Certificate of Creditable Coverage
Transactions & Code Sets
You can think of the certificate as written proof of prior health care coverage. When you accept a job offer and choose to purchase other insurance once you lose TRICARE eligibility, the other insurance plan may ask for a CoCC showing that you had prior health care coverage. The certificate shows TRICARE coverage for the period of time noted on the certificate. Health plans use the certificate to show prior coverage and to reduce the period of time that you might otherwise be excluded from coverage for a pre-existing condition.
Health care plans can refuse to pay for health care for conditions you had prior to being covered by that plan. Plans may refuse to cover you for these pre-existing conditions for a set period of time (for instance, they may say they will not cover you for your high blood pressure for six months), unless you can prove that you had coverage for your condition prior to enrolling in their particular plan. A CoCC is the paper that shows you had previous health care coverage.
Certificates are automatically generated when a beneficiary loses his or her eligibility (e.g., when a Service member separates from active duty, when a couple divorces, when a dependent child reaches age 21 (or age 23 if a full-time student), when a Reserve Component member gets deactivated, etc.). For individuals that lose TRICARE eligibility, a certificate is processed within five (5) to ten (10) working days from the date of loss of eligibility. It is important to make sure your mailing address in DEERS is current so that you receive your certificate promptly at the correct mailing address.
NOTE: Retirees do not lose TRICARE eligibility upon retirement. If a TRICARE eligible retiree, retired member's spouse, un-remarried former spouse, etc. needs a CoCC for a new employer, the individual
must submit a written request.
When a person loses health care coverage and then enrolls in another health care plan, or COBRA, as long as the beneficiary has not had a break in coverage of more than 63 days, he/she is considered to have continuous coverage. Here is an example that should help clarify:
Question: I began employment with my current employer 45 days after my previous group health plan coverage terminated. I had coverage under my previous employer's plan for 24 continuous months prior to the termination. I had no other coverage before my enrollment date in my new plan. If I enroll in my employer's health plan when I am first eligible, will not be subject to the 12-month pre-existing condition exclusion period imposed by my new employer?
Answer: The 45-day break in coverage does not count as a significant break in coverage under HIPAA. Under federal law, a significant break in coverage is a break in coverage of at least 63 consecutive days. Since you had over 12 months of creditable coverage from your previous group plan without a significant break, you would not be subject to the preexisting condition exclusion period imposed by your new employer's plan if you enroll when you are first eligible.
Note that the Patient Protection and Affordable Care Act allows for Young Adult coverage under an eligible sponsor up to age 26. For more information about the TRICARE Young Adult program, please visit http://www.tricare.mil/TYA.
Most health care plans use the "standard method" of crediting coverage. Under the standard method, you receive credit for your previous coverage that occurred without a break in coverage of
63 days or more. Any coverage occurring prior to a break in coverage of 63 days or more is not credited against a preexisting condition exclusion period. To illustrate, suppose an individual had
coverage for two years followed by a break in coverage of 70 days, and then resumed coverage for eight months. That individual would only receive credit for eight months of coverage; no credit
would be given for the two years of coverage prior to the break in coverage of 70 days.
If you misplaced, lost or did not receive your CoCC, you can request a replacement by contacting the DSO in writing at:
Defense Manpower Data Center Support Office (DSO)
ATTN: Certificate of Creditable Coverage
400 Gigling Road
Seaside, CA 93955-6771
You can also fax your request to the DSO at 1-831-655-8317.
When you write in for a certificate you must include the following information in your letter:
You cannot e-mail a request for a CoCC. You can either call or make a request in writing via mail or fax, using the procedure described above.
Beneficiaries seeking information about a certificate should call: 1-800-538-9552 (TTY/TDD: 1-866-363-2883); however, beneficiaries cannot request Certificates of Creditable Coverage over the phone.
If you need proof of current health care coverage for yourself or your family members, you may request an “Eligibility Letter.” An Eligibility Letter states that you are currently covered under a TRICARE program.
For example, if you retire from active duty, your medical coverage does not end. If you need a certificate to provide to a new employer's health plan administrator, you would request an Eligibility Letter instead of a
CoCC. The Eligibility Letter effective date will be a maximum of 18 months in the past.
Please use the same steps outlined in questions 6 and 7 to request a letter from DSO.
You can also generate an Eligibility Letter that shows proof of health care coverage if you are currently TRICARE eligible. Visit https://www.dmdc.osd.mil/milconnect/faces/index.jspx and sign in.
Then choose the "Health Care" menu item, and click "Proof of Insurance." Follow the directions to generate and print the letter. You will need a Common Access Card (CAC), DoD Self-Service Logon or Defense
Finance Accounting System (DFAS) Pin to use this website.
