1.0 BACKGROUND AND PROVISIONS
The Department of Health and
Human Services (HHS) published the first administrative simplification
related final rule on August 17, 2000, which added subchapter C,
“Administrative Data Standards and Related Requirements,” to 45
Code of Federal Regulations (CFR) subtitle A. Subchapter C includes
Parts 160 and 162, which will be referred to here as the Transaction
and Code Sets Rule. On January 16, 2009, HHS published a Final Rule
known as “Health Insurance Reform: Modifications to Health Insurance
Portability and Accountability Act (HIPAA) Electronic Transaction
Standards.” This Final Rule (referred to here as the “Modifications
to HIPAA Electronic Standards Final Rule”) adopted updated versions
of the standards for electronic transactions that were originally
adopted under the Administrative Simplification subtitle of HIPAA.
Since 2009, HHS has published additional Final Rules for HIPAA initiatives
which affect HIPAA transactions. As a HIPAA covered entity; TRICARE
must comply with applicable adopted HIPAA rules.
1.1 Compliance Dates
1.1.1 The contractor shall comply
with the most current Final Rules on HIPAA adopted Electronic Transaction Standards,
including compliance dates.
1.1.2 The contractor
shall comply with the most current Final Rules on HIPAA adopted
Transaction Operating Rules, including compliance dates.
1.1.3 The contractor
shall comply with Final Rules on HIPAA adopted code sets (e.g.,
the use of International Classification of Diseases, Tenth Revision
(ICD-10)), including compliance dates.
1.1.4 The contractor
shall comply with Final Rules on HIPAA adopted identifiers (e.g.,
the use of Health Plan Identifiers (HPID)), including compliance
dates.
1.2 Applicability
1.2.1 The contractor
shall comply with HIPAA Electronic Standards Final Rules as the
rules apply to health plans, health care clearinghouses, and health
care providers who transmit any health information in electronic
form in connection with a transaction covered by the rule.
1.2.2 These
Rules refer to health plans, health care clearinghouses, and health
care providers as “covered entities.” The initial Transaction and
Code Sets Rule specifically names the health care program for active
duty military personnel under Title 10 of the United States Code
(USC) and the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) as defined in 10 USC 1072(4), as health plans
and this designation has not changed in the Modifications to HIPAA
Electronic Standards Final Rule.
1.3 Transaction
Implementation Specification Standards
1.3.1 The contractor
shall comply with the most current HIPAA Electronic Standards Final
Rules, which adopt specifically stated HIPAA implementations of
ASC X12 standards, accompanying Errata, addenda, and Operating Rules.
1.3.2 The contractor
shall comply with the HIPAA-adopted transaction initiatives by the
compliance dates specified by HHS in Final Rules in the event that
additional HIPAA-adopted transactions, accompanying Errata, Addenda,
or Operating Rules are mandated for use in the future.
1.3.3 The contractor
shall comply with HIPAA-adopted National Council for Prescription
Drug Programs, (NCPDP) Telecommunication and Batch Standard Implementation
Guides named and adopted by Final Rule for retail pharmacy electronic
transactions covered under HIPAA.
1.3.3.1 The contractor shall accommodate
use of both NCPDP and HIPAA ASC X12 837 Health Care Claim: Professional
for billing of retail pharmacy supplies and professional services.
1.3.3.2 The contractor shall accommodate
use of the HIPAA-adopted standard for the subrogation of pharmacy
claims paid by Medicaid which is named and adopted in Final Rule
as the NCPDP Batch Standard Medicaid Subrogation Implementation
Guide. This standard is applicable to Medicaid agencies in their
role as health plans, as well as to other health plans such as TRICARE
that are covered entities under HIPAA.
1.3.4 The contractor
shall comply with HIPAA-related Final Rules associated with Section
1104 of the Administrative Simplification provisions of the Patient
Protection and Affordable Care Act (PPACA) (hereafter referred to
as the Affordable Care Act or ACA). The ACA establishes new requirements
for administrative transactions to improve the utility of the existing
HIPAA transactions and reduce administrative costs (e.g., standard Operating
Rules).
