1.0 Scope And Purpose
This section specifies which
individuals and entities may, or in some cases will,
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 the TRICARE Program.
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 temporary suspension
of claim payments.
1.1 The Uniformed
Services Family Health Plan (USFHP) is exempt from this requirement.
1.2 The
Accountable Care Organization (ACO) is partially exempt as follows:1.2.1 All claims where
care is provided and paid by the ACO are exempt from this requirement. These
claims are reported to DHA using the Batch TRICARE Encounter Data
(TED) Record(s) process.
1.2.2 All claims paid
by the Government but 100% reimbursed to the Government by the ACO are
exempt from this requirement. These claims are reported to DHA using
the Voucher TED Record(s) process.
1.2.3 All
claims where costs are shared by the ACO and the Government or are
paid entirely by the Government are subject to the requirements
specified in this section. These claims are reported to DHA using
the Voucher TED Record(s) process. All transactions related to these
claims, to include reimbursement by the ACO, shall be held in temporary
suspense in accordance with the provisions outlined in this section.
1.3 Future Healthcare
Programs Funded Under A Capitation AgreementAll healthcare
claims where the healthcare services provided are 100% covered under
a capitation (Appendix A) agreement are exempt from this
requirement. All healthcare claims not 100% covered under a capitation
agreement (to include shared costs) are subject to the temporary suspension
requirements outlined in this section.
2.0
DHA Authority
For
Temporary Suspension Of Claim
(s
)
Payments2.1 DHA
temporarily suspend
s claim
(s
) payments
to specific providers, pharmacies, entities or client beneficiaries based
upon
fraud, abuse or conflict of interest per 32 CFR 199.9(h) provisions.
See Appendix A for the definition of “client beneficiary.”
2.2 The Director, DHA or designee temporarily suspends claim(s)
payments without notifying the provider,
pharmacy, entity, or client beneficiary to
protect the public fisc. The Government will
advise the provider, pharmacy, or entity within
30 days of the claim(s)
payment suspension that
a temporary suspension has been ordered with a
statement of the basis of the decision to suspend payment.
2.3 The
contractor shall send the temporary suspension of payment notification
(Addendum A, Figure 13.A-6 or Figure 13.A-7 as
appropriate) to the provider, pharmacy, entity, or client beneficiary
in lieu of sending an Explanation of Benefits (EOB) or other claim
settlement notifications of a claim(s) payment suspension.2.3.1 The
contractor shall not send out claim(s) payment temporary suspension
notifications above normal claim(s) settlement notifications.
2.3.2 The
contractor shall not send out any document (EOB, etc.) to the client
beneficiary stating an amount owed by the client beneficiary to
the temporarily suspended provider during the suspension period.
2.4 The
claim(s) payment suspension
is for
a temporary period pending the completion of investigation
,
to include any ensuing legal or administrative proceedings,
unless sooner terminated by the Director, DHA or designee. See
32 CFR 199.9(h) for additional guidance.
Note: Both the Government
and the contractor are sending out temporary suspension notifications.
The contractor shall send out the standard temporary suspension
notification (Addendum A, Figure 13.A-6 or Figure 13.A-7 as
appropriate) in lieu of sending an EOB. The letters notify the provider
or client beneficiary the claim was received but not paid at Government
direction. The Government will send out the letter advising the
provider why payments were suspended and how to proceed to remove
the claim(s) from suspension.
2.5 Contractor Responsibilities2.5.1 Upon
notification from DHA to temporarily suspend claim(s) payments to
specific providers, pharmacies, entities, or client beneficiaries,
the contractor shall take the following six actions:2.5.1.1 Cancel all pending
non-underwritten and underwritten payments where funds have not been
mailed or electronically transmitted, and the contractor can stop
the release of funds in accordance with paragraph 2.5.2.
2.5.1.2 Follow Government
direction in regard to underwritten debt. If instructed to convert
debt from underwritten to non-underwritten, then submit an invoice
in accordance with paragraph 2.5.3. This paragraph does not apply
to the TRICARE Overseas Program (TOP), TRICARE Pharmacy (TPharm) and
TRICARE Dual Eligible Fiscal Intermediary (TDEFIC) contracts.
