ts08 change 97 published paper...

CHANGE 977950.2-MOCTOBER 19, 2017

2

REMOVE PAGE(S) INSERT PAGE(S)

CHAPTER 2

Section 2.4, pages 7 and 8 Section 2.4, pages 7 and 8

Section 2.5, pages 1 through 14 Section 2.5, pages 1 through 15


Section 2.7, pages 27, 28, 35, and 36 Section 2.7, pages 27, 28, 35, and 36

Section 2.10, pages 5, 6, 21, and 22 Section 2.10, pages 5, 6, 21, and 22



Section 5.2, pages 1 - 8, 15, 16, and 19 - 28 Section 5.2, pages 1 - 8, 15, 16, and 19 - 29





Section 7.1, page 5 Section 7.1, page 5

Addendum L, pages 1 through 5 Addendum L, pages 1 through 7

CHAPTER 3


Section 1.4, pages 1 - 4 and 7 - 43 Section 1.4, pages 1 - 4 and 7 - 49

TRICARE Systems Manual 7950.2-M, February 1, 2008Chapter 2, Section 2.4

Data Requirements - Institutional/Non-Institutional Record Data Elements (A - D)

7

DATA ELEMENT DEFINITION

ELEMENT NAME: AGR SERVICE LEGAL AUTHORITY CODE

RECORDS/LOCATOR NUMBERS

RECORD NAME LOCATOR# OCCURRENCES REQUIRED

InstitutionalNon-Institutional

1-0652-056

11

YesYes

PRIMARY PICTURE (FORMAT) One (1) alphanumeric character

DEFINITION The code that represents the source of the legal authority for Active Guard and Reserve service. Download field from DEERS.

CODE/VALUE SPECIFICATIONS A AGR under 10 USC 10301 (reference (b))

B AGR under 10 USC 10211 (reference (b))

C AGR under 10 USC 12301 (d) (reference (b))

D AGR under 10 USC 12310 (reference (b))

E AGR under 10 USC 12501 (reference (b))

F AGR under 10 USC 3015/3019/8019 (reference (b))

G AGR under 10 USC 3033/8033 (reference (b))

H AGR under 10 USC 3496/8496 (reference (b))

I AGR: 14 USC 276

J AGR under 32 USC 502(f ) (reference (m))

K AGR under 32 USC 503 (reference (m))

L AGR under 32 USC 708 (reference (m))

M MILTECH Section 10216 of 10 USC

N 32 USC 112 (reference (n)) (Drug Interdiction)

O 32 USC 504

P 32 USC 505

Q 32 USC 508

X AGR: Other

Z Unknown/Not Applicable

ALGORITHM N/A

SUBORDINATE AND/OR GROUP ELEMENTS

SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:If the DEERS response does not return an AGR SERVICE LEGAL AUTHORITY CODE, report ‘Z’ in this field.If the person is not on DEERS but claim is payable (i.e., government liability), report ‘Z’ in this field.

C-70, November 26, 2014


Data Requirements - Institutional/Non-Institutional Record Data Elements (A - D)

8


ELEMENT NAME: AMBULATORY PAYMENT CLASSIFICATION (APC) CODE



Non-Institutional 2-330 Up to 99 Yes1

PRIMARY PICTURE (FORMAT) Five (5) alphanumeric characters.

DEFINITION Grouping that categorizes outpatient visits according to the clinical characteristics, the typical resource use, and the costs associated with the diagnoses and the procedures performed when paid under the Outpatient Prospective Payment System (OPPS).

CODE/VALUE SPECIFICATIONS Refer to DHA’s OPPS web site at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Outpatient-Prospective-Payment-System. Must be left justified and blank filled.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:1 Required on all TED records reimbursed under the OPPS.

C-97, October 19, 2017

http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Outpatient-Prospective-Payment-System


1

TRICARE Systems Manual 7950.2-M, February 1, 2008TRICARE Encounter Data (TED)

Chapter 2 Section 2.5

Data Requirements - Institutional/Non-Institutional Record Data Elements (E - L)


ELEMENT NAME: END DATE OF CARE




1-2802-155

1Up to 99

YesYes

PRIMARY PICTURE (FORMAT) Eight (8) alphanumeric characters, YYYYMMDD.

DEFINITION Institutional: Latest date of care reported on this TED record.

Non-Institutional: The latest date of care for this procedure.

CODE/VALUE SPECIFICATIONS YYYY 4 digit calendar year

MM 2 digit calendar month

DD 2 digit calendar day

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:N/A



2


ELEMENT NAME: ENROLLMENT/HEALTH PLAN CODE




1-1102-300

1Up to 99

YesYes

PRIMARY PICTURE (FORMAT) Two (2) alphanumeric characters.

DEFINITION Code indicating whether the patient is enrolled with the contractor (Prime) or not (non-Prime) or a special care program.

CODE/VALUE SPECIFICATIONS T TRICARE Standard Program (Terminated 12/31/2017)

U TRICARE Prime, Civilian PCM

V TRICARE Extra (Terminated 12/31/2017)

W TPR ADSM - USA

X Foreign ADSM

Y CHCBP - Non-Network

Z TRICARE Prime, MTF/PCM

AA CHCBP - Network

AS TRICARE Select - Active Duty Survivors (Effective 01/01/2018)

AT TRICARE Select - Active Duty Transitional Survivors (Effective 01/01/2018)

BB TSP (Effective 10/01/1998 through 12/31/2001

FE TFL - Network (Effective 10/01/2001)

FS TFL - Non-Network (Effective 10/01/2001)

GS TRICARE Select - Guard/Reserve Survivors (Effective 01/01/2018)

GT TRICARE Select - Guard/Reserve Transitional Survivors (Effective 01/01/2018)

ME Medicare/TRICARE Dual Eligible Under 65/Network

MS Medicare/TRICARE Dual Eligible Under 65/Non-Network

PS TSRx (Effective 04/01/2001) - Non-Institutional Only

SN SHCP - Non-MTF-Referred Care (Effective 10/01/1999)

SO SHCP - Non-TRICARE Eligible (Effective 10/01/1999 through 05/31/2004)

SR SHCP - Referred Care (Effective 10/01/1999)

ST SHCP - TRICARE Eligible (Effective 10/01/1999 through 05/31/2004)

SU SHCP - Referral Designation Unknown (Effective 03/01/2002) - for Non-Institutional Pharmacy claims only

TS TSS Demonstration Program (Effective 04/01/2000 through 12/31/2002)

TV TRICARE Select (Effective 01/01/2018)

NOTES AND SPECIAL INSTRUCTIONS:Left justify and blank fill.Enrollment/Health Plan Code ‘U’ shall be used for CONUS and also for TRICARE Overseas Program Prime enrollees.

C-97, October 19, 2017



3

CODE/VALUE SPECIFICATIONS(CONTINUED)

WA TPR Foreign ADSM (Effective 09/01/2003)

WF TPR for enrolled ADFM Residing with a TPR Eligible ADSM (Effective 09/01/2002)

WO Includes Transitional Survivors Who Do Not Relocate TPR Foreign ADFM (Effective 09/01/2003)

XF Foreign ADFM (Effective 09/01/2003)

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


ELEMENT NAME: ENROLLMENT/HEALTH PLAN CODE (Continued)

NOTES AND SPECIAL INSTRUCTIONS:Left justify and blank fill.Enrollment/Health Plan Code ‘U’ shall be used for CONUS and also for TRICARE Overseas Program Prime enrollees.

C-97, October 19, 2017



4


ELEMENT NAME: FILING DATE




1-0152-015

11

YesYes

PRIMARY PICTURE (FORMAT) Seven (7) alphanumeric characters, YYYYDDD.

DEFINITION Date the request for payment of services rendered was received by the contractor for processing.

CODE/VALUE SPECIFICATIONS YYYY 4 digit calendar year of receipt

DDD 3 digit Julian date of receipt

ALGORITHM N/A


SUBORDINATE GROUP

N/A INTERNAL CONTROL NUMBER


C-97, October 19, 2017



5


ELEMENT NAME: FILING STATE/COUNTRY CODE




1-0202-020

11

YesYes

PRIMARY PICTURE (FORMAT) Three (3) alphanumeric characters.

DEFINITION Code that indicates the State or Country where the primary care was provided.

CODE/VALUE SPECIFICATIONS Refer to Addendum A1 and Addendum B1.

ALGORITHM N/A


SUBORDINATE GROUP

N/A INTERNAL CONTROL NUMBER

NOTES AND SPECIAL INSTRUCTIONS:1 State code will consist of two alphanumeric characters, which is left justify and blank fill. The foreign countries will

consist of three alphanumeric characters.

C-97, October 19, 2017



6


ELEMENT NAME: FREQUENCY CODE



Institutional 1-250 1 Yes1

PRIMARY PICTURE (FORMAT) One (1) alphanumeric character.

DEFINITION Code that describes the frequency of billing from the institution. For filing dates before January 1, 2011 all TED records for interim-interim and interim-final institutional bills must be submitted as an adjustment using the same TRI as the initial submission. Effective with filing dates on or after 01/01/2011 all TED records for interim-interim and interim-final institutional bills with the exception of interim billings reimbursed under the DRG or HHA payment methodology must be submitted as a unique TRI. See Section 1.1, paragraph 7.0.

CODE/VALUE SPECIFICATIONS 0 Non-Payment/Zero Claim

1 Admit through Discharge TED record

2 Interim-Initial TED record

3 Interim-Interim TED record

4 Interim-Final TED record

7 Replacement of Prior Claim

8 Void/Cancel of Prior Claim

9 Final claim for HHA PPS Episode

ALGORITHM N/A


SUBORDINATE GROUP

N/A TYPE OF BILL

NOTES AND SPECIAL INSTRUCTIONS:1 The initial, interim, and final TED records must be submitted to TMA in correct sequence. If the person is transferred

and the care is processed under DRG rules, then code ‘1’ must be used; all other Transfers must use code ‘1’ or ‘4’ as appropriate.

Effective with filing dates on or after January 1, 2011, interim-interim and interim-final TED records (FREQUENCY CODES ‘3’ and ‘4’) must be submitted on batch/vouchers with HEADER TYPE INDICATOR ‘0’ or ‘5’. DRG and HHA interim billings are excluded from this requirement.

C-97, October 19, 2017



7


ELEMENT NAME: HEALTH CARE COVERAGE (HCC) COPAYMENT FACTOR CODE




1-1362-201

1Up to 99

YesYes


DEFINITION The code used to identify for each insured in managed care the category of copayment and deductible they must pay based on external forces for a particular health care coverage period. Actual rates depend on HCDP Plan Coverage Code. Download field from DEERS.

CODE/VALUE SPECIFICATIONS A Active duty E-4 and below rate

B Active duty E-5 and above rate

C Retiree rate

W Unknown copayment factor

Z Not applicable

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:If person not on DEERS but claim is payable (i.e., government liability), report ‘Z’ in this field.

C-97, October 19, 2017



8


ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE




1-0662-285

1Up to 99

YesYes


DEFINITION The member category code during the Health Care Coverage period. Download field from DEERS.

CODE/VALUE SPECIFICATIONS 1 Transitional compensation not eligible for retirement

A Active duty

B Presidential Appointee

C DoD civil service employee, except Presidential employee

D Disabled American veteran

E DoD contract employee

F Former member (Reserve service, discharged from the Ready Reserve or Standby Reserve following notification of retirement eligibility)

G National Guard member (mobilized or on active duty for 31 days or more) Early ID Alert status

H Medal of Honor recipient

I Other Government Agency employee, except Presidential appointee

J Academy student (does not include Officer Candidate School or Merchant Marine Academy)

K Non-Appropriated Fund DoD employee

L Lighthouse service

M Non-government Agency Personnel

N National Guard member (not on active duty or on active duty for 30 days or less)

O Other Government contract employee

P TAMP member

Q Reserve retiree not yet eligible for retired pay (“gray-area retiree”)

R Retired military member eligible for retired pay

S Reserve member (mobilized or on active duty for 31 days or more) Early ID Alert status

T Foreign military member

U DoD OCONUS hires

V Reserve member (not on active duty or on active duty for 30 days or less)

NOTES AND SPECIAL INSTRUCTIONS:If person not on DEERS but claim is payable (i.e., government liability), report from the claim or report ‘Z’ in this field.

C-97, October 19, 2017



9

CODE/VALUE SPECIFICATIONS(CONTINUED)

W DoD beneficiary, a person who receives benefits from the DoD based on prior association, condition or authorization, an example is a former spouse

Y Service affiliates (including ROTC and Merchant Marines)

Z Unknown

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (Continued)


C-97, October 19, 2017



10


ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER RELATIONSHIP CODE




1-0702-295

1Up to 99

YesYes


DEFINITION The member relationship code for the HCC period. Download field from DEERS.

CODE/VALUE SPECIFICATIONS A Self (i.e., the person and the other person are the same person)

B Spouse

C Child or stepchild

D Pre-adoptive child

E Ward (court ordered)

F Dependent parent, dependent stepparent, dependent parent-in-law, or dependent stepparent-in-law

G Surviving spouse

H Former spouse (20/20/20)

I Former spouse (20/20/15)

J Former spouse (10/20/10)

K Former spouse (transitional assistance (composite))

L Foster child

Z Unknown

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


C-97, October 19, 2017



11


ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE CODE




1-1112-301

1Up to 99

YesYes


DEFINITION The code that represents the plan coverage a family member or sponsor has within a HCDP type. Download field from DEERS.

CODE/VALUE SPECIFICATIONS For valid values refer to Addendum L.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:If person not on DEERS but claim is payable (i.e, government liability), report ‘000’ in this field.

C-97, October 19, 2017



12


ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) SPECIAL ENTITLEMENT CODE




1-1862-306

1Up to 99

Yes1

Yes1


DEFINITION The code used to identify for each person insured in managed care any special category that they may have been given for copayment and deductible. Download field from DEERS.

CODE/VALUE SPECIFICATIONS 00 Not applicable

01 Bosnia Participation Special Entitlement (Sponsor Only)

02 Noble Eagle Participation Special Entitlement (Sponsor Only)

03 Enduring Freedom Participation Special Entitlement

042 TA 60 Benefits Period After Special Operation

052 TA 120 Benefits Period After Special Operation

06 Kosovo Participation Special Entitlement (Sponsor Only)

072 Iraqi Freedom Participation Special Entitlement (Sponsor Only)

30 TRICARE Senior Pharmacy Exception - Grandfathered Populations before 04/01/2001.

31 TRICARE Senior Pharmacy Exception - Direct Care (DC) over 65 members with Medicare A and B but no TFL.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:1 If the DEERS response does not return a HCDP SPECIAL ENTITLEMENT CODE, report ‘00’ in this field.2 Codes 04, 05, and 07 are no longer effective. Valid for adjustments or cancellations to previously submitted TED

records with these values.

If person not on DEERS but claim is payable (i.e., government liability), report ‘00’ in this field.

C-97, October 19, 2017



13


ELEMENT NAME: HIPPS CODE



Institutional 1-292 1 Yes1


DEFINITION HIPPS rate codes identify specific patient characteristics (or case mix) on which TRICARE SNF and HHA payment determinations are made.

CODE/VALUE SPECIFICATIONS SNF HIPPS codes: Consists of a three character RUG code plus a two character modifier which is an assessment indicator.

HHA HIPPS codes prior to January 1, 2008: First character is always ‘H’ for home health; the second, third, and fourth positions represent the care level of intensity; and the fifth character establishes the completeness of the OASIS data.

HHA HIPPS codes on or after January 1, 2008: The first position in the HIPPS code is a numeric value based on whether an episode is an early or later episode in a sequence of adjacent episodes; the second, third, and fourth positions of the code remain a one-to-one crosswalk to the three domains of the HHRG coding system; and the fifth position indicates a severity group for NRS.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:1 Required if available. If not applicable blank fill.

If multiple HIPPS Codes are reported on a claim, the initial HIPPS code (i.e., the HIPPS code initiating the 60 day Episode of Care (EOC)) should be coded on the TED record.

C-97, October 19, 2017



14


ELEMENT NAME: ICD VERSION




1-2932-114

11

YesYes


DEFINITION Code to indicate the International Classification of Diseases (ICD) version.

CODE/VALUE SPECIFICATIONS 0 ICD-10

9 ICD-9

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


C-97, October 19, 2017



15

- END -


ELEMENT NAME: INTERNAL CONTROL NUMBER (ICN)




1-0102-010

1Up to 99

YesYes

PRIMARY PICTURE (FORMAT) Group

DEFINITION N/A

CODE/VALUE SPECIFICATIONS Refer to subordinate element definitions.

ALGORITHM N/A


SUBORDINATE GROUP

FILING DATEFILING STATE/COUNTRY CODESEQUENCE NUMBER

TED RECORD INDICATOR


C-97, October 19, 2017

1



Data Requirements - Institutional/Non-Institutional Record Data Elements (M - O)


ELEMENT NAME: NATIONAL DRUG CODE




PRIMARY PICTURE (FORMAT) Eleven (11) alphanumeric characters.

DEFINITION Number assigned to pharmaceutical products by the FDA.

CODE/VALUE SPECIFICATIONS N/A

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:1 Only required for Outpatient Drug claims. Blank fill for non-pharmacy TED records.

This data element must be present for Mail Order Pharmacy (MOP) and Retail Pharmacy.



2


ELEMENT NAME: NUMBER OF SERVICES



Non-Institutional 2-175 Up to 99 Yes

PRIMARY PICTURE (FORMAT) Three (3) signed numeric digits.

DEFINITION Number of procedures performed/services or supplies rendered for medical, dental, and mental health care.


ALGORITHM Identical procedures must be combined when performed by the same provider, with the same charge for each, and within the same calendar month, provided the reason for allowance/denial is the same for each charge and combining procedures does not conflict with other TED record requirements (i.e., Number of Services field size). For ambulance services, allergy testing, DME rental, or POV mileage for ECHO, enter 01 for each service regardless of number of units or mileage. When multiple units are used in a single Episode Of Care (EOC), such as one box of twelve syringes, code only one (1) supply or service. Allowed prescription drugs must be combined separately from disallowed prescription drugs. Report the number of prescriptions (not pills or day’s supply) for prescriptions.


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:Number of Services should be reported as 999 for HCPCS J-codes when the actual quantity of the services on the claim form exceeds 999.For a list of maximum number of services allowed for a procedure code per day, refer to the Maximum Number of Services by Procedure Code list on DHA’s web site at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement. These values conform to CMS’ Medically Unlikely Edits (MUE) program for CPT/HCPCS codes that have been assigned a limit by CMS. Any CPT/HCPCS code not assigned a limit by CMS have been assigned a limit deemed reasonable by TRICARE. The edits for MUE program are published on the CMS web site at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/08_MUE.asp.

C-97, October 19, 2017

http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement

http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/08_MUE.asp





3


ELEMENT NAME: OCCURRENCE/LINE ITEM NUMBER




1-3802-145

Up to 450Up to 99

YesYes

PRIMARY PICTURE (FORMAT) Three (3) numeric digits.

DEFINITION A unique number for each utilization/revenue data occurrence within the TED record. Occurrence/line item number must be assigned in sequential ascending order.


ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A




4


ELEMENT NAME: OPPS PAYMENT STATUS INDICATOR CODE





DEFINITION Identifies how a service or procedure is paid under OPPS.

CODE/VALUE SPECIFICATIONS A Services paid under some payment method other than OPPS (e.g., payment for non-implantable prosthetic and orthotic devices, DME, ambulance services, and individual professional services).

B More appropriate code required for TRICARE OPPS.

C Inpatient services.

E Items or services not covered by TRICARE.3

F Acquisition of corneal tissue and certain CRNA services and Hepatitis B vaccines.

G Pass-through drugs and biologicals.

H 1. Pass-through device categories.2. Therapeutic radiopharmaceuticals.

K Non-pass-through drugs and biologicals.

N Items and services packaged into APC rates.

P Partial hospitalization service.

Q Packaged services subject to separate payment based on payment criteria. See codes Q1 through Q3 listed below.

R Blood and blood products.

S Significant procedures not subject to multiple procedure discounting.

T Significant procedures subject to multiple procedure discounting.

U Brachytherapy sources.

V Clinic or ED visits.

W Invalid HCPCS or invalid revenue code with blank HCPCS.

X Ancillary services.2

Z Valid revenue code with blank HCPCS and no other SI assigned.

NOTES AND SPECIAL INSTRUCTIONS:1 Required on all TED records reimbursed under OPPS.2 Effective January 1, 2015, SI of X is no longer recognized.3 Effective January 1, 2017, SI of E is no longer recognized.

Refer to the TRM for additional information and more complete definitions of the OPPS Payment SI Codes. Must be left justified and blank filled.

The list of Payment SIs For Hospital OPPS and OPPS Payment Status can be found at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Outpatient-Prospective-Payment-System.

C-97, October 19, 2017





5

CODE/VALUE SPECIFICATIONS (CONTINUED)

TB TRICARE reimbursement not allowed for CPT/HCPCS code submitted.

E1 Items or services not covered by TRICARE.

J1 Hospital outpatient department services paid through a comprehensive APC.

J2 Hospital outpatient department services that may be paid through a comprehensive APC.

Q1 STVX-packaged codes.

Q2 T-packaged codes.

Q3 Codes that may be paid through a composite APC.

Q4 Conditionally packaged laboratory services

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


ELEMENT NAME: OPPS PAYMENT STATUS INDICATOR CODE (Continued)

NOTES AND SPECIAL INSTRUCTIONS:1 Required on all TED records reimbursed under OPPS.2 Effective January 1, 2015, SI of X is no longer recognized.3 Effective January 1, 2017, SI of E is no longer recognized.

Refer to the TRM for additional information and more complete definitions of the OPPS Payment SI Codes. Must be left justified and blank filled.

The list of Payment SIs For Hospital OPPS and OPPS Payment Status can be found at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/Outpatient-Prospective-Payment-System.

C-97, October 19, 2017



6


ELEMENT NAME: OTHER GOVERNMENT PROGRAM (OGP) BEGIN REASON CODE




1-1322-192

1Up to 99

Yes1

Yes1


DEFINITION The code that indicates the reason that the person’s period of eligibility for a non-DoD OGP began. The OGP begin reason code only applies to OGP type codes of ‘A’ or ‘B’ only. Download field from DEERS.

CODE/VALUE SPECIFICATIONS A Eligible for Medicare. Eligibility began after age 65 (the person did not have enough quarters of Social Security contributions to qualify at age 65). This value applies to Medicare Part A.

B Enrollment in Medicare Part B, C or D; over or under age 65. Medicare Part B can only be obtained by payment of monthly premiums. This value applies to Medicare Part B, C, or D.

D Eligible for Medicare because of disability. This value applies to Medicare Part A.

E Eligible for Medicare at age 65. This value applies to Medicare Part A.

F Eligibility for Medicare defaulted at age 65; verification not received from Center for Medicare and Medicaid Services (CMS). Applies to Medicare Part A only.

G Enrollment in Medicare Part B declined by beneficiary.

N Not eligible for Medicare. Under age 65 this is the default value. At age 65 this indicates eligibility could not begin because the person did not have enough quarters of Social Security contributions to qualify. This value applies to Medicare Part A.

P Eligible for Medicare at or after 65 because of purchase. This value applies to Medicare Part A.

R Eligible for Medicare because of end-stage renal disease. This value applies to Medicare Part A.

V Eligible for the CHAMPVA.

W Not applicable.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:1 If the DEERS response does not contain an OGP BEGIN REASON CODE, report ‘W’ in this field.

If person not on DEERS but claim is payable (i.e., government liability), report ‘W’ in this field.

Note: For MOP use the data element Medicare Begin Reason Code from the DEERS inquiry/response to report this information. If the DEERS response does not contain an OGP BEGIN REASON CODE, report ‘W’ in this field.

C-21, September 8, 2010


Data Requirements - Institutional/Non-Institutional Record Data Elements (P)

27


ELEMENT NAME: PRINCIPAL TREATMENT DIAGNOSIS/PRESENT ON ADMISSION (POA) INDICATOR




1-3002-115

11

YesYes

PRIMARY PICTURE (FORMAT) Eight (8) alphanumeric characters.

DEFINITION Principal Treatment Diagnosis: The condition established, after study, to be the major cause for the patient to obtain medical care as submitted on the claim form or otherwise indicated by the provider.

POA Indicator: Diagnosis present at the time the order for inpatient admission occurs.

CODE/VALUE SPECIFICATIONS Principal Treatment Diagnosis (Positions 1 through 7): Use the most current diagnosis code edition (ICD-9-CM or ICD-10-CM), as directed by DHA. Must provide the most detailed code. Do not code the decimal point.

POA Indicator (Position 8):

Valid POA values are:

b Not reported

1 Unreported/Not Used - Exempt from POA reporting

N No - Not present at time of admission

U Unknown - Documentation insufficient to determine if the condition was present at time of admission

W Clinically Undetermined - The provider is unable to clinically determine if the condition was present at time of admission

Y Yes - Present at time of admission

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:For MOP and Retail Pharmacy, if a more specific diagnosis code is not available, use ICD-9-CM 799.89 on or before September 30, 2015, and ICD-10-CM R68.89 on or after October 1, 2015.

C-76, August 24, 2015



28


ELEMENT NAME: PROCEDURE CODE





DEFINITION The code that identifies the procedure performed or describes the care received as submitted on the claim form.

CODE/VALUE SPECIFICATIONS Refer to Physician’s Current Procedure Terminology, 4th Edition1 (CPT-4) or Healthcare Common Procedure Coding System (HCPCS) National Level II Medicare Codes or DHA approved codes (Addendum E, Figure 2.E-2). For Dental Services, use HCPC or ADA Dental procedure codes.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:1 CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

For MOP report procedure code 198800 for all drug prescriptions and procedure code1 99070 for all supplies. The first line item must report the information on the prescription and the second line item to report corresponding supplies that are issued such as alcohol pads, lancets, etc. The procedure code on the second occurrence/line item on MOP records must be procedure code 99070.

For Mail Order and Retail Pharmacy Prior Authorizations and Medical Necessity Reviews report 000PA or 000MN.

For the list of the No Government Pay Procedure Codes that are excluded from TRICARE coverage and are not payable under TRICARE, refer to the No Government Pay Procedure Code list on DHA’s web site at http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/No-Government-Pay-Procedure-Code-List.

C-97, October 19, 2017

http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/No-Government-Pay-Procedure-Code-List

http://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/No-Government-Pay-Procedure-Code-List



35


ELEMENT NAME: PROVIDER TAXONOMY (SPECIALTY)




PRIMARY PICTURE (FORMAT) Ten (10) alphanumeric characters.

DEFINITION Code describing the provider’s specialty.

CODE/VALUE SPECIFICATIONS Refer to http://www.wpc-edi.com/ for Provider Specialty Codes. Refer to Addendum C, Figure 2.C-1 as a reference when assigning Provider Major Specialty Codes to Outpatient Hospital Non-Institutional TED records.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:This data element must be ‘183500000X’ for MOP and ‘333600000X’ for Retail Pharmacy.

C-97, October 19, 2017

http://www.wpc-edi.com/



36


ELEMENT NAME: PROVIDER STATE OR COUNTRY CODE




1-1952-235

1Up to 99

YesYes


DEFINITION Code assigned to identify the state or foreign country in which the care was received. State Code must be left justified and blank fill to right.

CODE/VALUE SPECIFICATIONS Addendum A and Addendum B.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


C-55, December 12, 2013


Data Requirements - Provider Record Data

5


ELEMENT NAME: CONTRACTOR NUMBER



Provider 3-020 1 Yes


DEFINITION Identification code for the contractor. Used to identify each contractor submitting Provider File Records.

CODE/VALUE SPECIFICATIONS TMA assigned contractor number.

04 North Region (Effective 04/01/2011)

05 South Region (Effective 04/01/2012)

08 West Region (Effective 04/01/2013)

10 Overseas (Effective 09/01/2016)

12 East Region 2017

13 West Region 2017

15 Overseas (Effective 09/01/2010)

70 TPharm (Retail Pharmacy, MOP)

71 TDEFIC (Effective 08/03/2007)

73 TPharm (Effective 05/01/2015)

74 TDEFIC (Effective 01/01/2015)

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


C-97, October 19, 2017



6


ELEMENT NAME: EXEMPT/NON-EXEMPT INDICATOR



Provider 3-150 1 Yes1


DEFINITION Indicates whether the institutional provider is exempted from the TRICARE DRG-based payment system.

CODE/VALUE SPECIFICATIONS b Not applicable

C DRG Non-exempt/Contracted Reimbursement Arrangement

E DRG Exempt

N DRG Non-exempt

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A

NOTES AND SPECIAL INSTRUCTIONS:1 Report blank for all non-institutional providers.



21


ELEMENT NAME: PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION




PRIMARY PICTURE (FORMAT) Ten (10) alphanumeric characters.

DEFINITION Code describing a provider’s major specialty for non-institutional TEDs or a code describing the type of institution for institutional TEDs. Type of Institution must be left justified and blank filled to the right.

CODE/VALUE SPECIFICATIONS Refer to http://www.wpc-edi.com/ for non-institutional provider specialty codes. Refer to Addendum D, Figure 2.D-1 for type of institution codes for Institutional TEDs. Refer to Addendum C, Figure 2.C-1 for assistance when assigning Provider Specialty Codes to Outpatient Hospital non-institutional provider records.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A


C-97, October 19, 2017

http://www.wpc-edi.com/codes



22


ELEMENT NAME: PROVIDER NAME




PRIMARY PICTURE (FORMAT) Forty (40) alphanumeric characters.

DEFINITION Name of provider.

CODE/VALUE SPECIFICATIONS Must be left justified and blank filled. If this field is a person’s name, it should be in the form of last name, first name, middle initial (each name should be separated by a comma with no space between the name). Do not use articles such as ‘the,’ ‘A’, ‘An’, etc. Use standard abbreviations such as ‘St.’ for Saint, ‘Comm’ for community, ‘Hosp’ for hospital, etc.

ALGORITHM N/A


SUBORDINATE GROUP

N/A N/A



Header Edit Requirements (ELN 000 - 099)

5

ELEMENT NAME: BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025)

VALIDITY EDITS

0-025-01V MUST BE ALPHANUMERIC.

RELATIONAL EDITS

0-025-01R IF HEADER TYPE INDICATOR = 0 BATCH HEADER (USED ON ALL PROVIDER BATCHES, AND FOR INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN NON-ADMIN CLAIM RATE ELIGIBLE TED RECORDS) OR

9 BATCH HEADER (INSTITUTIONAL/NON-INSTITUTIONAL FINANCIALLY UNDERWRITTEN ADMIN CLAIM RATE ELIGIBLE TED RECORDS)

THEN BATCH/VOUCHER ASAP ACCOUNT NUMBER MUST BE ZERO.

0-025-02R IF HEADER TYPE INDICATOR = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR

6 VOUCHER HEADER ADMIN CLAIM RATE ELIGIBLE

AND BATCH/VOUCHER RESUBMISSION NUMBER = ZERO

THEN ASAP ACCOUNT NUMBER MUST BE VALID1 AND ACTIVE2 FOR THE CONTRACT NUMBER ON THE TED BATCH/VOUCHER RECORD.

0-025-05R IF CONTRACT NUMBER = (NEW TDEFIC CONTRACT) OR

MDA906-02-C-0013 (TMOP) OR

MDA906-03-C-0009 (WEST) OR

MDA906-03-C-0010 (SOUTH) OR

MDA906-03-C-0011 (NORTH) OR

MDA906-03-C-0015 (TDEFIC) OR

MDA906-03-C-0019 (TRRx)

THEN BYPASS THIS EDIT

ELSE IF HCDP PLAN COVERAGE CODE = 000 NO HEALTH CARE COVERAGE PLAN OR

121 CHCBP NON-NETWORK - INDIVIDUAL COVERAGE OR

122 CHCBP NETWORK - FAMILY COVERAGE OR

306 TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR

307 TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR

308 TRICARE SELECT - YOUNG ADULT OR

330 TRICARE PRIME - YOUNG ADULT ACTIVE DUTY/TAMP OR

331 TRICARE PRIME - YOUNG ADULT RETIRED OR

332 TRICARE PRIME REMOTE - YOUNG ADULT ACTIVE DUTY OR

401 TRS TIER 1 MEMBER-ONLY OR

402 TRS TIER 1 MEMBER AND FAMILY OR 1 TMA DATABASE.2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACTOR REQUIRES THE ABILITY TO SUBMIT

‘INITIAL SUBMISSIONS’ ON A CLOSED BATCH/VOUCHER CLIN/ASAP ACCOUNT, THEN CONTACT TMA, CRM FOR INSTRUCTIONS ON HOW TO PROCEED.

