Exhibit_9_-_BWE_System_Implementation_Plan_T3.pdf

Beneficiary Web Enrollment (BWE) Application System Implementation Plan for Managed Care Support Contractors and Designated Providers

Prepared by DMDC

400 Gigling Rd.

Seaside, California 93955

Revised: December 13, 2010 Version 2.5

Deleted: August 1

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BWE System Implementation Plan

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Document History

Document Version Date Change(s)

1.4.1 October 2, 2006 Original, created from CONOPS.

1.4.4 November 27, 2006

2.0 July 10, 2007

2.1 August 16, 2007

2.2 August 28, 2007

2.3 February 1, 2008 Appendix B: For “Cancel Pending Xfer,” changed Prior

EMC_ENL_ERSN_CD “E” to “Blank” for Losing Contractor (Defect 1561).

Appendix B: For BWE Event “Transfer (may include plan change or ind to fam conversion),” added “L” to Prior EMC_ENL_ERSN_CD for Gaining Contractor, and added “L” to Current EMC_ENL_ERSN_CD and Current PCM_ERSN_CD for Losing Contractor.

2.3a April 3, 2009 Accepted changes from v. 2.2; showing only 2.3 changes.

Added Document History, reformatted tables. Added “fam” to the Transfer description in the BWE Events section of the Notifications table.

2.4 August 2010 T3 release:

• Multiple changes for clarity to Section 2., “Functional

Requirements for Contractors”

• Multiple edits to Section 3.1., “Enrollments (New)” –

“Requirements of Contractor System/Processes to Support BWE Enrollments,” “Pre-conditions,” and “Business Rules”

• Multiple edits to Section 3.1.1., “Cancel Pending Enrollment” – “Requirements of Contractor System/Processes to Support BWE Enrollments” and “Business Rules”

• Multiple edits to Section 3.2., “Disenroll” – “Requirements of Contractor System/Processes to Support BWE Enrollments,” “Preconditions,” and “Business Rules”

• Edits to Section 3.3.1., “Transfer/Change Plan” – “The operator must contact the contractor to perform transfers from CONUS to OCONUS”

• Multiple edits to Section 4.1., “Login, Authorization, Deleted: Version 2.5

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• Multiple edits to Section 4.3., “Fee Calculations” –

“Business Rules”

• Multiple edits to Section 4.4., “Enrollment and PCM

Change Confirmation”

• Edits to Section 5., “Support Requirements” – “BWE requires support functions in three areas: Application Support, Eligibility Support, and Enrollment Support.”

• Multiple edits for clarity to Section 5.3., “Enrollment Support”

• Various edits to Appendix A, “Context Models”

• Edits to Appendix B, “Notifications” – Modified to account for new Enrollment End Reason Code values for the following events:

• BWE Transfer

• BWE Transfer & Plan Change

• Edits to Appendix B, “Notifications” – Removed the Prior End Reason Codes for the following Auto Approval and DOES Approval events:

• Auto Approval PCM Change

• Auto Approval Transfer

• Auto Approval Plan change

• Auto Approval Transfer & Plan change

• DOES Approve Xfer, Plan change

• Approve PCM change

• Edits to Appendix B, “Notifications” – Added the Prior PCM End Reason Codes for the following Auto Approval and DOES Approval events:

• DOES Approve Enrollment but Change PCM

• DOES Approve Plan Change/Transfer but Change

PCM

• DOES Change PCM Change

• Edits to Appendix B, “Notifications” – Added to Notes section, “For Transfer/Plan change transactions when EMC_ENRL_ERSN_CD or PRIOR_EMC_ENRL_ERSN_CD = “X” the corresponding EMC_ENRL_TRSNX_CD or PRIOR_EMC_ENRL_TRSNX_CD = “T1” on the PNT.” Deleted: Version 2.5

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• Edits to Appendix C to add relevant medical plans

• Inserted Appendix D to add relevant dental plans

• Edits to Appendix E to add or edit the following sections:

• Disenrollment – Verification Page, Confirmation

Page, Beneficiary to Disenroll (list) page, and Dental Disenrollment Lock-In

• View Beneficiary Listing

• Update Address – Update Address and

Transfer/Address Update confirmation page

• Enroll – Electronic Signature and Access Waiver page, Enrollment Verify Page, and Enrollment Confirmation Page

• PCM Change – Beneficiary listing for PCM Change page and Provider Selection Page

• Cancel Enrollment – Confirmation page

• Cancel Plan/Transfer Enrollment – Beneficiary listing for PCM Change page

2.5 December 13, 2010 Added notification rules for ATC waiver codes sent on pending PNTs.

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Contents

1. Overview

1.1. Purpose

1.2. Scope

2. Functional Requirements For contractors

3. Business Events Supported by BWE

3.1. Enrollments (New)

3.1.1. Cancel Pending Enrollment

3.2. Disenroll

3.3. Address Update

3.3.1. Transfer/Change Plan

3.4. PCM Change

3.4.1. Cancel Pending PCM Change

3.5. Add OHI

3.6. Request Enrollment Card

4. Other Processing Rules

4.1. Login, Authorization, and Family Display

4.2. Printing Forms

4.3. Fee Calculations

4.4. Enrollment and PCM Change Confirmation

4.5. Member Details

5. Support Requirements

5.1. Application Support

5.2. Eligibility Support

5.3. Enrollment Support

Appendix A: Context Models Appendix B: Notifications Appendix C: Medical Plans Supported by BWE Appendix D: Dental Plans Supported by BWE Appendix E: Static Messages and Instructions

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1. OVERVIEW

1.1. Purpose

This document provides contextual and application specific descriptions of the Beneficiary Web Enrollment (BWE) application to TRICARE Managed Care Support Contractors (MCSCs) and Designated Providers (DPs) so that they may integrate BWE into their business processes and systems. This document is intended to provide sufficient information to plan and execute all end-to-end testing and to outline the requirements needed to support BWE in full-scale production capacity.

1.2. Scope

This document focuses on BWE, the functionality it supports, and critical business rules that contractors need to know to be able to integrate with and test BWE supported business events.

Where necessary, it defines interfaces to external systems or business processes where there is a projected integration requirement. It also provides summary changes to DEERS applications that must be modified to support BWE generated business events.