1.3.5 HIPAA-Adopted Code Set Standards
The contractor shall comply
with HIPAA-adopted code sets in accordance with Final Rules (i.e.,
International Classification of Diseases, 10th Revision (ICD-10)).
2.0 CONTRACTOR RELATIONSHIPS TO
THE TRICARE HEALTH PLAN (THP)
2.1 The Transaction
and Code Sets Rule specifically names the health care program for
active duty military personnel under Title 10 of the USC and the
CHAMPUS as defined in 10 USC 1072(4), as health plans. For the purposes
of implementing the Transaction and Code Sets Rule, the term “TRICARE”
will be used in this chapter to mean a combination of both the Direct
Care (DC) and Purchased Care Systems. TRICARE is therefore a health
plan.
2.2 The relationships of the entities
that comprise TRICARE determine, in part, where standard transactions shall
be used. Determinations as to when and where the transaction standards
apply are not based on whether a transaction occurs within or outside
of a “corporate entity” but rather are based on the answers to the
two following questions:
• Is the transaction initiated
by a covered entity or its business associate? If the answer is
“no,” then the standard does not apply and does not need to be used.
If “yes,” then the standard applies and the next question needs
to be answered.
• Is the transaction one the
Secretary of HHS adopted as an adopted standard? If “no,” then the
standard is not required by HIPAA to be used. If “yes,” then the
standard shall be used.
2.3 To decide
if a standard has been adopted for transaction, the definition of
the transaction needs to be used as it is provided in the Final
Rule. Knowing who is and is not a business associate of the THP
is important in determining where standard transactions shall be
used within TRICARE. See
https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf for
the definition of “business associate.”
2.4 The following
table identifies TRICARE entities and their relationships to the
TRICARE health plan.
|
Entity
|
Covered
Entities
|
Non-Covered Entity
|
Business Associate
Of The TRICARE Health Plan?
|
|
Health Plan?
|
Provider?
|
Clearing-house?
|
Employer?
|
|
Department of Defense
(DoD) (Army, Navy, Air Force, Marines, Coast Guard*)
*In time of war
|
N
|
N
|
N
|
Y
|
N
|
|
TRICARE Health Plan (Represents
both the Health Care Program for Active Duty Military Personnel
under Title 10 of the USC and the CHAMPUS as defined in 10 USC 1072(4).)
|
Y
|
N
|
N
|
N
|
N
|
|
Military Treatment Facilities
(MTFs)/Enhanced Multi-Service Market (eMSM) (Supporting Systems:
Composite Health Care System (CHCS), Referral Management Suite (RMS),
Armed Forces Health Longitudinal Technology Application (AHLTA),
Third Party Outpatient Collections System (TPOCS)*, and others)
*Armed Forces Billing and Collection
Utilization Solution (ABACUS) expected to replace TPOCS in 2015.
|
N
|
Y
|
N
|
N
|
N
|
|
DMDC Defense Enrollment
Eligibility Reporting System (DEERS)
|
N
|
N
|
N
|
N
|
Y
|
|
Managed Care Support
Contractor (MCSC)
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC)
|
N
|
N
|
N
|
N
|
Y
|
|
Defense Finance and Accounting
Service (DFAS)
|
N
|
N
|
N
|
Y
|
N
|
|
TRICARE Dental Program (TDP)
Contractor
|
Y
|
N
|
N
|
N
|
Y
(for foreign claims processing
only)
|
|
Active Duty Dental Program
(ADDP) Contractor
|
Y
|
N
|
N
|
N
|
N
|
|
Pharmacy Data Transaction Service
(PDTS) Contractor
|
N
|
N
|
N
|
N
|
Y
|
|
Designated Provider (DP) Contractors
|
Y
|
Y
|
N
|
N
|
N
|
|
Defense Health Agency-Great
Lakes (DHA-GL)
|
N
|
N
|
N
|
N
|
Y
|
|
Continued Health Care Benefit
Program (CHCBP) Contractor
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Quality Management
Contract (TQMC)
|
N
|
N
|
N
|
N
|
Y
|
|
Contractor for Data Analysis
for the DP Contracts
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Overseas Program (TOP)
Contractor
|
N
|
N
|
N
|
N
|
Y
|
|
Defense Health Agency
(DHA) (Supporting Systems: DEERS Catastrophic Cap and Deductible
(CCDD), payment record databases (TRICARE Encounter Data (TED) records,
TED Provider (TEPRV) records, and TED Pricing (TEPRC) records),
management databases (Military Health System (MHS)) Data Repository
and its associated data marts)
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Pharmacy (TPharm) Contractor
|
N
|
Y
|
N
|
N
|
Y
|
|
TRICARE Regional Offices (TROs)
|
N
|
N
|
N
|
N
|
Y
|
|
TRICARE Area Offices (TAOs)
|
N
|
N
|
N
|
N
|
Y
|
3.0 HIPAA
TRANSACTION REQUIREMENTS FOR TRICARE CONTRACTORS
3.1 General
3.1.1 Transactions
shall be implemented in accordance with the transaction implementation
specifications and any addenda, errata, or Operating Rules named
and adopted by the Secretary of HHS, as standards.
