to15_160106.pdf

TRICARE Operations Manual 6010.59-M, April 1, 2015

SUMMARY OF CHANGES

This change includes multiple editorial edits in addition to the changes specified below.

CHAPTER 2

1. Section 2.

a. At the start-up planning meeting, each contractor on the telecommunication network shall provide DHA a technical POC, and a separate computer center (Help Desk) number which the DHA can use for resolution of problems related to data transmissions.

b. Removed confirmation of access to the web-based TRICARE Duplicate Claims System.

c. Deleted requirements for Need for the Mass Change Function.

2. Section 3. Added reference to a Contract Data Requirements List (CDRL) for providing the contractor’s approach for meeting Access to Care requirements.

3. Section 4.

a. Added requirements for the transfer of enrollment files between incoming and outgoing contractors and DEERS.

b. Added requirement for outgoing contractor to transfer Prime Service Area grandfathered status enrollments to incoming contractor.

c. Added requirement for outgoing South Region contractor to provide to the incoming East Region contractor additional enrollment information required for Continued Health Care Benefits Program (CHCBP) enrollees.

d. Clarified the incoming contractor shall obtain information from the outgoing contractor on fees that are being paid monthly and transition these monthly payment types in a way that does not require the beneficiary to personally stop and restart their electronic payments.

4. Section 6. Due date for draft MOU was changed.

CHAPTER 6

5. Section 1.

a. Clarified policy that a service member cannot request disenrollment.

b. Clarified electronic funds transfer may be used for quarterly enrollment fees.

1 January 6, 2016

CHAPTER 6 (Continued)

c. Clarified enrollment for ADFMs (including ADFM TYA Prime Enrollees) residing outside a PSA and the contractor’s responsibilities. They will remain enrolled in TRICARE Prime as long as they reside within 40 miles of their original residence where they were granted grandfathered status and maintain eligibility as ADFMs.

d. Clarified terms of grandfathered status.

CHAPTER 7

6. Section 3.

a. The TQMC Monthly Findings Report is now a quarterly report.

b. A Sentinel Event is defined by using the most current definition published by the Joint Commission.

CHAPTER 8

7. Section 1. Clarified the deemed enrollment period will continue for 60 calendar days from the newborn’s date of birth or to the effective date of enrollment, whichever is earlier.

8. Section 4. Clarified professional provider claims-- outpatient professional providers such as physician’s office and suppliers such as durable equipment and durable medical equipment may retain their own forms for each visit and obtain and retain a one-time payment authorization.

9. Section 5. The Required Data Element chart was clarified. The referral in Note 4 shall be considered a blanket authorization for any Department of Veterans Affairs to conduct the authorized number of Compensation & Pension exams and ancillary services provided by any Veterans Affairs facility.

10. Section 6. Added Durable Equipment (DE) claims as claims that will be split.

CHAPTER 11

11. Section 4. The non-network provider search tool shall be refreshed no less than monthly (was semi-annually).

2 January 6, 2016

CHAPTER 17

12. Section 3.

a. Non-mental health SHCP requests will have a benefit review only, the contractor will not do medical necessity reviews, those will be provided by the MTF/eMSM or civilian referring provider.

b. MTF/eMSM Referred Care. Clarification provided for prescriptions and referrals for breast pumps, the types of pumps being prescribed, and breast pump supplies.

c. TRICARE coverage limits continue to apply to services to non-active duty TRICARE-eligible covered beneficiaries provided under the SHCP.

d. No waiver (regardless of basic benefit standards) is required for care being received under the DoD/VA MOA or for emergent care at non-authorized facilities. On occasion under the SHCP, care may be referred or authorized for services from a provider of a type which is not TRICARE authorized. This is limited to emergent cases, care under the DoD/VA, MOA, or with a DHA waiver.

e. The Service member must be transferred to an authorized facility when a bed becomes available and it is safe to transfer the Service member (as determined by the Service member’s current provider and accepting provider). There is no time standard. The Service member will be held harmless during this process.

f. Guidance provided for determining whether a given service or supply would not have ordinarily been covered under TRICARE policy.

g. Paragraph 2.2.4 deleted, TRICARE benefits may not be extended for complications resulting from non-covered surgeries and treatment performed outside the MTF/ eMSM for a Service member without an approved waiver.

h. Clarification added for custom fitted orthotics (e.g. foot inserts for plantar fasciitis, flat feet, or similar diagnoses).

i. Hearing devices must be procured by the MTF/eMSM for Service members who reside in a Prime Service Area (PSA) with audiology services.

j. Service members residing outside of a PSA, or where the MTFs/eMSMs lack the audiology services necessary for hearing aid procurement may be referred to a network provider for hearing aid procurement, fittings, and/or adjustments throughout the SHCP without a waiver. Except for TRICARE Prime Remote enrollees, the referral must document the lack of MTF/eMSM audiology services. All services must be preauthorized.

k. Requirements added for Continuous Positive Airway Pressure (CPAP) Batteries.

l. Acupuncture services outside of the MTF/eMSM are non-waiverable health care services.

