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TRICARE Operations Manual 6010.62-M, April 2021
Records Management (RM)
Chapter 9
Section 2
File Numbers, Subject, and Description of Government Records
Revision:  
1.0  GENERAL
The purpose of this section is to list the most common categories of records maintained by the contractor on behalf of the Government.
1.1  The contractor shall, if applicable, maintain the following Defense Health Agency (DHA) records regardless of media in accordance with paragraphs 1.3.4 through 1.3.12.
1.1.1  The contractor shall follow the guidance in the tables below for indexing and file number requirements formerly known as record series.
1.1.2  The contractor shall follow the DHA Records Disposition Schedule (RDS) if this section does not contain a description of a record created by the contractor for the Government.
1.1.3  The contractor shall contact the DHA RM Office to obtain a current copy of the DHA RDS.
1.1.4  The contractor shall use the National Archives and Records Administration (NARA) General Records Schedule (GRS) available on NARA’s website if it cannot identify a specific file number from the DHA RDS to apply to a particular type of record.
1.2  The contractor shall deliver to the DHA RM Office or the incoming contractor the below information that shows by file numbers:
•  Include meaningful any metadata and unique identifiers it uses to efficiently retrieve electronic records or record objects.
•  Refer to Section 1 for further guidance.
1.3  The following file numbers are the typical records managed by DHA contractors. If the following list does not contain a description of record content the contractor is managing, refer to the DHA RDS for a complete list.
•  The record format shall be the original source format at the time the record was created or received.
•  The record shall be in a usable format and must be searchable.
•  The acceptable record formats are data files and searchable Portable Document Format (PDF) files.
•  The image files shall include supporting related index/metadata files that support the ability to search for a specific image.
•  The Health Insurance Portability and Accountability Act (HIPAA) transaction.
1.3.1  The HIPAA transaction data set is the source of the claim record data in the majority of transactions. Only if the hard copy claim is scanned and Optical Character Recognition (OCR) technology is used to create the claim record data should the claim image be considered the source of the claim record. Only if the claim image is the source of the data shall it be used as the record copy. The claim record data set shall be in usable, searchable, and retrievable formats. It is not required to recreate the claim images from the data set.
1.3.2  The incoming contractor shall validate, accept and sign off on the record format when received from an outgoing contractor, to continue seamless health care delivery (HCD).
1.3.3  The mainframe screen shots or any other system screen shots are not acceptable record formats. Records shall be provided in their source format when requested by the government.
1.3.4  Action/Operations Files
File Number:
101-01.2
Description:
Documents on the administration or operations of a Component’s activities that are pertain to more substantial activities than routine administrative files and are exclusive of official personnel files pertaining to individuals described in this Records Schedule. These files generally include the following:
•  Routine comments on regulations, directives, or other publications prepared by another office with primary responsibility. If comments result in additional action affecting the mission or functions of the office, documents should be filed with the appropriate mission function files.
•  Evaluations of suggestions that do not result in issuing an instruction or establishing a project.
•  Program and budget documents, management improvement reports, cost reduction reports, and comparable management reports prepared to submit data to offices responsible for these management functions.
•  Extracts of reports of inspections, surveys, or audits that pertain to the operation of the mission or functions.
•  Comments on or contributions to news releases or other media furnished to publicize and promote the mission or functions.
•  Preparation and submission of reports to and testimony and hearings before Congress as well as background papers containing comments on recommended legislation affecting programs.
Note:  Not to be confused with papers maintained under Series 102-18, Congressional Correspondence, or Series 1000, Office of the Assistant Secretary of Defense (Legislative Affairs).
Required Metadata:
Date, Subject
1.3.5  Congressional Correspondence - Routine
File Number:
102-18.1
Description:
Correspondence of a routine nature with no historical value. Congressional inquiries originated by Armed Forces personnel, the public, or members of Congress, that are forwarded to the OSD for reply. Examples include letters regarding the Office of Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS) benefits for dependents, rejections for military service, requests for information about commissary privileges for retirees and retirement benefit programs, physician pay bonus program eligibility, and public inquiries as to how and where military equipment can be purchased, discrimination complaints, and public inquiries on Defense spending.