2.5.1.3 Cease all further
collection of non-underwritten debt related to the temporarily suspended provider,
pharmacy, entity, and client beneficiary in accordance with paragraph 2.5.4.
2.5.1.4 Temporarily suspend
the processing of updates to all non-underwritten and underwritten claims
received and paid prior to receiving the notice of suspension in
accordance with paragraph 2.5.5.
2.5.1.5 Process all new
non-underwritten and underwritten claims received after the notification of
temporary suspension in accordance with paragraph 2.5.6.
2.5.1.6 Forward all funds
received after the notice of temporary suspension from or on behalf
of the suspended providers, pharmacies or entities to DHA, Contract
Resource Management (CRM) in accordance with paragraph 2.5.7.
2.5.2 Attempt To Withhold
The Release Of Payments Where Funds Have Not Been Mailed Or Electronically
Transmitted At The Time Of Temporary Suspension NoticeWhere
reasonably possible, the contractor shall try to prevent the release
of Government payments to a temporary suspended provider when notified
of the provider’s suspension. This requirement does not apply to
all payments pending release. The Government understands there is
a stage in the disbursement process where, though the payments have
not been mailed or transmitted, they have progressed to a point
where they cannot be stopped without significant effort and cost.
2.5.2.1 The
contractor shall determine the point, if any, where the release
of payments for claims received prior to receiving the notice of
temporary suspension can be stopped.
2.5.2.2 The
contractor shall, for all payments intercepted prior to release
and reported as paid to DHA on a TED Record(s), update (usually
Cancel) previously reported TED Record(s) (contractor report of
payment) to show no payment occurred.
2.5.2.3 The
contractor shall not cancel or issue a stop payment order on any
Electronic Funds Transfers (EFTs) or checks where the wire transfer
has already been sent, where the check has been mailed, or where
payment was not intercepted.
2.5.2.4 The
contractor shall, for any payment that is returned, or becomes stale-dated,
or is on the refund file (in the process of crediting back), process
claims in accordance with paragraph 2.6.
2.5.2.5 The
contractor shall process all collections received prior to the notice
of suspension from or on behalf of any temporarily suspended provider,
pharmacy, or entity in accordance with paragraph 2.6.
2.5.2.6 Pharmacy
contractor only. The contractor shall process all pending reversals
up to the date of temporary suspension notification. All reversals
received on or after receipt of the notice of suspension shall be
held by the contractor unless notified by DHA, PI to process the
reversals.
2.5.3 Procedure For
Converting Underwritten Debt To Non-Underwritten Debt (Excludes TOP,
TPharm, And TDEFIC Contracts)At the Government’s
discretion, the Government will require the contractor to convert
its underwritten debt to non-underwritten debt. The conversion of
debt (underwritten to non-underwritten) shall not involve the temporarily
suspended provider(s), pharmacy(s) or entity(s); the debt conversion
is an administrative transaction between the contractor and the
Government. If required to convert debt from underwritten to non-underwritten
the contractor shall:
2.5.3.1 Submit
an invoice billing the Government for the debt owed to the contractor
by the temporarily suspended provider, pharmacy, or entity. The
supporting documentation shall include the amount owed by TED Record(s)
Indicator (TRICARE Systems Manual (TSM), Chapter 2, Section 2.9).
2.5.3.2 The
Government will issue payment to the contractor and record an Accounts
Receivable entry in the accounting system under the temporarily
suspended provider, pharmacy, or entity name. The Government will
not attempt collection during the suspension period.
2.5.3.3 At
the Government’s discretion, debt converted from underwritten to
non-underwritten will be returned to the contractor as non-underwritten
debt in accordance with paragraph 2.9.5.
2.5.4 Procedure For
Existing Debt At The Time Of Temporary SuspensionDuring
the temporary suspension period and while the TED Record(s) Debt
is in a “do-not process” status the contractor shall:
2.5.4.1 Upon receipt
of notification of temporary suspension, cease all non-underwritten
debt collection efforts.