3 January 6, 2016

CHAPTER 17 (Continued)

m. Clarification provided for Benefit Coverage Comparable to the Extended Care Health Option for Seriously Ill or Injured Service Members, i.e., referrals, documentation, and coding.

n. Clarification added for Customized Hand Crank Bikes, must be preauthorized and be no more than the $5,500 cap.

o. Custodial care must be preauthorized with documentation of Category II/III illness or injury and other inclusion criteria in this section accompanying the request.

p. p. Reproductive Services for the Seriously or Severely Ill or Injured Service Member under the SHCP. Clarification added for assisted reproductive service centers to be invited to participate and accept payment at the network discount rate.

q. q. Medications will be purchased through the TPharm contract (to include home delivery, non-network retail pharmacy, and network retail pharmacy options) or MTF/ eMSM.

CHAPTER 18

13. Section 3.

a. Pilot Program for Refills of Maintenance Medications for TRICARE for Life (TFL) Beneficiaries through the TRICARE Mail Order Program (TMOP). Demo ended September 30, 2015, this section was deleted.

b. DHA Evaluation of Non-United States Food and Drug Administration Approved Laboratory Developed Tests Demonstration Project. Renumbered to Section 3.

Corrected Gene HFN1A to Gene HNF1A and repositioned it in the figure.

14. Section 5. A total revision of this demonstration. Clarification added for ABA therapy.

Guidance added for certification/standards for behavior analysts, assistant behavior analysts, behavior technicians, applied behavior analysis technicians, qualified autism services practitioners, cost sharing provisions and reimbursement methodology.

CHAPTER 22

15. Section 1. First Right of Refusal (ROFR) procedures were removed for TRS members and family members.

CHAPTER 23

16. Section 5. Clarified responsibilities for incoming and outgoing contractors.

4 January 6, 2016

CHAPTER 24

17. Section 5. Added telephone, Government furnished web-based self-service enrollment system/application, as additional means to collect TOP Prime enrollment requests.

18. Section 7. Removed “except for Puerto Rico.”

19. Section 9. Added, the TOP contractor shall process claims for Durable Equipment (DE).

5 January 6, 2016

HPOB April 1, 2015

Revision:

The TRICARE Operations Manual (TOM), 6010.59-M provides operational requirements and program guidance for contractors who are contractually bound by part, or all, of this manual.

The Department of Defense (DoD) has a License Agreement with the American Medical Association (AMA) regarding the use of the Physician’s Current Procedural Terminology (CPT), a coding work of medical nomenclature developed by the AMA. In accordance with the terms of that Agreement, the DoD has agreed to:

1. Include a Copyright notice in every section that references CPT codes;

2. Specifically identify procedure codes as CPT codes;

3. Use only short descriptions with CPT codes and delete all long descriptions; and

4. Italicize short descriptions whenever they are used.

The TRICARE Manuals provide instructions, guidance and responsibilities in addition to the requirements set forth in the incorporated federal statutes and the regulations and may not be interpreted in contradiction thereto.

John L. Arendale, Branch Chief Health Plan Operations Branch (HPOB) Defense Health Agency (DHA)

Definitions are available in the Apr 2015 TRICARE Operations Manual (TOM), Appendix A.

Acronyms and Abbreviations are available at http://www._______________.

Foreword

Chapter 1, Section 5

Compliance With Federal Statutes pace n http:// w on page ypertext

2.2.2 The contractor shall provide any updates to the information by e-mail to soc@us-cert.gov, with the Reporting Number in the subject line. The contractor shall provide a copy of the initial or updated US-CERT report to the DHA Privacy Office if requested. Contractor questions about US-CERT reporting shall be directed to the DHA Privacy Office, not the US-CERT office.

2.2.3 In conjunction with submitting the US-CERT report, the contractor shall immediately take steps to minimize the impact of a breach and initiate further investigation of any relevant details.

2.2.4 The contractor shall report a PII/PHI breach (suspected or confirmed) by submitting the form specified below within 24 hours of discovery to the DHA Privacy Office.

2.2.5 The breach reports required within the 24 hour deadline shall be sent by e-mail to:

PrivacyOfficerMail@dha.mil. Encryption is not required, because reports and notices shall not contain PII/PHI. If electronic mail is not available, telephone notification is also acceptable, but all notifications and reports delivered telephonically must be confirmed in writing as soon as technically feasible.

2.2.6 Contractors shall prepare the breach reports required within the 24 hour deadline by completing the Breach Reporting Form DD 2959 (Breach of PII Report), available at the Breach Response link on the DHA Privacy Office web site, http:// www.tricare.mil/tma/privacy/breach.aspx. The contractor shall coordinate with the Privacy Office for subsequent action such as beneficiary notification, and mitigation. The corresponding Contract Data Requirements List (CDRL) provides guidance on completing and updating the Breach Reporting Form DD 2959. The contractor must promptly update the DD Form 2959 as new information becomes available.

2.2.7 If the DHA Privacy Office determines that beneficiary notification is required, the contractor shall provide written notification to beneficiaries affected by the breach as soon as possible, but no later than 10 working days after the breach is discovered and the identities of the beneficiaries are ascertained. The 10 day period begins when the contractor is able to determine the identities (including addresses) of the beneficiaries whose records were impacted.

2.2.8 The contractor’s proposed notification to be issued to the affected beneficiaries shall be submitted to the Privacy Office for approval. The notification to the beneficiaries, at a minimum, shall include the following:

• Specific data elements.

• Basic facts and circumstances.

• Recommended precautions the beneficiary can take.

• Federal Trade Commission (FTC) identity theft hotline information.

• Any mitigation support services offered such as credit monitoring.

2.2.9 Contractors shall ensure that envelopes containing written notifications to affected beneficiaries are clearly labeled to alert the recipient to the importance of its contents, e.g., “Data Breach Information Enclosed,” and that the envelope is marked with the identity of the contractor and/ or subcontractor organization that suffered the breach.

