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TRICARE Operations Manual 6010.59-M, April 1, 2015
Value-Based Programs (VBPs), Pilots, And Demonstrations
Chapter 29
Addendum D
Accountable Care Organization (ACO) Demonstration - TRICARE Manuals Exclusion List
Revision:  C-62, January 28, 2020
Chapter and Section titles and numbers listed below are current as of September 27, 2019. The Addendum may be updated by the Government if there are significant changes to the TRICARE Manuals’ structure.
Figure 29.D-1  TRICARE Operations Manual (TOM)
Chapter
Section
Title
Details
Tier 1 providers are part of the Southeast Permanente Medical Group, Inc (TSPMG).
1
Administration
3
TRICARE Processing Standards
Exclude paragraphs 1.1 and 1.2 for Tier 11 care. Exclude paragraph 1.3 (Network Adequacy); paragraphs 1.4 - 1.8 and 6.0 only apply to inpatient claims.
4
Management
Paragraphs 2.2, 2.4, and 4.0 only apply to inpatient claims.
2
Transitions
1
Management and Administration
Exclude.
2
Systems Development
Exclude.
3
Critical Processes (CP) - Provider Networks
Exclude.
4
Critical Processes (CP) - Enrollment
Exclude.
5
Critical Processes (CP) - Customer Service
Exclude.
6
Critical Processes (CPs) - Management - Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs)
Exclude.
7
Critical Processes (CPs) - Referral Management
Exclude.
8
Critical Processes (CPs) - Claims Processing
Exclude.
9
Critical Processes (CPs) - Medical Management
Exclude.
10
Other requirements
Exclude.
3
Financial Administration
2
Payments To Beneficiaries/Providers
Exclude for care by Tier 1 providers1.
3
Claim Refund And Collection Procedures
Exclude for care by Tier 1 providers1.
4
Stale Dated, Voided, Or Returned Checks
Exclude for care by Tier 1 providers1.
4
Provider Certification and Credentialing
1
General
Paragraphs 2.2 - 2.4, 3.0, 5.0 and Addendum A only apply to inpatient.
6
Enrollment
1
TRICARE Prime And TRICARE Select Enrollment Processing
Exclude paragraphs 1.8 and 4.0.
5
Provider Networks
1
Network Development
Exclude.
7
Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
2
Preauthorizations
Exclude for Tier 1 providers1.
8
Claims Processing procedures
4
Signature Requirements
Exclude for Tier 1 providers1.
10
Claims Adjustment and Recoupments
4
Overpayments Recovery - Non-Financially Underwritten Funds
Exclude.
11
Communications And Customer Service (C&CS)
1
Education Requirements
Exclude.
2
Government Staff and Beneficiary Education
Exclude paragraphs 1.0, 2.0, 3.0 and 8.0.
6
Telephone Inquires
Exclude paragraph 5.0.
15
TRICARE Regional Offices (TROs)/Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) and Contractor Interfaces
1
Director, TRICARE Regional Offices (TROs), Military Treatment Facility (MTF) Commander/Enhanced Multi-Service Market (eMSM) Manager, and Contractor Interface
Exclude.
2
Resource Sharing
Exclude.
3
Clinical Support Agreement (CSA) Program
Exclude.
A
Memorandum Of Understanding (MOU) - Example
Exclude.
16
TRICARE Prime Remote (TPR) Program
1
General
Exclude.
2
Health Care Providers and Review Requirements
Exclude.
3
Enrollment, Beneficiary Education, and Support Services
Exclude.
4
Contractor Responsibilities and Reimbursement
Exclude.
5
Reports
Exclude.
6
TRICARE Prime Remote For Active Duty Family Member (TPRADFM) Program
Exclude.
A
Points Of Contact (POCs)
Exclude.
B
Specified Authorization Staff (SAS) Review: Protocols And Procedures
Exclude.
17
Supplemental Health Care Program (SHCP)
1
General
Exclude for care inside the designated ACO Demonstration area.
2
Providers of Care
Excludefor care inside the designated ACO Demonstration area.
3
Contractor Responsibilities
Excludefor care inside the designated ACO Demonstration area.
A
Points Of Contact (POCs)
Exclude for care inside the designated ACO Demonstration area.
