Back to Top Skip to main content

Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Operations Manual 6010.62-M, April 2021
Program Integrity
Chapter 13
Addendum A
Figures
Revision:  
Figure 13.A-1  Violation Of The Participation Agreement (Sample)
(Provider Address)
Dear__________:
We have been notified that you are in breach of the participation agreement. (Name of Patient) advised us that (He or She) has been billed for amounts in excess of (His or Her) cost-share for services provided on (Dates), which is a violation of your participation agreement.
Please be advised that by signing the TRICARE claim form and indicating your willingness to accept assignment for these services, you agreed to accept the TRICARE, determined allowable charge for medical services/supplies listed on the claim form as payment in full. This is true even if you requested the beneficiary to complete a form agreeing to pay the full amount not paid by other health coverage or insurance plans.
Under TRICARE, authorized professional providers and institutional providers, other than certain hospitals, have the option of participating on a claim-by-claim basis. Participation is required for inpatient claims only for hospitals which are Medicare-participating providers. Hospitals which are not Medicare-participating but which are subject to the TRICARE DRG-based payment system must sign agreements to participate on all TRICARE inpatient claims in order to be authorized providers under TRICARE. All other hospitals may elect to participate on a claim-by-claim basis. Participating providers must indicate participation by signing the appropriate space on the applicable TRICARE claims form and submitting it to the appropriate TRICARE contractor. In the case of an institution or medical supplier, the claim must be signed by an official having such authority. This signature certifies that the provider has agreed to accept the amount paid by TRICARE or the TRICARE payment combined with the cost-sharing amount paid by or on behalf of the beneficiary as full payment for the covered medical services or supplies. Therefore, when costs or charges are submitted on a participating basis, the patient is not obligated to pay any amounts disallowed as being over the TRICARE-determined allowable cost or charge for authorized medical services or supplies.
A breach of the participation agreement which results in the patient being billed in excess of the allowable amount is specifically listed in the 32 CFR 199.9 as a fraudulent act. Your failure to honor the participation agreement is considered to be a serious infraction of TRICARE rules and regulations which could have repercussions with your TRICARE-authorized provider status as well as that of other Government agencies, such as Medicare and Medicaid.
To preclude any adverse action against your authorized provider status, please notify (Name of Patient) in writing that all attempts to collect amounts in excess of (His or Her) deductible and cost-share have ceased.
The total billed amount is (Amount) and the correct TRICARE allowable is (Allowable Amount). (Name of Patient) cost-share amount is (Appropriate Percentage), of (Put In Dollar Amount). The total payment amount to you is (Government's Cost-Share Plus Patient's Deductible and Cost-Share Amount). (Name of Patient) is only responsible for (His or Her) cost-share amount (Amount). Any amounts billed to the patient in excess the patient’s cost-share and deducible amount (Deductible Amount, if any), is a violation of your participation agreement.
Please provide to us a copy of your letter to (Name of Patient) within 15 calendar days of the date of this letter. Please contact me in writing if you have any questions regarding this matter.
Sincerely,
Name, Title, and Office
cc:
Beneficiary
NOTE TO CONTRACTOR
Letter must be addressed to an individual. Do not use “Dear Provider.”
Figure 13.A-2  Violation Of The Participation Agreement - Follow-Up (Sample)
(Provider Address)
Dear__________:
In a letter dated (Date), we informed you that you violated your participation agreement for a TRICARE beneficiary. You were requested to write to (Name of Patient) and advise (Him or Her) that attempts to collect amounts in excess of the deductible and cost-share amount are canceled and to provide a copy of the letter to us within 15 calendar days of the date of our letter. To date, we have not heard from you.
The 32 CFR 199.9 cites a breach of provider participation agreement which results in the beneficiary being billed for amounts which exceed the TRICARE-determined allowable charge or cost as an example of fraud. Further, administrative remedies for fraud/abuse may result in a provider being excluded or suspended as an authorized TRICARE provider.
Cease collection action for amounts over the TRICARE-determined allowable amount, tell (Name of Patient) you are stopping all collection action; and provide a copy of your letter to us within 15 calendar days of the date of this letter. If we do not hear from you, we will refer this matter to the Defense Health Agency (DHA), Program Integrity Office (PI).
Sincerely,
Name, Title, and Office
cc:
Beneficiary
Figure 13.A-3  Violation Of Reimbursement Limitation (Balance Billing) (Sample)
(Provider Address)
RE:
Patient:
Sponsor:
Date(s) of Service:
ICN:
Total Charges:
Dear__________:
We have been advised that you have billed (Name of Patient) for an amount greater than 115% of the CHAMPUS Maximum Allowable Charge (CMAC). Federal Law, 10 USC 1079(h)(4) limits the amount that a nonparticipating provider may bill a beneficiary to the same percentage used by Medicare.