2.2.10 If notification cannot be accomplished within 10 working days, the contractor shall notify the Privacy Office to determine needed follow-up actions.

Delete s betwee and ww and in h link.

http://www.tricare.mil/tma/privacy/breach.aspx

Chapter 2, Section 2

Systems Development

2.4 Connectivity Requirements

2.4.1 The incoming contractor shall collaborate with the Government to establish the required interfaces with Government systems and applications. The contractor shall complete the submission of required forms (e.g., Business to Business Questionnaire, DD Form 2875, etc.) in accordance with the TSM, Chapter 1.

2.4.2 Data Transmission Start Up

2.4.2.1 The DHA will coordinate Business to Business (B2B) Gateway and DFAS connectivity for all contractors. DHA will also coordinate integration testing of the connectivity and data transmission.

DHA and the contractor will collaborate with DFAS/USCG/PHS on the development of a test plan and schedule.

2.4.2.2 At the start-up planning meeting, each contractor on the telecommunication network shall provide DHA the name, address, and telephone number of the person who will serve as a technical POC (update when a change occurs). Contractors shall also provide a separate computer center (Help Desk) number to DHA with the DHA computer operator can use for resolution of problems related to data transmissions.

2.5 Systems Development

Approximately 60 calendar days prior to the start of health care delivery (SHCD), the non-claims processing systems and the telecommunications interconnections between these systems shall be reviewed by DHA or its designees, to include a demonstration by the contractor of the system(s) capabilities, to determine whether the systems satisfy the requirements of TRICARE as otherwise provided in the contract. This includes the telecommunications links with DHA and Defense Enrollment Eligibility Reporting System (DEERS). The review will also confirm access to the web-based TRICARE Duplicate Claims System (DCS) (see the TSM, Chapter 4). The contractor shall effect any modifications required by DHA prior to the initiation of services.

2.6 Claims Processing System and Operations

During the period between the date of award and the SHCD, the incoming contractor shall, pursuant to the Integrated Master Plan/Integrated Master Schedule (IMP/IMS), meet the following contractor file conversions and testing requirements:

2.6.1 Contractor File Conversions and Testing

2.6.1.1 The incoming contractor shall perform initial conversion and testing of all Automated Data Processing (ADP) files (e.g., provider files, claims history files, and beneficiary history) no later than 30 calendar days following receipt of the files from the outgoing contractor(s). Integration testing will be conducted to validate the contractor’s internal interfaces to each of the TRICARE Military Health Systems (MHS) Information Management/Information Technology (IM/IT). This testing will verify the contractor’s system integration, functionality, and implementation process. The incoming contractor shall be responsible for the preparation and completion of Integration Testing 45 days prior to the

SHCD.

Systems Development Contractors shall provide the name(s), title(s), business address(es), and business telephone number(s) of their DCS POCs to the Procuring Contracting Officer (PCO), with courtesy copies to the Contracting Officer Representatives (CORs) and to the DHA DCS Program Representative. The DCS POCs shall be provided to the PCO no later than two weeks prior to implementation of the DCS.

4.1.9 DHA will provide each contractor with the list of all DCS POCs. Whenever a new contract is awarded, DHA will notify all contractors of the new contractor’s DCS POC. Once the initial listing is provided to the contractors, it is the responsibility of each contractor to maintain the listing and keep DHA and the other contractors informed of any changes.

4.1.10 In accordance with the Financial Procedures in the Transition Plan, the contract, and the TOM, the outgoing contractor shall package and forward to the incoming contractor, refund checks received and offsets taken for recoupments associated with duplicate claims payments and recoupment files associated with in progress duplicate claim recoupment 120 days following SHCD.

4.1.11 On the last day of the fourth month following the start of SHCD, or upon direction of the Government, the outgoing contractor shall cease researching Open claim sets and initiating new recoupments associated with duplicate claim payments. The outgoing contractor shall also cease entering refund data and linking adjustment data in the DCS for Pending and Validate claim sets.

4.1.12 The outgoing contractor shall move all Open DCS claim sets to a Pending, Validate, or Closed status by the last day of TED submissions (as defined by the transition plan).

4.1.13 When the outgoing contractor has ceased entering refund and adjustment data on the DCS, refunds may be received and/or TED adjustments may still be submitted for claims in Open and Pending sets. In this case, the incoming contractor may be required to resolve the set without knowing the amount of the refund received by the outgoing contractor.

4.1.14 If the actual recoupment amount was zero when the set was transferred from the outgoing contractor, the incoming contractor may apply the adjustment to the set while leaving the actual recoupment amount as zero dollars. Resolution would result in a Validate status, requiring an explanation by the incoming contractor that the outgoing contractor did not enter the actual recoupment amount.

4.1.15 Following the SHCD, the DCS will begin displaying identified potential duplicate claim sets for which the incoming contractor has responsibility for resolving. The incoming contractor shall begin using the DCS to resolve potential duplicate claim sets in accordance with the TSM, Chapter 4 and the IMP/IMS requirements.

4.1.16 The incoming contractor shall assume full responsibility for resolving all existing potential duplicate claim sets from the outgoing contractor (including completing existing recoupments) and for all new potential duplicate claims sets as agreed upon during the transition meeting.

