Amd_0001_Attach_J-2 _Definitions_4-9-13.doc

ATTACHMENT J-2

TDEFIC

DEFINITIONS

As used in this contract, the following terms have the meanings set forth below: (Additional definitions are located in the TRICARE Operations Manual (TOM) Appendix B.)

Appealable Issue – Disputed questions of fact which, if resolved in favor of the appealing party, would result in the authorization of benefits or approval as an authorized provider. An appealable issues does not exist if no facts are in dispute, if no benefits would be payable, or if there is no authorized provider, regardless of the resolution of any disputed facts. See 32 CFR 199.10 for additional information concerning the determination of “appealable issue”.

Billed Charge – The billed charge is equal to the undiscounted amount charged by a provider.

Contracting Officer – A Government employee having authority vested by a Contracting Officer’s Warrant to execute, administer, and terminate contracts and orders, and modification thereto, which obligate Government funds and commit the Government to contractual terms and conditions.

Covered Lives – Total number of persons enrolled or covered in another plan that is being submitted for past performance.

Excluded Claims – Claims retained at the discretion of the contractor for the external development of information necessary to process the claim to completion; claims requiring development for possible third-party liability; claims requiring intervention by another Prime contractor; and claims requiring Government intervention (i.e., claims held for CHAMPUS Maximum Allowable Charge (CMAC) updates, claims held pending the issuance of a policy change, etc.).

Former Spouse – A former husband or wife of a Uniformed Service member or former member who meets the criteria as set forth in 32 CFR 199.3(b)(2)(ii).

Key Personnel: Designated individuals with direct responsibility for ensuring, under this contract, that the work is being performed and the requirements are being met.

Retained Claims – Claims retained (held in the contractor’s possession) for any reason. Contractors shall retain all claims that contain sufficient information to allow processing to completion and all claims for which missing information may be developed from in-house sources, including DEERS and contractor operated or maintained electronic, paper, or film files. NOTE: Nothing in this definition prohibits a contractor from retaining a claim for external development.

TDEFIC, HT9402-12-R-0005, Amendment 0001, Apr 11, ’13 Attachment J-2 Page 1 of 1