1.0 Defense
Enrollment Eligibility Reporting System (DEERS) Catastrophic Cap And
Deductible Data (CCDD)
1.1 For non-network TRICARE claims, cost-share
and deductible amounts shall be applied toward the catastrophic
cap as the claims are processed for each fiscal year.
Beginning January 1, 2018, the amounts
shall be applied toward the catastrophic cap as the claims are processed
for each calendar year.
1.2 For TRICARE Prime, TRICARE Standard/Extra,
and TRICARE Select claims, all beneficiary cost-shares and deductibles
specified in the contract shall be applied toward the cap, including
nominal copayments for outpatient care. The amount applied toward
the cap on the current claim and the family’s cumulative total must
be reflected on the Explanation of Benefits (EOB), except on complete denials.
1.3 Once the
contractor determines that the maximum individual/family liability
is met for the fiscal year, cost-shares and deductibles will no
longer apply, and the TRICARE-determined allowable amount shall
be paid in full for all covered services and supplies under the
Basic Program through the end of that fiscal year. Calendar year
2017 is an exception as TRICARE converts from a fiscal year basis
to a calendar year basis. October, November and December 2017 will
be added to the 2017 fiscal year. Beginning January 1, 2018, all
TRICARE plans will convert to a calendar year basis for enrollment, catastrophic
cap, and deductible transactions.
1.4 To assist the contractor with
determining if changes to the CCDD need to be made, a monthly Claims
Reprocessing Alert Report will be made available to facilitate adjustments
of cost-share amounts and enrollment fee payments. This report will
identify beneficiaries that may need claim and/or fee payment adjustments
based on catastrophic cap activity. When a total amount exceeds
the fiscal year limit, a review of recent activity is required to
ensure proper processing has occurred. The report will identify
policies where the catastrophic cap limit has been exceeded as a
result of applying claim and/or enrollment fee amounts. The contractor
shall correct all accounts identified as exceeding the catastrophic
cap limit. These policies will be reported on an aging basis of
30, 60, 90, and 180 days. The report will also identify policies
where the catastrophic cap limit is reduced for any reason, resulting
in the total going under the annual limit. The contractor shall
determine if any previously waived/reduced cost-shares or enrollment
fee payments are now due from the beneficiary.
2.0 Claim
Order For Applying Deductible
The outpatient
deductible amounts shall be applied as the claims are processed.
When claims are adjusted, the contractor shall apply the deductible
based upon the date the claim was initially processed, not the date
the claim was subsequently adjusted. See the TRICARE Reimbursement
Manual (TRM),
Chapter 2, Section 1.
3.0 Deductible
Documentation
3.1 Contractors shall furnish a deductible certificate
or show the status of the deductible on the EOB except on complete
denials. For complete denials the contractor does not query any
internal or external catastrophic cap and deductible files and is
not required to send deductible information or catastrophic cap
information on the denial notice.
3.2 For claims processed for years
included in CCDD, the contractor shall obtain the amount met toward
the deductible from the CCDD.
3.3 When a claim is adjusted,
the contractor shall query CCDD and apply deductible and cap as directed
by the CCDD query response. The contractor shall not review any
intervening claims processed between the initial claim and the adjustment
for the purpose of adjusting deductible or cap amounts.
3.4 For services
in prior years, the beneficiary may request in writing the application
of deductibles and cost-shares taken by other contractors or paid
by Other Health Insurance (OHI). The contractor shall determine
from their deductible record, and/or EOBs from other contractors
submitted by the beneficiary, the amount the contractor has to apply
to the CCDD. When a beneficiary subsequently documents an excess
deductible, the claim shall be adjusted by the contractor that took
the excess, based on the order in which claims were processed. The
beneficiary must provide the EOB to the contractor for credit to
be given for years not maintained on the CCDD. The contractor must
determine which services are creditable toward the catastrophic
cap by reference to the
TRM,
Chapter 2, Section 3.
3.5 For purposes
of catastrophic loss protection, a TRICARE claim must be submitted
along with an EOB from other health insurance in order for the beneficiary
to receive credit for any amount paid by other health insurance,
even if the OHI paid the bill in total. Normal double coverage rules
remain in effect after the cap has been reached; the beneficiary
must submit a claim to the other health insurance before submitting
a claim to the TRICARE contractor.
4.0 Audit
Trail And History File
The contractor shall
ensure that the history file accurately reflects all transactions
pertaining to care received, cost-shares, deductible, copayments,
and adjustments. The contractor shall maintain the integrity of
the audit trail and protect the confidentiality and integrity of
the files.
5.0 Adjustments
And Recoupments
If the contractor is required
to recoup a benefit payment any deductible amount applied to the claim
to be recouped must be adjusted on the CCDD to reflect that amount
as an outstanding deductible. Any other credited deductible amount
resulting from an individual claim adjustment will be offset from
future claims received for the beneficiary. The Government has determined
that it is not cost effective to collect any outstanding deductible
amounts at the close of the timely filing period.