1.0 SCOPE
1.1 This chapter consolidates procedures
relating to claims adjustments and recoupments. Due to the nature of
agreements between network providers and contractors, pharmacy recoupment
procedures may be modified or adapted to conform to network agreements
subject to approval by the Defense Health Agency (DHA). The requirements
of this chapter shall apply if recoupment under the pharmacy network
agreements is not successful within 60 calendar days from the date
collection is initiated.
1.2 The method
to be used in recouping funds depends on whether financially underwritten
funds or non-financially underwritten funds are being recouped.
(See
Section 2 for procedures for recovery of financially underwritten
funds and
Section 3 for procedures for recovery of non-financially
underwritten funds.)
1.3 The contractor
shall follow procedures in
Section 4 for
all recoveries made under Third Party Liability (TPL) (subrogation)
statutes, whether financially underwritten or non-financially underwritten
funds. See
Chapter 24 and
the TRICARE Policy Manual (TPM) and
Chapter
12 for information on recoupment procedures for TRICARE Overseas
providers. References herein to provider or providers also applies
to a pharmacy or pharmacies.
2.0 THE FEDERAL CLAIMS COLLECTION
ACT (FCCA) (31 UNITED STATES CODE (USC) 3701 ET SEQ.)
The Federal Claims Collection
Act (FCCA) (31 USC 3701 et seq.) provides authority for the collection
of non-financially underwritten fund recoupments. The FCCA was enacted
to avoid unnecessary litigation in collecting debts owed to the
United States (US). This statute, implemented by joint regulations
of the Department of Justice (DOJ) and the General Accounting Office
(GAO), requires federal agencies to attempt collection of all federal
claims of the US arising from their respective activities. Under
this act, DHA is required to make necessary claims adjustments and
initiate recoupment actions for erroneous payments, when Government
funds are involved.
3.0 THE FEDERAL MEDICAL CARE RECOVERY
ACT (FMCRA) (42 USC 2651-2653)
The Federal Medical Care Recovery
Act (FMCRA) (42 USC 2651-2653), provides for the recovery of the
costs of medical care furnished by the US for the treatment of a
disease or injury caused by the action or negligence of a third
party. Under this act, the US has a right to recover the reasonable
value of the care and treatment from the person(s) responsible for
the injury.
4.0 APPLICATION
4.1 The procedures
which follow are for guidance and compliance by the contractor in
the recoupment of funds which have been incorrectly disbursed as
overpayments for whatever reason. Also included are procedures for
processing claims which fall within the diagnostic code ranges relating
to injuries where TPL may be involved.
4.2 The contractor
shall, in some cases, pursue and collect overpayments which occurred
under a contract administered by a third party administrator, such
as Continued Health Care Benefit Program (CHCBP). This could occur
when the contractor has taken over a region and overpayments are
subsequently discovered or when an installment collection is still
in progress. Procedures of this chapter shall be applied.
5.0 ERROR CORRECTION
5.1 The contractor shall correct
all erroneously processed claims. The required corrective actions
may include making additional payments of $1.00 or more, adjusting
deductibles and cost-shares, adjusting amounts applied toward the
catastrophic cap, recouping overpayments and correcting TRICARE
Encounter Data (TED) records.
5.2 The contractor
shall, when a claim is adjusted, query the Defense Enrollment Eligibility
Reporting System (DEERS) Catastrophic Cap and Deductible Data (CCDD)
and apply deductible and cap updates.
5.3 The contractor
shall not review any intervening claims processed between the initial
claim and the adjustment for the purpose of adjusting deductible
or cap amounts. The TRICARE Systems Manual (TSM),
Chapter 2,
provides instructions for submission of claim adjustment transactions
to the DHA.
5.4 The contractor shall use the
original Internal Control Number (ICN) to make any adjustments to
a processed claim, but there are exceptions.
6.0 TIME LIMITATIONS ON REQUESTS
FOR ADJUSTMENTS
6.1 Time limitations on requests
for adjustments applies to all non-network claims. For network claims,
time limitations apply only to beneficiary submitted claims. Acceptance
of a request for an adjustment to a processed claim is subject to
the time limitation guidelines below:
6.2 These
guidelines do not apply to required adjustments identified by the
contractor, DHA, or an audit agency.
6.3 The contractor
shall use the prior or earlier year’s profile, for adjustments made
to claims that predate the two profiles maintained by the contractor.
Refer to the TRICARE Reimbursement Manual (TRM),
Chapter 3, Section 1 for calculation of payment
amounts based on the appropriate profiles and the date of service
on the claim.
6.4 Timely Filing One Year From
Date Of Service/Discharge/Prescription Fill Rule
6.4.1 The contractor shall
process adjustments which have the effect of a new obligation of
Government funds in accordance with the one year from date of service/date
of discharge/prescription fill rule (refer to
Chapter 8, Section 3). An example would be
a supplemental (late) billing from a hospital. Beneficiary requested
adjustments for pharmacy claims must be received by the contractor
no later than one year from the date of the prescription fill.
6.5 Ninety
(90) Day Rule
A request
for a reconsideration must be received by the contractor within
90 calendar days from the issue date of the Explanation Of Benefits
(EOB). Examples include the beneficiary/provider providing additional
information about a service or supply already processed (paid or
denied) or the beneficiary’s/provider’s questioning the accuracy
of processing. This does not include claims denied at 35 calendar
days for failure to provide requested information.
6.6 Time
Limitations For Other Adjustments
Requests for adjustments which
do not fall into the above categories must be mailed within nine
months (with an additional 10-day grace period) of the date of the
initial EOB. Examples include the refiling of a claim after a retroactive
eligibility determination or the report of non-receipt of a benefit
check.
7.0 VOLUNTARILY RETURNED OR REFUNDED
PAYMENTS
Occasionally,
benefit payments will be returned to the contractor on a voluntary
basis separate from any recoupment action.
7.1 Reasons
For Voluntary Refunds
• Payment unwanted.
• Amount of payment questioned.
• Overpayment.
• Incorrect payee.
7.2 Disposition
Of Voluntary Refunds
The contractor
shall return the payment to the correct payee within five business
days of receipt, if payment is confirmed as accurate and the check
is still negotiable. In all returned check cases the correct payee
must be expeditiously identified and paid. Some special procedural
requirements are:
• Research the accuracy of the
payment and payee.
• Handle underpayment situations
in accordance with
Section 2.
• Handle overpayment recoveries
in accordance with
Sections 2 and
4.
7.3 The contractor shall inform
the participating provider that return of a TRICARE payment does
not relieve the obligations assumed by submitting a participating
claim in the event of unwanted payments. The provider cannot return
a payment and then bill the beneficiary. (See
Chapter
13, for assignment violations.)
7.4 Pharmacy
refunds will be deposited into applicable bank accounts and a credit
TED will be submitted.