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Manager, TRICARE
Provider Certification
(Appropriate
TRICARE Claims Processor’s Address)
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Dear Manager:
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The Director,
Defense Health Agency (DHA), has authorized exceptions, on a case-by-case
basis, to the TRICARE policy which excludes any civilian employee
of VHA from authorization as a TRICARE
provider. This letter identifies the individual VHA
employee(s) for whom an exception is requested based on my determination
that an exception is required to avoid a detrimental effect on VHA’s
ability to obtain the necessary part-time physician employee(s) essential
to the mission of this facility. By granting this exception, the
individual part-time physician employee will be an authorized TRICARE
physician and may file claims for services furnished in the physician’s
private, non-VHA employment practice.
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A request for
an exception to TRICARE policy is made for the following part-time
VHA physician employee(s):
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(List
each physician’s name, specialty, address, and the physician’s IRS/SSAN
or other identification number used to report income to the Internal Revenue
Service.)
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In support of
this request for exception to policy, the individual physician(s)
named have signed the attached certification, as part of the physician’s
application for authorization as a TRICARE provider, that:
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1. The physician understands the prohibitions
against dual compensation under Title 5, United States Code (USC),
Section 5536, as well as the standards of conduct provisions applicable
to Government employees who require the avoidance of actual conflict
of interest situations as well as situations in which the appearance
of conflict of interest may exist; and
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2. The physician has not violated the
dual compensation or standard of conduct provisions in providing
any service(s) for which a TRICARE claim is submitted for payment.
This certification shall be retained on file by the TRICARE claims
processor and be applicable to all claims for services of the physician
during the period of authorization as a TRICARE provider under this
requested exception. In addition, when filing individual TRICARE
claims, the physician shall annotate the signature block (Block 33)
of the TRICARE claims form with the words “additional certification
on file” in order to identify the claim as an exception to the general
TRICARE policy and confirming that the certification on file applies specifically
to that claim.
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By requesting
an exception to TRICARE policy, I agree that the administrators
of this VHA facility shall assume full
responsibility for informing the above-named part-time physician
employee(s) of the dual compensation and standard of conduct provisions
and for monitoring the conduct of the employee(s) and enforcing
the provisions regarding any TRICARE claims for service furnished
by the employee(s) while acting under this request for exception
to policy. In addition, for the above-named part-time physician
employee(s), I agree to provide the appropriate TRICARE claims processor
written notice of termination of VHA
employment or any other basis for withdrawal of this request for
exception to TRICARE policy.
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Thank you for
your prompt attention to this request. Should there be a need to
contact VHA regarding this request
or regarding any matter arising out of the implementation of this
request, my point of contact on this matter is ______________ who
may be contacted at the above address or by telephone number __________________.
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Sincerely,
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VHA
Facility Administrator
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Enclosure:
Physician’s
Certification
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