TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Duplicate Claims System (DCS) - TRICARE Encounter Data (TED) Version
Chapter 4
Section 1.1
Overview
Revision:C-72, August 28, 2023
1.0Introduction
1.1The TRICAREDuplicate Claims System (DCS) automates the resolution of duplicateclaim payments. The system facilitates the identification of actualduplicate claims payments, the initiation and tracking of recoupments,and the resolution of duplicate records from the TRICARE EncounterData (TED) database. The system also generates operational and managementreports.
1.2All data in the DCS is protectedby the Privacy Act of 1974 (PL 93-579); Department of Defense (DoD)Health Insurance Portability and Accountability Act (HIPAA) PrivacyRegulation; and the HIPAA Privacy Regulation.
1.3All processes associated withthe use of the system and all outputs and results generated by or associatedwith the system, including claims, encounters, dispositions, recoupments,collections, adjustments, and TEDs, are subject to audit by theGovernment. The DCS is the property of the United States (U.S.)Government.
Note:The DefenseHealth Agency (DHA) has a web-based DCS that runs on the Internet/NonsecureInternet Protocol Router Network (NIPRNET). The web version willbe accessed via a web browser (Microsoft® Internet Explorer (MSIE))in accordance with the Chapter 1, Section 1.1.
2.0System Functions
2.1The DCS provides a broad rangeof user functions to support contractor and DHA activities and toensure system integrity.
2.2AdditionalSystem Functions
A numberof other tasks and data handling procedures facilitate duplicateclaims resolution and maintenance of system integrity. These tasksand data handling procedures include:
2.2.1Verifyinguser authorization through the use of the Common Access Cards (CACs);
2.2.2Displaying to each contractoronly those potential duplicate claim sets associated with that contractor;
2.2.3Displaying TED adjustmentsassociated with duplicate institutional claims or duplicate non-institutionalline items;
2.2.4Providing capabilities to trackuser activities;
2.2.5Providingsystem maintenance and data administration capabilities, e.g., automated supportfor reassigning claim sets upon contractor transitions;
2.2.6Determining ownership of setsinvolving potential duplicate claims paid by two different contractors(i.e., multi-contractor sets);
Note:Although the owner designatedby the system is the contractor who paid the latest claim, ownershipcan be switched to other contractors involved;
2.2.7Highlighting claims that appearas potential duplicates in other sets;
2.2.8Appendingnew TED claims to existing sets; and
2.2.9Temporarilydisabling sets involving provisionally accepted TEDs.
3.0CONTRACTOR RESPONSIBILITIES
As specified in all PurchasedCare contracts, contractors are responsible for both preventingand resolving duplicate claim payments. The DCS supports contractorsin this responsibility by automating the resolution process. Theautomated process defines the rules under which the resolution ofclaim sets can be completed, provides users with screens to enterthe results of duplicate payment research, and maintains the necessaryinterfaces with the TED database to ensure and verify correctionof duplicate conditions.
3.1For eachregional contract for which a contractor is responsible, or forthe TRICARE Medicare Eligible Program (TMEP), the contractor shalldevelop internal operating procedures for the DCS. These internaloperating procedures shall designate the responsible areas for thevarious duplicate claims resolution functions and establish timelines. For example, one contractor may decide that the adjustmentunit shall be responsible for scanning the DCS on a weekly basisfor the appearance of adjustments submitted and for closing sets.Another contractor may decide that the unit responsible for researchingpotential duplicate claims should also be responsible for scanningfor adjustments and closing the sets on a daily basis.
3.1.1Contractor contract requirementsfor overpayment recovery, refunds and offsets, adjustments, etc.,including timeliness requirements, apply to the operation of theDCS. As a result, operating procedures must be developed which areconsistent with all applicable contract requirements. Proceduresmust be established to ensure that recoupments are initiated ina timely manner following the research determination that a duplicatepayment had been made. In other words, procedures must specify thatafter a decision has been made by the person responsible for determiningthat a duplicate payment was made, recoupment must be initiatedin a timely manner and must be consistent with all overpayment recoverytimeliness standards.
3.1.2Contractorsshall develop these procedures within 60 days of the date of system implementationand have them available for DHA review.
3.2Determine if a claim (or lineitem) does or does not represent an actual duplicate payment.
3.3Identify and determine thereason code(s) for each claim identified as a potential duplicate,and enter a narrative description when prompted to explain why aclaim does or does not represent an actual duplicate payment.
