1.0 Scope
And Purpose
This section specifies which
individuals and entities may, or in some cases must, be excluded from
the TRICARE program. It outlines the authority given to the Department
of Health and Human Services/Office of Inspector General (DHHS/OIG)
to impose exclusions from all Federal health care programs, including
TRICARE. This section also outlines the Defense Health Agency (DHA)
authority for exclusions and terminations. In addition, this section
states the effect of exclusion, factors considered in determining
the length of exclusion, and provisions governing notices, determinations,
and appeals. This section also outlines procedures and protocol
for suspension of claims processing.
2.0
DHA Authority
For Suspension Of Claims Processing
2.1 DHA may suspend claims processing
based on
32 CFR 199.9 provisions.
2.2 The Director,
DHA or designee may suspend claims processing without notifying
the provider or beneficiary of the intent to suspend payments. A
written notice will advise the beneficiary or provider, within 30
days of the claims suspension, that a temporary suspension has been
ordered and a statement of the basis of the decision to suspend
payment.
2.3 A suspension of claims processing shall be
for a temporary period pending the completion of investigation and
any ensuing legal or administrative proceedings, unless sooner terminated
by the Director, DHA or designee. See
32 CFR 199.9 for additional guidance.
3.0 DHA
Authority For Exclusions And Terminations
3.1 DHA may exclude any individual
or entity based on
32 CFR 199.9 provisions.
3.2 Effective
March 28, 2013, third party billing agents or entities became subject
to TRICARE sanction authority.
3.3 The contractor shall provide
written notice to DHA PI of any situation involving a TRICARE provider,
pharmacy, or entity whose actions warrant exclusion under DHA authority.
3.4 The Director,
DHA or designee, has the authority to exclude an authorized TRICARE
provider, pharmacy, or entity. The period of exclusion is at the
discretion of DHA. (See
32 CFR 199.9.)
3.5 DHA PI
is responsible for coordinating and issuing notification of exclusion
action. DHA PI will send written notice of the proposed exclusion,
and the potential effect thereof. The individual or entity may submit
evidence and written argument regarding the proposed exclusion.
3.6 DHA
PI has sole authority to issue an Initial Determination of Exclusion.
Written notice of this decision will include the basis for the exclusion,
the length of the exclusion, as well as the effect of the exclusion.
The determination also outlines the earliest date on which DHA PI
will consider a request for reinstatement, the requirements for
reinstatement, and appeal rights available. DHA PI will notify appropriate
agencies, to include contractors, of all DHA exclusion actions taken.
DHA PI will be responsible for initiating action based on reversed
or vacated decisions. Exclusion of a provider, pharmacy, or entity
shall be effective 15 calendar days from the date of the Initial
Determination.
3.7 The Director, DHA or designee has sole authority
for approval of any request for reinstatement.
4.0 Contractor
Actions Under TRICARE Exclusion Authority -
32 CFR 199.94.1 When the contractor recommends
exclusion to DHA PI of an authorized provider, pharmacy or entity,
supporting documentation must be submitted (e.g., provider, pharmacy,
or entity poses unreasonable potential for fraud).
4.2 The contractor
will be notified immediately of an exclusion action taken by DHA
PI and is responsible for:
• Ensuring that no payment
is made to an excluded provider, pharmacy, or entity for care provided
on or after the date of the DHA action (15 calendar days from the
date of the Initial Determination as noted in
paragraph 3.6). Neither the
provider, pharmacy, entity, nor the patient will be entitled to
TRICARE cost-sharing once the exclusion is in effect. The contractor
shall notify DHA PI should a provider, pharmacy, or entity attempt
to bill the program after the effective date of exclusion. It will
not be necessary for the contractor to issue a separate letter notifying
the provider, pharmacy or entity of the exclusion action. However,
notice of exclusion action taken by DHA shall be given to all Beneficiary Counseling
and Assistance Coordinators (BCACs) contractor employees that interface
with beneficiaries located within the provider’s service area (approximately
100 miles) of the practice address of the excluded provider. The
contractor will also notify the Director, TRICARE Regional Office
in the geographical area(s) of the provider’s practice of action taken.
TRICARE Area Offices (TAOs) for the region in which the provider’s
practice is located shall also be given notice of exclusion action
taken.
