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TRICARE Operations Manual 6010.51-M, August 2002
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Table of Contents
Table of Contents
TRICARE Operations Manual 6010.51-M, August 2002, Change 151 (February 12, 2013)
TOC
Foreword
Chap 1 -- Administration
Sect 1 -- Organization Of The TRICARE Management Activity (TMA)
Sect 2 -- Contract Administration And Instructions To Contractors
Sect 3 -- TRICARE Processing Standards
Sect 4 -- Management
Sect 5 -- Compliance With Federal Statutes
Sect 6 -- Legal Matters
Sect 7 -- Fiscal Controls And Access To Records
Sect 8 -- Transitions
Addendum A -- Figures
Chap 2 -- Records Management
Sect 1 -- General
Sect 2 -- Record Series Subject And Description Of Government Records
Sect 3 -- Digital Imaging (Scanned) And Electronic (Born-Digital) Records Process And Formats
Sect 4 -- Electronic Records Disposition, Storage, And Transfer
Sect 5 -- Transferring Records (Federal Records Centers (FRCs) And Transitions)
Sect 6 -- Destruction Of Records
Addendum A -- Paper Record Transfer Procedures
Addendum B -- Electronic Record Transfer Procedures
Chap 3 -- Financial Administration
Sect 1 -- General
Sect 2 -- Financing Mechanisms
Sect 3 -- TED - Voucher Preparation, Check Release Authorization And Payment Integrity
Sect 4 -- Non-TED Vouchers
Sect 5 -- Non-Routine Checks And Vouchers
Sect 6 -- Payments to Beneficiaries/Providers
Sect 7 -- Refund And Collection Procedures
Sect 8 -- Staledated, Voided, Or Returned Checks/EFTs
Sect 9 -- Administrative Contract Line Item Number (CLIN) Payments
Sect 10 -- Reports
Addendum A -- Figures
Chap 4 -- Provider Certification And Credentialing
Sect 1 -- General
Addendum A -- Figures
Addendum B -- Criminal History Background Checks On Individuals In Child Care Services
Chap 5 -- Provider Networks
Sect 1 -- Network Development
Chap 6 -- Enrollment
Sect 1 -- Enrollment Plan
Sect 2 -- Enrollment Portability
Sect 3 -- Split Enrollment
Sect 4 -- TRICARE Plus
Chap 7 -- Utilization And Quality Management
Sect 1 -- Management
Sect 2 -- Preauthorizations
Sect 3 -- Contractor Relationship With The Military Health System (MHS) TRICARE Quality Monitoring Contractor (TQMC)
Sect 4 -- Clinical Quality Management Program (CQMP)
Addendum A -- An Important Message From TRICARE
Addendum B -- Hospital Issued Notices Of Noncoverage
Addendum C -- Hospital Adjustments
Chap 8 -- Claims Processing Procedures
Sect 1 -- General
Sect 2 -- Jurisdiction
Sect 3 -- Claims Filing Deadline
Sect 4 -- Signature Requirements
Sect 5 -- Referrals/Preauthorizations/Authorizations
Sect 6 -- Claim Development
Sect 7 -- Application Of Deductible And Cost-Sharing
Sect 8 -- Explanation Of Benefits (EOBs)
Sect 9 -- Duplicate Payment Prevention
Addendum A -- Figures
Chap 9 -- TRICARE Duplicate Claims System - HCSR Version
Sect 1 -- Overview
Sect 2 -- Quick Start Instructions
Sect 3 -- Duplicate Claims Data
Sect 4 -- Claim Sets And The Claim Set Life Cycle
Sect 5 -- User's Guide
Sect 6 -- Multi-Contractor Claim Sets
Sect 7 -- Mass Change Function For Contract Transitions
Sect 8 -- Reports
Sect 9 -- System Implementation And Operational Requirements
Addendum A -- Duplicate Claims System Displayed Data Fields
Addendum B -- Reason Codes
Addendum C -- Incoming Contractor Support Of Both HCSR And TED Versions Of The TRICARE Duplicate Claims System
Addendum D -- Contractor To Contractor Transition Guide
Addendum E -- Report Descriptions And Examples
Addendum F -- Download Files
