1.0 Scope And
Purpose
This section specifies which individuals
and entities may, or in some cases must, be excluded from the TRICARE
program. It outlines the authority given to the Department of Health
and Human Services/Office of Inspector General (DHHS/OIG) to impose
exclusions from all Federal health care programs, including TRICARE.
This section also outlines the Defense Health Agency (DHA) authority
for exclusions and terminations. In addition, this section states
the effect of exclusion, factors considered in determining the length
of exclusion, and provisions governing notices, determinations,
and appeals. This section also outlines procedures and protocol
for suspension of claims processing.
2.0
DHA Authority
For Suspension Of Claims Processing
2.1 DHA may suspend claims processing based
on
32 CFR 199.9 provisions.
2.2 The Director,
DHA or designee may suspend claims processing without notifying
the provider or beneficiary of the intent to suspend payments. A
written notice will advise the beneficiary or provider, within 30
days of the claims suspension, that a temporary suspension has been
ordered and a statement of the basis of the decision to suspend
payment.
2.3 A suspension of claims processing
shall be for a temporary period pending the completion of investigation
and any ensuing legal or administrative proceedings, unless sooner
terminated by the Director, DHA or designee. See
32 CFR 199.9 for additional guidance.
3.0 DHA Authority
For Exclusions And Terminations
3.1 DHA may exclude any individual or entity
based on
32 CFR 199.9 provisions.
3.2 Effective March
28, 2013, third party billing agents or entities became subject
to TRICARE sanction authority.
3.3 The contractor shall provide written
notice to DHA PI of any situation involving a TRICARE provider,
pharmacy, or entity whose actions warrant exclusion under DHA authority.
3.4 The Director,
DHA or designee, has the authority to exclude an authorized TRICARE
provider, pharmacy, or entity. The period of exclusion is at the
discretion of DHA. (See
32 CFR 199.9.)
3.5 DHA PI
is responsible for coordinating and issuing notification of exclusion
action. DHA PI will send written notice of the proposed exclusion,
and the potential effect thereof. The individual or entity may submit
evidence and written argument regarding the proposed exclusion.
3.6 DHA
PI has sole authority to issue an Initial Determination of Exclusion.
Written notice of this decision will include the basis for the exclusion,
the length of the exclusion, as well as the effect of the exclusion.
The determination also outlines the earliest date on which DHA PI
will consider a request for reinstatement, the requirements for
reinstatement, and appeal rights available. DHA PI will notify appropriate
agencies, to include contractors, of all DHA exclusion actions taken.
DHA PI will be responsible for initiating action based on reversed
or vacated decisions. Exclusion of a provider, pharmacy, or entity
shall be effective 15 calendar days from the date of the Initial
Determination.
3.7 The
Director, DHA or designee has sole authority for approval of any
request for reinstatement.
4.0 Contractor
Actions Under TRICARE Exclusion Authority -
32 CFR 199.94.1 When the contractor recommends exclusion
to DHA PI of an authorized provider, pharmacy or entity, supporting
documentation must be submitted (e.g., provider, pharmacy, or entity
poses unreasonable potential for fraud).
4.2 The contractor will be notified
immediately of an exclusion action taken by DHA PI and is responsible
for:
• Ensuring
that no payment is made to an excluded provider, pharmacy, or entity
for care provided on or after the date of the DHA action (15 calendar
days from the date of the Initial Determination as noted in
paragraph 3.6).
Neither the provider, pharmacy, entity, nor the patient will be
entitled to TRICARE cost-sharing once the exclusion is in effect.
The contractor shall notify DHA PI should a provider, pharmacy,
or entity attempt to bill the program after the effective date of
exclusion. It will not be necessary for the contractor to issue
a separate letter notifying the provider, pharmacy or entity of
the exclusion action. However, notice of exclusion action taken
by DHA shall be given to all Beneficiary Counseling and Assistance
Coordinators (BCACs) contractor employees that interface with beneficiaries
located within the provider’s service area (approximately 100 miles)
of the practice address of the excluded provider. The contractor
will also notify the Director, TRICARE Regional Office in the geographical
area(s) of the provider’s practice of action taken. TRICARE Area
Offices (TAOs) for the region in which the provider’s practice is
located shall also be given notice of exclusion action taken.
• Ensuring that an excluded provider,
pharmacy, or entity is not included in the network. If cancellation
of a network provider, pharmacy, or entity agreement is required,
the contractor shall ensure that the network provider, pharmacy,
or entity whose contract has been cancelled clearly understands
his/her status. This shall be accomplished by providing written
notice, sent by certified mail, return receipt requested, that the
network provider’s or network pharmacy’s agreement has been cancelled.
(Contractor will send a copy to DHA PI).
• Issuing a special notice to any beneficiary
who submits a claim or for whom a claim is submitted, which includes
services involving an excluded provider pharmacy or entity. The notice
may be enclosed with the Explanation of Benefits (EOB, whether the
claim is payable or not, or be sent as a separate letter.
• Contractors shall ensure the enforcement
of all exclusion action taken, and notify appropriate parties of
the application of exclusions. For example, any claim received from an
excluded third party billing agent shall be returned to the provider
with instructions to resubmit the claim directly or through another
third party billing agent. The provider remains entitled to reimbursement
for covered services as long as they remain an authorized TRICARE
provider.
5.0 DHHS/OIG
Application Of Sanction Authority
5.1 DHHS/OIG can exclude individuals or entities
from participation in any federal health care program to include
the Department of Defense (DoD) Military Health System (MHS). Authority
and exclusion categories can be found on the DHHS/OIG web site.
5.2 DHHS/OIG has
sole responsibility for issuing a written notice of its intent to
exclude a provider, pharmacy, or entity, the basis for the exclusion,
the effective date, the period of exclusion, and the potential effect
of exclusion.
5.3 DHHS/OIG has sole authority for terminating
an exclusion imposed under their authority. DHHS/OIG will handle
notifications of approval/denial of a request for reinstatement
and are responsible for reversing or vacating decisions.
5.4 DHHS/OIG
exclusions and reinstatements are issued on a monthly basis. DHHS/OIG
will provide DHA PI with immediate access to this information, which
will then be forwarded to each contractor.
5.5 Exclusions taken by DHHS/OIG are binding
on Medicare, Medicaid, and all Federal health care programs with
the exception of the Federal Employee Health Benefit Program (FEHBP)
(42 USC 1320a-7b(f)). No payment will be made for any item or service
furnished on or after the effective date of exclusion until an individual
or entity is reinstated by DHHS/OIG, and subsequently meets the requirements
under
32 CFR 199.6.
6.0 Contractor
Actions Under DHHS/OIG Exclusion Authority
6.1 The contractor will be provided the
monthly issuance of DHHS/OIG exclusion and reinstatement actions.
6.2 The contractor
shall ensure that no payment is made to an excluded provider, network pharmacy,
or entity for care provided on or after the date of the DHHS/OIG
action. Neither the provider, pharmacy, or entity, nor the patient
will be entitled to TRICARE cost-sharing once the exclusion is effective.
The contractor shall notify DHA PI should a provider, network pharmacy,
or entity attempt to bill the program or if payment has been issued
after the effective date of exclusion. It is not be necessary for
the contractor to issue a separate letter notifying the provider,
network pharmacy, or entity of the exclusion action.
6.3 The contractor
shall ensure that an excluded provider, pharmacy, or entity is not
included in the network. If cancellation of a network, or if applicable,
participating provider agreement is required, the contractor shall
ensure that the network provider or network pharmacy whose contract
has been cancelled clearly understands his/her status. This shall
be accomplished by providing written notice, sent by certified mail,
return receipt requested, that the network provider’s or network
pharmacy’s agreement has been cancelled. (Contractor shall send
a copy to DHA PI.)
7.0 Contractor
Application Of Sanction Authority
Contractors
shall ensure the enforcement of all sanction action taken, and notify
appropriate parties of the application of sanctions. For example,
any claim received from an excluded third party billing agent shall
be returned to the provider with instructions to resubmit the claim
directly or through another third party billing agent. The provider
remains entitled to reimbursement for covered services as long as
they remain an authorized TRICARE provider.
8.0 Provider,
Network Pharmacy, Or Entity Termination Of Authorized Provider Status
8.1 The contractor
will terminate the authorized provider status of any provider, network pharmacy,
or entity determined not to meet program requirements. The request
for reinstatement will be processed under the procedures established
for initial requests for authorized provider or network pharmacy
status. See
Section 6 for further information.
8.2 Other Listings
Other listings of actions affecting
provider authorization status (e.g., Federation of State Medical
Boards of the United States (U.S.)) will be sent to each contractor.
