TRICARE Operations Manual 6010.59-M, April 1, 2015€¦ · TRICARE Operations Manual 6010.59-M, April 1, 2015 Provider Certification And Credentialing Chapter 4 Section 1 General

TRICARE Operations Manual 6010.59-M, April 1, 2015Administration

Chapter 1 Section 2

Contract Administration And Instructions

Revision: C-58, September 20, 2019

1.0 TRICARE MANUALS

These include the TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), and TRICARE Systems Manual (TSM). The TRICARE Manuals are the principal vehicles for general operating instructions to all health care delivery contractors and may be accessed at http://manuals.tricare.osd.mil/. The official archive copies of these documents are maintained at Defense Health Agency (DHA). The documents and all official changes to them will be maintained at DHA in an electronic medium using the PDF (Portable Document Format) format, and are available at the above web site. Distribution of paper copies will be on an exception basis. Regardless of publication medium, their printed and displayed appearance will be identical. The principal means of distribution will be via an electronic notification of publication and the contractor’s subsequent download of the manual or change from the above web site. All proposed changes to these documents will be distributed for review and comment in an electronic medium, using PDF as the document format, and comments must be returned to DHA in an acceptable electronic format. Contractors shall furnish the DHA Procuring Contracting Officer (PCO) with designated point(s) of contact and e-mail address(es) for review and comment on proposed manual changes, and notification of the final publication of manual changes.

2.0 IMPLEMENTATION OF MANUAL CHANGES

The contractor shall implement changes in requirements as specified by the PCO. If a contractor is unable to comply by the effective date, the PCO shall be notified in writing. The notification shall include the reasons for the noncompliance and a plan for reaching compliance. The proposal shall include milestones, if appropriate, and a firm date for completion.

3.0 COMMUNICATIONS WITH DHA

The contractor shall:

3.1 Provide complete replies to DHA requests for Rough Order Of Magnitude (ROM) estimates, comments, and/or cost estimates on proposed changes to the manuals no later than 30 days from the date of the request. In addition, in the event of an urgent need imposed by law or a program requirement under which significant loss to the Government would result from delay, a period of less than 30 days will be imposed, whether it is a major or minor change.

3.2 Provide timely responses to all requests for information directed to them by DHA.

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TRICARE Operations Manual 6010.59-M, April 1, 2015Chapter 1, Section 2

Contract Administration And Instructions

3.3 Use assigned Contracting Officer’s Representative (COR) at DHA as the initial POC for program interpretation or other forms of operational guidance.

4.0 DHA-REQUIRED MEETINGS

Generally, a 14 calendar day notice will be provided for all meetings hosted by DHA. The contractor shall provide representation at two regional contractors/TRICARE Regional Offices (TROs), meetings/conferences and two regional provider conferences. The contractor shall provide up to four contractor representatives at up to four additional meetings at the direction of the PCO per contract year.

5.0 DHA DELEGATION OF RESPONSIBILITY

Responsibility has been delegated to DHA Communications, to perform the following:

• Grant exceptions to the claims filing deadline.

• Grant “good faith payments.”

• Waive the signature requirements on TRICARE claims.

• Adjudicate and process unique claims requiring special handling, and claims for emergency care provided by a Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) facility or a facility under the Bureau of Indian Affairs (BIA).

• Authorize benefits for which the authority has not otherwise been delegated to other DHA officials or contractors.

• Authorize an “override” of information contained on Defense Enrollment Eligibility Reporting System (DEERS), pending a system update, based on appropriate documentation regarding eligibility under the law, regulation and policy.

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Chapter 4

Provider Certification And Credentialing


Section/Addendum Subject/Addendum Title

1 General

A FiguresFigure 4.A-1 Department of Veterans Affairs (DVA)/Veterans Health

Administration (VHA) Request For An Exception Figure 4.A-2 Provider Certification, Department Of Veterans Affairs (DVA)/

Veterans Health Administration (VHA) Part-Time Physician Employee

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Chapter 4 Section 1

General


1.0 PROVIDER CERTIFICATION CRITERIA

Refer to the 32 CFR 199.6 and the TRICARE Policy Manual (TPM), Chapters 1 and 11. All providers shall be TRICARE certified in accordance with the TPM. Network providers shall be credentialed in accordance with nationally accepted credentialing standards adopted by a national accrediting body. “Authorized Provider” is any provider who meets the requirements set forth in 32 CFR 199.6 and in the TPM, Chapters 1 and 11. If a beneficiary submits a claim for services provided by a non-participating individual professional provider who is known to be legally practicing and is eligible for TRICARE-authorization, the provider shall be certified and payment shall be made to the beneficiary. In no case shall a provider who refuses to provide proper Social Security Number (SSN)/Employer Identification Number (EIN) identification be paid directly.

2.0 PROVIDER APPROVALS

2.1 The contractor shall accurately authorize all providers of care using a single, centralized authorization process. The contractors shall ensure that all providers of care for whom a billing is made or claim submitted under TRICARE meet all conditions, limitations or exclusions specified or enumerated in 32 CFR 199, the TPM, and the TRICARE Operations Manual (TOM). The contractor shall maintain separate institutional and non-institutional provider files. Additions, deletions, and changes to these files, shall be reported to Defense Health Agency (DHA) as specified in the TRICARE Systems Manual (TSM).

2.2 Upon receipt of a claim or request for provider certification information involving a provider practicing in the contractor’s jurisdiction but not on the TRICARE Encounter Provider (TEPRV) file, the contractor shall contact the provider, the state licensing board, the appropriate national or professional association, or other sources to determine that the provider meets certification requirements. The contractor may establish eligibility for certification by any of these means. Documentation may be a copy of the page from the most recent state licensor listings, screen print from on-line access to state board licensing files, or other methods that show proof that the provider meets the certification requirements.

2.3 If certification cannot be accomplished, all pending and subsequent claims for services from that provider shall be denied. If the provider is later determined to be authorized based on receipt of the required documentation, claims may be reopened and processed if requested by the provider or beneficiary.

2.4 Services delivered by any provider must be within the scope of the license or other legal authorization. The contractor shall maintain a current computer listing of all certified providers,

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General

including at a minimum the data required by the TSM, Chapter 2, Section 2.10. If the provider was initially certified by the contractor, the certification shall be supported by a documented and readily accessible hardcopy or electronic file documenting each provider’s qualifications. A hardcopy or electronic file documenting the provider’s existence on the TEPRV shall be maintained for all other providers.

2.5 Any provider who has not submitted a claim or whose services have not been submitted on a claim within the past two years may be moved from the active file to the inactive file. However, even if the provider remains on the active file, if a claim is received from a provider who has not submitted a claim or whose services have not been submitted on a claim within the past two years, the provider must be fully recertified. Providers who have been terminated or suspended shall not be deleted. Suspended or terminated, or excluded providers shall remain on the file as flagged providers indefinitely or until the flag is dropped because the suspended provider has been reinstated. The contractor shall review all providers that have been flagged to ensure the flags are working at a minimum of once each year. To do this, the contractor shall maintain records of all suspended and terminated providers and audit the provider file flags and, as necessary, test to ensure they are operational.

2.6 The contractor shall accept the Medicare certification of individual professional providers who have a like class of individual professional providers under TRICARE without further authorization unless there is information indicating Medicare, TRICARE or other federal health care program integrity violations by the physician or other health care practitioner. Certification of individual professional providers without a like class (e.g., chiropractors) under TRICARE shall be denied.

3.0 PART-TIME PHYSICIAN EMPLOYEES OF THE DEPARTMENT OF VETERANS AFFAIRS (DVA)/VETERANS HEALTH ADMINISTRATION (VHA)

3.1 The Director, DHA, has authorized an exception, on a case-by-case basis, to the TRICARE policy which excludes any civilian employee of the DVA/VHA from certification as a TRICARE provider. This exception is for part-time physician (MD) employees only who file claims for service furnished in their private, non-DVA/VHA employment practice.

3.2 In order to be considered as a certified provider, the DVA/VHA facility administrator must send a request for an exception to the appropriate contractor (Addendum A, Figure 4.A-1) along with a Part-Time Physician Employee Provider Certification Form (Addendum A, Figure 4.A-2) signed by the physician. Upon receipt of these two documents, the contractor shall approve the physician as a TRICARE provider for services furnished by this provider in his private practice. The effective date is the date the contractor approves the waiver. The contractor shall notify the physician and requesting DVA/VHA facility by letter of the approval and the effective date. No retroactive approval dates shall be allowed. All claims from these providers shall be annotated on the signature block of the claim form, “additional certification on file”.

4.0 VENDORS OF MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), OR DURABLE EQUIPMENT (DE)

Medical supplies, DME, or DE otherwise allowable as a Basic Program or authorized Extended Care Health Option (ECHO) benefit purchased from an approved vendor (TPM, Chapter 11, Section 9.1), may be cost-shared (currently or retroactively) when payment is made directly to the beneficiary.

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Chapter 4 Addendum A

Figures


FIGURE 4.A-1 DEPARTMENT OF VETERANS AFFAIRS (DVA)/VETERANS HEALTH ADMINISTRATION (VHA) REQUEST FOR AN EXCEPTION

Manager, TRICARE Provider Certification(Appropriate TRICARE Claims Processor’s Address)

Dear Manager:

The Director, Defense Health Agency (DHA), has authorized exceptions, on a case-by-case basis, to the TRICARE policy which excludes any civilian employee of VHA from authorization as a TRICARE provider. This letter identifies the individual VHA employee(s) for whom an exception is requested based on my determination that an exception is required to avoid a detrimental effect on VHA’s ability to obtain the necessary part-time physician employee(s) essential to the mission of this facility. By granting this exception, the individual part-time physician employee will be an authorized TRICARE physician and may file claims for services furnished in the physician’s private, non-VHA employment practice.

A request for an exception to TRICARE policy is made for the following part-time VHA physician employee(s):

(List each physician’s name, specialty, address, and the physician’s IRS/SSAN or other identification number used to report income to the Internal Revenue Service.)

In support of this request for exception to policy, the individual physician(s) named have signed the attached certification, as part of the physician’s application for authorization as a TRICARE provider, that:

1. The physician understands the prohibitions against dual compensation under Title 5, United States Code (USC), Section 5536, as well as the standards of conduct provisions applicable to Government employees who require the avoidance of actual conflict of interest situations as well as situations in which the appearance of conflict of interest may exist; and

2. The physician has not violated the dual compensation or standard of conduct provisions in providing any service(s) for which a TRICARE claim is submitted for payment. This certification shall be retained on file by the TRICARE claims processor and be applicable to all claims for services of the physician during the period of authorization as a TRICARE provider under this requested exception. In addition, when filing individual TRICARE claims, the physician shall annotate the signature block (Block 33) of the TRICARE claims form with the words “additional certification on file” in order to identify the claim as an exception to the general TRICARE policy and confirming that the certification on file applies specifically to that claim.

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Figures

By requesting an exception to TRICARE policy, I agree that the administrators of this VHA facility shall assume full responsibility for informing the above-named part-time physician employee(s) of the dual compensation and standard of conduct provisions and for monitoring the conduct of the employee(s) and enforcing the provisions regarding any TRICARE claims for service furnished by the employee(s) while acting under this request for exception to policy. In addition, for the above-named part-time physician employee(s), I agree to provide the appropriate TRICARE claims processor written notice of termination of VHA employment or any other basis for withdrawal of this request for exception to TRICARE policy.

Thank you for your prompt attention to this request. Should there be a need to contact VHA regarding this request or regarding any matter arising out of the implementation of this request, my point of contact on this matter is ______________ who may be contacted at the above address or by telephone number __________________.

Sincerely,

VHA Facility Administrator

Enclosure:Physician’s Certification

FIGURE 4.A-1 DEPARTMENT OF VETERANS AFFAIRS (DVA)/VETERANS HEALTH ADMINISTRATION (VHA) REQUEST FOR AN EXCEPTION (CONTINUED)

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Figures

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FIGURE 4.A-2 PROVIDER CERTIFICATION, DEPARTMENT OF VETERANS AFFAIRS (DVA)/VETERANS HEALTH ADMINISTRATION (VHA) PART-TIME PHYSICIAN EMPLOYEE

I certify that I am a part-time physician employee of the VHA at (Name of VHA Facility) for whom a letter by the VHA facility administrator has requested an exception to the TRICARE policy excluding any civilian employee of the VHA from authorization as a TRICARE provider. Based on the exception granted to me, I will be authorized as a TRICARE provider for services furnished in my private, non-VHA employment physician practice. All TRICARE claims for services furnished by me under this exception shall be subject to the standard TRICARE provider certification except that I am a part-time civilian employee of the United States (U.S.) Government.

I certify that for all such TRICARE claims that:

1. I understand the prohibitions against dual compensation under Title 5, United States Code (USC), Section 5536, as well as the standards of conduct provisions applicable to Government employees which require the avoidance of actual conflict of interest situations as well as situations in which the appearance of conflict of interest may exist; and

2. I have not violated the dual compensation or standard of conduct provisions in providing a service(s) for which a TRICARE claim is submitted for services furnished by me.

When any TRICARE claim is filed, I agree to annotate the signature block on the claim form with the words, “additional certification file,” in order to identify the claim as an exception to the general TRICARE policy and confirming that this certification maintained on file by the TRICARE claims processor as part of my provider file applies specifically to each claim filed.

______________________________________

(Typed Physician’s Name, Address, and Identification Number)

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Network Development

submit claims on behalf of all Military Health System (MHS) and Medicare beneficiaries. All network provider agreements shall include the following provision:

3.3.1 The submission of a claim by a physician or supplier or their representative certifies that the services shown on the claim are medically indicated and necessary for the health of the patient and were personally furnished by the physician/supplier or furnished incident to his/her professional service by his/her employee under his/her immediate personal supervision, except as otherwise permitted by Medicare or TRICARE regulations. For services to be considered as “incident” to a physician’s professional service:

• They must be rendered under the physician’s immediate personal supervision by his/her employee;

• They must be an integral, although incidental part of a covered physician’s service;

• They must be of kinds commonly furnished in physician’s offices; and

• The services of non-physicians must be included on the physician’s bills.

3.3.2 The non-institutional network provider/supplier further certifies that he/she (or any employee) who rendered services is not an active duty member of the Uniformed Services or a civilian employee of the U.S. Government (refer to 5 USC 5536). An exception exists for part-time Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) employees fulfilling the requirements of Chapter 4, Section 1, paragraph 3.0. Anyone who misrepresents or falsifies essential information to receive payment from Federal funds may upon conviction be subject to fine and imprisonment under applicable Federal law.

3.4 Balance Billing

3.4.1 Providers in the contractor’s network may only bill MHS beneficiaries for applicable deductibles, copayments, and/or cost-sharing amounts. They may not bill for charges which exceed contractually allowed payment rates. Network providers may only bill MTFs/eMSMs/contractors for services provided to Service members at the contractually agreed amount, or less, and may not bill for charges which exceed the contractually agreed allowed payment amount. The contractor shall include this provision in provider contracts.

3.4.2 Network providers shall never bill an MHS eligible beneficiary for more than the contractually agreed amount, regardless of the beneficiary’s TRICARE health plan coverage. The contractor shall ensure that the amount charged MHS beneficiaries without civilian network PCMs is the same as the amount charged TRICARE Prime enrollees with civilian network PCMs. If the contractor is using different reimbursement mechanisms, the contractually agreed amount shall be equal to or less than the CHAMPUS allowable amount minus the discount the contractor proposed receiving as a result of the approved, alternative reimbursement method agreed to with the provider.

3.5 Billing For Non-Covered Services (Hold Harmless)

3.5.1 A network provider may not require payment from the beneficiary for any excluded or excludable services that the beneficiary received from the network provider (i.e., the beneficiary will be held harmless) except as follows:

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Network Development

• If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary, the provider may bill the beneficiary for services provided.

• If the beneficiary was informed that the services were excluded or excludable and he/she agreed in advance to pay for the services, the provider may bill the beneficiary. An agreement to pay must be evidenced by written records (“written records” include for example: 1) provider notes written prior to receipt of the services demonstrating that the beneficiary was informed that the services were excluded or excludable and the beneficiary agreed to pay for them; 2) a statement or letter written by the beneficiary prior to receipt of the services, acknowledging that the services were excluded or excludable and agreeing to pay for them; 3) statements written by both the beneficiary and provider following receipt of the services that the beneficiary, prior to receipt of the services, agreed to pay for them, knowing that the services were excluded or excludable). General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew specific services were excluded or excludable.

3.5.2 Certified marriage and family therapists (both network and non-network), in their participation agreements with TRICARE, agree to hold eligible beneficiaries harmless for non-covered care.

3.5.3 The beneficiary shall be entitled to a full refund of any amount paid by the beneficiary for the excluded services, including any deductible and cost-share amounts, provided the beneficiary informed the network provider (or the network or non-network certified marriage and family therapist) that he or she was a TRICARE beneficiary, and did not agree in advance to pay for the services after having been informed that the services were excluded or excludable.The beneficiary shall be refunded any payments made by the beneficiary or by another party on behalf of the beneficiary (excluding an insurer or provider) for the excluded services. The beneficiary, or other party making payment on behalf of the beneficiary, must request a refund in writing from the contractor by the end of the sixth month following the month in which payment was made to the provider or by the end of the sixth month following the month in which the Peer Review Organization (PRO), or the Defense Health Agency (DHA) advised the beneficiary that he or she was not liable for the excludable services. The time limit may be extended where good cause is shown. Good cause is defined as:

• Administrative error, such as, misrepresentation or mistake, of an officer or employee of DHA or a PRO, if performing functions under TRICARE and acting within the scope of the officer’s or employee’s authority.

• Mental incompetence of the beneficiary or, in the case of a minor child, mental incompetence of his or her guardian, parent, or sponsor.

• Adjudication delays by Other Health Insurance (OHI) (when not attributable to the beneficiary), if such adjudication is required under 32 CFR 199.8.

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6


Jurisdiction

7.2 Partially Out-Of-Jurisdiction

When a contractor receives a claim for services or supplies both within and outside its jurisdiction before processing the services or supplies within its jurisdiction, and within 72 hours of identifying the out-of-jurisdiction items, the contractor shall:

• Draw lines through the in-jurisdiction items.• Ensure the original date of receipt is clearly indicated on the claim.• Send a copy of the claim and all supporting documents to the appropriate contractor(s).

8.0 NON-TRICARE CLAIMS

The contractor shall return claims submitted on other than approved TRICARE claim forms to the sender or transfer to other lines of business, if appropriate.

8.1 Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Claims

When a claim is identified as a CHAMPVA claim, the contractor shall return the claim to the sender with a letter advising them of the CHAMPVA program’s toll-free telephone number, 1-800-733-8387, and instructing them to send the claim and all future CHAMPVA claims to:

Chief, Business Office Purchased CareCHAMPVAP.O. Box 469064Denver, Colorado 80246-9064

8.2 Veterans’ Claims

If a claim is received for care of a veteran not eligible for TRICARE and there is evidence the care was ordered by a Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) physician, the claim, with a letter of explanation, shall be sent to the VHA institution from which the order came. The claimant must also be sent a copy of the letter of explanation. If there is no clear indication that VHA ordered the care, return the claim to the sender with an explanation that the veteran is not eligible under TRICARE and that the care ordered by VHA should be billed to VHA.

8.3 Claims For Parents, Parents-In-Law, Grandchildren, And Others

On occasion, a claim may be received for care of a parent or parent-in-law, a grandchild, or other ineligible relative of a TRICARE sponsor. Return the claim to the claimant with a brief explanation that such persons are not eligible for TRICARE benefits.

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TRICARE Operations Manual 6010.59-M, April 1, 2015Claims Processing Procedures

Chapter 8 Section 3

Claims Filing Deadline


1.0 TIME LIMITATIONS ON FILING TRICARE CLAIMS

1.1 All claims for benefits must be filed with the appropriate TRICARE contractor no later than one year after the date the services were provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility. Professional services billed by the facility must be submitted within one year from the date of service.

Example:

1.2 Any written request for benefits, whether or not on a claim form, shall be accepted for determining if the “claim” was filed on a timely basis. However, when other than an approved claim form is first submitted, the claimant shall be notified that only an approved TRICARE claim form is acceptable for processing a claim for benefits. The contractor shall inform the claimant in writing that in order to be considered for benefits, an approved TRICARE claim form and any additional information (if required) must be submitted and received by the contractor no later than one year from the date of service or date of discharge, or 90 calendar days from the date they were notified by the contractor, whichever is later. The claimant should submit claims on either the Centers for Medicare and Medicaid Services (CMS) 1500 Claim Form, the CMS 1450 UB-04, or the Defense Department (DD) Form 2642 as appropriate.

2.0 EXCEPTIONS TO FILING DEADLINE

2.1 Retroactive Eligibility/Preauthorization Determinations

2.1.1 In order for an exception to be granted based on a retroactive eligibility/preauthorization determination, the retroactive determination must have been obtained/issued after the timely filing period elapsed. If a retroactive determination is obtained/issued within one year from the date of service/discharge, the one year timely filing period is still binding.

2.1.2 Only the Uniformed Services or the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) may determine retroactive eligibility. Once a retroactive eligibility determination is made, an exception to the claims filing deadline shall be granted. A copy of the retroactive eligibility decision must be provided. In any case where a retroactive “preauthorization” determination is made to

FOR SERVICE OR DISCHARGE MUST BE RECEIVED BY THE CONTRACTOR

March 22, 2015 No later than March 22, 2016

December 31, 2015 No later than December 31, 2016

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Claims Filing Deadline

cover such services as the Extended Care Health Option (ECHO), adjunctive dental care, surgical procedures requiring preauthorization, etc., the timely filing requirements shall be waived back to the effective date of the retroactive authorization. Claims which are past the filing deadline must; however, be filed not more than 180 calendar days after the date of issue of the retroactive determination.

2.2 Administrative Error

2.2.1 If an administrative error is alleged, the contractor shall grant an exception to the claims filing deadline only if there is a basis for belief that the claimant had been prevented from timely filing due to misrepresentation, mistake or other accountable action of an officer or employee of Defense Health Agency (DHA) (including TRICARE Overseas) or a contractor, performing functions under TRICARE and acting within the scope of that individual’s authority.

2.2.2 The necessary evidence shall include a statement from the claimant, regarding the nature and effect of the error, how he or she learned of the error, when it was corrected, and if the claim was filed previously, when it was filed, as well as one of the following:

• A written report based on agency records (DHA or contractor) describing how the error caused failure to file within the usual time limit; or

• Copies of an agency letter or written notice reflecting the error.

Note: The statement of the claimant is not essential if the other evidence establishes that his or her failure to file within the usual time limit resulted from administrative error, and that he or she filed a claim within 90 calendar days after he or she was notified of the error. There must be a clear and direct relationship between the administrative error and the late filing of the claim. If the evidence is in the contractor’s own records, the claim file shall be annotated to that effect.

2.3 Inability To Communicate And Mental Incompetency

2.3.1 For purposes of granting an exception to the claims filing deadline, ‘mental incompetency’ includes the inability to communicate even if it is the result of a physical disability. A physician’s statement, which includes dates, diagnosis(es) and treatment, attesting to the beneficiary’s mental incompetency shall accompany each claim submitted. Review each statement for reasonable likelihood that mental incompetency prevented the person from timely filing.

2.3.2 If the failure to timely file was due to the beneficiary’s mental incompetency and a legal guardian had not been appointed during the period of time in question, the contractor shall grant an exception to the claims filing deadline based on the required physician’s statement. (See above.) If the charges were paid by someone else, i.e., legal guardian, spouse or parent, request evidence from the spouse or parent that the claim was paid and by whom. When the required evidence is received, make payment to the signer of the claim, with the check made out: “Pay to the order of (legal guardian, spouse’s or parent’s name) for the use and benefit of (beneficiary’s name).”

2.3.3 If a legal guardian was appointed prior to the timely filing deadline and the claims filing deadline was not met, an exception cannot be granted due to mental incompetency of the beneficiary.

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TRICARE Prime And TRICARE Select Referrals/Preauthorizations/Authorizations

6.1.1 Using the UIN, the contractor shall locate related referrals, authorizations, and claims. Contractor generated MTF/eMSM reports shall be modified to accommodate the UIN and NPI. The UIN shall also be used for all related customer service inquiries. UINs and NPIs will be attached to all MTF/

SERVICE

Service 1 - Provider Specialty of Service Provider

Service 1 - Provider Sub-Specialty Additional Sub-Specialist Info if Needed (Free Text Clarifying Info Entered with Reason for Request) e.g., Pediatric Nephrologist

Service 1 - By Name Provider Request if Applicable - First and Last Name

Optional Info Regarding Preferred Specialist Provider (Free Text)

Service 1 - Service Type Inpatient, Specialty Referral, Durable Medical Equipment (DME) Purchase/Rental, Other Health Service, et al DME Provider to do Certificates of Medical Necessity (CMN)

Service 1 - Service Quantity Evaluate or Evaluate and Treat

CHCS Generated Order Number (DMIS-YYMMDD-XXXXX)

UIN. The UIN is the DMIS (of the referring facility identified in the “Referring MTF/eMSM” field on this request) --Date in format indicated-- Consult Order Number from CHCS.

