1.0 Application
1.1 This section
provides functional guidance for all contractors that interface
with the Defense Manpower Data Center (DMDC)/DEERS in support of
their contractual requirements.
1.2 For the purpose of defining
geographical areas, the 50 United States (U.S.) and the District
of Columbia are hereafter referred to as the Continental United
States (CONUS), and all other areas are considered Outside of the
Continental United States (OCONUS).
1.3 The TRICARE Program’s contracts
provide support for specific health care service categories. Each
major area of this section will be broken into health care service
categories for specific guidance. Some of the contracted health
care service categories are:
• Pharmacy: TPharm (Mail
Order Pharmacy (MOP) and Retail Pharmacy).
• Dental: TRICARE Dental
Program (TDP), TRICARE Retiree Dental Program (TRDP), Active Duty
Dental Program (ADDP), and Remote Active Duty Dental Program (RADDP).
• Medical: CONUS regional
contracts, OCONUS contract, Uniformed Services Family Health Plan
(USFHP) contracts.
• Nurse
Advice Lines (NALs): CONUS and OCONUS NALs.
• Medicare Eligible
Claims Processor: TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC):
CONUS, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa,
and the Northern Mariana Islands.
• Other Health Insurance
(OHI).
1.4 Some key executable business
processes that all contractors must accomplish are listed below.
1.4.1 For all
contractors and contracts:
• Beneficiary identification/authentication;
• DoD entitlements/TRICARE
benefits information (see also TRICARE Operations Manual (TOM) and
TRICARE Policy Manual (TPM)); and
• Identification of
Other Government Programs (OGPs) entitlement information, to include
Medicare.
1.4.2 When required by specific
contract requirements:
• Enrollment processing;
• Enrollment premiums/fees
maintenance (includes fee exclusion);
• Primary Care Manager
(PCM) assignment/re-assignment;
• Claims processing
(with associated beneficiary contact updates);
• Catastrophic Cap
And Deductible Data (CCDD);
• OHI Program; and
• Standard Insurance
Table (SIT) Program.
2.0 Contractor
Responsibility
Contractors shall understand
and execute the DEERS functionality described in this section. Contractors
shall also utilize the technical information and materials provided
by DMDC/DEERS via Defense Health Agency (DHA) Performance, Analysis,
Transition, and Integration Section (PAT&IS), and then must
consult with DEERS and DHA if clarification is required.
3.0 DEERS
Operational Environment And Characteristics
The
DEERS system environment consists of a Relational Database Management
System (RDBMS), rules-based applications processing DoD entitlements
and eligibility, a Transmission Control Protocol/Internet Protocol
(TCP/IP) sockets listener, application servers that enforce business
rules, and web servers.
3.1 Data Sequencing
Since DEERS is tasked with resolving data conflicts
from external systems using rules-based applications, all contractors
shall ensure proper data sequencing of transactions sent to DEERS,
when applicable to the specific interface involved. This aids in
maintaining data validity and integrity.
3.2 System Maintenance
And Downtime
3.2.1 DMDC has routinely scheduled times for system
maintenance and will schedule additional downtimes as required.
The routinely scheduled downtimes are:
• Weekly: 2100 Eastern
Saturday to 0600 Eastern Sunday
• Daily, if needed:
2355 Eastern to 0100 Eastern
3.2.2 When DMDC
identifies a telecommunications, hardware, or software problem outside
a scheduled maintenance window that results in downtime of contractors
interface for two contiguous or cumulative hours within a business
day, DMDC must notify the DHA of the problem and approximately when
it is expected to be corrected. DHA contractors reliant upon DEERS
will be notified of the situation and provided guidance as appropriate.
3.2.3 In addition
to the standard problem resolution procedures as referenced in DMDC documentation,
when contractors experience downtime in the DEERS interface for
two hours contiguously or cumulatively within a business day and
has not been contacted by DHA, contractors must report the downtime
to the DHA representative and shall report an updated status every
two hours until the problem is resolved. A final report upon resolution
is also required.
3.3 DEERS provides system-to-system
interfaces, applications, web-based applications, and web-based
services.
