Prescribing Document

lak

Department of Defense

October 30, 2002

SUBJECT: Delivery of Healthcare at Military Treatment Facilities: Foreign Service
Care; Third-Party Collection; Beneficiary Counseling and Assistance
Coordinators (BCACs)
References: (a) DoD Instruction 60 15.23, "Delivery of Healthcare at Military
Treatment Facilities (MTFs),"December 9, 1996 (hereby canceled)
(b) DoD Directive 5 136.1, "Assistant Secretary of Defense (Health
Affairs),"May 27, 1994
(c) Chapter 55 and Sections 1079(a), 1073, 1095, and 2559 of title 10,
United States Code
(d) DoD 5025.1 -M, "DoD Directives System Procedures," current edition
(e) through (i), see enclosure 1
1. REISSUANCE AND PURPOSE

This Instruction:
1.1. Reissues reference (a) to implement policy, assign responsibilities and
prescribe procedures on provisions of care in the delivery of healthcare at military
treatment facilities (MTFs) in the Military Health System.
1.2. Implements policy, assigns responsibilities and prescribes procedures:
1.2.1. On international military reciprocal healthcare agreements.
1.2.2. Under DoD Directive 5 136.1 (reference (b)).
1.2.3. On Beneficiary Counseling and Assistance Coordinator responsibilities
in accordance with 10 U.S.C. 1095e (reference (c)).

DODI 6015.23, October 30, 2002

1.3. Authorizes DoD 60 15.1-M, "Classification Nomenclature and Definitions
Relating to Fixed and Non-fixed MTFs" and DoD 60 10.15-M, "Military Treatment
Facility Uniform Business Office (UBO)," in accordance with DoD 5025.1 -M
(reference (d)).
2. APPLICABILITY
This Instruction applies to the Office of the Secretary of Defense, the Military
Departments, the Chairman of the Joint Chiefs of Staff, the Combatant Commands, the
Office of the Inspector General of the Department of Defense, the Defense Agencies,
the DoD Field Activities, and all other organizational entities in the Department of
Defense (hereafter referred to collectively as "the DoD Components").
3. POLICY
It is DoD policy that:
3.1. The Secretary of Defense, under Title 10 U.S.C. 1073 (reference (c)),
generally administers programs and activities of Chapter 55 of reference (c) for the
Armed Forces; under his jurisdiction, the Secretary of Transportation administers such
programs and activities for the Coast Guard when the Coast Guard is not operating as a
Service in the Navy; and the Secretary of Health and Human Services administers such
programs and activities for the Commissioned Corps of the National Oceanic and
Atmospheric Administration and for the Commissioned Corps of the U.S. Public Health
Service. Reference (b) delegates the Secretary of Defense's authority to the Assistant
Secretary of Defense for Health Affairs.
3.2. Under 10 U.S.C. 2559 (reference (c)), the Department of Defense shall make
MTF inpatient medical care available without cost (except for a subsistence charge, if it
applies) to the foreign force members and their dependents in the United States from
countries that have international reciprocal healthcare agreements with the Department
of Defense (as determined by the Assistant Secretary of Defense for Health Affairs)
and where comparable care is made available to a comparable number of U.S. Military
personnel and their dependents in the foreign country. Foreign force members eligible
for inpatient care under these criteria are also eligible for supplemental care similar to
that which is available for non-active duty patients receiving care in military treatment
facilities.