Special Instructions:

Note 1: *Above data elements are required unless otherwise noted as “Optional.”

Note 2: Use of the NPI is required in accordance with Health and Human Services (HHS) NPI Final Rule of May 23, 2007 or upon service direction and/or direction of the Contracting Officer (CO). Implementation requirements may be found at Chapter 19, Section 4.

Note 3: When issuing a preauthorization for a Service member while in terminal leave status to obtain medical care from the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA), as required by Chapter 17, Section 1, paragraph 4.5, the MTF/eMSM shall make special entries for data elements as follows:

Patient Primary Provisional Diagnosis Condition of a routine or urgent nature as specified by the patient at a future date.

Reason for Request Provide preauthorization for outpatient treatment by the DVA/VHA for routine or urgent conditions while the active duty patient is in a terminal leave status.

Service 1 - Provider Any DVA/VHA provider.


DVA/VHA provider only.

Note 4: When issuing an authorization for the DVA/VHA to provide a Compensation and Pension (C&P) examination for a Service member as required by Chapter 17, Section 2, paragraph 3.2.2, the MTF/eMSM shall make special entries for data elements as follows:

Patient Primary Provisional Diagnosis V68.01 - Disability Examination orZ02.71 - Disability Examination

Reason for Request DVA/VHA only: Integrated Disability Evaluation System (IDES) C&P Examinations for Fitness for Duty Determination

Service 1 - Provider Any DVA/VHA Provider


DVA/VHA Provider Only

Service 1 - Service Quantity Number of C&P Examinations Authorized

This blanket preauthorization is only for routine and urgent outpatient primary medical care provided by the DVA/VHA while the patient is in a terminal leave status and/or for C&P examinations through IDES. Terminal leave for this patient concludes at midnight on DD MM YY. The referral in Note 4 shall be considered a blanket authorization for any DVA/VHA to conduct the authorized number of C&P exams and ancillary services.

REQUIRED DATA ELEMENT* DESCRIPTION/PURPOSE/USE

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TRICARE Prime And TRICARE Select Referrals/Preauthorizations/Authorizations

eMSM referrals and will be portable across all regions of care. The UIN will be used to match claims to an MTF/eMSM generated referral. The contractor shall provide the MTF/eMSM a monthly adjudicated referral claim report which shall include the UIN against each claim. The contractor shall capture the NPIs from the referral transmission report and forward the NPI and corresponding UIN to the referred to provider on all referrals.

6.1.2 The contractor where care is rendered shall apply their best business practices when authorizing care for referrals to their network and shall retain responsibility for managing requests for additional services or inpatient concurrent stay reviews associated with the original referral as well as changes to the specialty provider identified to deliver the care. The contractor authorizing the care shall forward the referral/authorization information, including the range of codes authorized (i.e., Episode Of Care (EOC)) and the name, the NPI, and demographic information of the specialty provider to the contractor for the region to which the patient is enrolled. If the patient is enrolled overseas, the contractor shall provide the same service and information required above to the TOP contractor. If a CONUS Prime retiree/retiree family member receives authorization to obtain care overseas from a contractor, the contractor shall forward the authorization information to the TOP contractor to ensure appropriate adjudication of the claim. Claims submitted by the provider shall be processed by the contractor or the TOP contractor according to Chapter 8, Section 2.

6.1.3 The contractor shall screen the information provided and return incomplete requests within one business day to the MTF/eMSM by HIPAA-compliant 278 response. If the contractor’s system is temporarily not available, then the contractor shall send the information to the MTF’s/eMSM’s single POC via fax or other electronic means acceptable to the MTF/eMSM and the contractor. The return of a referral to the MTF/eMSM is considered processed to completion.

6.1.4 The contractor shall verify that the services are a TRICARE benefit through appropriate medical review and screening to ensure that the service requested is reimbursable through TRICARE. The contractor’s medical review shall be in accordance with the contractor’s best business practices. This process does not alter the TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), or TRICARE Systems Manual (TSM) provisions covering active duty personnel or TRICARE For Life (TFL) beneficiaries.

6.1.5 The contractor shall advise the patient, referring MTF/eMSM, and receiving provider of all approved referrals. The MTF/eMSM single Point of Contact (POC) shall be advised via HIPAA-compliant 278 response. (The MTF/eMSM single POC may be an individual or a single office with more than one telephone number.) The notice to the beneficiary shall contain the UIN and information necessary to support obtaining ordered services or an appointment with the referred to provider within the access standards. The notice shall also provide the beneficiary with instructions on how to change their provider, if desired. If the contractor is informed that the beneficiary changed the provider listed on the referral, the contractor shall make appropriate modifications to MTF/eMSM issued referral (to revise the provider the beneficiary was referred to by the MTF/eMSM). The revised referral shall contain the same level of data as the initial MTF/eMSM referral. The revised referral shall be issued to the current provider, with an updated HIPAA-compliant 278 response to the MTF/eMSM. If the contractor’s system is temporarily not available, then the contractor shall send the information to the MTF’s/eMSM’s single POC via fax or other electronic means acceptable to the MTF/eMSM and the contractor. For same day, 24-hour, and 72-hour referrals, no beneficiary notification shall be issued. The contractor shall notify the provider to whom the beneficiary is being referred of the approved services, to include clinical information furnished by the referring provider.

8

TRICARE Operations Manual 6010.59-M, April 1, 2015Claims Adjustments And Recoupments

Chapter 10 Section 4

Overpayments Recovery - Non-Financially Underwritten Funds


This section applies to funds for which the contractor is non-financially underwritten, with the exception of funds overpaid to the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) facilities (see paragraph 33.0). For recovery of overpayments involving funds for which the contractor is financially underwritten, see Section 3. For information on the processing of Overpayment Recovery-Non-Financially Underwritten Funds during contract transition, see Chapter 2, Section 10.

1.0 CAUSES OF OVERPAYMENTS

The occurrence of any of the following circumstances may result in an erroneous payment and a requirement for recoupment action. (This list is not intended to be all-inclusive).

• Erroneous calculation of the allowable charge.• Erroneous coding of a procedure.• Erroneous calculation of the cost-share or deductible.• Duplicate payment.• Incorrect payee.• Payment by Other Health Insurance (OHI).• Erroneous billing.• Patient not eligible.• Unauthorized provider.• Noncovered service or supply.• Service not actually received.• Services not medically necessary.

2.0 DETERMINATION OF LIABILITY FOR OVERPAYMENT

The general rule for determining liability for overpayments is that the person or provider who received the erroneous payment is responsible for the refund.

3.0 PROVIDER LIABLE

Overpayment refunds shall be sought from the provider who received the incorrect payment in the following situations:

3.1 The provider furnished erroneous information or failed to disclose facts that the provider knew or should have known were relevant to payment of the benefit. (Refer to Chapter 13.)

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3.2 The payment was based on an amount in excess of that allowable.

3.3 The provider received and retained duplicate TRICARE payments.

3.4 The provider turned a duplicate TRICARE payment over to the beneficiary.

3.5 The overpayment was due to a mathematical or clerical error; e.g., an error in calculation of overlapping or duplicate bills. Mathematical error does not include a failure to properly assess the deductible. Where a provider has been incorrectly paid a deductible, the provider shall be deemed to be without fault and any required recovery shall be sought from the beneficiary.

3.6 The overpayment was for noncovered services, supplies, or pharmaceutical agents.

3.7 The services, supplies, or pharmaceutical agents were not received by the beneficiary or there is no documentation to substantiate that the provider performed the services or provided the pharmaceutical agents claimed. (See Chapter 13, if fraud is suspected.)

3.8 The services, supplies, or pharmaceutical agents were furnished by an unauthorized provider.

3.9 The TRICARE payment was made to the participating provider and a primary health insurance or pharmacy plan also made a payment to the provider or beneficiary for the same services or supplies, and the combined payments exceed the lower of the amount remaining after the double coverage plan has paid its benefits or the amount TRICARE would have paid as primary payor. See TRICARE Reimbursement Manual (TRM), Chapter 4.

3.10 The payment was made to the wrong provider or a nonparticipating provider. In such cases, the contractor shall issue payment to the correct payee and concurrently initiate recoupment action against the erroneously paid provider. The contractor shall not postpone issuing payment to the correct provider pending completion of the recoupment.

3.11 The patient was not eligible at the time the services were provided.

3.12 The patient had OHI or pharmaceutical coverage primary to TRICARE.

4.0 BENEFICIARY LIABLE

Erroneous payment refunds shall be sought from the beneficiary in the following situations:

4.1 The overpayment was caused by incorrect application of the deductible or cost-share.

4.2 The patient was not an eligible beneficiary at the time services were provided and the payment was made to a participating provider for whom a good faith payment has been authorized under paragraph 6.0. When payment was made to a retail network pharmacy based on erroneous eligibility data provided by the Government from Defense Enrollment Eligibility Reporting System (DEERS), the pharmacy may retain the payment as a good faith payment. In addition, when the TRICARE Overseas Program (TOP) contractor creates an authorization for a TOP provider based upon erroneous DEERS data and improperly pays a TOP provider, the TOP provider may retain the payment as a good faith payment.

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4.3 The beneficiary who received TRICARE payment had OHI or pharmacy coverage primary to TRICARE.

4.4 The TRICARE payment was made to the beneficiary instead of the participating provider. The contractor shall immediately issue payment to the participating provider and concurrently take recoupment action against the beneficiary.

4.5 Any instance where the erroneous payment was made directly to the beneficiary.

5.0 OVERPAID PARTY IS DECEASED

If the contractor determines that liability for an overpayment rests with a beneficiary or provider who is deceased, the contractor shall seek recoupment of the overpayment from the estate of the deceased person. The procedures described in this Section shall be followed.

6.0 GOOD FAITH PAYMENT

6.1 Participating providers who exercise reasonable care and precaution in identifying persons claiming to be eligible TRICARE beneficiaries and furnish otherwise-covered services and supplies to such persons in good faith, may be granted a good faith payment, although the person receiving the services and supplies is subsequently determined to be ineligible for benefits. In order to meet the requirements for a good faith payment, the participating provider must have:

• Exercised reasonable care and precaution in identifying the patient as TRICARE eligible.

• Made reasonable efforts to collect payment for the services provided from the person who erroneously claimed to be a TRICARE beneficiary.

6.2 In order to qualify for a good faith payment, the provider must submit documentation to substantiate that he/she has met BOTH requirements. The usual evidence that a provider has exercised reasonable care and precaution in identifying the patient as TRICARE-eligible is a copy of the patient’s ID card which indicates that he/she was eligible for civilian medical care at the time services were provided. Generally, the provider must have obtained the copy of the ID card when the services were provided. If the provider did not obtain a copy of the ID card, he/she shall submit an explanation of why a copy was not obtained and the reason(s) for his/her determination that the patient was eligible for TRICARE benefits.

6.3 The documentation required to establish that a provider has made reasonable efforts to collect will vary, depending upon the facts of each case. Such documentation may include, but is not limited to, invoices or demand letters sent to the patient and memoranda of telephone calls to the patient demanding payment. If the TRICARE beneficiary has moved and left no forwarding address, the provider shall supply copies of returned letters or memoranda of unsuccessful attempts to reach the patient by telephone.

6.4 The contractor is not authorized to determine whether a provider exercised “reasonable care” which may qualify the provider for a good faith payment; nor are they authorized to seek, invite, or encourage good faith payment requests from providers. However, should a provider initiate an inquiry regarding denial of a claim due to the patient’s ineligibility, or a recoupment action in which the

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patient’s eligibility is the issue, the contractor shall advise the provider of the procedures for requesting a good faith payment.

6.5 If the contractor has NOT paid the participating provider (i.e., the claim is denied), the contractor shall advise the provider and the patient by Explanation Of Benefits (EOB) that the claim has been denied due to the patient’s ineligibility so that the provider may attempt collection from the patient in a timely manner. Occasionally, the patient may need only to update his DEERS record, so that the denied claim may be processed and paid. Upon notification of the patient’s ineligibility, the provider shall attempt collection from the patient. If the provider alleges that he/she exercised reasonable care and caution in identifying the patient as TRICARE-eligible and requests a good faith payment, the contractor shall be responsible for advising the provider in writing within 30 days of the date of the request that documentation of his/her efforts to collect from that patient is required. The file shall be referred to Defense Health Agency (DHA) Communications, for consideration of the request for a good faith payment and shall include:

• Pertinent claim form(s) and EOB(s). (If the pharmacy EOB does not contain certain data elements, then a separate report is required (see Addendum A, Figure 10.A-32). If offsets have been taken, additional data elements are required as listed in Addendum A, Figure 10.A-33.)

• Evidence of the patient’s ineligibility.

• The provider’s request for a good faith payment.

• Documentation of all contractor contacts with the provider and the patient.

• Documentation of efforts made by the provider to identify the patient as TRICARE-eligible prior to rendering service.

• Documentation of efforts to collect from the ineligible patient.

6.6 The contractor shall notify the provider that his request has been referred to DHA Communications. If DHA Communications grants the request for a good faith payment, the contractor shall then reprocess and pay the previously denied assigned claim and initiate recoupment action against the patient. The contractor shall cite Special Processing Code (SPC) G2 - Good Faith Payment (TRICARE Systems Manual (TSM), Chapter 2, Section 2.8, Record Locator 1-185 or 2-305) when submitting the TRICARE Encounter Data (TED) record.

6.7 If an assigned claim was paid before the contractor discovered the patient’s ineligibility, the contractor shall initiate recoupment action against the participating provider, and concurrently, advise the patient of his/her ineligibility for TRICARE benefits and his/her liability for payment to the provider. If the provider alleges that he/she exercised reasonable care and precaution in identifying the patient as TRICARE-eligible, and requests a good faith payment, the file shall be referred to DHA Communications, for consideration of the request. The provider is required to supply all of the documentation outlined in paragraph 6.2. If the provider’s good faith payment request does not include documentation to substantiate the provider’s efforts to collect from the patient, the contractor shall notify the provider in writing within 30 days of the date of the provider’s request of the requirement to provide the information. Upon receipt of the requested information, the contractor shall notify the provider that his/her request has been referred to DHA Communications. The contractor

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shall suspend recoupment action until a response to the good faith payment request has been received. If no response is received within 60 days, the contractor shall contact the DHA Office of General Counsel (OGC), to determine whether continued suspension of recoupment action is appropriate. If DHA Communications notifies the contractor that a good faith payment has been granted, the contractor shall terminate collection action against the provider, refund any monies collected from the provider, and initiate recoupment action against the ineligible patient. The contractor is NOT required to update the existing TED record with SPC = G2.

7.0 OVERPAYMENTS RESULTING FROM ALLEGED MISINFORMATION

An allegation by a patient or provider that information obtained from a Beneficiary Counseling and Assistance Coordinator (BCAC), contractor or other party resulted in the overpayment does not alter the liability for the overpayment nor is it grounds for termination of recoupment activity.

8.0 DENIAL OF BENEFITS PREVIOUSLY PROVIDED

In those instances where DHA clarification, interpretation, or a change in the TRICARE Regulation results in denial of services or supplies previously covered, no action need be taken to recover payments expended for these benefits prior to the date of such clarification or change, unless specifically directed by DHA.

9.0 DOUBLE COVERAGE SITUATIONS - PRIMARY HEALTH INSURANCE PLAN OR PHARMACY PLAN LIABLE

A “Primary Plan,” under TRICARE Law and Regulation is any Other Health Insurance (OHI) or pharmacy coverage the patient has, except Medicaid (Title XIX) or a supplement plan which is specifically designed to pay only TRICARE deductibles, coinsurance and other cost-shares (see the TRM, Chapter 4). Prior to payment of any claim for services or supplies rendered to any TRICARE beneficiary, regardless of eligibility status, it must be determined whether double coverage exists. If the reason for the overpayment is that another coverage plan primary to TRICARE was not considered in whole or in part in the coordination of benefits, then the following actions are required to recover the overpayment:

9.1 If the primary plan has not made payment to the beneficiary or provider, the contractor shall attempt to recover the overpayment from the primary plan following the contractor’s coordination of benefits procedures.

9.2 If the overpayment cannot be recovered from the primary plan, or if the primary plan has made payment, the overpayment will be recovered from the party that received the erroneous payment from TRICARE.

10.0 THIRD PARTY RECOVERIES

When potential recovery from or actual payment by a liable third party is discovered, the contractor shall refer the matter to the designated Uniformed Service Claims Office (USCO) as set forth in Section 5.

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11.0 PROCEDURES FOR RECOUPMENT OF OVERPAYMENTS

For the purpose of determining the amount of the overpayment in a particular case, the contractor shall include all claims overpaid for the same reason/case/Episode Of Care (EOC). All research required to establish the existence of a debt shall be accomplished and the initial demand letter shall be issued within 30 days from the date that a potential recoupment action is identified or notification is received that an erroneous payment has been made. (See sample letters Addendum A, Figure 10.A-4 and Figure 10.A-5.) The contractor shall ensure that all demand letters are sent to the correct debtor at the most current address on file, i.e., enrollment file, provider file, claims history, etc. When letters are returned by the post office the forwarding address shall be obtained and letters that are returned shall be reissued to the new address. For any recoupment case involving a large number of claims having low dollar overpayments, the contractor may request a waiver to the claim adjustment requirements on a case by case basis. Such requests are to be sent to the Chief, Claims Collection Section (CCS), DHA. The pharmacy contractor shall issue the initial demand letter to a network pharmacy within 30 calendar days of the end of the 60 calendar day period referenced in Section 1, paragraph 1.0 if collection pursuant to the network agreement is not successful.

12.0 ERRONEOUS PAYMENTS RESULTING FROM INCORRECT ASSESSMENT OF THE DEDUCTIBLE

12.1 If a contractor erroneously calculates the deductible and the error is discovered within the same fiscal year as the one in which the error was made, the error shall be corrected by properly assessing the deductible on the next claim or claims. No recoupment notice needs to be given if the deductible can be collected within the fiscal year in which the error was made.

12.2 If the deductible cannot be collected in the same fiscal year in which the error was made, the contractor shall initiate recoupment action in accordance with this chapter, regardless of the amount owed by the beneficiary, as a result of the erroneous calculation of the deductible.

13.0 OVERPAYMENTS TOTALING LESS THAN $110

The contractor shall take no recovery action when the overpayment to a single payee is less than $110.

14.0 OVERPAYMENTS TOTALING $110 OR MORE

The contractor shall take the following recovery actions when the overpayment resulted from reasons other than failure to properly assess the deductible and the overpayment totals $110 or more.

15.0 OTHER THAN PARTICIPATING PROVIDER

15.1 When an initial request for refund is sent, flag the record of the overpaid party for possible future offset action and suspend payment on a sufficient number of current claims to satisfy the amount of the debt.

15.2 Such claims shall be processed to the point of payment to expedite finalizing when the refund payment is received. If the debtor on the claim in question is other than a participating provider, a system flag shall be set for future offset action.

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15.3 If the refund request is unsuccessful after 30 days from the date of the request, offset against any claims suspended during the 30 days as required in this section. Offset shall be made against any claim or claims on which payment(s) would be made to the previously overpaid party, irrespective of who is the patient on the claim from which offset is taken. For example, where benefit payments have been made to either parent on behalf of a minor child; i.e., under 18 years of age, unless one parent has been named the custodial parent in a divorce decree, both parents are responsible for those debts and offset may be taken against claims of either parent. However, an offset shall not be taken against a sponsor for debts of the spouse or against a spouse for debts of the sponsor. If the overpayment is offset, prepare a EOB or substitute EOB for pharmacy claims (Addendum A, Figure 10.A-33) for each claim against which offset was made and send a notice to the overpaid party explaining the overpayment and the offset action (see sample letter, Addendum A, Figure 10.A-6).

16.0 PARTICIPATING PROVIDER

Within 30 days of identifying an overpayment, send a written request for refund to the overpaid party. At the same time, the beneficiary shall be notified in writing, that a recoupment action has been initiated against the rendering provider. This letter shall identify the beneficiary’s specific claims included in the recoupment action. The letter shall advise the beneficiary that no response is required and refer the beneficiary to the contractors customer service function if they have further questions. (See sample letter, Addendum A, Figure 10.A-7.) No offset flag is set at this point in the recoupment process (see paragraph 16.2.2). The pharmacy contractor is not required to issue the notice (Addendum A, Figure 10.A-7) to the beneficiary unless directed by DHA.

16.1 Account Balance $110 To Less Than $600

If the initial refund request is unsuccessful and there are insufficient funds available for a full offset send a follow-up letter 30 calendar days from the date of the initial letter. All follow-up requests shall include a copy of the original refund request and shall notify the overpaid party that unless arrangements for refund are made with the contractor within 30 days from the date of the follow-up request, an attempt shall be made to offset against future claims. (See instructions in paragraph 16.2.2 and the sample letters, Addendum A, Figure 10.A-8 and Figure 10.A-10). When one year has passed and the debt has not been collected, the contractor shall ascertain whether there are any other active recoupment cases under $600 against the same debtor. In those cases which are not transferred to DHA (i.e., cases below $600 in which the debtor has not requested relief from the indebtedness), the offset flag shall remain on the file of the overpaid party for the term of the TRICARE contract for potential future offset. The contractor shall submit a Non-Financially Underwritten Accounts Receivable Report. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. When there are one or more additional under $600 active recoupment cases against the same debtor and the total outstanding debt for all active recoupment cases is $600 or more, all cases shall be consolidated with a blank sheet between each debt and a covered sheet completed to reflect the combined total dollar amount of the consolidated cases. Before transfer of the combined debts to DHA OGC, a letter should be sent to the debtor advising that the debts have been consolidated, list the beneficiary name(s) dates of service and individual recoupment amounts. The letter should also state that the debts have been referred to DHA OGC, and therefore, future payments should be sent to the Contract Resource Management (CRM) office. A credit adjustment shall be submitted to include all amounts recouped up to the point of referral. The offset flag shall be removed when the cases are transferred. Documentation shall be included in the recoupment case file that the offset flag has been removed. The documentation may be a copy of the contractor’s internal form to direct removal of the offset flag. All cases shall be referred to

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DHA within five working days after the offset flag has been removed.

16.2 Account Balance $600 Or More

16.2.1 If the initial refund request is unsuccessful and there are insufficient funds available for a full offset (see paragraph 15.3, for suspended claims) the contractor shall send a follow-up letter 30 calendar days following the date of the initial letter. All follow-up requests shall include a copy of the original refund request and will notify the overpaid party that unless arrangements for refund are made with the contractor within 30 calendar days from the date of the follow-up request, an attempt shall be made to offset against future claims, and the matter shall be referred to DHA for further action (see sample letters, Addendum A, Figure 10.A-9 and Figure 10.A-11).

16.2.2 If the initial and follow-up refund requests and the offset attempt, if any, are unsuccessful for a period of 60 days from the date of the initial demand letter, set an offset flag on the file of the overpaid party (including a participating provider and other debtors) until the file is transferred to DHA in accordance with paragraph 19.0. When all or part of an overpayment is offset, prepare an EOB for each claim against which offset was made and send a notice to the overpaid party explaining the overpayment and the offset. (See the sample letter at Addendum A, Figure 10.A-6.) If the offset is against the provider, the provider shall be advised that reimbursement for the claim against which the offset was made may not be sought from the patient on whose behalf the services were provided. Additionally, a letter (see Addendum A, Figure 10.A-18) shall be sent to the TRICARE beneficiary against whose claim the offset was taken. The contractor shall remove the offset flag on an account when it is referred to DHA OGC, or when the contractor is advised to do so by that office. Documentation shall be included in the recoupment case file that the offset flag has been removed. The documentation may be a copy of the contractor’s internal form to direct removal of the offset flag. All cases shall be referred to TRICARE OGC within five working days after the offset flag has been removed. Cases $600 or more should not be consolidated.

16.2.3 If the debt has not been collected in full and there has been no positive response to the demand for payment such as a request for installment repayment agreement within 90 days from the date of the initial demand letter, and the balance remaining on the refund request is $600 or more, the contractor shall send a final demand letter to the debtor (see Addendum A, Figure 10.A-16). The final demand letter shall be sent regardless of whether the debtor is a beneficiary or a provider and shall be accompanied by a completed Promissory Note (see Addendum A, Figure 10.A-12).

16.2.4 If offsets have not resulted in collection of at least 50% of the amount of the debt, and there has been no positive response to the demands for payment within 150 days from the date of the initial demand letter and the balance remaining on the account is $600 or more, the case shall be referred to the DHA OGC. When a case is transferred to DHA, the contractor shall advise the debtor of the referral and the debtor shall be notified that future payments should be sent to DHA CRM (see Addendum A, Figure 10.A-24). The offset flag will be removed when the cases are transferred. A credit adjustment will be submitted to include all amounts recouped up to the point of referral. Cases $600 or more should not be consolidated.

