TRICARE Operations Manual 6010.59-M, April 1, 2015
Health Insurance Portability and Accountability Act (HIPAA) of 1996
Chapter 19
Section 2
HealthInsurance Portability And Accountability Act (HIPAA) Standards ForElectronic Transactions
Revision:C-120, June 12, 2023
1.0BackgroundAnd Provisions
The Departmentof Health and Human Services (DHHS) published the first administrativesimplification related final rule on August 17, 2000, which addedsubchapter C, “Administrative Data Standards and Related Requirements,”to 45 CFR subtitle A. Subchapter C includes Parts 160 and 162, whichwill be referred to here as the Transaction and Code Sets Rule.On January 16, 2009, HHS published a Final Rule known as “HealthInsurance Reform: Modifications to Health Insurance Portabilityand Accountability Act (HIPAA) Electronic Transaction Standards.”This Final Rule (referred to here as the “Modifications to HIPAAElectronic Standards Final Rule”) adopted updated versions of thestandards for electronic transactions that were originally adoptedunder the Administrative Simplification subtitle of HIPAA. Since2009, HHS has published additional Final Rules for HIPAA initiativeswhich affect HIPAA transactions. As a HIPAA covered entity; TRICAREwill comply with applicable adopted HIPAA rules.
1.1Compliance Dates
1.1.1The contractor shall complywith the most current Final Rules on HIPAA adopted Electronic TransactionStandards, including compliance dates.
1.1.2The contractorshall comply with the most current Final Rules on HIPAA adopted TransactionOperating Rules, including compliance dates.
1.1.3The contractor shall complywith Final Rules on HIPAA adopted code sets (e.g., the use of InternationalClassification of Diseases, Tenth Revision (ICD-10)), includingcompliance dates.
1.1.4The contractorshall comply with Final Rules on HIPAA adopted identifiers (e.g.,the use of Health Plan Identifiers (HPID)), including compliancedates.
1.2Applicability
The contractor shall complywith HIPAA Electronic Standards Final Rules as the rules apply tohealth plans, health care clearinghouses, and health care providerswho transmit any health information in electronic form in connectionwith a transaction covered by the rule. These Rules refer to healthplans, health care clearinghouses, and health care providers as“covered entities.” The initial Transaction and Code Sets Rule specificallynames the health care program for active duty military personnelunder Title 10 of the United States Code (USC) and the CivilianHealth and Medical Program of the Uniformed Services (CHAMPUS) asdefined in 10 USC 1072(4), as health plans and this designationhas not changed in the Modifications to HIPAA Electronic StandardsFinal Rule.
1.3TransactionImplementation Specification Standards
1.3.1The contractorshall comply with the most current HIPAA Electronic Standards FinalRules, which adopt specifically stated HIPAA implementations ofAccredited Standards Committee (ASC) X12 standards, accompanyingErrata, Addenda and Operating Rules. In the event that additionalHIPAA adopted transactions, accompanying Errata, Addenda, or OperatingRules are mandated for use in the future; the contractor shall complywith those HIPAA adopted transaction initiatives by the compliance datesspecified by HHS in Final Rules.
1.3.2For retailpharmacy electronic transactions covered under HIPAA, the contractorshall comply with HIPAA adopted National Council for PrescriptionDrug Programs, (NCPDP) Telecommunication and Batch Standard ImplementationGuides named and adopted by Final Rule.
1.3.2.1The contractor shall accommodateuse of both NCPDP and HIPAA ASC X12 837 Health Care Claim: Professionalfor billing of retail pharmacy supplies and professional services.
1.3.2.2The contractor shall accommodateuse of the HIPAA adopted standard for the subrogation of pharmacyclaims paid by Medicaid which is named and adopted in Final Ruleas the NCPDP Batch Standard Medicaid Subrogation ImplementationGuide. This standard is applicable to Medicaid agencies in theirrole as health plans, as well as to other health plans such as TRICAREthat are covered entities under HIPAA.