Required Metadata:
Date; Subject
1.3.6  RM Program Records
File Number:
203-01
Description:
Records related to the policies, procedures, and management of agency business records from creation to eventual disposition. Includes records created and maintained while planning, managing, evaluating, administering, and performing the function of agency RM. Activities include:
•  Providing oversight of entire RM Program.
•  Transferring, destroying, and retrieving records.
•  Inventorying records and conducting records surveys.
•  Scheduling records.
•  Providing other RM services to customer units (such as records storage/reference assistance, and technical assistance with files plans and other RM questions).
•  Conducting records “clean out” days.
•  Conducting special projects.
Records include:
•  Agency RM Program surveys or evaluations.
•  Reports of surveys or evaluations.
•  Reports of corrective action taken in response to agency program surveys or evaluations.
•  Disposal authorizations, schedules, and reports.
•  Records schedules, legacy records schedules (Standard Form (SF) 115, Electronic Remittance Advice (ERA) printouts, Request for Records Disposition Authority, and related studies, coordination actions, archival appraisals, and approvals or disapprovals).
•  SF 135, Records Transmittal and Receipt.
•  OF 11, Reference Request.
•  Transfer Request (TR); Legal Transfer Instrument (LTI); SF 258, Agreement to Transfer Records to NARA of the United States (US).
Required Metadata for SF135 and OF11:
Accession or Transfer Number; File Number; Contract Name; Contract Number; Record Freeze Number and title
Required Metadata for Disposition Authorities:
Accession/Transfer Number; File Number; Contract Name; Contract Number; Date; Subject; Record Freeze Number and title
Required Metadata for all other subcategories:
Date; Subject
1.3.7  Tracking and Control Records
File Number:
203-05
Description:
Records used to provide access to and control of records authorized for destruction by the GRS or a NARA - approved records schedule. Includes:
•  Indexes
•  Lists
•  Registers
•  Inventories
•  Logs
Exclusion 1: This schedule excludes records containing abstracts of records content or other information that can be used as an information source apart from the related records.
Exclusion 2: This authority does not apply to tracking and control records related to records scheduled as permanent.
Required Metadata:
Office Name, Primary Records Liaison, Alternate Records Liaison
1.3.8  HIPAA Records
File Number:
203-18
Description:
Records documenting authorizations, disclosures, access, complaints, amendments to, and control of protected health information, and HIPAA training and refresher training logs and training compliance reports including, but not limited to:
•  Authorizations from individuals for uses and disclosures of their Protected Health Information (PHI), including disclosure reports maintained in the Protected Health Information Management Tool (PHIMT) electronic information system;
•  Original requests for protected health information, copies of contractor responses, and all related supporting documentation;
•  Information that provides an accurate accounting of the date, nature, and purpose of each PHI disclosure, including documents that show the subject individual’s name, requestor’s name and address, purpose and date of disclosure, and proof of subject individual’s consent, when applicable;
•  Letters of complaint, contractor’s response, and other supporting documentation;
•  Requests for amendment, contractor’s agreement to amend or agreement not to amend records, and all supporting documentation;
•  Logs which track HIPAA requests; and
•  HIPAA birth month and refresher training completion logs of Military Health System (MHS) personnel and contractors, HIPAA birth month and refresher training completion logs commensurate with individual’s position and training compliance reports, including records maintained in the MHS Learn electronic information system.
Authorizations for Uses and Disclosures: Files that contain authorizations from individuals for uses and disclosures of their PHI.
Accounting Disclosures: Files that provide an accurate accounting of the date, nature, and purpose of each PHI disclosure, including documents that show the subject individual’s name; requestor’s name and address; purpose and date of disclosure; and proof of subject individual’s consent, when applicable. These files will be indexed alphabetically by individual’s name.
Amendment Case Files: Files contain requests for amendment, contractor’s agreement to amend, or agreement not to amend records and all supporting documentation.
