1.0 BACKGROUND AND PROVISIONS
The Department of Health and
Human Services (DHHS) 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 will 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 Accredited
Standards Committee (ASC) X12
standards, accompanying Errata, addenda 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 Private
Sector Care Systems. TRICARE is therefore a health plan.
2.2 The relationships
of the entities that comprise TRICARE determine, in part, where
the
contractor shall use standard transactions
shall
be used.
Determinations The
contractor shall not base 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 the
contractor shall base
d determinations 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 the contractor shall not
use it. If “yes,” then the contractor shall apply
the standard applies and answer the
next question needs to be answered.
• Is the transaction one the Secretary
of HHS adopted as an adopted standard? If “no,” then HIPAA
does not require using the standard is
not required by HIPAA to be used. If “yes,” then
the contractor shall use the standard shall
be used.
2.3 To decide
if a standard has been adopted for transaction,
the contractor
shall use the definition of the transaction
needs
to be used as it is provided in the Final Rule.
Knowing The
contractor shall know who is and is not a
THP business
associate
of the THP is important in determining where to
determine when to use 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 THP.
|
Entity
|
Covered
Entities
|
Non-Covered Entity
|
Business Associate
Of The TRICARE Health Plan THP?
|
|
Health Plan?
|
Provider?
|
Clearing-house?
|
Employer?
|
|
Department of Defense
(DoD) (Army, Navy, Air Force, Marines, Space Force, Coast
Guard*)
*In time of war
|
N
|
N
|
N
|
Y
|
N
|
|
TRICARE
Health Plan THP (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
|
|
Market/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) Medicare
Eligible Program (TMEP) Contractor
|
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 implementedThe contractor shall
implement transactions in accordance with the transaction
implementation specifications and any addenda Addenda, errata Errata,
or Operating Rules named and adopted by the Secretary of HHS, as
standards.
3.1.2 StandardThe
contractor shall accept 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 FrontThe
contractor shall not reject otherwise syntactically correct transactions
for 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 The
contractor shall apply front-end business or application
level edits shall be applied after accepting the
transaction has been accepted. Claims The contractor
shall reject, develop, or deny 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 The contractor shall
ensure HIPAA -adopted transactions
exchanged between the contractors and providers shall
be are 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
(COB) Transactions
[Receive 837
Coordination
of Benefits COB 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.
3.2.5 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 The contractor shall
ensure HIPAA -adopted
transactions exchanged between the contractor and other health plans
(including TRICARE supplemental plans) shall be are 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
BenefitsCOB 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 To More
Primary Payer
for For Payment
Already Made
by 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 used by
them. To the extent that Pharmacy Benefit Managers (PBMs) and
claims processors are required by contract or otherwise to process claims
on behalf of TRICARE, they both 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
upon
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 The
contractor shall use the standard format for transactions 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,
the
contractor may perform eligibility inquiry and response
transactions
between them may be performed with
DEERS in non-standard format.
3.4.1.1 RealThe
contractor shall perform real-time eligibility inquiries
and responses, associated with enrollment processing, between the
contractor and DEERS shall be performed using via 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 shall 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 to the contractor 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
AllThe
contractor shall use the standard format for 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 The
contractor shall ensure direct data entry systems shall
be are compliant with standard
transaction data content and conditions.
3.5.3 AThe
contractor shall ensure its direct data entry system shall does 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 The contractor
shall include 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 overseasOverseas Market/MTFs and
from (including United States (US) territories) will be
sent send electronic transactions directly
to the contractor in standard format or routed them through
a US based clearinghouse for translation into standard format prior
to being sent sending to
the contractor.
3.6.2 ElectronicThe
contractor shall accept 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 The
contractor shall accept 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
as
they are not covered transactions.
3.6.2.1 Except for transactions originating
from US territories or overseas Markets/MTFs (which will be in standard
format), the contractor may shall 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 another contractor
for reimbursement, the claims data
submitted to the other contractor in support
of the invoice shall be sent in standard format.
3.7 Transactions
Exchanged Between
the The Contractor
and 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 its 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 its 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 AllThe
contractor shall ensure all trading partner agreements,
including all existing and active trading partner agreements previously
executed, shall be are updated,
and kept updated, to reflect current requirements.
5.0 Implementation
Guide Requirements
5.1 ContractorThe
contractor shall ensure 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 TradingThe
contractor shall ensure trading partner agreements
shall do 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.
• UtilizeUse 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 its claims
processing subcontractor(s) in place of a contractor representative.
7.2.1.1.2 EveryThe
contractor shall make 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 shall
ensure its representative
(s
)
shall be are knowledgeable
of regarding TRICARE program
requirements, and of
their its own
administrative and claims processing systems.
7.2.1.2.1 Prior to attending a DSMO meeting,
the representatives contractor shall
identify from within their own organizations any issues that need
to be addressed at the DSMO meeting.
7.2.1.2.2 The contractor’s 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 shall not
divide their participation and attention with any commercial business
needs and concerns.
7.2.2.1 The contractor’s shall
ensure its 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 shall
ensure its 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 shall
ensure its 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 shall
ensure its representative(s)
shall register under the DoD/Health Affairs (HA) DSMO
memberships.
7.2.3.2 The contractor shall
ensure its representative(s)
are responsible for taking take proposed
changes through the processes necessary for adoption within the
DSMOs.
7.2.3.3 The contractor’s
representative(s) shall ensure its representatives 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 shall
ensure its 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 shall
ensure its 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 use 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 use 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 its 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 shall refer to Chapter
9 if directed by 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 The contractor
shall ensure 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 shall
make transaction histories shall be able
to be read in plain writing readable and understandable
by a person.
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.