1.0
Background
And Provisions
The
Department of Health and Human Services (DHHS) published the first
administrative simplification related final rule on August 17, 2000,
which added subchapter C, “Administrative Data Standards and Related
Requirements,” to 45 CFR subtitle A. Subchapter C includes Parts
160 and 162, which will be referred to here as the Transaction and
Code Sets Rule. On January 16, 2009, HHS published a Final Rule
known as “Health Insurance Reform: Modifications to Health Insurance Portability
and Accountability Act (HIPAA) Electronic Transaction Standards.”
This Final Rule (referred to here as the “Modifications to HIPAA
Electronic Standards Final Rule”) adopted updated versions of the standards
for electronic transactions that were originally adopted under the
Administrative Simplification subtitle of HIPAA. Since 2009, HHS
has published additional Final Rules for HIPAA initiatives which
affect HIPAA transactions. As a HIPAA covered entity; TRICARE will comply
with applicable adopted HIPAA rules.
1.1 Compliance
Dates
1.1.1 The
contractor shall comply with the most current Final Rules on HIPAA
adopted Electronic Transaction Standards, including compliance dates.
1.1.2 The contractor shall comply
with the most current Final Rules on HIPAA adopted Transaction Operating
Rules, including compliance dates.
1.1.3 The
contractor shall comply with Final Rules on HIPAA adopted code sets
(e.g., the use of International Classification of Diseases, Tenth
Revision (ICD-10)), including compliance dates.
1.1.4 The contractor shall comply
with Final Rules on HIPAA adopted identifiers (e.g., the use of Health
Plan Identifiers (HPID)), including compliance dates.
1.2 Applicability
The
contractor shall comply with HIPAA Electronic Standards Final Rules
as the rules apply to health plans, health care clearinghouses,
and health care providers who transmit any health information in
electronic form in connection with a transaction covered by the
rule. These Rules refer to health plans, health care clearinghouses,
and health care providers as “covered entities.” The initial Transaction
and Code Sets Rule specifically names the health care program for
active duty military personnel under Title 10 of the United States
Code (USC) and the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) as defined in 10 USC 1072(4), as health plans
and this designation has not changed in the Modifications to HIPAA
Electronic Standards Final Rule.
1.3
Transaction
Implementation Specification Standards
1.3.1 The
contractor shall comply with the most current HIPAA Electronic Standards
Final Rules, which adopt specifically stated HIPAA implementations
of Accredited Standards Committee (ASC) X12 standards, accompanying
Errata, Addenda and Operating Rules.
In the event that additional HIPAA adopted transactions, accompanying
Errata, Addenda, or Operating Rules are mandated for use in the future;
the contractor shall comply with those HIPAA adopted transaction
initiatives by the compliance dates specified by HHS in Final Rules.
1.3.2 For retail pharmacy electronic
transactions covered under HIPAA, the contractor shall comply with
HIPAA adopted National Council for Prescription Drug Programs, (NCPDP) Telecommunication
and Batch Standard Implementation Guides named and adopted by Final
Rule.
1.3.2.1 The
contractor shall accommodate use of both NCPDP and HIPAA ASC X12
837 Health Care Claim: Professional for billing of retail pharmacy
supplies and professional services.
1.3.2.2 The contractor shall accommodate
use of the HIPAA adopted standard for the subrogation of pharmacy
claims paid by Medicaid which is named and adopted in Final Rule
as the NCPDP Batch Standard Medicaid Subrogation Implementation
Guide. This standard is applicable to Medicaid agencies in their
role as health plans, as well as to other health plans such as TRICARE
that are covered entities under HIPAA.
1.3.3 The contractor shall comply
with HIPAA related Final Rules associated with Section 1104 of the
Administrative Simplification provisions of the Patient Protection
and Affordable Care Act (PPACA) (hereafter referred to as the Affordable
Care Act or ACA). The ACA establishes new requirements for administrative
transactions to improve the utility of the existing HIPAA transactions
and reduce administrative costs (e.g., standard Operating Rules).
