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TRICARE Systems Manual 7950.3-M, April 1, 2015
Defense Enrollment Eligibility Reporting System (DEERS)
Chapter 3
Section 5.2
Defense Enrollment Eligibility Reporting System (DEERS) Functions In Support Of The TRICARE Active Duty Dental Program (ADDP)
Revision:  C-30, September 27, 2019
1.0  Introduction
This section provides TRICARE ADDP and Remote Active Duty Dental Program (RADDP) specific/unique guidance that was not discussed or described elsewhere in the TSM.
2.0  Guidance
2.1  Health Care Delivery Program (HCDP) Eligibility and Enrollment
See Section 4.2, paragraphs 6.0 and 7.0. The contractor shall contact the DHA Dental Service Point of Contact (DSPOC) when they do not have proper documentation, such as military orders, to verify eligibility for those individuals who are indicated on DEERS as not eligible (e.g., not on active duty but who may have a Line of Duty (LOD) condition or a Foreign Force Member (FFM)). DSPOCs are the final decision authority for eligible Active Duty Service Members (ADSMs).
2.1.1  ADDP Eligibility
2.1.1.1  All Service members of the Uniformed Services (excluding Public Health Service (PHS), who are on continuous active duty orders for more than 30 days are eligible to receive ADDP dental coverage, subject to the requirements and limitations provided in the ADDP.
2.1.1.2  Who have a duty location and residence greater than 50 miles from a Dental Treatment Facility (DTF) are automatically eligible for RADDP benefits.
2.1.1.3  National Guard (NG)/Reserve members that serve on continuous active duty for more than 30 days are considered Service members. NG members are only TRICARE eligible if on federally funded orders for more than 30 days. If the NG member is on state orders, they are not eligible for TRICARE. The NG will determine if the orders qualify for TRICARE.
2.1.1.4  Reserve Component (RC) members (which includes NG) who are issued delayed-effective-date active duty orders for more than 30 days in support of a contingency operation are eligible for ADDP as defined in Department of Defense Instruction (DoDI) 7730.54.
2.1.1.5  A Line of Duty investigation is for RC members who incur or aggravate an injury, illness or disease while serving on active duty for 30 days or less as defined in DoDI 1241.2.
2.1.1.6  Foreign Force Members (FFMs) who are on temporary or permanent assignment in the ADDP geographic regions may be eligible to participate in the ADDP 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).
2.1.2  Enrollment Requirements (Unique)
2.1.2.1  Service members whose permanent duty location and/or residence is less than 50 miles from a DTF are automatically eligible for ADDP benefits and do not require enrollment.
2.1.2.2  Within the ADDP there are three types of Dental Coverage Plans that require enrollment. The RADDP plans are:
2.1.2.2.1  RADDP For Service Members Enrolled In TRICARE Prime Remote (TPR)
Eligibility to enroll in medical TPR requires that the Service member’s permanent duty location and residence be more than 50 miles from a Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) or designated clinic. DEERS will systematically enroll, disenroll, and maintain enrollments into the RADDP for Service members enrolled in TPR coverage plan based on the Service member’s medical TPR enrollment. Service members living in a TPR location must enroll in a medical TPR coverage plan to be enrolled in RADDP.
2.1.2.2.2  RADDP For Service Members Not Eligible For TPR
An Service member whose permanent duty location and/or residence is less than 50 miles from an MTF/eMSM or designated clinic is not eligible to enroll in TPR. If the Service member’s permanent duty location and residence is within 50 miles of an MTF/eMSM but more than 50 miles from a DTF, he or she will not be automatically enrolled into RADDP, but the ADDP contractor will be able to manually enroll the Service member into the RADDP. The ADDP contractor will be required to verify the coverage plan, and correct the enrollment begin date if it is different than the Government furnished web-based enrollment system/application default.
2.1.2.2.3  Automatic Enrollment in RADDP For National Oceanic And Atmospheric Administration (NOAA)
All NOAA active duty Service members will be eligible for RADDP. DEERS will systematically enroll, disenroll, and maintain enrollments into the RADDP for NOAA active duty Service members.
2.1.2.3  When enrolling an Service member into RADDP, the Government furnished web-based enrollment system/application will require the effective dates of the enrollment. Enrollments may be established with past effective dates, the current date, or future effective dates. The enrollment period cannot exceed the end of eligibility, nor precede the eligibility begin date. DEERS will ensure that the coverage plan sent with an enrollment is valid based upon the assigned eligibility.
2.2  Disenrollment Activities
2.2.1  Disenrollment actions are used to terminate an enrollment. Disenrollments will occur when there is a loss of eligibility, or when the Service member reports he or she no longer lives and/or works within a DTF non-catchment area. Upon disenrollment, DEERS will notify the Service member of the change in or loss of coverage.
2.2.2  Disenrollment - Loss Of Eligibility
A loss of eligibility refers to any loss or change in eligibility for:
•  DoD health care benefits according to the current DoDI 1000.13; or
•  A medical TPR coverage plan. Under these circumstances, DEERS will terminate any current enrollment or enrollment effective at the end of the month in which eligibility ends.
Example:  When the eligibility of a Service member enrolled in TPR and RADDP terminates due to separation from service, the eligibility for RADDP will be terminated, resulting in a disenrollment by DEERS. The termination of coverage will affect the insured’s current and/or future enrollment in a HCDP.
2.2.3  Disenrollment Due to No Longer Living or Working Within RADDP Eligible Location
When a Service member enrolled in a RADDP coverage plan for Service members living and working within 50 miles of an MTF/eMSM without a DTF, moves within 50 miles of a DTF, the work or home address will be updated. The ADDP contractor shall perform a disenrollment from the RADDP coverage plan if applicable.
Note:  Changing an Service member’s residence address will not cause an automatic disenrollment. DEERS will not disenroll an Service member from RADDP based on an address update.
2.3  Claims Processing [Unique To ADDP/RADDP]
2.3.1  The DEERS Claims Service (DCS) is used to determine benefit coverage for a given period. Contractors must use the DCS for all claims processing.
2.3.2  DCS Inquiry For Claims
Contractors shall install a prepayment eligibility verification system into its TRICARE operation that results in a query against DEERS for TRICARE claims and adjustments. The query should be conducted early in the claims processing cycle to assure extensive development/claims review is not done on claims for ineligible beneficiaries. The DCS Inquiry for Claims supports business events associated with data for processing dental claims. This inquiry may also be used for general customer service requests, beneficiary self-service purposes, or for predeterminations as long as there is prior coordination with Defense Health Agency (DHA) and Defense Manpower Data Center (DMDC).
2.4  Key Support POCs
A list of key DMDC Support Office (DSO) personnel and the Joint Uniformed Services Personnel Advisory Committee (JUSPAC) and the Joint Uniformed Services Medical Advisory Committee (JUSMAC) Members is provided by the DHA. These individuals are designated by the DHA to assist DoD beneficiaries on issues regarding claims payments. In extreme cases the DSO may direct the claims processor to override the DEERS information; however, in most cases the DSO is able to correct the database to allow the claim to be reprocessed appropriately. The procedure contractors shall use to request data corrections is in Section 4.3.
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