Defense Enrollment Eligibility Reporting System (DEERS)
Chapter 3
Section 5.1
Defense
Enrollment Eligibility Reporting System (DEERS) Functions In Support
Of The TRICARE Dental Program (TDP)
Revision:
1.0 Introduction
This section provides TDP-specific/unique
guidance that was not discussed or described elsewhere in the TRICARE Systems
Manual (TSM).
2.0 Guidance
2.1 Claims Processing
2.1.1 The DEERS
Claims Service (DCS) is used to determine benefit coverage for a
given period.
2.1.2 The contractor shall use the
DCS for all claims processing.
2.2 DCS Inquiry for Claims
2.2.1 The contractor
shall install a prepayment eligibility verification system into
its TRICARE operation that results in a query against DEERS for
TRICARE claims and adjustments.
2.2.2 The contractor’s
query should be conducted early in the claims processing cycle to
assure extensive development/claims review is not done on claims
for ineligible beneficiaries. The DCS Inquiry for Claims supports business
events associated with DCS data for processing dental claims. This
inquiry may also be used for general customer service requests,
beneficiary self-service purposes or for predeterminations as long
as there is prior coordination with the Defense Health Agency (DHA)
and DMDC.
2.3 Copayment
Factor for Coverage Inquiries (Does not apply to TRDP)
2.3.1 The Copayment Factor Code for
a beneficiary is determined by DEERS and is returned on a DCS claims inquiry,
but may be influenced by treatment information from a claim.
2.3.1.1 The contractor shall use this
factor code to determine the actual copayment for the claim.
2.3.1.2 The different factors are determined
by legislation, which considers factors such as pay grade. Although
the rates are based on the population to which they pertain, these
rates also apply to a sponsor’s family members. Examples of cost-share
factors are:
• Pay Grade E-1 to E-4.
• Pay Grade E-5 and above.
• Command Sponsored.
2.3.1.3 The contractor’s system shall
be flexible enough to permit additional rate codes to be added,
as required by the Department of Defense (DoD).
2.4 Special Entitlements
Congressional legislation may
affect rates. The Special Entitlement Code and dates if applicable
provide information to support this legislation. Effective dates
will also be included in the response from DEERS. Note that a person
may have multiple special entitlements. An example of a Special
Entitlement plan is the Survivor Benefit Plan.
2.5 Key Support POCs
2.5.1 A list
of key DMDC Support Office (DSO) personnel and the Joint Uniformed
Services Personnel Advisory Committee (JUSPAC) and the Joint Uniformed
Services Medical Advisory Committee (JUSMAC) Members is provided
by the DHA. These individuals are designated by the DHA to assist
DoD beneficiaries on issues regarding claims payments.
2.5.2 In extreme
cases, the DSO may direct the claims processor to override the DEERS
information; however, in most cases the DSO is able to correct the
database to allow the claim to be reprocessed appropriately.
2.5.3 The contractor
shall request data corrections using procedures in
Section 4.3.
2.6 Other Health Insurance (OHI)
Program
2.7 Standard Insurance Table (SIT)
Program
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