1.3.4 HIPAA Adopted Code Set Standards
The
contractor shall comply with HIPAA adopted code sets in accordance
with Final Rules (e.g., International Classification of Diseases,
10th Revision (ICD-10)).
2.0 TRICARE Objectives
2.1 The TRICARE program shall be
in full compliance with the HIPAA Transactions, Code Sets, and Identifiers
Final Rules.
2.2 Private Care
Systems shall be able to receive, process, and send HIPAA compliant
standard transactions where required.
3.0 Contractor Relationships To
The TRICARE Health Plan
(THP)3.1 The Transaction and Code Sets
Rule specifically names the health care program for active duty military
personnel under 10 USC and CHAMPUS as defined in 10 USC 1072(4),
as health plans. For the purposes of implementing the Transaction
and Code Sets Rule, the term “TRICARE” will be used in this chapter
to mean a combination of both the Direct Care (DC) and Private Care
Systems. TRICARE is therefore a health plan.
3.2 The
relationships of the entities that comprise TRICARE determine, in
part, where standard transactions shall be used. Determinations
as to when and where the transaction standards apply are not based
on whether a transaction occurs within or outside of a “corporate
entity” but rather are based upon the answers to the two following
questions:
• Is the
transaction initiated by a covered entity or its business associate?
If the answer is “no,” then the standard does not apply and is not used.
If “yes,” then the standard applies and the next question needs
to be answered.
• Is the transaction one the
Secretary of HHS adopted as an adopted standard? If “no,” then the
standard is not required by HIPAA to be used. If “yes,” then the
standard shall be used.
To decide if a standard has
been adopted for transaction, use the definition of the transaction as
it is provided in the Final Rule. Knowing who is and is not a business
associate of the
THP is important in
determining where standard transactions shall be used within TRICARE.
See
Appendix A for the definition of “business
associate.”
3.3 The following
table identifies TRICARE entities and their relationships to the
THP.
|
Entity
|
Covered
Entities
|
Non-Covered Entity
|
Business Associate
Of The THP?
|
|
Health Plan?
|
Provider?
|
Clearing-house?
|
Employer?
|
|
Department of Defense
(DoD) (Army, Navy, Air Force, Marines, Space Force, and Coast
Guard*)
*In time of war
|
N
|
N
|
N
|
Y
|
N
|
|
THP (Represents
both the Health Care Program for Active Duty Military Personnel
under 10 USC and the CHAMPUS as defined in 10 USC 1072(4).)
|
Y
|
N
|
N
|
N
|
N
|
|
Markets/Military Treatment
Facilities (MTFs) (Supporting Systems: Composite Health Care
System (CHCS), Referral Management Suite (RMS), Armed Forces Health
Longitudinal Technology Application (AHLTA), Third Party Outpatient
Collections System (TPOCS)*, and others)
*Armed Forces Billing and Collection
Utilization Solution (ABACUS) expected to replace TPOCS in 2015.
|
N
|
Y
|
N
|
N
|
N
|
|
Defense Manpower Data
Center (DMDC) Defense Enrollment Eligibility Reporting System
(DEERS)
|
N
|
N
|
N
|
N
|
Y
|
|
Managed Care Support
Contractor (MCSC)
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC)
|
N
|
N
|
N
|
N
|
Y
|
|
Defense Finance and Accounting
Service (DFAS)
|
N
|
N
|
N
|
Y
|
N
|
|
TRICARE Dental Program (TDP)
Contractor
|
Y
|
N
|
N
|
N
|
Y
(for foreign claims processing
only)
|
|
Active Duty Dental Program
(ADDP) Contractor
|
Y
|
N
|
N
|
N
|
N
|
|
Pharmacy Data Transaction Service
(PDTS) Contractor
|
N
|
N
|
N
|
N
|
Y
|
|
Designated Provider (DP) Contractors
|
Y
|
Y
|
N
|
N
|
N
|
|
Defense Health Agency-Great
Lakes (DHA-GL)
|
N
|
N
|
N
|
N
|
Y
|
|
Continued Health Care Benefit
Program (CHCBP) Contractor
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Quality Management
Contract (TQMC)
|
N
|
N
|
N
|
N
|
Y
|
|
Contractor for Data Analysis
for the DP Contracts
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Overseas Program (TOP)
Contractor
|
N
|
N
|
N
|
N
|
Y
|
|
Defense Health Agency
(DHA) (Supporting Systems: DEERS Catastrophic Cap and Deductible
(CCDD), payment record databases (TRICARE Encounter Data (TED) records,
TED Provider (TEPRV) records, and TED Pricing (TEPRC) records),
management databases (Military Health System (MHS)) Data Repository
and its associated data marts)
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Pharmacy (TPharm) Contractor
|
N
|
Y
|
N
|
N
|
Y
|
|
TRICARE Area Offices (TAOs)
|
N
|
N
|
N
|
N
|
Y
|
4.0
HIPAA
Transaction Requirements For TRICARE Contractors
4.1 General
4.1.1 The contractor shall implement
transactions in accordance with the transaction implementation specifications
and any Addenda, Errata, or Operating Rules named and adopted by
the Secretary of HHS, as standards.
