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) (prior
to October 31, 2018), 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 The contractor
shall accomplish the key executable business processes
listed
below
at a minimum: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
The
contractor shall understand
and execute the DEERS functionality described in this section. The
contractor shall also use the
technical information and materials provided by DMDC/DEERS via Defense
Health Agency (DHA) Health Plan Operations Support
Section (HPOSS), and shall consult
with DEERS and DHA for any required clarification.
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, the contractor
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 contractor
interface downtime for
two contiguous or cumulative hours within a business day, DMDC must
notify the DHA of the problem and estimated time of
correction. The Government/DEERS will
notify DEERS reliant contractors regarding the
situation and provide guidance as appropriate.
3.2.3 In addition to the standard
problem resolution procedures as referenced in DMDC documentation,
when the contractor experiences
DEERS interface downtime for
two hours contiguously or cumulatively within a business day and have not
been contacted by DHA, the contractor shall report
the downtime to the DHA representative and shall report an updated
status every two hours until the problem is resolved. The
contractor shall give a final report upon resolution.
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
The
contractor shall ensure all system-to-system interfaces
to DEERS 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 uses standard
message protocols where appropriate.
3.3.1.2 DEERS defines the content and
format of messages between DEERS and the contractor.
3.3.1.3 DEERS and the contractor shall
use 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. The contractor shall accept
and apply the full image sent by DEERS. The contractor shall
add the information, if not present in their system. The
contractor shall update
their system, if the information is present, by replacing their
information with the newly received DEERS information.
Notifications are only intended to synchronize the most current
information between DEERS and the contractor. They do
not synchronize history between DEERS and the contractor.
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 The contractor
shall use the web browser identified in the technical specification(s)
or the user guide(s) for the specified applications. The
web-based applications are all Government furnished equipment.
3.3.2.2 The contractor shall
use the Government furnished web-based applications for their intended
use only. The contractor shall
not use screen scraping, HTML stripping, or 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
to the contractor 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).
• 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 accessed 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 An
enrolling contractor shall 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
Market/Military Treatment
Facility (MTF)
requirements, and that
they will be contacted if additional information is needed. DEERS
will send the contractor a notification(s) informing the contractor
new
enrollment
information 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 the contractors
for various reasons and reflect the most current enrollment information
for a beneficiary. The contractor shall accept,
apply, and store the data contained in the notification as sent
from DEERS to remain in sync with DEERS. DEERS may
send notifications due
to new enrollments or updates to existing enrollments. If contractors
do not have the information contained in the notification, the contractor shall
add it to their system. If the contractor already has enrollment
information for the beneficiary, the contractor shall
apply all information contained in the notification to their system.
5.2 The contractor 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. The contractor shall not treat such
notifications as errors by the contractor
system and shall apply them.
5.3 The contractor
shall 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. The
contractor shall retrieve and apply 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 the contractor shall use only
the one remaining DoD Identification Number 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 contractor
shall correct the enrollments. The
contractor 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 contractor
shall select which of the multiple listings is correct
based on documents or information at hand. After this selection,
the requesting contractor shall 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 DEERS
uses rule-based software to determine a beneficiary’s
entitlement to health care benefits. 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 contractors shall 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
they are eligible
to use the benefits.
DEERS derives the
effective and expiration dates for assigned plan coverage
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.
The contractor shall only enroll
a beneficiary
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,
prior to October 31, 2018)
• Active
Duty Family Member (ADFM) plans. TDP, but can move into other dental
plans based on their beneficiary role change (e.g., TRDP prior
to October 31, 2018, and ADDP, if ADFM becomes an
active Service Member)
• Retirees.
TRDP with no expected change in plan where TRDP is
applicable.
• Retiree
dependents. TRDP prior to October 31, 2018,
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)
8.2.2 The contractor
shall use new enrollments 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, email address and/or telephone
number.
• Record that the enrollee has
OHI (does not apply to ADDP).
8.2.4 The contractor
shall use modifications of the current enrollment
(updates)
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.
Beneficiaries
must select a plan or will default to direct-care only.
Beneficiaries
are 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.
Beneficiaries
must select a plan or will default to DC only.
Beneficiaries
are 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 The contractor
shall use new enrollments 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, email address and/or telephone
number.
• PCM selection (if required/allowed
by HCDP).
• Record that the enrollee has
OHI.
8.3.4 The
contractor shall use modifications of the current
enrollment (updates)
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)
.
Note: TRDP enrollments
were terminated in accordance with this chapter effective December
31, 2018, 11:59 p.m. Eastern.
10.0 Beneficiary Contact Updates
And Enrollment Cards
10.1 Contact Updates (Applicable
To All Contractors)
Address,
telephone number, and email 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. The contractor shall
update the residential and mailing addresses in DEERS, whenever
possible. The contractor shall not update addresses to reflect
unit, Market/MTF,
or the contractor addresses unless that
information is 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 The contractor shall
process all mail returned for bad addresses and shall
research the address, correct it on DEERS, and re-mail the correspondence
to the beneficiary. If the contractor cannot
determine a valid address, the contractor 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). The contractor shall
make reasonable efforts to add or update telephone numbers.
10.1.3 E-Mail Addresses
DEERS
can store an email address for each
person. The contractor 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 email 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 email 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 email or postcard that the letter
is available. The contractor 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, the
contractor shall query
DEERS to determine eligibility and/or enrollment status for a given
period of time.
11.2 For audit
and performance review purposes, the contractor shall retain
a copy of every transaction and response sent and received for claims
adjudication procedures. The contractor shall retain
this information for
the period required by the TOM.
11.3 The
contractor shall not
override this data with information from other sources. The
contractor shall obtain Continued Health Care Benefits
Program (CHCBP) CC&D information from
the CHCBP contractor.
11.4 The
contractor 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 contractor
shall use OHI data received as part of the claims
inquiry as part of the claims adjudication
process. If the contractor has evidence of additional or more current
OHI information, the contractor 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 contractor shall
use address data received from the
claims inquiry as part of the claims
adjudication process. If the contractor has evidence of additional
or more current address information the contractor 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
contractor
shall use the CCDD Totals Inquiry
to
obtain CCDD balances for the year(s) that correspond to the requested
inquiry period.
The contractor
shall 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 shall determine
the existence of OHI. The contractor can
add or update minimal OHI data through the Government furnished
web-based enrollment system/application.
In addition, DEERS will accept OHI updates through
a system-to-system interface.
13.3 The contractor shall 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
shall develop the
OHI within 15 days but is not responsible for
pharmacy
coverage
development.
13.5.1 The pharmacy contractor(s) shall develop
and maintain pharmacy OHI. The pharmacy contractor
shall develop pharmacy placeholder policies,
regardless of which organization created the placeholder. The
contractor shall develop all other placeholder policies,
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) shall 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, the
contractor shall send DEERS two OHI coverage types,
one for medical coverage and one for vision coverage.
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.