C-97, October 19, 2017



6

403 TOBACCO CESSATION DEMONSTRATION PROGRAM OR

404 WEIGHT MANAGEMENT DEMONSTRATION PROGRAM OR


406 TRS TIER 2 MEMBER AND FAMILY OR



409 TRS SURVIVOR CONTINUING INDIVIDUAL COVERAGE OR

410 TRS SURVIVOR CONTINUING FAMILY COVERAGE OR

411 TRS SURVIVOR NEW INDIVIDUAL COVERAGE OR

412 TRS SURVIVOR NEW FAMILY COVERAGE OR

413 TRS MEMBER-ONLY COVERAGE OR

414 TRS MEMBER AND FAMILY COVERAGE OR

418 TRR MEMBER-ONLY COVERAGE OR

419 TRR MEMBER AND FAMILY COVERAGE OR

420 TRR SURVIVOR INDIVIDUAL COVERAGE OR

421 TRR SURVIVOR FAMILY COVERAGE OR

422 TYA TRICARE STANDARD FOR ADFMs OR

423 TYA TRICARE STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR

424 TYA TRS OR

425 TYA TRR OR

426 TYA PRIME FOR ADFMs OR

427 TYA TPR FOR ADFMs OR

428 TYA PRIME FOR RETIRED AND MOH FAMILY MEMBERS OR

429 TYA TRICARE OVERSEAS PRIME FOR ADFMs OR

430 TYA TRICARE OVERSEAS PRIME REMOTE FOR ADFMs

OR ENROLLMENT/HEALTH PLAN CODE = Y CHCBP NON-NETWORK - INDIVIDUAL COVERAGE OR

AA CHCBP NETWORK - FAMILY COVERAGE OR

SN SHCP - NON-MTF REFERRED CARE OR

SR SHCP - MTF REFERRED CARE

OR SPECIAL PROCESSING CODE = AN SHCP - NON-MTF REFERRED CARE OR

AR SHCP - MTF REFERRED CARE OR

DC DCPE-DVA OR

DE TDRL PHYSICAL EXAM OR

MM MMPCMHP OR

ELEMENT NAME: BATCH/VOUCHER ASAP ACCOUNT NUMBER (0-025) (Continued)

1 TMA DATABASE.2 DEFINED IN THE TRICARE OPERATIONS MANUAL (TOM), CHAPTER 3. IF CONTRACTOR REQUIRES THE ABILITY TO SUBMIT


C-97, October 19, 2017



7

PV RETAIL PHARMACY FOR DVA

OR HCC MEMBER CATEGORY CODE = A ACTIVE DUTY OR

G NATIONAL GUARD ACTIVE > 30 DAYS; AGR CODE A-H OR

J ACADEMY STUDENT, NOT OCS OR

N NATIONAL GUARD NOT ACTIVE OR < 31 DAYS OR

S RESERVE MEMBER ACTIVE > 30 DAYS OR

T FOREIGN MILITARY OR

V RESERVE MEMBER NOT ACTIVE OR < 31 DAYS OR

Y SERVICE AFFILIATES (ROTC, MERCHANT MARINE)

AND HCC MEMBER RELATIONSHIP CODE = A SELF

THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CORAMS MUST ≠ TF TRUST/ACCRUAL FUND

ELSE IF OGP TYPE CODE = A MEDICARE PART A OR

C MEDICARE PART A & B OR

I MEDICARE PART A & D OR

L MEDICARE PART A, B AND D

AND OGP BEGIN REASON CODE ≠ N NOT ELIGIBLE FOR MEDICARE

AND HCDP PLAN COVERAGE CODE = 004 DIRECT CARE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

005 TRICARE STANDARD FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

016 DIRECT CARE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

017 TRICARE STANDARD FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

021 TFL FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

023 TFL FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

110 TRICARE PRIME FOR INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

111 TRICARE PRIME FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

114 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR




C-97, October 19, 2017



8

115 TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

136 TRICARE PRIME INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

137 TRICARE PRIME FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

138 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

139 TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

143 TRICARE PLUS COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

144 TRICARE PLUS WITH CHC COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

148 TRICARE PLUS COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

149 TRICARE PLUS COVERAGE WITH CHC COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

315 TRICARE PRIME-RETIRED SPONSORS AND FAMILY MEMBERS OR

345 TRICARE PLUS-DIRECT CARE ONLY (PRESENTATION LAYER) OR

346 TRICARE PLUS

OR ENROLLMENT/HEALTH PLAN CODE = AS TRICARE SELECT-ACTIVE DUTY SURVIVORS OR

GS TRICARE SELECT-GUARD/RESERVE SURVIVORS

OR HCC MEMBER CATEGORY CODE = F FORMER MEMBER OR

H MEDAL OR HONOR RECIPIENT OR

R RETIRED OR

W FORMER SPOUSE

THEN BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CORAMS MUST = TF TRUST/ACCRUAL FUND

ELSE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER APPROPRIATION TYPE FOUND IN CORAMS MUST ≠ TF TRUST/ACCRUAL FUND

0-025-08R IF ANY OCCURRENCE OF TYPE OF SUBMISSION = B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR




C-97, October 19, 2017



9

E COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA


ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS = TD TRICARE DOMESTIC

AND CONTRACT NUMBER = HT9402-12-C-0001 (T3 NORTH)

AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START OF CONTRACT

OR CONTRACT NUMBER = T3 SOUTH


OR CONTRACT NUMBER = T3 WEST


OR CONTRACT NUMBER = T2017 EAST

AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD

OR CONTRACT NUMBER = T2017 WEST

AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ BEGIN DATE OF OLDEST OPEN OPTION PERIOD

THEN SPECIAL PROCESSING CODE MUST = AN SHCP - NON-MTF REFERRED CARE OR

AP ABA PILOT OR


AS COMPREHENSIVE AUTISM CARE DEMONSTRATION OR

AU AUTISM DEMONSTRATION OR

CE SHCP - CCEP OR

CL CLINICAL TRIALS OR

CM INDIVIDUAL CASE MANAGEMENT OR

CT CUSTODIAL CARE OR

DC DCPE-DVA OR

DE TDRL PHYSICAL EXAM OR

GU SERVICE MEMBER ENROLLED IN TPR OR

LD LDTs DEMONSTRATION OR

L2 NON-FDA APPROVED LDTs DEMONSTRATION

PC PROVISIONAL COVERAGE FOR EMERGING SERVICES AND SUPPLIES OR

PV RETAIL PHARMACY FOR DVA OR

RB RESPITE BENEFIT OR




C-97, October 19, 2017



10

SC SHCP - NON-TRICARE ELIGIBLE OR

SE SHCP - TRICARE ELIGIBLE OR

SM SHCP - EMERGENCY

OR ENROLLMENT/HEALTH PLAN CODE MUST = Y CHCBP - NON-NETWORK OR

AA CHCBP - NETWORK OR



OR HCDP PLAN COVERAGE CODE MUST = 000 CARE DLEIVIER TO INELIGIBLES OR

121 CHCBP - NON-NETWORK INDIVIDUAL COVERAGE OR

122 CHCBP - NETWORK FAMILY COVERAGE OR

306 TRICARE SELECT-RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR

307 TRICARE SELECT-RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR

308 TRICARE SELECT-YOUNG ADULT OR

330 TRICARE PRIME-YOUNG ADULT ACTIVE DUTY/TAMP OR

331 TRICARE PRIME-YOUNG ADULT RETIRED OR

332 TRICARE PRIME REMOTE-YOUNG ADULT ACTIVE DUTY OR



403 TOBACCO CESSATION DEMONTRATION PROGRAM OR

404 WEIGHT MANAGEMENT DEMONSTRATION PROGRAM OR











417 TRANSITIONAL CARE FOR SERVICE-RELATED CONDITIONS (TCSRC) OR




C-97, October 19, 2017



11





422 TYA TRICARE STANDARD FOR ADFMs OR

423 TYA TRICARE STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR

424 TYA TRS OR

425 TYA TRR OR

426 TYA PRIME FOR ADFMs OR

427 TYA TPR FOR ADFMs OR

428 TYA PRIME FOR RETIRED AND MOH FAMILY MEMBERS OR

429 TYA TRICARE OVERSEAS PRIME FOR ADFMs OR

430 TYA TRICARE OVERSEAS PRIME REMOTE FOR ADFMs OR

999 UNVERIFIED NEWBORN

OR PATIENT ZIP CODE IS IN ALASKA

OR PCM DMIS ID MUST = 0005 BASSETT ACH-FT. WAINWRIGHT OR

0006 3rd MED GRP-ELMENDORF OR

0130 USCG CLINIC KODIAK OR

0202 AHC-GREELY OR

0203 354th MED GRP-EIELSON OR

0204 TMC FT. RICHARDSON OR

0417 USCG CLINIC KETCHIKAN OR

6033 KAMISH CLINIC-FT. WAINWRIGHT OR

7044 USCG CLINIC JUNEAU OR

7047 USCG CLINIC SITKA

OR HCC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR

G NATIONAL GUARD > 30 DAYS OR

J ACADEMY STUDENT OR

N NATIONAL GUARD < 30 DAYS OR

S RESERVE > 30 DAYS OR

T FOREIGN MILITARY MEMBER OR

V RESERVE < 30 DAYS OR

Z UNKNOWN

AND HCC MEMBER RELATIONSHIP CODE MUST = A SELF OR




C-97, October 19, 2017



12

Z UNKNOWN




ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS = TC TRICARE CIVILIAN PRIME

THEN ENROLLMENT/HEALTH PLAN CODE MUST = U TRICARE PRIME CIVILIAN PCM

AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT NUMBER.




ELSE IF BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS = TN TRICARE NON-CIVILIAN PRIME

THEN ENROLLMENT/HEALTH PLAN CODE MUST = T TRICARE STANDARD PROGRAM OR

V TRICARE EXTRA OR

Z TRICARE PRIME, MTF/PCM OR

WF TRICARE PRIME REMOTE ADFM

AND BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) ≥ START DATE OF HEALTH CARE DELIVERY FOR THE CONTRACT NUMBER

0-025-11R IF HEADER TYPE INDICATOR = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE-ELIGIBLE OR


AND POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER = ‘MIPR’

THEN ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST = M MOP



AND TYPE OF SERVICE (POSITION 2) = M MOP

THEN POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER MUST = ‘MIPR’






C-97, October 19, 2017



13

AND CONTRACT NUMBER = H94002-08-C-0003 TPHARM OR

HT9402-14-D-0002 TPHARM

AND POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER ≠‘MIPR’

THEN ALL OCCURRENCES OF TYPE OF SERVICE (POSITION 2) MUST = B RETAIL PHARMACY

0-025-14R IF HCDP PLAN COVERAGE CODE = 018 TFL FOR RETIRED SPONSORS AND FAMILY MEMBERS AND MEDAL OF HONOR OR

020 TFL FOR TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR


022 TFL FOR TRANSITIONAL SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR


029 TFL FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS

AND TYPE OF SUBMISSION = I INITIAL SUBMISSION OR

R RESUBMISSION

THEN OTHER GOVERNMENT PROGRAM TYPE CODE MUST ≠ N NO MEDICARE OR

V CHAMPVA

AND OTHER GOVERNMENT PROGRAM BEGIN REASON CODE MUST ≠ N NOT ELIGIBLE FOR MEDICARE OR

W NOT APPLICABLE




C-97, October 19, 2017



14

ELEMENT NAME: BATCH/VOUCHER DATE (0-030)

VALIDITY EDITS

0-030-01V MUST BE A VALID JULIAN DATE AND CANNOT BE > TMA CURRENT SYSTEM DATE.

0-030-02V BATCH/VOUCHER DATE MUST BE ≥ CONTRACT BEGIN DATE1

AND BATCH/VOUCHER DATE MUST BE ≤ CONTRACT END DATE1

RELATIONAL EDITS



AND BATCH/VOUCHER RESUBMISSION NUMBER = 00

AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS = TD TRICARE DOMESTIC OR

TF TRICARE FOREIGN OR

TT TRICARE TARGET

AND TYPE OF SUBMISSION = D COMPLETE DENIAL OR

I INITIAL SUBMISSION OR

O ZERO PAYMENT WITH 100% OHI/TPL OR

R RESUBMISSION

THEN BATCH/VOUCHER DATE IN HEADER MUST BE EQUAL TO OR WITHIN ASAP BEGIN AND END DATES ON THE TMA DATABASE.



THEN BATCH/VOUCHER DATE IN HEADER MUST NOT BE LESS THAN THE ASAP BEGIN DATE ON THE TMA DATABASE.

0-030-03R IF BATCH/VOUCHER RESUBMISSION NUMBER = 00

THEN BATCH/VOUCHER DATE MUST ≠ 09/29/XXXX OR

09/30/XXXX

UNLESS BATCH/VOUCHER IDENTIFIER = 3 PROVIDER (BATCH ONLY)

0-030-04R IF BATCH/VOUCHER RESUBMISSION NUMBER = 00

AND TRANSMISSION FILE RECEIVED TIME/DATE STAMP > 10:00 AM 09/28/(CURRENT YEAR)

AND BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL (BATCH/VOUCHER)

THEN BATCH/VOUCHER DATE MUST NOT BE < 10/01/(CURRENT YEAR)



AND BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER ASAP DESCRIPTION FOUND IN CORAMS = TC TRICARE CIVILIAN PRIME OR

1 CONTRACT DATES ON THE TMA DATABASE. THESE DATES ARE TAKEN FROM THE TMA CONTRACTS.

C-97, October 19, 2017



15

TN TRICARE NON-CIVILIAN PRIME

THEN BEGIN DATE OF CARE (NON-INSTITUTIONAL) OR ADMISSION DATE (INSTITUTIONAL) MUST BE EQUAL TO OR WITHIN ASAP BEGIN AND END DATES ON THE TMA DATABASE

ELEMENT NAME: BATCH/VOUCHER SEQUENCE NUMBER (0-035)

VALIDITY EDITS

0-035-01V MUST BE NUMERIC AND > ZERO.

RELATIONAL EDITS

NONE

ELEMENT NAME: BATCH/VOUCHER RESUBMISSION NUMBER (0-040)

VALIDITY EDITS

0-040-01V MUST BE NUMERIC

AND IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL

THEN MUST BE 1 GREATER THAN THE PRIOR SUBMISSION NUMBER UNDER THE SAME CONTRACT IDENTIFIER1.

RELATIONAL EDITS

NONE1 TMA DATABASE.

ELEMENT NAME: TOTAL NUMBER OF RECORDS (0-045)

VALIDITY EDITS

0-045-01V MUST BE NUMERIC.

0-045-02V MUST EQUAL NUMBER OF TED RECORDS IN THE BATCH/VOUCHER.

0-045-03V TOTAL RECORDS MUST > 0

RELATIONAL EDITS

0-045-01R IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL

AND BATCH/VOUCHER RESUBMISSION NUMBER > ZERO

THEN NUMBER OF RECORDS IN THE BATCH/VOUCHER MUST = NUMBER OUTSTANDING RECORDS1.1 TMA DATABASE.

ELEMENT NAME: BATCH/VOUCHER DATE (0-030) (Continued)

1 CONTRACT DATES ON THE TMA DATABASE. THESE DATES ARE TAKEN FROM THE TMA CONTRACTS.

C-97, October 19, 2017



16

ELEMENT NAME: TOTAL AMOUNT PAID (0-050)

VALIDITY EDITS


RELATIONAL EDITS

0-050-01R IF BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL

THEN TOTAL AMOUNT PAID MUST = THE ACCUMULATED TOTAL OF AMOUNTS PAID BY GOVERNMENT CONTRACTOR AND AMOUNT OF INTEREST PAYMENT FOR ALL TED RECORDS IN THE BATCH/VOUCHER.

0-050-02R IF BATCH/VOUCHER IDENTIFIER = 3 PROVIDER

THEN TOTAL AMOUNT PAID MUST EQUAL ZERO.

0-050-03R2 IF POSITION 1 THRU 4 OF THE CLIN/ASAP NUMBER = ‘MIPR’

AND BATCH/VOUCHER DATE ≥ 07/14/2011


ELSE IF HEADER TYPE INDICATOR = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR


AND BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL


THEN TOTAL AMOUNT PAID MUST BE EQUAL TO THE VOUCHER BALANCE1.1 TMA DATABASE (EXCLUDES CONTRACT NUMBER MDA906-02-C-0013(TMOP).2 ALL TMOP BATCH/VOUCHERS WITH A ‘MIPR’ CLIN/ASAP NUMBER AND BATCH/VOUCHER DATE ≥ 07/14/2011 WILL

BYPASS THIS EDIT.

ELEMENT NAME: INITIAL TRANSMISSION DATE (TMA DERIVED) (0-055)

VALIDITY EDITS

NONE

RELATIONAL EDITS

NONE

ELEMENT NAME: TMA BATCH/VOUCHER PROCESSING DATE (TMA DERIVED) (0-060)

VALIDITY EDITS

NONE

RELATIONAL EDITS

NONE

C-97, October 19, 2017



17

- END -

ELEMENT NAME: FUND ACCOUNTING (0-065)

VALIDITY EDITS


RELATIONAL EDITS

0-065-02R2 IF POSITION 1 THRU 4 OF THE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER = ‘MIPR’


AND HEADER TYPE INDICATOR = 5 VOUCHER HEADER NON-ADMIN CLAIM RATE ELIGIBLE OR


AND BATCH/VOUCHER IDENTIFIER = 5 INSTITUTIONAL/NON-INSTITUTIONAL


THEN THE FUND ACCOUNTING MUST BE EQUAL TO THE VOUCHER BALANCE1.

0-065-03R3 IF POSITION 1 THRU 4 OF THE BATCH/VOUCHER CLIN/ASAP ACCOUNT NUMBER = ‘MIPR’


THEN THE FUND ACCOUNTING MUST = THE ACCUMULATED TOTAL OF AMOUNT ALLOWED BY PROCEDURE CODE FOR ALL TED RECORDS IN THIS VOUCHER.

1 TMA DATABASE.2 THIS EDIT IS PERFORMED FOR ALL MAIL ORDER BATCH/VOUCHERS.3 THIS EDIT IS PERFORMED FOR TPHARM MAIL ORDER BATCH/VOUCHERS.

C-97, October 19, 2017


Institutional Edit Requirements (ELN 000 - 099)

5

ELEMENT NAME: AGR SERVICE LEGAL AUTHORITY CODE (1-065)

VALIDITY EDITS

1-065-01V MUST BE A VALID AGR SERVICE LEGAL AUTHORITY CODE (REFER TO SECTION 2.4)

RELATIONAL EDITS

REFER TO SECTION 8.1.

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (1-066)

VALIDITY EDITS

1-066-01V MUST BE A VALID HCC MEMBER CATEGORY CODE (REFER TO SECTION 2.5)

RELATIONAL EDITS

1-066-01R IF HCC MEMBER RELATIONSHIP CODE = A SELF

THEN HCC MEMBER CATEGORY CODE MUST ≠ A ACTIVE DUTY OR

G NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR


N NATIONAL GUARD (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR

S RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR


V RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS)

W TPR ADSM - USA OR

UNLESS ENROLLMENT/HEALTH PLAN CODE = X FOREIGN ADSM OR

Y CHCBP - NON-NETWORK OR


SN SHCP - NON-MTF-REFERRED CARE OR

SO SHCP - NON-TRICARE ELIGIBLE OR

SR SHCP - REFERRED CARE OR

ST SHCP - TRICARE ELIGIBLE OR

WA TPR FOREIGN ADSM OR

WO TPR FOREIGN ADFM

OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE = SC SHCP - NON-TRICARE ELIGIBLE OR


SM SHCP - EMERGENCY

OR HCDP PLAN COVERAGE CODE = 306 TRICARE SELECT-RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR


401 TRS TIER 1 MEMBER-ONLY COVERAGE (CONTINGENCY OPERATIONS) OR

C-97, October 19, 2017



6

402 TRS TIER 1 MEMBER AND FAMILY COVERAGE (CONTINGENCY OPERATIONS) OR

405 TRS TIER 2 MEMBER-ONLY COVERAGE (CERTIFIED QUALIFICATIONS) OR

406 TRS TIER 2 MEMBER AND FAMILY COVERAGE (CERTIFIED QUALIFICATIONS) OR

407 TRS TIER 3 MEMBER-ONLY COVERAGE (SERVICE AGREEMENT) OR

408 TRS TIER 3 MEMBER AND FAMILY COVERAGE (SERVICE AGREEMENT) OR

409 TRS SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR

410 TRS SURVIVOR CONTINUING WITH FAMILY COVERAGE OR





418 TRICARE RETIRED RESERVE (TRR) MEMBER-ONLY COVERAGE OR



421 TRR SURVIVOR FAMILY COVERAGE

1-066-02R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = PF ECHO

THEN HCC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR



P TAMP MEMBER OR

S RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE)

1-066-03R IF HCC MEMBER CATEGORY CODE = T FOREIGN MILITARY MEMBER

THEN ONE OCCURRENCE OF OVERRIDE CODE = M NATO

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (1-066) (Continued)

C-97, October 19, 2017

1




ELEMENT NAME: PERSON SEX (PATIENT) (1-100)

VALIDITY EDITS

1-100-01V PERSON SEX (PATIENT) MUST = F FEMALE OR

M MALE OR

Z UNKNOWN

RELATIONAL EDITS

NONE

ELEMENT NAME: PATIENT ZIP CODE (1-105)

VALIDITY EDITS

1-105-01V MUST BE NINE DIGITS OR FIVE DIGITS WITH FOUR BLANKS

MUST BE A VALID ZIP CODE (BASED ON ADMISSION DATE) IN THE GOVERNMENT PROVIDED ELECTRONIC ZIP CODE FILE OR

MUST BE A THREE CHARACTER FOREIGN COUNTRY CODE (BASED ON THE COUNTRY CODES TABLE1) FOLLOWED BY SIX BLANKS

RELATIONAL EDITS

NONE1 WHEN FOREIGN COUNTRY CODES ARE SUBMITTED, THE FIRST THREE CHARACTERS WILL BE EDITED AGAINST

ADDENDUM A.



2

ELEMENT NAME: ENROLLMENT/HEALTH PLAN CODE (1-110)

VALIDITY EDITS

1-110-01V MUST BE A VALID ENROLLMENT/HEALTH PLAN CODE (REFER TO SECTION 2.5).

RELATIONAL EDITS

1-110-02R IF ENROLLMENT/HEALTH PLAN CODE = Y CHCBP - NON-NETWORK OR

AA CHCBP - NETWORK

THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN = CL CLINICAL TRIALS OR

PF ECHO

1-110-06R IF ENROLLMENT/HEALTH PLAN CODE = SN SHCP - NON-MTF-REFERRED CARE OR



ST SHCP - TRICARE ELIGIBLE

THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = AN SHCP - NON-MTF-REFERRED CARE OR

AR SHCP - REFERRED CARE OR

CE SHCP - CCEP OR



SM SHCP - EMERGENCY

1-110-09R • TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.WHEN BEGIN DATE OF CARE IS < 10/01/2001, THE OCCURRENCE/LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.

IF ENROLLMENT/HEALTH PLAN CODE = FE TFL - NETWORK OR

FS TFL - NON-NETWORK

AND TYPE OF INSTITUTION ≠ 10 GENERAL MEDICAL AND SURGICAL

THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001

AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = FF TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR

FG TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR

FS TFL (SECOND PAYOR)

ELSE IF BEGIN DATE OF CARE IS < 10/01/2001

THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAILED OCCURRENCE/LINE ITEM (EXCEPT FOR LINE CONTAINING REVENUE CODE 0001) MUST =

15 PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR

26 EXPENSES INCURRED PRIOR TO COVERAGE OR

27 EXPENSES INCURRED AFTER COVERAGE TERMINATED OR

1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN DATE OF CARE.

C-97, October 19, 2017



3

30 PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING OR RESIDENCY REQUIREMENTS OR

31 CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR

32 OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR

33 CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR

34 CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORN OR

62 PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR

141 CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE

1-110-10R • TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001UNLESS THE BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO 10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.



AND TYPE OF INSTITUTION = 10 GENERAL MEDICAL AND SURGICAL

THEN END DATE OF CARE ≥ 10/01/2001

AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = FF TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR

FG TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, I.E., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR


1-110-11R • TFL CLAIMS: THE PATIENT MUST BE 64 YEARS AND 11 MONTHS OR GREATER.IF THE PATIENT IS LESS THAN THIS AGE THE OCCURRENCE/LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.



THEN PATIENT AGE1 MUST BE ≥ 64 YEARS AND 11 MONTHS

ELSE IF PATIENT AGE1 IS < 64 YEARS AND 11 MONTHS

THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAILED OCCURRENCE/LINE ITEM (EXCEPT LINE CONTAINING REVENUE CODE 0001) MUST = 15 PAYMENT ADJUSTED BECAUSE THE SUBMITTED

AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR



ELEMENT NAME: ENROLLMENT/HEALTH PLAN CODE (1-110) (Continued)


C-97, October 19, 2017



4

30 PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR




34 CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR



1-110-12R IF ENROLLMENT/HEALTH PLAN CODE = ME MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR

MS MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON-NETWORK

THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = R MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST

PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR

T MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR

RS MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001



C-97, October 19, 2017



5

ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE CODE (1-111)

VALIDITY EDITS

1-111-01V MUST BE A VALID HCDP PLAN COVERAGE CODE LISTED IN ADDENDUM L.

1-111-02V IF FILING DATE ≥ 09/01/2007

AND HCDP PLAN COVERAGE CODE = 109 TRICARE USFHP DIRECT CARE COVERAGE FOR ADFMs OR



118 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR

119 TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR

133 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

138 TRICARE USFHP DIRECT CARE INDIVUDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR


316 USFHP PRIME - SPONSORS AND FAMILY MEMBERS (PRESENTATION ONLY)

THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO

RELATIONAL EDITS

1-111-01R IF HCDP PLAN COVERAGE CODE = 306 TRICARE SELECT-RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR









C-97, October 19, 2017



6










THEN ENROLLMENT/HEALTH PLAN CODE MUST = T TRICARE STANDARD OR

V TRICARE EXTRA OR

FE TFL - NETWORK OR

FS TFL - NON-NETWORK OR

PS TSRX OR


TV TRICARE SELECT

1-111-02R IF HCDP PLAN COVERAGE CODE = 306 TRICARE SELECT-RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
















ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE CODE (1-111) (Continued)

C-97, October 19, 2017



7



THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN = PF ECHO

1-111-03R IF HCDP PLAN COVERAGE CODE = 417 TCSRC

THEN ENROLLMENT/HEALTH PLAN CODE MUST = X FOREIGN ADSM OR

SR SHCP - REFERRED CARE

ELEMENT NAME: REGION INDICATOR (1-112)

VALIDITY EDITS

1-112-01V MUST BE VALID REGION INDICATOR (REFER TO SECTION 2.8).

1-112-02V IF TYPE OF SUBMISSION ≠ B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR


AND REGION INDICATOR = NC NORTH CONTRACT OR

OC OVERSEAS CONTRACT

SC SOUTH CONTRACT OR

WC WEST CONTRACT

THEN ADJUSTMENT KEY MUST = 0 BATCH OR

5 VOUCHER

RELATIONAL EDITS

NONE

ELEMENT NAME: PCM LOCATION DMIS-ID (ENROLLMENT) CODE (1-115)

VALIDITY EDITS

1-115-01V MUST BE A VALID FOUR DIGIT PCM LOCATION DMIS-ID.

1-115-03V IF FILING DATE ≥ 09/01/2007

AND PCM LOCATION DMIS-ID = 0190 JOHNS HOPKINS MEDICAL SERVICES CORPORATION OR

0191 BRIGHTON MARINE OR

0192 CHRISTUS HEALTH/ST JOHN’S OR

0193 ST VINCENTS CATHOLIC MEDICAL CENTERS OF NY OR

0194 PACIFIC MEDICAL CLINICS OR

0196 CHRISTUS HEALTH/ST JOSEPH’S OR

0197 CHRISTUS HEALTH/ST MARY’S OR

0198 MARTIN’S POINT HEALTH CARE OR

0199 FAIRVIEW HEALTH SYSTEM

THEN AMOUNT ALLOWED (TOTAL) MUST = ZERO

RELATIONAL EDITS

NONE


C-97, October 19, 2017



8

ELEMENT NAME: AMOUNT BILLED (TOTAL) (1-120)

VALIDITY EDITS


RELATIONAL EDITS

1-120-01R IF TYPE OF SUBMISSION = A ADJUSTMENT OR

C COMPLETE CANCELLATION OR

D COMPLETE DENIAL OR



R RESUBMISSION

THEN AMOUNT BILLED (TOTAL) MUST BE > ZERO

UNLESS ANY OCCURRENCE/LINE ITEM REVENUE CODE = 0022 OR 0023

AND AMOUNT ALLOWED (TOTAL) = ZERO

1-120-02R AMOUNT BILLED (TOTAL) MUST = TOTAL CHARGE BY REVENUE CODE FOR REVENUE CODE 0001




15

3 ADJUSTMENT/CANCELLATION (TYPE OF SUBMISSION A, B, C, OR E) TO CORRECT BOTH CLAIM PROCESSING ERRORS AND EDIT ERRORS ON A PROVISIONALLY ACCEPTED TED RECORD

RELATIONAL EDITS

1-165-01R IF TYPE OF SUBMISSION = O ZERO PAYMENT WITH 100% OHI/TPL

THEN THE AMOUNT OF OHI MUST BE > ZERO

AND AMOUNT ALLOWED (TOTAL) MUST BE > ZERO

AND AMOUNT PAID BY GOVERNMENT CONTRACTOR (TOTAL) MUST BE = ZERO

1-165-02R IF ALL OCCURRENCES/LINE ITEMS (EXCLUDING REVENUE CODE 0001) CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN ADDENDUM G, FIGURE 2.G-1)

THEN TYPE OF SUBMISSION MUST = C COMPLETE CANCELLATION OR



UNLESS THE TED RECORD CORRECTION INDICATOR = 1 ADJUSTMENT/CANCELLATION (TYPE OF SUBMISSION

A, B, C, OR E) SOLELY TO CORRECT A PROVISIONALLY ACCEPTED TED RECORD OR

3 ADJUSTMENT/CANCELLATION (TYPE OF SUBMISSION A, B, C, OR E) TO CORRECT BOTH EDIT ERRORS ON A PROVISIONALLY ACCEPTED TED RECORD AND TO CORRECT CLAIM PROCESSING ERRORS OR UPDATE PRIOR DATA WITH MORE CURRENT/ACCURATE INFORMATION

1-165-04R IF BATCH/VOUCHER RESUBMISSION NUMBER = ZERO FOR THIS BATCH OR VOUCHER

THEN TYPE OF SUBMISSION MUST ≠ R RESUBMISSION

1-165-05R IF BATCH/VOUCHER RESUBMISSION NUMBER > ZERO FOR THIS BATCH OR VOUCHER

THEN TYPE OF SUBMISSION MUST BE ≠ I INITIAL TED RECORD SUBMISSION

1-165-06R IF TYPE OF SUBMISSION = I INITIAL SUBMISSION OR

R RESUBMISSION

AND TYPE OF INSTITUTION ≠ 70 HHA OR

71 SNF

AND SPECIAL PROCESSING CODE ≠ 11 HOSPICE

THEN AMOUNT BILLED (TOTAL), AMOUNT ALLOWED (TOTAL), COVERED DAYS, AND TOTAL CHARGE BY REVENUE CODE MUST BE > 0.

1-165-07R IF TYPE OF SUBMISSION = B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR


THEN BEGIN DATE OF CARE MUST BE < 10/01/2010

ELEMENT NAME: TYPE OF SUBMISSION (1-165) (Continued)




16

ELEMENT NAME: CA/NAS NUMBER (1-170)

VALIDITY EDITS

1-170-01V IF BEGIN DATE OF CARE ≥ 03/28/2013

THEN CA/NAS NUMBER MUST BE BLANK

ELSE IF CA/NAS NUMBER IS NOT BLANK.

THEN MUST BE 1 TO 11 OR 1 TO 15 ALPHANUMERIC CHARACTERS.

RELATIONAL EDITS

NO ERROR IF TYPE OF SUBMISSION = C COMPLETE CANCELLATION OR

D COMPLETE DENIAL

THEN BYPASS ALL CA/NAS NUMBER RELATIONAL EDITING.

NO ERROR IF ADMISSION DATE IS OLDER THAN SIX YEARS

THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA

NO ERROR IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = R MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST



AN SHCP - NON-MTF-REFERRED CARE OR


CE SHCP - CCEP OR

PF ECHO OR

RS MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR



SM SHCP - EMERGENCY OR

ST SPECIALIZED TREATMENT OR

WR MENTAL HEALTH WRAP AROUND

THEN BYPASS ALL CA/NAS NUMBER EDITING

NO ERROR IF ENROLLMENT/HEALTH PLAN CODE = U TRICARE PRIME, CIVILIAN PCM OR

W TPR ADSM - USA OR

X FOREIGN ADSM OR




BB TSP OR

FE TFL - NETWORK OR


SN SHCP - NON-MTF-REFERRED CARE OR 1 CATCHMENT AREA DETERMINATION IS BASED ON ADMISSION DATE.2 MTF IS A 40 MILES CATCHMENT AREA.

C-97, October 19, 2017



19

ELEMENT NAME: CA/NAS EXCEPTION REASON (1-180)

VALIDITY EDITS


THEN CA/NAS EXCEPTION REASON MUST BE BLANK

ELSE VALUE MUST BE A VALID CA/NAS EXCEPTION REASON CODE OR BLANK (REFER TO SECTION 2.4).

RELATIONAL EDITS


D COMPLETE DENIAL

THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.

NO ERROR IF ADMISSION DATE IS OLDER THAN SIX YEARS







CE SHCP - CCEP OR

PF ECHO OR







THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING


W TPR ADSM - USA OR

X FOREIGN ADSM OR




BB TSP OR

FE TFL - NETWORK OR



SR SHCP - REFERRED CARE OR 1 CATCHMENT AREA DETERMINATION IS BASED ON ADMISSION DATE.2 MTF IS A 40 MILES CATCHMENT AREA.

C-97, October 19, 2017



20

WF TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE ADSM


NO ERROR IF HCC MEMBER CATEGORY CODE = T FOREIGN MILITARY MEMBER


NO ERROR IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE = 15 PAYMENT ADJUSTED BECAUSE THE SUBMITTED












NO ERROR IF AMOUNT OF OTHER HEALTH INSURANCE PAID IS > ZERO

THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS EXCEPTION REASON EDITING.

1-180-03R IF PATIENT ZIP CODE IS IN AN MTF2 CATCHMENT AREA1

AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) = 290-316 (MENTAL HEALTH, ICD-9-CM)

AND CA/NAS NUMBER IS NOT CODED

AND BEGIN DATE OF CARE IS < 03/28/2013

THEN CA/NAS EXCEPTION REASON MUST BE CODED

1-180-07R IF CA/NAS EXCEPTION REASON = 5 RTC

AND PATIENT ZIP CODE IS IN AN MTF2 CATCHMENT AREA1

THEN TYPE OF INSTITUTION = 72 RTC

1-180-08R IF CA/NAS EXCEPTION REASON = S HHA PPS

THEN TYPE OF INSTITUTION MUST = 70 HHA

AND ONE OCCURRENCE OF REVENUE CODE MUST = 0023 HHA PPS

ELEMENT NAME: CA/NAS EXCEPTION REASON (1-180) (Continued)

1 CATCHMENT AREA DETERMINATION IS BASED ON ADMISSION DATE.2 MTF IS A 40 MILES CATCHMENT AREA.

C-93, January 27, 2017



21

ELEMENT NAME: SPECIAL PROCESSING CODE (1-185)

VALIDITY EDITS

1-185-01V OCCURRENCE NUMBER 1--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO SECTION 2.8).




