1.0 Application
1.1 This section
provides functional guidance for all contractors that interface
with the Defense Manpower Data Center (DMDC)/DEERS in support of
their contractual requirements.
1.2 For the
purpose of defining geographical areas, the 50 United States (U.S.)
and the District of Columbia are hereafter referred to as the Continental
United States (CONUS), and all other areas are considered Outside
of the Continental United States (OCONUS).
1.3 The TRICARE
Program’s contracts provide support for specific health care service
categories. Each major area of this section will be broken into
health care service categories for specific guidance. Some of the
contracted health care service categories are:
• Pharmacy: TPharm (Mail Order
Pharmacy (MOP) and Retail Pharmacy).
• Dental: TRICARE Dental Program
(TDP), TRICARE Retiree Dental Program (TRDP) (prior to October 31,
2018), Active Duty Dental Program (ADDP), and Remote Active Duty
Dental Program (RADDP).
• Medical: CONUS regional contracts,
OCONUS contract, Uniformed Services Family Health Plan (USFHP) contracts.
• Nurse Advice Lines (NALs):
CONUS and OCONUS NALs.
• Medicare Eligible Claims Processor:
TRICARE Medicare Eligible Program (TMEP):
CONUS, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa,
and the Northern Mariana Islands.
• Other Health Insurance (OHI).
1.4 The contractor shall accomplish
the key executable business processes listed below at a minimum:
1.4.1 For all contractors and contracts:
• Beneficiary identification/authentication;
• DoD entitlements/TRICARE benefits
information (see also TRICARE Operations Manual (TOM) and TRICARE
Policy Manual (TPM)); and
• Identification of Other Government
Programs (OGPs) entitlement information, to include Medicare.
1.4.2 When required by specific contract
requirements:
• Enrollment processing;
• Enrollment premiums/fees maintenance
(includes fee exclusion);
• Primary Care Manager (PCM)
assignment/re-assignment;
• Claims processing (with associated
beneficiary contact updates);
• Catastrophic Cap And Deductible
Data (CCDD);
• OHI Program; and
• Standard Insurance Table (SIT)
Program.
2.0 Contractor Responsibility
The contractor shall understand
and execute the DEERS functionality described in this section. The contractor
shall also use the technical information and materials provided
by DMDC/DEERS via Defense Health Agency (DHA) Health Plan Operations
Support Section (HPOSS), and shall consult with DEERS and DHA for
any required clarification.
3.0 DEERS Operational Environment
And Characteristics
The DEERS
system environment consists of a Relational Database Management
System (RDBMS), rules-based applications processing DoD entitlements
and eligibility, a Transmission Control Protocol/Internet Protocol
(TCP/IP) sockets listener, application servers that enforce business
rules, and web servers.
3.1 Data
Sequencing
Since
DEERS is tasked with resolving data conflicts from external systems
using rules-based applications, the contractor shall ensure proper
data sequencing of transactions sent to DEERS, when applicable to
the specific interface involved. This aids in maintaining data validity
and integrity.
3.2 System
Maintenance And Downtime
3.2.1 DMDC has
routinely scheduled times for system maintenance and will schedule
additional downtimes as required. The routinely scheduled downtimes
are:
• Weekly: 2100 Eastern Saturday
to 0600 Eastern Sunday
• Daily, if needed: 2355 Eastern
to 0100 Eastern
3.2.2 When DMDC
identifies a telecommunications, hardware, or software problem outside
a scheduled maintenance window that results in contractor interface
downtime for two contiguous or cumulative hours within a business
day, DMDC must notify the DHA of the problem and estimated time of
correction. The Government/DEERS will notify DEERS reliant contractors
regarding the situation and provide guidance as appropriate.
3.2.3 In addition to the standard
problem resolution procedures as referenced in DMDC documentation,
when the contractor experiences DEERS interface downtime for two
hours contiguously or cumulatively within a business day and have
not been contacted by DHA, the contractor shall report the downtime
to the DHA representative and shall report an updated status every
two hours until the problem is resolved. The contractor shall give
a final report upon resolution.
