1.0 Application
1.1 This section
provides functional guidance for all contractors that interface
with the Defense Manpower Data Center (DMDC)/DEERS in support of
their contractual requirements.
1.2 For the purpose of defining geographical
areas, the 50 United States (U.S.) and the District of Columbia
are hereafter referred to as the Continental United States (CONUS),
and all other areas are considered Outside of the Continental United
States (OCONUS).
1.3 The TRICARE Program’s contracts provide
support for specific health care service categories. Each major
area of this section will be broken into health care service categories
for specific guidance. Some of the contracted health care service
categories are:
• Pharmacy: TPharm
(Mail Order Pharmacy (MOP) and Retail Pharmacy).
• Dental: TRICARE Dental Program (TDP), TRICARE
Retiree Dental Program (TRDP), Active Duty Dental Program (ADDP),
and Remote Active Duty Dental Program (RADDP).
• Medical: CONUS regional contracts, OCONUS
contract, Uniformed Services Family Health Plan (USFHP) contracts.
• Nurse Advice Lines (NALs): CONUS and OCONUS
NALs.
• Medicare Eligible
Claims Processor: TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC):
CONUS, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa,
and the Northern Mariana Islands.
• Other Health Insurance (OHI).
1.4 Some key executable
business processes that all contractors must accomplish are listed
below.
1.4.1 For
all contractors and contracts:
• Beneficiary identification/authentication;
• DoD entitlements/TRICARE benefits information
(see also TRICARE Operations Manual (TOM) and TRICARE Policy Manual
(TPM)); and
• Identification
of Other Government Programs (OGPs) entitlement information, to include
Medicare.
1.4.2 When required by specific contract requirements:
• Enrollment processing;
• Enrollment premiums/fees
maintenance (includes fee exclusion);
• Primary Care
Manager (PCM) assignment/re-assignment;
• Claims processing
(with associated beneficiary contact updates);
• Catastrophic
Cap And Deductible Data (CCDD);
• OHI Program;
and
• Standard Insurance
Table (SIT) Program.
2.0 Contractor
Responsibility
Contractors shall understand and
execute the DEERS functionality described in this section. Contractors
shall also utilize the technical information and materials provided
by DMDC/DEERS via Defense Health Agency (DHA) Performance, Analysis,
Transition, and Integration Section (PAT&IS), and then must
consult with DEERS and DHA if clarification is required.
3.0 DEERS Operational
Environment And Characteristics
The DEERS system
environment consists of a Relational Database Management System (RDBMS),
rules-based applications processing DoD entitlements and eligibility,
a Transmission Control Protocol/Internet Protocol (TCP/IP) sockets
listener, application servers that enforce business rules, and web
servers.
3.1 Data Sequencing
Since DEERS is tasked with resolving
data conflicts from external systems using rules-based applications,
all contractors shall ensure proper data sequencing of transactions
sent to DEERS, when applicable to the specific interface involved.
This aids in maintaining data validity and integrity.
3.2 System Maintenance
And Downtime
3.2.1 DMDC has routinely scheduled times
for system maintenance and will schedule additional downtimes as
required. The routinely scheduled downtimes are:
• Weekly: 2100 Eastern Saturday to 0600 Eastern
Sunday
• Daily, if needed:
2355 Eastern to 0100 Eastern
3.2.2 When DMDC
identifies a telecommunications, hardware, or software problem outside
a scheduled maintenance window that results in downtime of contractors
interface for two contiguous or cumulative hours within a business
day, DMDC must notify the DHA of the problem and approximately when
it is expected to be corrected. DHA contractors reliant upon DEERS
will be notified of the situation and provided guidance as appropriate.
3.2.3 In addition
to the standard problem resolution procedures as referenced in DMDC documentation,
when contractors experience downtime in the DEERS interface for
two hours contiguously or cumulatively within a business day and
has not been contacted by DHA, contractors must report the downtime
to the DHA representative and shall report an updated status every
two hours until the problem is resolved. A final report upon resolution
is also required.
3.3 DEERS provides system-to-system
interfaces, applications, web-based applications, and web-based
services.
