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TRICARE Operations Manual 6010.62-M, April 2021
Claims Processing Procedures
Chapter 8
Section 5
TRICARE Prime And TRICARE Select Referrals/Preauthorizations/Authorizations
The contractor shall ensure that TRICARE network providers hold beneficiaries harmless “held harmless” (i.e., considered not financially responsible for any charges) in cases where the network provider fails to request a referral and the contractor either denies payment or applies the Prime Point of Service (POS) option.
2.0  The contractor shall maintain an automated authorization file or an automated system of flagging to ensure claims are processed consistent with authorizations.
Note:  The Unique Identifier Number (UIN) is specific to the Composite Health Care System (CHCS)/Armed Forces Health Longitudinal Technology Application (AHLTA) which is the legacy Military Health System (MHS) Electronic Health Record (EHR) and the legacy Referral Management Suite (RMS). As the MHS phases out legacy CHCS/AHLTA and legacy RMS and moves to MHS Genesis as the new EHR, the UIN will no longer be used. MHS Genesis produces the “Referral ID” thus the UIN and Referral ID may be used interchangeably in this Section.
2.1  TRICARE Prime enrollees receiving emergency care or authorized care from non-network, non- participating providers shall be responsible for only the Prime copayment.
2.1.1  The contractor shall allow the amount the provider may collect under TRICARE rules; i.e., if the charges on a claim are subject to the balance billing limit (refer to the TRICARE Reimbursement Manual (TRM), Chapter 3, Section 1 for information on balance billing limit), the contractor shall allow the lesser of the billed charges or the balance billing limit (115% of allowable charge).
2.1.2  The contractor shall, if the charges on a claim are exempt from the balance billing limit, allow the billed charges. Refer to the TRM, Chapter 2, Section 1 for information on claims for certain ancillary services.
2.2  The contractor shall implement National Provider Identifier (NPI) checks or other business processes to ensure that authorizations are not issued to Market/Military Medical Treatment Facility (MTF) providers who are also providing services in private sector care.
The contractor shall reduce provider payments for failure to comply with the preauthorization requirements for certain types of care. See the TRM, Chapter 1, Section 28, for more information.
4.1  The contractor shall, if a claim for admission or extension to an RTC is submitted and no authorization form is on file, deny the claim.
4.1.1  The contractor may, for network claims, deny or develop in accordance with its agreements with network providers.
4.1.2  The contractor shall deny non-network claims.
4.2  The contractor shall, for any claims submitted for inpatient care at other than the RTC, pay the claim if the care was medically necessary.
4.2.1  The contractor shall, for RTC care during the period of time the beneficiary was receiving care from another inpatient facility, deny the claims.
4.2.2  The contractor shall, if the RTC has been paid and a claim for inpatient hospital care is received and the care was medically necessary, pay the inpatient hospital claim and recover the payment from the RTC.
5.1  A list of the beneficiaries who qualified for custodial care benefits prior to June 1, 1977 will be furnished to the contractor with instructions to flag the file for those beneficiaries on the list who are within its geographic area of responsibility. See Section 2 for transition-in requirements.
5.2  The contractor shall suspend claims for which no authorization is on file notify the appropriate Government Designated Authority (GDA). Refer to 32 CFR 199.4.
The contractor shall process referrals (from the Market/MTF to the contractor) in accordance with the following:
6.1  The contractor shall create a claims system that utilizes the UIN, at a minimum, to match claims with referral authorizations.
6.2  The contractor shall modify generated Market/MTF reports to accommodate the UIN and NPI.
6.3  The contractor shall provide the Market/MTF a monthly adjudicated referral claim report which shall include the UIN against each claim. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), in Section J of the applicable contract.
6.4  The contractor shall provide the same services and information required above to the TRICARE Overseas Program (TOP) contractor if the patient is enrolled overseas.
6.4.1  The contractor shall forward the authorization information to the TOP contractor to ensure appropriate adjudication of the claim.
6.4.2  The contractor or TOP contractor shall process claims according to Section 2.
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