3.1.2 Standard
transactions received by the contractor from trading partners that
are correct at the interchange control structure level (envelope)
and that are syntactically correct at the standard level and at
the implementation guide level and are semantically correct at the
implementation guide level shall be accepted.
3.1.3 Front-end
business or application level edits for transaction content, such
as an edit for a recognized provider number, shall not be the cause
of rejecting an otherwise syntactically correct transaction. Front-end business
or application level edits shall be applied after the transaction
has been accepted. Claims failing front-end business or application
edits, after passing syntax and semantic edits, shall be rejected,
developed or denied in accordance with established procedures for
such actions.
3.2 Transactions
Exchanged Between The contractor And Providers (Network And Non-Network Providers,
Markets/MTFs (CHCS and RMS))
3.2.1 HIPAA adopted transactions
exchanged between contractors and providers shall be in accordance
with HIPAA standards.
3.2.2 The contractor shall be HIPAA
compliant with the following HIPAA adopted transactions, when HIPAA compliant
usage applies:
3.2.3 Claims Transactions
[Receive Claims Transactions]
• The ASC X12N 837P - Health
Care Claim: Professional, most currently adopted version.
• The ASC X12N 837I - Health
Care Claim: Institutional, most currently adopted version.
• The ASC X12N 837D - Health
Care Claim: Dental, most currently adopted version.
• The most currently adopted
version of NCPDP Telecommunication Standard and equivalent
NCPDP Batch Standard including claims for retail pharmacy supplies
and professional services.
3.2.4 Coordination
Of Benefits Transactions
[Receive
837 Coordination of Benefits Transactions]
• The ASC X12N 837 - Health Care
Claim: most currently adopted version.
• The ASC X12N 837 - Health Care
Claim: most currently adopted version
• The ASC X12N 837 - Health Care
Claim: most currently adopted version.
3.2.5 Eligibility
Inquiry And Response Transactions
[Receive 270 Transactions and
Send 271 Transactions]
• The ASC X12N 270/271 - Health
Care Eligibility Benefit Inquiry and Response, most currently adopted
version
3.2.6 Referral
Certification And Authorization Transactions
[Receive 278 Requests and Send
278 Responses]
• The ASC X12N 278 - Health Care
Services Review - Request for Review and Response, most currently
adopted version.
3.2.7 Claim
Status Request And Response Transactions
[Receive 276 Transactions and
Send 277 Transactions]
• The ASC X12N 276/277 - Health
Care Claim Status Request and Response, most currently adopted version.
3.2.8 Payment
And Remittance Advice (RA) Transactions
[Send 835 Transactions]
• The ASC X12N 835 - Health Care
Claim Payment/Advice, most currently adopted version.
