1.0 Providers or pharmacies Sanctioned
By TRICARE
32 CFR 199.9 provides that the Director, Defense
Health Agency (DHA) or a designee, shall have the authority to reinstate
providers, pharmacies, or entities previously excluded or terminated
under TRICARE. For providers sanctioned by Department of Health
and Human Services (DHHS), see
paragraph 3.0.
1.1 DHHS/Office
of Inspector General (OIG) will advise on the monthly listing if
and when a previously excluded provider, pharmacy, or entity is
reinstated. Before initiating reinstatement action, the contractor
must first verify that the provider, pharmacy, or entity meets TRICARE
requirements as an authorized provider, pharmacy or entity under
32 CFR 199.6.
1.2 If
no funds have been paid for services by the provider, pharmacy,
or entity while excluded or are otherwise owed the Government for
claims paid prior to the exclusion, the contractor shall certify the
provider, pharmacy or entity as an authorized provider, and determine
the effective date of the reinstatement.
1.3 The
contractor shall advise the provider, pharmacy, or entity in writing
of the reinstatement date.
2.0 Contractor Responsibilities
Following Requests For Reinstatements From Providers Excluded Or
Terminated By DHA
2.1 The
contractor will send a provider certification package to the provider
to ensure that the provider meets the requirements to be an authorized
TRICARE provider. The exclusion or suspension remains in effect
until the provider completes and returns the certification package
and is determined by the contractor to meet the requirements.
2.2 If the provider is determined
to meet the requirements of an authorized provider, the contractor
shall advise the provider of the reinstatement date as determined
by DHA or designee.
2.3 If
the provider does not meet the requirements of an authorized provider,
the contractor shall advise the provider as to why he/she does not
meet them and offer appeal rights. A copy of the letter shall be
provided to the DHA Program Integrity Office (PI).
2.4 The contractor shall advise
the same Beneficiary Counseling and Assistance Coordinators (BCACs)
located within the provider’s service area that were initially advised
of the exclusion or suspension.
2.5 For
pharmacies, the contractor shall verify that the pharmacy has all
required state licenses necessary to operate as a pharmacy. The
exclusion or suspension remains in effect until the contractor has
determined that the pharmacy has obtained the required state licenses.
2.6 If the pharmacy has met the
state licensing requirements, the contractor shall advise the pharmacy
of the date it is eligible to negotiate a new network agreement
with the contractor, as determined by DHA.
2.7 If
the pharmacy does not have the required state licenses, the contractor
shall advise the pharmacy as to why it is not eligible to be a network
pharmacy and offer appeal rights. A copy of the letter shall be
provided to the DHA PI.
3.0
Contractor
Responsibilities Following Requests For Reinstatement From Providers
Excluded By DHHS
3.1 DHHS/OIG
will advise on the monthly listing if and when a previously excluded
provider, pharmacy, or entity is reinstated. Before initiating reinstatement
action, the contractor must first verify that the provider, pharmacy,
or entity meets TRICARE requirements as an authorized provider, pharmacy
or entity under
32 CFR 199.6.
3.2 If no funds have been paid
for services by the provider, pharmacy, or entity while excluded
or are otherwise owed the Government for claims paid prior to the
exclusion, the contractor shall certify the provider, pharmacy or
entity as an authorized provider, and determine the effective date
of the reinstatement.
3.3 The
contractor shall advise the provider, pharmacy, or entity in writing
of the reinstatement date.