3.0 DEERS Data Use Concepts
3.1 All DEERS data provided by
the DMDC to the DHA for the use of determining medical eligibility, enrollment,
and health care claims payment are subject to the Privacy Act of
1974, as amended. DEERS data includes all data that is provided
for test and/or production activities.
3.2 Release
is made to all globally executed TRICARE program support contractors
(hereafter referred to as “the contractor”) in accordance with the
provisions of the Privacy Act allowing for intra-department release
when an appropriate “need to know” exists. As such, the authorized
organizations shall use the protected Privacy Act data in accordance
with the applicable provisions of the Privacy Act or the DHA comparable
approved or accepted security check process for overseas contractors
accessible by personnel with at least an Automated Data Processing/Information
Technology-II (ADP/IT-II) designation.
3.3 This includes:
3.3.1 Granting access only personnel
(military, civilian, contractor) with a need to know in the official performance
of their duties, and using the data only for the specific purposes
agreed to by DMDC and DHA.
3.3.2 The contractor/organization
to which these data are provided shall ensure sufficient physical
and procedural safeguards are in place to satisfy the requirements
of the Privacy Act.
3.3.3 The contractor
shall return the data to DMDC or destroy the data when the approved
use has been accomplished. The contractor shall not retain copies.
3.3.4 The contractor shall first submit,
any additional intended uses through DHA to DMDC for approval and shall
not proceed until the request is favorably coordinated with DMDC.
3.3.5 In addition, DMDC only provides
the DEERS data for specific purposes, such as:
3.3.5.1 Eligibility data for reporting
the eligibility of a beneficiary on DEERS as of the time of the
eligibility inquiry.
3.3.5.2 Enrollment data for the authorized
enrollment of beneficiaries into valid HCDPs as defined under the provisions
of the respective Request For Proposal (RFP)/contract.
3.3.5.3 Claims data for the processing
and resolution of claims submitted for reimbursement of health care received.
3.3.5.4 CCDD for the processing and
resolution of Catastrophic Cap and Deductible (CC&D) information resulting
from heath care services received.
3.3.5.5 OHI and Standard
Insurance Table (SIT) data for the processing and resolution of
OHI resulting of and from heath care services received.
4.0 DEERS Overview
4.1 Program
Description
4.1.1 DEERS serves as a centralized
Department of Defense (DoD) data repository of personnel and medical data.
The DEERS database contains detailed personnel eligibility information
for benefits and entitlements distribution to Uniformed Services
members; U. S. sponsored Foreign Military members; DoD and Uniformed Services
civilians; other personnel as directed by the DoD; and their eligible
family members. DEERS supports essential day-to-day operations in
a broad range of functional areas, including personnel, benefit
entitlements, pharmacy, dental, medical, and finance.
4.1.2 DEERS is updated by transactions
from the Uniformed Services’ personnel, finance, medical, and mobilization
management systems, the Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA), and the Centers for Medicare and Medicaid
Services (CMS). DEERS is also accessed and updated by on-line DEERS
client applications, such as the Real-Time Automated Personnel Identification
System (RAPIDS), and interfacing client systems of the Military
Health System (MHS), such as Market/Military Medical Treatment Facility (MTF)
clinical, patient appointing, and Referral Management (RM) systems
and MHS GENESIS/applications. DEERS helps detect and prevent fraud
and abuse in DoD benefits and entitlements distribution.
4.1.3 DEERS provides and receives
updates to enrollment and eligibility verification data from existing DEERS’
applications and interfacing Information Systems (IS), as well as
from other DoD, Uniformed Services, and non-DoD IS, in accordance
with DoD Directive (DoDD) 8000.01. It provides statistical and demographic
data to support DoD and Uniformed Services peacetime and wartime
missions. DEERS maintains casualty identification data on members
of the Uniformed Services, and other personnel as designated by
DoD, to support casualty identification and verification of entitlement
eligibility for surviving family members.
6.0 TRICARE Populations
The TRICARE Program serves a
wide range of beneficiaries holding various statuses throughout
their lifetime. The following information details the populations
covered by the TRICARE benefit. The Government may modify the definition
of the populations as legislation or DHA requires. These populations
include:
6.1 Active Duty Service Members
(ADSMs) and Active Duty Family Members (ADFMs). These may include members
from both the active duty and RC.
