This section describes implementation
requirements for the Duplicate Claims System (DCS). It also defines
policies and procedures for the operation of the system. For transition
requirements related to this section, see the TRICARE Operations
Manual (TOM),
Chapter 2.
2.0 Software Requirements
2.1 Optional
Software
The contractor may, at it’s own
option and expense, procure and utilize full version database management
software packages such as Microsoft Access®, dBase®, Paradox For
Windows®, etc., on the DCS PCs for the purpose of generating customized
queries and reports utilizing optionally downloaded ASCII fixed
length files that can be created by the DCS. Downloaded ASCII fixed
length files may also be imported into Microsoft Excel®.
2.2 Security
Requirements - Defense Health Agency (DHA) Form 834, Patient Encounter Processing
and Reporting (PEPR) Account Activation Request Form
2.2.1 The contractor shall identify
a Security Manager to oversee the DCS registration process. DCS
registration requires the submission of one security document, for
each user, DHA Form 834, PEPR Account Activation Request Form (
https://www.milsuite.mil/book/groups/patient-encounter-processing-and-reporting-pepr).
Each DCS user shall complete and sign the form and provide the required
information, i.e., certification of completion of IA training.
2.2.2 In order
to access the DCS, users shall obtain a Common Access Card (CAC)
from DHA, see
Chapter 1, Section 1.1. CACs will be issued
following receipt and processing of properly completed registration
and security forms. Contractor users shall provide the required
information, and submit the completed form to their DCS Security
Manager for signature and transmittal to DHA.
2.2.3 DCS data
shall be encrypted. Encryption specifications will be provided by
DHA. See
Chapter 1 for additional security and communications
requirements.
2.3
Registration
And Security
Each individual user must complete
and sign Government provided security and access forms prior to
be granted DCS access.
3.0
Connectivity
Connectivity will be through the Internet to
the PEPR Portal via MSIE, Version 5.5, 6.0, or 7.0, or as directed
by the Government.
4.0 System
Support
For DCS support, contractors shall
file a problem ticket with the DHA Global Service Center at 1-800-600-9332,
then follow the prompts to the DCS.
5.0 Operating
Procedures
5.1 For each regional contract for which a contractor
is responsible, or for the TRICARE Dual Eligible Fiscal Intermediary
Contract (TDEFIC), the contractor shall develop internal operating
procedures for the DCS. These internal operating procedures shall
designate the responsible areas for the various duplicate claims
resolution functions and establish time lines. For example, one
contractor may decide that the adjustment unit shall be responsible
for scanning the DCS on a weekly basis for the appearance of adjustments
submitted and for closing sets. Another contractor may decide that
the unit responsible for researching potential duplicate claims
should also be responsible for scanning for adjustments and closing
the sets on a daily basis.
5.2 Contractor contract requirements
for overpayment recovery, refunds and offsets, adjustments, etc.,
including timeliness requirements, apply to the operation of the
DCS. As a result, operating procedures shall be developed which
are consistent with all applicable contract requirements. Procedures
must be established to ensure that recoupments are initiated in
a timely manner following the research determination that a duplicate
payment had been made. In other words, procedures must specify that
after a decision has been made by the person responsible for determining
that a duplicate payment was made, recoupment must be initiated
in a timely manner and must be consistent with all overpayment recovery
timeliness standards.
5.3 The contractor shall develop
these procedures within 60 days of the date of system implementation
and have them available for DHA review.