Within 30 calendar days of the date of this letter, you are to:
•  Refund the beneficiary the amount over the 115% of the CMAC, or
•  If no overpayment was made by the beneficiary, then credit the account and stop billing the beneficiary over 115% of the CMAC. The enclosed Explanation of Benefits (EOB) contains the procedure code(s) for each service, the date(s) of service, and the CMAC for each procedure. The 115% of the CMAC can be easily calculated from the information provided on the EOB (1.15 x CMAC = Balance Billed Amount).
•  As background, the DoD put provisions in place as noted in a final rule published in the Federal Register on October 1, 1993, effective November 1, 1993. These provisions apply to all services provided on or after that date. Failure by a nonparticipating provider to comply with this requirement is a basis for exclusion from TRICARE as an authorized provider.
If you have any further questions, contact (List Appropriate Point Of Contact/List Telephone Number).
Sincerely,
Name, Title, and Office
cc:
Beneficiary
NOTE TO CONTRACTOR
Letter must be addressed to an individual. Do not use “Dear Provider.”
Figure 13.A-4  Violation Of Reimbursement Limitation (Balance Billing) Follow-Up (Sample)
(Provider Address)
RE:
Patient:
Sponsor:
Sponsor SSN: XXX-XX-1234 (Provide only last four)
Dear__________:
In a letter dated (Date of Initial Letter), copy enclosed, you were advised of an incorrect billing practice, and advised to refund to the beneficiary (or credit the account) any amount billed in excess of 115% of the CHAMPUS Maximum Allowable Charge (CMAC). To date, we have not heard from you. Within 15 calendar days of the date of this letter, notify us of your intent to correct this error and follow public law. TRICARE’s limit is based on a similar Medicare law. Because TRICARE is a much smaller federal program not all providers are as familiar with the TRICARE requirements as they are with Medicare requirements.
If you require additional information or you disagree with our interpretation of your billing, please contact our Service Department at (List Appropriate Point Of Contact/List Telephone Number).
Sincerely,
Name, Title, and Office
cc:
Beneficiary
Figure 13.A-5  Provider Education And Prepayment Notification Sample
(Provider Address to include Provider Name)
Contractor shall include in the notification to the provider:
Provider Name
Provider Tax ID
Provider NPI
Provider Address
Identify the areas of potential concern/suspect behavior
Identify how it was identified (prepayment predictive analytics, data mining, etc.)
Identify Time Frame
Define what fraud and abuse is
Identify what potential future actions may include
Provider Point of Contact to include phone number and/or email
Additional language shall include:
XXXX is the Managed Care Support Contractor (MCSC) for the TRICARE X, Y, and Z region. XXXX Program Integrity (PI) is writing this educational letter and/or prepayment notification concerning billing discrepancies (Coding, Noncompliance, etc.) identified during a (Post-Payment Audit, Predictive Analytics, etc.).
If a probe audit or medical records review was performed:
Results of this medical records review disclosed that over XXX% of your claims contained services that should not have been reimbursed under TRICARE coverage, coding, billing, and payment policy. As a result of our audit findings, you will be placed on prepayment review starting (Date).
AUDIT FINDINGS (when a records review was performed):
The results of our audit findings from (list provider and/or group name) claims data are outlined below:
CPT Code
Associated Care
Identified Issue
Applicable TRICARE Regulations, and References
Recommended Modification
Documentation reviewed revealed that provider failed to document and perform the requirements set forth with the use of this code.
To include, but not limited to, 32 CFR 199; TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), American Medical Association (AMA) Current Procedural Terminology (CPT)
Properly document the description of service(s) provided and requirements in order to be reimbursed for this code use.
Documentation for XX% of the claim lines reviewed was not submitted and the billed service and were determined to be not rendered.
Additionally, all records reviewed listed Provider X as the rendering provider on the claim submitted. However, XX% the records submitted identified that the individual providing the service was a massage therapist, speech therapy assistant, or individuals with no identifiable credentials. TRICARE Policy does not recognize services provided by a massage therapist, speech therapy assistant, or unauthorized TRICARE providers. The policy further states that providers must indicate the name and profession of the individual who rendered the care.