This document does NOT define contractor business processes, though the nature of certain BWE functionality may require contractor processes or systems to support BWE generated business events.

2. FUNCTIONAL REQUIREMENTS FOR CONTRACTORS

BWE essentially provides benefits maintenance functionality directly to DoD beneficiaries that have historically been performed by operators of the Defense Online Enrollment System (DOES). All Government requirements for enrollment in a TRICARE plan will continue to apply. In certain cases, BWE generated business events (i.e., disenrollment) should require no support by contractor systems or processes. In other cases, contractor systems or processes must handle BWE generated events. The following list defines the basic requirements that contractors need to accommodate in order to support BWE functionality:

• Contractors need a Fee Gateway.

• Contractors need to be able to differentiate pending and non-pending notifications.

• Contractors need to take action on “pending” enrollments, transfers, and PCM changes to complete the transactions.

3. BUSINESS EVENTS SUPPORTED BY BWE

BWE provides a subset of the functionality of DOES to DoD beneficiaries. A set of context diagrams are provided in Appendix A: “Context Models” to identify where BWE functionality fits into existing processes and/or systems.

3.1. Enrollments (New)

Beneficiaries (BWE operators) use BWE to enroll themselves and/or their family member(s) into a plan. During the enrollment process, BWE asks the operator to confirm his or her address.

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The person’s address will determine the correct plan and enrolling region for each beneficiary being enrolled. As part of the enrollment, the following actions occur:

• BWE presents a disclaimer that by continuing, the operator accepts responsibility to comply with all DoD policies/regulations and laws. When the operator accepts, this shall constitute an electronic acceptance/signature.

• BWE presents a disclaimer that PCM options may be available to the operator that are outside the area supported by access to care policy. The operator must acknowledge that he or she may be selecting a PCM outside 30-minute drive time.

• Choose an enrollment date (which is always a date at least 6 to 90 days in the future).

• Select a PCM.

• Update OHI, if desired by operator.

• If required, BWE calculates fees and collects credit card information for real-time submission to contractor.

• The enrollment enters a “pending” status, which is visible in DOES.

• Notification of pending enrollment is sent to the appropriate contractor.

• A DOES operator is subsequently able to accept, override, or reject the enrollment.

• Once the contractor approves the enrollment, the Military Treatment Facility (MTF) receives a PIT.

• Pending enrollments are automatically approved after six calendar days if the contractor does not accept, override, or reject the enrollment.

Requirements of Contractor System/Processes to Support BWE Enrollments:

• Fee Gateway is needed to accept credit card data when fees are required.

• Notification processing must be able to accept pending/non-pending notifications.

• DOES operators need to be trained to confirm pending BWE Enrollments.

• Contractors must handle EFT/Allotment requests electronically through the Fee Gateway.

Preconditions:

1. The beneficiary cannot already be enrolled in a plan of the same plan type (Medical or Dental).

2. The enrollment period must be within the plan’s begin and end dates.

3. The eligibility end date must be after the first day the beneficiary is able to enroll.

4. No other family member has a pending enrollment in any BWE supported individual plan of the same plan type that would have to be converted to a family plan.

5. The enrolling beneficiary cannot have a current pending enrollment or Primary Care

Physician.

6. A lock out for prior enrollment cannot exist in the past year for the same plan type and

Program (Medical and TRICARE).

7. For TRICARE Dental, the user must be a sponsor or spouse.

8. For Medical Plans, NAD/D or ADFM with Non-TS (Transitional Survivor) sponsor not in enrolled in TPR must be within a PSA or USFHP ZIP Code to enroll using BWE. Deleted: Version 2.5

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Business Rules:

1. BWE requires electronic signature/access to care waiver before the enrollment process begins.

2. BWE determines one plan (Prime, TPR, or USFHP) to enroll the beneficiary based on the beneficiary’s eligibility to enroll.

3. If the beneficiary is eligible for TRICARE Prime Remote TPR, TPR determination is based on the beneficiary’s residence ZIP Code and Sponsor’s work ZIP Code.

4. Active Duty Family Members who reside in a ZIP Code that is both PSA and TPR will be enrolled in Prime.

5. If TRICARE Prime retiree eligibility starts within next 6 to 90 days, members can enroll themselves and/or other eligible family members on the first day of retiree eligibility.

6. BWE does not currently support OCONUS, CHCBP, or PLUS enrollments. However, BWE will support TRICARE Dental Prime enrollments in the future.

7. BWE determines whether the enrolling plan is family or individual, and will auto convert existing individual plans to family plans as required.

8. BWE determines the region based on ZIP Codes. OCONUS is based on non “US” country or “AE”/“AA”/“AP” state codes.

9. BWE determines the contractor based on the region (and DMIS for USFHP selection).

10. For medical plans, ADSMs can start enrollment on any day 6 to 90 days in the future, for

TDP Plans, BWE enrolls based on the 20th of the month rules for all supported beneficiaries.

11. Non ADSMs can start enrollment on the first day of the month (subject to 20th of the month rule) up to 90 days in the future.

12. The enrollment end date is automatically set to the end of eligibility.

13. Automatic enrollment card requests are not made until the pending enrollment is confirmed using DOES or automatically converted to Non-Pending by DEERS if not approved in 6 days.

14. If any beneficiary is a newborn, BWE notifies the operator to contact the contractor for retroactive enrollment of the newborn to the date of birth.

3.1.1. Cancel Pending Enrollment

A BWE operator can cancel a pending enrollment within 48 hours of the submission of the enrollment, as long as the pending enrollment is not part of an enrollment transfer or plan change based on address (i.e., Remote to non-Remote).

In the case of a pending enrollment for a transfer, the enrollment cannot be cancelled because the new address dictates a change of plan or transfer of enrollment to a new contractor, and the previous enrollment cannot be reinstated with the correct plan/contractor.

Requirements of Contractor System/Processes to Support Cancellation of Pending Enrollments:

• The contractor must support removing pending enrollments from their queue/report used to prompt DOES operators to confirm pending enrollments.

1. The enrollment must be the latest enrollment for a person.

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2. The enrollment is pending.

3. The enrollment was completed within the past 48 hours.

4. The enrollment cannot have been initiated by an individual to family conversion.

5. The enrollment cannot have been initiated by a transfer of Region or Policy (e.g., Prime to TPR or TPR to Prime plan change).