2.5.4.2 Not bill for
Other Health Insurance (OHI), transfer debt to DHA or conduct any
additional claims processing.
2.5.4.3 Not
update any TED Record(s). Any DHA-directed action to collect debt
or correct claims processing errors, to include: Duplicate Claims
System (DCS), OHI, Ineligibles, or beneficiary copay adjustments,
Tax Levy, Payment offset, etc. (this is not an all-inclusive list),
will be approved by DHA, PI prior to taking any action.
2.5.4.4 Forward all funds
collected after receipt of the notice of temporary suspension from
or on behalf of the suspended provider, pharmacy, or entity in accordance
with paragraph 2.5.7.
2.5.4.5 Comply
with applicable reporting requirements related to Accounts Receivable
by separately reporting Temporarily Suspended Fiscal Intermediary
(FI) Receivable debt for each suspended provider, pharmacy, or entity
by the following two categories:
• FI Receivable
debt by temporarily suspended providers in a “do-not process” (do-not-pursue
collection) status.
• FI Receivable
debt related to temporarily suspended providers in a “process” (actively pursuing
collection) status (see paragraph 2.7).
Continue to age
and include temporarily suspended debt on the monthly FI Receivable report.
Note: Temporarily Suspended
FI Receivable debt shall only relates to TED Record(s) data submitted
on Vouchers. The TED Record(s) data submitted on Batches was not
paid and therefore there is no associated debt. Details for reporting
suspended A/R for temporarily suspended providers are identified
in DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
2.5.4.6 Regional
contractors only: If underwritten debt existed prior to the notice
of temporary suspension and the Government did not convert the debt
to non-underwritten in accordance with paragraph 2.5.3, the contractor
may continue to pursue its underwritten debt collection efforts
against the suspended provider, pharmacy, entity, or client beneficiary.
All unsolicited/voluntary refunds (underwritten and non-underwritten)
shall be processed in accordance with paragraph 2.5.7.
2.5.4.7 Claims Processing
and Payment Exceptions for paragraph 2.5.4Contractor
shall not bill for Other Health Insurance (OHI), transfer debt to
DHA or conduct any additional claims processing unless:
2.5.4.7.1 Authorized by
DHA, PI;
2.5.5 Procedure For
Processing Updates To Claims Received Prior To Temporary Suspension Notice2.5.5.1 All proceeds
received prior to the temporary suspension notice are applied to
the suspended provider’s TED Record(s) Debt in accordance with paragraph 2.6.
2.5.5.2 All proceeds
received after the notice of temporary suspension are forwarded
by EFT, check, or special endorsement to DHA, CRM in accordance
with paragraph 2.5.7.
2.5.5.3 All
updates (positive or negative), received after the notice of temporary
suspension, to previously paid claims (claims received and paid
prior to the notice of suspension) are held in suspense by the contractor.
No TED Record(s) updates (Batch or Voucher) are done.Note: TED Record updates
received prior to the notice of temporary suspension pending submission
to DHA shall be processed to completion and sent to DHA after receiving
the notice of suspension. The contractor shall stop updates resulting
in payments if possible.
2.5.6 Procedure For
Processing New Claims Received After Temporary Suspension NoticeThe
contractor shall process all new claims submissions received after
notice of temporary suspension of a provider, pharmacy, entity,
or client beneficiary as an initial Batch TED Record then immediately
place TED Record(s) in a “do-not process” status suspending the
claim from further processing. The contractor shall not make payments
to the provider, pharmacy, entity, or client beneficiary nor apply
calculated payment amounts to the provider’s, pharmacy’s, or entity’s
TED Record(s) debt for any claim processed as a Batch. To submit
claims using the Batch process the contractor shall:
2.5.6.1 Cite Header Type
Indicator 0 (Batch
Header no claim rate) OR 9 (Batch
Header claim rate eligible) as appropriate (TSM Data Element 0-001);
2.5.6.2 Cite Contract
Line Item Number/Automated Standard Application for Payment (CLIN/ASAP) Account
Number 00000000 (TSM
Data Element 0-025);
2.5.6.3 Cite Adjustment
Key 0 (TSM
Data Element 1-035 or 2-035); and
2.5.6.4 Cite Override
Code NP -
Payment to provider, pharmacy, entity, or client beneficiary temporarily
suspended at the direction of DHA, PI (TSM Data Elements 1-160 and
2-095).2.5.6.4.1 Override Code NP is
only used for new claims received after the notice of temporary suspension,
processed as a Batch (informational TED Record(s)), and payment
is being held in accordance with the notice of suspension.
