SIT OHI IUG

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					                                                       SAIC GSA Doc. GS-SISS-5000A
                                                                        28 Oct 2005




           IMPLEMENTATION USER‟S GUIDE
      STANDARD INSURANCE TABLE/OTHER HEALTH
                 INSURANCE (SIT/OHI)




                            Submitted in Response to

                         GSA Contract GS-35F-4461G
                       Task Order W81XWH-04-F-0885
CITPO FY05 Software & Systems Engineering Infrastructure and Sustainment Support,
                              Deliverable Item 29

                                      For:

                       USA MED Research ACQ Activity
                      and CITPO/CHCS II Program Office
                         5113 Leesburg Pike, Suite 701
                            Falls Church, VA 22041
               LtCol Melanie Richardson, Task Manager and COTR



                                      By:

                  Science Applications International Corporation
                          Health Solutions Business Unit
                10260 Campus Point Drive, San Diego, CA 92121
             David Metcalf, Program Manager, Phone: (703) 824-8571
            Wendy Kammeyer, Project Manager, Phone: (858) 726-7170
            Christine Rhodes, Product Manager, Phone: (858) 826-3889
                                                                    SAIC GSA Doc. GS-SISS-5000A
                                                                                     28 Oct 2005


                                      Record of Changes
This record is maintained throughout the life of the document and summarizes the changes
between approved issues of this document. The summary description explains the changes made
and any new sections. The reference data will specify the Delivery Order Number, project, release
and date of that submittal. This document supersedes all previous versions of this Document.



   Issue                Summary Description                          Reference Data
                                                          SAIC GSA Doc. GS-SISS-5000
      1     Initial submittal
                                                          12 Sep 2005, GSA Contract GS-35F-
                                                          4461G, Task Order W81XWH-04-F-
                                                          0885, CITPO FY05 Software &
                                                          Systems Engineering Infrastructure
                                                          and Sustainment Support, Deliverable
                                                          Item 29.

                                                          SAIC GSA Doc. GS-SISS-5000A
      2     Revision A. Revised in accordance with
                                                          28 Oct 2005, GSA Contract GS-35F-
            changes resulting from Alpha Test.
                                                          4461G, Task Order W81XWH-04-F-
                                                          0885, CITPO FY05 Software &
                                                          Systems Engineering Infrastructure
                                                          and Sustainment Support, Deliverable
                                                          Item 29.




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                                                            TABLE OF CONTENTS

Section                                                                                                                                                         Page
1.       SUMMARY OUTLINE ................................................................................................................................. 1-1
     1.1         STANDARD INSURANCE TABLE (SIT) ENHANCEMENTS ........................................................................... 1-1
     1.2         OTHER HEALTH INSURANCE (OHI) ENHANCEMENTS .............................................................................. 1-1
     1.3         MEDICAL SERVICES ACCOUNTING/THIRD PARTY COLLECTIONS (MSA/TPC) ENHANCEMENTS............. 1-2
2.       SUBSYSTEM CHECKLIST ......................................................................................................................... 2-1
     2.1         USER TRAINING....................................................................................................................................... 2-1
     2.2         INSTALLATION AND IMPLEMENTATION ACTIVITIES ................................................................................. 2-1
        2.2.1       Pre-Install Activities .......................................................................................................................... 2-1
        2.2.2       Post-Install Activities ......................................................................................................................... 2-1
        2.2.3       Pre-Activation/Conversion Activities ................................................................................................. 2-2
        2.2.4       Post-Activation/Conversion Activities ............................................................................................... 2-2
     2.3         INTEGRATION ISSUES .............................................................................................................................. 2-3
     2.4         FILE AND TABLE CHANGES ..................................................................................................................... 2-3
     2.5         SECURITY KEYS ...................................................................................................................................... 2-4
3.       CHANGES AND ENHANCEMENTS ......................................................................................................... 3-1
     3.1      STANDARD INSURANCE TABLE (SIT) ENHANCEMENTS ........................................................................... 3-1
        3.1.1   Overview of Change........................................................................................................................... 3-1
        3.1.2   Detail of Change ................................................................................................................................ 3-1
        3.1.3   File and Table Changes ................................................................................................................... 3-30
        3.1.4   Implementation Issues...................................................................................................................... 3-31
     3.2      OTHER HEALTH INSURANCE (OHI) ENHANCEMENTS ............................................................................ 3-31
        3.2.1   Overview of Change......................................................................................................................... 3-31
        3.2.2   Detail of Change .............................................................................................................................. 3-32
        3.2.3   Summary of File and Table Changes ............................................................................................... 3-91
        3.2.4   Implementation Issues...................................................................................................................... 3-92
     3.3      MEDICAL SERVICES ACCOUNTING/THIRD PARTY COLLECTIONS (MSA/TPC) ENHANCEMENTS........... 3-93
        3.3.1   Overview of Change......................................................................................................................... 3-93
        3.3.2   Detail of Change .............................................................................................................................. 3-93
        3.3.3   File and Table Changes ................................................................................................................. 3-108
        3.3.4   Implementation Issues.................................................................................................................... 3-108
APPENDIX A.                   BUSINESS RULES ............................................................................................................... A-1

APPENDIX B.                   FAMILIARIZATION TRAINING PLAN ........................................................................... B-1

APPENDIX C.                   SAMPLE PRE-IMPLEMENTATION REPORTS ............................................................ C-1




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How To Use This Document

This Implementation User‟s Guide is a reference manual for the implementation of Standard
Insurance Table/Other Health Insurance (SIT/OHI) Enhancements, Composite Health Care
System (CHCS) Version 4.630. It is applicable primarily to the Data Administration (DA),
Patient Administration (PAD), and Medical Services Accounting /Third Party Collections
(MSA/TPC) subsystems.

The Table of Contents provides an outline of the information contained in this guide. The
guide is divided into the following sections:

How To Use This Document                    -        A description of the guide and how to use it.

1   Summary Outline                         -        Brief overview of changes, which can be used
                                                     as a handout to all users.

2   Subsystem Checklist                     -        A step-by-step list of implementation
                                                     activities to be completed when the SIT/OHI
                                                     software updates are installed.

3   Changes and Enhancements                -        A description of each software enhancement
                                                     with subsections, including an Overview,
                                                     Detail of Change, File and Table Change, and
                                                     Implementation Issues.

4   Appendices                              -        Applicable information pertaining to the
                                                     implementation of SIT/OHI enhancements.




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1. SUMMARY OUTLINE

This document provides an overview of the software changes associated with the SIT/OHI
enhancements; which are also a part of the TRICARE Next Generation (TNEX) enhancements.

1.1 Standard Insurance Table (SIT) Enhancements

Enhancements to the SIT data were needed to comply with necessary standardization of
Insurance Company (Payer) data as required by the Health Insurance Portability and
Accountability Act (HIPAA). The following changes have been made to the insurance-related
software in CHCS:

         Replaced the current, locally-maintained Standard Insurance Table with the Department
          of Defense‟s (DoD) Defense Enrollment Eligibility Reporting System (DEERS) Health
          Insurance Carrier (HIC) table.
         Automatically synchronized the DoD SIT data between CHCS and the Third Patient
          Outpatient Collections System (TPOCS).
         Converted existing OHI policies to new OHI policies, utilizing DoD DEERS Health
          Insurance Carriers.
         Automated the process for requesting the addition of Temporary Health Insurance
          Carriers and the process for requesting updates to information associated with standard
          health insurance carriers.

Coverage Codes and the ability to associate multiple addresses with a single insurance company
are also new enhancements. The data is structured so that:

         Each insurance company may have multiple „coverage types.‟
         Each Coverage Type may have multiple „payer types.‟
         Each Coverage Type/Payer Type will have one address.

The existing Standard Insurance Table (SIT) menu option has been replaced by the new SIT
menu option (Menu Path: DAA  CFT  CFM  STM  SIT). When the SIT option is
accessed, an action bar displays with a variety of actions, including those that allow the user to
add, update, and view SIT data. A new security key, “DOD SIT MGR,” allows a user to perform
all functions on the action bar. Users holding the existing DOD SIT key will be allowed access
to a subset of the actions.

1.2       Other Health Insurance (OHI) Enhancements

The primary change with this software update is the movement of the master OHI database from
CHCS to DEERS. The local CHCS has been the repository for OHI data since the
implementation of Outpatient Itemized Billing (OIB). With the new TNEX enhancements, the
responsibility for maintaining the OHI repository has been assumed by DEERS.

CHCS automatically contributes locally entered OHI data to the central repository through the
new CHCS  DEERS interface. Other subscribers (e.g., Managed Care Support Contractors


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(MCSCs) utilizing a web service) also contribute OHI data to the central OHI repository. CHCS
downloads OHI data entered by the MCSCs, as well as other subscribers, affording CHCS access
to policy information that might not otherwise be available for claims processing.

When OHI data is accessed through any CHCS pathway (Patient Administration (PAD), Patient
Appointment & Scheduling (PAS), Ambulatory Data Module (ADM), or MSA), CHCS sends
DEERS an “OHI Inquiry” prior to allowing the user to enter/edit any OHI data. DEERS returns
an “OHI Response” message that includes OHI data associated with each policy held by the
selected patient. Once the current DEERS OHI information is received by CHCS, an action bar
is displayed and allows a CHCS user to perform various functions on a patient‟s OHI data,
including the ability to add, update, and view the data. All users can view OHI data, but only
holders of the DG OHI Security Key can enter/edit OHI data.

1.3    Medical Services Accounting/Third Party Collections (MSA/TPC) Enhancements

With this update, inpatient TPC claims billing will be based on ranking and mailing addresses at
the Coverage Type level, as opposed to ranking and addresses at the policy level, which was the
case in previous versions of CHCS. The only Coverage Types applicable to inpatient TPC
claims are (XM) Comprehensive (MD) Medical, Medical Only, and (IP) Inpatient. Screen
displays, reports and UB-92 claim forms that utilize OHI data will be modified to reflect the
Coverage Type enhancements and new field names introduced with the TNEX SIT/OHI
enhancements. There will be no changes in the methodology used to calculate TPC billing
charges in CHCS for inpatient Diagnosis Related Groups (DRGs).




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2. SUBSYSTEM CHECKLIST

2.1    User Training
The CHCS Training Database does not include the SIT/OHI enhancements at the time of this
writing. Therefore, hands-on training or software demonstrations in the training environment are
not methods that can be used for training.

Database Administrators (DBAs) and users responsible for maintenance of the Insurance Table
file should be briefed on the enhancements. It is recommended that a one-hour PowerPoint
presentation be developed and presented.

Users who enter/edit insurance data for patients should be briefed on the changes to OHI screens.
It is recommended that a handout be developed, or a one-half to 1-hour demonstration using a
PowerPoint presentation, to inform users of the changes.

All MSA/TPC users who enter or process insurance data for patients should be briefed on the
enhancements that affect MSA/TPC screens and processes. Section 3.3 of this document may be
used as a reference to brief users on the MSA changes.
It is also recommended that any distance-learning training available on this enhancement be used
as a training tool. Associated Web Based Training (WBT) and Virtual Classroom (VC) sessions
may be available to your site. To check on access and availability, contact your on-site CHCS
training point of contact (POC).
2.2   Installation and Implementation Activities

2.2.1 Pre-Install Activities
___    Print the OHI Report sorted by Insurance Company, a minimum of 3 times − once for
       Standard Insurance Companies, once for Temporary Insurance Companies, and once for
       Inactivated Insurance Companies. These reports will be critical in post-implementation
       clean-up.

___    Print the Insurance Verification Report and clean-up old policies that may be obsolete.

2.2.2 Post-Install Activities

___    Assign the new security key, “DOD SIT MGR”, to the appropriate user(s) who will
       maintain the local SIT file. The key allows a user to perform all the functions on the
       action bar displayed through the SIT option. It also allows the user access to the “Full
       SIT Subscription Inquiry” option, which is used to perform a full, or partial, subscription
       update to the local SIT file. A partial subscription update adds and/or updates the local
       SIT with DEERS changes made within a user-specified time period (up to 7 days). A full
       subscription update downloads a fresh copy of the DEERS SIT table.

____ Assign the Pre-Implementation Report secondary options to the appropriate personnel.



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___    Verify that site POC(s) responsible for Insurance File maintenance are trained in the
       software enhancements.

___    Verify that all users who enter/edit OHI data in CHCS are briefed on the changes to the
       screens and actions for OHI data entry and edit.

___   Verify that the appropriate supervisory users are assigned the new security keys after the
      software conversion.

___    Verify that MSA/TPC users are briefed on the SIT/OHI enhancements that affect TPC.

___    Run the Pre-Implementation Reports 1-5. These reports are accessed using secondary
       sub-menu options under the acronym PRE. (Note: The Pre-Implementation Reports may
       be run multiple times, if necessary.)

___    After the Pre-Implementation Reports have been run, use the report information to
       perform any clean-up activities associated with the CHCS SIT and OHI files that can be
       done prior to the SIT/OHI conversion/activation.

2.2.3 Pre-Activation/Conversion Activities

___    Print the Insurance Verification Report the day before the SIT/OHI activation/conversion.

___    Print the MSA insurance accounts receivable the day before the SIT/OHI
       activation/conversion.

___    Confirm that the business office has performed all planned pre-activation clean-up
       activities.

2.2.4 Post-Activation/Conversion Activities

____ Print the OHI Report, sorted by Insurance Company, for each of the Health Insurance
     Carrier (HIC) statuses.

___    Print the Insurance Verification Report and compare the data to the pre-activation version
       of the Insurance Verification Report.

___    Print MSA insurance account receivables and compare the data to the insurance accounts
       receivable from the pre-activation version.

____ Use the Pre-Implementation Reports data, the OHI Report data, and the Insurance
     Verification Report data to re-point old “Temporary” insurance companies to new
     “Standard” insurance companies, as applicable, and perform other necessary clean-up
     activities associated with the CHCS SIT and OHI files.




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2.3     Integration Issues

      N/A


2.4     File and Table Changes

___ The new DoD DEERS Health Insurance Carrier (HIC) file replaces the current local
    insurance company table. Health Insurance Carrier data is maintained on DEERS and is
    downloaded to each local CHCS host on an initialization download, and is subsequently
    tasked on an hourly basis.

___ A new SIT menu option will replace the existing SIT menu option.

___ Although local CHCS users will enter/edit OHI on local CHCS host platforms, the master
    OHI database will no longer be maintained on the local CHCS hosts. DEERS will now
    maintain the master OHI database.

___ The conversions that run after the installation of the TNEX SIT/OHI software will convert
    all active OHI policies from the old CHCS Policy file (#8086) to new policy records in the
    new CHCS OHI file (#8074).

___ Coverage Type codes and Payer Type codes have been introduced for inclusion in the
    insurance company data. Addresses to which claims are submitted will be based on
    Coverage Type/Payer Type, rather than at the carrier level as they have been in the past.

___ The existing DG REPOINT OHI BATCH UTILITY option will be modified to reflect the
    changes from the data file structure in the old Policy file (#8086) to the new OHI file
    (#8074). The secondary menu option, Re-Point OHI Batch Utility (REP) [DG REPOINT
    OHI BATCH UTILITY], will allow a user to re-point all OHI policies associated with a
    user-selected SIT entry to a different user-selected SIT entry. This option is controlled by
    the new DG OHI MGMT security key.

___ The CPZ OHI security key will be converted to the new DG OHI security key for all
    holders of the old key. This key allows holders to access the OHI Enter/Edit option.

___ The CP OHI SUPPLEMENT security key will be converted to the DG OHI SUPPLEMENT
    security key for all holders of the old key. This will allow access to the new DG CREATE
    SUP OHI ASCII FILE secondary menu option for generation of the Supplemental ASCII
    SOHI file.

___ The CP OHI INITIALIZE security key will be converted to the DG OHI INITIALIZE
    security key for all holders of the old key. This will allow holders to access the CP
    CREATE COMP OHI ASCII FILE (Generate ASCII file – Snapshot of Current OHI).



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       Note: The CHCS Site Manager is typically the only holder of the DG OHI INITIALIZE
       security key.

___ Screen displays, reports, and UB-92 claim forms that support OHI data for MSA/TPC will
    contain minor modifications to reflect the Coverage Type enhancements and new field
    names.

___ A secondary sub-menu has been added for Pre-Implementation Reports 1-5. These menu
    options are locked by the DOD SIT MGR security key. In the Option File, the sub-menu
    option is called [DG PRE-IMP-SIT-OHI REPORTS].

2.5      Security Keys
      The following are new and/or existing security keys associated with this enhancement:

      DOD SIT: This is an existing security key that allows the user to access the basic SIT
      actions (Add, Update, View, Cancel, Report and Exit). Since it is an existing key, it is
      important for the sites to evaluate the current list of users who hold the existing key and
      make applicable changes for these users.
      DOD SIT MGR: In addition to the basic actions available through the Standard Insurance
      Table (SIT) option (i.e., Add, Update, View, Cancel, Report and Exit), this new security key
      allows the user to request the deactivation of an insurance carrier, send a SIT subscription
      inquiry to DEERS, generate a supplemental SIT TPOCS American Standard Code for
      Information Interchange (ASCII) file transmission, and generate the new Pre-Implementation
      Reports 1-5 under the acronym, PRE. These options are locked by the DOD SIT MGR
      security key. In the Option File, the menu option is called [DG PRE-IMP-SIT-OHI
      REPORTS].
      DG OHI: A conversion will assign this new key to current holders of the CPZ OHI key
      which allowed holders to access the OHI Enter/Edit option and actions in the old software.
      When the switch is flipped to allow users access to the new software, the new security key
      will be enabled.
      DG OHI SUPPLEMENT: When the switch is flipped to allow users to access the new
      software, holders of the CP OHI SUPPLEMENT key will be assigned this new key. This
      will allow access to the secondary menu option, DG CREATE SUP OHI ASCII FILE, which
      was formerly the CP CREATE SUP OHI ASCII FILE. This option allows the user to
      generate a supplemental OHI file (SOHI) to provide later-activating sites with OHI data that
      matches the other sites on that host.
      DG OHI INITIALIZE: This new key will replace the CP OHI INITIALIZE security key
      and is typically held by the CHCS Site manager. When the switch is flipped to allow the
      users access to the new software, a conversion will enable this key and assign it to holders of
      the old key. This key will allow users to access the secondary menu option used to generate
      the ASCII file that takes a snapshot of the current OHI data in CHCS when the IOHI option
      is run.




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DG OHI MGMT: This key controls the existing secondary menu option, Re-Point OHI
Batch Utility (REP) [DG REPOINT OHI BATCH UTILITY], which allows a user to re-point
all OHI policies associated with a user-selected SIT entry to a different user-selected SIT
entry. This option will be changed to reflect the changes from the data file structure in the
old Policy file (#8086) to the new OHI file (#8074).




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3. CHANGES AND ENHANCEMENTS

3.1        Standard Insurance Table (SIT) Enhancements

3.1.1 Overview of Change
Enhancements to the SIT data were needed to comply with necessary standardization of Insurance
Company (Payer) data as required by the Health Insurance Portability and Accountability Act
(HIPAA). The following changes have been made to the insurance-related software in CHCS:

          Replaced the current, locally-maintained Standard Insurance Table with the Department of
           Defense‟s (DoD) Defense Enrollment Eligibility Reporting System (DEERS) Health
           Insurance Carrier (HIC) table.
          Automatically synchronized the DoD SIT data between CHCS and the Third Patient
           Outpatient Collections System (TPOCS).
          Converted existing OHI policies to new OHI policies, utilizing DoD DEERS Health
           Insurance Carriers.
          Automated the process for requesting the addition of Temporary Health Insurance Carriers
           and the process for requesting updates to information associated with standard health
           insurance carriers.

Coverage Codes and the ability to associate multiple addresses with a single insurance company are
also new enhancements. The data is structured so that:

          Each insurance company may have multiple „coverage types.‟
          Each Coverage Type may have multiple „payer types.‟
          Each Coverage Type/Payer Type will have one address.

The existing Standard Insurance Table (SIT) menu option, has been replaced by the new SIT menu
option (Menu Path: DAA  CFT  CFM  STM  SIT). When the SIT option is accessed, an
action bar displays with a variety of actions, including those that allow the user to add, update, and
view SIT data. A new security key, “DOD SIT MGR,” allows a user to perform all functions on the
action bar. (Add, Update, View, Cancel, Deactivate, Report, Subscribe, TPOCS and Exit).

Users holding the existing DOD SIT key will be allowed access to a subset of the actions (Add,
Update, View, Cancel, Report and Exit).


          3.1.2   Detail of Change

SIT Menu Options

The options to access the SIT functionality are located on the DAA menu:

           Menu Path: DAA  CFT  CFM  STM (Standard Insurance Company Table Menu)



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------------------------------------------------ SIT Screen 1 --------------------------------------------


  CFS Common Files Supplementary Menu
  DEP Department and Service File Enter/Edit
  HOS Hospital Location File Enter/Edit
  HPN Host Platform Name Enter/Edit
  MCD Medical Center Division File Enter/Edit
  MTF Medical Treatment Facility File Enter/Edit
  PRO Provider File Enter/Edit
  STM Standard Insurance Company Table Menu
  UIC UIC Management Menu
  ZIP Zip Code File Enter/Edit
  ACT Inactivate/Reactivate File Entries

Select Common Files and Tables Maintenance Menu Option: STM

  SIT    Standard Insurance Company Table
  VIC    View Attorney Data
  ATT     Attorney Enter/Edit
  REP    Attorney Report

Select Standard Insurance Company Table Menu Option: SIT



When the user selects the SIT option from the Standard Insurance Company Table Menu (STM)
Option, the STANDARD INSURANCE TABLE screen displays. The actions displayed on the
action bar at the bottom of the screen are dependent upon the security key that is allocated to the
user. A new security key, DOD SIT MGR, allows a user to perform all the functions displayed on
the action bar, as depicted in SIT Screen 2.

------------------------------------------------- SIT Screen 2 ---------------------------------------------

                                       STANDARD INSURANCE TABLE


Add   Update   View   Cancel   Deactivate   Report   Subscribe   TPOCS   Exit
View the insurance company and coverage type data for a selected insurance
company.

The existing DOD SIT security key will allow a user to perform a subset of the above functions, as
displayed on the action bar in SIT Screen 3.




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------------------------------------------------------ SIT Screen 3 ---------------------------------------------


                                       STANDARD INSURANCE TABLE



Add   Update   View   Cancel   Report   Exit
View the insurance company and coverage type data for a selected insurance
company.



The table below provides a detailed description of each action.

Key to Actions on SIT Screen 3:

         Action                                                  Detail

Add                        Allows an authorized user to add a new insurance company if it does not
                           exist on the local CHCS SIT and needs to be added to a patient‟s OHI.

                           The user should provide as much information as possible when adding
                           and updating. The more insurer information transmitted with the
                           request to Add an insurance company to the DEERS SIT, the greater
                           opportunity for a rapid verification of the new SIT entry by the
                           Department of Defense (DOD) Uniform Business Office (UBO)
                           Verification Point of Contact (VPOC) − the person responsible for
                           verifying health insurance carrier information on the DEERS database.

Update                     Allows an authorized user to update existing insurance company
                           information, including coverage type.

View                       Allows an authorized user to view the insurance company and coverage
                           type data for a selected carrier.

Cancel                     Allows an authorized user to cancel a recent submission of a new
                           insurance company or new insurance coverage type that has not been
                           verified by the DoD UBO VPOC.
Deactivate                 Allows an authorized user to request a deactivation of an insurance
                           company if it is determined that the insurance company in the local SIT
                           is no longer valid. The DoD UBO VPOC will make the final
                           determination for deactivation.
Report                     Produces a report that displays insurance and coverage type data based
                           on selected parameters for type of insurance company, e.g., Standard,
                           Temporary, Deactivated, etc.




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Subscribe
                           Allows an authorized user to perform an inquiry and retrieval of the
                           latest DEERS SIT data.

                           A user may request a Partial Subscription, which displays a Date Last
                           Updated prompt, or a Full Subscription, which retrieves the entire
                           DEERS SIT data.

                           The Full Subscription should only be used if CHCS SIT has gotten out
                           of sync with the central SIT on DEERS for an extended period of time.
TPOCS                      This is a manual process that will create an ASCII file of Insurance
                           Company data for transmission from CHCS to TPOCS. This would
                           serve as a supplementary file in addition to the current daily file being
                           sent. This function is used as disaster recovery in the event the
                           CHCS/TPOCS data becomes out of sync.



„ADD‟ Action

Menu Path: DAA  CFT  CFM  STM  SIT  Add action

A new insurance company can be added by selecting the „Add‟ action on the STANDARD
INSURANCE TABLE screen through the SIT option off the Standard Insurance Company Table
Menu.

----------------------------------------------- SIT Screen 4 -----------------------------------------------


                                       STANDARD INSURANCE TABLE




Add   Update   View   Cancel                 Deactivate        Report        Subscribe        TPOCS       Exit
Add a new insurance company.



        Note: A new insurance company may also be added in CHCS through the OHI functionality
        (Sample Menu Path: PAD->ROM->PII). When a user wants to enter an insurance company
        into the OHI record, but the insurance company does not currently exist on the local SIT, the
        system will display the STANDARD INSURANCE TABLE - ADD INS CO screen. The
        user will be allowed to enter a Temporary HIC so that the entry of the OHI can be
        accomplished.

The following screen is the layout of the SIT Add. When the screen is displayed, all the fields will
be blank for the user to enter insurance company data.


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------------------------------------------------------ SIT Screen 5 ---------------------------------------------


SIT ID:                                              STANDARD INSURANCE TABLE - ADD INS CO

Insurance Company Name:
Additional Description:
       Carrier Website:
Customer Service Email:
            BC/BS Code:                       HIC Status Code:                  HIC Verification Code:

    Coverage/Payer Type:




  HIC Loc Cmmt:
  HIC Std Cmmt:

Last Update System Name: CHCS Test Site for Contractor Test
  Last Update User Name: PAWOLL,SALLON
 Last Update User Phone:                        Ext:
 Last Update User Email:




Key to Fields on SIT Screen 5:

      Field Name                                   Definition and Detail                             Required
SIT ID                       Identifier for insurance company. This is assigned by                        N
                             DEERS; the user will not be able to create the SIT ID.
Insurance Company            Name of insurance company                                                    Y
Name
Additional Description       Additional identification for the company                                    N
Carrier Website              Website for central billing office                                           N
Customer Service E-          Customer Service E-mail address associated with billing                      N
mail                         office

Blue Cross/Blue              The Blue Cross/Blue Shield code assigned to applicable                       N
Shield Code                  insurance companies




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HIC Status Code       Indicates whether a carrier has been verified as Standard,          N
                      or is still in a Temporary status. Also indicates that a
                      carrier is no longer active, or is active but does not have a
                      compete data set (Placeholder).
                      Values include:
                      S   =   Standard
                      T   =   Temporary
                      D   =   Deactivated
                      P   =   Placeholder
                      C   =   Cancelled
                      R   =   Rejected
                      Note: This field will always be blank on the “Add” screen
                      because DEERS assigns the value and the new carrier has
                      not yet been sent to DEERS.
HIC Verification      Indicates whether the DoD UBO VPOC has verified the                 N
Status                carrier and/or data associated with the carrier.
                      Set of Codes:
                      D = Unverified Data
                      U = Unverified Carrier
                      V = Verified
                      Note: This field will always be blank on the “Add” screen
                      because DEERS assigns the value and the new carrier has
                      not yet been sent to DEERS.
Coverage Type/Payer   Coverage Types and Payer Types define the claims‟                   Y
Type                  addresses associated with the insurance carrier. At least
                      one Coverage Type must be entered. See Table 1 below
                      for valid codes.
HIC Local Comment     Text (editable at the local medical treatment facility (MTF)        N
                      level) providing additional information about the insurance
                      company
HIC Standard          Text (editable by the DoD UBO VPOC) providing                       N
Comment               additional information about the insurance company
Last Update System    Defaults to current system to which the user is logged on           Y
Name
Last Update User      Defaults to current user                                            Y
Name
Last Update User      Defaults from user file. If value is null, user must enter          Y
Phone                 this value before filing the new HIC.
Last Update User      User must enter this value.                                         Y
Email



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When adding an insurance company, at least one Coverage Type and Payer Type must be entered.
The insurance company may have multiple Coverage Types assigned. Each of those Coverage
Types may have several Payer Types.

The following table lists the choices of Coverage Types and Payer Types that can be associated
with a single insurance company.

