The contractor shall determine that
claims received are within its contractual jurisdiction using the criteria
below.
6.0
Supplying
Out-Of-Area Provider Information
For out
of area claims the regional contractor responsible for certifying
providers and developing pricing data for the region where the services
were provided shall supply provider and pricing information (both
institutional and non-institutional) to the contractor responsible
for processing the claims. The contractor shall respond within five
workdays after receipt of such requests and shall designate a Point
Of Contact (POC) for this purpose. The contractor shall follow the procedures
below in requesting and providing information. Responses to such
requests shall include only that information not available in the
requester’s own records or in Defense Health Agency (DHA)-provided
records. The response shall verify whether or not the provider is
a TRICARE-authorized provider and whether or not the provider is
a network provider. The response shall also include the appropriate
pricing of the services/supplies as well as specific data needed
to complete contractor records and TRICARE Encounter Data (TED)
submissions to the DHA.
6.1
Contractor
Coordination On Out-Of-Jurisdiction Providers
Contractors
subject to the requirements of the TRICARE Systems Manual (TSM)
who are responsible for processing claims for care provided outside
of their provider certification jurisdiction shall first search
available provider files, including the DHA-supplied copy of the
TRICARE centralized provider file (to be provided at least weekly),
to determine provider certification status, obtain related provider
information, and determine if the certifying contractor has submitted
a TRICARE Encounter Provider (TEPRV) record for the out-of-area
provider.
6.2
File
Search Unsuccessful
If the file search is
unsuccessful, the following procedures apply:
6.2.1 The servicing
(claims processing) contractor shall request provider information
from the certifying contractor.
6.2.2 Each contractor shall designate
a POC who shall be responsible for initiating actions related to
such requests and ensuring these actions are timely and well documented.
6.2.3 The certifying
contractor shall respond within five workdays of the request with
either:
6.2.3.1 Complete provider information for the servicing
contractor to process the claim and submit TED in situations when
a TEPRV has already been accepted by DHA or,
6.2.3.2 The information
that a TEPRV for the provider in question has not been submitted
to or accepted by DHA and one of the following situations exist:
• The
certifying contractor has sufficient documentation (including the
provider’s Taxpayer Identification Number (TIN)) to complete the
certification process and determine the provider’s TRICARE status;
or
• The
certifying contractor does not have sufficient documentation to
determine the provider’s status and complete the certification process;
or
• The
certifying contractor has sufficient information to determine that
the provider does not meet TRICARE certification requirements without
going through the certification process; or
• The situations above
apply, but the certifying contractor is not subject to the requirements
of the TSM.
6.3
TEPRV
Record Submissions
6.3.1 Since the servicing contractor will be unable
to complete TED processing until a TEPRV is accepted by DHA, a coordinated
effort is required between the servicing contractor and the certifying contractor
in the above situations. The certifying contractor is responsible
for ensuring the TEPRV is accepted by DHA before supplying the provider
information indicated. Contractors shall not delay submitting TEPRVs
for providers who have requested certification and such certification
has been granted or denied, solely because the provider has not
yet submitted a TRICARE claim. When the TEPRV is accepted, the certifying
contractor shall notify the servicing contractor of this within
two workdays of its acceptance and supply the provider information.
Following are procedures and time frames to facilitate this coordination.
6.3.2 If the
certifying contractor has completed its provider certification process
but has yet to submit the TEPRV (or the TEPRV has not passed DHA
edits), the certifying contractor shall submit (or resubmit) the
TEPRV within one workday of contact by the servicing contractor
and notify the servicing contractor within two calendar weeks following
the initial contact, of the TEPRV submission action taken and whether
it was accepted.
6.3.3 If the certifying contractor
does not have sufficient documentation to complete the certification
process and submit a TEPRV, the certifying contractor shall initiate
(or follow up on) the certification process within two workdays
of the initial contact by the servicing contractor. If it is necessary
to obtain documentation from the provider, the certifying contractor
shall allow no longer than a two calendar week suspense from the
date of its request.
6.3.4 Upon determination that the
documentation is complete, the certifying contractor shall complete
the certification process, submit the TEPRV, and notify the servicing
contractor within one additional calendar week following completion
of the certification process (i.e., within three weeks of the initial
contact by the servicing contractor). The certifying contractor
shall also notify the provider of the certification determination
and of procedures for contacting the certifying contractor in the
future regarding provider-related (non-claim) matters (e.g., address
changes).
6.3.5 If the certifying contractor is unable to complete
the certification process within three calendar weeks following
the initial contact, it shall submit the TEPRV and notify the servicing contractor
within four calendar weeks following the initial contact.