2.5.6.4.2 Updates to claims
paid prior to receiving the notice of temporary suspension are held in
suspense (i.e., no TED Record(s) updates) in accordance with paragraph 2.5.5.
Do not cite Override Code = NP when
submitting Vouchers.
2.5.7 Procedure For
Processing Debt Payments And Unsolicited/Voluntary Refunds Received
Temporary After Suspension NoticeAll funds received
from or on behalf of the temporarily suspended provider(s), pharmacy(s) or
entity(s) for claims subject to the suspension are forwarded (by
EFT, check or special endorsement) to DHA, CRM and are not applied
as payment to the suspended provider’s, pharmacy’s, or entity’s
TED Record(s) Debt. All unsolicited/voluntary refunds (underwritten
and non-underwritten) are forwarded to DHA, CRM. The funds are placed
into a “Deposit Fund” in accordance with the Department of Defense
(DoD) Financial Management Regulation (DoD 7000.14-R, Volume 12,
Chapter 1, Paragraph 0108 & 010803) “Monies held by the U.S.
Government awaiting distribution on the basis of a legal determination
or investigation.” For all funds received after the notice of suspension
from or on behalf of the suspended provider, pharmacy, or entity,
the contractor shall:
2.5.7.1 Forward
checks payable to the contractor to DHA, CRM with the following
Special Endorsement: “Pay to the order of US Treasury, ALC 97000012”.
The contractor shall endorse the checks. If the remittance is deposited
by the contractor, the contractor shall remit the funds to DHA,
CRM by check or EFT payable to US Treasury, ALC 97000012. Funds
collected in accordance with paragraph 2.6 are excepted.
2.5.7.2 Not deposit proceeds
received after the notice of temporary suspension in its non-underwritten
bank account.
2.5.7.3 Not create TED
Record(s) updates for any funds transferred to DHA, CRM to be placed
in a “Deposit Fund” on behalf of the temporarily suspended provider,
pharmacy, or entity pending the outcome of the suspension investigation.
2.5.7.4 Advise the payer
using special notification the funds received have been placed in
a Government owned “Deposit Fund” (Addendum A, Figure 13.A-10).
2.6 TED Record(s)
Processing Exceptions For ClaimsThe following
TED Record(s) updates do not require approval from DHA, PI and TED
Record(s) updates are processed in accordance with the TSM.
2.6.1 The
contractor shall apply all collections received prior to the notice
of temporary suspension to the provider’s, pharmacy’s, or entity’s
TED Record(s) debt with corresponding TED Record(s) updates.
2.6.2 The
contractor shall, for any payment that is returned, becomes stale-dated,
intercepted in accordance with paragraph 2.5.2, or is on
a refund file (in the process of crediting back), process claims as
follows:2.6.2.1 NOT reissue payment
(even if a request is received from the payee).
2.6.2.2 Submit the corresponding
credit TED Record(s) reporting non-payment of claim in accordance
with Chapter 3, Section 4.
2.6.2.3 Deposit
the returned funds in the CLIN/ASAP Account originally used to make
payment (if applicable). If the CLIN/ASAP Account originally used
for payment is closed the contractor shall deposit funds into the
current Fiscal Year (FY) CLIN/ASAP Account assigned for the same
purpose.
2.6.2.4 Process TED Record(s)
adjustments (Vouchers) to temporarily suspended providers as necessary
to ensure the reported TED Record(s) payments (Amount Paid Government
Contractor, TSM, Chapter 2, Section 2.4, Record Locator 1-140
or 2-205) equal actual amounts executed under the contract (payments
excluding offsets). If the contractor is not sure a TED Record(s)
update is needed or authorized for non-underwritten bank reconciliation
or underwritten cost reimbursement purposes during the suspension
period, contact DHA, CRM for resolution.