                                  Table 1. Coverage and Payer Types

                       Coverage and                         Description
                       Payer Types

                     Coverage Type         The indicator for the type of coverage:
                                           List of Values:
                                           XM COMPREHENSIVE MEDICAL
                                           (default)
                                           DN    DENTAL
                                           IP    INPATIENT
                                           LT     LONGTERM CARE
                                           MD    MEDICAL ONLY
                                           MH    MENTAL HEALTH
                                           OP    OUTPATIENT
                                           PH    PARTIAL HOSPITALIZATION
                                           RX    PHARMACY ONLY
                                           SN    SKILLED NURSING
                                           VI    VISION
                     Payer Type Code B = both Institutional and Professional
                                         (default)
                                     I = Institutional Only
                                     P = Professional Only
                                     N = Nonbillable

The user will enter a new Coverage Type under the “Coverage/Payer Type” prompt. When a new
Coverage Type is added, a new screen (SIT Screen 6) is provided to enter the detailed information
specific to the Coverage Type/Payer Type combination.
------------------------------------------------- SIT Screen 6 ---------------------------------------------

SIT ID: CALAK0001                                 STANDARD INSURANCE COMPANY - UPDATE INS CO

Insurance Company Name: CALCO
         Coverage Type: COMPREHENSIVE MEDICAL (default)
       Payer Type Code: BOTH INSTITUTIONAL AND PROFESSIONAL
  Coverage Status Code: S              Coverage Verification Status: V




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                  ATTN:
   P.O. Box/St Address:        PO BOX 101422
              Zip Code:        99510                            Zip Ext:
         State/Country:        ALASKA
                  City:        ANCHORAGE

           Phone Number: 9072768177                        Phone Ext:
             FAX Number:

   Cvr Loc Cmmt:
   Cvr Std Cmmt:

Coverage Last Update System Name: CHCS Test Site for Contractor Test


Key to Fields on SIT Screen 6:
     Field Name                                 Description                           Required
SIT ID                 Identifier for insurance company. This is assigned by             N
                       DEERS; the user will not be able to create the SIT ID.
                       Note: This field will be blank on the “Add” screen because
                       the value must be returned from DEERS before it‟s
                       populated in CHCS.
Insurance Company      Name of insurance company.                                         Y
Name
Coverage Type          See Table 1 above for valid values.                                Y
Payer Type Code        See Table 1 above for valid values.                                Y
Coverage Status Code   Indicates whether a Coverage Type has been verified as             N
                       Standard, or is still in a Temporary status. Also indicates
                       that a Coverage Type is no longer active.
                       Values include:
                       S   =   Standard
                       T   =   Temporary
                       D   =   Deactivated
                       P   =   Placeholder
                       C   =   Cancelled
                       R   =   Rejected
                       Note: This field will always be blank on the “Add” screen
                       because DEERS assigns the value and the new carrier has not
                       yet been sent to DEERS.




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     Field Name                                 Description                             Required
Coverage Verification    Indicates whether the DoD UBO VPOC has verified the               N
Status                   Coverage Type and/or data associated with the Coverage
                         Type.
                         Set of Codes:
                         D = Unverified Data
                         U = Unverified Carrier
                         V = Verified

                         Note: This field will always be blank on the “Add” screen
                         because DEERS assigns the value and the new carrier has
                         not yet been sent to DEERS.
ATTN                     Special instructions, e.g., Attention, Dept, etc.                  N
P.O. Box/St. Address     Street address to which claims are to be mailed.                   Y
ZIP Code                 Zip Code associated with billing address.                          Y
ZIP Ext                  Zip Code extension associated with billing address.                N
State/Country            State associated with billing address or Country Code              Y
                         associated with billing address.
City                     City associated with billing address.                              Y
Phone Number             Primary phone number associated with billing office                Y
Phone Ext                Extension associated with primary phone number for                 N
                         billing office.
Fax Number               Fax Number associated with billing office                          N
Cvr Local Comment        Text (editable at the local MTF level) providing additional        N
                         information about the Coverage Type.
Cvr Standard             Information text associated with the Coverage Type, which          N
Comment                  is included in the standard insurance carrier record.
Coverage Last Update     Defaults to current system to which the user is logged on.         Y
System Name

When a new Health Insurance Carrier (HIC/SIT) is added in CHCS, a message is sent to DEERS
requesting that a “Temporary” insurance carrier be added. In the interim, the user within the OHI
functionality can complete the patient‟s OHI record using the new carrier, even though it is in a
“Temporary” status. The “Temporary” record will go through the DoD UBO VPOC verification
process and, if it is determined to be a new valid record, it will become “Standard” and “Verified”
in DEERS.

If a local CHCS host sends a request for a new carrier to be added, and DEERS can match the
submitted entry to an existing entry on the DEERS SIT database, DEERS will send a response
message to CHCS that includes the HIC ID of the existing SIT entry and a HIC STATUS CODE of
"S" (Standard) or other HIC STATUS CODE, if applicable. CHCS will use this HIC ID to
establish OHI.




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If the submitted entry does not exist on the DEERS SIT database, the DoD UBO VPOC will verify
the insurance company data submitted by CHCS to ensure that it is correct and not a duplicate of
another insurance company.

When the DoD UBO VPOC validates the SIT entry, a HIC STATUS CODE of "S" (Standard) and
a HIC VERIFICATION STATUS CODE of "V” (Verified) is assigned. Once verified, CHCS (and
all other authorized subscribers to the DEERS HIC SIT) receives the change of status in the next
hourly HIC download from DEERS.

„UPDATE‟ Action

Menu Path: DAA  CFT  CFM  STM  SIT  Update action

------------------------------------------------------ SIT Screen 7 ---------------------------------------------

                                       STANDARD INSURANCE TABLE




Add   Update   View   Cancel   Deactivate                       Report       Subscribe        TPOCS       Exit
Update an existing insurance company.




When a CHCS user identifies that an insurance company on the local CHCS SIT needs updating,
he/she uses the „Update‟ action and the following prompt displays:


Select Insurance Company Name:


At the prompt, the user can enter the HIC ID, Insurance Company Name, or a partial Insurance
Company Name.
An insurance carrier must meet the following criteria or the carrier record can not be updated:
    1. The HIC ID must already exist in the SIT table.
    2. The carrier record must have a HIC Verification Status of “Verified.”
    3. The carrier can not have a Carrier Cross-Reference ID assigned. (See more information on
       Cross-Referenced Carrier at the end of this SIT section.)
        If a user selects the „Update‟ action from the main SIT maintenance action bar, and selects a
        HIC that has a Carrier Status of “Unverified”, the following message displays:

             The carrier you selected has a HIC Verification Status of
             “Unverified.” Updating carrier records with an “Unverified” HIC
             Verification Status is not allowed. You will be allowed to update the




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             selected carrier record after the carrier has been verified by the UBO
             VPOC.

        If a user selects the „Update‟ action from the main SIT action bar and selects a carrier that
        has been cross-referenced, the following message displays:

                 The carrier you selected is cross-referenced to <Carrier Cross-
                 Reference Carrier ID>. Carriers that have a cross-reference
                 assigned are not editable. Do you want to view data associated
                 with the carrier you selected? N//

Once an insurance company is selected, the following Update screen (SIT Screen 8), and then the
companion screen, is displayed. The information associated with the last user who updated the HIC
record will display on the update screen. When the user completes the update on this screen, a
second screen will display so that the current user‟s information will replace the last update user‟s
information in the HIC record that is sent to DEERS.

------------------------------------------------------ SIT Screen 8---------------------------------------------


SIT ID: AETKY0005                                    STANDARD INSURANCE TABLE - UPDATE INS CO

Insurance Company Name: AETNA US HEALTHCARE
Additional Description:
       Carrier Website:
Customer Service Email:
            BC/BS Code:        HIC Status Code: S                           HIC Verification Code: V

   Coverage/Payer Type:
  COMPREHENSIVE MEDICAL (default) BOTH INSTITUTIONAL AND PROFESSIONAL



  HIC Loc Cmmt:
  HIC Std Cmmt: FOR NON HMO CLAIMS IN AK AZ CA HI ID NV NM OR UT AND WA
Last Update System Name:            WEB USER
  Last Update User Name:            ALEXANDRA LOPEZ
 Last Update User Phone:            7039338321             Ext:
 Last Update User Email:            Alexandra.lopez@tma.osd.mil




SIT ID: AETKY0005                              STANDARD INSURANCE TABLE - UPDATE INS CO


  Current System Name:           LEMOORE
    Current User Name:           ANDERSON,LYNN
   Current User Phone:           111-111-7502           Ext:
   Current User Email:           anderson.lynn@lemoore.com




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Key to fields on the Update screen (SIT Screen 8) that were not included, or contain values that are
defined slightly differently, on the Add screen (SIT Screen 5):

       Field Name                             Definition and Detail                     Required
SIT ID                   Identifier for insurance company. This is display-only on          Y
                         the Update screen.
Last Update System       Name of the system from which the last update was sent to          Y
Name                     the DEERS HIC database.
Last Update User         Name of the user who entered the last update to this HIC           Y
Name                     record that was sent to the DEERS HIC database.
Last Update User         Telephone Number of the user who entered the last update           Y
Phone                    to this HIC record that was sent to the DEERS HIC
                         database.
Last Update User         E-mail address of the user who entered the last update to          Y
Email                    this HIC record that was sent to the DEERS HIC database.
Current System Name      Defaults to the system to which the current user is logged         Y
                         on.
Current User Name        Defaults to name of the current user who is updating this          Y
                         HIC record.
Current User Phone       Telephone Number of the current user who is updating this          Y
                         HIC record. The user‟s telephone number should default
                         from the User file but, if it does not default, user is
                         required to enter this data.
Current User Email       E-mail address of the current user who is updating this HIC        Y
                         record. User is required to enter this data.

The SIT ID and the Insurance Company Name are the key identifier values for a Health Insurance
Carrier (HIC); and these two fields are not editable.

The following types of updates are allowed:

        Insurance company information may be changed.
        A Coverage Type may be added to an existing insurance company record.
        The information under an existing Coverage Type may be updated.

When the user selects a Coverage Type to edit, or adds a new Coverage Type, SIT Screen 9
displays to enter the detailed information for the Coverage Type/Payer Type.




                                                 3-12
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------------------------------------------------------ SIT Screen 9 ---------------------------------------------


SIT ID: AETCA0034                                    STANDARD INSURANCE COMPANY - UPDATE INS CO
Insurance Company Name: AETNA US HEALTH
         Coverage Type: COMPREHENSIVE MEDICAL (default)
       Payer Type Code: BOTH INSTITUTIONAL AND PROFESSIONAL

  Coverage Status Code: S                 Coverage Verification Status: V
                   ATTN:          Medical Claims
    P.O. Box/St Address:          111 PO BOX
               Zip Code:          92121                                    Zip Ext:
          State/Country:          CALIFORNIA
                   City:          SAN DIEGO

              Phone Number: 8581021928                               Phone Ext:
                FAX Number:

    Cvr Loc Cmmt:
    Cvr Std Cmmt:
Coverage Last Update System Name: CHCS Test Site for Contractor Test




Note: DEERS will not allow a user to update a carrier record if the HIC STATUS CODE is
“Temporary” or the HIC VERIFICATION STATUS is “Unverified.” Only “Standard/Verified”
carriers can be updated.

When the user files an update to a “Standard/Verified” carrier record, the HIC Verification Code
changes from “Verified” to “Unverified” and a “HIC Update” message is sent to DEERS.

The Carrier and/or Coverage Type updates are evaluated by the DoD UBO VPOC. If the updates
are accepted, the DoD UBO VPOC changes the HIC and/or Coverage Type Verification Code to
“Verified.”

After the DoD UBO VPOC verifies the update(s), all authorized subscribers to DEERS will receive
the update(s) in the next hourly download from DEERS.




                                                       3-13
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„VIEW‟ Action (SIT Screen 10)

Menu Path: DAA  CFT  CFM  STM  SIT  View

------------------------------------------------ SIT Screen 10 ------------------------------------------------


                                      STANDARD INSURANCE TABLE




Add   Update   View   Cancel   Deactivate   Report   Subscribe   TPOCS   Exit
View the insurance company and coverage type data for a selected insurance
company.



When the „View‟ action is selected from the “STANDARD INSURANCE TABLE” screen, the
following prompt displays:


Select Insurance Company Name: AETNA US HEALTH
DEVICE:


The user can enter the HIC ID, Insurance Company Name, or a partial Insurance Company Name.

After selecting an insurance company to view, the user can queue the data to a specific printer or, if
the user presses <Enter> at the “DEVICE:” prompt, the data will be displayed on the screen, as
shown below in SIT Screen 11.

If the data is displayed on the screen, the user will be able to scroll up and down the report to
review the contents.




                                                       3-14
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------------------------------------------------------ SIT Screen 11 -------------------------------------------


         STANDARD INSURANCE TABLE - VIEW INS CO             Page: 1
SIT ID: AETKY0005           HIC Status Code: S          HIC Verification Code:
U
Insurance Company Name: AETNA US HEALTHCARE
       Add'l Descrip:
     Carrier Website: www.aetnaushealthcare.com
     Cust Serv Email: customerservice@aetnaushealthcare.com
          BC/BS Code:

           HIC Loc Cmmt:
           HIC Std Cmmt: FOR NON HMO CLAIMS IN AK AZ CA HI ID NV NM OR UT AND WA

Cross-Reference Carrier:

HIC Last Update SysName:            CHCS Test Site for Contractor Test
  Last Update User Name:            PAWOLL,SALLON
 Last Update User Phone:            964-654-7654       Ext:
 Last Update User Email:            pawoll@website.com

Coverage/Payer Type:
COMPREHENSIVE MEDICAL (default)/Institutional Only:

       Coverage Status Code:T                    Coverage Verification Status: U

                ATTN:
    P.O. Box/St Adrs:         ADDRESS FOR INSTITUTIONAL ONLY
                City:         LA JOLLA                                                         St/Cnty: CA
                 Zip:         92121              Zip Ext:                             FAX:
               Phone:         827-0989            Ext:

          Cvr Loc Cmmt:
          Cvr Std Cmmt:

Cvr Last Update SysName:


Coverage/Payer Type:
COMPREHENSIVE MEDICAL (default)/Both Institutional and Professional:

       Coverage Status Code:S                    Coverage Verification Status: V
                ATTN:
    P.O. Box/St Adrs:         PO BOX 14089
                City:         LEXINGTON                                                     St/Cnty: KY
                 Zip:         40512                      Zip Ext:                     FAX: 8003777078
               Phone:         8003676276                  Ext:

          Cvr Loc Cmmt:
          Cvr Std Cmmt: FOR NON HMO CLAIMS IN AK AZ CA HI ID NV NM OR UT AND WA
Cvr Last Update SysName: WEB USER



The fields displayed with the „View‟ action are all fields that are familiar from the SIT Add/Edit
screens, except for the „Cross-Reference Carrier‟ field. A value in this field indicates that the
selected carrier has been cross-referenced to another carrier. The selected carrier is no longer a
valid carrier and all policies associated with the selected carrier have been re-pointed to the carrier


                                                       3-15
                                                                                   SAIC GSA Doc. GS-SISS-5000A
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that now serves as the cross-reference. (See more information on Cross-Referenced Carrier at the
end of this SIT section.)

„CANCEL‟ Action

Cancellation of Insurance Companies and/or Coverage Types
Menu Path: DAA  CFT  CFM  STM  SIT  Cancel

------------------------------------------------- SIT Screen 12 ------------------------------------------------


                                      STANDARD INSURANCE TABLE




Add   Update   View   Cancel   Deactivate   Report   Subscribe   TPOCS                                   Exit
Cancels a recent request for adding insurance company information.



If CHCS has sent a request to DEERS to add an insurance company, and a user then determines that
the „Add‟ request was erroneous, an authorized user can send a request to cancel the “Add” request.
 A cancellation can be applied to an insurance company and Coverage Type, or Coverage Type
only.

A carrier must meet the following criteria, or the carrier can not be canceled:

    1.   The SIT entry must have a HIC STATUS CODE of “T” (Temporary).
    2.   The SIT entry must have a HIC VERIFICATION STATUS CODE of “U” (Unverified).
    3.   The SIT entry must not have a HIC Cross-Reference assigned.
    4.   The user‟s site must be the site that initially requested the addition of the carrier, or the last
         site to request an update to the carrier‟s record. If any other DEERS SIT/OHI subscriber
         name is in the „Last Update System Name‟ field, the user is not allowed to cancel the carrier
         record.

         Note: Cancellation of a Coverage Type can only be performed if the record‟s HIC
         COVERAGE VERIFICATION STATUS CODE is “U” (Unverified).

When the user selects the „Cancel‟ action from the SIT action bar, the following prompt displays:


Select Insurance Company Name:



The user either enters the HIC Identifier, the full name of the insurance company, or the partial
name of the insurance company. If the user enters a partial name, the system provides a picklist.


                                                       3-16
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If the user selects a carrier that is not eligible for cancellation, the system displays the following
message:

        Cancellation of the selected carrier is not allowed for one of the
        following reasons: Your site was not the site from which DEERS received
        the request to add this carrier – or your site was not the last site to
        update this carrier - or – the carrier has already been “Verified” by the
        UBO VPOC.   If you feel that this carrier is no longer valid, please
        select the “Deactivate” action to send a deactivation request to the
        VPOC.

If the user selects a carrier that is eligible for cancellation, the system displays the following screen
(SIT Screen 13).


-------------------------------------------------- SIT Screen 13 -----------------------------------------------


SIT ID         A&IOR0001                                      STANDARD INSURANCE COMPANY - CANCEL
INS CO
Insurance Co: A&I BENEFIT PLAN
-------------------------------------------------------------------------
  Coverage                Payer Type
-------------------------------------------------------------------------
  MEDICAL                 INSTITUTIONAL
  MEDICAL                 PROFESSIONAL
 *DENTAL                  BOTH (INSTITUTIONAL/PROFESSIONAL
  PHARMACY                BOTH (INSTITUTIONAL/PROFESSIONAL

-------------------------------------------------------------------------
CancelCompany Cancel Coverage eXit




If the user selects „CancelCompany‟, the system displays the following prompt:


Are you sure you want to cancel A&I BENEFIT PLAN? NO//


If the user answers "YES", the system processes the cancellation of the insurance company. If the
user answers "NO", the system exits the option.

        Note: When an insurance company is cancelled, each Coverage Type associated with it is
        also cancelled. The record is purged and will no longer be available from DEERS. All OHI
        policies associated with the selected carrier are also cancelled.




                                                       3-17
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If the user selects „CancelCoverage‟, the system displays the screen below (SIT Screen 14):

--------------------------------------------------- SIT Screen 14 -------------------------------------------


SIT ID         A&IOR0001                            STANDARD INSURANCE COMPANY - CANCEL INS CO

Insurance Co: A&I BENEFIT PLAN
-------------------------------------------------------------------------
  Coverage                Payer Type
-------------------------------------------------------------------------
  MEDICAL                 INSTITUTIONAL
  MEDICAL                 PROFESSIONAL
 *DENTAL                  BOTH (INSTITUTIONAL/PROFESSIONAL
  PHARMACY                BOTH (INSTITUTIONAL/PROFESSIONAL


The user must select one or more coverage types to cancel. A confirmation message will be
presented to confirm each of the selected coverage types, sequentially.


Are you sure you want to cancel coverage <DENTAL BOTH
(INSTITUTIONAL/PROFESSIONAL)> for insurance company A&I BENEFIT PLAN? NO//


If the user answers "YES", the system processes the cancellation of the Coverage Type and returns
to the Cancel screen. If the user answers "NO", the system exits the option.

        Notes:

        When a Coverage Type is cancelled, only the Coverage Type will be cancelled. The status
        of the insurance company will remain unchanged.

        Only the system that issued the „Add‟ request on a particular record can issue a cancellation
        request on that transaction. CHCS will track this information on the local system. Updates
        cannot be cancelled.

„DEACTIVATE‟ Action

Deactivation of Insurance Companies
Menu Path: DAA  CFT  CFM  STM  SIT  Deactivate

When a CHCS user determines that an insurance company in the local SIT is no longer valid,
DEERS will allow authorized holders of a local copy of the SIT, to request that an insurance
company be deactivated.

The following screen (SIT Screen 15) shows the „Deactivate‟ action in highlighted text.




                                                       3-18
                                                                                   SAIC GSA Doc. GS-SISS-5000A
                                                                                                    28 Oct 2005

------------------------------------------------- SIT Screen 15 ------------------------------------------------


                                      STANDARD INSURANCE TABLE




Add   Update   View   Cancel   Deactivate                      Report       Subscribe         TPOCS      Exit
Deactivates an insurance company




A carrier must meet the following criteria, or the carrier can not be deactivated:

    1. The SIT entry must have a HIC STATUS CODE of “S” (Standard).
    2. The SIT entry must have a HIC VERIFICATION STATUS CODE of “V” (Verified).
    3. The SIT entry must not have a HIC Cross-Reference assigned.

If a CHCS user selects the „Deactivate‟ action from the main SIT maintenance action bar, and
selects a HIC that has a Carrier Cross-Reference ID assigned, the following message displays:

        The carrier you selected is cross-referenced to <Carrier Cross-Reference
        Carrier ID>. Carriers that have a cross-reference assigned can not be
        deactivated. Do you want to view data associated with the carrier you
        selected? N//

If a user selects the „Deactivate‟ action from the main SIT maintenance action bar, and selects a
HIC that serves as the cross-reference for one or more other carriers, the following message
displays:

        The carrier you selected serves as the cross-reference for <HI ID>, <HIC
        ID>, <HIC ID>. Deactivation of the selected carrier will automatically
        deactivate the selected carrier AND all of the other carriers for which
        it serves as a cross-reference as soon as the UBO VPOC verifies the
        deactivation of the selected carrier. All OHI policies associated with
        these carriers will also be deactivated. Do you still want to request
        deactivation? N//

After selecting „Deactivate‟, and then entering an insurance company name, the following prompt
displays.




                                                       3-19
                                                                                   SAIC GSA Doc. GS-SISS-5000A
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------------------------------------------------- SIT Screen 16 ------------------------------------------------


Are you sure you want to deactivate insurance company A&I BENEFIT PLAN? NO//


The user must type “YES” to confirm that the deactivation request is to be sent to DEERS. When
the user enters “YES,” the system prompts the user for a telephone number and e-mail address so
that the HIC record will be able to store the information about the user who deactivated the HIC ID.

Only the DoD UBO VPOC can verify a deactivation request on the DEERS SIT. All OHI policies
associated with the deactivated insurance company that don‟t show an end date will have an end
date entered by DEERS − one that matches the insurance company‟s deactivation date.

When an insurance company is deactivated, all associated coverage types for that carrier are also
deactivated.

DEERS will automatically deactivate all OHI policies associated with a deactivated HIC on the
DEERS database. Upon receipt of the verification of a deactivation of a HIC, CHCS is responsible
for deactivating all OHI policies where the insurance company has been deactivated on the local
CHCS database. CHCS does not deactivate OHI associated with a deactivated HIC until the Carrier
Verification Status is “V” for Verified.

„REPORT‟ Action

Standard Insurance Company Report

Menu Path: DAA  CFT  CFM  STM  SIT  Report

------------------------------------------------------ SIT Screen 17 -------------------------------------------

                                      STANDARD INSURANCE TABLE



Add   Update   View   Cancel   Deactivate   Report   Subscribe   TPOCS                                   Exit
Creates a report of insurance companies based on the selected insurance
company type



This action allows the user to print a report of Insurance companies in the SIT file. Following are
types of insurance company entries that can be selected for the report:




                                                       3-20
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Health Insurance Carrier Status Codes

  Insurance Co. Types                                               Details

Standard                         Insurance companies that have been verified by the DoD UBO
                                 VPOC and are standard entries that can be used by local
                                 subscribers to the DEERS SIT.

Temporary                        Insurance companies that have been submitted by local subscribers
                                 to the DEERS SIT as an „Add‟ or „Update‟ and are awaiting
                                 verification by the DoD UBO VPOC.

                                 These records include insurance companies that have been
                                 submitted to DEERS, but have not yet received any type of
                                 response from DEERS.

Deactivated                      Insurance companies that have been deactivated on the DEERS
                                 SIT.

Placeholder                      Insurance companies defined by the DoD UBO VPOC as
                                 “UNKNOWN”.

Cancelled                        Insurance company „Add‟ requests that have been cancelled by a
                                 local CHCS or a DEERS SIT subscriber.

Rejected                         Insurance companies that have been rejected by the DoD UBO
                                 VPOC.

The user may select one or several insurance company types, or press the <F11> key to select all
insurance company types to include in the report.

------------------------------------------------------ SIT Screen 18 -------------------------------------------


STANDARD INSURANCE COMPANY REPORT


-------------------------------------------------------------------------------
  Standard
  Temporary
  Deactivated
  Placeholder
  Cancelled
  Rejected




Select the type(s) of Insurance Company entries for the Report




                                                       3-21
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The next screen (SIT Screen 19) allows the user to select “All” insurance companies to print, or just
those companies that have been updated since a specified date.

------------------------------------------------------ SIT Screen 19 -------------------------------------------


                               STANDARD INSURANCE COMPANY REPORT




-------------------------------------------------------------------------------
  Based on Date Last Updated
  All



-----------------------------------------------------------------------------
Select whether All or Based on the Date Last Updated


The user is only able to select one of the items above. The <F11> key cannot be used to select all
items on this screen.
If the user requested the report based on the Date Last Updated, he/she is prompted for a Date.


Date Last Updated: 15 Mar 2003@0400




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As shown in SIT Screen 20, the resulting report will:
    Include all insurance companies of the selected type(s) with a Date Last Updated equal to or
     greater than the date entered. The date must be either a past date, or Today.
    Be sorted by the selected type(s) of insurance company entries and then by Coverage Type.

------------------------------------------------------ SIT Screen 20 -------------------------------------------


                   STANDARD INSURANCE TABLE - VIEW INS CO               Page: 1
SIT ID: AETKY0005           HIC Status Code: S         HIC Verification Code: U
 Insurance Company Name: AETNA US HEALTHCARE
       Add'l Descrip:
     Carrier Website: www.aetnaushealthcare.com
     Cust Serv Email: customerservice@aetnaushealthcare.com
          BC/BS Code:
           HIC Loc Cmmt:
           HIC Std Cmmt: FOR NON HMO CLAIMS IN AK AZ CA HI ID NV NM OR UT AND WA
Cross-Reference Carrier:

HIC Last Update SysName:            CHCS Test Site for Contractor Test
  Last Update User Name:            PAWOLL,SALLON
 Last Update User Phone:            964-654-7654       Ext:
 Last Update User Email:            pawoll@website.com

Coverage/Payer Type:
COMPREHENSIVE MEDICAL (default)/Institutional Only:

       Coverage Status Code:T                    Coverage Verification Status: U

                ATTN:
    P.O. Box/St Adrs:         ADDRESS FOR INSTITUTIONAL ONLY
                City:         LA JOLLA                                                         St/Cnty: CA
                 Zip:         92121              Zip Ext:                             FAX:
               Phone:         827-0989            Ext:
          Cvr Loc Cmmt:
          Cvr Std Cmmt:
Cvr Last Update SysName:


Coverage/Payer Type:
COMPREHENSIVE MEDICAL (default)/Both Institutional and Professional:
       Coverage Status Code:S                    Coverage Verification Status: V

                ATTN:
    P.O. Box/St Adrs:         PO BOX 14089
                City:         LEXINGTON                                                     St/Cnty: KY
                 Zip:         40512                      Zip Ext:                     FAX: 8003777078
               Phone:         8003676276                  Ext:

          Cvr Loc Cmmt:
          Cvr Std Cmmt: FOR NON HMO CLAIMS IN AK AZ CA HI ID NV NM OR UT AND WA

Cvr Last Update SysName: WEB USER




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„SUBSCRIBE‟ Action

Subscription Inquiries
To keep the local CHCS SIT synchronized with the DEERS SIT, CHCS will perform an automatic
subscription inquiry to the DEERS SIT once every hour, and will download all DEERS SIT updates.

In addition to hourly automatic subscription inquiries, CHCS will allow an authorized user to perform
a manual subscription inquiry from the SIT main screen. This process is described in the next section.

Menu Path: DAA CFT  CFM  STM  SIT  Subscribe

----------------------------------------------- SIT Screen 21 -------------------------------------------------


                                      STANDARD INSURANCE TABLE




Add   Update   View   Cancel   Deactivate   Report   Subscribe                                TPOCS      Exit
Allows the user to retrieve the most recent DEERS data.



An authorized user may request a “Full” or “Partial” subscription inquiry, which will return the most
current SIT data from DEERS.
A “Full” subscription inquiry will return the entire DEERS SIT to replace the local copy of the SIT.
The “Full” option should only be used if CHCS SIT has gotten out of sync with the central SIT on
DEERS for an extended period of time (greater than seven days).
For normal subscription updates, the user shall select “Partial” update of the changes based on a
specified date/time. For a Partial Subscription Inquiry, the maximum date/time allowed by DEERS
for retrieving SIT data is seven (7) days.
When the user selects the “Subscribe” action, and if the current date is seven days or less from the last
successful partial subscription inquiry, the following prompt will display:

Date/Time of last successful Subscription Inquiry: 07 Aug 2003@1200
Proceed with Partial Subscription Inquiry? YES//



When the user selects the „Subscribe‟ action, and if the current date is more than seven days, the
user will be required to perform a Full Subscription, which will replace the entire local copy of the
CHCS SIT. An authorized user with the DOD SIT MGR security key can access the Full
Subscription functionality through a secondary menu option, Full SIT Subscription Inquiry.

If a Full Subscription is requested, a warning message will be displayed to alert the user that this
will replace the entire local copy of the CHCS SIT.




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When CHCS downloads an updated entry from the DEERS SIT during a subscription inquiry, the
new or modified data elements will result in an “add” or “overwrite” to update the local copy of the
SIT. In all cases, whether it is a “Full” or “Partial” Subscription inquiry request, CHCS will
overwrite all updates to the local copy of the SIT since the downloaded data represents the most
current information available on the DEERS central SIT.

