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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Medicare Eligible Program (TMEP)
Chapter 20
Section 8
Claims Processing Procedures
All TRICARE requirements noted in Chapter 8 regarding claims processing shall apply to the TMEP unless specifically changed, waived, or superseded by this section (as indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.
1.0  General
1.1  The provisions of Chapter 8, Section 1 are applicable to TMEP.
1.2  In general, TRICARE pays secondary to Medicare and any other coverage.
1.3  Special double coverage procedures shall be used for all claims for beneficiaries who are eligible for Medicare, including active duty dependents who are age 65 and over as well as those beneficiaries under age 65 who are eligible for Medicare for any reason. For specific instructions, refer to the TRM, Chapter 4, Section 4.
2.0  Jurisdiction
The provisions of Chapter 8, Section 2 are applicable to TMEP, except for Chapter 8, Section 2, paragraphs 6.0 through
3.0  Claims Filing Deadline
The provisions of Chapter 8, Section 3 are applicable to TMEP.
4.0  Signature Requirements
4.1  The provisions of Chapter 8, Section 4, are applicable to TMEP, except the requirements for financially underwritten TRICARE claims.
4.2  Electronic “cross over” claims received from Medicare after Medicare completes its claims processing do not need a beneficiary or provider signature. For paper claims, when TRICARE is secondary payer to Medicare and a Medicare Explanation of Benefits (EOB) is attached, the TMEP contractor does not need to develop for provider or beneficiary signature.
5.0  TRICARE Prime and TRICARE Select Referrals/Preauthorization/Authorizations
5.1  The provisions of Chapter 8, Section 5 are not applicable to the contractor, except for Chapter 8, Section 5, paragraphs 3.0, 4.0, and 5.0 (network provider language in Chapter 8, Section 5, paragraphs 4.1 through 4.1.2 does not apply).
5.2  TMEP Prime-enrolled beneficiaries, to the extent practicable, should follow all TRICARE Prime requirements for Primary Care Manager (PCM) assignment, referrals and authorizations. The TMEP contractor is not responsible to obtaining or verifying that a TMEP Prime enrolled beneficiary has a referral for care not provided by their PCM. TMEP Prime enrolled beneficiaries are not subject to Point of Service (POS) cost-sharing.
5.3  TMEP beneficiaries can contact a regional Managed Care Support Contractor (MCSC) for assistance in locating a network provider. The MSCS shall provide the TRICARE/Medicare beneficiary with the name, telephone number, and address of network providers of the appropriate clinical specialty located within the beneficiary’s geographic area. The MCSC is not required to make appointments with network providers.
5.4  The contractor shall issue notification of preauthorization when requested for primary pay services in accordance with Chapter 7, Section 2 and TPM, Chapter 1, Section 7.1. Notification may be made in writing by letter, or on a form developed by the contractor. These forms and letters are all referred to as TRICARE authorization forms.
6.0  Claim Development
6.1  The provisions of Chapter 8, Section 6 are applicable to TMEP.
6.2  TMEP claims which TRICARE processes after Medicare, do not need to be developed to the individual provider level for home health or group practice claims.
6.3  Civilian claims for TMEP beneficiaries shall be processed by Medicare first without consideration of the Supplemental Health Care Program (SHCP).
6.4  The TMEP contractor shall not process a claims from any civilian provider in a Market/Military Medical Treatment Facility (MTF) under the Resource Sharing or Clinical Support Agreements (CSA) programs.
7.0  Application of Deductible and Cost-Sharing
7.1  The provisions of Chapter 8, Section 7 are applicable to TMEP.
7.2  TRICARE cost-shares and deductible are applied when TRICARE is the primary payer on TMEP beneficiary claims.
7.3  TMEP beneficiary cost-shares shall be based on the following when TRICARE is the primary payer. If the services were received by a TRICARE Prime enrollee (as indicated in Defense Enrollment Eligibility Reporting System (DEERS)), the TMEP contractor shall calculate the Prime copayments applicable on the date services were received. For a beneficiary who is not a Prime enroll, if a provider is known to be a network provider (e.g., Veterans Health Administration (VHA) medical facility) the TRICARE Extra cost-shares shall be applied to services received prior to January 1, 2018; if the provider is not a known network provider, the TRICARE Standard cost-share shall be applied. For a beneficiary who is a TRICARE Select enrollee, services received from a known network provider on or after January 1, 2018, will have the TRICARE Select network copayments applied; if the provider is not a known network provider, the TRICARE Select out-of-network cost-share shall be applied. For a TRICARE For Life (TFL) beneficiary who is not a TRICARE Prime enrollee, services received on or after January 1, 2018, shall have the TRICARE Standard copayment (see TRM, Chapter 2) applied as if TRICARE Standard were still being implemented.
7.4  Only the actual beneficiary out-of-pocket liability remaining after TRICARE payments will be counted for purposes of the annual catastrophic loss protection.
8.0  EOB
8.1  The provisions of Chapter 8, Section 8 are applicable to TMEP.
8.2  The provisions of Chapter 8, Section 8, paragraphs 1.0 through 1.2 is superseded by the following: The contractor shall issue and mail an appropriate and easily understood EOB to the beneficiary (parent/guardian for minors or incompetents) that appropriately describes the action taken for each clam processed to a final determination. The EOB shall be mailed in hardcopy, unless the beneficiary has provided written agreement to receive the EOB electronically. The contractor may elect to provide a monthly summary EOB in lieu of an EOB for each individual claim processed by the contractor. The mailed EOB shall include instructions regarding how to read your EOB.
8.3  The provisions of Chapter 8, Section 8, paragraphs 9.0 and 10.0 are applicable to TMEP with the exception of the specific location (front or back) of the required information. The information required on the EOB shall be provided in a clear easily understood layout.
9.0  Duplicate Payment Prevention
The provisions of Chapter 8, Section 9 are applicable to TMEP.
10.0  Additional Requirements/Exceptions
The TMEP contractor is not required to have the claims auditing software described in the TRM, Chapter 1, Section 3.
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