PROVIDER RESPONSIBILITY (this language shall be included in all education):
All authorized TRICARE providers have a duty to familiarize themselves with, and comply with program requirements as stated in 32 CFR 199.6 and 199.9. This information is available on-line and is accessible to the public. TRICARE Manuals and CFR can be found on-line at https://manuals.health.mil/.
TRICARE (Contractor Name) also supplies providers with toll-free numbers and billing seminars (Provider Network Training, etc.). There are a number of provider resources available on-line at (Website For Providers) including [insert education and communication that providers receive], the Provider Handbook, education and guides as well as links to https://www.mytricare.com/ (Include Region Website).
As an authorized (Participating/Network, etc.) TRICARE provider, you agree to abide by all rules and regulations of the TRICARE Program, but additionally you agree to bill for services that are only deemed reasonable and medically necessary. This includes submission of only accurate and truthful statements of work, to provide all supporting documentation of provided treatment and/or services rendered, to assure that any and all services are not in excess of the needs of TRICARE patients, and ultimately certify to the truthfulness, accuracy, and completeness of each attestation that is submitted to the TRICARE Program for reimbursement.
This education correspondence provides you as an authorized TRICARE provider (and/or network provider), the tools to be informed of TRICARE policies and program requirements.
32 CFR 199.9 defines abuse and fraud as [review/insert below references supporting allegations]:
32 CFR 199.9 Provide (b) and (c)
Abuse is defined as: “...any practice that is inconsistent with accepted sound fiscal, business, or professional practice which results in a TRICARE claim, unnecessary costs, or TRICARE payment for services or supplies that are: (1) not within the concepts of medically necessary and appropriate care as defined in this Regulation, or (2) that fail to meet professionally recognized standards for health care providers. The term “abuse” includes deception or misrepresentation by a provider, or any person or entity acting on behalf of a provider in relation to a TRICARE claim.”
Fraud is defined as: “...1) a deception or misrepresentation by a provider, beneficiary, sponsor, or any person acting on behalf of a provider, sponsor, or beneficiary with the knowledge (or who had reason to know or should have known) that the deception or misrepresentation could result in some unauthorized TRICARE benefit to self or some other person, or some unauthorized TRICARE payments, or 2) a claim that is false or fictitious, or includes or is supported by any written statement which asserts a material fact which is false or fictitious, or includes or is supported by any written statement that (a) omits a material fact and (b) is false or fictitious as a result of such omission and (c) is a statement in which the person making, presenting, or submitting such statement has a duty to include such material fact. It is presumed that, if a deception or misrepresentation is established and a TRICARE claim is filed, the person responsible for the claim had the requisite knowledge. This presumption is rebuttable only by substantial evidence. It is further presumed that the provider of the services is responsible for the actions of all individuals who file a claim on behalf of the provider (for example, billing clerks); this presumption may only be rebutted by clear and convincing evidence.”
Please discontinue any action that would violate TRICARE coverage, coding, reimbursement, and billing policies.
To ensure compliance with TRICARE guidelines, this letter is notification that all future services will be subject to prepayment review. This will require documentation to support what services were performed and who rendered the services billed. You may continue to submit claims electronically; however, each treatment note must be forwarded to XYZ within (XXX) calendar days for review. Claims submitted without treatment notes will be denied.
You may submit the treatment notes through following methods (fax or mail):
TRICARE Region X
Program Integrity Department
PO BOX 9999
NY, USA 29999
Fax: 800-PI-PROCESS
Please contact us if we can be of further assistance. Our toll free telephone number is 866-XXX-XXXX.
Sincerely,
Name of PI POC
Title
cc:
Subcontractor Program Integrity Manager who oversees PI Prepayment Reviews
Figure 13.A-6  Special Notice To Provider/Pharmacy When The Provider’s Or Network Pharmacy’s Claims Are Suspended (Sample)
(Provider Address)
Dear__________:
This letter serves as notice that as of (Date) we are suspending payment for claims for you or your organization’s services for an indefinite period of time. This action (in accordance with 32 CFR 199.9) is a result of the Government’s investigation of you/your organization’s medical and/or financial records.
Any participation terms or the agreements with patients remains in full force and effect and you cannot reject the agreements as a result of the delay in claims processing. You are also prohibited from assessing a finance charge, either to the beneficiary or the Government, on these suspended claims.
Within 30 calendar days of the date of this notice, you may present to the Director, Program Integrity Office (PI), Defense Health Agency (DHA):
•  Written information (including documentary evidence) and arguments against your suspension, provided the additional specific information raises a genuine dispute over the material facts.