3.2.9 Electronic
Funds Transfer (EFT) And Remittance Advice (RA)
The contractor shall be capable
to send the following transmissions:
3.2.9.1 [Stage 1 Payment Initiation,
transmission of health care payment and processing information]
The National Automated Clearing
House Association (NACHA) Corporate Credit or Deposit Entry with
Addenda Record (CCD+) implementation specifications as contained
in the 2011 NACHA Operating Rules & Guidelines, A Complete Guide
to the Rules Governing the Automated Clearing House (ACH) Network
as follows (incorporated by reference in § 162.920):
• 2011 NACHA Operating Rules
& Guidelines, A Complete Guide to the Rules Governing the ACH
Network, NACHA Operating Rules, Appendix One: ACH File Exchange
Specifications.
• 2011 NACHA Operating Rules
& Guidelines, A Complete Guide to the Rules Governing the ACH
Network, NACHA Operating Rules Appendix Three: ACH Record Format
Specifications, Part 3.1, Subpart 3.1.8 Sequence of Records for
CCD Entries.
• For the CCD Addenda Record
(“7”), field 3, the ASC X12 Standards for EDI Technical Report Type
3, “Health Care Claim Payment/Advice (835),” April 2006: Section
2.4: 835 Segment Detail: “TRN Re-association Trace Number,” Washington
Publishing Company, 005010X221.
3.2.9.2 [Stage 1 Payment Initiation,
transmission of health care RA]
• The ASC X12N 835 - Health Care
Claim Payment/Advice, most currently adopted version.
3.3 Transactions
Exchanged Between The Contractor And Other Health Plans (And Employers,
Where Applicable)
3.3.1 HIPAA adopted transactions
exchanged between the contractor and other health plans (including TRICARE
supplemental plans) shall be in accordance with HIPAA standard.
3.3.2 The contractor
shall be able to electronically transact with other health plans,
in accordance with HIPAA adopted Final Rules.
3.3.3 Coordination
Of Benefits Transactions
[Send
and Receive all HIPAA adopted 837 Transactions]
• The ASC X12N 837 - Health Care
Claim: Professional, most currently adopted version.
• The ASC X12N 837 - Health Care
Claim: Institutional, most currently adopted version.
• The ASC X12N 837 - Health Care
Claim: Dental, most currently adopted version.
3.3.4 Eligibility
Inquiry And Response Transactions
[Send and Receive 270 Transactions;
Send and Receive 271 Transactions]
• The ASC X12N 270/271 - Health
Care Eligibility Benefit Inquiry and Response, most currently adopted
version.
3.3.5 Referral
Certification And Authorization Transactions
[Send and Receive 278 Requests;
Send and Receive 278 Responses]
• The ASC X12N 278 - Health Care
Services Review - Request for Review and Response, most currently
adopted version.
3.3.6 Payment
And Remittance Advice (RA) Transactions
[Send 835 Transactions]
• The ASC X12N 835 - Health Care
Claim Payment/Advice, most currently adopted version.
3.3.7 Claim
Status Request And Response Transactions
[Receive 276 Transactions and
Send 277 Transactions]
• The ASC X12N 276/277 - Health
Care Claim Status Request and Response, most currently adopted version.
3.3.8 Health
Plan Premium Payment Transactions
[Receive 820 Transactions]
• The ASC X12N 820 - Payroll
Deducted and Other Group Premium Payment for Insurance Products,
most currently adopted version.
3.3.9 Request
to More Primary Payer for Payment Already Made by Subordinate Payer
(Medicaid)
[Receive
Medicaid Pharmacy Subrogation Transactions]
• NCPDP Batch Standard Medicaid
Subrogation, most currently adopted version. The Modifications to
HIPAA Electronic Standards Final Rule adopted a standard for the
subrogation of pharmacy claims paid by Medicaid. This transaction
is the Medicaid Pharmacy Subrogation Transaction. The standard for
that transaction is the NCPDP Batch Standard Medicaid Subrogation
Implementation guide. A Medicaid Pharmacy subrogation transaction
is defined as the transmission of a claim from a Medicaid agency
to a payer for the purpose of seeking reimbursement from the responsible
health plan for a pharmacy claim the State has paid on behalf of
a Medicaid recipient. This standard is applicable to Medicaid agencies
in their role as health plans, but not to providers or health care
clearinghouses because this transaction is not utilized by them.