3.4Identify the dollar amountidentified for recoupment for each actual duplicate claim.
3.5Identify the dollar amountactually received from the recoupment/offset action of each duplicateclaim.
3.5.1Submit the TED record(s) adjustmentwhere required.
3.5.2Applyany TED record(s) adjustments loaded to the DCS.
3.5.3Coordinate with other contractors whenpotential duplicates identified involve multi-contractor claim sets. Coordinationmethod shall be negotiated betweencontractors in the agreed upon communication form.
4.0Contractor Performance Requirements
4.1Contractorsshall use the TRICARE DCS to resolve DHA identified potential duplicateclaims payments. Performance standards are effective the first dayof the seventh month following the start of health care delivery(SHCD).
4.2Contractors shallmove Open status potential duplicate claim setsto Pending, Validate, or Closed statuson a first-in/first-out basis. To this end, contractor performance willbe measured against the percentageof claim sets in Open status at theend of a month with Current Load Dates over 30 days old. Nomore than 10% of the potential duplicate claim sets remaining inOpenstatusat the end of a month shall have Current Load Dates over 30 daysold. Contractor compliancewith this standard shall be determined from the Performance StandardReport generated by the DCS (see Addendum B,Summary Management Report titled “Performance Standards”, for adescription and example of the Performance Standard Report). The 10% standardbecomes effective on the first day of the seventh month following thestart of services or following system installation whichever islater.
4.3Contractors shall not be responsiblefor meeting the performance standard during any month in which availabilityof the DCS is prevented for two working days due to failure of anysystem component for which the Government is responsible. The Governmentis responsible for: DHA servers on which the DCS data resides; Government-suppliedcommunications lines, if any; Government-supplied routers, if any;Government-supplied Channel Sending Unit (CSU)/Data Sending Unit(DSU) equipment that connect the routers to the communication lines,if any; and the DCS application software.
4.4All overpayment recovery, refund,offset collection and adjustment requirements, including timelinessstandards, are applicable to the operation of the DCS.
5.0Jurisdiction
5.1Multi-ContractorSets
5.1.1Multi-contractor sets occurwhen two different contractors pay for the same billed service. Ina multi-contractor set, only one contractor should have processedand paid the claim if the claim was in their jurisdiction.
5.1.2Resolution of multi-contractorclaim sets requires close coordination between the contractors involvedto ensure that research efforts and resolution activities are conductedefficiently, appropriately, and in a timely manner. When researchinga multi-contractor set, the contractor with jurisdiction must coordinatewith the other contractor(s) involved to determine who is responsiblefor the duplicate payment(s) and for recouping the overpayment(s).The method of coordination must be negotiated between contractorsand may take whatever form is agreeable, i.e., by telephone, fax,e-mail, or combination thereof. This coordination is a courtesyamong contractors and should prevent indiscriminate transfers ofsets back and forth. Multi-contractor sets shall not be resolvedwithout communication and coordination among the involved contractors.
5.2Determining Jurisdiction ForClaim Sets
Duplicate claim sets assignjurisdiction in accordance with the TRICARE Operations Manual (TOM), Chapter8.
6.0Definition Of A Duplicate ClaimPayment
6.1A duplicate claim or encounteris a payment made for services for which reimbursem*nt has alreadybeen made on one or more previous claims or encounters. In otherwords, two or more payments were made for the same service for thesame beneficiary.
6.2For thepurposes of the DCS, when two or more payments are issued for thesame service for the same beneficiary, the additional payments areconsidered actual duplicate payments, regardless of whether theadditional payments were justified or made in error, recoupmentof the additional payments initiated, or refunds already received.
6.3The criterion to use in determiningif a claim represents an actual duplicate payment is an affirmativeanswer to the following question:
Have any or all of the servicespaid on this claim been paid on a previous claim/encounter?
6.4It must be noted that “claims”displayed in the DCS are in fact TED records the contractors submitted.The Government assumes that the TED records submitted by contractorsaccurately reflect the adjudication of the claims and the dollarspaid. When a user works in the DCS, they are seeing records thatreside on the TED database. They are seeing what appears to theGovernment to be duplicate payments. Users might think of TED recordsas entries in the Government’s checkbook. When a pair of TED recordsare displayed in the DCS, they are, in essence, representing twoentries in the Government’s checkbook. If these entries are notcancelled or adjusted, they represent actual dollars spent. Forthe purposes of the DCS, an unadjusted or non-cancelled TED recordon the TED database represents a claims payment even if the claimappears on the contractor’s claims processing system as having beenadjusted or cancelled. All duplicate TED records displayed in theDCS must be flagged as actual duplicates, and must be correctedthrough adjustments and cancellations to remove the duplicate conditionsfrom the TED database.
