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TRICARE Operations Manual 6010.62-M, April 2021
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TRICARE Program Manuals - 2015 Edition (T-2017)
TRICARE Operations Manual 6010.59-M, April 2015
TRICARE Policy Manual 6010.60-M, April 2015
TRICARE Reimbursement Manual 6010.61-M, April 2015
TRICARE Systems Manual 7950.3-M, April 2015
Other Manuals
32 CFR 199 (DHA Version), December 2016
DoD Women, Infants, and Children (WIC) Overseas Program Policy Manual, July 2017
Duplicate Claims System (DCS) User Guide, June 2017
10 USC 55 (DHA Version), January 2007
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TRICARE Operations Manual 6010.59-M, April 2015
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Table of Contents
Table of Contents
TRICARE Operations Manual 6010.59-M, April 2015, Change 132 (December 22, 2023)
Foreword
Chap 1 -- Administration
Sect 1 -- Organization Of The Defense Health Agency (DHA)
Sect 2 -- Contract Administration And Instructions
Sect 3 -- TRICARE Processing Standards
Sect 4 -- Management
Sect 5 -- Compliance With Federal Statutes
Sect 6 -- Legal Matters
Chap 2 -- Transitions
Sect 1 -- Management and Administration
Sect 2 -- Systems Development
Sect 3 -- Critical Processes (CPs) - Provider Networks
Sect 4 -- Critical Processes (CPs) - Enrollment
Sect 5 -- Critical Processes (CPs) - Customer Service
Sect 6 -- Critical Processes (CPs) - Management - Markets/Military Medical Treatment Facilities (MTFs)
Sect 7 -- Critical Processes (CPs) - Referral Management
Sect 8 -- Critical Processes (CPs) - Claims Processing
Sect 9 -- Critical Processes (CPs) - Medical Management
Sect 10 -- Other Requirements
Chap 3 -- Financial Administration
Sect 1 -- General
Sect 2 -- Payments To Beneficiaries/Providers
Sect 3 -- Claim Refund And Collection Procedures
Sect 4 -- Stale Dated, 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 -- 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 -- Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Sect 1 -- Medical Management/Utilization Management (MM/UM)
Sect 2 -- Preauthorizations
Sect 3 -- Contractor Relationships 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 -- Records Management (RM)
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
Addendum A -- Paper Record Transfer Procedures
Addendum B -- Electronic Record Transfer Procedures
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 -- Communications and Customer Service (C and CS)
Sect 1 -- Education Requirements
Sect 2 -- Government Staff And Beneficiary Education
Sect 3 -- Beneficiary, Congressional, Media, Beneficiary Counselling and Assistance Coordinator (BCAC), And Debt Collection Assistance Officer (DCAO) 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 -- Defense Health Agency (DHA) Appeals
Addendum A -- Figures
Chap 13 -- Program Integrity
Sect 1 -- General
Sect 2 -- Controls, Education, and Conflicts 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 -- Reports
Sect 1 -- Contract Data Requirements Lists (CDRLs), Plans And Access
Sect 2 -- Special Reports
Chap 15 -- TRICARE Regional Offices (TROs)/Market/Military Medical Treatment Facility (MTF) and Contractor Interfaces
Sect 1 -- Director, TRICARE Regional Offices (TROs), Market/Military Medical Treatment Facility (MTF) Director, and Contractor Interface
Sect 2 -- Resource Sharing
Sect 3 -- Clinical Support Agreement (CSA) Program
Addendum A -- Memorandum Of Understanding (MOU) - Example
Chap 16 -- TRICARE Prime Remote (TPR) Program
Sect 1 -- General
Sect 2 -- Health Care Providers And Review Requirements
Sect 3 -- Enrollment, Beneficiary Education, And Support Services
Sect 4 -- Contractor Responsibilities And Reimbursement
Sect 5 -- Reports
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 Service Members With SCI, TBI, Blindness, Or Polytraumatic Injuries
Chap 18 -- Demonstrations And Pilot Projects (Except Value-Based Initiatives)
Sect 1 -- General
Sect 2 -- DoD Enhanced Access to PCMH: Demonstration Project for Participation in the Maryland Multi-Payer Patient-Centered Medical Home Program (MMPCMHP)
Sect 3 -- Defense Health Agency (DHA) Evaluation Of Non-United States (U.S.) Food and Drug Administration (FDA) Approved Laboratory Developed Tests (LDTs) Demonstration Project
Sect 4 -- Department Of Defense (DoD) Comprehensive Autism Care Demonstration (ACD)
Sect 5 -- EXPIRED As Of January 1, 2018 - Pilot Program On Urgent Care For TRICARE Prime/TRICARE Prime Remote (TPR) Beneficiaries
Sect 6 -- EXPIRED - Department Of Defense (DoD) TRICARE Demonstration Project for the Philippines
Sect 7 -- 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)/Enhanced Multi-Service Markets (eMSMs)
Sect 8 -- Intensive Outpatient Program (IOP) Pilot To Address Behavioral Health Sequelae of Sexual Trauma
Sect 9 -- Low Back Pain (LBP) and Physical Therapy (PT) Demonstration
