With the exceptions noted in
paragraph 1.0,
the contractor shall have proof of any double coverage payments
prior to adjudication of the claim.
2.1 No Evidence Of Double Coverage
If there is no information to suggest the claim
could be covered by another health insurance plan or there is no
information on the claim to suggest that the charges have been submitted
to or paid by other insurance, the claim shall be processed.
2.2 Double Coverage
Is Known
2.2.1 Whether it is a network or non-network claim,
payment must be obtained from the primary insurance coverages or
plans. The contractor shall include procedures to ensure this requirement
is met in all agreements with its network providers of care. If
the provider of care is owned or operated by the contractor or is
in a clinic or other facility operated by the contractor as an employee
or subcontractor, the Other Health Insurance (OHI) shall also be
collected by the contractor or its designee. If the claim indicates
no OHI coverage, but the Defense Enrollment Eligibility Reporting
System (DEERS) or contractor’s file indicates otherwise, a signed
statement or verbal notice from the beneficiary or sponsor furnishing
the termination date of the other coverage will be necessary for
the contractor to inactivate the positive OHI record. The contractor
shall have acceptable evidence of processing by the double coverage
plan prior to processing the claim. If there is no such evidence
submitted with the claim, the contractor shall deny the claim and
send an Explanation of Benefits (EOB) to the beneficiary and to
the provider.
2.2.2 The contractor shall take
appropriate action to ensure that a sample of all Electronic Media Claims
(EMC) is audited on a no less than annual basis with verification
obtained from the provider to corroborate the submission of a zero
OHI payment amount. In addition, no less than annually, the contractor
shall audit past EMC submissions to identify all providers who may
show a pattern of submissions with OHI payment amounts of zero or
of a nominal amount (e.g., $.01, $1.00, $5.00, etc.). All EMC providers
who demonstrate a possible pattern of “plugging” nominal OHI payment
amounts shall be referred to the contractor’s Program Integrity
staff for further investigation.
2.2.3 Except for EMC claims, when
Medicare is the primary payer, an Explanation of Medicare Benefits
(EOMB) is required. This will enable the contractor to determine
whether the provider accepted assignment under Medicare; if the
provider accepts assignment, the provider cannot bill for any difference
between the billed charge and the Medicare allowed amount. In addition,
it will identify cost-share and deductible amounts as well as any
allowable charge reductions.
2.2.4 For double coverage situations
which do not involve the routine issuance of an EOB, the following
shall be
accepted in lieu of an EOB:
• Documentation that
the beneficiary belongs to the plan;
• Documentation that
there is a liability beyond the amounts paid by the primary payor;
• Documentation that
the liability is specified in the plan contract; and
• Documentation of
total liability on the claim.
2.2.5 If a contractor
becomes aware of the possible existence of OHI through means other
than the adjudication of a pending claim (e.g., a provider returns
all or a part of TRICARE payment because of payment by OHI), the
contractor shall establish an OHI record on DEERS for the patient
and request completion of a double coverage questionnaire. Depending
upon the circumstances of the individual occurrence, reopening and
adjustment of prior claims and/or a Program Integrity referral may
also be appropriate. All affected claims shall be adjusted appropriately,
although adjustment action may be temporarily deferred at the request
of Program Integrity staff if such adjustment would compromise their
investigation.
2.3 DRG-Based System
The contractor shall be able to identify OHI
payments for all separately-billable components of the inpatient
services on a claim. If the OHI EOB does not adequately identify
the payments for each separately-billable component, or if claims
for their charges are not received, the entire OHI payment is to
be applied to the inpatient operating costs. This also applies to
claims from higher volume mental health hospitals and units subject
to the TRICARE Inpatient Mental Health Per Diem Payment System that
are authorized to bill for institution-based professional services.
2.4 Medicare
Claims
Claims processed on which Medicare
is primary payer require review for possible double coverage. Contractors
shall be required to build other health insurance files on these
beneficiaries that identify coverages (primarily Medicare supplements)
that may be primary to TRICARE. Contractors shall use any reasonably
reliable indicator to identify other coverages including crossover
claims received from Medicare carriers and fiscal intermediaries,
crossover files received from Medicare carriers and fiscal intermediaries,
paper claims, information resulting from refunds, information from
providers, etc. Also, contractors shall ensure that providers are
aware that if they receive any TRICARE payments that duplicate payments
made by another coverage, they shall return the TRICARE payment.
Since TRICARE remains secondary payer to all other coverages, contractors
shall recover all payments that they subsequently identify as duplicating
a payment made by any coverage, including Medicare supplements,
that is primary to TRICARE.
2.5 Skilled Nursing Facility (SNF)
Prospective Payment System (PPS)
Payment
under the SNF PPS is dependent upon the PPS-specific information
submitted by the provider with the TRICARE Claim (see
Chapter 8, Section 1). However, if the beneficiary
has OHI which has processed the claim as primary payer, it is likely
that the information necessary to determine the TRICARE PPS payment
amount will not be available. Therefore, special procedures have
been established for processing SNF claims involving OHI. These
claims will not be processed as PPS claims. Such claims will be
allowed as billed unless there is a provider discount agreement.
TRICARE payment will be the difference between the billed charge
and the OHI payment. The only exception to this is cases when there
is evidence on the face of the claim that the beneficiary’s liability
is limited to less than the billed charge (e.g., the OHI has a discount
agreement with the provider under which the provider agrees to accept
a percentage of the billed charge as payment in full). In such cases,
the TRICARE payment is to be the difference between the limited
amount established by the OHI and the OHI payment.