Complaint Case Files: Files contain letters of complaint, contractor’s response and any supporting documentation.
Control Records: Files containing (1) logs which track authorizations, accounting, amendment, and complaint files, records maintained in the PHIMT system, and other HIPAA files relating to individual requests, such as requests for record access, restrictions on disclosure and requests for confidential communications, together with contractor responses and supporting documentation for such requests; and (2) logs which track other records within the scope of the HIPAA Privacy, Security, and Breach Rules, including contractor training logs, and records under other records series named in this section.
Requests for Access to PHI: Files contain original requests for PHI, copies of contractor responses and all related supporting documentation.
Required Metadata:
Sponsor Name; Sponsor Social Security Number (SSN); Sponsor Date of Birth (DOB); Beneficiary Name; Beneficiary SSN; Beneficiary DOB; DEERS Family Identification Number (DoD Benefits Number (DBN)); Provider Name; Provider Taxpayer Identification Number (TIN); National Provider Identifier (NPI); Requestor Name; Request Number; Date; Subject
1.3.9  Ad Hoc Quality Assurance Studies and Analyses of Healthcare Quality
File Number:
905-03
Description:
Studies and evaluations on a “when required” basis, not resulting in issuance of new standards.
Required Metadata:
TMA Claim Number; Sponsor SSN; Sponsor DOB; Sponsor Name; Beneficiary SSN, Beneficiary DOB, Beneficiary Name; Image Control Number; Program Name; Report Name; Date; Subject; Case Identifier
1.3.10  TRICARE Contractor Claims Records
File Number:
911-01
Description:
Abortion Claims Files: Documents required during the processing of abortion claims.
Adjusted Claims: Records which are acquired or utilized in the development and processing of adjusted claims.
Beneficiary History and Deductible Files: Computer generated records reflecting the contractor’s processing of claims and health care services.
Case Management (CM) Files (Medical Management (MM) Files): These records include the medical and mental health case files, all clinical history documentation, plans of care, treatment plans, case notes for beneficiaries past and present under CM (to include Extended Care Health Option (ECHO), Individual Case Management Program For Persons With Extraordinary Conditions (ICMP-PEC), and Custodial Care Transitional Policy (CCTP)), ECHO Home Health Care (EHHC), case notes for beneficiaries past and present under Disease Management (DM), claims and Explanations of Benefits (EOBs).
Preauthorization, Authorization, Referrals: This includes all those medical and mental health records generated within the health care services function involving preauthorization, authorization, referrals, beneficiary and provider denials letters, beneficiary and provider authorization letters, medical review, transition of care, peer review, concurrent review, and second level review performed by the medical directors, all UM appeal/reconsideration case files. These notes include copies of medical records and copies of prescriptions and other annotations that are maintained elsewhere in the original case files.
Enrollment and Disenrollment Files: Computer or manually generated records and all supporting documents which the contractor uses in the enrollment process.
Mental Health Case Files: These files consist of all documents required in the processing of mental health claims. This series includes cases which have gone to peer review or have been denied at the contractor level.
Peer reviews and all associated papers shall be filed in the case file, not kept separate.
Provider Files: Computer or manually generated records and supporting documents which are used in establishing and documenting a provider as authorized to provide services or supplies under DHA. Included are network agreements, sanction documents, provider signature on file, and provider power of attorney.
Reimbursement File Records: Computer or manually generated data and all supporting documents which the contractor uses in determining the payment to beneficiaries or providers. Included are all special rate agreements.
Third Party Liability (TPL) Case Records: Documents relating to a TPL cases.