If you need additional information included in the Eligibility Letter, please submit the request to DSO in writing and explain what you need included in the letter and the reason that the additional information is needed.
An Eligibility Letter serves as evidence that your health care coverage is ongoing. A CoCC is a document that shows your prior health care coverage, including the dates of coverage. TRICARE will
automatically send a CoCC when a beneficiary losses eligibility for all MHS medical benefits. An Eligibility Letter can be requested the same way as a CoCC would be requested, from the DSO
via telephone, fax or mail. For more information, visit the
An Eligibility Letter, which is issued by the DSO, serves as evidence of having current health care coverage. In some cases, you may need additional information. DSO only provides the basic
eligibility information to simply state that you are covered in order to protect your Personal Health Information (PHI). If you require more than just proof of coverage, you should contact your
Beneficiary Counseling and Assistance Coordinator (BCAC) for assistance. Your BCAC can assist you in obtaining the specific information you need. BCACs are located at Military Treatment
Facilities (MTFs) and at TRICARE Regional Offices (TROs). You can locate a BCAC by visiting the following website:
The TRICARE Managed Care Support Contractors (MCSCs) have provided companion guides for some of the transactions they perform. Please contact the MCSC point of contact for your region to
obtain the latest information.
The GIQD is a web-based, direct data entry system which allows authorized users to make eligibility inquiries. The GIQD has been updated to include HIPAA-compliant data elements and
can be used in lieu of a direct Electronic Data Interchange (EDI) with DEERS.
The DOES application is a web-based, direct data entry system which can be utilized by MCSCs and other users to enroll TRICARE beneficiaries into TRICARE programs in DEERS. DOES has
been updated to include HIPAA compliant data elements. The system includes upgraded security features and was deployed to all users as of May 2003. All TRICARE enrollments are performed using the
HIPAA-compliant DOES application.
The Centers for Medicare and Medicaid Services (CMS) published a Claims Attachments Notice of Proposed Rulemaking (NPRM) (CMS-005-0-F) in the Federal Register on September 23, 2005. However, that NPRM was
withdrawn in 2010 because of technology and business need changes. The Patient Protection and Affordable Care Act (PPACA) of 2010 requires that the Department of Health and Human Services (HHS) publish a Final
Rule to adopt a Claims Attachment Standard and Operating Rules by January 1, 2014 with an effective date not later than January 1, 2016.
In a Final Rule published by the Department of Health and Human Services (HHS) on January 16, 2009, covered entities were mandated to be in full compliance with Versions 5010 and NCPDP Version D.0 by January 1, 2012.
Yes, Version 5010 supports ICD-10, Procedure Coding System (PCS) and Clinical Modifications (CM) codes and is now fully implemented across the industry. Per the Final Rule published by HHS on September 5, 2012, covered entities are required to use ICD-10 in HIPAA transactions by October 1, 2014.
The NPI is a unique identification number for health care providers. Health care providers, health plans and health care clearinghouses use NPIs in the administrative and financial transactions specified by HIPAA.
The NPI is a 10-position numeric identifier with a check digit in the last position to help detect invalid NPIs. The NPI contains no embedded intelligence; that is, it contains no information about the health care
provider such as the type of health care provider or state where the health care provider is located.
There are two Health Affairs (HA) Policies and one HA Guideline that describe the types of providers in the MHS that require NPIs. These include: HA Policy 05-002 (NPI Enumeration of MHS Individual (Type 1)
Health Care Providers), HA Policy 05-012 (NPI Enumeration of MHS Organizational (Type 2) Health Care Providers) and HA Guideline dated May 21, 2007. According to these policies and guideline the following MHS
providers are required to obtain and use an NPI:
Individual (Type 1) Health Care Providers
Organizational (Type 2) Health Care Providers
MHS providers have been required to obtain and use the NPI since 2007.
Health care providers can obtain NPIs by submitting an application to the National Plan and Provider Enumeration System (NPPES). The NPPES was developed by CMS to process NPI applications.
Providers have two options when applying for their NPIs:
After an application is successfully processed, health care providers will be notified of their NPIs. HHS has contracted with an organization, known as the enumerator, to process NPI applications. In addition to
receiving and processing NPI applications and notifying health care providers of their NPIs, the enumerator uses the NPPES to perform the following functions: ensure the unique identification of a health care provider;
answer questions about the processes of applying for and obtaining NPIs and furnishing updates; collect information via the applications and updates, maintain the NPPES database containing NPIs and information
about the health care providers to which they are assigned; and furnish information upon request and in accordance with established guidelines.