To the extent that Pharmacy Benefit Managers and claims processors
are required by contract or otherwise to process claims on behalf
of TRICARE, they shall be able to receive the Medicaid Pharmacy
Subrogation Transaction in the standard format.
3.4 Transactions
Exchanged Between The Contractor And DMDC (DEERS)
3.4.1 Eligibility
Inquiries And Response Transactions
Based on the “two-question
rule” for determining when a transaction shall be in standard format
(see
paragraph 3.2), and the definition of the
Eligibility for a Health Plan Transaction in the Final Rule, eligibility
inquiry and response transactions occurring between business associates
of the same health plan need not be in standard format. Only when
the inquiries and responses are between providers and health plans
or between health plans and health plans shall these transactions
be in standard format. Because the contractor and DEERS are business associates
of the same health plan, eligibility inquiry and response transactions
between them may be performed in non-standard format.
3.4.1.1 Real-time eligibility inquiries
and responses, associated with enrollment processing, between the contractor
and DEERS shall be performed using the Government furnished web-based
system/application.
3.4.1.2 Real-time and batch eligibility
inquiries and responses between the contractor and DEERS for claims processing
and other administrative purposes will be in DEERS specified format.
3.4.2 Enrollment
And Disenrollment Transactions
The contractor may perform
TRICARE enrollment and disenrollment transactions between the contractor
and DEERS using the Government furnished web-based system/application.
The Government will provide a HIPAA standard data and condition
compliant version of Government furnished web-based system/application
for contractor use.
Note: Transactions generated by DEERS
that validate that enrollments have been established and that are
used by the contractor to update their system files, are not considered
covered transactions and may be sent in proprietary format.
3.5 Transactions
Exchanged Between The Contractor And Providers (Network And Non-Network Providers,
Markets/MTFs (CHCS and RMS)) Through Direct Data Entry Systems
3.5.1 Direct
Data Entry Systems
All transactions
covered under the Transaction and Code Sets Rule occurring between
the contractor and network or non-network providers and Market/MTFs
will be in standard format, unless subject to the direct data entry exception.
3.5.2 The contractor
may offer a direct data entry system for use by providers. A direct
data entry system however, does not replace the requirement to support
the standard transactions. Direct data entry systems shall be compliant
with standard transaction data content and conditions.
3.5.3 A direct
data entry system shall not add to or delete from the standard data
elements and code values. Direct data entry systems may take the
form of web applications. Non-standard data elements and code values may
be included in the direct data entry system if the non-standard
data is obtained or sent through a separate mechanism such as a
web page that is separate from the web page containing the standard
data content, and the resolution of the standard transaction does
not depend on the additional information.
3.6 Transactions
Involving Foreign Entities
3.6.1 Electronic transactions from
overseas Market/MTFs and from US territories will be sent directly
to the contractor in standard format or routed through a US based
clearinghouse for translation into standard format prior to being
sent to the contractor.
3.6.2 Electronic transactions submitted
by foreign entities, such as claims transactions from foreign providers,
may be accepted directly by the contractor or they may be routed
through a clearinghouse to the contractor for processing. Transactions
submitted by foreign entities, except for those originating from
US territories or overseas Market/MTFs, are not covered transactions
and may be accepted by the contractor in non-standard format.
3.6.2.1 Except for transactions originating
from US territories or overseas Markets/MTFs (which will be in standard
format), the contractor may define the format or formats acceptable
from foreign entities, either directly or through a clearinghouse.
3.6.2.2 Where the TRICARE Overseas
Program (TOP) health care contractor pays foreign claims and subsequently
bills the contractor for reimbursement, claim data submitted to
the contractor in support of the invoice shall be sent in standard
format.
3.7 Transactions Exchanged Between
the Contractor and DHA
3.7.1 Payment Record Submissions,
TED records, TEPRV records, and TEPRC records - Payment records are
considered reports and are not covered transactions.
3.7.2 The contractor
shall submit payment records in accordance with contract requirements.