16.2.5 If, on the 150th day, the contractor has been successful in collecting 50% or more of the total amount of the debt, the offset flag shall remain in place, and the contractor shall hold the case an additional 150 days. Those cases that are held 300 days because collection by offset during the first 150 days was largely successful, shall be transferred to DHA OGC, on the 301st day, if the balance remaining on the account is $600 or more. When the case is transferred to DHA OGC, the offset flag shall be

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removed. Documentation shall be included in the recoupment case file that the offset flag has been removed. The documentation may be a copy of the contractor’s internal form designed to direct removal of the offset flag. All cases shall be referred to DHA OGC within five working days after the offset flag has been removed. When a case is transferred to DHA OGC, the contractor shall advise the debtor of the referral and the debtor shall be notified that future payments should be sent to DHA CRM. A credit adjustment shall be submitted to include all amounts recouped up to the point of referral. Cases $600 or more should not be consolidated.

16.2.6 Any case, with an account balance of $600 or more in which a debtor unequivocally refuses to pay and no possibility of offset exists, shall be referred immediately to the DHA OGC. Any case in which a debtor seeks relief from the indebtedness due to financial hardship, or seeks other equitable relief shall be handled in accordance with paragraph 28.0.

17.0 BANKRUPTCY

All Notices of Bankruptcy, and letters from petitioners, attorneys for petitioners, and trustees of the bankrupt estate shall be forwarded to the DHA OGC, within three work days of receipt. Each Notice of Bankruptcy forwarded to DHA shall include: the debtor’s full name; the debtor’s full and complete Social Security Number (SSN)/Tax Identification Number (TIN); the name of the bankruptcy court wherein bankruptcy was filed; and the bankruptcy case number. (See sample coversheet, Addendum A, Figure 10.A-30). The contractor shall verify that the only bankruptcy cases forwarded to DHA are for debts which were paid with non-financially underwritten funds. Additionally, the contractor shall take the following actions:

17.1 If the petitioner in bankruptcy is indebted to TRICARE, all recoupment actions shall cease. If the debtor is on offset, the contractor shall terminate the offset immediately. If the recoupment case(s) against the bankrupt petitioner has not already been transferred to the DHA OGC, the complete case file(s), regardless of dollar value, shall be transferred with the Notice of Bankruptcy within three work days of receipt. Each case file shall contain all the documentation required by paragraph 19.0. However, the contractor shall not hold the Notice of Bankruptcy while they attempt to obtain all of the required documentation. A note will be placed in the case file to indicate when the missing documentation will be forwarded. If any amounts have been collected by offset or voluntary repayment by the debtor, the case file must contain the dates and amounts of each offset and/or payment. In addition, at the time the case file is forwarded to DHA OGC, a check for the total amount collected shall be forwarded to DHA CRM. The following information shall accompany the check:

• The debtor’s full name.• The sponsor’s SSN on the overpaid claim.• The Internal Control Number (ICN)/Refund Control Number (RCN) of the overpaid claim.• The dates and amounts of each offset and/or payment.

17.2 If there is no ongoing recoupment case against the petitioner in bankruptcy and the petitioner is a provider, the contractor shall ascertain whether any assigned claims are pending for the petitioner provider. If there are claims pending, payment on those claims shall be suspended, and the Notice of Bankruptcy will be forwarded within three work days of receipt to the DHA OGC, with advice as to the number of claims suspended and their value. The DHA OGC will advise the contractor when the pended claims may be processed and to whom payment should be issued. (See Addendum A, Figure 10.A-29 for a sample report of claims pended for provider bankruptcy.)

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17.3 The contractor shall identify individuals and providers who have, during the term of their DHA contract, filed a Petition in Bankruptcy, regardless of whether the petitioner is or has been indebted to TRICARE. The contractor shall initiate no recoupment action, either on their own initiative or upon the request of another DHA component, against a debtor who has filed a petition in bankruptcy, without prior approval by the DHA OGC.

18.0 PROCESSING CLAIMS WHEN THE PRIMARY INSURER IS BANKRUPT OR IN RECEIVERSHIP

18.1 When insurance companies which have been primary to TRICARE are filing petitions in bankruptcy or have been placed in receivership refuse to honor claims, this situation is different from that in which an employer or labor union stops paying premiums to an insurance company. In the latter case, insurance coverage ceases for the employee or member of the labor union when premiums have not been paid; the TRICARE claims should be processed in the same manner as any other claim on which the beneficiary has no OHI. Although the TRICARE beneficiary who was formerly covered by the bankrupt insurer may have a claim against the bankrupt estate, the beneficiary may have to wait years for distribution of assets, if any. Since TRICARE is, by federal statute and regulation, secondary to all health benefit and insurance plans (except Medicaid), extraordinary measures must be taken to allow TRICARE to pay claims as primary payer pending any distribution of assets from the bankrupt estate.

18.2 The contractor shall have documentation to prove that a claim was filed with the primary insurer or a Proof of Claim was filed with the bankruptcy court. This information may be requested using Addendum A, Figure 10.A-26. When a TRICARE beneficiary or participating provider provides evidence that the beneficiary’s primary insurer is in bankruptcy and is no longer honoring claims, the contractor may issue payment on a claim-by-claim basis, after the following steps have been taken:

18.3 Determine the time period that the TRICARE beneficiary was covered by the bankrupt insurer.

18.4 For each claim, ascertain whether the medical care claimed was received during the period of coverage by the bankrupt insurer.

18.5 If the medical care was received after the petition in bankruptcy was filed by the primary insurer, determine whether the TRICARE beneficiary has obtained alternative insurance which is primary to TRICARE. If alternative insurance has been obtained, process the claim under the double coverage provisions of the TRM.

18.6 If the medical care was received prior to the filing of a petition in bankruptcy by the primary insurer, determine whether the primary insurer has issued payment on the claimed services.

18.7 If the bankrupt primary insurer has not issued payment on the claimed services, and the medical care was received during the period of coverage by the bankrupt insurer, determine who the payee on the TRICARE check will be. Normally, if the claim is assigned, payment is issued to the provider of medical services. If the claim is not assigned, payment is issued to the TRICARE beneficiary, or, if the TRICARE beneficiary is a minor, or incompetent, to a parent, guardian, or conservator.

18.8 If the TRICARE payment is to be issued to a provider, complete the Power of Attorney (POA) and Agreement (Addendum A, Figure 10.A-25) and mail it to the provider. The date line on page two of the form is to be completed by the provider. Use the letter at Addendum A, Figure 10.A-26.

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18.9 If the TRICARE payment is to be issued to the TRICARE beneficiary, or his or her parent or guardian, complete the POA and Agreement (Addendum A, Figure 10.A-27) and mail it to the beneficiary. The date line on page two is to be completed by the beneficiary. Use the sample letter at Addendum A, Figure 10.A-28.

18.10 If the signed POA and Agreement has not been returned within 35 days from the date of the contractor’s letter (Addendum A, Figure 10.A-26 or Figure 10.A-28), the claim is to be denied.

18.11 When the signed POA and Agreement has been received, the contractor shall process the claim. The POA and Agreement must have an original signature; facsimile signatures (i.e., signature stamps) are not acceptable. An authorized agent of a participating provider may sign the POA and Agreement; however, no special designation of appointment is required. Only one signed POA and Agreement is required from each potential recipient of a TRICARE payment for medical care claimed during the period of coverage by the bankrupt insurer. A separate POA and Agreement is not needed for each claim. Each potential recipient of a TRICARE payment (i.e., beneficiary or participating provider) who signs a POA and Agreement may file more than one claim for services provided or received during the period the TRICARE beneficiary was covered by the bankrupt insurer.

18.12 The contractor shall maintain a record of all signed POAs and Agreement and all claims on which TRICARE payment has been issued as the primary payor. The contractor shall perform the required follow-up and complete the required report. Claim forms and EOBs shall be filed in the usual manner.

18.13 Biannually, the contractor shall follow-up with each beneficiary for whom claims have been paid by TRICARE as primary payor as a result of the filing of a petition in bankruptcy by the primary insurer. If any assets were distributed from the bankrupt estate to the TRICARE beneficiary for medical care, the amount received either by the TRICARE beneficiary or the participating provider will be treated as a payment made by the primary insurer, and benefits shall be coordinated in the usual manner. If the contractor determines that an overpayment has been made, recoupment action shall be initiated from the recipient of the TRICARE overpayment.

18.14 If, during a biannual follow-up, the contractor learns that the bankruptcy case has been closed, and no assets have been distributed, no further follow-up is required.

18.15 If a transition occurs before the contractor determined that the bankruptcy case has been closed, with or without distribution of assets, the POA and Agreement forms, with copies of claims and EOBs will be sent to DHA OGC for follow-up.

19.0 CASE REFERRALS

19.1 Cases referred to DHA OGC, at the request of DHA, or as required in paragraphs 16.2.4 and 17.0, shall include the documentation listed below. (If the pharmacy EOB does not contain certain data elements, then the contractor shall ensure missing data is included prior to referral to DHA. See Addendum A, Figure 10.A-32. If offsets have been taken, additional data elements are required as listed in Addendum A, Figure 10.A-33. All documentation shall be placed in the file in the order listed, with paragraph 19.2 on the bottom and paragraph 19.8 on top.

19.2 Legible copies of all claims involved in the recoupment. If copies of all claims cannot, with good reason, be provided, a copy of the automated claims history may be substituted. However, if a claims

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history is substituted for copies of the actual claims, a detailed explanation of each field on the claims history shall be provided.

19.3 Documentary evidence, i.e., workpapers, calculations reflecting how the amount of the overpayment was determined, establishing how the overpayment was identified and the basis for the erroneous TRICARE payment, including copies of checks and EOBs for both the erroneous payment and the correct payment, and documentation such as proof of Medicare eligibility, proof of OHI, (EOB from the OHI reflecting what the OHI paid for, the relevant care and the name of the OHI, policy number and the effective dates of coverage), signed Promissory Note, etc. When a check copy cannot be obtained the contractor shall document efforts to obtain it and include the documentation in the file. Normally cases shall not be forwarded without check copies and EOBs. When a contractor has determined that a check copy or EOB cannot be obtained, the contractor shall document efforts made to obtain it and include it in the file. The contractor shall also notify the DHA OGC by facsimile within five days of the date it determined that the documentation could not be obtained and provide the RCN, claim number, check date, provider name, patient name, sponsor SSN and date(s) of service. If DHA OGC cannot obtain the required check copies or EOBs, they will advise the contractor to forward the file without them.

19.4 Copies of checks and EOBs showing payment made to correct the erroneous payment, if any. When the recoupment is the result of a duplicate payment, copies of the check and EOB for the original payment and the copies of the check and the EOB for the duplicate payment shall be included in the file. When the recoupment is the result of a Medicare reversal or adjustment, copies of the corrected Medicare EOBs shall be included in the file.

19.5 Copies of all demand letters sent to the debtor, which must provide a full explanation of the circumstances surrounding the erroneous payment.

19.6 Copies of all correspondence received from the overpaid party or their representative relating to the recoupment case and the contractor response.

19.7 Copies of all EOBs reflecting collections by offset and copies of all payment acknowledgment letters issued to debtors. Also, the contractor shall maintain a tally sheet reflecting the original amount of the debt, each offset taken, and the balance remaining after each offset. Documentation shall be included in the recoupment case file that the offset flag has been removed. The documentation may be a copy of the contractor’s internal form to direct removal of the offset flag. All cases shall be referred to DHA within five working days after the offset flag has been removed.

19.8 A completed cover sheet containing data fields necessary for entry of the case into an automated case recoupment system (see Addendum A, Figure 10.A-13). Incomplete or incorrect cases that are transferred to DHA will be returned to the contractor for correction. The contractor shall account for returned cases on the Accounts Receivable Summary Report.

19.9 All refund checks shall be deposited in accordance with the instructions in Chapter 3, Section 3, paragraph 2.0. When a refund check is to be applied to a recoupment case which has been referred to DHA OGC, the amount shall be forwarded to DHA, CRM along with information identifying the payee and account being paid. The contractor shall notify the DHA OGC of the receipt of the payments the following work day after receipt. The contractor shall furnish identifying information to the DHA OGC as to how the funds were transferred, including the check number, date, amount, and the page number by completing the Collection Made by Offset/Refund Form (Addendum A, Figure 10.A-31). The contractor shall not delay notifying the DHA OGC that a payment has been received pending transfer of the funds.

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If the DHA OGC determines that the contractor has received a refund, the request for identifying information on the transfer of funds should be responded to the following work day.

19.10 For debts of $600 or more, the contractor shall establish, maintain, and retain for one year, or the term of their contract, whichever is longer, files containing all documentation pertaining to the recoupment cases which have been referred to DHA. A contractor may maintain such files for debts below $600, if it chooses to do so. Retention of the files will allow the contractor to fully respond to all questions generated by DHA OGC, as a result of the contractor’s referral of a recoupment case to that office. The contractor shall respond by the following work day to questions directed to them by DHA OGC. Additionally, the creation and retention of fully documented recoupment case files will facilitate responses to debtors’ inquiries and requests for administrative reviews. In the event of a contract transition, the outgoing contractor shall have complete documentation of recoupment cases ready for transfer to the incoming contractor. The contractor shall transmit recoupment case files to DHA OGC with a return receipt requested. Recoupment case files not transferred to the DHA OGC or to an incoming contractor shall be transferred to the Federal Records Center (FRC) in accordance with Chapter 9.

20.0 STATE OR LOCAL GOVERNMENT DEBTS

Offset is not to be applied with respect to debts owed by state or local governments. Such cases, valued at $600 or more, shall be referred to DHA OGC for collection. All other procedures apply as usual.

21.0 OFFSET REQUESTS FROM DHA COMPONENTS

When requested to do so by a DHA component (i.e., Program Integrity Office (PI), OGC), the contractor shall initiate recoupment action and/or set an offset flag on an overpaid party to collect erroneous payments. The contractor shall comply with the instructions issued by DHA with the request. The instructions will require one or more of the actions specified in paragraph 11.0. Normally, the requests will be made following resolution of an allegation of fraud or following a provider audit or as the result of an issuance of a Final Decision in the appeal process. At the direction of the DHA PI, the contractor shall provide a nonparticipating provider an opportunity to refund an erroneous payment in those instances where the nonparticipating provider has submitted a claim for services which were not provided or for incorrect payments, prior to initiating recoupment action against the beneficiary. This procedure shall only be allowed after the DHA PI, has determined that the case will be resolved through administrative action. (Refer to Chapter 13.)

22.0 OFFSET REQUESTS FROM OTHER AGENCIES

Any requests for offset from other agencies or orders for garnishment issued by the court shall be forwarded to DHA OGC. The contractor shall offset TRICARE claims to collect debts owed other federal agencies only when instructed to do so by DHA OGC. This paragraph does not apply to the federal tax levies.

23.0 INFORMATION TO BE INCLUDED IN REFUND REQUESTS

23.1 Refund requests shall include a preaddressed return envelope and the following claim and payment information:

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• Name and Address of the Beneficiary and Provider.• Last four digits of Debtor’s SSN.• ICN or RCN.• Date(s) and Type(s) of Service.• Principal Amount of Debt.• Date(s) of Check(s).• Amount(s) of Check(s).• Name of Payee.

23.2 A clear explanation of why the payment was not correct.

23.3 The amount of the overpayment and how it was calculated, and the amount of the correct payment, if any.

23.4 A notice that the overpaid party is required to refund the overpayment, or make acceptable arrangements to make the refund, within 30 days of the date of the request.

23.5 A notice that:

• Interest will begin to accrue from the date of the letter at the then current rate set by the United States (U.S.) Department of the Treasury.

• Accrued interest will be waived if payment is received within 30 days.

• Administrative costs will also be assessed for expenses in collecting the debt.

• A penalty charge of 6% per year will be assessed on any portion of the debt that is delinquent for more than 90 days and will accrue from the date that the debt became delinquent.

Note: The contractor shall obtain the current interest rate as published in the Federal Register. Interest is to be applied under criteria set forth in paragraph 32.0

23.6 A notice of the possibility of offset if the overpayment is not refunded.

23.7 Instructions that the refund shall be by check or money order made payable to the contractor.

23.8 A notice where appropriate (see sample letters, Addendum A, Figure 10.A-4 through Figure 10.A-11 and Figure 10.A-16), that unless a refund is made the case shall be referred to DHA OGC for further recovery action which can include referral to a credit reporting agency and the assessment of added administrative costs, penalties and interest.

23.9 A request where appropriate (see sample letters, Addendum A, Figure 10.A-8 through Figure 10.A-11), that the debtor provide his or her SSN/TIN.

23.10 An explanation as to rights for an administrative review and to appeal rights (see paragraph 26.0).

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24.0 CONTRACTOR RESPONSES TO DEBTORS

The contractor shall respond to any communication from the debtor within 30 days from its receipt.

25.0 INSTALLMENT REFUNDS

25.1 Recoupment claims shall be collected in one lump sum whenever possible. However, debtors may request repayment of a debt in monthly installments. Before installment repayment agreements are made, the contractor shall assure that the debt is amortized to completely refund the overpayment within 24 months. Debtors will be encouraged to repay the debt in monthly installments of no less than $50; however, if the debt can be repaid within 24 months at the interest rate properly reflected in the initial demand letter, the contractor may accept lower monthly payments. If it is alleged by the beneficiary that monthly installments cannot be made to complete the refund within 24 months, the debtor will be asked to complete a financial affidavit in accordance with paragraph 28.0, and the completed affidavit, along with the case file and the debtor’s request and the contractor demand letter(s) shall be transferred to DHA.

25.2 To determine the monthly installment amount, and assure that repayment can be made within the 24 months allowed, the contractor shall amortize the debt over a 24 month period (or less, if requested by the debtor), including interest on the unpaid balance at the appropriate interest rate. The use of commercial programs to perform this function is also acceptable.

25.3 Once the contractor has computed the amount required each month to repay the debt in 24 regular monthly installments, if the principal amount of the debt exceeds $600, the Promissory Note (see Addendum A, Figure 10.A-12) shall be completed and sent to the debtor for his/her signature (see Addendum A, Figure 10.A-22). If the debt is $600 or below, only a letter (see Addendum A, Figure 10.A-19) need be sent to establish the repayment agreement.

25.4 The following information is provided to assist the contractor in completing the Promissory Note:

25.5 “The principal sum of _________ dollars” is the amount of the overpayment that has not been refunded, either voluntarily by the debtor or by contractor offset.

25.6 Interest accrues from the date of the initial demand letter which advised the debtor of his rights pursuant to the Debt Collection Act of 1982 (Addendum A, Figure 10.A-4 or Figure 10.A-5). Interest shall be assessed at the rate that was in effect when the initial demand letter was mailed and that was properly reflected in that letter. DO NOT assess interest until the debtor has been properly advised of his rights. Note that the initial demand letter may be sent January 1, 2012, and the debtor may request an installment agreement five months later (June 1, 2012) or at any time before the case is referred to DHA in accordance with paragraph 19.0. Interest in all cases accrues from the date of the initial demand letter. (See Addendum A, Figure 10.A-20 for an example of interest calculations on a $1000 overpayment, with an annual interest rate of 8%. In the example, the initial demand letter was sent January 5, 2012.)

25.7 The interest rate varies, dependent upon the current value of funds to the U.S. Treasury (see paragraph 23.5). Once a debtor has established a repayment agreement, the rate of interest on THAT debt does not change, regardless of changes in the value of funds to the U.S. Treasury.

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25.8 Installment payments shall begin approximately 30 days after the request for an installment repayment agreement is made. If a debtor requests the agreement on March 1, 2014, his first installment will normally be due April 1, 2014. Some contractors may wish to have all installments due the first day of the month. If that is the case, and a debtor requests the arrangement on March 5, 2014, his first installment will be due April 1, 2014. If the debtor requests the arrangement on March 29, 2014, his first installment should be due May 1, 2014. Other contractors may choose to scatter the payments throughout the month, to even the workload. For consistency, do not require payments on the 29th, 30th or 31st of the month, since February normally has only 28 days.

25.9 The phrase “not less than_____dollars beginning on___,” is repeated in the Promissory Note to allow for an occasional debtor who, for example, wishes to pay one amount for six months and another amount for the last 18 months. The request may be for any number of personal reasons, i.e., a car loan may be repaid in six months and the debtor will have additional funds from which to repay TRICARE. The contractor is encouraged to be flexible in establishing a repayment agreement; however, repayment must be scheduled for completion within 24 months. If the same amount is to be paid for the entire term of the note, delete the second phrase from the note.

25.10 If the Promissory Note is not returned, or is returned unsigned, but the debtor makes the scheduled payments, the contractor shall treat the account as though the Promissory Note had been signed and returned.

25.11 Each payment received shall be acknowledged in writing and must advise the debtor of the amount received, the portion of each payment that was applied to interest and to principal, and the current balance due. The acknowledgment shall advise the debtor that the information provided may be useful in the preparation of his/her income tax return (see Addendum A, Figure 10.A-21).

25.12 Financially underwritten installment payments shall be maintained by the contractor. Non-financially underwritten related installment payments shall be reported to DHA. When the recoupment action is completed, the contractor shall process the collection action using a single transaction for each claim involved.

25.13 When the debtor enters into an installment repayment agreement, the offset flag shall be removed. Any suspended claims shall be processed and paid normally. If the debtor requests continuation of the offset, any amounts so collected shall be treated as an installment payment.

25.14 Written notification of delinquency shall be sent 35 days after the established due date if an installment, or any portion thereof, remains outstanding (see Addendum A, Figure 10.A-15). If the delinquent amount is not remitted within 30 days of the initial delinquency notice, and the amount remaining due on the account is $600 or greater, the case file, including all supporting documentation, shall be referred to the DHA OGC. If the debtor fails to bring the account current, but remits the missed installment, or a portion thereof, the contractor shall retain the case. Cases shall not be transferred to DHA until two full installment payments are past due. For example, a debtor may miss one payment entirely, but make all subsequent payments, and remain one month behind for the term of the agreement. The case would not be transferred to DHA. When a case is transferred to DHA, the contractor shall advise the debtor of the referral and shall be told that future payments should be sent to DHA CRM (see Addendum A, Figure 10.A-24).

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26.0 RECOUPMENT ACTION AND THE APPEALS PROCESS

26.1 The determination that an overpayment was made is not, in itself, an appealable issue. When a contractor receives a request from a debtor for an administrative review, the procedures outlined in paragraph 29.0 shall be followed to assure that, when appropriate, the debtor receives a reconsideration as outlined in Chapter 12.

26.2 If a service or supply which is not a TRICARE benefit was paid in error, the reversal of the payment decision constitutes an initial adverse determination. The overpaid party may appeal if an appealable issue exists. Such appeals are subject to the requirements and time limits outlined in Chapter 12. When the overpayment arises because inpatient mental health care was erroneously paid, the debtor will be advised that retroactive approval of the days paid may be requested from the TRICARE mental health review contractor. (See the TRICARE Policy Manual (TPM), Chapter 7, Section 3.1.)

26.3 Any funds recouped by offset after a reconsideration has been requested are to be identified and properly accounted. The appealing party is to be notified that the recoupment of the overpayment shall continue by offset. The contractor shall not terminate the offset action because of an appeal unless directed to do so by DHA.

26.4 When a requirement to recoup TRICARE funds is identified in a Formal Review Decision or a Final Decision resulting from a hearing, the case shall be forwarded by DHA OGC to the appropriate contractor for development and initial recoupment action in accordance with this section. If the contractor is unsuccessful in collecting the debt, the case shall be returned to the DHA OGC in accordance with paragraph 19.0.

27.0 OFFSET RECOUPMENT/PARTIAL PAYMENT

27.1 If the debtor is a hospital subject to the Diagnosis Related Group (DRG)-based payment system, offsets may be taken not only against claims on which payment would be issued to the debtor hospital, but also against annual payments due to debtor hospital as reimbursement for its Capital and Direct Medical Education (CAP/DME) costs. If the full amount is recouped through offset, an adjustment claim shall be reported with the current claim or in the next payment run. If the receivable was written off, it shall be reversed. If the receivable was transferred to DHA, immediately notify DHA OGC telephonically and follow up by letter within two work days after the telephone call. Also, reverse the transfer transaction on the next Accounts Receivable Report.

27.2 If a debtor has entered into an installment repayment agreement and has asked the contractor to continue to offset against future claims, the amount offset shall be applied first to interest and then to principal, as installment payments are applied. Generally, though, offset amounts shall be applied only to principal.

27.3 When a debt has been paid either by offset, partial payment or installment payments, to within $10.00 of the total amount due, including interest, if applicable, the contractor may consider the debt paid in full, if it is practical to do so. If the contractor chooses to consider the debt paid in full when the balance has been reduced to $10.00 or less, the debtor shall be so advised.

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28.0 REQUESTS FOR RELIEF OF INDEBTEDNESS

The contractor is not authorized to compromise or to suspend or terminate collection actions on federal claims. Requests for relief based upon financial hardship shall be handled in accordance with the below paragraphs. Requests for suspension of recoupment action pending the outcome of an appeal filed in accordance with 32 CFR 199.10, shall be forwarded to the DHA OGC.

