Attachment J-4 TMEP 2 Chapter 20 Clean Draft Copy 20260730.pdf

SECTION J – Attachment J-4

Chapter 20

TRICARE Operations Manual 6010.62-M, April 2021

TRICARE Medicare Eligible Program (TMEP)

Index

Section/Addendum Subject/Addendum Title

1 Administration

2 TRICARE Medicare Eligible Program (TMEP) Transition

3 Financial Administration

4 Provider Certifications And Credentialing

5 Provider Networks

6 Enrollment

7 Clinical Operations

8 Claims Processing Procedures

9 Records Management (RM)

10 Claims Adjustments and Recoupments

11 Communications and Customer Service (C and CS)

12 Appeals And Hearings

13 Program Integrity

14 Reporting Requirements

Chapter 20

Index

Section/Addendum Subject/Addendum Title

15 Market Directors/Military Medical Treatment Facilities (MTF) Directors and Contractor Interfaces

16 TRICARE Prime Remote (TPR) Program

17 Supplemental Health Care Program (SHCP)

18 Demonstrations, Pilot Projects, and Value-Based Initiatives

19 Health Insurance Portability and Accountability Act (HIPAA) of 1996

20 Other TMEP Requirements

21 TRICARE Alaska

22 Reserve Component (RC) Health Coverage Plans

23 TRICARE Pharmacy (TPharm)

24 TRICARE Overseas Program (TOP)

25 TRICARE Young Adult (TYA)

26 Continued Health Care Benefits Program (CHCBP)

27 Telehealth

28 Prescription Monitoring Program (PMP)

A TRICARE Medicare Eligible Program – TRICARE Operations Manual Exclusion List

Chapter 20 Section 1

Administration

In addition to the requirements below, all TRICARE requirements noted in Chapter 1 regarding administration shall apply to TMEP unless specifically changed, waived, or superseded by this section.

1.0 The information at Chapter 1, Section 1 is relevant to TMEP.

2.0 CONTRACT ADMINISTRATION AND INSTRUCTIONS

2.1 The contractor shall comply with the requirements in Chapter 1, Section 2.

2.2 The contractor shall submit a quarterly report outlining modifications and implementation dates in addition to the requirements in Chapter 1, Section 2, paragraph 2.0, in accordance with DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract.

3.0 TRICARE PROCESSING STANDARDS

3.1 The contractor shall comply with the requirements in Chapter 1, Section 3, except for those paragraphs listed in Addendum A.

3.2 The contractor shall track and report preauthorizations for Skilled Nursing Facilities (SNFs) separate from other preauthorizations noted in Chapter 7, Section 4 and TPM, Chapter 1, Section

6.1 in addition to the requirements in Chapter 1, Section 3, paragraph 5.1. The timeliness standards apply to the total volume of preauthorizations. See DD Form 1423, CDRL, located in Section J of the contract.

3.3 The contractor shall meet the following TED performance standards:

100% of initial submission vouchers/batches shall be submitted to DHA within five days of the date of the batch/voucher create date.

85% of all unprocessable vouchers/batches, including but not limited to, out-of-balance conditions and invalid header record information shall be corrected and returned to DHA within 20 days of the date the invalid data was transmitted to the contractor by DHA.

100% of unprocessable vouchers/batches shall be corrected and returned to DHA within 30 days of the date the invalid data was transmitted to the contractor by DHA.

99.5% of all vouchers/batches having TEDs (initial submissions, resubmissions, and adjustment/cancellation submissions) failing the edit system shall be corrected and resubmitted to DHA within 30 days after the errors and rejected TEDs were transmitted

Chapter 20 Section 1 to the contractor by DHA. Resubmissions shall include all TEDs rejected on the voucher/batch in question.

100% of all remaining vouchers/batches failing the TEDs edit system shall be corrected and resubmitted to DHA within 45 days after the errors and rejected TEDs were transmitted to the contractor by DHA. Resubmissions shall include TEDs rejected on the voucher/batch in question.

Following the start of services delivery, the contractor shall ensure that the following percentages of TEDS – including initial submissions, resubmissions, and adjustment or cancellation submissions successfully pass the DHA edit system within the following specified timelines:

- One through three months - 80%.

- Four through six months - 85%.

- Seven through nine months - 90%.

- Ten through 11 months - 95%.

- Twelve through 23 months - 96%.

- Month 24 through contract close - 97%.

Three months following the start of services delivery, the contractor shall ensure that no more than 2% of vouchers or batches are unprocessable due to issues including, but not limited to, the following: Out-of-balance; Invalid header conditions; Invalid record type;

Invalid contractor number; Invalid voucher/batch identifier; Invalid voucher/batch date;

Invalid sequence number; Invalid resubmission number; Invalid period begin date;

Invalid period end date; Invalid total number of records; and Invalid total amount paid.

4.0 MANAGEMENT

4.1 The contractor shall comply with the requirements in Chapter 1, Section 4, except for those

4.2 The contractor shall submit a weekly claims aging by status location report. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the contract.

5.0 COMPLIANCE WITH FEDERAL STATUTES

5.1 The contractor shall comply with the requirements in Chapter 1, Section 5.

6.0 LEGAL MATTERS

Chapter 20 Section 1

6.1 The contractor shall comply with the requirements in Chapter 1, Section 6.

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Chapter 20

Transitions

Section 2

In addition to the requirements below, all TRICARE requirements noted in Chapter 2 regarding transitions shall apply to TMEP unless specifically changed, waived or superseded by this section (as indicated below).

1.0 Management And Administration

1.1 The contractor shall comply with the requirements in Chapter 2, Section 1 except for those

1.2 Other TMEP Management and Administration Transition Requirements

1.2.1 Memorandum of Understanding (MOU) with TRICARE Contractors

1.2.1.1 The incoming contractor shall execute an MOU with the other TRICARE contractors (Managed Care Support, TRICARE Overseas, Pharmacy and Competitive Plans Demonstration (CPD) 60 days prior to the start of services delivery.

1.2.1.1.1 The incoming contractor shall ensure the MOU includes, but is not limited to, provider file update coordination, beneficiary history transfers, customer service coordination and marketing/education coordination.

1.2.1.1.2 For reporting requirements, see DD Form 1423 Contract Data Requirements List (CDRL), located in Section J of the contract.

