The
TMEP contractor shall comply with all TRICARE requirements noted
in
Chapter 8 regarding
claims processing unless specifically changed, waived, or superseded
by this section (as indicated below), the TRICARE Policy Manual
(TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual
(TSM), or TMEP contract.
1.0 General
1.2 In general,
TRICARE pays secondary to Medicare and any other coverage.
1.3 The
contractor shall use special double coverage procedures for all
claims for beneficiaries who are eligible for Medicare, including
active duty dependents who are age 65 and over as well as those beneficiaries
under age 65 who are eligible for Medicare for any reason. For specific
instructions, refer to the TRM,
Chapter 4, Section 4.
3.0 Claims
Filing Deadline
3.2 In
addition, the contractor shall date stamp all claims with an Internal
Control Number (ICN). The contractor shall count the actual date
of receipt as day one. The ICN uniquely identifies each claim, includes
the actual date received in the contractor’s custody, and permits
aging and counting of the claim for workload reporting purposes
at specific system locations at any time during its processing. The
contractor shall provide procedures to ensure the actual date of
receipt is entered into the ICN and all required claims aging and
inventory controls are applied for paperless claims.
4.0 Signature Requirements
4.1 The
TMEP contractor shall comply with the requirements in
Chapter 8, Section 4, except the requirements
for financially underwritten TRICARE claims.
4.2 Electronic “cross over” claims
received from Medicare after Medicare completes its claims processing
do not need a beneficiary or provider signature. For paper claims,
when TRICARE is secondary payer to Medicare and a Medicare EOB is
attached, the TMEP contractor does not need to develop for provider
or beneficiary signature.
5.0 TRICARE
Prime and Select Referrals/Preauthorization/Authorizations
5.2 TMEP
Prime-enrolled beneficiaries, to the extent practicable, should
follow all TRICARE Prime requirements for Primary Care Manager (PCM)
assignment, referrals and authorizations. The TMEP contractor is
not responsible to obtain or verify that a TMEP Prime enrolled beneficiary
has a referral for care not provided by their PCM. The contractor
shall not subject TMEP Prime enrolled beneficiaries to Point of
Service (POS) cost-sharing.
5.3 TMEP
beneficiaries can contact a regional Managed Care Support Contractor
(MCSC) for assistance in locating a network provider. The MCSCs
shall provide the TRICARE/Medicare beneficiary with the name, telephone
number, and address of network providers of the appropriate clinical specialty
located within the beneficiary’s geographic area. The MCSC is not
required to make appointments with network providers.
5.4 The
TMEP contractor shall issue notification of preauthorization when
requested for primary pay services in accordance with
Chapter 7, Section 2 and TPM,
Chapter 1, Section 7.1. The contractor may
make notification in writing by letter, or on a form developed by
the contractor. These forms and letters are all referred to as TRICARE
authorization forms.
6.0 Claim
Development
6.2 TMEP claims
which TRICARE processes after Medicare, do not need to be developed
to the individual provider level for home health or group practice
claims.
6.3 Civilian claims for TMEP beneficiaries
referred from a Market/MTF as an inpatient are processed first by
Medicare without consideration of the Supplemental Health Care Program
(SHCP) in accordance with
Chapter 17, Section 3.
6.4 The
TMEP contractor shall not process a claims from any civilian provider
in a Market/MTF under the Resource Sharing or Clinical Support Agreements
(CSA) programs.
7.0 Application
of Deductible and Cost-Sharing
7.2 The
TMEP contractor shall apply TRICARE cost-shares and deductible when
TRICARE is the primary payer on TMEP beneficiary claims. The contractor
shall base TMEP beneficiary cost-shares on the following when TRICARE
is the primary payer:
7.2.1 If
the services were received by a TRICARE Prime enrollee (as indicated
in DEERS), the TMEP contractor shall calculate the TRICARE Prime
copayments applicable on the date services were received.
7.2.2 For
a beneficiary who is not a TRICARE Prime enrollee, if a provider
is known to be a network provider (e.g., Department of Veterans
Affairs Medical Center (VAMC)) the contractor shall apply TRICARE
Extra cost-shares to services received prior to January 1, 2018;
if the provider is not a known network provider, the contractor
shall apply TRICARE Standard cost-shares.
7.2.3 For
a beneficiary who is a TRICARE Select enrollee, services received
from a known network provider on or after January 1, 2018, the contractor
shall apply TRICARE Select network copayments; if the provider is
not a known network provider, the contractor shall apply TRICARE
Select out-of-network cost-shares.
7.2.4 For
a TFL beneficiary who is not a TRICARE Prime enrollee, the contractor
shall apply TRICARE Standard copays for services received on or
after January 1, 2018, (see TRM,
Chapter 2, Section 1) as if TRICARE Standard
were still being implemented.
7.3 The
contractor shall count only the actual beneficiary out-of-pocket
liability remaining after TRICARE payments for purposes of the annual
catastrophic loss protection.
8.0 Explanation
of Benefits (EOB)
8.2 The
requirements in
Chapter 8, Section 8, paragraph 1.0 are superseded
by the following: The contractor shall issue and mail an appropriate
and easily understood EOB to the beneficiary (parent/guardian for
minors or incompetents) that appropriately describes the action
taken for each clam processed to a final determination. The contractor
shall mail a hardcopy EOB unless the beneficiary has provided written
agreement to receive the EOB electronically. The contractor may
elect to provide a monthly summary EOB in lieu of an EOB for each
individual claim processed by the contractor. The contractor shall
include instructions regarding how to read the EOB in the mailed
EOB.
8.3 The TMEP contractor shall comply
with the requirements in
Chapter 20, Section 8, paragraphs 9.0 and
10.0 with
the exception of the specific location (front or back) of the required
information. The contractor shall provide the information required
on the EOB in a clear and easily understood layout.