DODI 6015.23, October 30, 2002

3.3. Foreign force members and their dependents in the United States who do not
meet the criteria in paragraph 3.2., and who are otherwise eligible for and receive MTF
inpatient and outpatient medical care, must reimburse that facility for such care at the
appropriate DoD reimbursement rate.
3.4. Foreign military members and their dependents in the United States who are
not covered by an international reciprocal healthcare agreement shall be offered DoD
healthcare to the extent authorized by the regulations of the Military Departments.
3.5. Foreign governments may submit requests for international reciprocal
healthcare agreements to the Assistant Secretary of Defense for Health Affairs. The
request must include:
3.5.1. A description of the foreign country's military healthcare; and
3.5.2. The numbers of foreign military members and dependents expected to
be covered by the agreement.
3.6. Foreign personnel subject to North Atlantic Treaty Organization Status of
Forces Agreement (SOFA) or countries under the Partnership For Peace SOFA, their
dependents and diplomatic personnel accompanying the forces, may receive medical and
dental care in Uniformed Service facilities. Outpatient care in facilities of the
Uniformed Services is provided at no cost to the covered personnel or sponsoring
agency; inpatient care is provided at the appropriate DoD-established reimbursement
rate. CHAMPUS/TRICARE Standard coverage is only available for outpatient care.
3.7. The MTF or Unit Commander shall establish and maintain a business office
that encompasses Third-Party Collection, Medical Afirmative Claims, and Medical
Services Account Programs. The business office shall:
3.7.1. Collect those funds from third-party payers to the fullest extent allowed
by law and 32 CFR 220 (reference (e)).
3.7.1. Deposit all Third-Party Collection (TPC) Program funds into the
appropriations supporting the MTF where the billed service was provided in the fiscal
year in which collections were made. These collections shall be available to the local
facility of the Uniformed Services responsible for the collections and shall be over and
above the facility's direct budget amount in accordance with Title 10, section 1095,
Subchapter A, Part II, Chapter 55 (reference (c)).

DODI 6015.23, October 30,2002

3.7.1.1. Funds collected under the TPC Program shall be used, except for
amounts needed to finance collection activities, to enhance healthcare services.
3.7.1.2. Collect b d s through Medical Services Accounts and Medical
Affirmative Claims programs. These b d s shall be deposited into the appropriations
supporting the facility of the Uniformed Service in accordance with DoD and
Service-specific guidance.
3.8. MTFs shall issue a non-availability statement (NAS) to non-enrolled (i.e.,
Standard or Extra) TRICARE beneficiaries for authorized non-emergency inpatient
care. In some areas, the Managed Care Support Contractors may issue NASs after
reaching a formal agreement with the local MTF Commander (or Commanders) and the
appropriate Lead Agent Office. NAS may be issued only when the care required is not
available from an MTF and the catchment area includes the beneficiary's current
address. Occasionally, the MTF Commander (or designee) may decide it is medically
inappropriate for the beneficiary to use the MTF (e.g., a transportation support problem)
and issue the NAS on that basis. NAS issuance procedures shall be consistent with NAS
requirements in 32 CFR 199.7 (reference (0).
3.9. In accordance with 10 U.S.C 1095e (reference (c)) and prescribed herein, Lead
Agents and MTF Commanders shall establish full-time Beneficiary Counseling and
Assistance Coordinator (BCAC) positions at Lead Agent Offices, and either full-time or
collateral duty positions at MTFs, as the MTF Commander determines.
4. RESPONSIBILITIES
4.1. The Assistant Secretary of Defense for Health Affairs (ASD(HA)) shall:
4.1.1. Modify, supplement, and monitor compliance with this Instruction.
4.1.2. Determine parity, negotiate, and conclude the requests for reciprocal
healthcare agreements.
4.1.3. Be responsible for:
4.1.3.1. Coordinating proposed international reciprocal healthcare
agreements with the Under Secretary of Defense for Policy, Under Secretary of
Defense (Comptroller), General Counsel of the Department of Defense, and appropriate
other DoD Components;

