Military Health System

GRS 23, Number 8

Logs, registers, and other records used to control or document the status of correspondence, reports, or other records that are authorized for destruction by the GRS or a NARA-approved Standard Form (SF) 115.

(*Formally categorized as TRICARE Encounter Data (TED) 101-01 Records)

101-01

Documents relating to internal management or general administration of an office.

101-05

Documents used to locate files in the current files area, Records Holding Area (RHA) or records center. Included are retained copies of the records shipment transmittal sheets with backup (e.g., SF-135, Itemized Listings, File Plans, and Certificates of Destruction).

102-07

Correspondence, transmittal memoranda, instructions, and other related material of a non-policy nature on internal administration and operations.

102-15

Documents not required as supporting documentation of a TRICARE claim or health care service. Included are: administrative memoranda, courtesy copies of correspondence, copies of correspondence which are circulated for informational purposes only, papers, drafts, stenographic notebooks, tape or wire recordings, feeder reports which are transcribed to basic data reports, temporary or interim material, and other data used to prepare record material. Completed surveys from which electronic data is captured, working papers or background information which has been generated or accumulated for inclusion in a final report or document.

102-18

Inquiries received directly by the contractor from Congressional offices and the contractor’s reply.

103-03

Documents relating to the overall or general routine administration, but exclusive of specific records described elsewhere in this chapter. Included are: DHA, Department of Defense (DoD), or General Accounting Office (GAO) audit reports on contractor’s performance, administrative costs, benefit payments or any other issue including related correspondence; routine comments on instructions, directives or other publications prepared by another office, e.g., comments on coordinated drafts of manual instructions; evaluations of suggestions that do not result in issuing an instruction; management improvement reports; cost reduction information; travel arrangements; internal security arrangements; and administrative reports.

203-18

Authorizations for uses and Disclosures: Files that contain authorizations from individuals for uses and disclosures of their Protected Health Information (PHI).

Accounting Disclosures: Files that provide an accurate accounting of the date, nature, and purpose of each PHI disclosure, including documents that show the subject individual’s name; requestor’s name and address; purpose and date of disclosure; and proof of subject individual’s consent, when applicable. These files will be indexed alphabetically by individual’s name.

Amendment Case Files: Files contain requests for amendment, contractor’s agreement to amend, or agreement not to amend records and all supporting documentation.

Complaint Case Files: Files contain letters of complaint, contractor’s response and any supporting documentation.

Control Records: Files containing (1) logs which track authorizations, accounting, amendment, and complaint files, records maintained in the Protected Health Information Management Tool (PHIMT) system, and other HIPAA files relating to individual requests, such as requests for record access, restrictions on disclosure and requests for confidential communications, together with contractor responses and supporting documentation for such requests; and (2) logs which track other records within the scope of the HIPAA Privacy, Security, and Breach Rules, including contractor training logs, and records under other records series named in this section.

Requests for Access to PHI: Files contain original requests for PHI, copies of contractor responses and all related supporting documentation.

206-09

Bank analysis reports, accounts receivable reports, unable to adjust remittances and non-financially underwritten bank account reports, including enrollment financial records of payments made by the beneficiary. These files will be indexed upon contractor’s discretion.

905-02

Studies and evaluations when required, not resulting in issuance of new standards.

911-01

Abortion Claims Files: Documents required during the processing of abortion claims.

Adjusted Claims: Records which are acquired or utilized in the development and processing of adjusted claims.

Beneficiary History and Deductible Files: Computer generated records reflecting the contractor’s processing of claims and health care services.

Case Management Files (Preauthorization/Authorization): This series includes all those records generated within the health care services function involving preauthorization, authorization, medical review, peer review, concurrent review, and second level review performed by the medical directors. These notes include copies of medical records and copies of prescriptions and other annotations that are maintained elsewhere in the original case files. These records include the major case files noted as Case Management Files, Extended Care Health Option (ECHO), and other more complex medical case histories.