28.1 Account Balance Of Less Than $600

When debtors request relief from all or a portion of their indebtedness, including requests for relief from the assessment of interest, penalties, and administrative charges, the contractor shall remove the offset flag and ask the debtor to complete a Financial Affidavit (see Addendum A, Figure 10.A-23 and Figure 10.A-25). The debtor shall be notified that consideration cannot be given to his/her request for relief unless the completed Financial Affidavit is returned within 30 days. If the debtor fails to return the completed Financial Affidavit within 30 days, the offset flag shall again be set and recoupment action shall continue as though no request for relief had been made. When the completed Financial Affidavit is received, the contractor shall forward the affidavit, along with a copy of the demand letter(s), and the debtor’s request for relief to the DHA OGC. If directed to do so by DHA, following the review of the debtor’s request for relief, the contractor shall reset the offset flag and proceed with normal recoupment procedures.

28.2 Account Balance Of $600 Or More

The contractor shall remove the offset flag upon receipt of a request for relief from indebtedness and ask the debtor to complete a Financial Affidavit. The debtor will be notified that consideration cannot be given to his/her request for relief unless the completed Financial Affidavit is returned within 30 days. When the completed affidavit is received, the entire recoupment case as outlined in paragraph 19.0, including the completed Financial Affidavit, shall be referred to the DHA OGC, for resolution. If the debtor fails to return the completed Financial Affidavit within 30 days, the offset flag shall again be set and recoupment action shall continue as though no request for relief had been made. This paragraph does not apply to the automatic waiver of interest on accounts paid within the first 30 days. Once a case has been established, the contractor shall stop or amend a recoupment action, as necessary, to correct a contractor error.

29.0 ADMINISTRATIVE REVIEW OF INDEBTEDNESS

29.1 If a debtor requests an administrative review of his indebtedness, the contractor shall review the documentation contained in the case file and any additional information or documents submitted by the debtor. The contractor review shall be conducted by someone in a position of higher authority within the contractor than the individual who originated the recoupment action. Following the review, the contractor shall respond to the debtor. When the debtor questions a contractor determination that the care is not a covered benefit, the debtor’s request for review will be referred to the appropriate unit within the contractor for issuance of a Reconsideration pursuant to 32 CFR 199.10 unless the issue is not appealable under the provisions of Chapter 12, or the recoupment action was initiated for one of the following reasons:

• TRICARE payment was issued without regard to OHI or pharmacy benefit plan, or the TRICARE liability, after taking into consideration payments made by OHI or pharmacy benefit plan, was inaccurately calculated.

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• The action was initiated to recoup a duplicate payment.

• The action was initiated because an error was made in the original determination that a claim was a participating or a nonparticipating claim.

• The action was initiated because the payee was incorrect.

29.2 Based upon the above instructions, if it is inappropriate to provide the debtor a reconsideration, the contractor shall issue a response to the debtor’s request for administrative review. The contractor’s response shall describe the documentation reviewed, including any submitted by the debtor, and explain the reviewing party’s rationale for the decision to pursue or terminate the recoupment action. The response shall explain that further administrative appeal is not available. If the review results in a decision to recoup the overpayment, the debtor will be advised that full payment or other satisfactory arrangements for repayment must be made within 30 days. A debtor’s request for an administrative review of his or her indebtedness does not result in suspension of the accrual of interest from the date of the initial demand letter.

30.0 SUSPICION OF FRAUD

30.1 If there is reason to believe that the overpayment may have been caused by fraud, no request for refund shall be made until the fraud issue is resolved. However, the contractor shall retain any amount voluntarily refunded pending resolution of the fraud issue. These funds shall be deposited in the TRICARE account and an accounting record maintained capable of audit. Documentation of the refund and all other evidence relating to the case shall be sent to the DHA PI. Any recoupment action shall be taken in accordance with Chapter 13.

30.2 Once a determination has been made that a case shall not be prosecuted for fraud, the DHA OGC, will return the suspected fraud case to the appropriate contractor for development and recoupment under this section. If the recoupment action is successful, the contractor shall notify DHA OGC by telephone within one work day of the final collection and follow-up with written notification within three work days. If the contractor is unsuccessful in collecting the debt, the case should be returned to DHA OGC in accordance paragraph 19.0.

31.0 CONTRACTOR TRANSITIONS

31.1 The incoming contractor and the CCS, shall receive their designated cases from the outgoing contractor no later than 30 days from the start of health care delivery (SHCD) in accordance with Chapter 2, Section 10, paragraph 5.0.

31.2 If a transition occurs before the contractor determines that the bankruptcy case has been closed, with or without distribution of assets, the POA and Agreement forms, with copies of claims and EOBs shall be sent to the DHA OGC for follow-up.

32.0 INTEREST, PENALTIES AND ADMINISTRATIVE COSTS

32.1 The debtor shall be notified in the initial demand letter that interest will accrue from the date of that letter. The rate of interest to be assessed is the U.S. Treasury Current Value of Funds Rate. The Department of the Treasury publishes a new rate pursuant to Section 11 of the Debt Collection Act of 1982, as Amended (31 USC 3717). The contractor shall obtain the current rate as published in the

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Federal Register. The Treasury’s rate may change on a quarterly basis if the rolling 12 month average used for calculating the rate changes by two percentage points. However, the collection of interest shall be automatically waived on the debt or any portion thereof which is paid within 30 days after the date of the initial demand letter. The contractor is not authorized, under any other circumstances, to waive a debt or any portion of a debt owed the U.S. Government.

32.2 Debtors shall also be notified in the initial demand letter that a penalty charge, not to exceed 6% per year, will be assessed upon any portion of the debt that is delinquent for more than 90 days, and that administrative costs, (based upon those costs incurred in processing and handling the debt because it became delinquent) will also be added to their indebtedness. However, the contractor shall not assess administrative costs and penalties (DHA will assess administrative costs and penalties).

32.3 The contractor shall be responsible for the assessment and collection of interest only when the debtor enters into an installment repayment agreement as described in paragraph 25.0. The rate of interest assessed shall be the rate properly reflected in the initial demand letter mailed to the debtor. The rate of interest assessed shall be the rate of the current value of funds to the U.S. Treasury; i.e., the Treasury Tax and loan account rate. Each installment payment shall be applied first to the accrued interest and then to the outstanding principal balance.

32.4 Interest will not be assessed upon previously accrued interest charges. When the debtor and the contractor enter into an installment repayment agreement, interest will be assessed for the period beginning on the date of the initial demand letter and ending on the due date of the first installment payment. The interest shall be assessed at the rate properly reflected in the initial demand letter on that portion of the debt which remained outstanding 30 days after the date of the initial demand letter. The interest so assessed will be collected and applied to the debtor’s account before the due date of the first installment payment. Subsequently, interest shall be computed daily on the outstanding principal balance at the rate properly reflected in the initial demand letter, which shall also be reflected in any Promissory Note sent to the debtor as required by paragraph 16.2.3.

32.5 Interest collected under installment agreements shall be reported to DHA monthly with unidentified refunds and refunds $10.00 or less. The rate of interest, as initially assessed, shall remain fixed for the duration of the indebtedness, except that where a debtor has defaulted on a repayment agreement and seeks to enter into a new agreement, a new interest rate may be set which reflects the current value of funds to the Treasury at the time the new agreement is executed.

32.6 Delinquent installment accounts shall be handled in accordance with the procedures outlined in paragraph 25.0.

33.0 OVERPAYMENTS TO DVA/VHA FACILITIES

33.1 Overpayments to DVA/VHA facilities are not subject to the above procedures. When the contractor identifies an overpayment to a DVA/VHA facility, the contractor shall notify the facility and request repayment to the TRICARE Program. The contractor shall not offset funds due to DVA/VHA under any circumstances.

33.2 Upon identification of an overpayment, the TRICARE contractor shall issue written notice of the basis for the overpayment to the applicable DVA/VHA facility, including a request for repayment of an amount due. The facility will acknowledge receipt within 90 days of the contractor’s notification. In addition, the facility’s acknowledgment will contain any claim disputes, to include the basis for the

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overpayment or the calculation of the refund. The facility may request additional time to investigate potential disputes. If the facility does not respond, or the contractor cannot resolve a claim dispute, the contractor shall refer the case to the DHA, OGC, Chief, CCS. If the facility does not submit a claim dispute, DVA/VHA will refund the amount due within 180 days from the written notification. Upon resolution of a claim dispute, if appropriate, the DVA/VHA will issue a refund within 180 days.

33.3 The contractor shall provide a monthly status report of all DVA/VHA overpayment cases. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

- END -

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TRICARE Operations Manual 6010.59-M, April 1, 2015Communications and Customer Service (C&CS)


Telephone Inquiries


1.0 TELEPHONE SYSTEM

1.1 The contractor shall provide an incoming toll-free telephone inquiry system. Multiple telephone numbers may be utilized for telephone inquiries; however, at least one toll-free line must have the ability to seamlessly transfer calls (via a phone tree or other business process) to any telephone inquiry location maintained by the contractor and its subcontractors. All telephones must be staffed and able to respond in a manner that meets performance standards throughout the entire period. A recorded message indicating normal business hours shall be used on the telephone lines after hours. Calls shall be handled in the order they are received. The contractor shall advertise the toll-free service using all available media including the Explanation of Benefits (EOB), newsletters, telephone directories published by the contractor, military organizations, etc. and other appropriate sources.

1.2 The telephone system must include a 24-hour, seven days a week, nationally accessible service, for all Military Health System (MHS) beneficiaries, including beneficiaries traveling in the contractor’s region, seeking information and/or assistance in locating a network provider, to include behavioral health providers willing to accept TRICARE. Callers seeking this information must have the ability to speak with live personnel. These personnel shall be able to enter authorizations for urgent care for beneficiaries traveling outside of their Prime Service Area (PSA).

1.3 The contractor shall offer an automated telephone critique to 100% of toll-free service line callers who interact with a live customer service representative. Details for reporting are identified by the DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

2.0 RESPONSIVENESS

Telephone inquiries shall be answered according to the standards in Chapter 1, Section 3. Contractors may respond to telephone inquiries by letter if they cannot contact the caller by phone or if a complex explanation is required. The contractor staff shall be trained to respond in the most appropriate, accurate manner. Telephone inquiries reporting a potential fraud or abuse situation shall be documented and referred to the contractor’s Program Integrity Unit.

3.0 REQUIREMENTS

There should be no differentiation in the service provided whether the call originates locally or through the toll-free lines. The contractor shall provide toll-free telephone access to all TRICARE inquiries (active duty personnel, TRICARE beneficiaries, dual-eligible beneficiaries, Director, TRICARE

1


Telephone Inquiries

Regional Office (TRO), providers, Assistant Secretary of Defense (Health Affairs) (ASD(HA)), Defense Health Agency (DHA), Beneficiary Counseling and Assistance Coordinators (BCACs), Debt Collection Assistance Officers (DCAOs), and Congressional offices). At a minimum, the telephone system shall be fully staffed and service shall be continuous during normal business hours which are defined as 8:00 a.m. through 6:00 p.m. (except weekends and holidays) in all time zones within the region. All customer service provided by telephone shall be without long distance charges to the beneficiary. Telephone service is intended to assist the public in securing answers to various TRICARE questions including, but not limited to:

3.1 General program information.

3.2 Specific information regarding claims in process and claims completed, including explanations of the methods and specific facts employed in making reasonable charge and medical necessity determinations, and information regarding types of medical services submitted (The contractor shall transfer out-of-jurisdiction calls requiring the assistance of another contractor. The contractor shall answer program information and network provider availability/assistance calls without regard to jurisdiction.).

3.3 When the inquiry concerns questions about Defense Enrollment Eligibility Reporting System (DEERS) or DEERS eligibility, the contractor shall refer the caller to the Defense Manpower Data Center (DMDC) Beneficiary Telephone Center, 6:00 a.m. to 3:30 p.m. Pacific Time, toll-free 1-800-538-9552, TTY/TDD 1-866-363-2883. These numbers cannot be used by the contractor or other service provider; they are only for the beneficiary’s use.

3.4 Additional information needed to have a claim processed.

3.5 Information about review and appeal rights and the actions required by the beneficiary or provider to use these rights.

3.6 Information about and procedures for the TRICARE Program, i.e., enrollment, TRICARE plans available, Point of Service (POS) option, continuity of care, referral management, and provider directories.

3.7 Information concerning benefit authorization requirements and procedures for obtaining authorizations. Provisions must be included to allow the transfer of calls to the authorizing organization (within the contractor’s organization, to include subcontractor) without disconnecting the call. The contractor shall ensure eligibility for care and enrollment status of beneficiaries before making any arrangements for medical services.

3.8 General information on eligibility for the TRICARE Dental Plans (Active Duty Dental Program (ADDP), TRICARE Dental Plan (TDP), and TRICARE Retired Dental Plan (TRDP)) and how to obtain dental plan information from the appropriate dental contractor. The beneficiaries shall be referred to the appropriate dental contractor for additional information.

3.9 When the inquiry concerns questions about a Department of Defense (DoD) Self-Service Logon (DS Logon), the contractor shall refer the caller to the DoD MyAccessCenter application help section at https://myaccess.dmdc.osd.mil/. This web site provides information that will help the beneficiary determine the most efficient means for obtaining a DS Logon based on their affiliation and current status. A DS Logon is a secure, self-service logon that allows DoD and Department of Veterans Affairs

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https://myaccess.dmdc.osd.mil/


Telephone Inquiries

(DVA)/Veterans Health Administration (VHA) affiliates to access certain web sites using a single username and password.

3.10 Telephone Standards

Refer to Chapter 1, Section 3, paragraph 3.4.

3.11 Toll-Free Telephone Service

The contractor shall advertise the toll-free service using all available media including the EOB, newsletters, telephone directories published by the contractor, military organizations, etc. and other appropriate sources.

3.12 Telephone Monitoring Equipment

The contractor shall utilize telephone equipment that is programmed to measure and record response times of incoming calls and determine whether DHA standards are met. See Chapter 1, Section 3, paragraph 3.4 for standards.

3.12.1 Measure Busy Signal Level

“Busy signal level” is defined as the percentage of time a caller receives a busy signal.

3.12.2 Measure Call Volumes And Handling Times

Contractors shall measure the number of calls received each month and the time elapsing between acknowledgment and handling by a telephone representative or Automated Response Unit (ARU). Measures shall include all calls that are directly answered by an individual or ARU (no waiting time). The on-hold time period begins when the telephone call is acknowledged and does not include the ring time.

4.0 REPORTS

Telephone activity shall be reported via monthly management reports in accordance with contract requirements.

5.0 TELEPHONE APPRAISAL SYSTEM

The contractor shall provide real-time remote and on-site call monitoring capabilities to DHA Government staff identified by the applicable DHA office (the Director, TROs or other applicable Program Office for which this is a contractual requirement) and designated by the Contracting Officer (CO). This requirement for remote call monitoring access does not apply to the TRICARE Overseas Program (TOP) contractor.

6.0 BENEFICIARY CONTACT DATA

The contractors shall collect and report customer service and beneficiary support workload to include categorization of the reason and volume of beneficiary inquiries received by their call center, in

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Telephone Inquiries

accordance with government-directed data collection requirements contained in the contract and as directed in Chapter 14.

7.0 BENEFICIARY ENCOUNTER DOCUMENTATION ACCESS

The contractor shall supply the government access to all information obtained during beneficiary encounters. This includes encounters through emails, walk-ins, and phone calls. Summaries of each encounter should be made available in the contractor’s online system. The information will be available to select staff within the MHS, primarily those in a customer service capacity such as BCACs and DCAOs. Access to the information for staff outside the Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) will be approved by a designated TRO representative and for staff at the MTF/eMSM, access will be approved by the Contract Liaison. Quality reviews may be conducted when discrepancies in information provided by contractor staff to beneficiaries has been identified. Access to information will not include sensitive or behavioral health information. Information obtained from incoming correspondence and emails will be available upon request.

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4


Controls, Education, and Conflicts of Interest

2.7 Waiver of CHAMPUS Maximum Allowable Charge (CMAC)

As outlined in 32 CFR 199.7(a), the Director, DHA, or a designee, is responsible for ensuring that the benefits under TRICARE are paid to the extent described. The balance billing limit may be waived by the Director, DHA or a designee, on a case-by-case basis if requested by a TRICARE beneficiary in advance. Providers may not make this request. Any request submitted by a beneficiary must be prior to the date of service, identify the name of the provider, date of service, the specific procedure being performed, and an itemized cost of the service(s). A decision by the Director, DHA or a designee, to waive or not waive the limit in a particular case is not subject to the appeal and hearing procedures of 32 CFR 199.10.

3.0 CONFLICT OF INTEREST

Conflict of interest includes any situation where an active duty member of the Uniformed Services (including a reserve member while on active duty, active duty for training, or inactive duty training) or civilian employee (which includes employees of the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA)) of the U.S. Government, through an official federal position has the apparent or actual opportunity to exert, directly or indirectly, any influence on the referral of beneficiaries to himself/herself or others with some potential for personal gain or the appearance of impropriety. Although individuals under contract to the Uniformed Services are not considered “employees,” such individuals are subject to conflict of interest provisions by express terms of their contracts and, for purposes of the 32 CFR 199.9 may be considered to be involved in conflict of interest situations as a result of their contract positions. In any situation involving potential conflict of interest of a Uniformed Service employee, the Director, DHA, or a designee, may refer the case to the Uniformed Service concerned for review and action.

3.1 Federal Employees And Active Duty Military

The TRICARE Regulation, 32 CFR 199.6 prohibits active duty members of the Uniformed Services or employees (including part-time or intermittent), appointed in the civil service of the U.S. Government, from authorized TRICARE provider status. This prohibition applies to TRICARE payments for care furnished to TRICARE beneficiaries by active duty members of the Uniformed Services or civilian employees of the Government. The prohibition does not apply to individuals under contract to the Uniformed Services or the Government.

3.2 Exceptions

3.2.1 National Health Service Corps

TRICARE payment may be made for services furnished by organizations to which physicians of the National Health Service Corps (NHSC) are assigned. However, direct payments to the NHSC physician are prohibited by the dual compensation provisions.

3.2.2 Emergency Rooms

Any off-duty Government medical personnel employed in an emergency room of an acute care hospital will be presumed not to have had the opportunity to exert, directly or indirectly, any influence on the referral of TRICARE beneficiaries. However, since they cannot be recognized as TRICARE-authorized providers, there is no cost-sharing of professional services by the provider.

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Controls, Education, and Conflicts of Interest

3.2.3 Reserves Generally Exempt

Conflict of interest provisions do not apply to medical personnel who are Reserve members of the Uniformed Services or who are employed by the Uniformed Services through personal services contracts, including contract surgeons. Although Reserve members, not on active duty, and personal service contract medical personnel are subject to certain conflict of interest provisions by express terms of their membership or contract with the Uniformed Services, resolution of any apparent conflict of interest issues which concern such medical personnel is the responsibility of the Uniformed Services, not the DHA. National Guard and reservists on active duty are not exempt during the period of their active duty commitment.

3.2.4 Part-Time Physician Employees Of The U.S. Government

Refer to Chapter 4, Section 1, paragraph 3.0.

3.2.5 Referrals From Uniformed Services Facilities

Referrals from Uniformed Services facilities to individual civilian providers should, in every practical instance, be made to participating providers. However, referrals of TRICARE beneficiaries by Uniformed Services personnel to selected individual providers in the civilian community when other similar participating providers are available may involve a conflict of interest. Contractors should document any apparent problem of this nature and refer the case to the DHA PI for investigation.

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6

TRICARE Operations Manual 6010.59-M, April 1, 2015TRICARE Prime Remote (TPR) Program


Health Care Providers And Review Requirements


1.0 NETWORK DEVELOPMENT

The TRICARE Prime Remote (TPR) program has no network development requirements.

2.0 UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP)

2.1 In addition to receiving claims from civilian providers, the contractor may also receive TPR Program claims from certain USFHP designated providers (DPs). The provisions of TPR will not apply to services furnished by a USFHP DP if the services are included as covered services under the current negotiated agreement between the USFHP DP and Office of the Assistant Secretary of Defense, Health Affairs (OASD(HA)). However, the contractor shall process claims according to the requirements in this chapter for any services not included in the USFHP DP agreement.

2.2 The USFHP, administered by the DPs listed below currently have negotiated agreements that provide the Prime benefit (inpatient and outpatient care). Since these facilities have the capability for inpatient services, they can submit claims that the contractor will process according to applicable TRICARE and TPR reimbursement rules:

• CHRISTUS Health, Houston, TX (which includes):

• St. Mary’s Hospital, Port Arthur, TX• St. John Hospital, Nassau Bay, TX• St. Joseph Hospital, Houston, TX

• Martin’s Point Health Care, Portland, ME.

• Johns Hopkins Health Care Corporation, Baltimore, MD.

• Brighton Marine Health Center, Boston, MA.

• St. Vincent’s Catholic Medical Centers of New York, New York City, NY.

• Pacific Medical Clinics, Seattle, WA.

3.0 DEPARTMENT OF VETERANS AFFAIRS (DVA)/VETERANS HEALTH ADMINISTRATION (VHA)

The contractor shall reimburse for services under the current national Department of Defense/Department of Veterans Affairs (DoD/VA) Memorandum of Agreement (MOA) for “Referral of Active

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Health Care Providers And Review Requirements

Duty Military Personnel Who Sustain Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services.” (See Section 4, paragraph 2.2 for additional information.) The contractor shall not reimburse for services provided to TPR enrollees under any local Memoranda of Understanding (MOU) between the DoD (including the Army, Air Force and Navy/Marine Corps facilities) and VHA. Claims for these services will continue to be processed by the Military Services. However, the contractor shall process claims according to the requirements in this chapter for any services not included in the local MOU.

4.0 DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS) [INDIAN HEALTH SERVICE (IHS), PUBLIC HEALTH SERVICE (PHS), ETC.]

Claims for services not included in the current MOU between the DoD (including the Army, Air Force and Navy/Marine Corps facilities) and the DHHS (including the IHS, PHS, etc.) shall be processed in accordance with the requirements in this chapter.

5.0 REVIEW REQUIREMENTS

5.1 Provision Of Documents

If the Specified Authorization Staff (SAS) requests copies of supporting documentation related to care reviews, appeals, claims, etc., the contractor shall send the requested copies to the SAS within four work days of receiving the request.

5.2 Primary Care

Service members enrolled in the TPR program can receive primary care services under TRICARE Prime without a referral, an authorization, or a fitness-for-duty review by the SAS (see Addendum A). Service members with assigned Primary Care Managers (PCMs) will receive primary care services from their PCMs. Service members without assigned PCMs will receive primary care services from TRICARE-authorized civilian providers, where available, or from other civilian providers where TRICARE-authorized civilian providers are not available.

5.3 Care Requiring SAS Review

The following care requires SAS review: all inpatient hospitalization, mental health care, invasive medical and surgical procedures (with the exception of laboratory/diagnostic services), and substance abuse.

5.3.1 Referred Care

5.3.1.1 The requesting provider shall follow the contractor’s referral procedures and shall contact the contractor for an authorization. Upon receipt of a civilian provider referral, the contractor shall perform a covered service review. If an authorization is required, the contractor shall enter the information in Addendum B, required by the SAS for a fitness-for-duty review (paragraph 5.3). SAS will respond to the contractor within two business days. When a SAS referral directs evaluation or treatment of a condition, as opposed to directing a specific service(s), the contractor shall use its best business practices in determining the services encompassed within the Episode Of Care (EOC), indicated by the referral. A SAS authorization for health care includes authorization for any TRICARE covered ancillary or diagnostic services related to the health care authorized (i.e., associated with the

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Contractor Responsibilities And Reimbursement


1.0 CONTRACTOR RECEIPT AND CONTROL OF CLAIMS

1.1 The contractor may establish a dedicated post office box to receive claims related to the TRICARE Prime Remote (TPR) Program. This dedicated post office box, if established, may also be the one used for handling Supplemental Health Care Program (SHCP) claims.

1.2 The contractor shall follow appropriate SHCP requirements for claims received for medical care furnished to Service members not enrolled in the TPR Program.

2.0 CLAIMS PROCESSING

2.1 Jurisdiction

2.1.1 The contractor shall process inpatient and outpatient medical claims for health care services provided worldwide to the contractor’s TPR enrollees, except in the case of care provided overseas (i.e., outside of the 50 United States (U.S.) and the District of Columbia). Civilian health care while traveling or visiting overseas shall be processed by the TRICARE Overseas Program (TOP) contractor, regardless of where the beneficiary is enrolled. The contractor shall process claims for non-covered benefits in accordance with Section 2, paragraph 5.3.2.2.

2.1.2 The contractor shall forward claims for Service members enrolled in TPR in other regions to the contractors for the regions in which the members are enrolled according to provisions in Chapter 8, Section 2.

2.1.3 The contractor shall process claims received for Service members who receive care in their regions, but who are not enrolled in TPR, according to the instructions applicable to the SHCP.

2.1.4 The contractor shall forward Service member dental claims and inquiries to the Active Duty dental program contractor.

