Exhibit L-9 - TMEP CY24_25_26 Manual Changes Modification Log.xlsx
XLSX spreadsheet 47 KB Posted
- Solicitation number
- HT940226R0001
- Issued by
-
Defense Health Agency
About this file
This is a tracking document for TRICARE manual changes across three contract years (CY24, CY25, and CY26) for the TRICARE Medicare Eligible Program (TMEP) Second Generation contract, documenting modifications to the TRICARE Operations Manual (TOM), TRICARE Pharmacy Manual (TPM), TRICARE Reimbursement Manual (TRM), and TRICARE Systems Manual (TSM).
The document logs over 200 manual change packages organized by contract year and change type (manual vs. routine changes). Key modification categories include clinical policy updates (evolving practices covering new medical treatments and technologies), reimbursement rate adjustments, premium updates, administrative and systems changes, beneficiary eligibility clarifications, and coding/data element updates. Notable clinical changes across the three-year period include coverage expansions for digital breast tomosynthesis, HIV pre-exposure prophylaxis (PrEP), hearing aids for child dependents, childbirth and breastfeeding support, gender dysphoria treatment limitations in minors, and various advanced medical devices and therapies. Administrative updates address contractor requirements, personnel security, cybersecurity, records management, and duplicate claims system procedures. Reimbursement changes include annual DRG updates, foreign per diem adjustments, Home Health routine rate modifications, and pharmacy copay updates for calendar years 2025-2027. The document tracks change issuance dates, publication dates, and processing timelines, with associated costs noted for select high-impact changes (ranging from $0 to approximately $1.3 million for the NPI data expansion). Changes apply to both T17 (TRICARE North Region) and T5 (TRICARE South Region) managed care support contracts under the Defense Health Agency's TRICARE program.
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CY24 Manual_Changes
| CY24 Manual Changes Tracking |
| T17 & T5 |
| ConReq | Version | Title | Change Package Description | Manual | Cost |
| 23201 | T5 | T5 NDAA16, Section 717, Provider Readiness Designation | This change gives clarification to ensure that NDAA FY2016 Sec 717 requirements are implemented correctly. | TOM | 0 |
| 23200 | T5 | T5 Telehealth Services-Removing Market/MTF | This change removes “and Market/Military Treatment Facility (MTF)" language. | TOM | 0 |
| 23199 | T17 | T17/T5 Mission Partner Identify, Credential and Access Management (MP ICAM) | This change updates requirements. | TSM | 0 |
| T5 | |||||
| 23186 | T5 | T5 Call Resolution Definition Language | This change adds clarification and deletes ambiguous language. | TOM | 0 |
| 23185 | T5 | T5 Referral Management KSA Update | This change updates information. | TOM | 0 |
| 23184 | T17 | T17/T5 Provisional Coverage MABs for AD ΤΡΜ 9/16/2024 12/30/2024 72 138 | This change provides updates to include provisional coverage of monoclonal antibody drugs for Alzheimer's disease and mild cognitive impairment. | TSM | TMEP- $88,779,088 |
| T5 | TPM | 0 | |||
| 23162 | T17 | T17/T5 Discrepant Address Drive Time Waiver | This change updates contract requirements and administrative changes to minimize involuntary disenrollment through applying a default DTW to TRICARE Prime beneficiary accounts with discrepant addresses (within 100 miles of an MTF or within the MOU-authorized locations) and to new Prime enrollments. | TOM | 0 |
| T5 | |||||
| 23161 | T17 | NDAA FY 2017, Section 701, Prime Fee Waiver | This change limits Prime enrollment fee waiver to Group A Medicare-eligible beneficiaries. | TOM | 0 |
| T5 | |||||
| 23157 | T5 | T5 SHCP Expansion of Extended Benefits for ART & Administrative Edits | This change provides direction to the contractor on how to accommodate the expansion of the Assisted Reproductive Technology (ART) benefit available to Cat II/III ADSMs through the extended benefits authorized under 10 USC 1074(c)(4) under the Supplemental Health Care Program (SHCP). This change also includes administrative edits to clarify direction to the contractor regarding the coverage adjudication process under the SCHP. | TOM | 0 |
| 23145 | T17 | T17/T5 LDT Demo Update | This change adds newly covered LDTs moves the LDT list from the TOM to the TRICARE rates and reimbursement website. | TOM | 0 |
| T5 | |||||
| 23132 | T17 | T17/T5 Catastrophic Cap | This change directs the contractor to pend disenrollment and claims for 90 days, make additional tiered notifications to the beneficiary in the event of a CATCAP recalculation and allow the PSCSCs to reinstate coverage beyond the current reinstatement policy after a CATCAP recalculation occurs. | TOM | 0 |
| T5 | |||||
| 23075 | T17 | T17 Records Management Changes | This change updates DOD Manual 8180.01 Information Technology Planning for Electronic Records Management and adds Electronic Record Transfer Procedures. | TOM | 0 |
| 23074 | T5 | T5 Public Key Infrastructure (PKI) Requirements | This change updates the Public Key Infrastructure (PKI) requirements providing the Managed Care Support Contractors (MCSCs) with current DHA PKI requirements to utilize the capabilities afforded by their Common Access Card (CAC) to digitally sign and encrypt CUI transmitted digitally to DHA associates. | TSM | 0 |
