1.0 Application
1.1 This section
provides functional guidance for all contractors that interface
with the DMDC/DEERS in support of their contractual requirements.
1.2 For the purpose of defining
geographical areas, the 50 United States (US) 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), Active Duty Dental
Program (ADDP), and Remote Active Duty Dental Program (RADDP).
• Medical: CONUS regional contracts,
OCONUS contract (TRICARE Overseas Program (TOP)), Uniformed Services Family
Health Plan (USFHP) contracts.
• Nurse Advice Lines (NALs):
CONUS and OCONUS NALs.
• Medicare Eligible Claims Processor:
TRICARE Medicare Eligible Program (TMEP): CONUS, Puerto Rico, Guam,
the US Virgin Islands, American Samoa, and the Northern Mariana
Islands.
• Other Health Insurance (OHI).
1.4 Some key executable business
processes that all contractors must accomplish are listed below.
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
2.1 The contractor
shall understand and execute the DEERS functionality described in
this section.
2.2 The contractor shall utilize
the technical information and materials provided by DMDC/DEERS via Defense
Health Agency (DHA), and then must consult with DEERS and DHA if
clarification is required.
3.0 DEERS Operational Environment
And Characteristics
The DEERS
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
The contractor shall ensure
proper data sequencing of transactions sent to DEERS, when applicable
to the specific interface involved as DEERS is tasked with resolving
data conflicts from external systems using rules-based applications.
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 downtime of contractors
interface for two contiguous or cumulative hours within a business
day, DMDC must notify the DHA of the problem and approximately when
it is expected to be corrected. DHA contractors reliant upon DEERS
will be notified of the situation and provided guidance as appropriate.
3.2.3 The contractor shall, in addition
to the standard problem resolution procedures as referenced in DMDC documentation,
when contractors experience downtime in the DEERS interface for
two hours contiguously or cumulatively within a business day and
has not been contacted by DHA, contractors must report the downtime
to the DHA representative and shall report an updated status every
two hours until the problem is resolved.
3.2.4 The contractor
shall submit a final report upon downtime 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
All system-to-system
interfaces to DEERS must 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 DMDC.
3.3.1.1 DEERS utilizes standard message
protocols where appropriate.
3.3.1.2 DEERS defines the content and
format of messages between DEERS and contractors.
3.3.1.3 DEERS and all contractors must
utilize 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. Contractors
must accept and apply the full image sent by DEERS.
3.3.1.6 The contractor shall add the
information, if not present in their system.
3.3.1.7 The contractor shall update
their system, if the information is present, by replacing their
information with what is newly received from DEERS. Notifications
are only intended to synchronize the most current information between
DEERS and contractors. They do not synchronize history between DEERS
and contractors.
3.3.1.8 DMDC centrally enforces all
business rules for enrollment and enrollment-related events.
3.3.1.9 DEERS is the database of record
for all eligibility, enrollment information, and Catastrophic Cap
& Deductible (CC&D) information.
3.3.1.10 DEERS is the central repository
for OHI information.
3.3.2 Web-Based
Application Requirements and Functionality
3.3.2.1 All DMDC/DEERS web-based applications
require Microsoft® Internet Explorer (MIE) 6.0 or higher using HTTPS.
They are all Government furnished equipment.
3.3.2.2 The contractor shall use the
Government furnished web-based applications for their intended use only.
3.3.2.3 The contractor shall not utilize
screen scraping, HTML stripping, and any other technology or approach
to manipulate or alter the intended use of the application or the
application architecture.
3.3.2.4 The following functions are
available using Government furnished web-based applications, responsibilities
and functions based on contractual requirements. They are including,
but not limited to:
• 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).
• OHI information that allows
add, update, and cancellation of OHI policies as well as SIT carrier
adds, updates, cancellations and deactivations.
• 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 achieved
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 The 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
Market or Military Medical 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
that either a pending enrollment (for programs with PCM requirements)
or a new enrollment 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 contractors
for various reasons and reflect the most current enrollment information
for a beneficiary.
5.1.1 The contractor shall accept,
apply, and store the data contained in the notification as sent
from DEERS to remain in sync with DEERS.
5.1.2 The contractor
shall send notifications due to new enrollments or updates to existing
enrollments.
5.1.3 The contractor shall, if it
does not have the information contained in the notification, add
it to their system.
5.2 The contractor
shall apply all information contained in the notification to their
system, if the contractors already have enrollment information for
the beneficiary.
5.3 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, apply the notification.
5.4 The contractor shall acknowledge
all notifications sent by DEERS.
5.5 The contractor
shall, if DEERS does not receive an acknowledgment, continue to
send the notification 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.
6.1.2.1 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 only the one remaining DoD Identification
Number shall be used by the contractor 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 organizations are responsible for correcting the enrollments.