3.3.1 External
Systems - System-To-System Interfaces
All
system-to-system interfaces to DEERS must use TCP/IP, File Transfer
Protocol (FTP), Hypertext Transfer (Transport) Protocol (HTTP),
Secure File Transfer Protocol (SFTP), or Hypertext Transfer (Transport)
Protocol Secure (HTTPS) as specified by DEERS.
3.3.1.1 DEERS utilizes
standard message protocols where appropriate.
3.3.1.2 DEERS defines
the content and format of messages between DEERS and contractors.
3.3.1.3 DEERS and
all contractors must utilize encryption for all messages that contain
privacy level information.
3.3.1.4 DEERS specifies
the method of encryption and authentication for all external interfaces.
3.3.1.5 All notifications
are sent as full database images; they are not transaction-based. Contractors
must accept and apply the full image sent by DEERS. Contractors
shall add the information, if not present in their system. Contractors
shall update their system, if the information is present, by replacing
their information with what is newly received from DEERS. Notifications
are only intended to synchronize the most current information between
DEERS and contractors. They do not synchronize history between DEERS
and contractors.
3.3.1.6 DMDC centrally
enforces all business rules for enrollment and enrollment-related
events.
3.3.1.7 DEERS is the database of record for all eligibility,
enrollment information, and Catastrophic Cap & Deductible (CC&D)
information.
3.3.1.8 DEERS is
the central repository for OHI information.
3.3.2 Web-Based
Application Requirements And Functionality
3.3.2.1 All DMDC/DEERS
web-based applications require Microsoft® Internet Explorer (MIE)
6.0 or higher using HTTPS. They are all Government furnished equipment.
3.3.2.2 Contractors
shall use the Government furnished web-based applications for their
intended use only. Contractors shall not utilize screen scraping,
HTML stripping, and any other technology or approach to manipulate
or alter the intended use of the application or the application
architecture.
3.3.2.3 At a minimum,
the following functions are available using Government furnished
web-based applications, responsibilities and functions based on
contractual requirements:
• General Inquiry of
DEERS (GIQD) information used for research and customer service
to display demographics, Health Care Delivery Program (HCDP) eligibility
and enrollment. It may also allow other administrative functions
like address updates.
• Enrollment activities,
to include display of enrollment premiums/fees.
• Claims processing
eligibility checks, see also
Sections 5.1 and
5.2.
• CCDD information that
supports research and allows limited updates on the history of CC&Ds
and enrollment fee payment transactions posted to DEERS and stored
on-line (current plus previous five fiscal years).
• OHI information that
allows add, update, and cancellation of OHI policies as well as
SIT carrier adds, updates, cancellations and deactivations.
• PCM assignment, re-assignment,
capacities, and enrolled counts.
4.0 DEERS
Web-Based Applications And Notifications
Applications:
The following is a brief description of the available applications,
responsibilities and functions based on contractual requirements.
4.1 GIQD Information
GIQD information is achieved through a Government
furnished web-based system/application that is used for research
and customer service to display demographics, coverage and PCM assignment information.
It also allows address updates.
4.2
Government
Furnished Web-Based Enrollment System/Application
4.2.1 The Government furnished web-based
enrollment system/application is a full function Government Furnished
Equipment (GFE) application developed by DMDC to support enrollment-related
activity. The Government furnished web-based enrollment system/application
interacts with both the main DEERS database and the National Enrollment
Database (NED) satellite database to provide enrolling organizations
with eligibility and enrollment information, as well as the capability
to update the NED with new enrollments and modifications to existing
enrollments.
4.2.2 The Government furnished web-based enrollment
system/application meets the Health Insurance Portability and Accountability
Act (HIPAA) and DoD policy guidelines for a direct data entry application,
and is data-content compliant for enrollment and disenrollment functions.
4.2.3 Contractors
are required to perform enrollment related functions through the
Government furnished web-based enrollment system/application.
4.3 Government
Furnished Web-Based Beneficiary Self-service Enrollment System/Application
4.3.1 The Government
furnished web-based beneficiary self-service enrollment system/application
serves all TRICARE eligible beneficiaries and will support most
enrollment programs. The Government furnished web-based beneficiary
self-service enrollment system/application will interface with contractor
systems for the purposes of accommodating on-line payment of initial
enrollment fees.
