1.0 Application
1.1 This section provides functional
guidance for all contractors that interface with the Defense Manpower Data
Center (DMDC)/DEERS in support of their contractual requirements.
1.2 For the purpose of defining
geographical areas, the 50 United States (US) and the District of
Columbia are hereafter referred to as the Continental United States
(CONUS), and all other areas are considered Outside of the Continental
United States (OCONUS).
1.3 The TRICARE Program’s contracts
provide support for specific health care service categories. Each
major area of this section is broken into health care service categories
for specific guidance. Some of the contracted health care service
categories are:
• Pharmacy: TPharm (Mail Order
Pharmacy (MOP) and Retail Pharmacy).
• Dental: TRICARE Dental Program
(TDP), TRICARE Retiree Dental Program (TRDP) (prior to October 31,
2018), Active Duty Dental Program (ADDP), and Remote Active Duty
Dental Program (RADDP).
• Medical: CONUS regional contracts,
OCONUS contract (TRICARE Overseas Program (TOP)), Uniformed Services Family
Health Plan (USFHP) contracts.
• Nurse Advice Lines (NALs):
CONUS and OCONUS NALs.
• Medicare Eligible Claims Processor:
TRICARE Medicare Eligible Program (TMEP): CONUS, Puerto Rico, Guam,
the US Virgin Islands, American Samoa, and the Northern Mariana
Islands.
• Other
Health Insurance (OHI).
1.4 The contractor shall at a minimum,
accomplish the key executable business processes listed below.
1.4.1 For all contractors and contracts:
• Beneficiary identification/authentication;
• Department of Defense (DoD)
entitlements/TRICARE benefits information (see also TRICARE Operations Manual
(TOM) and TRICARE Policy Manual (TPM)); and
• Identification of Other Government
Programs (OGPs) entitlement information, to include Medicare.
1.4.2 When required by specific contract
requirements:
• Enrollment processing;
• Enrollment premiums/fees maintenance
(includes fee exclusion);
• Primary Care Manager (PCM)
assignment/re-assignment;
• Claims processing (with associated
beneficiary contact updates);
• Catastrophic Cap And Deductible
Data (CCDD);.
• OHI Program; and
• Standard Insurance Table (SIT)
Program.
2.0 Contractor
Responsibility
2.1 The contractor
shall understand and execute the DEERS functionality described in
this section.
2.2 The contractor
shall use the technical information and materials provided by DMDC/DEERS
via Defense Health Agency (DHA) Health Plan Operations Support Section
(HPOSS), and then shall consult with DEERS and DHA for any required
clarification.
3.0 DEERS
Operational Environment And Characteristics
The DEERS environment consists
of a Relational Database Management System (RDBMS), rules-based
applications processing DoD entitlements and eligibility, a Transmission
Control Protocol/Internet Protocol (TCP/IP) sockets listener, application
servers that enforce business rules, and web servers.
3.1 Data Sequencing
The contractor shall ensure proper
data sequencing of transactions sent to DEERS, when it applies to
the specific interface involved as DEERS is tasked with resolving
data conflicts from external systems using rules-based applications.
This aids in maintaining data validity and integrity.
3.2 System Maintenance and Downtime
3.2.1 DMDC has routinely scheduled
times for system maintenance and will schedule additional downtimes as
required. The routinely scheduled downtimes are:
• Weekly: 2100 Eastern Saturday
to 0600 Eastern Sunday.
• Daily, if needed: 2355 Eastern
to 0100 Eastern.
3.2.2 When DMDC identifies a telecommunications,
hardware, or software problem outside a scheduled maintenance window
that results in contractor interface downtime two contiguous or
cumulative hours within a business day, DMDC will notify the DHA
of the problem and estimated time of correction. Government/DEERS
will notify DEERS reliant contractors regarding the situation and
provide guidance as appropriate.
3.2.3 The contractor shall, in addition
to the standard problem resolution procedures as referenced in DMDC documentation,
when the contractor experiences DEERS interface downtime in the
DEERS interface for two hours contiguously or cumulatively within
a business day and have not been contacted by DHA, the contractor
shall report the downtime to the DHA representative and shall report
an updated status every two hours until the problem is resolved.