Business Rules:

1. Reinstate other enrollments if applicable (i.e., reinstate an individual enrollment if all other family enrollments are cancelled, one family enrollment remains, and that enrollment has a prior individual enrollment).

2. BWE will initiate a family to individual conversion if all but one family enrollment is cancelled. Note: This functionality will be released December 2010.

3.2. Disenroll

Disenrollments are voluntary actions that BWE users can take when enrolled in a BWE supported plan. BWE does not currently support disenrollment from non-BWE plans (i.e., PLUS or OCONUS Prime).

Requirements of Contractor System/Processes to Support BWE Disenrollment:

• There are no actions required by contractors to support disenrollment.

• Notifications and subsequent processing should be identical whether a disenrollment is performed using BWE or DOES.

Preconditions:

1. The enrollment is supported by BWE (Prime, TPR, or USFHP, TDP).

2. The enrollment must be the latest segment, non-pending, and currently in effect.

3. The enrollment must extend past the disenrollment date (last day of the month).

4. The latest PCM must be non-pending and have an effective date before the disenrollment date.

5. Active Duty Sponsors cannot disenroll using BWE.

6. The latest PCM cannot be a Legacy PCM carried over from conversion to T3.

1. For Medical plans, the disenrollment date is selectable from current day until the last day of the current month (default).

2. For TDP plans, the disenrollment date must be the last day of the current month and must be at least 12 months from the policy start date.

3. Disenrollment reasons are limited to (some don’t apply based on plan):

• Duty station change

• Voluntary termination sponsor

• Voluntary termination beneficiary

• Alternative health care

• Dissatisfied

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4. On disenrollment confirmation, USFHP enrollees will receive a message stating that their contractor will contact them to review the change.

3.3. Address Update

BWE allows users to change or update beneficiary addresses. Whenever an address change is initiated, BWE checks to see if the new address forces a transfer of enrollment or a change of plan (i.e., Prime to Remote or OCONUS to CONUS).

When changing addresses for multiple family members, some may require transfer or change, but others won’t. In such cases, updates that don’t affect enrollment are committed immediately, and all family members requiring a change in enrollment are prompted to enroll with their new contractor and/or plan information.

When enrolling, address verification is confirmed for each beneficiary to determine the correct plan. Should the address be updated, it is done before the individual beneficiary’s plan option is displayed.

Requirements of Contractor System/Processes to Support BWE Address Update:

• Address updates can result in transfers or plan changes that are subject to confirmation by the gaining contractor in DOES.

1. The beneficiary does not have a pending enrollment.

2. The beneficiary must be currently eligible to enroll in one or more BWE supported plan.

3. The beneficiary cannot be enrolled in a non BWE supported plan (Plus, TRS) except for

OCONUS plans.

Business Rules:

1. Request the sponsor’s work ZIP Code if it’s an AD family (only requested for the first enrollee and applied to the whole family; not requested if sponsor is deceased).

2. Data for all beneficiaries submitted is updated or an error is returned.

3. If the address changes remote eligibility, BWE initiates a transfer or plan change.

4. If the address change makes the beneficiary lose USFHP eligibility, BWE initiates a transfer or plan change.

5. If some family members require transfer and others don’t, address updates commit, then other beneficiaries will execute enrollment with the gaining contractor.

6. OCONUS address changes are allowed and will result in one of three outcomes:

• If the address remains with the existing OCONUS contractor, the address is accepted and a non-pending PNT is sent.

• If the address is in a BWE supported region, the member is prompted to transfer.

• If the address is in a new OCONUS contractor, the address is posted to DEERS, but

BWE also notifies the member that he or she is out of the region and instructs the member to contact the new, appropriate contractor to perform the enrollment. A non-pending PNT is sent.

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3.3.1. Transfer/Change Plan

Transfers and plan changes (specifically individual to family plan conversions or changes between remote, non-remote, and OCONUS plans) are not a direct option presented to a BWE operator. Rather, they are executed when a change in address makes the current enrollment invalid for the plan or region.

If beneficiaries require a transfer that BWE can support (i.e., North to South or Europe to West), BWE prompts the operator on the family listing page to initiate a transfer if desired.

Plan changes into OCONUS providers cannot be executed in BWE due to command sponsorship requirements. The operator must contact the contractor to perform transfers from CONUS to OCONUS. Transfers from OCONUS plans into BWE supported addresses are supported.

Requirements of Contractor System/Processes to Support Transfer/Plan Changes:

• There is no impact to the losing contractor. The losing contractor will receive a non-pending disenrollment with an end reason code indicating a transfer.

• The gaining contractor must process the transfer like any other new pending BWE enrollment.

• BWE does not attempt to collect any fees during a transfer. Contractors need to integrate any fee related activities as part of their transfer confirmation process.

1. The beneficiary is enrolled.

2. The beneficiary is no longer living in the region of the current enrollment and/or is no longer eligible for the current enrolled plan.

3. There is a current, but not a future enrollment or PCM segment for the beneficiary.

4. Enrollment end date must be at least six calendar days in the future.

1. A transfer/plan change requires accepting the electronic signature/access to care waiver.

If the operator declines, the address is committed, but the transfer/plan change does not go through, and the beneficiary is instructed to contact the contractor.

2. The plan change/transfer effective date is based on operator selected PCM begin dates (i.e., 6 to 90 days in future for Medical plans).

3. A prior enrollment is terminated one day prior to the transfer/plan change.

4. When the system performs individual to family conversions, the new family enrollment will NOT be sent as a pending enrollment. Note: A pending enrollment is sent for the new family enrollment(s) that caused the automatic conversion to occur.

3.4. PCM Change

With a few exceptions, the process of PCM selection is identical when enrolling or changing PCMs once enrolled. Depending on plan, the operator can choose Direct Care, Civilian, or USFHP (if they live in a USFHP area) provider type. USFHP provider information is not maintained in DEERS. Therefore, BWE operators must select the USFHP provider option at the DMIS level and must work directly with the USFHP provider to select or change a PCM.

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Requirements of Contractor System/Processes to Support PCM Change:

• PCM changes generate notifications with pending PCM data.

• PCM changes require confirmation by the contractor through DOES.