4.1.2 The
contractor shall accept standard transactions from trading partners
that are correct at the interchange control structure level (envelope)
and that are syntactically correct at the standard level and at
the implementation guide level and are semantically correct at the
implementation guide level. The contractor shall not reject otherwise
syntactically correct transactions
for front-end business or application level edits for transaction
content, such as an edit for a recognized provider number. The contractor
shall apply front-end business or application level edits after
accepting the transaction. The contractor shall reject, develop
or deny claims failing front-end business or application edits,
after passing syntax and semantic edits, in accordance with established
procedures for such actions.
4.2 Transactions
Exchanged Between Contractors And Providers (Network And Non-Network Providers, Markets/MTFs (CHCS
and RMS))
4.2.1 The
contractor shall ensure HIPAA adopted transactions exchanged between
contractors and providers are in accordance with HIPAA standards.
4.2.2 The contractors shall be HIPAA
compliant with the following HIPAA adopted transactions, when HIPAA
compliant usage applies:
4.2.2.1 Claims
Transactions
[Receive
Claims Transactions]
• The ASC
X12N 837P - Health Care Claim: Professional, most currently adopted
version.
• The ASC X12N 837I - Health
Care Claim: Institutional, most currently adopted version.
• The ASC
X12N 837D - Health Care Claim: Dental, most currently adopted version.
• The
most currently adopted version of NCPDP Telecommunication Standard
and equivalent NCPDP Batch Standard including claims for
retail pharmacy supplies and professional services.
4.2.2.2 Coordination Of Benefits (COB) Transactions
[Receive 837 Coordination of
Benefits Transactions]
• The ASC
X12N 837 - Health Care Claim: Professional, most currently adopted
version.
• The ASC X12N 837 - Health Care
Claim: Institutional, most currently adopted version.
• The ASC X12N 837 - Health Care
Claim: Dental, most currently adopted version.
4.2.2.3 Eligibility Inquiry And Response
Transactions
[Receive
270 Transactions and Send 271 Transactions]
• The ASC
X12N 270/271 - Health Care Eligibility Benefit Inquiry and Response,
most currently adopted version
4.2.2.4 Referral Certification And
Authorization Transactions
[Receive 278 Requests and Send
278 Responses]
• The ASC
X12N 278 - Health Care Services Review - Request for Review and
Response, most currently adopted version.
4.2.2.5 Claim Status Request And Response
Transactions
[Receive
276 Transactions and Send 277 Transactions]
• The ASC
X12N 276/277 - Health Care Claim Status Request and Response, most currently
adopted version.
4.2.2.6 Payment
And Remittance Advice (RA) Transactions
[Send 835 Transactions]
• The ASC
X12N 835 - Health Care Claim Payment/Advice, most currently adopted version.