Note: The term “active duty” is inclusive
of full-time active duty and RC on orders for 30 calendar days or
more. Plus, the term RC includes both the Reserves and National
Guard (NG).
6.2 Transitional
Assistance Management Program (TAMP) sponsors and family members.
6.3 Selected Reserve members and
their family members.
6.4 Retired
sponsors and family members. Retirees eligible for retirement pay
and their family members as well as Medal of Honor (MOH) recipients.
6.5 Survivors of Service members.
When an active duty sponsor dies (includes activated NG/Reserve members),
spouses and children become “transitional survivors.” As transitional
survivors, surviving family members remain eligible for TRICARE
as “ADFMs.” This means that health plan options and costs will not
change. After three years, the surviving spouse’s coverage will
change to be the same as retired family members. Children remain
covered as active duty family members until they lose eligibility
due to age or other reasons.
6.6 Survivors
of retired Service members. If a sponsor dies after retiring from
active duty (either regular or a medical retirement) their surviving
family members remain eligible for TRICARE with the same health
plan options and costs they had before their sponsor passed away.
6.7 Survivors of non-activated
NG/Reserve members. If an NG or Reserve sponsor dies when not on
active duty, surviving family members are only eligible for continued
TRICARE health benefits if the sponsor was covered by TRICARE Reserve
Select (TRS) or under the TAMP when he or she died.
6.8 Survivors of retired NG or
Reserve members. If a retired NG or Reserve member dies, surviving
family members may qualify for TRICARE benefits if the sponsor was
covered by TRICARE Retired Reserve (TRR) at the time he or she passed
away.
7.0 Identification Schema For Electronic
Data Interchange (EDI)
7.1 Primary and Secondary Identifiers
Person identification in the
DEERS database is established via the two DoD required identifiers;
DoD Identification Number and DoD Benefits Number (DBN). See
Section 3.1 for additional information on
beneficiary identification. The use of these two identifiers allows
for proper exchange between systems and software.
7.2 Beneficiary Identification
7.2.1 DEERS is the definitive system
for person identification for DoD benefits and entitlements. Every beneficiary
in DEERS that is authorized DoD benefits will have a DBN. See also
paragraph 9.3.
7.2.2 A person may have more than
one DBN, stemming from multiple entitlements over time and some
of these instances are described in
paragraph 9.3.
7.3 Patient Identification
7.3.1 As discussed
in
paragraphs 9.3 and
9.4, there are situational
difference between a beneficiary and a patient, which can affect
the data storage/retrieval within the MHS IS.
7.3.2 The contractor
shall use the DoD Identification Number and DBN as identifiers to
support their execution of contracted health care service delivery.
7.4 Person Identification and Secondary
Identification
7.4.1 Should a beneficiary or patient
not show a DBN, the contractor shall use secondary identifiers.
The secondary identifiers are:
• Sponsor’s Social Security Number
(SSN) or DoD Identification Number.
• First three characters of the
last name.
• Date of Birth (DOB).
7.4.2 Any one secondary identifier,
such as the sponsor SSN, could be duplicated across several beneficiaries. Therefore, the
contractor shall positively identify each beneficiary using a DMDC
interface/application and at least two secondary identifiers.
8.0 Types Of Data That DEERS Uses
And Stores
DEERS
stores different categories of information, including Person/Personnel,
Beneficiary, and Health Care Benefit. Each is detailed below.
8.1 Person/Personnel Information
This is basic characteristic
data about individuals, including both affiliations to DoD organizations
or organizations designated by DoD, and affiliations within family
units. Although historical data is available for longitudinal studies and
demographic trend analysis, only current data is required for day-to-day
health care operations.
8.1.1 Person
Data
• Primary (internal) identification
- A mutually agreed-upon internal identifier shared between the
repository and DoD approved external interfacing systems, i.e.,
Electronic Data Interchange Personal Identifier (EDIPI), also known
as the DoD Identification Number.
• Secondary (external) identification
- Name, DOB, and SSN (contractor’s use of SSN is by DEERS and DHA approval
only).