2.6.2.5 Process all TED
Record(s) updates as required under Section H.10. ANNUAL UNDERWRITTEN UNALLOWABLE
HEALTHCARE COST COMPLIANCE REVIEW Cost of Care audit requirements.
This requirement applies to TED Record(s) data submitted under a
Voucher header. TED Record(s) data submitted under a Batch header
is excluded from audit as the Batch TED Records are informational records
and no expenditure of Government funds occurred based upon the TED
Record(s) (TSM, Chapter 2, Section 2.3).
2.7 Procedure For
Partial Release Of Payments During Temporary SuspensionDuring
the temporary suspension period (pending the completion of investigation,
to include any ensuing legal or administrative proceedings) the
Government will, at its discretion, instruct the contractor to move
suspended provider, pharmacy, entity, and client beneficiary TED
Record(s) from a “do-not process” status to a “process” status while
retaining the suspension on all remaining and future claims received.
The Government will move claims from a “do-not-process” status to
a “process” status based upon date of receipt found embedded in
the Internal Control Number (ICN) (TSM, Chapter 2, Section 2.5). Claims will be released
using a date range on an oldest to newest basis. This action will release
some or all TED Record(s) processed to-date under suspense for a
specific provider, pharmacy, entity, or client beneficiary; however,
it does not change the providers’, pharmacies’, or entities’ suspension
status. The suspension remains in effect for all claims not covered
by the “process” release and for all new claims received.
2.7.1 For
all temporarily suspended provider claims set to a “process” status
the contractor shall:2.7.1.1 Process the claims
to-date as a Voucher citing Special Processing Code (SPC) NQ -
“PI Temporarily Suspended Provider, Pharmacy, Entity, or Client
Beneficiary claim in ‘PROCESS STATUS’.” Claim updates shall include,
but are not limited to: Duplicate Claims System (DCS), OHI, Ineligibles, beneficiary
copay adjustments, Cost of Care audit findings, Tax Levy, Payment
offset, etc., occurring after the suspension date. All TED Records
set to a “process” status while the provider, pharmacy, or entity
remains suspended are submitted as non-underwritten vouchers, cite
SPC NQ and
remain non-underwritten for the life of the claim. SPC NQ is
used for all claims submitted and adjusted as a Voucher and paid
as non-underwritten during the temporary suspension release(s).
SPC NQ allows
DHA to identify all claims actually paid and collected during the
temporary suspension waiver.
2.7.1.2 Cancel the corresponding
Batch TED Record(s) citing Override Code NP -
“Payment to Provider, Pharmacy, Client Beneficiary or Entity Temporarily
Suspended at the Direction of DHA, PI.” Do not cite Override Code
= NP when
submitting Vouchers.
Note: All TED Records
set to a “process” status are submitted to DHA as non-underwritten Vouchers
for the life of the claim.
2.7.2 For
all debt associated with TED Records in a “process” status, the
contractor shall follow the recoupment process as described in Chapter 10, Section 4. All funds recovered
for TED Records set to a “process” status are applied to the provider’s,
pharmacy’s, or entity’s TED Record(s) debt and are deposited by
the contractor into the CLIN/ASAP Account originally used for payment.
If the CLIN/ASAP Account originally used for payment is closed the
contractor shall deposit funds into the current FY CLIN/ASAP Account
assigned for the same purpose. The date Government notification
was received to set the TED Record(s) to “process” and funds covered
under the “process” order (if any) held by DHA, CRM in a “Deposit
Fund” were returned to the contractor is the start date to initiate
debt collection activities. The date of demand in accordance with
45 CFR § 30.11 is used as the new debt aging date and is the age-based
date for potential transfer to DHA if the claim(s) remain uncollectable.