1.3.3The contractor shall complywith HIPAA related Final Rules associated with Section 1104 of theAdministrative Simplification provisions of the Patient Protectionand Affordable Care Act (PPACA) (hereafter referred to as the AffordableCare Act or ACA). The ACA establishes new requirements for administrativetransactions to improve the utility of the existing HIPAA transactionsand reduce administrative costs (e.g., standard Operating Rules).
1.3.4HIPAA Adopted Code Set Standards
The contractor shall complywith HIPAA adopted code sets in accordance with Final Rules (e.g., InternationalClassification of Diseases, 10th Revision (ICD-10)).
2.0TRICARE Objectives
2.1The TRICARE program shall bein full compliance with the HIPAA Transactions, Code Sets, and IdentifiersFinal Rules.
2.2Private Care Systems shallbe able to receive, process, and send HIPAA compliant standard transactionswhere required.
3.0Contractor Relationships ToThe TRICARE Health Plan (THP)
3.1The Transactionand Code Sets Rule specifically names the health care program foractive duty military personnel under 10 USC and CHAMPUS as definedin 10 USC 1072(4), as health plans. For the purposes of implementingthe Transaction and Code Sets Rule, the term “TRICARE” will be usedin this chapter to mean a combination of both the Direct Care (DC)and Private Care Systems. TRICARE is therefore a health plan.
3.2Therelationships of the entities that comprise TRICARE determine, inpart, where standard transactions shall be used. Determinationsas to when and where the transaction standards apply are not basedon whether a transaction occurs within or outside of a “corporateentity” but rather are based upon the answers to the two followingquestions:
•Is the transaction initiatedby a covered entity or its business associate? If the answer is“no,” then the standard does not apply and is not used. If “yes,”then the standard applies and the next question needs to be answered.
•Is the transaction one theSecretary of HHS adopted as an adopted standard? If “no,” then the standardis not required by HIPAA to be used. If “yes,” then the standardshall be used.
To decide if a standard hasbeen adopted for transaction, use the definition of the transactionas it is provided in the Final Rule. Knowing who is and is not abusiness associate of the THP is important in determining wherestandard transactions shall be used within TRICARE. See Appendix A for the definition of “businessassociate.”
3.3The followingtable identifies TRICARE entities and their relationships to theTHP.
| Entity | CoveredEntities | Non-Covered Entity | Business AssociateOf The THP? | ||
|---|---|---|---|---|---|
| Health Plan? | Provider? | Clearing-house? | Employer? | ||
| Department of Defense(DoD) (Army, Navy, Air Force, Marines, Space Force, and CoastGuard*) *In time of war | N | N | N | Y | N |
| THP (Representsboth the Health Care Program for Active Duty Military Personnelunder 10 USC and the CHAMPUS as defined in 10 USC 1072(4).) | Y | N | N | N | N |
| Markets/Military TreatmentFacilities (MTFs) (Supporting Systems: Composite Health CareSystem (CHCS), Referral Management Suite (RMS), Armed Forces HealthLongitudinal Technology Application (AHLTA), Third Party OutpatientCollections System (TPOCS)*, and others) *Armed Forces Billing and CollectionUtilization Solution (ABACUS) expected to replace TPOCS in 2015. | N | Y | N | N | N |
| Defense Manpower DataCenter (DMDC) Defense Enrollment Eligibility Reporting System(DEERS) | N | N | N | N | Y |
| Managed Care SupportContractor (MCSC) | N | N | N | N | Y |
| TRICARE Medicare Eligible Program (TMEP) | N | N | N | N | Y |
| Defense Finance and AccountingService (DFAS) | N | N | N | Y | N |
| TRICARE Dental Program (TDP)Contractor | Y | N | N | N | Y (for foreign claims processingonly) |
| Active Duty Dental Program(ADDP) Contractor | Y | N | N | N | N |
| Pharmacy Data Transaction Service(PDTS) Contractor | N | N | N | N | Y |
| Designated Provider (DP) Contractors | Y | Y | N | N | N |
| Defense Health Agency-GreatLakes (DHA-GL) | N | N | N | N | Y |
| Continued Health Care BenefitProgram (CHCBP) Contractor | N | N | N | N | Y |
| TRICARE Quality ManagementContract (TQMC) | N | N | N | N | Y |
| Contractor for Data Analysisfor the DP Contracts | N | N | N | N | Y |
| TRICARE Overseas Program (TOP)Contractor | N | N | N | N | Y |
| Defense Health Agency(DHA) (Supporting Systems: DEERS Catastrophic Cap and Deductible(CCDD), payment record databases (TRICARE Encounter Data (TED) records,TED Provider (TEPRV) records, and TED Pricing (TEPRC) records),management databases (Military Health System (MHS)) Data Repositoryand its associated data marts) | N | N | N | N | Y |
| TRICARE Pharmacy (TPharm) Contractor | N | Y | N | N | Y |
| TRICARE Area Offices (TAOs) | N | N | N | N | Y |
4.0HIPAATransaction Requirements For TRICARE Contractors
4.1General
4.1.1The contractor shall implementtransactions in accordance with the transaction implementation specificationsand any Addenda, Errata, or Operating Rules named and adopted bythe Secretary of HHS, as standards.