4.2.2.7 Electronic Funds Transfer (EFT)
And Remittance Advice (RA)
The contractors shall be able
to send the following transmissions:
4.2.2.7.1 [Stage
1 Payment Initiation,
Transmission
of
Health
Care
Payment/
Processing
Information]
Automated Clearing
House (ACH) transmissions shall comply with the most current National
Automated Clearing House Association (NACHA) requirements. The NACHA
Rules are updated annually and govern every ACH payment, providing
exact guidelines for securely storing, accessing and transmitting
sensitive customer information. The contractor shall, when processing
ACH transactions:
• Populate
the ACH ENTRY DETAIL RECORD (6 Record, Field 10, Positions 79-79),
with 1. The value ‘1’ requires the ACH file to have an ADDENDA RECORD.
• Populate
the ADDENDA RECORD (7 Record Field 3, Positions 4-83) with “Health
Care Claim Payment/Advice (835)”. The contractor may provide additional
information in this field as needed.
4.2.2.7.2 [Stage 1 Payment Initiation,
Transmission
of
Health
Care
RA]
• The ASC
X12N 835 - Health Care Claim Payment/Advice, most currently adopted version.
4.3 Transactions Exchanged Between The Contractors
And Other Health Plans (And Employers, Where Applicable)
4.3.1 The contractor shall ensure HIPAA
adopted transactions exchanged between the contractor and other
health plans (including TRICARE supplemental plans) are in accordance
with HIPAA standard.
4.3.2 The
contractors shall be able to electronically transact with other
health plans, in accordance with HIPAA adopted Final Rules.
4.3.2.1 COB Transactions
[Send and Receive all HIPAA
adopted 837 Transactions]
• The ASC
X12N 837 - Health Care Claim: Professional, most currently adopted
version.
• The ASC X12N 837 - Health Care
Claim: Institutional, most currently adopted version.
• The ASC X12N 837 - Health Care
Claim: Dental, most currently adopted version.
4.3.2.2 Eligibility Inquiry And Response
Transactions
[Send
and Receive 270 Transactions; Send and Receive 271 Transactions]
• The ASC
X12N 270/271 - Health Care Eligibility Benefit Inquiry and Response,
most currently adopted version.
4.3.2.3 Referral Certification And
Authorization Transactions
[Send and Receive 278 Requests;
Send and Receive 278 Responses]
• The ASC
X12N 278 - Health Care Services Review - Request for Review and
Response, most currently adopted version.
4.3.2.4 Payment And Remittance Advice
(RA) Transactions
[Send
835 Transactions]
• The ASC
X12N 835 - Health Care Claim Payment/Advice, most currently adopted version.
4.3.2.5 Claim Status Request And Response
Transactions
[Receive
276 Transactions and Send 277 Transactions]
• The ASC
X12N 276/277 - Health Care Claim Status Request and Response, most currently
adopted version.
4.3.2.6 Health
Plan Premium Payment Transactions
[Receive 820 Transactions]
• The ASC
X12N 820 - Payroll Deducted and Other Group Premium Payment for Insurance
Products, most currently adopted version.
4.3.2.7 Request To Primary Payer For
Payment Already Made By Subordinate Payer (Medicaid)
[Receive Medicaid Pharmacy
Subrogation Transactions]
• NCPDP
Batch Standard Medicaid Subrogation, most currently adopted version.
The Modifications to HIPAA Electronic Standards Final Rule adopted
a standard for the subrogation of pharmacy claims paid by Medicaid.
This transaction is the Medicaid Pharmacy Subrogation Transaction.
The standard for that transaction is the NCPDP Batch Standard Medicaid
Subrogation Implementation guide. A Medicaid Pharmacy subrogation
transaction is defined as the transmission of a claim from a Medicaid agency
to a payer for the purpose of seeking reimbursement from the responsible health
plan for a pharmacy claim the State has paid on behalf of a Medicaid
recipient. This standard is applicable to Medicaid agencies in their
role as health plans, but not to providers or health care clearinghouses
because this transaction is not used by them. To the extent that
Pharmacy Benefit Managers (PBMs) and claims processors are required
by contract or otherwise to process claims on behalf of TRICARE, both shall receive
the Medicaid Pharmacy Subrogation Transaction in the standard format.
