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TRICARE Operations Manual 6010.56-M, February 2008
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Table of Contents
Table of Contents
TRICARE Operations Manual 6010.56-M, February 2008, Change 291 (August 30, 2022)
Master TOC
Foreword
Chap 1 -- Administration
Sect 1 -- Organization Of The TRICARE Management Activity (TMA)
Sect 2 -- Contract Administration And Instructions To Managed Care Support Contractors (MCSCs)
Sect 3 -- TRICARE Processing Standards
Sect 4 -- Management
Sect 5 -- Compliance With Federal Statutes
Sect 6 -- Legal Matters
Sect 7 -- 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 Addendum B
Chap 3 -- Financial Administration
Sect 1 -- General
Sect 2 -- Payments To Beneficiaries/Providers
Sect 3 -- Claim Refund And Collection Procedures
Sect 4 -- Lost, Stolen, Stale-Dated, Damaged, Misdirected, Or Returned Payments
Chap 4 -- Provider Certification And Credentialing
Sect 1 -- General
Addendum A -- Figures
Chap 5 -- Provider Networks
Sect 1 -- Network Development
Chap 6 -- Enrollment
Sect 1 -- TRICARE Prime And TRICARE Select Enrollment Processing
Sect 2 -- TRICARE Prime And TRICARE Select 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 Contract (TQMC) Contractor
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 -- TRICARE Prime And TRICARE Select Referrals/Preauthorizations/Authorizations
Sect 6 -- Claim Development
Sect 7 -- Application Of Deductible And Cost-Sharing
Sect 8 -- Explanation Of Benefits (EOB)
Sect 9 -- Duplicate Payment Prevention
Addendum A -- Figures
Chap 9 -- TRICARE Duplicate Claims System - TRICARE Encounter Data (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 (DCS) Displayed Data Fields
Addendum B -- Reason Codes
Addendum C -- Contractor To Contractor Transition Guide
Addendum D -- Report Descriptions And Examples
Addendum E -- Download Files
Chap 10 -- 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 11 -- Beneficiary Education And Support Division (BE&SD)
Sect 1 -- Education Requirements
Sect 2 -- Government Staff And Beneficiary Education
Sect 3 -- Beneficiary, Congressional, Media, Beneficiary Counselling and Assistance Coordinator (BCAC), Debt Collection Assistance Officer (DCAO), And Health Benefit Advisor (HBA) Relations
Sect 4 -- Inquiry Services Department - General
Sect 5 -- Correspondence Control, Processing, And Appraisal
Sect 6 -- Telephone Inquiries
Sect 7 -- Allowable Charge Reviews
Sect 8 -- Grievances And Grievance Processing
Sect 9 -- Collection Actions Against Beneficiaries
Addendum A -- TRICARE Logo
Chap 12 -- 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 -- TRICARE Management Activity (TMA) Appeals
Addendum A -- Figures
Chap 13 -- Program Integrity
Sect 1 -- General
Sect 2 -- Controls, Education, And Conflict Of Interest
Sect 3 -- Case Development And Action
Sect 4 -- Reports
Sect 5 -- Provider Exclusions, Terminations, And Temporary Suspension Of Claim(s) Payments
Sect 6 -- Provider Reinstatements
Addendum A -- Figures
Chap 14 -- Audits, Inspections, And Reports
Sect 1 -- Audits And Inspections
Sect 2 -- Reports And Plans
Sect 3 -- Special Reports
Chap 15 -- Regional Director (RD)/Military Treatment Facility (MTF) and Contractor Interfaces
Sect 1 -- Director of TRICARE Regional Offices (TROs)/Military Treatment Facility (MTF) Commanders and Enhanced Multi-Service Market (eMSM) Interface
Sect 2 -- Resource Sharing
Sect 3 -- Clinical Support Agreement (CSA) Program
Addendum A -- Model Memorandum Of Understanding (MOU)
Chap 16 -- TRICARE Prime Remote (TPR) Program
Sect 1 -- General
Sect 2 -- Health Care Providers And Review Requirements
Sect 3 -- Chap 16 Sect 3 --Enrollment, Beneficiary Education, And Support Services
Sect 4 -- Contractor Responsibilities And Reimbursement
Sect 5 -- Reports And Contractor Reimbursement
