1.0 GENERAL
1.1 All TRICARE
requirements regarding claims processing shall apply to the TRICARE
Overseas Program (TOP) unless specifically changed, waived, or superseded
by this section; the TRICARE Policy Manual (TPM),
Chapter 12;
or the TRICARE contract for health care support services outside
the 50 United States (U.S.) and the District of Columbia (hereinafter
referred to as the “TOP Contract”). See
Chapter 8 for
additional instructions.
1.5 The provisions of
Chapter 8, Section 1, paragraph 2.3 are applicable
the TOP; however, region or country-specific requirements regarding
third party payments or payment addresses may be established by
Defense Health Agency (DHA) at any time to prevent or reduce fraud.
Note: Benefit payment checks and Explanation Of Benefits
(EOB) to Philippine providers (and other nation’s providers as determined
by the Government) shall be mailed to the place of service identified
on the claim. This policy applies even if the provider uses a Third
Party Administrator (TPA). No provider payments shall be sent to
any other address. The Government may discontinue TPA payments to
other countries or specific agencies if it is determined that significant
fraud is occurring on a regular basis.
1.6 Acceptable
claim forms are identified in
Chapter 8, Section 1, paragraph 3.1. Additionally
the TOP contractor may accept any other claim form or alternative
documentation as long as these methods provide sufficient data to
facilitate claims processing and TRICARE Encounter Data (TED) submission.
1.8 The contractor’s claims processing procedures
shall integrate efforts to prevent and identify fraud/abuse.
2.0 JURISDICTION
2.1 In
the early stages of TOP claims review, the TOP contractor shall
determine whether claims received are within its contractual jurisdiction
using the criteria below. TOP jurisdiction for health care and remote
Service member dental care is identified in the TOP contract with
DHA.
2.2 Services rendered onboard a commercial ship
while outside U.S. territorial waters are the responsibility of
the TOP contractor. Claims for services provided on a commercial
ship that is outside the territorial waters of the U.S. shall be
processed as foreign claims regardless of the provider’s home address.
If the provider is certified within the U.S., reimbursement for
the claim is to be based on the provider’s home address. If the
provider is not certified within the U.S., reimbursement will follow
the procedures for foreign claims. This does not include health
care for enrolled Service members on a ship at sea or on a military
ship at home port.
2.3 The provisions of
Chapter 8, Section 2, paragraph 1.0 and
2.0 are superseded as described in
paragraphs 2.3.1 through
2.3.9.
2.3.1 When
a beneficiary is enrolled in TOP Prime or TOP Prime Remote, the
TOP contractor shall process all health care claims for the enrollee,
regardless of where the enrollee receives services. The contractor
shall also process dental care claims for remote overseas Service
members per the provisions of
Section 10.
Referral/authorization rules apply.
2.3.2 Claims for Active Duty Family
Members (ADFMs) (including Reserve Component (RC) ADFMs whose sponsors
have been activated for more than 30 days), retirees, and retiree
family members whose care is normally provided under one of the
regional contracts (i.e., beneficiaries enrolled or residing in
the 50 U.S. and the District of Columbia) who receive Civilian Health
Care (CHC) while traveling or visiting overseas shall be processed
by the TOP contractor, regardless of where the beneficiary resides
or is enrolled. Referral/authorization and Point Of Service (POS)
rules apply for TRICARE Prime/TRICARE Prime Remote (TPR) enrollees.
Note: This provision does not apply to beneficiaries
who are enrolled in the Uniformed Services Family Health Plan (USFHP)
or the Continued Health Care Benefit Program (CHCBP). Claims for
these beneficiaries are processed by their respective contractor
regardless of where the care is rendered.
2.3.3 Claims
for Service members residing in the 50 U.S. and the District of
Columbia (including RC Service members activated for more than 30
days) who are on Temporary Additional Duty/Temporary Duty (TAD/TDY),
deployed, deployed on liberty, or in an authorized leave status
in an overseas location shall be processed by the TOP contractor,
regardless of where the Service members resides or is enrolled.
Referral/authorization rules apply.
2.3.4 Claims for TOP-enrolled Service
members (including RC Service members activated for more than 30
days) on a military ship or with an overseas home port shall not
be processed by the member’s military unit. These claims shall be
processed by the TOP contractor.
2.3.5 Initial and follow-on Line
Of Duty (LOD) claims for RC Service members on orders for 30 consecutive
days or less, who are injured while traveling to or from annual
training or while performing their annual training who receive civilian
medical care overseas, shall have their claims processed by the
TOP contractor upon verification of LOD status. Defense Health Agency-Great
Lakes (DHA-GL) will validate LOD status for RC Service members in
the U.S. Virgin Islands.
2.3.6 The TOP contractor shall process
claims for Durable Equipment (DE) and Durable Medical Equipment
(DME) (otherwise coverable by TRICARE) that is purchased/ordered
by TOP-eligible beneficiaries in an overseas area from a stateside
provider (i.e., Internet, etc.).
