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TRICARE Operations Manual 6010.62-M, April 2021
Claims Processing Procedures
Chapter 8
Section 2
The contractor shall determine that claims received are within its contractual jurisdiction using the criteria below.
The contractor shall use the Defense Enrollment Eligibility System (DEERS) to determine a beneficiary’s enrollment status and shall process all TRICARE Prime enrollee claims in its jurisdiction regardless of where the services are received (except for care received overseas, see below), and exchange provider category information (network vs. non-network) with the contractor responsible for jurisdiction.
The contractor shall process claims for beneficiaries not enrolled in TRICARE Prime (using the beneficiary’s home address on the claim to determine jurisdiction) regardless of where the service was received and exchange provider category information (network vs. non-network) with the contractor responsible for jurisdiction. (See the TRICARE Systems Manual (TSM), Chapter 3, Section 4.2, if the beneficiary’s home address on the claim differs from the home address on DEERS).
3.1  The TRICARE Overseas Program (TOP) contractor shall process claims for beneficiaries who reside overseas or who are enrolled in the TOP regardless of where the enrollee receives the services.
3.2  The TOP contractor shall process claims for Continental United States (CONUS)-based beneficiaries who receive civilian health care while traveling or visiting abroad regardless of where the beneficiary resides or where they are enrolled. See Chapter 24, Section 9, for additional information.
The TRICARE Medicare Eligible Program (TMEP) contractor shall process claims for services rendered to TRICARE-Medicare dual eligibles within the 50 United States (US), the District of Columbia, Puerto Rico, Guam, US Virgin Islands, American Samoa, and the Northern Mariana Islands.
5.1  The TRICARE Pharmacy (TPharm) contractor shall process all claims for pharmaceuticals dispensed at a retail pharmacy or a Mail Order Pharmacy (MOP).
5.2  The Managed Care Support Contractor (MCSC) shall process claims for pharmaceuticals (e.g., injectables) ordered by and administered in a physician’s office or other place of practice such as a clinic for enrollees and residents of their geographic area of responsibility.
5.3  Claims for pharmaceuticals dispensed by a provider who does not have a National Council of Prescription Drug Plans (NCPDP) number are also the responsibility of the appropriate non-TPharm contractor.
6.1  The contractor shall respond within five business days after receipt of an out-of-area provider information request and shall designate a Point of Contact (POC) for these requests.
6.2  The contractor shall verify that the provider is TRICARE-authorized and whether or not the provider is a network provider.
6.3  Contractor Coordination On Out-Of-Jurisdiction Providers
The contractor shall first search available provider files, including the Defense Health Agency (DHA) supplied copy of the TRICARE centralized provider file before requesting out of area provider information.
6.3.1  The servicing contractor shall notify the DHA Contracting Officer’s Representative (COR) if the certifying contractor does not provide the required provider information and notification of the TRICARE Encounter Provider (TEPRV’s) acceptance by DHA within 35 calendar days from the time of the initial contact.
6.3.2  The servicing contractor shall, after notifying the COR, continue to pend the claim until they:  Receive the required provider information from the certifying contractor; or  Receive notification from the COR on how to proceed.
6.4  Provider Correspondence
6.4.1  The contractor shall send any provider correspondence which the servicing contractor forwards for the certifying contractor’s action or information to the certifying contractor’s POC to avoid misrouting.
6.4.2  The servicing contractor shall, within seven calendar days after receipt, forward for the certifying contractor’s action any correspondence or other documentation received which indicates the need to perform a provider file transaction. This includes, but is not limited to, such transactions as address changes, adding or deleting members of clinics or group practices, or changing a provider’s Taxpayer Identification Number (TIN).
6.5  Provider Certification Appeals
6.5.1  Requests for reconsideration of a contractor’s adverse determination of a provider’s TRICARE certification status are processed by the certifying contractor.  Any such requests received by the servicing contractor are to be forwarded to the certifying contractor within five business days of receipt and the appealing party notified of this action and the reason for the transfer.  The certifying contractor shall follow standard appeal procedures including aging the appeal from the date of receipt by the certifying contractor.  The contractor shall, if the reconsideration decision is favorable, notify the provider to resubmit any claims denied for lack of TRICARE certification to the servicing contractor with a copy of the reconsideration response.  The contractor shall ensure a TEPRV for this provider is accepted by DHA within seven calendar days from the date of the appeal decision.
6.5.2  The servicing contractor shall forward to the certifying contractor within five business days of receipt any provider requests for review of claims denied because the certifying contractor was unable to complete the certification process.  The servicing contractor shall notify the provider of the transfer with an explanation of the requirement to complete the certification process with the certifying contractor.  The certifying contractor shall, upon receipt of the provider’s request, follow its regular TRICARE provider certification procedures. In this case, no basis for an appeal exists. If the provider is determined to meet the certification requirements, the special provider notification and TEPRV submittal requirements apply.
7.1  The contractor shall, when the contractor receives an electronic claim with no services or supplies within its jurisdiction, transfer the claim to the appropriate jurisdictional contractor (including TPharm, TOP, TMEP) via a HIPAA-compliant 837 transaction within 72-hours of identifying out-of-jurisdiction on a claim.
7.2  The contractor shall, when it receives a paper claim that is identified as out-of-jurisdiction, transfer the paper claim (and any supporting documents) to the appropriate contractor.
7.3  Partially Out-of-Jurisdiction. The contractor shall process the claim for which services or supplies are within its jurisdiction.
The contractor shall return claims submitted on other than approved TRICARE claim forms to the sender or transfer to other lines of business, if appropriate.
8.1  Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Claims
The contractor shall return a claim identified as a CHAMPVA claim to the sender with a letter advising them of the CHAMPVA program’s toll-free telephone number, 1-800-733-8387, and instructing them to send the claim and all future CHAMPVA claims to:
Chief, Business Office Purchased Care
P.O. Box 469064
Denver, CO 80246-9064
8.2  Provider Moonlighting and Claims
8.2.1  Active duty military providers and General Schedule (GS) civil service providers employed full-time by the Department of Defense (DoD) may be permitted to moonlight in the civilian sector with Commander approval. However, 32 CFR 199.6, Title 32 “Dual Compensation/Conflict of Interest” and Chapter 4, Sections 1.0 and 2.1 strictly prohibit these providers from treating TRICARE beneficiaries, while moonlighting, and bill for such services. This includes civilian health care entities who employ moonlighting providers and knowingly bill TRICARE for beneficiaries seen by active duty military or GS civil service providers. There are limited circumstances where moonlighting providers are permitted to treat TRICARE beneficiaries including emergency services.
8.2.2  The contractor shall implement processes to screen claims to identify for active duty military or GS civil service moonlighting providers and shall deny such claims. Processes shall include, but not limited to, flagging the provider in its provider management system and its claims processing system and revalidating that the active duty military or GS civil service provider is still employed full time by the DoD.
8.2.3  The contractor shall, if it is made known to them that a claim is from a DoD moonlighting provider, take necessary action to deny the claim/s and educate the moonlighting provider’s civilian employer.
8.2.4  The contractor shall include information on moonlighting providers and billing TRICARE in its provider education materials and briefings.
8.2.5  The contractor shall report to the Government on a monthly basis all claims discovered and denied as moonlighting. For reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
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