BENEFICIARY SERVICES Clause Samples
The Beneficiary Services clause defines the range of services that will be provided to beneficiaries under an agreement. It typically outlines the specific types of assistance, support, or resources that beneficiaries are entitled to receive, such as healthcare, counseling, or financial aid, and may detail eligibility requirements or procedures for accessing these services. By clearly specifying what services are included and how they are delivered, this clause ensures that both the provider and the beneficiaries have a mutual understanding of the scope of support, thereby reducing misunderstandings and setting clear expectations.
BENEFICIARY SERVICES. 5.1 The TOP contractor shall achieve the highest level of beneficiary satisfaction possible in the overseas environment. This shall be accomplished by developing qualified purchased care sector provider networks (complemented by non-network purchased care sector providers as necessary), ensuring timely access to purchased care sector care, providing TOP information/education/training to beneficiaries and purchased care sector providers, and processing claims in a timely, accurate manner.
5.2 In addition to the beneficiary education requirements outlined in Chapter 11, Sections 1 and 2, the TOP contractor may be required to conduct beneficiary education/enrollment activities for arriving/deploying units in accordance with the enrollment protocols established in the MOU between the TOP contractor and the MTFs.
5.3 The TOP contractor shall maintain up-to-date lists of purchased care sector network providers, and shall make this information available at all TOP TSCs and via web-based access. Web-based network provider listings shall include information regarding authorization requirements that are applicable to TOP Prime and Prime Remote enrollees.
5.4 The TOP contractor’s beneficiary education activities and materials shall include information for TOP Prime and Prime Remote enrollees regarding care received in the 50 U.S. and the District of Columbia. This process shall include information regarding referrals/authorizations while stateside, TOP POS policy, and the recommended process for accessing care while stateside. TOP Prime and Prime Remote enrollees traveling stateside shall be encouraged to utilize MTF care whenever possible. If MTF care is not available, beneficiaries should be encouraged to seek care from a network provider before obtaining care from a non-network provider.
5.5 The requirement in Chapter 11, Section 2, paragraph 1.1, is superseded for the TOP contractor by a requirement for a total of nine three-day TRICARE training courses per contract option period (two per option period within the TRICARE Eurasia-Africa area; two within the TRICARE Pacific area; two within the TRICARE Latin America/Canada (TLAC) area; and three additional courses that may occur in any stateside or overseas location at the direction of the Contracting Officer (CO)). Note: Only the frequency requirements of Chapter 11, Section 2, paragraph 1.1 are superseded; all other requirements of the referenced paragraph apply to the TOP contractor.
5.6 The requirement for mail...
BENEFICIARY SERVICES.
2.9.1. Beneficiary Service Representatives (BSRs)
2.9.1.1. The ICDS Plan must employ BSRs trained to answer Beneficiary inquiries and concerns from Beneficiaries and prospective Beneficiaries, consistent with the requirements of 42 C.F.R. §§ 422.111(h) and 423.128(d) as well as the following requirements:
2.9.1.1.1. Be trained to answer inquiries and concerns from Beneficiaries and prospective Beneficiaries;
2.9.1.1.2. Be trained in the use of TTY, Video Relay services, remote interpreting services, how to provide accessible PDF materials, and other alternative formats;
2.9.1.1.3. Be capable of speaking directly with, or arranging for an interpreter to speak with, Beneficiaries in their primary language, including American Sign Language (ASL), or through an alternative language device or telephone translation service;
2.9.1.1.4. Inform callers that interpreter services are available and are free.
2.9.1.1.5. Be knowledgeable about Ohio Medicaid, Medicare, and the terms of the Contract, including the Covered Services listed in Appendix A;
2.9.1.1.6. Be able to respond to requests for information from beneficiaries regarding how to request a service, or the status of an existing Prior Authorization request/Coverage Determination request.
2.9.1.1.7. Be available to Beneficiaries to discuss and provide assistance with resolving Beneficiary Grievances and Appeals;
2.9.1.1.8. Have access to the ICDS Plan’s Beneficiary database and an electronic Provider directory;
2.9.1.1.9. Make oral interpretation services available free-of-charge to Beneficiaries in all non-English languages spoken by Beneficiaries, including ASL;
2.9.1.1.10. Maintain the availability of services, such as TTY services, computer-aided transcription services, telephone handset amplifiers, assistive listening systems, closed caption decoders, videotext displays and qualified interpreters and other services for deaf and hard of hearing Beneficiaries;
2.9.1.1.11. Demonstrate sensitivity to culture, including disability culture and the independent living philosophy;
2.9.1.1.12. Provide assistance to Beneficiaries with cognitive impairments; for example, provide written materials in simple, clear language, and individualized guidance from BSRs to ensure materials are understood;
2.9.1.1.13. Provide reasonable accommodations needed to assure effective communication and provide Beneficiaries with a means to identify their disability to the ICDS Plan;
2.9.1.1.14. Maintain employment standards and requ...