3.3.1 External
Systems - System-To-System Interfaces
All system-to-system
interfaces to DEERS must use TCP/IP, File Transfer Protocol (FTP), Hypertext
Transfer (Transport) Protocol (HTTP), Secure File Transfer Protocol
(SFTP), or Hypertext Transfer (Transport) Protocol Secure (HTTPS)
as specified by DEERS.
3.3.1.1 DEERS utilizes
standard message protocols where appropriate.
3.3.1.2 DEERS defines
the content and format of messages between DEERS and contractors.
3.3.1.3 DEERS and all
contractors must utilize encryption for all messages that contain
privacy level information.
3.3.1.4 DEERS specifies
the method of encryption and authentication for all external interfaces.
3.3.1.5 All notifications
are sent as full database images; they are not transaction-based. Contractors
must accept and apply the full image sent by DEERS. Contractors
shall add the information, if not present in their system. Contractors
shall update their system, if the information is present, by replacing
their information with what is newly received from DEERS. Notifications
are only intended to synchronize the most current information between
DEERS and contractors. They do not synchronize history between DEERS
and contractors.
3.3.1.6 DMDC centrally
enforces all business rules for enrollment and enrollment-related
events.
3.3.1.7 DEERS
is the database of record for all eligibility, enrollment information,
and Catastrophic Cap & Deductible (CC&D) information.
3.3.1.8 DEERS is the
central repository for OHI information.
3.3.2 Web-Based
Application Requirements And Functionality
3.3.2.1 All DMDC/DEERS
web-based applications require Microsoft® Internet Explorer (MIE)
6.0 or higher using HTTPS. They are all Government furnished equipment.
3.3.2.2 Contractors
shall use the Government furnished web-based applications for their
intended use only. Contractors shall not utilize screen scraping,
HTML stripping, and any other technology or approach to manipulate
or alter the intended use of the application or the application
architecture.
3.3.2.3 At a minimum,
the following functions are available using Government furnished
web-based applications, responsibilities and functions based on
contractual requirements:
• General Inquiry
of DEERS (GIQD) information used for research and customer service
to display demographics, Health Care Delivery Program (HCDP) eligibility
and enrollment. It may also allow other administrative functions
like address updates.
• Enrollment activities, to include display
of enrollment premiums/fees.
• Claims processing eligibility checks, see
also
Sections 5.1 and
5.2.
• CCDD information that supports research
and allows limited updates on the history of CC&Ds and enrollment
fee payment transactions posted to DEERS and stored on-line (current
plus previous five fiscal years).
• OHI information that allows add, update,
and cancellation of OHI policies as well as SIT carrier adds, updates,
cancellations and deactivations.
• PCM assignment, re-assignment, capacities,
and enrolled counts.
4.0 DEERS Web-Based
Applications And Notifications
Applications:
The following is a brief description of the available applications,
responsibilities and functions based on contractual requirements.
4.1 GIQD Information
GIQD
information is achieved through a Government furnished web-based
system/application that is used for research and customer service
to display demographics, coverage and PCM assignment information.
It also allows address updates.
4.2
Government
Furnished Web-Based Enrollment System/Application
4.2.1 The Government furnished web-based enrollment
system/application is a full function Government Furnished Equipment
(GFE) application developed by DMDC to support enrollment-related
activity. The Government furnished web-based enrollment system/application
interacts with both the main DEERS database and the National Enrollment
Database (NED) satellite database to provide enrolling organizations
with eligibility and enrollment information, as well as the capability
to update the NED with new enrollments and modifications to existing
enrollments.
4.2.2 The
Government furnished web-based enrollment system/application meets
the Health Insurance Portability and Accountability Act (HIPAA)
and DoD policy guidelines for a direct data entry application, and
is data-content compliant for enrollment and disenrollment functions.
4.2.3 Contractors
are required to perform enrollment related functions through the
Government furnished web-based enrollment system/application.
4.3 Government
Furnished Web-Based Beneficiary Self-service Enrollment System/Application
4.3.1 The Government
furnished web-based beneficiary self-service enrollment system/application
serves all TRICARE eligible beneficiaries and will support most
enrollment programs. The Government furnished web-based beneficiary
self-service enrollment system/application will interface with contractor
systems for the purposes of accommodating on-line payment of initial
enrollment fees.
