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:
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For Service Or Discharge
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Must Be Received By The Contractor
|
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March 22, 2015
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No later than
March 22, 2016
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December 31, 2015
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No later than
December 31, 2016
|
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) 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 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.
2.4
Other
Health Insurance (OHI)
2.4.1 The contractor may grant exceptions to the
claims filing deadline requirements, if the beneficiary submitted
a claim to a primary health insurance, i.e., double coverage, and
the OHI delayed adjudication past the TRICARE deadline.
2.4.2 These claims
must have been originally sent to the OHI prior to the TRICARE filing
deadline or must have been filed with a TRICARE contractor prior
to the deadline but returned or denied pending processing by the
OHI.
2.4.3 The beneficiary must submit with the claim
a statement indicating the original date of submission to the OHI,
and date of adjudication, together with any relevant correspondence
and an Explanation of Benefits (EOB) or similar statement.
2.4.4 The claim
form must be submitted to the contractor within 90 days from the
date of the OHI adjudication.
2.5 Dual Eligibility With Medicare
2.5.1 The contractor
may grant exceptions to the claims filing deadline if Medicare accepted
the claim as timely.
2.5.2 The claim must be submitted,
either by Medicare or by the beneficiary, within 90 calendar days
from the date of Medicare’s adjudication to be considered for a
waiver.
3.0 Time
Limitations For Exceptions
3.1 There is no time limit stipulated
for submitting written requests for exceptions to the claims filing
deadline before a claim has been submitted. However, after the proper
claim has been submitted and an exception to the claims filing deadline
granted, the contractor is authorized to consider for benefits only
those services or supplies received during the six years immediately
preceding the receipt of the request. Services or supplies claimed
for more than six years immediately preceding the receipt of the
request shall be denied.
3.2 If a contractor receives a
request for an exception to the filing deadline, but a completed
claim form is not enclosed, the contractor shall:
• Inform the claimant
of the requirement that an approved TRICARE claim form must be completed
and submitted before benefits may be considered;
• Advise the claimant
that the claim and supporting documentation must be resubmitted within
90 calendar days from the date of the contractor’s letter; and
• Provide the beneficiary
with appropriate forms.