4.4 Transactions Exchanged Between
Contractors And DMDC (DEERS)
4.4.1 Eligibility
Inquiries And Response Transactions
Based upon the “two-question
rule” for determining when a transaction shall be in standard format
(see
paragraph 3.2), and the definition of the
Eligibility for a Health Plan Transaction in the Final Rule, eligibility
inquiry and response transactions occurring between business associates
of the same health plan need not be in standard format. The contractor
shall use transactions in the standard format when the inquiries
and responses are between providers and health plans or between health
plans and health plans. Because the contractors and DEERS are business
associates of the same health plan, eligibility inquiry and response
transactions between them may be performed in non-standard format.
4.4.1.1 The contractor shall perform
real-time eligibility inquiries and responses, associated with enrollment
processing, between the contractor and DEERS via the Government
furnished web-based system/application.
4.4.1.2 Real-time and batch eligibility
inquiries and responses between the contractors and DEERS for claims
processing and other administrative purposes will be in DEERS specified
format.
4.4.2 Enrollment
And Disenrollment Transactions
TRICARE enrollment and disenrollment
transactions between the contractors and DEERS may be performed
using the Government furnished web-based system/application. The
Government will provide a HIPAA standard data and condition compliant
version of Government furnished web-based system/application for
contractor use. Note: Transactions generated by DEERS that validate
that enrollments have been established and that are used by the contractor to
update its system files, are not considered covered transactions
and may be sent in proprietary format.
4.5 Transactions Exchanged Between The Contractor And
Providers (Network And Non-Network Providers, Markets/MTFs (CHCS
and RMS)) Through Direct Data Entry Systems
4.5.1 Direct
Data Entry Systems
4.5.1.1 The
contractor shall use standard format for all transactions covered
under the Transaction and Code Sets Rule occurring between the contractor and
network/non-network providers and Markets/MTFs, unless subject to
the direct data entry exception. The contractor may offer a direct
data entry system for use by providers. A direct data entry system
however, does not replace the requirement to support the standard
transactions. The contractor shall ensure direct data entry systems are compliant
with standard transaction data content and conditions.
4.5.1.2 The contractor shall ensure
its direct data entry system does not add to or delete from the standard
data elements and code values. Direct data entry systems may take
the form of web applications. Non-standard data elements and code
values may be included in the direct data entry system if the non-standard
data is obtained or sent through a separate mechanism such as a
web page that is separate from the web page containing the standard
data content, and the resolution of the standard transaction does
not depend on the additional information.
4.6 Transactions Involving Foreign
Entities
4.6.1 Electronic
transactions from overseas Markets/MTFs and from United States (U.S.) territories will
be sent directly to the contractor in standard format or routed
through a U.S. based clearinghouse for translation into standard
format prior to being sent to the contractor.
4.6.2 The contractor shall accept
electronic transactions submitted by foreign entities, such as claims
transactions from foreign providers, directly or through a clearinghouse for
processing. The contractor shall accept transactions submitted by
foreign entities, except for those originating from U.S. territories
or overseas Markets/MTFs in non-standard format as they are not
covered transactions.
4.6.2.1 Except for transactions originating
from U.S. territories or overseas Markets/MTFs (which will be in
standard format), the contractor may define the format or formats
acceptable from foreign entities, either directly or through a clearinghouse.
4.6.2.2 Where the TRICARE Overseas
Program (TOP) contractor pays foreign claims and subsequently bills another contractor
for reimbursement, the claim data submitted to the other contractor
in support of the invoice shall be sent in standard format.
4.7 Transactions Exchanged Between The Contractor And
DHA
Payment
Record Submissions, TED records, TEPRV records, and TEPRC records -
Payment records are considered reports and are not covered transactions. The
contractor shall submit payment records in accordance with contract
requirements.
4.8 Clearinghouse
Use By The Contractor
4.8.1 The contractor may use contracted
clearinghouses for the purposes of receiving, translating, and routing
electronic transactions on its behalf. Contractor-contracted clearinghouses may
receive standard transactions, convert them into the contractors’
system formats and route them to the contractors’ systems for processing. The
contractor may send non-standard formatted transactions to its contracted
clearinghouses for the purposes of translating them into standard
format and routing them to the intended recipients.
4.8.2 Transactions between health
care clearinghouses shall be conducted in standard format.