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Contractor Responsibilities And Reimbursement

2.2 Claims for Care Provided Under the National DoD/DVA Memorandum of Agreement (MOA) for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), and Blind Rehabilitation

2.2.1 Effective January 1, 2007, the contractor shall process claims for Service member care provided by the DVA/VHA for SCI, TBI, and Blind Rehabilitation. Claims shall be processed in accordance with this chapter and the following:

2.2.1.1 Claims received from a DVA/VHA health care facility for Service member care with any of the following diagnosis codes (principal or secondary) shall be processed as an MOA claim: V57.4; 049.9; 139.0; 310.2; 323.x; 324.0; 326; 344.0x; 344.1; 348.1; 367.9; 368.9; 369.01; 369.02; 369.05; 369.11; 369.15; 369.4; 430; 431; 432.x; 800.xx; 801.xx; 803.xx; 804.xx; 806.xx; 851.xx; 852.xx; 853.xx; 854.xx; 905.0; 907.0; 907.2; and 952.xx.

2.2.1.2 The contractor shall verify whether the MOA DVA/VHA-provided care has been authorized by the Defense Health Agency-Great Lakes (DHA-GL) Specified Authorization Staff (SAS). SAS will send authorizations to the contractor by fax. If an authorization is on file, the contractor shall process the claim to payment. The contractor shall not deny claims for lack of authorization. Rather, if a required authorization is not on file, the contractor shall place the claim in a pending status and will forward appropriate documentation to SAS for determination.

2.2.2 MOA claims shall be reimbursed as follows:

2.2.2.1 Claims for inpatient care shall be paid using DVA/VHA interagency rates. The interagency rate is a daily per diem to cover an inpatient stay and includes room and board, nursing, physician, and ancillary care. These rates will be provided to the contractor by the Defense Health Agency (DHA) (including periodic updates as needed). There are three different interagency rates to be paid for rehabilitation care under the MOA. The Rehabilitation Medicine rate will apply to TBI care. Blind rehabilitation and SCI care each have their own separate interagency rate. Additionally, it is possible that two or more separate rates may apply to one inpatient stay. If the DVA/VHA-submitted claim identifies more than one rate (with the appropriate number of days identified for each separate rate), the contractor shall pay the claim using the separate rates. (For example, a stay for SCI may include days paid with the SCI rate and days paid at a surgery rate.)

2.2.2.2 Claims for outpatient services shall be paid at the appropriate TRICARE allowable rate (e.g., CHAMPUS Maximum Allowable Charge (CMAC)) with a 10% discount applied.

2.2.2.3 Claims for the following care shall be paid at the interagency rate if one exists and, if not, then at billed charges: transportation; prosthetics; orthotics; Durable Medical Equipment (DME); adjunctive dental care; home care; personal care attendants; and extended care (e.g., nursing home care).

2.2.2.4 Since this is care for Service members, normal TRICARE coverage limitations do not apply to services rendered for MOA care. As long as a service has been authorized by SAS, it will be covered regardless of whether it would have ordinarily not been covered under TRICARE policy.

2.2.3 All TRICARE Encounter Data (TED) records for this care must include Special Processing Code 17 - DVA/VHA medical provider claim.

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Chapter 16 Addendum B

Specified Authorization Staff (SAS) Review: Protocols And Procedures


1.0 INTERCONNECTIVITY BETWEEN THE CONTRACTOR AND SAS

1.1 ADP Protocols

1.1.1 The contractor shall provide the capability to edit the status and entry of a 13 digit disposition code indicating if the referral was approved for Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) or civilian network treatment (see paragraph 1.2). This disposition code may be used during the claims adjudication process.

1.1.2 The contractor shall provide the logic to automatically approve the referral if the SAS determination is not received within two work days of referral entry.

1.1.3 The contractor shall provide the telecommunications, hardware, and software necessary for data entry and report printing from the SAS location. The contractor shall provide initial and ongoing application training and support on an “as needed” basis.

1.1.4 The contractor shall provide a data dictionary of available data elements to be sent to the SAS automated information system. The contractor shall send all care referral records to the SAS in a tab delimited data flat file. The method of transfer can be File Transfer Protocol (FTP) or an e-mail attachment.

1.1.5 The contractors shall provide the SAS read only access to their subcontractor’s claims history database. The contractors shall provide the necessary training to the SAS staff in order to access the claims history database.

1.2 SAS Referral Data

1.2.1 The format of the referral number will be DMISYYJJJNNNS where:

1.2.1.1 DMIS = the DMIS ID Code of the issuing facility--(5203 = SAS);

1.2.1.2 YY = the year in which the referral number was issued;

1.2.1.3 JJJ = the Julian date on which the referral number was issued;

1.2.1.4 NNN = the Facility Sequence Number;

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TRICARE Operations Manual 6010.59-M, April 1, 2015Chapter 16, Addendum B


1.2.1.5 S = Status (the type of provider)

• C = Civilian Care (refer to Section 2, paragraph 5.3.1.2 for referral requirements)

• M = Military Care (military MTF/eMSM or clinic)

• V = Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) Care (DVA/VHA hospital or medical facility)

• P = Care rendered under the Department of Defense/Department of Veterans Affairs (DoD/VA) Memorandum of Agreement (MOA) for “Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services” (refer to Section 4, paragraph 2.2 for referral requirements).

1.2.2 The format of the effective date is YYYYMMDD where:

• YYYY = the year in which the SAS referral is effective;

• MM = the month in which the SAS referral is effective; and

• DD = the day on which the SAS referral is effective. A retroactive authorization is indicated by an effective date prior to the issue date.

1.2.3 The format of the expiration date is YYYYMMDD where:

• YYYY = the year in which the SAS referral expires;• MM = the month in which the SAS referral expires; and• DD = the day on which the SAS referral expires.

1.3 Data Elements

The following data elements are the minimum elements required by SAS for determining fitness-for-duty and for determining if care not covered under TRICARE Prime will be covered under TPR. The SAS will return the data elements furnished by the contractor when responding to a request for a fitness-for-duty or coverage/benefit determination. If the contractor is asking for a coverage/benefit determination, the contractor shall include the applicable elements marked with asterisks (*) below. If, for example, the contractor cannot authorize the care it is not a covered benefit under TRICARE, the contractor will include *Not a benefit. If the contractor cannot authorize the care because the care is not medically necessary, the contractor will include **Not medically necessary. If the contractor cannot authorize the care because the provider is not an authorized provider, the contractor shall include ***Provider not authorized.

DATA ELEMENTCONTRACTOR

TO SASSAS TO

CONTRACTOR

Patient Name X X

Patient’s DOB X X

Patient’s Sex X X

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- END -

Contact Date (for retroactive authorizations X X

Service Member SSN X X

Service Member Branch of Service X X

Duty Status X X

PCM Location Code X X

DMIS-ID X X

Contractor’s Authorization Number X X

Effective Date of Authorization X X

*Not a Benefit *If applicable

**Not Medically Necessary **If applicable

***Provider Not Authorized ***If applicable

SAS Fitness-for-Duty Referral Number or Benefit Determination Number X

Effective Date of SAS Referral X

Expiration Date of SAS Referral X

Status of Authorization (may be imbedded number) X

Number/Frequency of Services Requested for SAS Referral X X

Diagnosis X X

Procedure Code Range X X

Type of Service X X

Place of Service X X

Free Text (for available clinical information) X

DATA ELEMENTCONTRACTOR

TO SASSAS TO

CONTRACTOR

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TRICARE Operations Manual 6010.59-M, April 1, 2015Supplemental Health Care Program (SHCP)


General


1.0 INTRODUCTION

1.1 The Supplemental Health Care Program (SHCP), with specific exceptions discussed in this chapter, allows for payment of claims for civilian services rendered pursuant to a referral by a provider in a Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM), as well as for Civilian Health Care (CHC) received by eligible Uniformed Service members. The SHCP exists under authority of 10 USC 1074(c) and 32 CFR 199.16(a)(3). The use of the SHCP for pay for care referred by MTF/eMSM providers is governed by Assistant Secretary of Defense (Health Affairs) (ASD(HA)) Policy Memorandum 12-002, “Use of Supplemental Health Care Program Funds for Non-Covered TRICARE Health Care Services and the Waiver Process for Active Duty Service Members,” February 21, 2012.

1.2 SHCP-eligible Service members may include members in travel status (leave, TDY/TAD, permanent change of station), Navy/Marine Corps Service members enrolled to deployable units and referred by the unit Primary Care Manager (PCM) (not an MTF/eMSM), eligible Reserve Component (RC) personnel, Reserved Officer Training Corps (ROTC) students, cadets/midshipmen, and eligible foreign military.

1.3 The fact that civilian services have been rendered to an individual who is enrolled to an MTF/eMSM PCM does not mean that those services were MTF/eMSM referred care. If a claim is received for a Service member MTF/eMSM enrollee and no authorization is on file, the MTF/eMSM must be contacted to determine if the care was MTF/eMSM referred.

2.0 SPECIFIED AUTHORIZATION STAFF (SAS)/MILITARY SERVICE PARTICIPATION

2.1 For care that is in a TRICARE Prime Remote (TPR) designated area not referred by an MTF/eMSM and is not in an area served by the TRICARE Overseas Program (TOP) contractor, the SAS will identify, and coordinate the CHC furnished to Service members including preauthorization of care when required and notify the nearest same service MTF/eMSM for civilian routine and emergency hospital admissions so they can assume patient oversight responsibilities. The entities performing the SAS functions are identified in Addendum A.

2.2 The contractor will also receive claims for MTF/eMSM patients who may require medical care that is not available at the MTF/eMSM (e.g., MRI) and the MTF/eMSM refers a patient for civilian medical care (this includes all civilian care provided to a Service member MTF/eMSM enrollee). In these cases, the contractor shall contact the referring MTF/eMSM for any necessary medical oversight or authorization of care.

1


General

3.0 CONTRACTOR RESPONSIBILITIES

3.1 The contractor shall provide payment for inpatient and outpatient services, for MTF/eMSM-referred civilian care ordered by an MTF/eMSM provider for an MTF/eMSM patient for whom the MTF/eMSM provider maintains responsibility. This includes claims for members on the Temporary Disability Retirement List (TDRL) obtaining required periodic physical exams. After payment of the claim, the contractor shall furnish the Services with information regarding payment of the claim as specified in the contract.

3.2 The contractor shall provide payment for inpatient and outpatient medical services for CHC received by eligible Uniformed Service members in accordance with the provisions of this chapter. After payment of the claim, the contractor shall furnish reports as specified in the contract.

4.0 SHCP DIFFERENCES

4.1 Service members have no cost-shares, copayments, Point of Service (POS) charges, or deductibles. If they have been required by the provider to make “up front” payment they may upon approval be reimbursed in full for amounts in excess of what would ordinarily be reimbursable under TRICARE. Application of Other Health Insurance (OHI) is generally not considered (see Section 3, paragraph 1.2.3).

4.2 There will be no application by the contractor of OHI processing procedures for Service member claims under SHCP.

4.3 If Third Party Liability (TPL) is involved in a claim, claim payment will not be delayed while the TPL information is developed (see Section 3, paragraph 1.3).

4.4 The contractor shall provide MTF/eMSM-referred patients the full range of services offered to TRICARE Prime enrollees.

4.5 If a Service member intends, while in a terminal leave status, to reside outside of the Prime Service Area (PSA) of the MTF/eMSM where the Service member is enrolled, the MTF/eMSM shall issue to the TRICARE contractor a single preauthorization for the Service member to obtain from the Department of Veterans Affairs (DVA)/Defense Health Administration (VHA) any routine or urgent outpatient primary medical care that should be required anytime during the terminal leave period, except the preauthorization shall not apply to services provided under the terms of the Department of Defense (DoD)/DVA Memorandum Of Agreement (MOA) for “Medical Treatment Provided to Active Duty Service Members with Polytrauma Injury, Spinal Cord Injury, Traumatic Brain Injury or Blindness.” Claims from the DVA/VHA for services provided under terms of the MOA shall be processed as specified in Section 2, paragraph 3.0. The contractor shall process a claim received from the DVA/VHA for services provided within the scope of the preauthorization using the standards in Chapter 1 unless otherwise stated in this chapter. The claims tracking and retrieval requirements of Chapter 1, Section 3, paragraph 2.1 apply equally to such SHCP claims. The contractor for the region in which the patient is enrolled shall process the claim to completion.

4.6 Services that would not have ordinarily been covered under TRICARE policy (including limitations and exclusions) may be authorized for Service members in accordance with the terms of a waiver approved by the Director, DHA, at the request of an authorized official of the uniformed service concerned (paragraph 2.0).

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Providers Of Care

Copyright: CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.


1.0 GENERAL

1.1 The Supplemental Health Care Program (SHCP) payment structure applies to inpatient and outpatient medical claims submitted by civilian institutions, individual professional providers, suppliers, pharmacies, and other TRICARE authorized providers for Civilian Health Care (CHC) rendered to Uniformed Service members and other SHCP-eligible individuals. For Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM)-referred care, the contractor will make referrals to network providers as required by contract.

1.2 For care that is not MTF/eMSM referred (including care for MTF/eMSM enrollees), most patients covered by this chapter will have undergone medical care prior to any contact with the Specified Authorization Staff (SAS) (Addendum A) or the contractor. However, when the patient initiates contact prior to treatment and the SAS has authorized the care being sought, the contractor will issue authorizations and assist in finding network providers; if a network provider is not available, the referral will be made to a TRICARE authorized provider.

1.3 For service determined eligible patients other than active duty (e.g., Reserve Officer Training Corps (ROTC), Reserve Component (RC)), foreign military, etc.), the contractor, upon receiving an authorization from the SAS, will record and enter the authorization to enable appropriate claims processing, and, if necessary, will assist the patient with a network provider or TRICARE-authorized provider (if available).

1.4 Claims for active duty dental services in the 50 United States (U.S.), the District of Columbia, and U.S. territories and commonwealths will be processed and paid by a single, separate active duty dental program contractor. Claims for adjunctive dental care will be processed and paid by the contractor (or the TRICARE Overseas Program (TOP) contractor for overseas care).

2.0 UNIFORMED SERVICES FAMILY HEALTH PLAN (USFHP)

2.1 In addition to receiving claims from civilian providers, the contractor may also receive SHCP claims from certain USFHP Designated Providers (DPs). The provisions of the SHCP will not apply to services furnished by a USFHP DP if the services are included as covered services under the current negotiated agreement between the USFHP DP and the Defense Health Agency (DHA) (this includes care for a USFHP enrollee). However, any services not included in the USFHP DP agreement shall be paid by the contractor in accordance with the requirements in this chapter.

1


Providers Of Care

2.2 The USFHP, administered by the DPs listed below currently have negotiated agreements which provide the Prime benefit (inpatient and outpatient care). Since these facilities have the capability for inpatient services, they can submit claims which will be paid in accordance with applicable TRICARE reimbursement rules under the SHCP:

• CHRISTUS Health, Houston, TX (which also includes):

St. Mary’s Hospital, Port Arthur, TX

St. John Hospital, Nassau Bay, TX

St. Joseph Hospital, Houston, TX

• Martin’s Point Health Care, Portland, ME

• Johns Hopkins Health Care Corporation, Baltimore, MD

• Brighton Marine Health Center, Boston, MA

• St. Vincent’s Catholic Medical Centers of New York, New York City, NY

• Pacific Medical Clinics, Seattle, WA

3.0 DEPARTMENT OF VETERANS AFFAIRS (DVA)/VETERANS HEALTH ADMINISTRATION (VHA)

In addition to receiving claims from civilian providers, the contractor may also receive SHCP claims from the DVA/VHA. The provisions of the SHCP will not apply to services provided under any Memorandum of Agreement (MOA) for sharing between the Department of Defense (DoD) (including the Army, Air Force, Navy/Marine Corps, and Coast Guard facilities) and the DVA/VHA. Claims for these services will continue to be processed by the Services. However, any services not included in any MOA described below shall be paid by the contractor in accordance with the TRICARE Reimbursement Manual (TRM) to include claims referred for beneficiaries on the Temporary Disability Retirement List (TDRL).

3.1 Claims for Care Provided Under the National DoD/DVA MOA for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation, and Polytrauma

3.1.1 Effective August 4, 2009, the contractor shall process DVA/VHA submitted claims for Service members’ treated under the MOA in accordance with this chapter and the following (SCI, TBI MOA; see Addendum D for a full text copy of the MOA for references purposes only).

3.1.2 Claims received from a DVA/VHA health care facility for Service member care shall be processed as an MOA claim based upon the Defense Health Agency-Great Lakes (DHA-GL) Specified Authorization Staff (SAS) authorization number. As determined by SAS, all medical conditions shall be authorized and paid under this MOA if a condition of TBI, SCI, Blindness, or Polytrauma exists for the patient. The authorization shall clearly indicate that the care has been authorized under the SCI, TBI, Blindness, and Polytrauma MOA. The authorization shall specify type of care (inpatient, outpatient, etc.) to be given under the referenced MOA and limits of the authorization (inpatient days, outpatient visits, expiration date, etc.). Suggested authorization language to possibly include “all care authorized under

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Providers Of Care

the SCI, TBI, Blindness, and Polytrauma MOA” for inpatient, outpatient and rehabilitative care. SAS shall send authorizations to the contractor either by fax or by other mutually agreed upon modality.

3.1.3 The contractor shall verify whether the DVA/VHA-provided care has been authorized by the SAS. If an authorization is on file, the contractor shall process the claim to payment. The contractor shall not deny claims for lack of authorization. If a required authorization is not on file, the contractor shall place the claim in a pending status and forward the appropriate documentation to the SAS identifying the claim as a possible MOA claim for determination (following the procedures in Addendum B for the SAS referral and review procedures). Additionally, any DVA/VHA submitted claim for a Service member with a TBI, SCI, blindness, or polytrauma condition that does not have a matching authorization number shall be pended to the SAS for payment determination.

3.1.4 MOA claims shall be reimbursed as follows:

3.1.4.1 Claims for inpatient care shall be paid using DVA/VHA interagency rates, published in the Federal Register. The interagency rate is a daily per diem to cover inpatient stays and includes room and board, nursing, physician, and ancillary care. These rates will be provided to the contractor by DHA (including periodic updates as needed). There are three different interagency rates to be paid for rehabilitation care under the MOA. The Rehabilitation Medicine rate will apply to TBI care. Blind rehabilitation and SCI care each have their own separate interagency rate. Additionally, it is possible that two or more separate rates will apply to one inpatient stay. All interagency rates except the outpatient interagency rate in the Office of Management and Budget (OMB) Federal Register Notice provided by DHA will be applicable. If the DVA/VHA-submitted claim identifies more than one rate (with the appropriate number of days identified for each separate rate), the contractor shall pay the claim using the separate rates. (For example, a stay for SCI may include days paid with the SCI rate and days billed at a surgery rate.) Contractors shall verify the DVA/VHA billed rate on inpatient claims matches one of the interagency rates provided by DHA. DVA/VHA claims for inpatient care submitted with an applicable interagency rate shall not be developed any further (i.e., for revenue codes, diagnosis, etc.) if care has been approved by the DHA/SAS. Claims without an applicable interagency rate shall be denied and an Explanation of Benefits (EOB) shall be issued to the DVA/VHA, but not the beneficiary. The claim will need to be resubmitted for payment.

3.1.4.2 Claims for outpatient and ambulatory surgery professional services shall be paid at the appropriate TRICARE allowable rate (e.g., CHAMPUS Maximum Allowable Charge (CMAC)) with a 10% discount applied. For those services without a TRICARE allowable rate, DVA/VHA shall be reimbursed at billed charges.

3.1.4.3 The following care services, irrespective of health care delivery setting require authorization from SAS and are reimbursed at billed charges (actual DVA/VHA cost) separately from DVA/VHA inpatient interagency rates, if one exists:

• Transportation• Prosthetics• Non-medical rehabilitative items• Durable Equipment (DE) and Durable Medical Equipment (DME)• Orthotics (including cognitive devices)• Routine and adjunctive dental services• Optometry• Lens prescriptions

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Providers Of Care

• Inpatient/outpatient TBI evaluations• Special diagnostic procedures• Inpatient/outpatient polytrauma transitional rehabilitation program• Home care• Personal care attendants• Conjoint family therapy• Ambulatory surgeries• Cognitive rehabilitation• Extended care/nursing home care

3.1.4.4 Effective August 4, 2009, the contractor shall process all claims received on or after this date using the guidelines established under the updated MOA regardless of the date of service. All TRICARE Encounter Data (TED) records for this care shall include Special Processing Code (SPC) 17 - DVA/VHA medical provider claim.

3.1.4.5 If paid at per diem rates, the provisions of Chapter 8, Section 2, paragraph 7.2, apply when enrollment changes in the middle of an inpatient stay. If enrollment changes retroactively, prior payments will not be recouped.

3.2 Claims for Care Provided Under the National DoD/DVA MOA for Payment for Processing Disability Compensation and Pension Examinations (DCPE) in the Integrated Disability Evaluation System (IDES)

The contractor shall reimburse the DVA/VHA for services provided under the current national DoD/DVA MOA for “Processing Payment for Disability Compensation and Pension Examinations in the Integrated Disability Evaluation System” (IDES MOA; see Addendum C for a full text copy of the MOA for reference purposes only). The contractor shall process claims with dates of service October 1, 2014, and forward. Claims under the IDES MOA shall be processed in accordance with this chapter and the following:

3.2.1 Claims submitted by any DVA/VHA facility/provider for a Service member’s care with the Current Procedural Terminology (CPT) code of 99456, International Classification of Diseases, 9th Revision (ICD-9) diagnostic code of V68.01, or International Classification of Diseases, 10th Revision (ICD-10) diagnostic code of Z02.71 (Disability Examination) shall be processed as a IDES MOA claim. IDES MOA claims are SHCP claims.

3.2.2 The MTF/eMSM will generate a single referral and submit the referral to the contractor. Although the MTF/eMSM referral shall specify a particular DVA/VHA facility/provider to provide the IDES MOA services, the contractor shall consider the referral as a blanket authorization to process claims from any billing DVA/VHA facility/provider for authorized/DCPE exams and associated ancillary services under the IDES MOA. The MTF/eMSM will complete the referral as described in Chapter 8, Section 5, paragraph 6.1 including Note 4. The referral will specify the total number of Compensation and Pension (C&P) examinations authorized for payment by the contractor. It is not necessary for the referral to identify the various specialists who will render the different C&P examinations. The reason for referral will be entered by the MTF/eMSM as “DVA/VHA only: Disability Evaluation System (DES) C&P exams for fitness for duty determination - total __.”

3.2.3 The DVA/VHA will list one C&P examination (CPT code 99456) per the appropriate field of the claim form and indicate one unit such that there is a separate line item for each C&P examination.

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Providers Of Care

Related ancillary services may be billed on the same claim form or on a separate claim form identified by the single diagnosis of ICD-9/ICD-10 diagnostic code, V68.01/Z02.71 (Disability Examination).

3.2.4 If an IDES MOA claim is received from the DVA/VHA (paragraph 3.2.1) and an authorization to any DVA/VHA provider is on file, the contractor shall process the claim to payment (see paragraph 2.2). One C&P examination fee will be paid for each referred and authorized C&P examination up to the total number of C&P examinations authorized by the referring MTF/eMSM.

3.2.5 If an IDES MOA claim is received from the DVA/VHA (paragraph 3.2.1) and no authorization is on file, the contractor shall verify that the claim contains CPT procedure code 99456 and/or ICD-9/ICD-10 code V68.01/Z02.71, and process the claim to payment. The contractor shall provide a monthly report of the number of IDES MOA claims received without authorization. Details for reporting are identified by DD Form 1423, Contract Data Requirement List (CDRL), located in Section J of the applicable contract.

3.2.6 Claims for C&P exams shall be paid as SHCP using the pricing provisions agreed upon in the IDES MOA. CPT procedure code 99456 shall be used and will be considered to include all parts of each C&P examination, except ancillary services. Claims for related ancillary services shall be paid at the appropriate TRICARE allowable rate (e.g., CMAC) with a 10% discount applied.

3.2.7 All TED records for this care shall include SPC DC - Compensation and Pension Examinations-DVA/VHA, SPC 17 - DVA/VHA Medical Provider Claim, and Enrollment Health Plan Code SR - SHCP-Referred Care.

- END -

FIGURE 17.2-1 DISABILITY PAY SCHEDULE

EFFECTIVE DATE C&P DISABILITY EXAM (99456) ANCILLARY SERVICES

01/01/2011 $515.00 CMAC - 10%

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Contractor Responsibilities

1.1.8.1 Foreign Military Member

Foreign military members are eligible for civilian outpatient care, but are not eligible for civilian inpatient care (see the TRICARE Policy Manual (TPM), Chapter 1, Section 1.1). Any civilian outpatient care for an authorized foreign military member must be referred by an MTF/eMSM or SAS. For MTF/eMSM referral requests, the contractor shall accept and follow the referral requirements in Chapter 8, Section 5. If the foreign military member works and resides in a TRICARE Prime Remote (TPR) area, then the SAS will issue referrals for outpatient care. Essentially, the same referral processes in place for Service members (which includes pending a claim without a referral and forwarding to either an MTF/eMSM or SAS for review) shall be followed for foreign military member care. Authorized civilian outpatient care claims for foreign military members are processed with no copayment or cost-share. If the member has double coverage (not including national health plan coverage from his or her home country), the double coverage provisions in the TRICARE Reimbursement Manual (TRM), Chapter 4, apply to these claims. Foreign military members are not required nor are they eligible to enroll in any TRICARE plan for their civilian outpatient claims to be paid by TRICARE.

