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TRICARE Operations Manual 6010.62-M, April 2021
Provider Certification And Credentialing
Chapter 4
Section 1
General
Revision:  
1.0  PROVIDER CERTIFICATION CRITERIA
1.1  The contractor shall ensure all providers are TRICARE certified in accordance with 32 CFR 199.6 and the TRICARE Policy Manual (TPM), Chapters 1 and 11.
1.2  The contractor shall ensure network providers are credentialed in accordance with nationally accepted credentialing standards adopted by a national accrediting body.
1.3  If a beneficiary submits a claim for services provided by a non-participating individual professional provider who is known to be legally practicing and is eligible for TRICARE-authorization, the provider shall be certified and payment shall be made to the beneficiary. In no case shall a provider who refuses to provide proper Social Security Number (SSN) and Employer Identification Number (EIN) identification be paid directly.
2.0  PROVIDER APPROVALS
2.1   The contractor shall accurately authorize all providers of care using a single, centralized authorization process.
2.2  The contractor shall ensure that all providers of care for whom a billing is made or claim submitted under TRICARE meet all conditions, limitations or exclusions specified or enumerated in 32 CFR 199, the TPM, and the TRICARE Operations Manual (TOM).
2.3  The contractor shall maintain separate institutional and non-institutional provider files. Additions, deletions, and changes to these files, shall be reported to Defense Health Agency (DHA) as specified in the TRICARE Systems Manual (TSM).
2.4  The contractor shall contact the provider, the state licensing board, the appropriate national or professional association, or other sources to determine that the provider meets certification requirements, upon receipt of a claim or request for provider certification information involving a provider practicing in the contractor’s jurisdiction, but not on the TRICARE Encounter Provider (TEPRV) file.
2.5  The contractor may establish eligibility for certification by any of these means. Documentation may be a copy of the page from the most recent state licensor listings, screen print from on-line access to state board licensing files, or other methods that show proof that the provider meets the certification requirements.
2.6  The contractor shall, if certification cannot be accomplished, deny all pending and subsequent claims for services from that provider.
2.6.1  The contractor may, if the provider is later determined to be authorized based on receipt of the required documentation, reopen and reprocess the claim/s if requested by the provider or beneficiary.
2.6.2  Services delivered by any provider must be within the scope of the license or other legal authorization.
2.7  The contractor shall maintain a current computer listing of all certified providers, including, at a minimum, the data required by the TSM, Chapter 2, Section 2.10.
2.8  If the provider was initially certified by the contractor, the certification shall be supported by a documented and readily accessible hardcopy or electronic file documenting each provider’s qualifications. A hardcopy or electronic file documenting the provider’s existence on the TEPRV shall be maintained for all other providers.
2.9  The contractor shall remove from the active file any provider who has not submitted a claim or whose services have not been submitted on a claim within the past two years.
2.9.1  The contractor shall recertify a provider who remains on the active file, if a claim is received from a provider who has not submitted a claim or whose services have not been submitted on a claim within the past two years.
2.9.2  The contractor shall not delete providers who have been terminated or suspended.
2.9.3  Suspended or terminated, or excluded providers shall remain on the file as flagged providers indefinitely or until the flag is dropped because the suspended provider has been reinstated.
2.9.4  The contractor shall review all providers that have been flagged to ensure the flags are working at a minimum of once each year.
2.9.5  The contractor shall maintain records of all suspended and terminated providers and audit the provider file flags and, as necessary, test to ensure they are operational.
2.10  The contractor shall accept the Medicare certification of individual professional providers who have a like class of individual professional providers under TRICARE without further authorization, unless there is information indicating Medicare, TRICARE, or other federal health care program integrity violations by the physician or other health care practitioner.
2.11  The contractor shall deny certification of individual professional providers without a like class (e.g., chiropractors) under TRICARE.
3.0  PART-TIME PHYSICIAN EMPLOYEES OF THE DEPARTMENT OF VETERANS AFFAIRS/VETERANS HEALTH ADMINISTRATION (DVA/VHA)
3.1  The Director, DHA, has authorized an exception, on a case-by-case basis, to the TRICARE policy which excludes any civilian employee of the DVA/VHA from certification as a TRICARE provider. This exception is for part-time physician (MD) employees only who file claims for service furnished in their private, non-DVA/VHA employment practice.
3.2  In order to be considered as a certified provider, the DVA/VHA facility administrator must send a request for an exception to the appropriate contractor (Addendum A, Figure 4.A-1) along with a Part-Time Physician Employee Provider Certification Form (Addendum A, Figure 4.A-2) signed by the physician.
3.2.1  The contractor shall approve the physician as a TRICARE provider for services furnished by this provider in his private practice, upon receipt of these two documents. The effective date is the date the contractor approves the waiver.
3.2.2  The contractor shall notify the physician and requesting DVA/VHA facility by letter of the approval and the effective date. No retroactive approval dates shall be allowed.
3.2.3  All claims from these providers shall be annotated on the signature block of the claim form, “additional certification on file”.