Ensure the MHS has your NPI on file. MHS providers who furnish billable health care services, write prescriptions, initiate and/or receive referrals should have obtained, submitted and began using an NPI effective
May 23, 2007. This includes all privileged providers, residents, and certain non-privileged providers. Non-privileged providers are required to obtain an NPI if they request referrals, request consults, write prescriptions or
provide billable services. For example, Independent Duty Corpsmen who request referrals, Independent Duty Medical Technicians working in the cast clinic or a nurse giving Depo-Provera injections when the
patient has not seen the physician would need to be identified in certain HIPAA electronic transactions.
Once an MHS provider has an NPI, these offices will forward a copy of the NPI letter to the appropriate support office for entry of the NPI information into the Defense Manpower Human Resource
System internet (DMHRSi), which is the MHS repository for the NPI. If you are a new MHS provider, refer to question 20. (How are NPIs issued?).
Due to the inconsistency between state licensure requirements for Physician Assistants, Physician Assistants are allowed to obtain an NPI without having to furnish a license number and/or state of license.
Yes, you have just one NPI for life; no matter where you are working or what specialty you are practicing.
The NPI is used as a means of communicating the identity of providers in HIPAA standardized electronic transactions (e.g., billing and referral purposes) both within and external to the MHS.
NPIs are also used for non-HIPAA purposes where a provider identifier is needed, such as on paper claim forms (e.g., CMS-1500 and UB-04 claims) referral forms and on prescriptions.
The NPI must be used to identify providers in standard electronic transactions identified by HIPAA. In addition, the NPI may be used in several other ways:
(1) by health care providers to identify themselves in health care transactions identified in HIPAA or on related correspondence;
(2) by health care providers to identify other health care providers in health care transactions or on related correspondence;
(3) by health care providers on prescriptions (however, the NPI could not replace requirements for the Drug Enforcement Administration number or State license number);
(4) by health plans in their internal provider files to process transactions and communicate with health care providers;
(5) by health plans to coordinate benefits with other health plans;
(6) by health care clearinghouses in their internal files to create and process standard transactions and to communicate with health care providers and health plans;
(7) by electronic patient record systems to identify treating health care providers in patient medical records;
(8) by HHS to cross reference health care providers in fraud and abuse files and other program integrity files;
(9) for any other lawful activity requiring individual identification of health care providers, including activities related to the Debt Collection Improvement Act of 1996 and the Balanced Budget Act of 1997.
As of May 23, 2008, the NPI is the only identifier that can be used to identify a health care provider in standard transactions. Use of legacy identifiers (such as the Unique Physician Identification Number (UPIN),
Medicaid Provider Number, Medicare Provider Number, and others) were discontinued on May 23, 2008. Where a health care provider must be identified in standard transactions for tax purposes, it would
use its Taxpayer identification as required by the implementation specifications. Health care provider identifiers other than the NPI may continue to be used in the internal processes and files of health plans or
health care clearinghouses if they wish to continue to use those identification numbers in those internal processes and files.
Yes. Although the NPI Final Rule does not require that health care providers who are not covered entities under HIPAA obtain or use an NPI, the Rule also does not prohibit health plans from
requiring their enrolled health care providers that are eligible for an NPI to obtain one.
Note: The NPI Final Rule does prohibit health plans from requiring a health care provider with an NPI to obtain additional NPIs.
While the NPI final rule does not require providers who do not conduct HIPAA standard electronic transactions to obtain an NPI, all eligible providers are encouraged to obtain an NPI. One reason is that the
CMS-1500 and UB-04 paper claim forms were updated to accommodate the NPI and health plans have the option to require the NPI be used on these paper forms. Another reason for eligible providers to get an
NPI is that there may still be other instances where providers who do not conduct HIPAA standard electronic transactions would need to be identified in standard transactions conducted by other providers. For
example, a physician who writes a prescription (electronic or paper) but does not bill health plans directly is not required by the NPI Final Rule to obtain an NPI; however, there are transactions that will be generated
after the prescription is written, and some of those are standard electronic transactions. The pharmacy that fills the prescription will most likely bill for the prescription claim
electronically (a HIPAA standard electronic transaction). If the physician who wrote the prescription does not have an NPI, the pharmacy is left with the problem of how to identify the prescriber
on this billing transaction.
The NPI is meant to be a lasting identifier, and does not change based on changes in a health care provider's name, address, ownership, membership in health plans, or Healthcare Provider Taxonomy classification. There may be situations where use of an NPI for fraudulent purposes results in a health care provider requesting a different NPI. Such situations will be investigated and a different NPI may be assigned to the requesting health care provider.