1.1.8.2 Family Members of Foreign Military Members

Family members of foreign military members may be eligible for outpatient civilian care, but are not eligible for inpatient care (see the TPM, Chapter 1, Section 1.1). If the family member is registered and shown as eligible in DEERS (Health Care Coverage Member Category Code of T), then the contractor shall process the claim with TRICARE Standard/Extra cost-shares (through December 31, 2017) or TRICARE Select Group B ADFM cost-shares (starting January 1, 2018) (see the TRM, Chapter 2, Section 2) as appropriate. If the family member has double coverage (not including national health plan coverage from his or her home country), the double coverage provisions in the TRM apply.

1.1.9 Claims Received With Both MTF/eMSM-Referred And Non-Referred Lines

1.1.9.1 The contractor shall use its best business practices in determining Episode of Care (EOC) when claims are received with lines of care containing both -referred and non-referred (directs evaluation or treatment of a condition) lines. Laboratory tests, radiology tests, echocardiogram, holter monitors, pulmonary function tests, and routine treadmills logically associated with the referred EOC may be considered part of the originally requested services and do not need additional MTF/eMSM approval. Claims received which contain services outside the originally referred EOC on a Service member must come back to the MTF/eMSM for approval.

1.1.9.2 Non-mental health SHCP requests will have a benefit review only. The contractor will not do a medical necessity review. Medical necessity reviews will be provided by the MTF/eMSM or civilian referring provider.

1.2 Eligibility Verification

1.2.1 MTF/eMSM Referred Care

If an MTF/eMSM referral is on file and the service is either ordinarily covered by TRICARE or covered by TRICARE under paragraph 2.2.4, the contractor shall process the claim in accordance with the provisions in paragraph 1.2.2.2. The contractor shall verify that care provided was authorized by the MTF/eMSM. If an authorization is not on file, then the contractor shall place the claim in a pending file and verify authorization with the Service member’s MTF/eMSM (except for care provided by the DVA/

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Veterans Health Administration (VHA) under the current national MOA for SCI, TBI, and Blind Rehabilitation, see Section 2, paragraph 3.1). If the claim is for a breast pump, a prescription is required and the prescription must indicate whether it is for a manual, standard electric, or heavy-duty hospital grade breast pump. If the claim is for a manual or standard electric pump, no additional MTF/eMSM authorization is required. If the claim is for a heavy-duty hospital grade pump, a prescription is required and a referral must be on file. If no referral is on file, the contractor shall contact the MTF/eMSM for authorization as described below. Claims for breast pump supplies do not require a prescription or MTF/eMSM referral/authorization. The contractor shall contact the MTF/eMSM within one working day. If the MTF/eMSM retroactively authorizes the care, then the contractor shall enter the authorization and notify the claims processor to process the claim for payment. If the MTF/eMSM determines that the care was not authorized, the contractor shall notify the claims processor and an Explanation of Benefits (EOB) denying the claim shall be initiated. If the contractor does not receive a response within four working days from the MTF’s/eMSM’s response, the contractor shall, within one working day, enter the contractor’s authorization code into the contractor’s claims processing system. Claims authorized due to a lack of response from the MTF/eMSM shall be considered as “Referred Care”. Services that would not have ordinarily been covered under TRICARE policy shall be authorized for Service members only in accordance with the terms of a waiver approved by the Director, Defense Health Agency (DHA), at the request of an authorized official of the Uniformed Service concerned or SAS as appropriate.

1.2.2 Non-MTF/eMSM Referred Care

1.2.2.1 Check DEERS Status

If the Service member is listed in DEERS as TRICARE Prime, No PCM Selected, process the claim in accordance with paragraph 1.4 (Types of Care). If the DEERS check indicates the Service member is enrolled in TPR, then the claim shall be processed as a TPR claim in accordance with Chapter 16. Otherwise the claim shall be processed in accordance with the requirements of Chapter 17.

1.2.2.2 Check for SAS Preauthorization

If a SAS preauthorization exists, process the claim to completion in accordance with this chapter whether or not the Service member is listed in DEERS.

1.2.2.3 Check Claim For Attached Documentation

If the patient is listed in DEERS as not direct care eligible, but the claim or its attached documentation indicates potential eligibility (e.g., military orders, commander’s letter), pend the case and forward a copy of the claim and attached documentation to the SAS for an eligibility determination.

1.2.2.4 National Guard and Reserve

Claims for National Guard or Reserve sponsors with treatment dates outside their eligibility dates cannot be automatically adjudicated. Claims shall be checked for MTF/eMSM or SAS authorization before routing to SAS. Claims for ineligible sponsors are to be suspended and routed to SAS for payment approval or denial. If a payment determination is not received within the 85th day of receipt, the claim is to be denied.

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2.4.2.2 There are no cost-shares, copayments, or financial caps for any of these ECHO-like benefits when these services are authorized. There is no requirement to register in the Exceptional Family Member Program (EFMP). There is no time limit with disability/illness requirement. These benefits shall be preauthorized, to include documentation of Category II/III designation per Department of Defense Instruction (DoDI) 1300.24; and, documentation that the Service member has been referred to a Medical Evaluations Board (MEB).

2.4.2.3 The following categories of care listed under 10 USC 1079(e) are authorized (see 10 USC 1079(e)(1-7):

2.4.2.3.1 Diagnosis.

2.4.2.3.2 Inpatient, outpatient, and comprehensive Home Health Care (HHC) supplies and services which may include cost effective and medically appropriate services other than part-time or intermittent services, as these terms are currently used under the TRICARE ECHO Program.

2.4.2.3.3 Training, rehabilitation, special education, and assistive technology devices.

2.4.2.3.4 Institutional care in private nonprofit, public, and state institutions and facilities and, if appropriate, transportation to and from such institutions and facilities.

2.4.2.3.5 Home health services, including custodial care in conjunction with authorized home health services.

2.4.2.3.6 Seriously ill or injured Service members are defined as Category II or III per DoDI 1300.24.

2.4.2.3.6.1 Category II:

• Has a serious injury or illness.

• Is unlikely to return to duty within a time specified by his or her military department.

• May be medically separated from the military.

2.4.2.3.6.2 Category III:

• Has a severe or catastrophic injury or illness.• Is highly unlikely to return to duty.• Will most likely be medically separated from the military.

2.4.2.4 The Service member’s primary care provider or primary specialty care provider shall document and provide the Service member’s category status on a referral as well as documentation of a referral to an MEB. Preauthorization is required. If the documentation supports the category designation of Category II/III, the Service member is eligible for benefits comparable to ECHO. Using the Government furnished web-based enrollment application, the contractor shall apply the ECHO Health Care Delivery Plan (HCDP) code of 400 to the Service member. The provider’s documentation of Category II/III status is the authorizing document allowing the contractor to apply the ECHO HCDP

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code to the Service member. The contractor shall ensure all TED requirements outlined in the TSM, Chapter 2 are met, including appropriate use of Special Processing Code PF to identify TED records for care rendered under the ECHO benefit for seriously ill or injured Service members.

2.4.2.5 The contractor shall collaborate with all DVA/VHA case managers along with the Service member’s healthcare team to ensure continuity of care and transition to DVA/VHA care and management upon retirement or separation.

2.4.2.6 As much as practical, these benefits should mirror the ECHO Program and be coordinated between the contractor and the health care team. Benefits for these Service members arise from any physiological disorder or condition or anatomical loss affecting one or more body system and which precludes the person with the disorder, condition, or anatomical loss from unaided performance of at least one of the following major life activities: breathing, cognition, hearing, seeing, and ability to bathe, dress, eat, groom, speak, stair use, toilet use, transferring, and walking. Benefits include services for rehabilitative, habitative care as well as Durable Equipment (DE) and Durable Medical Equipment (DME).

2.4.2.7 Designation of comparable to ECHO benefits for Service members.

2.4.2.7.1 Requests for benefits under the comparable to ECHO will come from the Service member’s PCM or specialty provider with documentation of the category description (II/III) along with documentation to support that category description.

2.4.2.7.2 Documentation of a referral to an MEB must be provided.

2.4.2.8 Provision Of Respite Care

2.4.2.8.1 The eligibility rules and exclusions contained in 32 CFR 199.5(b)(3) and (5) do not apply to the provision of respite benefits for a Service member. See Appendix A for definitions, terms, and limitations applicable to the respite care benefit.

2.4.2.8.2 Seriously ill or injured Service members shall qualify for respite care benefits regardless of their enrollment status. Service members in the 50 U.S. and the District of Columbia shall qualify if they are enrolled in TRICARE Prime, TPR, or not enrolled and receiving services in accordance with the non-enrolled/non-referred provisions for the use of SHCP funds. Service members outside the 50 U.S. and the District of Columbia shall qualify if they are enrolled to TRICARE Overseas Program (TOP) Prime (with enrollment to an MTF/eMSM), TOP Prime Remote, or not enrolled and receiving services in accordance with the non-enrolled/non-referred provisions for Service member care overseas (see TPM, Chapter 12, Section 1.1).

Note: Respite care benefits must be performed by a TRICARE-authorized Home Health Agency (HHA), regardless of the Service member’s location (see 32 CFR 199.6(b)(4)(xv) for HHA definition).

2.4.2.8.3 There are no cost-shares or copays for Service member respite benefits when those services are approved by the Service member’s Direct Care System (DCS) case manager or other appropriate DCS authority (i.e., SAS, the enrolled or referring MTF/eMSM, TRICARE Area Office (TAO), or Community Care Units (CCUs)).

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2.4.2.8.4 All SHCP requirements and provisions of Chapters 16 and 17 apply to this benefit unless changed or modified by this paragraph. The appropriate chapter for the status of the Service member shall apply. Contractors shall follow the requirements and provisions of these chapters, to include:

• MTF/eMSM or SAS referrals and authorizations;

• Receipt and control of claims;

• Authorization, verification, reimbursement and payment mechanisms to providers;

• Reimbursement specifying no cost-share, copay, or deductible to be paid by the Service member or their lawful spouse; and

• Use of CHAMPUS Maximum Allowable Charges (CMACs)/Diagnosis Related Groups (DRGs) when applicable.

2.4.2.8.5 Contractors shall follow the provisions of the TSM, Chapter 2, Sections 2.8 and 6.4 regarding the TED SPC for the Service member respite benefit. Claims should indicate an appropriate procedure code for respite care (CPT 99600 or HCPCS S9122-S9124) and shall be reimbursed based upon the allowable charge or the negotiated rate.

2.4.2.8.6 Respite care services and requirements are as follows:

2.4.2.8.6.1 Respite care is authorized for a Service member of the Uniformed Services on active duty and has a qualifying condition as defined in Appendix A.

2.4.2.8.6.2 Respite care is available if a Service member’s plan of care includes frequent interventions by the primary caregiver(s).

2.4.2.8.6.3 Service members receiving respite care are eligible to receive a maximum of 40 respite hours in a calendar week, no more than five days per calendar week and no more than eight hours per calendar day. No additional benefit caps apply.

2.4.2.8.6.4 Respite benefits shall be provided by a TRICARE-authorized HHA and are intended to mirror the benefits under the TRICARE ECHO Home Health Care (EHHC) program described in the TPM, Chapter 9, Section 15.1.

Note: Contractors are not required to enroll Service members in the ECHO program (or a comparable program) for this respite benefit.

2.4.2.8.6.5 Authorized respite care does not cover care for other dependents or others who may reside in or be visiting the Service member’s residence.

2.4.2.8.6.6 In addition, consistent with the requirement that respite care services shall be provided by a TRICARE-authorized HHA, services or items provided or prescribed by a member of the patient’s family or a person living in the same household are excluded from respite care benefit coverage.

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2.4.2.8.6.7 The contractor shall follow the reimbursement methodology for the similar respite care benefit found in the TPM, Chapter 9, as modified by Service member SHCP reimbursement methodology contained in Chapters 16 and 17 (for Service members located in the 50 U.S. and the District of Columbia) or TOP reimbursement methodology contained in the TPM, Chapter 12 (for Service members located outside the 50 U.S. and the District of Columbia).

2.4.2.8.7 Should other services or supplies not outlined above, or those otherwise available under the TRICARE program, be considered necessary for the care or treatment of a Service member, a request shall be submitted to the SAS, MTF/eMSM, or TAO for authorization of payment. When preauthorization is possible it shall be done.

2.4.2.9 Customized Hand Crank Bikes

2.4.2.9.1 There is a cap of $5,500.

2.4.2.9.2 Bike must be custom fitted for the Service member’s unique injury.

2.4.2.9.3 Must be preauthorized and evidence of a Category II/III illness or injury must accompany the request. No request should be for more than the $5,500 cap.

2.4.2.10 Custodial Care

2.4.2.10.1 Limited to 30 days if Service member has not been referred to an MEB.

2.4.2.10.2 At the MTF/eMSM case manager’s request, the appropriate regional Medical Director, Clinical Operations Division (COD), TRICARE Health Plans may extend an additional 30 days if Service member is due to return to duty at the end of the additional 30 days.

2.4.2.10.3 Any additional extensions must be with a waiver from the Director, DHA for those Service members that have not been referred to a MEB.

2.4.2.10.4 For Service members who have been referred to an MEB, authorization is valid until Service member retires, separates, or returns to duty. No waiver is required.

2.4.2.10.5 May be provided in the home or authorized provider/facility. Use of an unauthorized provider/facility would require a waiver.

2.4.2.10.6 Custodial care services may be provided up to 24/7. The health care team will periodically review Service member’s care plan to revise amount of custodial care required.

2.4.2.10.7 The Service member’s health care team will determine the requirements of the Service member for Custodial Care, including the number of hours and duration of the service and will adjust these requirements accordingly as the Service member’s requirements change.

2.4.2.10.8 As required the contractors shall collaborate with DoD and DVA/VHA case managers along with the Service member’s health care team to ensure continuity of care and transition to DVA/VHA care and management upon retirement or separation.

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• The period of coverage for TCSRC shall be no more than 180 days from the date the diagnosed condition is validated by a DoD physician. If a medical condition is identified during the TAMP coverage period, but not validated by a DoD physician until a date after the TAMP coverage period, the start date will be the date the condition was validated by a DoD physician.

• Service members who are discovered to have a service-related condition, which cannot be resolved within the 180 day transitional care period, should be referred by SAS to the former Service member’s Service or to the DVA/VHA for a determination of eligibility for Government provided care.

• Care is authorized for the service-related condition(s) for 180 days from the date the DoD physician validates the service-related condition. For example, a service-related condition validated on day 90 of TAMP will result in the following time lines: Care under TAMP for other than the service-related condition terminates on day 180 after the beginning of TAMP coverage. Care for the service-related condition terminates on day 270 in this example (180 days from the day the service-related condition is validated by a DoD physician).

2.5.3 Eligibility

2.5.3.1 The eligible pool of beneficiaries are former Service members who are within their 180 day TAMP coverage period, regardless of where they currently reside.

2.5.3.2 A DoD physician must determine that the condition meets the criteria in paragraph 2.5.2. Final validation of the condition must be made by a DoD Physician associated with SAS. If the determination is made that the former Service member is eligible for this program, the former Service member shall be entitled to receive medical and adjunctive dental care for that condition only as if they were still on active duty. Enrollment into this program does not affect eligibility requirements for any other TRICARE program for the former Service member or their family members.

2.5.3.3 Enrollment in TCSRC includes limited eligibility for MTF/eMSM Pharmacy, Retail Pharmacy, TRICARE Pharmacy (TPharm) contract, and TRICARE Pharmacy Home Delivery Program benefits.

2.5.4 TCSRC Implementation Steps

The processes and requirements for a former Service member with a possible Section 1637 program condition are detailed in paragraphs 2.5.4.1 through 2.5.4.7. These steps, requirements, and responsibilities are applicable to SAS, the contractor, TRICARE civilian providers, and the Armed Forces.

2.5.4.1 DHA Communications will create materials to support beneficiary education on the Section 1637 benefit. Contractors shall collaborate with DHA Communications in the development of educational materials for both beneficiaries and providers.

2.5.4.2 A former Service member on TAMP that believes he/she has a service-related condition which may qualify them for the TCSRC program is to be referred to SAS for instructions on how to apply for the benefit.

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2.5.4.3 SAS reviews all TCRSC applications and determines if further clinical evaluation/testing of the former Service member is required. If further clinical evaluation/testing is needed. SAS will follow existing “defer to network” referral processes.

2.5.4.3.1 The contractor shall execute the referral and authorization to support health care delivery in the area in where the former Service member resides as follows:

2.5.4.3.2 If a DoD MTF/eMSM is within the one hour drive time Access To Care (ATC) standards and has the capabilities, they have first right of refusal.

2.5.4.3.3 If there is no MTF/eMSM or the MTF/eMSM does not have the capacity, then the contractor shall ascertain if a DVA/VHA medical facility (as a network provider) is within ATC standards and the facility has the necessary capabilities and capacity. The contractor shall pay these claims in the same manner as other active duty claims.

2.5.4.3.4 If neither an MTF/eMSM of DVA/VHA are available, the contractor shall locate a civilian provider that has both the capability and capacity to accept this referral request within the prescribed ATC standards. The contractor shall execute an active provider locator process (Health Care Finder (HCF)) to support the former Service member’s need for this referral request. SAS’s “defer to network” request shall be acted on by the contractor under the normal “urgent/72 hour” requirement.

2.5.4.3.5 The contractor shall inform the former Service member of the provider location and contact information so the former Service member can schedule an appointment. The contractor shall pay these claims in the same manner as other active duty claims.

• The contractor shall instruct the accepting provider to return the results of the encounter to SAS within 48 hours of the encounter.

2.5.4.3.6 Once the additional information is received, the DoD physician associated with SAS makes the determination of eligibility for the Section 1637 program. An eligibility determination for coverage under the Section 1637 will be made within 30 calendar days of receiving the former Service member’s request, inclusive of the time required to obtain additional information.

• If the coverage is denied, the former Service member may appeal the decision in writing to SAS within 30 calendar days of receipt of the denial. SAS will issue a final determination within 30 calendar days of receipt of the appeal. If SAS determines the condition should be covered under the Section 1637 program, coverage will begin on the date SAS renders the final determination.

2.5.4.4 If SAS determines the individual is eligible for the Section 1637 program, they will provide the enrollment information (Enrollment Start date and condition authorized for treatment) to the former Service member and the contractor responsible for enrollments in the region where the former Service member resides.

2.5.4.4.1 The notice will clearly identify it is for the Section 1637 program. The contractor shall enroll the former Service member into the Section 1637 program on DEERS using Government furnished web-based system/application within four business days of receiving the notification from SAS. This entry shall include the Start Date (date condition validated by the DoD physician); an EOC Code; and an EOC Description. The contractor shall enter the validated condition covered by the

22 C-58, September 20, 2019



Section 1637 program (received from SAS) into the contractor’s referral and authorization system within eight business days of receipt of the notification from SAS.

2.5.4.4.2 The contractor shall actively assist the former Service member using the HCF program to determine the location of final restorative health care for the identified Section 1637 condition. The location of service shall meet ATC standards.

2.5.4.4.3 The contractor shall instruct the accepting provider on the terms of this final “eval and treat” referral from SAS along with when and where to send clinical results/findings necessary to close out SAS’s files. DEERS will store the secondary Health Care Delivery Plan (HCDP) code, the date the condition was validated by the DoD physician, the EOC Code, and the EOC Description. DEERS shall return the HCDP code, the start and end dates for the coverage plan, the EOC Code, and the EOC Description with every eligibility query. This program is portable across all contractors.

2.5.4.5 Civilian and VHA claims for the specific condition will be processed as if the Service member were still on active duty, with no copayments required. If the “eval” or “eval and treat” referrals sent to the contractor from SAS are presented to an MTF/eMSM for execution, and the MTF/eMSM accepts, any subsequent MTF/eMSM generated “defer to network” requests will be accepted, recorded, and claim adjudicated; and this process may be outside the contractor’s EOC coding/criteria. The contractor may request clarifications from the MTF/eMSM on a subsequent “defer to network” request if the referral is for healthcare delivery that is not apparently related to the Section 1637 determined condition.

2.5.4.6 The Section 1637 benefit shall be terminated 180 days after the validated diagnosis is made by the DoD physician, no matter the status of the service-related condition. Following the termination of the Transitional Care period, further care for this service-related condition may be provided by the DVA/VHA.

2.5.4.7 Personnel on active duty for longer than 30 calendar days will have their Section 1637 coverage terminated by DEERS. Personnel scheduled to report for active duty (Early Alert Status), may have both the Section 1637 HCDP and HCDP 001 (for Active Duty). Once the active duty period actually begins, Section 1637 coverage will be terminated. If active duty orders are cancelled prior to entry on active duty, Section 1637 coverage will continue until the original end date. There is no reinstatement of the terminated Section 1637 coverage.

2.5.5 Claims Processing And Payment

2.5.5.1 The Section 1637 HCDP code may be present with any other HCDP code. During claims processing, if the TCSRC HCDP is received from DEERS, the contractor shall first determine if the claim being processed is for the Section 1637 condition or not. If the claim is for the specific service-related condition, the claim shall be processed and paid as if the Service member were an active duty Service member. The contractor shall determine if the claim is for an MTF/eMSM directed “defer to network” request for the Section 1637 condition which may not relate to the EOC codes determined by the contractor. If the claim is not for the covered condition, the claim shall be processed following the standard TRICARE procedures. If the claim includes services for the Section 1637 covered condition, and additional services, the contractor shall assess the claim’s status and take one of the following actions:

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2.5.5.1.1 Contractor Splits Claim

If a contractor receives a claim for a Service member eligible for Section 1637 coverage and the claim includes services not covered by the Section 1637 diagnosis, and the contractor can determine which services are covered under the Section 1637 condition, then the contractor shall split the claim into separate claims.

2.5.5.1.2 Contractor Returns Claim to Provider

If the claim does not meet the conditions described above, then the contractor shall return the claim to the submitter with an explanation that indicates the claim must be split in order to be paid.

2.5.5.2 Where a beneficiary has had clinical evaluation(s)/tests performed in order to determine eligibility for Section 1637 program coverage and has paid for those clinical evaluation(s)/tests out-of-pocket, the contractor shall process any claim(s) received for such clinical evaluation(s)/tests and shall pay any such claim as if the Service member were an active duty Service member.

2.5.5.3 Service members with multiple service-related conditions will have multiple Section 1637 enrollments. Each condition may have the same or different begin and end dates.

2.5.5.4 Jurisdiction rules for Section 1637 program coverage shall be in accordance with Chapter 8, Section 2.

2.5.5.5 The contractors shall pay all claims submitted for the specific service-related condition in the same manner as other active duty claims. There shall be no application of catastrophic cap, deductibles, cost-shares, copayments or coordination of benefits for these claims. Claims paid for the specific service-related condition under this change should be paid from non-financially underwritten funds.

2.5.5.6 Claims paid for medical care under the 180 day TAMP program, for other than the service-related condition, shall continue to be paid as an ADFM beneficiary under TRICARE with application of appropriate cost-shares and deductibles for these claims. The Section 1637 benefit does not extend the duration of the TAMP period beyond 180 days.

2.5.5.7 If the contractor is unable to determine if the care received is covered by the Section 1637 diagnosis, the claim is to be pended while the contractor obtains further clarification from SAS.

2.5.5.8 Pharmacy transactions at retail network pharmacies are processed on-line using the HIPAA data transaction standard of the National Council for Prescription Drug Programs (NCPDP). Under this standard, claims are adjudicated real time for eligibility along with clinical and administrative edits at the point of sale which includes cost-share determinations based on the Service member’s primary HCDP code.

2.5.5.8.1 Enrolled Service members determined to be eligible for pharmacy services based on their primary HCDP code will pay appropriate cost-shares as determined by their primary HCDP code and will submit a paper claim to the pharmacy contractor to seek reimbursement of these costs shares. Enrollment documentation that includes the specific condition for Section 1637 enrollment shall be submitted with their claim. The pharmacy contractor shall verify eligibility in DEERS and determine

24



coverage of the prescription based on the specific condition detailed in the supporting documentation.

2.5.5.8.2 Enrolled Service members determined to not be eligible for pharmacy services based on their primary HCDP code will pay out-of-pocket for the total cost of the prescription and then submit a paper claim to the pharmacy contractor for reimbursement. The pharmacy contractor shall verify eligibility in DEERS and determine coverage of the prescription based on the specific condition detailed in the supporting documentation.

2.5.5.8.3 In situations where the supporting document submitted by the former Service member to the pharmacy contractor does not provide sufficient detail of their covered condition, the pharmacy contractor shall contact SAS to obtain appropriate documentation of their covered condition needed to make a coverage determination and process the claim.