4.3.2 DEERS will pre-populate data elements
where possible.
4.3.3 The web application contains checks
for beneficiary eligibility and hard edits requiring the beneficiary
to fulfill established DEERS business rules and enrollment criteria.
Upon completion of the web process, the beneficiary is informed
that the enrollment actions may be reviewed by the appropriate contractor
for accuracy and compliance with established regional and/or Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM) requirements,
and that they will be contacted if additional information is needed.
DEERS will send the contractor a notification(s) informing the contractor
that either a pending enrollment (for programs with PCM requirements)
or a new enrollment exists for the beneficiary. See also
paragraph 5.0.
5.0
DEERS
System-To-System Notifications
5.1 Government furnished system information/data
notification(s) are sent to contractors for various reasons and
reflect the most current enrollment information for a beneficiary.
Contractors must accept, apply, and store the data contained in
the notification as sent from DEERS to remain in sync with DEERS.
Notifications may be sent due to new enrollments or updates to existing
enrollments. If contractors do not have the information contained
in the notification, contractors shall add it to their system. If
contractors already have enrollment information for the beneficiary,
contractors shall apply all information contained in the notification
to their system.
5.2 Contractors shall use the beneficiaries’
DEERS identifiers, DoD Identification Number and/or DoD Benefits
Number (DBN), to match the notification to the correct beneficiary
in their system. There are also circumstances where a contractor
may receive a notification that does not appear to be updating the
information that the contractor already has for the enrollee. Such
notifications shall not be treated as errors by the contractor system
and must be applied.
5.3 Contractors are expected to acknowledge
all notifications sent by DEERS. If DEERS does not receive an acknowledgment,
the notification will continue to be sent until acknowledgment is received.
The following information details examples of events that trigger
DEERS to send notifications to a contractor.
• Primary Notifications Resulting From Enrollment
Actions.
• Unsolicited
Notifications resulting from updates to beneficiaries’ status.
6.0
Beneficiary
Identification
6.1 Patient Identification
Merge
6.1.1 See
also
Section 3.1 for Beneficiary Identification.
6.1.2 Occasionally,
incomplete or inaccurate person data is provided to DEERS and a
single person may be temporarily assigned two DoD Identification
Numbers. When DEERS identifies this condition, DEERS makes this
information available on-line for all contractors. Contractors are responsible
for retrieving and applying this information on a weekly basis.
The merge brings the data gathered under only one of the DoD Identification
Numbers and discards the other. Although DEERS retains both numbers
for an indefinite period, from that point on only the one remaining
DoD Identification Number shall be used by the contractor for that
person and for subsequent interaction with DEERS and other Military
Health Systems (MHSs). If there are enrollments under both records being
merged that overlap, the enrolling organizations are responsible
for correcting the enrollments. Contractors shall also update the
catastrophic cap that has been posted for these records if necessary.
6.2 Partial Match
6.2.1 See also
Section 3.1 for Beneficiary Identification.
6.2.2 A partial
match response may be returned for any inquiry that does not use
a DoD Identification Number and/or DBN. Eligibility may result in
a partial match situation due to person ambiguity. There will be
a separate listing for each person or family matching the requested
DBN, or Sponsor Social Security Number (SSN).
6.2.3 The listing
includes the sponsor and family member information needed to determine
the correct beneficiary or family including the DBN(s).
6.2.4 The requesting
organization must select which of the multiple listings is correct
based on documents or information at hand. After this selection,
the requesting organization would use the additional information
returned (e.g., Date Of Birth (DOB), Name) to resend a DEERS inquiry.
7.0
HCDP
Eligibility For Enrollment
7.1 The rules for determining a beneficiary’s
entitlement to health care benefits are applied by rules-based software
within DEERS. DEERS is the sole repository for these DoD rules,
and no other eligibility determination outside of DEERS is considered
valid. Whenever data about an individual sponsor or a family member
changes, DEERS reapplies these rules. DEERS receives daily, weekly,
and monthly updates to this data, which is why organizations must
query DEERS for eligibility information before taking action. This
ensures that the individual is still eligible to use the benefits
and that the respective contractor has the most current information.