• Ensuring
that an excluded provider, pharmacy, or entity is not included in
the network. If cancellation of a network provider, pharmacy, or
entity agreement is required, the contractor shall ensure that the
network provider, pharmacy, or entity whose contract has been cancelled
clearly understands his/her status. This shall be accomplished by
providing written notice, sent by certified mail, return receipt
requested, that the network provider’s or network pharmacy’s agreement
has been cancelled. (Contractor will send a copy to DHA PI).
• Issuing a special
notice to any beneficiary who submits a claim or for whom a claim
is submitted, which includes services involving an excluded provider
pharmacy or entity. The notice may be enclosed with the Explanation
of Benefits (EOB, whether the claim is payable or not, or be sent
as a separate letter.
• Contractors shall
ensure the enforcement of all exclusion action taken, and notify appropriate
parties of the application of exclusions. For example, any claim
received from an excluded third party billing agent shall be returned
to the provider with instructions to resubmit the claim directly
or through another third party billing agent. The provider remains
entitled to reimbursement for covered services as long as they remain
an authorized TRICARE provider.
5.0 DHHS/OIG
Application Of Sanction Authority
5.1 DHHS/OIG can exclude individuals
or entities from participation in any federal health care program
to include the Department of Defense (DoD) Military Health System
(MHS). Authority and exclusion categories can be found on the DHHS/OIG
web site.
5.2 DHHS/OIG has sole responsibility for issuing
a written notice of its intent to exclude a provider, pharmacy,
or entity, the basis for the exclusion, the effective date, the
period of exclusion, and the potential effect of exclusion.
5.3 DHHS/OIG
has sole authority for terminating an exclusion imposed under their
authority. DHHS/OIG will handle notifications of approval/denial
of a request for reinstatement and are responsible for reversing
or vacating decisions.
5.4 DHHS/OIG exclusions and reinstatements
are issued on a monthly basis. DHHS/OIG will provide DHA PI with
immediate access to this information, which will then be forwarded
to each contractor.
5.5 Exclusions taken by DHHS/OIG
are binding on Medicare, Medicaid, and all Federal health care programs
with the exception of the Federal Employee Health Benefit Program
(FEHBP) (42 USC 1320a-7b(f)). No payment will be made for any item
or service furnished on or after the effective date of exclusion
until an individual or entity is reinstated by DHHS/OIG, and subsequently
meets the requirements under
32 CFR 199.6.
6.0 Contractor
Actions Under DHHS/OIG Exclusion Authority
6.1 The contractor will be provided
the monthly issuance of DHHS/OIG exclusion and reinstatement actions.
6.2 The contractor
shall ensure that no payment is made to an excluded provider, network pharmacy,
or entity for care provided on or after the date of the DHHS/OIG
action. Neither the provider, pharmacy, or entity, nor the patient
will be entitled to TRICARE cost-sharing once the exclusion is effective.
The contractor shall notify DHA PI should a provider, network pharmacy,
or entity attempt to bill the program or if payment has been issued
after the effective date of exclusion. It is not be necessary for
the contractor to issue a separate letter notifying the provider,
network pharmacy, or entity of the exclusion action.
6.3 The contractor
shall ensure that an excluded provider, pharmacy, or entity is not
included in the network. If cancellation of a network, or if applicable,
participating provider agreement is required, the contractor shall
ensure that the network provider or network pharmacy whose contract
has been cancelled clearly understands his/her status. This shall
be accomplished by providing written notice, sent by certified mail,
return receipt requested, that the network provider’s or network
pharmacy’s agreement has been cancelled. (Contractor shall send
a copy to DHA PI.)
7.0 Contractor
Application Of Sanction Authority
Contractors
shall ensure the enforcement of all sanction action taken, and notify
appropriate parties of the application of sanctions. For example,
any claim received from an excluded third party billing agent shall
be returned to the provider with instructions to resubmit the claim
directly or through another third party billing agent. The provider
remains entitled to reimbursement for covered services as long as
they remain an authorized TRICARE provider.
8.0 Provider,
Network Pharmacy, Or Entity Termination Of Authorized Provider Status
8.1 The contractor
will terminate the authorized provider status of any provider, network pharmacy,
or entity determined not to meet program requirements. The request
for reinstatement will be processed under the procedures established
for initial requests for authorized provider or network pharmacy
status. See
Section 6 for further information.
8.2 Other Listings
Other listings of actions affecting provider
authorization status (e.g., Federation of State Medical Boards of
the United States (U.S.)) will be sent to each contractor. A provider
who has licenses to practice in two or more jurisdictions and has
one or more licenses suspended or revoked shall be terminated as
a TRICARE provider in all jurisdictions.