4.1.2The contractorshall accept standard transactions from trading partners that arecorrect at the interchange control structure level (envelope) andthat are syntactically correct at the standard level and at theimplementation guide level and are semantically correct at the implementationguide level. The contractor shall not reject otherwise syntacticallycorrect transactions for front-end business or application leveledits for transaction content, such as an edit for a recognizedprovider number. The contractor shall apply front-end business orapplication level edits after accepting the transaction. The contractorshall reject, develop or deny claims failing front-end businessor application edits, after passing syntax and semantic edits, inaccordance with established procedures for such actions.
4.2Transactions Exchanged BetweenContractors And Providers (Network And Non-Network Providers, Markets/MTFs(CHCS and RMS))
4.2.1The contractor shall ensureHIPAA adopted transactions exchanged between contractors and providersare in accordance with HIPAA standards.
4.2.2The contractorsshall be HIPAA compliant with the following HIPAA adopted transactions, whenHIPAA compliant usage applies:
4.2.2.1ClaimsTransactions
[ReceiveClaims Transactions]
•The ASC X12N 837P - HealthCare Claim: Professional, most currently adopted version.
•The ASC X12N 837I - HealthCare Claim: Institutional, most currently adopted version.
•The ASC X12N 837D - HealthCare Claim: Dental, most currently adopted version.
•The most currently adoptedversion of NCPDP Telecommunication Standard and equivalent NCPDPBatch Standard including claims for retail pharmacy suppliesand professional services.
4.2.2.2Coordination Of Benefits (COB)Transactions
[Receive837 Coordination of Benefits Transactions]
•The ASC X12N 837 - Health CareClaim: Professional, most currently adopted version.
•The ASC X12N 837 - Health CareClaim: Institutional, most currently adopted version.
•The ASC X12N 837 - Health CareClaim: Dental, most currently adopted version.
4.2.2.3Eligibility Inquiry And ResponseTransactions
[Receive270 Transactions and Send 271 Transactions]
•The ASC X12N 270/271 - HealthCare Eligibility Benefit Inquiry and Response, most currently adoptedversion
4.2.2.4ReferralCertification And Authorization Transactions
[Receive 278 Requests and Send278 Responses]
•The ASC X12N 278 - Health CareServices Review - Request for Review and Response, most currently adoptedversion.
4.2.2.5ClaimStatus Request And Response Transactions
[Receive 276 Transactions andSend 277 Transactions]
•The ASC X12N 276/277 - HealthCare Claim Status Request and Response, most currently adopted version.
4.2.2.6Payment And Remittance Advice(RA) Transactions
[Send835 Transactions]
•The ASC X12N 835 - Health CareClaim Payment/Advice, most currently adopted version.
4.2.2.7Electronic Funds Transfer (EFT)And Remittance Advice (RA)
The contractors shall be ableto send the following transmissions:
4.2.2.7.1[Stage1 Payment Initiation, Transmission of Health Care Payment/Processing Information]
Automated Clearing House (ACH)transmissions shall comply with the most current National AutomatedClearing House Association (NACHA) requirements. The NACHA Rulesare updated annually and govern every ACH payment, providing exactguidelines for securely storing, accessing and transmitting sensitivecustomer information. The contractor shall, when processing ACHtransactions:
•Populate the ACH ENTRY DETAILRECORD (6 Record, Field 10, Positions 79-79), with 1. The value‘1’ requires the ACH file to have an ADDENDA RECORD.
•Populate the ADDENDA RECORD(7 Record Field 3, Positions 4-83) with “Health Care Claim Payment/Advice(835)”. The contractor may provide additional information in thisfield as needed.
4.2.2.7.2[Stage1 Payment Initiation, Transmission of Health Care RA]
•The ASC X12N 835 - Health CareClaim Payment/Advice, most currently adopted version.
4.3Transactions Exchanged BetweenThe Contractors And Other Health Plans (And Employers, Where Applicable)
4.3.1The contractor shall ensureHIPAA adopted transactions exchanged between the contractor andother health plans (including TRICARE supplemental plans) are inaccordance with HIPAA standard.
4.3.2The contractorsshall be able to electronically transact with other health plans,in accordance with HIPAA adopted Final Rules.
4.3.2.1COBTransactions
[Sendand Receive all HIPAA adopted 837 Transactions]
•The ASC X12N 837 - Health CareClaim: Professional, most currently adopted version.
•The ASC X12N 837 - Health CareClaim: Institutional, most currently adopted version.
•The ASC X12N 837 - Health CareClaim: Dental, most currently adopted version.
4.3.2.2Eligibility Inquiry And ResponseTransactions
[Sendand Receive 270 Transactions; Send and Receive 271 Transactions]
•The ASC X12N 270/271 - HealthCare Eligibility Benefit Inquiry and Response, most currently adoptedversion.
4.3.2.3ReferralCertification And Authorization Transactions
[Send and Receive 278 Requests;Send and Receive 278 Responses]
•The ASC X12N 278 - Health CareServices Review - Request for Review and Response, most currently adoptedversion.
4.3.2.4PaymentAnd Remittance Advice (RA) Transactions
[Send 835 Transactions]
•The ASC X12N 835 - Health CareClaim Payment/Advice, most currently adopted version.
4.3.2.5Claim Status Request And ResponseTransactions
[Receive276 Transactions and Send 277 Transactions]
•The ASC X12N 276/277 - HealthCare Claim Status Request and Response, most currently adopted version.
4.3.2.6Health Plan Premium PaymentTransactions
[Receive820 Transactions]
•The ASC X12N 820 - PayrollDeducted and Other Group Premium Payment for Insurance Products, mostcurrently adopted version.
4.3.2.7Request To Primary Payer ForPayment Already Made By Subordinate Payer (Medicaid)
[Receive Medicaid PharmacySubrogation Transactions]
•NCPDP Batch Standard MedicaidSubrogation, most currently adopted version. The Modifications toHIPAA Electronic Standards Final Rule adopted a standard for thesubrogation of pharmacy claims paid by Medicaid. This transactionis the Medicaid Pharmacy Subrogation Transaction. The standard forthat transaction is the NCPDP Batch Standard Medicaid SubrogationImplementation guide. A Medicaid Pharmacy subrogation transactionis defined as the transmission of a claim from a Medicaid agencyto a payer for the purpose of seeking reimbursem*nt from the responsible healthplan for a pharmacy claim the State has paid on behalf of a Medicaidrecipient. This standard is applicable to Medicaid agencies in theirrole as health plans, but not to providers or health care clearinghousesbecause this transaction is not used by them. To the extent thatPharmacy Benefit Managers (PBMs) and claims processors are requiredby contract or otherwise to process claims on behalf of TRICARE,both shall receive the Medicaid Pharmacy Subrogation Transactionin the standard format.
4.4Transactions Exchanged BetweenContractors And DMDC (DEERS)
4.4.1EligibilityInquiries And Response Transactions
Based upon the “two-questionrule” for determining when a transaction shall be in standard format (see paragraph 3.2),and the definition of the Eligibility for a Health Plan Transactionin the Final Rule, eligibility inquiry and response transactionsoccurring between business associates of the same health plan neednot be in standard format. The contractor shall use transactionsin the standard format when the inquiries and responses are betweenproviders and health plans or between health plans and health plans.Because the contractors and DEERS are business associates of thesame health plan, eligibility inquiry and response transactionsbetween them may be performed in non-standard format.
4.4.1.1The contractor shall performreal-time eligibility inquiries and responses, associated with enrollmentprocessing, between the contractor and DEERS via the Governmentfurnished web-based system/application.
4.4.1.2Real-time and batch eligibilityinquiries and responses between the contractors and DEERS for claimsprocessing and other administrative purposes will be in DEERS specifiedformat.
4.4.2EnrollmentAnd Disenrollment Transactions
TRICARE enrollment and disenrollmenttransactions between the contractors and DEERS may be performedusing the Government furnished web-based system/application. TheGovernment will provide a HIPAA standard data and condition compliantversion of Government furnished web-based system/application forcontractor use. Note: Transactions generated by DEERS that validatethat enrollments have been established and that are used by thecontractor to update its system files, are not considered coveredtransactions and may be sent in proprietary format.
4.5Transactions Exchanged BetweenThe Contractor And Providers (Network And Non-Network Providers,Markets/MTFs (CHCS and RMS)) Through Direct Data Entry Systems
4.5.1Direct Data Entry Systems
4.5.1.1The contractor shall use standardformat for all transactions covered under the Transaction and CodeSets Rule occurring between the contractor and network/non-networkproviders and Markets/MTFs, unless subject to the direct data entryexception. The contractor may offer a direct data entry system foruse by providers. A direct data entry system however, does not replacethe requirement to support the standard transactions. The contractorshall ensure direct data entry systems are compliant with standardtransaction data content and conditions.
4.5.1.2The contractor shall ensureits direct data entry system does not add to or delete from the standarddata elements and code values. Direct data entry systems may takethe form of web applications. Non-standard data elements and codevalues may be included in the direct data entry system if the non-standarddata is obtained or sent through a separate mechanism such as aweb page that is separate from the web page containing the standarddata content, and the resolution of the standard transaction doesnot depend on the additional information.
4.6Transactions Involving ForeignEntities
4.6.1Electronic transactions fromoverseas Markets/MTFs and from United States (U.S.) territories willbe sent directly to the contractor in standard format or routedthrough a U.S. based clearinghouse for translation into standardformat prior to being sent to the contractor.
4.6.2The contractor shall acceptelectronic transactions submitted by foreign entities, such as claimstransactions from foreign providers, directly or through a clearinghousefor processing. The contractor shall accept transactions submittedby foreign entities, except for those originating from U.S. territoriesor overseas Markets/MTFs in non-standard format as they are notcovered transactions.
4.6.2.1Except for transactions originatingfrom U.S. territories or overseas Markets/MTFs (which will be instandard format), the contractor may define the format or formatsacceptable from foreign entities, either directly or through a clearinghouse.
4.6.2.2Where the TRICARE OverseasProgram (TOP) contractor pays foreign claims and subsequently billsanother contractor for reimbursem*nt, the claim data submitted tothe other contractor in support of the invoice shall be sent instandard format.
4.7TransactionsExchanged Between The Contractor And DHA
Payment Record Submissions,TED records, TEPRV records, and TEPRC records - Payment records areconsidered reports and are not covered transactions. The contractorshall submit payment records in accordance with contract requirements.
4.8Clearinghouse Use By The Contractor
4.8.1The contractor may use contractedclearinghouses for the purposes of receiving, translating, and routingelectronic transactions on its behalf. Contractor-contracted clearinghouses mayreceive standard transactions, convert them into the contractors’system formats and route them to the contractors’ systems for processing.The contractor may send non-standard formatted transactions to itscontracted clearinghouses for the purposes of translating them intostandard format and routing them to the intended recipients.
4.8.2Transactions between healthcare clearinghouses shall be conducted in standard format.