4.2 Need For The Mass Change Function

4.2.1 When TEDs representing potential duplicate payments (along with their corresponding adjustment and cancellation TEDs) are extracted from the TED database and loaded into the Duplicate Claims database, ownership (i.e., the Owner FI field) of each claim set is assigned. Additionally, a Responsible FI is assigned for each claim in the set. (See the TSM, Chapter 4, Section 1.6, paragraph

Systems Development 1.7.2, for the definition of this field.) The contractor that is the Owner FI is responsible for resolving the set. When a contract transition occurs, responsibility for resolving a set may change. The Mass Change function manages this process by changing the Responsible FI field of all claims included in the transition plan. This field may be changed to the incoming contractor or to an inactive FI 99. It also may be left unchanged if the outgoing contractor remains an active contractor. The Mass Change function also changes the Owner FI field as appropriate.

4.2.2 For example, Contractor 1 has been using the DCS for a year and the DCS has been extracting potential duplicates, creating claim sets and assigning ownership of these sets to this contractor.

Effective, February 1, 2014, Contractor 2 is awarded the contract for this new region. The transition plan establishes that Contractor 2 will assume full responsibility for resolving potential duplicate claim sets, previously the responsibility of Contractor 1, on June 1, 2014. The DCS will identify the affected non-financially underwritten claims and change the Responsible FI field of the affected claims and the Owner FI field of the affected sets to Contractor 2 effective June 1, 2014.

4.2 Phase-Out of the Automated TRICARE DCS

The outgoing contractor shall phase-out the use of the automated TRICARE DCS in accordance with TSM, Chapter 4 and IMP/IMS.

5.0 PERFORMANCE ASSESSMENT REPORTING

5.1 Submission Requirements

Reports and plans for transition in and transition out shall be submitted as required by the Contract Data Requirements Lists (CDRLs), DD Forms 1423.

5.2 Method Of Submission

All deliverables shall be submitted to DHA via a web portal (E-Commerce Extranet) unless otherwise directed by the CDRL. The system is accessed via the Internet through a workstation browser (Internet Explorer (IE) Version 8 or higher) and requires a static Internet Protocol (IP) address. A Common Access Card (CAC) is required for access to the system and ActivClient must be installed in the workstation. Access to the Extranet must be requested using a user access form which will be provided by the Government.

5.3 Training

The incoming contractor shall schedule initial training on the submission of deliverables within 30 calendar days after award. Additional training for new users will be provided throughout the contract upon request.

5.4 Technical Support

Technical support is provided during the business week. A POC for access and deliverable submission will be provided during initial training.

Transitions Chapter 2 Section 3

Critical Processes (CPs) - Provider Networks

Revision:

1.0 PROVIDER NETWORKS

1.1 The contractor shall establish an adequate network of providers in accordance with access standards outlined in Chapter 5, Section 1 and 45 Code of Federal Regulations (CFR) 156.230, with minimal impact to beneficiaries. Provider network development shall be completed no later than 30 days prior to the start of health care delivery (SHCD). The contractor shall establish an adequate network of providers for Prime Service Areas (PSAs) in the Region. For the purposes of assessing adequacy, standards shall apply to all PSAs in the region.

1.2 The contractor shall ensure accurate and complete provider information is entered into contractor and Government automated provider files that interface directly with the Defense Enrollment and Eligibility Reporting System (DEERS), contractor medical management systems, and supporting medical management systems identified by the Government not later than 30 days prior to

SHCD.

1.3 The contractor shall ensure the network has the capability and capacity to permit each beneficiary enrolled in Prime, to enroll to a civilian Primary Care Manager (PCM) prior to the start of Option Period 1 and residing outside of PSAs under this contract to enroll to a PSA PCM, provided the beneficiary resides less than 100 miles from an available network PCM in the PSA and waives both primary and specialty care travel time standards. Beneficiaries enrolled in Prime to a civilian PCM prior to the beginning of Option Period 1 who reside outside of PSAs under this contract and are 100 miles or more from an available PCM in the PSA network, shall not be permitted to continue their enrollment.

1.4 The contractor shall comply with the Contract Data Requirements List (CDRL) requirements for providing the contractor’s approach for meeting Access to Care requirements.

2.0 EXECUTION OF AGREEMENTS WITH CONTRACT PROVIDERS

2.1 All contract provider agreements shall be executed, and loaded to the incoming contractor’s system, 60 calendar days prior to the SHCD, or at such other time as is mutually agreed between the contractor and the Defense Health Agency (DHA).

2.2 The incoming contractor shall begin reporting on network adequacy on a monthly basis during the transition.

3.0 INSTITUTIONAL PROVIDERS

The contractor shall ensure written agreements established with institutional providers comply

Chapter 2, Section 4

Critical Processes (CPs) - Enrollment

2.2 Phase-In of TRICARE Prime Enrollment

The contractor shall begin the enrollment process for the TRICARE Prime Program no later than 60 calendar days prior to the scheduled SHCD, with new enrollment processing to begin 40 days prior to the SHCD, subject to the Defense Health Agency (DHA) approval of systems under the contract.

2.2.1 Enrollment Actions During Enrollment Dual Processing Period

2.2.1.1 When the Defense Manpower Data Center (DMDC) creates the Enrollment Gold File for the incoming contractor, enrollment dual processing begins (Bbetween 45-60 days prior to SHCD). This process creates a future enrollment to the incoming contractor. The following must be followed until

SHCD.

