1.0 Contractor Receipt And Control
Of Claims
1.1 The contractor may establish
a dedicated post office box to receive claims related to the TRICARE
Prime Remote (TPR) Program. This dedicated post office box, if established,
may also be the one used for handling Supplemental Health Care Program
(SHCP) claims.
1.2 The contractor shall follow
appropriate SHCP requirements for claims received for medical care furnished
to Service members not enrolled in the TPR Program.
2.0 Claims Processing
2.1 Jurisdiction
2.1.1 The contractor shall process
inpatient and outpatient medical claims for health care services
provided worldwide to the contractor’s TPR enrollees, except in
the case of care provided overseas (i.e., outside of the 50 United
States (U.S.) and the District of Columbia). Civilian health care while
traveling or visiting overseas shall be processed by the TRICARE
Overseas Program (TOP) contractor, regardless of where the beneficiary
is enrolled. The contractor shall process claims for non-covered
benefits in accordance with
Section 2, paragraph 5.3.2.2.
2.1.2 The contractor shall forward
claims for Service members enrolled in TPR in other regions to the
contractors for the regions in which the members are enrolled according
to provisions in
Chapter 8, Section 2.
2.1.3 The contractor shall process
claims received for Service members who receive care in their regions,
but who are not enrolled in TPR, according to the instructions applicable
to the SHCP.
2.1.4 The contractor shall forward
Service member dental claims and inquiries to the Active Duty dental
program contractor.
2.2
Claims
for Care Provided Under the National DoD/DVA Memorandum of Agreement (MOA)
for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), and
Blind Rehabilitation
2.2.1 Effective January 1, 2007,
the contractor shall process claims for Service member care provided
by the DVA
/VHA for SCI, TBI, and Blind
Rehabilitation. Claims shall be processed in accordance with this
chapter and the following:
2.2.1.1 Claims received from a DVA/VHA health
care facility for Service member care with any of the following
diagnosis codes (principal or secondary) shall be processed as an
MOA claim: V57.4; 049.9; 139.0; 310.2; 323.x; 324.0; 326; 344.0x;
344.1; 348.1; 367.9; 368.9; 369.01; 369.02; 369.05; 369.11; 369.15;
369.4; 430; 431; 432.x; 800.xx; 801.xx; 803.xx; 804.xx; 806.xx;
851.xx; 852.xx; 853.xx; 854.xx; 905.0; 907.0; 907.2; and 952.xx.
2.2.1.2 The contractor shall verify
whether the MOA DVA/VHA-provided care
has been authorized by the Defense Health Agency-Great Lakes (DHA-GL)
Specified Authorization Staff (SAS). SAS will send authorizations
to the contractor by fax. If an authorization is on file, the contractor
shall process the claim to payment. The contractor shall not deny
claims for lack of authorization. Rather, if a required authorization
is not on file, the contractor shall place the claim in a pending
status and will forward appropriate documentation to SAS for determination.
2.2.2 MOA claims shall be reimbursed
as follows:
2.2.2.1 Claims for inpatient care shall
be paid using DVA/VHA interagency rates.
The interagency rate is a daily per diem to cover an inpatient stay
and includes room and board, nursing, physician, and ancillary care.
These rates will be provided to the contractor by the Defense Health
Agency (DHA) (including periodic updates as needed). There are three
different interagency rates to be paid for rehabilitation care under
the MOA. The Rehabilitation Medicine rate will apply to TBI care.
Blind rehabilitation and SCI care each have their own separate interagency
rate. Additionally, it is possible that two or more separate rates
may apply to one inpatient stay. If the DVA/VHA-submitted
claim identifies more than one rate (with the appropriate number
of days identified for each separate rate), the contractor shall
pay the claim using the separate rates. (For example, a stay for
SCI may include days paid with the SCI rate and days paid at a surgery
rate.)
