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.