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TRICARE Operations Manual 6010.59-M, April 1, 2015
Provider Certification And Credentialing
Chapter 4
Addendum A
Figures
Revision:  C-58, September 20, 2019
Figure 4.A-1  Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) Request For An Exception
Manager, TRICARE Provider Certification
(Appropriate TRICARE Claims Processor’s Address)
Dear Manager:
The Director, Defense Health Agency (DHA), has authorized exceptions, on a case-by-case basis, to the TRICARE policy which excludes any civilian employee of VHA from authorization as a TRICARE provider. This letter identifies the individual VHA employee(s) for whom an exception is requested based on my determination that an exception is required to avoid a detrimental effect on VHA’s ability to obtain the necessary part-time physician employee(s) essential to the mission of this facility. By granting this exception, the individual part-time physician employee will be an authorized TRICARE physician and may file claims for services furnished in the physician’s private, non-VHA employment practice.
A request for an exception to TRICARE policy is made for the following part-time VHA physician employee(s):
(List each physician’s name, specialty, address, and the physician’s IRS/SSAN or other identification number used to report income to the Internal Revenue Service.)
In support of this request for exception to policy, the individual physician(s) named have signed the attached certification, as part of the physician’s application for authorization as a TRICARE provider, that:
1.  The physician understands the prohibitions against dual compensation under Title 5, United States Code (USC), Section 5536, as well as the standards of conduct provisions applicable to Government employees who require the avoidance of actual conflict of interest situations as well as situations in which the appearance of conflict of interest may exist; and
2.  The physician has not violated the dual compensation or standard of conduct provisions in providing any service(s) for which a TRICARE claim is submitted for payment. This certification shall be retained on file by the TRICARE claims processor and be applicable to all claims for services of the physician during the period of authorization as a TRICARE provider under this requested exception. In addition, when filing individual TRICARE claims, the physician shall annotate the signature block (Block 33) of the TRICARE claims form with the words “additional certification on file” in order to identify the claim as an exception to the general TRICARE policy and confirming that the certification on file applies specifically to that claim.
By requesting an exception to TRICARE policy, I agree that the administrators of this VHA facility shall assume full responsibility for informing the above-named part-time physician employee(s) of the dual compensation and standard of conduct provisions and for monitoring the conduct of the employee(s) and enforcing the provisions regarding any TRICARE claims for service furnished by the employee(s) while acting under this request for exception to policy. In addition, for the above-named part-time physician employee(s), I agree to provide the appropriate TRICARE claims processor written notice of termination of VHA employment or any other basis for withdrawal of this request for exception to TRICARE policy.
Thank you for your prompt attention to this request. Should there be a need to contact VHA regarding this request or regarding any matter arising out of the implementation of this request, my point of contact on this matter is ______________ who may be contacted at the above address or by telephone number __________________.
Sincerely,
VHA Facility Administrator
Enclosure:
Physician’s Certification
Figure 4.A-2  Provider Certification, Department Of Veterans Affairs (DVA)/Veterans Health Administration (VHA) Part-Time Physician Employee
I certify that I am a part-time physician employee of the VHA at (Name of VHA Facility) for whom a letter by the VHA facility administrator has requested an exception to the TRICARE policy excluding any civilian employee of the VHA from authorization as a TRICARE provider. Based on the exception granted to me, I will be authorized as a TRICARE provider for services furnished in my private, non-VHA employment physician practice. All TRICARE claims for services furnished by me under this exception shall be subject to the standard TRICARE provider certification except that I am a part-time civilian employee of the United States (U.S.) Government.
I certify that for all such TRICARE claims that:
1.  I understand the prohibitions against dual compensation under Title 5, United States Code (USC), Section 5536, as well as the standards of conduct provisions applicable to Government employees which require the avoidance of actual conflict of interest situations as well as situations in which the appearance of conflict of interest may exist; and
2.  I have not violated the dual compensation or standard of conduct provisions in providing a service(s) for which a TRICARE claim is submitted for services furnished by me.
When any TRICARE claim is filed, I agree to annotate the signature block on the claim form with the words, “additional certification file,” in order to identify the claim as an exception to the general TRICARE policy and confirming that this certification maintained on file by the TRICARE claims processor as part of my provider file applies specifically to each claim filed.
______________________________________
(Typed Physician’s Name, Address, and Identification Number)
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