Back to Top Skip to main content

Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Operations Manual 6010.59-M, April 1, 2015
Program Integrity
Chapter 13
Section 6
Provider Reinstatements
Revision:  
1.0  Providers or pharmacies Sanctioned By TRICARE
32 CFR 199.9 provides that the Director, Defense Health Agency (DHA) or a designee, shall have the authority to reinstate providers, pharmacies, or entities previously excluded or terminated under TRICARE. For providers sanctioned by Department of Health and Human Services (DHHS), see paragraph 3.0.
1.1  DHHS/Office of Inspector General (OIG) will advise on the monthly listing if and when a previously excluded provider, pharmacy, or entity is reinstated. Before initiating reinstatement action, the contractor must first verify that the provider, pharmacy, or entity meets TRICARE requirements as an authorized provider, pharmacy or entity under 32 CFR 199.6.
1.2  If no funds have been paid for services by the provider, pharmacy, or entity while excluded or are otherwise owed the Government for claims paid prior to the exclusion, the contractor shall certify the provider, pharmacy or entity as an authorized provider, and determine the effective date of the reinstatement.
1.3  The contractor shall advise the provider, pharmacy, or entity in writing of the reinstatement date.
2.0  Contractor Responsibilities Following Requests For Reinstatements From Providers Excluded Or Terminated By DHA
2.1  The contractor will send a provider certification package to the provider to ensure that the provider meets the requirements to be an authorized TRICARE provider. The exclusion or suspension remains in effect until the provider completes and returns the certification package and is determined by the contractor to meet the requirements.
2.2  If the provider is determined to meet the requirements of an authorized provider, the contractor shall advise the provider of the reinstatement date as determined by DHA or designee.
2.3  If the provider does not meet the requirements of an authorized provider, the contractor shall advise the provider as to why he/she does not meet them and offer appeal rights. A copy of the letter shall be provided to the DHA Program Integrity Office (PI).
2.4  The contractor shall advise the same Beneficiary Counseling and Assistance Coordinators (BCACs) located within the provider’s service area that were initially advised of the exclusion or suspension.
2.5  For pharmacies, the contractor shall verify that the pharmacy has all required state licenses necessary to operate as a pharmacy. The exclusion or suspension remains in effect until the contractor has determined that the pharmacy has obtained the required state licenses.
2.6  If the pharmacy has met the state licensing requirements, the contractor shall advise the pharmacy of the date it is eligible to negotiate a new network agreement with the contractor, as determined by DHA.
2.7  If the pharmacy does not have the required state licenses, the contractor shall advise the pharmacy as to why it is not eligible to be a network pharmacy and offer appeal rights. A copy of the letter shall be provided to the DHA PI.
3.0  Contractor Responsibilities Following Requests For Reinstatement From Providers Excluded By DHHS
3.1  DHHS/OIG will advise on the monthly listing if and when a previously excluded provider, pharmacy, or entity is reinstated. Before initiating reinstatement action, the contractor must first verify that the provider, pharmacy, or entity meets TRICARE requirements as an authorized provider, pharmacy or entity under 32 CFR 199.6.
3.2  If no funds have been paid for services by the provider, pharmacy, or entity while excluded or are otherwise owed the Government for claims paid prior to the exclusion, the contractor shall certify the provider, pharmacy or entity as an authorized provider, and determine the effective date of the reinstatement.
3.3  The contractor shall advise the provider, pharmacy, or entity in writing of the reinstatement date.
- END -

Utility Navigation Links

DoD Seal

tricare.mil is the official website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Frequently Asked Questions page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.

v4.8.7983.18738

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.