| 23073 | T5 | T5 Records Management | This change updates records management and administration, critical processes, electronic records and disposition and storage, and automated data processing. | TSM | 0 |
| 23072 | T5 | T5 Personnel Security Updates | This change provides updates to ensure the Managed Care Support Contractors (MCSCs) have the current requirements and guidance to support their contract performance requirements. Gov ID Title | TSM | 0 |
| 23070 | T5 | T5 Clinical Changes | This change updates language | TOM | 0 |
| 23062 | T5 | T5 DOD Comprehensive Autism Care Demonstration Referral and Appointing Center/CDRL | This change updates language in the Department of Defense (DoD) Comprehensive Autism Care Demonstration (ACD) to include an update of the Referral and Appointing Center (RAC) Pilot and CDRLs. | TOM | 0 |
| 23061 | T17 | T17/T5 Batch/Voucher ASAP Account Number Format | This change updates Batch/Voucher ASAP Account Number Format. | TSM | 0 |
| T5 | |||||
| 23060 | T5 | T5 MMSO Changes | This change defines the contractor responsibilities and authorizations. Changes include instruction on Government designated system and medical management system. | TOM | 0 |
| 23058 | T5 | T5 OHI Repository Sunset TOM 6/3/2024 9/20/2024 | TPM | 0 | |
| 23045 | T5 | T5 ONLY Critical Processes (CPs) – Clinical Operations | This change aligns language in TOM Chapter 2, Section 9, with the rest of the T5 requirements when referencing the TRICARE Pharmacy (Tpharm) contractor. | TOM | 0 |
| 23042 | T5 | T5 Clarify Limitations of Sensory Integration Therapy | This change clarifies that SIT services are not payable separately or when billed in conjunction with other therapies. | TPM | 0 |
| 23041 | T5 | T5 Clarification of Rare Disease Policy for TOP and the USFHP/DPs | This change adds clarification to Rare Disease policy to specify TOP and USFHP beneficiaries are included in this coverage and removing the rare disease CDRL requirement for TOP and USFHP Designated Providers. | TPM | 0 |
| 23040 | T5 | T5 Laboratory Developed Tests Demonstration Non-Invasive Prenatal Testing Update | This change updates language for expansion of non-invastive prenatal testing (NIPT) of pregnant women. Gov ID Title | TSM | 0 |
| 23039 | T5 | T5 Automatic Blood Pressure Monitors | This change authorizes coverage of automatic blood pressure monitors for beneficiaries receiving covered RPM services and establishes requirements for coverage. | TPM | 0 |
| 23038 | T5 | T5 Mobile Medical Application | This change clarifies coverage criteria for Mobile Medical Applications and related sensors based on existing TRICARE policy and regulations. | TPM | 0 |
| 23037 | T5 | T5 Pediatirc COVID Policy | This change clarifies language for pediatiric NTAPS. | TRM | 0 |
| 23025 | T5 | T5 Companion Diagnostics Clarification | This change clarifies the TPM to establish that tests used for on-label indications as companion diagnostics are covered benefits. | TPM | 0 |
| 23022 | T5 | T5 Consolidated Change 24-001 | This consolidated change includes clarificaitons to policy regarding coverage of certain microcurrent devices and coverage of freestanding HBOT facilities. | TPM | 0 |
| 23023 | T5 | T5NDAA FY 2024, Section 703, Hearing Aids | This change aligns TRICARE policy with a provision in the NDAA for FY 2024 (Sec. 703) that expands coverage of hearing aids to child dependants of certain former members of the uniformed services. | 0 | |
| 23021 | T5 | T5 Complications Care Update | This change aligns complications policy with regulation. | TPM | 0 |
| 23020 | T5 | T5 Mastectomy Policy Clarification | This change adds definition of "mastectomy" to policy. | TPM | 0 |
| 23018 | T5 | T5 Controls for Excessive Charges for Professional Services, and DMEPOS/PEN Services without Established Rates | TRM 6/6/2024 8/23/2024 55 8 This change adds a new addendum to the TRM Chapter 1, regarding Billed charges and the Reimbursement for Professional and DMEPOS/PEN Services without Fee-Scheduled Rates. | TRM | 0 |
| 23017 | T5 | T5 NDAA FY 21 Sec 746 Childbirth and Breastfeeding Support Demonstration | This change implements adjustments to the demonstration and outlines special policies for implementation of the Childbirth and Breastfeeding Support Demonstration overseas. | TOM | 0 |
| 22984 | T17 | Companion Diagnostics Clarification | This change clarifies language to establish that tests used for on-label indications as companion diagnostics are covered benefits. | TPM | 0 |
| 22975 | T17 | Complications Care Update | This change aligns complications policy with regulation. | TPM | 0 |
| 22917 | T17 | Consolidated Change 24-001 | This consolidated change includes clarificaitons to policy regarding HIV PrEP coverage, coverage of certain microcurrents devices, and coverage of freestanding HBOT facilities. | 0 | |
| 22916 | T17 | NDAA FY 2024, Section 703, Hearing Aids | 0 | ||
| 22912 | T17 | OHI Repository Sunset | TOM | TMEP-$113,270 | |