1-185-05V A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).

1-185-06V ALL OCCURRENCES OF SPECIAL PROCESSING CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SPECIAL PROCESSING CODE.

1-185-07V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = AN SHCP - NON-MTF-REFERRED CARE OR

AR SHCP - REFERRED CARE


1-185-08V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = GF TPR FOR ELIGIBLE ADFM RESIDING WITH A TPR

ELIGIBLE ADSM


1-185-10V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = MN TSP - NON-NETWORK OR

MS TSP - NETWORK


1-185-11V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = SN TSS - NON-NETWORK OR

SS TSS - NETWORK


1-185-14V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = ST SPECIALIZED TREATMENT


RELATIONAL EDITS

1-185-08R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = PO TRICARE PRIME - POS

THEN ENROLLMENT/HEALTH PLAN CODE MUST = U TRICARE PRIME (CIVILIAN PCM) OR


WF TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE ADSM OR

XF FOREIGN ADFM

1-185-14R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = AN SHCP - NON-MTF-REFERRED CARE OR


CE SHCP - CCEP OR



SM SHCP - EMERGENCY1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.

C-93, January 27, 2017



22

THEN ENROLLMENT/HEALTH PLAN CODE MUST = SR SHCP - REFERRED CARE OR




1-185-32R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = E HHC/CM DEMO (AFTER 03/15/1999,

GRANDFATHERED INTO THE ICMP)

THEN BEGIN DATE OF CARE IS ≥ 03/15/1999

AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST = CM ICMP

1-185-34R • TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.IF BEGIN DATE OF CARE IS < 10/01/2001, THE LINE ITEMS MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.

IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = FF TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR

FG TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR


AND TYPE OF INSTITUTION ≠ 10 GENERAL MEDICAL AND SURGICAL


AND ENROLLMENT/HEALTH PLAN CODE MUST = FE TFL - NETWORK OR


ELSE IF BEGIN DATE OF CARE IS < 10/01/2001

THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAILED LINE ITEM (EXCEPT LINE CONTAINING REVENUE CODE 0001) MUST = 15 PAYMENT ADJUSTED BECAUSE THE SUBMITTED








ELEMENT NAME: SPECIAL PROCESSING CODE (1-185) (Continued)

1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.

C-97, October 19, 2017



23



141 CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE.

1-185-35R • TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001UNLESS THE BENEFICIARY IS AN INPATIENT AND THE ADMISSION DATE WAS PRIOR TO 10/01/2001, TFL WILL PAY FOR THE ENTIRE HOSPITAL STAY.

IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = FF TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR

FG TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, I.E., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) OR


AND TYPE OF INSTITUTION = 10 GENERAL MEDICAL AND SURGICAL

THEN END DATE OF CARE MUST BE ≥ 10/01/2001




THEN HCDP PLAN COVERAGE CODE MUST ≠ 306 TRICARE SELECT-RESERVE SELECT SPONSORS AND

FAMILY MEMBERS OR














C-97, October 19, 2017



24








1-185-49R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = AU AUTISM DEMONSTRATION


AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST = PF ECHO

AND PATIENT AGE1 MUST BE ≥ 18 MONTHS

1-185-50R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = 49 HOSPITAL REIMBURSEMENT REDUCED BY

MANUFACTURER CREDIT/REPLACEMENT OF DEVICE DURING WARRANTY PERIOD OR

50 HOSPITAL REIMBURSEMENT REDUCED BY MANUFACTURER CREDIT/RECALLED DEVICE

THEN DRG NUMBER MUST EQUAL A DRG SUBJECT TO THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.

AND IF END DATE OF CARE < 10/01/2014

THEN DATE OF ADMISSION MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE AS PER THE REPLACEMENT DEVICE POLICY POSTED ON TRICARE’S DRG WEB PAGE AT HTTP://WWW.HEALTH.MIL/DRG.

ELSE END DATE OF CARE MUST BE ≥ THE DRG EFFECTIVE DATE AND ≤ THE DRG TERMINATION DATE

1-185-51R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = PH PHILIPPINES DEMONSTRATION PROJECT


AND HCDP PLAN COVERAGE CODE MUST = 003 TRICARE STANDARD FOR ADFMs OR

005 TRICARE STANDARD SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

007 TRICARE STANDARD TRANSITIONAL ASSISTANCE SPONSORS AND FAMILY MEMBERS OR

009 TRICARE STANDARD RETIRED AND MOH SPONSORS AND FAMILY MEMBERS OR

010 TRICARE STANDARD TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

015 TRICARE STANDARD TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR

017 TRICARE STANDARD SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR



C-97, October 19, 2017

HTTP://WWW.HEALTH.MIL/DRG

HTTP://WWW.HEALTH.MIL/DRG



25

018 TFL RETIRED SPONSORS AND FAMILY MEMBERS AND MOH OR

020 TFL TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

021 TFL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

022 TFL TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR

023 TFL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR

028 TRICARE STANDARD FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR

029 TFL FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR

303 TRICARE SELECT-ACTIVE DUTY FAMILY MEMBERS OR

304 TRICARE SELECT-TAMP SPONSORS AND FAMILY MEMBERS OR

305 TRICARE SELECT-RETIRED SPONSORS AND FAMILY MEMBERS OR

306 TRICARE SELECT-RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR


308 TRICARE SELECT-YOUNG ADULT OR











422 TYA STANDARD FOR ADFMS OR

423 TYA STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR

424 TYA RESERVE SELECT OR

425 TYA RETIRED RESERVE OR


OR ENROLLMENT/HEALTH PLAN CODE = AS TRICARE SELECT-ACTIVE DUTY SURVIVORS OR



C-97, October 19, 2017



26

AT TRICARE SELECT-ACTIVE DUTY TRANSITIONAL SURVIVORS OR

GS TRICARE SELECT-GUARD/RESERVE SURVIVORS OR

GT TRICARE SELECT-GUARD/RESERVE TRANSITIONAL SURVIVORS

AND PATIENT ZIP CODE MUST = PHL PHILIPPINES

AND PROVIDER STATE OR COUNTRY CODE MUST = PHL PHILIPPINES

1-185-52R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = R MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST




THEN ENROLLMENT/HEALTH PLAN CODE MUST = ME MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/

NETWORK OR


ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) SPECIAL ENTITLEMENT CODE (1-186)

VALIDITY EDITS

1-186-01V MUST BE A VALID HCDP SPECIAL ENTITLEMENT CODE (REFER TO SECTION 2.5).

RELATIONAL EDITS

NONE



C-97, October 19, 2017



27

ELEMENT NAME: PRICING RATE CODE (1-190)

VALIDITY EDITS

1-190-01V VALUE MUST BE A VALID INSTITUTIONAL PRICING RATE CODE.

RELATIONAL EDITS

1-190-01R IF FILING STATE/COUNTRY CODE = MD MARYLAND

THEN PRICING RATE CODE MUST ≠ H TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR

I TRICARE DRG REIMBURSEMENT WITH COST OUTLIER OR

J TRICARE DRG REIMBURSEMENT WITH NO OUTLIER OR

DD DISCOUNTED DRG

1-190-02R IF DRG NUMBER IS CODED (OTHER THAN ZERO)

THEN PRICING RATE CODE MUST = H TRICARE DRG REIMBURSEMENT WITH SHORT STAY OUTLIER OR

I TRICARE DRG REIMBURSEMENT WITH COST OUTLIER OR

J TRICARE DRG REIMBURSEMENT WITH NO OUTLIER OR

U SHCP CLAIM OR ACTIVE DUTY MEMBER GSU CLAIM PAID OUTSIDE NORMAL LIMITS OR

V MEDICARE REIMBURSEMENT RATE OR

DD DISCOUNTED DRG

1-190-03R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = 11 HOSPICE

THEN PRICING RATE CODE MUST = D DISCOUNT RATE AGREEMENT OR

P PER DIEM RATE AGREEMENT OR

U SHCP CLAIM OR ACTIVE DUTY MEMBER GSU CLAIM PAID OUTSIDE NORMAL LIMITS OR

V MEDICARE REIMBURSEMENT RATE

UNLESS TYPE OF SUBMISSION = D COMPLETE DENIAL

OR AMOUNT ALLOWED (TOTAL) = ZERO

1-190-04R IF PRICING RATE CODE = V MEDICARE REIMBURSEMENT RATE

THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = T MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND

PAYOR) AND EARLIEST BEGIN DATE OF CARE ≥ 10/01/2001 OR

FS TFL (SECOND PAYOR) OR

MN TSP - NON-NETWORK OR

MS TSP - NETWORK

OR TYPE OF INSTITUTION = 70 HHA OR

76 SNF

1-190-05R IF PRICING RATE CODE = U SHCP CLAIM OR ACTIVE DUTY MEMBER TPR CLAIM PAID OUTSIDE NORMAL LIMITS

THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = AN SHCP - NON-MTF-REFERRED CARE OR

C-97, October 19, 2017



28


CE SHCP - CCEP OR

GU ADSM ENROLLED IN TPR OR



SM SHCP - EMERGENCY

OR ENROLLMENT/HEALTH PLAN CODE MUST = SN SHCP - NON-MTF-REFERRED CARE OR

SR SHCP - REFERRED CARE

1-190-06R IF ANY OCCURRENCE OF REVENUE CODE = 0022 SNF - PPS



UNLESS AMOUNT ALLOWED (TOTAL) = ZERO

1-190-07R IF ANY OCCURRENCE OF REVENUE CODE = 0023 HHA PPS



UNLESS AMOUNT ALLOWED (TOTAL) = ZERO

1-190-08R IF PRICING RATE CODE = CA CAH REIMBURSEMENT

THEN ADMISSION DATE MUST BE ≥ 12/01/2009

UNLESS PROVIDER STATE OR COUNTRY CODE = AK ALASKA

THEN ADMISSION DATE MUST BE ≥ 07/01/2007

1-190-09R IF PRICING RATE CODE = CR CCR

THEN ADMISSION DATE MUST BE ≥ 01/01/2014.


AND ADMISSION DATE ≥ 01/01/2014.

THEN TYPE OF INSTITUTION MUST = 93 CAH

ELEMENT NAME: PRICING RATE CODE (1-190) (Continued)

C-97, October 19, 2017



29

- END -

ELEMENT NAME: PROVIDER STATE OR COUNTRY CODE (1-195)

VALIDITY EDITS

1-195-01V VALUE MUST BE A VALID STATE OR COUNTRY CODE (REFER TO ADDENDUM A OR ADDENDUM B)

RELATIONAL EDITS

1-195-01R PROVIDER STATE/COUNTRY CODE MUST MATCH THE CORRESPONDING RECORD1 IN THE PROVIDER FILE.

UNLESS AMOUNT ALLOWED (TOTAL) ≤ ZERO

OR ADJUSTMENT/DENIAL REASON CODE = 38 SERVICES NOT PROVIDED OR AUTHORIZED BY

DESIGNATED (NETWORK) PROVIDERS OR

52 THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED OR

B7 THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE

OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE = T MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND

PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001

FG TFL (FIRST PAYOR - NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR


RS MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR - NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001

THEN DO NOT CHECK FOR MATCH ON PROVIDER FILE1 “CORRESPONDING RECORD” ON PROVIDER FILE IS BASED ON INSTITUTIONAL TAXPAYER NUMBER, PROVIDER SUB-

IDENTIFIER, PROVIDER ZIP CODE, AND TYPE OF INSTITUTION. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (1-200-02R).

C-97, October 19, 2017



9

ELEMENT NAME: BEGIN DATE OF CARE (1-275)

VALIDITY EDITS

1-275-01V MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.

1-275-02V BEGIN DATE OF CARE CANNOT BE < 01/01/1990.

1-275-03V BEGIN DATE OF CARE MUST BE ≤ END DATE OF CARE.

RELATIONAL EDITS

1-275-02R BEGIN DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION

1-275-03R BEGIN DATE OF CARE MUST BE ≥ PERSON BIRTH CALENDAR DATE (PATIENT)


B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR



THEN BEGIN DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED

UNLESS TED RECORD CORRECTION INDICATOR = 1 ADJUSTMENT/CANCELLATION (TYPE OF SUBMISSION

A, B, C, OR E) SOLELY TO CORRECT A PROVISIONALLY ACCEPTED TED RECORD

AND DATE ADJUSTMENT IDENTIFIED ON DHA DATABASE = ZEROES.

1-275-06R PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR THIS BEGIN DATE OF CARE





B7 THIS PROVIDER WAS NOT CERTIFIED ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE


PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR

FG TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR



THEN DO NOT CHECK PROVIDER FILE1 “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER

SUB-IDENTIFIER, PROVIDER ZIP CODE, TYPE OF INSTITUTION, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (1-200-02R).

C-93, January 27, 2017



10

ELEMENT NAME: END DATE OF CARE (1-280)

VALIDITY EDITS

1-280-01V MUST BE A VALID GREGORIAN DATE AND CANNOT BE > DHA CURRENT SYSTEM DATE.

1-280-02V END DATE OF CARE CANNOT BE < 01/01/1990.

1-280-03V END DATE OF CARE MUST BE ≥ BEGIN DATE OF CARE.

RELATIONAL EDITS

1-280-01R END DATE OF CARE MUST BE ≤ DATE TED RECORD PROCESSED TO COMPLETION


B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR



THEN END DATE OF CARE MUST BE ≤ DATE ADJUSTMENT IDENTIFIED

1-280-03R PROVIDER MUST BE “AUTHORIZED”1 ON PROVIDER FILE FOR THIS END DATE OF CARE





B7 THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE






THEN DO NOT CHECK PROVIDER FILE1 “AUTHORIZED” RECORD ON PROVIDER FILE IS BASED ON INSTITUTIONAL PROVIDER TAXPAYER NUMBER, PROVIDER

SUB-IDENTIFIER, PROVIDER ZIP CODE, TYPE OF INSTITUTION, AND PROVIDER ACCEPTANCE AND TERMINATION DATES. THIS IS ONLY DETERMINED ONCE A PROVIDER MATCH HAS BEEN OBTAINED (1-200-02R).

C-97, October 19, 2017


Non-Institutional Edit Requirements (ELN 100 - 199)

19

ELEMENT NAME: PROCEDURE CODE MODIFIER (2-165)

VALIDITY EDITS

2-165-01V MUST BE A VALID PROCEDURE CODE MODIFIER AS DEFINED IN SECTION 2.7

RELATIONAL EDITS

NONE

ELEMENT NAME: NATIONAL DRUG CODE (2-170)

VALIDITY EDITS

2-170-01V MUST BE A VALID NATIONAL DRUG CODE OR BLANK

RELATIONAL EDITS

2-170-01R IF NATIONAL DRUG CODE = BLANK

THEN TYPE OF SERVICE (SECOND POSITION) MUST ≠ B RETAIL DRUGS, SUPPLIES, PRESCRIPTION,

AUTHORIZATIONS, AND REVIEWS OR

M MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS

AND PROCEDURE CODE1 MUST ≠ 98800 FOR DRUGS

UNLESS PROVIDER STATE OR COUNTRY CODE IS A FOREIGN COUNTRY CODE (ADDENDUM A)

2-170-02R IF NATIONAL DRUG CODE ≠ BLANK

THEN TYPE OF SERVICE (SECOND POSITION) MUST = B RETAIL DRUGS, SUPPLIES, PRESCRIPTION,


M MOP DRUGS, SUPPLIES, PRESCRIPTION, AUTHORIZATIONS, AND REVIEWS

AND PROCEDURE CODE1 MUST = 98800 FOR DRUGS OR

99070 FOR SUPPLIES OR

000MN PRESCRIPTION MEDICAL NECESSITY REVIEWS OR

000PA PRESCRIPTION PRIOR AUTHORIZATIONS1 CPT ONLY © 2006 AMERICAN MEDICAL ASSOCIATION (OR SUCH OTHER DATE OF PUBLICATION OF CPT). ALL RIGHTS

RESERVED.

C-50, June 25, 2013



20

ELEMENT NAME: NUMBER OF SERVICES (2-175)

VALIDITY EDITS


RELATIONAL EDITS






R RESUBMISSION

THEN NUMBER OF SERVICES FOR EACH OCCURRENCE MUST BE > ZERO

UNLESS TYPE OF SERVICE (SECOND POSITION) = M MOP DRUGS, SUPPLIES, PRESCRIPTION,

AUTHORIZATIONS, AND REVIEWS

AND OCCURRENCE/LINE ITEM NUMBER = 002

THEN NUMBER OF SERVICES ON THIS LINE ITEM MUST = ZERO

2-175-02R2 • SURGERY PROCEDURE CODES

IF AMOUNT ALLOWED BY PROCEDURE CODE > ZERO

AND PROCEDURE CODE1 = 10000-36399 OR 36800-69999 (SURGERY)

THEN NUMBER OF SERVICES PER PROCEDURE CODE ON A LINE ITEM CANNOT EXCEED 10 PER DAY

UNLESS PROCEDURE CODE = 11201, 11721, 13102, 13122, 13133, 13153, 15001, 15003, 15101, 15201, 15221, 15241, 15261, 15301, 15321, 15331, 15341, 15343, 15361, 15366, 15401, 15421, 15431, 17003, 17004, 17110, 17111, OR 17310

OR ANY OCCURRENCE OF OVERRIDE CODE = NS CONTRACTOR HAS DETERMINED THA NUMBER OF

SERVICES IS MEDICALLY NECESSARY

2-175-03R2 • E/M PROCEDURE CODES


AND PROCEDURE CODE1 = 99201-99205 (OFFICE VISITS - NEW PATIENTS) OR

99211-99215 (OFFICE VISITS - ESTABLISHED PATIENTS) OR

99217 (DISCHARGE SERVICES) OR

99221-99233 (HOSPITAL CARE PER DAY) OR

99234-99236 (OBSERVATION OR IMPATIENT CARE SERVICES) OR

99238-99239 (HOSPITAL DISCHARGE SERVICES) OR

99241-99245 (OFFICE CONSULTATIONS) OR 1 CPT ONLY © 2006 AMERICAN MEDICAL ASSOCIATION (OR SUCH OTHER DATE OF PUBLICATION OF CPT). ALL RIGHTS

RESERVED.2 EDITS 2-175-02R, 2-175-03R, 2-175-04R, AND 2-175-06R ARE ONLY EXECUTED FOR FILING DATES < 02/01/2010.3 EDIT 2-175-07R IS ONLY EXECUTED FOR FILING DATES ≥ 02/01/2010. PROCEDURE CODE RECORD MATCH MADE IN 2-

160-01V OR 2-160-02V WILL BE USED IN EDIT 2-175-07R. BYPASS EDIT 2-175-07R IF RECORD FAILS EDIT 2-160-01V OR 2-160-02V.

4 TO DETERMINE MAXIMUM NUMBER OF SERVICES REFER TO THE MAXIMUM NUMBER OF SERVICES CODE LIST AT HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT.

C-97, October 19, 2017

HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT



21

99251-99255 (INITIAL INPATIENT CONSULTATIONS) OR

99261-99263 (FOLLOW-UP INPATIENT CONSULTATIONS) OR

99271-99275 (CONFIRMATORY CONSULTATIONS) OR

99281-99285 (EMERGENCY DEPARTMENT VISIT) OR

99291 (CRITICAL CARE) (NOTE: CODE 99292 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 15 MINUTES OF CARE) OR

99295-99298 (NEONATAL INTENSIVE CARE) OR

99301-99315 (NURSING FACILITY CHARGES) OR

99321-99333 (DOMICILIARY, REST HOME, OR CUSTODIAL CARE SERVICES) OR

99341-99350 (HOME SERVICES) OR

99354 (PROLONGED SERVICES) (NOTE: CODE 99355 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 30 MINUTES OF CARE) OR

99356 (PROLONGED SERVICES) (NOTE: CODE 99357 EXCLUDED BECAUSE UTILIZED TO REPORT FOR EACH ADDITIONAL 30 MINUTES OF CARE) OR

99361-99373 (CASE MANAGEMENT SERVICES) OR

99374-99380 (CARE PLAN OVERSIGHT) OR

99381-99429 (PREVENTIVE MEDICINE SERVICES) OR

99431-99440 (NEWBORN CARE) OR

99450-99456 (SPECIAL EVALUATION AND MANAGEMENT SERVICES)


UNLESS ANY OCCURRENCE OF OVERRIDE CODE = NS CONTRACTOR HAS DETERMINED THAT NUMBER OF


2-175-04R2 • MEDICAL PROCEDURE CODES


AND PROCEDURE CODE1 = 99500-99512 (HOME HEALTH VISIT) OR

99551-99568 (HOME INFUSION PER DIEM CODES)




2-175-06R2 • VACCINES (VACCINE PRODUCT ONLY) PROCEDURE CODES

ELEMENT NAME: NUMBER OF SERVICES (2-175) (Continued)

1 CPT ONLY © 2006 AMERICAN MEDICAL ASSOCIATION (OR SUCH OTHER DATE OF PUBLICATION OF CPT). ALL RIGHTS RESERVED.

2 EDITS 2-175-02R, 2-175-03R, 2-175-04R, AND 2-175-06R ARE ONLY EXECUTED FOR FILING DATES < 02/01/2010.3 EDIT 2-175-07R IS ONLY EXECUTED FOR FILING DATES ≥ 02/01/2010. PROCEDURE CODE RECORD MATCH MADE IN 2-



C-97, October 19, 2017



22


AND PROCEDURE CODE1 = 90476-90479 (VACCINES, TOXOIDS)




2-175-07R3 IF AMOUNT ALLOWED BY PROCEDURE CODE = ZERO

OR PRICING RATE CODE = P1 OPPS OR

P2 OPPS WITH COST OUTLIER OR

P3 OPPS WITH DISCOUNT OR

P5 HOSPITAL-BASED PARTIAL HOSPITALIZATION PAID AS OPPS

OR NO OCCURRENCE OF SPECIAL PROCESSING CODE = T MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND




ELSE NUMBER OF SERVICES CANNOT EXCEED THE MAXIMUM ALLOWED NUMBER OF SERVICES PER DAY FOR THE PROCEDURE CODE ON THIS LINE ITEM4 (BEGIN DATE OF CARE MUST BE ON OR AFTER THE MAXIMUM NUMBER OF SERVICES TABLE EFFECTIVE DATE AND NOT LATER THAN THE MAXIMUM NUMBER OF SERVICES TABLE TERMINATION DATE)



ELEMENT NAME: NUMBER OF SERVICES (2-175) (Continued)


2 EDITS 2-175-02R, 2-175-03R, 2-175-04R, AND 2-175-06R ARE ONLY EXECUTED FOR FILING DATES < 02/01/2010.3 EDIT 2-175-07R IS ONLY EXECUTED FOR FILING DATES ≥ 02/01/2010. PROCEDURE CODE RECORD MATCH MADE IN 2-



C-97, October 19, 2017



7

ELEMENT NAME: PROVIDER TAXONOMY (SPECIALTY) (2-255)

VALIDITY EDITS

2-255-01V THIS FIELD MUST BE A VALID PROVIDER SPECIALTY (REFER TO HTTP://WWW.WPC-EDI.COM/).

RELATIONAL EDITS

2-255-03R IF PROVIDER SPECIALTY = 333600000X (SUPPLIERS/PHARMACY)

THEN TYPE OF SERVICE (SECOND POSITION) = B RETAIL DRUGS, SUPPLIES, PRESCRIPTION


2-255-04R IF PROVIDER SPECIALTY = 183500000X (PHARMACY SERVICE PROVIDERS/PHARMACIST)

THEN TYPE OF SERVICE (SECOND POSITION) = M MOP DRUGS, SUPPLIES, PRESCRIPTION


ELEMENT NAME: PROVIDER PARTICIPATION INDICATOR (2-260)

VALIDITY EDITS

2-260-01V MUST BE A VALID PROVIDER PARTICIPATION INDICATOR.

RELATIONAL EDITS

NONE

ELEMENT NAME: PROVIDER NETWORK STATUS INDICATOR (2-265)

VALIDITY EDITS

2-265-01V PROVIDER NETWORK STATUS INDICATOR MUST = 1 NETWORK PROVIDER OR

2 NON-NETWORK PROVIDER

RELATIONAL EDITS

NONE

ELEMENT NAME: PHYSICIAN REFERRAL NUMBER (2-270)

VALIDITY EDITS

NONE

RELATIONAL EDITS

NONE

ELEMENT NAME: PLACE OF SERVICE (2-275)

VALIDITY EDITS

2-275-01V VALUE MUST BE A VALID PLACE OF SERVICE.

RELATIONAL EDITS

2-275-01R IF ADJUSTMENT/DENIAL REASON CODE IS NOT A CODE LISTED IN ADDENDUM G, FIGURE 2.G-2

THEN PLACE OF SERVICE MUST BE CONSISTENT WITH TYPE OF SERVICE, REFER TO ADDENDUM F.

2-275-06R IF PLACE OF SERVICE = 21 INPATIENT HOSPITAL

THEN TYPE OF SERVICE (FIRST POSITION) MUST = I INPATIENT

C-97, October 19, 2017

HTTP://WWW.WPC-EDI.COM/



8

ELEMENT NAME: TYPE OF SERVICE (2-280)

VALIDITY EDITS

2-280-01V FIRST POSITION MUST BE = ‘A’, ‘I’, ‘K’, ‘M’, ‘N’, ‘O’, OR ‘P’.

SECOND POSITION MUST BE = 1-9; A-M.

IF FIRST POSITION = ‘A’; SECOND POSITION MUST ≠ ‘C’.

IF FIRST POSITION = ‘P’; SECOND POSITION MUST = ‘H’.

IF FIRST POSITION = ‘N’; SECOND POSITION MUST = ‘I’.

2-280-02V IF CONTRACT NUMBER = MDA906-02-C-0013

THEN TYPE OF SERVICE (SECOND POSITION) MUST = M MOP DRUGS, SUPPLIES, PRESCRIPTION


RELATIONAL EDITS

2-280-07R IF TYPE OF SERVICE (FIRST POSITION) = A AMBULATORY SURGERY COST-SHARED AS INPATIENT (ACTIVE DUTY DEPENDENTS ONLY) OR

M OUTPATIENT MATERNITY COST-SHARED AS INPATIENT OR

N OUTPATIENT COST-SHARED AS INPATIENT OR

O OUTPATIENT, EXCLUDING M, P, OR N OR

P OUTPATIENT PARTIAL PSYCHIATRIC HOSPITALIZATION COST-SHARED AS INPATIENT

THEN PLACE OF SERVICE CANNOT = 21 INPATIENT HOSPITAL

2-280-08R IF TYPE OF SERVICE (SECOND POSITION) = B RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS

THEN NATIONAL DRUG CODE MUST ≠ BLANK


2-280-09R IF TYPE OF SERVICE (SECOND POSITION) = M MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS

THEN TYPE OF SUBMISSION MUST ≠ B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR


AND AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO

AND CA/NAS EXCEPTION REASON MUST = BLANK

AND CA/NAS NUMBER MUST = BLANK

AND CA/NAS REASON FOR ISSUANCE MUST = BLANK

AND NATIONAL DRUG CODE MUST ≠ BLANK

AND IF BEGIN DATE OF CARE < 01/01/2016

THEN PLACE OF SERVICE MUST = 19 PHARMACY

ELSE PLACE OF SERVICE MUST = 01 PHARMACY

AND PRICING RATE CODE MUST = 0

AND PROVIDER NETWORK STATUS INDICATOR MUST = 1 NETWORK PROVIDER

AND PROVIDER PARTICIPATING INDICATOR MUST = Y YES


C-81, December 16, 2015



9

AND PROVIDER SPECIALTY MUST = 183500000X (PHARMACY SERVICE PROVIDERS/PHARMACIST)

AND IF PROCEDURE CODE = 000MN PRESCRIPTION MEDICAL NECESSITY REVIEWS OR

000PA PRESCRIPTION PRIOR AUTHORIZATIONS

THEN AMOUNT PATIENT COST-SHARE MUST = ZERO

AND CLAIM FORM TYPE/EMC INDICATOR MUST = J OTHER

ELSE IF OCCURRENCE/LINE ITEM NUMBER = 002

THEN AMOUNT BILLED BY PROCEDURE CODE ON THIS LINE ITEM MUST = ZERO

AND AMOUNT PATIENT COST-SHARE ON THIS LINE ITEM MUST = ZERO

AND NUMBER OF SERVICES ON THIS LINE ITEM MUST = ZERO

ELSE CLAIM FORM TYPE/EMC INDICATOR MUST = I ELECTRONIC DRUG CLAIM SUBMISSION

AND NUMBER OF SERVICES = 1

2-280-10R IF TYPE OF SERVICE (SECOND POSITION) = B RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR

M MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS

THEN REGION INDICATOR MUST = BLANK


2-280-11R IF TYPE OF SERVICE (SECOND POSITION) = M MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS

AND OCCURRENCE/LINE ITEM COUNT = 002

THEN PROCEDURE CODE1 MUST = 99070 SUPPLIES

2-280-12R IF TYPE OF SERVICE (SECOND POSITION) = G DENTAL

THEN PROCEDURE CODE1 ≠ 00100 - 09999

2-280-13R IF TYPE OF SERVICE (SECOND POSITION) = B RETAIL PHARMACY DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR


AND CLAIM FORM TYPE/EMC INDICATOR = J OTHER

THEN PROCEDURE CODE MUST = 000MN PRESCRIPTION MEDICAL NECESSITY REVIEWS OR


ELEMENT NAME: TYPE OF SERVICE (2-280) (Continued)


C-81, December 16, 2015



10

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER CATEGORY CODE (2-285)

VALIDITY EDITS

2-285-01V MUST BE A VALID HCC MEMBER CATEGORY CODE (REFER TO SECTION 2.5)

RELATIONAL EDITS

2-285-01R IF HCC MEMBER RELATIONSHIP CODE = A SELF

THEN HCC MEMBER CATEGORY MUST ≠ A ACTIVE DUTY OR







UNLESS ENROLLMENT/HEALTH PLAN CODE = W TPR ADSM - USA OR

X FOREIGN ADSM OR







SU SHCP - REFERRAL DESIGNATION UNKNOWN OR

WA TPR FOREIGN ADSM

OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE = SC SHCP - NON-TRICARE ELIGIBLE OR


SM SHCP - EMERGENCY

OR HCDP PLAN COVERAGE CODE = 306 TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR







C-97, October 19, 2017



11













THEN HHC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR

G NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR


P TAMP MEMBER OR

S RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE)

2-285-03R IF TYPE OF SERVICE (FIRST POSITION) = A AMBULATORY SURGERY COST-SHARED AS INPATIENT

THEN HCC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR



N NATIONAL GUARD MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR

P TAMP MEMBER OR



V RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR

Z UNKNOWN

UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = 0

2-285-04R IF HCDP PLAN COVERAGE CODE = 004 DIRECT CARE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR


C-97, October 19, 2017



12

005 TRICARE STANDARD FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

016 DIRECT CARE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

017 TRICARE STANDARD FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR



110 TRICARE PRIME FOR INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

111 TRICARE PRIME FAMILY COVERAGE FOR SUVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR



136 TRICARE PRIME INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

137 TRICARE PRIME FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR



143 TRICARE PLUS COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

144 TRICARE PLUS WITH CHC COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

148 TRICARE PLUS COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

149 TRICARE PLUS COVERAGE WITH CHC FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR

205 TDP INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

206 TDP FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

212 TDP INDIVIDUAL COVERAGE FOR SURVIVORS OF SELECTED RESERVE (SelRes) DECEASED SPONSORS OR

213 TDP FAMILY COVERAGE FOR SURVIVORS OF SELCTED RESERVE (SelRes) DECEASED SPONSORS OR


C-97, October 19, 2017



13


345 TRICARE PLUS-DIRECT CARE ONLY (PRESENTATION LAYER) OR

346 TRICARE PLUS

409 RESERVE SELECT SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR

410 RESERVE SELECT SURVIVOR CONTINUING WITH FAMILY COVERAGE OR

411 RESERVE SELECT SURVIVOR NEW INDIVIDUAL COVERAGE OR

412 RESERVE SELECT SURVIVOR NEW FAMILY COVERAGE

OR ENROLLMENT/HEALTH PLAN CODE = AS TRICARE SELECT - ACTIVE DUTY SURVIVORS OR

GS TRICARE SELECT - GUARD/RESERVE SURVIVORS

OR AMOUNT ALLOWED BY PROCEDURE CODE = 0


ELSE IF TYPE OF SERVICE (SECOND POSITION) = C AMBULATORY SURGERY

THEN HCC MEMBER CATEGORY CODE MUST = D DISABLED AMERICAN VETERAN OR

F FORMER MEMBER OR

H MEDAL OF HONOR RECIPIENT OR

R RETIRED OR

W FORMER SPOUSE OR

Z UNKNOWN


THEN ONE OCCURRENCE OF OVERRIDE CODE = M NATO

ELEMENT NAME: PAY GRADE CODE (SPONSOR) (2-291)

VALIDITY EDITS

2-291-01V MUST BE A VALID PAY GRADE CODE (SPONSOR) (REFER TO SECTION 2.7)

RELATIONAL EDITS

NONE

ELEMENT NAME: PAY PLAN CODE (SPONSOR) (2-292)

VALIDITY EDITS

2-292-01V MUST BE A VALID PAY PLAN CODE (SPONSOR) (REFER TO ADDENDUM K)

RELATIONAL EDITS

NONE


C-97, October 19, 2017



14

- END -

ELEMENT NAME: HEALTH CARE COVERAGE (HCC) MEMBER RELATIONSHIP CODE (2-295)

VALIDITY EDITS

2-295-01V MUST BE A VALID HCC MEMBER RELATIONSHIP CODE (REFER TO SECTION 2.5)

RELATIONAL EDITS


THEN HCC MEMBER RELATIONSHIP CODE MUST = A SELF OR

B SPOUSE OR

C CHILD OR STEPCHILD OR

D PRE-ADOPTIVE CHILD OR

E WARD (COURT ORDERED) OR

G SURVIVING SPOUSE

2-295-07R IF TYPE OF SERVICE (FIRST POSITION) = A AMBULATORY SURGERY COST-SHARED AS INPATIENT


B SPOUSE OR

C CHILD OR STEPCHILD OR

D PRE-ADOPTIVE CHILD OR

E WARD (COURT ORDERED) OR

G SURVIVING SPOUSE OR

Z UNKNOWN

AND HCC MEMBER CATEGORY CODE ≠ W FORMER SPOUSE

UNLESS ANY OCCURRENCE OF SPECIAL PROCESSING CODE = SC SHCP - NON-TRICARE ELIGIBLE


AND HCC MEMBER RELATIONSHIP CODE = A SELF

THEN ANY OCCURRENCE OF SPECIAL PROCESSING CODE MUST = AN SHCP - NON-REFERRED CARE OR



SM SHCP - EMERGENCY

OR ENROLLMENT/HEALTH PLAN CODE MUST = SN SHCP - NON-MTF REFERRED OR


SR SHCP - REFERRED OR

SU SHCP - REFERRAL DESIGNATION UNKNOWN

UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = ZERO

THEN BYPASS THIS EDIT 1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND BEGIN CARE DATE.

