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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Medicare Eligible Program (TMEP)
Chapter 20
Section 13
Program Integrity
Revision:  C-108, May 18, 2022
TMEP contractor shall comply with all TRICARE requirements in Chapter 13 regarding program integrity unless specifically changed, waiver, or superseded by this section (as indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.
1.0  General
The TMEP contractor shall comply with the requirements in Chapter 13, Section 1 with the exception of Chapter 13, Section 1, paragraph 1.3.
2.0  Controls, Education, And Conflicts Of Interest
The TMEP contractor shall comply with the requirements in Chapter 13, Section 2 with the exception of paragraph 2.2 regarding a public education program. The TMEP contractor shall conduct beneficiary and provider education regarding fraudulent or abusive practices as appropriate.
3.0  Case Development And Action
The TMEP contractor shall comply with the requirements in Chapter 13, Section 3 with the exception of Chapter 13, Section 3, paragraphs 3.1.4, 3.1.5, and 7.5.
4.0  Reports
The TMEP contractor shall comply with the requirements in Chapter 13, Section 4 with the exception of Chapter 20, Section 13, paragraphs 3.0, and 4.0.
5.0  Provider Exclusions, Terminations, And Suspension Of Claims Processing
The TMEP contractor shall comply with the requirements in Chapter 13, Section 5 with the following exceptions:
5.1  The requirements in Chapter 13, Section 5, paragraph 2.5.3, procedures for converting underwritten debt to non-underwritten debt do not apply.
5.2  The requirements in Chapter 13, Section 5, paragraph 2.5.4.6, for regional contractors do not apply.
5.3  The requirements in Chapter 13, Section 5, paragraph 2.6.2.5 to process all TED Record updates as required under Section H.10 ANNUAL UNDERWRITTEN UNALLOWABLE HEALTHCARE COST COMPLIANCE REVIEW Cost of Care audit requirement do not apply.
5.4  The requirements in Chapter 13, Section 5, paragraph 2.9.5.5, for Regional contractors do not apply.
5.5  The requirements in Chapter 13, Section 5, paragraph 4.2, the first bullet, requiring a notice of exclusion do not apply.
5.6  The requirements in Chapter 13, Section 5, paragraph 4.2, the second bullet, regarding excluded providers being included in the network do not apply.
5.7  The requirements in Chapter 13, Section 5, paragraph 6.3, regarding excluded providers being included in the network do not apply.
5.8  The requirements in Chapter 13, Section 5, paragraph 9.2, contractor requirements for Termination, do not apply.
6.0  Provider Reinstatements
The requirements in Chapter 13, Section 6 do apply.
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