1
|
Administration
|
3
|
TRICARE Processing Standards
|
Exclude paragraphs 1.1 and
1.2 for Tier 11 care. Exclude paragraph
1.3 (Network Adequacy); paragraphs 1.4 - 1.8 and 6.0 only apply
to inpatient claims.
|
4
|
Management
|
Paragraphs 2.2, 2.4, and 4.0
only apply to inpatient claims.
|
2
|
Transitions
|
1
|
Management and Administration
|
Exclude.
|
2
|
Systems Development
|
Exclude.
|
3
|
Critical Processes (CP) - Provider
Networks
|
Exclude.
|
4
|
Critical Processes (CP) - Enrollment
|
Exclude.
|
5
|
Critical Processes (CP) - Customer
Service
|
Exclude.
|
6
|
Critical Processes (CPs) -
Management - Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets
(eMSMs)
|
Exclude.
|
7
|
Critical Processes (CPs) -
Referral Management
|
Exclude.
|
8
|
Critical Processes (CPs) -
Claims Processing
|
Exclude.
|
9
|
Critical Processes (CPs) -
Medical Management
|
Exclude.
|
10
|
Other requirements
|
Exclude.
|
3
|
Financial Administration
|
2
|
Payments To Beneficiaries/Providers
|
Exclude for care by Tier 1
providers1.
|
3
|
Claim Refund And Collection
Procedures
|
Exclude for care by Tier 1
providers1.
|
4
|
Stale Dated, Voided, Or Returned
Checks
|
Exclude for care by Tier 1
providers1.
|
4
|
Provider Certification and
Credentialing
|
1
|
General
|
Paragraphs 2.2 - 2.4, 3.0,
5.0 and Addendum A only apply to inpatient.
|
6
|
Enrollment
|
1
|
TRICARE Prime And TRICARE Select
Enrollment Processing
|
Exclude paragraphs 1.8 and
4.0.
|
5
|
Provider Networks
|
1
|
Network Development
|
Exclude.
|
7
|
Medical Management (MM), Utilization
Management (UM), And Quality Management (QM)
|
2
|
Preauthorizations
|
Exclude for Tier 1 providers1.
|
8
|
Claims Processing procedures
|
4
|
Signature Requirements
|
Exclude for Tier 1 providers1.
|
10
|
Claims Adjustment and Recoupments
|
4
|
Overpayments Recovery - Non-Financially Underwritten
Funds
|
Exclude.
|
11
|
Communications And Customer
Service (C&CS)
|
1
|
Education Requirements
|
Exclude.
|
2
|
Government Staff and Beneficiary
Education
|
Exclude paragraphs 1.0, 2.0,
3.0 and 8.0.
|
6
|
Telephone Inquires
|
Exclude paragraph 5.0.
|
15
|
TRICARE Regional Offices (TROs)/Military
Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM)
and Contractor Interfaces
|
1
|
Director, TRICARE Regional
Offices (TROs), Military Treatment Facility (MTF) Commander/Enhanced Multi-Service
Market (eMSM) Manager, and Contractor Interface
|
Exclude.
|
2
|
Resource Sharing
|
Exclude.
|
3
|
Clinical Support Agreement
(CSA) Program
|
Exclude.
|
A
|
Memorandum Of Understanding
(MOU) - Example
|
Exclude.
|
16
|
TRICARE Prime Remote (TPR)
Program
|
1
|
General
|
Exclude.
|
2
|
Health Care Providers and Review
Requirements
|
Exclude.
|
3
|
Enrollment, Beneficiary Education,
and Support Services
|
Exclude.
|
4
|
Contractor Responsibilities
and Reimbursement
|
Exclude.
|
5
|
Reports
|
Exclude.
|
6
|
TRICARE Prime Remote For Active
Duty Family Member (TPRADFM) Program
|
Exclude.
|
A
|
Points Of Contact (POCs)
|
Exclude.
|
B
|
Specified Authorization Staff
(SAS) Review: Protocols And Procedures
|
Exclude.
|
17
|
Supplemental Health Care Program
(SHCP)
|
1
|
General
|
Exclude for care inside the
designated ACO Demonstration area.
|
2
|
Providers of Care
|
Excludefor care inside the
designated ACO Demonstration area.
|
3
|
Contractor Responsibilities
|
Excludefor care inside the
designated ACO Demonstration area.
|
A
|
Points Of Contact (POCs)
|
Exclude for care inside the
designated ACO Demonstration area.
|
B
|
Specified Authorization Staff
(SAS) Review For Authorization: Protocols And Procedures
|
Exclude for care inside the
designated ACO Demonstration area.
|
C
|
Memorandum Of Agreement (MOA)
Between Department Of Veterans Affairs (DVA) And Department Of Defense
(DoD) For Processing Payment For Disability Compensation And Pension Examinations
(DCPE) In The Integrated Disability Evaluation System (IDES)
|
Exclude for care inside the
designated ACO Demonstration area.
|
D
|
Memorandum Of Agreement (MOA)
Between Department Of Veterans Affairs (DVA) And Department Of Defense
(DoD) For Medical Treatment Provided To Service Members With Spinal
Cord Injury (SCI), Traumatic Brain Injury (TBI), Blindness, Or Polytraumatic
Injuries
|
Exclude for care inside the
designated ACO Demonstration area.
|
18
|
Demonstrations and Pilot Projects
(except Value-Based initiatives)
|
4
|
Department Of Defense (DoD)
Comprehensive Autism Care Demonstration
|
Exclude.
|
A
|
Participation Agreement For
Comprehensive Autism Care Demonstration Corporate Services Provider
(ACSP)
|
Exclude.
|
20
|
TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC)
|
1
|
General
|
Exclude.
|
2
|
Jurisdiction
|
Exclude.
|
3
|
Claims Processing For TRICARE
Dual Eligibles
|
Exclude.
|
4
|
Other TRICARE Dual Eligibles
Contract Requirements
|
Exclude.
|
5
|
TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC) Contractor Transition
|
Exclude.
|
21
|
TRICARE Alaska
|
1
|
TRICARE Alaska
|
Exclude.
|
22
|
Reserve Component Health Coverage
Plans
|
1
|
TRICARE Reserve Select (TRS)
|
Exclude.
|
2
|
TRICARE Retired Reserve (TRR)
|
Exclude.
|
A
|
Figures
|
Exclude.
|
23
|
TRICARE Pharmacy (TPharm)
|
1
|
General
|
Exclude for care within the
PSA.
|
2
|
Out-of-Jurisdiction Claims
|
Exclude.
|
3
|
Pharmacy Claims Processing
|
Exclude.
|
4
|
Other Contract Requirements
|
Exclude.
|
5
|
Transition
|
Exclude.
|
26
|
Continued Health Care Benefit
Program (CHCBP)
|
1
|
Eligibility And Coverage
|
Exclude.
|
A
|
Continued Health Care Benefit
Program (CHCBP) Premiums
|
Exclude.
|
27
|
Prime Service Area (PSA) Reduction
Policies and Effective Dates
|
1
|
Prime Service Area (PSA) Reduction
Policies And Effective Dates
|
Exclude.
|
28
|
Prescription Monitoring Program
(PMP)
|
1
|
Prescription Monitoring Program
(PMP)
|
Exclude from Quarterly reporting (paragraphs
3.0 through 8.0).
|