C-84, February 25, 2016

1




ELEMENT NAME: ENROLLMENT/HEALTH PLAN CODE (2-300)

VALIDITY EDITS

2-300-01V MUST BE A VALID ENROLLMENT/HEALTH PLAN CODE (REFER TO SECTION 2.5)

RELATIONAL EDITS

2-300-02R IF ENROLLMENT/HEALTH PLAN CODE = Y CHCBP - NON-NETWORK OR

AA CHCBP - NETWORK

THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE = CL CLINICAL TRIALS OR

PF ECHO

2-300-07R IF ENROLLMENT/HEALTH PLAN CODE = SN SHCP - NON-MTF-REFERRED CARE OR


SR SHCP - MTF REFERRED CARE OR


THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = AN SHCP -NON-MTF-REFERRED CARE OR


CE SHCP - CCEP OR



SM SHCP - EMERGENCY

2-300-10R IF ENROLLMENT/HEALTH PLAN CODE = PS TSRx

THEN TYPE OF SERVICE (SECOND POSITION) MUST = B RETAIL DRUGS, SUPPLIES, PRESCRIPTION



2-300-11R IF ENROLLMENT/HEALTH PLAN CODE = PS TSRx

THEN NATIONAL DRUG CODE CANNOT BE BLANK.

OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE = 1 MEDICAID

OR PROVIDER STATE OR COUNTRY CODE MUST IS FOREIGN COUNTRY CODE (Addendum A)

2-300-12R • TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.FOR EACH LINE ITEM WHERE BEGIN DATE OF CARE IS < 10/01/2001, THE LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.


FS TFL - NON-NETWORK1 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.

C-97, October 19, 2017



2

THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = FF TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR



ELSE IF BEGIN DATE OF CARE IS < 10/01/2001 (FOR THAT DETAILED LINE ITEM)

THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE MUST = 15 PAYMENT ADJUSTED BECAUSE THE SUBMITTED











2-300-13R • TFL CLAIMS: THE PATIENT MUST BE 64 YEARS AND 11 MONTHS OR GREATER.IF THE PATIENT IS LESS THAN THIS AGE, THE LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.



PS TSRx

AND TYPE OF SERVICE (SECOND POSITION) ≠ M MOP DRUGS, SUPPLIES, PRESCRIPTION



ELSE IF PATIENT AGE1 IS < 64 YEARS AND 11 MONTHS



C-97, October 19, 2017



3












2-300-15R IF ENROLLMENT/HEALTH PLAN CODE = SU SCHP - REFERRAL DESIGNATION UNKNOWN




2-300-16R IF ENROLLMENT/HEALTH PLAN CODE = SU SCHP - REFERRAL DESIGNATION UNKNOWN

THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = SC SHCP - NON-TRICARE ELIGIBLE OR

SE SHCP - TRICARE ELIGIBLE

2-300-17R • FOR MOP ONLY: FOR TSRx, THE PATIENT MUST BE 64 YEARS AND 8 MONTHS OR GREATER. IF THE PATIENT IS LESS THAN THIS AGE, THE LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.

IF ENROLLMENT/HEALTH PLAN CODE = PS TSRx

AND TYPE OF SERVICE (SECOND POSITION) = M MOP DRUGS, SUPPLIES, PRESCRIPTION



ELSE IF PATIENT AGE1 < 64 YEARS AND 8 MONTHS



C-73, January 13, 2015



4












2-300-18R IF ENROLLMENT/HEALTH PLAN CODE = X FOREIGN ADSM


T FOREIGN MILITARY MEMBER

AND HCC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR






2-300-19R IF ENROLLMENT/HEALTH PLAN CODE = ME MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR


THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = R MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST




C-97, October 19, 2017



5





C-97, October 19, 2017



6

ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE CODE (2-301)

VALIDITY EDITS

2-301-01V MUST BE A VALID HCDP PLAN COVERAGE CODE LISTED IN ADDENDUM L.

2-301-02V IF FILING DATE ≥ 09/01/2007

AND HCDP PLAN COVERAGE CODE = 109 TRICARE USFHP DIRECT CARE COVERAGE FOR ADFMs OR



118 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR

119 TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR

133 TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR TRANSITIONAL SURVIVORS OR ACTIVE DUTY DECEASED SPONSORS OR



316 USFHP PRIME - SPONSOR AND FAMILY MEMBERS (PRESENTATION ONLY)

THEN THE TOTAL OF ALL OCCURRENCES/LINEITEMS OF AMOUNT ALLOWED BY PROCEDURE CODES MUST = ZERO

2-301-03R IF HCDP PLAN COVERAGE CODE = 417 TCSRC

THEN ENROLLMENT/HEALTH PLAN CODE MUST = X FOREIGN ADSM OR


RELATIONAL EDITS

2-301-01R IF HCDP PLAN COVERAGE CODE = 306 TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR






C-97, October 19, 2017



7













THEN ENROLLMENT/HEALTH PLAN CODE MUST = T TRICARE STANDARD OR

V TRICARE EXTRA OR

FE TFL - NETWORK OR


PS TSRx OR


TV TRICARE SELECT

2-301-02R IF HCDP PLAN COVERAGE CODE = 306 TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR











C-97, October 19, 2017



8









THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN = PF ECHO

ELEMENT NAME: REGION INDICATOR (2-303)

VALIDITY EDITS

2-303-01V MUST BE A VALID REGION INDICATOR (REFER TO SECTION 2.8)

2-303-02V IF TYPE OF SUBMISSION ≠ B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR


AND REGION INDICATOR = NC NORTH CONTRACT OR

OC OVERSEAS CONTRACT OR

SC SOUTH CONTRACT OR

WC WEST CONTRACT

THEN ADJUSTMENT KEY MUST = 0 BATCH OR

5 VOUCHER

RELATIONAL EDITS

NONE


C-97, October 19, 2017



9

ELEMENT NAME: SPECIAL PROCESSING CODE (2-305)

VALIDITY EDITS

2-305-01V OCCURRENCE NUMBER 1--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO SECTION 2.8)




2-305-05V A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).

2-305-06V ALL OCCURRENCES OF SPECIAL PROCESSING CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SPECIAL PROCESSING CODE.

2-305-07V • SHCP REFERRED/NON-REFERRED

IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = AN SHCP - NON-MTF-REFERRED CARE OR

AR SHCP - REFERRED CARE


2-305-08V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = GF TPR FOR ELIGIBLE ADFM RESIDING WITH A TPR

ELIGIBLE ADSM


2-305-10V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = MN TSP - NON-NETWORK OR

MS TSP - NETWORK


2-305-11V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = SN TSS - NON-NETWORK OR

SS TSS - NETWORK


2-305-14V IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = ST SPECIALIZED TREATMENT


RELATIONAL EDITS

2-305-02R IF CA/NAS EXCEPTION REASON = 6 RESOURCE SHARING

THEN AT LEAST ONE SPECIAL PROCESSING CODE MUST = S RESOURCE SHARING - EXTERNAL


THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE = 6 HHC OR

A PARTNERSHIP PROGRAM OR

E HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO THE ICMP) OR

S RESOURCE SHARING - EXTERNAL OR

CM ICMP OR 1 CPT ONLY © 2006 AMERICAN MEDICAL ASSOCIATION (OR SUCH OTHER DATE OF PUBLICATION OF CPT). ALL RIGHTS

RESERVED.2 PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.

C-97, October 19, 2017



10

CT CCTP OR

RI RESOURCE SHARING - INTERNAL

2-305-12R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = U BRAC MEDICARE PHARMACY



AND BEGIN DATE OF CARE MUST BE < 04/01/2001

2-305-13R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = 16 AMBULATORY SURGERY FACILITY CHARGE

THEN PRICING RATE CODE MUST = 0 PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS) OR

1 PRICED MANUALLY OR

C AMBULATORY SURGERY FACILITY PAYMENT RATE OR

D DISCOUNTED AMBULATORY SURGERY - FACILITY PAYMENT RATE OR

E AMBULATORY SURGERY-PAID AS BILLED OR

P CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-FACILITY PAYMENT RATE OR

Q CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, DISCOUNTED AMBULATORY SURGERY-FACILITY PAYMENT RATE OR

R CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-PAID AS BILLED OR

V MEDICARE REIMBURSEMENT RATE OR

CA CAH REIMBURSEMENT OR

P1 OPPS OR


P3 OPPS WITH DISCOUNT

2-305-14R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = PO TRICARE PRIME - POS

THEN ENROLLMENT/HEALTH PLAN CODE MUST = U TRICARE PRIME, CIVILIAN PCM OR


WF TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE ADSM OR

XF FOREIGN ADFM

2-305-22R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = AN SHCP - NON-MTF-REFERRED CARE OR


CE SHCP - CCEP OR





C-97, October 19, 2017



11


SM SHCP - EMERGENCY

THEN ENROLLMENT/HEALTH PLAN CODE MUST = SN SHCP - NON-MTF-REFERRED CARE OR




SU SHCP - REFERRAL DESIGNATION UNKNOWN

2-305-24R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = E HHC/CM DEMO (AFTER 03/15/1999,

GRANDFATHERED INTO THE ICMP)


AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST = CM ICMP

2-305-26R • TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.

IF AMOUNT ALLOWED BY PROCEDURE CODE IS ≤ 0


ELSE ANY OCCURRENCE OF SPECIAL PROCESSING CODE = FF TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR







THEN HCDP PLAN COVERAGE CODE MUST ≠ 306 TRICARE SELECT - RESERVE SELECT SPONSORS AND

FAMILY MEMBERS OR









C-97, October 19, 2017



12













2-305-31R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = AU AUTISM DEMONSTRATION


AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST = PF ECHO

AND PATIENT AGE2 MUST BE ≥ 18 MONTHS

2-305-32R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = RB RESPITE BENEFIT FOR ADSMs


AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST = SE SHCP - TRICARE ELIGIBLE

2-305-33R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = PS SPECIALTY PHARMACY SERVICES

THEN TYPE OF SERVICE (SECOND POSITION) MUST = M MOP DRUGS, SUPPLIES, PRESCRIPTION


AND PROCEDURE CODE MUST ≠ 000MN PRESCRIPTION MEDICAL NECESSITY REVIEWS OR


2-305-34R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = PV RETAIL PHARMACY FOR DVA BENEFICIARIES



AND PROVIDER NETWORK STATUS INDICATOR MUST = 1 NETWORK PROVIDER




C-97, October 19, 2017



13

AND PROCEDURE CODE MUST ≠ 000MN PRESCRIPTION MEDICAL NECESSITY REVIEWS OR


2-305-35R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = DE TDRL PHYSICAL EXAMS


AND ENROLLMENT/HEALTH PLAN CODE MUST = SR SHCP - MTF REFERRED CARE

AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST = SE SHCP - TRICARE ELIGIBLE

2-305-36R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = EF TRICARE RESERVE AND NATIONAL GUARD FAMILY

MEMBER BENEFITS

THEN BEGIN DATE OF CARE MUST BE ≥11/01/2009

AND ENROLLMENT/HEALTH PLAN CODE MUST = T TRICARE STANDARD PROGRAM OR

V TRICARE EXTRA OR

TV TRICARE SELECT

AND HCDP SPECIAL ENTITLEMENT CODE MUST = 02 NOBLE EAGLE PARTICIPATION SPECIAL ENTITLEMENT

OR

03 ENDURING FREEDOM PARTICIPATION SPECIAL ENTITLEMENT

AND AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO

2-305-37R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = DC DCPE-DVA


AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST = 17 VA MEDICAL PROVIDER CLAIM OR

AD FOREIGN ACTIVE DUTY CLAIMS

AND ENROLLMENT/HEALTH PLAN CODE MUST = W TPR ADSM - USA OR

X FOREIGN ADSM OR


WA TPR FOREIGN ADSM

AND AT LEAST ONE PROCEDURE CODE1 MUST = 99456

OR PRINCIPLE DIAGNOSIS CODE MUST = V68.01 OR Z02.71

2-305-38R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = PH PHILIPPINES DEMONSTRATION PROJECT


AND HCDP PLAN COVERAGE CODE MUST = 003 TRICARE STANDARD FOR ADFMS OR




C-97, October 19, 2017



14

005 TRICARE STANDARD SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

007 TRICARE STANDARD TRANSITIONAL ASSISTANCE SPONSORS AND FAMILY MEMBERS OR

009 TRICARE STANDARD RETIRED AND MOH SPONSORS AND FAMILY MEMBERS OR

010 TRICARE STANDARD TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

015 TRICARE STANDARD TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR

017 TRICARE STANDARD SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR

018 TFL RETIRED SPONSORS AND FAMILY MEMBERS AND MOH OR

020 TFL TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

021 TFL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR

022 TFL TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR

023 TFL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR

028 TRICARE STANDARD FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR

029 TFL FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR

303 TRICARE SELECT - ACTIVE DUTY FAMILY MEMBERS OR

304 TRICARE SELECT - TAMP SPONSORS AND FAMILY MEMBERS OR

305 TRICARE SELECT - RETIRED SPONSORS AND FAMILY MEMBERS OR



308 TRICARE SELECT - YOUNG ADULT OR










C-97, October 19, 2017



15





422 TYA STANDARD FOR ADFMS OR

423 TYA STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR

424 TYA RESERVE SELECT OR

425 TYA RETIRED RESERVE OR


OR ENROLLMENT/HEALTH PLAN CODE = AS TRICARE SELECT - ACTIVE DUTY SURVIVORS OR

ATTRICARE SELECT - ACTIVE DUTY TRANSITIONAL SURVIVORS OR

GS TRICARE SELECT - GUARD/RESERVE SURVIVORS OR

GT TRICARE SELECT - GUARD/RESERVE TRANSITIONAL SURVIVORS

AND PATIENT ZIP CODE MUST = PHL PHILIPPINES

AND PROVIDER STATE OR COUNTRY CODE MUST = PHL PHILIPPINES

2-305-39R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = AS COMPREHENSIVE AUTISM CARE DEMONSTRATION

THEN BPROCEDURE CODE MUST BE 0359T, 0360T, 0361T, 0364T, 0365T, 0368T, 0369T, OR 0370T

2-305-40R IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE = R MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST




THEN ENROLLMENT/HEALTH PLAN CODE MUST = ME MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/

NETWORK OR





C-97, October 19, 2017



16

ELEMENT NAME: HEALTH CARE DELIVERY PROGRAM (HCDP) SPECIAL ENTITLEMENT CODE (2-306)

VALIDITY EDITS

2-306-01V MUST BE A VALID HCDP SPECIAL ENTITLEMENT CODE (REFER TO SECTION 2.5)

RELATIONAL EDITS

NONE

C-97, October 19, 2017



17

ELEMENT NAME: CA/NAS NUMBER (2-310)

VALIDITY EDITS


THEN CA/NAS NUMBER MUST BE BLANK.

ELSE IF CA/NAS NUMBER IS NOT BLANK

THEN MUST BE 1 TO 11 OR 1 TO 15 ALPHANUMERIC CHARACTERS.

RELATIONAL EDITS


D COMPLETE DENIAL

THEN BYPASS ALL CA/NAS NUMBER RELATIONAL EDITING.

NO ERROR IF BEGIN DATE OF CARE IS OLDER THAN SIX YEARS

THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA1






CE SHCP - CCEP OR

PF ECHO







THEN BYPASS ALL CA/NAS NUMBER EDITING.


W TPR ADSM - USA OR

X FOREIGN ADSM OR




BB TSP OR

FE TFL - NETWORK OR


PS TSRx OR

SN SHCP - NON-MTF-REFERRED CARE OR 1 CATCHMENT AREA DETERMINATION IS BASED ON BEGIN DATE OF CARE.

C-97, October 19, 2017



18






NO ERROR IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE = 15 PAYMENT ADJUSTED BECAUSE THE SUBMITTED











THEN BYPASS ALL CA/NAS NUMBER EDITING


THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS NUMBER EDITING.

2-310-02R IF CA/NAS EXCEPTION REASON ≠ BLANK

THEN CA/NAS NUMBER MUST = BLANK

2-310-03R • MENTAL HEALTH CHECK

IF CA/NAS EXCEPTION REASON = BLANK

AND TYPE OF SERVICE (FIRST POSITION) = I INPATIENT


AND PATIENT ZIP CODE IS IN AN MTF CATCHMENT AREA1


THEN CA/NAS NUMBER MUST BE CODED

ELEMENT NAME: CA/NAS NUMBER (2-310) (Continued)

1 CATCHMENT AREA DETERMINATION IS BASED ON BEGIN DATE OF CARE.

C-97, October 19, 2017



19

UNLESS ANY OCCURRENCE OF OVERRIDE CODE = C GOOD FAITH PAYMENT

THEN CA/NAS NUMBER MUST = BLANK

2-310-04R IF CA/NAS NUMBER IS CODED

THEN CA/NAS EXCEPTION REASON MUST = BLANK

ELEMENT NAME: CA/NAS REASON FOR ISSUANCE (2-315)

VALIDITY EDITS


THEN CA/NAS REASON FOR ISSUANCE MUST BE BLANK.

ELSE VALUE MUST A VALID CA/NAS REASON FOR ISSUANCE.

RELATIONAL EDITS

2-315-02R IF CA/NAS NUMBER = BLANK

THEN CA/NAS REASON FOR ISSUANCE MUST = BLANK.

ELEMENT NAME: CA/NAS NUMBER (2-310) (Continued)


C-97, October 19, 2017



20

ELEMENT NAME: CA/NAS EXCEPTION REASON (2-320)

VALIDITY EDITS


THEN CA/NAS EXCEPTION REASON MUST BE BLANK.

ELSE VALUE MUST BE A VALID CA/NAS EXCEPTION REASON.

RELATIONAL EDITS


D COMPLETE DENIAL


NO ERROR IF BEGIN DATE OF CARE IS OLDER THAN SIX YEARS




T MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR



CE SHCP - CCEP OR

PF ECHO









W TPR ADSM - USA OR

X FOREIGN ADSM OR




BB TSP OR

FE TFL - NETWORK OR


PS TSRx OR

SN SHCP - NON-MTF-REFERRED CARE OR 1 CATCHMENT AREA DETERMINATION IS BASED ON BEGIN DATE OF CARE.

C-97, October 19, 2017



21






NO ERROR IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE = 15 PAYMENT ADJUSTED BECAUSE THE SUBMITTED













THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS EXCEPTION REASON EDITING

2-320-04R IF PATIENT ZIP CODE IS IN AN MTF CATCHMENT AREA1

AND TYPE OF SERVICE (FIRST POSITION) = I INPATIENT


AND CA/NAS NUMBER NOT CODED


THEN CA/NAS EXCEPTION REASON MUST BE CODED

ELEMENT NAME: CA/NAS EXCEPTION REASON (2-320) (Continued)


C-97, October 19, 2017



22

ELEMENT NAME: PRICING RATE CODE (2-325)

VALIDITY EDITS

2-325-01V VALUE MUST A VALID NON-INSTITUTIONAL PRICING RATE CODE.

RELATIONAL EDITS

2-325-01R IF PRICING RATE CODE = C AMBULATORY SURGERY FACILITY PAYMENT RATE OR

D DISCOUNTED AMBULATORY SURGERY FACILITY PAYMENT RATE OR

E AMBULATORY SURGERY-PAID AS BILLED OR

P CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-FACILITY PAYMENT RATE OR

Q CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, DISCOUNTED AMBULATORY SURGERY-FACILITY PAYMENT RATE OR

R CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-PAID AS BILLED

THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = 16 AMBULATORY SURGERY FACILITY CHARGE

2-325-02R IF ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM IS A CODE LISTED IN ADDENDUM G, FIGURE 2.G-1.

THEN PRICING RATE CODE MUST = 0 PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS)

2-325-03R IF PRICING RATE CODE FOR THAT OCCURRENCE/LINE ITEM = 0 PRICING NOT APPLICABLE (DENIED SERVICE/

SUPPLIES AND ALLOWED DRUGS)

THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO

UNLESS TYPE OF SERVICE (SECOND POSITION) = B RETAIL DRUGS, SUPPLIES, PRESCRIPTION



OR TYPE OF SUBMISSION = B ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR

E COMPLETE CANCELLATION OF NON-TED RECORD (HCSR)

2-325-04R IF PRICING RATE CODE = V MEDICARE REIMBURSEMENT RATE

THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = 16 AMBULATORY SURGERY FACILITY CHARGE OR



MN TSP - NON-NETWORK OR

MS TSP - NETWORK

2-325-05R IF PRICING RATE CODE = U SHCP CLAIM OR ACTIVE DUTY MEMBER TPR PAID OUTSIDE NORMAL LIMITS

THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST = AR SHCP - MTF REFERRED CARE OR


CE SHCP - CCEP OR

C-97, October 19, 2017



23

GU ADSM ENROLLED IN TPR OR



SM SHCP - EMERGENCY

OR ENROLLMENT/HEALTH PLAN CODE MUST = SN SHCP - NON-MTF-REFERRED CARE OR

SR SHCP - MTFREFERRED CARE

2-325-06R IF PRICING CODE = W PRICED OVER CMAC

AND ENROLLMENT/HEALTH PLAN CODE = T TRICARE STANDARD PROGRAM

AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE = NE OPERATION NOBLE EAGLE/OPERATION ENDURING

FREEDOM DEMONSTRATION

AND BEGIN DATE OF CARE ≥ 09/14/2001 AND < 11/01/2009

THEN PROVIDER PARTICIPATING INDICATOR MUST = N NO

2-325-08R IF PRICING RATE CODE = P1 OPPS OR



P5 PARTIAL HOSPITALIZATION - PAID AS OPPS

THEN APC CODE MUST ≠ BLANK OR ZEROES.



UNLESS PROVIDER STATE OR COUNTRY CODE = AK ALASKA


2-325-10R IF PRICING CODE = W PRICED OVER CMAC

AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE = EF TRICARE RESERVE AND NATIONAL GUARD FAMILY

MEMBER BENEFITS

AND ENROLLMENT/HEALTH PLAN CODE = T TRICARE STANDARD PROGRAM OR

TV TRICARE SELECT

THEN PROVIDER PARTICIPATING INDICATOR MUST = N NO

ELEMENT NAME: PRICING RATE CODE (2-325) (Continued)

C-97, October 19, 2017



24

- END -

ELEMENT NAME: AMBULATORY PAYMENT CLASSIFICATION (APC) CODE (2-330)

VALIDITY EDITS

2-330-01V MUST BE A VALID APC CODE AS LISTED ON DHA’S OPPS WEB SITE AT HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT/OUTPATIENT-PROSPECTIVE-PAYMENT-SYSTEM, BLANK, OR ALL ZEROES

UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = ZERO

RELATIONAL EDITS

2-330-01R IF APC CODE = BLANK OR ZEROES.

THEN PRICING RATE CODE ≠ P1 OPPS OR



P5 PARTIAL HOSPITALIZATION - PAID AS OPPS

ELEMENT NAME: OPPS PAYMENT STATUS INDICATOR CODE (2-331)

VALIDITY EDITS

2-331-01V MUST BE A VALID OPPS PAYMENT STATUS INDICATOR CODE (REFER TO SECTION 2.6) OR BLANK.

RELATIONAL EDITS

2-331-01R IF OPPS PAYMENT STATUS INDICATOR CODE = BLANK

THEN APC CODE MUST = ALL ZEROES OR BLANK.

ELEMENT NAME: AMOUNT NETWORK PROVIDER DISCOUNT (2-335)

VALIDITY EDITS

2-335-01V MUST BE NUMERIC AND ≥ ZERO

RELATIONAL EDITS

2-335-01R IF TYPE OF SUBMISSION = B ADJUSTMENT TO NON-TED (HCSR) DATA OR



E COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA OR

O ZERO GOVERNMENT TED RECORD DUE TO 100% OHI

THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO

2-335-02R IF PROVIDER NETWORK STATUS INDICATOR = 2 NON-NETWORK PROVIDER


2-335-03R IF REGION INDICATOR = BLANK


C-97, October 19, 2017

HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT/OUTPATIENT-PROSPECTIVE-PAYMENT-SYSTEM




Provider Edit Requirements (ELN 000 - 099)

5

- END -

ELEMENT NAME: PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION (3-090)

VALIDITY EDITS

NONE

RELATIONAL EDITS

3-090-01R IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR = I INSTITUTIONAL

THEN MUST BE VALID PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION (REFER TO ADDENDUM D, FIGURE 2.D-1).

3-090-02R IF INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR = N NON-INSTITUTIONAL

THEN MUST BE A VALID PROVIDER MAJOR SPECIALTY/TYPE OF INSTITUTION (REFER TO HTTP://WWW.WPC-EDI.COM/).

3-090-03R IF PROVIDER MAJOR SPECIALTY/TYPE INSTITUTION = 183500000X (PHARMACY SERVICE PROVIDERS/

PHARMACIST)

THEN CONTRACTOR NUMBER MUST = 02 TMOP OR

70 TPHARM OR

73 TPHARM

ELEMENT NAME: TYPE OF INSTITUTION TERM INDICATOR CODE (3-095)

VALIDITY EDITS

3-095-01V MUST BE A VALID TYPE OF INSTITUTION TERM INDICATOR CODE.

RELATIONAL EDITS

3-095-01R IF TYPE OF INSTITUTION CODE TERM INDICATOR = L LONG-TERM OR

S SHORT-TERM

THEN INSTITUTIONAL/NON-INSTITUTIONAL INDICATOR MUST = I INSTITUTIONAL

C-97, October 19, 2017

HTTP://WWW.WPC-EDI.COM/

1


Chapter 2 Addendum L

Data Requirements - Health Care Delivery Program (HCDP) Plan Coverage Code Values

VALID VALUE DESCRIPTION

EFFECTIVE DATE

TERMINATION DATE

000 No health care coverage plan (transfer records only) 00/00/0000 99/99/9999

001 TRICARE Prime for Active Duty Sponsors, no PCM Assigned 00/00/0000 99/99/9999

002 Direct Care for Active Duty Family Members 00/00/0000 99/99/9999

003 TRICARE Standard for Active Duty Family Members 00/00/0000 12/31/2017

004 Direct Care for Survivors of Active Duty Deceased Sponsors 00/00/0000 99/99/9999

005 TRICARE Standard for Survivors of Active Duty Deceased Sponsors 00/00/0000 12/31/2017

006 Direct Care for Transitional Assistance Family Members 00/00/0000 99/99/9999

007 TRICARE Standard for Transitional Assistance Sponsors and Family Members

00/00/0000 12/31/2017

008 Direct Care for Retired Sponsors and Family Members 00/00/0000 99/99/9999

009 TRICARE Standard for Retired and Medal of Honor Sponsors and Family Members

00/00/0000 12/31/2017

010 TRICARE Standard for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

011 Direct Care for CONUS DoD Affiliates 00/00/0000 99/99/9999

012 TRICARE Standard for CONUS DoD Affiliates 00/00/0000 99/99/9999

013 Direct Care for OCONUS DoD Affiliates 00/00/0000 99/99/9999

014 Direct Care for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 99/99/9999

015 TRICARE Standard for Transitional Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 99/99/9999

016 Direct Care for Survivors of Guard/Reserve Deceased Sponsors 00/00/0000 99/99/9999

017 TRICARE Standard for Survivors of Guard/Reserve Deceased Sponsors 00/00/0000 12/31/2017

018 TRICARE for Life for Retired Sponsors and Family Members and Medal of Honor

00/00/0000 99/99/9999

019 Limited Direct Care with Line of Duty Injuries for Guard/Reserve Sponsors

00/00/0000 99/99/9999

020 TRICARE for Life for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 99/99/9999

021 TRICARE for Life for Survivors of Active Duty Deceased Sponsors 00/00/0000 99/99/9999

022 TRICARE for Life for Transitional Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 99/99/9999

023 TRICARE for Life for Survivors of Guard/Reserve Deceased Sponsors 00/00/0000 99/99/9999

024 Direct Care for Transitional Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 99/99/9999

025 Direct Care Dental For Active Duty Sponsors 00/00/0000 99/99/9999

C-97, October 19, 2017

TRICARE Systems Manual 7950.2-M, February 1, 2008Chapter 2, Addendum L


2

026 Direct Care Dental For Active Duty Foreign Military 00/00/0000 99/99/9999

027 Direct Care for Early Alert for Guard/Reserve Service Members 00/00/0000 99/99/9999

028 TRICARE Standard for Medically Retired Sponsors and Family Members 00/00/0000 12/31/2017

029 TRICARE for Life for Medically Retired Sponsors and Family Members 00/00/0000 99/99/9999

030 Direct Care for Medically Retired Sponsors and Family Members 00/00/0000 99/99/9999

101 CHAMPUS Reform Initiative (CRI) - CHAMPUS Prime (history) 00/00/0000 99/99/9999

102 Fort Sill - Catchment Area Management (CAM) Program (history) 00/00/0000 99/99/9999

103 Fort Carson – Catchment Area Management (CAM) Program (history) 00/00/0000 99/99/9999

104 Bergstrom Air Force Base (AFB) - Catchment Area Management (CAM) program (history)

00/00/0000 99/99/9999

105 Luke/Williams Air Force base (AFB) - Catchment Area Management (CAM) Program (history)

00/00/0000 99/99/9999

106 TRICARE Prime Individual Coverage for Active Duty Sponsors 00/00/0000 12/31/2017

107 TRICARE Prime Individual Coverage for Active Duty Family Members 00/00/0000 12/31/2017

108 TRICARE Prime Family Coverage for Active Duty Family Members 00/00/0000 12/31/2017

109 TRICARE USFHP Direct Care Coverage for Active Duty Family Members 00/00/0000 99/99/9999

110 TRICARE Prime for Individual Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

111 TRICARE Prime Family Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

112 TRICARE Prime Individual Coverage for Transitional Assistance Sponsors and Family Members

00/00/0000 12/31/2017

113 TRICARE Prime Family Coverage for Transitional Assistance Sponsors and Family Members

00/00/0000 12/31/2017

114 TRICARE USFHP Direct Care Individual Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 99/99/9999

115 TRICARE USFHP Direct Care Family Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 99/99/9999

116 TRICARE Prime Individual Coverage for Retired and Medal of Honor Sponsors and Family Members

00/00/0000 12/31/2017

117 TRICARE Prime Family Coverage for Retired and Medal of Honor Sponsors and Family Members

00/00/0000 12/31/2017

118 TRICARE USFHP Direct Care Individual Coverage for Retired Sponsors and Family Members

00/00/0000 99/99/9999

119 TRICARE USFHP Direct Care Family Coverage for Retired Sponsors and Family Members

00/00/0000 99/99/9999

120 TRICARE Senior Prime Individual Coverage for Retired Sponsors and Family Members

00/00/0000 99/99/9999

121 Continued Health Care Benefits Program Individual Coverage 00/00/0000 99/99/9999

122 Continued Health Care Benefits Program Family Coverage 00/00/0000 99/99/9999

123 Federal Employees Health Benefits Program (FEHBP) Individual Standard Coverage

00/00/0000 99/99/9999

124 Federal Employees Health Benefits Program (FEHBP) Family Standard Coverage

00/00/0000 99/99/9999


EFFECTIVE DATE

TERMINATION DATE

C-97, October 19, 2017



3

125 Federal Employees Health Benefits Program (FEHBP) Individual High Coverage

00/00/0000 99/99/9999

126 Federal Employees Health Benefits Program (FEHBP) Family High Coverage

00/00/0000 99/99/9999

127 TRICARE Senior Supplement 00/00/0000 99/99/9999

128 TRICARE Remote Individual Coverage for Active Duty Sponsors 00/00/0000 12/31/2017

129 TRICARE Remote Individual Coverage for Active Duty Family Members 00/00/0000 12/31/2017

130 TRICARE Remote Family Coverage for Active Duty Family Members 00/00/0000 12/31/2017

131 TRICARE Prime Individual Coverage for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

132 TRICARE Prime Family Coverage for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

133 TRICARE USFHP Direct Care Coverage for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 99/99/9999

134 TRICARE Prime Individual Coverage for Transitional Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 99/99/9999

135 TRICARE Prime Family Coverage for Transitional Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 99/99/9999

136 TRICARE Prime Individual Coverage for Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 12/31/2017

137 TRICARE Prime Family Coverage for Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 12/31/2017

138 TRICARE USFHP Direct Care Individual Coverage for Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 99/99/9999

139 TRICARE USFHP Direct Care Family Coverage for Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 99/99/9999

140 TRICARE Plus with CHC Coverage for Active Duty Family Members 00/00/0000 12/31/2017

141 TRICARE Plus Coverage for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

142 TRICARE Plus with CHC Coverage for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

143 TRICARE Plus Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

144 TRICARE Plus with CHC Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

145 TRICARE Plus Coverage for Retired Sponsors, Family Members and Medal of Honor

00/00/0000 12/31/2017

146 TRICARE Plus with CHC Coverage for Retired Sponsors, Family Members and Medal of Honor

00/00/0000 12/31/2017

147 TRICARE Plus with CHC Coverage for Transitional Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 12/31/2017

148 TRICARE Plus Coverage for Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 12/31/2017

149 TRICARE Plus Coverage with CHC for Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 12/31/2017

150 TRICARE Plus Coverage for Active Duty Family Members 00/00/0000 12/31/2017


EFFECTIVE DATE

TERMINATION DATE

C-97, October 19, 2017



4

151 TRICARE Plus Coverage for Transitional Survivors of Guard/Reserve Deceased Sponsors

00/00/0000 12/31/2017

152 TRICARE Overseas Prime Individual Coverage for Active Duty Sponsors 00/00/0000 12/31/2017

153 TRICARE Overseas Prime Individual Coverage for Active Duty Family Members

00/00/0000 12/31/2017

154 TRICARE Overseas Prime Family Coverage for Active Duty Family Members

00/00/0000 12/31/2017

155 TRICARE Global Remote Overseas Prime Individual Coverage for Active Duty Sponsors

00/00/0000 12/31/2017

156 TRICARE Global Remote Overseas Prime Individual Coverage for Active Duty Family Members

00/00/0000 12/31/2017

157 TRICARE Global Remote Overseas Prime Family Coverage for Active Duty Family Members

00/00/0000 12/31/2017

158 TRICARE Remote Individual Coverage for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

159 TRICARE Remote Family Coverage for Transitional Survivors of Active Duty Deceased Sponsors

00/00/0000 12/31/2017

160 TRICARE Prime Individual Coverage for Medically Retired Sponsors and Family Members

00/00/0000 12/31/2017

161 TRICARE Prime Family Coverage for Medically Retired Sponsors and Family Members

00/00/0000 12/31/2017

201 TRICARE Dental Plan Individual Coverage for Active Duty Family Members

00/00/0000 99/99/9999

202 TRICARE Dental Plan Family Coverage for Active Duty Family Members 00/00/0000 99/99/9999

203 TRICARE Dental Plan Individual Remote Coverage for Active Duty Family Members

00/00/0000 99/99/9999

204 TRICARE Dental Plan Family Remote Coverage for Active Duty Family Members

00/00/0000 99/99/9999

205 TRICARE Dental Plan Individual Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 99/99/9999

206 TRICARE Dental Plan Family Coverage for Survivors of Active Duty Deceased Sponsors

00/00/0000 99/99/9999

207 TRICARE Dental Plan Individual Coverage for Selected Reserve (SelRes) Sponsors

00/00/0000 99/99/9999

208 TRICARE Dental Plan Individual Coverage for Selected Reserve (SelRes) Family Members

00/00/0000 99/99/9999

209 TRICARE Dental Plan family coverage for Selected Reserve (SelRes) family members

00/00/0000 99/99/9999

210 TRICARE Dental Plan Individual Remote Coverage for Selected Reserve (SelRes) Family Members

00/00/0000 99/99/9999

211 TRICARE Dental Plan Family Remote Coverage for Selected Reserve (SelRes) Family Members

00/00/0000 99/99/9999

212 TRICARE Dental Plan Individual Coverage for Survivors of Selected Reserve (SelRes) Deceased Sponsors

00/00/0000 99/99/9999

213 TRICARE Dental Plan Family Coverage for Survivors of Selected Reserve (SelRes) Deceased Sponsors

00/00/0000 99/99/9999


EFFECTIVE DATE

TERMINATION DATE

C-97, October 19, 2017



5

214 TRICARE Dental Plan Individual Coverage for Active Guard/Reserve (AGR) Family Members

00/00/0000 99/99/9999

215 TRICARE Dental Plan Family Coverage for Active Guard/Reserve (AGR) Family Members

00/00/0000 99/99/9999

216 TRICARE Dental Plan Individual Remote Coverage for Active Guard/Reserve (AGR) Family Members

00/00/0000 99/99/9999

217 TRICARE Dental Plan Family Remote Coverage for Active Guard/Reserve (AGR) Family Members

00/00/0000 99/99/9999

218 TRICARE Dental Plan Individual Coverage for Survivors of Active Guard/Reserve (AGR) Family Members

00/00/0000 99/99/9999

219 TRICARE Dental Plan Family Coverage for Survivors of Active Guard/Reserve (AGR) Family Members

00/00/0000 99/99/9999

220 TRICARE Dental Plan for Mobilization-Asset Individual Ready Reserve (IRR) Sponsors

00/00/0000 99/99/9999

221 TRICARE Dental Plan Individual Coverage for Mobilization-Asset Individual Ready Reserve (IRR) Family Member

00/00/0000 99/99/9999

222 TRICARE Dental Plan Family Coverage for Mobilization-Asset Individual Ready Reserve (IRR) Family Members

00/00/0000 99/99/9999

223 TRICARE Dental Plan Individual Remote Coverage for Mobilization-Asset Individual Ready Reserve (IRR) Family Members

00/00/0000 99/99/9999

224 TRICARE Dental Plan Family Remote Coverage for Mobilization-Asset Individual Ready Reserve (IRR) Family Members

00/00/0000 99/99/9999

225 TRICARE Dental Plan Individual Coverage for Survivors of Mobilization-Asset Individual Ready Reserve (IRR) Deceased Sponsors

