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TRICARE Operations Manual 6010.62-M, April 2021
Claims Processing Procedures
Chapter 8
Section 8
Explanation Of Benefits (EOB)
1.1  The contractor shall provide an EOB through electronic means, including but not limited to a web based secure online portal for beneficiaries (including parents or legal guardians of minors) to retrieve electronic EOBs that appropriately describe(s) the action taken for each claim processed to a final determination.
1.2  Beneficiaries (including parents and legal guardians) shall be given the option to opt-in for summary paper EOBs mailed to them on a monthly basis (if care is received).
1.3  The contractor shall:
•  Provide beneficiaries with multiple EOB status alerts and notification options, including email, text, web-portal and hardcopy letters (based on means the beneficiary chooses).
•  Educate beneficiaries on options to receive EOBs and notifications.
•  Make a copy of the EOB electronically accessible and printable to the beneficiary in the contractor’s portal regardless of which alert and notification option the beneficiary chooses.
•  Allow the beneficiary to opt in to hard copy, mailed EOBs.
•  Note what preference a beneficiary chooses, hard copy or electronic, as the means of providing Monthly Summary EOBs and change preference upon beneficiary request.
2.1  The contractor shall provide a secure online portal for non-participating providers to retrieve electronic EOBs. Non-participating providers shall be given the opportunity to opt-in for mailed paper EOBs. The EOB shall include the amount allowed so that the provider can determine what amount may be billed to the beneficiary under the balance billing provision (115% of the TRICARE allowable charge).
2.2  The contractor shall provide the non-participating provider with information where there is only a “need to know.” This means that if other information appears on the EOB that does not pertain to the non-participating provider, the TRICARE contractor shall suppress printing or remove it before sending the EOB to the non-participating provider.
2.3  The non-participating provider will receive only the EOB and the beneficiary will receive the TRICARE payment.
3.1  The contractor shall provide a secure on-line portal for network and participating providers to retrieve electronic EOBs. Network and participating providers shall be given the opportunity to opt-in for mailed paper EOBs.
3.1.1  The contractor shall issue an EOB to network and participating providers or issue summary vouchers covering multiple claims and beneficiaries in lieu of issuing multiple EOBs.
3.1.2  The contractor shall issue a summary voucher at least monthly (electronic or paper).
3.2  Sufficient information must be included on the vouchers to identify each beneficiary and explain the payment for each line item on each claim.
3.3  The contractor shall include adequate identification of the fiscal year involved applicable to the various charges listed on the EOB to help keep the deductible information clear to the beneficiary.
3.4  If the provider submits the claim electronically, a Health Insurance Portability and Accountability Act (HIPAA)-compliant Electronic Remittance Advice (ERA) shall be returned to the provider.
3.5  The contractor shall send Electronic Funds Transfers (EFTs) and ERA to the provider in HIPAA standard format as specified in the Chapter 19, Section 2.
4.1  The contractor shall include the same information on the copy sent to the state as it normally sends to participating providers if the claim is from a state Medicaid agency.
4.2  The contractor shall, if the state has a claims data need which cannot be accommodated except at extra expense, negotiate with the state, and if the state is willing to pay for the accommodation.
5.1  The contractor shall not issue an EOB to beneficiaries (parents or guardians of minors or incompetents) when claims involve services related to any of the following diagnoses:
•  Abortion
•  Acquired Immune Deficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV)
•  Alcoholism
•  Pregnancy
•  Substance Abuse
•  Sexually Transmitted Diseases (STDs)
•  Sexual Assault or Domestic Violence
5.2  The contractor shall issue an EOB to participating providers, except as noted above.
5.2.1  The contractor shall provide a paper EOB to a beneficiary upon request.
5.2.2  When a request is made for a normally suppressed EOB, the copy provided may be a facsimile or a hand-produced copy. It must, however, include the required data and be certified by the contractor.
5.3  The contractor shall send, when a service(s) is denied due to an abortion, a letter of explanation but only when the denial is questioned by the beneficiary.
Note:  Addendum A, Figure 8.A-3 provides suggested wording for abortion claims that are denied.
5.3.1  The explanation shall be provided only to the beneficiary and participating provider.
5.3.2  The special denial letter shall be sent in an envelope marked “personal”.
5.3.3  It is EMPHASIZED that using an EOB is NOT acceptable for denial of abortion services. Only an approved letter may be used.
6.1  The contractor shall provide beneficiaries with multiple claims action status alerts and notification options, including email, text, web portal and hard copy letters (based on means the beneficiary chooses).