2.2.1.2 For enrollments in the region with an effective date prior to the SHCD (e.g., active duty enrollment, mid-month enrollment; transfer-in), the incoming contractor must effect an enrollment to begin on the SHCD once notified by the outgoing contractor of the new enrollment. DMDC may run a report at the end of the transition period that reflects new additions.)

2.2.1.2.1 The outgoing contractor has until SHCD to send updated fee information to DEERS.

Beginning at the SHCD, the outgoing contractor will work with the incoming contractor to resolve any discrepancies of cumulative enrollment fees and paid-through dates on policies.

2.2.1.2.2 Beginning at the SHCD, the incoming contractor shall send the corrected fee information to DEERS using Fee/Catastrophic Cap and Deductible (CCD) Web Research application or the batch fee interface outline in the TSM, Chapter 3.

2.2.1.3 When a current enrollment in the region requires deletion with an effective date prior to the SHCD (e.g., transfers out; disenrollments for failure to pay fees; cancellations, etc.), when requested by another enrolling contractor, the incoming contractor must cancel the future enrollment segment and notify the outgoing contractor when this action has been completed.

2.2.1.4 For all other enrollment actions with an effective date prior to SHCD (e.g., Primary Care Manager (PCM) changes; Defense Medical Information System Identification Code (DMIS-ID) changes;

enrollment begin date changes; etc.), when requested by the outgoing contractor, the incoming contractor must cancel the future enrollment segment and notify the outgoing contractor when this action has been completed. When notified by the outgoing contractor that their change has been effected, the incoming contractor must verify/reinstate the future enrollment segment.

2.2.2 In addition to other contractually required enrollment reports, the contractor, shall provide progress updates on enrollment activities in accordance with the Integrated Master Plan /Integrated Master Schedule (IMP/IMS).

2.3 Transfer Of Enrollment Files

2.3.1 DMDC will provide the incoming contractor with initial enrollment policy information through an Enrollment Gold File. DMDC will provide the incoming contractor with an incremental enrollment load file for each contract transition. The incoming contractor shall obtain enrollment policy information from DEERS through an initial enrollment load file. DMDC will provide the incoming contractor with an enrollment load file for each contract transition. The outgoing contractor shall

Chapter 2, Section 4

Critical Processes (CPs) - Enrollment provide the additional enrollment information required for those Active Duty Family Members (ADFMs) enrolled in TRICARE Prime who reside outside of a Prime Service Area (PSA) who were granted grandfathered status and maintain their eligibility for TRICARE Prime. The additional enrollment information shall include, but is not limited to, the original address of the beneficiary when they were initially grandfathered. The incoming contractor shall process each enrollment load file within 24 hours or less from receipt of the file.

2.3.2 No later than the date specified at the Transition Specifications Meeting, the outgoing South Region contractor shall provide to the incoming East Region contractor, the additional enrollment information required for Continued Health Care Benefits Program (CHCBP) enrollees.

Note: Each contract transition shall require a global freeze of enrollment. This freeze will occur beginning the first weekend that precedes the 60 day window prior to the SHCD. The actual calendar dates will be determined during the transition meeting.

2.3.3 The incoming contractor shall send enrollment renewal notices for all enrollees whose current enrollment period expires on or after the SHCD. The incoming contractor shall send billing statements where the enrollment fee payment would be due on or after the SHCD. The incoming contractor shall start sending billing notices and process renewals 45 days prior to the SHCD.

2.3.4 Outstanding enrollment record discrepancies and issues reported to the DEERS Support Office (DSO) by the outgoing contractor will be transferred to the incoming contractor for reconciliation. Records will be reconciled in accordance with the TSM, Chapter 3.

2.4 Enrollment Fees

2.4.1 The incoming contractor shall obtain the cumulative total of enrollment fees and paid-through dates for the policies from DEERS. The contractor who collects the enrollment fee shall forward the fees to the Government in accordance with Chapter 6, Section 1. The outgoing contractor shall work with the incoming contractor to resolve any discrepancies of cumulative enrollment fees and paid-through dates within 90 days of start of the SHCD on policies inherited during the transition. The incoming contractor shall send the corrected fee information to DEERS using the Fee CCD Web Research application or the batch fee interface outlined in the TSM, Chapter 3.

2.4.2 The incoming contractor will shall obtain information from the outgoing contractor on fees that are being paid monthly (i.e., by allotment or Electronic Funds Transfer (EFT) and transition these monthly payment types in the least disruptive manner for the beneficiary a way that does not require the beneficiary to personally stop and restart their electronic payment(s).

2.4.3 The incoming contractor shall coordinate the transition of allotment data, through the Performance, Analysis, Transitions, and Integration Section (PAT&IS) and/or the applicable DHA Program office, with the Defense Finance and Accounting Service (DFAS), Public Health System (PHS), and U.S. Coast Guard (USCG) during the transition-in period of the contract (see the TSM, Chapter 1, Section 1.1).

2.5 Phase-Out Of Enrollment Activities

2.5.1 Prior to the SHCD under the successor contract, for all enrollment renewals or payments in which the new enrollment period or period covered by the premium payment will begin under the

Chapter 6, Section 1

TRICARE Prime Enrollment Processing

4.2.4 If an enrollee does not respond to the re-enrollment notification and fails to make an enrollment fee payment by the end of the grace period, the contractor shall assume that the enrollee has declined re-enrollment. The contractor shall disenroll the beneficiary retroactive to the enrollment expiration date.