4.8.3Where a contractor has contractedwith the same clearinghouse as the entity that is submitting orreceiving the transaction, the clearinghouse shall convert the nonstandardtransaction into the standard prior to converting it again to theintended recipient’s format and sending.
5.0Trading Partner Agreements
5.1The contractor shall have tradingpartner agreements with all entities with which electronic transactionsare exchanged. Where a provider uses a billing service or clearinghouseto exchange transactions, the contractor shall have a trading partneragreement with both the provider and billing service/clearinghouse.The contractor shall ensure trading partner agreements with providerscontain a “provider signature on file” provision that allows thecontractor to process the electronic transaction if the providersignature on file requirement is not being met through another vehicle(e.g., provider certification). The contractor shall develop andexecute trading partner agreements that comply with all DoD andDHA privacy and security requirements. See Appendix A forthe definition of “trading partner agreement.” The contractor shallensure all trading partner agreements, including all existing andactive trading partner agreements previously executed, are updated,and kept updated, to reflect current requirements.
5.2Implementation Guide Requirements
5.2.1The contractor shall ensuretrading partner agreements include, as recommended in the AmericanNational Standard Institute (ANSI) ASC X12N transaction implementationguides, any information regarding the processing, or adjudicationof the transactions that are helpful to the trading partners andsimplify implementation.
5.2.2The contractorshall ensure trading partner agreements do NOT:
•Modify the definition, condition,or use of a data element or segment in a standard Implementation Guide.
•Add any additional data elementsor segments to a standard Implementation Guide.
•Use any code or data values,which are not valid to a standard Implementation Guide.
•Change the meaning or intentof a standard Implementation Guide.
6.0Additional Non-HIPAA TransactionsRequired
The contractorshall implement the following non-HIPAA mandated transactions asappropriate.
6.1Acknowledgments
The following are requiredfor determining an incoming transaction to be HIPAA-compliant:
•The interchange or “envelope”shall be correct;
•The transaction shall be syntacticallycorrect at the standard level;
•The transaction shall be syntacticallycorrect at the implementation guide level; and
•The transaction shall be semanticallycorrect at the implementation guide level.
Syntax relates to the structureof the data. Semantics relates to the meaning of the data. Any transactionthat meets these four requirements is HIPAA-compliant and shallbe accepted.
Note:In the case of a claim transaction,“accepted” does not mean that it shall be paid. A transaction thatis accepted may then be subjected to business or application leveledits. “Accepted” transactions, i.e., those that are HIPAA-compliant,that subsequently fail business or application level edits shallbe rejected, developed, or denied in accordance with establishedprocedures for such actions.
6.1.1InterchangeAcknowledgment
The Interchangeor TA1 Acknowledgment is a means of replying to an interchange ortransmission that has been sent. The TA1 verifies the envelopesonly. The contractor shall develop and implement the capabilityto generate and send the following transaction. Reference the mostcurrently adopted HIPAA version of ASC X12C/231 Implementation Acknowledgmentfor Health Care Insurance (999) TR3, Appendix C.1, to address implementationuse of this transaction.
•The ANSI ASC X12N TA1 - InterchangeAcknowledgment Segment.
6.1.2Implementation Acknowledgment
The Implementation AcknowledgmentTransaction is used to report the results of the syntactical analysisof the functional groups of transaction sets. It is generally thefirst response to a transaction. (Exception: The TA1 will be thefirst response if there are errors at the interchange or “envelope”level.) Implementation acknowledgment transactions report the extentto which the syntax complies with the standards for transactionsets and functional groups. They report on syntax errors that prevented thetransaction from being accepted. Version 5010 of the implementationacknowledgment transaction does not cover the semantic meaning ofthe information encoded in the transaction sets. The implementationacknowledgment transaction may be used to convey both positive andnegative acknowledgments. Positive acknowledgments indicate thatthe transaction was received and is compliant with standard syntax.Negative acknowledgments indicate that the transaction did not complywith standard syntax. The contractor shall develop and implementthe capability to generate, send, and receive the following transaction(both positive and negative).
