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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Medicare Eligible Program (TMEP)
Chapter 20
Section 13
Program Integrity
Revision:  C-12, August 14, 2024
AllThe TMEP contractor shall comply with all TRICARE requirements in Chapter 13 regarding program integrity shall apply to TMEP unless specifically changed, waiver, or superseded by this section (as indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.
1.0  General
The provisions of TMEP contractor shall comply with the requirements in Chapter 13, Section 1 apply to TMEP with the exception of Chapter 13, Section 1, paragraphs 1.2, and paragraphs 2.2.3 through 2.2.3.2.1.
2.0  Controls, Education, and Conflicts of Interest
The provisions of TMEP contractor shall comply with the requirements in Chapter 13, Section 42 apply to TMEP. The TMEP contractor shall conduct beneficiary and provider education regarding fraudulent or abusive practices as appropriate.
3.0  Case Development and Action
The provisions of TMEP contractor shall comply with the requirements in Chapter 13, Section 42 apply to TMEP with the exception of Chapter 13, Section 3, paragraphs 4.6, 4.7 3.1.4, 3.1.5, and Chapter 13, Section 2, paragraph 3.9 7.5 regarding termination of network agreement.
4.0  Provider Exclusions, Terminations, and Suspension of Claims Processing
The provisions of TMEP contractor shall comply with requirements in Chapter 13, Section 5 apply to TMEP with the following exceptions:
4.1  The provisions of requirements in Chapter 13, Section 5, paragraph 2.5.3 4.3.1 through 4.3.3.3, requiring a notice of exclusion is not applicable to TMEP and excluded providers being included in the network is not applicable to TMEP procedures for converting underwritten debt to non-underwritten debt do not apply.
4.2  The provisions of requirements in Chapter 13, Section 5, paragraph 2.5.4.6, paragraphs 6.3 through 6.3.4, regarding excluded providers being included in the Network is not applicable to TMEP for regional contractors do not apply.
4.3  The provisions of requirements in Chapter 13, Section 5, paragraph 2.6.2.5, paragraphs 9.3.4 and 9.3.4.1, contractor requirements for termination, are not applicable to TMEP to process TRICARE Encounter Data (TED) Record updates as required under Section H.10 ANNUAL UNDERWRITTEN UNALLOWABLE HEALTHCARE COST COMPLIANCE REVIEW Cost of Care audit requirement do not apply.
4.4  The requirements in Chapter 13, Section 5, paragraph 2.9.5.5, for regional contractors do not apply.
4.5  The requirements in Chapter 13, Section 5, paragraph 4.3, requiring a notice of exclusion do not apply.
4.6  The requirements in Chapter 13, Section 5, paragraph 4.3.3, regarding excluded providers being included in the network do not apply.
4.7  The requirements in Chapter 13, Section 5, paragraph 6.3, regarding excluded providers being included in the network do not apply.
4.8  The requirements in Chapter 13, Section 5, paragraph 9.4.1, contractor requirements for Termination, do not apply.
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