4.8.3 Where a contractor has contracted
with the same clearinghouse as the entity that is submitting or
receiving the transaction, the clearinghouse shall convert the nonstandard
transaction into the standard prior to converting it again to the
intended recipient’s format and sending.
5.0 Trading Partner Agreements
5.1 The contractor shall have trading
partner agreements with all entities with which electronic transactions
are exchanged. Where a provider uses a billing service or clearinghouse
to exchange transactions, the contractor shall have a trading partner
agreement with both the provider and billing service/clearinghouse. The
contractor shall ensure trading partner agreements with providers contain
a “provider signature on file” provision that allows the contractor
to process the electronic transaction if the provider signature
on file requirement is not being met through another vehicle (e.g.,
provider certification). The contractor shall develop and execute
trading partner agreements that comply with all DoD and DHA privacy
and security requirements. See
Appendix A for
the definition of “trading partner agreement.” The contractor shall
ensure all trading partner agreements, including all existing and
active trading partner agreements previously executed, are updated,
and kept updated, to reflect current requirements.
5.2 Implementation Guide Requirements
5.2.1 The contractor shall ensure trading
partner agreements include, as recommended in the American National
Standard Institute (ANSI) ASC X12N transaction implementation guides,
any information regarding the processing, or adjudication of the
transactions that are helpful to the trading partners and simplify
implementation.
5.2.2 The
contractor shall ensure trading partner agreements do
NOT:
• Modify
the definition, condition, or use of a data element or segment in
a standard Implementation Guide.
• Add any
additional data elements or segments to a standard Implementation
Guide.
• Use any code or data values,
which are not valid to a standard Implementation Guide.
• Change
the meaning or intent of a standard Implementation Guide.
6.0 Additional Non-HIPAA Transactions
Required
The
contractor shall implement the following non-HIPAA mandated transactions
as appropriate.
6.1 Acknowledgments
The following are required
for determining an incoming transaction to be HIPAA-compliant:
• The
interchange or “envelope” shall be correct;
• The transaction shall be syntactically
correct at the standard level;
• The transaction shall be syntactically
correct at the implementation guide level; and
• The transaction shall be semantically
correct at the implementation guide level.
Syntax
relates to the structure of the data. Semantics relates to the meaning
of the data. Any transaction that meets these four requirements
is HIPAA-compliant and shall be accepted.
Note: In the case of a claim transaction,
“accepted” does not mean that it shall be paid. A transaction that
is accepted may then be subjected to business or application level
edits. “Accepted” transactions, i.e., those that are HIPAA-compliant,
that subsequently fail business or application level edits shall
be rejected, developed, or denied in accordance with established
procedures for such actions.
6.1.1 Interchange
Acknowledgment
The
Interchange or TA1 Acknowledgment is a means of replying to an interchange
or transmission that has been sent. The TA1 verifies the envelopes
only. The contractor shall develop and implement the capability
to generate and send the following transaction. Reference the most
currently adopted HIPAA version of ASC X12C/231 Implementation Acknowledgment
for Health Care Insurance (999) TR3, Appendix C.1, to address implementation
use of this transaction.
• The ANSI
ASC X12N TA1 - Interchange Acknowledgment Segment.
6.1.2 Implementation Acknowledgment
The
Implementation Acknowledgment Transaction is used to report the
results of the syntactical analysis of the functional groups of
transaction sets. It is generally the first response to a transaction.
(Exception: The TA1 will be the first response if there are errors
at the interchange or “envelope” level.) Implementation acknowledgment
transactions report the extent to which the syntax complies with
the standards for transaction sets and functional groups. They report
on syntax errors that prevented the transaction from being accepted.
Version 5010 of the implementation acknowledgment transaction does
not cover the semantic meaning of the information encoded in the transaction
sets. The implementation acknowledgment transaction may be used
to convey both positive and negative acknowledgments. Positive acknowledgments
indicate that the transaction was received and is compliant with
standard syntax. Negative acknowledgments indicate that the transaction
did not comply with standard syntax. The contractor shall develop
and implement the capability to generate, send, and receive the
following transaction (both positive and negative).
