Skip to main content

Military Health System

Utility Navigation Links

WEEKEND MAINTENANCE: The maintenance outage is scheduled for April 20th at 6:00am EST ending NLT Sunday, April 21st at 11:59pm Eastern EST. The TRICARE Manuals web site may be available intermittently during this period but it's usage is not recommended.

TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Medicare Eligible Program (TMEP)
Chapter 20
Section 8
Claims Processing Procedures
Revision:  C-108, May 18, 2022
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with all TRICARE requirements noted in Chapter 8 regarding claims processing unless specifically changed, waived, or superseded by this section (as indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.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
1.1  The TMEP contractor shall comply with the requirements in Chapter 8, Section 1.
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.
2.0  Jurisdiction
2.1  The TMEP contractor shall comply with the requirements in Chapter 8, Section 2.
2.2  The TMEP contractor shall comply with the TMEP contract provider certification requirements instead of the requirements in Chapter 8, Section 2, paragraphs 2.0 through 6.4.16.
2.3  The contractor shall comply with the requirements in Chapter 8, Section 2, paragraph 6.5 in cases where there is an Assigned Provider Number (APN).
3.0  Claims Filing Deadline
3.1  The TMEP contractor shall comply with the requirements in Chapter 8, Section 3.
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
5.1  The TMEP contractor shall comply with the requirements in Chapter 8, Section 5 in paragraphs 3.0, 4.0 (network provider language in paragraph 4.2 does not apply), and 5.0.
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
6.1  The TMEP contractor shall comply with the requirements in Chapter 8, Section 6 with the exception of paragraph 9.12.
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
7.1  The TMEP contractor shall comply with the requirements in Chapter 8, Section 7.
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)
8.1  The TMEP contractor shall comply with the requirements in Chapter 8, Section 8.
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.
9.0  Duplicate Payment Prevention
The TMEP contractor shall comply with the requirements in Chapter 8, Section 9.
10.0  Additional Requirements/Exceptions
The TMEP contractor is not required to have the claims auditing software described in the TRM, Chapter 1, Section 3.
- END -
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery