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TRICARE Operations Manual 6010.62-M, April 2021, Change 5001 (Jun 23, 2021)
Published Change
Revisions As A Result of Industry Questions
Published Date: June 23, 2021
CONREQ:None
Implementation Date:June 23, 2021
This change is made in conjunction with TRICARE Systems Manual 7950.4-M, April 2021, Change 5001.
Summary of Changes:
CHAPTER 1
  1. Section 3. Paragraph 5.2.1. In the first and third bullets change “within 24 hours” to “one business day.” Paragraph 5.2.2. Insert “The contractor shall complete a 100% audit of MTF Prime referrals and for Network Prime referrals the contractor shall random sample audit a statistically valid sample size at p = 0.5, at a 95% confidence level, with a margin of error of +-1 for each 12-month option period and provide monthly audit reports based on a minimum of 800 referrals per month” before the last sentence. Paragraphs 6.5.2 and 6.5.3. Add the following after the first sentence as follows: “Deferred claims include some claims that are excluded from the total monthly claims volumes. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. Deferred claims excluded from this requirement are defined as: Claims requiring development for possible Third Party Liability (TPL) or Other Health insurance (OHI); Claims requiring intervention by another Prime contractor; and Claims requiring Government intervention (i.e., claims held for pricing updates, claims held pending the issuance of a policy change or as a result of change orders, etc.).” EFFECTIVE DATE: June 23, 2021
CHAPTER 2
  1. Section 6. Paragraph 2.4. The first bullet is changed from “one hundred eigth” to “one hundred eighty.” Remove the fifth bullet and replace with “For the last 30 days of HCD, the outgoing contractor shall transfer records to the incoming contractor weekly. The records shall be transferred no later than the second business day of the week.” Paragraph 3.4. Delete the fifth bullet and replace with “For the last 30 days of HCD, the outgoing contractor shall transfer records to the incoming contractor weekly. The records shall be transferred no later than the second business day of the week.” EFFECTIVE DATE: June 23, 2021
CHAPTER 2
  1. Section 7. Paragraph 2.1.9. Delete “referrals by 8:00 am next for referrals received by 3:00 pm local time” and replace with “all requests within one business day.” EFFECTIVE DATE: June 23, 2021
CHAPTER 5
  1. Section 1. Paragraphs 7.6 and 9.5. Delete paragraphs. EFFECTIVE DATE: June 23, 2021
CHAPTER 7
  1. Section 1. Paragraph 4.1. Insert “between the Managed Care Support Contractor (MCSC) and TRICARE Pharmacy (T-Pharm) contractor (see DD Form 1423, CDRL, located in Section J of the applicable contract).” before the last sentence. EFFECTIVE DATE: June 23, 2021
CHAPTER 7
  1. Section 6. Paragraph 6.4. Insert “Clinical Quality” after “The Peer Review Committee shall assure all identified.” Paragraph 9.2. Change to “The contractor shall partner with network facilities partner and recommend performance improvement strategies and work with them to achieve measurable improvements in outcomes when unfavorable trends are shown within all CQM data monitored in the applicable contract.” EFFECTIVE DATE: June 23, 2021
CHAPTER 11
  1. Section 4. Paragraph 2.0. Military Health System (MHS) Staff Inquiry Processing. Insert the following: 2.1. The contractor shall designate staff with Government issued Common Access Cards (CACs) to respond to MHS staff customer service inquiries via a Government-designated, bi-directional, encrypted system. 2.2 The contractor shall respond to routine inquiries from MHS staff members within 10 business days and priority inquires within three business days. 2.3 Inquiries from designated staff shall be processed as priority for all cases. 2.4 The Government-designated, encrypted system shall be utilized by the prime contractor and all subcontractors. And renumber the subsequent paragraphs. EFFECTIVE DATE: June 23, 2021
CHAPTER 13
  1. Section 1. Paragraph 6.2.2.5. Insert “and includes a year to year variance comparison for all periods of the contract.” before the last sentence. EFFECTIVE DATE: June 23, 2021
CHAPTER 18
  1. Section 3. Deleted Section 3 and replaced in its entirety, same reference. EFFECTIVE DATE: June 23, 2021
CHAPTER 18
  1. Section 4. Section 4 is “Expired.” EFFECTIVE DATE: June 23, 2021
CHAPTER 13
  1. Section 4. Paragraphs 4.4.1 and 4.5.1. Change “two hours” to “two business days.” EFFECTIVE DATE: June 23, 2021
Affected Sections:

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