Sect 10 -- Referral And Appointing Center (RAC) Pilot
Sect 11 -- Childbirth And Breastfeeding Support Demonstration
Sect 12 -- Childbirth And Breastfeeding Support Demonstration - Special Policies for Overseas Implementation
Addendum A -- Participation Agreement For Comprehensive Autism Care Demonstration Corporate Services Provider (ACSP)/Sole Provider Practices
Addendum B -- Participation Agreement For Intensive Outpatient Program (IOP) Pilot To Address Health Sequelae of Sexual Trauma
Chap 19 -- Health Insurance Portability and Accountability Act (HIPAA) of 1996
Sect 1 -- General
Sect 2 -- Health Insurance Portability And Accountability Act (HIPAA) 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
Chap 20 -- TRICARE Medicare Eligible Program (TMEP)
Sect 1 -- Administration
Sect 2 -- TRICARE Medicare Eligible Program (TMEP) Transition
Sect 3 -- Financial Administration
Sect 4 -- Provider Certifications And Credentialing
Sect 5 -- Provider Networks
Sect 6 -- Enrollment
Sect 7 -- Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Sect 8 -- Claims Processing Procedures
Sect 9 -- Records Management
Sect 10 -- Claims Adjustments And Recoupments
Sect 11 -- Communications And Customer Service (C and CS)
Sect 12 -- Appeals And Hearings
Sect 13 -- Program Integrity
Sect 14 -- Reports
Sect 15 -- Markets/Military Treatment Facilities And Contractor Interfaces
Sect 16 -- TRICARE Prime Remote (TPR) Program
Sect 17 -- Supplemental Health Care Program (SHCP)
Sect 18 -- Demonstrations And Pilot Projects (Except Value-Based Initiatives)
Sect 19 -- Health Insurance Portability and Accountability Act (HIPAA)
Sect 20 -- Other TMEP Requirements
Sect 21 -- TRICARE Alaska
Sect 22 -- Reserve Component Health Coverage Plans
Sect 23 -- TRICARE Pharmacy
Sect 24 -- TRICARE Overseas Program (TOP)
Sect 25 -- TRICARE Young Adult (TYA) Program
Sect 26 -- Continued Health Care Benefits Program (CHCBP)
Sect 27 -- Prime Service Area Reduction Policies And Effective Dates
Sect 28 -- Prescription Monitoring Program (PMP)
Sect 29 -- Value-Based Programs, Pilots And Demonstrations
Chap 21 -- TRICARE Alaska
Sect 1 -- TRICARE Alaska
Sect 2 -- Alaska Internal Partnership Program
Addendum A -- TRICARE Internal Alaska Partnership Program
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 (MM)
Sect 7 -- Ambulance/Aeromedical Evacuation Services
Sect 8 -- Clinical Preventive Services
Sect 9 -- Claims Processing Procedures
Sect 10 -- Communications and Customer Service (C and CS)
Sect 11 -- TRICARE Overseas Program (TOP) Point Of Contact (POC) Program
Sect 12 -- Appeals And Hearings
Sect 13 -- Program Integrity
Sect 14 -- Audits, Inspections, Reports, And Plans
Sect 15 -- TRICARE Area Office (TAO) Executive Director/Military Medical Treatment Facility (MTF) And Contractor Interfaces
Sect 16 -- TRICARE Overseas Program (TOP) Prime Program
Sect 17 -- TRICARE Overseas Program (TOP) Prime Remote Program
Sect 18 -- TRICARE Overseas Program (TOP) Select
Sect 19 -- TRICARE Overseas Program (TOP) TRICARE For Life (TFL)
Sect 20 -- TRICARE Reserve Select (TRS) And TRICARE Retired Reserve (TRR)
Sect 21 -- TRICARE Plus
Sect 22 -- Extended Care Health Option (ECHO)
Sect 23 -- Transitional Assistance Management Program (TAMP)
Sect 24 -- Continued Health Care Benefit Program (CHCBP)
Sect 25 -- TRICARE Overseas Program (TOP) Supplemental Health Care Program (SHCP)
Sect 26 -- Value-Based Programs (VBPs), Pilots, And Demonstrations
Sect 27 -- Health Insurance Portability and Accountability Act (HIPAA) of 1996
Sect 28 -- 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 -- Eligibility And Coverage
Addendum A -- Continued Health Care Benefit Program (CHCBP) Premiums
Chap 27 -- Prime Service Area (PSA) Reduction 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)
Chap 29 -- Value-Based Programs (VBPs), Pilots, And Demonstrations
Sect 1 -- General
Sect 2 -- National Defense Authorization Act (NDAA) for Fiscal Year 2016 (NDAA FY 2016): Bundled Payments For Lower Extremity Joint Replacement And Reattachment (LEJR) Surgery And Post-Operative Care Demonstration Program
Sect 3 -- National Defense Authorization Act (NDAA) for Fiscal Year 2017 (NDAA FY 2017): Medication Adherence Pilot Program
Sect 4 -- Pilot Program on Performance-Based Maternity Payments (P-BMP)
Sect 5 -- Accountable Care Organization (ACO) Demonstration
Sect 6 -- Home Health Value Based Purchasing (HHVBP) Demonstration
Addendum A -- Performance-Based Maternity Payments (P-BMP) Data Elements
Addendum B -- The Performance-Based Maternity Payments (P-BMP) Incentive Calculations Methodology
Addendum C -- Medicare Severity-Diagnosis Related Groups (MS-DRGs) Available in Fiscal Year (FY) 2018
Addendum D -- Accountable Care Organization (ACO) Demonstration - TRICARE Manuals Exclusion List
Chap A -- Definitions
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