•The ASC X12N 999 - ImplementationAcknowledgment, most currently adopted version.
6.1.3Implementation Guide SyntaxAnd Semantic And Business Edit Acknowledgments
6.1.3.1The contractor may use a proprietaryacknowledgment to convey implementation guide syntax errors, implementationguide semantic errors, and business edit errors. Alternatively,for claim transactions (ANSI ASC X12N 837 Professional, Institutional,or Dental), the Health Care Claim Acknowledgment Transaction (ANSIASC X12N 277CA) may be used to indicate which claims in an 837 batchwere accepted into the adjudication system (i.e., which claims passedthe front-end edits) and which claims were rejected before enteringthe adjudication system.
6.1.3.2In the future, the standardsmay mandate transactions for acknowledgments to convey standardsyntax, implementation guide syntax, implementation guide semantic,and business/application level edit errors. The contractor shalldevelop and implement the capability to generate and send the followingtransaction(s).
6.1.3.2.1A proprietary acknowledgmentcontaining syntax and semantic errors at the implementation guidelevel, as well as business/application level edit errors.
6.1.3.2.2For 837 claim transactions,the contractor may use the Health Care Claim Acknowledgment TransactionSet (ANSI ASC X12N 277CA, most currently adopted version) in placeof a proprietary acknowledgment.
6.2Medicaid Non-Pharmacy SubrogationClaims
6.2.1When a beneficiary is eligiblefor both TRICARE and Medicaid, 32CFR 199.8 establishes TRICARE as the primary payer. ExistingTRICARE policy requires the contractor to arrange COB procedureswith the various states to facilitate the flow of claims and totry to achieve a reduction in the amount of effort required to reimbursestate funds erroneously disbursed on behalf of the TRICARE-eligiblebeneficiary. TRICARE Policy requires the contractor make disbursem*ntsdirectly to the billing state agency.
6.2.2Currently,a subrogation non-pharmacy claim from a Medicaid State Agency isnot a HIPAA covered transaction since the Transaction and Code SetsRule defines a health care claim or equivalent encounter informationtransaction as occurring between a provider and a health plan. SinceMedicaid State Agencies are not providers, their claims to TRICAREare not covered transactions and need not be in standard format;however, currently adopted HIPAA ASC X12 837 claim standards usedfor processing Institutional, Professional and Dental claims includethe ability to perform Medicaid subrogation. While they are notcurrently mandated for use under HIPAA, covered entities are not prohibitedfrom using currently adopted HIPAA transactions for non-pharmacyMedicaid subrogation transactions between willing trading partners.
•In accordance with existingTRICARE policy, the contractor shall coordinate with the MedicaidState Agencies submitting non-pharmacy claims and define the acceptableforms and formats of the claims the Medicaid State Agencies shalluse when billing TRICARE. State Agency Billing Agreements shallbe modified to reflect the acceptable forms and formats.
Note:It is expected that the Secretary,HHS will modify the standard to incorporate Medicaid subrogationclaims as HIPAA covered transactions sometime in the future. Ifthis occurs, this section will be modified to reflect the change.
7.0Miscellaneous Requirements
7.1Paper Transactions
7.1.1The contractor shall continueto accept and process paper-based transactions.
7.1.2The contractor may pay claimsvia electronic funds transfer or by paper check. The ASC X12N 835Health Care Claim Payment/Advice transaction contains two parts,a mechanism for the transfer of dollars and one for the transferof information about the claim payment. These two parts may be sentseparately. The 835 Implementation Guide allows payment to be sentin a number of different ways, including by check and electronicfunds transfer. The contractor shall be able to send the RA portionelectronically but may continue to send payment via check.
7.1.3Current applicable requirementsfor the processing of paper-based and electronic media transactions,such as claims splitting, forwarding out-of-jurisdiction claims,generating and sending EOBs to beneficiaries and providers, etc.,apply to the processing of electronic transactions.
