5.1 Identification Of Claims Subject
To Third Party Recovery (Not Applicable To Pharmacy Contract)
5.1.1 The
contractor is responsible for making a preliminary investigation
of all potential third party recovery claims. Any inpatient or outpatient
claim with International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM) diagnosis code 800-999 which exceeds
a TRICARE liability of $500, shall be considered a potential third
party claim and shall be developed with the questionnaire, “Statement
of Personal Injury - Possible Third Party Liability,” DoD Document
(DD) Form 2527.
(See
http://www.dtic.mil/whs/directives/forms/eforms/dd2527.pdf.)
For inpatient claims with dates of discharge or outpatient claims
with dates of service on or after the mandated date, as directed by
Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation, use ICD-10-CM
diagnosis
S and
T code ranges ending in
the letter “a” signifying the initial encounter. Also, use all additional
encounters identifying the date of injury with the date of injury for
the initial encounter. However, if the contractor can determine,
based upon a specific diagnosis code (e.g., certain external cause
codes), that there is little or no third party recovery potential,
the claim need not be developed. Examples of cases that usually
would not require development include a slip and fall incident at
home, private residence, or a one-car accident in which the TRICARE
beneficiary was the only occupant. Claims with the diagnoses listed
below do not require routine development for potential TPL. References
to the ICD-9-CM 800-999 diagnostic code and ICD-10-CM)
S and
T codes ending
with the seventh character of
A ranges category for
TPL purposes excludes these codes.
• ICD-9-CM: 910.2
- 910.7, 911.2 - 911.7, 912.2 - 912.7, 913.2 - 913.7, 914.2 - 914.7,
915.2 - 915.7, 916.2 - 916.7, 917.2 - 917.7, 918.0, 918.2, and 919.2
- 919.7.
• ICD-10-CM (with the exception
of codes indicating abrasion and contusion): S00.02 - S00.97,
S10.1 - S10.97, S20.1 - S20.9, S30.82 - S30.877, S40.22 - S40.879,
S50.32 - S50.879, S60.32 - S60.879, S70.22 - S70.379, S80.22 - S80.879,
S90.42 - S90.879, T15.1, and T16.
5.1.2 A system flag shall be set
when the DD Form 2527 is mailed. Any claims which appear to be possible
third party claims, after the contractor has reviewed the returned
statement, shall be referred to a Uniformed Service Claims Office
for determination and recovery action, if appropriate. These claims
shall be processed to completion in the usual manner prior to referral
to a claims officer. Normal processing includes appropriate Coordination
of Benefits (COB) under the provisions of
paragraph 6.0 and the TRICARE
Systems Manual (TSM),
Chapter 2.
5.1.3 Claims developed for TPL which
require COB may either be denied or be treated as uncontrolled returns
in accordance with
paragraph 5.2.1.2. If the contractor discovers
the potential other coverage through receipt of the completed DD
Form 2527, the other coverage information must be developed at that
point using the normal other coverage procedures in place for the
contractor. If during the course of claim adjudication, the contractor
becomes aware of a potential third party recovery arising as the
result of malpractice (civilian provider negligence), the contractor
shall process the claim(s) under the provisions of this section
regardless of the procedure codes involved.
5.2 Contractor Procedures
(
For
pharmacy contractor procedures, see
paragraph 5.2.8) The contractor
shall have automated identification of claims with ICD-9-CM diagnoses
codes 800-999. When the contractor receives a claim with ICD-9-CM
diagnoses codes 800-999, the processing clerk shall follow the instructions
below. Claims with dates of service or dates of discharge on or
after the mandated date, as directed by HHS, for ICD-10 implementation,
will have ICD-10-CM code ranges of
S and
T.
5.2.1 Continue normal processing
of the claim (including any required development or other insurance
actions) to the point of payment, but withhold payment pending the
actions that follow:
5.2.1.1 Search existing files to determine
whether there is a system flag indicating that a personal injury
questionnaire has been sent within the last 35 days, or an indicator
that a completed DD Form 2527 has been received for the same EOC.
5.2.1.2 If
there is no personal injury questionnaire attached to the claim,
and none has been requested within the last 35 days or received
previously for the same incident, suspend the claim payment regardless
of whether the claim has been assigned, and send a request to the
beneficiary asking that he/she complete the questionnaire. (See
Addendum A, Figure 10.A-2.) The beneficiary
must be advised that if a completed questionnaire is not returned
on a timely basis, the claim cannot be processed without the requested
information. Every effort shall be made to request any additional information
required to process the claim at the same time the questionnaire
is sent. If the claim indicates that there is other insurance, or
if contractor history or Defense Enrollment Eligibility Reporting
System (DEERS) reflects the existence of other health insurance,
the contractor may deny the claim(s) or return the claim(s) uncontrolled
and simultaneously request that the DD Form 2527 be completed.