B
Specified Authorization Staff (SAS) Review For Authorization: Protocols And Procedures
Exclude for care inside the designated ACO Demonstration area.
C
Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA) And Department Of Defense (DoD) For Processing Payment For Disability Compensation And Pension Examinations (DCPE) In The Integrated Disability Evaluation System (IDES)
Exclude for care inside the designated ACO Demonstration area.
D
Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA) And Department Of Defense (DoD) For Medical Treatment Provided To Service Members With Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blindness, Or Polytraumatic Injuries
Exclude for care inside the designated ACO Demonstration area.
18
Demonstrations and Pilot Projects (except Value-Based initiatives)
4
Department Of Defense (DoD) Comprehensive Autism Care Demonstration
Exclude.
A
Participation Agreement For Comprehensive Autism Care Demonstration Corporate Services Provider (ACSP)
Exclude.
20
TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
1
General
Exclude.
2
Jurisdiction
Exclude.
3
Claims Processing For TRICARE Dual Eligibles
Exclude.
4
Other TRICARE Dual Eligibles Contract Requirements
Exclude.
5
TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) Contractor Transition
Exclude.
21
TRICARE Alaska
1
TRICARE Alaska
Exclude.
22
Reserve Component Health Coverage Plans
1
TRICARE Reserve Select (TRS)
Exclude.
2
TRICARE Retired Reserve (TRR)
Exclude.
A
Figures
Exclude.
23
TRICARE Pharmacy (TPharm)
1
General
Exclude for care within the PSA.
2
Out-of-Jurisdiction Claims
Exclude.
3
Pharmacy Claims Processing
Exclude.
4
Other Contract Requirements
Exclude.
5
Transition
Exclude.
26
Continued Health Care Benefit Program (CHCBP)
1
Eligibility And Coverage
Exclude.
A
Continued Health Care Benefit Program (CHCBP) Premiums
Exclude.
27
Prime Service Area (PSA) Reduction Policies and Effective Dates
1
Prime Service Area (PSA) Reduction Policies And Effective Dates
Exclude.
28
Prescription Monitoring Program (PMP)
1
Prescription Monitoring Program (PMP)
Exclude from Quarterly reporting (paragraphs 3.0 through 8.0).
Figure 29.D-2  TRICARE Policy Manual (TPM)
Chapter
Section
Title
Details
1
Administration
9.1
Individual Case Management Program For Persons With Extraordinary Conditions (ICMP-PEC)
Exclude.
13.1
Relationship Between TRICARE and Employer-Sponsored Group Health Plans (GHPs)
Exclude.
4
Surgery  
1.2
Treatment Of Unfortunate Sequelae And/Or Medically Necessary Follow-On Care Subsequent To Authorized Noncovered Initial Surgery Or Treatment In A Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM)
Exclude.
8
Other Services
9.1
Pharmacy Benefits Program
Exclude.
15.1
Custodial Care Transitional Policy (CCTP)
Exclude.
12
TRICARE Overseas Program (TOP)
1.1
TRICARE Overseas Program (TOP)
Exclude.
1.2
TRICARE Overseas Program (TOP) Medical Benefit Variations
Exclude.
1.3
Outside The 50 United States And The District Of Columbia Locality-Based Reimbursement Rate Waiver
Exclude.
Figure 29.D-3  TRICARE Reimbursement Manual (TRM)
Chapter
Section
Title
Details
1
General
20
State Agency Billing
Exclude.
4
Double Coverage
1
Double Coverage
Exclude.
2
Double Coverage Review And Processing Of Claims
Exclude.
3
Coordination Of Benefits (COB)
Exclude.
4
Specific Double Coverage Actions
Exclude.
Figure 29.D-4  TRICARE Systems Manual (TSM)
Chapter
Section
Title
Details
3
Defense Enrollment Eligibility Reporting System (DEERS)
5.1
Defense Enrollment Eligibility Reporting System (DEERS) Functions In Support Of The TRICARE Dental Program (TDP) And The TRICARE Retiree Dental Program (TRDP)
Exclude.
5.2
Defense Enrollment Eligibility Reporting System (DEERS) Functions In Support Of The TRICARE Active Duty Dental Program (ADDP)
Exclude.
- END -

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