6.3.6 If the
certifying contractor has substantial evidence (e.g., state licensure
listing) that the provider meets TRICARE certification requirements,
it shall consider the provider certified and so inform the servicing
contractor one work day after acceptance.
6.3.7 If the certifying contractor
does not have substantial evidence that the provider meets TRICARE
certification requirements, it shall not consider the provider to
be certified. The servicing contractor shall deny the claim using
an appropriate Explanation Of Benefits (EOB) message.
6.3.8 In either
of the above cases, if the certifying contractor does not have the
provider’s TIN, it shall submit the TEPRV with a contractor Assigned
Provider Number (APN) as described in the TSM,
Chapter 2, Section 2.10, Provider Taxpayer
Number, and provide this number to the servicing contractor. The
servicing contractor shall issue payment only to the beneficiary
in this case if the claim is otherwise payable (even in the unlikely
event that the provider is participating).
6.3.9 If, at the time of the servicing
contractor’s initial contact, the certifying contractor is able
to determine that the provider does not meet the TRICARE certification
requirements without going through the certification process, it
shall submit the TEPRV and notify the servicing contractor within two
calendar weeks of the initial contact. If the provider’s TIN is
not known, the certifying contractor shall assign an APN. The servicing
contractor shall deny the claim using an appropriate EOB message.
6.3.10 If the
certifying contractor is not subject to the requirements of the
TSM, the servicing contractor will assign the provider sub-identifier
(sub-ID) and create the TEPRV. The certifying contractor shall provide
the servicing contractor with the minimum provider information listed
below, within two workdays of the initial contact by the servicing
contractor if the certification process has been completed or if
a determination can be made that the provider does not meet the
certification requirements without going through the process. If
it has not been completed, the servicing contractor shall be so
notified within two workdays of the initial contact and the procedures
and time frames above shall be followed.
6.3.11 The servicing
contractor shall notify the DHA Contracting Officer’s Representative
(COR) if the certifying contractor does not provide the required
provider information and notification of the TEPRV’s acceptance
by DHA within 35 calendar days from the time of the initial contact.
After notifying the COR, the servicing contractor shall continue
to pend the claim until they:
• Receive the required
provider information from the certifying contractor; or
• Receive notification
from the COR on how to proceed.
6.4
Provider Data
The minimum provider data to be provided by
the certifying contractor is the provider’s certification status
including the reason a provider is not certified if such is the
case, any special prepayment review status, and the following data:
6.4.1 Provider
Taxpayer Number or APN, or National Provider Identifier (NPI), as
appropriate.
6.4.2 Provider Sub-ID (not required for NPI). Provider
Sub-ID may need to be assigned by the servicing contractor if the
certifying contractor is not subject to the requirements of the
TSM.
6.4.3 Provider Contract Affiliation Code.
6.4.4 Provider
Street Address.
6.4.5 Provider “pay to” Address.
6.4.6 Provider
State or Country.
6.4.7 Provider Zip Code.
6.4.8 Provider
Specialty (non-institutional providers).
6.4.9 Type of Institution (institutional
providers).
6.4.10 Type of reimbursement applicable (DRG, MHPD,
etc.).
6.4.11 Per diem reimbursement amount, if applicable.
6.4.12 Indirect
Medical Education (IDME) factor (where applicable), Area Wage Index
(DRG).
6.4.13 Provider Acceptance Date.
6.4.14 Provider
Termination Date.
6.4.15 Record
Effective Date.
6.4.16 The certifying
contractor shall provide additional data upon request of the servicing contractor
or DHA to meet internal processing, prepayment review, file requirements
or to create a TEPRV when the certifying contractor is not under
the requirements of the TSM.
6.5
Maintenance
Of TEPRV With An APN
6.5.1 In all cases when an APN is assigned, the
certifying contractor shall attempt to obtain the provider’s actual
TIN. Within 10 workdays of receipt of the provider’s TIN, the certifying
contractor who is under the requirements of the TSM shall inactivate
the APN TEPRV and add the TEPRV with the provider’s TIN regardless
of whether the provider meets TRICARE certification requirements.
6.5.2 All APNs
must be associated with an NPI for providers who meet the Health
and Human Services (HHS) definition of a covered entity and submit
Health Insurance Portability and Accountability Act (HIPAA)-compliant
electronic standard transactions or who otherwise obtain an NPI. Guidance
for submitting the NPI on TEPRV records will be provided in a future
order.