•  A written request to personally present your case to the Director, DHA, or a designee. All such presentations shall be made at DHA, 16401 East Centretech Parkway, Aurora, Colorado 80011-9066 at your expense.
If you have any questions or comments concerning this action, we suggest you convey them in writing to this address:
(Contractor’s Address)
Sincerely,
Name, Title, and Office
NOTE TO CONTRACTOR
The DHA PI will be the sole authority for the direction of issuance of a notice of the suspension of a provider’s or pharmacy’s claims from processing. Instructions will be provided on an individual case-by-case basis. The contractor shall state the reason for the claims processing suspension provided by DHA.
Figure 13.A-7  Special Notice To Beneficiary When The Beneficiary’s Claims Are Suspended (Sample)
(Beneficiary Address)
Dear__________:
We are letting you know that as of (Date) we have suspended payment on your claims for an indefinite period of time. They are being reviewed by the Government in accordance with 32 CFR 199.9.
Within 30 calendar days of the date of this notice, you may present to the Director, Program Integrity Office (PI), Defense Health Agency (DHA):
•  Written information (including documentary evidence) and argument against this action, as long as the additional specific information raises a genuine dispute over the material facts; or
•  A written request to personally present, evidence to the Director, DHA, or a designee. All such presentations shall be made at your expense and conducted at: DHA, 16401 East Centretech Parkway, Aurora, Colorado 80011-9066.
If you have any questions or comments concerning this action, write to this address:
(Contractor’s Address)
Sincerely,
Name, Title, and Office
NOTE TO CONTRACTOR
The DHA PI will be the sole authority for the direction of issuance of a notice of the suspension of a provider’s claims from processing. Instructions will be provided on an individual case-by-case basis. The contractor shall state the reason for the claims processing suspension provided by DHA.
Figure 13.A-8  Special Notice To Beneficiary’s When A Beneficiary’s Claims Are Suspended (Provider/Pharmacy Sample)
(Beneficiary Address)
Dear__________:
This is to inform you that your claim(s) for services provided by (Provider’s/Pharmacy’s Name and Address) has been suspended pending review by the Defense Health Agency (DHA), for an indefinite period of time. This action is being taken by DHA under the provisions of the 32 CFR 199.9, because of further review by the Government of services/supplies provided by (Name of Provider/Pharmacy).
If you have any questions or comments concerning this action, we suggest you convey them in writing to this address:
(Contractor’s Address)
Sincerely,
Name, Title, and Office
NOTE TO CONTRACTOR
The DHA Program Integrity Office (PI) will be the sole authority for the direction of issuance of a notice of the suspension of a provider’s or pharmacy’s claims from processing. Instructions will be provided on an individual case-by-case basis. The contractor shall state the reason for the claims processing suspension provided by DHA.
Figure 13.A-9  Notice Of Proposed Action Terminating A Provider/Pharmacy (Sample)
Note:  For Pharmacy please change “provider” to “pharmacy” or “network pharmacy” as applicable.
(Provider Address)
Dear__________:
We are proposing to terminate you as a TRICARE authorized provider, effective (Date and provide one of the following statements: The date on which you did not meet these requirements, or June 10, 1977, the effective date of the Regulation, WHICHEVER DATE IS LATER). Your termination ends only after you successfully meet established qualification criteria and are reinstated as a TRICARE authorized provider.
Based on submitted documents, you do not qualify to be a TRICARE authorized provider, in accordance with 32 CFR 199.6. (NOTE: The contractor shall give the reasons and supporting facts for the proposed termination.)
Authority for this termination can be found in the 32 CFR 199.9, which provides administrative remedies for fraud, abuse and conflict of interest, and for termination when the provider has not met or satisfied the criteria for TRICARE authorized provider status. Since we lack evidence demonstrating you meet all the criteria, you are now considered to have lost or given up (forfeited or waived) any right to bill TRICARE beneficiaries. If you do bill a beneficiary, payment back to the beneficiary may be required by the Director, Defense Health Agency (DHA), or a designee, as a condition of reinstatement. (NOTE: If beneficiaries choose to continue to see you as a non-authorized provider, TRICARE will deny their claims.)
The retroactive effective date of termination shall not be limited due to the passage of time, erroneous payment of claims, or any other events which may be cited as a basis for TRICARE recognition of the provider, notwithstanding the fact that the provider does not meet program qualification requirements. Unless specific provision is made to “grandfather” or authorize a provider who does not otherwise meet the qualifications established in the 32 CFR 199.6 all unqualified providers shall be terminated.