• General characteristics - Sex,
blood type, etc.
• Person-based programs - Organ
donor.
• Family association - Self,
child, etc.
• Contact information - Address,
telephone number.
8.1.2 Personnel
Data
• Personnel category - active
duty, reserve, retired, etc.
• Service or organization - Army,
Navy, DoD civilians, etc.
• Position - Rank.
• Personnel readiness programs
- Deoxyribonucleic Acid (DNA), blood type.
8.2 Beneficiary Information
8.2.1 This information combines the
underlying rules-based system that captures DoDI 1000.13 “Identification
(ID) Cards for Members of the Uniformed Services, Their Dependents,
and Other Eligible Individuals” and other applicable regulations
and procedures with enrollment information, as maintained by the
MHS community. When the beneficiary is eligible for DoD benefits,
they will have a DBN. This data is provided for past, current, and
future periods from the inquiry date, and consists of specific HCDP
information.
8.2.2 Examples of this information
are:
• DoD HCDPs: DoD HCDPs are defined
by DEERS as the methods of providing basic health benefits. These
HCDPs indicate eligibility and/or enrollment for the following.
(examples only); TRICARE Pharmacy (TPharm), TRICARE Prime, TRICARE
Select, TRS, and Continued Health Care Benefit Program (CHCBP).
• Other Government Programs (OGPs): DEERS
defines OGP as programs or plans provided and supported by a US Government
agency other than the DoD.
• Commercial OHI: OHI information
is stored in DEERS to support third party collections.
8.3 Health Care Benefit Information
8.3.1 General Policy
Examples of health care benefit
information that DEERS tracks on a policy level include:
• Enrollment fee accumulation
and fee details (including fee exceptions).
• Deductible accumulation.
8.3.2 Person Related
ExamplesAn
example of health care benefit information that DEERS
tracks on a person level
include: is
enrollment fee waiver information.
• Enrollment fee waiver information.
• OHI.
9.0 Specific DEERS Beneficiary
Roles
9.1 Person Role
9.1.1 An individual
exists within DEERS as a person who may have multiple roles, including
but not limited to: a sponsor, a family member, a beneficiary, and
a patient. This implies the existence of certain attributes tied
to a person that do not normally change as his or her role within
the system changes. For example, a person has a name, DOB, weight,
height, hair color, eye color, and an SSN. These attributes make
up the information associated with the primary person identifier
DoD Identification Number.
9.1.2 Both sponsor
and family member are possible but not mutually exclusive roles
of a person in the DEERS database. The family member role is supported
by person association and condition data that is cross-referenced
to the family member’s sponsor. This family affiliation is associated
with the DBN identifier.
9.2 Sponsor
and Family Member Roles
9.2.1 A sponsor
is any person who, as a direct affiliate or Service member of an
organization within the DoD, is entitled to benefits from the DoD
and who, through that affiliation or membership, may entitle his
or her family members to benefits. Members of non-DoD organizations
whose employees are authorized DoD benefits are also sponsors, and
often accord eligibility to their family members.
9.2.2 Unremarried Former Spouses (URFSs)
who meet eligibility requirements are considered as sponsors and
are identified by their individual identifiers; DoD Identification
Number and DBN. TRICARE entitlement for an URFS is ended with the
existence of an employer sponsored health plan. The contractor can
identify an URFS on the DEERS claims response from their DoD Identification
Number and/or DBN.
9.2.3 Abused family
members also have a distinct member category (reflected in the DBN)
indicating their status.
The presence of OHI does
not remove an abused family member’s entitlement to TRICARE (see 32
CFR 199).
9.2.4 DEERS
defines which relationships to sponsors make individual family members
eligible for benefits. Some restrictions that influence the definition
of a child family member include age, degree of support by the sponsor,
physical disability, and educational status.
9.3
Beneficiary
Role - Multiple Entitlements/Dual Eligibility
9.3.1 DEERS
considers both sponsors and family members as beneficiaries (i.e.,
recipients of DoD benefits). The role of beneficiary is ambiguous,
a person may be entitled to DoD benefits via his or her simultaneous association
to more than one sponsor or by being a sponsor in one family while
being a member of another. An example is a person that is a family
member in two sponsored families at the same time. This situation
occurs when both spouses in a family are sponsors. This condition
is known as multiple entitlements. DEERS supports multiple entitlements
by not only storing persons but any combination of their current
and past associations.
