to Disclose’ form below, so that International SOS can respond directly to you. If we do not receive an ‘Authorization to Disclose’ form, then International SOS will respond directly to the adult beneficiary. {marginleft=20;downloaddocs=/beneficiaries/tco-media/documents/dd2870_beneficiaries:Authorization to Disclose} To file a grievance by email, <a href="mailto:TOPGlobalQualityAssu@internationalsos.com" target="_blank">click here</a>. {fontweight=500:*Note:} To protect your personal information, send the documents password-protected with the password in a separate email. Grievances can also be mailed to International SOS at the following address, using the attached PDF form: {marginleft=18;nomargin;downloaddocs=/beneficiaries/tco-media/documents/grievance--auth-to-disclose-form-final-june2016: Grievance Form}{margintop=-25;nomargin:} {marginleft=40;undecoratedlist;fontweight=normal: <ul> <li>International SOS Government Services, Inc.</li> <li>Reconsideration/Grievances Department</li> <li>P.O. Box 11570</li> <li>Philadelphia, PA 19116 USA}</li> </ul> {fontweight=500:Additional Information on Grievances} To learn more about grievances, including what to submit and what can be appealed, visit{nomargin:}  <a href="http://www.tricare.mil/appeals" target="_blank">www.tricare.mil/appeals</a> (or <a href="http://www.tricare.mil/grievance" target="_blank">www.tricare.mil/grievance</a>) If you have any questions about the grievance process, please {contentlink=/contact-us:contact your TOP Regional Call Center} (listen carefully to the prompts for the best option to serve you) or send an email to the TOP Quality Assurance Team at: <a href="mailto:TOPGlobalQualityAssu@internationalsos.com" target="_blank">TOPGlobalQualityAssu@internationalsos.com</a> {fontweight=500:Note:} To protect your personal information, please ensure when sending this document via email, that you send it as a password protected attachment, with the password sent in a separate email. <h4>Appeals</h4> {fontweight=500:What Is An Appeal?} An appeal under TRICARE is an administrative review of program determinations made under the provisions of law and regulation. Beneficiaries who disagree with certain decisions related to their benefits made by Defense Health Agency (DHA) or by International SOS/TRICARE Overseas Program have the right to appeal that decision. {fontweight=500:How Does The Appeal Process Work?} The appeals process varies, depending on the nature of the appeal. The specific appeal requirements and processes can be found by visiting: <a href="http://tricare.mil/appeals" target="_blank">http://tricare.mil/appeals</a> Those following areas that may be subject to appeal within the TRICARE Overseas Program are considered factual determinations: <ul> <li>A decision denying TRICARE payment for services or supplies received.</li> <li>A decision denying pre-authorization for requested services or supplies.</li> <li>A decision terminating TRICARE payment for continuation of services or supplies that were previously authorized.</li> </ul> For additional information about factual determination processes, visit: <a href="http://tricare.mil/appeals" target="_blank">http://tricare.mil/appeals</a> {fontweight=500:What If I Don’t Agree With The Appeal Decision?} If you disagree with our decision, you have the right to request reconsideration. Your request must be in writing and state the specific matter in which you disagree. It is necessary that your written request is received within 90 calendar days of the date that you received the notice of initial denial determination or EOB from International SOS / TRICARE Overseas Program Claims Processor. Upon receipt of your request for reconsideration, we shall complete a full review of your request within 60 calendar days after the date of receipt. Your reconsideration can be mailed to the following address:{marginleft=40;undecoratedlist;fontweight=normal: <ul> <li>International SOS Government Services, Inc.</li> <li>Reconsideration/Grievances Department</li> <li>P.O. Box 11570</li> <li>Philadelphia, PA 19116 USA}</li> </ul> If the reconsideration determination upholds the denial based on a statutory or regulatory exclusion, further appeal is not available. Disputes challenging a requirement of law or regulation are ineligible for appeal to a formal review or hearing. If the reconsideration determination offers further appeal rights, you have the right to file a written request for a formal review with the DHA Appeals and Hearings Division within 60 days of the date of the reconsideration decision:{marginleft=40;undecoratedlist;fontweight=normal: <ul> <li>Defense Health Agency</li> <li>Appeals, Hearings & Claims Collection Division</li> <li>16401 E. Centretech Parkway</li> <li>Aurora, CO 80011-9066}</li> </ul> If you cannot or do not wish to pursue the appeal personally, or wish to have another person directly assist in pursuing an appeal, you may appoint a representative to act in your behalf at any level of the appeal process. The appointment of a representative must be in writing and must be signed by the proper appealing party or an individual must be appointed to act as representative by a court of competent jurisdiction. All correspondence relating to the appeal shall be directed to the representative. {marginleft=20;downloaddocs=/beneficiaries/tco-media/documents/Appointment_of_Appeal_Representation_and_Authorization_to_Disclose_Information:Appointment of Appeal Representation & Authorization to Disclose Information Form} For any claims related appeals, please send the Appointment of Appeal Representative and Authorization to Disclose Information form to: {marginleft=40;undecoratedlist;fontweight=normal: <ul> <li>TRICARE Overseas Program Appeals</li> <li>P.O. Box 7889</li> <li>Madison, WI 53707-7889</li> <li>USA}</li> </ul>

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