1.0 Contractor
Receipt And Control Of Claims
1.1 The contractor may establish a dedicated
post office box to receive claims related to the TRICARE Prime Remote
(TPR) Program. This dedicated post office box, if established, may
also be the one used for handling Supplemental Health Care Program
(SHCP) claims.
1.2 The contractor shall follow appropriate
SHCP requirements for claims received for medical care furnished
to Service members not enrolled in the TPR Program.
2.0 Claims Processing
2.1 Jurisdiction
2.1.1 The contractor
shall process inpatient and outpatient medical claims for health
care services provided worldwide to the contractor’s TPR enrollees,
except in the case of care provided overseas (i.e., outside of the
50 United States (U.S.) and the District of Columbia). Civilian
health care while traveling or visiting overseas shall be processed
by the TRICARE Overseas Program (TOP) contractor, regardless of
where the beneficiary is enrolled. The contractor shall process
claims for non-covered benefits in accordance with
Section 2, paragraph 5.3.2.2.
2.1.2 The contractor
shall forward claims for Service members enrolled in TPR in other
regions to the contractors for the regions in which the members
are enrolled according to provisions in
Chapter 8, Section 2.
2.1.3 The contractor
shall process claims received for Service members who receive care
in their regions, but who are not enrolled in TPR, according to
the instructions applicable to the SHCP.
2.1.4 The contractor shall forward Service
member dental claims and inquiries to the Active Duty dental program
contractor.
2.2
Claims
for Care Provided Under the National DoD/DVA Memorandum of Agreement (MOA)
for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), and
Blind Rehabilitation
2.2.1 Effective January 1, 2007, the contractor
shall process claims for Service member care provided by the DVA
/VHA for
SCI, TBI, and Blind Rehabilitation. Claims shall be processed in
accordance with this chapter and the following:
2.2.1.1 Claims
received from a DVA/VHA health care
facility for Service member care with any of the following diagnosis
codes (principal or secondary) shall be processed as an MOA claim:
V57.4; 049.9; 139.0; 310.2; 323.x; 324.0; 326; 344.0x; 344.1; 348.1;
367.9; 368.9; 369.01; 369.02; 369.05; 369.11; 369.15; 369.4; 430;
431; 432.x; 800.xx; 801.xx; 803.xx; 804.xx; 806.xx; 851.xx; 852.xx;
853.xx; 854.xx; 905.0; 907.0; 907.2; and 952.xx.
2.2.1.2 The contractor
shall verify whether the MOA DVA/VHA-provided
care has been authorized by the Defense Health Agency-Great Lakes
(DHA-GL) Specified Authorization Staff (SAS). SAS will send authorizations
to the contractor by fax. If an authorization is on file, the contractor
shall process the claim to payment. The contractor shall not deny
claims for lack of authorization. Rather, if a required authorization
is not on file, the contractor shall place the claim in a pending
status and will forward appropriate documentation to SAS for determination.
2.2.2 MOA claims
shall be reimbursed as follows:
2.2.2.1 Claims
for inpatient care shall be paid using DVA/VHA interagency
rates. The interagency rate is a daily per diem to cover an inpatient
stay and includes room and board, nursing, physician, and ancillary
care. These rates will be provided to the contractor by the Defense
Health Agency (DHA) (including periodic updates as needed). There
are three different interagency rates to be paid for rehabilitation
care under the MOA. The Rehabilitation Medicine rate will apply
to TBI care. Blind rehabilitation and SCI care each have their own
separate interagency rate. Additionally, it is possible that two
or more separate rates may apply to one inpatient stay. If the DVA/VHA-submitted
claim identifies more than one rate (with the appropriate number
of days identified for each separate rate), the contractor shall
pay the claim using the separate rates. (For example, a stay for
SCI may include days paid with the SCI rate and days paid at a surgery
rate.)