Enrollment and Disenrollment Files: Computer or manually generated records and all supporting documents which the contractor uses in the enrollment process.

Mental Health Case Files: These files consist of all documents required in the processing of mental health claims. This series includes cases which have gone to peer review or have been denied at the contractor level. Peer reviews and all associated papers shall be filed in the case file, not kept separate.

Provider Files: Computer or manually generated records and supporting documents which are used in establishing and documenting a provider as authorized to provide services or supplies under DHA. Included are network agreements, sanction documents, provider signature on file, and provider power of attorney.

Reimbursement File Records: Computer or manually generated data and all supporting documents which the contractor uses in determining the payment to beneficiaries or providers. Included are all special rate agreements.

Third Party Liability (TPL) Case Records: Documents relating to a TPL cases.

TRICARE Contractor Claims Records: Any record acquired or used by the contractor in the development and processing of claims. These records include but are not limited to: claims (TRICARE claims or other forms approved by the DHA); and supporting documentation, i.e., receipts (itemized statements); medical reports (operative or daily nursing notes, lab results, etc.); authorization forms; certifications of eligibility; double coverage information; completed subrogation forms, certification of emergency statements; powers of attorney or statements of legal guardianship; claim development documentation includes development documentation maintained on an electronic record, i.e., notepad; and correspondence and other comparable documentation which result in or support specific claim processing and payment determinations.

911-02

Checks paid to beneficiaries or sponsors and providers, and any relevant records to include check vouchers, registers, and canceled or voided checks resulting from non-receipt, loss, theft, or non-delivery.

Electronic Funds Transfer (EFT) file information containing details about electronic payment to Providers or Beneficiaries.

911-03

Beneficiary EOBs: Forms used to advise beneficiaries and/or sponsors of the action taken on their TRICARE claims.

Provider EOBs (Summary Payment Vouchers): Forms used to advise Providers of the action taken on claims they submitted to TRICARE.

911-04

Claimant requests for reconsiderations, written statements or evidence, medical records pertaining to the claims under appeal, notices of review decision and other papers resulting from the appeals process.

911-05

Contractor agreements with subcontractors, leases for building space, equipment, consulting, and other services. Included are DHA approvals, amendments, and similar documents.

911-06

Certification of Institutional Providers of Healthcare Case Files: These files consist of certification’s of institutional providers of healthcare as authorized TRICARE providers that meet all applicable provisions of law and regulation. The files include: TRICARE forms, correspondence, and related documents certifying that each provider (institutional entity that provides medical services or supplies on an outpatient or inpatient basis) meets the criteria in the TRICARE Regulation, 32 CFR 199. They also include compliance with TRICARE standards, investigation of complaints, termination and reinstatement of providers, and assessment of the operational effectiveness of the provider certification program.

Health Facilities Registry File: This file consists of a computer printout registry of TRICARE-approved institutional providers of healthcare. The file includes the following categories of providers: Residential Treatment Centers (RTCs), Specialized Treatment Facilities (STFs), and Program for the Handicapped. (The registry is compiled from data contained in file 911-06, above.)

911-07

These files consist of all documents used to develop and execute recoupment cases at the contractor and TRICARE level. The files include: copies of TRICARE claim forms, correspondence and related documents, Explanations of Benefits, checks, investigative reports, court documents and other documents required to collect debts owed the Government. Information from these files may be given to consumer credit agencies. Documents relating to specific recoupment cases. The contractor shall follow the consolidation instruction in Chapter 10, Section 4, paragraph 16.1. If the debts do not total $600.00 or more, and have been on offset status more than 12 months, the contractor shall consider the recoupment files inactive once the final contract payment is made and follow the standard closing procedures.

911-08

These files consist of control forms, background papers, development records, external agencies reports/letters/investigative records, contractor products of processing, Utilization Review and Medical Analysis papers, and other documents required to process fraud and abuse cases.

911-11

Beneficiary’s written grievance report, the record of the contractor’s review and findings, the response to the aggrieved party and, where appropriate, the record of corrective action taken.