PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FOR TRICARE SYSTEMS MANUAL (TSM), FEBRUARY 2008

Size: px

Start display at page:

Download "PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FOR TRICARE SYSTEMS MANUAL (TSM), FEBRUARY 2008"

Wilfred Harrison
5 years ago
Views:

1 OFFICE OFTHE ASSISTAT SECRETARY OF DEFESE HEALTH AFFAIRS EAST CETRETECH PARKWAY AURORA, COLORADO TAICAAE MAAGEMET ACTIVITY PCSIB CHAGE 32 79S0.2-M DECEMBER 28, 2011 PUBLICATIOS SYSTEM CHAGE TRASMITTAL FOR TRICARE SYSTEMS MAUAL (TSM), FEBRUARY 2008 The TRICARE Management Activity has authorized the following addition(s)/revision(s). CHAGE TITLE: TRICARE OVERSEAS PROGRAM (TOP) SUPPLEMETAL HEALTH CARE PROGRAM (SHCP) COREQ: PAGE CHAGE(S): See page 2. SUMMARY OF CHAGE(S): This change revises language pertaining to the implementation of the SHCP in locations outside of the 50 United States and the District of Columbia. EFFECTIVE DATE: August 1, IMPLEMETATIO DATE: Upon direction of the Contracting Officer. This change is made in conjunction with Feb 2008 TOM, Change o. 66. Chief, Purchased Care Systems Integration Branch ATTACHMET(S): DISTRIBUTIO: 8 PAGES 79S0.2-M WHE PRESCRIBED ACTIO HAS BEE TAKE, FILE THIS TRASMITTAL WITH BASIC DOCUMET.

2 CHAGE M DECEMBER 28, 2011 REMOVE PAGE(S) ISERT PAGE(S) CHAPTER 2 Section 8.1, pages 9-12, Section 8.1, pages 9-12,

3 TRICARE Systems Manual M, February 1, 2008 ELEMET AME: SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) (1-060) VALIDITY EDITS REFER TO SECTIO 5.1. RELATIOAL EDITS F TPR [ADSM] IF HEADER TYPE IDICATOR = 5 VOUCHER HEADER O-ADMI CLAIM RATE- ELIGIBLE OR AD EROLLMET/HEALTH PLA CODE = W TPR ADSM - USA OR 6 VOUCHER HEADER ADMI CLAIM RATE-ELIGIBLE WA TPR FOREIG ADSM OR AY OCCURRECE OF SPECIAL PROCESSIG CODE = GU ADSM EROLLED I TPR AD TYPE OF SUBMISSIO B ADJUSTMET TO O-TED RECORD (HCSR) DATA OR E COMPLETE CACELLATIO OF O-TED RECORD (HCSR) DATA AD AMOUT PAID BY GOVERMET COTRACTOR (TOTAL) ERO THE SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) MUST = A ARMY OR C F H M O COAST GUARD OR AIR FORCE OR PUBLIC HEALTH SERVICE OR MARIES OR AVY OR OAA OR OT PROVIDED FROM DEERS AD HCC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR G J S V ATIOAL GUARD MEMBER (MOBILIED OR O ACTIVE DUTY FOR 31 DAYS OR MORE) OR ACADEMY STUDET OR ATIOAL GUARD (OT O ACTIVE DUTY OR O RESERVE MEMBER (MOBILIED OR O ACTIVE DUTY FOR 31 DAYS OR MORE) OR RESERVE MEMBER (OT O ACTIVE DUTY OR O AD HCC MEMBER RELATIOSHIP CODE MUST = A SELF OR F SHCP VOUCHER (ADSM CLAIMS OLY) IF EROLLMET/HEALTH PLA CODE = SR SHCP - REFERRED CARE (EFFECTIVE 10/01/1999) 9

4 ELEMET AME: TRICARE Systems Manual M, February 1, 2008 SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) (1-060) (Continued) OR AY OCCURRECE OF SPECIAL PROCESSIG CODE = AR SHCP - REFERRED OR TYPE OF SUBMISSIO = B ADJUSTMET TO O-TED RECORD (HCSR) DATA OR E COMPLETE CACELLATIO OF O-TED RECORD (HCSR) DATA OR AMOUT PAID BY GOVERMET COTRACTOR (TOTAL) = ERO ELSE IF HEADER TYPE IDICATOR = 5 VOUCHER HEADER O-ADMI CLAIM RATE- ELIGIBLE OR AD EROLLMET/HEALTH PLA CODE = X FOREIG ADSM OR 6 VOUCHER HEADER ADMI CLAIM RATE-ELIGIBLE SO ST SHCP - O-TRICARE ELIGIBLE OR SHCP - TRICARE ELIGIBLE OR AY OCCURRECE OF SPECIAL PROCESSIG CODE = AD FOREIG ACTIVE DUTY CLAIMS (EFFECTIVE 06/30/1996) OR CE SC SE SM SHCP - COMPREHESIVE CLIICAL EVALUATIO PROGRAM OR SHCP - O-TRICARE ELIGIBLE OR SHCP - TRICARE ELIGIBLE OR SHCP - EMERGECY THE SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) MUST = A ARMY OR C F H M O COAST GUARD OR AIR FORCE OR PUBLIC HEALTH SERVICE OR MARIES OR AVY OR OAA OR OT PROVIDED FROM DEERS OR 1 FOREIG ARMY OR 2 FOREIG AVY OR 3 FOREIG MARIE CORPS OR 4 FOREIG AIR FORCE AD HCC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR G J S ATIOAL GUARD MEMBER (MOBILIED OR O ACTIVE DUTY FOR 31 DAYS OR MORE) OR ACADEMY STUDET OR ATIOAL GUARD (OT O ACTIVE DUTY OR O RESERVE MEMBER (MOBILIED OR O ACTIVE DUTY FOR 31 DAYS OR MORE) OR 10

5 TRICARE Systems Manual M, February 1, 2008 ELEMET AME: SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) (1-060) (Continued) T FOREIG MILITARY MEMBER OR V RESERVE MEMBER (OT O ACTIVE DUTY OR O AD HCC MEMBER RELATIOSHIP CODE MUST = A SELF OR F AVY LIE OF DUTY CLAIMS IF AY OCCURRECE OF OVERRIDE CODE = H1 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, COTRACTOR ERROR OR H2 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, GOVERMET CAUSED ERROR ELSE IF HEADER TYPE IDICATOR = 5 O-CLAIM RATE VOUCHER OR AD COTRACTOR UMBER = 6 CLAIM RATE VOUCHER MDA C-0010 (SOUTH) AD BATCH/VOUCHER ASAP ACCOUT UMBER POSITIO 8 = 5 THE BRACH CLASSIFICATIO CODE MUST = AVY OR F MARIE LIE OF DUTY CLAIMS IF AY OCCURRECE OF OVERRIDE CODE = H1 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, COTRACTOR ERROR OR H2 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, GOVERMET CAUSED ERROR ELSE IF HEADER TYPE IDICATOR = 5 O-CLAIM RATE VOUCHER OR AD COTRACTOR UMBER = 6 CLAIM RATE VOUCHER MDA C-0010 (SOUTH) AD BATCH/VOUCHER CLI/ASAP ACCOUT UMBER POSITIO 8 = 6 THE BRACH CLASSIFICATIO CODE MUST = M MARIE OR F SHCP O-MTF REFERRED VOUCHER (ADSM CLAIMS OLY) IF TYPE OF SUBMISSIO = B ADJUSTMET TO O-TED RECORD (HCSR) DATA OR E COMPLETE CACELLATIO OF O-TED RECORD (HCSR) DATA OR AMOUT PAID BY GOVERMET COTRACTOR (TOTAL) = ERO ELSE IF HEADER TYPE IDICATOR = 5 VOUCHER HEADER O-ADMI CLAIM RATE ELIGIBLE OR 11

6 ELEMET AME: TRICARE Systems Manual M, February 1, 2008 SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) (1-060) (Continued) 6 VOUCHER HEADER ADMI CLAIM RATE ELIGIBLE AD EROLLMET/HEALTH PLA CODE = S SHCP O-MTF REFERRED CARE OR AY OCCURRECE OF SPECIAL PROCESSIG CODE = A SHCP O-MTF REFERRED CARE THE SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) MUST = A ARMY OR C F H M O COAST GUARD OR AIR FORCE OR PUBLIC HEALTH SERVICE OR MARIES OR AVY OR OAA OR OT PROVIDED FROM DEERS OR 1 FOREIG ARMY OR 2 FOREIG AVY OR 3 FOREIG MARIE CORPS OR 4 FOREIG AIR FORCE AD HCC MEMBER RELATIOSHIP CODE MUST = A SELF OR ELEMET AME: AGR SERVICE LEGAL AUTHORITY CODE (1-065) VALIDITY EDITS REFER TO SECTIO 5.3. RELATIOAL EDITS OE 12

7 TRICARE Systems Manual M, February 1, 2008 ELEMET AME: SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) (2-055) (Continued) F SHCP VOUCHERS (ADSM CLAIMS OLY) IF EROLLMET/HEALTH PLA CODE = SR SHCP - REFERRED CARE (EFFECTIVE 10/01/1999) OR AY OCCURRECE OF SPECIAL PROCESSIG CODE = AR SHCP REFERRED OR TYPE OF SUBMISSIO = B ADJUSTMET TO O-TED RECORD (HCSR) DATA OR E COMPLETE CACELLATIO OF O-TED RECORD (HCSR) DATA OR AMOUT PAID BY GOVERMET COTRACTOR (TOTAL) = ERO ELSE IF HEADER TYPE IDICATOR = 5 VOUCHER HEADER O-ADMI CLAIM RATE- ELIGIBLE OR AD EROLLMET/HEALTH PLA CODE = X FOREIG ADSM OR 6 VOUCHER HEADER ADMI CLAIM RATE-ELIGIBLE SO ST SU SHCP - O-TRICARE ELIGIBLE OR SHCP - TRICARE ELIGIBLE OR SHCP - REFERRAL DESIGATIO OR AY OCCURRECE OF SPECIAL PROCESSIG CODE = AD FOREIG ACTIVE DUTY CLAIMS (EFFECTIVE 06/30/1996) OR CE SC SE SM SHCP - COMPREHESIVE CLIICAL EVALUATIO PROGRAM OR SHCP - O-TRICARE ELIGIBLE OR SHCP - TRICARE ELIGIBLE OR SHCP - EMERGECY THE SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) MUST = A ARMY OR C F H M O COAST GUARD OR AIR FORCE OR PUBLIC HEALTH SERVICE OR MARIES OR AVY OR OAA OR OT PROVIDED FROM DEERS OR 1 FOREIG ARMY OR 2 FOREIG AVY OR 3 FOREIG MARIE CORPS OR 4 FOREIG AIR FORCE AD HCC MEMBER CATEGORY CODE MUST = A ACTIVE DUTY OR G J ATIOAL GUARD MEMBER (MOBILIED OR O ACTIVE DUTY FOR 31 DAYS OR MORE) OR ACADEMY STUDET OR 25

8 ELEMET AME: TRICARE Systems Manual M, February 1, 2008 SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) (2-055) (Continued) S T V ATIOAL GUARD (OT O ACTIVE DUTY OR O RESERVE MEMBER (MOBILIED OR O ACTIVE DUTY FOR 31 DAYS OR MORE) OR FOREIG MILITARY MEMBER OR RESERVE MEMBER (OT O ACTIVE DUTY OR O AD HCC MEMBER RELATIOSHIP CODE MUST = A SELF OR F AVY LIE OF DUTY CLAIMS IF AY OCCURRECE OF OVERRIDE CODE = H1 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, COTRACTOR ERROR OR H2 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, GOVERMET CAUSED ERROR ELSE IF HEADER TYPE IDICATOR = 5 O-CLAIM RATE VOUCHER OR AD COTRACT UMBER = 6 CLAIM RATE VOUCHER MDA (SOUTH) AD BATCH/VOUCHER ASAP ACCOUT UMBER POSITIO 8 = 5 THE SERVICE BRACH CLASSIFICATIO CODE MUST = AVY OR F MARIE LIE OF DUTY CLAIMS IF AY OCCURRECE OF OVERRIDE CODE = H1 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, COTRACTOR ERROR OR H2 BEEFIT PAYMET MADE USIG ICORRECT BATCH/ VOUCHER CLI/ASAP UMBER, GOVERMET CAUSED ERROR ELSE IF HEADER TYPE IDICATOR = 5 O-CLAIM RATE VOUCHER OR AD COTRACT UMBER = 6 CLAIM RATE VOUCHER MDA (SOUTH) AD BATCH/VOUCHER ASAP ACCOUT UMBER POSITIO 8 = 6 THE SERVICE BRACH CLASSIFICATIO CODE MUST = M MARIE OR F SHCP O-MTF REFERRED VOUCHER (ADSM CLAIMS OLY) IF TYPE OF SUBMISSIO = B ADJUSTMET TO O-TED RECORD (HCSR) DATA OR E COMPLETE CACELLATIO OF O-TED RECORD (HCSR) DATA 26

9 TRICARE Systems Manual M, February 1, 2008 ELEMET AME: SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) (2-055) (Continued) OR AMOUT PAID BY GOVERMET COTRACTOR (TOTAL) = ERO ELSE IF HEADER TYPE IDICATOR = 5 VOUCHER HEADER O-ADMI CLAIM RATE- ELIGIBLE OR 6 VOUCHER HEADER ADMI CLAIM RATE ELIGIBLE AD EROLLMET/HEALTH PLA CODE = S SHCP O-MTF REFERRED CARE OR AY OCCURRECE OF SPECIAL PROCESIG CODE = A SHCP O-MTF REFERRED CARE THE SERVICE BRACH CLASSIFICATIO CODE (SPOSOR) MUST = A ARMY OR C F H M O COAST GUARD OR AIR FORCE OR PUBLIC HEALTH SERVICE OR MARIES OR AVY OR OAA OR OT PROVIDED FROM DEERS OR 1 FOREGI ARMY OR 2 FOREIG AVY OR 3 FOREIG MARIE CORPS OR 4 FOREIG AIR FORCE AD HCC MEMBER RELATIOSHIP CODE MUST = A SELF OR ELEMET AME: AGR SERVICE LEGAL AUTHORITY CODE (2-056) VALIDITY EDITS REFER TO SECTIO 6.1 RELATIOAL EDITS OE 27

10 TRICARE Systems Manual M, February 1, 2008 ELEMET AME: ADMIISTRATIVE CLI (2-108) REFER TO SECTIO F O DUPLICATE CLIs O TED RECORD IF COTRACT UMBER OT = VALIDITY EDITS RELATIOAL EDITS MDA C-0013 (TMOP) OR MDA C-0009 (WEST) OR MDA C-0010 (SOUTH) OR MDA C-0011 (ORTH) OR MDA C-0015 (TDEFIC) OR MDA C-0019 (TRRx) ELSE IF HEADER TYPE IDICATOR = 6 VOUCHER HEADER (USED OLY FOR ISTITUTIOAL/ O-ISTITUTIOAL O-FIACIALLY UDERWRITTE ADMI CLAIM RATE ELIGIBLE TED RECORDS) OR 9 BATCH HEADER (ISTITUTIOAL/O- ISTITUTIOAL FIACIALLY UDERWRITTE ADMI CLAIM RATE ELIGIBLE TED RECORDS) THE AY OCCURRECE OF ADMIISTRATIVE CLI (POSITIOS 3-6) MUST HAVE O DUPLICATE I AY OCCURRECES (DUPLICATE BLAK ADMIISTRATIVE CLI OCCURRECES ARE ALLOWED) F O BASE ADMIISTRATIVE PAYMET FOR DEIAL OF SERVICES IF COTRACT UMBER OT = MDA C-0013 (TMOP) OR MDA C-0009 (WEST) OR MDA C-0010 (SOUTH) OR MDA C-0011 (ORTH) OR MDA C-0015 (TDEFIC) OR MDA C-0019 (TRRx) ELSE IF HEADER TYPE IDICATOR = 6 VOUCHER HEADER (USED OLY FOR ISTITUTIOAL/ O-ISTITUTIOAL O-FIACIALLY UDERWRITTE ADMI CLAIM RATE ELIGIBLE TED RECORDS) OR 9 BATCH HEADER (ISTITUTIOAL/O- ISTITUTIOAL FIACIALLY UDERWRITTE ADMI CLAIM RATE ELIGIBLE TED RECORDS) AD COTRACT UMBER = MDA C-0002 (TMOP) AD TYPE OF SUBMISSIO = D COMPLETE DEIAL THE RATE TYPE FOR CLI I THE TMA DATABASE MUST D DISPESIG FEE THIS DATA ELEMET OLY APPLIES TO THE FOLLOWIG COTRACT UMBERS: MDA C-0013, MDA C-0009, MDA C-0010, MDA C-0011, MDA C-0015, AD MDA C ADMIISTRATIVE CLI EDIT ERRORS ARE OT COUTED AGAIST THE COTRACTOR S PERFORMACE STADARDS. THE EDITS ARE DESIGED TO IFORM THE COTRACTOR WHE REQUEST FOR A ADMIISTRATIVE PAYMET HAS BEE DEIED BY TMA, CRM AD HOW TO CORRECT THE ERROR. 1 BYPASS EDIT F IF RECORD FAILS F. BYPASS EDIT F IF RECORD FAILS F. 28 C-3, June 10, 2008

invest in your futuretoday. Certified Public Finance Officer (CPFO) Program.

invest in your futuretoday. Certified Public Finance Officer (CPFO) Program. ivest i your futuretoday. Grow your professioal skills ad advace your career with GFOA s atioally recogized Certified Public Fiace Officer (CPFO) Program. i cojuctio with T he Govermet Fiace Officers Associatio