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.