The contractor shall give a final report upon resolution.
3.2.4 The contractor shall submit
a final report upon downtime resolution.
3.3 DEERS provides system-to-system
interfaces, applications, web-based applications, and web-based services.
3.3.1 External Systems - System-To-System
Interfaces
The contractor
shall ensure all system-to-system interfaces to DEERS use TCP/IP,
File Transfer Protocol (FTP), Hypertext Transfer (Transport) Protocol
(HTTP), Secure File Transfer Protocol (SFTP), or Hypertext Transfer (Transport)
Protocol Secure (HTTPS) as specified by DMDC.
3.3.1.1 DEERS uses standard message
protocols where appropriate.
3.3.1.2 DEERS defines the content and
format of messages between DEERS and the contractor.
3.3.1.3 DEERS and the contractor shall
use encryption for all messages that contain privacy level information.
3.3.1.4 DEERS specifies the method
of encryption and authentication for all external interfaces.
3.3.1.5 All notifications are sent
as full database images; they are not transaction-based. The contractor
shall accept and apply the full image sent by DEERS.
3.3.1.6 The contractor shall add the
information, if not present in their system.
3.3.1.7 The contractor shall update
their system, if the information is present, by replacing their
information with the newly received DEERS information. Notifications
are only intended to synchronize the most current information between
DEERS and the contractor. They do not synchronize history between
DEERS and the contractor.
3.3.1.8 DMDC centrally enforces all
business rules for enrollment and enrollment-related events.
3.3.1.9 DEERS is the database of record
for all eligibility, enrollment information, and Catastrophic Cap
& Deductible (CC&D) information.
3.3.1.10 DEERS is the
central repository for OHI information.
3.3.2 Web-Based Application Requirements
and Functionality
3.3.2.1 The contractor shall use the
web browser identified in the technical specification(s) or the
user guide(s) for the specified applications. The web-based applications
are all Government furnished equipment.
3.3.2.2 The contractors shall use the
Government furnished web-based applications for their intended use only.
3.3.2.3 The contractor shall not use
screen scraping, HTML stripping, or any other technology or approach
to manipulate or alter the intended use of the application or the
application architecture.
3.3.2.4 The following functions are
available to the contractor using Government furnished web-based applications,
responsibilities and functions based on contractual requirements.
They are including, but not limited to:
• General Inquiry of DEERS (GIQD)
information used for research and customer service to display demographics, Health
Care Delivery Program (HCDP) eligibility and enrollment. It may
also allow other administrative functions like address updates.
• Enrollment activities, to include
display of enrollment premiums/fees.
• Claims processing eligibility
checks, see also
Sections 5.1 and
5.2.
• CCDD information that supports
research and allows limited updates on the history of CC&Ds
and enrollment fee payment transactions posted to DEERS and stored
on-line (current plus previous five fiscal years).
• PCM assignment, re-assignment,
capacities, and enrolled counts.
4.0 DEERS
Web-Based Applications And Notifications
Applications: The following
is a brief description of the available applications, responsibilities
and functions based on contractual requirements.
4.1 GIQD Information
GIQD information is accessed
through a Government furnished web-based system/application that
is used for research and customer service to display demographics,
coverage and PCM assignment information. It also allows address
updates.
4.2
Government
Furnished Web-Based Enrollment System/Application
4.2.1 The Government furnished web-based
enrollment system/application is a full function Government Furnished
Equipment (GFE) application developed by DMDC to support enrollment-related
activity. The Government furnished web-based enrollment system/application
interacts with both the main DEERS database and the National Enrollment
Database (NED) satellite database to provide enrolling organizations
with eligibility and enrollment information, as well as the capability
to update the NED with new enrollments and modifications to existing
enrollments.
4.2.2 The Government
furnished web-based enrollment system/application meets the Health
Insurance Portability and Accountability Act (HIPAA) and DoD policy
guidelines for a direct data entry application, and is data-content
compliant for enrollment and disenrollment functions.
4.2.3 An enrolling contractor shall
perform enrollment related functions through the Government furnished web-based
enrollment system/application.