A provider who has licenses to practice in two or more jurisdictions
and has one or more licenses suspended or revoked shall be terminated
as a TRICARE provider in all jurisdictions.
9.0
Contractor
Requirements For Termination
When
status as an authorized provider, authorized network pharmacy or
authorized entity is ended, the contractor shall initiate termination
action based on a finding that the provider, pharmacy, or entity
does not meet the qualifications to be an authorized provider. Separate
termination action by the contractor is not required for a provider,
pharmacy, or entity sanctioned under the exclusion authority granted
DHHS/OIG.
9.1 The period of termination will be
indefinite and will end only after the provider, pharmacy, or entity
has successfully met the established qualifications for authorized
status under TRICARE and has been reinstated as outline in
Section 6.
9.2 The contractor shall notify the
provider, pharmacy, or entity in writing of the proposed action
to terminate them. The contractor shall specifically notify the
provider, pharmacy, or entity of the proposed action to terminate
their status as an authorized TRICARE provider when the provider, pharmacy,
or entity falls within the contractor’s certifying responsibility
and the provider, pharmacy, or entity fails to meet the requirements
of
32 CFR 199.6 (
Addendum A, Figure 13.A-9). The provider, pharmacy,
or entity is not to be terminated when he/she fails to return certification
packets. Such providers will be flagged as “inactive.” (Do not send
a copy of the proposed notice to DHA PI.) The notice will be sent
to the provider’s, pharmacy’s or entity’s last known business/office
address.
Note: The pharmacy contractor shall notify
the pharmacy in writing of the proposed action to terminate the
pharmacy status as a network pharmacy when it is not in compliance
with its agreement and the pharmacy fails to meet the requirements
of
32 CFR 199.6 (
Addendum A, Figure 13.A-9).
9.2.1 The notice
shall state that the provider, pharmacy, or entity will be terminated
as of the effective date of the termination notice. The notice shall
also inform the provider, pharmacy, or entity of the situation(s)
or action(s) which form the basis for the proposed termination.
9.2.2 For network
providers, the notice shall inform the provider that his/her patients
will be referred to another provider pending final action. For a
network pharmacy, the notice shall inform the pharmacy that beneficiary
prescriptions may not be filled and any claims submitted will be
denied.
9.2.3 The notice shall offer the provider,
pharmacy, or entity an opportunity to respond within 30 calendar
days from the date of the notice. An extension to 60 calendar days
may be granted if a written request is received during the 30 calendar
days showing good cause. The provider, pharmacy, or entity may respond
with either documentary evidence and written argument contesting
the proposed action or a written request to present in person evidence
or argument to a contractor’s designee at the contractor’s location.
Expenses incurred by the provider, pharmacy, or entity are their
responsibility.
9.2.4 Once the notice of proposed action
to terminate is sent, the provider’s claims will be suspended from
claims processing until an Initial Determination is issued. The
provider, pharmacy, or entity will be notified via the proposed
notice that the claims will be suspended from claims processing.
However, beneficiaries will not be notified of the suspension.
9.2.5 For pharmacy
claims, once the notice of proposed action to terminate is sent,
the pharmacy’s claims will not be processed as network claims until
an Initial Determination is issued. The pharmacy will be notified
via the notice that the claims will not be processed as network
claims. Beneficiaries will be advised by the pharmacy that it is
no longer a network pharmacy and that any prescription filled there
will require submittal of a claim for reimbursement by the beneficiary.
9.2.6 If the
provider being terminated is a Primary Care Manager (PCM), the contractor
shall assist Prime enrollees with selecting a new PCM. The contractor
is also responsible for assuring that the patient’s medical records
are transferred to the new PCM. Efforts shall be taken to notify non-TRICARE Prime beneficiaries
in a cost-effective manner.
9.3 Initial Determination
If after
the provider, pharmacy, or entity has exhausted, or failed to comply
with the procedures for appealing the proposed termination and the
decision to terminate remains unchanged, the contractor shall invoke
an administrative remedy of termination. The contractor shall accomplish
this by issuing a written notice of the Initial Determination via
certified mail to the effective entity. A copy of the Initial Determination
shall be sent to DHA PI along with supporting documentation The
Initial Determination written notice shall include the following:
• A Unique Identification Number (UIN) indicating
the fiscal year of the Initial Determination, a consecutive number
within that fiscal year and the contractor’s name. A sample letter
is found at
Addendum A, Figure 13.A-10.