| 22908 | T17 | SHCP Expansion of Extended Benefits for ART & Administrative Edits | This manual change provides direction to the contractor on how to accommodate the expansion of the Assisted Reproductive Technology (ART) benefit available to Cat II/III ADSMs through the extended benefits authorized under 10 USC 1074(c)(4) under the Supplemental Health Care Program (SHCP). This portion of the manual change will be accompanied by a new CDRL being processed. This change also includes administrative edits to clarify direction to the contractor regarding the coverage adjudication process under the SCHP. This change applies to both T17 and T5 contracts. | TOM | 0 |
| 22905 | T17 | Mail Order Specialty Pharmacy | This change includes 2 new Special processing codes RP and SD. RP- Mail Order Pharmacy (MOP), Specialty Clinical Services, Drugs Dispensed and SD - Mail Order Pharmacy (MOP) Specialty Supportive Drugs Dispensed. Also RP and SD have been added to two edits 2-305-33R and 2-30-48R. | TSM | 0 |
| 22902 | T17 | NDAA FY21, Section 746, Childbirth and Breastfeeding Support Demonstration (CBSD) Adjustments | This change adds adjustments to the demonstration. | TOM | 0 |
| 22984 | T17 | Mastectomy Policy Clarificaiton | This change adds definition of "mastectomy" to policy. | TPM | |
| 22893 | T17 | Discrepant Address and Claims Jurisdiction | This change clarifies direction to contractors regarding PCM changes versus when disenrollment is appropriate, as well as understanding contractor responsibilities for split claims. | TPM | 0 |
| 22881 | T17 | Type of Institution 94 | This change corrects a Provider Major Specialty Code and changes a Major Specialty Code Freestanding End Stage Renal Disease (ESRD) Facilities to 94. | TSM | 0 |
| 22877 | T17 | NDAA FY 2020, Section 702, New TRICARE Prime Retiree Payment by Allotment | This change directs the payment of enrollment fees via allotment from military pay, where feasible, for new TRICARE Prime Retiree Policies (effective January 1, 2021). | TOM | 0 |
| 22844 | T17 | Chapter 28-Prescription Monitoring Program | This change provides updates as a result of DoDIG audit. | TOM | 0 |
| 22842 | T17 | Professional and DMEPOS/PEN Services without Fee-Schedule Rates | This change adds a new addendum to the TRM Chapter 1, regarding Billed charges and the Reimbursement for Professional and DMEPOS/PEN Services without Fee-Schedule Rates. | TRM | 0 |
| 22834 | T17 | Limitations of Sensory Integration Therapy | This change clarifies that sensory integration therapy is unproven and excluded when provided and billed as a standalone service; however, it is covered when it is part of multidisciplinary therapeutic intercentions OR is a component of cognitive rehabilitation therapy. | 0 | |
| 22833 | T17 | Clarification of Rare Disease Policy for TOP and the USFHP/DPs | This change provides clarification of Rare Disease policy for TRICARE Overseas Program and the Uniformed Services Family Health Plan, Designated Providers. | TPM | 0 |
| 22767 | T17 | NIPT Coverage Update -LDT Demonstration | This package updates the coverage criteria for NIPT testing under the LDT Demonstration | TOM/TSM | 0 |
| 22687 | T17 | Contractor Loss of Funds While Making Payments | This change revises language | TOM | 0 |
| 22607 | T17 | Cybersecurity Updates | This change updates personnel security requirements, DoD policies, and PKI requirements/procedures. | TSM | 0 |
CY24_Routine
| CY24 Routine Changes Tracking |
| T17 & T5 |
| ConReq | Version | Title | Change Package Description | Manual |
| 23226 | T5 | T5 Reimbursement Update 24-006 | This change updates GTMCPA language regarding hold harmless payments. Manual Date Issued Date Days In Published Progress* Change Number | TRM |
| 23210 | T17 | T17/T5 Evolving Practices 24-005 | This package includes the following evolving practice manual changes related to recently signed Medical Benefit Determinations 1) Coronary Artery Calcium Scoring, 2) Liposuction for Lipedema, 3) Radiofrequency Ablation for the Treatment of Symptomatic Uterine Fibroids, 4) Continuous Glucose Monitoring System Devices, and 5) Cryoablation for Malignancies of the Lung. | TPM/TOM |
| T5 | ||||
| 23165 | T17 | Evolving Practices 24-004 | This change excludes coverage of electroconvulsive therapy for the treatment of autism with catatonia and the Volara device for oscillation and lung expansion (OLE) therapy in the home. | TPM |
| T5 | ||||
| 23103 | T5 | T5 Evolving Practices 24-003 | This change adds coverage of unilateral thaalamotomy using Magnetic Resonance Image guided Foscused Ultrasound for treatment of medication refractory essential tremor…. | TPM |
| 23077 | T17 | T17/T5 Reimbursement Update 24-005 | This change corrects an effective date for ESRD services, corrects values for the DRG Labor-Related and Non-Labor-Related Portions of the Adjusted Standardized Amounts for CY24, and corrects identifier. Gov ID Title | TRM |
| T5 | ||||
| 23024 | T5 | T5 Reimbursement Update 24-002 | This change updates the FY24 Foreign Per Diem for the Phillipines and Panama and also removes the 2020 per diems. | TRM |
| 23019 | T17 | T17/T5 Reimbursement Update 24-003 | This change updates the mental health reimbursement rates and moves an incorrect reference to the RTC 771 Form from TPM Chapter 11 Addendum D to Addendum E. | TRM/TPM |
| T5 | ||||
