1.0 GENERAL
1.1 The contractor
shall not subject a beneficiary to any ongoing collection action
undertaken by or on behalf of a provider of services or supplies
as a result of the inappropriate non-payment of claims for services
which should have been covered under TRICARE.
1.2 The Government will assist
in the resolution of collection matters brought to its attention,
the ultimate responsibility for resolving collection actions lies
with the patient, family member, or sponsor.
1.3 The Government
will not provide legal representation to resolve these issues and
will not pay attorneys’ fees, court costs, collection agency fees,
accrued interest, late charges, or any other fees or costs. TRICARE
can only assume responsibility for collection assistance for medically
necessary supplies and services as authorized for coverage under
the TRICARE regulation.
2.0 CONTRACTOR RESPONSIBILITIES
- DEBT COLLECTION ASSISTANCE
2.1 The contractor
shall provide records and information to Government Debt Collection
Assistance Officers (DCAOs), upon request, to support the investigation
and resolution of debt collection issues for all TRICARE beneficiaries.
2.2 The contractor
shall provide all requested records and information within 10 calendar
days of Government request.
2.3 The contractor
shall identify specific individuals to communicate, collaborate,
and coordinate with DCAOs on debt collection assistance cases during
normal business hours.
2.4 The contractor shall provide
full contact information for these individuals to the Government
no later than 30 calendar days prior to the start of health care
delivery (SHCD) and provide updated information to the Government
within 10 calendar days of any subsequent change(s).
2.5 The contractor
shall notify the appropriate Government DCAO through the use of
the Government designated system, when the contractor becomes aware
of a debt collection action against a TRICARE beneficiary.
2.6 The contractor
shall issue letters to providers and conduct provider education
when the debt collection action is determined to be a result of
balance-billing or violation of a participation agreement.
2.7 The contractor
shall prepare and submit a monthly report of all completed collection
cases utilizing the Government furnished system. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
2.8 The contractor
shall inform providers, at least once per quarter, to contact the
contractor’s priority unit for assistance with claims resolution
prior to taking collection actions.
3.0 CONTRACTOR
RESPONSIBILITIES - RESEARCH ASSISTANCE
3.1 The contractor
shall provide immediate assistance to the Government in support
of the debt collection assistance function.
3.2 The contractor
shall, in addition to identifying specific underpayments:
3.2.1 Designate
specific individuals and provide resources to work collection issues
with Government representatives during normal weekday business hours.
3.2.2 Provide
website access and/or email addresses, mailing addresses, fax numbers,
and direct phone number(s) of specialized collections research and
support staff to the Government.
3.2.3 Maintain
records and processing statistics on collection activity. The records
to be maintained shall include a detailed chronological record of
all actions taken, including names and telephone numbers of all
parties contacted in the course of the actions taken, as well as
copies of all correspondence sent and received.
3.2.4 When violation
of the participation agreement or balance billing is not at issue,
issue letters to providers and conduct provider education when the
provider was at fault.
3.2.5 Furnish reports of all completed
collection cases.
3.2.6 In newsletters and other materials,
publicize and educate beneficiaries and providers on the Debt Collection
Assistance Program.
3.2.6.1 This shall include informing
providers of the availability of the contractor’s support services
to assist in resolution of claims problems, and encourage providers
to contact the contractor’s priority unit for assistance prior to
initiating any collection action. If the contractor is asked to
participate in beneficiary, sponsor, or provider training, workshops
or briefings at Markets/Military Medical Treatment Facilities (MTFs)
or elsewhere in the geographic area of responsibility.
3.2.6.2 The contractor shall ensure
the Debt Collection Assistance Program is a topic.
3.3 Expedited
Payment
The contractor
shall expedite, within 10 calendar days, the reprocessing of any
claims in which the debt collections research reveals a processing
error by the contractor or subcontractor.
3.4 Referrals
to Program Integrity, Defense Health Agency (DHA)
The contractor shall take corrective
action when balance-billing or violation of the participation agreement
occurs in accordance with the existing program integrity guidelines
contained in
Chapter 13, Section 2.