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TRICARE Systems Manual 7950.3-M, April 1, 2015
Defense Enrollment Eligibility Reporting System (DEERS)
Chapter 3
Section 4.2
Defense Enrollment Eligibility Reporting System (DEERS) Functionality
Revision:  C-51, August 5, 2021
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.
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