| 22965 | T17 | Evolving Practices 24-002 | This change includes all signed MBDs with manual changes (evolving practices) for Q1 2024. It updates policy by excluding unproven treatments (BAT for heart failure and Botulinum toxin A for temporomandibular jaw disorder), and modernizes the benefit by establishing coverage for liposuction for lipedema. | TPM |
| T5 | ||||
| 22953 | T17 | Reimbursement Update 24-003 | This change standardizes wording to consistently refer to TRICARE-designated percentage amounts for NTAPS. | TRM |
| 22895 | T17 | Evolving Practices 24-001 | This change adds an exclusion to explicitly exclude eTNS for PTSD and deletes the limitation that restricts care when “the patient has not undergone preoperative systemic chemotherapy." | TPM |
| 22883 | T17 | Reimbursement & Coding 24-001 | This change updates the Home Health Routine Rate, DRG Routine CCR change, annual Mental Health, APC Logic, and the annual ESRD. There are also three misc minor language adjustments and one Chapter relocation. | TPM |
| 22868 | T17 | Reimbursement Update 24-002 | This change updates the FY24 Foreign Per Diem for the Philippines and Panama and also removes the 2020 per diems. | TRM |
| 22867 | T17 | Reimbursement Update 24-001 | TRM 1/18/2024 3/25/2024 47 77 This change updates applicability for Ambulatory Surgery Center reimbursement policy, GMTCPA language regarding hold harmless payments and the OPPS year dates. | TRM |
| 22752 | T17 | Reimbursement update 23-002 | This change updates forenign fee schedul, Hospice raes for fischal year 2023, and corrections. | TRM |
CY25 Manual_Changes CY25 Manual Changes Tracking
| ConReq | Version | Title | Manual | Manual | Cost |
| 23545 | T5 | T5 CPD Administrative Transition-in Clean-up Changes | T5 CPD Administrative Transition-in Clean-up Changes to Ch 18 Sec 12 Add E and Ch 28 Sec 1-3 23525 T17 NDAA FY 2024, Section 702, TRS and TRR - Survivor Qualifications For Purchase Of TRS Coverage and Survivor Eligibility TYA Coverage 8/13/2025 9/9/2025 19 153 Change Package Description: Update T5 TOM Chap 25, Section 1, and T17 TOM Chap 25, Section 1, on new survivor eligibility for TYA coverage under NDAA FY 2024, Section 702: Provide survivor TRICARE Young Adult (TYA) coverage under certain conditions to eligible family members for three years, effective October 1, 2025. | TOM | $0 |
| 23525 | T5 | NDAA FY 2024, Section 702, TRS and TRR - Survivor Qualifications For Purchase Of TRS Coverage and Survivor Eligibility TYA Coverage | Update T5 TOM Chap 25, Section 1, and T17 TOM Chap 25, Section 1, on new survivor eligibility for TYA coverage under NDAA FY 2024, Section 702: Provide survivor TRICARE Young Adult (TYA) coverage under certain conditions to eligible family members for three years, effective October 1, 2025. | TOM | $0 |
23514 T17 T17/T5 2026 Premium rates TRS TRR TYA CHCBP_T17 T17 Update of the Premium Rates for the TRS, TRR, TYA, CHCBP Plans for Calendar Year 2026. (This is in addition to the T5 contract premium rates that were updated on January 1.) T5 Update TRICARE manual with CY 2026 Premium Rates for TRS and TRR in TOM Chapter 22 Addendum A; TYA in TOM Chapter 25 Addendum A; and CHCBP in TOM Chapter 26 Addendum A. TOM HGB-
TRIWEST-
TOP-
| 23514 | T5 | T17/T5 2026 Premium rates TRS TRR TYA CHCBP | TOM | ||
| 23505 | T17 | T17/T5 2025 Pharmacy Copay Updates | Add tables for copays for calendar years 2026 and 2027 | TRM | $0 |
| T5 | |||||
| 23485 | T5 | T5 T17 Clerical Edits 25-001 | Clerical Edits to TOM Ch 6, Ch 22 & TPM Ch 10 to assist with calrity of requirements. | TOM | $0 |
| 23474 | T17 | Consolidated Change 25-003 | This change includes 5 edits that have been deleted due to obsolete logic. Modify edits in order to allow for proper processing of special processing codes. Creating new logic for 1 edit in order to allow procedure codes J1074 and J1075 to be submitted. | TSM | $0 |
| T5 | |||||
| 23433 | T5 | T17/T5 Evolving Practices 25-002 | This change updates the TPM on histotripsy for liver tumors; thermal pulsation devices for meibomian gland disorder; low-level laser therapy for arthritis; sustained acoustic medicine devices for pain; and wearable seizure monitoring devices. | TPM | |
| 23422 | T17 | T17/T5 Updating TRICARE Coverage of Chemotherapy Drugs for the Treatment of Cancer. | This change removes outdated information and clarifies that chemotherapy drugs, including paclitaxel, are covered consistent with FDA-labeled indications; or off-label use, consistent with National Comprehensive Cancer Network recommendations for the treatment of cancer. 23422 T5 T17/T5 Updating TRICARE Coverage of Chemotherapy Drugs for the Treatment of Cancer. 4/24/2025 8/12/2025 76 40 Change Package Description: This change removes outdated information and clarifies that chemotherapy drugs, including paclitaxel, are covered consistent with FDA-labeled indications; or off-label use, consistent with National Comprehensive Cancer Network recommendations for the treatment of cancer. | TPM | $0 |
| 23371 | T5 | T5 DCS Training Requirement Updates | Updates DCS training requirements for transition to online training application. | TOM | $0 |