We will treat any claims for dates of service on or after your termination as erroneous payments; they are subject to collection. Further claims actions are suspended until you get reinstated as an authorized provider.
We will consider any documentary evidence or written argument regarding the proposed action submitted within 30 calendar days of the date of this letter. You may also submit within 30 calendar days a written request to present in person, evidence or argument to (Unit or Name Of Person And Address To Whom The Provider Is To Submit Certification Documentation). All such presentations shall be made at the above mentioned office at your expense.
Documents postmarked within 30 calendar days of the date of this letter will be accepted. If you have a good reason as to why you cannot present additional evidence within 30 calendar days, you may submit a written request to extend the deadline to 60 calendar days from the date of this letter. All communications with this office must be in writing.
Sincerely,
Name, Title, and Office
NOTE TO CONTRACTOR
This letter is to be sent by Return Receipt Requested or any other method which will document receipt.
Figure 13.A-10  Initial Determination Terminating A Provider/Pharmacy (Sample)
(Provider Address)
} Initial Determination
} Contractor Name
} Case File YY-“#”
Dear__________:
On (Date of Proposed Action Notice) we sent notice we proposed terminating you as a TRICARE authorized (Provider/Pharmacy Type) under TRICARE. You were told you could submit, within 30 calendar days, either:
•  Written evidence you meet TRICARE’s authorization requirements as a (Provider Type) and written argument against the action; or
•  A written request to present, in person, at your expense, evidence or arguments supporting you meet qualification criteria as an authorized provider.
(State what the provider did: i.e., by letter dated ___, you submitted additional information, or on (Date) you personally appeared before (State Name and Position of the Informal Review Official), or you failed to take advantage of the opportunity to submit any documentation or argument contesting the proposed action.)
After reviewing all available information, this initial determination is issued terminating your status as an authorized TRICARE provider effective (Insert Either June 10, 1977, the Effective Date of the CHAMPUS Regulation or the Date on which the Provider was first approved or lost their license, WHICHEVER IS LATER), the date on which you first failed to meet the requirements as a (Provider/Pharmacy Type) under the 32 CFR 199.6. This termination action is being taken under authority of the 32 CFR 199.9. The retroactive date of termination is not limited due to the passage of time, erroneous payments of claims, or any other event which may be cited as a basis for TRICARE recognition of a provider notwithstanding the fact that the provider does not meet program qualifications. Termination under TRICARE shall continue even if you obtain a license to practice in a second jurisdiction during the period of exclusion or revocation of your license by the original licensing jurisdiction. Any claims previously cost-shared or paid under TRICARE for services or supplies furnished on or after the effective date of termination shall be deemed an erroneous payment and shall be subject to collection action under appropriate law and regulation.
Under the 32 CFR 199.6, to be an authorized (Provider/Pharmacy Type), an individual must be licensed or certified by the state and meet the following requirements:
(List Specific Requirements From The Regulation)
Our position is that you do not meet the requirements because (give specific basis for your decision; if the provider submitted any evidence or argument in writing or in person, identify that evidence or argument here and discuss its relevance to this decision).
The period of your termination as an authorized (Provider/Pharmacy Type) under TRICARE is indefinite under the provisions of the 32 CFR 199.9. The period of termination will end only upon receipt of documentation that you have successfully met the established qualifications and receipt of your request for reinstatement as an authorized provider under the procedures established by the 32 CFR 199.9. All requests for reinstatement of terminated providers must be submitted to:
CONTRACTOR PROGRAM INTEGRITY OFFICE (PI)
The TRICARE Regulation, 32 CFR 199.10, sets forth policies and procedures for providers to appeal a termination decision as long as there is an appealable issue, such as a question on factual matters of the case. If you question the fact(s) serving as the basis for your termination, you may file an appeal. (NOTE: The appeal process may not be used to challenge any provision of law or regulation.) You must mail a written request for a hearing within 60 calendar days from the date of this letter to: Chief, Office of Appeals and Hearings, Defense Health Agency (DHA), 16401 East Centretech Parkway, Aurora, Colorado 80011-9066. Include a copy of this letter and any additional documentation/evidence you want considered as part of your hearing package.
Sincerely,
Name, Title and Office
cc:
Program Integrity Office (PI)
Defense Health Agency (DHA)
NOTE TO CONTRACTOR
This letter is to be sent by Return Receipt Requested or any other method which will document receipt.
- END -

Utility Navigation Links

DoD Seal

tricare.mil is the official website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Frequently Asked Questions page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.

v4.8.7983.18738

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.