4.0  VENDORS OF MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), OR DURABLE EQUIPMENT (DE)
Medical supplies, DME, or DE otherwise allowable as a Basic Program or authorized Extended Care Health Option (ECHO) benefit purchased from an approved vendor (TPM, Chapter 11, Section 1.4), may be cost-shared (currently or retroactively) when payment is made directly to the beneficiary.
5.0  TRICARE PROVIDER FILE
5.1  The TRICARE provider file is created from contractor submissions of TEPRVs as required in the TSM, Chapter 2, Section 1.2 and is a singular database which is added to or changed through contractors’ reporting activity.
5.1.1  The concept of the TRICARE centralized provider file is based on the agency’s commitment to a singular database which operates on the premise of accountability.
5.1.2  The contractor having contractual authority for provider certification in a given region has accountability for the TEPRVs for providers in that region and is responsible for ensuring these TEPRVs pass the TRICARE edits and for performing all maintenance transactions. This responsibility extends to those TEPRVs submitted in support of the claims processing by another contractor, except the Pharmacy contractor.
5.2  Due to the various methods in use for defining contractor claims processing jurisdictions, a contractor having claims processing responsibility may not be the contractor having accountability for the TEPRV (i.e., having provider certification responsibility) for the provider rendering the service(s) on a claim. In this case, the servicing contractor (i.e., the claims processor) may have to obtain provider data from the certifying contractor. See Chapter 8, Section 2 for instructions regarding development of out-of-jurisdiction provider certification information.
6.0  PROVIDER FILE AUDITS
6.1  The contractor shall conduct an annual provider file audit prior to the start of each option period, of a statistically valid sample, of all TRICARE Prime contractors’ and subcontractors’ individual network provider credentialing and privileging files to ensure that information is appropriately verified. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
6.2  The contractor shall invite the Government Designated Authority (GDA) to observe the contractor’s audit no later than 30 calendar days prior to the scheduled audit. At the time of the audit, the Government will identify the provider and facility type of files to be audited. Not less than 95% of the audited files shall be in full compliance with all provider file requirements.
6.3  The contractor shall submit a written Corrective Action Plan (CAP) within five business days of the completion of the audit, which addresses all credentialing and privileging file deficiencies. Within 30 calendar days after completion of the audit, the incomplete or incorrect files shall be corrected to full compliance.
6.4  The contractor shall provide a report detailed the corrections made and submit thorough e-Commerce. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
7.0  CRIMINAL HISTORY BACKGROUND CHECKS (CHBCs)
7.1  The contractor shall perform CHBCs in accordance with Department of Defense Instruction (DoDI) 1402.5 for https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodm/140205_dodm_2017b.pdf clinical support agreement personnel working in a Market/Military Medical Treatment Facility (MTF) that are involved on a frequent and regular basis in the provision of care and services to children under the age 18.
7.2  The background checks are required by Criminal Control (CC) Act, Public Law 101-647, Section 231 (CC Act 1990, 42 United States Code (USC) Section 13041) and shall be completed by the contractor. The contractor may not accept background checks completed by other agencies.
7.3  The contractor shall assemble all necessary documentation required by DoDI 1402.5 (https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodm/140205_dodm_2017b.pdf for the background checks and forward the documentation to the office designated by the Procurement Contracting Officer (PCO) or to the office designated in the Memorandum of Understanding (MOU).
7.4  The contractor shall furnish the completed documentation, for individuals who require background checks but not clinical privileges, to the Market Director/MTF Director prior to employment at, or assignment to, the Market/MTF.
7.5  The contractor shall follow the CHBC Procedures outlined in DoDI 1402.5 (https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodm/140205_dodm_2017b.pdf) while waiting the 30-day minimum period for a background check to be completed.
7.6  The contractor shall complete the criminal history background check at the time of initial credentialing and shall continue to follow the DoDI 1402.5 (https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodm/140205_dodm_2017b.pdf) which calls for a re-check after five years. A CHBC is not required during the re-credentialing process.
8.0  CRIMINAL HISTORY REVIEWS
8.1  The contractor shall perform criminal history reviews on certain physician (see paragraph 8.2) and non-physician (paragraph 8.4) network providers.
8.1.1  A criminal history review is not required during the recredentialing process.
8.1.2  The contractor may search federal, state, and county public records in performing criminal history checks.
8.1.3  The contractor may subcontract for these services; for example, MEDI-NET, Inc., provides physician screening services, and ADREM Profiles, Inc., performs criminal history checks.
8.1.4  The contractor shall document, in a form of the contractors’ choosing, the American Medical Association (AMA) screen and the results of all criminal history checks.
8.2  The contractor shall screen their TRICARE network physicians’ licensure and discipline histories using the AMA’s master file.
8.3  The contractor shall check the criminal histories of all physicians with anomalies in their licensure history (i.e., who have four or more active or expired licesnses) or who have been disciplined.
8.4  The contractor shall perform criminal history reviews on all non-physician providers who practice independently and who are not supervised by a physician (refer to 32 CFR 199.6(c)(3) for types of providers).
8.5  The contractor shall maintain a copy of all background check documentation with the provider certification files.
8.6  The contractor shall be financially responsible for all credentialing requirements, including background reviews.
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