4.3.2 DEERS will pre-populate data
elements where possible.
4.3.3 The web application contains
checks for beneficiary eligibility and hard edits requiring the beneficiary
to fulfill established DEERS business rules and enrollment criteria.
Upon completion of the web process, the beneficiary is informed
that the enrollment actions may be reviewed by the appropriate contractor
for accuracy and compliance with established regional and/or Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM) requirements,
and that they will be contacted if additional information is needed.
DEERS will send the contractor a notification(s) informing the contractor
that either a pending enrollment (for programs with PCM requirements)
or a new enrollment exists for the beneficiary. See also
paragraph 5.0.
5.0
DEERS
System-To-System Notifications
5.1 Government furnished system
information/data notification(s) are sent to contractors for various
reasons and reflect the most current enrollment information for
a beneficiary. Contractors must accept, apply, and store the data
contained in the notification as sent from DEERS to remain in sync with
DEERS. Notifications may be sent due to new enrollments or updates
to existing enrollments. If contractors do not have the information
contained in the notification, contractors shall add it to their system.
If contractors already have enrollment information for the beneficiary,
contractors shall apply all information contained in the notification
to their system.
5.2 Contractors shall use the
beneficiaries’ DEERS identifiers, DoD Identification Number and/or DoD
Benefits Number (DBN), to match the notification to the correct
beneficiary in their system. There are also circumstances where
a contractor may receive a notification that does not appear to
be updating the information that the contractor already has for
the enrollee. Such notifications shall not be treated as errors
by the contractor system and must be applied.
5.3 Contractors
are expected to acknowledge all notifications sent by DEERS. If
DEERS does not receive an acknowledgment, the notification will
continue to be sent until acknowledgment is received. The following
information details examples of events that trigger DEERS to send
notifications to a contractor.
• Primary Notifications
Resulting From Enrollment Actions.
• Unsolicited Notifications resulting
from updates to beneficiaries’ status.
6.0
Beneficiary
Identification
6.1 Patient
Identification Merge
6.1.1 See also
Section 3.1 for
Beneficiary Identification.
6.1.2 Occasionally, incomplete or
inaccurate person data is provided to DEERS and a single person
may be temporarily assigned two DoD Identification Numbers. When
DEERS identifies this condition, DEERS makes this information available
on-line for all contractors. Contractors are responsible for retrieving
and applying this information on a weekly basis. The merge brings
the data gathered under only one of the DoD Identification Numbers
and discards the other. Although DEERS retains both numbers for
an indefinite period, from that point on only the one remaining
DoD Identification Number shall be used by the contractor for that
person and for subsequent interaction with DEERS and other Military
Health Systems (MHSs). If there are enrollments under both records being
merged that overlap, the enrolling organizations are responsible
for correcting the enrollments. Contractors shall also update the
catastrophic cap that has been posted for these records if necessary.
6.2 Partial Match
6.2.1 See also
Section 3.1 for Beneficiary Identification.
6.2.2 A partial
match response may be returned for any inquiry that does not use
a DoD Identification Number and/or DBN. Eligibility may result in
a partial match situation due to person ambiguity. There will be
a separate listing for each person or family matching the requested
DBN, or Sponsor Social Security Number (SSN).
6.2.3 The listing
includes the sponsor and family member information needed to determine
the correct beneficiary or family including the DBN(s).
6.2.4 The requesting
organization must select which of the multiple listings is correct
based on documents or information at hand. After this selection,
the requesting organization would use the additional information
returned (e.g., Date Of Birth (DOB), Name) to resend a DEERS inquiry.
7.0
HCDP
Eligibility For Enrollment
7.1 The rules for determining
a beneficiary’s entitlement to health care benefits are applied
by rules-based software within DEERS. DEERS is the sole repository
for these DoD rules, and no other eligibility determination outside
of DEERS is considered valid. Whenever data about an individual sponsor
or a family member changes, DEERS reapplies these rules. DEERS receives
daily, weekly, and monthly updates to this data, which is why organizations
must query DEERS for eligibility information before taking action.