6.2  The contractor shall notify the beneficiary, based on the means the beneficiary chooses, that a claim has been paid or denied and that they can access the claims information via the portal.
6.3   The contractor shall take into account, where applicable, the following:
6.3.1   The special rules for alcohol and drug abuse program patient records referenced in DoD 6025.18-R, C5.4 and C8.9;
6.3.2  The provisions on abuse, neglect and endangerment situations in DoD 6025.18-R, C8.7.5;
6.3.3  The beneficiary’s right to request restrictions on disclosure under DoD 6025.18-R, C10.1; and
6.3.4  The beneficiary’s right to request confidential communications under DoD 6025.18-R, C10.2.
6.4  The processing of claims for the diagnoses listed above requires sensitivity to the beneficiary’s right to privacy.
6.5   Because of the need for contractors to apply reasonable judgment on a case-by-case basis, Defense Health Agency (DHA) has not prescribed specific procedures except in the case of abortion claims.
6.6  For claims involving services and supplies for the other diagnoses, a phone call to the beneficiary may serve to obtain information on how the beneficiary wishes to have the EOB handled in some instances.
6.7  In other cases, a request that the provider serve as an intermediary, or a personal letter to the beneficiary, using a plain envelope, may be appropriate.
6.8  The contractor shall take into account the intent, as well as the letter, of the Privacy Act, the HIPAA of 1996, and the DoD Health Information Privacy Regulation, DoD 6025.18-R.
7.1  The form design of the EOB is not specifically prescribed.
7.2  The contractor shall design the form to fit their individual equipment and system needs.
7.3  The contractor shall provide their toll-free inquiry number on the EOB.
7.4  Only the last four digits of the Social Security Number (SSN), or the DoD Benefits Number (DBN) shall appear on the EOB.
8.1  The following detailed information shall be included on the EOB:
•  Provider or Pharmacy Name
•  Provider or Pharmacy Address
•  Provider or Pharmacy Taxpayer Identification Number (TIN)
•  Check Number
•  Voucher Date
•  Patient Name
•  Sponsor Name
•  Last four digits of Sponsor SSN or DBN
•  Date(s) of Service/Date(s) Prescription(s) Filled
•  Pharmacy EOB - Prescription Number
•  Pharmacy EOB - Prescription Name
•  Billed Amount
•  Reason Codes
•  Allowed Covered Charges
•  Deductible
•  Cost-Share or Copayment Amount
•  Total Paid by Other Health Insurance (OHI)
•  Catastrophic Cap
•  Remarks
•  Description(s) of Reason Code(s)
•  Interest Paid
•  Federal Tax Withheld
•  Accumulated Toward Catastrophic Cap
•  Accumulated Toward Individual Deductible
•  Accumulated Toward Family Deductible
•  Offset (In the event payment is offset or partially offset and applied toward a debt.)
•  Amount Paid (If payment was not issued but money was withheld and applied towards another debt, information regarding where the funds were applied).
8.2  In addition to the fields specified in paragraph 9.1, offset EOBs shall also contain the following additional information:
•  Total Amount Offset
•  Amount Paid
•  Statement:
“$ was offset from this remittance and applied towards your outstanding overpayment listed below. You may not seek reimbursement from the TRICARE beneficiary for whom you rendered services. We will send you a letter providing detailed claim information within five to seven business days. If you have any questions, please contact our customer service department for assistance.”
•  Information regarding where the offset will be applied:
•  Patient Name
•  Claim Number
•  Date Repayment Requested
•  Amount Requested
•  Offset Amount
•  Collected To Date
•  Amount Outstanding
The following information shall be on the reverse of the EOB:
9.1  Beneficiary Notice Regarding Services
9.1.1  Please review the services/supplies shown on the front of your EOB. If you find that TRICARE has paid for any services that you did not receive or that you were charged by a health care professional you did not see, please call the (Contractor’s Name) Fraud and Abuse Hotline at (Toll-Free Number).
9.1.2  The contractor shall include, on the TRICARE Provider Electronic Remittance Advice (ERA), a reminder to providers of requirements to familiarize with, comply with TRICARE program requirements, rules and responsibility for medically necessary and appropriate care.
9.2  Right To Appeal
If you disagree with the determination on your claim, you have the right to request a reconsideration. Your signed written request must state the specific matter with which you disagree and MUST be sent to the following address no later than 90 calendar days from the date of this notice. If the postmark on the envelope is not legible, then the date of receipt is deemed the date of filing, unless proof of mailing, such as a certified mail receipt documents a different date. Include a copy of this notice. On receiving your request, all TRICARE claims for the entire course of treatment will be reviewed.
(Contractor’s Address)
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