1.2.1.2 The incoming contractor shall execute an MOU with the TRICARE Claims Review Contractor for safe and secure electronic transmittal of claims processing documentation/information 60 days prior to the start of services delivery. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the contract.

1.2.2 Bank Accounts

1.2.2.1 The incoming contractor shall establish bank accounts in accordance with Section G of the contract, not later than 60 days prior to the start of services delivery.

2.0 Systems Development

2.1 The contractor shall comply with the requirements in Chapter 2, Section 2 except those

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Transitions

2.2 The requirements in paragraph 4.2 to communicate, collaborate, and coordinate with the Government Designated Authority no later than 30 days of contract award do not apply except with respect to scheduling the following interface meetings:

System Integration Interface Meeting (SIIM) TRICARE Encounter Data (TED) Integration Interface Meeting (TIIM) E-Commerce System Interface Meeting

3.0 CRITICAL PROCESSES (CPs) – PROVIDER NETWORKS

3.1 The TRICARE requirements in Chapter 2, Section 3 regarding network development do not apply to TMEP.

3.1.1 The outgoing contractor shall provide all provider participation agreements to the incoming contractor 60 days prior to the start of the incoming contractor’s services delivery date.

3.1.2 The outgoing contractor shall provide all prior authorizations which cover from the start of services delivery under the new contract or are for care potentially occurring during the incoming contractor’s services delivery period. The outgoing and incoming contractor shall mutually agree to the date and schedule for transfer of this information.

4.0 CRITICAL PROCESSES (CPs) – ENROLLMENT

4.1 The TRICARE transition requirements in Chapter 2, Section 4 regarding enrollment do not apply to TMEP.

5.0 CRITICAL PROCESSES (CPs) – CUSTOMER SERVICE

5.1 The contractor shall comply with the requirements in Chapter 2, Section 5 except for those

5.2 TMEP Mailing Requirements

5.2.1. The incoming contractor shall execute TMEP mailing requirements as follows:

5.2.1.1 The incoming contractor shall deliver a proposed mailer for Congressional offices to the Government for review no later than 90 days prior to the start of services delivery.

5.2.1.2 The incoming contractor shall send the approved Government mailer to Congressional offices no later than 45 days prior to the start of service delivery.

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Transitions

5.2.1.3 The incoming contractor shall mail an introductory letter to all beneficiary households who had claims activity in the previous 12 months no later than 10 days prior to the start of services delivery.

5.2.1.4 The incoming contractor shall provide the TFL handbook to beneficiaries via e-mail or as a download from the contractor’s website. Only one printed (hardcopy) TRICARE handbook shall be mailed per household, when specifically requested by a beneficiary.

6.0 CRITICAL PROCESSES (CPs) – RECORDS MANAGEMENT

6.1 The TRICARE transition requirements in Chapter 2, Section 6 regarding records management apply to TMEP except for those paragraphs listed in Addendum A.

7.0 CRITICAL PROCESSES (CPs) – REFERRAL MANAGEMENT (RM)

7.1 The TRICARE transition requirements in Chapter 2, Section 7 regarding referral management do not apply to TMEP.

8.0 CRITICAL PROCESSES (CPs) – CLAIMS PROCESSING

8.1 The TRICARE transition requirements in Chapter 2, Section 8 regarding claims processing apply to TMEP except those paragraphs listed in Addendum A.

8.2 Dual Operations

8.2.1 The requirements in paragraph 3.2 are superseded as follows:

8.2.1.1 The outgoing contractor shall maintain toll-free lines and web-based customer service capabilities, accessible to the public during the first 90 days of dual operations in order to properly respond to inquiries related to claims processed for services incurred during the period of their liability. Beneficiary inquiry lines shall continue to be staffed as defined in the contract.

8.3 Final Processing of Outgoing Contractor

8.3.1 The requirements in paragraphs 4.1 through 4.1.2 are superseded as follows:

8.3.1.1 The outgoing contractor shall process all claims, including adjustments, received during its period of services delivery.

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Transitions

8.3.1.2 The outgoing contractor shall complete processing these claims within 90 days following the start of the incoming contractor’s services delivery.

8.3.1.3 The outgoing contractor shall meet all contract standards for these claims.

8.4 Claims Processing PRV

8.4.1 The negotiated network discount rates discussed in paragraph 5.1.4 do not apply to TMEP.

8.4.2 The requirement for validation of the contractor’s claims processing system to accurately and appropriately apply referrals discussed in paragraph 5.1.6 does not apply to TMEP.

8.5 Other TMEP Claims Processing Transitions Requirements:

8.5.1 The incoming contractor shall process claims received on or after the start of services delivery.

8.5.2 Medicare Crossover Claims

8.5.2.1 The incoming contractor shall establish a trading partner agreement with the Medicare Benefits Coordinator Recovery Contractor (BCRC) to receive claims no later than 120 days prior to the start of the services delivery. For reporting requirements, see DD Form 1423 Contract Data Requirements List (CDRL), located in Section J of the contract.

8.5.2.2 The incoming contractor shall demonstrate to DHA successful receipt and testing of electronic claims batches from Medicare for processing no later than 90 days prior to the start of services delivery.

8.5.2.3 The outgoing contractor shall terminate their trading partner agreement with the BCRC to ensure crossover claims conclude with the end of the period of performance.

9.0 CRITICAL PROCESSES (CPs) – CLINICAL OPERATIONS

9.1 All TRICARE transition requirements in Chapter 2, Section 9 regarding Clinical Operations do not apply to TMEP.

9.2 The incoming contractor shall honor outstanding authorizations issued by the outgoing contractor, covering care through 60 days after the start of services delivery under the incoming contract, in accordance with the outgoing contractor’s existing practices and protocols, within the scope of the TRICARE program and applicable statues, regulations, and manual requirements.

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10.0 OTHER REQUIREMENTS

10.1 The transition requirements in Chapter 2, Section 10, Other Requirements apply to TMEP except those paragraphs listed in Addendum A.

10.2 Other TMEP Transition Requirements:

10.2.1 The incoming contractor shall continue to monitor and manage outstanding Veteran’s Affairs overpayments in accordance with Chapter 10, Section 3.

