1.0 Time Limitations on Filing
TRICARE Claims
1.1 All
claims for benefits must be filed with the appropriate TRICARE contractor
no later than one year after the date the services were provided
or one year from the date of discharge for an inpatient admission
for facility charges billed by the facility. Professional services
billed by the facility must be submitted within one year from the
date of service.
Example:
|
For Service Or Discharge
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Must Be Received By The Contractor
|
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March 22, 2015
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No later than March 22, 2016
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December 31, 2015
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No later than December 31,
2016
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1.2 Any
written request for benefits, whether or not on a claim form, shall
be accepted for determining if the “claim” was filed on a timely
basis. However, when other than an approved claim form is first
submitted, the claimant shall be notified that only an approved
TRICARE claim form is acceptable for processing a claim for benefits.
The contractor shall inform the claimant in writing that in order
to be considered for benefits, an approved TRICARE claim form and
any additional information (if required) must be submitted and received
by the contractor no later than one year from the date of service
or date of discharge, or 90 calendar days from the date they were
notified by the contractor, whichever is later. The claimant should
submit claims on either the Centers for Medicare and Medicaid Services
(CMS) 1500 Claim Form, the CMS 1450 UB-04, or the Defense Department
(DD) Form 2642 as appropriate.
2.0
Exceptions
To Filing Deadline
2.1 Retroactive Eligibility/Preauthorization
Determinations
2.1.1 In order
for an exception to be granted based on a retroactive eligibility/preauthorization determination,
the retroactive determination must have been obtained/issued after
the timely filing period elapsed. Absent an Explanation
of Benefits (EOB), contractors must have proof that beneficiaries received
medical care for a covered service (or waived service). A bill does
not suffice as such proof. If a retroactive determination
is obtained/issued within one year from the date of service/discharge,
the one year timely filing period is still binding.
2.1.2 Only the Uniformed Services
or the Department of Veterans Affairs (DVA)/Veterans Health Administration
(VHA) may determine retroactive eligibility. Once a retroactive
eligibility determination is made, an exception to the claims filing
deadline shall be granted. A copy of the retroactive eligibility decision
must be provided. In any case where a retroactive “preauthorization”
determination is made to cover such services as the Extended Care
Health Option (ECHO), adjunctive dental care, surgical procedures
requiring preauthorization, etc., the timely filing requirements
shall be waived back to the effective date of the retroactive authorization.
Claims which are past the filing deadline must; however, be filed
not more than 180 calendar days after the date of issue of the retroactive
determination.
2.2 Administrative Error
2.2.1 If an administrative error
is alleged, the contractor shall grant an exception to the claims filing
deadline only if there is a basis for belief that the claimant had
been prevented from timely filing due to misrepresentation, mistake
or other accountable action of an officer or employee of Defense Health
Agency (DHA) (including TRICARE Overseas) or a contractor, performing
functions under TRICARE and acting within the scope of that individual’s
authority.
2.2.2 The
necessary evidence shall include a statement from the claimant,
regarding the nature and effect of the error, how he or she learned
of the error, when it was corrected, and if the claim was filed
previously, when it was filed, as well as one of the following:
• A written
report based on agency records (DHA or contractor) describing how
the error caused failure to file within the usual time limit; or
• Copies
of an agency letter or written notice reflecting the error.
Note: The statement of the claimant
is not essential if the other evidence establishes that his or her
failure to file within the usual time limit resulted from administrative
error, and that he or she filed a claim within 90 calendar days
after he or she was notified of the error. There must be a clear
and direct relationship between the administrative error and the
late filing of the claim. If the evidence is in the contractor’s
own records, the claim file shall be annotated to that effect.
2.3 Inability To Communicate And
Mental Incompetency
2.3.1 For
purposes of granting an exception to the claims filing deadline,
‘mental incompetency’ includes the inability to communicate even
if it is the result of a physical disability. A physician’s statement,
which includes dates, diagnosis(es) and treatment, attesting to
the beneficiary’s mental incompetency shall accompany each claim
submitted. Review each statement for reasonable likelihood that
mental incompetency prevented the person from timely filing.
2.3.2 If the failure to timely file
was due to the beneficiary’s mental incompetency and a legal guardian
had not been appointed during the period of time in question, the
contractor shall grant an exception to the claims filing deadline
based on the required physician’s statement. (See above.) If the charges
were paid by someone else, i.e., legal guardian, spouse or parent,
request evidence from the spouse or parent that the claim was paid
and by whom. When the required evidence is received, make payment
to the signer of the claim, with the check made out: “Pay to the
order of (legal guardian, spouse’s or parent’s name) for the use
and benefit of (beneficiary’s name).”
2.3.3 If a legal
guardian was appointed prior to the timely filing deadline and the
claims filing deadline was not met, an exception cannot be granted
due to mental incompetency of the beneficiary.
2.4
Other
Health Insurance (OHI)
2.4.1 The contractor may grant exceptions
to the claims filing deadline requirements, if the beneficiary submitted
a claim to a primary health insurance, i.e., double coverage, and
the OHI delayed adjudication past the TRICARE deadline.
2.4.2 These claims must have been
originally sent to the OHI prior to the TRICARE filing deadline or
must have been filed with a TRICARE contractor prior to the deadline
but returned or denied pending processing by the OHI.
2.4.3 The beneficiary must submit
with the claim a statement indicating the original date of submission
to the OHI, and date of adjudication, together with any relevant
correspondence and an Explanation of Benefits (EOB) or similar statement.
2.4.4 The claim form must be submitted
to the contractor within 90 days from the date of the OHI adjudication.
2.5 Dual Eligibility With Medicare
2.5.1 The contractor may grant exceptions
to the claims filing deadline if Medicare accepted the claim as
timely.
2.5.2 The claim must be submitted,
either by Medicare or by the beneficiary, within 90 calendar days
from the date of Medicare’s adjudication to be considered for a
waiver.
3.0 Time Limitations For Exceptions
3.1 There is no time limit stipulated
for submitting written requests for exceptions to the claims filing
deadline before a claim has been submitted. However, after the proper
claim has been submitted and an exception to the claims filing deadline
granted, the contractor is authorized to consider for benefits only
those services or supplies received during the six years immediately
preceding the receipt of the request. Services or supplies claimed
for more than six years immediately preceding the receipt of the
request shall be denied.
3.2 If
a contractor receives a request for an exception to the filing deadline,
but a completed claim form is not enclosed, the contractor shall:
• Inform
the claimant of the requirement that an approved TRICARE claim form
must be completed and submitted before benefits may be considered;
• Advise
the claimant that the claim and supporting documentation must be
resubmitted within 90 calendar days from the date of the contractor’s
letter; and
• Provide the beneficiary with
appropriate forms.