00/00/0000 99/99/9999

226 TRICARE Dental Plan Family Coverage for Survivors of Mobilization-Asset Individual Ready Reserve (IRR) Deceased Sponsors

00/00/0000 99/99/9999

227 TRICARE Dental Plan for Non-Mobilization-Asset Individual Ready Reserve (IRR) Sponsors

00/00/0000 99/99/9999

228 TRICARE Dental Plan Individual Coverage for Non-Mobilization-Asset Individual Ready Reserve (IRR) Family Members

00/00/0000 99/99/9999

229 TRICARE Dental Plan Family Coverage for Non-Mobilization-Asset Individual Ready Reserve (IRR) Family Members

00/00/0000 99/99/9999

230 TRICARE Dental Plan Individual Remote Coverage for Non-Mobilization-Asset Individual Ready Reserve (IRR) Family Members

00/00/0000 99/99/9999

231 TRICARE Dental Plan Family Remote Coverage for Non-Mobilization-Asset Individual Ready Reserve (IRR) Family Members

00/00/0000 99/99/9999

301 BRAC Pharmacy 00/00/0000 99/99/9999

302 Pharmacy Redesign Pilot Project (PRPP) 00/00/0000 99/99/9999

303 TRICARE Select-Active Duty Family Members 01/01/2018 99/99/9999

304 TRICARE Select-TAMP Sponsors and Family Members 01/01/2018 99/99/9999

305 TRICARE Select-Retired Sponsors and Family Members 01/01/2018 99/99/9999

306 TRICARE Select-Reserve Select Sponsors and Family Members 01/01/2018 99/99/9999

307 TRICARE Select-Retired Reserve Sponsors and Family Members 01/01/2018 99/99/9999

308 TRICARE Select-Young Adult 01/01/2018 99/99/9999

310 TRICARE Prime-Active Duty Sponsors 01/01/2018 99/99/9999


EFFECTIVE DATE

TERMINATION DATE

C-97, October 19, 2017



6

311 TRICARE Prime-Active Duty Family Members 01/01/2018 99/99/9999

312 TRICARE Prime Remote-Active Duty Sponsors 01/01/2018 99/99/9999

313 TRICARE Prime Remote-Active Duty Family Members 01/01/2018 99/99/9999

314 TRICARE Prime-TAMP Sponsors and Family Members 01/01/2018 99/99/9999

315 TRICARE Prime-Retired Sponsors and Family Members 01/01/2018 99/99/9999

316 USFHP Prime Sponsors and Family Members (Presentation Only) 01/01/2018 99/99/9999

330 TRICARE Prime-Young Adult Active Duty/TAMP 01/01/2018 99/99/9999

331 TRICARE Prime-Young Adult Retired 01/01/2018 99/99/9999

332 TRICARE Prime Remote-Young Adult Active Duty 01/01/2018 99/99/9999

345 TRICARE Plus-Direct Care Only (Presentation Layer) 01/01/2018 99/99/9999

346 TRICARE Plus 01/01/2018 99/99/9999

400 TRICARE Extended Care Health Option (ECHO) Program 00/00/0000 99/99/9999

401 TRICARE Reserve Select Tier 1 Member-Only Coverage (Contingency Operations)

00/00/0000 99/99/9999

402 TRICARE Reserve Select Tier 1 Member and Family Coverage (Contingency Operations)

00/00/0000 99/99/9999

403 Tobacco Cessation Demonstration Program 00/00/0000 99/99/9999

404 Weight Management Demonstration Program 00/00/0000 99/99/9999

405 TRICARE Reserve Select Tier 2 Member-Only Coverage (Certified Qualifications)

00/00/0000 99/99/9999

406 TRICARE Reserve Select Tier 2 Member and Family Coverage (Certified Qualifications)

00/00/0000 99/99/9999

407 TRICARE Reserve Select Tier 3 Member-Only Coverage (Service Agreement)

00/00/0000 99/99/9999

408 TRICARE Reserve Select Tier 3 Member and Family Coverage (Service Agreement)

00/00/0000 99/99/9999

409 TRICARE Reserve Select Survivor Continuing with Individual Coverage 00/00/0000 12/31/2017

410 TRICARE Reserve Select Survivor Continuing with Family Coverage 00/00/0000 12/31/2017

411 TRICARE Reserve Select Survivor New Individual Coverage 00/00/0000 99/99/9999

412 TRICARE Reserve Select Survivor New Family Coverage 00/00/0000 99/99/9999

413 TRICARE Reserve Select Member-Only Coverage 00/00/0000 12/31/2017

414 TRICARE Reserve Select Member and Family Coverage 00/00/0000 12/31/2017

415 Wounded, Ill, and Injured (e.g., Warrior Transition/MEDHOLD Unit (WTU))

00/00/0000 99/99/9999

416 Wounded, Ill, and Injured - Community-Based (e.g., Community-Based Health Care Organization (CBHCO))

00/00/0000 99/99/9999

417 Transitional Care For Service-Related Conditions (TCSRC) 00/00/0000 99/99/9999

418 TRICARE Retired Reserve Member-Only Coverage 00/00/0000 12/31/2017

419 TRICARE Retired Reserve Member and Family Coverage 00/00/0000 12/31/2017

420 TRICARE Retired Reserve Survivor Individual Coverage 00/00/0000 12/31/2017

421 TRICARE Retired Reserve Survivor Family Coverage 00/00/0000 12/31/2017

422 TRICARE Young Adult TRICARE Standard for Active Duty Family Members

00/00/0000 12/31/2017


EFFECTIVE DATE

TERMINATION DATE

C-97, October 19, 2017



7

- END -

423 TRICARE Young Adult TRICARE Standard for Retired and Medal of Honor Family Members

00/00/0000 12/31/2017

424 TRICARE Young Adult TRICARE Reserve Select 00/00/0000 12/31/2017

425 TRICARE Young Adult TRICARE Retired Reserve 00/00/0000 12/31/2017

426 TRICARE Young Adult TRICARE Prime for Active Duty Family Members 00/00/0000 12/31/2017

427 TRICARE Young Adult TRICARE Prime Remote for Active Duty Family Members

00/00/0000 12/31/2017

428 TRICARE Young Adult TRICARE Prime for Retired and Medal of Honor Family Members

00/00/0000 12/31/2017

429 TRICARE Young Adult TRICARE Overseas Prime for Active Duty Family Members

00/00/0000 12/31/2017

430 TRICARE Young Adult TRICARE Overseas Prime Remote for Active Duty Family Members

00/00/0000 12/31/2017

602 Direct Care and TRICARE Mail Order Pharmacy (TMOP) and Retail Pharmacies

00/00/0000 99/99/9999

603 Direct Care Only 00/00/0000 99/99/9999

999 Unverified Newborn 00/00/0000 99/99/9999


EFFECTIVE DATE

TERMINATION DATE

C-97, October 19, 2017


DEERS Concepts And Definitions

7

6.7 Family Member, Beneficiary, And Insured Roles

As a sponsor, the person may also be the subscriber who holds the DoD policy for health care benefits. Another person, through associations and relationships, may be a family member to the sponsor, which implies a role as a beneficiary. As a beneficiary, the person may also be an insured who is covered by a DoD policy for health care benefits.

7.0 TRICARE POPULATIONS

The TRICARE programs serve a wide range of beneficiaries holding various statuses throughout their lifetime. The following information details the populations covered by the TRICARE benefit. The definition of the populations may be modified as legislation or DHA requires. These populations include:

• Active Duty Service Members (ADSMs) and ADFMs. These may include members from both the active and reserve components.

• Transitional Assistance Management Program (TAMP) Sponsors and Family Members

• Transitional Survivors of Active Duty Deceased Sponsors - Family members of an ADSM who died while on Active Duty. This also includes the family members of a Guard/Reserve sponsor who died while on active duty for more than 30 days. Children of an ADSM or a Guard/Reserve sponsor who died while on active duty on or after October 7, 2001 remain in “transitional survivor” status until they “age out” or otherwise lose TRICARE eligibility.

• Survivors of Active Duty Deceased Sponsors - Primarily spouses of an ADSM or Guard/Reserve sponsor on active duty for more than 30 days who died over three years ago while on active duty. This group includes children of an ADSM or Guard/Reserve sponsor on active duty for more than 30 days that died while on active duty prior to October 7, 2001.

• Retired Sponsors and Family Members - Retirees eligible for retirement pay and their family members as well as Medal of Honor (MOH) recipients.

• Transitional Survivors of Guard/Reserve Deceased Sponsors - Family members of a Guard/Reserve sponsor who died within the past three years, while on active duty for 30 days or less.

• Survivors of Guard/Reserve Deceased Sponsors - Family members of a Guard/Reserve sponsor who died in service over three years ago, while on active duty for 30 days or less.

• Selected Reserve members and their family members.

8.0 TYPES OF HCDP PLANS

Delivery programs are methods of providing basic health benefits. Coverage under these programs may be either individual or family, depending on the number of beneficiaries enrolled and beneficiaries’ affiliation to the sponsor, as well as the program definition. There are two types of plans within DEERS: assigned and enrolled.

C-74, July 1, 2015



8

• Assigned plans represent the base entitlement of a beneficiary (e.g., TRICARE Standard). Assigned plans are based on a sponsor’s affiliation to a DoD organization (e.g., Army Active Duty); therefore, when a sponsor’s DoD affiliation changes (e.g., Army Active Duty to Army Reserves), a new assigned plan is created for both the service member and family members.

• Enrolled plans represent another level of benefit into which the beneficiary has elected enrollment (e.g., TRICARE Prime).

• TRICARE Extra allows a beneficiary eligible for TRICARE Standard to seek care from a TRICARE network provider, thus obtaining a discount on services and reduced cost-share. Since TRICARE Extra acts like TRICARE Standard for DEERS purposes, DEERS does not track this option.

8.1 Medical Health Care Delivery Plans

The following sections detail the various types of health care plans currently available within the DoD. The contractor is required to implement a system that allows changes to health care plans and HCDP plan coverage codes as legislation and regulation require. Refer to HCDP Plan Codes on the DEERS web site (https://www.dmdc.osd.mil/appj/dwp/index.jsp), for specific information related to each plan.

8.1.1 Assigned Plans

These plans are the defaults assigned by DEERS for beneficiaries based on their eligibility status. Assigned plans do not require enrollment actions.

8.1.1.1 Assigned Health Care Plan: ADSMs - TRICARE Prime, No Primary Care Manager (PCM) Selected

TRICARE Prime for AD Sponsors, No PCM Assigned is the default coverage assigned by DEERS for active duty sponsors. They are entitled to Direct Care (DC) and pharmacy benefits. This plan is the default for ADSMs who are not enrolled in a specific MTF or TRICARE Prime Remote (TPR). These enrollees are deemed Prime but do not have a PCM. (See Section 1.4.)

8.1.1.2 Assigned Health Care Plan: TRICARE Standard (Prior to January 1, 2018)

The TRICARE Standard HCDP is the basic coverage assigned by DEERS for eligible beneficiaries and results when a beneficiary under the age of 65, or 65 and over but not Medicare eligible, is entitled to both DC and Civilian Health Care (CHC).

8.1.1.3 Assigned Health Care Plan: DC Only

This plan identifies beneficiaries who are entitled only to DC in MTFs on or after January 1, 2018, the default benefit for all non-ADSM beneficiaries. Examples of the eligible population include dependent parents and parents-in-law, or beneficiaries who are eligible for the Medicare benefit that do not have both Medicare Parts A and B.

C-97, October 19, 2017

https://www.dmdc.osd.mil/appj/dwp/index.jsp



9

8.1.1.4 Assigned Health Care Plan: TRICARE For Life (TFL)

Beneficiaries eligible for TRICARE under 10 USC 1086(d) with Medicare Parts A and B are eligible for the TFL benefit.

8.1.1.5 Assigned Health Care Plans for DoD Affiliates

DoD affiliates are a conglomerate category of individuals entitled to DC or CHC at different levels than the groups defined in other HCDPs. The currently defined compositions of the DC categories are:

8.1.1.5.1 Assigned Health Care Plan: DC For Continental United States (CONUS) For DoD Affiliates (Effective January 1, 2018, Reimbursable Direct Care For DoD Affiliates (CONUS Only))

This health care plan is available for the following population(s):

• North Atlantic Treaty Organization (NATO) Sponsored, Partnership for Peace, and NATO Non-Sponsored Foreign Military and their Family Members

• Non-NATO Sponsored Foreign Military and their Family Members

8.1.1.5.2 Assigned Health Care Plan: DC For Outside The Continental United States (OCONUS) DoD Affiliates (Effective January 1, 2018, Reimbursable Direct Care For DoD Affiliates (OCONUS Only))


• NATO and Non-NATO Foreign Military and their family members

• Civilian Personnel of DoD and other government agencies and their accompanying family members

• Civilian contractors under contract to the DoD or the Uniformed Services

• Uniformed and non-uniformed full-time personnel of the Red Cross and their family members

• Area executives, center directors, and assistant directors of the USO and their family members

• United Seaman’s Service (USS) personnel and their accompanying family members

• Military Sealift Command (MSC) Civil Service personnel

C-97, October 19, 2017



10

8.1.1.5.3 Assigned Health Care Plan: TRICARE Standard For CONUS DoD Affiliates (Effective January 1, 2018, Reimbursable Civilian Coverage For DoD Affiliates (CONUS Only))


• Family members of sponsored and non-sponsored NATO Foreign Military

8.1.2 Enrolled Plans

8.1.2.1 Enrolled Health Care Plan: TRICARE Prime - ADSM

ADSMs eligible for DC benefits are required to enroll into TRICARE Prime. Beneficiaries then select or are assigned a PCM in a MTF.

8.1.2.2 Enrolled Health Care Plan: TRICARE Select

Beginning January 1, 2018, the self-managed, Preferred Provider Organization (PPO) network option under the TRICARE program established by 10 USC 1075 and 32 CFR 199.17 to replace TRICARE Extra and Standard after December 31, 2017.

8.1.2.3 Enrolled Health Care Plan: TPR

The National Defense Authorization Act (NDAA) of 1998 requires medical care coverage for ADSMs assigned to remote locations. This coverage is provided through the TPR Program.

Eligibility for this health care coverage requires that the ADSM’s permanent duty location and residence be more than 50 miles or approximately one hour’s drive from a MTF or designated clinic or in a authorized zip code. Under this program, the ADSM may enroll and select a civilian or USFHP PCM. Since in some locations PCMs are not available, ADSMs may be enrolled in TPR without a PCM assignment.

8.1.2.4 Enrolled Health Care Plan: TRICARE Prime

Eligible beneficiaries may elect to enroll into TRICARE Prime, with an MTF, a civilian network provider, or a USFHP coverage. Beneficiaries must enroll through an authorized enrolling organization. Beneficiaries then select or are assigned a PCM, and under some coverage plans may pay an annual fee for coverage. All the TRICARE Prime enrolled populations will share the same HCDPs and may be differentiated only by the network provider type code.

8.1.2.5 Enrolled Health Care Plan: TPRADFM

Eligibility for this health care coverage requires that the ADSM’s permanent duty location and residence be more than 50 miles or approximately one hour’s drive from an MTF or designated clinic, as determined by residential and daily work location zip codes; and that the family member has the same residential zip code as the sponsor. Resides with rules vary based on the status of the sponsor. Under this program the family members may enroll and select a civilian PCM. Since in some locations PCMs are not available, ADFMs may be enrolled in TPRADFM without a PCM assignment.

C-97, October 19, 2017



11

8.1.2.6 Enrolled Health Care Plan: TRICARE Plus

The TRICARE Plus program is an MTF-based primary care program. There are two types of TRICARE Plus coverage to differentiate between those beneficiaries with a CHC entitlement and those without. Coverage is at the individual level; each enrolled person will have an individual policy.

8.1.2.7 Enrolled Health Care Plan: Uniformed Services Family Health Plan (USFHP)

The USFHPs cover beneficiaries age 65 and over that are Medicare-eligible, as well as dependent parent and parent-in-laws that have been grandfathered into the program. These beneficiaries are enrolled in separate USFHP plans for persons only having a DC entitlement. Other categories of beneficiaries who enroll to the USFHP are enrolled into the appropriate TRICARE Prime plan with a USFHP network provider type code.

8.1.2.8 Enrolled Health Care Plan: Continued Health Care Benefit Program (CHCBP)

The CHCBP is optional coverage to which beneficiaries may subscribe for a specified period (not to exceed 36 months) after the sponsor’s entitlement to DoD benefits ends. Enrollment into the CHCBP program is performed by the CHCBP enrollment contractor. Details of this program are beyond the scope of this document (see the TPM, Chapter 10).

8.1.2.9 Enrolled Health Care Plan: TRICARE Reserve Select (TRS) Program

The TRS program is optional coverage to which Reserve Component (RC) members may subscribe while in the Selected Reserve.

8.1.2.10 Enrolled Health Care Plan: TRICARE Retired Reserve (TRR) Program

TRR is a premium-based TRICARE health plan available for purchase by qualified members of the Retired Reserve and qualified survivors that offers health coverage for Retired Reserve members and their eligible family members. The RCs will validate members’ and survivors’ qualifications to purchase TRR coverage and will identify qualified members/survivors in the DEERS. Beneficiaries enrolled in the TRR program are entitled to care at the MTF.

8.1.2.11 Enrolled Health Care Plan: TRICARE Young Adult (TYA) Standard (Effective January 1, 2018, TYA Select)

TYA Standard is a premium-based TRICARE health plan available for purchase by qualified young adult dependents/survivors of ADSMs, retired service members, members of the Selected Reserve, and members of the Retired Reserve. This plan allows young adult dependents to purchase TRICARE Standard coverage until reaching the age of 26, after they have lost eligibility for TRICARE due to age and not otherwise eligible for TRICARE Program medical coverage. Beneficiaries purchasing TYA Standard coverage are entitled to space available care at the MTF.

C-97, October 19, 2017



12

8.1.2.12 Enrolled Health Care Plan: TYA Prime

TYA Prime is a premium-based TRICARE health plan available for purchase by qualified young adult dependents/survivors of ADSMs and retired service members. These plans allow young adult dependents to purchase TRICARE Prime coverage until reaching the age of 26 after they have lost eligibility for TRICARE due to age and not otherwise eligible for TRICARE Program medical coverage. Beneficiaries may enroll to a PCM in their regional contractor network, within a MTF, or a USFHP.

8.2 Special Health Care Programs

DEERS supports any special health care program mandated by the DoD. These special health care programs are programs into which a beneficiary can enroll or register concurrently with other assigned or enrolled health care coverage plans to which they are entitled. Information needed for claims processing purposes shall be returned as a Special Health Care Program within the Health Care Coverage Claims Response. Contractors may also utilize the web-based General Inquiry of DEERS (GIOD) application to obtain special program coverage information. See the TPM and the TRICARE Operations Manual (TOM) for details regarding these programs.

8.2.1 TRICARE Extended Care Health Option (ECHO)

ECHO beneficiaries must be ADFMs, have a qualifying condition, and be registered to receive ECHO benefits on DEERS. Contractors are required to review appropriate documentation, including registration documents, and ascertain that individuals are ECHO eligible. Once a determination that an individual is ECHO eligible, contractors must register the individual on DEERS. Registration will be performed through DOES and will include entering at least the following information: 1) ECHO, as a Special Health Care Coverage Plan Code and 2) Registration Start Date. If the Begin Date is not entered, DOES will enter a default date using the 20th of the month rule. (NOTE: Many ECHO enrollees may have received benefits and had claims under the Program for Persons with Disabilities (PFPWD) in the past.)

8.2.2 Community Based Health Care Organizations (CBHCO)

CBHCO is a program that allows Guard and Reserve members injured while on active duty to return home for continued health care while they are evaluated for return to duty, medical release, or medical board. CBHCO enrollees must also be enrolled in TRICARE Prime or TPR, depending on where they reside. Enrollment in the program requires approval by the member’s service.

8.2.3 Medical Retention Processing Unit (MRPU)

MRPU is a program assigned to service members who are medically non-deployable but who are retained in the MTF’s service area for medical reasons. MRPU enrollees must be enrolled to TRICARE Prime at that MTF that retained medical management.

8.2.4 Smoking Cessation

Smoking Cessation is a demonstration program restricted to certain states. This plan may be shown in eligibility history or claims responses.

C-97, October 19, 2017



13

8.2.5 TRICARE Dental Program (TDP)

The TDP offers worldwide coverage to all eligible family members of Uniformed Service active duty personnel and to members of the Selected Reserve and Individual Ready Reserve (IRR) and their eligible family members. ADSMs, former spouses, parents, in-laws, disabled veterans, foreign personnel, and retirees and their families are not eligible for the TDP. For purposes of this contract, the geographic area of coverage for the CONUS includes the 50 United States, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. OCONUS service area includes Canada, all other countries, island masses and territorial waters.

8.2.6 TRICARE Retiree Dental Program (TRDP)

The TRDP offers coverage to all eligible personnel retired from the Uniformed Services, unremarried surviving spouses, eligible dependents, and former members of the armed forces who are Medal of Honor (MOH) recipients and their immediate dependents. The TRDP currently has two programs: the Basic program which is closed to new enrollments and the Enhanced program to which all TRDP enrollees shall be enrolled. The TRDP is a worldwide program. The TRDP Basic program offers coverage for dental services rendered in the 50 United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, the Commonwealth of the Northern Mariana Islands, and Canada. TRDP Enhanced program benefits are offered worldwide.

8.2.7 Active Duty Dental Program (ADDP)

The ADDP provides worldwide dental coverage to all ADSMs of the Uniformed Services, eligible members of the Reserves and National Guard, and those Foreign Force Members (FFMs) eligible for care pursuant to an approved agreement (e.g., reciprocal health care agreement, NATO Status of Forces Agreement (SOFA), Partnership for Peace (PFP) SOFA). The Uniformed Services include the U.S. Army, the U.S. Navy (USN), the U.S. Air Force (USAF), the U.S. Marine Corps (USMC), the U.S. Coast Guard (USCG), the Commissioned Corps of the NOAA, and the Commissioned Corps of USPHS. The Commissioned Corps of the USPHS is not included in this program. The ADDP shall supplement care provided in the DoD’s Dental Treatment Facilities (DTFs), and shall provide care to those ADSMs living in regions without access to DTFs. The ADDP has two components:

• ADSMs referred from military DTFs for civilian dental care; and

• ADSMs having a duty location and residence greater than 50 miles from a DTF will be required to comply with the requirements and limitations of the Remote Active Duty Dental Program (RADDP) before receiving dental care.

9.0 IDENTIFICATION SCHEMA FOR ELECTRONIC DATA INTERCHANGE

9.1 Primary And Secondary Identifiers

Identification of persons in the DEERS database is established via primary identifiers and secondary identifiers. A primary identifier must be unambiguous, so that information systems and software can process it without the need for intervention by users. Secondary identifiers can be ambiguous and must be processed by users who match these secondary identifiers to persons in the DEERS database. More information on primary and secondary identifiers is explained in the next section of this document.

C-97, October 19, 2017



14

9.2 Beneficiary Identification

DEERS is the definitive system for person identification. Beneficiaries in the DEERS database are positively identified using a system-generated DEERS Identifier (DEERS ID). DEERS IDs are intended to be system-to-system identifiers and may not be assigned or altered by users. Each DEERS ID is formed by a combination of the following:

• Family Identifier (Family ID), a DEERS-assigned nine digit number unique to each family, plus a

• Beneficiary Identifier (Beneficiary ID), a DEERS-assigned two digit number unique to each individual in a family

A person may have more than one DEERS ID, stemming from multiple entitlements. DEERS IDs positively identify each beneficiary. DEERS IDs serve as primary identifiers and are used by information systems when passing data about individual beneficiaries and families.

A person may have multiple DEERS IDs over time and some of these instances are described as follows:

• A person may be entitled to DoD benefits via his or her simultaneous association to more than one sponsor. For example, a person may be a family member in two sponsored families at the same time, such as when both spouses in a family are sponsors. This condition is known as multiple entitlements. While beneficiaries may have multiple entitlements in such situations, they may only receive benefits under one entitlement at any given moment in time.

• Entitlement periods may be sequential, such as when a son or daughter of a sponsor joins a Uniformed Service and becomes a sponsor. In this case, the person would have a DEERS ID as a family member and a second DEERS ID as a sponsor. However, becoming a sponsor terminates the individual’s previous eligibility for benefits as a family member.

9.3 Patient Identification

All persons in DEERS have a primary identifier called the Electronic Data Interchange Person Identifier (EDIPI), which is a DEERS-assigned 10 digit number. This field is also known as the Electronic Data Interchange Person Number (EDIPN) or the Patient Identifier (PatID). The primary purpose is to reliably access patient and person level information.

9.4 Person Identification and Secondary Identification

Sources external to DEERS identify persons initially in the DEERS database using only secondary identifiers. The secondary identifiers are:

• Sponsor’s SSN• First three characters of the last name• DOB

C-97, October 19, 2017



15

Any one secondary identifier, such as the sponsor SSN, could be duplicated across several beneficiaries. Therefore, each beneficiary must be positively identified using at least two secondary identifiers. Usually, a person may be positively identified by an end user by matching an SSN along with the first three characters of the last name and/or the DOB. Data for both sponsors and individual family members may be accessed in this manner.

Since DEERS does not contain every family member’s SSN, the user may access these individuals by using the sponsor’s secondary identification information. This returns a list of each family member associated with the sponsor.

In order to obtain a DEERS ID for a beneficiary, a system interfacing with DEERS must provide secondary identification information in one of several forms. This ensures the correct beneficiary is found, received, and stored with a DEERS Identifier. In Figure 3.1.2-1, the “Inquiry Information” column describes required information entering DEERS, and the “Response” column describes information returned by DEERS.

9.5 Person Identification For Business Events

The following table identifies the options and type of data necessary to perform a DEERS/Medical business event for system-to-system interactions. Legend (an “X” in a column indicates that the information may be used):

• Secondary identification: refer to the secondary identification section above.

• Individual (I)/Family (F): indicates if the business event can be done for an individual, a family, or both.

FIGURE 3.1.2-1 SECONDARY IDENTIFICATION

INQUIRY INFORMATION RESPONSE

Family Member’s Person Identifier and Person Identifier Type Code (S= SSN, D=DEERS assigned Temporary ID, F=DEERS assigned Foreign ID), Inquiry Person Type Code (sponsor or family member), Last Name and DOB (optional).

Family member option may return more than one DEERS ID if this beneficiary is in more than one family. User must then select correct beneficiary.

Sponsor’s Person Identifier and Person Identifier Type Code (S=SSN, F=DEERS assigned foreign ID), Last Name and DOB (optional), and family option.

Returns entire family of beneficiaries (one DEERS Family ID). User must select beneficiary from family.

Sponsor’s Person Identifier and Person Identifier Type Code (S=SSN, F=DEERS assigned foreign ID), Last Name and DOB (optional).ANDFamily Member’s Person Identifier and Person Identifier Type Code (S=SSN, D=DEERS assigned Temporary ID, F=DEERS assigned foreign ID).

Returns one beneficiary.

Sponsor’s Person Identifier and Person Identifier Type Code (S=SSN, F=DEERS assigned foreign ID), Last Name and DOB (optional).ANDFamily Member’s First Name and DOB.

Usually returns only one beneficiary except in some rare cases of same named twins.

C-97, October 19, 2017



16

9.6 HCDP Enrollment Management Contractor (EMC) Identification

HCDP EMCs are entities that are authorized to enroll MHS-eligible sponsors and family members into DoD coverage plans and are responsible for maintaining an individual’s HCDP policy. These organizations include MCSCs, USFHP providers, and the TRICARE Overseas Program (TOP) contractor. DEERS tracks the enrolling organization that is responsible for an individual’s policy. A person only has one EMC that is responsible for managing their coverage at any given point in time. DEERS creates a system identifier for each enrolling organization, and distributes the identifier to each system. This system identifier is used to identify the enrolling organization system in system-to-system interactions with DEERS.

9.7 PCM Enrolling Division Identification

Within the MHS, enrollment locations are identified using the identifiers within Defense Medical Information System (DMIS). These DMISs may represent an actual physical location such as an MTF, or a grouping of providers within the DC, Civilian, or USFHP network. Examples include MTFs, satellite clinics of MTFs, and possibly clinics within the MTF, USFHPs, and designated administrative DMISs.

Downloads are available on the DMIS web site (http://health.mil/Military-Health-Topics/Technology/Support-Areas/Geographic-Reference-Information/DMIS-ID-Tables).

9.8 PCM Identification

DEERS uses the NPI as the National Provider ID. The contractor is responsible for assigning a PCM ID to its PCMs and providing this identifier to DEERS. The contractor is also responsible for

FIGURE 3.1.2-2 PERSON IDENTIFICATION FOR BUSINESS EVENTS

SECONDARY IDENTIFICATION DEERS ID

PATIENT ID INDIVIDUAL/FAMILY BUSINESS EVENT

X X I Policy Notification

X(Subscriber only)

I, FDepending on policy type

Enrollment Fee Payment

X(Subscriber only)

I, FDepending on policy type

Disenrollment for failure to pay fees

X I, FDepending on policy type

Enrollment Fee Payment

X I, F Health Care Coverage Inquiry for Claims

X I Catastrophic Cap & Deductible Updates

X I, F Catastrophic Cap & Deductible Transaction History Request

X I, F Catastrophic Cap & Deductible Totals Inquiry

X I, F OHI Inquiry

X I, F OHI Policy Add/Update

X I, F OHI Cancellation

C-97, October 19, 2017

http://health.mil/Military-Health-Topics/Technology/Support-Areas/Geographic-Reference-Information/DMIS-ID-Tables



17

maintaining a crosswalk from the contractor’s provider ID to the national provider ID (if applicable). Contractors must not re-use PCM IDs.