1. The enrollment is supported by BWE.

2. The enrollment must be the last enrollment, non-pending, and currently in effect.

3. The existing PCM must be the last PCM selected, non-pending, non-legacy, and currently in effect. A Legacy PCM is a PCM that was carried over from TNEX.

4. A Change Plan/Transfer Enrollment cannot be required for the beneficiary.

5. For a “US” address, a ZIP Code must be provided.

6. When currently enrolled, the enrollment end date must be more than 6 days in the future.

1. Change reasons are limited to:

• Dissatisfied with primary care manager

• Permanent Change of Station (PCS)

• Relocation

2. Start dates are from 6 to 90 days in the future for Medical plans.

3. A Civilian or Direct Care PCM must be selected. (USFHP only requires the facility.)

4. Resource Sharing Providers are treated like Direct Care Providers.

5. PLOCs must be active (start and end dates are currently valid).

6. PLOCs must have capacity within the PLOC, Group, and PCM.

7. The enrolling division type must be “Admin,” “Clinic,” “Hosp,” “NonCat,” or “Ship.”

8. CONUS PLOCs are filtered by ZIP Codes in the DMIS distance table.

9. DMIS selections are restricted to DMISs within 50 miles.

10. For ADSMs, the PCM change must be to another DMIS.

11. If no DMIS or PLOC is found, the operator is instructed to contact the contractor.

12. DC PCMs must have capacity within the PLOC, Group, and PCM.

13. DC PCMs are filtered based on patient age requirements.

14. DC PCMs are filtered based on sponsor/dependent enrollment categories.

15. For TRICARE Prime Remote enrollments, remote PCMs will be identified.

16. Pseudo PCMs are excluded from all Direct Care PCM selections.

17. If enrolled with USFHP, the beneficiary can select the Change PCM option, but they will only be given static content with a link to the USFHP provider directory and contact information to work directly with the USFHP provider to complete the PCM change.

3.4.1. Cancel Pending PCM Change

Cancelling a PCM change has the same behaviors as canceling an enrollment.

Requirements of Contractor System/Processes to Support Canceling Pending PCM Change:

• Contractors will need to remove pending enrollment confirmation from queue/report so DOES users are aware that no action is required. Deleted: Version 2.5

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1. The PCM is still pending in DEERS and is the latest PCM segment for the beneficiary.

2. The PCM selection must have been submitted in the last 48 hours.

3. An enrollment is not pending.

4. A prior PCM can be reinstated for the enrollment.

1. The prior PCM is reinstated through the end of enrollment.

3.5. Add OHI

BWE supports the operator adding OHI. Basic policy information is captured and a Default Medical Coverage type is added to the DEERS repository.

Requirements of Contractor System/Processes to add OHI:

• There is no notification to the contractor that default OHI has been added in BWE.

Preconditions:

1. The operator must be authorized as sponsor or spouse.

2. The beneficiary must be currently eligible to enroll in one or more BWE supported plan.

1. None.

3.6. Request Enrollment Card

BWE Users can request replacement cards in BWE. This function is executed automatically for enrollments once the enrollment status is confirmed using DOES or auto-confirmed after six days. Enrollment cards are not provided through DEERS for USFHP providers; USFHP enrollees will receive contact information and be given instructions to work directly with their USFHP provider to get new enrollment cards.

Requirements of Contractor System/Processes to Support Enrollment Card Request:

• None.

Preconditions:

1. The enrollment is non-pending and is the latest enrollment segment.

2. The beneficiary cannot have performed an enrollment card request in the last 14 days.

1. None.

4. OTHER PROCESSING RULES

In addition to the basic business events above, there are additional areas of understanding where information would be helpful for contractors to understand how BWE works to enable planning and testing.

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4.1. Login, Authorization, and Family Display

BWE supports operator authentication using CAC, DFAS PIN, and DS Logon. CAC and DFAS PINs are sponsor-based credentials.

For testing purposes, contractors will be authorized to access BWE with a DEERS user name and password managed by their Contractor Test site security manager (SSM). They can provide the Sponsor’s Patient ID (and optionally a family member’s patient ID) for testing purposes. Person Identifiers (i.e., SSNs, FINs, TINs, etc.) are not supported through the SNT login. Contractors will not be given this level of access in Production.

Business Rules:

1. The sponsor and spouse can see/update all members in a family.

2. For Medical Plans, Non-spouse dependents over age 18 can see/update themselves only.

3. For Dental Plans, only Sponsor can update self. Spouse can update family.

4. Non-spouse dependents under age 18 are not allowed access.

5. The sponsor is always displayed in the family.

6. If the sponsor is deceased, no actions are allowed to be taken on the sponsor.

7. If a member is enrolled in non-BWE plan no actions can be taken on that beneficiary.

8. All non-terminated family members are displayed.

9. Enrollment for the family members will be displayed according to the following precedence:

• Current enrollments

• First future enrollment if none is current

• None

10. The events and actions a user can perform using BWE is based on the preconditions for each business event.

11. If anyone in the family has a null DOB, BWE will return an error, prompting the user to contact the contractor.

4.2. Printing Forms

When a user is enrolling and elects to print forms, BWE will pre-populate as much information in the form as possible that was filled out in the application. BWE does not pre-populate forms for disenrollment or PCM changes, but will print the blank form if the user requests.

Business Rules:

1. The operator must be in the process of enrolling to get a pre-populated form.

2. The user must print one form per contractor with which the family is enrolling.

3. No more than six family members are included per form (not including sponsor).

4. OHI/Medicare indicators are only checked on forms with a beneficiary who has

Medicare/OHI.

4.3. Fee Calculations

When fees are required for an enrollment, BWE calculates Annual, Quarterly, and Monthly fee amounts (for payment by EFT/Allotment). The beneficiary selects one of these options, and Deleted: Version 2.5

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BWE collects credit card information to submit a fee transaction to the contractor via the Fee Gateway prior to completing enrollment. If fees are required, but DEERS cannot receive a valid confirmation from the contractor’s Fee Gateway, the enrollment will not be processed. In all cases, BWE requires a minimum credit card payment of three months’ fees, unless the enrollment period is less than three months. BWE also collects account information for the Fee Gateway transaction when EFT is selected. When Allotment is selected, BWE provides an electronic authorization to the contractor via the Fee Gateway to establish an allotment with Defense Finance and Accounting (DFAS).

