TRICARE Operations Manual 6010.59-M, April 1, 2015 Chapter 10 Claims Adjustments And Recoupments Revision: Section/Addendum Subject/Addendum Title 1 General 2 Underpayments 3 Overpayments Recovery - Financially Underwritten Funds 4 Overpayments Recovery - Non-Financially Underwritten Funds 5 Third Party Recovery Claims A Figures Figure 10.A-1 Sample Letter To Beneficiary Regarding Overpayment (Recoupment) (Financially Underwritten Funds Involved) Figure 10.A-2 Sample Liability Questionnaire Transmittal Letter Figure 10.A-3 Sample Transmittal Letter To Government Claims Officer Figure 10.A-4 Sample Letter To Beneficiary Regarding Overpayment (Recoupment) (Non-Financially Underwritten Funds Involved) Figure 10.A-5 Sample Letter To Provider Regarding Overpayment (Non-Financially Underwritten Funds Involved) Figure 10.A-6 Sample Letter To Beneficiary Or Provider Advising Of Offset (Non-Financially Underwritten Funds Involved) Figure 10.A-7 Sample Letter To Beneficiary Advising Provider Responsible For Overpayment (Non-Financially Underwritten Funds Involved) Figure 10.A-8 Sample Follow-Up Letter To Beneficiary (Account Balance Less Than $600) If No Response To Refund Request Within 30 Days (Non-Financially Underwritten Funds Involved) Figure 10.A-9 Sample Follow-Up Letter To Beneficiary (Account Balance $600 Or More) If No Response To Refund Request Within 30 Days (Non-Financially Underwritten Funds Involved) Figure 10.A-10 Sample Follow-Up Letter To Provider (Account Balance Less Than $600) If No Response To Refund Request Within 30 Days (Non-Financially Underwritten Funds Involved) Figure 10.A-11 Sample Follow-Up Letter To Provider (Account Balance $600 Or More) If No Response To Refund Request Within 30 Days (Non-Financially Underwritten Funds Involved) Figure 10.A-12 Promissory Note In Repayment Of Pre-Existing Debt (Non-Financially Underwritten Funds Involved) Figure 10.A-13 Cover Sheet - Case Recoupment Figure 10.A-14 Codes To Be Used When Completing The Cover Sheets (Non-Financially Underwritten Funds Involved) Figure 10.A-15 Delinquency Notice (Non-Financially Underwritten Funds Involved) Figure 10.A-16 Sample Final Demand Letter (Account Balance $600 Or More) If No Response To Refund Request Within 90 Days (Non-Financially Underwritten Funds Involved) Figure 10.A-17 Sample Amortization Schedule Figure 10.A-18 Letter To Beneficiary Whose Claim Was Offset Against Debt Owed By Participating Provider (Non-Financially Underwritten Funds Involved) Figure 10.A-19 Letter Establishing Installment Payment Agreement When The Debt Does Not Exceed $600.00 (Non-Financially Underwritten Funds Involved) Figure 10.A-20 Sample Calculation And Application Of Interest (Non-Financially Underwritten Funds Involved) Figure 10.A-21 Sample Payment Acknowledgment (Non-Financially Underwritten Funds Involved) Figure 10.A-22 Letter Establishing Installment Repayment Agreement When Debt Exceeds $600.00 (Non-Financially Underwritten Funds Involved) Figure 10.A-23 Financial Affidavit Transmittal Letter (Non-Financially Underwritten Funds Involved) Figure 10.A-24 Letter Advising Debtor That His Account Has Been Referred To Defense Health Agency (Non-Financially Underwritten Funds Involved) Figure 10.A-25 Provider’s Power Of Attorney And Agreement (Non-financially Underwritten Funds Involved) Figure 10.A-26 Sample Letter To Provider (Non-Financially Underwritten Funds Involved) Figure 10.A-27 Beneficiary’s Power Of Attorney And Agreement (Non-financially Underwritten Funds Involved) Figure 10.A-28 Sample Letter To Beneficiary (Non-Financially Underwritten Funds Involved) Figure 10.A-29 Provider Bankruptcy Worksheet Figure 10.A-30 Sample Contractor Bankruptcy Notice Cover Sheet Figure 10.A-31 Referral To Defense Health Agency Office of General Counsel Figure 10.A-32 Substitute Report for Pharmacy Explanation Of Benefits - Required Data Elements Figure 10.A-33 Substitute Report for Pharmacy Offset Explanation Of Benefit - Required Data Elements B Listing Of Government Claims Offices