2.2.2.2 Claims for outpatient services shall
be paid at the appropriate TRICARE allowable rate (e.g., CHAMPUS
Maximum Allowable Charge (CMAC)) with a 10% discount applied.
2.2.2.3 Claims
for the following care shall be paid at the interagency rate if
one exists and, if not, then at billed charges: transportation;
prosthetics; orthotics; Durable Medical Equipment (DME); adjunctive
dental care; home care; personal care attendants; and extended care
(e.g., nursing home care).
2.2.2.4 Since this
is care for Service members, normal TRICARE coverage limitations
do not apply to services rendered for MOA care. As long as a service
has been authorized by SAS, it will be covered regardless of whether
it would have ordinarily not been covered under TRICARE policy.
2.2.3 All TRICARE
Encounter Data (TED) records for this care must include Special
Processing Code 17 - DVA/VHA medical
provider claim.
3.0 Claim Reimbursement
3.1 For network
providers, the contractor shall pay TPR medical claims at the CHAMPUS
allowable charge or at a lower negotiated rate.
3.2 No deductible,
cost-sharing, or copayment amounts shall be applied to Service member
claims.
3.3 If a non-participating provider
requires a TPR enrollee to make an “up front” payment for health care
services, in order for the enrollee to be reimbursed, the enrollee
must submit a claim to the contractor with proof of payment and
an explanation of the circumstances. The contractor shall process
the claim according to the provisions in this chapter. If the claim
is payable without SAS review, the contractor shall allow the billed
amount and reimburse the enrollee for the charges on the claim.
If the claim requires SAS review the contractor shall pend the claim
to the SAS for determination. If the SAS authorizes the care, the
contractor shall allow the billed amount and reimburse the enrollee
for charges on the claim.
3.4 If the contractor becomes aware
that a civilian provider is trying to collect “balance billing” amounts
from a TPR enrollee or has initiated collection action for emergency
or authorized care, the contractor shall follow contract procedures
for notifying the provider that balance billing is prohibited. If
the contractor is unable to resolve the situation, the contractor
shall pend the file and forward the issue to the SAS for determination.
The SAS will issue an authorization to the contractor for payments
in excess of the applicable TRICARE payment ceilings provided the
SAS has requested and has been granted a waiver from the Deputy
Director, DHA, or designee.
3.5 If
required services are not available from a network or participating
provider within the medically appropriate time frame, the contractor
shall arrange for care with a non-participating provider subject
to the normal reimbursement rules.
3.5.1 The contractor initially shall make
every effort to obtain the provider’s agreement to accept, as payment
in full, a rate within the 100% of CMAC limitation. If this is not
feasible, the contractor shall make every effort to obtain the provider’s
agreement to accept, as payment in full, a rate between 100% and
115% of CMAC. If the latter is not feasible, the contractor shall
determine the lowest acceptable rate that the provider will accept.
3.5.2 The contractor
shall then request a waiver of CMAC limitation from the Director,
TRICARE Regional Offices (TROs), as the designee of the Deputy Director,
DHA, before patient referral is made to ensure the patient does
not bear any out-of-pocket expense. The waiver request shall include
the patient name, TPR location, services requested (Current Procedural
Terminology, 4th Edition [CPT-4] codes), CMAC rate, billed charge,
and anticipated negotiated rate. The contractor shall obtain approval from
the RD before the negotiation can be concluded. The contractors
shall ensure that the approved payment is annotated in the authorization/claims
processing system, and that payment is issued directly to the provider,
unless there is information presented that the Service member has
personally paid the provider.
5.0 Third Party Liability (TPL)
TPL processing requirements (
Chapter 10) apply to all claims covered by
this chapter. However, the contractor shall not delay adjudication
action on a claim while awaiting completion of the TPL questionnaire
and compilation of documentation. Instead, the contractor shall
process the claim(s) to completion. When the contractor receives
a completed TPL questionnaire and/or other related documentation,
the contractor shall forward the documentation as directed in
Chapter 10.