On occasion, two different contractors
will pay for the same billed services. These types of duplicate payments
are a result of jurisdictional processing errors. To ensure that
this type of duplicate payment is addressed in the Duplicate Claims
System (DCS), special data fields and procedures have been incorporated.
1.0 Description
Of A Multi-Contractor Claim Set
1.1 A multi-contractor claim set contains potential
duplicate claims processed by two or more contractors. A multi-contractor
set, consisting of
Responsible FIs 50 and 55, is shown
in
Figure 4.1.3-1. The
resolution of multi-contractor claim sets requires coordination
between/among the contractors involved. Multi-contractor sets always
involve an erroneous payment because only one contractor is responsible
for processing and paying for services within a jurisdiction at
any given time. When two different contractors pay for the same
billed service, it means that one or more of the claims in the set were
erroneously processed and paid by a contractor who did not have
processing jurisdiction.
Figure 4.1.3-1 Sample
Multi-Contractor Claim Set
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1.2 As
with all other potential duplicate claim sets, the DCS assigns ownership
of each set, i.e., responsibility for resolving the set, to the
contractor who submitted the claim with the latest processed to
completion (PTC) date. This contractor becomes the Owner FI,
who must research the claims in the set to determine if they had
jurisdiction for the billed services. If the assigned Owner
FI determines that they did not have processing jurisdiction
for the claims in the set and, therefore, paid the claims in error, the Owner
FI must resolve the duplicate situation. This means that
the Owner FI must remain as the Owner FI,
indicate that a duplicate condition exists in the set, initiate
recoupment of the overpayments, ensure receipt of the refunds/offsets,
submit appropriate TRICARE DCS-TRICARE Encounter Data (TED) Version
adjustments, verify that these adjustments are reflected in the
TED database, and resolve the set.
1.3 If, however, the Owner FI determines
that they did have processing jurisdiction for the claims in the
set and, therefore, the other contractor paid the claim(s) in the
set in error, the current Owner FI must change ownership
of the set to the other contractor for resolution.
1.4 Changing set
ownership (i.e., the Owner FI field) is a function
limited to multi-contractor sets. Ownership of other duplicate claim
sets cannot be changed by a contractor. Only multi-contractor sets can
be changed. The Owner FI change is restricted to the
contractors (Responsible FIs) that processed claims
in the set or are responsible for claims transferred in a contract
transition.
1.5 When ownership
of a multi-contractor claim set is changed, the set is moved from
the view of the old Owner FI to the new Owner
FI. The new Owner FI becomes the new “owner”
of the set and assumes responsibility for resolving the duplicate
situation in the set. The old Owner FI uses the Modify
function on the menu bar to re-assign ownership of the claim set
to the other contractor.
1.6 The system uses three fields to manage
the assignment of responsibility for resolving duplicate claims
in multi-contractor claim sets. By default, the system assigns the Owner
FI field to the contractor that processed the claim with
the latest PTC date. Multi-contractor claim sets appear along with
all other claim sets assigned to the same Owner FI.
Other contractors will not have access to these sets.
1.7 The
Responsible
FI field is used to identify the contractor who is currently
responsible for a claim. This field is shown for each claim listed
on the CLAIM SET SCREEN and the CLAIM DETAIL SCREEN. The
Processing
FI field is used to identify the contractor that paid the
claim. This field is shown on the CLAIM DETAIL SCREEN. These fields
are described below.
1.7.1 Owner FI
Field
This field is assigned by the DCS to each
claim set. The Owner FI field designates the contractor
responsible for resolving the claim set.
1.7.2
Responsible
FI Field
This field is assigned by the DCS
to each claim in a set to identify the contractor responsible for
correcting any errors in the claim and for recouping any overpayments
of actual duplicate payments. The
Responsible FI of
the claim with the latest PTC date is also assigned as the
Owner
FI of the set. During a contract transition, the system looks
at all claims belonging to the outgoing contractor and determines
if the
Responsible FI field should be changed to the
incoming contractor. If the claim is included in the transition
plan, the system will change the
Responsible FI field
to the incoming contractor or to the inactive designation of FI
99. The FI 99 designation will appear on the screen in red. If the
claim is not included in the transition plan, the system will leave
the field unchanged. See
paragraph 5.0, for additional information.
1.7.3 Processing
FI Field
This field is a claim-level data element
that is extracted from the TED. It contains the FI number of the
contractor that originally processed the claim. The Processing
FI field cannot be changed in the DCS.