• A statement of the action being
invoked and the effective date of the action. The effective date
shall be the date the provider, pharmacy, or entity no longer meets
the regulatory requirements. If there is no documentation the provider
ever met the requirements, the effective date will be either June
10, 1977 (the effective date of the Regulation) or the date on which
the provider, pharmacy or entity was first approved, whichever date
is later. In the case of a pharmacy, it would be the date on which
the pharmacy first became part of the network.
• A statement of the facts, circumstances,
and/or actions that forms the basis for the termination and a discussion
of any information submitted by the provider, pharmacy, or entity
relevant to the termination.
• A statement of the provider’s, pharmacy’s,
or entity’s right to appeal.
• The requirements and procedures for reinstatement.
• A copy of the Initial Determination
will be sent to DHA PI along with supporting documentation.
9.4 Providers
Failing To Return Recertification Documentation
Providers,
pharmacies, or entities failing to return recertification documentation
shall not be terminated but will be placed on the “inactive” provider
listing. The contractor shall first verify that the recertification
package was mailed to the correct address and was not returned by
the U.S. Postal Service (USPS). The provider’s file shall be flagged
to deny claims for services regardless of who submits the claim.
The provider, pharmacy, or entity shall be advised that such action
will be taken. Refer to
Section 3 regarding
development of possible fraud/abuse cases.
9.5 Requirement
To Recoup Erroneous Payments
After
the Initial Determination has been sent, the contractor shall initiate
recoupment for any claims cost-shared, paid for services, or supplies
furnished by the provider (or pharmacy for any previously paid claims
for pharmaceuticals or supplies furnished by the pharmacy) or entity
on or after the effective date of termination, even when the effective
date is retroactive, unless a specified exception is provided by
32 CFR 199. This applies to claims processed by previous contractors
as well. All monies paid by previous contractors and recouped by
the current contractor will be refunded to DHA Finance and Accounting
Office (F&AO). Refer to
Chapter 3.
9.6
File
Requirements For A Terminated Provider, Pharmacy, Or Entity
The Initial Determination file for
the provider, pharmacy, or entity shall include the following documentation:
• Initial Determination of Termination Action
as well as Proposed Notice to Terminate.
• Provider certification file (i.e., the
documentation upon which the original certification of the provider
was based) or network pharmacy agreement.
• All correspondence and documentation relating
to the termination (copies of the enclosures must be attached to
the copy of the original correspondence).
• Documentation that the contractor considered
or relied upon for issuing the determination.
9.7 Special Action/Notice
Requirements When An Institution Is Terminated
When
a DHA determination is made that an institutional provider does
not meet qualifications or standards to be an authorized TRICARE
provider, the contractor shall take appropriate action.
9.7.1 Provider
And Beneficiary Notification
The contractor
shall:
• Instruct the
institution by certified mail to immediately give written notice
of the termination to any TRICARE beneficiary (or his/her parent,
guardian, or other representative) admitted to or receiving care
at the institution on or after the effective date of the termination.
• When the termination effective date
is after the date of the initial determination, notify any beneficiary
(or their parent, guardian, or other representative) admitted prior
to the date of the termination by certified mail that TRICARE cost-sharing
ended as of the termination date. Advise the beneficiary (or their
parent, guardian, or other representative) of their financial liability.
The contractor shall also use a fast, effective means of notice
(e.g., phone, fax, express mail, or regular mail, depending on the circumstances.).
• If an institution is granted a grace
period to effect correction of a minor violation, notify any beneficiary
(or his/her parent, guardian, or other representative) admitted
prior to the grace period of the violation that TRICARE cost-sharing
of covered care will continue during that period. (Cost-sharing
is to continue through the last day of the month following the month
in which the institution is terminated.)
• In addition, notify any beneficiary (or
their parent, guardian, or other representative) admitted prior
to a grace period of the institution’s corrective action, when such
has been determined to have occurred, and the continuation of the
institution as an authorized TRICARE provider.
• For a beneficiary admitted during a grace
period, cost-share only that care received after 12:01 a.m., on
the day written notice of correction of a minor violation was received
or the day corrective action was completed.
9.7.2 Cost-Sharing
Actions
The contractor shall deny cost-sharing
for any:
• New patient
admitted after the effective date of the termination.
• Beneficiary admitted during a grace period
granted an institution involved in a minor violation.
• Beneficiary already in an institution involved
in a major violation beginning with the effective date of the termination.