Back to Top Skip to main content

Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Operations Manual 6010.62-M, April 2021
Transitions
Chapter 2
Section 8
Critical Processes (CPs) - Claims Processing
Revision:  
1.0  TRANSITION-IN GENERAL
1.1  The incoming contractor shall include in its Integrated Master Plan (IMP) and Integrated Master Schedule (IMS) the details and schedule of activities to begin claims processing at the start of health care delivery (SHCD) as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
1.2  The incoming contractor shall process claims with dates of service following the SHCD in accordance with Chapter 6 and TRICARE Policy Manual (TPM), Chapter 10.
1.3  The incoming contractor shall maintain of the TRICARE Encounter Provider (TEPRV) record beginning with the SHCD.
2.0  TRANSFER OF CLAIMS FILES AND DATA
2.1  The outgoing contract shall transfer to the incoming contractor Automated Data Processing (ADP) files to include but not limited to provider files, beneficiary history files, claims history and associated notes, in accordance with Chapter 2, Section 6 and Chapter 9.
2.2  Receipt of Outgoing Contractor’s Shipment of History Updates
The incoming contractor shall begin the validation, conversion, and loading of all beneficiary and claims history updates from the outgoing contractor(s) into its claims system no later than 14 calendar days following receipt.
3.0  DUAL OPERATIONS
3.1  The outgoing contractor shall continue to process claims during dual operation for 180 calendar days after the incoming contractor’s SHCD.
3.2  The outgoing contractor shall maintain toll-free lines and web-based customer service capabilities, accessible to the public during the first 180 calendar days of dual operations in order to properly respond to inquiries related to claims processed for services incurred during the period of their liability. Beneficiary inquiry lines shall continue to be staffed as defined in the contract.
3.3  The outgoing contractor shall maintain adequate toll-free line coverage to ensure that the blockage rate does not exceed the blockage rate on the contractor’s most critical private or other Government business access line.
3.4  The incoming and outgoing contractors shall maintain close interface on claims history update exchanges and provider file information to ensure accuracy of claims processing.
3.5  The outgoing contractor shall process claims with dates of service prior to the SHCD for up to 120 calendar days following the incoming contractor’s SHCD.
3.6  The outgoing contractor shall provide beneficiary claims history updates during dual operations to the incoming contractor with each claims processing cycle run.
3.7  The incoming contractor shall assume processing of all incoming claims beginning with day 121 after the SHCD.
3.7.1   The incoming contractor shall use historical claims history data and or obtain any negotiated rate or discount information for reimbursement purposes for network claims.
3.7.2  The incoming contractor shall reimburse claims using standard TRICARE reimbursement methodologies as if no negotiated or discount rates were in effect if the incoming contractor is unable to obtain historical claims history data and or obtain any negotiated rate or discount information for reimbursement purposes for network claims.
4.0  FINAL PROCESSING OF OUTGOING CONTRACTOR
4.1  The outgoing contractor shall process all claims and adjustments for care rendered prior to the SHCD of the new contract that are received through the 120th calendar day following cessation of the outgoing contractor’s health care delivery (HCD).
4.1.1  The outgoing contractor shall complete processing of these claims within 180 calendar days following the start of the incoming contractor’s HCD. All claims shall meet the same standards as outlined in the current outgoing contract.
4.1.2  The outgoing contractor shall transfer any residual claim received after 120 calendar days to the incoming contractor within 24 hours of receipt.
4.1.3  The outgoing contractor shall be liable, after the termination of services under this contract, for any payments to subcontractors of the contractor arising from events that took place during the period of this contract.
4.1.4  The outgoing contractor shall process all correspondence, allowable charge complaints, and incoming telephonic inquiries which pertain to claims or services processed or delivered under this contract within the time frames established for response by the standards of the contract.
4.1.5  The outgoing contractor shall complete all appeal and grievance cases that pertain to claims or services processed or delivered under this contract within the time frames established for response by the standards of the contract.
4.1.6  The outgoing contractor shall complete Payment Processing and TED Record Payment Reporting accordance with the TRICARE Systems Manual (TSM), Chapter 2.
4.2   The above paragraph 4.0 does not apply to the overseas contractor. The outgoing TRICARE Overseas Program (TOP) contractor is only required to process claims and adjustments received during its period of service delivery. Processing of all claims shall be completed within 280 calendar days following the start of the incoming contractor’s services delivery.
4.3  The outgoing contractor shall provide the incoming contractor and GDA with a current list of beneficiaries within their geographic area of responsibility who qualified for custodial care benefits (prior to June 1, 1977) no later than 60 calendar days prior to the SHCD.