2.3.7 For inpatient claims that
are paid under the Diagnosis Related Group (DRG)-based payment system,
the TOP contractor, on the date of admission, shall process and
pay the entire DRG claim, including cost outliers. For inpatient
claims paid on a per diem basis, to include DRG transfers and short stay
outlier cases, and for professional claims that are date-driven,
the contractor shall process and pay the claims.
2.3.8 When a
beneficiary’s enrollment changes from one TRICARE region to another
during a hospital stay that will be paid under the DRG-based payment
system, the contractor with jurisdiction on the date of admission
shall process and pay the entire DRG claim, including cost outliers.
2.3.9 For
information on portability claims for relocating TOP Prime/TOP Prime
Remote enrollees, refer to
Chapter 6, Section 2.
2.7 Refer to
the TRICARE Reimbursement Manual (TRM),
Chapter 4, Section 4, paragraph 5.0 for jurisdictional
guidance regarding health care claims for work-related illness or
injury which is covered under a Worker’s Compensation Program.
2.8 The provisions
of
Chapter 8, Section 2, paragraph 5.0 are applicable
to the TOP in those locations where the TRICARE Pharmacy (TPharm)
contractor has established services (the U.S. territories of Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands). The TOP contractor cannot process pharmacy claims
from these locations except for pharmacy that is part of an emergency
room visit or inpatient treatment. Any prescriptions from this care
that are
not provided at time of treatment for inpatient/emergency
care, shall be required to be submitted through the TPharm contractor.
Copays will apply.
2.9 The TOP contractor shall forward
all retail pharmacy claims to the TPharm contractor within 72 hours
of identifying them as being out-of-jurisdiction. In all other overseas
locations, the contractor shall process claims from purchased care
sector retail pharmacies and providers.
2.10 ADFMs with TRICARE Standard
through December 31, 2017, or TRICARE Select starting January 1,
2018, and retirees or their family members residing overseas obtaining
prescription from an overseas purchased care sector pharmacy shall
submit their claims to the TOP contractor. For cost-share/deductible
provisions, see TRM,
Chapter 2 regarding
the mandatory collection of pharmacy copayment amounts at the time
of service are waived for foreign providers.
3.0
CLAIMS
FILING DEADLINE
3.1 The provisions of
Chapter 8, Section 3 are applicable to the
TOP except that claims for services provided outside the 50 U.S.
or the District of Columbia, the Commonwealth of Puerto Rico, or
the possessions of the U.S. are considered to be filed in a timely
manner if they are filed no later than three years after the date
the services were provided or three years from the date of discharge
for an inpatient admission. All other claims must be filed within
one year according to the requirements listed in
Chapter 8, Section 3, unless an exception
to the filing deadline has been granted. See
Chapter 1, Section 2, paragraph 5.0 for the
timely filing waiver process.
3.2 Claims received with dates
of service December 31, 2017 or earlier shall be processed in accordance
with TRICARE Standard guidelines. Claims received with dates of
service starting January 1, 2018 will be processed in accordance
with TRICARE Select guidelines.
4.0 SIGNATURE
REQUIREMENTS
4.1 The provisions of
Chapter 8, Section 4 are
applicable to the TOP unless a different process has been directed
by the DHA Contracting Officer (CO).
4.2 The TOP contractor may, at
its discretion, accept a thumb print in lieu of a signature on a
claim form, unless otherwise directed by the Government. When directed
by the DHA CO, the TOP contractor shall not use signature on file
and may not accept facsimile or thumb print signatures on claims.
5.0 REFERRALS/PREAUTHORIZATIONS/AUTHORIZATIONS
The provisions of
Chapter 8, Section 5 are
altered for the TOP by the requirements listed below.
5.1 Referral/Preauthorization/Authorization
Requirements for TOP Prime and TOP Prime Remote Enrollees
5.1.1 Unless
otherwise directed by the Government, referrals/preauthorizations/
authorizations are not required for emergency care, clinical preventive
services, ancillary services, radiological diagnostics (excluding
Magnetic Resonance Imaging (MRI) and Positron Emission Tomography
(PET) scans), drugs, and services provided by a TOP Partnership
Provider. Additionally, TOP Prime/TOP Prime Remote ADFMs
will
require a referral for all mental health and Substance Use Disorder
(SUD) services except outpatient office-based visits. TOP Prime/TOP
Prime Remote ADFMs will also require preauthorization for treatment
of SUDs as outlined in the TPM, Chapter 7, Section 3.5, paragraph 4.0 and
for the treatment of mental disorders as outlined in the TPM, Chapter 7, Section 3.8, paragraph 6.0. All
other care that is provided to a TOP Prime/TOP Prime
Remote-enrolled
Service member or ADFM by anyone other than their Primary Care Manager
(PCM) requires authorization, regardless of where the care is rendered.
5.1.2 Claims
for Service member care not authorized by the TOP contractor shall
be pended for a review to make a determination regarding authorization.
If the care is retroactively authorized by the Government (including
submission of an approved waiver for a non-covered service), then
the contractor shall enter the authorization and process the claim
for payment. If the contractor determines that the care was not
authorized, the contractor shall deny the claim. Refer to
Section 26 for additional information.
5.1.3 TOP Service
member claims for non-emergent care obtained in the 50 U.S. and
the District of Columbia shall only be paid when accompanied by
the appropriate payment authorization forms (SF 1034 or NAVMED 6320/10)
or a referral with justification statement from the Service member’s
Primary Care Manager (PCM).
5.1.4 Claims for self-referred,
non-emergency care for TOP Prime and TPR enrolled ADFMs shall process
with POS deductibles and cost-shares unless the appropriate TRICARE
Area Office (TAO) or TRICARE Overseas Program Office (TOPO) has
approved a retroactive authorization.
5.2
Point
of Service (POS) Provisions
5.2.1 Unless specifically excluded
by this section, all self-referred, non-emergency care provided to
TOP Prime/TOP Prime Remote-enrolled ADFMs which is not either provided/referred
by the beneficiary’s PCM or specifically authorized shall be reimbursed
under the POS option. This provision applies regardless of where
the care is rendered. POS provisions also apply to the following
stateside beneficiaries when traveling overseas: ADFMs, retirees,
and retiree family members who are enrolled in TRICARE Prime, and
ADFMs enrolled in TPR for ADFMs.
5.2.2 POS cost-sharing only applies
to TRICARE-covered services. Claims for services that are not a
covered TRICARE benefit shall be denied.
5.2.3 The TOP contractor shall adjust
POS deductibles and cost-shares when TOP PCMs or Health Care Finders
(HCFs) do not follow established referral/authorization procedures.
For example, if the contractor processes a claim under the POS option
because there was no evidence of a referral and/or an authorization,
and the contractor later verifies that the PCM or other appropriate
provider referred the beneficiary for the care, the contractor shall
adjust the claim and reverse the POS charges. The contractor need
not identify past claims that may be eligible for POS adjustment;
however, the contractor shall adjust these claims as they are brought
to their attention.
5.2.4 On a case-by-case basis, following
stabilization of the patient, the TAO Director or MTF Commander
may require an enrolled beneficiary to transfer to a TOP network
facility or an MTF. The TAO Director or MTF Commander shall provide
written notice to the beneficiary (or responsible party) advising
them of the impending transfer to a TOP network facility/MTF. If
a beneficiary who is subject to TOP POS provisions elects to remain
in the non-network facility after such notification, POS cost-sharing
provisions will apply beginning 24 hours following the receipt of
the written notice. Neither the TOP Director nor the MTF Commander
will require a transfer until such time as the transfer is deemed medically
safe.
5.2.5 The following deductible and cost-sharing amounts
apply to all TOP POS claims for health care support services:
• Enrollment
year deductible for outpatient claims: $300 per individual; $600
per family. No deductible applies to inpatient services.
• Beneficiary cost-share
for inpatient and outpatient claims: 50% of the allowable charge after
the deductible has been met (deductible only applies to outpatient
claims).
• POS
deductible and cost-share amounts are not creditable to the enrollment/Fiscal Year
(FY) catastrophic cap and they are not limited by the cap.
• POS deductible and
cost-share amounts do not apply to claims for care received by newborns
and newly adopted children who are deemed enrolled in TOP Prime
or TOP Prime Remote.
5.2.6 POS deductible and cost-share
amounts do not apply if a TOP enrollee has Other Health Insurance
(OHI) that provides primary coverage (i.e., the OHI must be primary
under the provisions of the TRM,
Chapter 4, Section 1). Evidence of OHI claims
processing (including the exact amount paid on the claim) must be
submitted with the TOP claim.
5.2.7 EOB shall clearly indicate
that a claim has been processed under the POS Option.
5.2.8 POS is
not applicable to Service members or to TRICARE Standard.
5.3 Extended
Care Health Option (ECHO) benefits in overseas locations must be
authorized by the TOP contractor. Refer to
Section 23 and
the TPM,
Chapter 9 for additional guidance.
5.4 Refer to
Section 10 for referral/preauthorization/authorization
requirements for Service member dental care in remote overseas locations.
6.0 CLAIM
DEVELOPMENT
6.1 Development
of missing information shall be kept to a minimum. The TOP contractor
shall use available in-house methods, contractor files, telephone,
Defense Enrollment Eligibility Reporting System (DEERS), etc., to
obtain incomplete or discrepant information. If this is unsuccessful,
the contractor may return the claims to sender with a letter which
indicates that the claims are being returned, the reason for return
and requesting the required missing documentation. The contractor’s system
shall identify the claim as returned, not denied. The Government
reserves the right to audit returned claims as required, therefore
the contractor shall retain sufficient information on returned claims
to permit such audits. The contractor shall review all claims to
ensure TOP required information is provided prior to payment. For
the Philippines, claims requiring development of missing or discrepant
information, or those being developed for medical documentation,
shall be pended for 90 days and are excluded from the claims processing
standard.
6.2 Claims may be filed by eligible TRICARE beneficiaries,
purchased care sector providers, TOP POCs, and TRICARE authorized
providers in the 50 U.S. and the District of Columbia as allowed
under TRICARE (see
Chapter 8, Section 1).
Providers may submit claims by fax if the TOP contractor provides
a secure fax for claims receipt by the contractor.
6.3 Confidentiality
requirements for TOP are identical to TRICARE requirements outlined
in
Chapter 8.
6.5 The following
minimal information is required on each overseas claim prior to
payment:
6.5.1 Signatures
Beneficiary and purchased care sector provider
signatures (signature on file is acceptable unless specifically
prohibited by the Government).
6.5.2 Name and Address
6.5.2.1 Complete
beneficiary and purchased care sector provider name and address.
6.5.2.2 If an address
is not available on the claim, obtain the address either from previously submitted
claims, directly from the beneficiary/purchased care sector provider
via phone, fax, or e-mail, DEERS per
paragraph 6.1, or notify the
TAO Director as appropriate.
Note: The TOP contractor
shall accept APO/FPO for the beneficiary address.
6.5.3 Diagnosis(es)
6.5.3.1 Prior to
returning a claim that is missing a diagnosis, the TOP contractor
shall research the patient’s history and determine whether a diagnosis
from a related claim can be applied.
6.5.3.2 Claims
received for dates of service for outpatient services or dates of
discharge for inpatient services before the mandated date, as directed
by Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation, with ICD-10
codes shall be converted to International Classification of Diseases,
9th Revision, Clinical Modifications (ICD-9-CM) codes by the TOP
contractor. Claims received for dates of service for outpatient
services or dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 or ICD-9-CM codes shall be converted to ICD-10-CM codes
by the TOP contractor. Refer to
Chapter 8, Section 6, paragraph 4.0 and
5.0 regarding the use of ICD-9-CM
V codes (factors
influencing health status and contact with health services) and
ICD-10-CM
Z codes (factors influencing health status
and contact with health services).
6.5.4 Procedures/Services/Supply/DME
The TOP contractor shall identify the procedure(s)/service(s)/supply/DME
ordered, performed or prescribed, including the date ordered performed
or prescribed. The TOP contractor may use the date the claim form
was signed as the specific date of service, if the service/purchase
date/order date is not on the bill.
6.5.5 Claims received with a narrative
description of services provided shall be coded by the TOP contractor
with as accurate-coding as possible based upon the level of detail
provided in the narrative description or as directed by the DHA
CO. The provisions of
paragraph 6.1 apply for narrative claims that
cannot be accurately coded due to insufficient or vague information.
Claims received for dates of service for outpatient services or
dates of discharge for inpatient services before the mandated date,
as directed by HHS, for ICD-10 implementation, with ICD-10 codes
shall be converted to ICD-9 codes by the TOP contractor. Claims
received for dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 codes shall be converted to ICD-10 codes by the TOP contractor.
Refer to
Chapter 8, Section 6, paragraph 4.0 regarding
the use of
V and
Z codes.
6.5.5.1 Inpatient Institutional Procedures
Inpatient institutional (i.e., hospital) claims
received for dates of discharge for inpatient services before the
mandated date, as directed by HHS, for ICD-10 implementation, shall
have the procedure narratives coded by the TOP contractor using
ICD-9-CM, Volume 3 procedure codes. Inpatient institutional (i.e.,
hospital) claims received for dates of discharge on or after the
mandated date, as directed by HHS, for ICD-10 implementation, shall
have the procedure narratives coded by the TOP contractor using
ICD-10-Procedure Classification System (ICD-10-PCS) procedure codes.
6.5.5.2 Outpatient
Institutional Procedures and Professional Services
Claims received for outpatient institutional
(e.g., ambulance services, laboratory, Ambulatory Surgery Centers
(ASCs), partial hospitalizations, outpatient hospital services)
services and professional services shall be coded using Healthcare
Common Procedure Coding System (HCPCS) or Current Procedural Terminology
(CPT).
6.5.6 Care authorizations (when
required).
6.5.7 Itemization of total charges. (Itemization
of hospital room rates are not required on institutional claims).
6.5.8 Proof of
payment is required for all beneficiary submitted claims if the
claim indicates that the beneficiary made payment to the provider
or facility. Acceptable documentation for demonstrating proof of
payment includes, but is not limited to, canceled checks, bank or
credit card statements, dated/itemized receipts from the provider/facility,
etc. Due to cultural differences, there may be significant variation
in provider processes for issuing receipts to the beneficiaries.
Therefore, the overseas claims processor shall use best business
practices when determining if the documentation provided is acceptable
for the country where the services were rendered.
6.6 Non-prescription
(Over-The-Counter (OTC)) drugs are to be denied. This includes drugs
that are considered OTC by U.S. standards, even when they require
a prescription in a foreign country.
6.7 The TOP contractor shall use
a schedule of allowable charges based on the Average Wholesale Price
(AWP) as a reference source for processing drug related TRICARE
overseas claims.
6.8 Claims for medications prescribed
by a host-nation physician, and commonly used in the host-nation
country, shall be cost-shared unless they are considered OTC by
U.S. standards.
6.9 For the Philippines, prescription
drugs may only be cost-shared when dispensed by a certified retail
pharmacy or hospital-based pharmacy. The TOP contractor shall deny
claims for prescription drugs dispensed by a physician’s office.
Certification requirements outlined in
Section 4, paragraph 4.7 apply.
Note: This does not apply to Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS).
6.10 Claims
for DME involving lease/purchase shall always be developed for missing
information.
6.11 The TOP contractor shall use ECHO claims processing
procedures outlined in TPM,
Chapter 9, Section 18.1, when processing ECHO
overseas claims.
6.12 The TOP contractor shall deny
claims from non-certified or non-confirmed purchased care sector
providers when the DHA CO has directed contractor certification/confirmation
of the purchased care sector provider prior to payment.
6.13 Requests
for missing information shall be sent on the TOP contractor’s TRICARE/TOP
letterhead. When development is necessary in TRICARE Eurasia-Africa
Region, the contractor shall include a special insert in German,
Italian, Spanish, Tagalog, Japanese, and Korean which indicates
what missing information is required to process the claim and includes
the contractor’s address for returning requested information.
6.14 If the
TOP contractor elects to develop for additional/missing information,
and the request for additional information is not received/returned
within 45 days, the contractor shall deny the claim.
6.15 If the
TOP contractor has no record of referral/authorization prior to
denial/payment of the claim, the contractor shall follow the TOP
POS rules, if the service would otherwise be covered under TOP.
6.16 The TOP
contractor shall develop procedures for the identification and tracking
of TOP enrollee claims submitted by either a purchased care sector
designated or non-designated overseas purchased care sector provider
without preauthorization/authorization. Upon receipt of a claim
for a TOP-enrolled ADFM submitted by a purchased care sector designated
or non-designated overseas purchased care sector provider without
preauthorization/authorization, the contractor shall process the
claims following POS payment procedures. For Service member claims
submitted by a purchased care sector provider without preauthorization/authorization,
the contractor shall pend the claim for review prior to denying
the claim.
6.17 The TOP contractor must have an automated data
system for eligibility, deductible and claims history data and must
maintain on the automated data system all the necessary TOP data
elements to ensure the ability to reproduce both TED and EOBs as
outlined in
Chapter 8, Section 8, except for requiring
overseas providers to use HCPCS to bill outpatient rehabilitation
services, issue provider’s the Form 1099 and suppression of checks/drafts
for less than $1.00. The contractor may split claims to accommodate
multiple invoice numbers in order to reference invoice numbers on
EOBs when necessary. Refer to
Chapter 8, Section 6 for
additional requirements related to claims splitting.
6.18 The TOP
contractor shall not pay for pharmacy services obtained through
the Internet.
6.19 The TOP contractor shall pay all TOP Service
member stateside claims as outlined in
Section 26.
6.20 All claims
shall be submitted in a Health Insurance Portability and Accountability
Act (HIPAA) compliant format. Refer to
Section 28 for
more information on HIPAA requirements.
6.21 Electronic claims not accepted
by the TOP contractor’s Electronic Data Information (EDI) system/program
shall be rejected.
6.22 For all overseas claims, the
TOP contractor shall create and submit TEDs following current guidelines
in the TSM for TED development and submission. Claim information
will be able to be accessed through the TRICARE Patient Encounter
Processing and Reporting (PEPR) Purchased Care Detail Information
System (PCDIS).
6.23 The TOP contractor shall establish
Utilization Management (UM) high dollar/frequency thresholds in
accordance with
Section 6.
6.24 Claims either denied as “beneficiary
not eligible” or “found to be not eligible on DEERS” may be processed
as a “good faith payment” when received from the Defense Health
Agency (DHA) Communications Office. The TAO Director shall work
with the TOP contractor on claims issues related to good faith payment
documentation (e.g., a completed claim form and other documentation
as required by
Chapter 10, Sections 3 and
4).
6.26 The Claims Auditing Software
requirements outlined in the TRM,
Chapter 1, Section 3 do not apply to TOP claims;
however, the TOP contractor shall implement an internal process
for identifying upcoding, unbundling, etc. on coded claims.
7.0 Application
Of Deductible and Cost-sharing
Application
of TOP deductible and cost-sharing procedures shall follow the guidelines
outlined in
Chapter 8, Section 7.
8.0 EOB
Vouchers
The TOP contractor shall follow
the EOB voucher requirements in
Chapter 8, Section 8,
where applicable, with the following exceptions and additional requirements:
8.1 The letterhead on all TOP EOBs shall also reflect
“TRICARE Overseas Program” and shall be annotated Prime or Standard
(through December 31, 2017) or TRICARE Select (starting January
1, 2018).
8.2 TOP EOBs may be issued on
regular stock, shall provide a message indicating the exchange rate used
to determine payment and shall clearly indicate that “This is not
a bill”.
8.3 TOP EOBs shall include the
toll-free number for beneficiary and provider assistance.
8.4 TOP EOBs for overseas enrolled Service member
claims shall be annotated “ACTIVE DUTY.”
8.5 For Point of Sale or Vendor pharmacy overseas
claims, TOP EOBs shall have the name of the provider of service
on the claim.
8.6 For beneficiary submitted
pharmacy claims, TOP EOBs shall contain the name of the provider
of service, if the information is available. If the information
is not available, the EOBs shall contain “your pharmacy” as the
provider of service.
8.7 The TOP contractor shall insert the provider’s
payment invoice numbers in the patient’s account field on all provider
EOBs, if available.
8.8 The following EOB message shall be used on
overseas claims rendered by non-network purchased care sector providers
who are required to be certified, but have not been certified by
the TOP contractor, “Your provider has not submitted documentation
required to validate his/her training and/or licensure for designation
as an authorized TRICARE provider”.
8.9 When a provider’s/beneficiary’s EOB, EOB and
check, or letter is returned as undeliverable, the check shall be
voided.
8.10 The TOP contractor may utilize
secure electronic EOB delivery to beneficiaries unless mail/courier
delivery has been requested by the beneficiary.
9.0 Duplicate
Payment Prevention
9.1 The TOP contractor shall follow the duplicate
payment prevention requirements outlined in
Chapter 8, Section 9.
9.2 The TOP
contractor shall ensure that business processes are established
which require appropriate system and/or supervisory controls to
prevent erroneous manual overrides when reviewing potential duplicate
payments.
10.0 Double
Coverage
10.1 TOP claims require double coverage review as
outlined in the TRM,
Chapter 4.
10.2 Beneficiary/provider
disagreements regarding the contractor’s determination shall be coordinated
through the overseas TAO Director for resolution with the contractor.
10.3 Overseas
insurance plans such as German Statutory Health Insurance, Japanese
National Insurance (JNI), and Australian Medicare, etc., are considered
OHI. National Health Insurance (NHI) plans do not always provide
EOBs to assist in the adjudication of TRICARE claims. If a beneficiary
has attempted unsuccessfully to obtain an EOB from their NHI plan,
they may submit a beneficiary attestation and an itemized claim
checklist (approved by DHA) with their claim. The TOP contractor shall
waive the requirement for an EOB from the NHI plan when accompanied
by the DHA-approved document.
Note: If the Japanese
insurance points are not clearly indicated on the claim/bill, the
TOP contractor shall contact the submitter or the appropriate TOP
POC for assistance in determining the Japanese insurance points
prior to processing the claim.
11.0 Third
Party Liability (TPL)
The TOP contractor
shall reimburse TOP claims suspected of TPL and then develop for
TPL information. Upon receipt of the information, the contractor
shall refer claims/documentation to the appropriate Judge Advocate
General (JAG) office, as outlined in the
Chapter 10.
12.0 Reimbursement/Payment
Of Overseas Claims
When processing TOP claims,
the TOP contractor shall follow the reimbursement payment guidelines
outlined in the TRM,
Chapter 1, Section 34 and the cost-sharing
and deductible policies outlined in the TRM,
Chapter 2, Section 1, and shall:
12.1 Reimburse
claims for purchased care sector services/charges for care rendered
to TOP eligible beneficiaries which is generally considered purchased
care sector practice and incidental to covered services, but which
would not typically be covered under TRICARE. An example of such
services may be, charges from purchased care sector ambulance companies
for driving purchased care sector physicians to accidents or private
residences, or the manner in which services are rendered and considered
the standard of care in a purchased care sector country, such as
rehabilitation services received in an inpatient setting.
12.2 Reimburse
claims at the lesser of the billed amount, the negotiated reimbursement
rate, the CHAMPUS Maximum Allowable Charge (CMAC), or the Government
established fee schedules (when applicable) (TRM,
Chapter 1, Sections 34 and
35), unless a different reimbursement rate
has been established as described in TPM,
Chapter 12, Section 1.3.
Note: Government established fee schedules (per TRM,
Chapter 1, Sections 34 and
35) are only applicable to retirees or their
eligible family members or Standard (through December 31, 2017)
or TRICARE Select (starting January 1, 2018) ADFMs.
12.3 Not reimburse
for purchased care sector care/services specifically excluded under
TRICARE.
12.4 Not reimburse for purchased care sector care/services
provided in the Philippines unless all of the certification requirements
listed in
Section 14 have been met.
12.5 Not reimburse
for administrative charges billed separately on claims, except for
individual administrative charges as determined by the Government.
The contractor shall reimburse these charges only in instances when
the fee is billed concurrently with the corresponding health care services.
If a bill is received for these charges without a corresponding
health care service, the charges shall be denied.
12.6 Determine
exchange rates as follows:
12.6.1 Use
the exchange rate in effect on the ending date that services were
received unless evidence of OHI and then the TOP contractor shall
use the exchange rate of the primary insurer, not the rate based
on the last date of service to determine the TOP payment amount,
and/or;
12.6.2 Use the ending dates of the last service to
determine exchange rates for multiple services.
12.6.3 Use the
exchange rate in
paragraph 12.6.1 to determine deductible and
copayment amounts, if applicable, and to determine the amount to
be paid in foreign currency.
12.6.4 Overseas
drafts/checks and EOBs. Upon completion of processing, the contractor
shall create checks (payable in U.S. dollars). The TOP contractor
shall do this within 48 hours after approval by DHA Contract Resource
Management (CRM). Drafts (payable in foreign currency units) shall
be created by the TOP contractor within 96 hours following CRM approval,
unless a different process has been authorized by DHA. Payments
that need to be converted to a foreign currency shall be calculated based
on the exchange rate in effect on the last date of service listed
on the EOB. Drafts/checks shall be matched with the appropriate
EOB, and mailed to the beneficiary/sponsor/purchased care sector provider/POC
as applicable.
Note: Drafts for certain foreign currency
units may require purchase from a bank location other than the one
normally used by the TOP contractor (out of state or out of country).
Currency units that must be purchased from an alternate bank (out
of state or out of country) may take up to 10 business days for
the draft to be returned and matched up with the EOB.
12.7 Convert
lump sum payments, instead of line items, to minimize conversion
problems.
12.8 Pay provider claims for all overseas locations
(excluding claims from Korean providers) by foreign currency/drafts.
Drafts may not be changed to a U.S. dollar check after the contractor
has issued a foreign draft. Claims from Korean providers will be
paid in U.S. dollars.
12.9 Know that foreign overseas
drafts (in local currency) are good for 190 days and may be cashed at
any time, unless a different process has been established by DHA.
U.S. dollar checks are good for 120 days unless a different process
has been established by DHA. The provisions of
Chapter 3, Section 4 regarding staledated,
voided, or returned checks/Electronic Funds Transfers (EFTs) are
applicable to the TOP.
12.10 Pay
TOP claims submitted by a beneficiary in U.S. dollars, unless there
is a beneficiary request on the claim at the time of submission
for payment in a foreign currency. The TOP contractor may reissue
the payment in U.S. dollars if a request is subsequently received
from the beneficiary and the foreign draft is included in the request
or the payment has staledated, or if directed by the appropriate DHA
COR.
12.11 Make payment to Germany, Belgium, Finland,
France, Greece, Ireland, Italy, Luxembourg, Netherlands, Austria,
Portugal, Spain, Cyprus, and Malta in Euros. As other countries
transition to Euros, the TOP contractor shall also switch to Euros.
12.12 Issue drafts/checks
for German claims which look like German drafts/checks.
Note: In order for TRICARE drafts/checks to look like
German drafts/checks, a German address must be used. The TOP contractor
may use a corporate address in Germany or the TAO Eurasia-Africa address
for this purpose.
12.13 Pay U.S. licensed Partnership
provider’s claims for treating patients based upon signed agreements.
Refer to
Section 29 for additional information related
to the Partnership Program.
12.14 The contractor shall pay all
beneficiary-submitted claims for TRICARE covered drugs dispensed by
a U.S. embassy health clinic to the beneficiary. The contractor
is not to make payments directly to the embassy health clinic.
12.15 Know that
professional services rendered by a U.S. embassy health clinic are
not covered by TRICARE/TOP. These services are covered under International
Cooperative Administrative Support Services (ICASS) agreements.
Embassy providers (acting as PCMs) may refer TOP enrollees to purchased care
sector providers, these claims shall be processed per TOP policy
and procedures.
12.16 Reimburse claims for drugs
or diagnostic/ancillary services purchased overseas following applicable
deductible/cost-share policies.
12.17 In emergency situations, the
requirement for Medicare certification for facilities in U.S. commonwealths
and territories may be waived. After a review of the facts, the
contractor may cost-share otherwise covered services or supplies
rendered in an emergency situation by an unauthorized provider to
the beneficiary, or on behalf of the beneficiary, to the beneficiary's
appointed payee, guardian, or parent in accordance with TPM,
Chapter 11, Section 4.2 and TRM,
Chapter 1, Section 29.
12.18 The contractor
shall mail the drafts/checks and EOBs to purchased care sector providers
unless the claim indicates payment should be made to the beneficiary.