Health care providers are not required to renew their NPI once issued.
A covered health care provider must notify the enumerator of changes in any of the information that it furnished on its application for an NPI, and must do so within 30 days of the change. Health care providers who have been assigned NPIs, but are not covered entities, should do the same.
According to the enumerator, it is difficult to predict the amount of time it takes to obtain an NPI because several factors come into play. Such factors include the volume of applications being processed at a given time, whether the application was submitted electronically or on paper, and whether the application was complete and passed all edits. It is expected that a health care provider who submits a properly completed electronic application could have their NPI within 10 days.
No. A health care provider is not charged, and does not have to pay a fee in order to obtain an NPI.
Yes, there will be enough NPIs. The format of the NPI and the assignment strategy will enable the enumeration of over 200 million health care providers. Yes, the availability of NPIs will eventually run out. At the current rate of increase in the number of providers in the United States, this should enable HHS to enumerate health care providers for 200 years.
The use of NPIs on paper claims transactions is allowed. The health plan receiving the claim may make the determination on the use of NPIs on paper claims transactions. HIPAA regulations adopt standards for format and content of certain electronic health transactions; they do not address the content of paper claims transactions.
In some cases, an SSN may be the most appropriate identifier (e.g., in uses where there are tax implications). Over time, users of the NPI will likely find places where the NPI can take the place of
other identifiers (possibly including some places where the SSN is currently used). HIPAA only requires the use of NPI for HIPAA-covered electronic transactions, but the MHS and other health care organizations
may decide to use the NPI to improve or simplify other healthcare business processes.
To update information associated with your NPI, such as a tax ID and Provider name, or to apply for an NPI, contact the NPI Enumerator. The NPI Enumerator is responsible for assisting health care
providers in applying for their NPIs and updating information in the National Plan and Provider Enumeration System (NPPES). For more information, visit the
NPI submission is based on region. Please choose the appropriate region from the following links:
North - http://www.mytricare.com/internet/tric/tri/mtc_nprov.nsf/sectionmap/BllngInfrmtn_NtnlPrvdrIdntfrNP
South - http://www.mytricare.com/internet/tric/tri/mtc_sprov.nsf/sectionmap/BllngInfrmtn_NtnlPrvdrIdntfrNP
West - http://www.mytricare.com/internet/tric/tri/mtc_wprov.nsf/sectionmap/BllngInfrmtn_NtnlPrvdrIdntfrNP
MTFs are not providing lists of individual providers' NPIs; however, a list of MHS organizational provider NPIs is available on the Defense Medical Information Systems Identifier (DMIS ID) table which is published monthly and can be downloaded at http://www.tricare.mil/tma/gri/dmis/.
NPIs of individual providers and organizational providers are included as required on referrals, and HIPAA transactions such as electronic claims, etc.
In addition, the CMS/NPI Enumerator made an online search Registry available to the public. The NPIs of all providers and facilities that have obtained NPIs are available via this query only database known as the NPI Registry located at: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
UserIDs and passwords are not needed to use the NPI Registry and there is no charge to use it. The NPI Registry enables users to query using the NPI or the name of the provider. The NPI Registry will return the results of the query to the user, and the user will click on the record(s) he/she wants to see. The NPI Registry will then display the Freedom of Information Act (FOIA)-disclosable data for those records.
NPI data is also available in monthly downloadable files at no charge or need for UserIDs and passwords. Just like the search registry, the file will contain the FOIA-disclosable NPI data for health care providers who have been assigned NPIs. The files are available at http://nppes.viva-it.com/NPI_Files.html
Each month CMS makes a file available that replaces the previous month's file. This is a full replacement, not an update file. It reflects updates and changes that were applied to the NPPES records of enumerated health care providers between the date the previous file was created and the date the full replacement file is created.
* For TRICARE HIPAA Privacy and Security pages, please click here.
“On October 1, 2013, the Department of Defense established the Defense Health Agency (DHA) to manage the activities of the Military Health System. These activities include those previously managed by TRICARE Management Activity (TMA), which was disestablished on the same date. During the next several months, all TMA websites will change to reflect the new DHA. We appreciate your patience during this transition."
7700 Arlington Boulevard, Suite 5101, Falls Church, VA 22042-5101
The appearance of hyperlinks to external Web sites does not constitute
endorsement by the Defense Health Agency of these Web sites or the
information, products or services contained therein. For other than
authorized government activities. The Defense Health Agency does not
exercise any editorial control over the information you may find at other
locations. Such links are provided consistent with the stated purpose of
this DoD Web site. Accessibility/Section 508