3.3 DEERS
provides system-to-system interfaces, applications, web-based applications,
and web-based services.
3.3.1 External Systems - System-To-System
Interfaces
The contractor
shall ensure all system-to-system interfaces to DEERS use TCP/IP,
File Transfer Protocol (FTP), Hypertext Transfer (Transport) Protocol
(HTTP), Secure File Transfer Protocol (SFTP), or Hypertext Transfer
(Transport) Protocol Secure (HTTPS) as specified by DEERS.
3.3.1.1 DEERS uses standard message
protocols where appropriate.
3.3.1.2 DEERS defines the content and
format of messages between DEERS and the contractor.
3.3.1.3 DEERS and the contractor shall
use encryption for all messages that contain privacy level information.
3.3.1.4 DEERS specifies the method
of encryption and authentication for all external interfaces.
3.3.1.5 All notifications are sent
as full database images; they are not transaction-based. The contractor
shall accept and apply the full image sent by DEERS. The contractor
shall add the information, if not present in their system. The contractor
shall update their system, if the information is present, by replacing
their information with the newly received DEERS information. Notifications
are only intended to synchronize the most current information between
DEERS and the contractor. They do not synchronize history between
DEERS and the contractor.
3.3.1.6 DMDC centrally enforces all
business rules for enrollment and enrollment-related events.
3.3.1.7 DEERS is the database of record
for all eligibility, enrollment information, and Catastrophic Cap
& Deductible (CC&D) information.
3.3.1.8 DEERS is the central repository
for OHI information.
3.3.2 Web-Based
Application Requirements And Functionality
3.3.2.1 The contractor shall use the
web browser identified in the technical specification(s) or the user
guide(s) for the specified applications. The web-based applications
are all Government furnished equipment.
3.3.2.2 The contractor shall use the
Government furnished web-based applications for their intended use
only. The contractor shall not use screen scraping, HTML stripping,
or any other technology or approach to manipulate or alter the intended
use of the application or the application architecture.
3.3.2.3 At a minimum, the following
functions are available to the contractor using Government furnished
web-based applications, responsibilities and functions based on
contractual requirements:
• General Inquiry of DEERS (GIQD)
information used for research and customer service to display demographics,
Health Care Delivery Program (HCDP) eligibility and enrollment.
It may also allow other administrative functions like address updates.
• Enrollment activities, to include
display of enrollment premiums/fees.
• Claims processing eligibility
checks, see also
Sections 5.1 and
5.2.
• CCDD information that supports
research and allows limited updates on the history of CC&Ds
and enrollment fee payment transactions posted to DEERS and stored
on-line (current plus previous five fiscal years).
• PCM assignment, re-assignment,
capacities, and enrolled counts.
4.0 DEERS Web-Based Applications
And Notifications
Applications:
The following is a brief description of the available applications,
responsibilities and functions based on contractual requirements.
4.1 GIQD Information
GIQD information is accessed
through a Government furnished web-based system/application that
is used for research and customer service to display demographics,
coverage and PCM assignment information. It also allows address
updates.
4.2
Government
Furnished Web-Based Enrollment System/Application
4.2.1 The Government
furnished web-based enrollment system/application is a full function Government
Furnished Equipment (GFE) application developed by DMDC to support
enrollment-related activity. The Government furnished web-based
enrollment system/application interacts with both the main DEERS
database and the National Enrollment Database (NED) satellite database
to provide enrolling organizations with eligibility and enrollment
information, as well as the capability to update the NED with new
enrollments and modifications to existing enrollments.
4.2.2 The Government furnished web-based
enrollment system/application meets the Health Insurance Portability
and Accountability Act (HIPAA) and DoD policy guidelines for a direct
data entry application, and is data-content compliant for enrollment
and disenrollment functions.
4.2.3 An enrolling
contractor shall perform enrollment related functions through the Government
furnished web-based enrollment system/application.