Every update provided in the response to a subscription inquiry will contain every Coverage Type
pertaining to a HIC, whether they have an update or not.


„TPOCS‟ ACTION

TPOCS ASCII FILE
        Menu Path: DAA  CFT  CFM  STM  SIT  TPOCS

------------------------------------------------ SIT Screen 22 -------------------------------------------------


                                      STANDARD INSURANCE TABLE




Add     Update       View      Cancel       Deactivate         Report       Subscribe         TPOCS      Exit



There is an automated daily process that creates and transmits an ASCII file of information to
TPOCS. This file includes changes made to insurance company entries. The TPOCS action shown
above is only to be used to transmit a supplementary file to TPOCS. It should only be used if the
TPOCS is no longer synchronized with CHCS for insurance company entries.

The following types of insurance company entries can be sent in a TPOCS ASCII file:

       Standard
       Temporary
       Deactivated
       Rejected
       Cancelled
       Placeholder

After selecting the „TPOCS‟ action from the SIT action bar, the user is prompted to select the types
of insurance company entries to include on the report.

The user can select one or several insurance types, or press the <F11> key to select all insurance
company types to include in the TPOCS extract.




                                                       3-25
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------------------------------------------------------ SIT Screen 23 -------------------------------------------



         Generate TPOCS Extract for Standard Insurance Table

This process will create an ASCII file of Insurance Company data for
transmission to TPOCS. There is a daily process that creates and transmits
information to TPOCS with changes made to Insurance Company entries. This
process is only to be used to transmit a supplementary file to TPOCS. This
process should only be used in the event that the TPOCS system is no longer
synchronized with CHCS for Insurance Company entries.
 *Standard
  Temporary
  Deactivated
  Placeholder
  Cancelled
  Rejected


Select the type(s) of Insurance Company entries to include in the ASCII File




The user may select all insurance companies of a selected type or just those that have been updated
since a specified date, as shown in SIT Screen 24.


------------------------------------------------- SIT Screen 24 ------------------------------------------------



          Generate TPOCS Extract for Standard Insurance Table
This process will create an ASCII file of Insurance Company data for
transmission to TPOCS. There is a daily process that creates and transmits
information to TPOCS with changes made to Insurance Company entries. This
process is only to be used to transmit a supplementary file to TPOCS. This
process should only be used in the event that the TPOCS system is no longer
synchronized with CHCS for Insurance Company entries.

  Based on Date Last Updated
  All



Select whether All or Based on the Date Last Updated



If the user requests the extract to be based on Date Last Updated, he/she is prompted for a Date.


Date Last Updated: 15 Mar 2003@0400




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The resulting TPOCS extract file will include all insurance companies of the selected type with a
“Date Last Updated” equal to or greater than the date entered. The date must be either a past date,
or Today.

Cross-Referenced Carriers

When the DoD UBO VPOC determines that an insurance carrier should be consolidated with
another carrier on the DEERS SIT, or should be replaced with a different carrier, the DoD UBO
VPOC may assign a cross-reference to a carrier record. The Carrier Cross Reference ID is assigned
by the DoD UBO VPOC (through the DEERS VPOC web application), during initial verification,
or as a subsequent update.

When CHCS receives a SIT record from DEERS that has a HIC Cross-Reference Carrier assigned,
CHCS automatically re-points all OHI associated with the cross-referenced carrier to the carrier to
which it has been cross-referenced. The original OHI policy is cancelled, and a new policy is
created to replace it. All data associated with the policy is copied to the new policy, except for the
HIC ID. The “End Date” associated with the obsolete policy is set to the “Policy Effective Date”
and the “End Reason Code” is set to “E”, indicating that the original policy was cancelled.

The Carrier Cross-Reference Carrier ID is assigned at the carrier level only, not at the Coverage
Type level.

Note: The „Carrier Cross-Reference Carrier ID‟ field is not displayed on the SIT enter/edit screen
because the CHCS user does not enter that value, and a carrier with the Carrier Cross-Reference
Carrier ID assigned is not editable, so it would always be blank on the SIT enter/edit screen..

               For example:

                 HIC ID            CROSS REFERENCE ID
               ABCVA0001          ABCMD0001
               ABCLA0001          ABCMD0001
               ABCWA0001          ABCMD0001
               ABCMD0001

               CHCS and DEERS do not allow ABCVA0001 to be deactivated.

               CHCS and DEERS allow ABCMD0001 to be deactivated.

               Once the DoD UBO VPOC verifies the deactivation of HIC ID ABCMD0001 -
               ABCVA0001, ABCLA0001, and ABCWA0001 will also be deactivated, as well as
               all policies associated with ABCMD0001, ABCVA0001, ABCLA0001, and
               ABCWA0001.




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Change to SIT Look-ups:

Partial look-ups will now display both Address Line 1 (when available) and Address Line 2.


       The following are the HIC partial lookup list for BOAPA0002

--------------------------------------------------------------------------------
   Carrier Name/Carrier ID                    Carrier Status/Verification Status
     Cov Typ Pay Typ    Address
--------------------------------------------------------------------------------
 * BOARD OF PENSIONS PRESBYTERIAN CH - BOAPA0002    STANDARD/UNVERIFIED DATA
       MD       B       LEVEL II EMPLOYEE CLAIMS
                        PO BOX 13896 PHILADELPHIA PA 19101
       MD       B       PO BOX 13896 PHILADELPHIA PA 19101
       XM       B       PO BOX 13896 PHILADELPHIA PA 19101



SIT Conversion
CHCS will create a new file to store the local copy of the SIT data, which will be synchronized with
the DEERS SIT. To initialize the CHCS SIT baseline file, CHCS will perform a manual “Full”
subscription inquiry to DEERS. During the site activation, the manual “Full” subscription to DEERS
must be closely coordinated to ensure appropriate initialization and synchronization of the local
CHCS SIT file.

In order to retain existing insurance company information for internal CHCS use and implement the
new SIT table, a file conversion will be performed. This conversion will:

       Inactivate menu options from the previous SIT functionality
       Activate the new SIT menu options
       Map the old Standard Insurance Company file (#8064) insurance carriers to the new Health
        Insurance Carrier file (#8192), based on Short Name from the old file being mapped to HIC
        ID in the new file
       When there is no match between the old HIC Short Name and the new HIC ID, the old SIT
        carrier will be created in the new HIC file as “inactivated.” The old carrier‟s attributes will
        carry over to the new file, but will not accessible to the user.
   Notes:

       The three values, Insurance Company Qualifier, BC/BS Code, and Local Comment, are the
        only values that will be carried over from the old file to the new file for all records that can
        be mapped.
       An initialization SIT ASCII file will be transmitted to TPOCS that includes all SIT entries
        populated by the conversion in the new HEALTH INSURANCE CARRIER file (# 8192).




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Pre-Implementation Reports
Five Pre-Implementation Reports have been created and should be run prior to activating the new
TNEX SIT/OHI software. These reports will provide information to be used during both pre- and
post- implementation cleanup. These reports will be on a secondary sub-menu and are shown
below.
New Secondary Menu Option and Sub-Menu Options
Secondary sub-menu options have been added for Pre-Implementation Reports 1-5. These options are
locked by the DOD SIT MGR security key. In the Option File, the menu is [DG PRE-IMP-SIT-OHI
REPORTS].

PRE    Pre-Implementation SIT/OHI Reports Menu
      PI1 SIT - No DEERS HIC ID Match but Address Match
      PI2 SIT - No DEERS HIC ID Match, No Address Match
      PI3 SIT - Duplicate Addresses within Old CHCS SIT File
      PI4 OHI Policies Missing Policy Effective Date
      PI5 OHI Policies Missing Policyholder/Subscriber Info

The following table provides descriptions for the reports.

                       Table 2: Description of Options on the PRE Menu

 Option
                     Option Text                              Option Description
Synonym

PRE         Pre-Implementation SIT/OHI        Includes five Pre-Implementation Reports that
            Reports Menu                      should be run prior to activating the new TNEX
                                              SIT/OHI software. These reports will provide
                                              information to be used during both pre- and post-
                                              implementation clean-up.

                                              When the user runs the first two reports on the sub-
                                              menu, CHCS will query DEERS and download the
                                              DEERS health insurance carriers from the new
                                              DEERS SIT database. This download populates the
                                              CHCS HIC file and allows the user to proceed with
                                              running the first two reports.

                                              The other three reports pull data from the existing
                                              local CHCS SIT file only. There is no DEERS
                                              interface query triggered by Reports PI3, PI4, or PI5.

PI1         SIT Carriers with No DEERS        Lists insurance carriers in the local (old) SIT file
            HIC ID Match, but Address         (#8064) that have a SIT Short Name that does not
            Match Report                      match any HIC ID in the new DEERS HIC table, but
                                              has an address that exactly matches the address


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 Option
                    Option Text                             Option Description
Synonym
                                            associated with one of the Coverage Type/ Payer
                                            Type combinations under one of the carriers in the
                                            new DEERS HIC table.

                                            A DEERS SIT query will automatically be triggered
                                            when a user runs this report.

PI2        SIT Carriers with No DEERS       Lists insurance carriers in the local (old) SIT file
           HIC ID Match, and No             #8064 that have a SIT Short Name that does not
           Address Match Report             match any HIC ID in the new DEERS HIC table,
                                            and has an address that does NOT match the address
                                            associated with any of the Coverage Type/ Payer
                                            Type combinations under any of the carriers in the
                                            new DEERS HIC table.

                                            A DEERS SIT query will automatically be triggered
                                            when a user runs this report.

PI3        SIT Carriers with Duplicate      Lists insurance carriers in the local (old) SIT file
           Addresses within CHCS SIT        (#8064) that have different SIT Short Names but
           File Report                      have the same address. The address may be an exact
                                            match, or may match select word/letter patterns.

PI4        OHI Policies Missing Policy      Lists OHI Policies in the local (old) Policy file
           Effective Date Report            (#8086) (currently active, or have been active
                                            anytime between 2 Oct 2002 and the current date),
                                            which are missing the Policy Effective Date.

PI5        OHI Policies Missing             Lists OHI policies in the local (old) Policy file
           Policyholder/Subscriber          (#8086) (currently active, or have been active
           Information Report               anytime between 2 Oct 2002 and the current date), –
                                            which are missing some of the required
                                            Policyholder/ Subscriber information.

3.1.3   File and Table Changes

The “old” Insurance Company File (#8064) will be converted to (#8192) − the Health Insurance
Carrier (SIT) File. This replaces the existing insurance company table (SIT) with a copy of the
DoD DEERS SIT table. A new SIT option will replace the existing SIT menu option. “Coverage”
codes have been introduced for inclusion in the insurance company data.

Five new Pre-Implementation reports have been created to run prior to the SIT/OHI conversion.
These reports will provide information to be used during both pre- and post-implementation cleanup



                                              3-30
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of the SIT and OHI files. Secondary sub-menu options have been added for Pre-Implementation
Reports 1-5. These options are locked by the DOD SIT MGR security key. The option file is [DG
PRE-IMP-SIT-OHI REPORTS].

 3.1.4 Implementation Issues

____ Assign the Pre-Implementation Report file (DG PRE-IMP SIT-OHI REPORTS) option as a
     secondary menu option to one or two appropriate personnel who will run the reports. The
     acronym should be PRE for the sub-menu. The security key DOD SIT MGR must also be
     assigned to these users.

____   Run Pre-Implementation Reports 1-3. These reports are accessed using secondary sub-menu
       options under the acronym PRE. Report 1 will identify carriers with a potential match in the
       new DEERS HIC table. After the conversion they can be re-pointed to a valid HIC ID.
       Report 2 identifies carriers that do not have a potential match with a valid HIC ID. These
       carriers must be entered as new SIT Insurance Carriers and validated by the DEERS VPOC.
        Report 3 will identify additional carriers that might be re-pointed after the conversion.

____   Assign the new security key, DOD SIT MGR, to the appropriate user(s) who will maintain
       the SIT local file. The key will allow a user to perform all the functions displayed on the
       action bar that is available through the SIT option. This will also allow the user access to
       the secondary option, Full SIT Subscription Inquiry, to perform a “Full” subscription to
       replace the local SIT file with the DEERS SIT.

____ Verify that site POC(s) responsible for Insurance File maintenance are trained in the
     software enhancements.

3.2    Other Health Insurance (OHI) Enhancements

 3.2.1 Overview of Change
The primary change with this enhancement is the creation of a master OHI data repository, which
will be stored on the DEERS Other Health Insurance database. Each CHCS platform has
maintained its own local OHI repository since the implementation of Outpatient Itemized Billing
(OIB). With implementation of TNEX SIT/OHI enhancements, the responsibility for storing OHI
data from multiple subscribers has been assumed by DEERS. CHCS is only one contributor to the
DEERS OHI repository. Other subscribers (and contributors) are the MCSCs and the Pharmacy
Data Transaction Service (PDTS).

The new Interface System between CHCS and DEERS will allow CHCS users to query the DEERS
OHI database for updated OHI information. Additions and updates to OHI data may also be
transmitted from CHCS to DEERS through the interface.

When OHI data is accessed through any CHCS pathway [Patient Administration (PAD), Patient
Appointment & Scheduling (PAS), Ambulatory Data Module (ADM), or Medical Services
Accounting (MSA)], CHCS sends DEERS an “OHI inquiry” message prior to allowing the user to



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enter/edit any OHI data. DEERS returns a “DEERS OHI Response” message with associated data
for each policy held by the selected patient. Once the current OHI information is sent from
DEERS, an action bar is displayed for the user to perform various functions on OHI data including
the ability to add, update and view patient insurance data.

3.2.2 Detail of Change

There are several menu paths through which OHI data may be entered into CHCS. Following is a
summary of the various paths:

       Menu Path # 1: CA → PAD → ROM → PII → enter Patient Name → DEERS OHI query
       → Screen 1

       When a user selects the Patient Insurance Information (PII) option from the Registration
       Options Menu in PAD, and enters a patient‟s name, the system queries DEERS for existing
       OHI information associated with the selected patient. The data returned from DEERS
       displays on the Other Health Insurance screen. (See OHI Screen 1).

       Menu Path # 2: CA → PAD → ROM → FRG or MRG → Patient Name → enter/edit
       registration information

       When a user accesses the full registration (FRG) or mini-registration (MRG) option in
       CHCS, the user is allowed to enter/edit OHI information for Third Party Collections (TPC)-
       eligible beneficiaries.

           After filing registration information, the system displays the following prompt:

              Does this patient have OTHER HEALTH INSURANCE? Yes//

           If the selected patient has Other Health Insurance and the user accepts the default, the
           system will display the following prompt:

              Do you want to Add/Edit the patient’s OHI data now? Yes//

           If the user accepts the “Yes” default, the system queries DEERS for existing OHI
           information associated with the selected patient. The data returned from DEERS
           displays on the Other Health Insurance screen. (See OHI Screen 2).

       Menu Path # 3: CA → PAS → MCP → Health Care Finder -BHCF→ enter Patient
       Name → (continue through DEERS check to Health Care Finder Booking
       screen(D)emographics → (O)HI → Add or Update

       The OHI enter/edit capability is accessible through the Demographic Display window in any
       Managed Care Program (MCP) option where patient demographics are entered or edited for
       a TPC-eligible beneficiary.




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       Menu Path # 4: CA → PAS → Emergency Room Menu → NER, WER, or RER → enter
       Patient Name → (D)emographics → (O)HI → DEERS OHI query → OHI Screen 2

       The OHI enter/edit capability is accessible through the Demographic Display window in any
       Emergency Room option where patient demographics are entered or edited for a TPC-
       eligible beneficiary.

       Menu Path # 5: CA → PAD → ADT → ADM → enter Patient Name → enter/edit
       demographics → DEERS OHI query → OHI Screen 2

       When patients are admitted to the hospital as inpatients and demographic data are
       entered/edited, the system immediately sends a query to the DEERS OHI database.

       Menu Path # 6: ADS (secondary menu option) → 1 ADM Data Entry Menu → 3 Clerk
       Check-in Processing → select Location → select Provider → select appointment date range
       → select Patient → complete encounter data entry → OHI&Demog → (O)HI → DEERS
       OHI query → OHI Screen 2

       When the ADM clerk checks in a patient during Encounter processing, the clerk is prompted
       to enter OHI for the selected patient.

       Menu Path # 7: CA → MSA → IFM → IAP → select Patient or Account → 5 or 8

       When the MSA user is processing an account, CHCS allows the user to enter/edit OHI
       information (inpatient episodes only).

In each of the menu path scenarios above, CHCS sends DEERS an “OHI Inquiry” message, prior to
allowing the user to enter/edit any OHI data. In response to the “OHI Inquiry” message, DEERS
returns a “DEERS OHI Response” message, with all associated data for each policy held by the
selected patient.
The OHI data downloaded from DEERS automatically updates existing OHI policies, or adds
policies that do not exist in the local OHI file (#8074).

After the OHI data download has been received, and the CHCS OHI file (#8074) has been updated
with additions or updates to the patient‟s OHI profile, CHCS then displays all of the policies in the
patient‟s OHI History in the middle window of the Other Health Insurance. (See OHI Screen 1).

Note: If CHCS is not able to complete the DEERS OHI database inquiry due to connectivity
problems, the query will be batched to send as soon as connectivity is restored. In that situation, the
user may proceed with adding or updating the OHI data on the CHCS database. The “add” or
“update” message will be created and sent to DEERS.

The main Other Health Insurance (OHI) Enter/Edit screen is shown in OHI Screen 1. This screen
will display as soon as CHCS receives the most current OHI information from DEERS. The
authorized user selects an action, and then selects a policy from the list on the screen.



                                                 3-33
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-------------------------------------------------- OHI Screen 1 ----------------------------------------------

                                        OTHER HEALTH INSURANCE

         Patient: SHAW,SHEILA                          FMP/SSN: 30/000-00-0000
Patient Category: USN FAM MBR AD                   Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY C           DMDC Pat Id: 0000011111
     Region Code: 01                                       Sex: FEMALE
              PCM: WOLLIN,MAGDALENA                    DOB/Age: 12 Aug 1972/30Y
--------------------------------------------------------------------------------
  Insurance Co Name              Policy Id             Eff Date   End Date   Pol
    Coverage Types and Ranking                                               Stat
--------------------------------------------------------------------------------
  ADVANCE PCS                    4848394               28Jan2003 INDEF       (S)
    RX(P)
  AETNA HEALTH PLANS OF TEXAS    AE12345               09Dec2002 INDEF       (S)
    XM(P) RX(S) IP(P) OP(P) PH(P) SN(P) LT(P) MH(P) DN(P) VI(P)
  RX ADVANCE PCS                 484839485j4h5u3y4655 28Jan2003 INDEF        (T)
    RX(N)
+ PREMIER BLUE                   568-97-6857           18Sep2002 03Jan2004 (I)
    MD(S)
-------------------------------------------------------------------------------
Add   Update    modKey   Cancel   copyFrom   copyTo   View/Print   PreCert   eXit
Add a new policy to selected patient’s OHI profile



Policy Status
The insurance policies on OHI Screen 1 are displayed based on Policy Status. The sort order is as
listed in Table 3 (from top to bottom). The active policies will always be displayed first on the
screen, followed by the policies that may be selected by the user for updating. The policies listed
last are the policies that are view-only and can no longer be updated.

The status of the policies may be identified based on the status of the carrier with which the policy
is associated, the policy start/end dates, and/or the completeness of the data associated with the
policy in the OHI file (#8074).

                                         Table 3. Policy Status
                           (Displayed on OHI Screen 1, in the far right column)

 Policy Status                                       Definition and Detail

       (S)          A policy is marked as (S)tandard when the policy is associated with a carrier that
                    is verified as Standard by the DoD UBO VPOC. (Note: The standard carriers
                    will always have a value of “V” in the Carrier Verification Status in the HIC file
                    (#8192) because the source of the standardization is always the DoD UBO
                    VPOC.)

       (T)          A policy is marked as (T)emporary when the policy is associated with a carrier
                    that has not been verified as Standard by the DoD UBO VPOC. (Note: The
                    temporary carriers will always have a value of “U” in the HIC file (#8192)


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Policy Status                                 Definition and Detail
                because the VPOC has not yet marked the carrier as standard in the DEERS HIC
                central repository.)

     (P)        Indicates that the policy is a Placeholder.
                Either of two conditions results in a policy being marked with a “P” in the Policy
                Status column:
                1. The Health Insurance Carrier associated with this policy has a Carrier Status
                   Code of “P.” A “P” will be displayed when the carrier associated with this
                   policy has a value of “P” in the „Carrier Status Code‟ field in the HIC file
                   (#8192).
                2. The policy data has been entered by a DEERS subscriber other than CHCS and
                   is missing one or more data values that CHCS considers to be required for a
                   valid policy in the OHI file (#8074). Typically, this would be any missing
                   values in any of the Subscriber fields.
                  If the user has knowledge of this information he/she should select the policy
                  and populate the additional values. Note: This policy will not be transmitted
                  to TPOCS until it contains a complete data set required by the CHCS ->
                  TPOCS Interface Control Document (ICD).

     (I)        Policy has been Inactivated as a result of the conversion. The only policies that
                will show an (I) in the „Policy Status‟ field are those policies in which the
                „Inactivation Date‟ field is populated in the OHI file (#8074).
                Policies marked with an “I” on OHI Screen 1 are policies that were associated
                with “Temporary” Insurance companies in the old CHCS Insurance Company
                file (#8064). These policies were imported from the old Policy file (#8086) at the
                time the TNEX SIT/OHI software was installed, but are not considered valid
                OHI policies unless a user manually associates them with a DoD UBO VPOC-
                approved standard SIT entry from the new TNEX SIT baseline.
                A policy is marked as inactive only when there is a value in the „Policy
                Inactivation Date‟ field in the OHI file (#8074). If an inactivated policy
                displays, that means that the inactivated policy has not been replaced by a valid
                policy in the new OHI file (#8074).

                To change an “I” policy to a valid policy, an authorized user may select the
                „Update‟ action from the action bar on OHI Screen 1, and then select an “I”
                policy to edit. When OHI Screen 2 displays, the user enters a valid SIT
                Insurance Company Name and other required data elements.

                When the user files his/her updates, the following occurs:

                (Note: All actions are performed on records in the new OHI file [# 8074].)



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Policy Status                                 Definition and Detail

                 The system automatically marks the old policy as uneditable and is view-
                  only on the OHI View screen.

                 The system automatically populates the date that the replacement policy was
                  filed into the „Policy End Date‟ field of the obsolete policy record.

                 The system automatically populates “Q” (for “Date is Certain”) into the
                  „Policy End Reason‟ field of the obsolete policy record.

                 The system automatically creates a new OHI policy record that includes all
                  updates. This new policy is considered a replacement for the old policy.

                 The system automatically populates the Internal Entry Number (IEN) of the
                  new replacement policy into the „Copied to New Policy IEN‟ field of the old
                  policy record. This will document the link between the two policies.

                 An “Add OHI” message is triggered so that the new policy can be sent to
                  DEERS. Note: The old obsolete record will never be sent to DEERS.

    (DU)        A policy is marked as “Deactivated/Unverified” when a request for deactivation
                of the HIC ID with which the policy is associated has been sent to DEERS, but
                verification of the deactivation has not been returned to CHCS from DEERS.

    (D)         A policy is marked “Deactivated” as the result of an automatic system process
                that has deactivated all policies associated with a deactivated HIC ID.
                Two conditions must be met for a policy to be marked as deactivated:
                    1. The Carrier Status Code for the carrier with which the policy is
                       associated has a value of “D” in the HIC file (#8192).
                    2. The Carrier Verification Status for the carrier with which the policy is
                       associated has a value of “V” in the HIC file (#8192) - meaning that the
                       DoD UBO VPOC has verified the deactivation.

                Note: When a CHCS user requests deactivation of a carrier (through a HIC
                Maintenance message to DEERS), neither DEERS nor CHCS will deactivate the
                policies associated with that carrier until the DoD UBO VPOC has verified the
                deactivation.

    (C)         Indicates that this policy has been cancelled.

                Either of two conditions results in a policy being marked with a “C” in the
                Policy Status column.

                    1. Cancellation of a policy represents an error correction and was requested


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 Policy Status                                Definition and Detail
                         because the user determined that the policy was entered in error, or data
                         in one of the key fields (Patient Name, HIC ID, Policy Effective Date, or
                         Policy Identifier) was entered incorrectly and filed. A “C” will be
                         displayed if the Policy End Reason Code in the OHI file (#8074) is equal
                         to “E.”

                      2. A policy marked with a “C” on OHI Screen 1 might also represent a
                         policy that was associated with a HIC ID that was cancelled. A “C” will
                         be displayed when the carrier associated with this policy has a value of
                         “C” in the „Carrier Status Code‟ field in the HIC file (#8192).
                 A policy is marked as “Rejected” as the result of an automatic system process
      (R)
                 that has cancelled all policies associated with a rejected HIC ID.
                 A policy must meet one criterion to be marked as rejected: The HIC Status Code
                 for the carrier with which the policy is associated has a value of “R” in the HIC
                 file (#8192). (Note: The rejected carriers will always be marked “V” because
                 the source of the cancellation is always the DoD UBO VPOC.)

Coverage Type Codes

The Coverage Type codes associated with each policy and Coverage Precedence codes (Ranking)
associated with each Coverage Type Code are displayed on the line beneath the policy on OHI
Screen 1 above. See the definition of valid Coverage Type codes in Table 4 below.

Only currently active Coverage Type codes display on OHI Screen 1. “Currently active” is defined
as Coverage Type codes that have a Coverage Effective Date of “Today” or in the past, and have a
Coverage End Date of in the future. Coverage Type codes that are no longer active will not display
on OHI Screen 1.


                                 Table 4. Coverage Type Codes
                   (Displayed in this order on OHI Screen 1, under each policy)

             Coverage                          Definition
              Type
              Code

                 XM      Comprehensive Medical (default)

                 MD      Medical Only

                 RX      Pharmacy Only




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            Coverage                           Definition
             Type
             Code

                IP      Inpatient

                OP      Outpatient

                PH      Partial Hospitalization

                SN      Skilled Nursing

                LT      Long Term Care

               MH       Mental Health

               DN       Dental

                VI      Vision



Coverage Precedence Codes (Ranking)
The Coverage Precedence codes are used to identify “ranking” of policies. Coverage Precedence
codes display in parentheses next to the Coverage Type code with which they are associated.

                         Table 5. Coverage Precedence Codes (Rank)
                 (Displayed on OHI Screen 1, next to Coverage Type line items)

   Policy
               Definition and Detail
  Ranking

               Selected patient‟s PRIMARY policy to be billed for any charges associated with
     P
               the Coverage Type.

               Selected patient‟s SECONDARY policy to be billed for any charges associated
               with the Coverage Type. This policy may be billed after the primary policy has
     S         been billed and no further collection is anticipated from the primary policy. The
               secondary policy is not billed automatically; therefore, billing against a secondary
               policy requires user intervention.

               Selected patient‟s TERTIARY policy to be billed for any charges associated with
               the Coverage Type. This policy may be billed after the primary and secondary
     T         policies have been billed and no further collections are anticipated from the
               primary or secondary policies. Billing against a tertiary policy requires user
               intervention since the tertiary policy is not billed automatically.


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   Policy
                Definition and Detail
  Ranking

                The policy is not one of the ranked policies. A Non-Ranked policy will be sent to
                DEERS, just as any ranked policy will be sent to DEERS; however, Non-Ranked
      N         policies will not be sent to TPOCS unless the policy previously had a Rank and
                the Rank was changed to Non-Ranked. TPOCS receives these Non-Ranked
                policies to communicate that the policies are no longer billable.

The actions on the action bar at the bottom of OHI Screen 1 are detailed in the following Table.




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Key to Actions on OHI Screen 1 Action Bar:

      Action                     Help Text (in italics) and Navigation Detail

Add                 Used to add a new policy to a selected patient‟s OHI profile.

                    When the user selects the „Add‟ action, the system prompts for an
                    Insurance Carrier. The user can enter the name of an Insurance Carrier,
                    the HIC ID, or a partial Insurance Carrier Name.

                    If the user selects a carrier that is a valid entry in the HIC file, CHCS
                    takes the user to OHI Screen 2 and subsequent enter/edit screens, so that
                    the user can add a new policy for the selected patient.

                    If the user presses <RETURN> without entering an Insurance Carrier at
                    the „Select Insurance Carrier‟ prompt, the system re-prompts for a
                    carrier.

                    If the user enters the name of an Insurance Carrier that CHCS does not
                    recognize, the system allows the user to enter a Temporary carrier so
                    that he/she may continue entering the OHI.

                    Expanded Help Text:
                    The “Add” action is used to add a new policy to the selected patient‟s
                    OHI profile.

                    You may enter a new OHI policy to the selected patient‟s OHI profile.
                    You should have the patient‟s policy information available before
                    beginning. It is important to enter as much information as possible, and
                    to be as accurate as possible in order to assure correct billing for costs
                    incurred. The minimum data set that you will need is as follows:
                    Insurance Company Name
                    Policy Number
                    Policy Effective Date
                    Subscriber (Policyholder) SSN
                    Subscriber (Policyholder) Gender
                    Subscriber (Policyholder) DOB




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     Action                 Help Text (in italics) and Navigation Detail

Update        Select a policy to edit/update

              When the user selects the „Update‟ action from the action bar on OHI
              Screen 1, CHCS displays a list of all of the patient‟s policies that are
              available for editing (including any “Inactivated” policies that have not
              been updated to point to standard HIC IDs). The user selects a policy to
              edit from the picklist.

