Skip to main content

Military Health System

Utility Navigation Links

TRICARE Operations Manual 6010.62-M, April 2021
Chapter 1
Section 4
The contractor shall establish and maintain sufficient staffing and management support services and commit other resources and facilities to achieve and maintain compliance with all quantitative and qualitative standards of the contract.
2.1  Implementation of Changes in Program Requirements
The contractor shall have the capacity and personnel to maintain and operate all required systems, and to achieve timely implementation of changing program requirements as directed by the Contracting Officer (CO).
2.2  Maintaining Current Status of Diagnostic and Procedural Coding Systems (PCS)
2.2.1  The contractor shall use the current versions of applicable coding systems, including, but not limited to: Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS), International Classification of Diseases, 10th Revision (ICD-10-Clinical Modification (CM) and ICD-10-PCS).
2.2.2  The contractor shall use the most current diagnostic and procedural codes correctly, which includes implementing any revisions based on periodic updates issued by the publishers.
2.3  ZIP Code File
2.3.1  The contractor shall maintain and update an electronic file of all ZIP codes using a Government-furnished electronic ZIP code directory.
2.3.2  The contractor shall incorporate this electronic file in its claims processing system to determine the validity of a beneficiary or provider ZIP code. The Government will provide this directory no less than four and no more than 12 times per calendar year.
2.4  Updating and Maintaining TRICARE Reimbursement Systems
The contractor shall implement policy changes and clarifications to existing TRICARE reimbursement systems affecting both the level of payment and the basic method of reimbursement as they apply to current provider categories implemented at the time of contract award. The TRICARE Reimbursement Manual (TRM) is the source for instructions and guidance on existing reimbursement systems for current provider categories.
The contractor shall develop and employ management procedures to ensure control, accuracy, and timeliness of transactions associated with operation of its call center, TRICARE Service Center (TSC) functions (TRICARE overseas contract only), enrollment, authorizations, provider referrals, claims processing, beneficiary services, provider services, reconsiderations, grievances, Automatic Data Processing (ADP), and financial functions to comply with contract requirements and standards.
4.1  The contractor shall develop and implement a quality control program consisting of supervisory review of appeals, grievances, correspondence, and telephone responses. The review shall include a statistically valid sample or 30 records, whichever is greater, of each of the following: appeals, grievances, correspondence processed and telephonic responses completed. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
4.2  The contractor shall develop and implement an end-of-processing quality review program which assures accurate input and correct payments for authorized services received from certified providers by eligible beneficiaries. This shall begin by the end of the third month after the SHCD and be carried out quarterly thereafter. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3  The contractor shall retain copies of the reviewed appeals, grievances, correspondence, and related working documents, in separate files, for a period of no less than four months following submission of contract deliverables. Electronic file storage is an acceptable form of storage. All stored files shall have a tamper-proof date attached for version control purposes.
4.4  The contractor shall provide all documentation to the Government within 10 calendar days of a Government request.
5.1  The contractor shall provide special programming reports to the Defense Health Agency (DHA) on an “as needed” basis. The DHA CO or Contract Officer’s Representative (COR) will not request a special programming report more than 10 times per contract period. The CO or COR will tell the contractor what information to include in the report. Examples of these reports include claims history data (either limited or complete) by provider, including one or more sub-identifiers; beneficiary; specific diagnosis(es); specific procedure code(s); and/or geographic region delineated by ZIP code(s).
5.2  The contractor shall submit the reports by means of electronic medium or a disc as specified by the CO or COR.
5.3  The contractor shall provide the completed reports to the CO or COR within 60 calendar days of the date on the written request from the PCO or COR.
5.4  The contractor shall inform the CO or COR of the cost, if any.
5.5  The contractor shall complete the special report within the time requested by DHA unless a different delivery date is approved.
5.6  For reporting requirements, see the DD Form 1423, CDRL, located in Section J of the applicable contract.
6.1  The contractor shall develop and implement formal initial and ongoing training program for both internal contractor and subcontractor staff, including training on program updates as they occur, to ensure a high quality of service to beneficiaries and providers.
6.2  The contractor shall document the personnel files of staff members who receive the training. The contractor shall maintain centralized documentation of the training session agendas, identity of attendees, actual dates and duration of training sessions.
7.1  The contractor shall verify that its accounting data are correct, reliable and comply with all Government accounting standards and requirements.
7.2  The contractor’s corporate internal review staff shall conduct regular, routine and ad-hoc reviews to ensure proper monitoring in the areas of finance, financial accounting, internal controls, and special checks issued and returned, and selected history maintenance transactions for possible fraud or abuse.
8.1  In accordance with Department of Defense Instruction (DoDI) 1100.13, and Health Affairs Policy Memorandum 97-012, surveys of military members, retirees and their families must be approved and licensed through issuance of a Report Control Symbol (RCS).
8.2  The contractor shall not conduct written or telephonic beneficiary surveys without the approval of the DHA.
8.3  DHA has an ongoing survey research and analysis program which includes periodic population-based and encounter-based surveys of DoD beneficiaries. The surveys address beneficiary information seeking strategies and preferences, health status, use of care, satisfaction with military and civilian care, and attitudes toward TRICARE. The data are collected at the Prime Service Area (PSA) level and can be aggregated to the geographic area of responsibility.
8.4  The contractor shall work with the Government Designated Authority (GDA) to define their ongoing and special purpose requirements for survey data.
8.5  The contractor may submit surveys, sampling plans, and cost estimates through the GDA to the DHA Decision Support Division (DSD) for approval and licensing if it has a special need for a survey.
- END -
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery