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TRICARE Operations Manual 6010.59-M, April 1, 2015
Communications and Customer Service (C&CS)
Chapter 11
Section 9
Collection Actions Against Beneficiaries
Revision:  C-24, May 18, 2018
1.0  General
1.1  No patient, family member or sponsor shall be subjected to ongoing collection action undertaken by or on behalf of a provider of services or supplies, as a result of the inappropriate non-payment of claims for services which should have been covered under TRICARE. When the Government becomes aware that such collection action has been initiated, it will intervene on behalf of the party against whom the collection action has been taken.
1.2  While the Government will assist in the resolution of collection matters brought to their attention, the ultimate responsibility for resolving collection actions lies with the patient, family member, or sponsor. The Government will not provide legal representation to resolve these issues and will not pay attorneys’ fees, court costs, collection agency fees, accrued interest, late charges, etc. TRICARE can only assume responsibility for collection assistance for medically necessary supplies and services as authorized for coverage under the TRICARE regulation.
2.0  Debt Collection Assistance Intervention
Upon notification of a problem, Department of Defense (DoD) will investigate and, when appropriate, resolve and/or assist in the clarification of collection issues for TRICARE beneficiaries.
3.0  Contractor responsibilities
3.1  Research Assistance
The contractor shall provide immediate assistance to the Government in support of the debt collection assistance function. In addition to identifying specific underpayments, the contractor shall also:
3.1.1  Designate specific individuals and provide resources to work collection issues with Government representatives during normal weekday business hours.
3.1.2  Provide Web-site access and/or e-mail addresses, mailing addresses, fax numbers and direct phone number(s) of specialized collections research and support staff to the Government.
3.1.3  Maintain records and processing statistics on collection activity. The records to be maintained shall include a detailed chronological record of all actions taken, including names and telephone numbers of all parties contacted in the course of the actions taken, as well as copies of all correspondence sent and received.
3.1.4  When violation of the participation agreement or balance billing is not at issue, issue letters to providers and conduct provider education when the provider was at fault.
3.1.5  The contractor shall furnish reports of all completed collection cases.
3.1.6  In newsletters and other materials, publicize and educate beneficiaries and providers on the Debt Collection Assistance Program. This shall include informing providers of the availability of the contractor’s support services to assist in resolution of claims problems, and encourage providers to contact the contractor’s priority unit for assistance prior to initiating any collection action. If the contractor is asked to participate in beneficiary, sponsor or provider training, workshops or briefings at Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs) or elsewhere in the Region in accordance with specific regional requirements, the contractor shall ensure the Debt Collection Assistance Program is a topic.
3.2  Expedited Payment
All requests for expedited payment will be coordinated through the TRICARE contractor for the region. When research reveals a processing error by the contractor or subcontractor, any additional payment due shall be processed on an expedited basis, and the contractor’s response to the Government shall reflect an expected date of payment.
3.3  Referrals to Program Integrity, Defense Health Agency (DHA)
When it has been determined that balance billing or violation of the participation agreement is at issue, the matter will continue to be handled in accordance with the existing program integrity guidelines contained in Chapter 13, Section 2.
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