Chap 10 -- TRICARE Duplicate Claims System - TED Version
Sect 1 -- Overview
Sect 2 -- Quick Start Instructions
Sect 3 -- Duplicate Claims Data
Sect 4 -- Claim Sets And The Claim Set Life Cycle
Sect 5 -- User's Guide
Sect 6 -- Multi-Contractor Claim Sets
Sect 7 -- Mass Change Function For Contract Transitions
Sect 8 -- Reports
Sect 9 -- System Implementation And Operational Requirements
Addendum A -- Duplicate Claims System Displayed Data Fields
Addendum B -- Reason Codes
Addendum C -- Incoming Contractor Support Of Both HCSR And TED Versions Of The TRICARE Duplicate Claims System
Addendum D -- Contractor To Contractor Transition Guide
Addendum E -- Report Descriptions And Examples
Addendum F -- Download Files
Chap 11 -- Claims Adjustments And Recoupments
Sect 1 -- General
Sect 2 -- Underpayments
Sect 3 -- Overpayments Recovery - Financially Underwritten Funds
Sect 4 -- Overpayments Recovery - Non-Financially Underwritten Funds
Sect 5 -- Third Party Recovery Claims
Addendum A -- Figures
Addendum B -- Listing Of Government Claims Offices
Chap 12 -- Beneficiary And Provider Services
Sect 1 -- Marketing And Education Requirements
Sect 2 -- Beneficiary Education
Sect 3 -- TRICARE Service Centers
Sect 4 -- Beneficiary, Congressional, And Health Benefit Advisor Relations
Sect 5 -- Inquiry Services Department - General
Sect 6 -- Correspondence Control, Processing And Appraisal
Sect 7 -- Telephone Inquiries
Sect 8 -- Allowable Charge Reviews (Includes DRGs)
Sect 9 -- Grievances And Grievance Processing
Sect 10 -- Collection Actions Against Beneficiaries
Addendum A -- TRICARE Logo
Chap 13 -- Appeals And Hearings
Sect 1 -- General
Sect 2 -- Governing Principles
Sect 3 -- Reconsideration Procedures
Sect 4 -- Appeals Of Medical Necessity Determinations
Sect 5 -- Appeal Of Factual (Non-Medical Necessity) Determinations
Sect 6 -- TMA Appeals
Addendum A -- Figures
Chap 14 -- Program Integrity
Sect 1 -- General
Sect 2 -- Case Development And Action
Sect 3 -- Prevention And Detection
Sect 4 -- Evaluation
Sect 5 -- Reporting
Sect 6 -- Provider Exclusions, Suspensions And Terminations
Sect 7 -- Provider Reinstatements
Sect 8 -- Threats Against Contractors
Addendum A -- Figures
Chap 15 -- Audits, Inspections, And Reports
Sect 1 -- Audits And Inspections
Sect 2 -- Weekly Reports To TMA
Sect 3 -- Monthly Reports
Sect 4 -- Monthly Workload and Cycletime Reports
Sect 5 -- Quarterly Reports
Sect 6 -- Annual Reports
Sect 7 -- Special Reports
Addendum A -- Figures
Chap 16 -- Regional Director/MTF And Contractor Interfaces
Sect 1 -- Regional Directors/MTF Commanders Interface
Sect 2 -- Resource Sharing
Sect 3 -- Clinical Support Agreement (CSA) Program
Addendum A -- Model Memorandum Of Understanding
Chap 17 -- TRICARE Prime Remote Program
Sect 1 -- General
Sect 2 -- Health Care Providers And Review Requirements
Sect 3 -- Marketing, Enrollment, And Support Services
Sect 4 -- Contractor Responsibilities And Reimbursement
Sect 5 -- Reports And Contractor Reimbursement
Sect 6 -- TRICARE Prime Remote for Active Duty Family Members Program
Addendum A -- Points Of Contacts
Addendum B -- Active Duty Care Guidelines
Addendum C -- Dental Coverage For Active Duty Service Members (ADSMS) Enrolled In The TRICARE Prime Remote Program
Addendum D -- Service Point Of Contact (SPOC) Review For Fitness For Duty: Protocols And Procedures
Chap 18 -- Civilian Care Referred By MHS Facilities
Sect 1 -- General
Sect 2 -- Providers Of Care
Sect 3 -- Contractor Responsibilities
Sect 4 -- Payment For Contractor Services Rendered