Sect 6 -- TRICARE Prime Remote For Active Duty Family Member (TPRADFM) Program
Addendum A -- Points Of Contact (POCs)
Addendum B -- Specified Authorization Staff (SAS) Review: Protocols And Procedures
Chap 17 -- Supplemental Health Care Program (SHCP)
Sect 1 -- General
Sect 2 -- Providers Of Care
Sect 3 -- Contractor Responsibilities
Addendum A -- Points Of Contact (POC)
Addendum B -- Specified Authorization Staff (SAS) Review For Authorization: Protocols And Procedures
Addendum C -- MOA Between DVA And DoD For Processing Payment For DCPE In The IDES
Addendum D -- MOA Between DVA And DoD For Medical Treatment Provided To ADSMs With SCI, TBI, Blindness, Or Polytraumatic Injuries
Chap 18 -- Demonstrations And Pilot Projects
Sect 1 -- General
Sect 2 -- EXPIRED - Department Of Defense (DoD) Cancer Prevention And Treatment Clinical Trials Demonstration
Sect 3 -- EXPIRED - Department Of Defense (DoD) In-Utero Fetal Surgical Repair Of Myelomeningocele Clinical Trial Demonstration
Sect 4 -- EXPIRED - Department Of Defense (DoD) Weight Management Demonstration
Sect 5 -- EXPIRED - Department Of Defense (DoD) Tobacco Cessation Demonstration
Sect 6 -- EXPIRED - Department Of Defense (DoD) Alcohol Abuse Prevention And Education Demonstration
Sect 7 -- EXPIRED - TRICARE Demonstration Project For The State Of Alaska - Critical Access Hospital (CAH) Payment Rates
Sect 8 -- Department Of Defense (DoD) Enhanced Access To Autism Services Demonstration
Sect 9 -- Chap 18 Sect 9 --EXPIRED - Operation Noble Eagle/Operation Enduring Freedom Reservist And National Guard (NG) Benefits Demonstration
Sect 10 -- EXPIRED - Web-Based TRICARE Assistance Program (TRIAP) Demonstration
Sect 11 -- Expired As Of May 4, 2015 - TRICARE South Region United States Coast Guard (USCG) Access To Care (ATC) Demonstration For TRICARE Prime/TRICARE Prime Remote (TPR) Beneficiaries
Sect 12 -- EXPIRED - Department Of Defense (DoD) TRICARE Demonstration Project for the Philippines
Sect 13 -- TRICARE Evaluation Of Centers For Medicare And Medicaid Services (CMS) Approved Laboratory Developed Tests (LDTs) Demonstration Project
Sect 14 -- EXPIRED - Department Of Defense (DoD) Enhanced Access to Patient-Centered Medical Home (PCMH): Demonstration Project for Participation in the Maryland Multi-Payer Patient-Centered Medical Home Program (MMPCMHP)
Sect 15 -- EXPIRED - Department of Defense (DoD) Applied Behavior Analysis (ABA) Pilot For Non-Active Duty Family Members (NADFMs)
Sect 16 -- EXPIRED As Of September 30, 2015 - Pilot Program for Refills of Maintenance Medications for TRICARE For Life (TFL) Beneficiaries through the TRICARE Mail Order Program (TMOP)
Sect 17 -- Defense Health Agency (DHA) Evaluation of Non-United States Food and Drug Administration (FDA) Approved Laboratory Developed Tests (LDTs) Demonstration Project
Sect 18 -- Department Of Defense (DoD) Comprehensive Autism Care Demonstration (ACD)
Sect 19 -- EXPIRED As Of January 1, 2018 - Pilot Program On Urgent Care For TRICARE Prime/TRICARE Prime Remote (TPR) Beneficiaries
Sect 20 -- Demonstration Projects On Value-Based Purchasing (VBP) Initiatives
Sect 21 -- Bundled Payments For Lower Extremity Joint Replacement And Reattachment (LEJR) Surgery And Post-Operative Care Demonstration Program
Sect 22 -- National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017 Value-Based Purchasing (VBP) Initiative Medication Adherence Pilot
Sect 23 -- Department of Defense (DoD) TRICARE Pilot Project To Redirect Uniformed Services Beneficiaries Identified For Inpatient Admission At Civilian Emergency Departments (EDs) For Admission To Designated Military Treatment Facilities (MTFs)
Sect 24 -- Accountable Care Organization (ACO) Demonstration
Sect 25 -- Low Back Pain (LBP) and Physical Therapy (PT) Demonstration