4.3 Government Furnished Web-Based
Beneficiary Self-service Enrollment System/Application
4.3.1 The Government furnished web-based
beneficiary self-service enrollment system/application serves all
TRICARE eligible beneficiaries and will support most enrollment
programs. The Government furnished web-based beneficiary self-service
enrollment system/application will interface with contractor systems
for the purposes of accommodating on-line payment of initial enrollment
fees.
4.3.2 DEERS will pre-populate data
elements where possible.
4.3.3 The web
application contains checks for beneficiary eligibility and hard
edits requiring the beneficiary to fulfill established DEERS business
rules and enrollment criteria. Upon completion of the web process,
the beneficiary is informed that the enrollment actions may be reviewed
by the appropriate contractor for accuracy and compliance with established
regional and/or Market/Military Treatment Facility (MTF) requirements,
and that they will be contacted if additional information is needed.
DEERS will send the contractor a notification(s) informing the contractor
new enrollment information exists for the beneficiary. See also
paragraph 5.0.
5.0
DEERS
System-To-System Notifications
5.1 Government
furnished system information/data notification(s) are sent to the
contractors for various reasons and reflect the most current enrollment
information for a beneficiary. The contractor shall accept, apply,
and store the data contained in the notification as sent from DEERS
to remain in sync with DEERS. DEERS may send notifications due to
new enrollments or updates to existing enrollments. If contractors
do not have the information contained in the notification, the contractor shall
add it to their system. If the contractor already has enrollment
information for the beneficiary, the contractor shall apply all
information contained in the notification to their system.
5.2 The contractor shall use the
beneficiaries’ DEERS identifiers, DoD Identification Number and/or DoD
Benefits Number (DBN), to match the notification to the correct
beneficiary in their system. There are also circumstances where
a contractor may receive a notification that does not appear to
be updating the information that the contractor already has for
the enrollee. The contractor shall not treat such notifications
as errors by the contractor system and shall apply them.
5.3 The contractor shall acknowledge
all notifications sent by DEERS. If DEERS does not receive an acknowledgment,
the notification will continue to be sent until acknowledgment is
received. The following information details examples of events that
trigger DEERS to send notifications to a contractor.
• Primary Notifications Resulting
From Enrollment Actions.
• Unsolicited Notifications resulting
from updates to beneficiaries’ status.
6.0
Beneficiary
Identification
6.1 Patient Identification Merge
6.1.1 See also
Section 3.1 for
Beneficiary Identification.
6.1.2 Occasionally,
incomplete or inaccurate person data is provided to DEERS and a
single person may be temporarily assigned two DoD Identification
Numbers. When DEERS identifies this condition, DEERS makes this
information available on-line for all contractors. The contractor
shall retrieve and apply this information on a weekly basis. The
merge brings the data gathered under only one of the DoD Identification
Numbers and discards the other. Although DEERS retains both numbers for
an indefinite period, from that point on the contractor shall use
only the one remaining DoD Identification Number for that person
and for subsequent interaction with DEERS and other Military Health
Systems (MHSs). If there are enrollments under both records being
merged that overlap, the enrolling contractor shall correct the
enrollments. The contractor shall also update the catastrophic cap that
has been posted for these records if necessary.
6.2 Partial Match
6.2.1 See also
Section 3.1 for Beneficiary Identification.
6.2.2 A partial match response may
be returned for any inquiry that does not use a DoD Identification
Number and/or DBN. Eligibility may result in a partial match situation
due to person ambiguity. There will be a separate listing for each
person or family matching the requested DBN, or Sponsor Social Security
Number (SSN).
6.2.3 The listing
includes the sponsor and family member information needed to determine
the correct beneficiary or family including the DBN(s).
6.2.4 The requesting contractor shall
select which of the multiple listings is correct based on documents
or information at hand. After this selection, the requesting contractor
shall use the additional information returned (e.g., Date Of Birth
(DOB), Name) to resend a DEERS inquiry.
7.0
HCDP
Eligibility For Enrollment
7.1 DEERS
uses rule-based software to determine a beneficiary’s entitlement
to health care benefits. DEERS is the sole repository for these
DoD rules, and no other eligibility determination outside of DEERS
is considered valid. Whenever data about an individual sponsor or
a family member changes, DEERS reapplies these rules. DEERS receives
daily, weekly, and monthly updates to this data, which is why contractors
shall query DEERS for eligibility information before taking action.