Sect 5 -- Points Of Contact
Addendum A -- Points Of Contact
Addendum B -- Dental Coverage For Active Duty Service Members (ADSMS)
Addendum C -- Definitions, Terms, And Limitations As Applied To The Respite Benefit Under This Section
Addendum D -- Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA) And Department Of Defense (DoD) For Processing Payment For Disability Compensation And Pension Examinations (DCPE) In The Integrated Disability Evaluation System (IDES)
Chap 19 -- Civilian Health Care Of Uniformed Service Members
Sect 1 -- General
Sect 2 -- Providers Of Care
Sect 3 -- Contractor Responsibilities
Sect 4 -- Payment For Contractor Services Rendered
Addendum A -- Points Of Contact
Addendum B -- Service Point Of Contact (SPOC) Review For Authorization: Protocols And Procedures
Addendum C -- Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA) And Department Of Defense (DoD) For Medical Treatment Provided To Active Duty Service Members (ADSMs) With Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blindness, Or Polytraumatic Injuries
Chap 20 -- Demonstrations
Sect 1 -- General
Sect 2 -- Department Of Defense Cancer Prevention And Treatment Clinical Trials Demonstration
Sect 3 -- Department Of Defense In-Utero Fetal Surgical Repair Of Myelomeningocele Clinical Trial Demonstration
Sect 4 -- Operation Noble Eagle/Operation Enduring Freedom Reservist And National Guard Benefits Demonstration
Sect 5 -- Department Of Defense Weight Management Demonstration
Sect 6 -- Department Of Defense Tobacco Cessation Demonstration
Sect 7 -- Department Of Defense Alcohol Abuse Prevention And Education Demonstration
Sect 8 -- TRICARE Demonstration Project For The State Of Alaska - Critical Access Hospital (CAH) Payment Rates
Sect 9 -- Department Of Defense (DoD) Enhanced Access To Autism Services Demonstration
Sect 10 -- Web-Based TRICARE Assistance Program (TRIAP) Demonstration
Sect 11 -- TRICARE South Region United States Coast Guard (USCG) Access To Care (ATC) Demonstration For TRICARE Prime/TRICARE Prime Remote (TPR) Beneficiaries
Sect 12 -- TRICARE Evaluation Of Centers For Medicare And Medicaid Services (CMS) Approved Laboratory Developed Tests (LDTs) Demonstration Project
Addendum A -- Participation Agreement For Autism Demonstration Corporate Services Provider (ACSP)
Chap 21 -- Health Insurance Portability And Accountability Act of 1996 (HIPPA)
Sect 1 -- General
Sect 2 -- Standards For Electronic Transactions
Sect 3 -- Privacy Of Individually Identifiable Health Information
Sect 4 -- Health And Human Services (HHS) Standard Unique Health Identifier For Health Care Providers Final Rule
Addendum A -- HIPAA Definitions
Addendum B -- Additional Supporting Information Pertaining To The Transaction And Code Sets Final Rule
Addendum C -- Reports
Chap 22 -- TRICARE Dual Eligible Fiscal Intermediary Contract
Sect 1 -- General
Sect 2 -- Jurisdiction
Sect 3 -- Claims Processing for Dual Eligibles
Sect 4 -- Other Contract Requirements
Sect 5 -- Transition
Chap 23 -- TRICARE Alaska
Sect 1 -- TRICARE Alaska
Chap 24 -- Reserve Component Health Coverage Plans
Sect 1 -- TRICARE Reserve Select
Sect 2 -- TRICARE Retired Reserve
Addendum A -- Figures
Chap 25 -- TRICARE Young Adult (TYA)
Sect 1 -- TRICARE Young Adult (TYA)
Chap 26 -- Continued Health Care Benefit Program (CHCBP)
Sect 1 -- Continued Health Care Benefit Program (CHCBP), Eligibility And Coverage
Acronyms And Definitions
Acronyms And Definitions
MEPRS Manual Definition Of “Visit”
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