Business Rules:

1. A minimum of three months’ fees for quarterly payment or monthly payment by EFT/Allotment must be submitted with enrollment.

2. If annual enrollment fee option is selected, payment of the 12 months of fees is required.

3. BWE only allows quarterly payment option (w/prorated fees) if the enrollment is for one or two months.

4. BWE prorates fees if the enrollment period is only one or two months.

5. BWE prorates fees to 12 months if the enrollment period is more than 12 months and the annual enrollment option was selected.

6. Fees collected cannot exceed the CatCap balance, BWE will prorate fees if the CCD balance is less than fees owed.

7. When converting an individual plan to a family plan and fees are owed in a prior fiscal year, the beneficiary is instructed to contact the contractor to resolve and complete the enrollment. The BWE enrollment will not be completed.

8. BWE will convert individual plans to family plans where appropriate and carry forward under/overpayment amounts for individual plans converted to family plan.

9. If a beneficiary with individual plan has fee waiver, BWE will treat the enrollment as if they are paid through the day before the new family enrollment starts.

10. BWE excludes credit segments after the last payment segment when determining the enrollment paid thru date.

11. BWE prorates annual fees when there are family members with Medicare A&B (Note: It is implied that enrollments are for plans that require fees.)

4.4. Enrollment and PCM Change Confirmation

When enrollments (including transfers and plan changes) are completed in BWE, the pending enrollments must be approved by the contractor. The purpose is to ensure that the PCM selected by the BWE user complies with policies and rules established by the MTFs, as well as any other contractor specific rules that must be applied during enrollment. BWE enforces certain rules to facilitate this; however, final determination of PCM appropriateness must be done by the contractor. BWE supporting contractors must be able to accept notifications to identify pending enrollments and PCM changes so that they can assign a DOES operator to review the enrollment.

The DOES operator will be able to accept, override, or reject an enrollment or PCM change.

Once action is taken in DOES, a second notification is sent to the contractor with an updated status (in cases of overrides or rejections, updated data).

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CHCS sites will not receive notifications for the pending transactions. Instead, they will get a notification indicating the final status of the enrollment (or if cancelled, no notification at all). In the case of changes that switch PCMs (transfers, plan changes, elective PCM change), the existing CHCS site will receive a disenrollments notification, and a second PIT will be sent out (potentially to the same CHCS site) with updated PCM data once confirmed.

For a complete reference of status codes for BWE and the corresponding DOES approve/cancel events, see Appendix B: “Notifications.”

4.5. Member Details

When a member is clicked from the family display, the following details are provided for the individual:

• Enrollment information (all current and future enrollments)

• Corresponding PCM data for each enrollment (PCMs up to 365 days in the past)

• Corresponding fee last payment and paid thru dates for each enrollment (if applicable;

credits are excluded when determining the paid through date)

• Address

• OHI

• Medicare

5. SUPPORT REQUIREMENTS

BWE requires support functions in three areas: Application Support, Eligibility Support, and Enrollment Support.

5.1. Application Support

General application support calls are managed by the DMDC Support Center (DSC). Events that fall into this category include:

• Logon

• Timeout errors that occur during Fee Gateway processing (descriptive error messages should provide time out message errors during enrollment process)

• BWE outages

5.2. Eligibility Support

The DMDC Support Office (DSO) provides eligibility support for all DoD benefits.

5.3. Enrollment Support

BWE provides beneficiaries capabilities similar to those provided to trained operators using DOES. However, certain circumstances (for example, OCONUS enrollments) require the beneficiary to contact the contractor for enrollment support. All existing TRICARE enrollment requirements continue to apply, and the contractors are still responsible for meeting all enrollment requirements. As such, contractors will need to continue to execute existing

Version 2.5 12 processes that support TRICARE business events. The availability of BWE does not invalidate current contractor processes.

BWE provides appropriate information to help BWE operators contact the correct contractor based on the address provided, and the contractors should respond to service calls from beneficiaries using BWE as they would field enrollment questions from beneficiaries regardless of the mechanism they used to enroll (BWE or paper form).

Version 2.5 13

Appendix A: Context Models

Note 1: If fees are not collected, steps for collecting fees are omitted from diagram.

Note 2: The model depicts collection of fees at time fee gateway transaction is complete.

Note 3: This diagram is for general context. Should other requirements conflict with the interpretation of this diagram, all other rules and requirements take precedence.

Version 2.5 14

<<System>>

BWE

Receive Notification

Beneficiary Transfers

<<System>>

DEERS

Notifications

Send Notication

[PNT (Pending) No PIT]

<<System>> Gaining Contractor

Notifications Listener

Process Enrollment/PCMs

<<System>> Gaining System

<<Person>> Gaining Contractor

DOES Operator

Approve Pending Enrollment

Send Notication

<<System>> DEERS Batch Fees

Receive Notification

[PNT (non-pending) and PIT if applicable]

<<System>> Gaining Contractor

Backend

Update System w/ New enrollment

TRANSFER Process

<<System>> Losing Contractor

Backend

Receive Notification

[PNT (Non-Pending) and PIT if applicable]

Disenroll for transfer

Note: This diagram is for general context. Should other requirements conflict with the interpretation of this diagram, all other rules and requirements take precedence.

Version 2.5 15

<<System>>

BWE

Receive Notification

Beneficiary changes PCM

<<System>>

DEERS

Notifications

Send Notication

[PNT (Pending) No PIT]

<<System>> Notifications

Listener

Process PCMs<<System>> Contractor System

<<Person>> DOES Operator

Approve Pending

PCM

Send Notication

Receive Notification

[PNT (non-pending) and PIT if applicable]

<<System>> Cntractor Backend

PCM Process

Update System

Note: This diagram is for general context. Should other requirements conflict with the interpretation

Version 2.5 16

<<Beneficiary>> BWE Operator

Enroll or perform PCM Change

<<DEERS>

<<MCSC>

DOES

Accept BWE Pending Enrollment or PCM Change

Approve Pending Enrollment or PCM Change

Auto-Approve Pending

Send PNT

6 Days with No Approval Report

Autoapproved Records

Send PNT

Note: This diagram is for general context. Should other requirements conflict with the interpretation

Version 2.5 17

Appendix B: Notifications The following table describes the business events, how the data is managed in BWE/DOES, and what notifications are sent. Yellow columns indicate business events. Orange columns indicate specific codes being changed. White indicates whether PNT/PIT is sent.