6.1.2.2 The contractor shall 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 organization
must select which of the multiple listings is correct based on documents or
information at hand. After this selection, the requesting organization
would 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 The rules
for determining a beneficiary’s entitlement to health care benefits
are applied by rules-based software within DEERS. 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 organizations must 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 he or she is eligible to use the benefits. The
effective and expiration dates for assigned plan coverage are derived
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. A beneficiary can only be enrolled 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).
• Active Duty Family Member (ADFM)
plans. TDP, but can move into other dental plans based on their
beneficiary role change (e.g., ADDP, if ADFM becomes an active Service
Member).
• Retirees. No longer supported
by DEERS. Replaced by Federal Employees Dental and Vision Program
(FEDVIP), which is overseen by the Office of Personnel Management
(OPM).
• Retiree dependents. FEDVIP,
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 New enrollments are used 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 Modifications of the current
enrollment (updates) are used 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. Starting January
1, 2018, beneficiaries must select a plan or will default to direct-care
only. However, Calendar Year (CY) 2018 is a grace period where they
can elect a plan at any point. Beginning with CY 2019, beneficiaries
will be 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.
Starting January 1, 2018, beneficiaries must select a plan or will
default to DC only. However, CY 2018 is a grace period where they
can elect a plan at any point. Beginning with CY 2019, beneficiaries
will be 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 New enrollments are used 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 Modifications
of the current enrollment (updates) are used 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 TMEP: Enrollment Functionality
No enrollment requirement,
as TMEP 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).
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.
10.1.1.2 The contractor shall update
the residential and mailing addresses in DEERS, whenever possible.
These addresses shall not reflect unit, Market/MTF, or contractor’s
addresses unless 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.
10.1.1.3 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.
10.1.1.4 The contractor shall update
the Mail Delivery Quality Code (MDQC) in DEERS to prevent future mailings
to that address if the contractor cannot determine a valid address.
10.1.2 Telephone Numbers
10.1.2.1 DEERS has several types of
telephone numbers for a person (e.g., home, work, and cellular).
10.1.2.2 The contractor shall make reasonable
efforts to add or update telephone numbers.
10.1.3 Email Addresses
10.1.3.1 DEERS can store an email address
for each person.
10.1.3.2 The contractor shall make reasonable
efforts to add or update this email 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.
10.2.2 The 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.
10.2.3 DEERS also generates letters
to beneficiaries upon changes to their enrollment, and notifies
beneficiary via email or postcard that the letter is available.
10.2.4 The contractor shall not send
additional letters that duplicate those already provided by DEERS.
11.0
Claims
Processing And Database Of Record
11.1 The contractor
shall query DEERS in the process of claims adjudication to determine
eligibility and/or enrollment status for a given period of time
DEERS is the system of record for eligibility and enrollment information.
11.2 For audit and performance review
purposes, contractors are required to retain a copy of every transaction and
response sent and received for claims adjudication procedures. This
information is to be retained for the period required by the TOM.
11.3 The contractor shall not override
this data with information from other sources. Continued Health
Care Benefits Program (CHCBP) CC&D information shall be obtained
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 OHI data received as
part of the claims inquiry shall be used as part of the claims adjudication
process.
11.6 The contractor shall, if it
has evidence of additional or more current OHI information, either
‘pend’ the claim or 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.
11.7 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 address data received as part of the claims inquiry
shall be used as part of the claims adjudication process.
11.8 The contractor shall, if it
has evidence of additional or more current address information,
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 CCDD Totals Inquiry is
used to obtain CCDD balances for the year(s) that correspond to
the requested inquiry period.
12.3 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.
13.2.1 The contractor shall, at the
time of enrollment, determine the existence of OHI.
13.2.2 The contractor shall add or
update minimal OHI data through the Government furnished web-based enrollment
system/application used by the contractors to enter enrollments
into DEERS.
13.2.3 DEERS will accept OHI updates
from a claims processor through a system-to-system interface.
13.2.4 Other MHS users can add or
update the OHI through the OHI/SIT web application provided by DEERS.
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.
13.5.1 The medical contractor must
develop the OHI within 15 calendar days but is not responsible for development
of pharmacy.
13.5.2 The pharmacy contractor shall
develop and maintain pharmacy OHI.
13.5.3 The pharmacy shall develop
placeholder policies, regardless of which organization created the placeholder.
13.5.4 The contractor shall develop
all other placeholder policies, regardless of which organization
created the placeholder.
13.5.5 MHS users will not normally
enter placeholder policies but would develop them if they created
them.
13.5.6 The dental contractor 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, two OHI coverage
types, one for medical coverage and one for vision coverage, would be
sent to DEERS.
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 TMEP contractor.
15.3 The TMEP contractor shall send
the information to the CMS Fiscal Intermediaries (FIs) for identification
of Medicare eligible beneficiaries during claims adjudication.