DODI 6015.23, October 30,2002

4.1.3.2. Providing copies of concluded agreements to appropriate DoD
Components;
4.1.3.3. Furnishing guidance concerning application of the agreements.
4.1.4. Determine that comparable care is available to a comparable number of
United States force members and their dependents in the foreign country concerned and
that an appropriate international agreement exists with the foreign country.
4.1.5. Act on recommendations for international reciprocal healthcare
agreements foreign governments submit, and negotiate and conclude any necessary
international agreements, consistent with DoD Directive 5530.3 (reference (g)).
4.1.6. Set policies concerning NASs and catchment areas.
4.2. The Secretaries of the Military Departments shall:
4.2.1. Be responsible for reviewing procedures that the Military Departments
establish to ensure compliance with this Instruction.
4.2.2. Comply with international reciprocal healthcare agreements.
4.2.3. Budget for the medical and dental care it anticipates furnishing to
eligible foreign personnel under its sponsorship in non-military and U.S. Government
facilities, other than military. They shall also use payment procedures and rates they
use for U.S. personnel.
4.2.4. Ensure that each Commander of an MTF submit, to their respective
biometrics agencies, workload information, including live births, admissions and
dispositions, days of care, visits, and ancillary services, by the fifth of the next month.
The biometrics agencies review it and, if necessary, work with the site to correct it.
The MTF shall release the report by the fifteenth of the following month.
4.2.5. Act on requests for changes in clinical services at MTFs as
recommended by respective military command authorities and inform the regional Lead
Agent regarding these decisions.
4.2.6. Ensure that each Commander of an MTF designates a BCAC, and
Alternate BCAC, either full time or as a collateral duty.
4.3. The Director. TRICARE Management Activitv (TMA) shall:

DODI 6015.23. October 30,2002

4.3.1. Ensure each Lead Agent designates a full-time BCAC and an Alternate
BCAC.
4.3.2. Assume responsibility to coordinate with the Services regarding any
modifications to that portion of this Instruction dealing with BCAC support.
4.3.3. Ensure toll-free telephone communication between beneficiaries and
Lead Agent BCACs.
4.3.4. Ensure Lead Agent BCACs receive the most current TRICARE policy
information to help address beneficiary issues and concerns.
4.3.5. Ensure that Lead Agent BCACs receive customer service training.
4.3.6. Ensure that appropriate directorates within TMAprovide Lead Agent
BCACs with current TRICARE policy information and customer service training.
5. PROCEDURES

5.1.1. ANAS is not required when there is a medical emergency, when a
beneficiary has another health insurance plan that provides primary coverage for the
cost of their medical services, or when the beneficiary is enrolled in TRICARE Prime.
For TRICARE Prime enrollees, the primary care manager or healthcare finder shall
write a referral. The MTFs, OCONUS Lead Agents, the Military Medical Support
Office, or regional managed care support contractors issue a "valid care authorization."
5.1.1.1. Electronically issued NASs shall be valid for thirty (30) days.
All issued NASs shall be reported on the Defense Eligibility Enrollment Reporting
System or Composite Health Care System.
5.1.1.2. The h4TF Commander (or senior designated physician) may issue
a NAS retroactively for medical care provided by civilian sources.
5.1.2. The h4TF Commander (or senior designated physician) shall determine
the availability of equitable services provided within the MTF. Adecision regarding the
medical necessity of each beneficiary's request for inpatient care is not to be a
consideration in the issuance of a NAS. The timeframe to issue a NAS, once requested,

DODI 6015.23, October 30, 2002

is the same as the pre-authorization review timeline standards specified in the managed
care support contracts.
5.1.3. The first-level appeal for decisions surrounding NAS issuance is the
MTF Commander, the second-level appeal is the TRICARE Lead Agent, and the third and
final level of appeal is the Service Surgeon General of the sponsor's Service.

6. INFORMATION REOUIREMENTS
The patient care data collected for compliance with this requirement shall be reported
using the Report Control Symbol of RCS DD-HA(AR)1453, in accordance with DoD
8910.1-M (reference (h)). Definitions of the data elements and codes must be the
same for all three Military Services. New facilities must be given identification codes
by the OASD(HA) and properly identified when initially reporting their data. The
reporting requirement identified at subparagraph 4.2.4. is exempt from licensing in
accordance with section 6 of DoD Directive 89 10.1 (reference (i)).
7. EFFECTIVE DATE
This Instruction is effective immediately.