9.3.2 Entitlement
periods may be sequential, such as when a son or daughter of a sponsor
joins a Uniformed Service and he or she becomes a sponsor. Becoming
a sponsor terminates the individual’s previous eligibility for benefits
as a family member.
9.3.3 In some
cases, the roles leading to multiple entitlements may change back
and forth. For example, a child of a married reservist who moves
in and out of active duty assignments may have transitory periods
of entitlement to health care benefits under each sponsor. Each
sponsor in this family has the potential to provide health care
benefits for the family member (child) for various periods of time.
Therefore, this multiple-entitled child will reflect different DBNs
for each sponsorship/situation and the contractor shall ensure they
have the correct DBN for the health care service encounter being
reviewed or executed. The concept of dual eligibility occurs when multiple
entitlements are concurrent. This situation can occur when a sponsor
is both a retired sponsor and a civil servant on overseas assignment.
The beneficiary would have a coverage plan as the retired sponsor
and another coverage plan as the civil servant. Hence, dual eligibility
results when a person is associated with more than one DoD affiliation.
9.3.4 All instances of family membership
and/or sponsorship are stored as the DBN. See
Section 3.1 for additional
information on beneficiary identification. All information about
TRICARE enrollments and policies to and from DEERS and the contractor
shall be done using the DoD Identification Number and/or DBN (as
prescribed by DEERS and DHA). Updates of all other secondary attributes
including SSN (on DEERS/DHA approval), Name, or DOB are exchanged
using the DoD Identification Number and/or DBN (as prescribed by
DEERS and DHA) as the primary means of identification.
9.4
Patient
Role
9.4.1 The patient role results from
an association or interaction between a person and a DoD health
care delivery provider.
Note: Civilian providers contracted
by a TRICARE Program support contractor are considered DoD health
care delivery providers.
9.4.2 It is
important to note that a person is not required to be currently
eligible for DoD benefits to be considered a patient. For example,
the patient may have been a beneficiary in the past but is no longer
eligible for DoD benefits.
9.4.3 In certain
cases, an individual who is not an authorized DoD beneficiary may
be treated in an emergency situation at a DoD Market/MTF, and is
therefore a patient.
9.4.4 Persons on DEERS and on clinical
systems within the DoD are identified in the patient role by the
DoD Identification Number.
9.4.5 The contractor
shall exchange all clinical data by using the DoD Identification
Number.
9.4.6 The contractor shall, in addition
to the DBN, store the DoD Identification Number associated with
each beneficiary on their database.
9.5 Beneficiary
Roles within HCDPs
9.5.1 Subscriber Role
A subscriber is an individual
who is the primary holder of a DoD policy (i.e., the primary holder
of a DoD entitlement) for health care benefits based on his or her
affiliation with the DoD. The subscriber is the sponsor.
9.5.2 Insured Role
An insured is an individual
who is covered by a Uniformed Services health benefits program (i.e.,
an HCDP) for health care coverage. The individual is entitled to
these programs based upon his or her association to a subscriber. A
person may be both a subscriber and an insured. For example, under
TRICARE Prime Individual Coverage for Retired Sponsors and Family
Members, the sponsor is both the subscriber and an insured. However,
other sponsors may be a subscriber and not be an insured. For example,
a sponsor on active duty may be the subscriber for his or her family
members that are insured under TRICARE Prime Family Coverage for
ADFMs.
9.6 Sponsor,
Subscriber, Beneficiary, and Insured Roles
As a sponsor, the person may
also be the subscriber who holds the DoD “policy” for health care
benefits. As a beneficiary, the person may also be an insured who
is covered by a DoD “policy” for health care benefits.
9.7 Family Member, Beneficiary,
and Insured Roles
As a sponsor,
the person may also be the subscriber who holds the DoD policy for
health care benefits. Another person, through associations and relationships,
may be a family member to the sponsor, which implies a role as a beneficiary.
