1.0 Beneficiary,
Parent/Guardian
The contractor shall issue and mail
an appropriate and easily understood EOB to the beneficiary (parent/guardian
for minors or incompetents) that appropriately describes the action
taken for each claim processed to a final determination. The EOB
should be provided electronically unless there is no e-mail on file
or the beneficiary has specifically requested the EOB to be mailed
in hard copy. The contractor may elect to provide a monthly summary
EOB in lieu of an EOB for each individual claim processed by the
contractor.
2.0 Non-Participating
Provider
The EOB shall be provided to the
non-participating provider with the amount allowed so that he/she
can determine what amount may be billed to the beneficiary under
the balance billing provision (115% of the TRICARE allowable charge).
Only the charges of the non-participating provider would normally
appear on the EOB; however, the non-participating provider should
only be provided with information where there is a “need to know.”
This means that if other information appears on the EOB that does
not pertain to the non-participating provider, the TRICARE contractor
is to suppress printing or remove it before sending the EOB to the
non-participating provider. The non-participating provider will
receive only the EOB and the beneficiary will receive the TRICARE
payment.
3.0 Network And
Participating Providers
The contractor
shall also issue an EOB to network and participating providers or
issue summary vouchers covering multiple claims and beneficiaries
in lieu of issuing multiple EOBs. (A summary voucher must be sent
at least monthly.) Sufficient information must be included on the
vouchers to identify each beneficiary and explain the payment for
each line item on each claim. Use of a summary voucher does not
change the requirement for a separate EOB to be sent to each beneficiary
for each claim. Each contractor shall include adequate identification
of the fiscal year involved applicable to the various charges listed
on the EOB to help keep the deductible information clear to the
beneficiary. If the provider submits the claim electronically, a
Health Insurance Portability and Accountability Act (HIPAA)-compliant
Remittance Advice (RA) shall be returned to the provider. Electronic
Funds Transfers (EFTs) and Electronic Remittance Advice (ERA) sent
from the contractor to the provider must be in HIPAA standard format
as specified in the
Chapter 19, Section 2.
4.0 State Medicaid
Agency
If the claim is from a state Medicaid
agency, the EOB copy usually sent to a participating provider shall
be sent to the state agency. The contractor shall include the same
information on the copy sent to the state as it normally sends to
participating providers. If the state has a need which cannot be
accommodated except at extra expense, the contractor may negotiate
with the state, if it chooses, and if the state is willing to pay
for the accommodation.
5.0 EOB Issuance
Exceptions
5.1 Contractors
shall not issue an EOB to beneficiaries (parents/guardians of minors
or incompetents) when claims involve services related to any of
the following diagnoses:
• Abortion.
• Acquired Immune
Deficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV).
• Alcoholism.
• Pregnancy.
• Substance Abuse.
• Sexually Transmitted
Diseases (STDs).
• Sexual Assault
or Domestic Violence.
5.2 An EOB
must be issued to participating providers, except as noted above.
The contractor shall provide an EOB to a beneficiary upon request.
When a request is made for a normally suppressed EOB, the copy provided
may be a facsimile or a hand-produced copy. It must, however, include
the required data and be certified by the contractor.
5.3 When
a service(s) is denied due to an abortion, a letter of explanation
shall be sent, but only when the denial is questioned by the beneficiary.
Addendum A, Figure 8.A-3 provides suggested wording
for abortion claims that are denied.
The explanation shall
be provided only to the beneficiary and participating provider. The
special denial letter shall be sent in an envelope marked “personal”.
It
is EMPHASIZED that using an EOB is NOT acceptable for denial of
abortion services. Only an approved letter may be used.
