1.0 Causes Of
Underpayments
An underpayment adjustment may be required
as a result of any one or more of a number of circumstances, such
as reimbursement based on an incomplete billing, reversal of a previous
coverage or eligibility based denial of benefits, or correction
of an erroneous payment to an incorrect party.
2.0 Procedures
For Disposition Of Underpayment Cases
The correction
of most underpayments is readily handled by determining the correction required,
calculating the added amount, making appropriate changes to the
Beneficiary History file, the TRICARE Encounter Data (TEDs) and
issuing a check, if necessary, and a revised Explanation of Benefits
(EOB). For correction of reports of non-receipt of payment, see
paragraph 3.0.
3.0
Disposition
Of Non-Receipt Of Payment Reports
3.1 If the contractor is made aware
that a payee has not received payment, the contractor shall determine
if the check has been negotiated, voided, or stale dated. If payment
was negotiated by other than the appropriate payee, and the report
of non-receipt was received by the contractor within six years of
the date the services or supplies were provided, and it is a contractor
financially underwritten case, the contractor shall reissue payment
to the appropriate payee and handle the case as a possible forgery
in accordance with
Chapter 13.
3.2 If the check has not been negotiated
the contractor shall take immediate steps to replace the check if
more than 30 days have elapsed since the issue date.
3.3 If it is not
a contractor issued check, refer the case to the contractor handling
the case, or if there is no appropriate contractor, refer the case
to Office of General Counsel (OGC) in Aurora, Colorado. Notify the
sender of the action being taken, sending a copy of the notice with
all available information to the contractor.
3.4 If the
check is stale dated, the contractor shall reissue the check to
the appropriate payee, if notice of non-receipt was received within
six years following the date of service or delivery of supply.
3.5 If the
check has been returned as undeliverable and voided, the contractor
shall reissue payment whenever new information; e.g., corrected
address, is received which has the potential for leading to the
successful delivery. The reissue must be accomplished within six
years from the date the services or supplies were provided.