This ensures that the individual is still eligible to use the benefits
and that the respective contractor has the most current information.
7.2 A beneficiary
who is considered eligible for DoD benefits (pharmacy, dental, medical)
in accordance with Title 10 United States Code (USC),
32 CFR 199.13,
32 CFR 199.22,
and DoD Instruction (DoDI) 1000.13 is not required to “sign up”
for the TRICARE benefits associated with any DEERS assigned plan.
If an authorized organization inquires about that beneficiary’s
eligibility, DEERS reflects if he or she is eligible to use the
benefits. The effective and expiration dates for assigned plan coverage
are derived from DoDI 1000.13 rules and supporting information.
7.3 Eligibility
For Enrollment
DEERS provides coverage plan
information identifying the period of eligibility and/or enrollment
for the coverage plan. A beneficiary can only be enrolled into the
coverage plans that have an “eligible for” status. When a sponsor
and/or family member are first added, or when sponsor or member
status updates occurs, DEERS determines basic eligibility for health
care benefits in accordance with Title 10 USC,
32 CFR 199.13,
32 CFR 199.22,
and DoDI 1000.13 and then establishes an assigned HCDP coverage
plan together with coverage dates.
8.0
Enrollment
Activities
Enrollment-related business events
include, by contracted health care service category:
8.1 Pharmacy:
Enrollment Functionality
No enrollment requirement,
as pharmacy is an assigned HCDP plan.
8.2 Dental: Enrollment Functionality
8.2.1 Eligibility
for enrollment identifies current enrolled coverage plans and eligibility
for enrollment into other coverage plans (as the sponsor and/or
beneficiaries role changes over time). See also
Section 4.1.
Some examples of plan changes over time:
• Service member plans.
ADDP, but can move into other dental plans based on their beneficiary
role change (e.g., TDP and TRDP)
• Active Duty Family
Member (ADFM) plans. TDP, but can move into other dental plans based
on their beneficiary role change (e.g., TRDP and ADDP, if ADFM becomes
an active Service Member)
• Retirees. TRDP with
no expected change in plan.
• Retiree dependents.
TRDP, but can move into other dental plans based on their beneficiary
role change (e.g., TDP and ADDP, if retiree dependent becomes an
active Service Member)
• The
TRDP contractor shall cease new enrollment actions on October 31,
2018.
8.2.2 New enrollments are used for
enrolling eligible sponsors and family members into a HCDP coverage
plans or for adding family members to an existing family policy.
Enrollments begin on the date specified by the enrolling organization
and extend through the beneficiaries’ end of eligibility for the
HCDP.
8.2.3 New enrollments may also perform the following
functions:
• Update
address, e-mail address and/or telephone number.
• Record that the
enrollee has OHI (does not apply to ADDP).
8.2.4 Modifications
of the current enrollment (updates) are used to change some information
in the current enrollment plan. Modifications of the current enrollment
include the following functions:
• Change enrollment
begin date.
• Cancel
enrollment/disenrollment.
• Change prior enrollment
end date.
• Change
prior enrollment end reason.
• Request an enrollment
card replacement.
• Add OHI information
for an enrollee (does not apply to ADDP).
8.3 Medical:
Enrollment Functionality
8.3.1 Eligibility for enrollment
identifies current enrolled coverage plans and eligibility for enrollment
into other coverage plans (as the sponsor and/or beneficiaries role
changes over time). See also
Section 4.1.
Some examples of plan changes over time:
• Service member plans.
TRICARE Prime for Service member only, but can move into other medical
plans based on their beneficiary role change (e.g., TRICARE Prime Remote
(TPR), TRICARE Standard, TRICARE Select, TRICARE Prime, TRICARE
Reserve Select (TRS), etc.).
• ADFM plans. Starting
January 1, 2018, beneficiaries must select a plan or will default
to direct-care only. However, Calendar Year (CY) 2018 is a grace
period where they can elect a plan at any point. Beginning with
CY 2019, beneficiaries will be limited to making changes to enrollments
only during an annual enrollment open season or following a Qualifying
Life Event (QLE). Direct Care (DC) only is the default assigned,
but can enroll into other medical plans based on their beneficiary
role change (e.g., TRICARE Select, TRICARE Prime, TRICARE Plus,
TPRADFM, etc.). See TOM,
Chapter 6, Section 1.