| 23369 | T17 | *FAST TRACK* T5/T17 TRICARE Coverage Limitations on Treatment of Gender Dysphoria in Minors | Adding coverage limitations on treatment of Gender Dysphoria in minors and other updates. 23368 T17 T5/T17 Removal of Expired Home Health Value-Based Purchasing Demonstration 11/4/2024 9/16/2025 217 154 TRM 11/4/2024 9/16/2025 217 86 TSM 11/4/2024 9/16/2025 217 90 Change Package Description: This change removes the Home Health Value-Based Purchasing (HHVBP) Requirement due to the expiration of the program effective 31 December 2022. 23368 T5 T5/T17 Removal of Expired Home Health Value-Based Purchasing Demonstration 11/4/2024 9/17/2025 218 50 TSM 11/4/2024 9/17/2025 218 29 Change Package Description: This change removes the Home Health Value-Based Purchasing (HHVBP) Requirement due to the expiration of the program effective 31 December 2022. Conreq Gov ID Title Manual Date Issued Date Published Days In Progress* Change Number | TPM | $0 |
| T5 | |||||
| 23368 | T5 | T5/T17 Removal of Expired Home Health Value-Based Puchasing Demonstration | This change removes the Home Health Value-Based Purchasing (HHVBP) Requirement due to the expiration of the program effective 31 December 2022. | TPM | $0 |
| T17 | TOM |
TRM
| TSM | $0 | |||||
| 23364 | T17 | T17 TRS and TRR FEHB Clarification | Further clarification on FEHB eligibility and enrollment options under TRS and TRR. | TOM | TMEP-$27,796 |
| 23363 | T5 | T5 Clerical Edits to TOM and TPM | Clerical edits to TOM Ch 1, 6, 22, 26 & TPM Ch 10 to assist with clarity of requirements. | TOM | $0 | ||
| 23362 | T5 | Consolidated Change 25-001 | This consolidated change changes the supervision requirements for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) in private practice; corrects an outdated reference to hearing aid coverage in the Otorhinolaryngologic services section; and updates the rare disease policy to more closely align with the regulations. 23348 T17 Digital Breast Tomosynthesis for Breast Cancer Screening 2/13/2025 7/30/2025 116 147 Change Package Description: This change makes digital breast tomosynthesis, also known as DBT or 3D mammography, a covered clinical preventive services benefit for breast cancer screening for eligible TRICARE beneficiaries, per 2024 USPSTF recommendation. Conreq Gov ID Title Manual Date Issued Date Published Days In Progress* Change Number 23348 T5 Digital Breast Tomosynthesis for Breast Cancer Screening 2/13/2025 7/31/2025 117 39 Change Package Description: This change makes digital breast tomosynthesis, also known as DBT or 3D mammography, a covered clinical preventive services benefit for breast cancer screening for eligible TRICARE beneficiaries, per 2024 USPSTF recommendation. | TPM | $0 | ||
| 23348 | T17 | T5 Digital Breast Tomosynthesis for Breast Cancer Screening | This change makes digital breast tomosynthesis, also known as DBT or 3D mammography, a covered clinical preventive services benefit for breast cancer | TPM | $0 | ||
| T5 | TOM | ||||||
| TPM | $0 | ||||||
| 23347 | T5 | T5 Discrepant Address and Claims Jurisdiction | screening for eligible TRICARE beneficiaries, per 2024 USPSTF recommendation. | TOM | $0 | ||
| 23338 | T17 | T17/T5 HIV Pre-Exposure Prophylaxis (PrEP) | This change allows cost-sharing of pre-exposure prophylaxis (PrEP) for the prevention of HIV as covered preventive care services for TRICARE Prime and Select | TPM | $0 | ||
| T5 | $0 | ||||||
| 23337 | T5 | T5 Mail Order Specialty Pharmacy Edit Update | This change adds new codes "RP" and "SD" for Mail Order Pharmacies. | TSM | $0 | ||
| 23335 | T17 | T17/T5 Reimbursement & Coding Update 25-001 | TPM | ||||
| 23335 | T17 | T17/T5 Reimbursement & Coding Update 25-001 | This change updates breast MRI codes, audio-only telehealth codes, and corrects language for treatments for scars. | TRM | |||
| 23335 | T5 | T17/T5 Reimbursement & Coding Update 25-001 | TPM | ||||
| 23320 | T17 | T17/T5 Uniformed Service Headquarters/Service Project Officers | This change removes the Uniformed Services Headquarters/Service Project Officers. | TOM | $0 | ||
| 23319 | T17 | T17/T5 Update Reporting Procedures | This change updates email address and reporting procedures. | TOM | |||
| T5 | $0 | ||||||
| 23318 | T5 | T5 Prime Enrollee In-Network Claims Metric | This change adds language that measures the percent of claims for TRICARE Prime enrollees region-wide (excluding TRICARE Prime Remote enrollees) rendered by a network provider versus a non-network provider as one of many tools to measure the adequacy of the network. | TOM | $0 | ||
| 23311 | T17 | T17/T5 Mail Order Specialty Pharmacy | This change updates T17 and T5 TSM language regarding edit 2-305-48R for the Mail Specialty Pharmacy. | TSM | $0 |
| T5 | |||||
| 23310 | T17 | T17 Premium Updates CY25 TRS/TRR/TYA & CHCBP | This change updates the Premium Rates for the TRS, TRR, TYA, CHCBP Plans for Calendar Year 2025. | TOM | |
| 23309 | T5 | T5 Type of Institution 94 | This change corrects a Provider Major Specialty Code to 94 for Freestanding End Stage Renal Disease (ESRD) Facilities. | TSM | $0 |
| 23307 | T5 | T5 Chapter 28-Prescription Program | This change provides updates as a result of DoDIG audit | TOM | $0 |