2.0
System
Features Unique To Multi-Contractor Claim Sets
The layout of
the data and the screens available for viewing and entering data
in multi-contractor claim sets is the same as the layout of single
contractor claim sets. In multi-contractor sets, though, the contractor
who is designated the Owner FI can change the Owner
FI field to designate the other contractor as the Owner
FI. This process is initiated as follows:
2.1 Click on the Modify
function on the menu bar.
2.2 Click on the Owner FI option
from the drop-down menu.
2.3 The system displays the FI number(s) of
the other contractor(s) in the set. Click on the contractor to be
designated as the new Owner FI.
2.4 This
feature also requires the current
Owner FI to document
contact with the contractor to which the set will be transferred
and provide an explanation for why ownership of and responsibility for
resolving the set is being changed. When a new
Owner FI is
assigned, the
Owner Region field changes to
<to
be assigned>. The new
Owner FI subsequently
can click on the
Modify function,
Owner
Region option, and select the appropriate
Owner Region.
• A system feature unique to multi-contractor
sets is the rule for changing the status of a set to Pending. In
effect, the system ignores the claims in the set in which the Responsible
FI is not the Owner FI. It allows an Owner
FI to move a set to a Pending status if there is one BASE
claim and all of the Owner FI’s claims meet the general
conditions for Pending status. That is, all Owner FI claims
must have a dupeflag and reason code, there must be a Y claim, and
every Y claim must have an identified recoupment amount
greater than $0.00. According to this rule, the status of a multi-contractor
set may change as the Owner FI changes. For example,
if the Owner FI identifies all of their claims as actual
duplicates and enters a Y in the Dupe? fields,
selects reason codes and enters amounts identified for recoupment,
and leaves the other contractor’s claim as the BASE claim, and clicks
the UPDATE CHANGES button, the status of the set will
move to Pending. However, if the Owner FI changes
the Owner FI field to the other contractor that has
only the BASE claim, the new Owner FI will receive
the set in Open status. According to the rules,
the new Owner FI does not have actual duplicate claims
with associated amounts identified for recoupment. Since Pending status
means pending recoupment and since the new Owner FI’s
claim is the BASE claim and is not one of the duplicates, the set
cannot be pending recoupment for the new Owner FI.
The set would be in Pending status for the old Owner FI not
the new Owner FI.
2.5 Another
system feature unique to multi-contractor claim sets is the special
logic invoked for multi-contractor appended sets. When a new claim
is identified during the monthly extract as a potential duplicate
of a claim in an existing set, the set is called an appended set.
In appending a new claim to a set, the system applies the general
rule of assigning the
Owner FI to the
Responsible
FI of the claim with the latest PTC date if the status of
the set is
Open or
Closed. If
the status of the set is
Pending or
Validate,
the system ignores this rule and leaves the current assignment of
the
Owner FI. The system also applies special logic
to determine the status of multi-contractor appended sets. The status
of multi-contractor sets with an appended claim is determined as
follows:
• Open sets
will remain Open because recoupment had not been
initiated on the set prior to the new claim being appended.
• Pending sets will
remain Pending to allow the Owner FI to
complete recoupment of actual duplicate payments prior to determining
if additional research is required or if the set should be transferred
to another contractor.
• Validate sets will
be changed to Pending to allow the Owner
FI to determine if the appended claim changes the Validate situation
prior to determining if additional research is required or if the
set should be transferred to another contractor.
• Closed sets will
be changed to Open to allow the Owner FI to
determine if the appended claim requires additional research or
if the set should immediately be transferred to another contractor.
3.0 Coordination
Requirements When Working With Multi-Contractor Sets
Resolution
of multi-contractor claim sets requires close coordination between
the contractors involved to ensure that research efforts and resolution
activities are conducted efficiently, appropriately, and in a timely
manner. When researching a multi-contractor set, the Owner
FI must coordinate with the other contractor(s) involved
to determine who is responsible for the duplicate payment(s) and
for recouping the overpayment(s). The method of coordination must
be negotiated between contractors and may take whatever form is
agreeable, i.e., by telephone, fax, e-mail, or combination thereof.
This coordination is a courtesy among contractors and should prevent indiscriminate
transfers of sets back and forth. If the current Owner FI is
not responsible for the duplicate payment, the current Owner
FI should contact the other contractor to advise them of
the set, its upcoming transfer, and to discuss or describe the circumstances
involved. Ownership of the set must not be changed to another contractor
until the receiving contractor has been consulted and an explanation
has been entered into the system justifying the switch. The explanation
entered into the system must contain:
• The date the other contractor was contacted.