This ensures that the individual is still eligible to use the benefits
and that the respective contractor has the most current information.
7.2 A beneficiary who is considered
eligible for DoD benefits (pharmacy, dental, medical) in accordance
with Title 10 United States Code (USC),
32
CFR 199.13,
32 CFR 199.22,
and DoD Instruction (DoDI) 1000.13 is not required to “sign up”
for the TRICARE benefits associated with any DEERS assigned plan.
If an authorized organization inquires about that beneficiary’s
eligibility, DEERS reflects if they are eligible to use the benefits.
DEERS derives the effective and expiration dates for assigned plan
coverage from DoDI 1000.13 rules and supporting information.
7.3 Eligibility For Enrollment
DEERS provides coverage plan
information identifying the period of eligibility and/or enrollment
for the coverage plan. The contractor shall only enroll a beneficiary
into the coverage plans that have an “eligible for” status. When
a sponsor and/or family member are first added, or when sponsor
or member status updates occurs, DEERS determines basic eligibility
for health care benefits in accordance with Title 10 USC
32
CFR 199.13,
32 CFR 199.22,
and DoDI 1000.13 and then establishes an assigned HCDP coverage
plan together with coverage dates.
8.0
Enrollment
Activities
Enrollment-related
business events include, by contracted health care service category:
8.1 Pharmacy: Enrollment Functionality
No enrollment requirement,
as pharmacy is an assigned HCDP plan.
8.2 Dental:
Enrollment Functionality
8.2.1 Eligibility
for enrollment identifies current enrolled coverage plans and eligibility
for enrollment into other coverage plans (as the sponsor and/or
beneficiaries role changes over time). See also
Section 4.1.
Some examples of plan changes over time:
• Service member plans. ADDP,
but can move into other dental plans based on their beneficiary
role change (e.g., TDP and TRDP, prior to October 31, 2018)
• Active Duty Family Member (ADFM)
plans. TDP, but can move into other dental plans based on their beneficiary
role change (e.g., TRDP prior to October 31, 2018, and ADDP, if
ADFM becomes an active Service Member)
• Retirees. TRDP with no expected
change in plan where TRDP is applicable.
• Retiree dependents. TRDP prior
to October 31, 2018, but can move into other dental plans based on
their beneficiary role change (e.g., TDP and ADDP, if retiree dependent
becomes an active Service Member)
8.2.2 The contractor shall use new
enrollments for enrolling eligible sponsors and family members into
a HCDP coverage plans or for adding family members to an existing
family policy. Enrollments begin on the date specified by the enrolling
organization and extend through the beneficiaries’ end of eligibility
for the HCDP.
8.2.3 New enrollments
may also perform the following functions:
• Update address, email address
and/or telephone number.
• Record that the enrollee has
OHI (does not apply to ADDP).
8.2.4 The contractor shall use modifications
of the current enrollment (updates) to change some information in
the current enrollment plan. Modifications of the current enrollment
include the following functions:
• Change enrollment begin date.
• Cancel enrollment/disenrollment.
• Change prior enrollment end
date.
• Change prior enrollment end
reason.
• Request an enrollment card
replacement.
• Add OHI information for an
enrollee (does not apply to ADDP).
8.3 Medical: Enrollment Functionality
8.3.1 Eligibility for enrollment
identifies current enrolled coverage plans and eligibility for enrollment
into other coverage plans (as the sponsor and/or beneficiaries role
changes over time). See also
Section 4.1.
Some examples of plan changes over time:
• Service member plans. TRICARE
Prime for Service member only, but can move into other medical plans
based on their beneficiary role change (e.g., TRICARE Prime Remote
(TPR), TRICARE Standard, TRICARE Select, TRICARE Prime, TRICARE
Reserve Select (TRS), etc.).