7.2 A beneficiary
who is considered eligible for DoD benefits (pharmacy, dental, medical)
in accordance with Title 10 United States Code (USC),
32 CFR 199.13,
32 CFR 199.22,
and DoD Instruction (DoDI) 1000.13 is not required to “sign up”
for the TRICARE benefits associated with any DEERS assigned plan.
If an authorized organization inquires about that beneficiary’s
eligibility, DEERS reflects if he or she is eligible to use the
benefits. The effective and expiration dates for assigned plan coverage
are derived from DoDI 1000.13 rules and supporting information.
7.3 Eligibility
For Enrollment
DEERS provides coverage plan information
identifying the period of eligibility and/or enrollment for the
coverage plan. A beneficiary can only be enrolled into the coverage
plans that have an “eligible for” status. When a sponsor and/or
family member are first added, or when sponsor or member status
updates occurs, DEERS determines basic eligibility for health care
benefits in accordance with Title 10 USC,
32 CFR 199.13,
32 CFR 199.22,
and DoDI 1000.13 and then establishes an assigned HCDP coverage
plan together with coverage dates.
8.0
Enrollment
Activities
Enrollment-related business events include,
by contracted health care service category:
8.1 Pharmacy: Enrollment Functionality
No
enrollment requirement, as pharmacy is an assigned HCDP plan.
8.2 Dental: Enrollment
Functionality
8.2.1 Eligibility for enrollment identifies
current enrolled coverage plans and eligibility for enrollment into
other coverage plans (as the sponsor and/or beneficiaries role changes
over time). See also
Section 4.1. Some examples of plan changes
over time:
• Service member
plans. ADDP, but can move into other dental plans based on their beneficiary
role change (e.g., TDP and TRDP)
• Active Duty Family Member (ADFM) plans.
TDP, but can move into other dental plans based on their beneficiary
role change (e.g., TRDP and ADDP, if ADFM becomes an active Service
Member)
• Retirees. TRDP
with no expected change in plan.
• Retiree dependents. TRDP, but can move
into other dental plans based on their beneficiary role change (e.g.,
TDP and ADDP, if retiree dependent becomes an active Service Member)
• The
TRDP contractor shall cease new enrollment actions on October 31,
2018.
8.2.2 New enrollments are used for enrolling
eligible sponsors and family members into a HCDP coverage plans
or for adding family members to an existing family policy. Enrollments
begin on the date specified by the enrolling organization and extend
through the beneficiaries’ end of eligibility for the HCDP.
8.2.3 New enrollments
may also perform the following functions:
• Update address, e-mail address and/or telephone
number.
• Record that
the enrollee has OHI (does not apply to ADDP).
8.2.4 Modifications
of the current enrollment (updates) are used to change some information
in the current enrollment plan. Modifications of the current enrollment
include the following functions:
• Change enrollment begin date.
• Cancel enrollment/disenrollment.
• Change prior
enrollment end date.
• Change prior
enrollment end reason.
• Request an enrollment
card replacement.
• Add OHI information
for an enrollee (does not apply to ADDP).
8.3 Medical:
Enrollment Functionality
8.3.1 Eligibility for enrollment identifies
current enrolled coverage plans and eligibility for enrollment into
other coverage plans (as the sponsor and/or beneficiaries role changes
over time). See also
Section 4.1. Some examples of plan changes
over time:
• Service member
plans. TRICARE Prime for Service member only, but can move into other
medical plans based on their beneficiary role change (e.g., TRICARE
Prime Remote (TPR), TRICARE Standard, TRICARE Select, TRICARE Prime,
TRICARE Reserve Select (TRS), etc.).
• ADFM plans. Starting January 1, 2018,
beneficiaries must select a plan or will default to direct-care
only. However, Calendar Year (CY) 2018 is a grace period where they
can elect a plan at any point. Beginning with CY 2019, beneficiaries
will be limited to making changes to enrollments only during an
annual enrollment open season or following a Qualifying Life Event
(QLE). Direct Care (DC) only is the default assigned, but can enroll
into other medical plans based on their beneficiary role change
(e.g., TRICARE Select, TRICARE Prime, TRICARE Plus, TPRADFM, etc.).