10.2.2 The incoming contractor shall assume responsibility for processing new reconsiderations received on and after the start of services delivery.

10.2.3 Explanation of Benefits (EOB) Record Data Retention and Transmittal

10.2.3.1 The outgoing contractor shall, provide either a full set of electronic records covering the current and two prior years, or, at the Contracting Officer’s discretion, provide the data and necessary program to reproduce the EOB in acceptable form and transfer such data and programs to the incoming contractor or to DHA.

10.2.3.2 The Government will be the final authority in determining the form and acceptability of the data.

10.2.3.3 See Chapters 2 and 9 for additional information on transitioning electronic EOBs.

10.2.4 Transfer of Beneficiary Information

10.2.4.1 The outgoing contractor shall provide a list of all TMEP special programs Extended Health Care Option (ECHO), Individual Case Management Program for Persons with Extraordinary Conditions (ICMP-PEC), etc. and Laboratory Developed Test (LDT) Demonstration beneficiaries to the incoming contractor.

Chapter 20 Section 3

Financial Administration

In addition to the requirements below, all TRICARE requirements regarding financial administration shall apply to TMEP unless specifically changed, waived, or superseded by this

1.0 GENERAL

1.1 The provisions of Chapter 3, Section 1 apply to TMEP.

1.2 The contractor shall comply with the Financial Administration non-financially underwritten funds requirements in Chapter 3.

2.0 PAYMENTS TO BENEFICIARIES/PROVIDERS

2.1 The contractor shall comply with the requirements in Chapter 3, Section 2. Chapter 3, Section 2, paragraphs 2.0 through 2.1 Electronic Funds Transfer (EFT) are superseded as described in paragraph 2.2.

2.2 The contractor shall follow the contract requirements regarding provider Electronic Funds Transfer (EFT). The contractor shall not make EFT payments to beneficiaries.

3.0 CLAIM REFUND AND COLLECTION PROCEDURES

3.1 The contractor shall comply with the requirements in Chapter 3, Section 3, except for those

4.0 STALE DATED, VOIDED, OR RETURNED CHECKS

4.1 The contractor shall comply with the requirements in Chapter 3, Section 4.

5.0 QUARTERLY AND ANNUAL CLAIMS PAYMENT AND DATA ACCURACY

REVIEWS

5.1 The contractor shall comply with the requirements in Chapter 3, Section 5 except for those

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Chapter 20 Section 4

Provider Certifications And Credentialing

Except as specified below, the contractor shall comply with all TRICARE requirements in Chapter 4 regarding provider certification unless specifically changed, waived, or superseded by this section.

1.0 GENERAL

1.1 The provisions regarding credentialing, Market/Military Medical Treatment Facility (MTF), Clinical Support Agreements (CSAs), and network provider requirements are not applicable to

TMEP.

Chapter 20

Provider Networks

Section 5

Except as specified below the TRICARE requirements set forth in Chapter 5 regarding network development are not applicable to TMEP.

1.0 PROVIDER NETWORKS

1.1 The contractor shall comply with the requirements listed in Chapter 5, Section 1, paragraphs

9.0 and 10.0 for services provided to a TRICARE/Medicare dual eligible beneficiary by a network provider when TRICARE is primary payer.

Chapter 20

Enrollment

Section 6

The TRICARE requirements set forth in Chapter 6 regarding enrollment do not apply. However, the contractor shall be aware of the enrollment procedures in Chapter 6 in order to appropriately handle customer service inquiries and process claims appropriately.

Chapter 20

Clinical Operations

Section 7

In addition to the requirements below, TRICARE requirements in Chapter 7 regarding clinical operations shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.0 MEDICAL MANAGEMENT (MM)

1.1 The requirements in Chapter 7, Section 1 do not apply to TMEP.

2.0 CASE MANAGEMENT (CM)

2.1 The requirements in Chapter 7, Section 2 do not apply to TMEP except:

2.2 MEDICARE/TRICARE dual eligible beneficiaries are not eligible for the contractor’s CM program, except for care under the Custodial Care Transitional Policy (CCTP) and Individual Case Management Program For Persons With Extraordinary Conditions (ICMP-PEC) programs.

3.0 POPULATION HEALTH (PH) CARE

3.1 The requirements in Chapter 7, Section 3 are not applicable to TMEP.

4.0 UTILIZATION MANAGEMENT

4.1 The contractor shall comply with the requirements in Chapter 7, Section 4 when TRICARE is primary payer, except for those paragraphs listed in Addendum A.

5.0 REFERRAL MANAGEMENT (RM)

5.1 The requirements in Chapter 7, Section 5 are not applicable to TMEP.

6.0 CLINICAL QUALITY MANAGEMENT PROGRAM (CQMP)

6.1 The provisions of Chapter 7, Section 6 are not applicable to TMEP.

7.0 CONTRACTOR RELATIONSHIPS WITH THE MILITARY HEALTH SYSTEM

(MHS) TRICARE QUALITY MONITORING (TQMC) CONTRACTOR

7.1 The contractor shall comply with the requirements in Chapter 7, Section 7 in instances where records are requested. The Government does not anticipate routine record requests from TMEP.

Chapter 20

Claims Processing Procedures

Section 8

In addition to the requirements below, all TRICARE requirements noted in Chapter 8 regarding claims processing shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.1 The contractor shall comply with the requirements in Chapter 8, Section 1.

1.2 In general, TRICARE pays secondary to Medicare and any other coverage.

1.3 The contractor shall use special double coverage procedures for all claims for beneficiaries who are eligible for Medicare, including active duty dependents who are age 65 and over as well as those beneficiaries under age 65 who are eligible for Medicare for any reason. For specific instructions, refer to the TRM, Chapter 4, Section 4.

2.0 JURISDICTION

2.1 The contractor shall comply with the requirements in Chapter 8, Section 2 except for:

2.2 The contractor shall comply with the TMEP contract provider certification requirements instead of the requirements in Chapter 8, Section 2, paragraphs 5.0.

3.0 CLAIMS FILING DEADLINE

3.1 The contractor shall comply with the requirements in Chapter 8, Section 3 except those

3.2 The contractor shall date stamp all claims with an Internal Control Number (ICN).

3.2.1 The contractor shall count the actual date of receipt as day one.

3.2.2 The ICN uniquely identifies each claim, includes the actual date received in the contractor’s custody, and permits aging and counting of the claim for workload reporting purposes at specific system locations at any time during its processing.