• ADFM plans. Beneficiaries must
select a plan or will default to direct-care only. Beneficiaries
are limited to making changes to enrollments only during an annual
enrollment open season or following a Qualifying Life Event (QLE).
Direct Care (DC) only is the default assigned, but can enroll into
other medical plans based on their beneficiary role change (e.g.,
TRICARE Select, TRICARE Prime, TRICARE Plus, TPRADFM, etc.). See
TOM,
Chapter 6, Section 1.
• Retirees and their family members.
Beneficiaries must select a plan or will default to DC only. Beneficiaries
are limited to making changes to enrollments only during an annual
enrollment open season or following a QLE. DC only is the default
assigned, but can elect to enroll into other medical plans (e.g.,
TRICARE Select, TRICARE Prime, TRICARE Plus, etc.). See TOM,
Chapter 6, Section 1.
8.3.2 The contractor shall use new
enrollments for enrolling eligible sponsors and family members into
a HCDP coverage plans or for adding family members to an existing
family policy. Enrollments begin on the date specified by the enrolling
organization and extend through the beneficiaries’ end of eligibility
for the HCDP.
8.3.3 New enrollments
may also perform the following functions:
• Update address, email address
and/or telephone number.
• PCM selection (if required/allowed
by HCDP).
• Record that the enrollee has
OHI.
8.3.4 The contractor
shall use modifications of the current enrollment (updates) to change
some information in the current enrollment plan. Modifications of
the current enrollment include the following functions:
• Change or cancel a PCM selection.
• Transfer enrollment (enrollment
portability) or cancel a transfer.
• Change enrollment begin date.
• Cancel enrollment/disenrollment.
• Change prior enrollment end
date.
• Change prior enrollment end
reason.
• Request an enrollment card
replacement.
• Add OHI information for an
enrollee.
• Request a replacement letter
for PCM change or disenrollment.
8.4 NAL: Enrollment Functionality
No enrollment requirement,
as NAL is a service program that supports all DoD eligible beneficiaries.
8.5
TMEP:
Enrollment Functionality
No enrollment
requirement, as TMEP is a claims processing
contract that supports all dual eligible beneficiaries.
9.0 Disenrollments Activities
9.1 Once actively enrolled in a
coverage plan, an individual or family may voluntarily disenroll
or be involuntarily disenrolled. Voluntary disenrollment is self-elected,
but does not apply to Service Member as they are not authorized
to voluntarily disenroll from mandated medical or dental plans.
Involuntary disenrollment occurs from failure to pay enrollment
fees or from loss of eligibility. Upon disenrollment, DEERS will
notify the beneficiary of the change in or loss of coverage.
9.2 For medical plans only, see
TOM,
Chapter 6, Section 1 for disenrollment rules
and eligibility for re-enrollment.
9.3 When there
is a disenrollment, the appropriate systems are notified, as necessary
(see also
paragraph 4.2).
Note: TRDP enrollments were terminated
in accordance with this chapter effective December 31, 2018, 11:59
p.m. Eastern.
10.0 Beneficiary Contact Updates
And Enrollment Cards
10.1 Contact Updates (Applicable
To All Contractors)
Address,
telephone number, and email address updates.
10.1.1 Addresses
10.1.1.1 DEERS receives address information
from a number of source systems. Although most systems only update
the residence address, DEERS actually maintains multiple addresses
for each person. The contractor shall update the residential and
mailing addresses in DEERS, whenever possible. The contractor shall
not update addresses to reflect unit, Market/MTF, or the contractor
addresses unless that information is provided directly by the beneficiary.
The mailing address captured on DEERS is primarily used to mail
the enrollment card and other correspondence. The residential address
is used to determine enrollment jurisdiction at the Zip Code level.
DEERS uses a commercial product to validate address information
received on-line and from batch sources.
10.1.1.2 The contractor shall process
all mail returned for bad addresses and shall research the address,
correct it on DEERS, and re-mail the correspondence to the beneficiary.
If the contractor cannot determine a valid address, the contractor
shall update the Mail Delivery Quality Code (MDQC) in DEERS to prevent
future mailings to that address.
