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TRICARE Systems Manual 7950.4-M, April 2021
Defense Enrollment Eligibility Reporting System (DEERS)
Chapter 3
Section 5.2
Defense Enrollment Eligibility Reporting System (DEERS) Functions In Support Of The TRICARE Active Duty Dental Program (ADDP)
Revision:  
1.0  Introduction
This section provides TRICARE ADDP and Remote Active Duty Dental Program (RADDP) specific/unique guidance that was not discussed or described elsewhere in the TRICARE Systems Manual (TSM).
2.0  Guidance
2.1  Health Care Delivery Program (HCDP) Eligibility and Enrollment
2.1.2  The contractor shall contact the DHA Dental Service Point of Contact (DSPOC) when they do not have proper documentation, such as military orders, to verify eligibility for those individuals who are indicated on DEERS as not eligible (e.g., not on active duty but who may have a Line of Duty (LOD) condition or a Foreign Force Member (FFM)).
2.1.3  DSPOCs are the final decision authority for eligible Active Duty Service Members (ADSMs).
2.2  ADDP Eligibility
2.2.1  All ADSMs of the Uniformed Services (excluding Public Health Service (PHS), who are on continuous active duty orders for more than 30 calendar days are eligible to receive ADDP dental coverage, subject to the requirements and limitations provided in the ADDP.
2.2.2  Who have a duty location and residence greater than 50 miles from a Military Medical Treatment Facility (MTF) dental center are automatically eligible for RADDP benefits.
2.2.3  National Guard (NG)/Reserve members that serve on continuous active duty for more than 30 calendar days are considered ADSMs. NG members are only TRICARE eligible if on federally funded orders for more than 30 calendar days. If the NG member is on state orders, they are not eligible for TRICARE. The NG will determine if the orders qualify for TRICARE.
2.2.4  Reserve Component (RC) members (which includes NG) who are issued delayed-effective-date active duty orders for more than 30 calendar days in support of a contingency operation are eligible for ADDP as defined in Department of Defense Instruction (DoDI) 7730.54.
2.2.5  A Line of Duty (LOD) investigation is for RC members who incur or aggravate an injury, illness or disease while serving on active duty for 30 calendar days or less as defined in DoDI 1241.2.
2.2.6  Foreign Force Members (FFMs) who are on temporary or permanent assignment in the ADDP geographic area of responsibilities may be eligible to participate in the ADDP pursuant to an approved agreement (e.g., reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), Partnership for Peace (PfP) SOFA).
2.2.7  Enrollment Requirements (Unique)
2.2.7.1  ADSMs whose permanent duty location and/or residence is less than 50 miles from an MTF dental center are automatically eligible for ADDP benefits and do not require enrollment.
2.2.7.2  Within the ADDP there are three types of Dental Coverage Plans that require enrollment. The RADDP plans are:
2.2.7.2.1  RADDP for ADSMs Enrolled in TRICARE Prime Remote (TPR)
Eligibility to enroll in medical TPR requires that the ADSM’s permanent duty location and residence be more than 50 miles from a Market/MTF or designated clinic. DEERS will systematically enroll, disenroll, and maintain enrollments into the RADDP for ADSMs enrolled in TPR coverage plan based on the ADSM’s medical TPR enrollment. ADSMs living in a TPR location must enroll in a medical TPR coverage plan to be enrolled in RADDP.
2.2.7.2.2  RADDP for ADSMs Not Eligible for TPR
2.2.7.2.2.1  ADSMs whose permanent duty location and/or residence is less than 50 miles from a Market/MTF or designated clinic are not eligible to enroll in TPR. If the ADSM’s permanent duty location and residence is within 50 miles of a Market/MTF, but more than 50 miles from an MTF dental center, he or she will not be automatically enrolled into RADDP. The ADDP contractor will be able to manually enroll the ADSM into the RADDP.
2.2.7.2.2.2  The ADDP contractor shall verify the coverage plan, and correct the enrollment begin date if it is different than the Government furnished web-based enrollment system/application default.
2.2.7.2.3  Automatic Enrollment in RADDP for National Oceanic and Atmospheric Administration (NOAA)
2.2.7.2.3.1  All NOAA ADSMs will be eligible for RADDP. DEERS will systematically enroll, disenroll, and maintain enrollments into the RADDP for NOAA ADSMs.
2.2.7.2.3.2  When enrolling an ADSM into RADDP, the Government furnished web-based enrollment system/application will require the effective dates of the enrollment. Enrollments may be established with past effective dates, the current date, or future effective dates. The enrollment period cannot exceed the end of eligibility, nor precede the eligibility begin date. DEERS will ensure that the coverage plan sent with an enrollment is valid based upon the assigned eligibility.
2.3  Disenrollment Activities
2.3.2  Disenrollment actions are used to terminate an enrollment. Disenrollments will occur when there is a loss of eligibility, or when the ADSM reports he or she no longer lives and/or works within a MTF non-catchment area. Upon disenrollment, DEERS will notify the ADSM of the change in or loss of coverage.
2.3.3  Disenrollment - Loss of Eligibility
A loss of eligibility refers to any loss or change in eligibility for:
•  DoD health care benefits according to the current DoDI 1000.13; or
•  A medical TPR coverage plan. Under these circumstances, DEERS will terminate any current enrollment or enrollment effective at the end of the month in which eligibility ends.
Example:  When the eligibility of a ADSM enrolled in TPR and RADDP terminates due to separation from service, the eligibility for RADDP will be terminated, resulting in a disenrollment by DEERS. The termination of coverage will affect the insured’s current and/or future enrollment in a HCDP.
2.3.4  Disenrollment Due to No Longer Living or Working within RADDP Eligible Location
2.3.4.1  When an ADSM enrolled in a RADDP coverage plan for ADSMs living and working within 50 miles of a Market/MTF without dental capability, moves within 50 miles of a Market/MTF with dental capability, the work or home address will be updated.
2.3.4.2  The ADDP contractor shall perform a disenrollment from the RADDP coverage plan if applicable.
Note:  Changing an ADSM’s residence address will not cause an automatic disenrollment. DEERS will not disenroll an ADSM from RADDP based on an address update.
2.4  Claims Processing [Unique to ADDP/RADDP]
2.4.2  The DEERS Claims Service (DCS) is used to determine benefit coverage for a given period. Contractors must use the DCS for all claims processing.
2.4.3  DCS Inquiry for Claims
The contractor 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 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 Defense Health Agency (DHA) and DMDC.
2.5  Key Support POCs
2.5.1  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.
2.5.2  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.
2.5.3  The contractor shall request data corrections using procedures in Section 4.3.
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