3.2.3 The contractor shall ensure the actual date of receipt is entered into the ICN and all required claims aging and inventory controls are applied for paperless claims.

4.0 SIGNATURE REQUIREMENTS

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Claims Processing Procedures

4.1 The contractor shall comply with the requirements in Chapter 8, Section 4, except for those

4.2 Electronic “crossover” claims received from Medicare after Medicare completes its claims processing do not need a beneficiary or provider signature. For paper claims, when TRICARE is secondary payer to Medicare and a Medicare Explanation of Benefits (EOB) is attached, the TMEP contractor does not need to develop for provider or beneficiary signature.

5.0 TRICARE PRIME AND TRICARE SELECT

REFERRALS/PREAUTHORIZATION/AUTHORIZATIONS

5.1 The contractor shall comply with the requirements in Chapter 8, Section 5, except for those

5.2 TMEP Prime-enrolled beneficiaries, to the extent practicable, should follow all TRICARE Prime requirements for Primary Care Manager (PCM) assignment, referrals and authorizations.

5.2.1 The contractor is not responsible for obtaining or verifying a TMEP Prime enrolled beneficiary has a referral for care not provided by their PCM.

5.2.2 The contractor shall not subject TMEP Prime enrolled beneficiaries to Point of Service cost-sharing.

5.3 TMEP beneficiaries can contact a regional Managed Care Support Contractor (MCSC) for assistance in locating a network provider.

5.3.1 The MSCS shall provide the TRICARE/Medicare beneficiary with the name, telephone number, and address of network providers of the appropriate clinical specialty located within the beneficiary’s geographic area.

5.3.2 The MCSC is not required to make appointments with network providers.

5.4 The contractor shall issue notification of preauthorization when requested for primary pay services in accordance with Chapter 7, Section 2 and TPM, Chapter 1, Section 7.1.

5.4.1 The contractor may make notification in writing by letter, or on a form developed by the contractor.

5.4.2 These forms and letters are all referred to as TRICARE authorization forms.

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Claims Processing Procedures

6.0 CLAIM DEVELOPMENT

6.1 The contractor shall comply with the requirements in Chapter 8, Section 6 except for paragraph 9.12.

6.2 TMEP claims processed after Medicare, do not need to be developed to the individual provider level for home health or group practice claims.

6.3 Civilian claims for TMEP beneficiaries shall be processed by Medicare first without consideration of the Supplemental Health Care Program (SHCP).

6.4 The contractor shall not process claims from any civilian provider in a Market/Military Medical Treatment Facility (MTF) under the Resource Sharing or Clinical Support Agreements (CSA) programs.

7.0 APPLICATION OF DEDUCTIBLE AND COST-SHARING

7.1 The contractor shall comply with the requirements in Chapter 8, Section 7.

7.2 The contractor shall apply TRICARE cost-shares and deductible when TRICARE is the primary payer on TMEP beneficiary claims. The contractor shall base TMEP beneficiary cost-shares on the following when TRICARE is the primary payer:

7.2.1 If the services were received by a TRICARE Prime enrollee (as indicated in Defense Enrollment Eligibility Reporting System (DEERS)), the contractor shall calculate the Prime copayments applicable on the date services were received.

7.2.2 For a beneficiary who is covered by TRICARE Standard and receives care from a known network provider (e.g., Veterans Health Administration (VHA) medical facility) TRICARE Extra cost-shares shall be applied to services received prior to January 1, 2018; if the provider is not a known network provider, the TRICARE Standard cost-share shall apply.

7.2.3 For a beneficiary who is a TRICARE Select enrollee, services received from a known network provider on or after January 1, 2018, the contractor shall apply the TRICARE Select network copayments; if the provider is not a known network provider, the contractor shall apply the TRICARE Select out-of-network cost-share.

7.2.4 For a TRICARE For Life (TFL) beneficiary who is not a TRICARE Prime enrollee, the contractor shall apply standard copays for services received on or after January 1, 2018, (see TRM, Chapter 2, Section 1) as if TRICARE Standard were still being implemented.

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Claims Processing Procedures

7.3 The contractor shall calculate the annual catastrophic loss protection based solely on the actual beneficiary out-of-pocket liability remaining after TRICARE payments have been applied.

8.0 EOB

8.1 The contractor shall comply with the requirements in Chapter 8, Section 8.

8.2 The requirements in Chapter 8, Section 8, paragraph 1.0 through 1.3 are superseded by the following:

8.2.1 The contractor shall issue and mail an appropriate and easily understood EOB to the beneficiary (parent/guardian for minors or incompetents) that appropriately describes the action taken for each clam processed to a final determination.

8.2.2 The contractor shall mail a hard copy EOB, unless the beneficiary has provided written agreement to receive the EOB electronically.

8.2.3 The contractor may elect to provide a monthly summary EOB in lieu of an EOB for each individual claim processed by the contractor.

8.2.4 The contractor shall include instructions regarding how to read the EOB in the mailed

EOB.

8.2.5 The contractor shall make a copy of the EOB electronically accessible and printable to the beneficiary in the contractor’s portal regardless of which notification option the beneficiary chooses.

8.3 The contractor shall comply with the requirements in Chapter 8, Section 8, paragraphs

7.0 and 8.0. The contractor shall provide the information required on the EOB in a clear, easily understood layout.

9.0 DUPLICATE PAYMENT PREVENTION

9.1 The contractor shall comply with the requirements in Chapter 8, Section 9.

10.0 ADDITIONAL REQUIREMENTS/EXCEPTIONS

10.1 The contractor is not required to have the claims auditing software described in the TRM, Chapter 1, Section 3.

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Claims Processing Procedures

Chapter 20

Records Management (RM)

Section 9

All TRICARE requirements noted in Chapter 9 regarding records management shall apply unless specifically changed, waived, or superseded by this section.

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Chapter 20

Claims Adjustments and Recoupments

Section 10

Except as specified below, all TRICARE requirements noted in Chapter 10 regarding claims adjustments and recoupments shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.1 The contractor shall comply with the requirements of Chapter 10 except for Section 2 related to Overpayments Recovery – Financially Underwritten Funds.