10.1.2 Telephone
Numbers
DEERS
has several types of telephone numbers for a person (e.g., home,
work, and cellular). The contractor shall make reasonable efforts
to add or update telephone numbers.
10.1.3 E-Mail
Addresses
DEERS
can store an email address for each person. The contractor shall
make reasonable efforts to add or update this e-mail address.
10.2 Enrollment Cards And Letter
Production
10.2.1 DEERS sends a notification
directly to the enrollee at the residential mailing address specified
in the enrollment request or via email advising them how to obtain
a copy of their Universal TRICARE Beneficiary Card. New enrollment
cards are automatically generated upon a new enrollment or an enrollment
transfer to a new region (medical only). Beneficiaries are notified
of the availability by email or postcard, unless the enrollment
operator specifies in the Government furnished web-based enrollment
system/application not to generate an enrollment card. A contractor
may request a replacement notification at any time. DEERS sends
a notification to the contractor indicating the last date an enrollment
card notification was generated for the enrollee.
10.2.2 DEERS also generates letters
to beneficiaries upon changes to their enrollment, and notifies beneficiary
via email or postcard that the letter is available. The contractor
shall not send additional letters that duplicate those already provided
by DEERS.
11.0
Claims
Processing And Database Of Record
11.1 DEERS
is the system of record for eligibility and enrollment information.
As such, in the process of claims adjudication, the contractor shall
query DEERS to determine eligibility and/or enrollment status for
a given period of time.
11.2 For audit
and performance review purposes, the contractor shall retain a copy
of every transaction and response sent and received for claims adjudication
procedures. The contractor shall retain this information for the
period required by the TOM.
11.3 The contractor
shall not override this data with information from other sources.
The contractor shall obtain Continued Health Care Benefits Program
(CHCBP) CC&D information from the CHCBP contractor.
11.4 The contractor shall deny a
claim (either totally or partially) if the services were received partially
or entirely outside any period of eligibility.
11.5 The contractor system is the
database of record for OHI within the TRICARE Program. DEERS is the
data repository for OHI, using its centralized repository of OHI
information that is reliant on the MHS organizations to verify,
update and add to at every opportunity. The contractor shall use
OHI data received as part of the claims inquiry as part of the claims
adjudication process. If the contractor has evidence of additional
or more current OHI information, the contractor shall either ‘pend’
the claim, submit the new OHI information to DEERS, and then reprocess
the claim, or develop business processes to simultaneously accomplish
both DEERS OHI update and claims processing using the newly discovered
OHI data. Any process executed by the contractors must not interfere
with the contractors required claims processing time lines.
11.6 Although DEERS is not the database
of record for address, it is a centralized repository that is reliant
on numerous organizations to verify, update and add to at every
opportunity. The contractor shall use address data received from
the claims inquiry as part of the claims adjudication process. If
the contractor has evidence of additional or more current address
information the contractor shall process claims using the additional
or more current information and update DEERS within two business
days.
12.0 CCDD
12.1 DEERS
stores Enrollment Year (EY), Fiscal Year (FY), and CY CC&D data
in a central repository. DEERS stores the current and the four prior
yearly CC&D totals. The purpose of the DEERS CCDD repository
is to maintain and provide accurate CC&D amounts, making them
universally accessible to DoD claims processors.
Note: To transition to CY catastrophic
caps as required in NDAA FY 2017, Section 701, the FY 2017 catastrophic
cap covers the period from October 1, 2016 to December 31, 2017.
12.2 The contractor shall use the
CCDD Totals Inquiry to obtain CCDD balances for the year(s) that correspond
to the requested inquiry period. The contractor shall inquire and
lock CCDD totals before updating DEERS CCDD amounts.
Note: A catastrophic cap record is
not required for persons who are authorized benefits but are not
on DEERS or eligible for medical benefits, such as prisoners or
Government employees. The purpose of the catastrophic cap is to
benefit those beneficiaries who are eligible for MHS benefits. Those
persons that are authorized benefits who would not under any other
circumstances be eligible, are not subject to catastrophic cap requirements.