See TOM,
Chapter 6, Section 1.
• Retirees and their family members.
Starting January 1, 2018, beneficiaries must select a plan or will
default to DC only. However, CY 2018 is a grace period where they
can elect a plan at any point. Beginning with CY 2019, beneficiaries
will be limited to making changes to enrollments only during an
annual enrollment open season or following a QLE. DC only is the
default assigned, but can elect to enroll into other medical plans (e.g.,
TRICARE Select, TRICARE Prime, TRICARE Plus, etc.). See TOM,
Chapter 6, Section 1.
8.3.2 New enrollments
are used for enrolling eligible sponsors and family members into
a HCDP coverage plans or for adding family members to an existing
family policy. Enrollments begin on the date specified by the enrolling
organization and extend through the beneficiaries’ end of eligibility
for the HCDP.
8.3.3 New enrollments may also perform the following
functions:
• Update address,
e-mail address and/or telephone number.
• PCM selection
(if required/allowed by HCDP).
• Record that
the enrollee has OHI.
8.3.4 Modifications
of the current enrollment (updates) are used to change some information
in the current enrollment plan. Modifications of the current enrollment
include the following functions:
• Change or cancel a PCM selection.
• Transfer enrollment
(enrollment portability) or cancel a transfer.
• Change enrollment
begin date.
• Cancel enrollment/disenrollment.
• Change prior
enrollment end date.
• Change prior
enrollment end reason.
• Request an enrollment
card replacement.
• Add OHI information
for an enrollee.
• Request a replacement
letter for PCM change or disenrollment.
8.4 NAL: Enrollment
Functionality
No enrollment requirement, as NAL is a
service program that supports all DoD eligible beneficiaries.
8.5 TDEFIC: Enrollment
Functionality
No enrollment requirement, as TDEFIC is
a claims processing contract that supports all dual eligible beneficiaries.
9.0 Disenrollments
Activities
9.1 Once actively enrolled in a coverage
plan, an individual or family may voluntarily disenroll or be involuntarily
disenrolled. Voluntary disenrollment is self-elected, but does not
apply to Service Member as they are not authorized to voluntarily
disenroll from mandated medical or dental plans. Involuntary disenrollment
occurs from failure to pay enrollment fees or from loss of eligibility.
Upon disenrollment, DEERS will notify the beneficiary of the change
in or loss of coverage.
9.2 For medical plans only, see TOM,
Chapter 6, Section 1 for disenrollment rules
and eligibility for re-enrollment.
9.3 When there is a disenrollment, the appropriate
systems are notified, as necessary (see also
paragraph 4.2).
9.4 Effective December
31, 2018, 11:59 p.m. Eastern, all TRDP enrollments shall terminate,
in accordance with this chapter.
10.0 Beneficiary
Contact Updates And Enrollment Cards
10.1 Contact Updates (Applicable To All Contractors)
Address,
telephone number, and e-mail address updates.
10.1.1 Addresses
10.1.1.1 DEERS
receives address information from a number of source systems. Although
most systems only update the residence address, DEERS actually maintains
multiple addresses for each person. Contractors shall update the
residential and mailing addresses in DEERS, whenever possible. These
addresses shall not reflect unit, MTF/eMSM, or contractors addresses
unless provided directly by the beneficiary. The mailing address
captured on DEERS is primarily used to mail the enrollment card and
other correspondence. The residential address is used to determine
enrollment jurisdiction at the Zip Code level. DEERS uses a commercial
product to validate address information received on-line and from
batch sources.
10.1.1.2 Contractors
are responsible for processing all mail returned for bad addresses
and shall research the address, correct it on DEERS, and re-mail
the correspondence to the beneficiary. If contractors cannot determine
a valid address, contractors shall update the Mail Delivery Quality
Code (MDQC) in DEERS to prevent future mailings to that address.
10.1.2 Telephone
Numbers
DEERS has several types of telephone
numbers for a person (e.g., home, work, and cellular). Contractors
shall make reasonable efforts to add or update telephone numbers.