• The name and telephone number of the person
making the contact from the current Owner FI.
• The name and telephone number of the person
contacted at the contractor to which ownership of the set is being
changed.
• A brief explanation
for the change of ownership (e.g., “This claim falls within the
jurisdiction of the West Region. Contractor for the East Region
14 paid claim in error and is responsible for recoupment of the
overpayment.”).
4.0 Resolving
Multi-Contractor Claim Sets
Multi-contractor
claim sets are resolved in the same manner as all other claim sets
in the DCS.
4.1 When
the initial Owner FI conducts research and determines
that they were responsible for the duplicate payment, the contractor
can initiate recoupment and resolve the claim set in accordance with
the rules of resolution.
4.2 When the initial Owner FI determines
that the duplicate payment belongs to a different contractor, the
current Owner FI must contact the other (receiving)
contractor and discuss or describe the situation before the current Owner
FI can change ownership. The current Owner FI must document
the contact and the reason for the change in set ownership. Although
the current Owner FI may enter a Y in
the Dupe? field of the other contractor’s claim, it
is recommended that this action be reserved for the Responsible
FI of the claim. The Owner FI transferring the
set may not enter an amount identified for recoupment for the other
contractor’s claims.
4.3 After documenting the contact and agreement
to change set ownership, the current Owner FI may change
ownership to the other (receiving) contractor. Once ownership is
changed in the system, the receiving contractor (the new Owner
FI) can view the set, initiate recoupment action, and resolve the
claim set in accordance with the rules of resolution. Multi-contractor
sets must not be resolved without communication and coordination
among the involved contractors. The only exceptions to this are
multi-contractor sets in which the only other contractor involved
is FI 99.
4.4 If
a multi-contractor set contains a BASE claim and two or more additional
claims processed by different contractors, ownership must be transferred
to each contractor responsible for the non-BASE claims in order
to resolve the set. Each contractor is responsible for identifying
their duplicate payments, initiating recoupments, and submitting
TED adjustments corresponding to their refunds and offsets. The
set cannot be resolved unless all resolution requirements have been
met.
4.5 Ownership
of multi-contractor sets may switch back and forth between contractors
as research is conducted and determinations about jurisdictional
responsibility are made. When a set changes ownership, only the
current Owner FI can view the set, including all adjustments.
The current Owner FI is never permitted to enter recoupment
amounts in the other contractor’s claim. The current Owner
FI is, however, permitted to flag an adjustment submitted
by another contractor to facilitate resolution.
5.0
Resolving
Claim Sets Containing Inactive FI 99 Claims
5.1 The transition
plan will determine if an outgoing contractor’s claim should be
transferred to the incoming contractor or to an inactive status
of FI 99. If a claim in a multi-contractor set is transferred to FI
99, special logic is applied to the resolution of the set. The system
will not permit a multi-contractor set to have an Owner FI of
99. Therefore, if the Responsible FI on the claim with
the latest PTC date is FI 99, the Owner FI will be
assigned to another Responsible FI.
5.2 The resolution
of multi-contractor sets normally requires Owner FIs
to identify at least one actual duplicate claim in the set. However,
special logic is applied to multi-contractor sets containing an inactive
FI 99 claim. If there are no other active contractors in the set,
the Owner FI can resolve the set without identifying
an actual duplicate claim. In other words, if the Owner FI is
the Responsible FI of one claim in the set and the
other claim has a Responsible FI of 99, the Owner
FI can identify both claims as non-duplicates and resolve
the set to a Closed status. The Owner FI also
can resolve sets containing FI 99s according to the general rules
of resolution in which actual duplicates are identified, recoupments
are received, and adjustments are processed.
5.3 Sets with FI
99 claims are simply another type of multi-contractor set. When
confronted with an FI 99 set, the
Owner FI needs to
determine if it had jurisdiction for the claim(s) it paid. For FI
99 sets the
Owner FI should enter an
N in
the
Dupe? fields and enter either
BASE or
N300 in
the
Reason Code fields of the FI 99 claims. For the
Owner
FI’s claims, an
N or a
Y may be
entered in the
Dupe? field and a valid reason code
should be entered.
Note: An Owner
FI claim may be designated as the BASE claim. If the Owner
FI determines that it did not have jurisdiction for the claim(s)
it paid, then it must put a Y in the Dupe? field(s)
of its claim(s).
6.0 Determining
Jurisdiction For Claim Sets
Duplicate claim
sets assign jurisdiction in accordance with TRICARE Operations Manual
(TOM),
Chapter 8.