              When the user selects a policy to edit, OHI Screen 2 displays with the
              policy information as it currently appears in the policy record.

              The user may edit data on OHI Screen 2 and other subsequent policy
              enter/edit screens, and then file the updated information.

              Expanded Help Text:

              The “Update” action is used to edit/update information associated with a
              policy in the selected patient‟s OHI profile.

              All active, inactivated, and expired policies are available for
              editing/updating.

              Important Note on editing: You may not edit the following fields using
              the “Update” action:
                Insurance Company Name
                Policy ID
                Policy Effective Date
              If you need to edit any of these values, you must use the “ModKey”
              action.




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    Action                Help Text (in italics) and Navigation Detail

ModKey       Used to correct Insurance Company Name, Policy Effective Date, or
             Policy ID – key policy identifiers.

             When the user selects the “ModKey” action from the action bar on OHI
             Screen 1, the system displays a picklist of the patient‟s active OHI
             policies. The user selects one policy and the system displays a screen
             where the user can modify the insurance company, Policy Effective
             Date, and/or the Policy ID.

             Because the HIC ID, Policy ID, and Policy Effective Date are the key
             identifiers for a policy, those values may not be modified, once the
             policy is filed. When a user discovers that one (or more) of those three
             field values is incorrect, the policy with the incorrect value(s) must be
             canceled, and a new policy must be entered to replace that policy.

             Rather than making the user manually step through that process, the
             “ModKey” action automates those steps.

             With the “ModKey” action, the system automatically cancels the policy
             with the incorrect values, and then automatically creates a new policy,
             replicating the values from the old policy. The user is prompted to enter
             new value(s) for the correct key fields before filing the new policy.

             Expanded Help Text

             The “ModKey” action is used to edit/update the insurance company,
             Policy Effective Date, and/or Policy ID associated with a selected
             policy. You are not allowed to edit these three fields using the “Update”
             action because these three fields uniquely identify a policy in the
             database.

             The system automatically cancels the policy with the incorrect values
             and then creates a new policy, replicating the correct values from the old
             policy. You will be prompted to enter new value(s) to replace the
             incorrect values in the key fields.




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         Action                Help Text (in italics) and Navigation Detail

Cancel            Used to select a Policy or Coverage Type to cancel.
                  When the user selects the „Cancel‟ action from OHI Screen 1 action bar,
                  the system displays a picklist of the selected patient‟s policies which has
                  the name of the system to which the user is currently logged on, in the
                  OHI Transaction System Name field of the policy record. The user
                  selects a policy from the picklist. Another action bar displays allowing
                  the user to choose whether he/she wants to cancel the policy or cancel a
                  Coverage Type associated with the selected policy.

                  Cancellation of a policy represents an error correction and should be
                  requested only when the user determines that the policy was a mistake
                  or when the Policy Effective Date is incorrect.

                  Canceling an OHI policy on CHCS triggers an “OHI Cancel” message
                  to DEERS.

                  Cancellation of an OHI policy blocks all further access to that OHI
                  policy.

                  When an OHI policy is cancelled, all Coverage Type Codes associated
                  with the cancelled policy are also cancelled.
                  Only users who are currently logged on to the same system (as the
                  system currently in the „OHI Transaction System Name‟ field in the
                  OHI policy record) may submit an update message to DEERS
                  requesting cancellation of the policy.
                  Expanded Help Text:
                  The “Cancel” action is used to mark a policy as cancelled. Once a policy
                  has been cancelled, the system does not allow that policy to be
                  edited/updated or copied. A cancelled policy may only be viewed or
                  printed.
                  Cancellation of a policy represents an error correction and should be
                  requested only when you have determined that the policy was a mistake
                  or when the Policy Effective Date is incorrect.
                  Policies are available for canceling only when your military treatment
                  facility (MTF) was the originating MTF for the policy, or when your
                  MTF was the last system to edit the policy; however, even if you are not
                  allowed to cancel a policy using the “Cancel” action, you are always
                  allowed to “end” that policy by entering a “Policy End Date” and an
                  “End Reason” code of “Q.”




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     Action                Help Text (in italics) and Navigation Detail

CopyFrom      Copy policies from OHI profiles of other family members.

              When the user selects “CopyFrom” from the OHI Screen 1 action bar,
              the system displays OHI Screen 11 which includes all active policies
              that may be copied to the selected family member. The user selects a
              policy and OHI Screen 12 displays.

              Expanded Help Text:
              The „CopyFrom‟ action is used to copy OHI policies from the selected

              accessing. You may copy from patients who have the same Sponsor
              SSN as the selected patient and who are TPC-eligible. Most data
              defaults from the copied policy; however, you will have to enter data in
              the ‟Patient's Relationship to the Policyholder.‟ Field.

              You may edit/update other data in the copied policy that is not
              applicable to the patient you are currently accessing.




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     Action                Help Text (in italics) and Navigation Detail

CopyTo        Select a policy to copy to other family member(s)‟ OHI profile(s).
              When the user selects the “CopyTo” action from the OHI Screen 1
              action bar, the system displays all active OHI policies held by the
              selected patient. The user selects one policy to copy to other family
              members.

              The system then displays OHI Screen 13 so that the user may select a
              family member to whom to copy the selected policy.

              The user will need to populate the “Patient‟s Relationship to
              „Subscriber‟ field, rank each Coverage Type as applicable, and then file
              the new policy.
              Expanded Help Text:

              The “CopyTo” action should be used when you want to copy only one
              policy to other family members. If you want to copy more than one
              policy, it is more efficient to go to each family member‟s OHI profile
              and use the “CopyFrom” action.

              The “CopyTo” action is used to copy a selected OHI policy from the
              patient you are currently accessing, to other family members. You may
              copy to patients who have the same Sponsor SSN as the selected patient
              and who are TPC eligible only.

              Most data defaults from the copied policy; however, you will have to
              enter the “Patient‟s Relationship to the Subscriber” for each of the
              patients to whom you copied the policy and you will need to rank
              Coverage Types as applicable.

              You may edit/update other data in the copied policy that is not
              applicable to the patient selected.




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      Action                 Help Text (in italics) and Navigation Detail

View/Print     View or Print patient‟s OHI policies based on user-selected criteria.

               When the user selects the‟ „View/Print‟ action from the action bar on
               OHI Screen 1, he/she is presented with a selection list to choose the
               following Policy Status(es) to include on the display/report:
                   View All policies
                   View Active policies
                   View Expired policies
                   View Inactivated policies

               The user selects the Policy Status of the policies that he/she wants to
               view.

               The user is prompted for a device. He/she can display the data on the
               screen or print a hard copy.

               A list of all policies that comply with the selection criteria displays. See
               OHI Screen 16 for the format of the report.

               Expanded Help Text:

               The “View/Print” action is used to view or print policies from the
               selected patient‟s OHI profile. You may view the policies or print them
               to a printer. All data associated with each policy is displayed/printed.

               You may view/print policies for the selected patient, based on the
               following selection criteria:
                   All Policies
                   Active Policies
                   Expired Policies
                   Inactivated Policies (inactivated by the install conversion)




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      Action                 Help Text (in italics) and Navigation Detail

PreCert        Select a policy for which to enter pre-certification information.

               When the user selects the „PreCert‟ action from the action bar on Screen
               1, the system displays a list of active policies held by the selected
               patient. The user selects one policy and the system displays OHI Screen
               17 for the user to select a Coverage Type/Payer Type. The Coverage
               Type/Payer Type must be selected to find the correct phone number to
               call for the pre-certification. After selecting the Coverage Type/Payer
               Type, the system displays OHI Screen 18 for the user to enter the
               following pre-certification information:

                a text description of pre-certification and utilization review
                 requirements necessary to comply with the terms of the policy being
                 entered/edited.

                        Note: The PreCert/UR comments may also be entered on the
                        policy enter/edit screen (see OHI Screen 2). Historically, the
                        sites have used this field for general comments about the
                        policy (e.g., deductibles, etc.) rather than strictly for pre-
                        certification or utilization review information.

                an authorization code provided by the insurance company indicating
                 that they have authorized an inpatient admission.

                a flag to indicate that the policy will automatically be included in the
                 Insurance Policy Precert/Ur Nightly Roster.

               A sample of the Insurance Company Precert/UR Nightly Roster can be
               seen on OHI Screen 19.

               Expanded Help Text:

               The “PreCert” action is used to enter the following pre-certification
               information:

               -   a text description of pre-certification and utilization review
                   requirements necessary to comply with the terms of the policy being
                   entered/edited,

               -   an authorization code provided by the insurance company indicating
                   that they have authorized an inpatient admission, and

               -   a flag to indicate that the policy will automatically be included in the
                   INSURANCE POLICY PRECERT/UR NIGHTLY ROSTER.



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       Action                         Help Text (in italics) and Navigation Detail

eXit                    Return to the menu option/action from which you navigated.

                        When the user selects the „eXit‟ action from the action bar on OHI
                        Screen 1, the user returns to the point in the functionality from which
                        he/she navigated to the OHI enter/edit screens; i.e., the PAD
                        Registration menu, the PAS MCP Booking option, the PII menu, or the
                        MSA Insurance Account Processing menu options

                        Expanded Help Text:

                        The “Exit” action is used to take you back to the previous menu
                        option/action. You will exit the selected patient‟s OHI profile.

„ADD‟ Action

Adding a New Policy

When the user selects „Add‟, the system prompts for an Insurance Carrier.

The user may enter the full Insurance Company Name or the HIC ID associated with the insurance
company. If the user enters the first few letters of the Insurance Company Name, the system will
display a picklist of standard insurance companies from which the user may select.

       Note: CHCS will allow the value of “UNK” (Unknown) to be entered into the Insurance
       Company Name field when a user enters a policy in the CHCS OHI Policy file and the user
       does not know the name of the insurance company. There will be one DEERS-assigned
       HIC ID that corresponds to “UNK.” This will allow the user to complete the process of
       entering the OHI and avoid losing the information associated with the OHI that the
       beneficiary is able to provide.

If the user selects a carrier that is a valid entry in the SIT file, the system takes the user to OHI
Screen 2 and subsequent enter/edit screens, so that the user may add a new policy for the selected
patient.

If the user presses <RETURN> without entering an Insurance Carrier at the „Select Insurance
Carrier‟ prompt, the system returns the user to OHI Screen 1.

If the user enters the name of an insurance company that is not found in the HIC file (#8192), the
system displays the following message:
       Are you adding 'Insurance Carrier X' as a new HEALTH INSURANCE CARRIER?

If the user answers “No” to the question, he/she is prompted again for an insurance company.




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If the user answers “Yes” to the question, the system displays the following:
        You must select an Insurance Carrier from the Standard Insurance Company
         file, or request that DEERS add a new Temporary Insurance Company before
        the system will allow you to continue entering data for this policy.

        Do you want to request that DEERS add a new Temporary Insurance Company
        now? ? No//”
If the user answers, “No”, he/she is returned to OHI Screen 1.

If the user answers, “Yes”, the system displays the “Insurance Company Add” screen, so that a
Temporary Insurance Company can be added, and the user can move forward in entering the new
OHI policy for the patient.

Once a valid Standard or Temporary Insurance Company has been entered, OHI Screen 2 displays.

The OHI Screen 2 header displays the demographics associated with the selected patient. The user
may enter policy information, as applicable.


------------------------------------------------- OHI Screen 2 ----------------------------------------------------


                             OTHER HEALTH INSURANCE
         Patient: MUNN,JUSTIN HAMILTON                  FMP/SSN: 02/000-00-0000
Patient Category: USA FAM MBR AD                   Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY COVERAGE     DMDC Pat ID: 1005814312
     Region Code:                                           Sex: MALE
             PCM:                                       DOB/Age: 06 Jul 1989/15Y
================================================================================
Insurance Company: E & E BENEF   E & E BENEFIT PLANS INC
        Policy Id:                       Card Holder Id:
  Policy Eff Date:               End Date:               End Reason:
    Ins Type Code: CI    Claim Filing Code: 09    Policy Obsolete?: NO
 PreCert Comments:


===============================================================================
  Coverage Type          Payer Type        Eff Date     End Date     Rank
===============================================================================
  COMPREHENSIVE MEDICAL BOTH INST & PROF                             PRIMARY



Policy Last Modified:                              Policy Txn Sys:




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Key to Fields on Screen 2:

     Field Name                                      Definition and Detail
 Insurance Company     The user may enter the full Insurance Company Name or the HIC ID
                       associated with the insurance company. If the user enters the first few letters
                       of the Insurance Company Name, the system will display a picklist of
                       standard insurance companies from which the user may select. The user
                       must use one of the Insurance Companies from the SIT file (#8192).

                              Note: CHCS shall allow the value of “UNK” to be entered into the
                              Insurance Company Name field when a user enters a policy in the
                              CHCS OHI Policy file and the user does not know the name of the
                              insurance company. There will be one DEERS-assigned HIC ID
                              that corresponds to “UNK.” (UNKVA001). This will allow the user
                              to complete the process of entering the OHI and avoid losing the
                              information associated with the OHI that the beneficiary is able to
                              provide. The Insurance Company Name that corresponds with UNK
                              is “Placeholder HIC ID.”

                       If the Insurance Company that the user wishes to use is not on the picklist,
                       the user is taken to the SIT Enter/Edit screen to add the insurance company
                       as a Temporary entry. The system sends an “Add SIT” message to DEERS
                       to have the newly entered insurance company verified by the VPOC.
                       After the “Add SIT” message is sent, the system returns the user to Screen
                       2, where he/she may proceed with entry of the new policy.
                               Note: When you jump from OHI to enter a new SIT, the system
                               will not take you back to the OHI enter/edit screen and allow you to
                               use that new SIT until a response has been received from DEERS,
                               which provides the HIC ID that DEERS has just assigned to your
                               new SIT. If there is some disruption in the communication between
                               CHCS and DEERS, and CHCS is not able to get a HIC ID for the
                               newly entered SIT right away, the system displays the following
                               message:
                             You have sent a request to DEERS to add a new insurance
                             carrier. CHCS must receive a HIC ID from DEERS for the
                             new insurance carrier before you will be allowed to
                             enter an OHI policy associated with carrier. The
                             connection with the DEERS SIT is not available at this
                             time. Do you want to continue wait? No//

                        If the user‟s answer is “Yes” that they do want to wait, the system will wait
                        another 10 seconds, and then display the message again.




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     Field Name                                       Definition and Detail

                        If the wait is too long, the user might want to answer “No”, write down the
                        OHI information provided by the patient, and wait until later to enter the
                        OHI data.


Policy Id               Number provided by beneficiary (from beneficiary‟s insurance card).

                        Note: If this is a GROUP policy that has no Policy Number, the user may
                        enter the Subscriber's Social Security Number in this field.

Cardholder Id           Used if the insured has a separate Card Holder ID Number issued by the
                        Health Insurance Carrier. This is most often the Patient‟s SSN (not the
                        Subscriber‟s SSN).

Policy Effective Date   Date that coverage under this policy begins/began. The user may enter a
                        date in the past, today‟s date, or a future date.

Policy End Date         Date that all insurance coverage under this policy ends/ended. The user
                        may enter a date in the past, today‟s date, or a future date. If the user does
                        not enter a Policy End Date, the system assumes that the OHI policy is
                        effective indefinitely.

Policy End Reason       Reason that the policy is no longer active.
Code
                        Table values include the following:
                          E = Cancelled
                          Q = Date is Certain (when End Date is today or in the past)
                          R = Date is Estimated (when End Date is in the future)
                          S = Terminated (DEERS has terminated the policy)
                          U = No Date Can Be Predicted (End Date is null)
                        Value defaults are based on the date in the „Coverage End Date‟ field and
                        may not be edited.




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    Field Name                                     Definition and Detail

Insurance Type Code   Code to indicate the type of policy.
                      Table values include the following:

                        AP = Auto Insurance Policy
                        CI = Commercial (default)
                        CP = Medicare Conditionally Primary
                        GP = Group Policy
                        HM = HMO
                        IP = Individual Policy
                        LD = Long Term Policy
                        LT = Litigation
                        MB = Medicare Part B
                        MC = Medicaid
                        MI = Medigap Part B
                        MP = Medicare Primary
                        OT = Other
                        PP = Personal Payment
                        SP = Supplemental Policy
                      If the user enters “Group Policy” in the „Insurance Type Code‟ field on
                      Screen 2, the system displays OHI Screen 5 after the user completes the
                      Coverage Type and the Subscriber information on OHI Screens 3 and 4.
                      The OHI Screen 5 allows the user to enter the group policy information,

                      Note: If the user enters any Insurance Type Code other than “Group
                      Policy” in the Insurance Type Code field on OHI Screen 2, the system skips
                      OHI Screen 5.




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     Field Name                                    Definition and Detail

Claim Filing Code   Defines the type of claim.

                    Table values include:

                      09 = Self-pay (default)
                      10 = Central Certification
                      11 = Other Non-Federal Programs
                      12 = Preferred Provider Organization (PPO)
                      13 = Point of Service (POS)
                      14 = Exclusive Provider Organization (EPO)
                      15 = Indemnity Insurance
                      16 = Health Maintenance Organization (HMO)Medicare Risk
                      AM = Automobile Medical
                      BL = Blue Cross/Blue Shield
                      CH = CHAMPUS
                      CI = Commercial Insurance Co.
                      DS = Disability
                      HM = Health Maintenance Organization
                      LI = Liability
                      LM = Liability Medical
                      MB = Medicare Part B
                      MC = Medicaid
                      OF = Other Federal Program
                      TV = Title V
                      VA = Veteran Administration Plan
                      WC = Workers‟ Compensation Health Claim
                      ZZ = Mutually Defined Unknown

Policy Obsolete?    This field allows a user to mark a policy so that it will not be displayed on
                    the Insurance Verification Report. If a user sees a policy on the Insurance
                    Verification Report that he/she knows has not been renewed and is no
                    longer valid, this is the only way to keep the policy from showing up again
                    and again on the Insurance Verification Report.

                    The default is “NO.”

                    If the user changes the value to “YES”, the policy will not be displayed on
                    future Insurance Verification Reports. The field is editable so if, for some
                    reason a user wants the policy to again be included on the Insurance
                    Verification Report, he/she may change the value to “NO” again.




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    Field Name                                   Definition and Detail

PreCert Comments   Comments regarding PreCertification and/or Utilization Review. May be
                   used for general comments associated with the policy.

                   This field is data common to all Coverage Types associated with the policy.
                   The PreCert Comments may also be entered using the PreCert action on the
                   OHI Screen 2 action bar and selecting a Coverage Type.

Coverage Type      Value that identifies the specific scope of the coverage.
(Multiple)
                   From the view of the user, Coverage Type Code plus the Coverage
                   Effective Date uniquely identify a Coverage Type within a policy.

                   When the user enters a new Coverage Type or selects an existing Coverage
                   Type to edit, the system displays Screen 3 for the user to enter/edit the
                   values specifically applicable to the added or selected Coverage Type.

                   Note: Any Coverage Code may be entered for any carrier. There does not
                   have to be a one-to-one relationship between the Coverage Type in the
                   policy and the Coverage Type in the HIC record.
                   Coverage Type Codes include the following:
                          XM = Comprehensive Medical (default)
                          MD = Medical Only
                          DN = Dental
                          IP = Inpatient
                          OP = Outpatient
                          LT= Long Term Care
                          RX = Pharmacy Only
                          MH = Mental Health
                          VI = Vision
                          PH = Partial Hospitalization
                          SN = Skilled Nursing
                          Default is “XM”




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       Field Name                                    Definition and Detail

Payer Type              The Payer Type Code indicates the type of claims to be sent to the
                        Coverage Type/Payer Type address.
                        Set of Codes include the following:
                             B = Both Institutional and Professional
                             I = Institutional
                             P = Professional
                             N = Non-billable

                        Default is “B”
Effective Date          Start date for the line item Coverage Type for the selected policy.
End Date                End date for the line item Coverage Type for the selected policy.
Rank                    Coverage Precedence Code for the line item Coverage Type for the selected
                        policy.
Policy Last Modified    Date defaults to today.

Policy Txn Sys          System that initially added the policy, or system from which the last update
                        of this policy was sent to DEERS.



OHI Screen 3 provides the user with data entry points for Coverage Type Code information. This is
the screen where the scope of the coverage provided by the policy is entered/edited.




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----------------------------------------------- OHI Screen 3 -------------------------------------------------


                                                              OTHER HEALTH INSURANCE - ENTER/EDIT
         Patient: SHAW,SHEILA                                               FMP/SSN: 30/000-00-0000
Patient Category: USN FAM MBR AD                                        Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY C                                DMDC Pat Id: 0000011111

================================================================================
 <234444>                             Effective Date: DD MMM YYYY                  End Date: DD MMM YYYY

 -------------------------------------------------------------------------------

          Insurance Carrier: AETKY0005 – AETNA US HEALTHCARE
     OHI Coverage Type Code: MD MEDICAL ONLY
    OHI Coverage Payer Type: B BOTH INSTITUTIONAL AND PROFESSIONAL

Match to HIC Coverage Type: XM Comprehensive Medical                                 HIC Payer Type: B
 HIC Coverage Type Address: 4282 Atkins Blvd                                      Phone: 888-888-8888
                      City: Anytown        State: KY                                Zip: 22222
    Coverage Effective Date:            01 Jan 2004
          Coverage End Date:            31 Dec 2004
        Coverage End Reason:            R DATE IS ESTIMATED
              Coverage Rank:            P PRIMARY

     Coverage Last Modified: 15 SEP 2004@1549
           Coverage Txn Sys: TRIPLER ARMY MEDICAL CENTER




Key to fields on OHI Screen 3:

Field Name                   Definition and Detail
                             Value that identifies the specific scope of the coverage.
OHI Coverage Type
Code
                             Coverage Type Code plus the Coverage Effective Date uniquely identify a
                             Coverage Type within a policy.
OHI Coverage Payer           Indicates the type of claims to be sent to the address within the multiple.
Type
                             Set of Codes include:
                             B = Both Institutional and Professional
                             I = Institutional
                             P = Professional
                             N = Non-billable




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Field Name      Definition and Detail

Match to HIC    When the user selects an OHI Payer Type, the system checks the HIC file
Coverage Type   (#8192) for an exact match on that OHI Coverage Type/OHI Payer Type
                combination in the HIC record for the carrier.
                If an exact match is found between the OHI Coverage Type/ OHI Payer
                Type (selected in the fields above) and a HIC Coverage Type/HIC Payer
                Type in the carrier record, the system defaults the HIC Coverage
                Type/HIC Payer Type and the address associated with the HIC Coverage
                Type/ HIC Payer Type combination from the HIC file.
                However, if the system does not find an exact match between the OHI
                Coverage Type/ OHI Payer Type that the user has selected, and a HIC
                Coverage Type/ HIC Payer Type combination in the HIC file (#8192), the
                system does not default any data. The cursor moves to this field („Match
                to HIC Coverage Type‟).
                The user may enter a HIC Coverage Type or may enter “??.” If the user
                enters a HIC Coverage Type that matches a HIC Coverage Type for the
                carrier in the HIC file, and there is only a single match in the HIC file for
                that HIC Coverage Type, the system defaults the HIC Payer Type and the
                address associated with that HIC Coverage Type/ HIC Payer Type
                combination.
                If the user enters a “??” at the „Match to HIC Coverage Type‟ field, the
                system displays a list of all HIC Coverage Type/ HIC Payer Types (with
                addresses) associated with the selected carrier. (See Screen 3a.)
                The user must select a HIC Coverage Type/ HIC Payer Type which he/she
                wants to use for billing address for claims associated with the OHI
                Coverage Type/ OHI Payer Type entered above.
                   Note: When the user selects/confirms an address, the system
                   populates the „HIC Coverage Type/HIC Payer Type‟ fields in the
                   policy record in the OHI file under the OHI Coverage Type/OHI
                   Payer Type multiple, for that policy only.
                If the user tries to bypass the field (because he/she does not see an address
                he/she feels would be appropriate to associate with the OHI Coverage
                Type/Payer Type at the top of the window), the system displays the
                following direction:
                   You must select a HIC Coverage Type Address to which
                   claims associated with this OHI Coverage Type/Payer Type
                   will be sent. If you do not feel that an appropriate
                   address was displayed on the picklist, please contact
                   the business office to request that the HIC Coverage
                   Type/ HIC Payer Type address you wish to use is added to
                   the Health Insurance Carrier file.




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Field Name                 Definition and Detail

HIC Payer Type             This value defaults when the user selects the HIC Coverage Type/HIC
                           Payer Type address that he/she wants to use for billing claims associated
                           with the selected OHI Coverage Type/OHI Payer Type. The HIC Payer
                           Type is not editable.

HIC Coverage Type          The HIC Coverage Type Address is the Address Line 2 from the HIC file
Address                    (#8192). This is the street address or P.O. Box where claims are to be
                           sent.

Phone                      This is the HIC Coverage Type/HIC Payer Type telephone number from
                           the HIC file (#8192).

City                       This is the City from the HIC file (#8192), which is associated with the
                           HIC Coverage Type/HIC Payer Type Address.

State                      This is the State from the HIC file (#8192), which is associated with the
                           HIC Coverage Type/HIC Payer Type Address.

Zip                        This is the Zip Code from the HIC file (#8192), which is associated with
                           the HIC Coverage Type/HIC Payer Type Address.

Following are some key rules for Coverage Ranking:

      1. The user must enter a Coverage Rank or OHI Screen 3 will not file. If it is unknown, an
         “N” for Non-Ranked may be entered.
      2. Only policies with at least one ranked (P, S, or T) Coverage Type will be transmitted to
         TPOCS. Non-ranked policies will not be transmitted to TPOCS unless sent previously with
         a ranked Coverage Type and it was changed to “N.” Users must make sure there is a
         “Primary” coverage type; if not, they will not be able to produce a bill.
      3. There may be multiple Primary, Secondary, Tertiary, or Non-Ranked Coverage Types.
         There is no longer an edit to prevent duplicate ranking, or skipped ranks. If there is more
         than one Primary coverage type entered, users should note the correct one to bill.
On OHI Screen 3, if the user enters “??” to see his/her options for selecting a HIC Coverage
Type/HIC Payer Type, the system displays OHI Screen 3a with all of the HIC Coverage Type/HIC
Payer Type addresses in the HIC file (#8192) that are associated with the selected policy‟s
insurance company.

The user selects the address he/she wants to use as the billing address for claims associated with the
selected OHI Coverage Type/OHI Payer Type.




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------------------------------------------------------ OHI Screen 3a ------------------------------------------



        Available Coverage Types from Carrier AETNA US HEALTHCARE/AETCA0033

            Insurance Carrier: AETKY0005 – AETNA US HEALTHCARE
 OHI Coverage Type/Payer Type: MD B
--------------------------------------------------------------------------------
  Cov_Typ Payer_Typ Address
--------------------------------------------------------------------------------
   XM       B        4282 Atkins Blvd ANYTOWN, KY 22222
   RX       I        PO BOX 24019 ANYTOWN, KY 22222
   IP       B        PO BOX 2319 ANYTOWN, KY 22222

--------------------------------------------------------------------------------
Use SELECT key to select the HIC Coverage Type/Payer Type you want to use
as the billing address for the selected OHI Coverage Type/Payer Type




The HIC Coverage Type, HIC Payer Type, and address are populated into the appropriate fields on
OHI Screen 3.

When creating new policies in the new file, from old policies in the old file, a conversion will
perform the following:

           Enter all of the HIC Coverage Type/HIC Payer Type Code combinations that exist in the
            HIC file for the carrier associated with the policy into the OHI Coverage Type Code and
            OHI Coverage Payer Type Code fields in the new policy.

           Enter the HIC Coverage Type Code internal IEN and the HIC Coverage Type Code
            multiple IEN into the HIC Coverage Type Code IEN and the HIC Coverage Type Code
            multiple IEN fields under the corresponding OHI Coverage Type Code/OHI Coverage
            Payer Type Code multiple in the policy record.

When the user finishes entering Coverage Type information and files OHI Screen 3, the system
automatically displays OHI Screen 4 with Subscriber information as shown below.




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--------------------------------------------------- OHI Screen 4 -----------------------------------------------


                                                               OTHER HEALTH INSURANCE - ENTER/EDIT

          Patient: SHAW,SHEILA                         FMP/SSN: 30/000-00-0000
 Patient Category: USN FAM MBR AD                  Patient SSN: 000-00-0000
             HCDP: TRICARE PRIME FAMILY C          DMDC Pat Id: 0000011111
      Region Code: 01                                      Sex: FEMALE
              PCM: WOLLIN,MAGDALENA                    DOB/Age: 12 Aug 1972/30Y
  ============================================================================
          Subscriber Name: (70)
           Subscriber SSN: nnn-nn-nnnn
           Subscriber DOB: DD MM YYYY
        Subscriber Gender: (1)
     Subscriber Address 1: (36)
     Subscriber Address 2: (36)
          Subscriber City:
 Subscriber State/Country: (2)
      Subscriber Zip Code: (5)
     Subscriber Telephone: (20)
 Patient’s Relationship to Subscriber: (2) (35)



    Note: Numbers in parentheses represent the length of the field values.