• Retirees and their
family members. Starting January 1, 2018, beneficiaries must select
a plan or will default to DC only. However, CY 2018 is a grace period
where they can elect a plan at any point. Beginning with CY 2019,
beneficiaries will be limited to making changes to enrollments only
during an annual enrollment open season or following a QLE. DC only is
the default assigned, but can elect to enroll into other medical
plans (e.g., TRICARE Select, TRICARE Prime, TRICARE Plus, etc.). See
TOM,
Chapter 6, Section 1.
8.3.2 New enrollments
are used for enrolling eligible sponsors and family members into
a HCDP coverage plans or for adding family members to an existing
family policy. Enrollments begin on the date specified by the enrolling
organization and extend through the beneficiaries’ end of eligibility
for the HCDP.
8.3.3 New enrollments may also perform
the following functions:
• Update address, e-mail
address and/or telephone number.
• PCM selection (if
required/allowed by HCDP).
• Record that the
enrollee has OHI.
8.3.4 Modifications of the current
enrollment (updates) are used to change some information in the
current enrollment plan. Modifications of the current enrollment
include the following functions:
• Change or cancel a
PCM selection.
• Transfer
enrollment (enrollment portability) or cancel a transfer.
• Change enrollment
begin date.
• Cancel
enrollment/disenrollment.
• Change prior enrollment
end date.
• Change
prior enrollment end reason.
• Request an enrollment
card replacement.
• Add OHI information
for an enrollee.
• Request a replacement
letter for PCM change or disenrollment.
8.4 NAL: Enrollment
Functionality
No enrollment requirement,
as NAL is a service program that supports all DoD eligible beneficiaries.
8.5 TDEFIC: Enrollment
Functionality
No enrollment requirement,
as TDEFIC is a claims processing contract that supports all dual eligible
beneficiaries.
9.0 Disenrollments
Activities
9.1 Once actively enrolled in a coverage plan,
an individual or family may voluntarily disenroll or be involuntarily
disenrolled. Voluntary disenrollment is self-elected, but does not
apply to Service Member as they are not authorized to voluntarily
disenroll from mandated medical or dental plans. Involuntary disenrollment
occurs from failure to pay enrollment fees or from loss of eligibility.
Upon disenrollment, DEERS will notify the beneficiary of the change
in or loss of coverage.
9.2 For medical plans only, see
TOM,
Chapter 6, Section 1 for disenrollment rules
and eligibility for re-enrollment.
9.3 When there is a disenrollment,
the appropriate systems are notified, as necessary (see also
paragraph 4.2).
9.4 Effective December 31, 2018,
11:59 p.m. Eastern, all TRDP enrollments shall terminate, in accordance
with this chapter.
10.0 Beneficiary
Contact Updates And Enrollment Cards
10.1 Contact Updates (Applicable
To All Contractors)
Address, telephone number,
and e-mail address updates.
10.1.1 Addresses
10.1.1.1 DEERS receives
address information from a number of source systems. Although most systems
only update the residence address, DEERS actually maintains multiple
addresses for each person. Contractors shall update the residential
and mailing addresses in DEERS, whenever possible. These addresses
shall not reflect unit, MTF/eMSM, or contractors addresses unless
provided directly by the beneficiary. The mailing address captured
on DEERS is primarily used to mail the enrollment card and other
correspondence. The residential address is used to determine enrollment
jurisdiction at the Zip Code level. DEERS uses a commercial product
to validate address information received on-line and from batch
sources.
10.1.1.2 Contractors are responsible for processing
all mail returned for bad addresses and shall research the address,
correct it on DEERS, and re-mail the correspondence to the beneficiary.
If contractors cannot determine a valid address, contractors shall
update the Mail Delivery Quality Code (MDQC) in DEERS to prevent
future mailings to that address.
10.1.2 Telephone Numbers
DEERS has several types of telephone numbers
for a person (e.g., home, work, and cellular). Contractors shall
make reasonable efforts to add or update telephone numbers.