| 23305 | T17 | T17/T5 Evolving Practices 25-001 | This change consists of the following changes: 1.Coronary computed tomography angiography of the heart and coronary arteries for the evaluation of chest pai, 2.Automated computed tomography perfusion for the evaluation of mechanical thrombectomy in cases of acute ischemic strke, 3.High-intensity focused ultrasound for the salvage treatment of localized radio-recurrent prostate caner, 4.Leadless Pacemakers for the treatment of illness or injury involving the cardiovascular syste. | TPM | |
| 23305 | T5 | T17/T5 Evolving Practices 25-001 | This change consists of the following changes: 1.Coronary computed tomography angiography of the heart and coronary arteries for the evaluation of chest pai, 2.Automated computed tomography perfusion for the evaluation of mechanical thrombectomy in cases of acute ischemic strke, 3.High-intensity focused ultrasound for the salvage treatment of localized radio-recurrent prostate caner, 4.Leadless Pacemakers for the treatment of illness or injury involving the cardiovascular syste. | TPM | |
| 23304 | T17 | T17/T5 TRICARE Coverage of EHHC Services | This change excludes Extended Care Health Option (ECHO) Home Health Care (EHHC) services for the purpose of covering primary caregiver(s) absences due to deployment, employment, seeking employment, or to pursue education. | TPM | $0 |
| T5 | $0 | ||||
| 23263 | T5 | T5 Clarification Low Value Care Start Dates for Data Collection and Risk Sharing | This change clarifies the start date of specific activities. | TRM | $0 |
| 23245 | T17 | T17/T5 Safety Beds Clarification | This manual change clarifies that safety beds are a convenience item and not a medical item and therefore cannot be covered under TRICARE. | TPM | $0 |
| T5 | $0 | ||||
| 23228 | T5 | T5 Population Health (PH) Care Update for HEDIS Audit | This change removes language. | TOM | $0 |
| 23212 | T17 | T17/T5 Duplicate Claims System Access Requirements | This change updates DCS access requirements. Conreq Gov ID Title Manual Date Issued Date Published Days In Progress* Change Number | TSM | $0 |
| T5 | $0 | ||||
| 23205 | T5 | T5 Premium Updates CY25 TRS/TRR/TYA & CHCBP | This change adds CY 2025 Premium Rates for TRS, TRR, TYA and CHCBP. | TOM | |
| 23202 | T17 | T17/T5 Beneficiary Notifications & Reinstatement Situations | This change reduces involuntary disenrollment and streamlines the enrollment process. | TOM | $0 |
| T5 | |||||
| 23166 | T17 | Consolidated Change 24-002 | This change revises current language, adds codes, removes codes and provides administrative changes. | TSM | $0 |
| T5 | |||||
| 23071 | T5 | T5 NDAA FY17, Sec 705, Competitive Plans Demonstrations (CPD) | This change adds a new demonstration. | TOM | $0 |
| 23059 | T17 | TMEP Transitions | This change revises format/language. | TOM | $0 |
| T5 | $0 | ||||
| 23046 | T5 | T5 NDAA FY2020, Section 702, New TRICARE Prime Retiree Payment by Allotment | This change directs the payment of enrollment fees via allotment from military pay, where feasible, for new TRICARE Prime Retiree Policies. | TOM | $0 |
CY25_Routine CY25 Routine Changes Tracking
| ConReq | Version | Title | Change Package Description | Manual |
| 23433 | T5 | T17/T5 Evolving Practices 25-002 | This change updates the TPM on histotripsy for liver tumors; thermal pulsation devices for meibomian gland disorder; low-level laser therapy for arthritis; sustained acoustic medicine devices for pain; and wearable seizure monitoring devices. | TPM |
| 23335 | T17 | T17/T5 Reimbursement & Coding Update 25-001 | This change updates breast MRI codes, audio-only telehealth codes, and corrects language for treatments for scars. | TPM |
TRM
| T5 | TPM | ||||
| 23310 | T17 | T17 Premium Updates CY25 TRS/TRR/TYA & CHCBP | This change updates the Premium Rates for the TRS, TRR, TYA, CHCBP Plans for Calendar Year 2025. | TOM | |
| 23305 | T17 | T17/T5 Evolving Practices 25-001 | This change consists of the following changes: 1. Coronary computed tomography angiography of the heart and coronary arteries for the evaluation of chest pain, 2. Automated computed tomography perfusion for the evaluation of mechanical thrombectomy in cases of acute ischemic strke, 3. High-intensity focused ultrasound for the salvage treatment of localized radio-recurrent prostate cancer, 4. Leadless Pacemakers for the treatment of illness or injury involving the cardiovascular system. | TPM | |
| T5 | |||||
| 23205 | T5 | T5 Premium Updates CY25 TRS/TRR/TYA & CHCBP | This change adds CY 2025 Premium Rates for TRS, TRR, TYA and CHCBP. | TOM | |
| 23514 | T17 | T17/T5 2026 Premium rates TRS TRR TYA CHCBP_T17 | T17 Update of the Premium Rates for the TRS, TRR, TYA, CHCBP Plans for Calendar Year 2026. (This is in addition to the T5 contract premium rates that were updated on January 1. | ||
| T5 Update TRICARE manual with CY 2026 Premium Rates for TRS and TRR in TOM Chapter 22 Addendum A; TYA in TOM Chapter 25 Addendum A; and CHCBP in TOM Chapter 26 Addendum A. | TOM | ||||
| T5 |
CY26 Manual_Changes
| CY26 Manual Changes Tracking |
| T17 & T5 |
| ConReq | Version | Title | Change Package Description | Manual | Cost |
| 23840 | T17 | T5/T17 PCS Provider Services and Clerical Edits | Removal of the last sentence in paragraph 5.1 to eliminate confusion. | TOM | 0.0 |
| T5 | |||||