4.3 Government Furnished Web-Based
Beneficiary Self-service Enrollment System/Application
4.3.1 The Government furnished web-based
beneficiary self-service enrollment system/application serves all TRICARE
eligible beneficiaries and will support most enrollment programs.
The Government furnished web-based beneficiary self-service enrollment
system/application will interface with contractor systems for the
purposes of accommodating on-line payment of initial enrollment
fees.
4.3.2 DEERS
will pre-populate data elements where possible.
4.3.3 The web application contains
checks for beneficiary eligibility and hard edits requiring the
beneficiary to fulfill established DEERS business rules and enrollment
criteria. Upon completion of the web process, the beneficiary is
informed that the enrollment actions may be reviewed by the appropriate
contractor for accuracy and compliance with established Market or
Military Medical Treatment Facility (MTF) requirements, and that
they will be contacted if additional information is needed. DEERS
will send the contractor a notification(s) informing the contractor
new enrollment information exists for the beneficiary. See also
paragraph 5.0.
5.0
DEERS
System-To-System Notifications
5.1 Government furnished system
information/data notification(s) are sent to the contractor for
various reasons and reflect the most current enrollment information
for a beneficiary.
5.1.1 The contractor
shall accept, apply, and store the data contained in the notification
as sent from DEERS to remain in sync with DEERS.
5.1.2 The contractor shall send notifications
due to new enrollments or updates to existing enrollments.
5.1.3 The contractor shall, if it
does not have the information contained in the notification, add
it to their system.
5.2 The contractor shall apply
all information contained in the notification to their system, if
the contractors already have enrollment information for the beneficiary.
5.3 The contractor shall use the
beneficiaries’ DEERS identifiers, DoD Identification Number or DoD
Benefits Number (DBN), to match the notification to the correct
beneficiary in their system.
• There are also circumstances
where a contractor may receive a notification that does not appear
to be updating the information that the contractor already has for
the enrollee.
• The contractor shall not treat
such notifications as errors, apply the notification.
5.4 The contractor shall acknowledge
all notifications sent by DEERS.
5.5 The contractor shall, if DEERS
does not receive an acknowledgment, continue to send the notification until
acknowledgment is received. The following information details examples
of events that trigger DEERS to send notifications to a contractor.
• Primary notifications resulting
from enrollment actions.
• Unsolicited notifications resulting
from updates to beneficiaries’ status.
6.0
Beneficiary
Identification
6.1 Patient
Identification Merge
6.1.1 See also
Section 3.1 for Beneficiary Identification.
6.1.2 Occasionally, incomplete or
inaccurate person data is provided to DEERS and a single person
may be temporarily assigned two DoD Identification Numbers. When
DEERS identifies this condition, DEERS makes this information available
on-line for all contractors.
6.1.2.1 The contractor shall retrieve
and apply this information on a weekly basis. The merge brings the
data gathered under only one of the DoD Identification Numbers and
discards the other. Although DEERS retains both numbers for an indefinite
period, from that point on the contractor shall use only the one
remaining DoD Identification Number for that person and for subsequent
interaction with DEERS and other Military Health Systems (MHSs).
If there are enrollments under both records being merged that overlap,
the enrolling contractor shall correcting the enrollments.
6.1.2.2 The contractor shall update
the catastrophic cap that has been posted for these records if necessary.
6.2 Partial Match
6.2.1 See also
Section 3.1 for
Beneficiary Identification.
6.2.2 A partial match response may
be returned for any inquiry that does not use a DoD Identification Number
or DBN. Eligibility may result in a partial match situation due
to person ambiguity. There will be a separate listing for each person
or family matching the requested DBN, or Sponsor Social Security
Number (SSN).
6.2.3 The listing
includes the sponsor and family member information needed to determine
the correct beneficiary or family including the DBN(s).
6.2.4 The requesting contractor shall
select which of the multiple listings is correct based on documents
or information at hand. After this selection, the requesting contractor
shall use the additional information returned (e.g., Date Of Birth
(DOB), Name) to resend a DEERS inquiry.
