This
section describes implementation requirements for the Duplicate
Claims System (DCS). It also defines policies and procedures for
the operation of the system. For transition requirements related
to this section, see the TRICARE Operations Manual (TOM),
Chapter 2.
2.0 Software Requirements
2.1 Optional Software
The contractor
may, at it’s own option and expense, procure and utilize full version
database management software packages such as Microsoft Access®,
dBase®, Paradox For Windows®, etc., on the DCS PCs for the purpose
of generating customized queries and reports utilizing optionally
downloaded ASCII fixed length files that can be created by the DCS.
Downloaded ASCII fixed length files may also be imported into Microsoft
Excel®.
2.2 Security
Requirements - Defense Health Agency (DHA) Form 834, Patient Encounter Processing
and Reporting (PEPR) Account Activation Request Form
2.2.2 In order to access the DCS
and
ECRS, users shall obtain a
CAC
from
DHA, see
Chapter 1, Section 1.1. CACs will be issued
following receipt and processing of properly completed registration and
security forms. Contractor users shall provide the required information,
and submit the completed form to their DCS
Information Security
Officer for
signature and transmittal to DHA.
2.2.3 DCS data shall be encrypted. Encryption
specifications will be provided by DHA. See
Chapter 1 for
additional security and communications requirements.
2.3
Registration
And Security
Each individual user must complete and
sign Government provided security and access forms prior to be granted
DCS access.
3.0
Connectivity
Connectivity will be through the Internet
to the PEPR Portal via MSIE, Version 5.5, 6.0, or 7.0, or as directed
by the Government.
4.0 System Support
For DCS support, contractors shall
file a problem ticket with the DHA Global Service Center at 1-800-600-9332,
then follow the prompts to the DCS.
5.0 Operating
Procedures
5.1 For each regional contract for which
a contractor is responsible, or for the TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC), the contractor shall develop internal
operating procedures for the DCS. These internal operating procedures
shall designate the responsible areas for the various duplicate
claims resolution functions and establish time lines. For example,
one contractor may decide that the adjustment unit shall be responsible
for scanning the DCS on a weekly basis for the appearance of adjustments
submitted and for closing sets. Another contractor may decide that
the unit responsible for researching potential duplicate claims
should also be responsible for scanning for adjustments and closing
the sets on a daily basis.
5.2 Contractor contract requirements
for overpayment recovery, refunds and offsets, adjustments, etc.,
including timeliness requirements, apply to the operation of the
DCS. As a result, operating procedures shall be developed which
are consistent with all applicable contract requirements. Procedures
must be established to ensure that recoupments are initiated in
a timely manner following the research determination that a duplicate
payment had been made. In other words, procedures must specify that
after a decision has been made by the person responsible for determining
that a duplicate payment was made, recoupment must be initiated
in a timely manner and must be consistent with all overpayment recovery
timeliness standards.
5.3 The contractor shall develop these
procedures within 60 days of the date of system implementation and
have them available for DHA review.