| 23839 | T5 | Eliminating Dermatology Review for PS Laser Hair Removal for PFB in ADSM | Amend paragraph 2.5.5.7.1.3 to read, “The ADSM’s PCM referred the case to a qualified dermatologist or physician who provides laser therapy in the MTF or the civilian sector.” • Delete paragraph 2.5.5.7.1.4, “The Market/MTF dermatologist has recommended laser therapy and the laser therapy is not available at the Market/MTF.”• Delete paragraph 2.5.5.7.2, “The Market/MTF dermatologist will assess each case to limit inappropriate referrals, encourage laser therapy in Markets/MTFs, and ensure referred care is consistent with any Service-specific polices on PFB. The Market/MTF dermatologist may establish local policies to streamline this process.”• Amend paragraph 2.5.5.7.3 to read, “The contractor shall ensure the laser therapy in the civilian sector is provided by a dermatologist or a physician qualified to provide laser therapy.” | TOM | 0.0 |
| 23798 | T17 | Consolidated Change 26-001 | Chapter 2 Addendum G: Adjustment/Remark Codes - This change adds adjustment code 308 to the TSM.Chapter 2 Section 5.3: Relational Edit 1-250-01R - These changes allow frequency codes A and D if type of institution is home health agency. Chapter 2 Section 2.7: Data Element – Procedure Code Modifier- This change allows the modification of added codes AA through AD.Chapter 2 Section 2.6: Data Element - OPPS Payment Status Indicator - This change adds Data element H1 – Non-Opioid Medical Devices for post-Surgical Pain Relief to the TSM. | TSM | 0.0 |
| T5 | |||||
| 23796 | T17 | NDAA FY 2021, Section 746, 2026 Extension of CBSD | This change extends the Childbirth and Breastfeeding Support Demonstration by five years. | TOM | 0.0 |
| T5 | |||||
| 23778 | T17 | *Fast Track* T17 T-5 DMDC myAuth Implementation DS Logon Sunset | Replacing DS Logon language with myAuth | TOM | TMEP -$6625 |
| T5 | |||||
| 23777 | T17 | T17 T5 Requirement Update to Radiofrequency Ablation Policy for Facet Joint Pain | Clarifying change to remove requirement that patients must not have nerve root compression to be eligible for RFA of the lumbar/cervical spinal joints for pain of facet joint origin. | TPM | 0.0 |
| T5 | |||||
| 23759 | T17 | CY 2026 Annual DRG Update | Annual DRG Update | TRM | 0.0 |
| T5 | |||||
| 23758 | T17 | T17/T5 Third-Party Authorization for TRICARE TPA TYA Coverage | This manual change updates TOM 17 and TOM 5 Chapters 6 and 25 to provide Third Party Authorization for a sponsor to make TRICARE Young Adult payments and complete enrollment on behalf of family members. See attached decision paper signed by Director, THP on July 14, 2025. | TOM | 0.0 |
| T5 | |||||
| 23755 | T17 | T17/T5 Expansion of DHA DCS Data Elements for Identification of Potential Post Payment Duplicate Claims | This draft package consists of changes to the TRICARE Systems Manual for the implementation of expansion of DHA Duplicate Claims System data elements for the identification of post payment potential duplicate payments to include the NPI. The changes support NPI Requirements in accordance with the Health Insurance Portability and Accountability Act (HIPAA), Administrative Simplification Provision, 45 CFR, Part 162, National Provider Identifier (NPI). Although the change was published, implementation was delayed due to the unanticipated increase in the number of potential duplicates identified. | TSM | TMEP-$1,307,546.00 |
| T5 | |||||
| 23749 | T17 | T17/T5 Mental Health to Replace Behavioral Health | The Defense Health Agency (DHA) is requested to conduct a review and replacement of DHA’s current use of “behavioral health” (BH) terminology with “mental health” (MH) across the agency. | TOM TPM TRM TSM | 0.0 |
| T5 | TOM TPM TRM TSM | ||||
| 23747 | T17 | T17/T5 TOPO Clerical Edits to TPM Ch 7 Sec 2.1 | Clarifying language added to paragraph 1.1.2.3.3 | TPM | 0.0 |
| T5 | |||||
| 23746 | T17 | T17 T5 TENS Devices Cost Sharing Update | This change adds new TEN's policy and updates manual reference link. | TPM | TMEP-$21,151.00 |
| T5 | |||||
| 23743 | T17 | T17/T5 NDAA FY 2025, Section 702, TPR Rx Copay Waiver for Certain Dependents Enrolled in TPR | Add language about waiving in-network pharmacy copays (clarification that this is an exception to the statement that TPR cost-shares are the same as Prime). | TOM | TMEP-$3355.00 |
| T5 | |||||
| 23741 | T17 | T17/T5 CY2026 Home Health Care Annual Update | Change all 2025 data to 2026 data | TRM | 0.0 |
| T5 | |||||
| 23714 | T5 | *FAST TRACK* T5 TRICARE Prime Travel Benefit Removal of Attestation Requirements | Revising the T-5 TRM Chapter 1, Section 30 and eliminating Prime Travel Benefit (PTB) attestation requirements. | TRM | 0.0 |
| 23713 | T5 | T5 MTF ROFR processing timeline change from one to three days | Change the requirement for the MTF to process ROFRs from one day to three days for routine referrals. Urgent referrals will remain at one day. | TOM | 0.0 |
| 23711 | T17 | ESRD Reimbursement Rate Correction | This change fixes the ESRD reimbursement rates for CY2025 and adds a note stating that at the beginning in CY 2026, annual updates will no longer be published in the TRICARE manuals; they will continue to be published to the TRICARE website. | TRM | 0.0 |
| T5 | |||||