2.7.3 All amounts owed
to the provider, pharmacy, or entity for TED Records set to a “process” status
are first applied to the provider’s, pharmacy’s, or entity’s active
debt (debt related to TED Records set to a “process” status) and
any remaining amounts owed are paid to the provider, pharmacy, entity, or
client beneficiary.
2.7.4 The
contractor shall deposit any funds applied to the provider’s, pharmacy’s,
or entity’s debt into its current FY non-underwritten bank account
and submit a TED Record “cancellation” showing the reduction in
amount paid to the provider, pharmacy, or entity. If the contractor
is unable to submit a TED Record Cancellation or Adjustment, the
contractor shall report the deposit(s) on the monthly Bank Reconciliation
Report in accordance with paragraph 2.9.5.5.
2.8 Procedure For
Full Release Of Temporary SuspensionUpon
notification from DHA PI that the provider, pharmacy or entity is
no longer under suspension the contractor shall:
2.8.1 For all claims
received after notification by DHA PI the temporary suspension has
ended, receive specific guidance from DHA as to how to proceed.
2.8.2 If instructed
by DHA, PI to process temporarily suspended TED Record(s) data,
coordinate with DHA, CRM regarding the disposition of all pending
adjustments and cancellations to TED Record(s) paid prior to the
notice of suspension (in accordance with paragraph 2.5.5) that remain
in a “do-not process” status at the time of suspension release.
This coordination ensures the TED Record-based transactions submitted
by the contractor are recorded and paid correctly by the DHA financial systems.
2.8.3 Receive specific
instruction from DHA, CRM regarding the disposition of all funds
held in “Deposit Fund.”
2.8.4 The
contractor shall reset the debt aging date to the date of temporary
suspension release when directed by DHA. The date Government notification
was received to release suspension of claims and the date funds
(if any) held by DHA, CRM in a “Deposit Fund” were returned to the
contractor is used as the start date to initiate debt collection
activities. The date of demand in accordance with 45 CFR § 30.11
is used as the new debt aging date.
2.9 Other Instructions
To The Contractor2.9.1 On contracts
where TED Record(s)-based administrative (also known as claim rate) payments
are authorized, the contractor is authorized one administrative
payment for each new TED Record required by Government direction
(e.g., claims processed as a Batch and then changed to a “process”
status or released from temporary suspension shall receive one administrative
payment for creating the original Batch TED Record and a second
administrative payment for creating the new Voucher TED Record).
2.9.2 All claims being
held based upon the notice of temporary suspension are excluded
from Section H audit requirements except, in accordance with paragraph 2.6.2.5, the Section H.10 ANNUAL UNDERWRITTEN
UNALLOWABLE HEALTHCARE COST COMPLIANCE REVIEW Cost of Care audit requirements.
2.9.3 The
contractor shall not apply the identified patient responsibility
(applicable cost-shares, copayments, deductibles) toward the catastrophic
cap for claims that are not fully processed. The contractor shall
apply the identified patient responsibility on claims fully processed
prior to the temporary suspension notice (and not intercepted, paragraph 2.5.2)
or fully processed in accordance with paragraphs 2.6, 2.7,
or 2.8.
2.9.4 At
the end of the contract and for all providers, pharmacies, entities,
or client beneficiaries that remain in temporary suspense, the contractor
shall transfer all Batch and Voucher TED Record(s) data to the new
contractor in accordance with Chapter 2, Section 8.
All additional materials being held in suspense related to the suspended
Batch and Voucher TED Record(s) data is transferred to the new contractor’s
Program Integrity (or equivalent) office in accordance with Chapter 2, Section 10, paragraph 1.0.
2.9.5 Debt Transferred
To DHA And Returned To The ContractorWhen
a provider, pharmacy, or entity is under a temporary suspense order,
all non-underwritten debt collection efforts shall cease, to include
collection efforts related to debt previously transferred to DHA
that remains uncollected. Upon release of suspense or partial release
of suspense (Process Status), any debt falling within the suspense
release period and transferred to DHA will be transferred back to
the contractor and the collection process shall start over. The
contractor shall:
2.9.5.1 Reestablish the
debt on its Accounts Receivable system within 30 days after receiving
funds placed in “Deposit Fund” and debt information from the DHA,
Office of General Counsel (OGC). Regional contractors: All debt
returned to the contractor is non-underwritten debt.