5.0  Defense Health Agency (DHA) PERFORMANCE READINESS VALIDATION (PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)
During transition, the incoming contractor’s performance readiness status regarding claims processing will be subject to PRV/PRAV reviews as described below.
5.1  Claims Processing PRV
5.1.1  The incoming contractor shall validate its ability to process all TRICARE claim types with a minimum of a 98% accuracy rate no later than 90 calendar days prior to the SHCD. Claims testing shall include multiple claim types that represent a level of complexity involved in claims for TRICARE benefits. Validation shall include claims processing at the operational volume, stress testing at projected claims volumes and include claims representing all active demonstrations.
5.1.2  The contractor shall provide validation results, to include test scenarios used, to the Government within 10 business days following conclusion of the contractor’s validation.
5.1.3  The incoming contractor shall validate it can receive and utilize claims history file transfers from the outgoing contractor no later than 14 calendar days following receipt of the files from the outgoing contractor.
5.1.3.1  The incoming contractor shall include in its validation process a test of a statistically valid number of records to ensure readability and usability of information. Tests shall include accessibility to records, accuracy of data, and the contractor’s ability to use the data to correctly apply TRICARE policy, such as time or episode limited benefits.
5.1.3.2  Results must reach a minimum of 98% accuracy no later than 45 calendar days prior to the SHCD.
5.1.3.3  The incoming contractor shall provide test scenarios as well as testing results to the Government no later than 45 calendar days prior to the SHCD.
5.1.4  The incoming contractor shall develop tests to ensure reimbursement rate system applications are correctly loaded and functioning properly. Areas tested shall include negotiated network discount rates, non-network rates, and specific reimbursement rates as required by policy (e.g., Sole Community Hospitals (SCHs), low/high-volume mental health facilities, partial hospitalization facilities). Validation shall include demonstrating a variety of claims scenarios where reimbursement rate system applications are applied.
5.1.4.1  The incoming contractor shall complete its reimbursement rate system validation no later than 90 calendar days prior to the SHCD and provide the Government with validation results, to include test case scenarios used, within 10 business days following conclusion of the contractor’s validation.
5.1.4.2  The incoming contractor shall submit a detailed mitigation plan no later than 14 calendar days following receipt of the Government’s findings, if, after review, the Government finds the contractor’s testing or outcomes are deficient.
5.1.4.3  The incoming contractor shall process test claims no later than 120 calendar days prior to the SHCD with a first pass auto-adjudication rate of 80% of the test claims volume that do not require human intervention (i.e. preauthorization or other manual reviews).
5.1.5  The incoming contractor shall validate that its claims processing system clearly identifies and appropriately differentiates between beneficiary categories to facilitate claims processing accuracy by testing a multitude of scenarios with different beneficiary categories (as specified in the TRICARE Systems Manual (TSM)) to ensure appropriate application of cost-shares, co-pays and rates.
5.1.5.1  The incoming contractor shall complete its system testing no later than 120 calendar days prior to the SHCD with a 95% accuracy rate. The contractor shall complete its claims processing system differentiation validation no later than 120 calendar days prior to the SHCD and provide the Government with validation results, to include test case scenarios used, within 10 business days following conclusion of the contractor’s validation.
5.1.5.2  The incoming contractor shall submit a detailed mitigation plan no later than 10 business days, if after review, the Government finds the contractor’s testing or outcomes to be deficient.
5.1.6  The incoming contractor shall validate that the contractor’s claims processing system accurately and appropriately applies referrals and authorizations.
5.1.7  The incoming contractor shall validate its bi-directional referral, authorization and claims interface system with DHA-Great Lakes (DHA-GL) is operational no later than 60 calendar days prior to the SHCD.
5.2  Claims Processing PRAV
5.2.1  The incoming contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding claims activities as described above.The incoming contractor shall submit a detailed mitigation plan no later than 10 business days following the Government’s findings if, after review, the Government finds the incoming contractor’s performance readiness for claims processing to be deficient.Specific PRAV activities, assessment techniques, and performance readiness thresholds will be identified by the Government during the Transition Specification (TRANSPEC) Meeting.
- END -

Utility Navigation Links

DoD Seal

tricare.mil is the official website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Frequently Asked Questions page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.

v4.8.7983.18738

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.