Military Health System

The TDEFIC contractor is not required to have the claims auditing software described in the TRM, Chapter 1, Section 3.

The TDEFIC contractor shall grant exceptions to the claims filing deadline if Medicare accepted the claim as timely. If submitted by the beneficiary, the claim must be submitted within 90 calendar days from the date of Medicare’s adjudication to be considered for a waiver.

Reference Chapter 8, Section 3, paragraph 2.4.

Civilian claims for TRICARE dual eligible beneficiaries shall be processed by Medicare first without consideration of the Supplemental Health Care Program (SHCP).

Special authorization/preauthorization services outlined in Chapter 7, Section 2 and in the TRICARE Policy Manual (TPM), Chapter 1, Section 6.1 require preauthorization, and if necessary, review of waivers of the day limits for dual eligible beneficiaries when TRICARE is the primary payer. As secondary payer, TRICARE will rely on and not replicate Medicare’s determination of medical necessity and appropriateness in all circumstances where Medicare is primary payer (see the TRM, Chapter 4, Section 4). In the event that TRICARE is primary payer for these services and preauthorization was not obtained, the TDEFIC contractor shall obtain the necessary information and perform a retrospective review. Skilled Nursing Facility (SNF) preauthorizations shall be tracked separately from the required preauthorizations noted in Chapter 7, Section 2 and TPM, Chapter 1, Section 7.1.

The TDEFIC contractor shall not process a claim from any civilian provider in an MTF/eMSM under the Resource Sharing or Clinical Support Agreement (CSA) programs.

End of Processing. TRICARE For Life (TFL) beneficiary cost-shares shall be based on the following when TRICARE is the primary payer. If the services were received by a TRICARE Prime enrollee (as indicated on DEERS), the TDEFIC contractor shall calculate the Prime copayments applicable on the date services were received. For a beneficiary who is not a Prime enrollee, if a provider is known to be a network provider (e.g., Veterans Health Administration (VHA) medical facility) the Extra cost-shares shall be applied to services received prior to January 1, 2018; if the provider is not a known network provider, the TRICARE Standard cost-share shall be applied. For a beneficiary who is a TRICARE Select enrollee, services received from a known network provider on or after January 1, 2018, will have the TRICARE Select network copayments applied; if the provider is not a known network provider, the TRICARE Select out-of-network cost-share shall be applied. For a TFL beneficiary who is not a Prime enrollee, services received on or after January 1, 2018, shall have the TRICARE Standard copayment (see TRM, Chapter 2) applied as if TRICARE Standard were still being implemented.

Only the actual beneficiary out-of-pocket liability remaining after TRICARE payments will be counted for purposes of the annual catastrophic loss protection.

Initial Determinations. Services and supplies denied payment by Medicare will not be considered for coverage by TRICARE if the Medicare denial of payment is appealable under the Medicare appeal process. If, however, a Medicare appeal results in some payment by Medicare, the services and supplies covered by Medicare will be considered for coverage by TRICARE. Services and supplies denied payment by Medicare will be considered for coverage by TRICARE, if the Medicare denial of payment is not appealable under the Medicare appeal process. The appeal procedures set forth in Chapter 12 are applicable to initial denial determinations by TRICARE under TDEFIC. Appeals of SNF preauthorizations follow concurrent review procedures.