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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 96 (March 22, 2013)
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 -- Staledated, Voided, Or Returned Checks
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 -- Enrollment Processing
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 (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 -- Contractor To Contractor Transition Guide
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 And Provider Services (BPS)
Sect 1 -- Education Requirements
Sect 2 -- Government Staff And Beneficiary Education
Sect 3 -- TRICARE Service Centers (TSCs)
Sect 4 -- Beneficiary, Congressional, Media, Beneficiary Counselling and Assistance Coordinator (BCAC), Debt Collection Assistance Officer (DCAO), And Health Benefit Advisor (HBA) Relations
Sect 5 -- Inquiry Services Department - General
Sect 6 -- Correspondence Control, Processing, And Appraisal
Sect 7 -- Telephone Inquiries
Sect 8 -- Allowable Charge Reviews
Sect 9 -- Grievances And Grievance Processing
Sect 10 -- 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 -- 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 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 -- Regional Directors (RDs)/Military Treatment Facility (MTF) Commanders 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 -- 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 Member (TPRADFM) Program
Addendum A -- Points Of Contact (POCs)
Addendum B -- Active Duty Care Guidelines
Addendum C -- Service Point Of Contact (SPOC) Review For Fitness For Duty: 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 -- Service Point Of Contact (SPOC) 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
Sect 1 -- General
Sect 2 -- Department Of Defense (DoD) Cancer Prevention And Treatment Clinical Trials Demonstration
Sect 3 -- Department Of Defense (DoD) In-Utero Fetal Surgical Repair Of Myelomeningocele Clinical Trial Demonstration
Sect 4 -- Department Of Defense (DoD) Weight Management Demonstration
Sect 5 -- Department Of Defense (DoD) Tobacco Cessation Demonstration
Sect 6 -- Department Of Defense (DoD) Alcohol Abuse Prevention And Education Demonstration
Sect 7 -- 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 -- Operation Noble Eagle/Operation Enduring Freedom Reservist And National Guard (NG) Benefits 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 -- 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
Addendum A -- Participation Agreement For Corporate Services Provider (CSP)
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 Individually Identifiable Health Information (IIHI)
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
Addendum B -- Reports
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
Sect 6 -- Audits, Inspections, And Reports
Chap 21 -- TRICARE Alaska
Sect 1 -- TRICARE Alaska
Chap 22 -- TRICARE Reserve Select (TRS)
Sect 1 -- TRICARE Reserve Select (TRS)
Sect 2 -- TRICARE Retired Reserve (TRR)
Chap 22 -- Figures Addendum A
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
Addendum A -- Covered Specialty Pharmaceuticals
Chap 24 -- TRICARE Overseas Program (TOP)
Sect 1 -- Administration
Sect 2 -- Records Management
Sect 3 -- Financial Administration
Sect 4 -- Host Nation 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 (Prime/Standard)
Sect 9 -- Claims Processing Procedures
Sect 10 -- Active Duty Dental Care In Remote Overseas Locations
Sect 11 -- Beneficiary Education And Support Division (BE&SD)
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
Sect 20 -- TRICARE Overseas Program (TOP) TRICARE For Life (TFL)
Sect 21 -- TRICARE Reserve Select (TRS)
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 -- Civilian Health Care (CHC) Of Uniformed Service Members
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
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 Abbreviations
Definitions
Index
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