4.2.5 Service members may not decline reenrollment nor request disenrollment.

4.2.6 DMDC sends written notification to the beneficiary of the disenrollment and the reason for the disenrollment within five business days of the disenrollment transaction.

4.3 Disenrollment

4.3.1 Disenrollment requests must be initiated by the sponsor, spouse, other legal guardian of the beneficiary, or an eligible beneficiary 18 or older. An official disenrollment request includes those with:

• An original signature;

• An electronic signature offered by and collected by the contractor;

• A verbal consent provided vial telephone and documented in the contractor’s call notes; and

• A self-attestation by the beneficiary when using the Government furnished web-based self-service enrollment system/application. (A sponsor service member cannot be disenrolled request disenrollment per paragraph 4.2.5.)

4.3.2 The contractor shall automatically disenroll beneficiaries when the appropriate enrollment fee payment is not received by the 30th calendar day following the paid through date. The contractor shall set the disenrollment effective date retroactive to the paid through date. An enrollment fee payment includes the correct amount for the period the fee is intended to cover (i.e., monthly, quarterly, or annually).

4.3.3 Prior to processing a disenrollment for “non-payment of fees,” the contractor shall reconcile their fee payment system against the fee totals in DEERS. Once the contractor confirms that the payment amounts match, the disenrollment may be entered in the Government furnished web-based enrollment system/application.

4.3.4 The disenrolled beneficiary is responsible for the deductible and cost-shares applicable under TRICARE Extra or Standard for any health care received during the 30 day grace period. In addition, the beneficiary is responsible for the cost of any services received during the 30 day grace period that may have been covered under TRICARE Prime but are not a benefit under TRICARE Extra or Standard.

4.3.5 The contractor may suspend claims processing during the grace period to avoid the need to recoup overpayments.

4.3.6 See the TPM, Chapter 10, Sections 2.1 and 3.1 for additional information on disenrollment.

TRICARE Prime Enrollment Processing

5.1.1 Fiduciary Responsibilities

5.1.1.1 The contractor shall act as a fiduciary for all funds acquired from Prime enrollment fees, which are Government property. The contractor shall develop strict funds control processes for its collection, retention and transfer of enrollment fees to the Government. All enrollment fees received by the contractor shall be maintained in accordance with these procedures.

5.1.1.2 A separate non-interest bearing account shall be established for the collection and disbursement of enrollment fees. The contractor shall deposit enrollment fees into the established account within one business day of receipt.

5.1.1.3 The contractor shall wire-transfer the enrollment fees minus any refund payments twice monthly, on the first (business day) and the 15th to a specified Government account as directed by the Defense Health Agency (DHA) Contract Resource Management (CRM) Office, refer to Section J of the contract. The Government will provide the contractor with information for this Government account.

The contractor shall notify the DHA CRM, by e-mail, within one business day of the deposit stating the date and amount of the deposit.

5.1.1.4 The contractor shall maintain a clear, auditable record of all enrollment fees received, the date received and the date transferred to the Government. The contractor’s record shall also document all refunds issued, to whom the refund was issued, the amount of the refund, and the date reported to the Government.

5.1.2 Annual Payment Fee Option

An annual installment is collected in one lump sum. For initial enrollments, Contractors shall prorate the fee from the enrollment date to September 30. Contractors shall accept payment of the annual enrollment fee only by credit card (e.g., Visa/MasterCard). See paragraph 4.3 for disenrollment information if the appropriate enrollment fee payment is not received.

5.1.3 Quarterly Payment Fee Option

Quarterly installments are equal to one-fourth (1/4) of the total annual fee amount. For initial enrollments, contractors shall prorate the quarterly fee to cover the period until the next fiscal year quarter. (Fiscal quarters begin on January 1, April 1, July 1, and October 1.) Contractors shall collect quarterly fees thereafter. Contractors shall accept payment of the quarterly enrollment fee only by credit card (e.g., Visa/MasterCard) or Electronic Funds Transfer (EFTs) from the enrollee’s designated financial institution. Payments may be made on a recurring basis. See paragraph 4.3 for disenrollment information if the appropriate enrollment fee payment is not received.

5.1.4 Monthly Payment Fee Option

Monthly installments are equal to one-twelfth (1/12) of the total annual fee amount.

Monthly enrollment fees must be paid-through an automated, recurring electronic payment either in the form of an allotment from retirement pay or through Electronic Funds Transfer (EFTs) from the enrollee’s designated financial institution (which may include a recurring credit or debit card charge).

These are the only acceptable payment methods for the monthly payment option.

TRICARE Prime Enrollment Processing than 100 miles but more than 30 minutes from their PCM will remain in effect until the beneficiary changes residence.

9.2 The contractor must estimate the travel time or distance between a beneficiary’s residence to a PCM (either a civilian PCM or an MTF/eMSM) using at least one web-based mapping program. The choice of the mapping program(s) is at the discretion of the contractor, but the contractor must use a consistent process to determine the driving distance for each enrollee applicant who may reside more than 30 minutes travel time from their PCM. The time or distance shall be computed between the enrollee’s residence and the physical location of the PCM (including MTFs/eMSMs). It is not acceptable to use a geographic substitute, such as a geographic centroid.

9.3 The contractor (in conjunction with MTFs/eMSMs for MTF/eMSM enrollees) shall provide beneficiary drive-time waiver education and ensure that beneficiaries who choose to waive these standards have a complete understanding of the rules associated with their enrollment and the travel time standards they are forfeiting. This includes educating beneficiaries, who waive their ATC travel standards, of the following:

• They should expect to travel more than 30 minutes for access to primary care (including urgent care) and possibly more than one hour for access to specialty care services.