2.6 Advanced Rehabilitation Centers

See Chapter 8, Section 5, paragraph 2.8.

3.0 ENROLLMENT STATUS EFFECT ON CLAIMS PROCESSING

3.1 Active duty claims shall be processed without application of a cost-share, copayment, or deductible. These are SHCP claims.

3.2 Claims for TRICARE Prime enrollees who are in MTF/eMSM inpatient status shall be processed without application of a cost-share, copayment, or deductible. These are SHCP claims.

3.3 Claims for services provided under the current MOU between the DoD (including Army, Air Force, and Navy/Marine Corps facilities) and the DHHS (including the Indian Health Service, Public Health Service, etc.) are not SHCP claims. They shall be adjudicated under the claims processing provisions applicable to those specific agreements.

3.4 Claims for services provided under any local MOU between the DoD (including the Army, Air Force, and Navy/Marine Corps facilities) and the DVA/VHA are not SHCP claims. They shall be adjudicated under the claims processing provisions applicable to those specific agreements. (Claims for services provided under the current national MOA for SCI, TBI, and Blind Rehabilitation are covered, see Section 2, paragraph 3.1.)

3.5 Claims for participants in the CCEP shall be processed for payment solely on the basis of MTF/eMSM authorization. There will not be a cost-share, copayment, or deductible applied to these claims. These are SHCP claims.

3.6 Claims for non-TRICARE eligibles shall be processed for payment solely on the basis of MTF/eMSM or SAS authorization. There shall not be a cost-share, copayment, or deductible applied to these claims. These are SHCP claims.

3.7 Outpatient claims for non-TRICARE Medicare eligibles shall be returned to the submitting party for filing with the Medicare claims processor. These are not SHCP or TRICARE claims.

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3.8 Claims for TDRL participants shall be processed for payment in accordance with DoD/HA Policy Letter dated March 30, 2009, Subject: Policy Guidance for Use of Supplemental Health Care Program Funds to Pay for Required Physical Examinations for Members on the Temporary Disability Retirement List. There shall not be a cost-share, copayment, or deductible applied to these claims. These are SHCP claims. SHCP funds shall only be applied to the exam. SHCP funds shall not be used to treat the condition which caused Service member to be placed on the TDRL or for conditions discovered during the exam.

3.9 Claims from Service members enrolled in the FRCP shall be processed without application of a cost-share, copayment, or deductible. These are SHCP claims.

4.0 MEDICAL RECORDS

The current contract requirements for medical records shall also apply to Service members in this program, with the additional requirement that Service members shall also be given copies directly. Narrative summaries and other documentation of care rendered (including laboratory reports and X-rays) shall be given to the Service member for delivery to his/her PCM and inclusion in his/her military health record. The contractor shall be responsible for all administrative/copying costs. Under no circumstances will the Service member be charged for this documentation. Network providers shall be reimbursed for medical records photocopying and postage costs incurred at the rates established in their network provider participation agreements. Participating and non-participating providers shall be reimbursed for medical records photocopying and postage costs on the basis of billed charges. Service members who have paid for copied records and applicable postage costs shall be reimbursed for the full amount paid to ensure they have no out-of-pocket expenses. All providers and/or patients must submit a claim form, with the charges clearly identified, to the contractor for reimbursement. Service member’s claim forms should be accompanied by a receipt showing the amount paid.

5.0 REIMBURSEMENT

5.1 Allowable amounts shall be determined based upon the TRICARE payment reimbursement methodology applicable to the services reflected on the claim, (e.g., DRGs, mental health per diem, CMAC, Outpatient Prospective Payment System (OPPS), or TRICARE network provider discount). Reimbursement for services not ordinarily covered by TRICARE and/or rendered by a provider who cannot be a TRICARE authorized provider shall be at billed amounts unless a CMAC/DRG exists. Cost-sharing and deductibles shall not be applied to supplemental health care claims.

5.2 Claims with codes on the TRICARE inpatient only list performed in an outpatient setting shall be denied, except in those situations where the beneficiary dies in an emergency room prior to admission. Reference the TRM, Chapter 13, Section 2, paragraph 3.4. Professional providers may submit with modifier CA. No bypass authority is authorized for inpatient only procedure editing.

5.3 Pending development and implementation of recently enacted legislative authority to waive CMACs under TRICARE, the following interim procedures shall be followed when necessary to assure adequate availability of health care to Service members under SHCP. If required services are not available from a network or participating provider within the medically appropriate time frame, the contractor shall arrange for care with a non-participating provider subject to the normal reimbursement rules. The contractor initially shall make every effort to obtain the provider’s agreement to accept, as payment in full, a rate within the 100% of CMAC limitation. If this is not feasible, the contractor shall make every effort to obtain the provider’s agreement to accept, as payment in full, a

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Chapter 17 Addendum B

Specified Authorization Staff (SAS) Review For Authorization: Protocols And Procedures


1.0 INTERCONNECTIVITY BETWEEN THE CONTRACTOR AND DEFENSE HEALTH AGENCY-GREAT LAKES (DHA-GL) (THE SAS FOR ARMY, AIR FORCE, NAVY, MARINE CORPS, AND COAST GUARD)

1.1 Automated Data Processing (ADP) Protocols

1.1.1 For those Government staff who will remotely access the contractor’s system from the DHA-GL location, the contractor shall provide access for entry and edit of referrals into the contractor’s systems. The contractor shall include a status code indicating that SAS review is required.

1.1.2 The contractor shall submit a standard management report which provides the number of deferred claims that SAS staff reviewed and processed during each month. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

1.1.3 The contractor shall provide the capability to edit the status and entry of a 16 digit disposition code indicating if the referral was approved for civilian network treatment (see paragraph 1.2). This disposition code may be used during the claims adjudication process.

1.1.4 The contractor shall provide the logic to automatically approve the referral if the SAS determination is not received within two work days of referral entry.

1.1.5 The contractor shall provide the telecommunications, hardware, and software necessary for data entry and report printing from the SAS location. The contractor shall provide application training and support to the SAS staff who utilize the contractor’s referral system.

1.1.6 The contractor shall provide a data dictionary of available data elements to be sent to the SAS automated information system. The contractor shall send all care referral records to the SAS in a tab delimited data flat file. The method of transfer shall be File Transfer Protocol (FTP) or a secure, password-protected e-mail attachment.

1.1.7 The contractor shall provide the SAS with read-only access to their subcontractor’s claims history database. The contractor shall provide the necessary training to the SAS staff in order to access the claims history database.

1


Specified Authorization Staff (SAS) Review For Authorization: Protocols And Procedures

1.2 SAS Referral Data

1.2.1 The format of the referral number shall be DMISYYJJJNNNS where:

1.2.1.1 DMIS = the DMIS ID Code of the issuing facility (5203 = SAS);

1.2.1.2 YY = the last two digits of the year in which the referral number was issued;

1.2.1.3 JJJ = the Julian date on which the referral number was issued;

1.2.1.4 NNN = the Facility Sequence Number;

1.2.1.5 S = Status (the type of provider)

• C = Civilian Care (refer to Chapter 16, Section 2, paragraph 5.3.1.2 for referral requirements)

• M = Military Care (medical Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) or clinic)

• V = Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) Care (DVA/VHA hospital or medical facility)

• P = Care rendered under the Department of Defense/Department of Veterans Affairs (DoD/VA) Memorandum of Agreement (MOA) for “Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services” (refer to Section 2, paragraph 3.1 for referral requirements).

1.2.2 The format of the effective date is YYYYMMDD where:

• YYYY = the year in which the SAS referral is effective;

• MM = the month in which the SAS referral is effective; and

• DD = the day on which the SAS referral is effective. A retroactive authorization is indicated by an effective date prior to the issue date.

1.2.3 The format of the expiration date is YYYYMMDD where:

• YYYY = the year in which the SAS referral expires;• MM = the month in which the SAS referral expires; and• DD = the day on which the SAS referral expires.

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Claims Processing For TRICARE Dual Eligibles

5.0 UTILIZATION MANAGEMENT (UM)

Any UM provisions applied under the TRICARE MCSCs, except for those specifically required by the TPM, TRM, or TRICARE Operations Manual (TOM), shall not apply under TDEFIC. Region-specific requirements shall not apply.

6.0 END OF PROCESSING

6.1 Beneficiary Cost-Shares

End of Processing. TRICARE For Life (TFL) beneficiary cost-shares shall be based on the following when TRICARE is the primary payer. If the services were received by a TRICARE Prime enrollee (as indicated on DEERS), the TDEFIC contractor shall calculate the Prime copayments applicable on the date services were received. For a beneficiary who is not a Prime enrollee, if a provider is known to be a network provider (e.g., Veterans Health Administration (VHA) medical facility) the Extra cost-shares shall be applied to services received prior to January 1, 2018; if the provider is not a known network provider, the TRICARE Standard cost-share shall be applied. For a beneficiary who is a TRICARE Select enrollee, services received from a known network provider on or after January 1, 2018, will have the TRICARE Select network copayments applied; if the provider is not a known network provider, the TRICARE Select out-of-network cost-share shall be applied. For a TFL beneficiary who is not a Prime enrollee, services received on or after January 1, 2018, shall have the TRICARE Standard copayment (see TRM, Chapter 2) applied as if TRICARE Standard were still being implemented.

6.2 Application Of Catastrophic Cap

Only the actual beneficiary out-of-pocket liability remaining after TRICARE payments will be counted for purposes of the annual catastrophic loss protection.

6.3 Appeals

Initial Determinations. Services and supplies denied payment by Medicare will not be considered for coverage by TRICARE if the Medicare denial of payment is appealable under the Medicare appeal process. If, however, a Medicare appeal results in some payment by Medicare, the services and supplies covered by Medicare will be considered for coverage by TRICARE. Services and supplies denied payment by Medicare will be considered for coverage by TRICARE, if the Medicare denial of payment is not appealable under the Medicare appeal process. The appeal procedures set forth in Chapter 12 are applicable to initial denial determinations by TRICARE under TDEFIC. Appeals of SNF preauthorizations follow concurrent review procedures.

7.0 TED SUBMISSION

For every claim processed to completion, the TDEFIC contractor shall submit a TRICARE Encounter Data (TED) record to DHA in accordance with the requirements of the TRICARE Systems Manual (TSM).

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Claims Processing For TRICARE Dual Eligibles

8.0 TRICARE PROCESSING STANDARDS

All TRICARE Processing Standards in Chapter 1, Section 3 apply except for Chapter 1, Section 3, paragraphs 1.2, 1.3, 1.4, and 5.0.

- END -

4


Transition

2.2 Execution of Agreements with Network Pharmacies

2.2.1 Retail network pharmacy agreements shall be executed, and loaded into the incoming contractor’s system(s) 60 calendar days prior to the start of retail pharmacy services, or at other such time as is mutually agreed upon between the incoming contractor and the PCO.

2.2.2 The incoming contractor shall report on the adequacy of the network on a monthly basis during the transition. These reports are due to the PCO and the COR within 10 calendar days following the last day of the reporting period, and shall provide the following information:

• The number of network pharmacies;

• The number of network additions/deletions since the last reporting period;

• Activities undertaken to contract with additional pharmacies in areas lacking an adequate network; and

• A listing of network pharmacies.

3.0 BENCHMARK TESTING

3.1 General

Prior to the start of services, the incoming contractor shall demonstrate the ability of its staff and its automated systems to accurately process all types of TRICARE Pharmacy (TPharm) claims in accordance with current requirements. This will be accomplished through a comprehensive Benchmark test. The Benchmark test is administered by the incoming contractor under the oversight of DHA, and must be completed no later than 60 days prior to the start of services under this contract.

3.1.1 The Benchmark test shall consist of up to 1,000 claims, testing a multitude of claim conditions, including TPharm covered and non-covered services, eligible and non-eligible beneficiaries, formulary and non-formulary processing, coordination of benefits, Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) claims, Medicaid claims, etc. The benchmark may require up to 17 consecutive calendar days at the contractor’s site(s). The test may also include adjustments and reversals, and submission of TRICARE Encounter Data (TED) records for these actions.

3.1.2 The Benchmark test is comprised of one or more cycles or batches of claims. When more than one cycle is used, each cycle may be submitted on consecutive days. Each cycle after the initial one will include new test claims, as well as claims not completed during preceding cycles. All aspects of claims processing may be tested.

3.1.3 The incoming contractor shall demonstrate its ability to conduct eligibility verification and claims processing functions to include:

• Claims control and development; accessing and updating DEERS for eligibility status;

• Calculating cost-shares and deductibles;

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Transition

• Querying and updating internal and external family and patient deductible and cost-share files on the Catastrophic Cap and Deductible Data (CCDD) file;

• Accessing and updating PDTS;

• Applying utilization review criteria;

• Adjusting and canceling previously processed claims (inside and outside the 10-day window for network retail pharmacy claims); and

• Producing required output for paper and electronic transactions.

3.1.4 The Benchmark test may include testing of any and all systems (internal and external) used by the incoming contractor to process claims. The Benchmark will also test generation and submission of TED records for every test claim. Incoming contractor compliance with applicable Health Insurance Portability and Accountability Act (HIPAA) and security requirements will be included in the Benchmark test, as appropriate.

3.1.5 The incoming contractor shall conduct the benchmark test. The test will be comprised of both paper and electronic (batch and Point of Service (POS)) claim transactions. The incoming contractor shall be required to create test claims, including prior authorizations and medical necessity reviews from test scenarios provided to the contractor by DHA. The incoming contractor shall supplement these test scenarios with any internal conditions if appropriate for testing.

3.1.6 A Benchmark test of a current contractor’s system may be administered at any time by DHA upon instructions by the PCO. All incoming contractor costs incurred to comply with the performance of the Benchmark test are the responsibility of the incoming contractor.

3.2 Benchmark Procedures

3.2.1 Approximately 60 calendar days following contract award, DoD/DHA representatives will conduct a pre-benchmark meeting with the incoming contractor to provide an overview of the test process, receive an overview of the contractor’s system(s), collect data for use in the benchmark, discuss the involvement of external systems in the test (e.g., DEERS and PDTS), and discuss the dates of the test and information regarding the administration of the test. At this time, DHA shall provide the test scenarios to the incoming contractor that are to be used in the development of the test claims.

Note: At DHA’s discretion, the test must be completed no later than 60 calendar days prior to the start of services to allow time to make any needed corrections. The pre-benchmark meeting will be conducted at the incoming contractor’s site. Data requirements will be coordinated at the pre-benchmark meeting to ensure that the incoming contractor adequately prepares all files prior to the benchmark. Electronic transaction requirements shall be discussed to include timing and logistics.

3.2.2 At this pre-benchmark meeting, the incoming contractor shall be advised of the logistics of the Benchmark test including the number of DoD/DHA staff who will monitor and evaluate the results of the test; the amount of time the incoming contractor shall have to process test claims; the process and point of contacts for the incoming contractor to use for questions related to the test scenarios provided by DHA; space requirements for the DHA team including access to telephones, computer terminals, and printers; and what reference documents the incoming contractor shall make available to

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TRICARE Operations Manual 6010.59-M, April 1, 2015TRICARE Overseas Program (TOP)


Communications and Customer Service (C&CS)


1.0 GENERAL

1.1 All TRICARE requirements regarding C&CS shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (U.S.) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 11 for additional instructions.

1.2 Per Department of Defense Instruction (DoDI 6010.21 (“TRICARE Marketing Policy”) dated December 18, 2001, TRICARE marketing materials developed by contractors must be coordinated with each TRICARE Regional Office (TRO) and approved by Defense Health Agency (DHA). For the TOP contract, this coordination includes the TRICARE Area Office (TAO) Directors and the TOP Office (TOPO). Coordination of local administrative changes is at the local discretion of Military Treatment Facilities (MTFs).

2.0 TRICARE SERVICE CENTERS (TSCs)

2.1 Location, Operations, And Staffing

2.1.1 TSCs are jointly staffed by MTF personnel and TOP contractor personnel. TSCs in the MTFs shall be staffed at a minimum, Monday - Friday (except holidays recognized by the installation) during the administrative hours of the MTF.

2.1.2 The TOP contractor shall provide Beneficiary Service Representatives (BSRs) on a full-time basis at each location as designated in the contract. BSRs shall be qualified to perform enrollments/disenrollments/Primary Care Manager (PCM) changes; perform registrations in Composite Health Care System (CHCS) (as required to support TRICARE enrollments) and update patient information in CHCS and Defense Enrollment Eligibility Reporting System (DEERS); resolve PCM Information Transfer (PIT) discrepancies; assist beneficiaries with TRICARE benefit/coverage or claims questions; assist beneficiaries with debt collection issues; and provide TRICARE briefings as requested by the MTF. The TOP contractor shall provide sufficient BSR staffing to accomplish all work in a timely manner; however, at least one full-time BSR will be assigned to each location regardless of actual workload unless the Government has specifically authorized part-time coverage. The TOP contractor shall advise the Government of any locations where the workload does not justify full-time BSR coverage. The TOP contractor shall implement appropriate business processes to provide full-time TSC coverage if the assigned Customer Service Representative(s) (CSR(s)) are unavailable due to planned or unplanned absences (e.g., illness, leave, personal emergencies, etc.) for more than two consecutive business days. Local processes for managing short-term CSR absences (up to two consecutive business days) shall be

1



addressed in the Statement of Responsibilities (SOR) between the affected MTF Commander(s) and the TOP contractor.

2.1.3 The TSC shall meet the standards in Chapter 1, Section 3, as applicable.

2.2 TSC Functions

2.2.1 The contractor shall provide overseas TSCs with BSR support to provide all Military Health System (MHS) beneficiaries with information and services as specified below. The contractor shall confirm eligibility for care and enrollment status of beneficiaries before making any arrangements for medical services. (Eligibility for the non-active duty patients is determined by the MTF per Section 26, paragraph 2.4.4.) TSCs shall have an interface with the automated claims processing and enrollment systems to support the functions of the TSC no later than 30 calendar days prior to the start of health care delivery (SHCD).

2.2.2 The contractor shall provide all MHS beneficiaries with information regarding:

• TOP Prime, TOP Prime Remote, and TOP Select enrollment information;

• Access to and referral for care;

• Information on the Point of Service (POS) option;

• Information on claims (including on-line access to the claims processing system for information about the status of a claim);

• Assistance regarding claim problems when the TOP contractor is responsible for processing the claim; and

• Continuity-of-care services to all MHS beneficiaries including, but not limited to, active duty personnel, dependents of active duty personnel, retirees and their dependents, survivors, Medicare-eligible beneficiaries and all other categories of individuals eligible to receive MHS services.

TSCs shall have a fully operational, on-line interface with the automated claims processing and enrollment systems to support the functions of the TSC no later than 30 calendar days prior to the SHCD and shall maintain that interface through the life of the contract. The activities of the TSC shall include:

2.2.2.1 MHS Beneficiary Information

The TOP contractor shall provide personal assistance to all MHS beneficiaries seeking information about TRICARE Prime, TRICARE Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018), and TRICARE For Life (TFL). The TOP contractor shall ensure that the TSCs are supplied with enrollment and educational information for TRICARE Prime and TRICARE Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018), dual-eligible program and claims submission information, Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), TRICARE dental programs and all other relevant materials. Through the BSRs and call centers, the TOP contractor shall establish mechanisms to advise beneficiaries of care options,

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including the POS option, and services offered.

2.2.2.2 BSR Interface With MTFs

BSRs shall act as the focal point for providing information, referral, and assistance to beneficiaries seeking access to TRICARE services. BSRs shall maintain day-to-day liaison with MTF staff to promote MTF optimization and ensure effective performance of the access, referral, information, and continuity of care functions.

2.2.2.3 Enrollment

BSRs and contractor call center staff shall provide personal assistance to eligible beneficiaries, electing to enroll or disenroll, and permanently assigned active duty personnel enrolling in TRICARE Prime. The TOP contractor shall provide assistance to all MHS beneficiaries, including active duty, Medicare eligibles, and others, in understanding program requirements, by answering questions, adhering to MTF Commanders’ and TAO Director’s determinations for Primary Care Manager (PCM) assignment, and following grievance and inquiry procedures in accordance with this manual.

2.2.2.4 Providers

The TOP contractor shall maintain an up-to-date on-line provider search tool for all providers and facilities in the contractor’s network in accordance with Chapter 11, Section 4. A copy of the most current list will be maintained by each BSR for TSC use. MTF Commanders, TAO and TOPO staff, and MHS beneficiaries shall be granted access to these lists on an as-needed basis. Contractor staff in the TSCs shall provide lists of Direct Care (DC) PCMs to MHS beneficiaries when required for PCM selection, if these lists are provided to the contractor by the MTF.

2.2.2.5 Claims

Contractor staff in the TSCs shall assist all TRICARE beneficiaries with all claims issues when the TOP contractor is responsible for processing the claim. When the TOP contractor is not responsible for processing the claim, the contractor staff in the TSC shall assist the beneficiary in identifying and contacting the organization that is responsible for processing the claim.

2.2.2.6 TRICARE Dental Plans

Contractor staff in the TSCs shall provide general information on eligibility for the TRICARE Dental Plans (Active Duty Dental Program (ADDP), TRICARE Dental Program (TDP), and TRICARE Retired Dental Program (TRDP)) and how to obtain dental plan information from the appropriate dental contractor. The beneficiaries shall be referred to the appropriate dental contractor for additional information.

2.3 Creating And Updating Department of Defense (DoD) Self-Service Logon (DS Logon) Accounts

DoD affiliates and Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) affiliates qualify for a DS Logon account. A DS Logon is a secure, self-service logon ID that allows DoD/DVA/VHA affiliates to access certain web sites using a single username and password. DoD/DVA affiliates are DoD sponsors, spouses (regardless of age), and dependents (18 and older), and retirees

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and veterans who have an active affiliation in the Defense Enrollment Eligibility Reporting System (DEERS), which includes Reserve Component (RC) sponsors (including all subcomponents such as the Selected Reserve, Retired Reserve, Individual Ready Reserve (IRR), and Standby Reserve) along with their spouses, and dependents (18 and older). The DoD Self-Service Access Station (DS Access Station) is an on-line web application developed by the Defense Manpower Data Center (DMDC) for the purpose of creating DS Logon account requests on behalf of DoD/DVA/VHA affiliates. When a beneficiary inquiry concerns the DS Logon, the contractor shall refer the caller to the DoD MyAccessCenter application help section at https://myaccess.dmdc.osd.mil/.

2.3.1 DS Access Station

Upon request by DoD/DVA/VHA affiliates, TSC personnel shall use the DS Access Station and perform In-Person Proofing (IPP) to generate requests for DMDC to create and update DS Logon accounts following instructions specified in the current version of the DS Logon - Access Station User Guide. DS Access Station is currently available at https://www.dmdc.osd.mil/appj/dsaccessstation/. The contractor shall request DS Access Station user authorization for TSC personnel from DMDC through the contractor’s DEERS site security manager. A copy of the current DS Logon - Access Station User Guide will be provided upon request.

2.3.2 DS Logon Account Levels

Two account levels of DS Logon access are available to DoD/DVA/VHA affiliates, each with progressing security features and each with a different user-authentication procedure:

2.3.2.1 Basic Account (Level 1)

This is an entry level user account established online that only provides limited view access to the user’s personal information that the user has provided on-line. This level of account is provided to individuals who have registered online at the eBenefits web site (http://www.ebenefits.va.gov) without being in-person proofed. Many applications will not allow access with a Basic (Level 1) Account.

2.3.2.2 Premium Account (Level 2)

This account is given to a DoD/DVA/VHA affiliate who has self-registered using their Common Access Card (CAC) or Defense Financing and Accounting Service (DFAS)/myPay Login ID or who has completed an IPP process with designated representatives such as TSC personnel. To provide enhanced security to the user’s personal information, access to most applications including TRICARE-related applications require a Premium (Level 2) Account.

2.3.3 Generating DS Logon Requests

2.3.3.1 Before generating a request for a Premium Account, TSC personnel shall determine if the requestor has an existing Basic Account. If they do, TSC personnel shall follow DS Logon user guide instructions to generate a request to upgrade the Basic Account to a Premium Account. Upon successful completion of an upgrade, the Premium Account is immediately available for use.

2.3.3.2 If a Premium Account is created outright rather than being upgraded from a Basic Account, the Premium Account will not be effective and available for use until the requestor receives a letter in

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http://www.ebenefits.va.gov

https://www.dmdc.osd.mil/appj/dsaccessstation/

https://myaccess.dmdc.osd.mil/



postal mail from DMDC and follows the instructions in the letter before the specified deadline to activate the Premium Account. If the requestor does not have an existing Basic Account, TSC personnel shall inform the requestor of the advantages of establishing a Basic Account and provide the requestor with the procedures for obtaining a Basic Account. If the requestor does not wish to create a Basic Account first, TSC personnel shall proceed with the procedures for a new DS Logon request.