7.0
HCDP
Eligibility For Enrollment
7.1 DEERS
uses rule-based software to determine a beneficiary’s entitlement
to health care benefits. DEERS is the sole repository for these
DoD rules, and no other eligibility determination outside of DEERS
is considered valid. Whenever data about an individual sponsor or
a family member changes, DEERS reapplies these rules. DEERS receives
daily, weekly, and monthly updates to this data, which is why contractors
shall query DEERS for eligibility information before taking action.
This ensures that the individual is still eligible to use the benefits
and that the respective contractor has the most current information.
7.2 A beneficiary who is considered
eligible for DoD benefits (pharmacy, dental, medical) in accordance
with Title 10 United States Code (USC),
32
CFR 199.13,
32 CFR 199.22, and
DoD Instruction (DoDI) 1000.13 is not required to “sign up” for
the TRICARE benefits associated with any DEERS assigned plan. If
an authorized organization inquires about that beneficiary’s eligibility,
DEERS reflects if they are eligible to use the benefits. DEERS derives
the effective and expiration dates for assigned plan coverage from
DoDI 1000.13 rules and supporting information.
7.3 Eligibility for Enrollment
DEERS provides coverage plan
information identifying the period of eligibility and/or enrollment
for the coverage plan. The contractor shall only enroll a beneficiary
into the coverage plans that have an “eligible for” status. When
a sponsor and/or family member are first added, or when sponsor
or member status updates occurs, DEERS determines basic eligibility
for health care benefits in accordance with Title 10 USC,
32
CFR 199.13,
32 CFR 199.22, and
DoDI 1000.13 and then establishes an assigned HCDP coverage plan
together with coverage dates.
8.0
Enrollment
Activities
Enrollment-related
business events include, by contracted health care service category:
8.1 Pharmacy: Enrollment Functionality
No enrollment requirement,
as pharmacy is an assigned HCDP plan.
8.2 Dental: Enrollment Functionality
8.2.1 Eligibility for enrollment
identifies current enrolled coverage plans and eligibility for enrollment
into other coverage plans (as the sponsor and/or beneficiaries role
changes over time). See also
Section 4.1.
Some examples of plan changes over time:
• Service member plans. ADDP,
but can move into other dental plans based on their beneficiary
role change (e.g., TDP, prior to October 31, 2018).
• Active Duty Family Member (ADFM)
plans. TDP, but can move into other dental plans based on their
beneficiary role change (e.g., ADDP, if ADFM becomes an active Service
Member).
• Retirees. No longer supported
by DEERS. Replaced by Federal Employees Dental and Vision Program
(FEDVIP), which is overseen by the Office of Personnel Management
(OPM).
• Retiree dependents. FEDVIP,
but can move into other dental plans based on their beneficiary
role change (e.g., TDP and ADDP, if retiree dependent becomes an
active Service Member).
8.2.2 The contractor shall use new
enrollments for enrolling eligible sponsors and family members into
a HCDP coverage plans or for adding family members to an existing
family policy. Enrollments begin on the date specified by the enrolling
organization and extend through the beneficiaries’ end of eligibility
for the HCDP.
8.2.3 New enrollments
may also perform the following functions:
• Update address, email address,
and/or telephone number.
• Record that the enrollee has
OHI (does not apply to ADDP).
8.2.4 The contractor shall use modifications
of the current enrollment (updates) to change some information in
the current enrollment plan. Modifications of the current enrollment
include the following functions:
• Change enrollment begin date.
• Cancel enrollment/disenrollment.
• Change prior enrollment end
date.
• Change prior enrollment end
reason.
• Request an enrollment card
replacement.
• Add
OHI information for an enrollee (does not apply to ADDP).
8.3 Medical: Enrollment Functionality
8.3.1 Eligibility for enrollment
identifies current enrolled coverage plans and eligibility for enrollment
into other coverage plans (as the sponsor and/or beneficiaries role
changes over time). See also
Section 4.1.
Some examples of plan changes over time:
• Service member plans. TRICARE
Prime for Service member only, but can move into other medical plans
based on their beneficiary role change (e.g., TRICARE Prime Remote
(TPR), TRICARE Standard, TRICARE Select, TRICARE Prime, TRICARE
Reserve Select (TRS), etc.).
• ADFM plans. Beneficiaries must
select a plan or will default to direct-care only. Beneficiaries
are limited to making changes to enrollments only during an annual
enrollment open season or following a Qualifying Life Event (QLE).