TRICARE Contractor Claims Records: These files consist of any record acquired or used by the fiscal intermediary and/or contractor in the development and processing of TRICARE CHAMPVA claims. These records include but are not limited to: claims (TRICARE claims or other forms approved by TRICARE) receipts (itemized statements); medical reports (operative or daily nursing notes, lab results, etc.) authorization forms; non-availability statements; certifications of eligibility; double coverage information; completed TPL (guardianship); peer reviews and other correspondence that support payments to beneficiaries, physicians, and other suppliers of service under TRICARE. Includes the following database:
•  TRICARE Latin America and Canada (TLAC) Claims Database Master File: Information system used for analyzing claims processed by DHA (formerly TRICARE). Included are claim receipts, medical reports, authorization forms, Non-Availability Statements (NAS), certifications of eligibility, double coverage information, completed TPL, peer reviews and other correspondence that support payment to beneficiaries, physicians, and other suppliers of service.
•  Third Party Outpatient Collection System (TPOCS): Information system that enables the collection, tracking, and reporting of data required for the outpatient billing process. Records include Employer Information (i.e., name, address, policyholder POC); Insurance Policy data (i.e., policy number, group number, group name, effective date, policy category, insurance company, insurance type, policy holder, drug coverage data); Accounting data (i.e. control number, transaction code, debit amount, credit amount, check number, Batch posting number, balance, patient identification, patient name, encounter date, comments, entry date, follow-up date).
Customer Service Records: Correspondence and other comparable documentation which result in or support specific claim processing and payment determinations.
Required Metadata for Provider Files:
Provider Name; Provider TIN; NPI; Facility Name
Required Metadata for all other sub categories:
TMA Claim Number; Sponsor Name; Sponsor SSN; Sponsor DOB; Beneficiary Name; Beneficiary SSN; Beneficiary DOB; Image Control Number; DEERS Family Identification Number (DBN); Provider Name; Provider TIN; NPI
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.11  TRICARE Benefit Check Records
File Number:
911-02
Description:
These files consist of paid checks that contractors receive from banks covering amounts paid to beneficiaries and/or sponsors, physicians, and other suppliers of service under the TRICARE program. Also included are check vouchers and canceled or voided checks resulting from non-receipt, loss, theft, or non-delivery where the beneficiary and/or sponsor cannot be reached.
Electronic Funds Transfer (EFT) file information containing details about electronic payment to providers or beneficiaries.
Required Metadata:
Check Number; Check Issue Date; Check Amount; Bank Account Number; Bank Routing Number; Payee Name Beneficiary Name or Provider Name; Payee Identifier; (Sponsor SSN or Provider TIN); NPI
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.12  Explanation of TRICARE Benefits Records
File Number:
911-03
Description:
These files consist of explanation of TRICARE benefit notices TRICARE Explanation of Benefits (TEOB) used to advise beneficiaries and/or sponsors about TRICARE claims. Included are forms that are developed locally by contractors regarding explanation of TRICARE benefits.
Beneficiary EOBs: Forms used to advise beneficiaries, sponsors or both of the action taken on their TRICARE claims.
Provider EOBs (Summary Payment Vouchers): Forms used to advise providers of the action taken on claims they submitted to TRICARE.
Required Metadata:
Sponsor Name; Sponsor SSN; Sponsor DOB; Beneficiary Name; Beneficiary SSN; Beneficiary DOB; TMA Claim Number; DEERS Family Identification Number (DBN); Image Control Number; Provider Name; Provider TIN; NPI; Check Number
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.13  Appeals and Hearings Case Files
File Number:
911-04
Description:
These files accumulate when a beneficiary and/or sponsor, physician, or supplier of service is dissatisfied with the contractor’s determination denying a request for payment, or with the amount of the payment, or when the individual believes that the request for payment is not being acted upon with reasonable promptness. Included are copies of the claimants’ request for review, together with relevant written statements or evidence, notices or review decision, requests for a hearing to protest adverse decisions, hearing proceedings, hearing officers to protest adverse decisions, hearing proceedings, hearing officers’ final decisions, and other papers resulting from the appeals process.
