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.