This section describes implementation
requirements for the Duplicate Claims System (DCS). It also defines
policies and procedures for the operation of the system. For transition
requirements related to this section, see the TRICARE Operations
Manual (TOM),
Chapter 2.
2.0 Software
Requirements
2.1 Optional Software
The contractor may, at it’s
own option and expense, procure and utilize full version database management
software packages such as Microsoft Access®, dBase®, Paradox For
Windows®, etc., on the DCS PCs for the purpose of generating customized
queries and reports utilizing optionally downloaded ASCII fixed
length files that can be created by the DCS. Downloaded ASCII fixed
length files may also be imported into Microsoft Excel®.
2.2 Security Requirements - Defense
Health Agency (DHA) Form 834, Patient Encounter Processing and Reporting
(PEPR) Account Activation Request Form
2.2.2 In order to access the DCS
and ECRS, users shall obtain a CAC from DHA, see
Chapter 1, Section 1.1. CACs will be issued
following receipt and processing of properly completed registration and
security forms. Contractor users shall provide the required information,
and submit the completed form to their DCS Information Security
Officer for signature and transmittal to DHA.
2.2.3 DCS data shall be encrypted.
Encryption specifications will be provided by DHA. See
Chapter
1 for additional security and communications requirements.
2.3
Registration
And Security
Each individual
user must complete and sign Government provided security and access
forms prior to be granted DCS access.
3.0
Connectivity
Connectivity will be through
the Internet to the PEPR Portal via MSIE, Version 5.5, 6.0, or 7.0,
or as directed by the Government.
4.0 System Support
For DCS support, contractors
shall file a problem ticket with the DHA Global Service Center at 1-800-600-9332,
then follow the prompts to the DCS.
5.0 Operating Procedures
5.1 For each regional contract for
which a contractor is responsible, or for the TRICARE Medicare Eligible Program (TMEP),
the contractor shall develop internal operating procedures for the
DCS. These internal operating procedures shall designate the responsible
areas for the various duplicate claims resolution functions and
establish time lines. For example, one contractor may decide that
the adjustment unit shall be responsible for scanning the DCS on
a weekly basis for the appearance of adjustments submitted and for
closing sets. Another contractor may decide that the unit responsible for
researching potential duplicate claims should also be responsible
for scanning for adjustments and closing the sets on a daily basis.
5.2 Contractor contract requirements
for overpayment recovery, refunds and offsets, adjustments, etc.,
including timeliness requirements, apply to the operation of the
DCS. As a result, operating procedures shall be developed which
are consistent with all applicable contract requirements. Procedures
must be established to ensure that recoupments are initiated in
a timely manner following the research determination that a duplicate
payment had been made. In other words, procedures must specify that
after a decision has been made by the person responsible for determining
that a duplicate payment was made, recoupment must be initiated
in a timely manner and must be consistent with all overpayment recovery
timeliness standards.
5.3 The contractor
shall develop these procedures within 60 days of the date of system implementation
and have them available for DHA review.