Direct Care (DC) only is the default assigned, but can enroll into
other medical plans based on their beneficiary role change (e.g.,
TRICARE Select, TRICARE Prime, TRICARE Plus, TPRADFM, etc.). See
TOM,
Chapter 6, Section 1.
• Retirees and their family members.
Beneficiaries will select a plan or will default to DC only. Beneficiaries
are limited to making changes to enrollments only during an annual
enrollment open season or following a QLE. DC only is the default
assigned, but can elect to enroll into other medical plans (e.g.,
TRICARE Select, TRICARE Prime, TRICARE Plus, etc.). See TOM,
Chapter 6, Section 1.
8.3.2 The contractor shall use new
enrollments for enrolling eligible sponsors and family members into
a HCDP coverage plans or for adding family members to an existing
family policy. Enrollments begin on the date specified by the enrolling
organization and extend through the beneficiaries’ end of eligibility
for the HCDP.
8.3.3 New enrollments
may also perform the following functions:
• Update address, email address,
and/or telephone number.
• PCM selection (if required/allowed
by HCDP).
• Record
that the enrollee has OHI.
8.3.4 The contractor shall use modification
of the current enrollment (updates) to change some information in
the current enrollment plan. Modifications of the current enrollment
include the following functions:
• Change or cancel a PCM selection.
• Transfer enrollment (enrollment
portability) or cancel a transfer.
• Change enrollment begin date.
• Cancel enrollment/disenrollment.
• Change prior enrollment end
date.
• Change prior enrollment end
reason.
• Request an enrollment card
replacement.
• Add
OHI information for an enrollee.
• Request a replacement letter
for PCM change or disenrollment.
8.4 NAL: Enrollment Functionality
No enrollment requirement,
as NAL is a service program that supports all DoD eligible beneficiaries.
8.5 TMEP: Enrollment Functionality
No enrollment requirement,
as TMEP is a claims processing contract that supports all dual eligible
beneficiaries.
9.0 Disenrollments
Activities
9.1 Once actively
enrolled in a coverage plan, an individual or family may voluntarily
disenroll or be involuntarily disenrolled. Voluntary disenrollment
is self-elected, but does not apply to Service Member as they are not
authorized to voluntarily disenroll from mandated medical or dental
plans. Involuntary disenrollment occurs from failure to pay enrollment
fees or from loss of eligibility. Upon disenrollment, DEERS will
notify the beneficiary of the change in or loss of coverage.
9.2 For medical plans only, see
TOM,
Chapter 6, Section 1 for disenrollment rules
and eligibility for re-enrollment.
9.3 When there is a disenrollment,
the appropriate systems are notified, as necessary (see also
paragraph 4.2).
10.0 Beneficiary
Contact Updates And Enrollment Cards
10.1 Contact Updates (Applies to all
Contractors)
Address,
telephone number, and email address updates.
10.1.1 Addresses
10.1.1.1 DEERS receives address information
from a number of source systems. Although most systems only update
the residence address, DEERS actually maintains multiple addresses
for each person.
10.1.1.2 The contractor shall update
the residential and mailing addresses in DEERS, whenever possible.
The contractor shall not update addresses to reflect unit, Market/MTF,
or the contractor addresses unless the information is provided directly
by the beneficiary. The mailing address captured on DEERS is primarily
used to mail the enrollment card and other correspondence. The residential
address is used to determine enrollment jurisdiction at the ZIP
Code level. DEERS uses a commercial product to validate address
information received on-line and from batch sources.
10.1.1.3 The contractor shall process
all mail returned for bad addresses and shall research the address, correct
it on DEERS, and re-mail the correspondence to the beneficiary.
10.1.1.4 The contractor shall update
the Mail Delivery Quality Code (MDQC) in DEERS to prevent future mailings
to that address if the contractor cannot determine a valid address.
10.1.2 Telephone Numbers
10.1.2.1 DEERS has several types of
telephone numbers for a person (e.g., home, work, and cellular).
10.1.2.2 The contractor shall make reasonable
efforts to add or update telephone numbers.