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Chapter 20

Communications and Customer Service (C&CS)

Section 11

In addition to the requirements below, all TRICARE requirements noted in Chapter 11 regarding Communications And Customer Service shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.0 EDUCATION REQUIREMENTS

1.1 The contractor shall comply with the requirements in Chapter 11, Section 1, except for paragraph 2.2.

1.2 The contractor shall submit an education plan, outlining how it intends to conduct targeted- TMEP education for beneficiaries and providers.

1.2.1 The Government will review the plan and provide feedback for recommended changes through the Program Office and DHA Communications.

1.2.2 Details for submission of the Education Plan are identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract.

1.2.3 The contractor shall submit a yearly exhibition plan for approval if the contractor intends to exhibit at conferences.

2.0 GOVERNMENT STAFF AND BENEFICIARY EDUCATION

2.1 The contractor shall comply with the requirements in Chapter 11, Section 2 except for those

3.0 BENEFICIARY, CONGRESSIONAL, MEDIA, BENEFICIARY COUNSELING AND

ASSISTANCE COORDINATOR (BCAC), AND DEBT COLLECTION ASSISTANCE

OFFICER (DCAO) RELATIONS

3.1 The contractor shall comply with the requirements in Chapter 11, Section 3.

4.0 INQUIRY SERVICE DEPARTMENT – GENERAL

4.1 The contractor shall comply with the requirements in Chapter 11, Section 4, except for those

5.0 CORRESPONDENCE CONTROL, PROCESSING AND APPRAISAL

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Communications and Customer Service (C&CS)

5.1 The contractor shall comply with the requirements in Chapter 11, Section 5 except for those

6.0 DEFENSE HEALTH AGENCY (DHA) COMMUNICATIONS

6.1 The contractor shall comply with the requirements in Chapter 11, Section 6 except for those

7.0 TELEPHONE INQUIRIES

7.1 The contractor shall comply with the requirements in Chapter 11, Section 7, except those paragraphs listed in Addendum A and with the changes noted below.

7.1.1 The requirements in Chapter 11, Section 7, paragraphs 1.1 through 1.6, are superseded by the following:

7.1.2 The TMEP contractor shall provide a U.S. toll-free telephone inquiry system 24-hours, seven days a week, for both providers and beneficiary callers.

7.1.3 The contractor shall fully and continuously staff the system and provide beneficiary callers with the option to speak with a customer service representative by selecting 0, between the hours of 6:00 am and 11:00 pm EST (except weekends and federal holidays).

7.1.3.1 During those hours, after a caller has identified as a beneficiary, the caller must have the immediate ability to select 0 to speak to a customer service representative; providers may attempt self-service options within the Interactive Voice Response (IVR) prior to selecting the option to speak to a customer service representative.

7.1.4 The contractor may use an (IVR) unit to meet the telephone access requirements outside of the hours listed in above paragraph 7.1.3.

7.2 The contractor shall comply with the requirements in paragraphs 3.0 through 3.4, with the following exceptions:

7.2.1 The noted normal business hours in above paragraph 7.1.3 apply to TMEP.

7.2.2 -The requirements in paragraphs 3.2.1.1 and 3.2.1.2 to be staffed and operational on federal holidays which fall during open season do not apply to TMEP.

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7.3 The contractor shall comply with the requirements in paragraph 3.2.1.3.4 with the exception of providing network provider information.

7.4 In addition to the requirements in paragraph 6 the contractor shall collect and report customer support data, operational data and analytics in accordance with DD Form 1423, CDRL, located in Section J of the contract.

7.5 The contractor shall comply with the requirements in paragraph 6.2 with the exception of providing access to information for staff outside the Market/Military Medical Treatment Facility.

8.0 GRIEVANCES AND GRIEVANCES PROCESSING

8.1 The contractor shall comply with the requirements in Chapter 11, Section 8, except for those

8.1.1 The contractor shall comply with the requirements in paragraph 2.1.1. The contractor shall refer quality of care issues to Centers for Medicare & Medicaid Services (CMS) when CMS is the primary payer.

9.0 COLLECTION ACTIONS AGAINST BENEFICIARIES

The contractor shall comply with the requirements in Chapter 11, Section 9, except for those

10.0 TRICARE LOGO

10.1 The contractor shall comply with the requirements in Chapter 11, Addendum A. The link to the TRICARE Logo Style Guide is at https://tricare.mil/trademark.

Chapter 20

Appeals and Hearings

Section 12

In addition to the requirements below, all TRICARE requirements noted in Chapter 12 regarding appeals and hearings shall apply unless specifically changed, waived, or superseded by this

1.1 Appeals of Skilled Nursing Facility (SNF) preauthorizations follow concurrent review procedures.

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Program Integrity

Section 13

Except as specified below, all TRICARE requirements in Chapter 13 regarding program integrity shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.1 The contractor shall comply with the requirements in Chapter 13, Section 1 except for those

2.0 ANTI-FRAUD CONTROLS AND CONTRACTOR ACTIONS

2.1 The contractor shall comply with the requirements in Chapter 13, Section 2 except for those

2.2 The requirements related to predictive analytics software in paragraphs 2.2 and 2.7.3, and requirements related to network providers in paragraph 3.1 do not apply.

3.0 STATISTICAL SAMPLING AND AUDITS

3.1 The contractor shall comply with the requirements in Chapter 13, Section 3 except for those

4.0 CASE DEVELOPMENT

4.1 The contractor shall comply with the requirements in Chapter 13, Section 4.

5.0 PROVIDER EXCLUSIONS, TERMINATIONS, AND SUSPENSION OF CLAIMS

PROCESSING

5.1 The contractor shall comply with requirements in Chapter 13, Section 5 except for

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Reporting Requirements

Section 14

All TRICARE requirements noted in Chapter 14 regarding Reporting Requirements shall apply unless specifically changed, waived, or superseded by this section.

Chapter 20 Section 15

Markets/Military Medical Treatment Facilities (MTF) and Contractor Interfaces

The TRICARE requirements set forth in Chapter 15 related to markets/MTFs and contractor interfaces are not applicable.

