Military Health System

3

TRICARE Processing Standards

Exclude paragraphs 1.1 and 1.2 for Tier 11 care. Exclude paragraph 1.3 (Network Adequacy); paragraphs 1.4 - 1.8 and 6.0 only apply to inpatient claims.

4

Management

Paragraphs 2.2, 2.4, and 4.0 only apply to inpatient claims.

1

Management and Administration

Exclude.

2

Systems Development

Exclude.

3

Critical Processes (CP) - Provider Networks

Exclude.

4

Critical Processes (CP) - Enrollment

Exclude.

5

Critical Processes (CP) - Customer Service

Exclude.

6

Critical Processes (CPs) - Management - Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs)

Exclude.

7

Critical Processes (CPs) - Referral Management

Exclude.

8

Critical Processes (CPs) - Claims Processing

Exclude.

9

Critical Processes (CPs) - Medical Management

Exclude.

10

Other requirements

Exclude.

2

Payments To Beneficiaries/Providers

Exclude for care by Tier 1 providers1.

3

Claim Refund And Collection Procedures

Exclude for care by Tier 1 providers1.

4

Stale Dated, Voided, Or Returned Checks

Exclude for care by Tier 1 providers1.

1

General

Paragraphs 2.2 - 2.4, 3.0, 5.0 and Addendum A only apply to inpatient.

1

TRICARE Prime And TRICARE Select Enrollment Processing

Exclude paragraphs 1.8 and 4.0.

1

Network Development

Exclude.

2

Preauthorizations

Exclude for Tier 1 providers1.

4

Signature Requirements

Exclude for Tier 1 providers1.

4

Overpayments Recovery - Non-Financially Underwritten Funds

Exclude.

1

Education Requirements

Exclude.

2

Government Staff and Beneficiary Education

Exclude paragraphs 1.0, 2.0, 3.0 and 8.0.

6

Telephone Inquires

Exclude paragraph 5.0.

1

Director, TRICARE Regional Offices (TROs), Military Treatment Facility (MTF) Commander/Enhanced Multi-Service Market (eMSM) Manager, and Contractor Interface

Exclude.

2

Resource Sharing

Exclude.

3

Clinical Support Agreement (CSA) Program

Exclude.

A

Memorandum Of Understanding (MOU) - Example

Exclude.

1

General

Exclude.

2

Health Care Providers and Review Requirements

Exclude.

3

Enrollment, Beneficiary Education, and Support Services

Exclude.

4

Contractor Responsibilities and Reimbursement

Exclude.

5

Reports

Exclude.

6

TRICARE Prime Remote For Active Duty Family Member (TPRADFM) Program

Exclude.

A

Points Of Contact (POCs)

Exclude.

B

Specified Authorization Staff (SAS) Review: Protocols And Procedures

Exclude.

1

General

Exclude for care inside the designated ACO Demonstration area.

2

Providers of Care

Excludefor care inside the designated ACO Demonstration area.

3

Contractor Responsibilities

Excludefor care inside the designated ACO Demonstration area.

A

Points Of Contact (POCs)

Exclude for care inside the designated ACO Demonstration area.

B

Specified Authorization Staff (SAS) Review For Authorization: Protocols And Procedures

Exclude for care inside the designated ACO Demonstration area.

C

Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA) And Department Of Defense (DoD) For Processing Payment For Disability Compensation And Pension Examinations (DCPE) In The Integrated Disability Evaluation System (IDES)

Exclude for care inside the designated ACO Demonstration area.

D

Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA) And Department Of Defense (DoD) For Medical Treatment Provided To Service Members With Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blindness, Or Polytraumatic Injuries

Exclude for care inside the designated ACO Demonstration area.

4

Department Of Defense (DoD) Comprehensive Autism Care Demonstration

Exclude.

A

Participation Agreement For Comprehensive Autism Care Demonstration Corporate Services Provider (ACSP)

Exclude.

1

General

Exclude.

2

Jurisdiction

Exclude.

3

Claims Processing For TRICARE Dual Eligibles

Exclude.

4

Other TRICARE Dual Eligibles Contract Requirements

Exclude.

5

TRICARE Medicare Eligible Program (TMEP) Contractor Transition

Exclude.

1

TRICARE Alaska

Exclude.

1

TRICARE Reserve Select (TRS)

Exclude.

2

TRICARE Retired Reserve (TRR)

Exclude.

A

Figures

Exclude.

1

General

Exclude for care within the PSA.

2

Out-of-Jurisdiction Claims

Exclude.

3

Pharmacy Claims Processing

Exclude.

4

Other Contract Requirements

Exclude.

5

Transition

Exclude.

1

Eligibility And Coverage

Exclude.

A

Continued Health Care Benefit Program (CHCBP) Premiums

Exclude.

1

Prime Service Area (PSA) Reduction Policies And Effective Dates

Exclude.

1

Prescription Monitoring Program (PMP)

Exclude from Quarterly reporting (paragraphs 3.0 through 8.0).

9.1

Individual Case Management Program For Persons With Extraordinary Conditions (ICMP-PEC)

Exclude.

13.1

Relationship Between TRICARE and Employer-Sponsored Group Health Plans (GHPs)

Exclude.

1.2

Treatment Of Unfortunate Sequelae And/Or Medically Necessary Follow-On Care Subsequent To Authorized Noncovered Initial Surgery Or Treatment In A Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM)

Exclude.

9.1

Pharmacy Benefits Program

Exclude.

15.1

Custodial Care Transitional Policy (CCTP)

Exclude.

1.1

TRICARE Overseas Program (TOP)

Exclude.

1.2

TRICARE Overseas Program (TOP) Medical Benefit Variations

Exclude.

1.3

Outside The 50 United States And The District Of Columbia Locality-Based Reimbursement Rate Waiver

Exclude.

20

State Agency Billing

Exclude.

1

Double Coverage

Exclude.

2

Double Coverage Review And Processing Of Claims

Exclude.

3

Coordination Of Benefits (COB)

Exclude.

4

Specific Double Coverage Actions

Exclude.

5.1

Defense Enrollment Eligibility Reporting System (DEERS) Functions In Support Of The TRICARE Dental Program (TDP) And The TRICARE Retiree Dental Program (TRDP)

Exclude.

5.2

Defense Enrollment Eligibility Reporting System (DEERS) Functions In Support Of The TRICARE Active Duty Dental Program (ADDP)

Exclude.