10.1.3 Email Addresses
10.1.3.1 DEERS can store an email address
for each person.
10.1.3.2 The contractor shall make reasonable
efforts to add or update this email address.
10.2 Enrollment Cards and Letter
Production
10.2.1 DEERS sends a notification
directly to the enrollee at the residential mailing address specified
in the enrollment request or via email advising them how to obtain
a copy of their Universal TRICARE Beneficiary Card. New enrollment
cards are automatically generated upon a new enrollment or an enrollment
transfer to a new region (medical only). Beneficiaries are notified
of the availability by email or postcard, unless the enrollment operator
specifies in the Government furnished web-based enrollment system/application
not to generate an enrollment card.
10.2.2 The contractor may request
a replacement notification at any time. DEERS sends a notification
to the contractor indicating the last date an enrollment card notification
was generated for the enrollee.
10.2.3 DEERS also generates letters
to beneficiaries upon changes to their enrollment, and notifies
beneficiary via email or postcard that the letter is available.
10.2.4 The contractor shall not send
additional letters that duplicate those already provided by DEERS.
11.0
Claims
Processing And Database Of Record
11.1 The contractor shall query
DEERS in the process of claims adjudication to determine eligibility
and/or enrollment status for a given period of time. DEERS is the
system of record for eligibility and enrollment information.
11.2 For audit and performance review
purposes, the contractor shall retain a copy of every transaction
and response sent and received for claims adjudication procedures.
The contractor shall retain this information for the period required
by the TOM.
11.3 The contractor
shall not override this data with information from other sources.
The contractor shall obtain Continued Health Care Benefits Program
(CHCBP) CC&D information from the CHCBP contractor.
11.4 The contractor shall deny a
claim (either totally or partially) if the services were received
partially or entirely outside any period of eligibility.
11.5 The contractor
system is the database of record for OHI within the TRICARE Program.
DEERS is the data repository for OHI, using its centralized repository
of OHI information that is reliant on the MHS organizations to verify,
update and add to at every opportunity. The contractor shall use
OHI data received as part of the claims inquiry as part of the claims
adjudication process.
11.6 The contractor
shall, if it has evidence of additional or more current OHI information,
either ‘pend’ the claim or submit the new OHI information to DEERS,
and then reprocess the claim, or develop business processes to simultaneously
accomplish both DEERS OHI update and claims processing using the
newly discovered OHI data. The contractor shall ensure its process
do not interfere with claims processing time lines.
11.5 Although DEERS is not the database
of record for address, it is a centralized repository that is reliant
on numerous organizations to verify, update and add to at every
opportunity. The contractor shall use address data received from
the claims inquiry as part of the claims adjudication process.
11.6 The contractor shall, if it
has evidence of additional or more current address information,
process claims using the additional or more current information
and update DEERS within two business days.
12.0 CCDD
12.1 DEERS stores Enrollment Year
(EY), Fiscal Year (FY), and CY CC&D data in a central repository.
DEERS stores the current and the four prior yearly CC&D totals.
The purpose of the DEERS CCDD repository is to maintain and provide
accurate CC&D amounts, making them universally accessible to
DoD claims processors.
Note: To transition to CY catastrophic
caps as required in NDAA FY 2017, Section 701, the FY 2017 catastrophic cap
covers the period from October 1, 2016 to December 31, 2017.
12.2 The contractor shall use the
CCDD Totals Inquiry to obtain CCDD balances for the year(s) that
correspond to the requested inquiry period.
12.3 The contractor shall inquire
and lock CCDD totals before updating DEERS CCDD amounts.
Note: A catastrophic cap record is
not required for persons who are authorized benefits but are not
on DEERS or eligible for medical benefits, such as prisoners or
Government employees. The purpose of the catastrophic cap is to benefit
those beneficiaries who are eligible for MHS benefits. Those persons
that are authorized benefits who would not under any other circumstances
be eligible, are not subject to catastrophic cap requirements.
13.0 OHI
Program13.1 OHI
identifies non-DoD health insurance held by a beneficiary. The requirements
for OHI are validated by the DHA Uniform Business Office (UBO).
OHI information includes:
• OHI policy and carrier.
• Policyholder.
• Type of coverage provided by
the additional insurance policy.