Chapter 20

TRICARE Prime Remote (TPR) Program

Section 16

Except as specified below, TRICARE requirements noted in Chapter 16 regarding TPR shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.1 Chapter 16, Sections 1 through 5 do not apply.

1.2 The contractor shall comply with the requirements in Chapter 16, Section 6.

1.3 The contractor shall process TPR claims in accordance with the TRM, Chapter 4, Section 4.

The contractor shall perform customer service functions to the same extent as for other TMEP beneficiaries.

1.4 The contractor shall comply with the requirements in paragraphs 12.0, 13.0, and 14.0.

1.4.1 The provision in paragraph 12.3 for the contractor to pay network providers at the negotiated rate does not apply.

Chapter 20

Supplemental Health Care Program (SHCP)

Section 17

The TRICARE requirements set forth in Chapter 17 regarding the SHCP are not applicable.

Chapter 20

Demonstrations, Pilot Projects, and Value-Based Initiatives

Section 18

Except as specified below, all TRICARE requirements noted in Chapter 18 regarding Demonstrations and Pilot Projects shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.0 GENERAL

1.1 The contractor shall comply with the requirements in Chapter 18 except for those sections listed in Addendum A.

1.2 The requirements in Chapter 18, Section 3, Department of Defense (DoD) Comprehensive Autism Care Demonstration (ACD) - The regional contractors manage the care for beneficiaries receiving ACD services Extended Care Health Option (ECHO) for Active Duty Family Members (ADFMs) which may include TRICARE and Medicare eligible beneficiaries. The contractor shall process claims for beneficiaries authorized benefits under the ACD that are within the TMEP scope. The regional contractor shall share the authorizations for TMEP beneficiaries with the contractor as established in the Memorandum of Understanding (MOU).

The contractor shall contact the appropriate regional contractor regarding claims with ACD services without an authorization.

Chapter 20

Health Insurance Portability and Accountability Act (HIPAA)

Section 19

All TRICARE requirements noted in Chapter 19 regarding HIPAA shall apply unless

Chapter 20

Other TMEP Requirements

Section 20

1.1 The TMEP encompasses the processing of all TRICARE claims for services rendered within the United States (US) and the District of Columbia, as well as Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Mariana islands, to individuals who have dual eligibility under both TRICARE and Medicare.

2.0 DUAL ELIGIBLES

2.1 There are six general categories of beneficiaries who have dual eligibility under both TRICARE and Medicare and whose claims the contractor shall process under TMEP:

2.2 TRICARE beneficiaries, who are 65 or older and who are entitled to premium-free Medicare Part A and who have Medicare Part B;

2.3 TRICARE beneficiaries who are 65 or older and who are not entitled to premium-free Medicare Part A on their own record or the record of their current, former, or deceased spouse but have Medicare Part B;

2.4 Active Duty Family Members (ADFMs) who are 65 or older and who are entitled to premium-free Medicare Part A only;

2.5 TRICARE beneficiaries who are entitled to premium-free Medicare Part A because of a disability or End Stage Renal Disease (ESRD) and who have Medicare Part B;

2.6 ADFMs who have a disability or ESRD and are entitled to premium-free Medicare Part A only (while those with Medicare based on disability get a special enrollment period and therefore are not subject to the Part B premium surcharge, the special enrollment period does not apply to those with ESRD. ESRD patients who do not keep Medicare Part B when first eligible may have to pay a surcharge of 10% for each 12 month period that they could have enrolled in Part B but did not); and

2.7 TRICARE beneficiaries, who are entitled to premium-free Medicare Part A because of a disability, where Social Security Disability Insurance (SSDI) is awarded on appeal. These beneficiaries who have a Medicare Part B effective date of October 1, 2009, or later and a six-month minimum gap between their Medicare Part A and Medicare Part B effective dates will remain TRICARE eligible for the period where only Part A was effective. If a beneficiary declines Part B coverage, he or she will be ineligible for TRICARE from the original Part B effective date until Part B coverage is established.

Chapter 20

TRICARE Alaska

Section 21

The TRICARE requirements set forth in Chapter 21 regarding TRICARE Alaska are not applicable.

Chapter 20

Reserve Component (RC) Health Coverage Plans

Section 22

In addition to the requirements below, all TRICARE requirements noted in Chapter 22 regarding RC Health Coverage Plans shall apply to TMEP unless specifically changed, waived, or superseded by this section (as indicated below).

1.0 TRICARE RESERVE SELECT (TRS) AND TRICARE RETIRED RESERVE (TRR)

1.1 The enrollment and collection of premiums requirements in Chapter 22, Section 1, do not apply.

1.2 The contractor shall process claims in accordance with TRM, Chapter 4, Section 4.

1.3 The contractor shall perform customer service functions to the same extent as other TMEP beneficiaries and meet the requirements of Section 11.

Chapter 20

TRICARE Pharmacy (TPharm)

Section 23

The TRICARE requirements set forth in Chapter 23 regarding TPharm are not applicable.

Chapter 20

TRICARE Overseas Program (TOP)

Section 24

The TRICARE requirements set forth in Chapter 24 regarding TOP are not applicable.

Chapter 20

TRICARE Young Adult (TYA) Program

Section 25

In addition to the requirements below, all TRICARE requirements in Chapter 25 regarding TYA shall apply unless specifically changed, waived, or superseded by this section (as indicated below).

1.1 The enrollment and collection of premiums requirements in Chapter 25, Section 1 do not apply.

1.2 The contractor shall process claims in accordance with TRM, Chapter 4, Section 4.

1.3 The contractor shall perform customer service functions to the same extent as other TMEP beneficiaries and meet the requirements of Section 11.

Chapter 20

Continued Health Care Benefit Program (CHCBP)

Section 26

The TRICARE requirements set forth in Chapter 26 regarding CHCBP are not applicable.

Chapter 20

Telehealth

Section 27

The TRICARE requirements set forth in Chapter 27 regarding telehealth are not applicable.

Chapter 20

Prescription Monitoring Program (PMP)

Section 28

All TRICARE requirements noted in Chapter 28 regarding the PMP shall apply unless

Chapter 18, Addendum A

TRICARE Medicare Eligible Program - Exclusion List

TRICARE Medicare Eligible Program

Chapter 20 Addendum A

TRICARE Medicare Eligible Program - TRICARE Operations Manual Exclusion List

Chapter and Section titles and numbers listed below are current as of April 29, 2026. The Addendum may be updated by the Government if there are significant changes to the TRICARE Manual’s structure.