9.9 Policy Identification

The contractor must be able to match a policy using this information. DEERS uses the following combination to uniquely identify a policy:

• DEERS Family ID• HCDP Plan Coverage Code• DEERS Policy Begin Date

A sponsor can be a subscriber to multiple policies but may be enrolled as a beneficiary only to one.

- END -

C-97, October 19, 2017

1

TRICARE Systems Manual 7950.2-M, February 1, 2008Defense Enrollment Eligibility Reporting System (DEERS)


DEERS Functions

1.0 As the person-centric centralized data repository of Department of Defense (DoD) personnel and medical data and the National Enrollment Database (NED) for the portability of the Military Health System (MHS) worldwide TRICARE program, Defense Enrollment Eligibility Reporting System (DEERS) is designed to provide benefits eligibility and entitlements, TRICARE enrollments, and claims coverage processing.

This chapter will detail the events to verify eligibility, perform enrollments, perform a claims inquiry, and the associated updates of address information, enter fees, Catastrophic Cap And Deductible (CC&D) information, Other Health Insurance (OHI) and the Standard Insurance Table (SIT). The expected data stores for the contractor are illustrated in Figure 3.1.4-1 through Figure 3.1.4-4. Deviation from the intended concept of operations between the contractor and DEERS shown in the figure below is at the contractor’s technical and financial risk.

1.1 Partial Match

A partial match response may be returned for any inquiry that does not use a DEERS ID or Patient ID. Eligibility may result in a partial match situation due to person ambiguity. There will be a separate listing for each person or family matching the requested Social Security Number (SSN). The listing includes the sponsor and family member identification information needed to determine the correct beneficiary or family including the DEERS ID, the Patient ID, or possibly both. The requesting organization must select which of the multiple listings is correct based on documents or information at hand. After this selection, the requesting organization would use the additional information returned (e.g., Date Of Birth (DOB), Name) “to resend the inquiry.”

1.2 Health Care Delivery Program (HCDP) Eligibility and Enrollment

The rules for determining a beneficiary’s entitlement to health care benefits are applied by rules-based software within DEERS. DEERS is the sole repository for these DoD rules, and no other eligibility determination outside of DEERS is considered valid. Whenever data about an individual sponsor or a family member changes, DEERS reapplies these rules. DEERS receives daily, weekly, and monthly updates to this data, which is why organizations must query DEERS for eligibility information before taking action. This ensures that the individual is still eligible to use the benefits and that the contractor has the most current information.

A beneficiary who is considered eligible for DoD benefits in accordance with DoD Instruction (DoDI) 1000.13 is not required to “sign up” for the TRICARE benefits associated with any DEERS assigned plan. If an authorized organization inquires about that beneficiary’s eligibility, DEERS reflects if he or she is eligible to use the benefits. The effective and expiration dates for assigned plan coverage are derived from DoDI 1000.13 rules and supporting information.

C-97, October 19, 2017


DEERS Functions

2

Note: Effective January 1, 2018, the “assigned plan” will be Direct Care (DC) Only for non-Active Duty Service Members (ADSMs).

1.2.1 Enrollment-Related Business Events

Enrollment related business events include:

• Eligibility for enrollment identifies current enrolled coverage plans and eligibility for enrollment into other coverage plans

• New enrollments are used for enrolling eligible sponsors and family members into a HCDP coverage plans or for adding family members to an existing family policy. Enrollments begin on the date specified by the enrolling organization and extend through the beneficiaries’ end of eligibility for the HCDP. New enrollments may also perform the following functions:

• Primary Care Manager (PCM) selection (if required/allowed by HCDP)• Update address, e-mail address and/or telephone number• Record that the enrollee has OHI

• Modifications of the current enrollment (updates) are used to change some information in the current enrollment plan. Modifications of the current enrollment include the following functions:

• Change or cancel a PCM selection• Transfer enrollment (enrollment portability) or cancel a transfer• Change enrollment begin date• Cancel enrollment/disenrollment• Change prior enrollment end date• Change prior enrollment end reason• Request an enrollment card replacement• Add OHI information for an enrollee• Request a replacement notice for PCM change or disenrollment

• Individual fee waiver information is used to indicate that an enrollee is exempt from paying enrollment fees.

• Enrollment fee payments and enrollment fee waiver entitlements are used to indicate payment of, or exception from payment of, enrollment fees. The Fee/Catastrophic Cap and Deductible (Fee/CCD) Web Research application is used to view this detailed information for a specified policy or to apply applicable fee/premium payments.

• Disenrollments are used to terminate the specified beneficiary’s enrollment. Disenrollments occur when a beneficiary has lost eligibility, voluntarily disenrolls (e.g., chooses not to re-enroll), or is involuntarily disenrolled (e.g., fails to pay enrollment fees).

• Defense Online Eligibility And Enrollment System (DOES) will display enrollment fee waiver entitlement periods that apply to the policy and details of the last fee

C-97, October 19, 2017


DEERS Functions

3

payment. This information is used to determine eligibility for enrollment transfers and disenrollments for failure to pay fees.

The following figures show the data and process flow required by the government. Deviations from this diagram are at the contractor’s technical and financial risk.

FIGURE 3.1.4-1 DEERS ENROLLMENT AND CLAIMS INTERACTION - MANAGED CARE SUPPORT CONTRACTOR (MCSC)

Enrollment Server

PCMServer

NotificationsServer

FeeServer

DEERS SYSTEM

ClaimsServer

CCDServer

OHIServer

ClaimsSubsystem

OHISubsystem

FeeSubsystem

Correspondence Subsystem

Notifications Receive & Store

ProviderSubsystem

MCSC SYSTEM

DOES/BWE

MCSC Operator/Beneficiary User

PCM add/update

Fee Update

Coverage Inquiry/Response

CCD Inquiry/Update

OHI Update

NED

PDR

PNTs

C-97, October 19, 2017


DEERS Functions

4

FIGURE 3.1.4-2 DEERS ENROLLMENT AND CLAIMS INTERACTION - UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP)

Enrollment Server

PCMServer

NotificationsServer

FeeServer

DEERS SYSTEM

CCDServer

OHIServer

CopaySubsystem

OHISubsystem

FeeSubsystem

Correspondence Subsystem

Notifications Receive & Store

ProviderSubsystem (FUTURE)

USFHP SYSTEM

DOES/BWE

DP Operator/Beneficiary User

PCM add/update

Fee Update

CCD Inquiry/Update

OHI Update

NED

PDR

PNTs


DEERS Functions

7

1.2.2 Defense Online Eligibility And Enrollment System (DOES)

DOES is a full function Government Furnished Equipment (GFE) application developed by Defense Manpower Data Center (DMDC) to support enrollment-related activity. DOES interacts with both the main DEERS database and the NED satellite database to provide enrolling organizations with eligibility and enrollment information, as well as the capability to update the NED with new enrollments and modifications to existing enrollments. The contractors are required to perform enrollment related functions through DOES, including:

• Enrollment• Disenrollment• PCM Change• PCM Cancellation and Transfer Cancellation• Transfer• Enrollment Period Change

FIGURE 3.1.4-5 DEERS ENROLLMENT AND CLAIMS INTERACTION - OUTSIDE THE CONTINENTAL UNITED STATES (OCONUS)

Enrollment Server

PCMServer

NotificationsServer

FeeServer

DEERS SYSTEM

ClaimsServer

CCDServer

OHIServer

ClaimsSubsystem

OHISubsystem

MCP File

PCM File/Table

CHCS SYSTEMDOES/BWE

OCONUS TAO Operator/Beneficiary User

PCM adds/updatesSent via RITPO RMG

Coverage Inquiry/Response

CCD Inquiry/Update

OHI Update

NED

PDR

PITs

OCONUS CLAIMS PROCESSOR

SYSTEM



DEERS Functions

8

• Enrollment End Reason Code Change• Enrollment/Disenrollment Cancellation• Beneficiary Update• OHI Add• Confirm Enrollment/PCM change (to support beneficiary web enrollment)• Request new or replacement enrollment ID card• Request PCM notice

DOES will display enrollment fees for the last Fiscal Year (FY) that DEERS has fees applied to the policy.

Note: Eligible TRICARE Standard beneficiaries will be automatically enrolled into the new TRICARE Select Plan with an enrollment date of January 1, 2018. Starting January 1, 2018, enrollments and catastrophic caps will be based on a Calendar Year (CY). To transition the fiscal year 2017 to the calendar year, FY 2017 will be extended to cover October 1, 2017 to December 31, 2017.

The DOES application meets the Health Insurance Portability and Accountability Act of 1996 (HIPAA) guidelines for a direct data entry application, and is data-content compliant for enrollment and disenrollment functions.

1.2.3 Beneficiary Self-Service Enrollment

Beneficiary Web Enrollment (BWE) serves all TRICARE eligible beneficiaries and will support most enrollment programs. BWE will interface with the contractor systems for the purposes of accommodating on-line payment of initial enrollment fees. See the BWE Enrollment Fee Gateway Technical Specification for more details.

DEERS will pre-populate data elements where possible. The beneficiary can perform the following enrollment events:

• Enrollment• PCM change• Address update• Transfer of enrollment (as a result of address update)• Disenrollment• Limited cancellation events• Submit an initial enrollment application, including any required fee payment• Add limited OHI• Request replacement enrollment card• Electronic Funds Transfer (EFT) or Recurring Credit/Debit Card (RCC) payment

election• Allotment payment election (for programs where premium/fee payments may be

made by allotment)

The web application contains checks for beneficiary eligibility and hard edits requiring the beneficiary to fulfill established DEERS business rules and enrollment criteria. Upon completion of the web process, the beneficiary is informed that the enrollment actions may be reviewed by the appropriate contractor for accuracy and compliance with established regional and/or Military Treatment Facility (MTF) requirements, and that they will be contacted if additional information is

C-97, October 19, 2017


DEERS Functions

9

needed.

For effective dates prior to January 1, 2018, DEERS will send the contractor a Policy Notification Transaction (PNT), informing the contractor that either a pending enrollment (for programs with PCM requirements) or a new enrollment exists for the beneficiary. The contractor shall apply all PNTs for pending enrollments and/or PCMs and use the pending status to create workload reports. Using DOES, the contractor shall review or modify all pending enrollment-related activities within six calendar days of submission to DEERS, including any necessary contact with the beneficiary. DEERS will perform a daily process to finalize enrollment actions after six calendar days. DEERS will send a policy notification indicating the approval. If the enrollment is not accepted, the contractor shall cancel the enrollment using DOES, and send the beneficiary an explanatory letter within five calendar days. The contractors shall consider beneficiary provided data from BWE as having the same validity as beneficiary provided data on paper enrollment forms. DEERS will not provide support or interfaces to contractor web applications that perform any enrollment-related functions.

On and after January 1, 2018, there is no six day pending period for enrollments. However, for enrollments that require PCM assignment, the contractor is still required to review and verify PCM assignment following the MTF MOUs.

1.2.4 Eligibility For Enrollment

The DoD provides assigned HCDPs and plans when a person joins the DoD. DEERS determines coverage plans for which a beneficiary is eligible to enroll by using the DoD-assigned coverage in conjunction with additional eligibility information. The Eligibility for Enrollment Inquiry in DOES is used to view a person’s or family’s eligibility to enroll. [NOTE: The Eligibility For Enrollment Inquiry in DOES should not be used for other eligibility determinations. For example, USFHP providers should use Government Inquiry of DEERS (GIQD) and not DOES to determine if a person is eligible for a hospital admission.]

DEERS provides coverage plan information identifying the period of eligibility and/or enrollment for the coverage plan. A beneficiary can only be enrolled into the coverage plans that have an “eligible for” status. When a sponsor and family member are first added into DEERS, DEERS determines basic eligibility for health care benefits in accordance with DoDI 1000.13 and establishes an assigned HCDP coverage plan together with coverage dates.

For example, when an active duty sponsor and family members are added to DEERS:

• A sponsor is assigned TRICARE Prime for ADSMs, No PCM Selected in which he or she is the subscriber and the insured. The dates on the coverage represent the dates determined by the eligibility rules.

• A sponsor with family members is listed as the subscriber under the TRICARE Standard for Active Duty Family Members (ADFMs) assigned plan. The sponsor is not insured under this coverage plan.

• Eligible family members are assigned TRICARE Standard for ADFMs plan as insured with both DC and Civilian Health Care (CHC) coverage, prior to January 1, 2018. The coverage plan dates are determined by the eligibility rules. There are no enrollment

C-97, October 19, 2017


DEERS Functions

10

dates, since this option requires no enrollment.

• Beginning January 1, 2018, eligible family members are assigned DC Only (Space Available) MTF, however ADFMs CONUS will be auto-enrolled in Prime with no PCM, and if they reside outside a Prime Service Area (PSA), they will be enrolled TRICARE Select. ADFMs OCONUS will be enrolled in TRICARE Select.

1.2.5 Enrollment Prior to January 1, 2018

The assigned plans provide the foundation for enrollment into various coverage plans. Enrollment plans are mandatory for ADSMs and include:

• TRICARE Prime for ADSMs. This plan requires the assignment of a PCM.

• TRICARE Prime Remote (TPR) for ADSMs. This plan requires a PCM if one is available.

• TRICARE Overseas Prime for ADSMs. This plan requires a PCM to be assigned.

• TRICARE Remote Overseas Prime for ADSMs. This plan requires a PCM if one is available.

For other beneficiary categories, such as ADFMs and retirees and their family members, enrollment is optional. Beginning January 1, 2018 in order to have purchased care coverage, these beneficiaries must be in an enrolled Plan.

Enrollments are at the individual or family level, depending on the plan and the number of family members wishing to enroll. Beginning January 1, 2018 enrollments will be based on the individual, but enrollment fees will be determined by the number of family members in the enrolled Plan. Therefore, a family may have members enrolled in different Plans.

Up to December 31, 2017, DEERS creates a policy that encompasses all enrollments for a family and a HCDP. DEERS automatically switches enrollment policies from individual to family or family to individual when required. It is the contractor’s responsibility to correct the fees based on the policy notification of the plan change. DEERS will adjust fees for a policy to ‘$0’ any time an enrolled policy with fees is systematically cancelled. Some HCDP’s, such as TRICARE Plus, only offer enrollment on an individual basis. For these plans, DEERS does not limit the number of individual policies that a family may have.

The contractors are required to enter the following information into DOES in order to complete an enrollment. Required data elements vary by plan. For instance, TRICARE Prime for ADFMs requires the following data elements:

• Coverage plan• Enrollment begin date (if different than DOES default)• Address verification

• PCM assignment• PCM Network Provider Type Code (if not defaulted by DOES)• PCM Enrolling Division (if more than one is available for the coverage plan and

PCM Network Provider Type Code)

C-97, October 19, 2017


DEERS Functions

11

• Individual PCM selection

Enrollments may be backdated up to 18 months.

Enrollment policies for all enrollees on or before December 31, 2017 shall be on a FY basis, i.e., October 1 through September 30. To accomplish this, the contractor shall establish the policy and prorate the enrollment fees as described below. At the end of that FY, the contractor shall renew the policy for the next FY. FY 2017 enrollments will end on December 31, 2017, in order to implement the change from FY to CY in accordance with NDAA 2017, Section 701.

For enrollees that pay fees on an annual basis, the contractor shall collect the entire prorated fee covering the period through September 30 of the current FY. However, for FY 2017 the prorated fee will cover the period through December 31, 2017 to support the transition from FY to CY. A prorated fee must be paid for each month of the enrollment period.

For enrollees that pay fees on a quarterly basis, the contractor shall collect a prorated fee covering the period until the next FY quarter (e.g., January 1, April 1, July 1, October 1) and collect quarterly fees thereafter through September 30 of the current FY. However, for FY 2017 the prorated fee will cover the period through December 31, 2017 to support the transition from FY to CY. A prorated fee must be paid for each quarter of the enrollment period.

For enrollees that pay fees on a monthly basis (by EFT or monthly allotments), contractors must collect and post an amount equal to three months of fees at the time of enrollment with monthly EFT or allotments beginning on the first day of the fourth month following the enrollment anniversary date.

• If the first payment crosses into the next FY, the contractor shall send DEERS the three month payment amount, indicating the applicable paid-through date and a payment plan type of “Request to begin allotment”. DEERS will apply one or two months of the three month payment (whichever is applicable) to the enrollment ending in the current FY and the remaining one or two months of fees to the beginning of the new enrollment beginning on October 1 of the next FY.

Note: The proration will remain the same when enrollments are converted from a FY to a CY.

Note: If the first three month payment crosses into FY 2013, the contractor shall send DEERS the portion that applies to FY 2012, indicating the applicable paid-through date and a payment plan type of “Request to begin allotment”; and shall send a second transaction containing the dollar amount of payment that applies to FY 2013 to DEERS with a payment plan type of “Request to begin allotment” and DEERS will calculate the paid-through date and notify the contractor.

• Enrollments effective on and after October 1, 2012: The contractor will send the fee amount collected for the first three month payment and a payment type of “Request to begin allotment” to DEERS and DEERS will calculate the paid-through date and notify the contractor.

C-97, October 19, 2017


DEERS Functions

12

1.2.5.1 Prime Enrollment Fees Prior to January 1, 2018

1.2.5.1.1 Enrollment Year To FY Alignment

By statute, Prime enrollees are entitled to both an enrollment year and a FY for the purposes of enrollment fees and catastrophic cap amounts. Tracking two sets of amounts for each enrollee is cumbersome, confusing, expensive, and can lead to inaccurate totals as well as negatively affecting enrollment portability. To ease portability and resolve problems, enrollment anniversary dates for all enrollees are on a FY basis, i.e., October 1 through September 30. For new enrollments, the policy end date will be set to the end of the FY. Enrollment fees and catastrophic cap amounts are prorated accordingly.

1.2.5.1.2 Prorated Enrollment Fees

For new Prime enrollments that do not begin on October 1, DEERS will establish abbreviated (less than 12 months) policies ending September 30 and the contractor shall collect the enrollment fees necessary to align the policy with the FY. The monthly prorated enrollment fee is 1/12 of the respective annual enrollment fee (rounded down). DEERS will apply any fee overage from the abbreviated enrollment year to the next FY enrollment policy and shall set the paid period end dates in accordance with those amounts. At the end of the abbreviated enrollment (end of the current FY), the contractor shall renew the policy for the next FY with a begin date of October 1 and resume collecting the full enrollment fees.

1.2.5.1.3 Survivors of Active Duty Deceased Sponsors and Medically Retired Uniformed Services Members and their Dependents

Effective FY 2012, beneficiaries who are (1) survivors of active duty deceased sponsors, or (2) medically retired Uniformed Services members and their dependents, shall have their Prime enrollment fees frozen at the rate in effect when classified and enrolled in a fee paying Prime plan. (This does not include TRICARE Young Adult (TYA) plans). Beneficiaries in these two categories who were enrolled in FY 2011 will continue paying the FY 2011 rate. The beneficiaries who become eligible in either category and enroll during FY 2012, or in any future fiscal year, shall have their fee frozen at the rate in effect at the time of enrollment in Prime. The fee for these beneficiaries shall remain frozen as long as at least one family member remains enrolled in Prime. The fee for the dependent(s) of a medically retired Uniformed Services member shall not change if the dependent(s) is later re-classified a survivor.

1.2.5.1.4 Prorated Catastrophic Cap Amounts

TRICARE Prime enrollees who are other than Active Duty (AD) or ADFM, (e.g., Retirees and Retiree Family Members), are entitled to an enrollment year catastrophic cap. As with enrollment fees, catastrophic cap amounts must also be prorated in order to complete the enrollment year to FY alignment. In order to align the enrollment year to the FY, a one time prorated catastrophic cap credit will be applied to each new enrollment for each month that the beneficiary was not enrolled during the current FY. The monthly prorated catastrophic cap credit for non-AD and non-ADFMs will be 1/12 of the fiscal year catastrophic cap limit.

C-97, October 19, 2017


DEERS Functions

13

1.2.5.2 PCM Assignment Within The DOES Application

DEERS has a centralized PCM file containing both the PCMs for the DC facilities and all MCSC civilian network PCMs. The DOES application accesses the central PCM file to perform provider assignments. The DEERS PCM Repository will accept additions, terminations, and modifications of civilian network PCMs in real time to support enrollment activities. All PCM additions, terminations, or modifications shall be transmitted to DEERS no less than daily. To deactivate a PCM, contractors shall send DEERS a modification where the PCM’s effective date is equal to the PCM’s end date, and DEERS will deactivate the PCM from the central file. DEERS will not allow subsequent assignments to a deactivated PCM. Contractors are responsible for the quality of the PCM data transmitted to DEERS. Contractors will not submit inaccurate data.

1.2.5.2.1 DC PCM Assignment

The contractor shall perform DC PCM assignment at the time of enrollment in the DOES application. The contractor shall use the PCM preference indicated in the enrollment request in addition to guidance contained in any MOU agreement or other government-provided direction, if available. For ADSMs, if the enrollment request has a Unit Identification Code (UIC) specified and the MTF has established a default provider for the UIC, the contractor should use the default. If the enrollment request contains a specialty or gender preference, the contractor shall use the preference filters available in DOES to select a PCM. In the case where a beneficiary has not indicated a preference and there is not precise direction in a Memorandum Of Understanding (MOU) or other government direction, the contractor shall use the search criteria in DOES to select a PCM. DOES and BWE will only display PCMs with available capacity in the selected Defense Medical Information System (DMIS)-ID. The contractor is responsible for determining the appropriate DMIS-ID based on MOUs, access standards, and any specific guidance from the government. If there is no capacity at a DC facility, the contractor shall contact the MTF to confirm that enrollment is closed; MTFs must respond to such requests within two business days or the contractor may enroll the beneficiary to their civilian network.

1.2.5.2.2 Civilian PCM Assignment

The contractor shall perform Civilian PCM assignment at the time of enrollment in the DOES application. The contractor shall use the PCM preference indicated in the enrollment request. If the enrollment request contains a specialty or gender preference, the contractor shall use the preference filters available in DOES to select a PCM.

1.2.6 Disenrollment

Once actively enrolled in a coverage plan, an individual or family may voluntarily disenroll or be involuntarily disenrolled. Voluntary disenrollment is self-elected. Involuntary disenrollment occurs from failure to pay enrollment fees or from loss of eligibility. Upon disenrollment, DEERS will notify the beneficiary of the change in or loss of coverage. If disenrollment occurs at other than the renewal date, the beneficiary incurs a 12 month lockout. Contractors must set the lockout manually, and may cancel the lock and disenrollment in accordance with established administrative procedures.

C-97, October 19, 2017


DEERS Functions

14

1.2.6.1 Disenrollment - Loss Of Eligibility

A loss of eligibility refers to any loss or change in eligibility for DoD health care benefits in accordance with the current DoDI 1000.13 or additional legislation authorizing benefits or for a specific health coverage plan. At the time of enrollment, DEERS provides the end of eligibility date to the contractors via the notification. If that end date does not change, DEERS will provide no additional notifications. If the end date changes, DEERS will provide another notification with the new end date. DEERS also cancels any future actions for that beneficiary, including future enrollments, PCM changes, etc. If a contractor has applied fees to a policy that DEERS is cancelling, DEERS will adjust the fees to ‘$0’.

1.2.6.2 Retroactive Eligibility/Enrollment Maintenance

There may be instances where DEERS receives notice of a loss of eligibility from the Uniformed Services, only to later be informed of the immediate reinstatement. Upon the receipt of the initial loss of eligibility, DEERS terminates the enrollment. Upon receipt of the notice of reinstatement, DEERS reinstates the eligibility and enrollment as long as there are no gaps in eligibility. DEERS will reinstate eligibility and enrollments only if DEERS receives new personnel information reinstating eligibility within 90 days of the initial loss of eligibility and only if the plan does not require fee payment.

1.2.6.3 Disenrollment - Voluntary

An enrollee may choose to terminate his or her current enrollment prior to the end date, or choose not to re-enroll into the current coverage plan. This transaction is performed in DOES. DEERS then terminates the enrolled coverage plan for the beneficiary and reverts to the DEERS assigned coverage, starting on the day after the termination of the enrollment. If additional systems need notification of the disenrollment, DEERS sends disenrollment notifications as necessary, notifying them of the termination of coverage benefits.

1.2.6.4 Disenrollment - Involuntary

The enrollee may fail to pay enrollment fees. In this case, the enrolling organization performs a disenrollment with a reason code of “failure to pay fees”. Individuals who are waived from paying enrollment fees are not disenrolled because of this exemption from enrollment fee payments. Disenrollment for failure to pay fees is either performed in DOES or through a batch ‘disenrollment for failure to pay fees’ system to system interaction.

Prior to processing a disenrollment with a reason of “non-payment of fees”, the contractor must reconcile their fee payment system against the fee totals in DEERS. Once the contractor confirms that payment amounts match, the disenrollment may be entered in DOES or through the failure to pay fees interface.

When there is a disenrollment, the appropriate systems are notified, as necessary. The following table lists the functions and applications that allow each action:

C-97, October 19, 2017


DEERS Functions

15

1.2.7 Modification Of Enrollment

Whenever there is a modification to an enrollment, the appropriate systems are notified, as necessary.

1.2.7.1 PCM Change And Cancellation

PCM reassignments occur when the enrollee changes regions or desires to change PCM’s within the region or MTF. An enrollee changes PCMs by completing a PCM change request form and submitting the change request to the contractor, which makes the change via DOES. Only the current enrolling organization may change the PCM selection. A PCM change can be made only on the latest PCM segment. DEERS then terminates the previous PCM with an end date, which will be the day before the begin date for the new PCM. Upon change of PCM, DEERS will notify the enrollee of the new PCM information, as well as sending notifications to the appropriate MTFs and contractors.

DOES BWEFEE

INTERFACEPCM PANEL

REASSIGNMENTCCDFEE

DEERS (UNSOLICITED)

Enrollment X X

Enrollment Cancellation X X(if

pending)

Disenrollment X X X(failure to pay fees

only)

X

Disenrollment Cancellation X

PCM Change X X X

PCM Cancellation X X(if

pending)

PCM Panel Reassignment X

Modify Enrollment Begin Date

X X

Modify Prior Enrollment End Date

X X

Modify Prior Enrollment End Reason

X X

Modify PCM Effective Date X

Transfer X X

Transfer Cancellation X X X(if loss of

eligibility before transfer)

Apply Enrollment Fee/TRICARE Reserve Select (TRS)/TRICRE Retired Reserve (TRR)/TYA Premium

X(initial)

X X

C-97, October 19, 2017


DEERS Functions

16

DOES will allow PCM’s with available capacities to be assigned as new PCM’s. If a contractor is canceling a PCM assignment, DOES will permit reinstatement of a PCM whose capacity has been reached.

1.2.7.2 PCM Panel Reassignment

PCM Panel Reassignment Application (PCMRA) allows the user to select all or part of a PCM’s panel for reassignment to other PCMs. PCM reassignments are processed periodically by DEERS. DEERS will decrement and increment PCM capacities when processing panel reassignments, but will not prevent the reassignment if the selected gaining PCM does not have available capacity. As part of the moves, DEERS sends notifications to the appropriate systems. Note that PCM change notices may be suppressed during a panel reassignment, but the suppression must apply to the entire transaction.

1.2.7.2.1 DC Care PCM Panel Reassignment

All PCM changes for DC PCMs must be performed by the MCSC. The MTF will set up the panel reassignments using PCMRA. The contractor shall complete the required moves using PCMRA within three business days of submission.

Panel changes that cross Composite Health Care System (CHCS) platforms must be coordinated not only with the contractor but with the designated Defense Health Agency (DHA) Representative and DEERS.

Emergency moves may be coordinated by the MTF with the MCSC by the best available means, including phone, fax, or secure e-mail.

1.2.7.2.2 Civilian Panel Reassignment

DMDC provides a web application to allow contractors to perform mass reassignments of a civilian PCM’s enrollees. There is an option to suppress the PCM change notices for civilian PCM panel reassignments.

C-97, October 19, 2017


DEERS Functions

17

1.2.7.3 Transfer Of Enrollment And Transfer Cancellation

A transfer of enrollment moves the enrollment from one contract to another and thus moves the responsibility for the administration of the enrollment to the gaining contractor. DEERS supports transfers within plans (e.g., TRICARE Prime). A transfer may include a change to the Health Care Coverage (HCC) plan in some cases, such as TRICARE Prime for ADSMs to TPR for ADSMs. DEERS will enforce when such transfers are allowed.

FIGURE 3.1.4-6 PCM ASSIGNMENT PROCESS

Enterprise Wide Provider System

(EWPS)

DOES• Enrollment

• Individual PCM Assignment

• Individual PCM Change• Transfer• PCM Cancellation

PCM Assignment

PCM Reassignment

PCM Centralization

DEERS PCM Management

System

DC PCM Data Repository

(CHCS)

DP PCMData

Repository

MCSC PCMData

Repository NED

PCM Reassignment• DC PCM Panel Reassignment• Civilian PCM Panel

Reassignment

C-97, October 19, 2017


DEERS Functions

18

If an enrollment transfer is performed in error, a transfer cancellation may be performed. This action results in reinstatement of the enrollment with the previous enrolling organization and the previous PCM.

1.2.7.4 Enrollment Period Change

This event is used to update an enrollee’s begin or end date. Modifications can only be performed by the enrolling organization responsible for managing the enrollment. A contractor may change the enrollment end date only after performing a disenrollment. If the enrollment end date is the same as the loss of eligibility date, the user is not allowed to change the end date to a later date. DEERS changes the date range for the applicable PCM selection and policy to correspond with the new end dates if necessary.

If a person’s eligibility in DEERS changes and affects an enrollment because the eligibility period is either greater or less than originally stated, DEERS updates the enrollment period and pushes the PCM and policy changes to the appropriate systems managing the enrollment.

1.2.7.5 Enrollment End Reason Change

Disenrollments can be done for various reasons and are mostly done by enrolling organizations. If a disenrollment is performed by an enrolling organization using an incorrect end reason code, the end reason code can be updated. Enrolling organizations enter an end date that

FIGURE 3.1.4-7 ENROLLMENT TRANSFER PROCESS

7. Confirmed PCM Information For DC PCM and Acknowledge

MCSC OR USFHP PROVIDER SYSTEM DMDC / DEERS

DOES

Receiveand

Store

MCSCData Store

1. Inquiry2. Eligibility to enroll3. Transfer4. Acknowledge

5. Confirmed Policy Notification and Acknowledge

Communications through:Defense Information

Systems Network (DISN)

Enrollment Server

Application National Enrollment Database

(NED)

CHCS SYSTEM GAINING ENROLLMENT

Receiveand

Store

CHCSData Store

9. If already enrolled then notification(s) sent MCSC and/or CHCS Losing Enrollment and Acknowledge

MCSC SYSTEM LOSING ENROLLMENT

Receiveand

Store

Data Store

Receiveand

Store

Data Store

CHCS SYSTEM LOSING ENROLLMENT

C-97, October 19, 2017


DEERS Functions

19

precedes the date of loss of eligibility.

1.2.7.6 Enrollment/Disenrollment Cancellation

1.2.7.6.1 Enrollment cancellations can only be performed by the enrolling organization. An enrollment cancellation completely removes the enrollment from DEERS and it will not be shown on subsequent inquiries. Assuming that the beneficiary is still eligible, the prior enrollment and PCM will be reinstated if there was a contiguous change of plan (family to individual or Prime to TPR).

1.2.7.6.2 Disenrollment cancellations can only be performed by the enrolling organization. A disenrollment cancellation removes the disenrollment event and reinstates the enrollment and PCM assignment as if the disenrollment never occurred.

1.2.8 Enrollment Fees, Premiums, And Enrollment Fee Waivers

DEERS records and displays enrollment fee payment information and returns accumulated enrollment fee payment information by policy for the enrollment year in the Fee/CCD Web Research application.

DEERS provides a number of applications to support enrollment-fee-related transactions:

• Enrollment Fee Payment (Fee/CCD Web Research application and Fee Interface)• Update an enrollee’s free-rider code (DOES)• Terminate Policy For Failure To Pay Fees (DOES and Fee Interface)• Premium Billing Service (for policies in effect on or after October 1, 2012)

DEERS will automatically set enrollment fee waivers for a policy based on the following events:

• One or more enrollees have Medicare Parts A and B• The family has met their catastrophic cap• Mid-month retiree enrollment

Fee waivers are stored at the family level. DEERS will provide the reason for fee waiver and the begin and end dates, a status code, and status date associated to that waiver on the PNT. The status code indicates whether the waiver is active or inactive. Inactive waivers reflect waiver information that is no longer applicable because there has been a change to the fee waiver entitlement. Inactive waivers do not have an effect on the determination of fees due for the policy and are for audit purposes only. A fee waiver that indicates that a family has met their fiscal year catastrophic cap limit will be considered inactive if the fee waiver end date is not September 30th of the fiscal year for which the waiver exists. All waiver data is displayed in the Fee/CCD Web Research application and DOES (limited to only current fee waivers and those effective within the past two years).

C-97, October 19, 2017


DEERS Functions

20

1.2.8.1 Enrollment Fee and Premium Payment Processing (For Enrollment Periods Prior to October 1, 2012 and up Through December 31, 2017)

1.2.8.1.1 Prime Enrollment Fee Payment (For Enrollment Periods Prior to October 1, 2012 and up Through December 31, 2017)

1.2.8.1.1.1 Enrollment fees may be paid monthly, quarterly, or annually. The beneficiary specifies this payment option during enrollment and the contractor shall enter the fee information in the Enrollment Fee Payment interface or the Fee/CCD Web Research application as part of the enrollment transaction. Contractors shall update DEERS with all subsequent enrollment fee payments and shall update a fee paid-through date for each. They shall transmit this information, including any credits to DEERS within one business day. With the exception of claims recoupments and Non-Sufficient Fund (NSF) fees, all monetary receipts from beneficiaries must be treated as fee payments and reported to DEERS either as fee payments or credits, unless they are refunded to the beneficiary. There is no option to retain such records in the contractor’s system. The contractor’s system shall be able to process fee refunds as necessary.

