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Manager, TRICARE
Provider Certification
(Appropriate
TRICARE Claims Processor’s Address)
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Dear Manager:
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The
Director, Defense Health Agency (DHA), has authorized exceptions,
on a case-by-case basis, to the TRICARE policy which excludes any
civilian employee of VHA from authorization
as a TRICARE provider. This letter identifies the individual VHA
employee(s) for whom an exception is requested based on my determination
that an exception is required to avoid a detrimental effect on VHA’s
ability to obtain the necessary part-time physician employee(s) essential
to the mission of this facility. By granting this exception, the
individual part-time physician employee will be an authorized TRICARE
physician and may file claims for services furnished in the physician’s
private, non-VHA employment practice.
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A
request for an exception to TRICARE policy is made for the following
part-time VHA physician employee(s):
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(List
each physician’s name, specialty, address, and the physician’s IRS/SSAN
or other identification number used to report income to the Internal Revenue
Service.)
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In
support of this request for exception to policy, the individual
physician(s) named have signed the attached certification, as part
of the physician’s application for authorization as a TRICARE provider, that:
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1. The physician understands
the prohibitions against dual compensation under Title 5, United
States Code (USC), Section 5536, as well as the standards of conduct
provisions applicable to Government employees who require the avoidance
of actual conflict of interest situations as well as situations
in which the appearance of conflict of interest may exist; and
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2. The physician has not
violated the dual compensation or standard of conduct provisions
in providing any service(s) for which a TRICARE claim is submitted
for payment. This certification shall be retained on file by the
TRICARE claims processor and be applicable to all claims for services
of the physician during the period of authorization as a TRICARE
provider under this requested exception. In addition, when filing
individual TRICARE claims, the physician shall annotate the signature
block (Block 33) of the TRICARE claims form with the words “additional
certification on file” in order to identify the claim as an exception
to the general TRICARE policy and confirming that the certification
on file applies specifically to that claim.
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By
requesting an exception to TRICARE policy, I agree that the administrators
of this VHA facility shall assume full
responsibility for informing the above-named part-time physician
employee(s) of the dual compensation and standard of conduct provisions
and for monitoring the conduct of the employee(s) and enforcing
the provisions regarding any TRICARE claims for service furnished
by the employee(s) while acting under this request for exception
to policy. In addition, for the above-named part-time physician
employee(s), I agree to provide the appropriate TRICARE claims processor
written notice of termination of VHA
employment or any other basis for withdrawal of this request for
exception to TRICARE policy.
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Thank
you for your prompt attention to this request. Should there be a
need to contact VHA regarding this
request or regarding any matter arising out of the implementation
of this request, my point of contact on this matter is ______________
who may be contacted at the above address or by telephone number
__________________.
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Sincerely,
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VHA
Facility Administrator
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Enclosure:
Physician’s Certification
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