Legend: None means no exceptions to the Section.

Notes in the Exceptions column are specific exclusions or changes to that Section/paragraph.

TRICARE OPERATIONS MANUAL (TOM) 6010.62-M

CHAPTER SECTION TITLE EXCEPTIONS

1 Administration

1 Organization Of The Defense Health Agency

(DHA)

None

2 Contract Administration and Instructions None 3 TRICARE Processing Standards Paragraphs 2.0-2.7, 3.2.1 Bullet #7, 3.2.5, 4.0-4.2, 5.1 Bullet #3, 5.2-5.2.2.3 and 7.1

4 Management Paragraphs 2.3-2.3.2

5 Compliance With Federal Statutes None 6 Legal Matters None 2 Transitions

1 Management And Administration Paragraphs 2.0-2.6, 3.0.-3.10, 5.6, 6.0, 7.0-Enrollments, Provider Networks, Referral Management, and Medical Management Performance Readiness Validation

2 Systems Development Paragraph 4.2-Bullet #3, #4, #5 and #7, paragraphs 5.0-5.4 and 12.0-12.5 3 Critical Processes (CPs) - Provider Networks Not applicable except as stated in

Chapter 20, Sec 3 para 4.1.1 and 4.1.2 4 Critical Processes (CPs) - Enrollment Not Applicable 5 Critical Processes (CPs) - Customer Service Paragraphs 1.1, 3.0 through 3.4, and 4.0-

4.2.

6 Critical Processes (CPs) - Records

Management 4th and 6th bullet in paragraph 2.4 - Enrolled Beneficiary and Primary Care Manager (PCM) Assignment Files and Case Management (CM)/Care Coordination Files and Case Management (CM)/Care Coordination Files. 4th bullet in paragraph 3.4 – Enrolled Beneficiary and Primary Care Manager (PCM) Assignment Files.

7 Critical Processes (CPs) - Referral Management

Not Applicable

8 Critical Processes (CPs) - Claims Processing Paragraphs 1.2, 1.3, 3.5, 3.7-3.7.2, 4.2, 4.3, 5.1.5-5.1.5.2, and 5.1.7

9 Critical Processes (CPs) – Clinical Operations Not applicable-except as stated in Chapter 20, Section 2 paragraph 9.2.

10 Other Requirements Paragraphs 7.0-7.4 3 Financial Administration

1 General None 2 Payments To Beneficiaries/Providers None 3 Claim Refund And Collection Procedures Paragraphs 2.1-2.1.2.3 4 Lost, Stolen, Stale-Dated, Damaged, Misdirected, or Returned Payments None

5 Quarterly and Annual Claims Payment and Data Accuracy Reviews

4th bullet in paragraph 1.7, 5th and 7th bullet in paragraph 2.1.4

4 Provider Certification and Credentialing 1 General None except as stated in paragraph

1.1

2 Figures None 5 Provider Networks

Network Development Not applicable

6 Enrollment 1 TRICARE Enrollment Processing Not applicable

2 TRICARE Prime and TRICARE Select Enrollment Portability

Not applicable

3 Split Enrollment Not Applicable 4 TRICARE Plus Not Applicable 7 Clinical Operations

1 Medical Management (MM) Not Applicable

2 Case Management (CM) Not Applicable except as stated in Ch 20 Sec 7 para 2.2

3 Population Health (PH) Care Not Applicable 4 Utilization Management (UM) Paragraphs 1.4, 4.6, 4.8, 5.0-5.4, 6.1.5, 6.1.6, 6.2-6.3, 9.0-9.5, 11.0-11.3, 12.2, 13.0-13.4.3 and 14.0

5 Referral Management (RM) Not Applicable

6 Clinical Quality Management Program

(CQMP)

Not Applicable

7 Contractor Relationship with the Military Health System (MHS) TRICARE Quality Monitoring Contract (TQMC) Contractor

None

A An Important Message from TRICARE None B Hospital Issued Notices of Noncoverage None C Hospital Adjustments None 8 Claims Processing Procedures

1 General None 2 Jurisdiction Paragraph 5.0 3 Claims Filing Deadline Paragraphs 2.1.3 and 2.2.4 4 Signature Requirements Paragraphs 1.1 and 9.0

5 TRICARE Prime And TRICARE Select Referrals/ Preauthorizations/Authorizations

Paragraphs 1.0, 2.1, 2.1.2, 2.2, 2.3, 4.1- 4.1.2, and 6.0-6.2

6 Claim Development Paragraph 9.12

7 Application Of Deductible And Cost- Sharing None 8 Explanation Of Benefits (EOBs) Paragraphs 1.0-1.3 9 Duplicate Payment Prevention None A Figures None 9 Records Management (RM)

1 General None 2 File Numbers, Subject, And Description Of

Government Records None

3 Digital Imaging (Scanned), And Electronic (Born- Digital) Records Process And Formats

None

4 Electronic Records, Disposition and Storage None 5 Destruction of Records None A Paper Record Transfer Procedures None B Electronic Record Transfer Procedures None 10 Claims Adjustments and Recoupments

1 General None 2 Overpayments Recovery – Financially

Underwritten Funds Not Applicable

3 Overpayments Recovery – Non-Financially Underwritten Funds

None

4 Third Party Recovery Claims None A Figures None B Listing Of Government Claims Offices None 11 Communications And Customer Service (C&CS)

1 Education Requirements Paragraph 2.2 2 Government Staff And Beneficiary Education Paragraphs 1.0-3.2 and 7.0

3 Beneficiary, Congressional, Media, Beneficiary Counseling and Assistance Coordinator (BCAC), and Debt Collection Assistance Officer (DCAO) Relations

None

4 Inquiry Services Department - General Paragraphs 2.0-2.3

5 Correspondence Control, Processing, And Appraisal

Paragraphs 1.2 and 4.3

6 Defense Health Agency (DHA) Communications

Paragraphs 1.5-1.5.2, 3.0-3.2, 4.1.2- 4.1.2.1, 4.4.2, 6.1, 6.3, 7.4, 10.1 and 10.6