1.2.8.1.1.2 DEERS will automatically apply any fee payments and adjustments posted through DOES or the Enrollment Fee Payment interface to the beneficiary’s catastrophic cap (if applicable). For individual policies, the beneficiary will be credited with the fee amount; for family policies, the fee will be posted under the sponsor’s family contribution towards the catastrophic cap. If the catastrophic cap is locked at the time the fee payment is sent, DEERS will reject the fee payment. The contractor shall resend the fee amount to DEERS daily until it is accepted. If the record remains locked longer than 48 hours, the contractor should contact the claims processor that placed the lock to determine the reason for the lock and when it will be released.

1.2.8.1.1.3 The enrollment fee payment interface perform edits against the submitted fee data. The contractor shall research and correct any data discrepancies identified by DEERS (both warnings and errors) within three business days.

1.2.8.1.1.4 DEERS records both the enrollment fee payment date and the enrollment fee paid-through date. The enrollment fee payment date reflects the date the fee was received by the contractor. The enrollment fee paid-through date reflects the last date for which coverage is paid. The purpose of tracking the paid-through date is to ensure portability. On an enrollment transfer, DEERS includes the last fee information from the enrollee’s policy on the notification to the new contractor.

1.2.8.1.1.5 DEERS does not prorate fees, determine the amount of the next enrollment fee payment, determine the date of the next enrollment fee payment, send enrollment fee payment due notifications, or identify which entity is responsible for enrollment fee payments. These actions are the responsibility of the enrolling organization. Additionally, the enrolling organization must be able to accommodate policies that are less than 12 months in length and prorate enrollment fees appropriately.

1.2.8.1.1.6 DEERS will automatically apply any fee payments posted through the Enrollment Fee Payment interface to the catastrophic cap.

1.2.8.1.1.7 Credits extending into FY 2013, have to be removed prior to initialization of the new premium fee model and then later sent to DEERS if those funds apply to an FY 2013 payment. For

C-97, October 19, 2017


DEERS Functions

21

payments effective October 1, 2012 and later, DEERS will not post credits amounts to the catastrophic cap.

1.2.8.1.2 Fee Payments Interface (For Enrollment Periods Prior to October 1, 2012 and up Through December 31, 2017)

The contractor will send enrollment fee payment information to DEERS through a system-to-system interface. This interface includes new payments, payment adjustments, and updates to paid-through dates. Contractors must correct and resubmit enrollment fee payments rejected by DEERS or research, correct and resubmit fee payments for which DEERS has provided a warning within three business days of the error.

1.2.8.1.3 Premium Payment Programs: TRS, TRR, and TYA (Payments For Enrollment Periods Prior to October 1, 2012 and up Through December 31, 2017)

For the TRS, TRR, and TYA programs, DEERS will accept premium payment paid-through dates.

1.2.8.1.3.1 Contractors are required to submit paid-through dates to DEERS upon receipt of premium payments. Contractors will refund all overpayments of premiums to the member. In the event the member moves from one region to another region, billings for premiums shall be initiated on the next month with coverage effective the first day following the previous paid-through date. Transfers shall be made per the TRICARE Operations Manual (TOM), Chapter 22, Sections 1 and 2 and Chapter 25, Section 1.

1.2.8.1.3.2 As with any other enrollment fee or premium payment, overpayments are considered part of the fee or premium amount that must be reported to DEERS.

Note: TRS/TRR/TYA premium payments are not applicable to the FY catastrophic cap.

1.2.8.2 Enrollment Fee and Premium Payment Processing (For Enrollment Periods On or After October 1, 2012)

1.2.8.2.1 Prime Enrollment Fee Payment and Refunds (For Enrollment Periods On or After October 1, 2012)

1.2.8.2.1.1 Enrollment fees may be paid monthly, quarterly, or annually. The beneficiary specifies this payment option during enrollment and the contractor shall enter the dollar amount received from the beneficiary or the dollar amount refunded to a beneficiary or forfeited by a beneficiary in the Premium/Fee Interface or the Fee/CCD Web Research application. DEERS will calculate the policy paid period end date and return the information to the enrolling contractor. Contractors shall send the dollar amount of all subsequent enrollment fee transactions, including refunds of enrollment fees and forfeited fee amounts, to DEERS within one business day. With the exception of claims recoupments and NSF fees, all monetary receipts from beneficiaries or refund/forfeitures of enrollment fees shall be treated as enrollment fee transactions and shall be reported to DEERS. The contractor’s system shall be able to process fee refunds as necessary.

1.2.8.2.1.2 The contractor shall send enrollment fee transactions to DEERS through a system- to-system interface. This interface includes new payments and payment adjustments, including

C-97, October 19, 2017


DEERS Functions

22

refunds and forfeitures. DEERS will calculate the new paid period end date based on the amount submitted by the contractor. The contractor shall correct and resubmit enrollment fee transactions rejected by DEERS or research, correct and resubmit transactions for which DEERS has provided a warning within three business days of the error.

1.2.8.2.1.3 If applicable, DEERS will automatically apply fee transactions to the beneficiary’s catastrophic cap. For individual policies, the beneficiary will be credited with the fee amount; for family policies, the fee will be posted under the sponsor’s family contribution towards the catastrophic cap. If the catastrophic cap is locked at the time the fee payment is sent, DEERS will reject the fee payment. The contractor shall resend the fee amount to DEERS daily until it is accepted. If the record remains locked longer than 48 hours, the contractor shall contact the claims processor that placed the lock to determine the reason for the lock and when it will be released.

1.2.8.2.1.4 The Premium/Fee Interface performs edits against the submitted fee data. The contractor shall research and correct any data discrepancies identified by DEERS (both warnings and errors) within three business days.

1.2.8.2.1.5 DEERS calculates paid period end dates based on the premium/fee amounts collected, refunded, or forfeited and entered into DEERS by the contractor. It does not determine the date of the next premium/fee payment, send premium/fee payment due notifications, or identify which entity is responsible for premium/fee payments. These actions are the responsibility of the contractor. Additionally, the contractor shall be able to accommodate policies that are less than 12 months in length, and collect only the enrollment fees due.

1.2.8.2.1.6 DEERS records both the enrollment fee transaction date and the enrollment fee paid, refunded, or forfeited amount. The enrollment fee transaction date reflects the date the fee was received or refunded by the contractor, or the date the fees were forfeited by the beneficiary. The enrollment fee paid, refunded, or forfeited amount will be used by DEERS to calculate the paid period end date, and any credits associated to the policy. DEERS includes the last fee information from the enrollee’s policy on notifications to the contractors. DEERS calculates and reports credits to all policies.

1.2.8.2.1.7 The contractor shall remove all existing credits on DEERS prior to the initialization of the new premium model. Credits not refunded to the beneficiary shall be re-posted as a FY 2012 credit or a FY 2013 payment after initialization. Any credits remaining on or after October 1, 2012, shall be removed from FY 2012 and either refunded to the beneficiary or posted as a payment for FY 2013. Effective October 1, 2012 and later, DEERS will not post credit amounts to the catastrophic cap.

1.2.8.2.2 Premium Payment and Refunds: TRS, TRR, and TYA Programs (For Enrollment Periods On or After October 1, 2012 and up Through December 31, 2017)

1.2.8.2.2.1 For the TRS, TRR, and TYA programs, the contractor will enter into DEERS the premium amount collected and the premiums refunded for the policy and DEERS will calculate and return to the contractor the paid period end date.

1.2.8.2.2.2 Contractors are required to submit all premium amounts collected or premiums refunded to the beneficiary to DEERS upon receipt. Contractors will refund all overpayments of premiums to the member at termination of coverage. In the event the member moves from one

C-97, October 19, 2017


DEERS Functions

23

region to another region, billings for premiums shall be initiated the next month with coverage effective the first day following the previous paid period end date. Enrollment transfers shall be made per the TRICARE Operations Manual (TOM), Chapter 22, Sections 1 and 2 and Chapter 25, Section 1.

1.2.8.2.2.3 As with any other enrollment fee or premium payment, overpayments not refunded to the beneficiary are considered part of the fee or premium amount that must be reported to DEERS.

Note: TRS/TRR/TYA premium payments are not applied to the FY catastrophic cap.

1.2.8.3 Enrollment Fee Waivers

1.2.8.3.1 DEERS will automatically maintain fee waiver entitlement data for families. Multiple fee waiver entitlements may exist at the same time (i.e., the family has a waiver for Medicare at the same time that they have met the catastrophic cap for part of a fiscal year). DEERS will supply all fee waiver entitlements and calculate fees due based on all waiver entitlement data.

1.2.8.3.2 When new enrollments are processed, certain fee waiver entitlements will be immediately available on the enrollment PNT. Under certain circumstances (i.e., Medicare enrollments), the enrollment data will be processed and a PNT is sent prior to the calculation of the fee waiver entitlements. In such cases, a subsequent PNT will be sent immediately after the fee waiver entitlement recalculation that will include the updated waiver data. DEERS will calculate fees due.

1.2.8.3.3 When primary data changes in DEERS that affect fee waivers, the corresponding entitlement periods will be recalculated. If a fee waiver entitlement affects the current or future fiscal years for an active policy, DEERS will send an unsolicited notification to the most recent contractor.

1.2.8.3.4 Additionally, if primary data in DEERS changes that makes an existing entitlement invalid (i.e., the family going back under the catastrophic cap), the existing entitlement will be marked inactive and an unsolicited PNT will be sent to the contractor if it affects an active policy’s current or future fiscal years. DEERS will calculate or recalculate any fees due.

1.3 Address, Telephone Number, and E-Mail Address Updates

1.3.1 Addresses

DEERS receives address information from a number of source systems. Although most systems only update the residence address, DEERS actually maintains multiple addresses for each person. The contractor shall update the residential and mailing addresses in DEERS, whenever possible. These addresses shall not reflect unit, MTF, or MCSC addresses unless provided directly by the beneficiary. The mailing address captured on DEERS is primarily used to mail the enrollment card and other correspondence. The residential address is used to determine enrollment jurisdiction at the Zip Code level. DEERS uses a commercial product to validate address information received online and from batch sources.

C-97, October 19, 2017


DEERS Functions

24

1.3.2 Telephone Numbers

DEERS has several types of telephone numbers for a person (e.g., home, work, and cellular). Contractors shall make reasonable efforts to add or update telephone numbers.

1.3.3 E-mail Addresses

DEERS can store an e-mail address for each person. Contractors shall make reasonable efforts to add or update this e-mail address.

1.4 Notifications

Notifications are sent to contractor for various reasons and reflect the most current enrollment information for a beneficiary. The contractor must accept, apply, and store the data contained in the notification as sent from DEERS. Notifications may be sent due to new enrollments or updates to existing enrollments. If the contractor does not have the information contained in the notification, the contractor shall add it to their system. If the contractor already has enrollment information for the beneficiary, the contractor shall apply all information contained in the notification to their system. The contractor shall use the DEERS ID to match the notification to the correct beneficiary in their system. There are also circumstances where a contractor may receive a notification that does not appear to be updating the information that the contractor already has for the enrollee. Such notifications shall not be treated as errors by the contractor system and must be applied. The contractor is expected to acknowledge all notifications sent by DEERS. If DEERS does not receive an acknowledgement, the notification will continue to be sent until acknowledgement is received. The following information details examples of events that trigger DEERS to send notifications to a contractor.

1.4.1 Notifications Resulting From Enrollment Actions Prior to January 1, 2018

DEERS sends notifications to the contractor detailing any enrollment update performed in the DOES or BWE application. This includes address updates made for enrollees. Additionally, DOES supports a feature for the contractor to request a notification to be sent without updating any address or enrollment information. The purpose of this request is to re-sync the contractor systems with the latest DEERS enrollment data.

Notifications sent as a result of enrollments, transfers, or PCM changes in BWE will indicate a pending status. The contractor shall apply all pending PNTs received, as well as reviewing and either confirming, rejecting or modifying the enrollment as needed. A second notification is sent when the action is confirmed in DOES. If the DOES operator modified the enrollment or PCM data, the second notification will contain the corrected data in a non-pending status.

During transfers in BWE, one non-pending disenrollment notification is sent to the losing contractor. There is no subsequent notification sent to the losing contractor when the enrollment information is confirmed in DOES. If the transfer is cancelled before the gaining contractor approves it, the losing contractor will receive a cancellation of the disenrollment.

C-97, October 19, 2017


DEERS Functions

25

1.4.2 Unsolicited Notifications Prior to January 1, 2018

Unsolicited notifications result from updates to a sponsor or family member’s information made by an entity other than the enrolling contractor. Unsolicited notifications may result from various types of updates made in DEERS:

• Change to eligibility. As updates are made in DEERS that affect a beneficiary’s entitlements to TRICARE benefits, DEERS modifies policy data based on those changes and sends notifications to the contractor and to CHCS, if appropriate. One example of this type of notification is notification of loss of eligibility.

• Extended Eligibility. For example, in the case of a 21-year old child that shows proof of being a full-time student, eligibility may be extended until the 23rd birthday.

• SSN, name, and date of birth changes. Updates to an enrolled sponsor or beneficiary’s SSN, name, or date of birth are communicated via unsolicited notification to the contractor.

• Address changes. The notification also includes information as to which type of entity made the update. Address changes performed by CHCS are also sent to the contractor.

• Data corrections made by the DMDC Support Office (DSO) or the DOES Help Desk. If a contractor requests the DSO to make a data correction for a current or future enrollment that the contractor cannot make themselves, notification detailing the update is sent to the contractor, and to CHCS, if appropriate.

• Automatic approvals of BWE actions. DEERS will send unsolicited notifications for all BWE actions approved without contractor action in DOES.

• Fee waiver updates. Changes to an enrolled sponsor or beneficiary’s fee waiver status will be sent via unsolicited notifications to the contractor.

• Changes to premium information as a result of a premium or fee recalculation by DEERS.

1.5 Patient ID Merge

Occasionally, incomplete or inaccurate person data is provided to DEERS and a single person may be temporarily assigned two patient IDs. When DEERS identifies this condition, DEERS makes this information available online for all contractors. The contractor is responsible for retrieving and applying this information on a weekly basis. The merge brings the data gathered under the two IDs under only one of the IDs and discards the other. Although DEERS retains both IDs for an indefinite period, from that point on only the one remaining ID shall be used by the contractor for that person and for subsequent interaction with DEERS and other MHS systems. If there are enrollments under both records being merged that overlap, the enrolling organizations are responsible for correcting the enrollments. The contractor shall also update the catastrophic cap that has been posted for these records if necessary. DEERS merges OHI by assigning the last updates of OHI active policies (not cancelled or systematically terminated) to the remaining Patient ID.

C-97, October 19, 2017


DEERS Functions

26

1.6 Enrollment Cards And Notice Production

1.6.1 The contractor is responsible for processing all mail returned for bad addresses and shall research the address, correct it on DEERS, and re-mail the correspondence to the beneficiary.

1.6.2 DEERS is responsible for producing the TRICARE universal beneficiary card for both Continental United States (CONUS) and Outside the Continental United States (OCONUS). The cards are produced for beneficiaries enrolled in TRICARE Prime TRS, TRR, and TYA programs. Enrollment cards are not produced for enrollments to USFHPs.

• DEERS sends a notification directly to the enrollee at the residential mailing address specified in the enrollment request or via e-mail advising them how to obtain a copy of their Universal TRICARE Beneficiary Card. New enrollment cards are automatically generated upon a new enrollment or an enrollment transfer to a new region, unless the enrollment operator specifies in DOES not to generate an enrollment card. A contractor may request a replacement enrollment card for an enrollee at any time. DEERS sends enrollment card request information in a notification to the contractor indicating the last date an enrollment card was generated for the enrollee.

• In addition to the enrollment card, DEERS sends a notice to the beneficiary indicating their PCM selection, if applicable. This notice is sent even if no card is generated. PCM change notices may be suppressed through both DOES and PCM Panel Reassignment (PCMRS).

• DEERS also sends a notice to a beneficiary upon disenrollment. If the disenrollment is due to loss of eligibility for all MHS medical benefits, DEERS will send a Termination Notice (TN) instead of the disenrollment letter. DEERS will send appropriate notices when the loss of eligibility is due to death of the beneficiary. The contractor shall not send additional notices that duplicate those already provided by DEERS.

1.7 Enrollments On Or After January 1, 2018

1.7.1 Effective January 1, 2018, in accordance with the NDAA 2017, for FY 17, Section 701, all beneficiaries other than ADSMs must elect purchased care coverage if they want other than DC coverage only. DC will be provided only on a space available basis.

• A one-time grace period will be in effect for the enrollment period beginning January 1, 2018 and ending December 31, 2018. Beneficiaries enrolled in Prime as of December 31, 2017, will be automatically continued as a TRICARE Prime enrollee with the option to decline at the beneficiary’s request. Beneficiaries under TRICARE Standard will be enrolled into the TRICARE Select Program with the option to decline at any time during the 2018 enrollment period.

1.7.2 Eligibility For Enrollment

The DoD provides assigned HCDPs and plans when a person joins the DoD. DEERS determines coverage plans for which a beneficiary is eligible to enroll by using the DoD-assigned coverage in conjunction with additional eligibility information. The Eligibility for Enrollment Inquiry in DOES is used to view a person’s or family’s eligibility to enroll.

C-97, October 19, 2017


DEERS Functions

27

Note: The Eligibility For Enrollment Inquiry in DOES should not be used for other eligibility determinations. For example, USFHP providers should use GIQD and not DOES to determine if a person is eligible for a hospital admission.

1.7.2.1 DEERS provides coverage plan information identifying the period of eligibility and/or enrollment for the coverage plan. A beneficiary can only be enrolled into the coverage plans that have an “eligible for” status. When a sponsor and family member are first added into DEERS, DEERS determines basic eligibility for health care benefits in accordance with DoDI 1000.13 and establishes an assigned HCDP coverage plan together with coverage dates.

1.7.2.2 For example, when an active duty sponsor and family members are added to DEERS:

• Eligible family members are assigned DC Only, however ADFMs CONUS will be auto enrolled TRICARE in Prime with no PCM if they reside within a PSA and meet certain other criteria. If they reside outside a PSA, they will be enrolled in TRICARE Select. ADFMs OCONUS will be enrolled in TRICARE Select.

• NATO members and family members will not be auto enrolled.

• Eligible retirees and retiree family members are assigned DC Only until they elect enrollment in a covered plan. Retirees and retiree family members will not be auto enrolled in any enrolled plan.

1.7.3 The assigned plans provide the foundation for enrollment into various coverage plans. Enrollment plans are mandatory for ADSMs and include:

• TRICARE Prime for ADSMs. This plan requires the assignment of a PCM.• TRICARE Prime Remote (TPR) for ADSMs. This plan requires a PCM if one is available.• TRICARE Overseas Prime for ADSMs. This plan requires a PCM to be assigned.

1.7.3.1 For other beneficiary categories, such as ADFMs and retirees and their family members, enrollment is optional. Beginning January 1, 2018 in order to have purchased care coverage, beneficiaries must be in an enrolled plan.

1.7.3.2 Beginning January 1, 2018 enrollments will be based on the individual, but enrollment fees will be determined by the number of family members in the enrolled plan. Therefore, a family may have members enrolled in different Plans.

1.7.3.3 DEERS creates a policy(ies) that encompasses all enrollments for a family and a HCDP. For these plans, DEERS does not limit the number of individual policies that a family may have.

1.7.3.4 The contractors are required to enter the following information into DOES in order to complete an enrollment. Required data elements vary by plan. For instance, TRICARE Prime for ADFMs requires the following data elements:

• Coverage plan

• Enrollment begin date (if different than DOES default)

C-97, October 19, 2017


DEERS Functions

28

• Address verification

• PCM assignment

• PCM Network Provider Type Code (if not defaulted by DOES)

• PCM Division (if more than one is available for the coverage plan and PCM Network Provider Type Code)

• Individual PCM selection

1.7.3.5 Enrollments may be backdated up to 18 months.

Note: If a policy is backdated prior to January 1, 2018, prior enrollment policies apply.

1.7.3.6 Enrollment policies beginning January 1, 2018 for all enrollees shall be on a CY basis. Policies will be automatically continued unless there is loss of eligibility or the beneficiary effects a change during the annual open season or following a Qualifying Life Event (QLE) (see the TOM, Chapter 6).

1.7.3.7 Fees can be paid on an annual or quarterly or monthly basis in accordance with the TOM, Chapter 6.

1.8 Enrollment Fees On Or After January 1, 2018

1.8.1 Prorated Enrollment Fees

Enrollment fees shall be paid:

For new enrollments that do not begin on the first day of the month, the contractor shall collect prorated enrollment fees to cover the remaining days of coverage for the month and collect full months thereafter. The monthly prorated enrollment fee is 1/12 of the respective annual enrollment fee (rounded down). The daily prorated enrollment fee is 1/30 of the monthly amount regardless of the number of days remaining in the month for each day they are enrolled. For an annual fee payer the enrollee will pay a prorated fee for the effective date until the end of the CY. The enrollee will not pay more than the amount of the annual fees to the end of the CY (see TOM, Chapter 6).

1.8.2 Survivors of Active Duty Deceased Sponsors and Medically Retired Uniformed Service Members and Their Dependents

1.8.2.1 Beneficiaries whose Sponsor has an initial service date on or after January 1, 2018:

There are no TRICARE Prime or TRICARE Select enrollment fee freezes or waivers for these beneficiaries.

C-97, October 19, 2017


DEERS Functions

29

1.8.2.2 Beneficiaries whose Sponsor has an initial service date before January 1, 2018:

1.8.2.2.1 Effective Fiscal Year (FY) 2012, these beneficiaries shall have their TRICARE Prime enrollment fees frozen at the rate in effect when classified and enrolled in a fee paying Prime plan. (This does not include TRICARE Young Adult (TYA) plans). Beneficiaries in these two categories who were enrolled in FY 2011 will continue paying the FY 2011 rate. The beneficiaries who become eligible in either category and enroll during FY 2012, or in any future fiscal year, shall have their fee frozen at the rate in effect at the time of enrollment in Prime. The fee for these beneficiaries shall remain frozen as long as at least one family member remains enrolled in Prime. The fee for the dependent(s) of a medically retired Uniformed Services member shall not change if the dependent(s) is later re-classified a survivor.

1.8.2.2.2 There are no TRICARE Select enrollment fee freezes or waivers for these beneficiaries.

1.8.3 Enrollment Fee Waivers

Beneficiaries under age 65, that have Medicare Part A and B, that are enrolled in Prime will continue to have a Prime enrollment fee waiver. If the family has more than two beneficiaries with Medicare Part A and B enrolled in Prime, the entire Prime fee is waived. There are no fee waivers for TRICARE Select.

1.9 PCM Assignment Within The DOES Application On Or After January 1, 2018

DEERS has a centralized PCM file containing both the PCMs for the DC facilities and all MCSC civilian network PCMs. The DOES application accesses the central PCM file to perform provider assignments. The DEERS PCM Repository will accept additions, terminations, and modifications of civilian network PCMs in real time to support enrollment activities. All PCM additions, terminations, or modifications shall be transmitted to DEERS no less than daily. To deactivate a PCM, contractors shall send DEERS a modification where the PCM’s effective date is equal to the PCM’s end date, and DEERS will deactivate the PCM from the central file. DEERS will not allow subsequent assignments to a deactivated PCM. Contractors are responsible for the quality of the PCM data transmitted to DEERS. Contractors will not submit inaccurate data.

1.9.1 DC PCM Assignment

The contractor shall perform DC PCM assignment at the time of enrollment in the DOES application. The contractor shall use the PCM preference indicated in the enrollment request in addition to guidance contained in any MOU agreement or other government-provided direction, if available. For ADSMs, if the enrollment request has a Unit Identification Code (UIC) specified and the MTF has established a default provider for the UIC, the contractor should use the default. If the enrollment request contains a specialty or gender preference, the contractor shall use the preference filters available in DOES to select a PCM. In the case where a beneficiary has not indicated a preference and there is not precise direction in a MOU or other government direction, the contractor shall use the search criteria in DOES to select a PCM. DOES and BWE will only display PCMs with available capacity in the selected Defense Medical Information System (DMIS)-ID. The contractor is responsible for determining the appropriate DMIS-ID based on MOUs, access standards, and any specific guidance from the government. If there is no capacity at a DC facility, the contractor shall contact the MTF to confirm that enrollment is closed; MTFs must respond to such requests within two business days or the contractor may enroll the beneficiary to their civilian

C-97, October 19, 2017


DEERS Functions

30

network.

1.9.2 Civilian PCM Assignment

The contractor shall perform Civilian PCM assignment at the time of enrollment in the DOES application. The contractor shall use the PCM preference indicated in the enrollment request. If the enrollment request contains a specialty or gender preference, the contractor shall use the preference filters available in DOES to select a PCM.

1.10 Disenrollment On Or After January 1, 2018

Once actively enrolled in a coverage plan, an individual or family may voluntarily disenroll or be involuntarily disenrolled. Voluntary disenrollment is self-elected. Involuntary disenrollment occurs from failure to pay enrollment fees or from loss of eligibility. Upon disenrollment, DEERS will notify the beneficiary of the change in or loss of coverage. Starting January 1, 2018, beneficiaries can disenroll at any time for their enrolled plan and will be DC only (space available) at the MTF. Re-enrollment changes are only available during open season or when a QLE occurs.

1.10.1 Disenrollment - Loss of Eligibility

A loss of eligibility refers to any loss or change in eligibility for DoD health care benefits in accordance with the current DoDI 1000.13 or additional legislation authorizing benefits or for a specific health coverage plan. At the time of enrollment, DEERS provides the end of eligibility date to the contractors via the notification. If that end date does not change, DEERS will provide no additional notifications. If the end date changes, DEERS will provide another notification with the new end date. DEERS also cancels any future actions for that beneficiary, including future enrollments, PCM changes, etc. If a contractor has applied fees to a policy that DEERS is canceling, DEERS will adjust the fees to ‘$0’.

1.10.2 Retroactive Eligibility/Enrollment Maintenance

There may be instances where DEERS receives notice of a loss of eligibility from the Uniformed Services, only to later be informed of the immediate reinstatement. Upon the receipt of the initial loss of eligibility, DEERS terminates the enrollment. Upon receipt of the notice of reinstatement, DEERS reinstates the eligibility and enrollment as long as there are no gaps in eligibility. DEERS will reinstate eligibility and enrollments only if DEERS receives new personnel information reinstating eligibility within 90 days of the initial loss of eligibility. Beneficiaries must make fee payments to cover period of eligibility to include retroactive coverage, as required.

1.10.3 Disenrollment - Voluntary

An enrollee may choose to terminate his or her current enrollment prior to the end date, or choose not to re-enroll into the current coverage plan. This transaction is performed in DOES. DEERS then terminates the enrolled coverage plan for the beneficiary and reverts to the DEERS assigned coverage, starting on the day after the termination of the enrollment. If additional systems need notification of the disenrollment, DEERS sends disenrollment notifications as necessary, notifying them of the termination of coverage benefits.

C-97, October 19, 2017


DEERS Functions

31

1.10.4 Disenrollment - Involuntary

The enrollee may fail to pay enrollment fees. In this case, the enrolling organization performs a disenrollment with a reason code of “failure to pay fees”. Individuals who are waived from paying enrollment fees are not disenrolled because of this exemption from enrollment fee payments. Disenrollment for failure to pay fees is either performed in DOES or through a batch ‘disenrollment for failure to pay fees’ system to system interaction.

Prior to processing a disenrollment with a reason of “non-payment of fees”, the contractor must reconcile their fee payment system against the fee totals in DEERS. Once the contractor confirms that payment amounts match, the disenrollment may be entered in DOES or through the failure to pay fees interface.

When there is a disenrollment, the appropriate systems are notified, as necessary. The following table lists the functions and applications that allow each action:

DOES BWEFEE

INTERFACEPCM PANEL

REASSIGNMENTCCDFEE

DEERS (UNSOLICITED)

Enrollment X X

Enrollment Cancellation X X(if

pending)

Disenrollment X X X(failure to pay fees

only)

X

Disenrollment Cancellation X

PCM Change X X X

PCM Cancellation X X(if

pending)

PCM Panel Reassignment X

Modify Enrollment Begin Date

X X

Modify Prior Enrollment End Date

X X

Modify Prior Enrollment End Reason

X X

Modify PCM Effective Date X

Transfer X X

Transfer Cancellation X X X(if loss of

eligibility before transfer)

Apply Enrollment Fee/TRICARE Reserve Select (TRS)/TRICRE Retired Reserve (TRR)/TYA Premium

X(initial)

X X

C-97, October 19, 2017


DEERS Functions

32

1.11 Modification Of Enrollment On Or After January 1, 2018

Whenever there is a modification to an enrollment, the appropriate systems are notified, as necessary.

1.11.1 PCM Change and Cancellation

PCM changes are not restricted to open season and QLEs. PCM reassignments occur when the enrollee changes regions or desires to change PCM’s within the region or MTF. Only the current enrolling organization may change the PCM selection. A PCM change can be made only on the latest PCM segment. DEERS then terminates the previous PCM with an end date, which will be the day before the begin date for the new PCM. Upon change of PCM, DEERS will notify the enrollee of the new PCM information, as well as sending notifications to the appropriate MTFs and contractors.

DOES will allow PCM’s with available capacities to be assigned as new PCM’s. If a contractor is canceling a PCM assignment, DOES will permit reinstatement of a PCM whose capacity has been reached.

1.11.2 PCM Panel Reassignment

PCM Panel Reassignment Application (PCMRA) allows the user to select all or part of a PCM’s panel for reassignment to other PCMs. PCM reassignments are processed periodically by DEERS. DEERS will decrement and increment PCM capacities when processing panel reassignments, but will not prevent the reassignment if the selected gaining PCM does not have available capacity. As part of the moves, DEERS sends notifications to the appropriate systems. Note that PCM change notices may be suppressed during a panel reassignment, but the suppression must apply to the entire transaction.

1.11.3 DC PCM Panel Reassignment

All PCM changes for DC PCMs must be performed by the MCSC. The MTF will set up the panel reassignments using PCMRA. The contractor shall complete the required moves using PCMRA within three business days of submission.

Panel changes that cross Composite Health Care System (CHCS) platforms must be coordinated not only with the contractor but with the designated Defense Health Agency (DHA) Representative and DEERS.

Emergency moves may be coordinated by the MTF with the MCSC by the best available means, including phone, fax, or secure e-mail.

1.11.4 Civilian Panel Reassignment

DMDC provides a web application to allow contractors to perform mass reassignments of a civilian PCM’s enrollees. There is an option to suppress the PCM change notices for civilian PCM panel reassignments.

C-97, October 19, 2017


DEERS Functions

33

1.11.5 Transfer of Enrollment and Transfer Cancellation

A transfer of enrollment moves the enrollment from one contract to another and thus moves the responsibility for the administration of the enrollment to the gaining contractor. DEERS supports transfers within plans (e.g., TRICARE Prime). A transfer may include a change to the Health Care Coverage (HCC) plan in some cases, such as TRICARE Prime for ADSMs to TPR for ADSMs. DEERS will enforce when such transfers are allowed.

1.12 Claims, CCD Data On Or After January 1, 2018

DEERS is the system of record for eligibility and enrollment information. As such, in the process of claims adjudication, the contractor shall query DEERS to determine eligibility and/or enrollment status for a given period of time. The contractor shall use DEERS as the database of record for:

• Person Identification• Eligibility• Enrollment and PCM information• Enrollment and FY or CY, as applicable to date totals for TRICARE CC&D amounts• Other Government Programs (OGP)

The contractor shall not override this data with information from other sources. Continued Health Care Benefits Program (CHCBP) CC&D information shall be obtained from the CHCBP contractor.

Although DEERS is not the database of record for address, it is a centralized repository that is reliant on numerous organizations to verify, update and add to at every opportunity. The address data received as part of the claims inquiry shall be used as part of the claims adjudication process. If the contractor has evidence of additional or more current address information they shall process claims using the additional or more current information and update DEERS within two business days.

Although DEERS is not the database of record for OHI, it is a centralized repository of OHI information that is reliant on the MHS organizations to verify, update and add to at every opportunity. The OHI data received as part of the claims inquiry shall be used as part of the claims adjudication process. If the contractor has evidence of additional or more current OHI information they shall process claims using the additional or more current information. After the claims adjudication process is complete, the contractor shall send the updated or additional OHI information to DEERS within two business days.

DEERS stores enrollment and FY CC&D data in a central repository. DEERS stores the current and the four prior enrollment and FY CC&D totals. The purpose of the DEERS CCDD repository is to maintain and provide accurate CC&D amounts, making them universally accessible to DoD claims processors.

C-97, October 19, 2017


DEERS Functions

34

1.12.1 Data Events: Inquiries And Responses

This section identifies the main events, including the inquiries and responses between the contractors and DEERS, associated with CCDD transactions. The main events to support processing this information include:

• HCC Inquiry for Claims• CCDD Totals Inquiry• CCDD Amounts Update• CCDD Transaction History Request

1.12.1.1 HCC Inquiry For Claims

The contractor shall install a prepayment eligibility verification system into its TRICARE operation that results in a query against DEERS for TRICARE claims and adjustments. The interface should be conducted early in the claims processing cycle to assure extensive development/claims review is not done on claims for ineligible beneficiaries. The DEERS HCC Inquiry for Claims supports business events associated with HCC and CCDD data for processing medical claims. This inquiry may also be used for general customer service requests or for referrals and authorizations.

The contractor must use the eligibility, enrollment, OGPs (e.g., Medicare), and the PCM information returned on the DEERS response to process the claim. The contractor must use CCDD information either from this DEERS response or from a totals inquiry completed immediately prior to adjudication. The contractor may use address and OHI information from any source but must update DEERS with any differing information within two business days if the information is more current.

