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TRICARE Operations Manual 6010.62-M, April 2021
Claims Processing Procedures
Chapter 8
Section 3
Claims Filing Deadline
1.1  All claims for benefits must be filed with the appropriate TRICARE contractor no later than one year after the date the services were provided or one year from the date of discharge for an inpatient admission for facility charges billed by the facility. Professional services billed by the facility must be submitted within one year from the date of service.
March 22, 2015
No later than March 22, 2016
December 31, 2015
No later than December 31, 2016
1.2  The contractor shall accept any written request, whether or not a claim form, for benefits for determining if the claim was filed on a timely basis.
1.3  The contractor shall notify the claimant in writing that only an approved TRICARE claim form is acceptable for processing a claim for benefits, when the contractor receives an other than approved claim form.
1.4  The contractor shall inform the claimant in writing that in order to be considered for benefits, an approved TRICARE claim form and any additional information (if required) must be submitted and received by the contractor no later than one year from the date of service or date of discharge, or 90 calendar days from the date they were notified by the contractor, whichever is later.
1.5  The claimant should submit claims on either the Centers for Medicare and Medicaid Services (CMS) 1500 Claim Form, the CMS 1450 UB-04, or the Defense Department (DD) Form 2642 as appropriate.
2.1  Retroactive Eligibility/Preauthorization Determinations
2.1.1  In order for an exception to be granted based on a retroactive eligibility or preauthorization determination, the retroactive determination must have been obtained or issued after the timely filing period elapsed. If a retroactive determination is obtained or issued within one year from the date of service or discharge, the one year timely filing period is still binding.
2.1.2  The contractor shall process all claims resulting from retroactive eligibility (i.e., equitable relief and CHAMPVA claims).
2.2  Administrative Error
2.2.1  The contractor shall grant an exception to the claims filing deadline if an administrative error is alleged, only if there is a basis for belief that the claimant had been prevented from timely filing due to misrepresentation, mistake or other accountable action of an officer or employee of Defense Health Agency (DHA) (including TRICARE Overseas) or a contractor, performing functions under TRICARE and acting within the scope of that individual’s authority.
2.2.2  The necessary evidence shall include a statement from the claimant, regarding the nature and effect of the error, how he or she learned of the error, when it was corrected, and if the claim was filed previously, when it was filed, as well as one of the following:
•  A written report based on agency records (DHA or contractor) describing how the error caused failure to file within the usual time limit; or
•  Copies of an agency letter or written notice reflecting the error.
Note:  The statement of the claimant is not essential if the other evidence establishes that his or her failure to file within the usual time limit resulted from administrative error, and that he or she filed a claim within 90 calendar days after he or she was notified of the error. There must be a clear and direct relationship between the administrative error and the late filing of the claim. If the evidence is in the contractor’s own records, the claim file shall be annotated to that effect.
2.2.3  The contractor shall waive recoupment of erroneous payments or reprocess recovered claims based on full reconciliation caused by administrative error under the TRICARE program that has been granted Equitable Relief (EQR) by DHA in accordance with National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2016, Section 711, (a); 1095g.
2.2.4  The contractor shall collect all TRICARE premiums, if applicable, before processing or reprocessing EQR claims in accordance with 32 CFR 199.4 and 199.5, the TRICARE Policy Manual (TPM), TRICARE Operations Manual (TOM), and TRICARE Reimbursement Manual (TRM).
2.3  Inability To Communicate And Mental Incompetency
2.3.1  For purposes of granting an exception to the claims filing deadline, ‘mental incompetency’ includes the inability to communicate even if it is the result of a physical disability. A physician’s statement, which includes dates, diagnosis(es) and treatment, attesting to the beneficiary’s mental incompetency shall accompany each claim submitted.
2.3.2  The contractor shall review each statement for reasonable likelihood that mental incompetency prevented the person from timely filing.
2.3.3  The contractor shall grant an exception to the claims filing deadline based on the required physician statement (paragraph 2.3.1) due the beneficiary’s mental incompetency and the lack of a legal guardian being appointed during the period of time in question.
2.3.4  The contractor shall request evidence from the spouse or parent that the claim was paid and by whom if the charges were paid by someone else, i.e., legal guardian, spouse or parent.
2.3.5  The contractor shall, when the required evidence is received, make payment to the signer of the claim, with the check made out: “Pay to the order of (legal guardian, spouse’s or parent’s name) for the use and benefit of (beneficiary’s name).”
2.3.6  If a legal guardian was appointed prior to the timely filing deadline and the claims filing deadline was not met, an exception cannot be granted due to mental incompetency of the beneficiary.
2.4  Other Health Insurance (OHI)
2.4.1  The contractor shall grant exceptions to the claims filing deadline requirements if the beneficiary submitted a claim to a primary health insurance, i.e., double coverage, and the OHI delayed adjudication past the TRICARE deadline.These claims must have been originally sent to the OHI prior to the TRICARE filing deadline or must have been filed with a TRICARE contractor prior to the deadline but returned or denied pending processing by the OHI.
2.4.3  The beneficiary must submit with the claim a statement indicating the original date of submission to the OHI, and date of adjudication, together with any relevant correspondence and an Explanation of Benefits (EOB) or similar statement.
2.4.4  The claim form must be submitted to the contractor within 90 calendar days from the date of the OHI adjudication.
2.5  Dual Eligibility With Medicare
2.5.1  The contractor shall grant exceptions to the claims filing deadline if Medicare accepted the claim as timely.
2.5.2  The claim must be submitted, either by Medicare or by the beneficiary, within 90 calendar days from the date of Medicare’s adjudication to be considered for a waiver.
There is no time limit stipulated for submitting written requests for exceptions to the claims filing deadline before a claim has been submitted.
Note:  Time limitations for exceptions does not apply to the processing of retroactive eligibility claims.
3.1  The contractor shall consider for benefits only those services or supplies received during the six years immediately preceding the receipt of the request.
3.2  The contractor shall deny any services or supplies claimed for more than six years immediately preceding the receipt of the request.
3.3  The contractor shall, upon receipt of a request for an exception to the filing deadline without the completed claim form enclosed:
•  Inform the claimant of the requirement that an approved TRICARE claim form must be completed and submitted before benefits may be considered;
•  Advise the claimant that the claim and supporting documentation must be resubmitted within 90 calendar days from the date of the contractor’s letter; and
•  Provide the beneficiary with appropriate forms.
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