Where a row is split, there are actually two segments in DEERS that are being updated, and the corresponding data and notification indicators are described for each segment in DEERS.

Current STAT_CD Current ERSN_CD (PNT) Prior ERSN_CD

BWE EVENTS HCDP_EMC_PLN PCM_SLCT EMC_ENL PCM_SLCT EMC_ENL PCM_SLCT PNT PIT

New enrollment P P Q, U Q, U Blank Blank Yes No Fam Plan B B Q, U Q, U K Blank Yes YesNew enroll (individual to family plan conversion) Ind Plan B B K K n/a n/a No No New Plan P P Q, U Q, U L Blank Yes No Plan Change Old Plan B B L L Blank Blank No Yes Gaining Cntc P P Q, U Q, U T Blank Yes No Transfer

Losing Cntc B B T T Blank Blank Yes Yes Gaining Cntc P P Q, U Q, U X/T1 Blank Yes No Transfer & Plan Change

Losing Cntc B B X/T1 X/T1 Blank Blank Yes Yes New PCM n/a P Q, U Q, U Blank P,H,I Yes No PCM Change Old PCM n/a B Q, U P,H,I Blank Blank No Yes

Disenroll B B G,N,O,5,P C Blank Blank Yes Yes Address Update (not Transfer) n/a n/a Q, U Q, U Blank Blank Yes Yes Request Card n/a n/a Q, U Q, U Blank Blank Yes No Cancel Pending Enrollment C C E E Blank Blank Yes No

Ind Plan B B Q, U Q, U E Blank Yes YesCancel Family Enrollment; Reinstate Indiv Plan Fam Plan B B E E n/a n/a No No

Reinstated

PCM

n/a B Q, U Q, U Blank E Yes YesCancel Pending PCM change

Cancelled

PCM

n/a C n/a E n/a Q, U No No

Version 2.5 18

Current STAT_CD Current ERSN_CD (PNT) Prior ERSN_CD AUTO APPROVE EVENTS HCDP_EMC_PLN PCM_SLCT EMC_ENL PCM_SLCT EMC_ENL PCM_SLCT PNT PIT

Pending Enrollment N N Q, U Q, U Blank Blank Yes Yes PCM Change n/a N Q, U Q, U Blank Blank Yes Yes Transfer N N Q, U Q, U Blank Blank Yes Yes Plan change N N Q, U Q, U Blank Blank Yes Yes Transfer & Plan Change N N Q, U Q, U Blank Blank Yes Yes

Current STAT_CD Current ERSN_CD (PNT) Prior ERSN_CD

DOES EVENTS HCDP_EMC_PLN PCM_SLCT EMC_ENL PCM_SLCT EMC_ENL PCM_SLCT PNT PIT

Approve/Change Pending Approve Enrollment A A Q, U Q, U Blank Blank Yes Yes Approve Xfer, Plan Change A A Q, U Q, U Blank Blank Yes Yes

New PCM A O Q, U Q, U Blank E Yes YesApprove Enrollment but Change PCM (no notification) Old PCM n/a R n/a E n/a n/a No No

New PCM A O Q, U Q, U Blank E Yes YesApprove Plan Change/ Transfer but Change PCM (no notification) Old PCM n/a R n/a E n/a n/a No No Approve PCM Change E A Q, U Q, U Blank Blank Yes Yes

New PCM E O Q, U Q, U Blank E Yes YesChange PCM Change (no notification) Old PCM n/a R n/a E n/a n/a No No Pending Cancellation Cancel Pending Enrollment R R E E Blank Blank Yes No

Old Plan O O Q, U Q, U E Blank Yes YesCancel Pending Enroll (plan change) New Plan R R E E Q, U Q, U No No

Old/Ind Plan E E Q, U Q, U E Blank Yes YesCancel Enroll (ind to fam conversion) New/Fam

Plan E E E E Q, U Q, U No No

Gaining Cntc R R E E Blank Blank Yes No Cancel Pending Xfer

Losing Cntc E E Q, U Q, U Blank Blank Yes Yes Fam Plan O O Q, U Q, U E Blank Yes YesCancel Pending Ind

Replace w/Fam (no notification) Ind Plan R R E E n/a n/a No No Deleted: Version 2.5

Version 2.5 19

Old PCM E O Q, U Q,U Blank E Yes YesCancel Pending PCM Change (no notification) New PCM n/a R n/a E n/a n/a No No Other DOES Pending/Approved Update Address – pend enroll P P Q, U Q, U Blank Blank Yes No Update Addrs – p xfer/pln chng P P Q, U Q, U Blank Blank Yes No PNT rqst – apprvd enroll E E Q, U Q, U Blank Blank Yes No PNT rqst – apprvd PCM change E E Q, U Q, U Blank Blank Yes No

BWE-Specific Access To Care Waivers (PCM_ATC_WVR_CD) Rules:

PNTs sent to a T3 Contractor will have Access To Care (ATC) waiver (PCM_ATC_WVR_CD) on the PNT layout. If it is a pending PNT resulting from a BWE action (Pending Enrollments, Transfers, PCM Changes, or plan changes requiring the selection of a new PCM), the PNT will contain an ATC Waiver Code of either “A” (Pending DTW/NET Waiver) or “L” (Pending DTW/MTF waiver) based on the following rules:

1. If the pending enrollment is not an Active Duty Family Member, a Non Active Duty (retiree) beneficiary, or a Non Active Duty

Dependent enrolling in prime, BWE will set the ATC Waiver Code for the pending enrollment (or PCM) to blank.

2. If the beneficiary is enrolling in Civilian Care, BWE will set the ATC Waiver Code for the pending enrollment (or PCM) to “A”.

3. If the beneficiary is enrolling in Direct Care, BWE will set the ATC Waiver Code for the pending enrollment (or PCM) to “L”.

4. For all other updates or transactions, BWE will not set the ATC Waiver Code, and the waiver code returned will be the existing waiver code on file with DEERS.

NOTES:

• Whenever an event occurs on an enrollment or PCM that is currently pending (i.e., the current status is “P”), you will continue to receive a P on the PNT status until action is taken upon the pending enrollment/PCM.