2.9.5.2 Issue a demand
letter within 30 days after the debt has been reestablished using
the date of demand as the new debt aging date in accordance with
45 CFR § 30.11.
2.9.5.3 All
interest and penalty timelines shall start over with the date of
demand as the aging start date of debt.
2.9.5.4 If the debt remains
uncollectable it is transferred back to the DHA, OGC in accordance
with Chapter 10, Section 4 using the date of demand
after the debt was transferred back as the aging start date.
2.9.5.5 Regional contractors
only: Deposit all collections of converted debt into the current
FY non-underwritten bank account assigned to them. Because TED Record(s)
credit data submissions shall have already been sent to DHA for
all underwritten debt converted to non-underwritten debt, the monthly
deposits of converted debt will create an out-of-balance on the
bank reconciliation report. The contractor shall separately report
on its monthly bank reconciliation report (in summary) all collections
for converted debt. Details for reporting are identified in DD Form
1423, CDRL, located in Section J of the applicable contract.
3.0 DHA Authority For Exclusions
And Terminations
3.1 DHA
exclusion
of any individual or entity
is based
upon
32 CFR 199.9(h) provisions.
3.2 Effective March 28, 2013, third
party billing agents or entities became subject to TRICARE Program 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 will coordinate and issue 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 initiate action based upon
reversed or vacated decisions. Exclusion of a provider, pharmacy,
or entity will be effective 15 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 shall 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
shall:
• Ensur
e 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
days
from the date of the Initial Determination as noted in
paragraph 3.6).
Neither the provider, pharmacy, entity, nor the
client
beneficiary is entitled to TRICARE cost-sharing once
the exclusion is in effect. The contractor shall notify DHA PI
if a
provider, pharmacy, or entity attempt
s to
bill the program after the effective date of exclusion. It
is not
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)
and 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
shall also
notify the Director, TRICARE Regional Office
(TRO) in
the geographical area(s) of the provider’s practice of action taken.
TROs
in the geographical area(s) of the provider’s practice are also
given notice of exclusion action taken. TRICARE Area
Offices (TAOs) for the region in which the provider’s practice is
located
are also
given
notice of exclusion action taken.
• Ensure 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 their status. This
shall be accomplished by providing written notice, sent by certified
mail, return receipt requested, stating the
network agreement has been cancelled. The
contractor shall send
a copy to DHA PI.
• Issue a
special notice to any client 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 EOB,
whether the claim is payable or not, or sent
as a separate letter.
• 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 is 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 excludes individuals
or entities from participation in any Federal
health care program, to include the DoD Military
Health System (MHS), based upon the authority
and exclusion categories 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 its 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
is 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 client beneficiary are entitled
to TRICARE cost-sharing once the exclusion is effective. The contractor
shall notify DHA PI when a provider,
network pharmacy, or entity attempts to bill
the program or if payment has been issued after the effective date
of exclusion. It is not 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 their status. This
shall be accomplished by providing written notice, sent by certified
mail, return receipt requested, stating the
network provider’s or network pharmacy’s agreement has been cancelled. The
contractor shall send a copy to DHA PI.
7.0 Contractor Application Of Sanction
Authority
Contractors
shall ensure the enforcement of all sanction actions taken,
and notify appropriate parties of the application of sanctions.
For example, any claim received from an excluded third party billing
agent is 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
shall terminate the authorized
provider status of any provider, network pharmacy, or entity determined
not to meet program requirements. The request for reinstatement
shall 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
The
contractor shall ensure receipt of the appropriate state medical
board listings of actions affecting provider authorization
status (e.g., Federation of State Medical Boards of the United States (U.S.)). 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 upon 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
the TRICARE
Program and
has been reinstated as outline
d in
Section 6.
