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TRICARE Systems Manual 7950.4-M, April 2021
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)
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.  The contractor shall use this factor code to determine the actual copayment for the claim.  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.  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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