10.1.3 E-Mail Addresses
DEERS can store an e-mail address
for each person. Contractors shall make reasonable efforts to add
or update this e-mail address.
10.2 Enrollment Cards And Letter Production
10.2.1 DEERS sends
a notification directly to the enrollee at the residential mailing
address specified in the enrollment request or via e-mail advising
them how to obtain a copy of their Universal TRICARE Beneficiary
Card. New enrollment cards are automatically generated upon a new
enrollment or an enrollment transfer to a new region (medical only).
Beneficiaries are notified of the availability by e-mail or postcard,
unless the enrollment operator specifies in the Government furnished
web-based enrollment system/application not to generate an enrollment
card. A contractor may request a replacement notification at any
time. DEERS sends a notification to the contractor indicating the
last date an enrollment card notification was generated for the
enrollee.
10.2.2 DEERS also generates letters to
beneficiaries upon changes to their enrollment, and notifies beneficiary
via e-mail or postcard that the letter is available. Contractors
shall not send additional letters that duplicate those already provided
by DEERS.
11.0
Claims
Processing And Database Of Record
11.1 DEERS is the system of record for
eligibility and enrollment information. As such, in the process of
claims adjudication, contractors shall query DEERS to determine
eligibility and/or enrollment status for a given period of time.
11.2 For audit and
performance review purposes, contractors are required to retain
a copy of every transaction and response sent and received for claims
adjudication procedures. This information is to be retained for
the period required by the TOM.
11.3 Contractors shall not override this
data with information from other sources. Continued Health Care
Benefits Program (CHCBP) CC&D information shall be obtained
from the CHCBP contractor.
11.4 Contractors shall deny a claim (either
totally or partially) if the services were received partially or
entirely outside any period of eligibility.
11.5 The contractor
system is the database of record for OHI within the TRICARE Program.
DEERS is the data repository for OHI, using its centralized repository
of OHI information that is reliant on the MHS organizations to verify,
update and add to at every opportunity. The OHI data received as
part of the claims inquiry shall be used as part of the claims adjudication
process. If the contractor has evidence of additional or more current
OHI information they shall either ‘pend’ the claim, submit the new
OHI information to DEERS, and then reprocess the claim, or develop
business processes to simultaneously accomplish both DEERS OHI update
and claims processing using the newly discovered OHI data. Any process
executed by the contractors must not interfere with the contractors
required claims processing time lines.
11.6 Although DEERS is not the database
of record for address, it is a centralized repository that is reliant
on numerous organizations to verify, update and add to at every
opportunity. The address data received as part of the claims inquiry
shall be used as part of the claims adjudication process. If the contractor
has evidence of additional or more current address information they
shall process claims using the additional or more current information
and update DEERS within two business days.
12.0 CCDD
12.1 DEERS stores
Enrollment Year (EY), Fiscal Year (FY), and CY CC&D data in
a central repository. DEERS stores the current and the four prior
yearly CC&D totals. The purpose of the DEERS CCDD repository
is to maintain and provide accurate CC&D amounts, making them
universally accessible to DoD claims processors.
Note: To transition
to CY catastrophic caps as required in NDAA FY 2017, Section 701,
the FY 2017 catastrophic cap covers the period from October 1, 2016
to December 31, 2017.
12.2 The CCDD Totals Inquiry is used to obtain
CCDD balances for the year(s) that correspond to the requested inquiry
period. Contractors must inquire and lock CCDD totals before updating
DEERS CCDD amounts.
Note: A catastrophic
cap record is not required for persons who are authorized benefits
but are not on DEERS or eligible for medical benefits, such as prisoners
or Government employees. The purpose of the catastrophic cap is
to benefit those beneficiaries who are eligible for MHS benefits. Those
persons that are authorized benefits who would not under any other
circumstances be eligible, are not subject to catastrophic cap requirements.
13.0
OHI
Program
13.1 OHI
identifies non-DoD health insurance held by a beneficiary. The requirements
for OHI are validated by the DHA Uniform Business Office (UBO).
OHI information includes:
• OHI policy and
carrier.
• Policyholder.
• Type of coverage
provided by the additional insurance policy.