Most of the information in OHI Screen 4 is defaulted if the subscriber is in the Patient file. If not,
the following key describes the Subscriber fields that may be populated.




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Key to Fields on OHI Screen 4:

     Field Name                                 Definition and Detail

Subscriber Name        Full name of Subscriber. (Required)
                       The user may enter the name, using the CHCS convention
                       LASTNAME,FIRSTNAME MI.
                       The user can enter the Sponsor‟s SSN and get a family picklist from
                       which to select the Subscriber‟s name (if the Subscriber is registered
                       in CHCS).
                       If the Subscriber‟s name is in the CHCS Patient file, a pointer
                       relationship is established.
                       If the Subscriber‟s name is not in the CHCS Patient file, the name is
                       entered as free text.

Subscriber SSN         SSN associated with Subscriber. (Required)

Subscriber DOB         Date of Birth associated with Subscriber. (Required)

Subscriber Gender      Gender associated with Subscriber. (Required)

Subscriber Address 1   1st line of street address or P.O. Box number associated with
                       Subscriber.

Subscriber Address 2   2nd line of street address or P.O. Box number associated with
                       Subscriber.

Subscriber City        City associated with Subscriber‟s Street Address. Automatically
                       defaults when Zip Code is entered.

                       Will be null when Subscriber‟s address is outside of the United States.

Subscriber             State or Country associated with Subscriber‟s street address.
State/Country
                       If the Subscriber‟s address is in the United States, the State will
                       display in this field. Automatically defaults when Zip Code is
                       entered.

                       If the Subscriber‟s address is outside of the United States, the Country
                       Code will display in this field.

Subscriber Zip Code    Zip Code associated with Subscriber‟s street address.

Subscriber Telephone   Telephone Number associated with the Subscriber.



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     Field Name                                  Definition and Detail

Patient‟s Relationship   Represents the association of the insured patient to the Subscriber.
to Subscriber            (Required)

                         HIPAA table values include:
                         01 = Spouse
                         04 = Grandfather or
                              Grandmother
                         05 = Grandson or Granddaughter
                         07 = Nephew or Niece
                         09 = Adopted Child
                         10 = Foster Child
                         15 = Ward
                         17 = Stepson or Stepdaughter
                         18 = Self
                         19 = Child
                         20 = Employee
                         21 = Unknown
                         22 = Handicapped Dependent
                         23 = Sponsored Dependent
                         24 = Dependent of a Minor
                              Dependent
                         29 = Significant Other
                         32 = Mother
                         33 = Father
                         34 = Other Adult
                         36 = Emancipated Minor
                         39 = Organ Donor
                         40 = Cadaver Donor
                         41 = Injured Plaintiff
                         43 = Child Where Insured Has
                              No Financial Responsibility
                         53 = Life Partner
                         G8 = Other Relationship

When the user finishes entering the Subscriber information on OHI Screen 4, the system either
returns the user to OHI Screen 1, where he/she may choose to perform other OHI maintenance
activities. However, if the user had entered “GP” (Group Policy) in the Insurance Type field on
OHI Screen 2, the system takes the user to OHI Screen 5, providing the user with data entry points
for Group Policy information.

Note: If the Insurance Type Code entered on OHI Screen 2 is anything other than “Group Policy”,
the user never sees OHI Screen 5.


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------------------------------------------------------ OHI Screen 5 -------------------------------------------



                             OTHER HEALTH INSURANCE - ENTER/EDIT

         Patient: SHAW,SHEILA                         FMP/SSN: 30/000-00-0000
Patient Category: USN FAM MBR AD                  Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY C          DMDC Pat Id: 0000011111
     Region Code: 01                                      Sex: FEMALE
             PCM: WOLLIN,MAGDALENA                    DOB/Age: 12 Aug 1972/30Y
 =============================================================================

              Group Plan Name:              (35)
              Group Policy Id:              (17)
          Group Employer Name:              (35)
Grp Emp PO Box/Street Address:              (50)
    Group Employer ATTEN Line:              (50)
          Group Employer City:              (30)
 Group Employer State/Country:              (2)
      Group Employer Zip Code:              (5)                           Zip Code Extension: (4)
     Group Employer Telephone:              (2)                          Telephone Extension: (5)




Key to Fields on OHI Screen 5:

Field Name                   Definition and Detail

Group Plan Name              Name of the company/organization or plan.

                             * Required for Group Policies.

Group Policy Id              Id that represents the group with which the policy is associated.

                             * Required for Group Policies.

                             If there is no Group Policy Id attached to the group, the user may enter
                             the Subscriber‟s SSN.

Group Employer               Employer with which the Group Policy is associated.
Name
                             * Required for Group Policies.

Grp Emp PO Box or            Actual P.O. Box or Street Address used as the mailing address for the
Street Address               employer with which the Group Policy is associated. This is Address
                             Line 2 in the database.

Group Employer               The first address line is always reserved for information such as
ATTEN Line                   ATTEN. This is Address Line 1 in the database.




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Field Name               Definition and Detail

Group Employer City      City associated with the employer‟s mailing address. Automatically
                         defaults when Zip Code is entered.

                         Will be null when employer address is outside of the United States.

Group Employer           State or Country associated with the employer‟s mailing address.
State/Country
                         If the Employer Address is in the United States, the State will display
                         in this field. Automatically defaults when Zip Code is entered.

                         If the Employer Address is outside of the United States, the Country
                         Code will display in this field.

Group Employer Zip       City associated with the employer‟s mailing address. Populated only
Code                     when the address is in US Zip Code file.

Group Employer Zip
                         Zip Code Extension associated with the employer‟s mailing address.
Code Extension

Group Employer           Telephone number for the employer with which the Group Policy is
Telephone                associated.

                         * Required for Group Policies.

Group Employer           Telephone number extension associated with the Group Employer
Telephone Extension      Telephone Number.

When the user finishes entering all policy information for the new policy and files, the system either
takes the user back to OHI Screen 1 or, if there are other family members to whom the user may
copy the new policy, the system prompts the user to select the family members.

In order to facilitate the user‟s adding the policy to another family member‟s OHI record, the
system displays the following question after a new policy is filed:
<family member name>
<family member name>
<family member name>

     Would you like to add Policy nnnnnnnnnn to the OHI record of any of these
     other family members? Yes//

       Note: The only family member names displayed above are those family members who (1)
       do not already have the policy in their OHI record, and (2) are eligible to have OHI entered
       into CHCS, i.e., not Active Duty or K Codes.




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An “Add OHI” message is triggered to DEERS for each new policy created for each family
member.
„Update‟ Action

Editing/Updating an Active or Expired Policy
If the user selects the „Update‟ action from the OHI Screen 1 action bar, the cursor moves to the
middle window and the user can select a policy to edit. If the user selects an active or expired
policy (a policy where the insurance company is a valid SIT entry) to edit/update, the system
displays OHI Screen 2. The user may move through the OHI Enter/Edit screens and modify policy
information, as applicable. The following fields can not be modified using the „ Update‟ action:

    Insurance Company
    Policy Id
    Policy Effective Date

When the user files the modified OHI data, CHCS triggers an “OHI Update” message to DEERS.
DEERS will overwrite the information that is currently have stored for the policy on the DEERS
database.

Editing/Updating an Inactivated Policy
If the user selects the „Update‟ action from the OHI Screen 1 action bar and the user selects an
Inactivated policy (a policy marked with an “I” − because it has not yet been linked to a valid HIC
Id) from the list of policies, the system displays OHI Screens 2,3, 4, (and 5, if a group policy) for
the user to enter any missing data that did not convert from the old Policy file (#8086) to the new
OHI file (#8074) at the time of the initial conversion.

When OHI Screen 2 displays, a subset of the information associated with the inactivated policy
displays so that the user can reference the “old policy” data while entering a valid SIT to create a
“new policy.” As the user moves through the subsequent OHI Enter/Edit screens, data from the
“old policy” that can be re-used in the “new policy” will default.

Upon completion of the data entry, the system takes the user back to OHI Screen 1 and CHCS
triggers an “OHI Add” message to DEERS to update the patient‟s OHI profile with this new policy.
 The “old policy” was never in DEERS because it was not linked to a valid SIT entry.
Consequently, there is no need to send any type of OHI message to DEERS regarding the “old
policy.”

********************************************************************************
IMPORTANT: Once an Inactivated policy has been updated with a valid HIC Id, the old policy is
no longer accessible on CHCS to edit. The new policy with the valid HIC Id becomes the “new”
valid policy and may be edited, just the same as any other OHI policy.
********************************************************************************




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„MODKEY‟ Action

Modifying Key Fields That Uniquely Identify a Policy

The user is not allowed to edit/update the Insurance Company Name, the Policy Effective Date,
and/or the Policy Id using the „Update‟ action on OHI Screen 1 because “updating” any of these key
fields (that uniquely identify a policy on DEERS) would result in a mismatch between the policy on
CHCS and the policy on DEERS.

When a user discovers that one or more of those three key values are incorrect, the policy with the
incorrect value(s) must be canceled, and a new policy must be entered to replace that policy. Rather
than having to manually step through that process, the „ModKey‟ action may be used to automate
those steps.

With the „ModKey‟ action, the system automatically cancels the policy with the incorrect values,
then automatically creates a new policy, replicating the values from the old policy. The user is
prompted to enter new value(s) to correct the key fields before filing the new policy.
When the user selects the „ModKey‟ action from the action bar on OHI Screen 1, the system
displays a picklist of the patient‟s active OHI policies. The user selects one policy and the system
displays OHI screen 6 where the user can modify the insurance company, the Policy Effective Date,
and/or the Policy Id.


------------------------------------------------- OHI Screen 6 -------------------------------------------------


                            OTHER HEALTH INSURANCE – MODIFY KEY FIELDS

         Patient: SHAW,SHEILA                         FMP/SSN: 30/000-00-0000
Patient Category: USN FAM MBR AD                  Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY C          DMDC Pat Id: 0000011111
     Region Code: 01                                      Sex: FEMALE
             PCM: WOLLIN,MAGDALENA                    DOB/Age: 12 Aug 1972/30Y
 =============================================================================

        Insurance Company: (9) (35)
                Policy Id: (20)
    Policy Effective Date: DD MMM YYYY




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Key to Fields on OHI Screen 6:

Field Name               Definition and Detail

Insurance Company        The HIC Id and the full Insurance Company Name defaults from the
                         old policy.

                         The user may change the default by entering the HIC Id, the full
                         Insurance Company Name, or a partial Insurance Company Name.

                         If the Insurance Company that the user wants to use is not on the
                         picklist, the user is taken to the SIT Enter/Edit screen to add the
                         insurance company as a Temporary entry. The system sends an “Add
                         SIT” message to DEERS to have the newly entered insurance
                         company verified by the DoD UBO VPOC.

                         After the “Add SIT” message is sent, the system returns the user to
                         OHI Screen 2, where he/she can proceed with entry of the new policy.

Policy Id                The Policy Id defaults from the old policy.

                         The user can change the defaulted value.

Policy Effective Date    The Policy Effective Date defaults from the old policy.

                         The user can change the defaulted value.



„ CANCEL‟ Action

Canceling an OHI Policy
Cancellation of a policy represents an error correction and should be requested only when the user
determines that the policy was a mistake.

When the user selects “Cancel” from the OHI Screen 1 action bar, the system displays OHI Screen
7, where the user indicates whether he/she wants to cancel the policy or cancel a Coverage Type.




                                                 3-67
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------------------------------------------------------ OHI Screen 7 -------------------------------------------


                                     OTHER HEALTH INSURANCE

         Patient: JOHNSON,GARETH M                    FMP/SSN: 01/000-00-0000
Patient Category: USAF FAM MBR AD                  Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY COVERAGE    DMDC Pat ID: 0000000000
     Region Code:                                          Sex: MALE
             PCM:                                      DOB/Age: 26 Jun 1996/09Y
================================================================================
  Insurance Carrier            Policy ID            Eff Date   End Date   Pol
    Coverage Types and Ranking                        Subscriber          Stat
--------------------------------------------------------------------------------
  GAILFITZ                     54858458             01Jan2005 31Dec2005 (S)
    DN(P)                                             BEAULIEU,GARETH M
  GALLAGHER BASSETT            54858458             01Jan2005 31Dec2005 (S)
    DN(P)                                             BEAULIEU,GARETH M


--------------------------------------------------------------------------------
cancelPolicy   CancelCoverage   eXit
Select a policy to cancel




A picklist of the selected patient‟s policies that originated, or were last edited, by a user on the
current user‟s CHCS platform, displays in the middle window.

        Note: Only the subscriber whose name is currently in the „Policy Coverage Transaction
        System Name‟ field for the selected policy may cancel it.

If the user selects “cancelPolicy”, the cursor moves to the middle window. The user selects a
policy, and the system asks the user to confirm that he/she wants to cancel the policy:

        Do you want to cancel <HIC Id>                <Policy Id> <Policy Effective Date>? N//

                If the user answers “Yes” to the question, the system automatically populates the
                 Policy Effective Date value associated with that policy into the „Policy End Date‟
                 field, and an “E” into the „Policy End Reason Code‟ field (in OHI Policy file #8074).
                 Cancelling the policy on CHCS triggers an “OHI Cancel” message to DEERS.

                If the user answers “No” to the question, the system returns to OHI Screen 1.

If the user cancels a policy for one family member, the system asks the user if
he/she wants to cancel the policy for the other family members:

        You have canceled a policy under which the following family members are
        covered.

        ADAMS,MARSHA A
        ADAMS,JERRY R
        ADAMS,SHARON S

        Do you want to cancel the policy for the other family members too?                               N//



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          If the user answers “YES” to the question, the policy will be canceled for all family
          members covered by that policy.

Canceling an OHI policy on CHCS triggers an “OHI Cancel” message to DEERS. Cancellation of
an OHI policy blocks all further access to that OHI policy except to View or Print. A cancelled
policy may not be updated or modified. When an OHI policy is cancelled, all Coverage Type codes
associated with the cancelled policy are also cancelled.

Canceling a Coverage Type
In addition to canceling a policy, the „Cancel‟ action on the OHI Screen 1 action bar may also be
used to cancel a Coverage Type.

When the user selects „Cancel‟ from the OHI Screen 1 action bar, the system displays OHI Screen
7, where the user indicates whether he/she wants to cancel the policy or cancel a Coverage Type.

If the user selects “cancelCoverage”, the cursor moves to the middle window. The user selects a
policy, and the system displays OHI Screen 8, where the system displays a list of the Coverage
Types associated with the selected policy, and prompts the user to select Coverage Type(s) that
he/she wants to cancel. Cancellation of a coverage type represents an error correction and should be
requested only when the user determines that the Coverage Type or the Coverage Effective date is
in error.

          Note: Only the subscriber whose name is currently in the „Policy Coverage Transaction
          System Name‟ field (in the selected Coverage Type) may cancel the Coverage Type.

------------------------------------------------ OHI Screen 8 -----------------------------------------------

                                            OTHER HEALTH INSURANCE – CANCEL COVERAGE TYPE(S)

          Patient: HUDSON,LYNN                           FMP/SSN: 02/000-00-0000
Insurance Company: AETNA HEALTH PLANS OF TEXAS    Effective Date: 01 Jan 2003
        Policy Id: AE123451234512345123                 End Date: INDEF
================================================================================
 Coverage Type     Payer Type                          Eff Date   End Date Rank
--------------------------------------------------------------------------------
 MEDICAL           Both (Institutional and Profession 01Jun2003 INDEF       P
 PHARMACY          Institutional                       01Jun2003 INDEF      S
 DENTAL            Both (Institutional and Profession 01Jun2003 INDEF       N
 VISION            Professional                        01Jun2003 INDEF      P
--------------------------------------------------------------------------------
Use SELECT Key to choose a Coverage Type or Press <RETURN> to continue


          The user can select one or more Coverage Types to cancel. The system will ask for
           confirmation of each selection. As the user confirms that he/she wants to cancel a
           Coverage Type, the system automatically populates the Coverage Effective Date value
           associated with that Coverage Type into the „Coverage End Date‟ field, and an “E” into
           the „Coverage End Reason Code‟ field (in OHI Policy file #8074).



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         If the user enters “NO” at the confirmation prompt after selecting a Coverage Type, the
          user is returned to OHI screen 7.

         If the user presses <RETURN> without selecting any of the Coverage Types from the list,
          the system takes the user back to OHI Screen 1 without canceling any of the Coverage
          Types.

            Note: If the user attempts to cancel the only active Coverage Type associated with the
            policy, the system displays the following message:
                You have selected the only active Coverage Type associated with
                this policy. Canceling the only active Coverage Type will also
                cancel the policy. Do you want to cancel? No/

Cancelling a Coverage Type triggers an “OHI Cancel” message to DEERS. Only the selected
Coverage Type is cancelled for that policy, not the OHI policy itself or other Coverage Types
within that policy. All further access to the cancelled OHI policy is blocked other than View or
Print. Modifications and updates are no longer allowed.

If the user cancels a Coverage Type for one family member, the system asks the user if he/she
wants to cancel the policy for the other family members.

         You have canceled a Coverage Type associated with a policy under which
         the following family members are covered.

         ADAMS,MARSHA A
         ADAMS,JERRY R
         ADAMS,SHARON S
         Do you want to cancel the Coverage Type for the other family members too?
          N//

         If the user answers “YES” to the question, the Coverage Type will be canceled for all family
         members who have that Coverage Type associated with the selected policy.

Cancellation of a Coverage Type represents an error correction and should be requested only when
the user determines that the Coverage Type was a mistake or when the Coverage Effective Date is
incorrect.

Canceling a Coverage Type triggers an “OHI Cancel” message to DEERS.

   Note: DEERS does not mistake this for a policy cancellation because the “E” is in the
   „Coverage End Reason Code‟ field, not the „Policy End Reason Code‟ field.

Cancellation of a Coverage Type blocks all further access to that Coverage Type.
When a Coverage Type is cancelled, only the selected Coverage Type within the selected policy is
cancelled. Canceling a selected Coverage Type does not cancel the policy or any other Coverage
Types associated with the policy.



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       Exception: If the user attempts to cancel the only active Coverage Type associated with a
       policy, the system displays the following message:

               You have selected the only active Coverage Type associated with
               this policy. Canceling the only active Coverage Type will also
               cancel the policy. Do you want to cancel the policy? N//

       If the user answers “YES” to the question, the system populates an End Date of “today” and
       an End Reason Code of “E” at both the Coverage Type level and the Policy level, indicating
       that the policy, as well as the Coverage Type, is canceled.
Only the subscriber whose name is currently in the „Policy Coverage Transaction System Name‟
field (in the selected Coverage Type) may submit a cancel message to DEERS requesting
cancellation of the Coverage Type.

Deactivating a Policy (Automatic, no user action necessary)
Deactivation of an OHI policy automatically occurs when CHCS receives verification that DEERS
has deactivated the insurance carrier with which the OHI policy is associated. A request would
have to be made for DEERS to deactivate an insurance carrier and verified by the DoD UBO
VPOC.

Note: Deactivation of an OHI policy is an automatic process, no user intervention is required.

   When CHCS receives verification that DEERS has deactivated the carrier with which an OHI
    policy is associated, CHCS populates the Policy End Date value in the CHCS OHI file (# 8074),
    based on the Carrier Deactivation Date value from the SIT record associated with the insurance
    company that was deactivated. All OHI policies associated with the deactivated carrier are
    deactivated.

   The system populates the Carrier Deactivation Date value from the SIT record associated with
    the insurance company that was deactivated, into the Coverage End Date field associated with
    each of the Coverage Types in the policy record in the CHCS OHI file (#8074).

   The system populates a value of “D” into the „Policy End Reason Code‟ field of the OHI policy
    record in the CHCS OHI file (#8074).

   The system populates a value of “D” into the „Coverage End Reason Code‟ field associated with
    each of the Coverage Types in the policy record in the CHCS OHI file (#8074).

   The system changes the Coverage Precedence Code to “Non-Ranked” for all Coverage Types
    associated with the deactivated policy.

   The system does NOT trigger an “OHI Update” message to DEERS when an OHI policy is
    deactivated as the result of a SIT deactivation, because DEERS has already automatically
    deactivated all policies associated with the deactivated SIT on the DEERS database.

CHCS does not deactivate OHI policies associated with a deactivated carrier until AFTER the DoD
UBO VPOC verifies the deactivation of the carrier. In other words, the carrier record in the SIT file


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(#8192) must contain a “D” in the „Carrier Status Code‟ field, and a “V” in the „Carrier Verification
Status Code‟ field BEFORE CHCS will automatically deactivate the OHI policies associated with
the carrier.

Deactivated policies are included in the download of OHI so that the local user can see that the
policy was once valid; however, deactivated policies can not be reactivated. A new policy, using a
valid (active) HIC Id, must be entered to replace the deactivated policy.

Deactivation of an OHI Policy deactivates the selected policy and all Coverage Type codes
associated with the deactivated policy.

Note: Deactivation of an OHI policy is always at the policy (parent) level only, never at the
Coverage Type Code (child) level. A Coverage Type associated with a policy can not be
deactivated independent of the policy.

„COPY FROM‟ Action

Copying Policies FROM Another Family Member
The user should use the “CopyFrom” action when he/she wants to copy one or more policies from
one or more family members to one patient. When using the “CopyFrom” action, the DEERS OHI
query will not have to be repeated for each policy copied to the selected patient.

When the user selects „CopyFrom‟ on the OHI Screen 1 action bar, the system displays all active
policies held by other TPC beneficiaries who have the same Sponsor SSN as the selected patient.
(See OHI Screen 9.)

------------------------------------------------- OHI Screen 9 -------------------------------------------------

                                     OTHER HEALTH INSURANCE - COPY POLICY
 Copy to Patient: SHAW,BRENDA                          FMP/SSN: 03/000-00-0000
     Patient SSN: 000-00-0000                       DOB/Gender: 04 Feb 1994/F
-----------------------------------------------------------------------------
  Insurance Co Name            Policy Id             Eff Date   Subscriber
    Coverage Types
-----------------------------------------------------------------------------
  ADVANCE PCS                  4848394               28Jan2003 SHAW,SHEILA
    RX
  AETNA HEALTH PLANS OF TEXAS AE123458765654446666 09Dec2002 SHAW,SHEILA

    MD RX IP OP PH SN LT MH DN VI
  RX ADVANCE PCS               4848394               28Jan2003 SHAW,SHEILA
    RX
 +PREMIER BLUE                 568-97-6857           18Sep2002 SHAW,SHEILA
    MD
 ------------------------------------------------------------------------------
 Use Select key to select Policy to copy or Press <RETURN> to continue




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Only one occurrence of each policy eligible for copying, will display on the OHI Screen 9 picklist.
The rule for determining which occurrence will display is as follows: If the Subscriber‟s OHI record
includes the policy, display that policy because that is the policy that will include all of the eligible
coverage types that can be applied to the selected patient. If the other family member‟s OHI profiles
contain policies that meet the criteria for copying to the selected patient, but the Subscriber does not
have any OHI records in CHCS, the system will display the first available occurrence of the policy.

       Note: The system does not display policies on OHI Screen 9 under the following
       conditions:

          If the policy has been cancelled (End Reason Code is “E”)

          If the policy has been terminated by an automatic process on DEERS (End Reason Code
           is “S”)

          If the policy is associated with a HIC that has been rejected (End Reason Code is “S”)

          If the policy is associated with a HIC that has been deactivated (End Reason Code is
           “D”)

          If the policy is inactivated (the „Inactivation Date‟ field is populated)

          If the policy has expired („Policy End Date‟ value is in the past)

          If a Coverage Type associated with the policy has expired, then the expired Coverage
           Type does not get copied.

          If a Coverage Type has an End Reason Code of 'E', 'S', or 'D', it will not be copied.

Note: There are no ranks displayed for the Coverage Types on OHI Screen 9 because the user must
rank the Coverage Types based on the circumstances applicable to the patient to whom he/she is
copying the policy.
When the user selects a policy to copy, the system automatically creates a new policy for the
selected patient, using policy data from the selected policy held by the other family member, then
the system displays a subset of that policy information. (See OHI Screen 10.) The user must enter
the “Patient‟s Relationship to Insured” and the “Cardholder Identifier.”




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-------------------------------------------------- OHI Screen 10 ----------------------------------------------

                                                                OTHER HEALTH INSURANCE - COPY
POLICY

Copy to Patient: SHAW,BRENDA                          FMP/SSN: 03/000-00-0000
    Patient SSN: 000-00-0000                       DOB/Gender: 04 Feb 1994/F
-----------------------------------------------------------------------------
Insurance Company: AETNA HEALTH PLANS OF TEXAS    Effective Date: 01 Jan 2003
        Policy Id: AE123451234512345123                 End Date: INDEF
       Subscriber: SHAW,SHEILA
Patient’s Relationship to Insured: CHILD
            Cardholder Identifier: 000-00-0000
=============================================================================
 Coverage Type     Payer Type           Eff Date   End Date Rank
=============================================================================
 MEDICAL           Both (Inst and Prof 01Jan2003 31May2003 PRIMARY
 MEDICAL           Both (Inst and Prof 01Jun2003 INDEF       SECONDARY
 PHARMACY          Institutional        01Jun2003 INDEF      PRIMARY
 INPATIENT         Institutional        01Jun2003 INDEF      NON-RANKED
 OUTPATIENT        Both (Inst and Prof 01Jun2003 INDEF       NON-RANKED
 PARTIAL HOSPITAL Both (Inst and Prof 01Jun2003 INDEF        NON-RANKED
 SKILLED NURSING   Professional         01Jun2003 INDEF      NON-RANKED
+LONG TERM CARE    Both (Inst and Prof 01Jun2003 INDEF       NON-RANKED




Note: Field values displayed in bold on the screen above, may be entered/edited.

Key to Fields on Screen 10:

      Field Name                                               Comments

Copy to Patient              Defaulted. Not editable.

FMP/SSN                      Defaulted. Not editable.

Patient SSN                  Defaulted. Not editable.

DOB/Gender                   Defaulted. Not editable.

Insurance Company            Defaulted. Not editable.

Policy Id                    Defaulted. Not editable.

Subscriber                   Defaulted. Not editable.

(Policy) Effective Date Defaulted. May be edited as applicable to the selected patient.

                             Note: After this new policy is filed for this patient, the Policy
                             Effective Date is no longer editable.


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     Field Name                                          Comments

(Policy) End Date        Defaulted. Policy End Date may be edited as applicable to the selected
                         patient.

Patient‟s Relationship   Not defaulted. This value is required.
to Insured

Cardholder Identifier    Not defaulted. User should enter this value. May enter the patient‟s
                         SSN, if value is not known.

Coverage Type            All Coverage Types default from the policy being copied. This is a
                         multiple.

                         When the user positions the cursor on one of the Coverage Types and
                         presses <ENTER>, the system displays OHI Screen 3 with the cursor
                         positioned in the „Coverage Rank‟ field. The user MUST enter a
                         Coverage Rank for every Coverage Type being applied to the selected
                         patient‟s OHI record. The user can also modify the other editable
                         fields on OHI Screen 3 to customize the Coverage Type for the
                         selected patient; or the user can press <Page Down> and return to OHI
                         Screen 13.

                         If the user does not want to include any of the Coverage Types that are
                         defaulted for the policy, he/she can delete the Coverage Code on OHI
                         Screen 3. This will delete the Coverage Type from the list of
                         Coverage Types that will be filed with the new policy.

                         The user is not allowed to delete ALL Coverage Types. A policy may
                         not be filed without, at least, one Coverage Type.

                         After each Coverage Type is filed, the system returns the user to OHI
                         Screen 13.

Payer Type               The indicator for the type of payer:

                         B = Both Institutional and professional (default)

                         I = Institutional Only

                         P = Professional Only

                         N = Nonbillable

After the „Patient‟s Relationship to Subscriber‟ and „Cardholder Identifier‟ fields have been
populated, and all of the Coverage Types have been ranked, the user can file the policy. If there are
any discrepancies, as when filing any new policy, the user will be alerted with an on-screen


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message. After filing the policy for a selected patient, the system takes the user back to OHI Screen
9 so that the user can copy other policies from family members to the selected patient.

An “OHI Add” message is sent to DEERS for each policy copied from other family members to the
selected patient.

„COPY TO‟ Action

Copying Policies TO Other Family Members
There are two functional paths through which a user can copy policies from the selected patient to
another family member (paths 1 and 2 below).

    1. Path # 1: The first path is provided when the user adds a new policy to a patient‟s record
       and there are additional TPC-eligible family members in the CHCS Patient file who are also
       covered under the policy.

        When the user files the newly entered policy on OHI Screen 4 or 5 (depending upon the
        Insurance Type), the user is prompted to answer the following question:

            Do you want to add this policy {AETNC0004 A2341930} to other family members?
            No//
                     If the user accepts the “No” default, the system takes the user back to Screen 1.
                     If the user answers “Yes” to the question, the system displays a list of the TPC
                      eligible beneficiaries who have the same Sponsor SSN as the selected patient‟s
                      Sponsor SSN – and who do not already have the selected policy in their OHI
                      profile (See OHI Screen 11).