10.1.3 E-Mail Addresses
DEERS can store an e-mail address for each
person. Contractors shall make reasonable efforts to add or update
this e-mail address.
10.2 Enrollment Cards And Letter
Production
10.2.1 DEERS sends a notification directly to the
enrollee at the residential mailing address specified in the enrollment
request or via e-mail advising them how to obtain a copy of their
Universal TRICARE Beneficiary Card. New enrollment cards are automatically
generated upon a new enrollment or an enrollment transfer to a new
region (medical only). Beneficiaries are notified of the availability
by e-mail or postcard, unless the enrollment operator specifies
in the Government furnished web-based enrollment system/application
not to generate an enrollment card. A contractor may request a replacement
notification at any time. DEERS sends a notification to the contractor
indicating the last date an enrollment card notification was generated
for the enrollee.
10.2.2 DEERS also
generates letters to beneficiaries upon changes to their enrollment,
and notifies beneficiary via e-mail or postcard that the letter
is available. Contractors shall not send additional letters that
duplicate those already provided by DEERS.
11.0
Claims
Processing And Database Of Record
11.1 DEERS is the system of record
for eligibility and enrollment information. As such, in the process of
claims adjudication, contractors shall query DEERS to determine
eligibility and/or enrollment status for a given period of time.
11.2 For audit
and performance review purposes, contractors are required to retain
a copy of every transaction and response sent and received for claims
adjudication procedures. This information is to be retained for
the period required by the TOM.
11.3 Contractors shall not override
this data with information from other sources. Continued Health Care
Benefits Program (CHCBP) CC&D information shall be obtained
from the CHCBP contractor.
11.4 Contractors shall deny a claim
(either totally or partially) if the services were received partially or
entirely outside any period of eligibility.
11.5 The contractor
system is the database of record for OHI within the TRICARE Program.
DEERS is the data repository for OHI, using its centralized repository
of OHI information that is reliant on the MHS organizations to verify,
update and add to at every opportunity. The OHI data received as
part of the claims inquiry shall be used as part of the claims adjudication
process. If the contractor has evidence of additional or more current
OHI information they shall either ‘pend’ the claim, submit the new
OHI information to DEERS, and then reprocess the claim, or develop
business processes to simultaneously accomplish both DEERS OHI update
and claims processing using the newly discovered OHI data. Any process
executed by the contractors must not interfere with the contractors
required claims processing time lines.
11.6 Although DEERS is not the
database of record for address, it is a centralized repository that
is reliant on numerous organizations to verify, update and add to
at every opportunity. The address data received as part of the claims
inquiry shall be used as part of the claims adjudication process.
If the contractor has evidence of additional or more current address
information they shall process claims using the additional or more
current information and update DEERS within two business days.
12.0 CCDD
12.1 DEERS stores
Enrollment Year (EY), Fiscal Year (FY), and CY CC&D data in
a central repository. DEERS stores the current and the four prior yearly CC&D
totals. The purpose of the DEERS CCDD repository is to maintain
and provide accurate CC&D amounts, making them universally accessible
to DoD claims processors.
Note: To transition to CY catastrophic caps as required
in NDAA FY 2017, Section 701, the FY 2017 catastrophic cap covers
the period from October 1, 2016 to December 31, 2017.
12.2 The CCDD
Totals Inquiry is used to obtain CCDD balances for the year(s) that
correspond to the requested inquiry period. Contractors must inquire
and lock CCDD totals before updating DEERS CCDD amounts.
Note: A catastrophic cap record is not required for
persons who are authorized benefits but are not on DEERS or eligible
for medical benefits, such as prisoners or Government employees.
The purpose of the catastrophic cap is to benefit those beneficiaries
who are eligible for MHS benefits. Those persons that are authorized
benefits who would not under any other circumstances be eligible, are
not subject to catastrophic cap requirements.
13.0
OHI
Program
13.1 OHI identifies non-DoD health insurance held
by a beneficiary. The requirements for OHI are validated by the
DHA Uniform Business Office (UBO). OHI information includes:
• OHI
policy and carrier.
• Policyholder.
• Type of coverage
provided by the additional insurance policy.