• Employer information
offering coverage, if applicable.
• Effective period
of the policy.
13.2 OHI transactions allow adding, updating,
canceling, or viewing all OHI policy information. OHI policy updates
can accompany enrollments or be performed alone. OHI information
can be added to DEERS or updated on DEERS through multiple mechanisms.
At the time of enrollment the contractor will determine the existence
of OHI. Contractors can add or update minimal OHI data through the Government
furnished web-based enrollment system/application used by the contractors
to enter enrollments into DEERS. In addition, DEERS will accept
OHI updates from a claims processor through a system-to-system interface.
Other MHS can add or update the OHI through the OHI/SIT web application
provided by DEERS.
13.3 The contractor will perform an OHI
Inquiry before attempting to add or update an OHI policy. The MHS
organizations are reliant on the individual beneficiary to provide
accurate OHI information and DEERS is reliant on the MHS organizations
for the accurate assignment of policy information to the individual
record. DEERS is not the system of record for OHI information. Performing
an OHI Inquiry on a person before adding or attempting to update
an OHI policy helps ensure that the proper policy is updated based
on the most current information or the person.
13.4 Examples of
OHI coverage are:
• Comprehensive
Medical coverage (Plans with multiple coverage types).
• Medical coverage.
• Inpatient coverage.
• Outpatient coverage.
• Pharmacy coverage.
• Dental coverage.
• Long-term care
coverage.
• Mental health
coverage.
• Vision coverage.
• Partial hospitalization
coverage.
• Skilled nursing
care coverage.
13.5 The default coverage will be Comprehensive
Medical Coverage unless another of the above coverages is selected.
The indication of Comprehensive Medical Coverage presumes medical
coverage, inpatient coverage, outpatient coverage, and pharmacy
coverage. Medical contractors must develop the OHI within 15 days
but is not responsible for development of pharmacy.
13.5.1 The pharmacy
contractor(s) is/are expected to develop and maintain pharmacy OHI. Pharmacy
placeholder policies will be developed by the pharmacy contractor,
regardless of which organization created the placeholder. All other
placeholder policies will be developed by the contractor, regardless
of which organization created the placeholder. MHS organizations
will not normally enter placeholder policies but would develop them
if they created them.
13.5.2 The dental contractor(s)
are expected to develop and maintain dental OHI.
13.6 A person can
have multiple types of OHI coverage for one policy. For example,
to add an OHI policy that covers medical and vision, two OHI coverage
types, one for medical coverage and one for vision coverage, would
be sent to DEERS.
13.7 A person can have multiple OHI policies.
Multiple OHI policies may have the same or different Health Insurance
Carriers (HICs), and/or the same or different OHI policy effective
periods.
14.0
SIT
Program
The SIT Program supports the MHS billing
and collection process. The SIT is validated by the DHA UBO through
the DoD Verification Point of Contact (VPOC). The VPOC is ultimately
responsible for maintaining the SIT in DEERS, which is the system
of record for SIT information. The SIT provides uniform billing
information for reimbursement of pharmacy, dental, and medical care
costs covered through commercial policies held by the DoD beneficiary
population. MHS personnel use the SIT to obtain other payer information
in a standardized format.
14.1 All systems identified as trading
partners will request an initial full SIT subscription from DEERS. In
addition, holders of the SIT shall subscribe to DEERS at least daily
in order to receive subsequent updates of the SIT.
14.2 The SIT Verification
Application is used exclusively by the VPOC. The application queues
all SIT transactions entered through the OHI Maintenance Application
for review and verification by the VPOC.
15.0 Medicare
Data
15.1 DEERS
performs a match with the Centers for Medicare and Medicaid Services
(CMS) to obtain Medicare data and incorporates the Medicare data
into the DEERS database as OGPs entitlement information. This information
includes Medicare Parts A, B, C, and D eligibility along with the
effective dates. The match includes all potential Medicare-eligible
beneficiaries.
15.2 DEERS sends Medicare Parts A and B information
to the TDEFIC. The TDEFIC sends the information to the CMS Fiscal
Intermediaries for identification of Medicare eligible beneficiaries
during claims adjudication.