----------------------------------------------- OHI Screen 11 -------------------------------------------------


                  OTHER HEALTH INSURANCE - COPY TO ANOTHER FAMILY MEMBER

Insurance Company:         AETNA HEALTH PLANS OF TEXAS
        Policy Id:         AE12345                                           Effective Date: 27Dec2001
   Insurance Type:         CI COMMERCIAL                                           End Date: INDEF
       Subscriber:         SHAW,SHEILA
   Coverage Types:         XM(P)

Copy From Patient: SHAW,SHEILA                         FMP/SSN: 30/000-00-0000
-----------------------------------------------------------------------------
  Patient                                     FMP/SSN         DOB
Gender
-----------------------------------------------------------------------------
* SHAW,AMANDA E                               02/000-00-0000 07 Sep 1992 F

  SHAW,MICHELLE E                                                 01/000-00-0000         23 Jun 1986       F

-----------------------------------------------------------------------------
Select Patient and copy policy to the selected patient's OHI profile



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        Because CHCS must send an “OHI Inquiry” message to DEERS prior to copying the policy to
        each of the patients, the user can only select one patient at a time from the list of patients on
        OHI Screen 11.

        After receipt of the patient‟s OHI profile from DEERS, the system displays a list of policies
        held by the selected family member (See OHI Screen 12).

-------------------------------------------------- OHI Screen 12 ---------------------------------------------


                                                             OTHER HEALTH INSURANCE - COPY POLICY


         Patient: SHAW,AMANDA                         FMP/SSN: 02/000-00-0000
Patient Category: USN FAM MBR AD                  Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY C          DMDC Pat Id: 0000011111
     Region Code: 01                                      Sex: FEMALE
             PCM: HURST,RICHARD                       DOB/Age: 07 Sep 1992/10Y
-----------------------------------------------------------------------------
  Insurance Co Name             Policy Id            Eff Date   End Date
    Coverage Types and Ranking
-----------------------------------------------------------------------------
  PREMIER BLUE                  568-97-6857          18Sep2002 03Jan2004 (I)
    MD(N)

Copy Policy <AETNC0004 A2341930> to <SHAW,AMANDA>                       Y//



        The user confirms that he/she wants to copy the selected policy to the family member, and
        the system displays OHI Screen 12. Most data on Screen 12 defaults from the copied
        policy.

        After the „Patient‟s Relationship to Subscriber‟ and „Cardholder Identifier‟ fields have been
        populated and all of the Coverage Types have been ranked, the user can file the policy data.
         If there are any discrepancies, as when filing any new policy, the user will be alerted with
        an on-screen message.
        After filing the policy data, the system takes the user back to OHI Screen 11 so that he/she
        may select another family member to whom to copy the policy.
        An “OHI Add” message is sent to DEERS for each new policy that has been created by the
        “CopyTo” function.
    2. Path # 2: The second path through which the user can copy policies from a selected patient
       to other family members begins by selecting the „CopyTo‟ action from the OHI Screen 1
       action bar.

            Important: The “CopyTo” action should be used when the user wants to copy only one
            policy to one or more family members. The reason for this recommendation is as
            follows: When the user selects a policy to copy, each time he/she returns to OHI Screen


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   11 to select a different family member to whom to copy the policy, the system performs
   a DEER OHI inquiry. If there are five (5) family members to whom the user is copying
   the policy, there are five associated DEERS OHI queries. Then when the user selects
   another policy to copy to those five family members, the system repeats the OHI
   DEERS query five more times (each time a different family member is selected from
   OHI Screen 11). So if the user wants to copy more than one policy from the selected
   patient to one or more family members, it is more efficient to access each of those
   family members from the PII menu option, individually, and use the “CopyFrom” action
   instead.
When the user selects the „CopyTo‟ action from the OHI Screen 1 action bar, the system
displays all active OHI policies held by the selected patient. (See OHI Screen 1 for the
screen format.) The cursor is in the middle window and the user selects one policy to copy
to other family members.
   Note: The system does not display policies on OHI Screen 12 under the following
   conditions:
     If the policy has been cancelled (End Reason Code is “E”)
     If the policy has been terminated by an automatic process on DEERS (End Reason
      Code is “S”)
     If the policy is associated with a HIC that has been rejected (End Reason Code is
      “S”)
     If the policy is associated with a HIC that has been deactivated (End Reason Code is
      “D”)
     If the policy is inactivated (the Inactivation Date field is populated)
     If the policy has expired (Policy End Date is in the past)
     If a Coverage Type associated with the policy has expired, then just the Coverage
      Type does not get copied.
     If a Coverage Type has an End Reason Code of 'E', 'S', or 'D', it will not be copied.

The system then displays OHI Screen 11 so that the user can select a family member to
whom to copy the selected policy. The user may select only one patient at a time from the
list of patients on OHI Screen 11 because CHCS must send an “OHI Inquiry” message to
DEERS prior to copying any policies to the patient.

After receipt of the patient‟s OHI profile from DEERS, the system displays a list of policies
held by the selected family member (See OHI Screen 12).

The user confirms that he/she wants to copy the selected policy to the family member, and
the system displays OHI Screen 10. Most data on OHI Screen 10 defaults from the copied
policy.

After the “Relationship to Subscriber” and “Cardholder Identifier” fields have been
populated and all of the Coverage Types have been ranked, the user can file the policy data .
 If there are any discrepancies, as when filing any new policy, the user will be alerted with



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       an on-screen message. After filing the policy data, the system takes the user back to OHI
       Screen 9 so that he/she can select another family member to whom to copy the policy.

       An “OHI Add” message is sent to DEERS for each new policy that has been created by the
       “CopyTo” function.

„VIEW/PRINT‟ Action

View/Print Selected Policies on Screen or Printer
After selecting „View/Print‟ from the OHI Screen 1 action bar, the system prompts the user to
choose the search criteria for the view/printout. The user can select one or more of the following:

        View Individual Policies
        View All Policies
        View Active Policies
        View Expired Policies
        View Inactivated Policies
The user is prompted for a device. Depending upon the device entered, the user can view the
policies on the screen, or can queue them to a printer.

If the user views the policies on the screen, the screens are read-only. The user can scroll through
the data, and then press <ENTER> to return to OHI Screen 1. If the user chooses to print a
hardcopy, as soon as the report is queued to the printer, the system returns the user to OHI Screen 1.

See OHI Screen 13 for the View/Print format.




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----------------------------------------------------- OHI Screen 13 -------------------------------------------


                                                          09 Jun 2005@1342                     Page 1
                    Personal Data - Privacy Act of 1974 (PL 93-579)
                          OTHER HEALTH INSURANCE - VIEW/PRINT

         Patient: SHAW,SHEILA                         FMP/SSN: 30/000-00-0000
Patient Category: USAF FAM MBR RET                Patient SSN: 000-00-0000
            HCDP: 117 - TRICARE PRIME FAMILY C    DMDC Pat Id: 0000000000
     Region Code: 01                                      Sex: FEMALE
             PCM: LUCE,RONDA                          DOB/Age: 13 May 1940/65Y
================================================================================
       Insurance Company: BANIL0003 - BANKERS LIFE & CASUALTY INS
               Policy Id: 1616162                   Card Holder Id: 000-00-0000
   Policy Effective Date: 01 Jan 2005              Policy End Date: 31 Dec 2005
       Policy End Reason: R   Ins Type Code: CI Claim Filing Code: 09

PreCert Comments:

Policy Inactivation Date:                     Policy Last Modified: 09 Jun 2005
  Policy Transaction Sys: CHCS Test Site for Contractor Test

       Subscriber Name: SHAW,SHEILA
        Subscriber SSN: 000-00-0000
        Subscriber DOB: 13 May 1940                            Subscriber Gender: F
    Subscriber Address: 1414 CENTRAL PKWY WEST
       Subscriber City: SAN DIEGO                                   State/Country: CALIFORNIA
  Subscriber Telephone: 858-864-6543                                                 Zip Code: 92131
  Patient's Relationship to Subscriber: SELF

              Group Plan Name:          EMPLOYEE BENEFIT AARCO
              Group Policy Id:          AARCO123456789
          Group Employer Name:          American Architectural Restore Corp
Grp Emp PO Box/Street Address:
    Group Employer ATTEN Line:          4348 GRAHAM STREET
          Group Employer City:          SAN DIEGO
 Group Employer State/Country:          CA                          Zip/Ext Code: 92121
     Group Employer Telephone:          858-457-3456                   Extension: 6754

       Insurance Carrier: BANKERS LIFE & CASUALTY INS
  OHI Coverage Type Code: XM COMPREHENSIV          OHI Payer Type:                    B
Match to HIC Coverage Type: XM COMPREHENSIV        HIC Payer Type:                    B
         Carrier Address: PO BOX 66927                      Phone:                    8006213724
                    City: CHICAGO               State: IL     ZIP:                    60666
 Coverage Effective Date: 01 Jan 2005           Coverage End Date:                    31 Dec 2005
           Coverage Rank: PRIMARY             Coverage End Reason:                    R
  Coverage Last Modified: 11 May 2005
        Coverage Txn Sys: CHCS Test Site for Contractor Test

       Insurance Carrier: BANKERS LIFE & CASUALTY INS
  OHI Coverage Type Code: MD MEDICAL ONLY          OHI Payer Type:                    B
Match to HIC Coverage Type: MD MEDICAL ONLY        HIC Payer Type:                    B
         Carrier Address: PO BOX 66927                       Phone:                   8006213724
                    City: CHICAGO               State: IL      ZIP:                   60666
 Coverage Effective Date: 01 Jan 2005           Coverage End Date:                    31 Dec 2005
           Coverage Rank: SECONDARY           Coverage End Reason:                    R
  Coverage Last Modified: 11 May 2005
        Coverage Txn Sys: CHCS Test Site for Contractor Test




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„PRECERT‟ Action

Pre-Certification/UR
When the user selects „PreCert‟ from the OHI Screen 1 action bar, the system displays a list of the
selected patient‟s ACTIVE OHI policies. (The list is similar to list of policies on OHI Screen 1,
except that any inactivated or expired policies are screened out, before the list of policies is
displayed.) The user selects a policy and the system displays OHI Screen 14 so that the user can
select the Coverage Type and the Payer Type under which the procedure will be authorized.

Note: The reason that the user has to select Coverage Type and Payer Type is because the address
and phone number for the insurance company is associated with the Coverage Type/Payer Type
combination. The system has to know which Coverage Type/Payer Type is authorizing the
procedure in order to display the phone number. The user can select only one Coverage Type at a
time from the list on Screen 14.

----------------------------------------------- OHI Screen 14 -------------------------------------------------


                                                               OTHER HEALTH INSURANCE – PRECERT/UR

  Patient: SHAW,SHEILA                         FMP/SSN: 30/000-00-0000
 ==============================================================================

          Insurance Company: (9) (35)
                  Policy Id: (20)                                   Effective Date: DD MMM YYYY

===============================================================================
 Coverage Type Payer Type                       Eff Date     End Date     Rank
===============================================================================
 *Medical Only   Institutional                  DD MMM YYYY DD MMM YYYY P
 Medical Only   Professional                    DD MMM YYYY DD MMM YYYY P
 Pharmacy Only Both Institutional and Profess DD MMM YYYY DD MMM YYYY S




After the user selects the Coverage Type Code and Payer Type Code, the system displays OHI
Screen 15.

OHI Screen 15 provides the user with the data entry points where he/she may define the pre-
certification and/or utilization review requirements necessary to comply with the terms of this
policy. The user can also enter the Pre-Certification Authorization Code, and can flag the patient
for inclusion on the “Insurance Policy PreCert/UR Nightly Roster.”




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----------------------------------------------- OHI Screen 15 ------------------------------------------------


POLICY: AETNC0004          58475847385958                       OTHER HEALTH INSURANCE - PRECERT

         Patient: SHAW,SHEILA                         FMP/SSN: 30/000-00-0000
Patient Category: USN FAM MBR AD                  Patient SSN: 000-00-0000
            HCDP: TRICARE PRIME FAMILY C          DMDC Pat Id: 0000011111
     Region Code: 01                                      Sex: FEMALE
             PCM: WOLLIN,MAGDALENA                  DOB/Age: 12 Aug 1972/30Y
==============================================================================
        Insurance Company:           (9) (35)
                Policy Id:           (20)            Ins Type Code: (2)
           Card Holder Id:           (20)        Claim Filing Code: (2)
    Policy Effective Date:           DD MMM YYYYPolicy End Date: DD MMM YYYY
                                            Policy End Reason Code: (1)
==============================================================================

 Insurance Carrier POC Phone: (20)                                      Phone Extension: (5)
 PreCert/UR Rqmts: (65)

Pre-Cert/UR Authorization Code: (15)
  Display on PreCert/UR Roster: (Y/N)



Note: Numbers in parentheses represent the length of the field values.

Insurance Policy Precert/UR Nightly Roster
OHI Screen 16 provides an example of the “Insurance Policy Precert/Ur Nightly Roster.”

The “Insurance Policy Precert/UR Nightly Roster” has been modified to retrieve data from the new
Other Health Insurance file (# 8074). The purpose and the format of the report remain as in
previous versions of the software except for the following:

       The term “Policy Number” is replaced by “Policy Id” in the header.

       The telephone number displayed on the report is the telephone number associated with the
        Health Insurance Carrier/Coverage Type/Payer Type selected using the PreCert action in the
        OHI enter/edit functionality.

Menu Path: CA → MSA → IFM → OPM → URR → device




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---------------------------------------------------------- OHI Screen 16 --------------------------------------



1 MEDICAL GROUP (ACC)                               17 Mar 2003 1219                                 Page 1
                Personal Data - Privacy Act of 1974 (PL 93-579)

                  * * * INSURANCE POLICY PRECERT/UR NIGHTLY ROSTER * * *

-----------------------------------------------------------------------------
Reg No    Patient Name                  Adm Date/Time         PreCert Code
   Insurance Co Name                Policy Id             Ins Co Phone
   PreCert/UR Comments
-----------------------------------------------------------------------------




                                         *** End of Report ***



“RE-POINT OHI BATCH UTILITY” (secondary menu option)
The [DG REPOINT OHI BATCH UTILITY] is an existing secondary menu option. It will be
changed to reflect the changes from the data file structure in the old Policy file (#8086), to the new
OHI file (#8074).

The secondary menu option, REP Re-Point OHI Batch Utility [DG REPOINT OHI BATCH
UTILITY], allows a user to re-point all Other Health Insurance (OHI) policies associated with a user-
selected Standard Insurance Table (SIT) entry to a different user-selected SIT entry.

DG REPOINT OHI BATCH UTILITY is locked by the existing DG OHI MGMT security key. The
DG OHI MGMT security key does not require a conversion, as the name of the security key will not
change with this project.

Re-Point OHI Batch Utility Navigation Steps:
When the authorized user selects the secondary menu option, REP Re-Point OHI Batch Utility, the
system displays screens, as shown under OHI Re-Point Screen 17a-c below. The file name for this
option is DG REPOINT BATCH UTILITY. This is an existing secondary option, but will now
reflect the changes with the new OHI policy file (#8074). The option is locked by a security key,
DG OHI MGMT, an existing key, so the name of the key is unchanged and requires no conversion.

When the secondary option is accessed, the user is prompted for an obsolete insurance company,
then prompted for an insurance company with which to replace the obsolete carrier from the OHI
file (#8074).




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Once the user has entered the obsolete carrier and the carrier with which he/she intends to replace
the obsolete carrier, the user may choose the sort order in which to display the policies that will be
repointed (OHI Repoint Screens 17a-17b).
----------------------------------------------- OHI Re-Point Screen 17a----------------------------------------

                 OHI MAINTENANCE - REPOINT OHI POLICIES TO VALID SIT

--------------------------------------------------------------------------------

      Obsolete Carrier Identifier: DARMI0001
           Full Insurance Co Name: DART MGMT CORP




 Replace with Carrier Identifier: DAKSD0001
          Full Insurance Co Name: DAKOTA HEALTH PLANS



The user may choose to perform the re-point of OHI policies by patient name, or by sponsor SSN.

------------------------------------------------ OHI Re-Point Screen 17b---------------------------------------

                 OHI MAINTENANCE - REPOINT OHI POLICIES TO VALID SIT

   Obsolete HIC: <DARMI0001>
Replacement HIC: <DAKSD0001>
--------------------------------------------------------------------------------




--------------------------------------------------------------------------------
Patient_name   Sponsor_SSN   eXit
Sort policy repointing list by patient name


If the user chooses to re-point by Sponsor SSN, the system displays the list of patients as shown on
the OHI Re-Point Screen 17c. If the user chooses to re-point by Patient Name, the system displays
the list of patients as shown on OHI Re-Point Screen 18.

------------------------------------------------ OHI Re-Point Screen 17c---------------------------------------
-

                 OHI MAINTENANCE - REPOINT OHI POLICIES TO VALID SIT

          Obsolete HIC: <DARMI0001>
       Replacement HIC: <DAKSD0001>
--------------------------------------------------------------------------------
   Sponsor SSN/FMP Patient Name         Policy ID      Covrge Types and Ranking
                        Claim #         Status Billed Paid           Balance
-------------------------------------------------------------------------------
   000-00-0000/01 MUNN,KYLE HAMILTON    384838          XM(P)
   000-00-0000/02 MUNN,JUSTIN HAMILTO 3843749893        XM(P)
   000-00-0000/02 MUNN,JUSTIN HAMILTO 384838            XM(P)
   000-00-0000/30 BAGSHAW,JENNIFER      384838          XM(N)
   000-00-0000/30 BAGSHAW,JENNIFER      384838          XM(P)




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-------------------------------------------------------------------------------
preView   Repoint   Quit
Preview a list of policies & claims that will be repointed



The list on OHI Re-Point Screen 17c is sorted first by Sponsor SSN, within Sponsor SSN by FMP,
and within Sponsor SSN/FMP by Patient Name.

------------------------------------------------ OHI Re-Point Screen 18 ---------------------------------------

                OHI MAINTENANCE - REPOINT OHI POLICIES TO VALID SIT

      Obsolete HIC: <DARMI0001>
   Replacement HIC: <DAKSD0001>
--------------------------------------------------------------------------------
   Patient Name         Sponsor SSN/FMP Policy ID       Covrge Types and Ranking
                        Claim #         Status Billed Paid       Balance
--------------------------------------------------------------------------------
   BAGSHAW,JENNIFER     000-00-0000/30 384838           XM(N)
   BAGSHAW,JENNIFER     000-00-0000/30 384838           XM(P)
   MUNN,JUSTIN HAMILTO 000-00-0000/02 3843749893        XM(P)
   MUNN,JUSTIN HAMILTO 000-00-0000/02 384838            XM(P)
   MUNN,KYLE HAMILTON   000-00-0000/01 384838           XM(P)


--------------------------------------------------------------------------------
preView   Repoint   Quit
Preview a list of policies & claims that will be repointed



The list on OHI Re-Point Screen 18 is sorted alphabetically by Patient Name, then, within Patient
Name, by SSN/FMP.

Note: If a patient has two policies that are associated with the obsolete carrier, the patient‟s name
will display on the list twice. This might be useful as a check for duplicate policies with slightly
different data.

If the user wants to view or print the list in order to carefully decide whether or not to re-point these
policies, he/she may select the “preView” action and enter a DEVICE.

If the user does not require further review, he/she may select the “Repoint” action. After the
“Repoint” action is selected, the system displays OHI Re-Point Screen 19.

The user may choose to re-point policies for all patients who have policies associated with the
obsolete insurance company, or may choose to re-point policies for only user-selected patients. See
OHI Re-Point Screen 19.




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---------------------------------------------- OHI Re-Point Screen 19------------------------------------------

                 OHI MAINTENANCE - REPOINT OHI POLICIES TO VALID SIT

          Obsolete HIC: <DARMI0001>
       Replacement HIC: <DAKSD0001>
--------------------------------------------------------------------------------
   Sponsor SSN/FMP Patient Name         Policy ID      Covrge Types and Ranking
                        Claim #         Status Billed Paid           Balance
--------------------------------------------------------------------------------
   000-00-0000/01 MUNN,KYLE HAMILTON    384838          XM(P)
   000-00-0000/02 MUNN,JUSTIN HAMILTO 3843749893        XM(P)
   000-00-0000/02 MUNN,JUSTIN HAMILTO 384838            XM(P)
   000-00-0000/30 BAGSHAW,JENNIFER      384838          XM(N)
   000-00-0000/30 BAGSHAW,JENNIFER      384838          XM(P)


---------------------------------------------------------------------------------
repoint_All_Patients   repoint_Selected_Patients   Quit
Repointing for all policies associated with the obsolete carrier



If the user chooses to re-point policies for only user-selected patients, the system displays OHI Re-
Point Screen 20.

---------------------------------------------- OHI Re-Point Screen 20------------------------------------------

                 OHI MAINTENANCE - REPOINT OHI POLICIES TO VALID SIT

          Obsolete HIC: <DARMI0001>
       Replacement HIC: <DAKSD0001>
--------------------------------------------------------------------------------
   Sponsor SSN/FMP Patient Name         Policy ID      Covrge Types and Ranking
                        Claim #         Status Billed Paid           Balance
--------------------------------------------------------------------------------
 * 000-00-0000/01 MUNN,KYLE HAMILTON    384838          XM(P)
   000-00-0000/02 MUNN,JUSTIN HAMILTO 3843749893        XM(P)
   000-00-0000/02 MUNN,JUSTIN HAMILTO 384838            XM(P)
   000-00-0000/30 BAGSHAW,JENNIFER      384838          XM(N)
   000-00-0000/30 BAGSHAW,JENNIFER      384838          XM(P)

-------------------------------------------------------------------------------
Use SELECT key to select individual SSN(s)
or press F11 to select ALL



When the user selects one or more policies to be re-pointed, the system asks the user to confirm
with the following prompt:

        Are you sure you want to replace <obsolete HIC ID> with <replacement HIC
        ID> in all selected OHI policy records currently associated with
        <obsolete HIC ID>? N//

If the user accepts the default answer of “No”, the system cancels the re-point and returns the user
to OHI Re-Point Screen 17b.




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If the user answers, “Yes” to the question, the system automatically cancels all selected policies
associated with the obsolete Insurance Company in the OHI file (#8074) and automatically creates
new policies to replace those that were cancelled with the HIC ID of the new carrier.
Appropriate OHI Cancel and OHI Add messages are sent to DEERS.
When the user re-points the OHI associated with one carrier to a different carrier, the utility will
evaluate each new policy and populate the „HIC Coverage Type Code‟ field and HIC Coverage
Payer Type field based on the following:

        When the new policy is created, the system will look at the new carrier and try to match the
        OHI Coverage Type/Payer Type(s) in the policy to the HIC Coverage Type/Payer Type(s) in
        the HIC record of the new carrier. If there is(are) an exact match(es), the HIC Coverage
        Type/Payer Type will be set to the exact match.

        If any of the HIC Coverage Type/Payer Type combinations associated with OHI Coverage
        Type/Payer Type combinations in the old policy do not have a corresponding HIC Coverage
        Type/Payer Type combination in the new carrier HIC record, the re-point utility will use the
        following defaults to populate the HIC Coverage Type/Payer Type in the OHI Coverage
        Type multiple of the newly created policies:

                1st default = XM/B
                2nd default = MD/B
                3rd default = first HIC Coverage Type/Payer Type combination
                             found in HIC file carrier record

Note: At this point, the replacement occurs only in the selected OHI records in the OHI file
(#8074). There is no change in the Standard Insurance Company file (#8192) without further user
action, as described below:

        If the user has chosen to re-point all policies associated with the obsolete HIC, and the
        obsolete HIC does not have a Carrier Status of Temporary, Cancelled, or Rejected, the
        system allows the user to request deactivation of the obsolete HIC ID. (See the question on
        OHI Re-Point Screen 21.)

        If there are any remaining OHI policies associated with the obsolete HIC ID in the OHI file
        that were not re-pointed, the system will not prompt the user to request deactivation of the
        carrier.

--------------------------------------------- OHI Re-Point Screen 21 ------------------------------------------

                 OHI MAINTENANCE - REPOINT OHI POLICIES TO VALID SIT

If you wish to block <DARMI0001> from being assigned to patient policies
in the future and from displaying on SIT picklists, you may request deactivation of this
insurance carrier.
Are you sure you want to deactivate <DARMI0001>? NO//




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If the user answers “YES” to the question on the OHI Re-Point Screen 21, the system sends a
deactivation request message to DEERS, asking that the carrier be deactivated in the central HIC
repository.

OHI Conversion from Policy file (#8086) to OHI file (#8074)

General Overview
CHCS will convert all active OHI policies from the old CHCS Policy file (#8086) to new policy
records in the new CHCS OHI file (#8074). An active policy in the old CHCS Policy file (#8086)
is any policy record that has no value in the “Inactivation Date” field. When the policies are created
in the new OHI file, the policies will either be active or inactivated, based on the following rules.
All active policies that are associated with “Standard” Insurance Companies in the old Policy file
(#8086), at the time of the conversion, will convert to active policies in the new OHI file (#8074).
The old Insurance Company Short Name values will be mapped to the new HIC Id values.

         The new values will replace the old values when the policy record is created in the new
          OHI file.
       Note: Prior to converting policies, CHCS will send an Eligibility Query to DEERS for any
       patient in the Patient file # 2 who has policies in the Policy file (#8086), but does not have a
       Defense Management Data Center (DMDC) Patient Id in the Patient file. If the Eligibility
       response indicates that no DMDC Patient Id exists for the patient, new policies will still be
       created, but those policies will not be sent to DEERS.

         All active policies that are associated with “Temporary” Insurance Companies in the old
          Policy file (#8086), at the time of the conversion, will convert to inactivated policies in
          the new OHI file (#8074).

           -   The date of the conversion will be populated in the „Policy Inactivation Date‟ field in
               the new policy record in the new OHI file (#8074).
           -   The value in the „Insurance Company‟ field from the old Policy file (#8086) will be
               stuffed into the „Insurance Company Name‟ field in the new OHI file (#8074).
           -   The „Carrier Identifier‟ field in the new OHI file (#8074) will be left empty.

          There is a minimum data set which DEERS requires to make a policy a valid OHI. The
           rules of the conversion shall, therefore, require that this minimum data set be available
           for each record in the old Policy file (#8086), or the record will not be imported to the
           new OHI file (#8074).

           -   Patient Identifier 2, .13 (based on the value in the Patient field 8083,.01 in the
               Insured Party file # 8083) or Patient SSN 2,.17
           -   Policy Number 8086,.01
           -   Insurance Company 8086,13
           -   Policy Effective Date 8086,15



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Ranking (Coverage Precedence Code) Rules Associated with the Policy Data Conversion
The OHI conversion will take the rank from the policy level in the old Policy file #8086 and use
that same rank to populate the Coverage Precedence Code for all Coverage Types associated with
the new policy created in the new OHI file #8074.
Message Trigger Rules Associated with the Policy Data Conversion

      At the time of the conversion, when the new OHI policy records are created in the new OHI
       file (#8074), an “Add OHI” message will be triggered to send all the newly created policies
       to DEERS.
      Only policies where all required fields are populated will be sent to DEERS.
      All available data elements consistent with the prescribed message content of the “Add
       OHI” messages will be included.

Conversion to Assign DG OHI Security Key
The CPZ OHI security key allowed holders to access the OHI Enter/Edit option and actions in the
old software. There will be a switch to disable the old software and re-point users to the new
software. When the switch is flipped to allow the users access to the new software, a new security
key will be enabled, and there will be a conversion to assign the new DG OHI security key to all of
the holders of the old CPZ OHI security key.

Conversion to Assign DG OHI SUPPLEMENT Security Key
When a host Defense Medical Information System (DMIS) activates Outpatient Itemized Billing
(OIB), but one or more of the DMIS sites under that host activates several days later (up to 90
days), CHCS must bring the sites into sync with OHI data. This can not be done simply by sending
a snapshot of Policy file data from the host to the child site. A snapshot would not capture the
enter/edit activity that has taken place between the time that the host site is activated, and the time
that the later site is activated. Consequently, when a child site activates on a later date than the
parent, CHCS must transmit a supplemental OHI file (SOHI) to provide the later-activating site
with OHI data that matches the other sites on that host.

The CP OHI SUPPLEMENT security key allowed holders to access the secondary menu option: CP
CREATE SUP OHI ASCII FILE (Generate ASCII file - OHI Activities by Date Range). There will
be a switch to disable the old software and re-point users to the new software. When the switch is
flipped to allow the users access to the new software, a new security key will be enabled and there
will be a conversion to assign the new DG OHI SUPPLEMENT security key to all of the holders of
the old CP OHI SUPPLEMENT security key.

Note: The DG OHI SUPPLEMENT security key will allow access to the new DG CREATE SUP
OHI ASCII FILE secondary menu option. The DG CREATE SUP OHI ASCII FILE secondary
menu option performs the same function as described above for the CP CREATE SUP OHI ASCII
FILE; however, the DG CREATE SUP OHI ASCII FILE will pull data from the new OHI file
(#8074), rather than the old Policy file (#8086).