• When action is taken on a pending segment, you will receive A, O, R, C, or N.

• All subsequent notification should have a status code of “E”. Note: This status change occurs immediately once an enrollment/PCM change is approved, as well as with any BWE generated events (Status code B). Once a PNT is sent for an A, O, N, or B status, all subsequent PNTs, even those requested via DOES immediately thereafter, will be sent with E status.

• Whenever a new segment is added in lieu of a pending segment in DOES (i.e., overriding the pending segment and putting a new one in its place), the new segment will have an “O” status. Contractors should interpret an “O” like an “A”, except they also need to cancel the existing pending enrollment that they received for that beneficiary. Deleted: Version 2.5

Formatted: Bullets and Numbering

Version 2.5 20

• When changing enrollment/PCM data of pending segments, DOES will suppress the PRIOR HCDP_ENRL_EMC_ERSN_CD and PRIOR PCM_SLCT_ERSN_CD values from the PIT because the CHCS site does not receive a PIT for the pending data that is being overridden.

• (See Data Dictionary) All prior ERSN_CD values are not itemized for DOES here, as the values are at the discretion of the DOES operator doing the review. Refer to the DEERS Data Dictionary for a list of all possible values.

• A column value of “n/a” indicates BWE or DOES will not change the column value.

• When changing an address, BWE allows a member to both transfer (move outside region) and simultaneously switch plans

(enroll into remote with the new contractor). This event should be considered a transfer.

• (2) Since PITs are not sent on pending PCM change transactions, when examining overridden PCM changes, the prior PCM select end reason code represents the original PCM changed, not the PCM requested in BWE and overridden by the contractor.

• Prior PCM end reason codes are suppressed on PNTs unless the action is a PCM change or PCM change cancellation event.

• Blank indicates no value is sent (format per the PNT Tech Spec).

• For Transfer/Plan change transactions when EMC_ENRL_ERSN_CD or PRIOR_EMC_ENRL_ERSN_CD = “X” the corresponding EMC_ENRL_TRSNX_CD or PRIOR_EMC_ENRL_TRSNX_CD = “T1” on the PNT.

STATUS CODES for enrollments and PCM selections (Will be updated in the Data Dictionary):

P BWE initiated change that requires confirmation B BWE initiated change that does NOT require confirmation C BWE cancelled Enrollment/Transfer/Plan Change/PCM change that does not require confirmation N Enrollment/Transfer/Plan Change/PCM Change automatically approved in DEERS after six days (does not require confirmation) E DEERS action against a non-pending Enrollment/Transfer/Plan Change/PCM Change A DEERS confirmation of a BWE initiated Enrollment/Transfer/Plan Change/PCM Change (does not require confirmation) O DEERS override of a BWE initiated Enrollment/Transfer/Plan Change/PCM Change (does not require confirmation) R DEERS rejection of a BWE initiated Enrollment/Transfer/Plan Change/PCM Change (does not require confirmation)

Version 2.5 21

Appendix C: Medical Plans Supported by BWE The table defines the Medical plans that BWE supports and shows how to process these plans.

COLOR CODE NOTATIONS:

AVAILABLE PLANS FOR ENROLLMENT IN BWE

! MAINTAINANCE (No new enrollments allowed, but other options are allowed.)

* NOT AVAILABLE IN BWE

# TRANSFER ALLOWED OUT OF PLAN INTO CONUS

GROUP 01 - TRICARE PRIME GROUP 04 – TRICARE PLUS

106 Prime Individual Cvg for ADSM * 140 TRICARE Plus with CHC Cvg for ADFM 107 Prime Individual Cvg for ADFM * 141 TRICARE Plus Cvg for Transitional Surv of ADSM 108 Prime Family Cvg for ADFM * 142 TRICARE Plus with CHC Cvg for Transitional Survivors of ADSM 110 Prime Individual Cvg for Survivors of ADSM * 143 TRICARE Plus Cvg for Survivors of ADSM 111 Prime Family Cvg for Survivors of ADSM * 144 TRICARE Plus with CHC Cvg for Survivors of ADSM 112 Prime Individual Cvg for TAMP Sponsor/Family * 145 TRICARE Plus Cvg for NAD and Medal of Honor 113 Prime Family Cvg for TAMP Sponsor/Family * 146 TRICARE Plus with CHC Cvg for NAD and Medal of Honor 116 Prime Individual Cvg for NAD and Medal of Honor * 147 TRICARE Plus with CHC Cvg for Transitional Survivors of GRDS 117 Prime Family Cvg for NAD and Medal of Honor * 148 TRICARE Plus Cvg for Survivors of GRDS 131 Prime Individual Cvg for Transitional Survivors of ADSM * 149 TRICARE Plus with CHC Cvg for Survivors of GRDS 132 Prime Family Cvg for Transitional Survivors of ADSM * 150 TRICARE Plus Coverage for ADFMs 134 Prime Individual Cvg for Transitional Survivors of GRDS * 151 TRICARE Plus Coverage for Transitional Survivors of GRDS 135 Prime Family Cvg for Transitional Survivors of GRDS 136 Prime Individual Cvg for Survivors of GRDS GROUP 05 – FEHBP/TSSD 137 Prime Family Cvg for Survivors of GRDS * 123 FEHBP Individual Standard Cvg # 152 TRICARE Overseas Prime Individual Cvg for ADSM * 124 FEHBP Family Standard Cvg # 153 TRICARE Overseas Prime Individual Cvg for ADFM * 125 FEHBP Individual High Cvg # 154 TRICARE Overseas Prime Family Cvg for ADFM * 126 FEHBP Family High Cvg

GROUP 02 - TRICARE PRIME REMOTE GROUP 06 – CHCBP

128 TPR Individual Cvg for ADSMs * 121 CHCBP Individual Cvg 129 TPR Individual Cvg for ADFMs * 122 CHCBP Family Cvg 130 TPR Family Cvg for ADFMs # 155 TRICARE Global Remote Overseas Prime Individual Cvg for ADSM GROUP 07 – TRICARE Reserve Select and TRICARE Senior Supplement # 156 TRICARE Global Remote Overseas Prime Individual Cvg for ADFM * 127 TRICARE Senior Supplement Demonstration # 157 TRICARE Global Remote Overseas Prime Family Cvg for ADFM * 401 Reserve Select Tier 1 mbr only cvg (contingency ops) 158 TRICARE Remote Individual Coverage for Trans Surv of ADDS * 402 Reserve Select Tier 1 mbr & family cvg (contingency ops) 159 TRICARE Remote Family Coverage for Trans Surv of ADDS * 405 Reserve Select Tier 2 mbr-only cvg (certified quals)