William Winkenweder, Jr., MI3
Assistant S w m w of Dcfcnsc {Health Affiin)

Enclosures - 2
E 1. References, continued
E2. Roles and Responsibilities for Beneficiary Counseling and Assistance
Coordinators

DODI 6015.23. October 30, 2002

El. ENCLOSURE 1
REFERENCES, continued
(e) Title 32, Code of Federal Regulations, Part 220, "Collection from Third-Party
Payers of Reasonable Costs of Healthcare Services," current edition
(f) Title 32, Code of Federal Regulations, Part 199, "Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS),"current edition
(g) DoD Directive 5530.3, "International Agreements," June 11, 1987
(h) DoD 89 10.1-M, "DoD Procedures for Management of Information Requirements,"
November 28,1986
(i) DoD Directive 89 10.1, "Management and Control of Information Requirements,"
June 11,1993,

ENCLOSURE 1

DODI 6015.23. October 30,2002

E2. ENCLOSURE 2
ROLES AND RESPONSIBILITIES FOR
BENEFICIARY COUNSELING AND ASSISTANCE COORDINATORS (BCACs]
E2.1. GENERAL ROLES
As developed between the Services and TMA, BCACs shall carry out their
responsibilities and fulfill their generalized roles to:
E2.1.1. Serve as beneficiary advocates and problem solvers, providing dedicated
service to all MHS beneficiaries.
E2.1.2. Receive inquiries directly from beneficiaries, the DoD Components, other
Agencies, and various interested parties.
E2.1.3. Coordinate with appropriate points of contact throughout the MHS,
including Managed Care Support Contractor (MCSC) points of contact, to best meet
beneficiary needs for information or assistance.
E2.1.4. Help resolve issues by openly communicating with all involved parties.
E2.1.5. Ensure TRICARE information and assistance with accessing healthcare
services is available across the TRICARE system for eligible beneficiaries.
E2.1.6. Help beneficiaries resolve concerns when they are not satisfied with
services from other parties.
E2.1.7. Counsel beneficiaries and clarify information on their TRICARE benefit
(including such options as TRICARE Prime Remote, TRICARE For Life, Dental
Programs, and other Demonstrations1 Projects, etc.) and consult with others as
necessary.
E2.1.8. Work with functional experts to provide enrollment, beneficiary
counseling, and claims processing information. BCACs shall describe or seek
clarification on eligibility requirements and benefits based on the category of
beneficiary seeking assistance.
E2.1.9. Respond, as directed, to beneficiary, provider, and congressional inquires
on TRICARE matters.

ENCLOSURE 2

DODI 6015.23, October 30, 2002

E2.1.10. Address access to healthcare complaints, ensuring that beneficiaries get
the appropriate benefits and services to which they are entitled.
E2.2. OPERATIONAL ACTMTIES
E2.2.1. Lead Agent BCACs shall:
E2.2.1.1. Be responsible for working beneficiary issues that cross regional
boundaries.
E2.2.1.2. Disseminate current and correct information on TRICARE
regulations and policies to MTF BCACs as needed to facilitate MTF BCACs' ability to
perform their jobs.
E2.2.1.3. Act as liaisons to resolve issues with MTF BCACs, MCSCs, Fiscal
Intermediaries, the Services, and other concerned parties, when such issues are not
resolved at the local level.
E2.2.2. BCACs shall:
E2.2.2.1. Follow-up on and troubleshoot problems beneficiaries have
processing claims, enrolling in programs, and receiving authorization for services or
other system problems that are exceedingly complicated, unduly delayed, or
inappropriately handled.
E2.2.2.2. Bring identified systemic problems to the appropriate Lead Agent or
h4TF point of contact to address.
E2.2.2.3. Analyze, research, and resolve TRICARE inquires, regardless of how
they were received; i.e., written, telephonic, and/or electronic (e-mail).
E2.2.2.4. Provide information and assistance based on personal, written, or
telephone inquiries and address inpatient and outpatient care based on TRICARE
program elements.
E2.2.2.5. Maintain statistical data and generate reports to Lead Agent
Directors and/or MTF Commanders on workload volume and categories of issues they
encountered.

