File Number:
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911-01
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Description:
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Abortion Claims Files: Documents
required during the processing of abortion claims.
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Adjusted Claims: Records
which are acquired or utilized in the development and processing
of adjusted claims.
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Beneficiary History and
Deductible Files: Computer generated records reflecting the contractor’s
processing of claims and health care services.
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Case Management (CM)
Files (Medical Management (MM) Files): These records include
the medical and mental health case files, all clinical history documentation,
plans of care, treatment plans, case notes for beneficiaries past
and present under CM (to include Extended Care Health Option (ECHO),
Individual Case Management Program For Persons With Extraordinary
Conditions (ICMP-PEC), and Custodial Care Transitional Policy (CCTP)),
ECHO Home Health Care (EHHC), case notes for beneficiaries past
and present under Disease Management (DM), claims and Explanations
of Benefits (EOBs).
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Preauthorization, Authorization,
Referrals: This includes all those medical and mental health
records generated within the health care services function involving preauthorization,
authorization, referrals, beneficiary and provider denials letters, beneficiary
and provider authorization letters, medical review, transition of
care, peer review, concurrent review, and second level review performed
by the medical directors, all UM appeal/reconsideration case files.
These notes include copies of medical records and copies of prescriptions
and other annotations that are maintained elsewhere in the original
case files.
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Enrollment and Disenrollment
Files: Computer or manually generated records and all supporting
documents which the contractor uses in the enrollment process.
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Mental Health Case Files: These
files consist of all documents required in the processing of mental
health claims. This series includes cases which have gone to peer
review or have been denied at the contractor level.
Peer reviews and all associated
papers shall be filed in the case file, not kept separate.
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Provider Files: Computer
or manually generated records and supporting documents which are
used in establishing and documenting a provider as authorized to
provide services or supplies under DHA. Included are network agreements,
sanction documents, provider signature on file, and provider power
of attorney.
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Reimbursement File Records: Computer
or manually generated data and all supporting documents which the
contractor uses in determining the payment to beneficiaries or providers.
Included are all special rate agreements.
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Third Party Liability
(TPL) Case Records: Documents relating to a TPL cases.
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TRICARE Contractor Claims
Records: These files consist of any record acquired or used by
the fiscal intermediary and/or contractor in the development and
processing of TRICARE CHAMPVA claims. These records include but
are not limited to: claims (TRICARE claims or other forms approved
by TRICARE) receipts (itemized statements); medical reports (operative
or daily nursing notes, lab results, etc.) authorization forms;
non-availability statements; certifications of eligibility; double
coverage information; completed TPL (guardianship); peer reviews
and other correspondence that support payments to beneficiaries,
physicians, and other suppliers of service under TRICARE. Includes
the following database:
• TRICARE Latin America
and Canada (TLAC) Claims Database Master File: Information
system used for analyzing claims processed by DHA (formerly TRICARE). Included
are claim receipts, medical reports, authorization forms, Non-Availability Statements
(NAS), certifications of eligibility, double coverage information, completed
TPL, peer reviews and other correspondence that support payment
to beneficiaries, physicians, and other suppliers of service.
• Third Party Outpatient
Collection System (TPOCS): Information system that enables
the collection, tracking, and reporting of data required for the
outpatient billing process. Records include Employer Information
(i.e., name, address, policyholder POC); Insurance Policy data (i.e.,
policy number, group number, group name, effective date, policy
category, insurance company, insurance type, policy holder, drug
coverage data); Accounting data (i.e. control number, transaction
code, debit amount, credit amount, check number, Batch posting number,
balance, patient identification, patient name, encounter date, comments,
entry date, follow-up date).
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Customer Service Records: Correspondence
and other comparable documentation which result in or support specific
claim processing and payment determinations.
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Required Metadata for
Provider Files:
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Provider Name; Provider TIN;
NPI; Facility Name
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Required Metadata for
all other sub categories:
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TMA Claim Number; Sponsor Name;
Sponsor SSN; Sponsor DOB; Beneficiary Name; Beneficiary SSN; Beneficiary
DOB; Image Control Number; DEERS Family Identification Number (DBN);
Provider Name; Provider TIN; NPI
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Record Format:
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See paragraph 1.3 for detailed
instructions.
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