6.6
Provider
Correspondence
Any provider correspondence
which the servicing contractor forwards for the certifying contractor’s
action or information shall be sent directly to the certifying contractor’s
POC to avoid misrouting. Within one week of receipt, the servicing
contractor shall forward for the certifying contractor’s action
any correspondence or other documentation received which indicates
the need to perform a provider file transaction. This includes,
but is not limited to, such transactions as address changes, adding
or deleting members of clinics or group practices, or changing a
provider’s TIN.
6.7
Provider
Certification Appeals
6.7.1 Requests for reconsideration of a contractor’s
adverse determination of a provider’s TRICARE certification status
are processed by the certifying contractor. Any such requests received
by the servicing contractor are to be forwarded to the certifying
contractor within five workdays of receipt and the appealing party
notified of this action and the reason for the transfer. The certifying
contractor shall follow standard appeal procedures including aging
the appeal from the date of receipt by the certifying contractor,
except that, if the reconsideration decision is favorable, the provider
shall be notified to resubmit any claims denied for lack of TRICARE
certification to the servicing contractor with a copy of the reconsideration
response. In this case, the certifying contractor shall ensure a
TEPRV for this provider is accepted by DHA within one calendar week
from the date of the appeal decision.
6.7.2 The servicing contractor shall
forward to the certifying contractor within five workdays of receipt
any provider requests for review of claims denied because the certifying
contractor was unable to complete the certification process. The
servicing contractor shall notify the provider of the transfer with
an explanation of the requirement to complete the certification
process with the certifying contractor. Upon receipt of the provider’s
request, the certifying contractor shall follow its regular TRICARE
provider certification procedures. In this case, no basis for an
appeal exists. If the provider is determined to meet the certification
requirements, the special provider notification and TEPRV submittal
requirements apply.
7.0 Out-of-Jurisdiction
TRICARE Claims
Contractors shall transfer
out-of-jurisdiction claims to the appropriate contractor (including
the retail pharmacy (TPharm) contractor, TRICARE Overseas Program
(TOP) contractor, and the TRICARE Dual Eligible Fiscal Intermediary
Contractor (TDEFIC)) within 72 hours of identifying out-of-jurisdiction services
on a claim. The transferring contractor shall not notify the provider
claimant of the transfer. The transferring contractor shall notify
the beneficiary claimant of the action taken and provide the address of
the contractor to which the claim was forwarded. The processing
contractor may include an EOB message indicating that the claim
was transferred from another TRICARE contractor.
7.1
Totally
Out-Of-Jurisdiction
When the contractor receives
an electronic claim with no services or supplies within its jurisdiction,
they shall transfer the claim to the appropriate jurisdictional
contractor via a HIPAA-compliant 837 transaction. When the contractor
receives a paper claim that is totally out of its jurisdiction,
the paper claim (and any attachments) shall be transferred to the
appropriate contractor.
7.2
Partially
Out-Of-Jurisdiction
When a contractor receives
a claim for services or supplies both within and outside its jurisdiction
before processing the services or supplies within its jurisdiction,
and within 72 hours of identifying the out-of-jurisdiction items,
the contractor shall:
• Draw lines through
the in-jurisdiction items.
• Ensure the original
date of receipt is clearly indicated on the claim.
• Send a copy of
the claim and all supporting documents to the appropriate contractor(s).
8.0 Non-TRICARE
Claims
The contractor shall return claims
submitted on other than approved TRICARE claim forms to the sender
or transfer to other lines of business, if appropriate.
8.1
Civilian
Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA) Claims
When a claim is identified
as a CHAMPVA claim, the contractor shall return the claim to the sender
with a letter advising them of the CHAMPVA program’s toll-free telephone
number, 1-800-733-8387, and instructing them to send the claim and
all future CHAMPVA claims to:
Chief,
Business Office Purchased Care
CHAMPVA
P.O. Box 469064
Denver, Colorado 80246-9064
8.2
Veterans’ Claims
If a claim is received for care of a veteran
not eligible for TRICARE and there is evidence the care was ordered
by a Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) physician, the claim,
with a letter of explanation, shall be sent to the VHA
institution from which the order came. The claimant must also be
sent a copy of the letter of explanation. If there is no clear indication
that VHA ordered the care, return the
claim to the sender with an explanation that the veteran is not
eligible under TRICARE and that the care ordered by VHA
should be billed to VHA.
8.3
Claims
For Parents, Parents-In-Law, Grandchildren, And Others
On occasion, a claim may be received for care
of a parent or parent-in-law, a grandchild, or other ineligible
relative of a TRICARE sponsor. Return the claim to the claimant
with a brief explanation that such persons are not eligible for
TRICARE benefits.