ENCLOSURE 2

DODI 6015.23. October 30,2002

E2.2.2.6. Use information gleaned from reports to make suggestions for
developing and marketing beneficiary education efforts to improve understanding of
issues.
E2.2.2.7. Maintain formal documentation process for tracking problem
resolution.
E2.2.2.8. Ensure external communications are consistent with the strategies
and objectives established by Lead Agents.
E2.3. CONTACTS REOUlRED FOR BCAC DUTIES
BCACs shall:
E2.3.l. Facilitate ongoing, appropriate, and effective communication with Lead
Agent Offices, MTF BCACs, TRICARE Service Centers (TSCs), MCSCs, and others
when coordinating on and resolving issues.
E2.3.2. Coordinate with staff subject matter experts on issues, as necessary.
E2.3.3 Keep the military chain of command, the Services, and TMA informed of
ongoing issues and special cases.
E2.3.4. Maintain a continuing cooperative relationship with various agencies,
including Offices of the Lead Agent; the Service Surgeon General offices; MTFs, TSCs,
MCSC regional and corporate offices; TRICARE Management Activity; Social Security
Administration; Centers for Medicare and Medicaid Services; Department of Veterans
Affairs; Dental Agencies; Fiscal Intermediaries and/or Claims Processing Offices; and
Congressional field offices.
E2.4. CLAIMS ASSISTANCE
BCACs shall:
E2.4.1. Provide or directly communicate information on healthcare services that
TRICARE covers and excludes and convey how these benefits and policies integrate with
other healthcare sources.
E2.4.2. Explain a beneficiary's costs and responsibilities when enrolling in
TRICARE Prime or accessing services under the TRICARE Extra or Standard options.
11

ENCLOSURE 2

DODI 6015.23, October 30,2002

E2.4.3. Help beneficiaries understand the TRICARE claims process, including
information on resolving unpaid healthcare claims, pre-authorization requirements, and
third-party liability.
E2.4.4. Help resolve DEERS eligibility and enrollment problems.
E2.5. APPEALS AND GRIEVANCES
E2.5.1. Lead Agent BCACs shall:
E M . 1.1. Handle issues received from beneficiaries, MTFs, or TSCs that staff
there has not been able to resolve.
E2.5.1.2. Work directly with beneficiaries who feel they have exhausted the
MHSIMCSC system andlor have become dissatisfied with services they received.
E2.5.2. BCACs shall:
E2.5.2.1. Explain appeals and grievance procedures and advise beneficiaries on
the appropriate use of these procedures.
E2.5.2.2. Refer cases to points of contact that can provide detailed and
specific information on how to access TRICARE services and what steps beneficiaries
can take if not satisfied with services received.
E2.6. KNOWLEDGE AND SKILLS
The Lead Agent BCAC requires the following:
E2.6.1. Expert knowledge of the TRICARE program policies and reference
manuals.
E2.6.2. In-depth knowledge, experience, and training to handle and solve complex
issues that arise when addressing healthcare benefits.
E2.6.3. Tact, diplomacy, and restraint in counseling and explaining entitlements,
benefits, and responsibilities to all beneficiaries.
E2.6.4. Understanding of the MHS and TRICARE program elements.

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DODI 6015.23. October 30,2002

E2.6.5. Mastery of oral and written communication skills and customer service
principles, methods, practices, and techniques and analytic methods, including using
research tools, analysis, and interpersonal relations practices.
E2.6.6. Practical knowledge and understanding of TRICARE contract language,
regional healthcare issues and initiatives, and other Federal health benefits programs.
E2.6.7. Knowledge of basic principles and practices relating to the entire military
healthcare delivery system.
E2.6.8. Knowledge of TRICARE healthcare claims processing regulations,
procedures, and policies to ensure payment of legitimate claims.
E2.6.9. Knowledge of region-specific TRICARE contracts relating to authorized
benefits and requirements needed to obtain healthcare.
E2.7. COMPLEXITIES ASSOCIATED WITH THE BCAC POSITION
The BCAC shall:
E2.7.1. Have a thorough understanding of the TRICARE benefit, related regional
contracts, and MTF andlor Service-specific regulations, including practical knowledge
of TRICARE special benefit programs and general understanding of the MHS.
E2.7.2. Remain abreast of continual updateslchanges to the variety of health
benefits programs available to beneficiaries at the appropriate OASD(HA), Th4A,
regional, and h4TF level.
E2.7.3. Be able to organize, prioritize, complete, and track multiple complaints,
issues, and projects.
E2.7.4. Exercise a great deal of initiative, independence, and considerable
judgment in interpreting issues and adapting existing practices and precedents, using
these skills when developing approaches that integrate all aspects of TMA's objectives
to establish a unified beneficiary services program.
E2.7.5. Prioritize and reconcile benefit issues, working through different
sources/agencies.

