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TRICARE Operations Manual 6010.62-M, April 2021
Communications and Customer Service (C&CS)
Chapter 11
Section 9
Collection Actions Against Beneficiaries
Revision:  
1.0  GENERAL
1.1  The contractor shall not subject a beneficiary to any ongoing collection action undertaken by or on behalf of a provider of services or supplies as a result of the inappropriate non-payment of claims for services which should have been covered under TRICARE.
1.2  The Government will assist in the resolution of collection matters brought to its attention, the ultimate responsibility for resolving collection actions lies with the patient, family member, or sponsor.
1.3  The Government will not provide legal representation to resolve these issues and will not pay attorneys’ fees, court costs, collection agency fees, accrued interest, late charges, or any other fees or costs. TRICARE can only assume responsibility for collection assistance for medically necessary supplies and services as authorized for coverage under the TRICARE regulation.
2.0  CONTRACTOR RESPONSIBILITIES - DEBT COLLECTION ASSISTANCE
2.1  The contractor shall provide records and information to Government Debt Collection Assistance Officers (DCAOs), upon request, to support the investigation and resolution of debt collection issues for all TRICARE beneficiaries.
2.2  The contractor shall provide all requested records and information within 10 calendar days of Government request.
2.3  The contractor shall identify specific individuals to communicate, collaborate, and coordinate with DCAOs on debt collection assistance cases during normal business hours.
2.4  The contractor shall provide full contact information for these individuals to the Government no later than 30 calendar days prior to the start of health care delivery (SHCD) and provide updated information to the Government within 10 calendar days of any subsequent change(s).
2.5  The contractor shall notify the appropriate Government DCAO through the use of the Government designated system, when the contractor becomes aware of a debt collection action against a TRICARE beneficiary.
2.6  The contractor shall issue letters to providers and conduct provider education when the debt collection action is determined to be a result of balance-billing or violation of a participation agreement.
2.7  The contractor shall prepare and submit a monthly report of all completed collection cases utilizing the Government furnished system. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
2.8  The contractor shall inform providers, at least once per quarter, to contact the contractor’s priority unit for assistance with claims resolution prior to taking collection actions.
3.0  CONTRACTOR RESPONSIBILITIES - RESEARCH ASSISTANCE
3.1  The contractor shall provide immediate assistance to the Government in support of the debt collection assistance function.
3.2  The contractor shall, in addition to identifying specific underpayments:
3.2.1  Designate specific individuals and provide resources to work collection issues with Government representatives during normal weekday business hours.
3.2.2  Provide website access and/or email addresses, mailing addresses, fax numbers, and direct phone number(s) of specialized collections research and support staff to the Government.
3.2.3  Maintain records and processing statistics on collection activity. The records to be maintained shall include a detailed chronological record of all actions taken, including names and telephone numbers of all parties contacted in the course of the actions taken, as well as copies of all correspondence sent and received.
3.2.4  When violation of the participation agreement or balance billing is not at issue, issue letters to providers and conduct provider education when the provider was at fault.
3.2.5  Furnish reports of all completed collection cases.
3.2.6  In newsletters and other materials, publicize and educate beneficiaries and providers on the Debt Collection Assistance Program.
3.2.6.1  This shall include informing providers of the availability of the contractor’s support services to assist in resolution of claims problems, and encourage providers to contact the contractor’s priority unit for assistance prior to initiating any collection action. If the contractor is asked to participate in beneficiary, sponsor, or provider training, workshops or briefings at Markets/Military Medical Treatment Facilities (MTFs) or elsewhere in the geographic area of responsibility.
3.2.6.2  The contractor shall ensure the Debt Collection Assistance Program is a topic.
3.3  Expedited Payment
The contractor shall expedite, within 10 calendar days, the reprocessing of any claims in which the debt collections research reveals a processing error by the contractor or subcontractor.
3.4  Referrals to Program Integrity, Defense Health Agency (DHA)
The contractor shall take corrective action when balance-billing or violation of the participation agreement occurs in accordance with the existing program integrity guidelines contained in Chapter 13, Section 2.
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