7 Telephone Inquiries Paragraphs 3.2.1.1, 3.2.1.2, 3.2.1.3.4, and 3.2.1.3.8

8 Grievances And Grievance Processing Paragraph 2.6 9 Collection Actions Against Beneficiaries Paragraph 2.8 A TRICARE Logo None 12 Appeals And Hearings

1 General None 2 Governing Principles None 3 Reconsideration Procedures None 4 Appeals Of Medical Necessity Determinations None 5 Appeal Of Factual (Non-Medical Necessity)

Determinations None

6 Defense Health Agency (DHA) Appeals None 7 Figures None 13 Program Integrity

1 General Paragraphs 1.2-1.2.11, 1.3-1.3.2 and 2.4.4-2.4.4.3

2 Anti-Fraud Controls And Contractor Actions Paragraphs 3.3.3 and 3.9-3.9.3 3 Statistical Sampling Audits Paragraphs 4.6-4.6.7 and 4.7-4.7.5 4 Case Development None 5 Provider Exclusions, Terminations, Temporary Suspension of Claims(s) Payments

Paragraphs 2.5.3-2.5.3.3, 2.5.4.6, 2.6.2.5, 2.9.5.5, 4.3.3-4.3.3.2 and 9.4.1-9.4.5.2

A Figures None 14 Reporting Requirements

1 Reporting Requirements None A Figures None 15 Defense Health Network (DHN)/Military Medical Treatment Facility (MTF) Directors, and

Contractor Interfaces 1 Market Directors, Military Treatment Facility

(MTF) Directors, and Contractor Interfaces Not Applicable

2 Resource Sharing Not Applicable

3 Clinical Support Agreement (CSA) Program Not Applicable 16 TRICARE Prime Remote (TPR) Program

1 General Not Applicable 2 Health Care Providers And

Review Requirements Not Applicable

3 Enrollment, Beneficiary Education, And Support Service

Not Applicable

4 Contractor Responsibilities And Reimbursement

Not Applicable

5 Reports Not Applicable 6 TRICARE Prime Remote For Active Duty

Family Member (TPRADFM) Program None

A Points Of Contacts (POCs) Not Applicable 17 Supplemental Health Care Program (SHCP)

1 General Not Applicable 2 Providers Of Care Not Applicable 3 Contractor Responsibilities Not Applicable A Points of Contact (POC) Not Applicable B Memorandum Of Agreement (MOA)

Between Department Of Veterans Affairs (DVA/VHA) And Department Of Defense (DoD) For Processing Payment For Disability Compensation And Pension Examinations (DCPE) In The Integrated Disability Evaluation System (IDES)

Not Applicable

C Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA/VHA) And Department Of Defense (DoD) For Medical Treatment Provided to Service Members with Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blindness, or Polytraumatic Injuries

Not Applicable

18 Demonstrations, Pilot Projects, and Value-Based Initiatives 1 General None 2 Defense Health Agency (DHA) Evaluation

Of Non-United States (U.S.) Food And Drug Administration (FDA) Approved Laboratory Developed Tests (LDTs) Demonstration Project

3 Department Of Defense (DoD) Comprehensive Autism Care Demonstration

(ACD)

Except as stated in Ch 20 Sec 18 para 1.2

4 Expired - Department Of Defense (DoD) Hearing Center of Excellence (HCE)/ Department of Veteran Affairs (VA) Hearing Aid Procurement Model (HAPM) Expansion Demonstration

Not Applicable

5 National Defense Authorization Act 2017 (NDAA FY 2017): Medication Adherence Pilot Program

Not Applicable

6 Pilot Program on Performance-Based Maternity Payments (P-BMP)

Not Applicable

7 Expired - Home Health Value-Based Purchasing (HHVBP) Demonstration

Not Applicable

8 Low Back Pain (LBP) and Physical Therapy (PT) Demonstration

9 Referral And Appointing Center (RAC) Pilot Not Applicable

Childbirth and Breastfeeding Support Demonstration

Not Applicable

11 Childbirth And Breastfeeding Support Demonstration-Special Policies for Overseas Implementation

Not Applicable

12 Competitive Plans Demonstration Not Applicable

A Participation Agreement for Comprehensive Autism Care Demonstration (ACD) Corporate Services Provider (ACSP)/Sole Provider Practices

Not Applicable

B Performance-Based Maternity Payments (P- BMP) Data Elements

Not Applicable

C Performance-Based Maternity Payments (P- BMP) Incentive Calculations Methodology

Not Applicable

D Medicare Severity-Diagnosis Related Groups (MS-DRGs) Available in Fiscal Year (FY) 2018

Not Applicable

E Competitive Plans Demonstration (CPD) – TRICARE Manuals Exclusion List

Not Applicable

19 Health Insurance Portability and Accountability Act (HIPAA) of 1996

1 General None 2 Health Insurance Portability And

Accountability Act (HIPAA) Standards For Electronic Transactions

None

3 Privacy And Security Of Protected Health Information (PHI)

None

4 Health Insurance Portability And Accountability Act (HIPAA) Standard Unique Health Identifier For Health Care Providers (HCPs) Final Rule

None

20 TRICARE Medicare Eligible Program (TMEP)

Other TMEP Requirements None 21 TRICARE Alaska Not Applicable 22 Reserve Component (RC) Health Coverage Plans

1 TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR)

None except as stated in Ch 20 Sec 22 para 1.1

A Figures Not Applicable 23 TRICARE Pharmacy (TPharm)

1 General Not Applicable 2 Out-Of-Jurisdiction Claims Not Applicable 3 Pharmacy Claims Processing Not Applicable 4 Other Contract Requirements Not Applicable 5 Transition Not Applicable 24 TRICARE Overseas Program (TOP) Not Applicable 25 TRICARE Young Adult (TYA)

1 TRICARE Young Adult (TYA) None except as stated in Ch 20 Sec 25 para 1.1

A TRICARE Young Adult (TYA) Premiums Not Applicable 26 Continued Health Care Benefit Program (CHCBP) Not Applicable 27 Chapter 27 - Telehealth Not applicable 28 Prescription Monitoring Program (PMP)

1 General None 2 Beneficiary Prescription Monitoring Program

(PMP)

None

3 Provider Prescription Monitoring Program (PMP)