2.2.2.2 Claims for outpatient services
shall be paid at the appropriate TRICARE allowable rate (e.g., CHAMPUS
Maximum Allowable Charge (CMAC)) with a 10% discount applied.
2.2.2.3 Claims for the following care
shall be paid at the interagency rate if one exists and, if not, then
at billed charges: transportation; prosthetics; orthotics; Durable
Medical Equipment (DME); adjunctive dental care; home care; personal
care attendants; and extended care (e.g., nursing home care).
2.2.2.4 Since this is care for Service
members, normal TRICARE coverage limitations do not apply to services
rendered for MOA care. As long as a service has been authorized
by SAS, it will be covered regardless of whether it would have ordinarily
not been covered under TRICARE policy.
2.2.3 All TRICARE Encounter Data
(TED) records for this care must include Special Processing Code 17 -
DVA/VHA medical provider claim.
3.0 Claim Reimbursement
3.1 For network providers, the
contractor shall pay TPR medical claims at the CHAMPUS allowable charge
or at a lower negotiated rate.
3.2 No deductible,
cost-sharing, or copayment amounts shall be applied to Service member
claims.
3.3 If a non-participating provider
requires a TPR enrollee to make an “up front” payment for health care
services, in order for the enrollee to be reimbursed, the enrollee
must submit a claim to the contractor with proof of payment and
an explanation of the circumstances. The contractor shall process
the claim according to the provisions in this chapter. If the claim
is payable without SAS review, the contractor shall allow the billed
amount and reimburse the enrollee for the charges on the claim.
If the claim requires SAS review the contractor shall pend the claim
to the SAS for determination. If the SAS authorizes the care, the
contractor shall allow the billed amount and reimburse the enrollee
for charges on the claim.
3.4 If the
contractor becomes aware that a civilian provider is trying to collect
“balance billing” amounts from a TPR enrollee or has initiated collection
action for emergency or authorized care, the contractor shall follow
contract procedures for notifying the provider that balance billing
is prohibited. If the contractor is unable to resolve the situation,
the contractor shall pend the file and forward the issue to the
SAS for determination. The SAS will issue an authorization to the
contractor for payments in excess of the applicable TRICARE payment
ceilings provided the SAS has requested and has been granted a waiver
from the Deputy Director, DHA, or designee.
3.5 If
required services are not available from a network or participating
provider within the medically appropriate time frame, the contractor
shall arrange for care with a non-participating provider subject
to the normal reimbursement rules.
3.5.1 The contractor
initially shall make every effort to obtain the provider’s agreement
to accept, as payment in full, a rate within the 100% of CMAC limitation.
If this is not feasible, the contractor shall make every effort
to obtain the provider’s agreement to accept, as payment in full,
a rate between 100% and 115% of CMAC. If the latter is not feasible,
the contractor shall determine the lowest acceptable rate that the
provider will accept.
3.5.2 The contractor
shall then request a waiver of CMAC limitation from the Director,
TRICARE Regional Offices (TROs), as the designee of the Deputy Director,
DHA, before patient referral is made to ensure the patient does
not bear any out-of-pocket expense. The waiver request shall include
the patient name, TPR location, services requested (Current Procedural
Terminology, 4th Edition [CPT-4] codes), CMAC rate, billed charge,
and anticipated negotiated rate. The contractor shall obtain approval from
the RD before the negotiation can be concluded. The contractors
shall ensure that the approved payment is annotated in the authorization/claims
processing system, and that payment is issued directly to the provider,
unless there is information presented that the Service member has
personally paid the provider.
5.0 Third
Party Liability (TPL)
TPL processing
requirements (
Chapter 10) apply
to all claims covered by this chapter. However, the contractor shall
not delay adjudication action on a claim while awaiting completion
of the TPL questionnaire and compilation of documentation. Instead,
the contractor shall process the claim(s) to completion. When the
contractor receives a completed TPL questionnaire and/or other related documentation,
the contractor shall forward the documentation as directed in
Chapter
10.