As a beneficiary, the person may also be an insured who is covered
by a DoD policy for health care benefits.
10.0 TYPES OF HCDP PLANS
HCDP plans are methods of providing
pharmacy, dental, and medical benefits. Coverage under these programs may
be either individual or family, depending on the number of beneficiaries
enrolled and beneficiaries’ affiliation to the sponsor, as well
as the program definition.
10.1 There
are two types of plans within DEERS: Assigned and Enrolled.
10.1.1 Assigned plans represent the
base entitlement of a beneficiary (e.g., TRICARE For Life (TFL)
and Pharmacy). Dental plans (e.g., TRICARE Dental Program (TDP),
is done by enrollment and thus not assigned (see
paragraphs 10.1.2 and
10.3).
Assigned plans are based on a sponsor’s affiliation to a DoD organization
(e.g., Army active duty); therefore, when a sponsor’s DoD affiliation
changes (e.g., Army active duty to Army Reserves), a new assigned
plan is created for both the service member and family members.
10.1.2 Enrolled
plans represent another level of benefit into which the beneficiary
has elected enrollment (e.g., TDP, TRICARE Prime, TRICARE Select,
TRS, TRICARE Young Adult (TYA), etc).
10.2 Pharmacy HCDP (Assigned and
Enrolled)
10.2.1 The contractor shall implement
a system that allows changes to pharmacy plans and HCDP plan coverage
codes as legislation and regulation require.
10.2.2 TPharm benefits, assigned only
at this time.
10.2.2.1 The TPharm benefit includes
Market/MTF, mail order, and retail prescription services, medications provided
by physicians and other appropriate clinicians, and pharmaceutical
agents provided in support of home health care.
10.2.2.2 The TPharm Benefits Program is
available to all TRICARE eligible beneficiaries. Eligible beneficiaries need
not enroll in order to use the pharmacy program. The TPharm contractor
shall use DEERS to verify TRICARE eligibility prior to dispensing
pharmaceuticals (or paying any claim) for all beneficiaries. The
TPharm contractor shall
also develop,
maintain and update
Other Health Insurance
(OHI
) (see TRICARE Operations Manual (TOM), Chapter 8, Section 1) and CC&D.
The TPharm contractor shall update the CHCBP CC&D centralized
repository provided by the CHCBP contractor with cost share amounts
using a HIPAA compliant standard transaction set.
10.3
Dental
HCDP (Assigned and Enrolled)
The contractor shall implement
a system that allows changes to dental plans and HCDP plan coverage
codes as legislation and regulation require.
10.3.1 Active
Duty Dental Program (ADDP) (and Associated Remote Active Duty Dental
Program (RADDP))
10.3.1.1 The ADDP provides worldwide dental
coverage to all ADSMs, eligible members of the Reserves and NG,
and those Foreign Force Members (FFMs) eligible for care pursuant
to an approved agreement (e.g., reciprocal health care agreement,
North Atlantic Treaty Organization (NATO) Status of Forces Agreement
(SOFA), Partnership for Peace (PFP) SOFA). The Uniformed Services
include the US Army, the US Navy, the US Air Force, the US Space Force,
the US Marine Corps, the US Coast Guard, the Commissioned Corps
of NOAA, and the Commissioned Corps of USPHS. The Commissioned Corps
of the USPHS is not included in this program. The ADDP contractor shall supplement
care provided in the DoD’s MTF dental centers), and shall provide
care to those ADSMs living in regions without access to MTF dental
centers (i.e., RADDP).
10.3.1.2 The ADDP has two components:
• ADSMs referred from MTF dental
centers for civilian dental care; and
• ADSMs with a duty location and
residence greater than 50 miles from an MTF dental center will be
required to comply with the requirements and limitations of the
RADDP before receiving dental care.
10.3.2 TDP
10.3.2.1 The TDP is a voluntary dental
insurance program that is available to ADFMs, Selected Reserve and Individual
Ready Reserve (IRR) members, and their eligible family members.
10.3.2.2 TDP offers worldwide (CONUS
and OCONUS) coverage to all eligible family members of Uniformed Service
active duty personnel and to members of the Selected Reserve and
IRR and their eligible family members. ADSMs, former spouses, parents,
in-laws, disabled veterans, foreign personnel, and retirees and
their families are not eligible for the TDP.