| 23644 | T17 | T5/T17 2025 Q4 TSM Consolidated Change | Chapter 2 Section 2.4: Adjustment Sequence Number Data Element DefinitionThis change corrects the identified processing order of adjustment and cancellation of records in the TSM.Chapter 2 Addendum L: HPCD Plan CodesThese changes are required in order to support the CPD.Chapter 2 Addendum I: T17 ONLY Redlines for Data RequirementsThese redlines show ownership of the T17 and T5 contracts.Chapter 2 Section 6.4 T5 Redline: Mail Order Specialty Pharmacy codes to match both TSM manuals.Chapter 2 Section 2.5: T17 Enrollment Code addedChapter 2 Section 2.8: T17 Special Processing Code DBTThis change adds the DB Digital Breast Tomosynthesis code in the T17 Manual. | TSM | 0.0 |
| T5 | |||||
| 23642 | T17 | *FAST TRACK* T5/T17 Establishing Competitive Plans Demonstration in T17 and Administrative Manual Changes | Multiple changes required from Transition-In activities | TSM | 0.0 |
| T5 | TOM | ||||
| 23641 | T17 | T5/T17 Clarifying Tumor Profile and LDT Demo Web Link | adds note language clarifying the allowed use of certain genetic tests, following a recently signed decision paper and updates LDT demo web link | TPM | 0.0 |
| T5 | |||||
| 23608 | T17 | T17 TMEP Ch 20 Sec 11 Telephone Inquiries | This change is to require the contractor's telephone inquiry system to have a designated option to speak with a customer service representative. | TOM | 0.0 |
| 23597 | T17 | Government Email Update | Updated procedural requirements for the contractors to utilize their Government email address in the AVHE without incurring software licensing costs | TSM | 0.0 |
| T5 | |||||
| 23588 | T5 | Clerical Edits TOM Ch 22 Sec 1 | Clerical edits to standardize language throughout chapter. | TOM | 0.0 |
| 23577 | T17 | Clinical Trials Modifications | These changes implement the DoD's rulemaking promulgating changes to which clinical trials are eligible for coverage by TRICARE. The final rule published July 28, 2025 and can be found at https://www.federalregister.gov/documents/2025/07/28/2025-14206/tricare-coverage-of-clinical-trials-and-termination-of expanded-access-treatments | TSM | TMEP-$71,465.00 |
| T5 | |||||
| 23565 | T17 | T5/T17 Updates to Cervical Cancer Screening Policy | This change updates TRICARE coverage of cervical cancer screening. | TPM | TMEP-$37,616.00 |
| T5 | |||||
| 23412 | T17 | Consolidated Change 25-002 | This change updates the TRICARE Reimbursement Manual. It adds language to the Ambulatory Surgery Centers (ASCs) section. It also adds language to the 3.1.5.7.1 General TMCPA (GTMCPA) Payments section. | TRM | 0.0 |
| T5 |
CY26_Routine
| CY26 Routine Changes Tracking |
| 17 & T5 |
| ConReq | Version | Title | Change Package Description | Manual |
| 23934 | T17 | FAST TRACK CY 2027 Premium Rates for TRS, TRR, TYA, and CHCBP | T5 and T17 Update TRICARE manual with CY 2026 Premium Rates for TRS and TRR in TOM Chapter 22 Addendum A; TYA in TOM Chapter 25 Addendum A; and CHCBP in TOM Chapter 26 Addendum A.See attached Memorandum from ASW(HA) for approval.AOs - POCs for Questions:Ms. Debra Fisher - 571-643-4775, Email: debra.l.fisher2.civ@health.milMr. Brian Smith - 303-676-3729, brian.d.smith120.civ@health.mil | TOM |
| T5 | ||||
| 23841 | T17 | CY 2026 Evolving Practice-003 | This consolidated change gathers manual changes from MBDs signed between 1/1/26 and 3/31/26; this quarter, the changes include adding coverage of ablative fractional laser (AFS) for the treatment of symptomatic scars, and establishing coverage for ambulatory blood pressure monitoring (ABPM) for the diagnosis of white coat hypertension or masked hypertension in adults and pediatric patients, diagnosis of abnormal nocturnal blood pressure in pediatric patients, and other pediatric indications when recommended by the AAP or AHA. EFFECTIVE DATES: ABPM for masked hypertension 1/1/2008; ABPM for pediatric indications 9/1/2017; ABPM for white coat hypertension 1/1/2005; AFS for symptomatic scars 2/24/2026. | TPM |
| T5 | ||||
| 23776 | T17 | T17 T5 Reimbursement and Coding 26-001 | Adding 4 SIs to TRM for contractors to be able to code properly. Added SIs are H1, K1, S1, & TB. SIs are like coding identifiers that categorize codes, how they are used, and sometimes what they are used for. | TRM |
| T5 | ||||
| 23757 | T17 | T17/T-5 Coding 26-001 | Miscellaneous coding updates to remove deleted codes and update current codes. | TPM |
| T5 | ||||
| 23745 | T17 | T17/T5 CY 2026 Evolving Practice-002 | Updates TPM to reflect MBDs signed in the last quarter | TPM |
| T5 | ||||
| 23742 | T17 | T17/T5 CY 2026 Evolving Practice-001 | Hearing Aid Trials; BVNA; DISCSEEL; Liver Transplant CRC with LM; SLAH for MTLE (FDCD) | TPM |
| T5 | ||||
| 23607 | T17 | T17/T5 MB&R Fall 2025 No-cost Routine Updates | This changes package includes coding changes, minor policy language revisions to the TPM and a change to the LDT list in the TOM. | TPM |
| T5 | TOM | |||
| 23557 | T17 | T17 T5 Evolving Practices 25-003 | Devices for treatment of PTSD and mental health disorders related to traumatic brain injury; risk reducing surgeries for cancer; and devices for treatment of acute and chronic post-operative pain. | TPM |
| T5 |
File details come from the government source that posted it. Updated .