• Employer information offering
coverage, if applicable.
• Effective period of the policy.
13.2 OHI transactions
allow adding, updating, canceling, or viewing all OHI policy information.
OHI policy updates can accompany enrollments or be performed alone.
OHI information can be added to DEERS or updated on DEERS through
multiple mechanisms.13.2.1 The
contractor shall, at the time of enrollment, determine the existence
of OHI.
13.2.2 The
contractor shall add or update minimal OHI data through the Government
furnished web-based enrollment system/application used by the contractors
to enter enrollments into DEERS.
13.2.3 DEERS will accept
OHI updates from a claims processor through a system-to-system interface.
13.3 The contractor
shall perform an OHI Inquiry before attempting to add or update
an OHI policy. The MHS organizations are reliant on the individual
beneficiary to provide accurate OHI information and DEERS is reliant
on the MHS organizations for the accurate assignment of policy information
to the individual record. DEERS is not the system of record for
OHI information. Performing an OHI Inquiry on a person before adding
or attempting to update an OHI policy helps ensure that the proper
policy is updated based on the most current information or the person.
13.4 Examples of
OHI coverage are:
• Comprehensive Medical Coverage
(plans with multiple coverage types).
• Medical coverage.
• Inpatient coverage.
• Outpatient coverage.
• Pharmacy coverage.
• Dental coverage.
• Long-term care coverage.
• Mental health coverage.
• Vision coverage.
• Partial hospitalization coverage.
• Skilled nursing care coverage.
13.5 The default
coverage will be Comprehensive Medical Coverage unless another of
the above coverages is selected. The indication of Comprehensive
Medical Coverage presumes medical coverage, inpatient coverage, outpatient
coverage, and pharmacy coverage.13.5.1 The medical
contractor shall develop the OHI within 15 calendar days but is
not responsible for pharmacy coverage development.
13.5.2 The pharmacy
contractor(s) shall develop and maintain pharmacy OHI.
13.5.3 The pharmacy
shall develop placeholder policies, regardless of which organization
created the placeholder.
13.5.4 The contractor
shall develop all other placeholder policies, regardless of which
organization created the placeholder.
13.5.5 MHS users will
not normally enter placeholder policies but would develop them if
they created them.
13.5.6 The dental contractor
shall develop and maintain dental OHI.
13.6 A person can
have multiple types of OHI coverage for one policy. For example,
to add an OHI policy that covers medical and vision, the contractor
shall send DEERS two OHI coverage types, one for medical coverage
and one for vision coverage.
13.7 A person can
have multiple OHI policies. Multiple OHI policies may have the same
or different Health Insurance Carriers (HICs), and/or the same or
different OHI policy effective periods.
14.0 SIT
ProgramThe
SIT Program supports the MHS billing and collection process. The
SIT is validated by the DHA UBO through the DoD Verification Point
of Contact (VPOC). The VPOC is ultimately responsible for maintaining
the SIT in DEERS, which is the system of record for SIT information.
The SIT provides uniform billing information for reimbursement of pharmacy,
dental, and medical care costs covered through commercial policies
held by the DoD beneficiary population. MHS personnel use the SIT
to obtain other payer information in a standardized format.
14.1 All systems
identified as trading partners will request an initial full SIT
subscription from DEERS. In addition, holders of the SIT shall subscribe
to DEERS at least daily in order to receive subsequent updates of
the SIT.
14.2 The
SIT Verification Application is used exclusively by the VPOC. The
application queues all SIT transactions entered through the OHI
Maintenance Application for review and verification by the VPOC.
13.0 Medicare Data
13.1 DEERS performs a match with
the Centers for Medicare and Medicaid Services (CMS) to obtain Medicare data
and incorporates the Medicare data into the DEERS database as OGPs
entitlement information. This information includes Medicare Parts
A, B, C, and D eligibility along with the effective dates. The match
includes all potential Medicare-eligible beneficiaries.
13.2 DEERS sends Medicare Parts
A and B information to the TMEP contractor.
13.3 The TMEP contractor shall send
the information to the CMS Fiscal Intermediaries (FIs) for identification
of Medicare eligible beneficiaries during claims adjudication.