10.4 Medical HCDP (Assigned and
Enrolled)
The contractor
shall implement a system that allows changes to medical health care
plans and HCDP plan coverage codes as legislation and regulation
require.
10.4.1 Assigned Plans
These plans are the defaults
assigned by DEERS for beneficiaries based on their eligibility status.
Assigned plans do not require enrollment actions.
10.4.1.1 ADSMs - TRICARE Prime, No Primary
Care Manager (PCM) Selected
TRICARE Prime for Active Duty
Sponsors, No PCM Assigned is the default coverage assigned by DEERS
for active duty sponsors. They are entitled to Direct Care (DC),
Civilian Health Care (CHC) under the Supplemental Health Care Program
(SHCP), and pharmacy benefits. This plan is the default for Service
members who are not enrolled in a specific Market/MTF or TRICARE
Prime Remote (TPR). These enrollees are deemed TRICARE Prime but
do not have a PCM.
10.4.1.2 TRICARE
Standard (Prior to January 1, 2018)
The TRICARE Standard HCDP is
the basic coverage assigned by DEERS for eligible beneficiaries
and results when a beneficiary under the age of 65, or 65 and over
but not Medicare eligible, is entitled to both DC and CHC.
10.4.1.3 DC Only
This plan identifies beneficiaries
who are entitled only to DC in Markets/MTFs on a space available
basis or under TRICARE Plus enrollment (see the TOM). This is the
assigned plan for all non-active duty beneficiaries. Examples of this
population include dependent parents and parents-in-law, or Non-ADFMs
(NADFMs) who are eligible for Medicare benefits that do not have
both Medicare Parts A and B, and all non-ADSM beneficiaries that
have not been enrolled in either TRICARE Prime or TRICARE Select.
10.4.1.4 TFL
Beneficiaries eligible for
TRICARE under 10 USC 1086(d) with Medicare Parts A and B are eligible
for the TFL benefit.
10.4.1.5 Care
Plans for DoD Affiliates
DoD affiliates
are a conglomerate category of individuals entitled to DC or CHC
at different levels than the groups defined in other HCDPs. The
most commonly defined DoD Affiliates follow (may not be all-inclusive):
10.4.1.5.1 DC within the CONUS DoD Affiliates
This health care plan is available
for the following population(s):
• NATO Sponsored, PFP, and NATO
non-sponsored Foreign Military and their family members.
• Non-NATO sponsored Foreign
Military and their family members.
10.4.1.5.2 DC for OCONUS DoD Affiliates
This health care plan is available
for the following population(s):
• NATO and non-NATO Foreign Military
and their family members.
• Civilian personnel of DoD and
other Government agencies and their accompanying family members.
• Civilian contractors under
contract to the DoD or the Uniformed Services.
• Uniformed and non-uniformed
full-time personnel of the Red Cross and their family members.
• United Service Organization (USO)
area executives, center directors, and assistant directors and their
family members.
• United Seaman’s Service (USS)
personnel and their accompanying family members.
• Military Sealift Command (MSC)
Civil Service personnel.
10.4.2 Enrolled Plans
See the TRICARE Policy Manual
(TPM) and TOM for types of CONUS and OCONUS plans and eligibility
requirements. They include:
• TRICARE Prime (Service member)
• TRICARE Select
• TPR (Service member)
• TRICARE Prime
• TPRADFM
• TRICARE Plus
• USFHP
• CHCBP
• TRS Program
• TRR Program
• TYA Standard (effective January
1, 2018, TYA Select)
• TYA Prime
10.5 Special Health Care Programs
10.5.1 DEERS supports any special
health care program mandated by the DoD. These special health care programs
are programs into which a beneficiary can enroll or register concurrently
with other assigned or enrolled health care coverage plans to which
they are entitled.
10.5.2 The contractor may also use a
Government furnished web-based general inquiry of DEERS/application to
obtain special program coverage information. See the TPM and the
TOM for details regarding these special programs. They include,
but may not be limited to:
• TRICARE Extended Care Health
Option (ECHO).
• Wounded Ill and Injured (WII).