• They will be held responsible for POS charges for care they seek that has not been referred by their PCM (or for MTF/eMSM enrollees, by another MTF/eMSM provider).

• They should consider whether any delay in accessing their enrollment site might aggravate their health status or delay receiving timely medical treatment.

9.4 Beneficiaries, enrolling in TRICARE Prime or TPR, may apply to enroll in a Region other than their home of residence region. Beneficiaries shall apply to the region where the desired PCM is located. All TRICARE Prime and TPR enrollment policies apply, i.e., PCM selection, utilization, referrals and TPR eligibility. An access to care drive-time waiver is required. Examples of applicable policies are: the beneficiary must live within 100 miles of an available PCM located in a PSA and must obtain all care from or as referred by their PCM.

9.5 MTF/eMSM Enrollees

9.5.1 Non-active duty beneficiaries must reside within 30 minutes travel time from an MTF/ eMSM to which they desire to enroll. If a beneficiary desiring enrollment resides more than 30 minutes (but less than 100 miles) from the MTF/eMSM, they may be enrolled so long as they waive primary and specialty ATC standards and the MTF Commander/eMSM Manager, or designee, approves the enrollment. (If the MOU includes zip codes or drive-time distances for which the MTF/eMSM is willing to accept enrollments that are beyond a 30 minute drive, this constitutes approval. See 32 CFR 199.17 for information on access standards. If not addressed in the MOU, the contractor shall submit each request to the MTF Commander/eMSM Manager, (or designee), in a method that is outlined in the MOU.) The Director, TROs may approve waiver requests from beneficiaries who desire to enroll to an MTF/eMSM and who reside 100 miles or more from the MTF/eMSM. In these cases, the MTF Commander/eMSM Manager must also be agreeable to the enrollment and have sufficient capacity and capability.

9.5.2 If the contractor determines that the beneficiary resides 100 miles or more from the MTF/ eMSM to which they are enrolled, and there is no 100 mile waiver on file, the contractor shall inform the

TRICARE Prime Enrollment Processing from the MTF/eMSM are not to be renewed at the end of the enrollment period. The contractor shall inform such beneficiaries no later than two months prior to expiration of the current enrollment period that they are no longer qualified for renewal of enrollment to the MTF/eMSM. Prior to notification, the contractor shall obtain the rationale for the change from the MTF/eMSM to include in the notice to the beneficiary. The proposed notice shall be reviewed and concurred on by the Director, TROs prior to being sent to the impacted beneficiaries. (The TRO will coordinate notices with the DHA Communications prior to approval.)

9.5.5 At any time during the enrollment period, if the contractor determines there is no signed travel time waiver on file for a current MTF/eMSM enrollee who resides more than 30 minutes from the MTF/eMSM, the contractor shall, at the next annual TRICARE Prime renewal point, require the beneficiary to waive the primary and specialty care travel standards before the enrollment will be renewed. (This includes monitoring address changes received by the contractor from all sources.) The contractor shall notify the beneficiary of this waiver requirement no later than two months before expiration of the annual enrollment period. The language for all beneficiary notices shall be reviewed and concurred on by the TRO prior to being sent to beneficiaries. (The TRO will coordinate notices with the DHA Communications prior to approval.)

• Any notice to a beneficiary that is requesting they sign a waiver of access standards, denying their enrollment, or advising them they are not eligible for re-enrollment to an MTF/eMSM, shall include information on any alternative options for enrollment. The notice must also advise the beneficiary of the option to participate in TRICARE Standard, Extra, or the USFHP where available.

9.5.6 When an enrollment request requires MTF Commander/eMSM Manager or Director, TROs approval, any contractual requirements relating to processing timeliness for enrollment requests will begin when the contractor has obtained direction from the MTF Commander/eMSM Manager or Director, TROs regarding waiver approval or disapproval.

9.6 Civilian PCMs

9.6.1 Within a PSA, the contractors’ civilian network shall have the capability and capacity to allow beneficiaries who reside in the PSA to enroll to a PCM within access standards. If a beneficiary who resides in the PSA requests enrollment to a specific PCM who is located more than a 30 minute drive from the beneficiary’s residence, the contractor may allow the enrollment if beneficiary waives travel time access standards. (Also, see Chapter 5, Section 1.)

9.6.2 Outside a PSA, for new enrollments (including portability transfers), the contractor is not required to establish a network with the capability and capacity to grant enrollment to beneficiaries who reside outside a PSA. Requests for new enrollments to the civilian network from beneficiaries residing outside a PSA will be granted provided there is sufficient unused network capacity and capability to accommodate the enrollment and that the PSA civilian network PCM to be assigned is located less than 100 miles from the beneficiary’s residence. Beneficiaries who reside outside the PSA and enroll in TRICARE Prime must waive their primary and specialty care travel time access standards.

9.6.2.1 ADFMs (Including ADFM TYA Prime Enrollees) Residing Outside A PSA

ADFMs (including ADFM TYA Prime enrollees) enrolled in TRICARE Prime and who reside outside of a T-3 PSA on September 30, 2013, will be grandfathered in TRICARE Prime starting October 1, TRICARE Prime Enrollment Processing 2013. They will remain enrolled in TRICARE Prime as long as they reside within 40 miles of the residence where they were originally granted grandfathered status and maintain eligibility as ADFMs. The contractors must continue to have a PCM available for these beneficiaries and ensure all claims and benefits are administered as TRICARE Prime. ADFMs shall remain enrolled in TPRADFM, as appropriate.

