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TRICARE Program Manuals - 2021 Edition (T-5)
TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Policy Manual 6010.63-M, April 2021
TRICARE Reimbursement Manual 6010.64-M, April 2021
TRICARE Systems Manual 7950.4-M, April 2021
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 6010.62-M, April 2021
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Table of Contents
Table of Contents
TRICARE Operations Manual 6010.62-M, April 2021, Baseline (December 5, 2022)
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 - Records Management
Sect 7 -- Critical Processes (CPs) - Referral Management (RM)
Sect 8 -- Critical Processes (CPs) - Claims Processing
Sect 9 -- Critical Processes (CPs) - Clinical Operations
Sect 10 -- Other Requirements
Chap 3 -- Financial Administration
Sect 1 -- General
Sect 2 -- Payments To Beneficiaries And Providers
Sect 3 -- Claim Refund And Collection Procedures
Sect 4 -- Lost, Stolen, Stale-Dated, Damaged, Misdirected, Or Returned Payments
Sect 5 -- Quarterly and Annual Claims Payment and Data Accuracy Reviews
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 Enrollment Processing
Sect 2 -- TRICARE Prime And TRICARE Select Enrollment Portability
Sect 3 -- Split Enrollment
Sect 4 -- TRICARE Plus
Chap 7 -- Clinical Operations
Sect 1 -- Medical Management (MM)
Sect 2 -- Case Management (CM)
Sect 3 -- Population Health (PH) Care
Sect 4 -- Utilization Management (UM)
Sect 5 -- Referral Management (RM)
Sect 6 -- Clinical Quality Management Program (CQMP)
Sect 7 -- Contractor Relationships With The Military Health System (MHS) TRICARE Quality Monitoring Contract (TQMC) Contractor
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 -- File Numbers, Subject, and Description of Government Records
Sect 3 -- Digital Imaging (Scanned) And Electronic (Born-Digital) Records Process And Formats
Sect 4 -- Electronic Records Disposition and Storage
Sect 5 -- Destruction of Records
Addendum A -- Paper Record Transfer Procedures
Addendum B -- Electronic Record Transfer Procedures
Chap 10 -- Claims Adjustments And Recoupments
Sect 1 -- General
Sect 2 -- Overpayments Recovery - Financially Underwritten Funds
Sect 3 -- Overpayments Recovery - Non-Financially Underwritten Funds
Sect 4 -- 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 Counseling 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 -- Defense Health Agency (DHA) Communications
Sect 7 -- Telephone Inquiries
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 -- Anti-Fraud Controls And Contractor Actions
Sect 3 -- Statistical Sampling And Audits
Sect 4 -- Case Development
Sect 5 -- Administrative Remedies And Actions (Provider Exclusions, Terminations, Suspension Of Claims Processing, Reinstatement, Conflict Of Interest, Reporting Refunds, Self-Disclosure)
Addendum A -- Figures
Chap 14 -- Reporting Requirements
Sect 1 -- Reporting Requirements
Addendum A -- Figures
Chap 15 -- Market Directors/Military Medical Treatment Facility (MTF) Directors, and Contractor Interfaces
Sect 1 -- Market Directors, Military Medical Treatment Facility (MTF) Directors, and Contractor Interfaces
Sect 2 -- Resource Sharing
Sect 3 -- Clinical Support Agreement (CSA) Program
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)
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 -- Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA/VHA) And Department Of Defense (DoD) For Processing Payment For Disability Compensation And Pension Examinations (DCPE) In The Integrated Disability Evaluation System (IDES)
Addendum C -- Memorandum Of Agreement (MOA) Between Department Of Veterans Affairs (DVA/VHA) And Department Of Defense (DoD) For Medical Treatment Provided To Service Members With Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blindness, Or Polytraumatic Injuries
Chap 18 -- Demonstrations, Pilot Projects, and Value-Based Initiatives
Sect 1 -- General
Sect 2 -- Defense Health Agency (DHA) Evaluation Of Non-United States (US) Food and Drug Administration (FDA) Approved Laboratory Developed Tests (LDTs) Demonstration Project
Sect 3 -- Department Of Defense (DoD) Comprehensive Autism Care Demonstration (ACD)
Sect 4 -- Expired - Department of Defense (DoD) Hearing Center of Excellence (HCE)/Department of Veteran Affairs (VA) Hearing Aid Procurement Model (HAPM) Expansion Demonstration
Sect 5 -- National Defense Authorization Act for Fiscal Year 2017 (NDAA FY 2017): Medication Adherence Pilot Program
Sect 6 -- Pilot Program on Performance-Based Maternity Payments (P-BMP)
Sect 7 -- Home Health Value-Based Purchasing (HHVBP) Demonstration
Sect 8 -- Low Back Pain (LBP) and Physical Therapy (PT) Demonstration
Sect 9 -- Referral And Appointing Center (RAC) Pilot
Addendum A -- Participation Agreement For Comprehensive Autism Care Demonstration (ACD) Corporate Services Provider (ACSP)/Sole Provider Practices
Addendum B -- Performance-Based Maternity Payments (P-BMP) Data Elements
Addendum C -- The Performance-Based Maternity Payments (P-BMP) Incentive Calculations Methodology
Addendum D -- Medicare Severity-Diagnosis Related Groups (MS-DRGs) Available in Fiscal Year (FY) 2018
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 (HCPs) 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 Medical Treatment Facilities (MTF) 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 (RC) Health Coverage Plans
Sect 23 -- TRICARE Pharmacy (TPharm)
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 (PSA) 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
Chap 22 -- Reserve Component (RC) Health Coverage Plans
Sect 1 -- TRICARE Reserve Select (TRS) And 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 -- Private Sector Care Providers
Sect 5 -- 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 -- Active Duty Dental Care In Remote Overseas Locations
Sect 11 -- Communications and Customer Service (C and CS)
Sect 12 -- 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 Medical Treatment Facility (MTF) And Contractor Interfaces
Sect 17 -- TOP Prime Program
Sect 18 -- TOP Prime Remote Program
Sect 19 -- TOP Select
Sect 20 -- 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 -- TOP Supplemental Health Care Program (SHCP)
Sect 27 -- Value-Based Programs (VBPs), Pilots, And Demonstrations
Sect 28 -- Health Insurance Portability And Accountability Act (HIPAA) Of 1996
Sect 29 -- 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 -- Telehealth
Sect 1 -- Telehealth Services
Chap 28 -- Prescription Monitoring Program (PMP)
Sect 1 -- General
Sect 2 -- Beneficiary Prescription Monitoring Program (PMP)
Sect 3 -- Provider Prescription Monitoring Program (PMP)
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