1.0 Time Limitations
on Filing TRICARE Claims
1.1 All
claims for benefits must be filed with the appropriate TRICARE contractor
no later than one year after the date the services were provided
or one year from the date of discharge for an inpatient admission
for facility charges billed by the facility. Professional services
billed by the facility must be submitted within one year from the
date of service.
Example:
|
For
Service Or Discharge
|
Must
Be Received By The Contractor
|
|
March 22, 2015
|
No later than
March 22, 2016
|
|
December 31,
2015
|
No later than
December 31, 2016
|
1.2 Any written request for benefits,
whether or not on a claim form, shall be accepted for determining
if the “claim” was filed on a timely basis. However, when other
than an approved claim form is first submitted, the claimant shall
be notified that only an approved TRICARE claim form is acceptable
for processing a claim for benefits. The contractor shall inform
the claimant in writing that in order to be considered for benefits,
an approved TRICARE claim form and any additional information (if required)
must be submitted and received by the contractor no later than one
year from the date of service or date of discharge, or 90 calendar
days from the date they were notified by the contractor, whichever
is later. The claimant should submit claims on either the Centers
for Medicare and Medicaid Services (CMS) 1500 Claim Form, the CMS
1450 UB-04, or the Defense Department (DD) Form 2642 as appropriate.
2.0
Exceptions
To Filing Deadline
2.1 Retroactive
Eligibility/Preauthorization Determinations
2.1.1 In order for
an exception to be granted based on a retroactive eligibility/preauthorization determination,
the retroactive determination must have been obtained/issued after
the timely filing period elapsed. If a retroactive determination
is obtained/issued within one year from the date of service/discharge,
the one year timely filing period is still binding.
2.1.2 Only
the Uniformed Services or the Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) may determine retroactive
eligibility. Once a retroactive eligibility determination is made,
an exception to the claims filing deadline shall be granted. A copy
of the retroactive eligibility decision must be provided. In any
case where a retroactive “preauthorization” determination is made
to cover such services as the Extended Care Health Option (ECHO),
adjunctive dental care, surgical procedures requiring preauthorization,
etc., the timely filing requirements shall be waived back to the effective
date of the retroactive authorization. Claims which are past the
filing deadline must; however, be filed not more than 180 calendar
days after the date of issue of the retroactive determination.
2.2 Administrative
Error
2.2.1 If an administrative error is alleged,
the contractor shall grant an exception to the claims filing deadline
only if there is a basis for belief that the claimant had been prevented
from timely filing due to misrepresentation, mistake or other accountable
action of an officer or employee of Defense Health Agency (DHA)
(including TRICARE Overseas) or a contractor, performing functions
under TRICARE and acting within the scope of that individual’s authority.
2.2.2 The necessary
evidence shall include a statement from the claimant, regarding
the nature and effect of the error, how he or she learned of the
error, when it was corrected, and if the claim was filed previously,
when it was filed, as well as one of the following:
• A written report based on agency records
(DHA or contractor) describing how the error caused failure to file
within the usual time limit; or
• Copies of an agency letter or written notice
reflecting the error.
Note: The
statement of the claimant is not essential if the other evidence
establishes that his or her failure to file within the usual time
limit resulted from administrative error, and that he or she filed
a claim within 90 calendar days after he or she was notified of
the error. There must be a clear and direct relationship between
the administrative error and the late filing of the claim. If the
evidence is in the contractor’s own records, the claim file shall
be annotated to that effect.
2.3 Inability To Communicate And Mental
Incompetency
2.3.1 For purposes of granting an exception
to the claims filing deadline, ‘mental incompetency’ includes the
inability to communicate even if it is the result of a physical
disability. A physician’s statement, which includes dates, diagnosis(es)
and treatment, attesting to the beneficiary’s mental incompetency
shall accompany each claim submitted. Review each statement for
reasonable likelihood that mental incompetency prevented the person
from timely filing.
2.3.2 If the failure to timely file was
due to the beneficiary’s mental incompetency and a legal guardian
had not been appointed during the period of time in question, the
contractor shall grant an exception to the claims filing deadline
based on the required physician’s statement. (See above.) If the charges
were paid by someone else, i.e., legal guardian, spouse or parent,
request evidence from the spouse or parent that the claim was paid
and by whom. When the required evidence is received, make payment
to the signer of the claim, with the check made out: “Pay to the
order of (legal guardian, spouse’s or parent’s name) for the use
and benefit of (beneficiary’s name).”
2.3.3 If a legal guardian was appointed prior
to the timely filing deadline and the claims filing deadline was
not met, an exception cannot be granted due to mental incompetency
of the beneficiary.
2.4
Other
Health Insurance (OHI)
2.4.1 The
contractor may grant exceptions to the claims filing deadline requirements,
if the beneficiary submitted a claim to a primary health insurance,
i.e., double coverage, and the OHI delayed adjudication past the
TRICARE deadline.
2.4.2 These claims must have been originally
sent to the OHI prior to the TRICARE filing deadline or must have
been filed with a TRICARE contractor prior to the deadline but returned
or denied pending processing by the OHI.
2.4.3 The beneficiary must submit with the claim
a statement indicating the original date of submission to the OHI,
and date of adjudication, together with any relevant correspondence
and an Explanation of Benefits (EOB) or similar statement.
2.4.4 The claim form
must be submitted to the contractor within 90 days from the date
of the OHI adjudication.
2.5 Dual Eligibility With Medicare
2.5.1 The contractor
may grant exceptions to the claims filing deadline if Medicare accepted
the claim as timely.
2.5.2 The claim must be submitted, either by
Medicare or by the beneficiary, within 90 calendar days from the
date of Medicare’s adjudication to be considered for a waiver.
3.0 Time Limitations
For Exceptions
3.1 There is no time limit stipulated
for submitting written requests for exceptions to the claims filing
deadline before a claim has been submitted. However, after the proper
claim has been submitted and an exception to the claims filing deadline
granted, the contractor is authorized to consider for benefits only
those services or supplies received during the six years immediately
preceding the receipt of the request. Services or supplies claimed
for more than six years immediately preceding the receipt of the
request shall be denied.
3.2 If a contractor receives a request
for an exception to the filing deadline, but a completed claim form
is not enclosed, the contractor shall:
• Inform the claimant of the requirement
that an approved TRICARE claim form must be completed and submitted
before benefits may be considered;
• Advise the claimant that the claim and
supporting documentation must be resubmitted within 90 calendar
days from the date of the contractor’s letter; and
• Provide the beneficiary with appropriate
forms.