The contractors will manage the grandfathered ADFMs as stated in this chapter.

9.6.2.2 Terms Of Grandfathered Status

The ADFM must maintain a residence within 40 miles of the residence where they were originally granted grandfathered status in order to retain grandfathered status. Grandfathered ADFMs must be assigned a PCM. Grandfathered ADFMs may add or terminate enrollment of dependents like any other ADFM (marriage, birth, adoption, divorce, etc.). Dependents may live in a separate residence outside a T-3 PSA and still be grandfathered.

9.6.2.3 Grandfathered ADFMs lose their grandfathered status when they are:

• No longer TRICARE eligible;

• No longer residing within 40 miles of the residence where they were originally granted grandfathered status; or

• Change to retired status.

9.6.3 Beneficiaries who reside outside the PSA and are 100 miles or greater from an available civilian network PCM in the PSA shall not be allowed to enroll in TRICARE Prime.

10.0 REPORTS

The contractor shall provide monthly Service member enrollment and beneficiary services reports according to the Contract Data Requirements List (CDRL).

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Chapter 7, Section 3

Contractor Relationships With The Military Health System (MHS) TRICARE Quality Management Contract (TQMC) Contractor Provider Program Office (DPPO) and the DHA Privacy Office. The notifications shall provide available details about the shipment and the circumstances. The TQMC contractor shall verify that these notifications are sent, and shall provide the notifications itself if the sender of the records fails to do so.

Thereafter, the MCSC, DP, or TDEFIC shall comply with breach response requirements of Chapter 1, Section 5 and applicable law.

3.0 The MCSCs, DPs, and TDEFIC shall provide the appropriate TRO/DPPO and TDEFIC Contracting Officer’s Representative (COR) written responses to all TQMC contractor findings. The MCSC’s, DP’s, and TDEFIC contractor’s responses shall state agreement, partial agreement, or nonconcurrence with each discrepancy found by the TQMC contractor, and include supporting rationale, and proposed follow-up actions to address the issues (see contract CDRLs for reporting requirements). Details for content and submission of the TQMC Monthly Quarterly Findings Report are contained in the contract, DD Form

1423, CDRL.

4.0 At the direction of the Defense Health Agency (DHA) Clinical Support Division (CSD), the MCSCs, DPs, and TDEFIC and TOP contractors shall attend two face-to-face meetings annually, of one to two days duration, at a location chosen by CSD. Additionally, contractors shall participate in two teleconference meetings not to exceed one day per meeting.

(Logo or Letterhead of Company)

Inside mailing address identifying Organization and Person Shipping POC

Privacy/HIPAA Warning Notice:

The information in the enclosed documents may be subject to the Privacy Act of 1974, the Health Insurance Portability and Accountability Act (HIPAA) and other Federal Laws protecting the privacy and security of Personally Identifiable Information (PII), including health information. Personal information contained in this inventory and in the enclosed documents may be used and disclosed only by authorized persons in the conduct of official business and only in accordance with the Privacy Act, HIPAA and other applicable Federal law. Any unauthorized use or disclosure of personal information may result in criminal and/or civil penalties. If you are not the intended recipient of this correspondence, you must notify the sender upon receipt and transfer the documents in accordance with the sender’s instructions. If you inspect, copy or transfer the enclosed documents other than as instructed, a violation of applicable law may occur.

This is Box X of Y mailed on MM/DD/YEAR

Record Request Received by Contractor: Month & Year

Recommended Per Box Inventory Letter Example (to be included in each box)

Name of Contractor: Date Mailed: M/D/YR Month of Chart Request: M/YR Number of records in box =

ICN Patient Name Patient Year of Birth Admission Date Discharge Date

FIGURE 7.3-1 BOX INVENTORY DOCUMENT (SAMPLE)

Chapter 7, Section 4

Clinical Quality Management Program (CQMP) contractor shall process to completion 95% of all PQIs within 90 calendar days from date of identification and 100% within 180 calendar days of identification. For reporting of PQIs and QIs, see DD Form 1423, CDRL, CQM Monthly Quality Intervention Reporting.

5.1 Quality Intervention

The contractor shall implement appropriate quality interventions using evidence based medicine/guidelines and best medical practices to reduce the number of QIs and improve patient safety. When the contractor confirms a QI or determines there is deviation in the standard of practice or care, the determination shall include assignment of an appropriate severity level and/or sentinel event, and describe the actions taken to resolve the quality problem. Details for content and submission of a Clinical Quality Management Intervention Report are contained in the contract, DD Form 1423, CDRL.

5.2 Definitions

5.2.1 PQI

A PQI is a clinical or system variance, warranting further review and investigation for determination of the presence of an actual QI.

5.2.2 No QI

Following investigation there is NO QI finding.

5.2.3 QI

A QI is a verified deviation, as determined by a qualified reviewer, from acceptable standard of practice or standard of care as a result of some process, individual, or institutional component of the health care system.

• Severity Level 1. QI is present with minimal potential for significant adverse effects on the patient.

• Severity Level 2. QI is present with the potential for significant adverse effects on the patient.

• Severity Level 3. QI is present with significant adverse effects on the patient.

• Severity Level 4. QI is present with the most severe adverse effect and warrants…