Required Metadata:
TMA Claim Number; Sponsor Name; Sponsor SSN; Sponsor DOB; Beneficiary Name; Beneficiary SSN; Beneficiary DOB; DEERS Family Identification Number (DBN); Image Control Number; Provider Name; Provider TIN; NPI
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.14  Contractor Subcontractor Files
File Number:
911-05
Description:
These files consist of copies of contractor agreements with subcontractors, leases for building space, equipment, and consulting and other services. Included are TRICARE approvals, amendments, and similar papers.
Required Metadata:
Contract Name; Contract Number; Sub Contract Name; Sub Contract Number; Agreement Title or Document Name; Date
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.15  TRICARE Provider Authorization File - Certification of Institutional Providers of Healthcare Cases Files
File Number:
911-06.1
Description:
These files consist of certification of institutional providers of healthcare as authorized TRICARE providers that meet all applicable provisions of law and regulation. The files include: TRICARE forms, correspondence, and related documents certifying that each provider (institutional entity that provides medical services or supplies on an outpatient or inpatient basis) meets the criteria in the TRICARE Regulation, 32 CFR 199. They also ensure compliance with TRICARE standards, investigation of complaints, termination and reinstatement of providers, and assessment of the operational effectiveness of the provider certification program.
Required Metadata:
Provider Name; Provider TIN; NPI; Facility Name
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.16  TRICARE Provider Authorization File - Health Facilities Registry File
File Number:
911-06.2
Description:
This file consists of a computer printout registry of DHA (formerly TRICARE)-approved institutional providers of health care. The file includes the following categories of providers: Residential Treatment Centers (RTCs), Specialized Treatment Facilities (STFs), and Program for the Handicapped (PFTH).
Note:  The registry is compiled from data contained in file number 911-06.1.
Required Metadata:
Provider Name; Provider TIN; NPI; Facility Name
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.17  TRICARE Recoupment Files
File Number:
911-07
Description:
These files consist of all documents used to develop and execute recoupment cases at the contractor and TRICARE level. The files include: copies of TRICARE claim forms, correspondence and related documents, Explanations of Benefits, checks, investigative reports, court documents and other documents required to collect debts owed the Government. Information from these files may be given to consumer credit agencies. Documents relating to specific recoupment cases. The contractor shall follow the consolidation instruction in Chapter 10, Section 3. If the debts do not total $600.00 or more, and have been on offset status more than 12 months, the contractor shall consider the recoupment files inactive once the final contract payment is made and follow the standard closing procedures.
Required Metadata:
TMA Claim Number; Sponsor Name; Sponsor SSN; Sponsor DOB; Beneficiary DOB; Beneficiary Name; DEERS Family Identification Number (DBN); Provider Name; Provider TIN; NPI; Case ID; Refund Control Number
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.18  Fraud and Abuse Files
File Number:
911-08
Description:
These files consist of control forms, background papers, development records, external agencies reports/letters/investigative records, contractor products of processing, Utilization Review and Medical Analysis papers, and other documents required to process fraud and abuse cases.
Required Metadata:
TMA Claim Number; Sponsor Name; Sponsor SSN; Sponsor DOB; Beneficiary Name; Beneficiary SSN; Beneficiary DOB; DEERS Family Identification Number (DBN); Image Control Number; Provider Name; Provider TIN; NPI; Facility Name; Case ID; Case Name; Investigator
Record Format:
See paragraph 1.3 for detailed instructions.
1.3.19  TRICARE Medical Care Grievance Case Files
File Number:
911-11
Description:
These files consist of beneficiary’s written complaints of a TRICARE provider, healthcare finder, or other contractor or subcontractor personnel to furnish the level or quality of care and/or service to which the beneficiary may believe they are entitled. This includes the record of the contractor’s review and findings, the response to the aggrieved party and, where appropriate, the record of the corrective action taken.
Required Metadata:
TMA Claim Number; Sponsor Name; Sponsor SSN; Sponsor DOB; Beneficiary Name; Beneficiary SSN; Beneficiary DOB; DEERS Family Identification Number (DBN); Image Control Number; Provider Name; Provider TIN; NPI; Facility Name, Case ID, Case Name, Investigator
Record Format:
See paragraph 1.3 for detailed instructions.
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