• The ASC
X12N 999 - Implementation Acknowledgment, most currently adopted version.
6.1.3 Implementation Guide Syntax
And Semantic And Business Edit Acknowledgments
6.1.3.1 The contractor may use a proprietary
acknowledgment to convey implementation guide syntax errors, implementation
guide semantic errors, and business edit errors. Alternatively,
for claim transactions (ANSI ASC X12N 837 Professional, Institutional,
or Dental), the Health Care Claim Acknowledgment Transaction (ANSI
ASC X12N 277CA) may be used to indicate which claims in an 837 batch
were accepted into the adjudication system (i.e., which claims passed
the front-end edits) and which claims were rejected before entering
the adjudication system.
6.1.3.2 In the future, the standards
may mandate transactions for acknowledgments to convey standard
syntax, implementation guide syntax, implementation guide semantic,
and business/application level edit errors. The contractor shall
develop and implement the capability to generate and send the following
transaction(s).
6.1.3.2.1 A proprietary acknowledgment
containing syntax and semantic errors at the implementation guide
level, as well as business/application level edit errors.
6.1.3.2.2 For 837 claim transactions, the contractor may
use the Health Care Claim Acknowledgment Transaction Set (ANSI ASC
X12N 277CA, most currently adopted version) in place of a proprietary
acknowledgment.
6.2 Medicaid
Non-Pharmacy Subrogation Claims
6.2.1 When
a beneficiary is eligible for both TRICARE and Medicaid,
32 CFR 199.8 establishes TRICARE as the primary
payer. Existing TRICARE policy requires the contractor to arrange COB procedures
with the various states to facilitate the flow of claims and to
try to achieve a reduction in the amount of effort required to reimburse state funds erroneously
disbursed on behalf of the TRICARE-eligible beneficiary. TRICARE
Policy requires the contractor make disbursements directly to the
billing state agency.
6.2.2 Currently,
a subrogation non-pharmacy claim from a Medicaid State Agency is
not a HIPAA covered transaction since the Transaction and Code Sets
Rule defines a health care claim or equivalent encounter information
transaction as occurring between a provider and a health plan. Since
Medicaid State Agencies are not providers, their claims to TRICARE
are not covered transactions and need not be in standard format;
however, currently adopted HIPAA ASC X12 837 claim standards used
for processing Institutional, Professional and Dental claims include
the ability to perform Medicaid subrogation. While they are not
currently mandated for use under HIPAA, covered entities are not prohibited
from using currently adopted HIPAA transactions for non-pharmacy
Medicaid subrogation transactions between willing trading partners.
• In
accordance with existing TRICARE policy, the contractor shall coordinate
with the Medicaid State Agencies submitting non-pharmacy claims
and define the acceptable forms and formats of the claims the Medicaid
State Agencies shall use when billing TRICARE. State Agency Billing
Agreements shall be modified to reflect the acceptable forms and
formats.
Note: It is expected that the Secretary,
HHS will modify the standard to incorporate Medicaid subrogation
claims as HIPAA covered transactions sometime in the future. If
this occurs, this section will be modified to reflect the change.
7.0 Miscellaneous Requirements
7.1 Paper Transactions
7.1.1 The contractor shall continue
to accept and process paper-based transactions.
7.1.2 The contractor may pay claims
via electronic funds transfer or by paper check. The ASC X12N 835
Health Care Claim Payment/Advice transaction contains two parts,
a mechanism for the transfer of dollars and one for the transfer
of information about the claim payment. These two parts may be sent
separately. The 835 Implementation Guide allows payment to be sent
in a number of different ways, including by check and electronic
funds transfer. The contractor shall be able to send the RA portion
electronically but may continue to send payment via check.
7.1.3 Current applicable requirements
for the processing of paper-based and electronic media transactions,
such as claims splitting, forwarding out-of-jurisdiction claims,
generating and sending EOBs to beneficiaries and providers, etc.,
apply to the processing of electronic transactions.