In conformity with banking requirements, the drafts/checks shall
contain the contractor’s address. Drafts and EOBs shall be mailed using
U.S. postage. Additionally, payments/checks may be made to network
providers, with an Embassy address.
12.19 Mail benefit payment checks
and EOBs to Philippine providers, and other nations’ providers as directed
by the DHA CO, to the place of service identified on the claim.
No provider checks or EOBs for Philippine providers, and other nations’
providers as directed by the DHA CO may be sent to any other address.
12.20 Process/pay
inpatient and outpatient claims for TRICARE overseas eligible beneficiaries, including
Service member claims, as indicated below:
12.20.1 The TPharm
contractor shall allow TOP Service members to use the TPharm retail
pharmacy network under the same contract requirements as other Military
Health System (MHS) eligible beneficiaries (see TPM,
Chapter 8, Section 9.1).
12.20.2 The TPharm
contractor shall allow TOP enrolled ADFM beneficiaries to use their
stateside retail pharmacy network under the same contract requirements
as other MHS eligibles (see TPM,
Chapter 8, Section 9.1).
12.20.3 The TOP
contractor shall process claims for overseas health care received
by TRICARE beneficiaries enrolled to or residing in a stateside
contractor’s region following the guidelines outlined in this chapter.
Payment shall be made from applicable bank accounts and shall be
based on billed charges unless a lower reimbursement rate has been
established by the Government or the contractor.
12.21 EFT payments.
Upon purchased care sector provider request, the TRICARE Overseas
health care support contractor shall provide EFT payment to a U.S.
or overseas bank on a weekly basis. Bank charges incurred by the
provider for EFT payment shall be the responsibility of the provider.
Upon beneficiary request, EFT payments to a U.S. bank may be provided.
Bank charges associated with beneficiary EFT payments shall be the
responsibility of the beneficiary.
12.22 The TOP contractor shall process
90% of all retained and adjustment TOP claims to completion within
30 calendar days from the date of receipt. Claims pended per Government
direction are excluded from this standard. However, the number of
excluded claims shall be reported on the Overseas Weekly/Monthly
Workload/Cycletime Aging report. One hundred percent (100%) of all
claims (both retained and excluded, including adjustments) shall
be processed to completion within 90 calendar days from the date
of receipt, unless the CO specifically directs the contractor to
continue pending a claim or group of claims.
12.23 Exclude
correspondence pended due to stop payment orders, check tracers
on foreign banks, and conversion on currency from the routine 45
calendar day correspondence standard and the priority 10 calendar
day correspondence standard. However, the number of excluded routine
and priority correspondence must be reported on the Overseas Monthly
Workload/Cycletime Aging report.
12.24 The TOP contractor shall pay
Value Added Tax (VAT) included on German health care claims for all
beneficiary categories.
12.25 Reimburse fees for transplant
donor searches in Germany on a global flat fee basis since the German
Government does not permit health care facilities to itemize such
charges.
12.26 Reimburse itemized fees for supplies that are
related or incidental to inpatient treatment (e.g., hospital gowns)
if similar supplies would be covered under reimbursement methodologies
used within the U.S. The TOP contractor shall implement internal
management controls to ensure that payments are reasonable and customary
for the location.
13.0 Claims
Adjustment And Recoupment
13.1 The TOP contractor shall follow
the adjustment requirements in
Chapter 10 except
for the requirements related to financially underwritten funds.
13.2 The TOP
contractor shall follow the recoupment requirements in
Chapter 10 for non-financially underwritten
funds, except for providers. The contractor shall use the following
procedures for purchased care sector provider recoupments. Recoupment
actions shall be conducted in a manner that is considered culturally
appropriate for the purchased care sector provider’s country. The
contractor shall:
• Send an initial demand
letter;
• Send
a second demand letter at 90 days;
• Send a final demand
letter at 120 days; and
• Refer the case to
DHA at 240 days, if the case is over $600, and if under $600 the
case shall remain open for an additional four months and then shall
be written off at 360 days.
13.3 Recoupment
letters (i.e., the initial letter, the 90 day second request and
the 120 day final demand letter) shall be modified to delete references
to U.S. law. Invoice numbers shall be provided on all recoupment
letters. The TOP contractor shall include language in the recoupment
letter requesting that refunds be returned/provided in the exact
amount requested.
13.4 Provider recoupment letters
sent to Germany, Italy, Spain, Japan, and Korea, shall be written
in the respective language.
13.5 The TOP contractor may hand
write the dollar amount and the purchased care sector provider’s name
and address, on all recoupment letters.
13.6 If the recoupment action is
the result of an inappropriately processed claim by the TOP contractor,
recoupment is the responsibility of the contractor, not the beneficiary/provider.
13.7 The TOP
contractor shall have a TOP bank account capable of receiving/accepting
wire transfers for purchased care sector provider recoupment/overpayment
returns. The TOP contractor shall accept the amount received as
payment against the amount owed. Any fees associated with the wire
transfer are the responsibility of the payer/provider.