1.0 Provider
Certification Criteria
Refer to the
32 CFR 199.6 and the TRICARE Policy Manual
(TPM),
Chapters 1 and
11.
All providers shall be TRICARE certified in accordance with the
TPM. Network providers shall be credentialed in accordance with
nationally accepted credentialing standards adopted by a national accrediting
body. “Authorized Provider” is any provider who meets the requirements
set forth in
32 CFR 199.6 and
in the TPM,
Chapters 1 and
11. 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)/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. The contractors 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).
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).
2.2 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, 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. 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.
2.3 If certification
cannot be accomplished, all pending and subsequent claims for services
from that provider shall be denied. If the provider is later determined
to be authorized based on receipt of the required documentation,
claims may be reopened and processed if requested by the provider
or beneficiary.
2.4 Services delivered by any provider
must be within the scope of the license or other legal authorization.
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. 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.
2.5 Any provider who has not submitted
a claim or whose services have not been submitted on a claim within
the past two years may be moved from the active file to the inactive
file. However, even if the provider 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, the provider must be fully recertified. Providers
who have been terminated or suspended shall not be deleted. 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. The contractor shall
review all providers that have been flagged to ensure the flags
are working at a minimum of once each year. To do this, 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.
2.6 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. Certification
of individual professional providers without a like class (e.g.,
chiropractors) under TRICARE shall be denied.
3.0
Part-Time
Physician Employees Of The Department Of Veterans Affairs (DVA)
/Veterans
Health Administration (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.
Upon receipt of these two documents, the contractor shall approve
the physician as a TRICARE provider for services furnished by this
provider in his private practice. The effective date is the date
the contractor approves the waiver. 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. 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 9.1), 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.
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. 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, paragraph 6.0 for instructions
regarding development of out-of-jurisdiction provider certification
information.
6.0 Provider File Audits
Each
year, the contractor shall conduct an audit, which must include
either 5% or 50, whichever is less, of all prime contractors’ and
subcontractors’ individual network provider credentialing and privileging
files to ensure that information is appropriately verified. The
audit shall be completed prior to the start of each option period.
Thirty calendar days prior to each audit, the contractor shall invite the
Director, TRICARE Regional Offices (TROs), and the TDEFIC Contracting
Officer’s Representative (COR), to monitor and/or participate in
the audit. Not less than 85% of the audited files shall be in full compliance
with all provider file requirements. Within five business days of
the completion of the audit’s provider file review, the contractor
shall submit to the Procuring Contracting Officer (PCO) and the
Director, TROs, and the TDEFIC COR, a written Corrective Action
Plan (CAP) which addresses all credentialing and privileging files
not in full compliance. Within 30 calendar days after completion
of the audit’s provider file review, the incomplete or incorrect
files shall be corrected to full compliance and the contractor shall
notify the Government when the files have been corrected.
7.0 Criminal History Background Checks (CHBC
s)
7.1 Contractors shall perform CHBCs
in accordance with Department of Defense Instruction (DoDI) 1402.5
(“Criminal History Background Checks on Individuals in Child Care
Services”, see
http://www.dtic.mil/whs/directives/corres/pdf/140205p.pdf)
for clinical support agreement personnel working in a Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM) that are involved on
a frequent and regular basis in the provision of care and services
to children under the age 18. 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). The contractor
shall assemble all necessary documentation required by DoDI 1402.5
(
http://www.dtic.mil/whs/directives/corres/pdf/140205p.pdf) for
the background checks and forward the documentation to the office
designated by the PCO or to the office designated in the Memorandum
of Understanding (MOU) (see
Chapter 15, Addendum A).
7.2 For health care practitioners requiring
MTF/eMSM clinical privileges, the contractor shall furnish completed
background check documentation to the MTF Commander/eMSM Manager
prior to the award of privileges.
7.3 For individuals who require background
checks but not clinical privileges, the contractor shall furnish
the completed documentation to the MTF Commander/eMSM Manager prior
to employment at, or assignment to, the MTF/eMSM.
8.0
Criminal
History Reviews
8.1 Contractors shall perform criminal
history reviews on certain physician (see
paragraph 8.2) and non-physician
(see
paragraph 8.3) network providers. Contractors
may search federal, state, and county public records in performing
criminal history checks. Contractors may subcontract for these services; for
example, MEDI-NET, Inc., provides physician screening services,
and ADREM Profiles, Inc., performs criminal history checks. 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 Contractors
shall screen their TRICARE network physicians’ licensure and discipline
histories using the AMA’s master file. Contractors shall check the
criminal histories of physicians with anomalies in their licensure
history [i.e., who have four or more active and/or expired licenses]
or who have been disciplined.
8.3 Contractors
also 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).
8.4 The contractor shall maintain a
copy of all background check documentation with the provider certification
files.
8.5 The contractor is financially responsible
for all credentialing requirements, including background reviews.
Note: A
criminal history review is not required during the recredentialing
process. A criminal history review shall be completed by the contractor
at the time of initial credentialing for those providers for whom
criminal history reviews are required.