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Conversion to Assign DG OHI INITIALIZE Security Key
The CP CREATE COMP OHI ASCII FILE menu option allowed authorized users to generate an
ASCII file that includes a snapshot of the OHI data in CHCS when the IOHI option is run. Unlike
the SOHI, the IOHI does not include all of the enter/edit activities that have taken place over time,
but captures only the active policies (both ranked and non-ranked) for each TPC beneficiary as a
current picture of their OHI.
The CP OHI INITIALIZE security key allowed holders to access the menu option CP CREATE
COMP OHI ASCII FILE (Generate ASCII file - Snapshot of Current OHI). There will be a switch
to disable the old software and re-point users to the new software. When the switch is flipped to
allow the users access to the new software, a new security key will be enabled and there will be a
conversion to assign the new DG OHI INITIALIZE security key to all of the holders of the old CP
OHI INITIALIZE security key.
Note: The DG OHI INITIALIZE security key will allow access to the new DG CREATE COMP
OHI ASCII FILE secondary menu option. The DG CREATE COMP OHI ASCII FILE secondary
menu option performs the same function as described above for the CP CREATE COMP OHI
ASCII FILE; however, the DG CREATE COMP OHI ASCII FILE will pull data from the new OHI
file (#8074), rather than the old Policy file (#8086).
The CHCS Site Manager is typically the only holder of the DG OHI INITIALIZE security key.
He/she is allowed to select the IOHI secondary menu option but, because of the potentially
destructive nature of the option, site personnel should not run the IOHI. When a user selects the
IOHI option, the following message is displayed on the screen:


Only authorized MHS Help Desk personnel may run the IOHI option. Please call the MHS Help
Desk with a request to generate the IOHI ASCII file. The IOHI file should never be transmitted to
TPOCS without prior coordination with the TPOCS System Manager. This file will overwrite
existing data in the TPOCS OHI file and should be run with extreme caution.


Pre-Implementation Reports
Five Pre-Implementation Reports have been created which should be run prior to activating the new
TNEX SIT/OHI software. These reports will provide information to be used during both pre- and
post- implementation cleanup. These reports will be on a secondary sub-menu and are shown
below.
New Secondary Menu option and sub-menu options (locked by the DOD SIT MGR Security
Key):

PRE    Pre-Implementation SIT/OHI Reports Menu
      PI1 SIT - No DEERS HIC ID Match but Address Match
      PI2 SIT - No DEERS HIC ID Match, No Address Match
      PI3 SIT - Duplicate Addresses within Old CHCS SIT File


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         PI4   OHI Policies Missing Policy Effective Date
         PI5   OHI Policies Missing Policyholder/Subscriber Info
   When the user runs the first two reports on the sub-menu, CHCS will query DEERS and download
   the DEERS Health Insurance Carriers from the new DEERS SIT database. This download
   populates the CHCS HIC file and allows the user to proceed with running the first two reports.
   The other three reports pull data from the existing local CHCS SIT file only. There is no DEERS
   interface query triggered by Reports PI3, PI4, or PI5.

   Refer to Table 2 for a description of the reports.

3.2.3     Summary of File and Table Changes

   Responsibility for maintaining the OHI repository has moved from CHCS to DEERS. The OHI
   stored on CHCS is a local copy of the DEERS OHI database.

   The existing DG REPOINT OHI BATCH UTILITY option will be changed to reflect the changes
   from the data file structure in the old Policy file (#8086) to the new OHI file (#8074). The
   secondary menu option, Re-Point OHI Batch Utility (REP), [DG REPOINT OHI BATCH
   UTILITY], allows a user to re-point all OHI policies associated with a user-selected SIT entry to a
   different user-selected SIT entry.

   CHCS will convert all active OHI policies from the old CHCS Policy file (#8086) to new policy
   records in the new CHCS OHI file (#8074).

   The CPZ OHI security key will be converted to the new DG OHI security key for all holders of the
   old key. This key allows holders to access the OHI Enter/Edit option.

   The CP OHI SUPPLEMENT security key will be converted to the DG OHI SUPPLEMENT
   security key for all holders of the old key. This will allow access to the new secondary menu
   option, DG CREATE SUP OHI ASCII FILE, for generation of the ASCII SOHI file.

   The CP OHI INITIALIZE security key allowed users to access the CP CREATE COMP OHI
   ASCII FILE (Generate ASCII file – Snapshot of Current OHI). A conversion will give the new DG
   OHI INITIALIZE key to all holders of the old CP OHI INITIALIZE key. The CHCS Site Manager
   is typically the only holder of the DG OHI INITIALIZE security key.

   Five new Pre-Implementation Reports have been created and are listed as secondary sub-menu
   options, as described above in Section 3.2.2. The last two reports, PI4 and PI5, are used to assist in
   OHI policy file clean-up.




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3.2.4     Implementation Issues

   ____ Assign the Pre-Implementation Report file (DG PRE-IMP SIT-OHI REPORTS) as a
        secondary menu option to one or two appropriate personnel who will run the reports. The
        acronym should be PRE for the sub-menu. The security key DOD SIT MGR must also be
        assigned to these users.

   ____ Run Pre-Implementation Reports 4-5. These reports are accessed using secondary sub-
        menu options under the acronym PRE.

   _____ Verify that all users who enter/edit OHI data in CHCS are briefed on the changes to the
         screens and actions for OHI data entry and edit.

   _____ Verify that the appropriate supervisory users are assigned the new security keys after
         conversion.




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  3.3      Medical Services Accounting/Third Party Collections (MSA/TPC) Enhancements

3.3.1       Overview of Change
   CHCS currently bills inpatient TPC claims based on the patient‟s insurance policy. With this
   enhancement, inpatient TPC claims billing will be based on the ranking of the Coverage Type
   associated with a policy. The only Coverage Types applicable to inpatient TPC claims will be
   Comprehensive, Medical, and Inpatient. There will be no changes in the methodology used to
   calculate charges for CHCS Inpatient Diagnosis Related Group (DRG) TPC billing. Screen
   displays, reports, and UB-92 claim forms that support OHI data will be modified to reflect the
   Coverage Type enhancements and new field names.

3.3.2       Detail of Change

   Inpatient TPC claims will be billed in order of precedence based on the ranking of the Coverage
   Type for a billable policy and the chronological order in which they were entered. Inpatient TPC
   claims will be limited to Coverage Types of Comprehensive, Medical and Inpatient. The default
   Coverage Type will be Comprehensive. The system will automatically create a TPC claim based
   on the patient‟s primary Coverage Type and Payer Type Code(s). If a policy has more than one
   primary Coverage Type, the system will automatically create a TPC claim based on the first active
   TPC billable Coverage Type that was defined for the policy. The TPC users will be required to
   manually select a different policy to produce a claim form for secondary billing. The system will
   then automatically create a TPC claim based on the ranking of the Coverage Type and the
   chronological order in which they were entered.
   Insurance Account Processing
            Menu Path: MSAIFMIAP
   The insurance billing screens that support the capture and display of OHI data will be modified
   based on the changes that are being made to support the OHI enhancements described in Section
   3.2. Modifications will be made to screen displays to reflect the Coverage Type enhancements and
   new field names.
   -------------------------------------------------- MSA Screen 1 -----------------------------------------------

   Dt/Time:    03 Jun 2005@1130                                                     INSURANCE BILLING
   Patient:    JOHNSON,GLEN J   MSG                                           FMP/SSN: 20/000-00-0000
   Reg No.:    0405734                        Adm Dt: 30 Apr 2004                    DOB: 02 Jan 1952
   Pat Cat:    USAF RET LOS (ENL)             Dis Dt: 30 Apr 2004               cct St: O   HCDP: 117

                                       *** ACCOUNT SUMMARY DATA ***
   Account status        O                                   Date of change                  02 Jun 2004

   Total: Charges            1057.84      Payment          0.00       Balance               1057.84
                                                                      Transferred              0.00
                                                                      Uncollectable            0.00
        Reason Code     Text
         1- Review Daily Charges                     4- Update Account Status Information
         2- Review Claim History                     5- Insurance Claim Processing
         3- Review/Clear Notify Messages             6- Quit
   SELECT? 6//




                                                        3-93
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Inpatient Policy Claim Summary
        Menu Path: MSAIFMIAP5

Screen changes will be made to replace old CHCS field names with the new SIT/OHI field names.
Data values displayed will be based on the new table updates. (See MSA Screen 2.)

--------------------------------------------- MSA Screen 2 ---------------------------------------------------

 Dt/Time:     13 Mar 2005@0754                                                         INSURANCE BILLING
 Patient:     DAVIES,INSURED PARTY1             CAPT                              FMP/SSN: 20/000-00-
 0000
 Reg No.:     0010062                        Adm Dt: 03 Feb 2003                      DOB: 03 Apr 1943
 Pat Cat:     USN RET LOS (OFF)              Dis Dt: 12 Feb 2003                  Acct St: Z      ACV:

 -------------------------------------------------------------------------------
                     *** INSURANCE POLICY CLAIM SUMMARY ***
        SIT Id: AETVA0001       Policy Id: 072111309                                     Type: CI
    Subscriber: DAVIES,INSURED PARTY1              FMP: 20                           Relation: SELF
  Claim Status:    Date of change:              Reason:

 Policy: Amount Bill                  0.00          Charges   Total:2894.00
         Payment                      0.00          Payments        2894.00
         Balance                      0.00          Balance            0.00
                                                   Transferred         0.00
                                                   Uncollectable       0.00
 -------------------------------------------------------------------------------
 1- Update Claim Stat Data 4- Patient Ins Policy Data 7- Produce Ins Inform
 Sheet
 2- Post Ins Payment       5- Produce Ins Refund      8- Patient Ins Cand List
 3- Review Insured Family 6- Produce Ins Claim Form 9- Quit



Review Insured Family
        Menu Path: MSA IFM  IAP  5  3

As stated above, screen changes will be made to replace old CHCS field names with new SIT/OHI
field names. Policy information will be expanded to include Coverage Types.




                                                       3-94
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--------------------------------------------- MSA Screen 3 ----------------------------------------------------

Dt/Time:    13 Mar 2005@0754                                                          INSURANCE BILLING
Patient:    DAVIES,INSURED PARTY1   CAPT                                         FMP/SSN: 20/000-00-0000
Reg No.:    0010062               Adm Dt: 03 Feb 2001                                DOB: 03 Apr 1943
Pat Cat:    USN RET LOS (OFF)     Dis Dt: 12 Feb 2001                            Acct St: Z      ACV:

---------------------------------------------------------------------------------
         *** LIST OF FAMILY MEMBERS COVERED UNDER INSURANCE POLICY ***

 SIT Id:      AETVA0001                     Policy Id:       AET1113099            Type: CI
--------------------------------------------------------------------------------
           Name          FMP   Relation to        End      Admission Account
                               Subscriber         Date      Status   Number
   Coverage Types and Rank
--------------------------------------------------------------------------------
 DAVIES,INSURED PARTY2               20      SPOUSE                31 Dec 2001 Previous           0010026

    XM(P) RX(S) IP(P) OP(P) DN(P) VI(P)



Patient Insurance Candidate List
        Menu Path: MSA IFM IAP  5  8

The Patient Insurance Candidate List provides the user with a list of all insurance policies and
coverages for a patient. It is used to select and bill secondary insurance policies. Secondary
policies can also be selected using Insurance Account Processing. There will be no changes to the
existing functionality to select and bill secondary insurance companies. Screen changes will be
made to include the Coverage Type and Ranking in the display and selection lists. (See MSA
Screen 4.)

------------------------------------------------- MSA Screen 4 ------------------------------------------------

Dt/Time:    13 Mar 2005@0802                                                            INSURANCE
BILLING
Patient:    DAVIES,INSURED PARTY1              CAPT                              FMP/SSN: 20/000-00-
0000
Reg No.:    0010062                         Adm Dt: 03 Feb 2003                      DOB: 03 Apr 1943
Pat Cat:    USN RET LOS (OFF)               Dis Dt: 12 Feb 2003                  Acct St: O      ACV:

------------------------------------------------------------------------
HIC ID            Policy Id             Eff Date   End Date Claim
    Coverage Types and Ranking
Status
---------------------------------------------------------------------------
  AETNA HEALTH PLANS OF TEXAS AE12345xxxxxxxxxxxxx 09Dec2002 INDEF
    XM(P) RX(S) IP(P) OP(P) DN(P) VI(P)
  RX ADVANCE PCS               4848394               28Jan2003 INDEF
    RX(P)
  PREMIER BLUE                 568-97-6857           18Sep2002 03Jan2004
    MD(P)




                                                      3-95
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MSA Parameters
        Menu Path: MSA  OFM  MPF
The “Effective Date” will be added and will display for the Current and Prior Hospital, Ancillary,
and Professional Fee Percentages (See MSA Screen 5). The Effective Date is entered using the
TPC Reimbursement Percentages option. Menu Path: MSA -> OFM -> TRP.

        Important: There is a correlation between the TPC Rate Effective Date and the Percentage
        Effective Date. An update to the Percentage Effective Date should be done at the same time
        the TPC Rate Effective Date is updated. In other words, when a site receives its annual
        update of rates, the DOD Reimbursement Rates Memorandum indicates whether there is a
        change in the percentages for distribution between Hospital and Professional Fees, as well
        as providing a rate update. If the TPC Rate changes, but there is no change to the
        percentages, the site will just need to update the TPC Rate with a new effective date.
        However, if both the TPC Rate and the percentages change, the site will need to update the
        rate and the percentages and the Percentage Effective Date and the Rate Effective Date must
        be the same date.

----------------------------------------------- MSA Screen 5 --------------------------------------------------

  MSA PARAMETERS                                             MSA PARAMETER - ARMY --CONTINUATION

=============================================================================

                              **** INSURANCE PROCESSING ****
  INS AUTO TRANSFER FLAG: NO                          INS DAYS TO TRANSFER:
 INS DAYS TO 1st DEL LTR: 60                       INS DAYS TO 2nd DEL LTR: 120
CURRENT HOSP %: 96   ANCILLARY SVC %: 0     PROF FEE %: 4                            EFF DT:1 OCT 2005
PRIOR HOSP %: 95   ANCILLARY SVC %: 0     PROF FEE %: 5                            EFF DT:1 OCT 2005
 BC/BS PROVIDER NUMBER: ARMY                     DMIS ID:                          0121
    FEDERAL TAX NUMBER:                        MTF INDEX:                          LARGE URBAN
       MEDICARE NUMBER: MCARE        TYPE INS CLAIM FORM:                          UB92
       MEDICAID NUMBER: MCAID           TPC OFFICE PHONE:                          535-7931
      INSURANCE REMARK: INSURANCE REMARK GOES
                        RIGHT HERE ON THESE
                        THREE LINES

       OFFICIAL MTF NAME:         MCDONALD MTF NAME
             MTF ADDRESS:         ARMY HOSPITAL ADDRESS LINE
             MTF CITY-ST:         SEATTLE WA
           OFFICE SYMBOL:         MCD'S




                                                      3-96
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Office Functions Menu
        Menu Path: MSA  OFM

A new option, TPC Reimbursement Percentages (TRP), will be added to the Office Functions Menu
to allow authorized users to update the percentages for institutional, ancillary, and professional fees.
 Users will be allowed to enter new percentages with an effective date of T+1. If the effective date
is a future date, users will be allowed to edit the percentages. Users will not be permitted to edit
entries with current dates or dates in the past.


Select MSA System Menu Option: OFM                 Office Functions Menu

    AAS       Schedule of Accounts by Age
    TRP       TPC Reimbursement Percentages
    BCP       Balance Check
    DAR       Detail Schedule of Accounts by Age
    ERS       Rate Schedule Enter/Edit
    FDF       Fund Description Edit
    EXC       Outpatient Charge Exclusion Enter/Edit
    GMS       Group Meal Sales Enter/Edit
    MPF       MSA Parameters Definition
    NMR       Notify Messages Review/Clear
    PCE       Patient Category Enlisted Billing Info
    RDS       Rate Detail Summary
    RSS       Rate Schedule Summary
    SRC       Statement of Receivables and Collections
    VRS       View Rate Schedule Detail

Select Office Functions Menu Option:




------------------------------------------------MSA Screen 6 -------------------------------------------------


Select UB92 PCT EFF DATE: t+20   23 Jun 2005
   Are you adding '23 Jun 2004' as a new UB92 PCT EFF DATE (the 9th
          for this MSA PARAMETERS)? y (YES)
                        TPC REIMBURSEMENT PERCENTAGES ENTER-EDIT

PERCENTAGE EFFECTIVE DATE: 23 Jun 2005


 INSTITUTIONAL %: 50                     ANCILLARY %: 0                    PROFESSIONAL %: 50




File/exit         Abort        Edit




                                                      3-97
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Inpatient TPC UB-92
CHCS currently produces an Inpatient TPC UB-92 based on the ranking of the Insurance Policy.
UB-92 claim forms are addressed to a single Insurance Company address defined in the Insurance
Company file. Changes will be made to address claims based on the address specified for a Payer
Type Code(s) for a specific Coverage Type. Possible Payer Type Codes are: Institutional (I),
Professional (P), or (B)oth Institutional and Professional. If a single Payer Type code exists (i.e., I,
P or B) for a specific Coverage Type, one TPC UB-92 will be produced and addressed to a single
address. If multiple Payer Type Codes (i.e., I and P) exist for a specific Coverage Type, a separate
TPC UB-92 will be produced for each coverage type.

Billed charges on the TPC UB-92 are distributed between all inclusive hospital charges and
professional fees. This distribution is based on an Institutional Fee Percentage and a Professional
Fee Percentage that is defined in the MSA Parameter File. If the Payer Type Code for a specific
Coverage Type is (B)oth Institutional and Professional, one claim form will be produced including
both institutional and professional charges. If there are two Payer Type Codes (I and P) for a
specific Coverage Type, two separate claim forms will be produced − one for institutional charges
and one for professional fees. Each bill will be addressed to the address specified for the Payer
Type Code. Payments posted to such claims will be evenly distributed to the account based on the
Institutional and Professional Fee Percentage that is defined in the MSA Parameter File.

If there is a single Payer Type Code of either I or P for a specific Coverage Type, one claim form
will be produced and only the applicable billed charges − either institutional or professional will be
included on the claim form. Payments posted to this claim will only be credited to the Institutional
or Professional Fee that was billed.

MSA UB-92
CHCS currently produces an MSA UB-92 as a convenience for self-pay patients who have OHI.
Because OHI is not captured for these patients, the MSA user must manually enter OHI-related data
for the MSA account to support preparation of the UB-92. The system will default insurance
company information if the Insurance Company entry exists in the Standard Insurance Company
file. The OHI data is stored in the Cashier Account file. The „Policy Number‟ field will be changed
to „Policy Id‟ and the Coverage Type and Payer Type Codes will be added to associate the correct
billing address with the Payer Type Code for the Coverage Type. If there is a single Payer Type
Code, one MSA UB-92 will be produced and sent to a single address. If there are two Payer Type
Codes, a separate MSA UB-92 will be produced for each Payer Type Code.

When a TPC account is billed, if the patient‟s OHI policy has a Coverage Type with two different
Payer Type Codes (Institutional and Professional), separate claim forms will be produced − one is
for the institutional charges and one for the professional charges. Each claim will be addressed
based on the address associated with the Payer Type Code (See MSA Screen 7).




                                                  3-98
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----------------------------------------------------MSA Screen 7 ----------------------------------------------

Dt/Time:      13 Mar 2005@0830                                                                  MSA UB-92 Policy
Data
Patient:      DAVIES,DOD SCHL TEACH                                                       FMP/SSN: 20/000-00-
0000
Reg No.:      10332                              Adm Dt: 30 Jan 2005                      Status: T
Pat Cat:      DOD TEACHER OCONUS                 Dis Dt: 05 Feb 2005                    Sales Cd: IAR
Ins Sta:                OGP:                       HCDP: UNK                            Pay Mode:

Remarks:
-----------------------------------------------------------------------------
                  Policy Id: 10038742
     Insurance Company Name: AETNA
              Coverage Type:
          Payer Type Code 1:
          Payer Type Code 2:

          Insurance Group Name:                                            Group Number:
         Precertification Code:
               Subscriber Name:
               Subscriber SSN :
         Patient Relationship to Subscriber:

         Subscriber's Employer:
              Employer Address:

Upon entering an Insurance Company Name, a HIC partial lookup list will display (See MSA Screen
8). Upon selecting the insurance carrier, the Coverage Type(s), Payer Type Code(s), and addresses
associated with the selected insurance carrier will display. The user must then select the appropriate
Coverage Type and Payer Type Code (See MSA Screen 9). After selecting the Coverage Type and
Payer Type Code, the Insurance Company Address screen will display (MSA Screen 10) indicating
the addresses that will print on the MSA UB-92. When the user presses <Return> to continue, they
will be returned to the MSA UB-92 Policy Data screen to complete the remaining fields as
appropriate (MSA Screen 11).
----------------------------------------------------MSA Screen 8----------------------------------------------

                  The following are the HIC partial lookup list for AET

--------------------------------------------------------------------------------
       Carrier Name/Carrier ID                                                    Carrier Status/Verification Status
            Cov Typ Pay Typ                               Address

       AETNA US HEALTH - AETCA0034                                                    STANDARD/VERIFIED
                 XM                    B                  XYZ UNION CLAIMS
                                                          PO BOX 111 SAN DIEGO CA 92121
                 MD                    P                  PO BOX 111 SAN DIEGO CA 92121
       AETNA US HEALTH - AETCA0035                                                      STANDARD/VERIFIED
                 XM                    B                  ABC MANUF CLAIMS
                                                          111 PO BOX SAN DIEGO CA 92121
       AETNA US HEALTHCARE - AETCA0033                                                  STANDARD/UNVERIFIED DATA
                 MD                    B                  PO BOX 24019 FRESNO CA 93779
                 MD                    B                  PO BOX 2319 FRESNO CA 93779
+ AETNA US HEALTHCARE - AETKY0004                                                       STANDARD/VERIFIED

Use SELECT key to select the CARRIER




                                                             3-99
                                                                                 SAIC GSA Doc. GS-SISS-5000A
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----------------------------------------------------MSA Screen 9---------------------------------------------


The following are Coverage & Payer Codes/Claims Addresses for:
  AETNA US HEALTHCARE

-------------------------------------------------------------------------------
   Coverage/Payer Code   Claims Address

        XM          B         XYZ UNION CLAIMS
                              PO BOX 111 SAN DIEGO CA 92121
        MD          P         PO BOX 111 SAN DIEGO CA 92121

  Use SELECT key to select the Coverage & Payer Code/Claims Address




---------------------------------------------------MSA Screen 10----------------------------------------------

                                                                           Insurance Company Address


            Coverage Type:            MD
        Payer Type Code 1:            BOTH INSTITUITONAL AND PROFESSIONAL
Insurance Company Address:            PO BOX 24019
                     City:            FRESNO
                    State:            CA                 Zip: 93779

            Coverage Type:
        Payer Type Code 2:
Insurance Company Address:
                     City:
                    State:                                   Zip:



The UB92(s) will be printed with the above address(es).
Press <Return> to Continue:




                                                     3-100
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---------------------------------------------------MSA Screen 11----------------------------------------------


Dt/Time:    13 Mar 2003@0830                                                       MSA UB-92 Policy
Data
Patient:    DAVIES,DOD SCHL TEACH                                              FMP/SSN: 20/000-00-0000
Reg No.:    10332                 Adm Dt: 30 Jan 2005                           Status: I
Pat Cat:    DOD TEACHER OCONUS    Dis Dt: 05 Feb 2005                         Sales Cd: IAR
Ins Sta:                             OGP:      ACV:                           Pay Mode:

Remarks:
                    Policy Id:           10038742
       Insurance Company Name:           AETNA US HEALTHCARE
                Coverage Type:           MD
            Payer Type Code 1:           BOTH INSTITUIONAL AND PROFESSIONAL
            Payer Type Code 2:
         Insurance Group Name:                                    Group Number:
        Precertification Code:
              Subscriber Name:           DAVIES,DOD
              Subscriber SSN :           800750625
        Patient Relationship
                to Subscriber:
        Subscriber's Employer:
             Employer Address:




                                                     3-101
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OHI Report
        Menu Path: MSA  IFM  IOR  OHI

The OHI Report will be modified to reflect the new SIT/OHI field names in the header, add the
Coverage Type and associated rankings to the report, and add the new Health Insurance Carrier Status
Codes to the selection criteria. Also, additional selection criteria will be added to help users identify
the “Placeholder” policies.

When the user selects “OHI” from the Insurance and OHI Report menu, he/she is first prompted for
the DMIS ID. This is the Enrolling DMIS ID. The report will include all policies for patients with
the selected Enrolling DMIS ID that also meet the other selection criteria.

The user then chooses to sort the OHI Report one of three ways: by Insurance Company, by Sponsor
SSN, or by Patient Name.

------------------------------------------ OHI Report Screen 1 -------------------------------------------------


                                    Other Health Insurance Report

Enrolling DMIS ID: 0124
          Sort by:
=============================================================================



-----------------------------------------------------------------------
Report by (S)ponsor SSN, (P)atient Name, (I)nsurance Company, or (Q)uit: I




                                                      3-102
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    1. If the user chooses to sort by Insurance Company, the system asks if he/she wants to include
       all insurance companies based on HIC Status, or only user-selected insurance companies (See
       OHI Report Screen 2).

------------------------------------------ OHI Report Screen 2 -----------------------------------------------


                                    Other Health Insurance Report

Enrolling DMIS ID: 0124
          Sort by: Insurance Company
=============================================================================




-----------------------------------------------------------------------
Do you want to print OHI associated with (U)ser-selected Insurance Companies
or (A)ll Insurance Companies or (Q)uit: U//




       If the user chooses to include only user-selected insurance companies, he/she must enter the
        companies that he/she wants to include (See OHI Report Screen 3). The OHI policies
        associated with the selected insurance companies will display on the report.


---------------------------------------- OHI Report Screen 3 ------------------------------------------------

                                    Other Health Insurance Report


Enrolling DMIS ID: 0124
          Sort by: Insurance Company
=============================================================================
                                      <----- Enter Insurance Company Name



-----------------------------------------------------------------------------


Enter a valid Insurance Company Name.


       If the user chooses to include “All” insurance companies, the system then displays a list of
        HIC Status Codes on the screen and prompts the user to indicate whether he/she wants to
        include policies based on the Policy Statuses shown in OHI Report Screen 4).




                                                      3-103
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------------------------------------------- OHI Report Screen 4 ------------------------------------------------

MCDONALD ACH                                                            17 Mar 2005@0642            Page 1

                       Personal Data - Privacy Act of 1974 (PL 93-579)
                                Other Health Insurance Report
DMIS ID: 0124
=====================================================================
Use the select key to select Policy Statuses (F11 selects all). The report
will include OHI associated with the Policy Statuses you selected.


  Standard (not expired)
  Standard (expired)
  Temporary (not expired)
  Temporary (expired)
  Placeholder (not expired)
  Placeholder (expired)
  Deactivated
  Cancelled
  Rejected
  Inactivated (by the initial TNEX SIT/OHI conversion)
  Policies missing Subcriber data (not expired)
  Policies missing Subcriber data (expired)




        Then the system prompts the user to confirm that he/she wants to proceed with the report and
        prompts for a Device.

    2. If the user chooses to sort by Sponsor SSN (OHI Report Screen 6), the system asks if he/she
       wants to include all Sponsor SSNs or only user-selected Sponsor SSNs. The same
       conventions, as described above, will apply for selecting insurance companies based on Policy
       Statuses.

    3. If the user chooses to sort by Patient Name (OHI Report Screen 7), the system asks if he/she
       wants to include all patients or only user-selected patients. The same conventions, as
       described above will apply for selecting insurance companies based on Policy Statuses.




