1.0 TIME LIMITATIONS ON FILING
TRICARE CLAIMS
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.
Example:
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FOR SERVICE OR DISCHARGE
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MUST BE RECEIVED BY THE CONTRACTOR
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March 22, 2015
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No later than March 22, 2016
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December 31, 2015
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No later than December 31,
2016
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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.
2.0 EXCEPTIONS TO FILING DEADLINE
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.
3.0 TIME LIMITATIONS FOR EXCEPTIONS
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.