Addendum A -- EXPIRED - Participation Agreement For Corporate Services Provider (CSP)
Addendum B -- Participation Agreement For Comprehensive Autism Care Demonstration Corporate Services Provider (ACSP)/Sole Provider Practices
Addendum C -- Accountable Care Organization (ACO) Demonstration - TRICARE Manuals Exclusion List
Chap 19 -- Health Insurance Portability and Accountability Act (HIPAA) of 1996
Sect 1 -- General
Sect 2 -- Standards For Electronic Transactions
Sect 3 -- Privacy And Security Of Protected Health Information (PHI)
Sect 4 -- Health Insurance Portability And Accountability Act (HIPAA) Standard Unique Health Identifier For Health Care Providers Final Rule
Addendum A -- Additional Supporting Information Pertaining To The Transaction And Code Sets Final Rule
Chap 20 -- TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
Sect 1 -- General
Sect 2 -- Jurisdiction
Sect 3 -- Claims Processing For Dual Eligibles
Sect 4 -- Other Contract Requirements
Sect 5 -- Transition
Chap 21 -- TRICARE Alaska
Sect 1 -- TRICARE Alaska
Chap 22 -- Reserve Component Health Coverage Plans
Sect 1 -- TRICARE Reserve Select (TRS)
Sect 2 -- TRICARE Retired Reserve (TRR)
Addendum A -- Figures
Chap 23 -- TRICARE Pharmacy (TPharm)
Sect 1 -- General
Sect 2 -- Out-Of-Jurisdiction Claims
Sect 3 -- Pharmacy Claims Processing
Sect 4 -- Other Contract Requirements
Sect 5 -- Transition
Chap 24 -- TRICARE Overseas Program (TOP)
Sect 1 -- Administration
Sect 2 -- Records Management
Sect 3 -- Financial Administration
Sect 4 -- Purchased Care Sector Providers
Sect 5 -- TRICARE Overseas Program (TOP) Eligibility And Enrollment
Sect 6 -- Medical Management
Sect 7 -- Ambulance/Aeromedical Evacuation Services
Sect 8 -- Clinical Preventive Services
Sect 9 -- Claims Processing Procedures
Sect 10 -- Active Duty Dental Care In Remote Overseas Locations
Sect 11 -- Beneficiary Education And Support (BE&S)
Sect 12 -- TRICARE Overseas Program (TOP) Point Of Contact (POC) Program
Sect 13 -- Appeals And Hearings
Sect 14 -- Program Integrity
Sect 15 -- Audits, Inspections, Reports, And Plans
Sect 16 -- TRICARE Area Office (TAO) Director/Military Treatment Facility (MTF) And Contractor Interfaces
Sect 17 -- TRICARE Overseas Program (TOP) Prime Program
Sect 18 -- TRICARE Overseas Program (TOP) Prime Remote Program
Sect 19 -- TRICARE Overseas Program (TOP) Standard/Select
Sect 20 -- TRICARE Overseas Program (TOP) TRICARE For Life (TFL)
Sect 21 -- TRICARE Reserve Select (TRS) And TRICARE Retired Reserve (TRR)
Sect 22 -- TRICARE Plus
Sect 23 -- Extended Care Health Option (ECHO)
Sect 24 -- Transitional Assistance Management Program (TAMP)
Sect 25 -- Continued Health Care Benefit Program (CHCBP)
Sect 26 -- TRICARE Overseas Program (TOP) Supplemental Health Care Program (SHCP)
Sect 27 -- Demonstrations
Sect 28 -- Health Insurance Portability and Accountability Act (HIPAA) of 1996
Sect 29 -- TRICARE Overseas Program (TOP) Partnership Program
Sect 30 -- Figures
Sect 31 -- Department Of Defense (DoD) TRICARE Preferred Provider Network (PPN) for the Philippines
Chap 25 -- TRICARE Young Adult (TYA)
Sect 1 -- TRICARE Young Adult (TYA)
Addendum A -- TRICARE Young Adult (TYA) Premiums
Chap 26 -- Continued Health Care Benefit Program (CHCBP)
Sect 1 -- Continued Health Care Benefit Program (CHCBP), Eligibility And Coverage
Addendum A -- Continued Health Care Benefit Program (CHCBP) Premiums
Chap 27 -- Prime Service Area (PSA) Reduction in Fiscal Year (FY) 2014 Policies And Effective Dates
Sect 1 -- Prime Service Area (PSA) Reduction Policies And Effective Dates
Chap 28 -- Prescription Monitoring Program (PMP)
Sect 1 -- General
Sect 2 -- Beneficiary Prescription Monitoring Program (PMP)
Sect 3 -- Provider Prescription Monitoring Program (PMP)
Acronyms And Abbreviations
Definitions
Index
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