There are multiple options for inquiring about coverage information while including CCDD information. These different inquiry options allow the inquirer to receive coverage information and CCDD totals with or without locking the CCDD information for the family. A coverage inquiry and lock of the CCDD accumulations is necessary prior to updating this data on

FIGURE 3.1.4-8 CLAIMS INQUIRY TO DEERS

Cat Cap Application

DEERS

Coverage Inquiries

MCSC SYSTEM

ClaimsSystem

1 - Claims Inquiry

3 - Apply CCDD Updates

2MCSC

Claims Data Store

• Eligibility• Enrollments• Fees• Cat Cap/

Deductible• Civilian & DC

PCM• OHI

NED

C-97, October 19, 2017


DEERS Functions

35

DEERS.

For audit and performance review purposes, the contractor is required to retain a copy of every transaction and response sent and received for claims adjudication procedures. This information is to be retained for the period required by the TRICARE Policy Manual (TPM) or TOM.

Unless authorized by the contracting officer, the contractor may not bypass the query/response process. If either DEERS or the contractor is down for 24 hours or any other extended period of time the contractor shall work directly with DEERS and DHA to develop a mutually agreeable method and schedule for processing the backlog or implementing their disaster recovery processes.

1.12.1.2 Exceptions To The DEERS Eligibility Query Process

Claims processing adjudication requires a query to DEERS except in cases where a claim contains only services that will be totally denied and no monies are to be applied to the CCDD. No query is needed for:

• Another claim or adjustment for the same beneficiary that is being processed at the same time.

• Negative Adjustments

• Total Cancellations

1.12.1.3 Information Required For A HCC Inquiry For Claims

The information needed to perform this type of coverage inquiry includes:

• Person identification information, including person or family transaction type• Begin and end dates for the inquiry period

1.12.1.4 Person Identification

A beneficiary’s information is accessed with the coverage inquiry using the identification information from the claim. DEERS performs the identification of the individual and returns the system identifiers (DEERS ID and Patient ID). The DEERS IDs shall be used for subsequent communications on this claim.

1.12.1.4.1 Inquiry Options: Person Or Family

The inquirer must specify if the coverage inquiry is for a person or the entire family. The person inquiry option should be used when specific person identification is known. If person information is incomplete, the family inquiry mode can be used. In family inquiries, the Inquiry Person Type Code is required to indicate if the SSN, Foreign ID, or Temporary ID is for the sponsor or family member. In such inquiries, DEERS returns both sponsor and family member information. If there is more than one person or family match, DEERS will return a partial match response. The contractor shall select the correct person and resend the coverage inquiry.

C-97, October 19, 2017


DEERS Functions

36

1.12.1.4.2 Inquiry Period

In addition to identifying the correct person or family, the inquirer must supply the inquiry period. The inquiry period may either be a single day or can span multiple days. Historical dates are valid, as long as the requested dates are within five years. The inquirer queries DEERS for information about the coverage plans in effect during that inquiry period for the sponsor and/or family member. The reply may include one or more coverage plans in effect during the specified period. For claims, the contractor shall use the dates of service on the claim.

FIGURE 3.1.4-9 INQUIRY PERSON TYPE CODE

PERSONS TO RETURNWHAT INFORMATION IS AVAILABLE FROM THE CLAIM VALUES TO SET USAGE

RETURN ONLY A SINGLE SPONSOR/FAMILY MEMBER (PNF_TXN_TYP_CD = P)

SPONSOR INFORMATION IS PROVIDED (INQ_PN_TYPE_CD=S)

INQUIRY SPONSOR INFO SECTION:SPN_INQ_PN_IDSPN_INQ_PN_ID_TYP_CDSPN_PN_LST_NMSPN_PN _1ST_NMSPN_PN-BRTH_DT

INQUIRY PERSON INFO SECTION:INQ-PN_IDINQ-PN_ID_TYP_CDand/orPN-LST-NMPN-1ST_NMPN_BRTH_DT

RROOO

SS

NASS

RETURN ONLY A SINGLE PERSON SINGLE SPONSOR/FAMILY MEMBER(PNF_TXN_TYP_CD=P)

NO SPONSOR INFORMATION IS PROVIDED**(INQ_PN_TYP_CD=P)

INQUIRY SPONSOR INFO SECTION:

INQUIRY PERSON INFO SECTION:INQ_PN_IDINQ_PN_ID_TYP_CDPN_LST_NMPN_1ST_NMPN_BRTH_DT

NA

RROOO

RETURN THE WHOLE FAMILY(PNF_TXN_TYP_CD=F)

SPONSOR INFORMATIONPROVIDED(INQ_PN_TYP_CD=S)

INQUIRY SPONSOR INFO SECTION:SPN_INQ_PN_IDSPN_NQ_PN_ID_TYP_CDSPN_PN_LST_NMSPN_PN_1ST_NMSPN_PN_BRTH_DT

INQUIRY PERSON INFO SECTION:

RROOO

NA

LEGEND: R - Required; O - Optional; S - Situational

Note: * The Inquiry Person information section on a family member inquiry must either have the INQ_PN_ID and INQ_PN_TYP_CD OR if none is available then at least a PN_1ST_NM and PN_BRTH_DT.

**The period of time required for this type of inquiry to DEERS is significantly longer than for a family member based inquiry using a sponsor and should be used only infrequently when NO sponsor PN_ID information is provided on the claim.

The HICN (H) is only valid in the Person Inquiry section, not in the sponsor section and only on PERSON pulls (leave sponsor section blank).

C-97, October 19, 2017


DEERS Functions

37

1.12.1.4.3 Lock indicator

The contractor chooses whether to lock Catastrophic Cap Deductible Database (CCDD) totals. If the contractor intends to update the CCD amounts, the contractor must lock the totals.

1.12.1.5 Information Returned In The HCC Inquiry For Claims

The DEERS ID is returned in response to a coverage inquiry. The contractor shall store the DEERS ID for use in subsequent CCDD update transactions for this claim. In addition, the Patient ID is returned in the coverage response. The contractor shall store the Patient ID. The contractor must put the Patient ID and DEERS ID on the TRICARE Encounter Data (TED) record.

When implementing applications that use system to system interfaces that return partial matches (such as claims), those applications must allow the operator to view and select the correct individual, as described above. The partial match response is designed to provide unique identifiers (Patient ID or DEERS ID) that can ensure that subsequent processing will uniquely identify the correct individual or beneficiary.

1.12.1.5.1 Data Returned In A Coverage Inquiry That Repeats For Every Coverage Plan

In response to a HCC Inquiry for Claims, DEERS returns the specified coverage information in effect for the inquiry period. The following list shows the information DEERS returns for each coverage plan in effect during the inquiry period:

• Coverage plan information (assigned or enrolled)• Coverage plan begin and end dates within the inquiry period• Sponsor branch of service and family member category and relationship to the

sponsor during coverage period

Note: Newborn coverage information will only be reflected after the newborn is added to DEERS. See TOM, Chapter 8, Section 1 and TPM, Chapter 10, Section 3.1.

1.12.1.5.2 Data Returned In A Coverage Inquiry Independently From The Coverage Plan Information

The DEERS coverage response will always return:

• Sponsor Personnel Information: All current personnel segments will be returned, including dual eligible segments. The contractor shall not use this information for claims processing. This information is intended to be used for the TED only.

• Person information including the mailing address.

• The residential zip code will be returned for jurisdiction purposes.

• CCDD totals: Both family and individual CCDD accumulations are provided in the coverage response.

C-97, October 19, 2017


DEERS Functions

38

• Lock Indicator: The status of the lock on CCDD totals is returned on the coverage response.

The DEERS coverage response may include the following information. If nothing is returned, this means that DEERS does not have this information for the requested inquiry dates.

• PCM information is returned for some enrolled coverage plans. No PCM information is present for the DoD assigned coverage plans and some enrolled coverage plans. PCM information provided includes DMIS, the PCM Network Provider Type Code, and individual PCM information if available in DEERS.

• OHI: Limited OHI information is returned.

• OGPs: Complete OGP information is provided in the response.

1.12.1.5.3 HCC Copayment Factor For Coverage Inquiries

The HCC Copayment Factor Code for a beneficiary is determined by DEERS and is returned on a claims inquiry, but may be influenced by treatment information from a claim. The contractor shall use this factor code to determine the actual copayment for the claim.

The different factors are determined by legislation, which considers factors such as pay grade and personnel category, such as retired sponsor or active duty. Although the rates are based on the population to which they pertain, such as retired sponsor, these rates also apply to a sponsor’s family members. Examples of copayment factors are:

• Pay Grade Corporal/Sergeant or Petty Officer Third Class and below rate• Pay Grade Sergeant/Staff Sergeant or Petty Officer Second Class and above rate• Retiree and Surviving family members of deceased active duty sponsors rate• Foreign Military rate

The contractor’s system should be flexible enough to permit additional rate codes to be added, as required by the DoD.

1.12.1.5.4 Special Entitlements

Congressional legislation may affect deductibles and rates. The Special Entitlement Code and dates if applicable provide information to support this legislation. Effective dates will also be included in the response from DEERS. Note that a person may have multiple special entitlements. Examples are:

• Special entitlement for participation in Operation Joint Endeavor. This code, when returned from a claims inquiry to DEERS, will waive or reduce the annual deductible charges of the beneficiary for the period indicated by the effective and expiration dates of the special entitlement section of the data returned.

• Special entitlement for participation in Operation Noble Eagle. This code, when returned from a claims inquiry to DEERS, will waive or reduce the annual deductible charges of the beneficiary for the period indicated by the effective

C-97, October 19, 2017


DEERS Functions

39

and expiration dates of the special entitlement section of the data returned. In addition, non-participating physicians will be paid up to 115% of the CHAMPUS Maximum Allowable Charge (CMAC) or billed charges whichever is less.

1.12.1.6 Multiple Responses To A Single HCC Inquiry for Claims

DEERS may need to send multiple responses to a single HCC Inquiry for Claims if a person has multiple DEERS IDs within the inquiry period. It is necessary for DEERS to capture family member entitlements and benefit coverage corresponding to each instance of the person’s DEERS ID. For example, in a joint service marriage, a child may be covered by the mother from January through May (DEERS ID #1) and covered by the father from June through December (DEERS ID #2). These responses are returned in a single transaction. (Note: multiple responses are returned only when an individual inquiry is submitted.) Family inquiries will not produce multiple responses. Upon receiving a multiple response, the contractor shall select the correct beneficiary and resubmit a properly configured claims inquiry.

Contractors shall deny a claim (either totally or partially) if the services were received partially or entirely outside any period of eligibility.

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

CHAMPVA claims shall be forwarded to Health Administration Center, CHAMPVA Program, PO Box 65024, Denver CO 80206-5024.

A list of key DSO personnel and the Joint Uniformed Services Personnel Advisory Committee (JUSPAC) and the Joint Uniformed Services Medical Advisory Committee (JUSMAC) Members is provided at the DHA web site at http://www.tricare.mil. These individuals are designated by the DHA to assist DoD beneficiaries on issues regarding claims payments. In extreme cases the DSO may direct the claims processor to override the DEERS information; however, in most cases the DSO is able to correct the database to allow the claim to be reprocessed appropriately. The procedure the contractor shall use to request data corrections is in Section 1.7.

Any overrides issued by the DSO will be in writing detailing the information needed to process the claim. Overrides cannot be processed verbally, and overrides are not allowed in cases where correction of the data is the appropriate action. Only in cases of aged data that can not be corrected will DSO authorize an override. The contractor will provide designated Point Of Contact (POC) for the DSO personnel and the JUSPAC/JUSMAC members identified on the DHA web site.

1.12.1.7 CCDD Totals Inquiry

The CCDD Totals Inquiry is used to obtain CCDD balances for the year(s) that correspond to the requested inquiry period. The contractor must inquire and lock CCDD totals before updating DEERS CCDD amounts.

Note: A catastrophic cap record is not required for persons who are authorized benefits but are not on DEERS or eligible for medical benefits, such as prisoners or government employees. The purpose of the catastrophic cap is to benefit those beneficiaries who are eligible for MHS benefits.

C-97, October 19, 2017

http://www.tricare.mil


DEERS Functions

40

Those persons that are authorized benefits who would not under any other circumstances be eligible, are not subject to catastrophic cap requirements.

1.12.1.7.1 Information Required To Inquire For Totals

The following information details the data required to inquire for CCDD totals.

1.12.1.7.1.1 Person Information

The contractor must use the DEERS ID for the beneficiary whose claim is being processed for this inquiry. The DEERS ID is returned by DEERS on the policy notification or coverage response. Even though only one person’s DEERS ID is used, both individual and family totals will be returned in the response.

1.12.1.7.1.2 CCDD Totals Inquiry Period

The inquiry period used for the CCDD Totals Inquiry may be a single date or a date range, not more than six years in the past (current FY and five prior FYs). Future dates are not valid.

1.12.1.7.1.3 Lock Indicator

If the contractor intends to update the CCDD amounts, the contractor must lock the CCDD totals.

1.12.1.7.2 Response To CCDD Totals Inquiry

The following information details the information returned from a CCDD totals and inquiry.

1.12.1.7.2.1 CCDD Totals

DEERS sends a response showing year-to-date CCDD totals for each FY or CY, based on the inquiry dates requested. Dates must be within the current FY or CY (as appropriate) or five prior FYs or CYs (as appropriate) for a total of six FYs or CYs (as appropriate). Both individual and family totals are displayed. If there are no CCDD totals accumulated for any FY in the inquiry period requested, DEERS will show a zero value for that fiscal year.

If the inquiry period spans multiple FYs, the CCDD totals would repeat multiple times. For example, if the inquiry dates are September 1, 2007 through October 25, 2007, there would be two sets of CCDD totals, one for FY 2007 and one for FY 2008.

1.12.1.7.2.2 Lock Information

• If a contractor inquires for CCDD totals and does not request a lock on the totals, DEERS returns any totals accumulated for the inquiry period and any lock information if the totals were already locked.

• If a contractor inquires for totals with a request to lock and the totals were not already locked, DEERS would return the accumulated totals and the lock

C-97, October 19, 2017


DEERS Functions

41

information, including the locking organization, the lock date, and the lock time.

• If a contractor inquires and requests a lock for a beneficiary whose totals are already locked, only the locking organization, the lock date, and the lock time will be returned. No totals will be returned in this situation.

1.12.1.8 Updating CCDD Amounts

The CCDD total can be updated online for the current and five prior FYs. This update transaction requires the DEERS ID, which may be obtained from a coverage or CCDD totals inquiry. Only the same organization that placed the lock may update the locked record and remove the lock. DEERS validates that the updating organization is the same as the organization that placed the lock. If there is a discrepancy, DEERS does not allow the update and sends a response that the update was not successful. If there are more claims outstanding for the same family, the contractor may choose not to remove the lock. In this case, the record would remain locked until the 48-hour time period expires, or the lock is removed, whichever comes first.

Each transaction should only include updates for one claim. CCDD amounts for multiple claims should be sent in separate transactions. In the split claim situation, multiple transactions must be sent for the same claim. For example, if a claim spans FYs or CYs, (as appropriate) and is split, updates for FY 2000 and FY 2001 must be sent in two transactions using the claim extension identifier to distinguish the two updates from one another. If a claim does not span multiple fiscal or enrollment years, the claim extension identifier should be set to ‘000’. Split claims will use a unique claim extension identifier for each FY or CY, (as appropriate) in which the claim occurs.

If cost-shares, copays or deductibles are collected, these amounts must be posted to CCDD, even if the catastrophic cap has been met. If cost-shares, copays or deductibles were reduced or waived based on the CCDD totals returned, those amounts shall also be posted to DEERS even if the catastrophic cap has been met. If the catastrophic cap is exceeded, the contractor shall refund the overage to the beneficiary.

Do not send CCDD updates for programs for which they do not apply (e.g., Extended Care Health Option (ECHO)). See the TPM.

1.12.1.8.1 Information Required To Update CCDD Amounts

The contractor must provide the following information to update the CCDD amounts:

• DEERS ID: This identifies the beneficiary for whom the update is applied.

• Catastrophic cap, deductible, and/or Point Of Service (POS) dollar amount. The contractor sends DEERS the CCDD amount for the beneficiary. DEERS knows to which family the beneficiary belongs and rolls up the totals for the correct family using the DEERS ID.

• Identifier for the claim, enrollment fee, or adjustment.

Note: If there is a discrepancy between the identifier used for locking and the identifier used for updating, DEERS does not allow the update.

C-97, October 19, 2017


DEERS Functions

42

• Claim extension identifier. When a claim spans FYs, the claim extension is used to identify a split claim. These claims should have the same claim identifier with a different claim extension identifier. Splitting the claim is the responsibility of the claims processor, who splits the claim, adds the claim extension, and sends this information to DEERS.

• Lock information (remove or do not remove lock).

• Dates provided for the catastrophic cap and/or deductible update. The dates shall include the date(s) of service for the claim (both begin and end date). These dates are necessary for accumulating the CCDD totals for the correct time period and HCDP.

1.12.1.8.2 Types Of CCDD Updates

DEERS supports CCDD update functionality including adding and adjusting amounts. Adds and adjustments may be made for the current and previous five FYs or CYs, (as appropriate).

1.12.1.8.2.1 Adds

The contractor utilizes the CCDD update to add new CCDD amounts to the DEERS CCDD repository.

1.12.1.8.2.2 Adjustments

The contractor utilizes the CCDD update to adjust posted CCDD amounts. The same claim identifier as the original claim must be provided for the adjustment. The appropriate negative or positive amount should be entered, in order to correct the net amount. In order to adjust a claim, a contractor must provide the same information for updating a claim as outlined in the previous section. For example, a contractor updates a claim with a $50 catastrophic cap amount, then two weeks later discovers that the claim was incorrectly adjudicated and the catastrophic cap amount should have been $35. The contractor would then update the beneficiary’s catastrophic cap for the same claim number with an amount of -$15. The DEERS catastrophic cap balance would then show $35 for that claim. To cancel a catastrophic cap amount, adjust the claims to zero out the previous amount applied for that claim.

1.12.1.8.2.3 The 48-Hour Rule

If a contractor places a lock on a record and fails to update that record within the specified 48-hour time period, the contractor will be unable to update CCDD amounts, because the lock will have expired. To remove a lock, a contractor shall perform a CCDD update specifying to remove the lock. In this case, the contractor would send no catastrophic cap or deductible amounts, only an indication of the removal of the lock.

1.12.1.8.2.4 Add Newborn

CCDD amounts for a newborn are posted to DEERS by using the CCDD update transaction and setting the Newborn Addition Indicator Code to ‘Y’. The ‘Y’ code indicates that a newborn placeholder is to be added. If DEERS returns an error code on a newborn add indicating

C-97, October 19, 2017


DEERS Functions

43

that the person is already on the database, the contractor shall query to determine if this is actually the same person. If so, then the contractor shall use the returned information to apply the CCDD to the existing record. Contractors shall not create duplicate newborn placeholders within the same family; special care should be taken when the newborn may have multiple sponsors (e.g., the child of two active duty sponsors should be tracked only under one of the two sponsors if at all possible).

The CCDD update transaction shall include both the newborn information and the CCDD amounts. After the newborn has been added to DEERS, the CCDD update will be posted to the database (provided that the family record is not locked). In the event that the CCDD update was unable to be posted, it is the contractor’s responsibility to query DEERS to verify that the newborn has been created. The contractor is then to resend the CCDD update transaction, setting the Newborn Addition Indicator Code to ‘(blank)’.

Adding the newborn in DEERS via CCDD updates will not generate eligibility for the newborn, but the newborn will show in GIQD and in claims responses. Once the sponsor “adds” the newborn in DEERS through the Real-Time Automated Personnel Identification System (RAPIDS), the newborn will be eligible like any other beneficiary.

1.12.2 CCDD Transaction History Request

CCDD transaction history information is useful for customer service requests, for auditing purposes, or for researching any problems associated with CCDD updates in relation to a particular claim. DEERS maintains a record of each update transaction applied toward CCDD information. This detailed transaction information is available through the CCDD web application.

Note: As a result of the conversion from the Fee Interface to the Fee Premium Interface, there may be situations in which there will be discrepancies between fee payments collected and applied to the CCDD, across FYs. Fees collected in one fiscal year may be applied in whole to the CCDD and then may have to be modified (removed from the fiscal year applied) and then, after conversion is complete, reapplied via the Fee Premium Interface, to the next fiscal year as a credit or refunded to the beneficiary, as applicable. DEERS will adjust the CCDD and recalculate the paid period end date and return the new paid period end date to the contractor. Any fees that were not adjusted in accordance with the noted process will remain in the Fee Interface and will not be converted to the Fee Premium Interface.

1.13 SIT Program

The SIT program supports the MHS billing and collection process. The SIT is validated by the DHA Uniform Business Office (UBO) through the DoD Verification Point of Contact (VPOC). The VPOC is ultimately responsible for maintaining the SIT in DEERS, which is the system of record for SIT information. The SIT provides uniform billing information for reimbursement of medical care costs covered through commercial policies held by the DoD beneficiary population. MHS personnel use the SIT to obtain other payer information in a standardized format.

The Health Insurance Carrier (HIC) Identifier (ID) is the unique identifier for a carrier. Once a standard national health plan identifier is adopted by the Secretary, Health and Human Services (HHS), DEERS and MHS trading partners will migrate to that identifier.

All systems identified as trading partners will request an initial full SIT subscription from

C-97, October 19, 2017


DEERS Functions

44

DEERS. See the Technical Specification, “Health Insurance Carrier/Other Health Insurance” for subscription procedures. In addition, holders of the SIT shall subscribe to DEERS at least daily in order to receive subsequent updates of the SIT.

Field users perform five actions with the SIT:

• Inquiry actions can be performed on the OHI/SIT web application or through the local SIT file.

• An add action to report a new SIT entry for validation by the DoD VPOC.

• An update action to report an updated SIT entry for validation by the DoD VPOC.

• The cancellation of a carrier add sent to the SIT for verification by the DoD VPOC.

Note: Only the organization requesting a carrier to be added can cancel the request.

• A request to deactivate a verified HIC previously sent to the SIT for verification by the DoD VPOC.

1.13.1 SIT Inquiry

Local holders of the SIT cannot perform system-to-system inquiries against the central SIT maintained on DEERS.

1.13.2 SIT Add

When MHS personnel add a complete OHI record to a person or patient, they will need the HIC ID from the SIT. The HIC ID represents the identifier assigned to insurance carriers in the SIT provided by DEERS. The HIC ID Status Code identifies the ID as standard or temporary. See the “Technical Specifications for the HIC SIT and the OHI” for detailed information about the data elements required for the SIT add process.

When a HIC is not on the SIT, the user may send a request to add it to the SIT on DEERS. DEERS responds with a HIC ID, a HIC Status Code with the designation of “temporary,” and a HIC Verification Status Code of “unverified”. Unverified carriers are made available to all local holders of the SIT through the daily subscription process to prevent duplicate requests requiring VPOC validation. OHI may be assigned to unverified carriers. When the DoD VPOC validates the SIT, the HIC Verification Status Code will be changed from “unverified” to “verified.”

1.13.3 SIT Update

For updates to an existing SIT record, the existing HIC ID must be sent with the update. These updates are sent to all subscribers though the daily subscription process. Rejection of SIT updates by the DoD VPOC is reported to all local holders of the SIT. DEERS does not allow an update to a HIC when the HIC has a Verification Status Code of “unverified.”

C-97, October 19, 2017


DEERS Functions

45

1.13.4 SIT Add Cancellation

The MHS personnel may need to cancel a previously submitted “add” to the SIT. A cancel can only be done by the system that submitted the “add” and only if the “add” has not yet been verified by the DoD VPOC. DEERS cancels any OHI policy on the DEERS database associated with the cancelled “unverified” HIC. After the “add” request is cancelled, DEERS will provide the cancellations to all local holders of the SIT through the daily subscription process.

1.13.5 Validation Of HIC Information

Validation of a SIT update includes verifying the name, mailing address, and telephone number information for the HIC. In addition, the DoD VPOC assigns the HIC Status Code of “Standard” to validated HICs. If the DoD VPOC determines that the requested update is not correct, the DoD VPOC assigns a HIC Status Code of “rejected”. Rejected updates are returned to all local holders of the SIT.

If a SIT “add” or “update” request is rejected by the DoD VPOC, DEERS cancels any OHI policy on the DEERS database associated with the rejected HIC. All SIT additions and updates that are validated by the DoD VPOC are made available to all systems identified to DEERS as authorized holders of a local copy of the SIT.

1.13.6 Deactivation of a HIC

MHS organizations can request the DoD VPOC to deactivate any HIC on the SIT. DEERS does not allow a deactivation of a HIC with a HIC Status Code of “temporary” and/or a HIC Verification Status Code of “unverified”, until validated by the DoD VPOC. DEERS deactivates any OHI policy on the DEERS database associated with the deactivated HIC. DEERS reports the deactivation of the HIC to all local holders of the SIT.

1.14 OHI

OHI identifies non-DoD health insurance held by a beneficiary. The requirements for OHI are validated by the DHA UBO. OHI information includes:

• OHI policy and carrier• Policyholder• Type of coverage provided by the additional insurance policy• Employer information offering coverage, if applicable• Effective period of the policy

OHI transactions allow adding, updating, canceling, or viewing all OHI policy information. OHI policy updates can accompany enrollments or be performed alone. OHI information can be added to DEERS or updated on DEERS through multiple mechanisms. At the time of enrollment the contractor will determine the existence of OHI. The contractor can add or update minimal OHI data through the DOES application used by the contractor to enter enrollments into DEERS. In addition, DEERS will accept OHI updates from a claims processor through a system to system interface. Other MHS systems can add or update the OHI through the OHI/SIT Web application provided by DEERS. The presence of an OHI Policy discovered during routine claims processing shall be updated on DEERS within two business days of receipt of the required information.

C-97, October 19, 2017


DEERS Functions

46

The minimum information necessary to add OHI to a person record is:

• Policy Identifier (policy number)• OHI Effective Date• HIPAA Insurance Type Code• HIPAA Person Association Code• Claim Filing Code• OHI Coverage Type Code• OHI Coverage Payer Type Code• OHI Coverage Effective Date• OHI Policy Coverage Precedence Code• HIC Name or HIC ID• Health Insurance Coverage Type Code• Health Insurance Payer Type Code

Note: There are additional data elements necessary if the policy being added is a Group Employee policy.

If only the minimum required data is entered by the contractor, the contractor is required to fully develop the remaining OHI data necessary to complete the OHI record within 15 business days. Detailed requirements for the exchange of OHI information are contained in the “Technical Specifications for the Health Insurance Carriers Standard Insurance Table (SIT) and the Other Health Insurance (OHI) Carriers.” HIC information is validated against the SIT which maintains the valid insurance carrier information on DEERS.

DEERS requires the contractor to perform an OHI Inquiry before attempting to add or update an OHI policy. The MHS organizations are reliant on the individual beneficiary to provide accurate OHI information and DEERS is reliant on the MHS organizations for the accurate assignment of policy information to the individual record. DEERS is not the system of record for OHI information. Performing an OHI Inquiry on a person before adding or attempting to update an OHI policy helps ensure that the proper policy is updated based on the most current information or the person.

Examples of OHI coverages are:

• Comprehensive Medical coverage (Plans with multiple coverage types)• Medical coverage• Inpatient coverage• Outpatient coverage• Pharmacy coverage• Dental coverage• Long-term care coverage• Mental health coverage• Vision coverage• Partial hospitalization coverage• Skilled nursing care coverage

The default coverage will be Comprehensive Medical Coverage unless another of the above coverages is selected. The indication of Comprehensive Medical Coverage presumes medical coverage, inpatient coverage, outpatient coverage, and pharmacy coverage. The MCSC must

C-97, October 19, 2017


DEERS Functions

47

develop the OHI within 15 days but is not responsible for development of pharmacy. The pharmacy contractor is expected to develop pharmacy OHI.

In addition, each OHI policy carries a code indicating whether the policy is active, inactive, or deactivated. The deactivation of an OHI policy only occurs when the DoD VPOC at DHA deactivates the HIC on the SIT. DEERS retains OHI policy data for five years after an OHI policy expires or is deactivated or terminated.

1.14.1 OHI Policy Inquiry

1.14.1.1 Person Identification For OHI Policy Inquiry

OHI information is requested using the Patient ID, which is person-level identification. Person identification is used for the sponsor or family member. If the Patient ID is unknown, a coverage inquiry to DEERS can be performed to obtain it.

1.14.1.2 OHI Person Inquiry

The OHI data is by person. A system-to-system OHI inquiry is only for individual person requests. The OHI/SIT web application allows a family OHI inquiry. DEERS allows multiple OHI policies for each person. DEERS does not support an inquiry that shows all insured persons in a particular policy.

1.14.1.3 OHI Information

In addition, queries may be filtered by the HIC ID or the HIC Name, the OHI Policy ID or the OHI Coverage Type Code.

The HIC ID represents the identifier assigned to insurance carriers in the SIT provided by the DoD VPOC to DEERS. A requester can seek information on a specific coverage for a beneficiary by using the OHI Coverage Type Code in the OHI inquiry sent to DEERS, or for a specific insurance carrier by using the HIC Name. If a requestor is unsure about a specific OHI Policy, a time period should be specified for the inquiry to return the OHI Policy information in effect.

1.14.1.4 Information Returned In The OHI Inquiry Response

The DEERS response returns all OHI policies in effect during the specified time period for the beneficiary. OHI policies that are inactive or deactivated are returned if the OHI policies were in effect for any portion of the OHI inquiry period. If a specific coverage type is selected in the inquiry, only policies having that coverage type are included in the DEERS response.

The OHI/SIT web application will return OHI for a requested beneficiary or a sponsor and family. OHI is displayed one person at a time. If DEERS cannot find OHI information, DEERS does not return any OHI policies for the requested OHI inquiry period. When the Patient ID is included in the OHI inquiry, the Patient ID is returned in the response.

C-97, October 19, 2017


DEERS Functions

48

1.14.2 OHI Policy Add

DEERS allows the MHS and contractor systems to add an OHI policy for a person when information is presented to them. An OHI Inquiry should be done prior to updating an OHI policy. This ensures that updates are performed with the most current information. Following the OHI Inquiry, the OHI data can be added as necessary. OHI data can be added during an enrollment via the DOES application. OHI can be updated any time after enrollment through the web application provided by DEERS, or through the system to system interface. The presence of an OHI Policy discovered during routine claims processing shall be entered on DEERS within two business days. Within 15 business days, the contractor shall provide all OHI data not initially entered.

The fields required to add an OHI policy for a person are:

• Patient ID• HIC ID• OHI Policy ID• OHI Effective Calendar Date• HIPAA Insurance Type Code• HIPAA Person Association Code• OHI Claims Filing Code• OHI Policy Coverage Effective Date• OHI Policy Coverage Precedence Code• HIC Coverage Type Code• HIC Coverage Payer Type Code• OHI Coverage Type Code• OHI Carrier Coverage Payer Type Code

When the MHS organization enters the HIC ID DEERS will check it against the SIT for validation of the HIC information. If the HIC ID is not on the SIT, the MHS organization may add a new HIC and Coverage. If the insurance carrier is not known, the MHS organization shall use the carrier “Placeholder HIC ID”, which is the placeholder entry on the SIT. The HIC “Placeholder HIC ID” has an assigned HIC ID of “UNKVA0001” with a coverage type of “XM”. For “Placeholder HIC ID” OHI policies, the default coverage indicator is “comprehensive medical”; however, any coverage indicator can be assigned to it. The single placeholder OHI policy can be used to indicate that an OHI policy exists for a beneficiary. The enrolling entity or updating system is responsible for obtaining the complete OHI information and updating the placeholder OHI policy in DEERS within 15 business days.

Pharmacy placeholder policies will be developed by the pharmacy contractor, regardless of which organization created the placeholder. All other placeholder policies will be developed by the contractor, regardless of which organization created the placeholder. MHS organizations will not normally enter placeholder policies but would develop them if they created them.

A person can have multiple types of OHI coverage for one policy. For example, to add an OHI policy that covers medical and vision, two OHI coverage types, one for medical coverage and one for vision coverage, would be sent to DEERS.

A person can have multiple OHI policies. Multiple OHI policies may have the same or different HICs, and/or the same or different OHI policy effective periods.

C-97, October 19, 2017


DEERS Functions

49

The HIC ID, OHI Policy ID, and OHI Effective Date cannot be updated once an OHI policy has been added to DEERS. These attributes, along with the person identification, uniquely associate an OHI Policy to a person. All messages sent to DEERS are acknowledged as either accepted or rejected.

1.14.3 OHI Policy Update

DEERS allows the MHS systems to update existing OHI policy and coverage information for a person when policy change information is presented. Policy and coverage updates include modifications to existing policy and coverage information. Updates can also be used to terminate an existing policy or coverage, that is when the policy or coverage no longer applies to the person. An OHI Inquiry must be done prior to updating an OHI policy. Following the OHI Inquiry, the OHI data can be updated as necessary.

If OHI is identified during routine claims processing or other contract activities, the contractor shall send the OHI information to DEERS within two business days.

1.14.4 OHI Policy Cancellation

Cancellation of an OHI policy is used to remove a policy that was erroneously associated to a person. The OHI Policy Cancellation is not used to terminate an existing policy (see OHI Policy Update above). An OHI policy cancellation completely removes the policy. DEERS verifies that the cancellation is performed by the entity that added or last updated the OHI policy.

Note: Terminations do not remove the policy from a person’s record.

When canceling an OHI policy, an OHI Policy Inquiry must be done to verify the information necessary to perform a cancellation. Canceling an OHI policy requires the following data elements:

• Patient ID• HIC ID• OHI Policy ID• OHI Effective Calendar Date• OHI Expiration Calendar Date• OHI End Reason Code

1.15 Medicare Data

DEERS performs a match with the Centers for Medicare and Medicaid Services (CMS) to obtain Medicare data and incorporates the Medicare data into the DEERS database as OGPs entitlement information. This information includes Medicare Parts A, B, C, and D eligibility along with the effective dates. The match includes all potential Medicare-eligible beneficiaries.

DEERS sends Medicare Parts A and B information to the TDEFIC. The TDEFIC sends the information to the CMS Fiscal Intermediaries for identification of Medicare eligibles during claims adjudication.

- END -

C-97, October 19, 2017

ts08 change 97 published paper...

Documents