9.2 The
Government
will direct the contractor to notify the provider,
pharmacy, or entity in writing of the proposed action to terminate
their
status as an authorized TRICARE provider when the provider, pharmacy,
or entity
fails to meet the requirements
of
32 CFR 199.6 (
Addendum A, Figure 13.A-8)
.9.2.1 The
notice will offer the provider, pharmacy,
or entity an opportunity to respond within 30 days
from the date of the notice. An extension to 60 days
may be granted if a written request is received during the 30 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 DHA,PI. Expenses incurred
by the provider, pharmacy, or entity are their responsibility.
9.2.2 Once
the notice of proposed action to terminate is sent, the provider’s
claims are temporarily suspended from
claims processing until an Initial Determination is issued. The
provider, pharmacy, or entity is notified
via the proposed notice that the claims are suspended
from claims processing.
9.2.3 For
pharmacy claims, once the notice of proposed action to terminate
is sent, the pharmacy’s claims are not processed
as network claims until an Initial Determination is issued. The pharmacy is notified
via the notice that the claims will not be processed as network
claims. Beneficiaries are advised by
the pharmacy that it is no longer a network pharmacy and that any prescription
filled there requires submittal
of a claim for reimbursement by the beneficiary.
9.2.4 If
the provider being terminated is a Primary Care Manager (PCM), the
contractor shall assist Prime enrollees with selecting a new PCM.
The contractor shall ensure that the client
beneficiary’s medical records are transferred to
the new PCM. Efforts shall be taken to notify non-TRICARE Prime client 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 Government
will invoke an administrative remedy of termination by
directing the contractor to issue a written notice of the Initial
Determination via certified mail. A
copy of the Initial Determination is sent to
DHA PI along with supporting documentation The Initial Determination shall
include:
• A Unique
Identification Number (UIN) indicating the
FY of
the Initial Determination, a consecutive number within that
FY and
the contractor’s name. A sample letter is found at
Addendum A, Figure 13.A-9.
• A
statement of the action being invoked and the effective date of
the action. The effective date will 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 is the date on which
the pharmacy first became part of the network.
• A statement
of the facts, circumstances, 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.
9.4 Providers Failing To Return
Recertification Documentation
Upon notification
from the Government the providers, pharmacies, or
entities
who failed to return recertification
documentation
, the contractor shall
not
terminate
but
shall
place the providers, pharmacies, or entities on the
“inactive” provider listing.
Prior to notification
the
Government will first verify
that the recertification package was mailed to the correct address
and was not returned by the U.S. Postal Service (USPS). The
contractor
shall flag the provider’s file
to
deny claims for services regardless of who submits the claim. The
Government
will notify the provider, pharmacy, or entity
their TRICARE
claims will be
denied for failing to
return their recertification documentation. 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
shall be
refunded to DHA
, CRM. Refer to
Chapter 3.
9.6
File
Requirements For A Terminated Provider, Pharmacy, Or Entity
The
Initial Determination file maintained by the Government
only includes documentation that is releasable to the
provider, pharmacy, or entity. This file also includes:
• Initial
Determination of Termination Action as well as Proposed Notice to
Terminate;
• Provider/pharmacy/entity certification
file (i.e., the documentation upon which the original certification
of the provider/pharmacy/entity was
based) or network pharmacy agreement;
• All correspondence
and documentation relating to the termination. Copies
of the enclosures are attached to the
copy of the original correspondence;
• Documentation
that the contractor considered or relied upon in 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
Client Beneficiary
Notification
The Government
will:
• Instruct
the institution by certified mail to immediately give written notice
of the termination to any TRICARE client beneficiary
(or beneficiary’s 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 by certified mail any client beneficiary
(or beneficiary’s 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 client beneficiary
(or beneficiary’s parent, guardian,
or other representative) of the client beneficiary’s 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 client beneficiary
(or beneficiary’s parent, guardian,
or other representative) admitted prior to the grace period of the
violation that TRICARE cost-sharing of covered care continues during
that period. (Cost-sharing continues through
the last day of the month following the month in which the institution
is terminated.)
• In addition, notify any client beneficiary
(or beneficiary’s 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 client 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.
9.7.3 The
contractor shall cost-share covered care for those beneficiaries
admitted prior to a grace period.