6.0
Procedures
For Informing The Beneficiary Of Claim Action
The processing
of claims for the diagnoses listed above requires sensitivity to
the beneficiary’s right to privacy. Because of the need for contractors
to apply reasonable judgment on a case-by-case basis, Defense Health
Agency (DHA) has not prescribed specific procedures except in the
case of abortion claims. For claims involving services and supplies
for the other diagnoses, a phone call to the beneficiary may serve
to obtain information on how the beneficiary wishes to have the
EOB handled in some instances. In other cases, a request that the
provider serve as an intermediary, or a personal letter to the beneficiary,
using a plain envelope, may be appropriate. Whatever approach is
chosen, contractors must observe the intent, as well as the letter,
of the Privacy Act, the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) and the DoD Health Information Privacy Regulation, DoD
6025.18-R. The contractor shall take into account, where applicable,
the following: the special rules for alcohol and drug abuse program
patient records referenced in DoD 6025.18-R, C5.4 and C8.9; the provisions
on abuse, neglect and endangerment situations in DoD 6025.18-R,
C8.7.5; the beneficiary’s right to request restrictions on disclosure
under DoD 6025.18-R, C10.1; and the beneficiary’s right to request
confidential communications under DoD 6025.18-R, C10.2.
7.0 Payment To
The Provider Or Beneficiary Is 99 Cents Or Less
Summary
voucher payments or individual claims payment checks for $.99 or
less, shall be written by the contractor, but NOT mailed to the
beneficiary or provider, using an appropriate EOB message. The checks
shall be voided. At the end of the year when the contractor issues
the provider’s Form 1099, the withheld amounts shall NOT be shown
on the Form 1099.
8.0 EOB Format
The form design of the EOB is not
specifically prescribed. Contractors shall design the form to fit their
individual equipment and system needs. The contractor shall provide
their toll-free inquiry number on the EOB. Only the last four digits
of the Social Security Number (SSN) shall appear on the EOB.
9.0
Required
Information On The EOB
9.1 The
following detailed information shall be included on the EOB:
• Provider/Pharmacy Name.
• Provider/Pharmacy
Address.
• Provider/Pharmacy
Taxpayer Identification Number (TIN).
• Check Number.
• Voucher Date.
• Patient Name.
• Sponsor Name.
• Last four digits
of Sponsor SSN.
• Date(s) of Service/Date(s)
Prescription(s) Filled.
• Pharmacy EOB
- Prescription Number.
• Pharmacy EOB
- Prescription Name.
• Billed Amount.
• Reason Codes.
• Allowed Covered
Charges.
• Deductible.
• Cost-Share/Copayment
Amount.
• Total Paid by
Other Health Insurance (OHI).
• Catastrophic
Cap.
• Remarks.
• Description(s)
of Reason Code(s).
• Interest paid.
• Federal tax
Withheld.
• Accumulated
Toward Catastrophic Cap.
• Accumulated
Toward Individual Deductible.
• Accumulated
Toward Family Deductible.
• Offset (In the
event payment is offset or partially offset and applied toward a
debt)
• Amount Paid
(If payment was not issued but money was withheld and applied towards another
debt, information regarding where the funds were applied).
9.2 In addition
to the fields specified in
paragraph 9.1, offset EOBs shall also contain
the following additional information:
• Total Amount Offset.
• Amount Paid.
• Statement: “$____ was offset from
this remittance and applied towards your outstanding overpayment
listed below. You may not seek reimbursement from the TRICARE beneficiary for
whom you rendered services. We will send you a letter providing
detailed claim information within five to seven business days. If
you have any questions, please contact our customer service department
for assistance.”
• Information
regarding where the offset will be applied:
• Patient Name.
• Claim Number.
• Date Repayment
Requested.
• Amount Requested.
• Offset Amount.
• Collected To
Date.
• Amount Outstanding.
10.0 Reverse Of
The EOB Form
The following information shall
be on the reverse of the EOB:
10.1 Beneficiary Notice Regarding Services
Please review the services/supplies shown
on the front of your EOB. If you find that TRICARE has paid for
any services that you did not receive or that you were charged by a
health care professional you did not see, please call the (Contractor’s
Name) Fraud and Abuse Hotline at (Toll-Free Number).
10.2
Right
To AppealIf you
disagree with the determination on your claim, you have the right
to request a reconsideration. Your signed written request must state
the specific matter with which you disagree and MUST be
sent to the following address no later than 90 days from the date
of this notice. If the postmark on the envelope is not legible,
then the date of receipt is deemed the date of filing. Include a
copy of this notice. On receiving your request, all TRICARE claims
for the entire course of treatment will be reviewed.
(Contractor’s
Address)