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.
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.