2.3.4 DS Access Station Users and Confidentiality

Only users authorized by the DMDC may access the DS Access Station and perform IPP. Furthermore, only authorized DS Access Station users may view any documents presented for IPP or be informed in any way of information available in the DS Access Station. Every authorized user must safeguard the confidentiality of such information at all times to comply with the Privacy Act of 1974. The contractor shall return all documents presented for IPP to the requester and shall not retain any documents. The contractor shall not make photocopies or any other images of documents presented for IPP.

3.0 HEALTH CARE FINDER (HCF) SERVICES

3.1 TOP HCF functions are performed by TOP contractor personnel located in the TSCs or in contractor-operated call center(s). The TOP contractor shall offer call center operations to support HCF services via toll-free lines 24 hours per day, seven days per week, 365 days per year.

Note: The contractor shall offer claims assistance via toll-free lines seven days per week, 365 days per year, between the hours of 2:00 AM and 7:00 PM Central Standard Time (CST). These service hours for claims assistance apply even if claims assistance is provided via the contractor’s call center(s).

3.1.1 HCFs are responsible for facilitating access to purchased care sector provider care (including, but not limited to, primary care, specialty care, mental health care, ancillary services, Durable Medical Equipment (DME), and pharmacy services), and for authorizing certain health care services. Additionally, HCFs shall inform beneficiaries of access mechanisms, referral procedures, and rules regarding use of network/non-network providers. They shall also improve patient continuity of care by establishing mechanisms to facilitate necessary consultations, follow-up appointments and the sharing of medical records. TOP HCFs will serve all MHS beneficiaries in the region, regardless of their enrollment status. This includes dual-eligible beneficiaries and beneficiaries residing or enrolled in the 50 U.S. and the District of Columbia who may require assistance when accessing care in an overseas location.

3.1.2 For MTF enrollees, the specialty care referral process includes a covered benefit review; entering appropriate authorizations into the contractor’s system; locating a qualified network or non-network purchased care sector provider to provide the care on a cashless, claimless basis; providing the beneficiary with a written care authorization and the purchased care sector provider’s information; and assisting the beneficiary with establishing an appointment with the purchased care sector provider (upon beneficiary request).The contractor shall also provide information to MTF personnel regarding the status of specialty care referrals and shall work cooperatively with the MTF to assist in obtaining consult results from purchased care sector providers; however, the contractor is not responsible for tracking receipt of consult results.

3.1.3 For TOP Prime Remote enrollees, the specialty care referral process includes a medical necessity review; a covered benefit review; entering appropriate authorizations into the contractor’s

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system; locating a qualified network or non-network purchased care sector provider to provide the care on a cashless, claimless basis; providing the beneficiary with a written care authorization and the purchased care sector provider’s information; and assisting the beneficiary with establishing an appointment with the purchased care sector provider (upon beneficiary request). This process is also applicable to Service members who are on Temporary Additional Duty/Temporary Duty (TAD/TDY), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location, and to TRICARE Prime/TRICARE Prime Remote (TPR) enrollees who require urgent specialty care while traveling outside the 50 U.S. and the District of Columbia.

Note: This process applies to all TOP Prime Remote enrollees, regardless of the status/location of the referring provider or health unit.

3.1.4 Beneficiaries enrolled to the Uniformed Services Family Health Plan (USFHP) and the Continued Health Care Benefit Program (CHCBP) must follow the requirements of those programs when obtaining overseas care.

3.2 The TOP HCF is responsible for the following functions:

3.2.1 Referral Assistance for TOP Beneficiaries

The TOP contractor (working in concert with the MTF Commander) shall ensure optimal use of MTFs and to foster coordination of all care delivered in the civilian sector and care referred to and from the MTF. The TOP HCF is the primary mechanism for achieving these objectives. The referral services of the TOP HCF are primarily to ensure access to care for enrolled beneficiaries, but the TOP HCF is also available to assist non-enrollees in finding network/non-network purchased care sector providers. For TOP Prime/TOP Prime Remote enrollees, the referral is generally initiated by the beneficiary’s PCM. The PCM or beneficiary contacts the TOP HCF for assistance in locating an appropriate purchased care sector provider and to obtain authorization for the care (see Sections 17 and 18 for additional information on HCF referral assistance).

3.2.2 Referral Assistance for Beneficiaries Enrolled or Residing in the 50 U.S. and the District of Columbia

The TOP contractor shall provide referral assistance for TRICARE Prime/TPR enrollees who require urgent or emergent health care while traveling outside the 50 U.S. and the District of Columbia. These referrals will generally be initiated by the beneficiary, a purchased care sector provider, or an overseas MTF provider. Emergency care never requires preauthorization; however, ADFMs enrolled to TRICARE Prime/TPR may receive urgent and emergency health care services in locations outside the 50 U.S. and the District of Columbia (to include emergency medical evacuation per Section 7) on a cashless, claimless basis if the care is coordinated in advance with the TOP contractor. The TOP contractor shall implement guarantee of payment or other business processes to ensure that ADFMs enrolled to TRICARE Prime/TPR may receive urgent or emergency medical services on a cashless, claimless basis upon beneficiary request.

Note: Routine care will not be authorized for traveling TRICARE Prime/TPR enrollees overseas.

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TRICARE Operations Manual 6010.59-M, April 1, 2015Prescription Monitoring Program (PMP)


Prescription Monitoring Program (PMP)


1.0 SCOPE

1.1 The prescription monitoring program is a quarterly review of all beneficiaries who received prescriptions using TRICARE benefits. The program below applies to the regional contractors and TRICARE Pharmacy (TPharm) contractor. Uniformed Services Family Health Plan (USFHP), Dental, TRICARE for Life (TFL), Veterans Health Administration (VHA), or overseas contractors are excluded from quarterly reporting but may be contacted as necessary to resolve non-routine cases such as a beneficiary who is seeing multiple dentists or a beneficiary assigned to overseas contractor who is obtaining large volumes of prescriptions within TPharm contractor’s jurisdiction. Military Treatment Facilities/Enhanced Multi-Service Markets (MTFs/eMSMs) will receive data of persons for whom the MTF is (or acts as) a Primary Care Manager (PCM), but are not required to participate in this program (for details refer to DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract). Any contractor or MTF/eMSM may use the restriction portion of the program at their discretion. The goal of the program is to identify beneficiaries who may need additional medical assistance by providing knowledge of resources and maintaining compliance with the guidelines described within 32 CFR 199.4.

1.2 The prescription monitoring program performs automated review using predefined algorithms to identify beneficiaries with a higher use of controlled substances (Schedule II-V) than parameter thresholds. Other non-controlled substances maybe included if they are known to be combined with Schedule II-V for purposes of substance abuse. The results will be sent to the appropriate contractor based on beneficiary’s PCM assignment (Prime) or location (Select) for review.

1.3 The contractors shall designate a “reviewer”. The reviewer can be a contractor’s Chief Medical Officer (CMO) or a person approved by the CMO. The reviewer should have the appropriate credentials to review all types of claims. The reviewer is responsible for reviewing individuals on the quarterly list and making determinations based on the beneficiaries’ entire profile regardless of individual providers seen over the duration of the report. The reviewer will conduct a medical review of the patient history to validate utilization with medical diagnosis and appropriateness of care. The level of review necessary is the breadth and depth needed to make an accurate determination. It may include claims review, record review, or any other relevant information as necessary to make an accurate determination. Any inconsistencies with utilization and medical diagnosis and/or over-utilization concerns for medical diagnosis noted by the reviewer will necessitate the contractor to develop a support plan. A support plan could be restrictions only or include case management, pain management, behavioral health, or any other contractually available services. If the plan includes restrictions, the contractor will notify the TPharm contractor and the TPharm contractor will begin the process outlined in paragraph 5.2.

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Prescription Monitoring Program (PMP)

1.4 All communication and coordination will comply with Health Insurance Portability and Accountability Act (HIPAA) standards.

2.0 BACKGROUND

2.1 The 32 CFR 199.4(e)(11) states that:

“TRICARE benefits cannot be authorized to support or maintain an existing or potential drug abuse situation whether or not the drugs (under other circumstances) are eligible for benefit consideration and whether or not obtained by legal means. Drugs, including the substitution of a therapeutic drug with addictive potential for a drug of addiction, prescribed to beneficiaries undergoing medically supervised treatment for a Substance Use Disorder (SUD) as authorized under paragraph (e)(4)(ii) of this section are not considered to be in support of, or to maintain, an existing or potential drug abuse situation and are allowed.”

This does not preclude payment for medically necessary services.

2.2 Both contractors and the TPharm contractor are responsible for implementing utilization control and quality measures designed to identify possible drug abuse situations. Each contractor is responsible for screening all claims within their system for medication line items that show potential over-utilization and irrational prescribing of drugs, and to subject any such cases to an extensive review to establish the necessity for the drugs and their appropriateness on the basis of diagnosis or definitive symptoms. This program is to supplement the objective of the Code of Federal Regulations (CFR) language and not meant to be the sole means of utilization control.

3.0 INITIAL REVIEW AND SUPPORT SERVICES

3.1 Each quarter, the TPharm contractor shall generate for each of the contractors, a list of all beneficiaries surpassing the current established parameters. The parameters are based on pharmacy’s commercial best practices for identifying potential fraud and abuse. These parameters are constantly evolving and not made publicly available. The TPharm contractor will be responsible for communicating the parameters to the Government and identifying when changes are necessary. The data provided to the contractor will be divided into subsets based on beneficiary’s PCM assignment (Prime or TRICARE Plus) or region location (e.g., residential address of Select beneficiaries). The data will be arranged in a two tiered report. One section will be a summary of individuals included for the quarter and one page will be claim level detail for the past 180 days. The report will contain the latest status (see paragraph 3.3) reported by the contractor. The list will also identify how many times within the past five years each beneficiary has been identified on the report. The report is sent to the contractor for medical review.

3.2 During the quarter, if concerns about controlled substance use are identified by other entities such as private providers (physician, nurse practitioners, etc.) or reviewers in the course of business, the TPharm contractor shall refer the identified beneficiaries to the appropriate contractor. Individuals identified by clinicians shall be put on 100% prepayment review by the TPharm contractor and must be provided a medical review by the contractor as received to determine final status. These should be given priority over the quarterly list and may be counted towards the minimum 20 cases per quarter.

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TRICARE Operations Manual 6010.59-M, April 1, 2015Appendix A, Definitions

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

A program of medical care for spouses and dependent children of disabled or deceased disabled veterans who meet the eligibility requirements of the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA).

Change Order

A written directive from the DHA Procuring Contracting Officer (PCO) to the contractor directing modifications, within the general scope of the contract, as authorized by the “changes clause” at FAR 52.243-1, Changes--Fixed Price.

Christian Science Nurse (Defined in 32 CFR 199.2)

An individual who has been accredited as a Christian Science Nurse by the Department of Care of the First Church of Christ, Scientist, Boston, Massachusetts, and listed (or eligible to be listed) in the Christian Science Journal at the time the service is provided. The duties of Christian Science nurses are spiritual and are nonmedical and nontechnical nursing care performed under the direction of an accredited Christian Science practitioner. There are two levels of Christian Science nurse accreditation:

1. Graduate Christian Science Nurse. This accreditation is granted by the Department of Care of the First Church of Christ, Scientist, Boston, Massachusetts, after completion of a three year course of instruction and study.

2. Practical Christian Science Nurse. This accreditation is granted by the Department of Care of the First Church of Christ, Scientist, Boston, Massachusetts, after completion of a one year course of instruction and study.

Christian Science Practitioner (Defined in 32 CFR 199.2)

An individual who has been accredited as a Christian Science Practitioner for the First Church of Christ, Scientist, Boston, Massachusetts, and listed (or eligible to be listed) in the Christian Science Journal at the time the service is provided. An individual who attains this accreditation has demonstrated results of his or her healing through faith and prayer rather than by medical treatment. Instruction is executed by an accredited Christian Science teacher and is continuous.

Christian Science Sanatorium (Defined in 32 CFR 199.2)

A sanatorium either operated by the First Church of Christ, Scientist, or listed and certified by the First Church of Christ, Scientist, Boston, Massachusetts.

Claim

Any request for reimbursement for health care services rendered, received from a beneficiary, a beneficiary’s representative, or a network or non-network provider, by a contractor on any TRICARE-approved claim form or approved electronic medium.

Note: If two or more forms for the same beneficiary are submitted together, they shall constitute one claim unless they qualify for separate processing under the claims splitting rules. (It is recognized that services may be provided in situations in which no claims, as defined here, are generated. This

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does not relieve the contractor from collecting the data necessary to fulfill the requirements of the TED record for all care provided under the contract.)

Note: Any request for reimbursement of a dispensed pharmaceutical agent or diabetic supply item. For electronic media claims, one prescription equals one claim. For paper claims, reimbursement for multiple prescriptions may be requested on a single paper claim.

Claim File

The collected records submitted with or developed in the course of processing a single claim. It includes the approved TRICARE claim form and may include attached bills, medical records, records of telephone development, copies of correspondence sent and received in connection with the claim, the EOB, and records of adjustments to the claim. It may also include the records of appeals and appeal actions. The claim file may be in microcopy, hard copy, or in a combination of media.

Claim Form

A fixed arrangement of captioned spaces designed for entering and extracting prescribed information, including ADP system forms.

Claims Cycle Time

That period of time, recorded in calendar days, from the receipt of a claim into the possession/custody of the contractor to the completion of all processing steps (see the definition of “Processed to Completion (or Final Disposition)” in this appendix, and the TSM, Chapter 2, Section 2.4, “Date TED Record Processed to Completion”).

Claims Payment Data

The record of information contained on or derived from the processing of a claim or encounter.

Clinical Quality Outcomes

The American College of Medical Quality in their 2010 revision of their recommended Core Curriculum for Medical Quality Management describes clinical outcomes as part of the definition of quality measures. These are:

1. Structural Measures - health care setting, appropriate equipment and supplies, education, certification and experience of clinicians;

2. Process Measures - actions taken and how well these were performed to achieve a given outcome, use of evidence-based clinical guidelines;

3. Outcome Measures - capture of changes in health status following the provision of a set of healthcare processes and including the cost of delivering the processes -- hospitalizations, physician office visits, or care provided in post-acute care setting, patient satisfaction.

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Clinical Support Agreement (CSA)

An arrangement requested by the military, between an MTF/eMSM and the TRICARE contractor for the contractor to provide needed clinical personnel at an MTF/eMSM. The arrangement must be formalized by modification to the TRICARE contract prior to implementation of the provisions of the arrangement.

Code Set (HIPAA/Privacy Definition)

Any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions, as outlined in HIPAA of 1996.

Code Set Maintaining Organization (HIPAA/Privacy Definition)

An organization that creates and maintains the code sets adopted by the Secretary of Home Health Services (HHS) for use in the transactions for which standards are adopted as outlined in HIPAA of 1996.

Combined Daily Charge (Defined in 32 CFR 199.2)

A billing procedure by an inpatient facility that uses an inclusive flat rate covering all professional and ancillary charges without any itemization.

Concurrent Review/Continued Stay Review

Evaluation of a patient’s continued need for treatment, the appropriateness of current and proposed treatment, as well as the setting in which the treatment is being rendered or proposed. Concurrent review applies to all levels of care (including outpatient care).

Confidentiality Requirements

The procedures and controls that assure the privacy of personal medical information in compliance with the Freedom of Information Act, the Comprehensive Alcohol Abuse and Alcoholism Prevention and Rehabilitation Act, the Privacy Act, and HIPAA of 1996.

Confirmed Breach

An incident in which it is known that unauthorized access could occur. For example, if a laptop containing PII/PHI is lost and the contractor knows that the PII/PHI is unencrypted, then the contractor should classify and report the incident as a confirmed breach, because unauthorized access could occur due to the lack of encryption (the contractor knows this even without knowing whether or not unauthorized access to the PII/PHI has actually occurred). If the laptop is subsequently recovered and forensic investigation reveals that files containing PII/PHI were never accessed, then the possibility of unauthorized access can be ruled out, and the contractor should re-classify the incident as a non-breach incident.

Conflict Of Interest (Defined in 32 CFR 199.2)

Includes any situation where an active duty member (including a reserve member while on active duty) or civilian employee of the U.S. Government, through an official federal position, has the apparent or actual opportunity to exert, directly or indirectly, any influence on the referral of TRICARE beneficiaries

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to himself or herself or others with some potential for personal gain or appearance of impropriety. Individuals under contract to a Uniformed Service may be involved in a conflict of interest situation through the contract position.

Consultation (Defined in 32 CFR 199.2)

A deliberation with a specialist physician, dentist, or qualified mental health provider requested by the attending TRICARE authorized provider primarily responsible for the medical care of the patient, with respect to the diagnosis or treatment in any particular case. A consulting physician or dentist or qualified mental health provider may perform a limited examination of a given system or one requiring a complete diagnostic history and examination. To qualify as a consultation, a written report to the attending TRICARE authorized provider of the findings of the consultant is required.

Note: Staff consultations required by rules and regulations of the medical staff of a hospital or institutional provider do not qualify as consultations.

Consultation Appointment (Defined in 32 CFR 199.2)

An appointment for evaluation of medical symptoms resulting in a plan for management which may include elements of further evaluation, treatment and follow-up evaluation. Such an appointment does not include surgical intervention or other invasive diagnostic or therapeutic procedures beyond the level of very simply office procedures, or basic laboratory work but rather provides the beneficiary with an authoritative option.

Consulting Physician or Dentist (Defined in 32 CFR 199.2)

A physician or dentist, other than the attending physician, who performs a consultation.

Continued Health Care Benefit Program (CHCBP)

A TRICARE benefit program that provides temporary continued health care for certain former beneficiaries of the MHS. Coverage under the CHCBP is purchased on a premium basis.

Continuity of Care

Follow on of health care services from a specific individual professional provider as part of a specific procedure or service that was performed within the previous six months in order to not disrupt therapy or repeat services.

Continuum of Care

All patient care services provided from “pre-conception to grave” across all types of settings. Requires integrating processes to maintain ongoing communication and documentation flow between the DC system and network.

Contract Performance Evaluation (CPE)

A review by DHA, of a contractor’s level of compliance with the terms and conditions of the contract. Usually, an operational audit performed by DHA staff that focuses on timeliness, accuracy, and responsiveness of the contractor in performing all aspects of the work required by the contract.

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Director, TRICARE Regional Offices (TROs)

An individual responsible for:

1. Overseeing and ensuring there is an integrated health care delivery system for TRICARE beneficiaries in the region; and

2. Oversight of the management/monitoring of the daily administration of the TRICARE contract/contractor(s) in the region; and

3. Managing the daily activities of the TRO.

Disaster Response Duty

For purposes of TPM, Chapter 10, Section 10.1 only, the term “disaster response duty” means duty performed by a member of the National Guard in State status pursuant to an emergency declaration by the Governor of the State (to include the four United States Territories, or with respect to the District of Columbia, the mayor of the District of Columbia) in response to a disaster or in preparation for an imminent disaster.

Discharge Planning

The development of an individualized discharge health care plan for the patient prior to leaving an institution to follow at home, with the aim of improving patient outcomes, reducing the chance of unplanned readmission to an institution, and containing costs.

Disclosure (HIPAA Definition)

The release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information as defined in HIPAA of 1996.

Distant Site

The “distant site” is where the physician or practitioner providing the professional service is located at the time the services are provided via an interactive telecommunications system.

DoD Information

Information that is provided by the DoD to a non-DoD entity, or that is collected, developed, received, transmitted, used, or stored by a non-DoD entity in support of an official DoD activity, where that information has not been cleared for public release.

Domiciliary Care (Defined in 32 CFR 199.2)

Care provided to a patient in an institution or home-like environment because:

1. Providing support for the ADLs in the home is not available or is unsuitable; or

21


2. Members of the patient’s family are unwilling to provide the care.

Note: The terms “domiciliary” and “custodial care” represent separate concepts and are not interchangeable. Custodial care and domiciliary care are not covered under the TRICARE programs or the Extended Care Health Option (ECHO).

Donor (Defined in 32 CFR 199.2)

An individual who supplies living tissue or material to be used in another body, such as a person who furnishes a kidney for renal transplant.

Double Coverage (Defined in 32 CFR 199.2)

When a TRICARE beneficiary also is enrolled in another insurance, medical service, or health plan that duplicates all or part of a beneficiary’s TRICARE benefits.

Double Coverage Plan (Defined in 32 CFR 199.2)

The specific insurance, medical service, or health plan under which a TRICARE beneficiary has entitlement to medical benefits that duplicate TRICARE benefits in whole or in part. Double coverage plans do not include:

1. Medicaid.

2. Coverage specifically designed to supplement TRICARE benefits.

3. Entitlement to receive care from the Uniformed Services medical care facilities; or

4. Entitlement to receive care from DVA/VHA medical care facilities; or

5. Entitlement to receive care from Indian Health Services medical care facilities; or

6. Services and items provided under Part C (Infants and Toddlers with Disabilities) of the Individuals With Disabilities Education Act (IDEA).

Dual Compensation (Defined in 32 CFR 199.2)

Federal law (5 USC 5536) prohibits active duty members or civilian employees of the U.S. Government from receiving additional compensation from the Government above their normal pay and allowances. This prohibition applies to TRICARE cost-sharing of medical care provided by active duty members or civilian Government employees to TRICARE beneficiaries.

Edit Error (TEDs Only)

Errors found on TEDs (initial submissions, resubmissions, and adjustments/cancellation submissions) which result in non-acceptance of the records by DHA. These require correction of the error by the contractor and resubmission of the corrected TED to DHA for acceptance.

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Mental Health Therapeutic Absence (Defined in 32 CFR 199.2)

A therapeutically planned absence from the inpatient setting. The patient is not discharged from the facility and may be away for periods of several hours to several days. The purpose of the therapeutic absence is to give the patient an opportunity to test his or her ability to function outside the inpatient setting before the actual discharge.

Military Health System (MHS) Beneficiary

Any individual who is eligible to receive treatment in an MTF/eMSM. Eligibility is determined by the Uniformed Services and is reported on DEERS.

Note: The categories of MHS beneficiaries shall be broadly interpreted unless otherwise specifically restricted. (For example: Authorized parents and parents-in-law are not eligible for TRICARE Program, but may receive treatment in an MTF/eMSM (on a space available basis) and may access the Nurse Advise Line (NAC)).

Military Treatment Facility (MTF)

A Uniformed Services hospital or clinic.

Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) Optimization

Filling every appointment and bed available within the MTF or in the eMSM based on the capacity and capabilities of the MTF/eMSM and the MTF’s/eMSM’s readiness/training requirements, as defined by the MTF Commander/eMSM Manager before referral to outside civilian providers.

Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM)-Referred Care

Medical care or services/supplies required by a patient that are not available at the MTF or in the eMSM area and therefore must be provided by an outside civilian provider. Such care requires an MTF/eMSM referral for the civilian medical care.

Mobilization Plan - TRICARE

A detailed proposal designed to ensure the Government’s ability to continue to meet the health care needs of the TRICARE-eligible beneficiaries in the event of a military mobilization that precludes the use of all or parts of the military DC system for provision of care to TRICARE-eligible beneficiaries.

Monthly Pro-Rating

A calculation process for determining the amount of the enrollment fee to be credited to a new enrollment period. For example, if a beneficiary pays their annual enrollment fee, in total, on January 1, (the first day of their enrollment period) and a change in status occurs on February 15. The beneficiary will receive credit for 10 months of the enrollment fee. The beneficiary will lose that portion of the enrollment fee that would have covered the period from February 15 through February 28.

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Most-Favored Rate (Defined in 32 CFR 199.2)

The lowest usual charge to any individual or third-party payer in effect on the date of the admission of a TRICARE beneficiary.

National Appropriate Charge Level

The charge level established from a 1991 national appropriate charge file developed from July 1986 - June 1987 claims data, by applying appropriate MEI updates through 1990, and prevailing charge cuts, freeze or MEI updates for 1991 as discussed in the September 6, 1991, Final Rule.

National Conversion Factor (NCF)

A mathematical representation of what is currently being paid for similar services nationally. The factor is based on the national allowable charges actually in use.

National Disaster Medical System (NDMS)

A Federally coordinated framework that augments the nation’s medical response capability. The primary purpose of the NDMS is to supplement an integrated national medical response for assisting state and local authorities in dealing with medical impacts of major peacetime disasters and to provide support to the military and the DVA/VHA medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflict. The NDMS framework involves private sector hospitals located throughout the U.S. that will provide care for victims of any incident that exceeds the medical care capability of any affected state, region, or federal medical care system. For more detailed information see NDMS at the DHHS web site.

National Prevailing Charge Level

A rate that does not exceed the amount equivalent to the eightieth (80th) percentile of billed charges made for similar services during a 12 month base period.

National Provider Identifier (NPI) (HIPAA Definition)

A 10-digit number assigned to all HCPs mandated by HIPAA of 1996. These numbers are to be used for all financial and administrative transactions. The 10-digit number, containing checksum, prevents technical errors during data transmission. The number doesn’t have built-in correlation with any other identifier associated with the provider.

Negotiated (Discounted) Rate

An amount that represents the reimbursable amount that a provider agrees to accept for covered services.

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