TRICARE Manuals - Display Chap 3 Sect 5.1 (Change 37, Jun 12, 2020)

Defense Enrollment Eligibility Reporting System (DEERS)

Chapter 3

Section 5.1

Defense Enrollment Eligibility Reporting System (DEERS) Functions In Support Of The TRICARE Dental Program (TDP) And The TRICARE Retiree Dental Program (TRDP)

Revision: C-17, August 7, 2018

1.0 Introduction

This section provides TDP and TRDP specific/unique guidance that was not discussed or described elsewhere in the TSM.

2.0 TERMINATION OF THE TRDP EFFECTIVE DECEMBER 31, 2018

Effective January 1, 2019, dental coverage options for eligible retired members and their families will be provided by the Office of Personnel Management (OPM) through the Federal Employees Dental and Vision Insurance Program (FEDVIP).

3.0 Guidance

3.1 Claims Processing

The DEERS Claims Service (DCS) is used to determine benefit coverage for a given period. Contractors must use the DCS for all claims processing.

3.1.1 DCS Inquiry For Claims

Contractors shall install a prepayment eligibility verification system into its TRICARE operation that results in a query against DEERS for TRICARE claims and adjustments. The query should be conducted early in the claims processing cycle to assure extensive development/claims review is not done on claims for ineligible beneficiaries. The DCS Inquiry for Claims supports business events associated with DCS data for processing dental claims. This inquiry may also be used for general customer service requests, beneficiary self-service purposes or for predeterminations as long as there is prior coordination with the Defense Health Agency (DHA) and Defense Manpower Data Center (DMDC).

3.1.2 Copayment Factor For Coverage Inquiries (Does not apply to TRDP)

3.1.2.1 The Copayment Factor Code for a beneficiary is determined by DEERS and is returned on a DCS claims inquiry, but may be influenced by treatment information from a claim. Contractors shall use this factor code to determine the actual copayment for the claim.

3.1.2.2 The different factors are determined by legislation, which considers factors such as pay grade. Although the rates are based on the population to which they pertain, these rates also apply to a sponsor’s family members. Examples of cost-share factors are:

• Pay Grade E-1 to E-4.

• Pay Grade E-5 and above.

• Command Sponsored.

3.1.2.3 A contractor’s system should be flexible enough to permit additional rate codes to be added, as required by the Department of Defense (DoD).

3.1.2.4 Special Entitlements

Congressional legislation may affect rates. The Special Entitlement Code and dates if applicable provide information to support this legislation. Effective dates will also be included in the response from DEERS. Note that a person may have multiple special entitlements. An example of a Special Entitlement plan is the Survivor Benefit Plan.

3.2 Key Support POCs

A list of key DMDC Support Office (DSO) personnel and the Joint Uniformed Services Personnel Advisory Committee (JUSPAC) and the Joint Uniformed Services Medical Advisory Committee (JUSMAC) Members is provided by the DHA. These individuals are designated by the DHA to assist DoD beneficiaries on issues regarding claims payments. In extreme cases the DSO may direct the claims processor to override the DEERS information; however, in most cases the DSO is able to correct the database to allow the claim to be reprocessed appropriately. The procedure contractors shall use to request data corrections is in Section 4.3.

3.3 Other Health Insurance (OHI) Program

3.3.1 See Section 4.2, paragraph 13.0.

3.3.2 The TRDP contractor shall utilize their own OHI database and is not required to perform any OHI updates within DEERS. However, the TRDP contractor is encouraged to query DEERS for OHI.

3.4 Standard Insurance Table (SIT) Program

3.4.1 Section 4.2, paragraph 14.0.

3.4.2 Even though the TRDP contractor utilizes their own OHI database, the contract shall participate by utilizing the SIT and providing updates.

- END -

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.