9.0
Contractor
Requirements For Termination
When status
as an authorized provider, authorized network pharmacy or authorized
entity is ended, the contractor shall initiate termination action
based on a finding that the provider, pharmacy, or entity does not
meet the qualifications to be an authorized provider. Separate termination
action by the contractor is not required for a provider, pharmacy,
or entity sanctioned under the exclusion authority granted DHHS/OIG.
9.1 The period
of termination will be indefinite and will end only after the provider,
pharmacy, or entity has successfully met the established qualifications
for authorized status under TRICARE and has been reinstated as outline
in
Section 6.
9.2 The contractor shall notify
the provider, pharmacy, or entity in writing of the proposed action
to terminate them. The contractor shall specifically notify the
provider, pharmacy, or entity of the proposed action to terminate
their status as an authorized TRICARE provider when the provider, pharmacy,
or entity falls within the contractor’s certifying responsibility
and the provider, pharmacy, or entity fails to meet the requirements
of
32 CFR 199.6 (
Addendum A, Figure 13.A-9). The provider, pharmacy,
or entity is not to be terminated when he/she fails to return certification
packets. Such providers will be flagged as “inactive.” (Do not send
a copy of the proposed notice to DHA PI.) The notice will be sent
to the provider’s, pharmacy’s or entity’s last known business/office
address.
Note: The pharmacy contractor shall notify
the pharmacy in writing of the proposed action to terminate the
pharmacy status as a network pharmacy when it is not in compliance
with its agreement and the pharmacy fails to meet the requirements
of
32 CFR 199.6 (
Addendum A, Figure 13.A-9).
9.2.1 The notice
shall state that the provider, pharmacy, or entity will be terminated
as of the effective date of the termination notice. The notice shall
also inform the provider, pharmacy, or entity of the situation(s)
or action(s) which form the basis for the proposed termination.
9.2.2 For network
providers, the notice shall inform the provider that his/her patients
will be referred to another provider pending final action. For a
network pharmacy, the notice shall inform the pharmacy that beneficiary
prescriptions may not be filled and any claims submitted will be
denied.
9.2.3 The notice shall offer the provider, pharmacy,
or entity an opportunity to respond within 30 calendar days from
the date of the notice. An extension to 60 calendar days may be
granted if a written request is received during the 30 calendar
days showing good cause. The provider, pharmacy, or entity may respond
with either documentary evidence and written argument contesting
the proposed action or a written request to present in person evidence
or argument to a contractor’s designee at the contractor’s location.
Expenses incurred by the provider, pharmacy, or entity are their
responsibility.
9.2.4 Once the notice of proposed
action to terminate is sent, the provider’s claims will be suspended
from claims processing until an Initial Determination is issued.
The provider, pharmacy, or entity will be notified via the proposed
notice that the claims will be suspended from claims processing.
However, beneficiaries will not be notified of the suspension.
9.2.5 For pharmacy
claims, once the notice of proposed action to terminate is sent,
the pharmacy’s claims will not be processed as network claims until
an Initial Determination is issued. The pharmacy will be notified
via the notice that the claims will not be processed as network
claims. Beneficiaries will be advised by the pharmacy that it is
no longer a network pharmacy and that any prescription filled there
will require submittal of a claim for reimbursement by the beneficiary.
9.2.6 If the
provider being terminated is a Primary Care Manager (PCM), the contractor
shall assist Prime enrollees with selecting a new PCM. The contractor
is also responsible for assuring that the patient’s medical records
are transferred to the new PCM. Efforts shall be taken to notify non-TRICARE Prime beneficiaries
in a cost-effective manner.
9.3 Initial Determination
If after the provider, pharmacy, or entity
has exhausted, or failed to comply with the procedures for appealing
the proposed termination and the decision to terminate remains unchanged,
the contractor shall invoke an administrative remedy of termination.
The contractor shall accomplish this by issuing a written notice
of the Initial Determination via certified mail to the effective
entity. A copy of the Initial Determination shall be sent to DHA
PI along with supporting documentation The Initial Determination
written notice shall include the following:
• A Unique Identification
Number (UIN) indicating the fiscal year of the Initial Determination, a
consecutive number within that fiscal year and the contractor’s
name. A sample letter is found at
Addendum A, Figure 13.A-10.
• A statement of the
action being invoked and the effective date of the action. The effective date
shall be the date the provider, pharmacy, or entity no longer meets
the regulatory requirements. If there is no documentation the provider
ever met the requirements, the effective date will be either June
10, 1977 (the effective date of the Regulation) or the date on which
the provider, pharmacy or entity was first approved, whichever date
is later. In the case of a pharmacy, it would be the date on which
the pharmacy first became part of the network.
• A statement of the
facts, circumstances, and/or actions that forms the basis for the termination
and a discussion of any information submitted by the provider, pharmacy,
or entity relevant to the termination.
• A statement of the
provider’s, pharmacy’s, or entity’s right to appeal.
• The requirements and
procedures for reinstatement.
• A copy of the Initial
Determination will be sent to DHA PI along with supporting documentation.
9.4 Providers
Failing To Return Recertification Documentation
Providers,
pharmacies, or entities failing to return recertification documentation
shall not be terminated but will be placed on the “inactive” provider
listing. The contractor shall first verify that the recertification
package was mailed to the correct address and was not returned by
the U.S. Postal Service (USPS). The provider’s file shall be flagged
to deny claims for services regardless of who submits the claim.
The provider, pharmacy, or entity shall be advised that such action
will be taken. Refer to
Section 3 regarding
development of possible fraud/abuse cases.
9.5 Requirement
To Recoup Erroneous Payments
After the Initial
Determination has been sent, the contractor shall initiate recoupment
for any claims cost-shared, paid for services, or supplies furnished
by the provider (or pharmacy for any previously paid claims for
pharmaceuticals or supplies furnished by the pharmacy) or entity
on or after the effective date of termination, even when the effective
date is retroactive, unless a specified exception is provided by
32 CFR 199. This applies to claims processed by previous contractors
as well. All monies paid by previous contractors and recouped by
the current contractor will be refunded to DHA Finance and Accounting
Office (F&AO). Refer to
Chapter 3.
9.6
File
Requirements For A Terminated Provider, Pharmacy, Or Entity
The Initial Determination file for the provider,
pharmacy, or entity shall include the following documentation:
• Initial
Determination of Termination Action as well as Proposed Notice to
Terminate.
• Provider
certification file (i.e., the documentation upon which the original
certification of the provider was based) or network pharmacy agreement.
• All correspondence
and documentation relating to the termination (copies of the enclosures
must be attached to the copy of the original correspondence).
• Documentation that
the contractor considered or relied upon for issuing the determination.
9.7 Special Action/Notice
Requirements When An Institution Is Terminated
When
a DHA determination is made that an institutional provider does
not meet qualifications or standards to be an authorized TRICARE
provider, the contractor shall take appropriate action.
9.7.1 Provider
And Beneficiary Notification
The contractor
shall:
• Instruct the institution
by certified mail to immediately give written notice of the termination
to any TRICARE beneficiary (or his/her parent, guardian, or other representative)
admitted to or receiving care at the institution on or after the
effective date of the termination.
• When the termination
effective date is after the date of the initial determination, notify any
beneficiary (or their parent, guardian, or other representative)
admitted prior to the date of the termination by certified mail
that TRICARE cost-sharing ended as of the termination date. Advise
the beneficiary (or their parent, guardian, or other representative)
of their financial liability. The contractor shall also use a fast,
effective means of notice (e.g., phone, fax, express mail, or regular
mail, depending on the circumstances.).
• If an institution
is granted a grace period to effect correction of a minor violation,
notify any beneficiary (or his/her parent, guardian, or other representative)
admitted prior to the grace period of the violation that TRICARE
cost-sharing of covered care will continue during that period. (Cost-sharing
is to continue through the last day of the month following the month
in which the institution is terminated.)
• In addition, notify
any beneficiary (or their parent, guardian, or other representative) admitted
prior to a grace period of the institution’s corrective action,
when such has been determined to have occurred, and the continuation
of the institution as an authorized TRICARE provider.
• For a beneficiary
admitted during a grace period, cost-share only that care received after
12:01 a.m., on the day written notice of correction of a minor violation
was received or the day corrective action was completed.
9.7.2 Cost-Sharing
Actions
The contractor shall deny cost-sharing
for any:
• New patient admitted
after the effective date of the termination.
• Beneficiary admitted
during a grace period granted an institution involved in a minor violation.
• Beneficiary already
in an institution involved in a major violation beginning with the effective
date of the termination.