7.2Attendance At Designated StandardsMaintenance Organization (DSMO) Meetings
7.2.1The contractorshall regularly send representatives to the following separate DSMO Trimestermeetings: ANSI Accredited Standards Committee X12 (ASC X12) StandingMeetings, and the Health Level Seven (HL7) Working Group Meetings.The contractor shall send one representative to each DSMO Trimestermeeting. The contractor may elect to send representatives from itsclaims processing subcontractor(s) in place of a contractor representative.The contractor shall make every effort to have the same representativesattend each meeting for continuity purposes. The team lead willbe the DHA representative in attendance.
7.2.2The contractorshall ensure its representatives are knowledgeable regarding TRICARE programrequirements, and of its own administrative and claims processingsystems. Prior to attending a DSMO meeting, the contractor shallidentify from within their own organizations any issues that need tobe addressed at the DSMO meeting. The contractor shall inform theDHA representative (team lead) of the issues at least one week priorto the meetings.
7.2.3The contractorshall ensure its representatives attend the DSMO meetings as exclusive advocatesfor TRICARE business needs and shall not divide their participationand attention with any commercial business needs and concerns. Thecontractor shall ensure its representatives attend and participatein workgroup and full committee meetings. The contractor shall ensureits representatives work within the DSMOs to incorporate into thestandards and implementation guides any data elements, code values,etc., that are required to conduct current and future TRICARE business.The contractor shall ensure its representatives also work to preventremoval of any existing data elements, code values, etc., from thestandards and implementation guides that are necessary to conductcurrent and future TRICARE business.
7.2.4When attendingthe DSMO meetings, the contractor shall ensure its representativesshall work as a team and collaborate with other Government and DoD/TRICARErepresentatives. The contractor shall ensure its representativesregister under the DoD/Health Affairs (HA) DSMO memberships. Thecontractor shall ensure its representatives take proposed changesthrough the processes necessary for adoption within the DSMOs. Thecontractor shall ensure its representatives track and reportingon the status of each proposed change as it progresses through theprocess.
7.2.5Contractor representativesshall keep DHA apprised of any additions to the standards that shallbe made to accommodate TRICARE business needs and of any proposedchanges to existing standards and implementation guides. Followinga DSMO meeting, each representative attendee shall prepare a summaryreport that includes, at a minimum; the work group and full committeemeetings attended, a brief description of the content of the meetings,the status of any changes in progress, and any problems or informationof which the Government/DHA should be aware. Each representativeshall submit their reports to the DHA team lead within 10 businessdays following the DSMO meetings.
7.3ProviderMarketing
7.3.1The contractor shall encourageproviders to use electronic transactions only through marketingand provider education vehicles permitted within existing contractlimitations and requirements. No additional or special marketingor provider education campaigns are required. The contractor shalleducate providers on the cost and efficiency benefits that may berealized through adoption and use of electronic transactions.
7.3.2The contractor shall assistand work with providers, who wish to exchange electronic transactions,to establish trading partner agreements and connectivity with itssystems and to implement the transactions in a timely manner. Thecontractor is not required to perfect transactions on behalf oftrading partners.
7.4DataAnd Audit Requirements
7.4.1The contractor shall storeall HIPAA-covered electronic transaction data, including eligibility andclaims status transaction data, as outlined in Chapter9. The contractor shall refer to Chapter9 if directed by DHA to freeze records, to include, electronictransaction data.
7.4.2The contractorshall generate transaction histories covering a period of up toseven years upon request by DHA in a text format (delimited textformat for table reports) that is able to be imported, read, edited,and printed by Microsoft® Word (Microsoft® Excel for table reports).The contractor shall have the ability to generate transaction historieson paper. The contractor shall ensure transaction histories includeat a minimum, the transaction name or type, the dates the transactionwas sent or received and the identity of the sender and receiver.The contractor shall ensure transaction histories are readable andunderstandable by a person.
7.4.3Transactiondata is subject to audit by DHA, DoD, HHS, and other authorizedGovernment personnel. The contractor shall have the ability to retrieveand produce all electronic transaction data upon request from DHA(for up to seven years, or longer if the data is being retainedpursuant to a records freeze), to include reasons for transactionrejections as outlined in Chapter 9.
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