* 406 Reserve Select Tier 2 mbr & family cvg (certified quals)

GROUP 03 - USFHP * 407 Reserve Select Tier 3 mbr-only cvg (svc agreement) ! 109 USFHP DC Cvg for ADFM * 408 Reserve Select Tier 3 mbr & family cvg (svc agreement) 114 USFHP DC Individual Coverage for Survivors of ADDS * 409 Reserve Select Tier 1 survivor continuing w/individual cvg 115 USFHP DC Family Coverage for Survivors of ADDS * 410 Reserve Select Tier 1 survivor continuing w/family cvg 118 USFHP DC Individual Cvg for NAD * 411 Reserve Select Tier 1 survivor new individual cvg 119 USFHP DC Family Cvg for NAD * 412 Reserve Select Tier 1 survivor new family cvg ! 133 USFHP DC for Transitional Survivors of ADDS * 413 Reserve Select - Member Only 138 USFHP DC Individual Cvg for Survivors of GRDS * 414 Reserve Select - Member and Family 139 USFHP DC Family Cvg for Survivors of GRDS

Version 2.5 22

GROUP 09 – TRICARE Dental Program (Supported) GROUP 08 – TRICARE Reserve Retired

201 TDP Individual Cvg for ADFMs *418 TRICARE Retired Reserve-member only

202 TDP Family Cvg for ADFMs *419 TRICARE Retired Reserve-member and family

205 TDP Individual for Survivors of ADFMs *420 TRICARE Retired Reserve Survivor-individual only

206 TDP Family for Survivors of ADFMs *421 TRICARE Retired Reserve Survivor-family

207 TDP Individual Cvg for SelRes Sponsor

208 TDP Individual Cvg for SelRes FMs GROUP 10 – TRICARE Dental Program (Unsupported)

209 TDP Family Cvg for SelRes FMs *203 TDP Individual Remote for ADFMs

212 TDP Ind for Survivors of SelRes Deceased Sponsor *204 TDP Family Remote for ADFMs

213 TDP Fam for Survivors of SelRes Deceased Sponsor *210 TDP Individual Remote Cvg for SelRes FMs

214 TDP Individual Cvg for AGR FMs *211 TDP Family Remote Cvg for SelRes FMs

215 TDP Family Cvg for AGR FMs *216 TDP Individual Remote Cvg for AGR FMs

218 TDP Ind for Survivors of AGR Deceased Sponsor *217 TDP Family Remote Cvg for AGR FMs

219 TDP Fam for Survivors of AGR Deceased Sponsor *223 TDP Individual Remote for Mobil-asset IRR FMs

220 TDP Individual Cvg for Mobil-asset IRR Sponsor *224 TDP Family Remote for Mobil-asset IRR FMs

221 TDP Individual for Mobil-asset IRR FMs *230 TDP Individual Remote for non-Mobil-asset IRR FMs

222 TDP Family for Mobil-asset IRR FMs *231 TDP Family Remote for non-Mobil-asset IRR FMs

225 TDP Ind for Survivors of Mob-asset IRR Deceased Sponsor

226 TDP Fam for Survivors of Mob-asset IRR Deceased Sponsor

227 TDP Individual for non-Mobil-asset IRR Sponsor

228 TDP Individual for non-Mobil-asset IRR FMs

229 TDP Family for non-Mobil-asset IRR FMs

Version 2.5 23

Appendix D: Dental Plans Supported by BWE

COLOR CODE NOTATIONS:

*AVAILABLE PLANS FOR ENROLLMENT IN BWE (Black)

* NOT AVAILABLE TO ENROLL IN BWE

TRICARE Active Duty Dental Program

Active Duty Plans:

Gov.

Premium

HCDP

Pln Cvg Cd

HCDP

Cd

Dnt Pln Typ Cd

TDP Individual Coverage for AD Family Member 60% 201 006 01 TDP Family Coverage for AD Family Members 60% 202 006 01 TDP Individual Remote Coverage for AD Family Members 60% 203 006 01 TDP Family Remote Coverage for AD Family Members 60% 204 006 01 TDP Individual Coverage for Survivors of AD Deceased Sponsors 100% 205 006 02 TDP Family Coverage for Survivors of AD Deceased Sponsors 100% 206 006 02

TRICARE Guard/Reserve Dental Program

Selected Reserve Plans: (RSVCC = SA, TA, UA) TDP Individual Coverage for SelRes Sponsors 60% 207 007 03 TDP Individual Coverage for SelRes Family Members 60% 208 007 04 TDP Family Coverage for SelRes Family Members 60% 209 007 04 TDP Individual Remote coverage for SelRes Family Members 60% 210 007 04 TDP Family Remote Coverage for SelRes Family Members 60% 211 007 04 TDP Individual Coverage for Survivors of SelRes Deceased Sponsors 100% 212 007 05 TDP Family Coverage for Survivors of SelRes Deceased Sponsors 100% 213 007 05

Guard/Reserve on Active Duty Plans: (RSVCC = SG or PNLEC_TYP_CD = '01') TDP Individual Coverage for Grd/Rsv on AD Family Members 60% 214 007 06 TDP Family Coverage for Grd/Rsv on AD Family Members 60% 215 007 06 TDP Individual Remote Coverage for Grd/Rsv on AD Family Member 60% 216 007 06 TDP Family Remote Coverage for Grd/Rsv on AD Family Members 60% 217 007 06 TDP Individual Coverage for Survivors of Grd/Rsv on AD Family Member 100% 218 007 07 TDP Family Coverage for Survivors of Grd/Rsv on AD Family Members 100% 219 007 07

Individual Ready Reserve (IRR) Mobilization-Asset Plans: (RSVCC = RM) TDP for Mob-Asset IRR Sponsors 60% 220 007 08 TDP Individual Coverage for IRR-AA Family Member 60% 221 007 09 TDP Family Coverage for IRR-AA Family Members…