ENCLOSURE 2

DODI 6015.23, October 30,2002

E2.7.6. Use Guidelines and Regulations that are often complex and under
continuous change, cover many different programs, and may require extensive
interpretive judgment.
E2.8. RESOURCES AVAILABLE TO BCACS
E2.8.1. The BCACs most frequently use OASD(HA)KRICARE policy and program
documents, managed care support contracts, DoD documents, Directives, Manuals, and
Service-level instructions. They also use:
E2.8.1.1. General policy statements and statutory mandates, such as general
guidance in DoD Instructions pertaining to correspondence.
E2.8.1.2. Applicable TMAOperations and Policy Manuals, including the
appropriate Code of Federal Regulations.
E2.8.2. MTF Commanders shall define, under the guidance of their respective
Military Departments, specific details regarding MTF BCAC roles and responsibilities.
E2.9. OPERATIONAL ACI'MTIES PERFORMED BY BCACs
E2.9.1. The BCAC, whom the beneficiary contacts, assumes responsibility for the
issue and/or inquiry from the time of initial contact until the issue is resolved.
E2.9.2. BCACs shall assign a case identifier to each beneficiary case, using a
Service and/or TMA-developed database or program. BCACs shall track cases,
categorizing caseload by data elements and timeliness of resolution.
E2.9.2.1. After the Lead Agent BCAC assigns a case identifier and the data is
entered, BCACs shall determine whether the issue shall be resolved at the Lead Agent
or other level, i.e., MTF, Services, TMA, or MCSC, forwarding appropriate cases as
necessary. MTF's BCACs shall follow these same procedures.
E2.9.2.2. Lead Agent BCACs shall annotate confirmation of case acceptance
and identification of the responsible action point of contact for cases referred out to
others. MTF Commanders and MTF BCACs shall develop internal processes to ensure
tracking of all cases.

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DODI 6015.23, October 30,2002

E2.9.2.3. Lead Agent BCACs shall assist and ensure cases referred to other
action offices meet identified resolution timeline requirements. MTF Commanders and
MTF BCACs shall establish internal procedures to achieve the same result.
E2.9.3. BCACs shall comply with case completion time requirements as follows:
Resolve "Priority"cases, i.e., those cases forwarded on behalf of a beneficiary by
OASD(HA), TMA, members of Congress or those otherwise designated as Priority by
the Lead Agent/MTF Commander, within ten (10)-calendar days. Resolve Routine
issues within thirty (30)-calendar days. BCACs may modify the established case
resolution timelines to meet compliance standards.
E2.10. CASE CLOSURE
The BCAC accepting a specific case shall notify the beneficiary of case closure and
determine beneficiary satisfaction with case outcome via an oral, written, or automated
process.
E2.11. COORDINATION
BCACs are responsible for coordinating data and generating reports on beneficiary issue
caseloads.
E2.11.1. Lead Agent and MTF BCACs shall provide data input based on established
methodology to support MHS-wide reporting. TMA (Communications and Customer
Service) will create and distribute regional and Service-specific reports, based on data
input received through coordination with the Services.
E2.11.2. Lead Agent BCACs shall generate regional or MTF-specific ad hoc
reports as required by Lead Agent Directors andlor MTF Commanders to meet specific
needs.

ENCLOSURE 2