13.0
OHI Program
13.1 OHI identifies non-DoD health
insurance held by a beneficiary. The requirements for OHI are validated
by the DHA Uniform Business Office (UBO). OHI information includes:
• OHI policy and carrier.
• Policyholder.
• Type of coverage provided by
the additional insurance policy.
• Employer information offering
coverage, if applicable.
• Effective period of the policy.
13.2 OHI transactions allow adding,
updating, canceling, or viewing all OHI policy information. OHI policy
updates can accompany enrollments or be performed alone. OHI information
can be added to DEERS or updated on DEERS through multiple mechanisms.
At the time of enrollment, the contractor shall determine the existence
of OHI.
13.3 The contractor shall perform
an OHI Inquiry before attempting to add or update an OHI policy. The
MHS organizations are reliant on the individual beneficiary to provide
accurate OHI information and DEERS is reliant on the MHS organizations
for the accurate assignment of policy information to the individual
record. DEERS is not the system of record for OHI information. Performing
an OHI Inquiry on a person before adding or attempting to update
an OHI policy helps ensure that the proper policy is updated based
on the most current information or the person.
13.4 Examples of OHI coverage are:
• Comprehensive Medical coverage
(Plans with multiple coverage types).
• Medical coverage.
• Inpatient coverage.
• Outpatient coverage.
• Pharmacy coverage.
• Dental coverage.
• Long-term care coverage.
• Mental health coverage.
• Vision coverage.
• Partial hospitalization coverage.
• Skilled nursing care coverage.
13.5 The default coverage will be
Comprehensive Medical Coverage unless another of the above coverages
is selected. The indication of Comprehensive Medical Coverage presumes
medical coverage, inpatient coverage, outpatient coverage, and pharmacy
coverage. Medical contractors shall develop the OHI within 15 days
but is not responsible for pharmacy coverage development.
13.5.1 The pharmacy contractor(s)
shall develop and maintain pharmacy OHI. The pharmacy contractor
shall develop pharmacy placeholder policies, regardless of which
organization created the placeholder. The contractor shall develop
all other placeholder policies, regardless of which organization
created the placeholder. MHS organizations will not normally enter
placeholder policies but would develop them if they created them.
13.5.2 The dental contractor(s) shall
develop and maintain dental OHI.
13.6 A person
can have multiple types of OHI coverage for one policy. For example,
to add an OHI policy that covers medical and vision, the contractor
shall send DEERS two OHI coverage types, one for medical coverage
and one for vision coverage.
13.7 A person
can have multiple OHI policies. Multiple OHI policies may have the
same or different Health Insurance Carriers (HICs), and/or the same
or different OHI policy effective periods.
14.0
SIT Program
The SIT Program supports the
MHS billing and collection process. The SIT is validated by the
DHA UBO through the DoD Verification Point of Contact (VPOC). The
VPOC is ultimately responsible for maintaining the SIT in DEERS,
which is the system of record for SIT information. The SIT provides uniform
billing information for reimbursement of pharmacy, dental, and medical
care costs covered through commercial policies held by the DoD beneficiary
population. MHS personnel use the SIT to obtain other payer information
in a standardized format.
14.1 All systems
identified as trading partners will request an initial full SIT
subscription from DEERS. In addition, holders of the SIT shall subscribe
to DEERS at least daily in order to receive subsequent updates of
the SIT.
14.2 The SIT Verification Application
is used exclusively by the VPOC. The application queues all SIT transactions
entered through the OHI Maintenance Application for review and verification
by the VPOC.
15.0 Medicare Data
15.1 DEERS
performs a match with the Centers for Medicare and Medicaid Services
(CMS) to obtain Medicare data and incorporates the Medicare data
into the DEERS database as OGPs entitlement information. This information
includes Medicare Parts A, B, C, and D eligibility along with the
effective dates. The match includes all potential Medicare-eligible
beneficiaries.
15.2 DEERS
sends Medicare Parts A and B information to the TMEP.
The TMEP sends the information to the
CMS Fiscal Intermediaries for identification of Medicare eligible
beneficiaries during claims adjudication.