6.5TEDDupes
6.5.1The DCS identifies two kindsof duplicate TEDs:
•Those that represent actualoverpayments (where two or more payments were actually made and recoupmentsmust be initiated to recover the erroneous payments); and
•Those that were submitted butno actual payments were made (and therefore no recoupment actionsneed to be initiated).
6.5.2It is this second kind of duplicateTED that we refer to as a “TED Dupe”. TED Dupes most often occurwhen claims are processed but for some reason are pulled beforethe checks are actually sent and then re-processed under differentclaim numbers. If the original claims processed to the point thatTEDs were created, submitted, and accepted by DHA, and not subsequentlycancelled, the TEDs representing the reprocessed claims (with differentclaim numbers) will “dupe out” with the original, uncancelled, TEDsresiding on the TED database. In this instance, the Government isnot able to determine if payments have been made.
6.6System Objectives
6.6.1The system was designed tomeet the following objectives:
•To create a user-friendly,cost-effective application using web-based technology;
•To preserve TED data integrityand display only those potential duplicate claims records applicable toeach contractor;
•To provide as much data aspossible to assist contractors in their efforts to identify actualduplicate payments;
•To improve the detection ofactual duplicate claims payments through the use of match criteria thathave been found to be successful in identifying duplicate claimpayments;
•To automate methods for groupingand displaying institutional and non-institutional potential duplicateTEDs to contractors for research and resolution;
•To automate and simplify methodsfor contractors to report their determinations as to whether the identifiedpotential duplicate TEDs represent actual duplicate payments and,if they do, to report the corresponding amounts expected to be recouped;
•To automate and simplify methodsfor contractors to report actual recoupment amounts and providea mechanism for verifying that TED adjustments/cancellations weresubmitted and accepted, thereby correcting the duplicate conditionin the TED database;
•To automate methods to facilitateDHA and contractor audits and performance monitoring; and
•To provide the capability togenerate user defined reports and graphs.
6.6.2In meeting these objectives,the system provides the tools to monitor timely contractor researchand accurate identification of actual duplicate payments and aidsin diagnosing processing problems that cause duplicate payments.
7.0Functional Capabilities OfThe DCS
7.1The DCS is an on-line, real-time,user-friendly system. The DCS employs five different TED-based,duplicate detection match criteria to identify potential duplicateclaims. It also accommodates contractor transitions, financiallyunderwritten/non-financially underwritten claims, and duplicate claimspayments caused by jurisdictional processing errors. The DCS improvesDHA and contractor accountability of actual duplicate payments throughthe tracking of the amounts identified for recoupment, amounts actuallyreceived in refunds or offsets, and TED adjustments or cancellations submittedon receipt of the refunded or offset overpayments. The functionalcapabilities of the DCS supports the claims resolution process.
7.2User defined, pre-formattedreports are included in the DCS to help analyze trends, contractor performance,and processing or procedural problems in contractor operations.
7.3Extracting TED Data To CreateAnd Maintain The Duplicate Claims Databases
Using the duplicate claimsdetection criteria, the DCS identifies potential duplicate claimsfrom TEDs residing in the TED database. Copies of these claims areextracted from the TED database. At the same time, data elementsand values required for system operation are added and the datais loaded to tables on a DHA Database 2 (DB2) Server. These tablescomprise the Duplicate Claims Databases. TED data and DCS data residingin the Duplicate Claims databases are accessible to users throughthe DCS application. See Section 1.2, paragraph 1.0 for details onthe building of the Duplicate Claims databases.
8.0System Design
The DCS is a web-based applicationthat interfaces with a transaction-based “server” environment that processestransactions, maintains databases, and optimizes the access andtransfer of data between the two environments.
8.1Communications
The DCS uses two system platformsas shown in Figure 4.1.1-1 that operate independently.Data is transmitted from one platform to another through interfacesand a communications network. Users connect to this network andthe DCS via contractor-supplied web communications.
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