7.2 Attendance At Designated Standards
Maintenance Organization (DSMO) Meetings
7.2.1 The
contractor shall regularly send representatives to the following
separate DSMO Trimester meetings: ANSI Accredited Standards Committee
X12 (ASC X12) Standing Meetings, and the Health Level Seven (HL7)
Working Group Meetings. The contractor shall send one representative
to each DSMO Trimester meeting. The contractor may elect to send
representatives from its claims processing subcontractor(s) in place
of a contractor representative. The contractor shall make every effort to
have the same representatives attend each meeting for continuity
purposes. The team lead will be the DHA representative in attendance.
7.2.2 The contractor shall ensure
its representatives are knowledgeable regarding TRICARE program
requirements, and of its own administrative and claims processing
systems. Prior to attending a DSMO meeting, the contractor shall
identify from within their own organizations any issues that need to
be addressed at the DSMO meeting. The contractor shall inform the
DHA representative (team lead) of the issues at least one week prior
to the meetings.
7.2.3 The
contractor shall ensure its representatives attend the DSMO meetings
as exclusive advocates for TRICARE business needs and shall not
divide their participation and attention with any commercial business
needs and concerns. The contractor shall ensure its representatives attend
and participate in workgroup and full committee meetings. The contractor shall ensure
its representatives work within the DSMOs to incorporate into the
standards and implementation guides any data elements, code values,
etc., that are required to conduct current and future TRICARE business.
The contractor shall ensure its representatives also work to prevent
removal of any existing data elements, code values, etc., from the
standards and implementation guides that are necessary to conduct
current and future TRICARE business.
7.2.4 When
attending the DSMO meetings, the contractor shall ensure its representatives
shall work as a team and collaborate with other Government and DoD/TRICARE
representatives. The contractor shall ensure its representatives register
under the DoD/Health Affairs (HA) DSMO memberships. The contractor shall
ensure its representatives take proposed changes through the processes
necessary for adoption within the DSMOs. The contractor shall ensure
its representatives track and reporting on the status of each proposed
change as it progresses through the process.
7.2.5 Contractor representatives
shall keep DHA apprised of any additions to the standards that shall
be made to accommodate TRICARE business needs and of any proposed
changes to existing standards and implementation guides. Following
a DSMO meeting, each representative attendee shall prepare a summary
report that includes, at a minimum; the work group and full committee
meetings attended, a brief description of the content of the meetings,
the status of any changes in progress, and any problems or information
of which the Government/DHA should be aware. Each representative
shall submit their reports to the DHA team lead within 10 business days
following the DSMO meetings.
7.3 Provider
Marketing
7.3.1 The
contractor shall encourage providers to use electronic transactions
only through marketing and provider education vehicles permitted
within existing contract limitations and requirements. No additional
or special marketing or provider education campaigns are required. The contractor shall
educate providers on the cost and efficiency benefits that may be
realized through adoption and use of electronic transactions.
7.3.2 The contractor shall assist
and work with providers, who wish to exchange electronic transactions,
to establish trading partner agreements and connectivity with its systems
and to implement the transactions in a timely manner. The contractor is not
required to perfect transactions on behalf of trading partners.
7.4 Data And Audit Requirements
7.4.1 The contractor shall store
all HIPAA-covered electronic transaction data, including eligibility and
claims status transaction data, as outlined in
Chapter 9. The
contractor shall refer to
Chapter 9 if directed
by DHA to freeze records, to include, electronic transaction data.
7.4.2 The contractor shall generate
transaction histories covering a period of up to seven years upon
request by DHA in a text format (delimited text format for table
reports) that is able to be imported, read, edited, and printed
by Microsoft® Word (Microsoft® Excel for table reports). The contractor
shall have the ability to generate transaction histories on paper. The
contractor shall ensure transaction histories include at a minimum,
the transaction name or type, the dates the transaction was sent
or received and the identity of the sender and receiver. The contractor
shall ensure transaction histories are readable and understandable by
a person.
7.4.3 Transaction
data is subject to audit by DHA, DoD, HHS, and other authorized
Government personnel. The contractor shall have the ability to retrieve
and produce all electronic transaction data upon request from DHA
(for up to seven years, or longer if the data is being retained
pursuant to a records freeze), to include reasons for transaction
rejections as outlined in
Chapter 9.