With
the exceptions noted in
paragraph 1.0, the contractor shall have proof
of any double coverage payments prior to adjudication of the claim.
2.1 No Evidence Of Double Coverage
If
there is no information to suggest the claim could be covered by
another health insurance plan or there is no information on the
claim to suggest that the charges have been submitted to or paid by
other insurance, the claim shall be processed.
2.2 Double Coverage Is Known
2.2.1 Whether it is a network or
non-network claim, payment must be obtained from the primary insurance
coverages or plans. The contractor shall include procedures to ensure
this requirement is met in all agreements with its network providers
of care. If the provider of care is owned or operated by the contractor
or is in a clinic or other facility operated by the contractor as
an employee or subcontractor, the Other Health Insurance (OHI) shall
also be collected by the contractor or its designee. If the claim indicates
no OHI coverage, but the Defense Enrollment Eligibility Reporting
System (DEERS) or contractor’s file indicates otherwise, a signed
statement or verbal notice from the beneficiary or sponsor furnishing
the termination date of the other coverage will be necessary for
the contractor to inactivate the positive OHI record. The contractor
shall have acceptable evidence of processing by the double coverage
plan prior to processing the claim. If there is no such evidence
submitted with the claim, the contractor shall deny the claim and
send an Explanation of Benefits (EOB) to the beneficiary and to
the provider.
2.2.2 The
contractor shall take appropriate action to ensure that a sample
of all Electronic Media Claims (EMC) is audited on a no less than
annual basis with verification obtained from the provider to corroborate
the submission of a zero OHI payment amount. In addition, no less
than annually, the contractor shall audit past EMC submissions to
identify all providers who may show a pattern of submissions with
OHI payment amounts of zero or of a nominal amount (e.g., $.01,
$1.00, $5.00, etc.). All EMC providers who demonstrate a possible
pattern of “plugging” nominal OHI payment amounts shall be referred
to the contractor’s Program Integrity staff for further investigation.
2.2.3 Except for EMC claims, when
Medicare is the primary payer, an Explanation of Medicare Benefits
(EOMB) is required. This will enable the contractor to determine
whether the provider accepted assignment under Medicare; if the
provider accepts assignment, the provider cannot bill for any difference
between the billed charge and the Medicare allowed amount. In addition,
it will identify cost-share and deductible amounts as well as any
allowable charge reductions.
2.2.4 For
double coverage situations which do not involve the routine issuance
of an EOB, the following
shall be accepted
in lieu of an EOB:
• Documentation
that the beneficiary belongs to the plan;
• Documentation that there is
a liability beyond the amounts paid by the primary payor;
• Documentation that the liability
is specified in the plan contract; and
• Documentation of total liability
on the claim.
2.2.5 If
a contractor becomes aware of the possible existence of OHI through
means other than the adjudication of a pending claim (e.g., a provider
returns all or a part of TRICARE payment because of payment by OHI),
the contractor shall establish an OHI record on DEERS for the patient
and request completion of a double coverage questionnaire. Depending
upon the circumstances of the individual occurrence, reopening and
adjustment of prior claims and/or a Program Integrity referral may
also be appropriate. All affected claims shall be adjusted appropriately,
although adjustment action may be temporarily deferred at the request
of Program Integrity staff if such adjustment would compromise their
investigation.
2.3 DRG-Based
System
The
contractor shall be able to identify OHI payments for all separately-billable
components of the inpatient services on a claim. If the OHI EOB
does not adequately identify the payments for each separately-billable
component, or if claims for their charges are not received, the
entire OHI payment is to be applied to the inpatient operating costs.
This also applies to claims from higher volume mental health hospitals
and units subject to the TRICARE Inpatient Mental Health Per Diem
Payment System that are authorized to bill for institution-based
professional services.
2.4 Medicare
Claims
Claims
processed on which Medicare is primary payer require review for
possible double coverage. Contractors shall be required to build
other health insurance files on these beneficiaries that identify
coverages (primarily Medicare supplements) that may be primary to
TRICARE. Contractors shall use any reasonably reliable indicator
to identify other coverages including crossover claims received from
Medicare carriers and fiscal intermediaries, crossover files received
from Medicare carriers and fiscal intermediaries, paper claims,
information resulting from refunds, information from providers,
etc. Also, contractors shall ensure that providers are aware that
if they receive any TRICARE payments that duplicate payments made
by another coverage, they shall return the TRICARE payment. Since
TRICARE remains secondary payer to all other coverages, contractors
shall recover all payments that they subsequently identify as duplicating
a payment made by any coverage, including Medicare supplements,
that is primary to TRICARE.
2.5 Skilled
Nursing Facility (SNF) Prospective Payment System (PPS)
Payment
under the SNF PPS is dependent upon the PPS-specific information
submitted by the provider with the TRICARE Claim (see
Chapter 8, Section 1). However, if the beneficiary
has OHI which has processed the claim as primary payer, it is likely
that the information necessary to determine the TRICARE PPS payment
amount will not be available. Therefore, special procedures have
been established for processing SNF claims involving OHI. These
claims will not be processed as PPS claims. Such claims will be
allowed as billed unless there is a provider discount agreement.
TRICARE payment will be the difference between the billed charge
and the OHI payment. The only exception to this is cases when there
is evidence on the face of the claim that the beneficiary’s liability
is limited to less than the billed charge (e.g., the OHI has a discount
agreement with the provider under which the provider agrees to accept
a percentage of the billed charge as payment in full). In such cases,
the TRICARE payment is to be the difference between the limited
amount established by the OHI and the OHI payment.