1.0 Providers
or pharmacies Sanctioned By TRICARE
32 CFR 199.9 provides that the Director, Defense
Health Agency (DHA) or a designee, shall have the authority to reinstate
providers, pharmacies, or entities previously excluded or terminated
under TRICARE. For providers sanctioned by Department of Health
and Human Services (DHHS), see
paragraph 3.0.
1.1 DHHS/Office of Inspector General
(OIG) will advise on the monthly listing if and when a previously
excluded provider, pharmacy, or entity is reinstated. Before initiating
reinstatement action, the contractor must first verify that the
provider, pharmacy, or entity meets TRICARE requirements as an authorized
provider, pharmacy or entity under
32 CFR 199.6.
1.2 If no funds
have been paid for services by the provider, pharmacy, or entity
while excluded or are otherwise owed the Government for claims paid
prior to the exclusion, the contractor shall certify the provider,
pharmacy or entity as an authorized provider, and determine the
effective date of the reinstatement.
1.3 The contractor shall advise
the provider, pharmacy, or entity in writing of the reinstatement date.
2.0 Contractor
Responsibilities Following Requests For Reinstatements From Providers
Excluded Or Terminated By DHA
2.1 The contractor will send a
provider certification package to the provider to ensure that the provider
meets the requirements to be an authorized TRICARE provider. The
exclusion or suspension remains in effect until the provider completes
and returns the certification package and is determined by the contractor
to meet the requirements.
2.2 If the provider is determined
to meet the requirements of an authorized provider, the contractor
shall advise the provider of the reinstatement date as determined
by DHA or designee.
2.3 If the provider does not meet
the requirements of an authorized provider, the contractor shall advise
the provider as to why he/she does not meet them and offer appeal
rights. A copy of the letter shall be provided to the DHA Program
Integrity Office (PI).
2.4 The contractor shall advise
the same Beneficiary Counseling and Assistance Coordinators (BCACs)
located within the provider’s service area that were initially advised
of the exclusion or suspension.
2.5 For pharmacies, the contractor
shall verify that the pharmacy has all required state licenses necessary
to operate as a pharmacy. The exclusion or suspension remains in
effect until the contractor has determined that the pharmacy has
obtained the required state licenses.
2.6 If the pharmacy has met the
state licensing requirements, the contractor shall advise the pharmacy
of the date it is eligible to negotiate a new network agreement
with the contractor, as determined by DHA.
2.7 If the pharmacy does not have
the required state licenses, the contractor shall advise the pharmacy
as to why it is not eligible to be a network pharmacy and offer
appeal rights. A copy of the letter shall be provided to the DHA
PI.
3.0
Contractor
Responsibilities Following Requests For Reinstatement From Providers
Excluded By DHHS
3.1 DHHS/OIG will advise on the monthly listing
if and when a previously excluded provider, pharmacy, or entity
is reinstated. Before initiating reinstatement action, the contractor
must first verify that the provider, pharmacy, or entity meets TRICARE
requirements as an authorized provider, pharmacy or entity under
32 CFR 199.6.
3.2 If no funds have been paid
for services by the provider, pharmacy, or entity while excluded
or are otherwise owed the Government for claims paid prior to the
exclusion, the contractor shall certify the provider, pharmacy or
entity as an authorized provider, and determine the effective date
of the reinstatement.
3.3 The contractor shall advise
the provider, pharmacy, or entity in writing of the reinstatement date.