5.2.2 If a personal injury questionnaire
has been requested within the last 35 days, related claims with
ICD-9-CM diagnosis codes 800-999, or ICD-10-CM code ranges of S and T,
received subsequent to the request shall be suspended. Added requests
for the DD Form 2527 are not necessary. However, the contractor
shall develop such claims for any other needed information to expedite
processing when the response is received. When a claim is received
with services and/or supplies connected with a probable TPL case
and services and/or supplies not so connected, treatment encounter
data must be reported on TRICARE Encounter Data (TED) using claim
breakdown.
5.2.3 If
the requested personal injury questionnaire is not received within
a 35 day period following the initial request, the contractor shall
deny the claim which triggered the TPL development and all related
claims which are in suspense status waiting for receipt of the personal
injury questionnaire.
5.2.4 When
the personal injury questionnaire is received, the system shall
be flagged to indicate receipt and the questionnaire shall be evaluated
to determine whether there is indication that there is a potential
for third party recovery. (This evaluation is not expected to be
a detailed legal analysis of the recovery potential of a case.)
DD Form 2527 forms must have enough information to allow the contractor
to make a determination regarding the potential for TPL. If the
DD Form 2527 returned by the beneficiary does not have enough information
to allow the contractor to make such a determination, or if the
DD Form 2527 has not been signed, and 35 days have not passed since
the DD Form 2527 was mailed to the beneficiary, the DD Form 2527
shall be returned to the beneficiary. The beneficiary will be asked
to sign the DD Form 2527 and/or told that the DD Form 2527 did not
provide sufficient information to allow the contractor to make a
benefit determination, as appropriate. The beneficiary shall also
be advised that if the form is not properly completed and returned
within 10 days from the date the contractor returned the form for
addition to or correction of the DD Form 2527, his or her claims
will be denied. When the 35 day suspension period, or the 10 day
period allowed for addition to or correction of the DD Form 2527,
whichever is later, has expired, the contractor shall deny the pended
claims. When the properly completed and signed DD Form 2527 is returned,
the contractor shall reopen the denied claims and process them in
accordance with the provisions of this manual.
5.2.5 There may be times when the
beneficiary cannot complete the DD Form 2527. Completion of the
form by a responsible relative who signs the form is acceptable.
The contractor shall confirm the relationship between the beneficiary
and the individual who completed and signed the DD Form 2527.
5.2.6 When the provider can demonstrate,
based upon the medical records, that there is no potential for TPL,
and the beneficiary or next of kin has refused to complete the DD
Form 2527 or can not be located by the provider, there is no need
to require a completed DD Form 2527 before the claims are processed.
If the DD 2527 is not returned and the provider alleges that there
is no potential for TPL, the contractor shall request that the provider
submit copies of medical records. If the contractor review of the
records determines that no potential TPL exists, the claim may be
processed and paid without a completed DD 2527. Cases in which there
is any doubt about possible TPL shall be resolved by referral to
a claims officer. However, cases in which it is clear that there
is no potential for recovery from a liable third party (such as
the slip and fall incident at home or a one-car accident noted above)
need not be referred to a claims officer. The contractor shall be
alert to other avenues of recovery in these cases, however, such
as medical payment coverage or no-fault automobile insurance. The
contractor shall retain a copy of the DD Form 2527 that has been
completed and returned by the beneficiary. The evaluation shall
include consideration of the following:
5.2.6.1 Evaluation for possible TPL
under the FMCRA. As stated above, all claims processed to completion
with potential for recovery under the FMCRA are to be referred to
the appropriate claims officer. Denied claims need not be forwarded
to claims officers unless they have been specifically requested.
5.2.6.2 Evaluation for third party
recovery through the beneficiary’s other insurance. Even if there is
determined to be no potential for recovery from a liable third party,
claims may possess potential for recovery from other insurance.
When processing claims involving Other Health Insurance (OHI), the contractor
shall follow
paragraphs 5.2.1.2 and
6.0 and
the TRICARE Reimbursement Manual (TRM),
Chapter 4,
Double Coverage.
5.2.6.3 Evaluation of the potential
for mixed recovery under the FMCRA and other third party recovery.
Many cases will have potential for recovery under both the FMCRA
and other third party recovery such as other health insurance. In
such cases, the contractor shall follow the COB provisions of
paragraphs 5.2.1.2 and
6.0 and
TRM,
Chapter 4, Double Coverage. If a third party
recovery (DD Form 2527) is received late and after the denial of
related claims, the denied claims shall be reopened and processed
in accordance with the provisions of this manual. Any subsequent
claim related to the same incident or EOC received after the denial
of an initial claim for failure to return a third party recovery questionnaire
shall be processed as a new case; i.e., with a new 35 day suspension
period and a new questionnaire being sent unless a DD Form 2527
has previously been received for this EOC.