3.8 Clearinghouse
Use By The Contractor
3.8.1 The contractor may use contracted
clearinghouses for the purposes of receiving, translating, and routing
electronic transactions on their behalf. Contracted clearinghouses
may receive standard transactions, convert them into the contractors’
system formats and route them to the contractors’ systems for processing.
3.8.2 The contractor
may send non-standard formatted transactions to their contracted
clearinghouses for the purposes of translating them into standard
format and routing them to the intended recipients.
3.8.3 Transactions
between health care clearinghouses shall be conducted in standard
format.
3.8.4 Where a contractor has contracted
with the same clearinghouse as the entity that is submitting or receiving
the transaction, the clearinghouse shall convert the nonstandard
transaction into the standard prior to converting it again to the
intended recipient’s format and sending.
4.0 TRADING
PARTNER AGREEMENTS
The contractor
shall have trading partner agreements with all entities with which
electronic transactions are exchanged.
4.1 The contractor
shall have a trading partner agreement with both the provider and
billing service or clearinghouse where a provider uses a billing
service or clearinghouse to exchange transactions.
4.2 Trading
partner agreements with providers shall contain a “provider signature
on file” provision that allows the contractor to process the electronic
transaction if the provider signature on file requirement is not
being met through another vehicle (e.g., provider certification).
4.4 All trading
partner agreements, including all existing and active trading partner
agreements previously executed, shall be updated, and kept updated,
to reflect current requirements.
5.0 Implementation
Guide Requirements
5.1 Contractor trading partner
agreements shall include, as recommended in the American National Standard
Institute (ANSI) ASC X12N transaction implementation guides, any
information regarding the processing, or adjudication of the transactions
that are helpful to the trading partners and simplify implementation.
5.2 Trading
partner agreements shall not:
• Modify the definition, condition,
or use of a data element or segment in a standard Implementation
Guide.
• Add any additional data elements
or segments to a standard Implementation Guide.
• Utilize any code or data values,
which are not valid to a standard Implementation Guide.
• Change the meaning or intent
of a standard Implementation Guide.
7.0 MISCELLANEOUS
REQUIREMENTS
7.1 Paper Transactions
7.1.1 The contractor
shall continue to accept and process paper-based transactions.
7.1.2 The contractor
may pay claims via electronic funds transfer or by paper check.
The ASC X12N 835 Health Care Claim Payment/Advice transaction contains
two parts, a mechanism for the transfer of dollars and one for the
transfer of information about the claim payment. These two parts
may be sent separately. The 835 Implementation Guide allows payment
to be sent in a number of different ways, including by check and
electronic funds transfer.
7.1.3 The contractor
shall be able to send the RA portion electronically but may continue
to send payment via check.
7.1.4 Current
applicable requirements for the processing of paper-based and electronic
media transactions (e.g., claims splitting, forwarding out-of-jurisdiction
claims, generating and sending Explanation of Benefits (EOBs) to
beneficiaries and providers) apply to the processing of electronic
transactions.
7.2 Attendance At Designated Standards
Maintenance Organization (DSMO) Meetings
7.2.1 The contractor
shall send representatives to the following separate DSMO Trimester
meetings: ANSI Accredited Standards Committee X12 (ASC X12) Standing
Meetings, and the Health Level Seven (HL7) Working Group Meetings.
7.2.1.1 The contractor shall send one
representative to each DSMO Trimester meeting.
7.2.1.1.1 The contractor may elect to
send representatives from their claims processing subcontractor(s)
in place of a contractor representative.
7.2.1.1.2 Every effort shall be made
to have the same representatives attend each meeting for continuity purposes.
The team lead will be the DHA representative in attendance.
7.2.1.2 The contractor’s representative(s)
shall be knowledgeable of TRICARE program requirements, and of their
own administrative and claims processing systems.
7.2.1.2.1 Prior to attending a DSMO meeting,
the representatives shall identify from within their own organizations
any issues that need to be addressed at the DSMO meeting.
7.2.1.2.2 The representatives shall inform
the DHA representative (team lead) of the issues at least one week prior
to the meetings.