• Employer information
offering coverage, if applicable.
• Effective period
of the policy.
13.2 OHI transactions allow adding,
updating, canceling, or viewing all OHI policy information. OHI policy
updates can accompany enrollments or be performed alone. OHI information
can be added to DEERS or updated on DEERS through multiple mechanisms.
At the time of enrollment the contractor will determine the existence
of OHI. Contractors can add or update minimal OHI data through the Government
furnished web-based enrollment system/application used by the contractors
to enter enrollments into DEERS. In addition, DEERS will accept
OHI updates from a claims processor through a system-to-system interface.
Other MHS can add or update the OHI through the OHI/SIT web application
provided by DEERS.
13.3 The contractor will perform
an OHI Inquiry before attempting to add or update an OHI policy. The
MHS organizations are reliant on the individual beneficiary to provide
accurate OHI information and DEERS is reliant on the MHS organizations
for the accurate assignment of policy information to the individual
record. DEERS is not the system of record for OHI information. Performing
an OHI Inquiry on a person before adding or attempting to update
an OHI policy helps ensure that the proper policy is updated based
on the most current information or the person.
13.4 Examples
of OHI coverage are:
• Comprehensive Medical
coverage (Plans with multiple coverage types).
• Medical coverage.
• Inpatient coverage.
• Outpatient coverage.
• Pharmacy coverage.
• Dental coverage.
• Long-term care
coverage.
• Mental
health coverage.
• Vision coverage.
• Partial hospitalization
coverage.
• Skilled
nursing care coverage.
13.5 The default
coverage will be Comprehensive Medical Coverage unless another of
the above coverages is selected. The indication of Comprehensive
Medical Coverage presumes medical coverage, inpatient coverage,
outpatient coverage, and pharmacy coverage. Medical contractors
must develop the OHI within 15 days but is not responsible for development
of pharmacy.
13.5.1 The pharmacy contractor(s) is/are expected
to develop and maintain pharmacy OHI. Pharmacy placeholder policies
will be developed by the pharmacy contractor, regardless of which organization
created the placeholder. All other placeholder policies will be
developed by the contractor, regardless of which organization created
the placeholder. MHS organizations will not normally enter placeholder
policies but would develop them if they created them.
13.5.2 The dental
contractor(s) are expected to develop and maintain dental OHI.
13.6 A person
can have multiple types of OHI coverage for one policy. For example,
to add an OHI policy that covers medical and vision, two OHI coverage
types, one for medical coverage and one for vision coverage, would
be sent to DEERS.
13.7 A person can have multiple
OHI policies. Multiple OHI policies may have the same or different Health
Insurance Carriers (HICs), and/or the same or different OHI policy
effective periods.
14.0
SIT
Program
The SIT Program supports the MHS
billing and collection process. The SIT is validated by the DHA
UBO through the DoD Verification Point of Contact (VPOC). The VPOC
is ultimately responsible for maintaining the SIT in DEERS, which
is the system of record for SIT information. The SIT provides uniform
billing information for reimbursement of pharmacy, dental, and medical
care costs covered through commercial policies held by the DoD beneficiary
population. MHS personnel use the SIT to obtain other payer information
in a standardized format.
14.1 All systems identified as
trading partners will request an initial full SIT subscription from
DEERS. In addition, holders of the SIT shall subscribe to DEERS
at least daily in order to receive subsequent updates of the SIT.
14.2 The SIT
Verification Application is used exclusively by the VPOC. The application
queues all SIT transactions entered through the OHI Maintenance
Application for review and verification by the VPOC.
15.0 Medicare
Data
15.1 DEERS performs a match with the Centers for
Medicare and Medicaid Services (CMS) to obtain Medicare data and
incorporates the Medicare data into the DEERS database as OGPs entitlement information.
This information includes Medicare Parts A, B, C, and D eligibility
along with the effective dates. The match includes all potential
Medicare-eligible beneficiaries.
15.2 DEERS sends Medicare Parts
A and B information to the TDEFIC. The TDEFIC sends the information
to the CMS Fiscal Intermediaries for identification of Medicare
eligible beneficiaries during claims adjudication.