5.2.6.4 The contractor shall provide
an audit trail for each lump-sum Explanation of Benefits (EOB) received
from another health insurer. A lump-sum payment shall be applied
to claims for the same EOC in the order in which claims were received.
5.2.7 Within 15 working days following
the completion of the processing of a claim for which it has been
determined that TPL might exist, the contractor shall send to the
appropriate claims officer a copy of the EOB applicable to paid
claims, and the original DD Form 2527. Before forwarding the EOB and
DD Form 2527 to the appropriate claims officer, the contractor shall
contact the TRICARE Pharmacy contractor and determine whether payment
has been made for any prescriptions prescribed on or after the date
of the accident/injury. If so, the contractor shall obtain copies
of any substitute EOB and include them with the EOB and DD Form
2527. An additional 15 work days will be allowed to permit time
for claim records to be received from the retail pharmacy contractor.
The contractor shall retain a copy of the completed DD Form 2527.
All processed EOB associated with claims bearing ICD-9-CM diagnoses
codes 800-999, or ICD-10-CM code ranges of
S and
T,
that are related to an incident or EOC shall be referred to the
claims officer at the time the completed questionnaire is sent.
Actual claim forms need not be sent to the claims officer unless
they are specifically requested. See
Addendum A, Figure 10.A-3, “Transmittal Letter
to Government Claims Officers.” The contractor shall maintain logs
of all cases and claims referred to the Uniformed Service Claims
Offices. The log shall contain the beneficiary’s name, sponsor’s
name, Social Security Number (SSN), claim number and amount, to whom
sent, and the date sent.
5.2.8 Upon
receipt of a request from DHA, a TRICARE contractor or a Government
Claims Office (see
Addendum B for a listing of Government Claims
Offices) the pharmacy contractor will provide EOB applicable to
paid claims related to the accident/injury/EOC. (If the pharmacy
substitute EOB does not contain certain data elements, then a separate
report is required (see
Addendum A, Figure 10.A-32). If offsets have
been taken, additional data elements are required as listed in
Addendum A, Figure 10.A-33.) Denied claims
need not be forwarded unless specifically requested. (Claim copies
need not be provided unless requested by DHA, a TRICARE contractor
or a Government Claims Office.) This information shall be provided
within five working days from the date of the request. The contractor shall
maintain logs of all EOBs referred to the DHA, TRICARE contractor,
or Government Claims Offices. The log shall contain the beneficiary’s
name, sponsor name, SSN, claim number and amount, to whom sent and
date sent. The pharmacy contractor shall provide an audit trail
for each lump-sum EOB received from another health insurer and/or
pharmacy plan. A lump-sum payment shall be applied to claims for
the same EOC in the order in which claims were received.
5.5 TPL And Diagnosis Related Group
(DRG) Claims
5.5.1 When
a hospital subject to the TRICARE DRG-based payment system submits
a TRICARE claim for inpatient services, it becomes bound by the
participating requirements. These require that hospitals accept
the TRICARE-determined allowable amount (the DRG-based amount) as
payment in full. Therefore, hospitals may not bill or otherwise
seek recovery from the beneficiary (or file a lien against a beneficiary’s
liability insurance proceeds or recovery from a liable third party)
for the difference between the billed charge and the DRG allowable
amount. Hospitals attempting to do so shall be advised that this
constitutes a violation of the TRICARE participation requirements,
may constitute Program fraud or abuse and may subject them to DHA
administrative sanctions and the loss of their status as a TRICARE
and Medicare provider. Situations in which a hospital persists in
seeking recovery from the beneficiary for the difference between
the billed charge and the DRG allowable shall be referred to the
contractor’s Program Integrity staff for further review and possible
consultation with DHA regarding what additional actions may be taken.
5.5.2 To the extent a hospital may
seek recovery of its billed charge directly from the liable third party
or insurer, including auto or home-owner's insurance, no-fault auto
or uninsured motorist coverage, it may only do so prior to filing
a TRICARE claim. In the case of Service members, however, the provider
is always limited to seeking payment the U.S. Government under the
Supplemental Health Care Program (SHCP) through TRICARE. In addition,
the hospital must also file a TRICARE claim, if required to be a
TRICARE participating provider by a network agreement or other authority.
In all cases, the hospital may not seek recovery of any amount,
other than the applicable beneficiary deductible and cost-share,
from the beneficiary, the third party or the liability insurer,
for the medical care provided to the beneficiary, because of the
limitations imposed by TRICARE participation requirements.
Example: A Service member is injured
in an auto accident by a negligent third party and receives care
at a civilian hospital. The U.S. Government is required to pay the
costs of the medical care. The hospital must bill TRICARE and may
not seek payment from any other party. TRICARE will pay the claim
on behalf of the U.S. and the U.S. will seek recovery, as appropriate
under the FMCRA.