                                                      3-104
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------------------------------------------- OHI Report Screen 5 ------------------------------------------------

Sorted by Insurance Company

MCDONALD ACH                                                            13 Mar 2005@1305            Page 1

                       Personal Data - Privacy Act of 1974 (PL 93-579)
                                Other Health Insurance Report
                                 Sorted by Insurance Company

Enrolling DMIS ID: 0124
=====================================================================
 Carrier HIC Id              Insurance Co Name                Ins Type/Pol
Stat
   Policy Identifier           Subscriber                       Eff Date
     Insured Patient             FMP/Sponsor SSN                End Date
       Coverage Type(s) and Ranking                               Date Last
Serv
=====================================================================
 21SPA0001                   21ST CENTURY HEALTH                CI/S/Active
   1234567                     DAVIES,TPC PP1                     22 Oct 2003
     DAVIES,TPC PP1              20/000-00-0000                   23 Oct 2004
       MD(P) RX(S) IP(P) OP(P) DN(P) VI(P)                        14 Feb 2004




Sorted by Sponsor SSN
--------------------------------------------- OHI Report Screen 6 ----------------------------------------------

MCDONALD ACH                                                                 17 Mar 2005@0642
Page 1

                       Personal Data - Privacy Act of 1974 (PL 93-579)
                                Other Health Insurance Report
                                    Sorted by Sponsor SSN
Enrolling DMIS ID: 0124
=====================================================================
Sponsor SSN/FMP      Insured Patient                      Ins Type/Pol Stat
  Carrier HIC ID       Subscriber                           Eff Date
    Policy Id            Enrolling DMIS ID                  End Date
      Coverage Type(s) and Ranking                            Date Last
Service
=====================================================================
000-00-0000/20       MCALLISTER,DOUGLAS C                 CI/P/Active
  PRUNC0001                                                 01 Jan 2000
    MC584737                                                12 Jun 2005
      MD(P) RX(S) IP(P) OP(P) DN(P) VI(P)                   23 Oct 2002

 000-00-0000/30       BREWSTER,SAMANTHA                                            CI/T/Active
   AETCA0004          BREWSTER,SAMANTHA                                              28 Feb 2003
     123567                                                                          28 Feb 2004
       MD(P) DN(P) VI(P)                                                             17 Mar 2003




                                                      3-105
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Sorted by Patient Name

------------------------------------------- OHI Report Screen 7 ------------------------------------------------

MCDONALD ACH                                                            17 Mar 2005@0643            Page 1

                 Personal Data - Privacy Act of 1974 (PL 93-579)
                          Other Health Insurance Report
                              Sorted by Patient Name
Enrolling DMIS ID: 0124
=====================================================================
Insured Patient                 FMP/Sponsor SSN                Ins Type/Pol
Stat
  Carrier HIC ID                  Subscriber                     Eff Date
    Policy Id                                                    End Date
      Coverage Type(s) and Ranking                                 Date Last
Serv
=====================================================================
AANDERUD,HANNAH C               01/000-00-0000                 CI/S/Expired
  AETVA0001                       AANDERUD,BENJAMIN              01 Jun 2001
    019823028                                                    06 Mar 2004

        IP(P) OP(P) DN(P)                                                                      17 Mar 2003

AANDERUD,HANNAH C                    01/000-00-0000                                      CI/S/Active
  21SPA0001                            AANDERUD,BENJAMIN27                                 04 Jan 2000
    2304601982                                                                             19 Jul 2005
      MD(P)                                                                                17 Mar 2003



Insurance Claim Summary
        Menu Path: MSA  IFM  OPM  CSD
The listing of All Insurance Claims Opened will be modified to reflect the new „SIT/OHI‟ field
names of SIT ID and Policy ID (See MSA Screen 10).
----------------------------------------------MSA Screen 10 --------------------------------------------------

MCDONALD ARMY COMMUNITY HOSPITAL                    21 Mar 2005 0654                                  Page 1
                Personal Data - Privacy Act of 1974 (PL 93-579)
                            * * * ALL INSURANCE CLAIMS OPENED * * *
                              From: 01 Jan 2005   To: 21 Mar 2005

---------------------------------------------------------------------------------
                                                                      Amt Billed
Reg No   Patient Name                          SIT ID                Policy ID
            On Claim
---------------------------------------------------------------------------------
0010246 DAVIES,OLD TPC1             BCBNE0001      BCBS380183             0.00
0010250 DAVIES,TPC TEST1            AETVA0001      AET311963          10579.50
0010251 DAVIES,TPC TEST1            BCBDC0001      BC20004952          7359.00
                               TOTAL CLAIMS: 3                TOTAL DOLLARS BILLED:                 17938.50




                                                      3-106
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Insurance Print Queue/ Preview Roster
        Menu Path: MSA  IFM  OPM  QRS

The Insurance Print Queue/ Preview Roster will be modified to reflect the new „SIT/OHI‟ field name
of Policy ID in the header (See MSA Screen 12).

--------------------------------------------------- MSA Screen 12 --------------------------------------------


  NMC PORTSMOUTH VA                                   03 Jun 2005 1202                                 Page 1
                 Personal Data - Privacy Act of 1974 (PL 93-579)

                      * * * INSURANCE PRINT QUEUE/ PREVIEW ROSTER * * *

  -----------------------------------------------------------------------------

                         DELINQUENT LETTER PRINT QUEUE
 -----------------------------------------------------------------------------
                                                                        To be
Reg No Patient Name         Ins Company   Policy ID        Balance    printed

Form/Letter
-------------------------------------------------------------------------------
-
0347256 HEWITT,LILIA                      YDG 13A           2804.00       X
0382775 HAAG,STANLEY S                    YDG 13A           1067.00       X
0404732 QUEVEDO,ERNEST A                  YDG 13A            420.00       X
0405401 SPIKES,REPORT                     YDG 13A            538.59       X
0405448 SHOEMAKE,FOUR FIVE T              YDG 13A            538.59       X
0405551 MESSIER,MODIFY                    YDG 13A            454.35       X
0405553 PHARR,NUMTPC                      YDG 13A           1065.17       X
0405563 SPIKES,REPORT                     YDG 13A            454.35       X
0405659 SHOEMAKE,FOUR FIVE T              YDG 13A            326.12       X
0405699 FAGAN,WILLIAM M                   YDG 13A            519.32       X
0405735 MURRAY,MICHAEL GILMOCALAK0001     2528 #4            439.76       X
0405736 GUILER,CATHERINE J FARIN0001      0290 #1           1167.74       X
0405737 GUILER,CAROLINE ELIZFARIN0001     0290 #1           2298.97       X
0405748 SWETT,LINDA L        DAKSD0001    5416 #2           1199.25       X


                            Total Claims: 14             Total Amount:        13293.21




                                                     3-107
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 Third Party Collection Program – Aging Schedule Report
          Menu Path: MSA  IFM  QRS  GSC

 The Third Party Collection Program – Aging Schedule Report sort for Format 1 will be changed
 from Insurance Company Short Name to SIT Identifier.

 -------------------------------------------------- MSA Screen 13 --------------------------------------------


 THIRD PARTY COLLECTION PROGRAM - AGING SCHEDULE REPORT

                                    Current Quarter
                                    FY 1998     Second          Quarter
                                    FY 1997     Third          Quarter
                                    FY 1996     First          Quarter
                                    FY 1994     Third          Quarter
                                    FY 1994     Second          Quarter
                                    FY 1994     First          Quarter
                                    FY 1993     Fourth         Quarter
                                    FY 1993     Third          Quarter
                                    FY 1993     Second          Quarter
                                    FY 1993     First          Quarter
                                    FY 1992     Fourth         Quarter
 +                                  FY 1992     Third          Quarter


 Co-Insurance Claim File (# 8055) Conversion (TPC Accounts)
 Currently, the Insurance Policy and Insurance Policy Number in the Co-Insurance Claim file
 (#8055) point to the old Policy file (#8086). As shown in Table 4, CHCS will convert the Insurance
 Policy and the Insurance Policy number for all entries in the Co-Insurance Claim file to map to the
 new CHCS OHI file (#8074). TPC accounts with inactive policies will not be converted.
                Table 4: CHCS Co-Insurance Claim File Conversion Data Elements

 Current field location in the Co-Insurance              New “pointed to” field location in the new OHI
 Claim file (#8055)                                      file (#8074)

 Current Insurance Policy 8055,3 (Pointer to
                                                         Policy Identifier 8074.1, 02
 8086,01)
 Insured Name 8055.02, .01 (Pointer to 8086,3)           Patient IEN 8074, .01

3.3.3      File and Table Changes

     Screen displays, reports, and UB-92 claim forms that support OHI data for MSA/TPC will be
     modified to reflect the Coverage Type enhancements and new field names.

     3.3.4 Implementation Issues

     _____ Verify that MSA/TPC users are briefed on the SIT/OHI enhancements that impact TPC.


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************************************************************************



                 APPENDIX A.       BUSINESS RULES


************************************************************************




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Appendix A: Business Rules
Business Rules (SIT)

    Add Business Rules

    1. To add an insurance company, the following fields are required:

       Insurance Company
          a. HIC ACTION CODE = “A” (Add)
          b.    HIC NAME
          c.    HIC UPDATE POINT OF CONTACT NAME
          d.    HIC UPDATE POINT OF CONTACT TELEPHONE NUMBER CODE
          e.    HIC UPDATE POINT OF CONTACT EMAIL

       Insurance Coverage
          a. HIC COVERAGE ACTION CODE = “A” (Add)
          b. HIC COVERAGE TYPE CODE
          c. HIC PAYER TYPE CODE
          d. HIC COVERAGE MAILING ADDRESS LINE 2
          e. HIC COVERAGE MAILING ADDRESS CITY
          f. HIC COVERAGE MAILING ADDRESS STATE CODE (Situational)
          g. HIC COVERAGE MAILING ADDRESS COUNTRY CODE (Situational)
          h. HIC COVERAGE MAILING ADDRESS POSTAL REGION ZIP CODE
             (Situational)
          i. HIC COVERAGE TELEPHONE NUMBER 1 CODE

    Update Business Rules

    2. Only records that have a HIC STATUS CODE of “S” (Standard) and a HIC
       VERIFICATION STATUS CODE of “V” (Verified) can be updated.

    3. To update an insurance company, the HIC ID must already exist on the DEERS SIT and
       the record must be a currently verified record.

    4. To update an insurance company, CHCS must supply the following information:
           a.   Existing HIC ID
           b.   HIC ACTION CODE = "N" (No change)
           c.   HIC NAME
           d.   HIC UPDATE POINT OF CONTACT NAME
           e.   HIC UPDATE POINT OF CONTACT TELEPHONE NUMBER CODE
           f.   HIC UPDATE POINT OF CONTACT EMAIL




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      For adding a new Coverage Type to an existing insurance company, the following fields
      are required:

          a. HIC COVERAGE ACTION CODE = "A" (Add)
          b. NEW HIC COVERAGE TYPE CODE
          c. New HIC PAYER TYPE CODE
          d. HIC COVERAGE MAILING ADDRESS LINE 2
          e. HIC COVERAGE MAILING ADDRESS CITY
          f. HIC COVERAGE MAILING ADDRESS STATE CODE (situational)
          g. HIC COVERAGE MAILING ADDRESS COUNTRY CODE (situational)
          h. HIC COVERAGE MAILING ADDRESS POSTAL REGION ZIP CODE
             (situational)
          i. HIC COVERAGE TELEPHONE NUMBER 1 CODE

      To update an existing Coverage Type for an existing insurance company, the following
      fields are required:

          a. HIC COVERAGE ACTION CODE = "U" (Update)
          b. New HIC COVERAGE TYPE CODE
          c. New HIC PAYER TYPE CODE
          d. HIC COVERAGE MAILING ADDRESS LINE 2
          e. HIC COVERAGE MAILING ADDRESS CITY
          f. HIC COVERAGE MAILING ADDRESS STATE CODE (situational)
          g. HIC COVERAGE MAILING ADDRESS COUNTRY CODE (situational)
          h. HIC COVERAGE MAILING ADDRESS POSTAL REGION ZIP CODE
             (situational)
          i. HIC COVERAGE TELEPHONE NUMBER 1 CODE

Cancel Business Rules

    5. Only the system that issued the Add on a particular record can issue a cancellation on
       that transaction. Updates cannot be cancelled.

    6. A cancellation on a coverage can only be performed if the record‟s HIC
       VERIFICATION STATUS CODE is “U” (Unverified).

    7. A cancellation can be applied to an insurance company and coverage, or a coverage
       only.
          a. To cancel an insurance company and coverage:
                   i. HIC ACTION CODE must be set to “C” (Cancel)
                  ii. HIC COVERAGE ACTION CODE must be set to “C” (Cancel)




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           b. To cancel a coverage only:
                   i. HIC ACTION CODE will be set to “N” (No Change)
                   ii. HIC COVERAGE ACTION CODE must be set to “C” (Cancel)

       Canceling an insurance company cancels all the coverages associated with that HIC ID.

Subscription Inquiry Business Rules

    8. When CHCS downloads an updated entry from the DEERS SIT during a subscription
       inquiry, the new or modified data elements will result in an “add” or “overwrite” to
       update local copy of the SIT.

    9. In all cases, whether a Full or Partial subscription inquiry request, CHCS must write all
       updates to the local copy of the SIT. This data represents the most current information
       available on the DEERS central SIT.

    10. During a Partial subscription inquiry, if the requested date range is greater than 7 or is
        blank, the current records for the past 7 days will be provided.

    11. Every update provided in the response to a subscription inquiry will contain every
        coverage pertaining to a HIC ID whether there is an update or not.


Business Rules (OHI)
   1. OHI can be updated any time after a patient is enrolled through Defense Online
      Enrollment System (DOES) or the Web application.

   2. CHCS shall allow users to enter OHI information into CHCS for all TPC eligible
      beneficiaries. The system shall not allow users to enter OHI information into CHCS for
      patients with the following Patient Categories:
             Active Duty
             Patient Category Codes beginning with “K”
   3. CHCS shall overwrite existing OHI data in the CHCS OHI file (#8074) with data
      received from DEERS in update messages, if the OHI Transaction Calendar Date/Time
      or Coverage Transaction Calendar Date/Time downloaded in the record from DEERS is
      later than the Policy Date Last Updated or the Coverage Date Last Updated in the CHCS
      OHI file.

   4. The subscriber that currently occupies the OHI Transaction System Name may submit an
      update message to DEERS requesting cancellation of a policy. This may or may not be
      the subscriber who originally entered the policy.



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5. A CHCS user may not change the Policy ID, Carrier ID, or Policy Effective Date of a
   policy after the policy has been sent to DEERS. These three fields, in combination with
   the Patient ID, are the key fields that uniquely identify an OHI Policy on the DEERS
   database.

6. A CHCS user may not change the Coverage Effective Date associated with a Coverage
   Type after the Coverage Type has been sent to DEERS. This field in combination with
   the Coverage Type Code, are the key fields that uniquely identify a Coverage Type on
   the DEERS database.

7. When adding or updating an OHI policy, users must verify that there is always, at least
   one <XM, MD, or IP> Coverage Type defined as Primary; otherwise, MSA is unable to
   generate a UB-92.




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Business Rules (Pre-Implementation Reports)
REPORT #1. Business Rules for matching fields between the (old) SIT file (#8064) and the
(new) HIC file (#8192):

First, find the carriers in the old SIT file (#8064) that have a Short Name which does not match a
HIC ID in the new Health Insurance Carrier file (#8192).

Next, using that subset of carriers where there is no match between the Short Name and HIC ID,
try to match on the following:

    - Zip (SIT file #8064) matches Zip (HIC file #8192) – just the first 5 digits
    - State/Country (SIT file #8064) matches State/Country (HIC file #8192)
    - City (SIT file #8064) matches City (HIC file #8192)

If the Zip, State/Country, and City match, then continue to compare the following combination
of address fields:

   If Address Line 2 (SIT file #8064) matches Address Line 2 (HIC file #8192), then include on
   the report.

   If Address Line 2 (SIT file #8064) does not match Address Line 2 (HIC file #8192), check
   next set of fields.

   If Address Line 2 (SIT file #8064) matches Address Line 1 (HIC file #8192), then include on
   the report.

   If Address Line 2 (SIT file #8064) does not match Address Line 1 (HIC file #8192), check
   next set of fields.

   If Address Line 1 (SIT file #8064) matches Address Line 1 (HIC file #8192), then include on
   the report.

   If Address Line 1 (SIT file #8064) does not matches Address Line 1 (HIC file #8192), check
   next set of fields.

   If Address Line 1 (SIT file #8064) matches Address Line 2 (HIC file #8192), then include on
   the report.

   If Address Line 1 (SIT file #8064) does not match Address Line 2 (HIC file #8192), the
   attempts at matching are complete – the carrier will not be included on the report.




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Exclusions:

The report will exclude insurance companies (SIT file #8064) and insurance carriers (HIC file
#8192), based on the following rules:

   1. Insurance companies in the SIT file (#8064) will not be included on the report if they are
      inactive (that is, if the Inactive Date is not null).

   2. Insurance companies in the SIT file (#8064) will not be included on the report if they are
      not associated with at least one OHI policy in the Policy file (#8086) that meets the
      following criteria:

        Policy Inactivation Date (Policy file #8086) must be 2 October 2002 or later.
        Policy Expiration Date (Policy file #8086) must be 2 October 2002 or later.
        Patient Policy Deletion Date (Insured Party file #8083) must be null.
        Policy has not been re-pointed to a new carrier (“Copy to New Policy” field (Insured
         Party file #8083) must be null).

   3. HIC carriers in the HIC file (#8192) will not be included on the report if the Carrier
      Status Code is “Deactivated”, “Rejected”, or “Cancelled.”

       Note: The system will display a warning message to alert the user that he/she needs to
       select a printer that is capable of printing 132 columns.

REPORT #2. Business Rules for matching fields between the (old) SIT file #8064 and the
(new) HIC file #8192:

First, find the carriers in the old SIT file (#8064) that have a Short Name, which does not match
a HIC ID in the new Health Insurance Carrier file (#8192).

Next, using that subset of carriers where there is no match between the Short Name and HIC ID,
try to match on the following:

    - Zip (SIT file #8064) matches Zip (HIC file #8192) – just the first 5 digits
    - State/Country (SIT file #8064) matches State/Country (HIC file #8192)
    - City (SIT file #8064) matches City (HIC file #8192)

If the Zip, State/Country, and City match, then continue to compare the following combination
of address fields:

   If Address Line 2 (SIT file #8064) matches Address Line 1 or Address Line 2 (HIC file
   #8192), then do NOT include the carrier on the report.

   If Address Line 2 (SIT file #8064) does not match either Address Line 1 or Address Line 2
   (HIC file #8192), check next set of fields.



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   If Address Line 1 (SIT file #8064) matches Address Line 1 or Address Line 2 (HIC file
   #8192), then do NOT include the carrier on the report.

   If neither Address Line 1 nor Address Line 2 (SIT file #8064) match either Address Line 1 or
   Address Line 2 (HIC file #8192), include the carrier on the report.

Exclusions:

The report will exclude insurance companies (SIT file #8064) based on the following rules:

   4. Insurance companies in the SIT file (#8064) will not be included on the report if they are
      inactive (that is, if the Inactive Date is not null).

   5. Insurance companies in the SIT file (#8064) will not be included on the report if they are
      not associated with, at least, one OHI policy in the Policy file (#8086) that meets the
      following criteria:

        Policy Inactivation Date (Policy file # 8086) must be 2 October 2002 or later.
        Policy Expiration Date (Policy file # 8086) must be 2 October 2002 or later.
        Patient Policy Deletion Date (Insured Party file #8083) must be null.
        Policy has not been re-pointed to a new carrier (“Copy to New Policy” field (Insured
         Party file #8083) must be null).

REPORT #3. Business Rules for matching addresses between the SIT records in the (old)
SIT file #8064:

First find matches on Zip Code.
Then, using the records where the Zip Code matches, find matches on State/Country.
Then, using the records where the Zip Code and State/Country match, find matches on City.
Then, using the records where the Zip Code, State/Country, and City match, compare the
following combination of address fields:

   If Address Line 2 matches Address Line 1 or Address Line 2 in one or more other carrier
   records, include the carrier on the report.

   If Address Line 2 does not match either Address Line 1 or Address Line 2 in one or more
   other carrier records, check next set of fields.

   If Address Line 1 matches Address Line 1 or Address Line 2 in one or more other carrier
   records, then include the carrier on the report.

   If neither Address Line 1 nor Address Line 2 match either Address Line 1 or Address Line 2
   in one or more other carrier records, do not include the carrier on the report.


                                              A-8
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Exclusions:

The report will exclude insurance companies (SIT file #8064) based on the following rules:

    6. Insurance companies in the SIT file #8064 will not be included on the report if they are
       inactive (that is, if the Inactive Date is not null).

    7. Insurance companies in the SIT file (#8064) will not be included on the report if they are
       not associated with at least one OHI policy in the Policy file (#8086) that meets the
       following criteria:

         Policy Inactivation Date (Policy file #8086) must be 2 October 2002 or later.
         Policy Expiration Date (Policy file #8086) must be 2 October 2002 or later.
         Patient Policy Deletion Date (Insured Party file #8083) must be null.
         Policy has not been re-pointed to a new carrier (“Copy to New Policy” field (Insured
          Party file #8083) must be null).

           Note: The system will display a warning message to alert the user that he/she needs
           to select a printer that is capable of printing 132 columns.

REPORT #4. Business Rules for including OHI policies in the report:

First, check for OHI Policies in the Policy file where the Policy Effective Date is null.

Then, using the subset of policies where the Policy Effective Date is null, include policies on the
report, based on the following:

       Policy Inactivation Date (Policy file # 8086) must be 2 October 2002 or later.
       Policy Expiration Date (Policy file # 8086) must be 2 October 2002 or later.
       Patient Policy Deletion Date (Insured Party file #8083) must be null.
       Policy has not been re-pointed to a new carrier; that is, “Copy to New Policy” field
        (Insured Party file #8083) must be null.
       Insurance Company associated with the policy must be currently active, or has been
        active at some time since 1 October 2002 (field 8064.9 in the SIT file is null, or contains
        a date later than 1 October 2002).

REPORT #5. Business Rules for including OHI policies in the report:

First, check for OHI Policies in the Policy file (#8086) where the following Subscriber fields are
null:

   Insured Name or (Pointer)
   Relational Relationship
   Insured FMP


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   Insured SSN
   Insured DOB
   Insured Gender

Then, using the subset of policies where the Subscriber data is missing, include policies on the
report, based on the following:

 Policy Inactivation Date (Policy file # 8086) must be 2 October 2002 or later.
 Policy Expiration Date (Policy file # 8086) must be 2 October 2002 or later.
 Patient Policy Deletion Date (Insured Party file #8083) must be null.
 Policy has not been re-pointed to a new carrier - that is, „Copy to New Policy‟ field (Insured
  Party file #8083) must be null.
 Insurance Company associated with the policy must be currently active, or has been active at
  some time since 1 October 2002 (field 8064.9 in the SIT file is null, or contains a date later
  than 1 October 2002).

Business Rules (MSA/TPC)

    1. A CHCS inpatient TPC account must have at least one Primary “XM”, “MD”, or “IP”
       Coverage Type in order for a claim to be generated.

    2. The only Coverage Types applicable to inpatient TPC billing will be “XM”, “MD”, or
       “IP”.

    3. The Payer Type Code for a Coverage Type must be Institutional, Professional, or Both in
       order for the TPC account to be billable.

    4. If a patient has more than one policy that has any Coverage Type/Payer Type
       combination ranked as Primary, a CHCS user must verify that the correct policy is billed.




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************************************************************************



      APPENDIX B.       FAMILIARIZATION TRAINING PLAN

************************************************************************




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Appendix B. Familiarization Training Plan

It is recommended that any existing distance-learning training be utilized as a training tool. Web
Based Training and Virtual Classroom sessions on this enhancement may be available to your
site at the time this document is published. To check on access and availability, inquire with
your on-site CHCS training point of contact (POC) or visit the Clinical Information Technology
Program Office (CITPO) training portal at www.distributivelearning.net.
.




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************************************************************************

  APPENDIX C.       SAMPLE PRE-IMPLEMENTATION REPORTS
************************************************************************




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PRE-IMPLEMENTATION REPORT #1 (SIR# 34044)
Format of the Report:
SAN DIEGO NMC                                                                                         11 Jul 2005
                                                                                                           Page 1
                                        PRE-IMPLEMENTATION REPORT #1
                         SIT CARRIERS WITH NO DEERS HIC ID MATCH, BUT ADDRESS MATCH
==========================================================================================================
SIT FILE #8064                                                          Address Match in HIC FILE #8192
-----------------------------------------------------------------------------------------------------------

Ins Co Name:   MADISON INS FOR CAL                        Carrier Name: MADISON CALIFORNIA INS CO
 Short Name:   123456789                                        HIC ID: MADCA0014
Address Ln1:   Atten: Susan Smith                           Car Status: STANDARD/VERIFIED
Address Ln2:   P.O. BO 3535                               Car Std Comt:
City/St/Zip:   SAN DIEGO             CA   92121
                                                      HIC Coverage Type: MD MEDICAL ONLY
Standard Comment:                                        HIC Payer Type: BOTH INSTITUTIONAL AND PROFESSIONAL
                                                             Cvr Status: STANDARD/VERIFIED
                                                            Address Ln1:
                                                            Address Ln2: 1413 ARIZONA AVE
Local Comment:                                              City/St/Zip: SAN DIEGO CA 92121
                                                            Coverage Standard Comment:

# of Policies:                                        HIC Coverage Type: M COMPREHENSIVE MEDICAL (default)
                                                         HIC Payer Type: BOTH INSTITUTIONAL AND PROFESSIONAL
                                                             Cvr Status: STANDARD/VERIFIED
                                                            Address Ln1:
                                                            Address Ln2: P.O. BO 3535
                                                            City/St/Zip: SAN DIEGO CA 92121
                                                            Coverage Standard Comment:
                                                     Carrier Name: MADIISON CALIFORNIA INS CO
                                                        HIC ID: MADCA0018
                                                    Car Status: STANDARD/VERIFIED
                                                  Car Std Comt:
                                                       HIC Coverage Type: M COMPREHENSIVE MEDICAL (default)
                                                          HIC Payer Type: BOTH INSTITUTIONAL AND PROFESSIONAL
                                                              Cvr Status: STANDARD/VERIFIED
                                                             Address Ln1:
                                                             Address Ln2: 1413 ARIZONA AVE
                                                             City/St/Zip: SAN DIEGO CA 92121
                                                             Coverage Standard Comment:




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PRE-IMPLEMENTATION REPORT #2 (SIR #34045)
Format of the Report:


SAN DIEGO NMC
                                                                    11 Jul 2005
                                                                         Page 1
                         PRE-IMPLEMENTATION REPORT #2
        SIT CARRIERS WITH NO DEERS HIC ID MATCH, AND NO ADDRESS MATCH
============================================================================
SIT FILE #8064
-----------------------------------------------------------------------------
      Ins Co Name:   MADISON INS FOR CAL
       Short Name:   123456789
   Address Line 1:   Atten: Susan Smith
   Address Line 2:   P.O. BO 3535
      City/St/Zip:   SAN DIEGO CA    92121
 Standard Comment:
    Local Comment:
# of OHI Policies:




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PRE-IMPLEMENTATION REPORT #3 (SIR #34046)
Format of the Report:


SAN DIEGO NMC
                                                                                                  11 Jul 2005
                                                                                                       Page 1
                                        PRE-IMPLEMENTATION REPORT #3
                      SIT CARRIERS WITH DUPLICATE ADDRESSES WITHIN CHCS SIT FILE #8064
==========================================================================================================
 Insurance Company                            Other Insurance Companies with Possible Duplicate Address
-----------------------------------------------------------------------------------------------------------
Ins Co Name: MADISON INS FOR CAL               Ins Co Name: MADISON CALL INS
 Short Name: 123456789                          Short Name: 123456789
 Addrs Ln 1: Atten: Susan Smith                 Addrs Ln 1: Atten: Susan Smith
 Addrs Ln 2: P.O. BO 3535                       Addrs Ln 2: P.O. BO 3535
 Cty/St/Zip: SAN DIEGO CA 92121                 Cty/St/Zip: SAN DIEGO CA 92121
   Standard Comment:                              Standard Comment:

   Local Comment:                                  Local Comment:
   # of OHI Policies:                              # of OHI Policies:

                                                Ins Co Name: MADIISON INS FOR CAL
                                                 Short Name: 678987654
                                                 Addrs Ln 1: Atten: Susan Smith
                                                 Addrs Ln 2: P.O. BO 3535
                                                 Cty/St/Zip: SAN DIEGO CA 92121
                                                   Standard Comment:

                                                   Local Comment:

                                                   # of Policies associated with this Ins Co:




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PRE-IMPLEMENTATION REPORT #4 (SIR #34047)
Format of the Report:



SAN DIEGO NMC                                                                                     11 Jul 2005
                                                                                                       Page 1
                                         PRE-IMPLEMENTATION REPORT #4
                                  OHI POLICIES MISSING POLICY EFFECTIVE DATE
DMIS ID: 0035
===========================================================================================================
     Patient Name:   BAKER,JAMES ROBERT
          SSN/FMP:   000000000/00
   SIT Short Name:   BADCA0003
Insurance Co Name:   BADEN HEALTHCARE
    Policy Number:   6484848
     Patient Name:   DAVIDSON,ARLENE P
          FMP/SSN:   00/000000000
   SIT Short Name:   AETCA0004
Insurance Co Name:   AETNA US HEALTHCARE
    Policy Number:   DAV-25983 483

     Patient Name:   SUTTON,DEREK DAVID
          FMP/SSN:   00/000000000
   SIT Short Name:   USHMI0004
Insurance Co Name:   US HEALTHCARE
    Policy Number:   000456-6483




                                                     C-5
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PRE-IMPLEMENTATION REPORT #5 (SIR #34048)
Format of the Report:



SAN DIEGO NMC                                                          11 Jul 2005
                                                                            Page 1
                             PRE-IMPLEMENTATION REPORT #5
                OHI POLICIES MISSING POLICYHOLDER/SUBSCRIBER INFORMATION
DMIS ID: 0035
=============================================================================
      Patient Name:    BAKER,JAMES ROBERT    SSN/FMP: 000000000/00
    SIT Short Name:    BADCA0003                   Policy #: 6484848
 Insurance Co Name:    BADEN HEALTHCARE
 Policy Effec Date:    13 Aug 2004               Policy End Date: 31 Dec 2004
   Subscriber Name:    BAKER,JAMES ROBERT
Subscriber FMP/SSN:    00/000000000             Subscriber Phone: 858-584-6857
Subscriber Address:    4344 THROUGH DE LA VALLE
Subscrb Cty/St/Zip:    SAN DIEGO CA 92121
    Subscriber DOB:                            Subscriber Gender: MALE
                           Patient’s Relationship to the Insured: CHILD




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