7.2.2 The contractor’s
representative(s) shall attend the DSMO meetings as exclusive advocates
for TRICARE business needs and should not divide their participation
and attention with any commercial business needs and concerns.
7.2.2.1 The contractor’s representatives
shall attend and participate in work-group and full committee meetings
and shall work within the DSMOs to incorporate into the standards
and implementation guides any data elements, code values, etc.,
that may be required to conduct current and future TRICARE business.
7.2.2.2 The contractor’s representative(s)
shall also work to prevent removal of any existing data elements, and
code values from the standards and implementation guides that are
necessary to conduct current and future TRICARE business.
7.2.3 The contractor’s
representative(s) shall work as a team and collaborate with other
Government and DoD representatives when attending the DSMO meetings.
7.2.3.1 The contractor representative(s)
shall register under the DoD/Health Affairs (HA) DSMO memberships.
7.2.3.2 The contractor representative(s)
are responsible for taking proposed changes through the processes necessary
for adoption within the DSMOs.
7.2.3.3 The contractor’s representative(s)
shall track and report on the status of each proposed change as
it progresses through the process. For reporting requirements, see
DD Form 1423, Contract Data Requirements List (CDRL), located in
Section J of the applicable contract.
7.2.4 The contractor’s
representative(s) shall keep DHA apprised of any additions to the
standards that shall be made to accommodate TRICARE business needs
and of any proposed changes to existing standards and implementation
guides.
7.2.4.1 Following a DSMO meeting, each
representative attendee shall prepare a summary report that includes,
at a minimum; the work group and full committee meetings attended,
a brief description of the content of the meetings, the status of
any changes in progress, and any problems or information of which
the Government and DHA should be aware.
7.2.4.2 The contractor representative(s)
shall submit their reports to the DHA team lead within 10 business days
following the DSMO meetings. For reporting requirements, see DD
Form 1423, CDRL, located in Section J of the applicable contract.
7.3 Provider
Marketing
7.3.1 The contractor shall encourage
providers to utilize electronic transactions only through marketing
and provider education vehicles permitted within existing contract
limitations and requirements. No additional or special marketing
or provider education campaigns are required.
7.3.1.1 The contractor shall educate
providers on the cost and efficiency benefits that can be realized through
adoption and utilization of electronic transactions in its marketing
efforts.
7.3.1.2 The contractor may use provider
incentives/disincentives, at no additional cost to the Government,
to encourage use of electronic transactions.
7.3.2 The contractor
shall assist and work with providers, who wish to exchange electronic
transactions, to establish trading partner agreements and connectivity
with their systems and to implement the transactions in a timely
manner.
7.3.3 The contractor is not required
to perfect transactions on behalf of trading partners.
7.4 Data
And Audit Requirements
7.4.1 The contractor shall store
all HIPAA-covered electronic transaction data, including eligibility
and claims status transaction data as outlined in
Chapter
9.
7.4.2 The contractor, upon direction
from DHA to freeze records, shall follow
Chapter
9.
7.4.3 The contractor shall generate
transaction histories covering a period of up to six years upon
request by DHA in a text format (delimited text format for table
reports) that is able to be imported, read, edited, and printed by
Microsoft® Word (Microsoft® Excel for table reports).
7.4.3.1 The contractor shall have the
ability to generate transaction histories on paper. Transaction
histories shall include at a minimum, the transaction name or type,
the dates the transaction was sent or received and the identity
of the sender and receiver.
7.4.3.2 The contractor’s transaction
histories shall be able to be read in plain writing.
7.4.4 The contractor’s
transaction data is subject to audit by DHA, DoD, HHS, and other
authorized Government personnel.
7.4.4.1 The contractor shall have the
ability to retrieve and produce all electronic transaction data
upon request from DHA (for up to six years, or longer if the data
is being retained pursuant to a records freeze), to include reasons
for transaction rejections as outlined in
Chapter
9.
7.4.4.2 Electronic transaction data
remains property of the Government, and shall be turned over in
its entirety upon termination of the contract, or upon request by
the Government before that time.