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TRICARE Operations Manual 6010.59-M, April 1, 2015
Claims Processing Procedures
Chapter 8
Section 7
Application Of Deductible And Cost-Sharing
Revision:  C-52, August 30, 2019
1.0  Defense Enrollment Eligibility Reporting System (DEERS) Catastrophic Cap And Deductible Data (CCDD)
1.1  For non-network TRICARE claims, cost-share and deductible amounts shall be applied toward the catastrophic cap as the claims are processed for each fiscal year. Beginning January 1, 2018, the amounts shall be applied toward the catastrophic cap as the claims are processed for each calendar year.
1.2  For TRICARE Prime, TRICARE Standard/Extra, and TRICARE Select claims, all beneficiary cost-shares and deductibles specified in the contract shall be applied toward the cap, including nominal copayments for outpatient care. The amount applied toward the cap on the current claim and the family’s cumulative total must be reflected on the Explanation of Benefits (EOB), except on complete denials.
1.3  Once the contractor determines that the maximum individual/family catastrophic cap liability is met for the fiscal year (prior to January 1, 2018) or calendar year (starting January 1, 2018), cost-shares and deductibles will no longer apply, and the TRICARE-determined allowable amount shall be paid in full for all covered services and supplies under the Basic Program through the end of that fiscal year or calendar year. Calendar year 2017 is an exception as TRICARE converts from a fiscal year basis to a calendar year basis. October, November and December 2017 will be added to the 2017 fiscal year. Beginning January 1, 2018, all TRICARE plans will convert to a calendar year basis for enrollment, catastrophic cap, and deductible transactions.
1.4  To assist the contractor with determining if changes to the CCDD need to be made, a monthly Claims Reprocessing Alert Report will be made available to facilitate adjustments of cost-share amounts and enrollment fee payments. This report will identify beneficiaries that may need claim and/or fee payment adjustments based on catastrophic cap activity. When a total amount exceeds the fiscal (effective January 1, 2018, calendar) year limit, a review of recent activity is required to ensure proper processing has occurred. The report will identify policies where the catastrophic cap limit has been exceeded as a result of applying claim and/or enrollment fee amounts. The contractor shall correct all accounts identified as exceeding the catastrophic cap limit. These policies will be reported on an aging basis of 30, 60, 90, and 180 days. The report will also identify policies where the catastrophic cap limit is reduced for any reason, resulting in the total going under the annual limit. The contractor shall determine if any previously waived/reduced cost-shares or enrollment fee payments are now due from the beneficiary.
2.0  Claim Order For Applying Deductible
The outpatient deductible amounts shall be applied as the claims are processed. When claims are adjusted, the contractor shall apply the deductible based upon the date the claim was initially processed, not the date the claim was subsequently adjusted. See the TRICARE Reimbursement Manual (TRM), Chapter 2, Section 1.
3.0  Deductible Documentation
3.1  Contractors shall furnish a deductible certificate or show the status of the deductible on the EOB except on complete denials. For complete denials the contractor does not query any internal or external catastrophic cap and deductible files and is not required to send deductible information or catastrophic cap information on the denial notice.
3.2  For claims processed for years included in CCDD, the contractor shall obtain the amount met toward the deductible from the CCDD.
3.3  When a claim is adjusted, the contractor shall query CCDD and apply deductible and cap as directed by the CCDD query response. The contractor shall not review any intervening claims processed between the initial claim and the adjustment for the purpose of adjusting deductible or cap amounts.
3.4  For services in prior years, the beneficiary may request in writing the application of deductibles and cost-shares taken by other contractors or paid by Other Health Insurance (OHI). The contractor shall determine from their deductible record, and/or EOBs from other contractors submitted by the beneficiary, the amount the contractor has to apply to the CCDD. When a beneficiary subsequently documents an excess deductible, the claim shall be adjusted by the contractor that took the excess, based on the order in which claims were processed. The beneficiary must provide the EOB to the contractor for credit to be given for years not maintained on the CCDD. The contractor must determine which services are creditable toward the catastrophic cap by reference to the TRM, Chapter 2, Section 3.
3.5  For purposes of catastrophic loss protection, a TRICARE claim must be submitted along with an EOB from other health insurance in order for the beneficiary to receive credit for any amount paid by other health insurance, even if the OHI paid the bill in total. Normal double coverage rules remain in effect after the cap has been reached; the beneficiary must submit a claim to the other health insurance before submitting a claim to the TRICARE contractor.
4.0  Audit Trail And History File
The contractor shall ensure that the history file accurately reflects all transactions pertaining to care received, cost-shares, deductible, copayments, and adjustments. The contractor shall maintain the integrity of the audit trail and protect the confidentiality and integrity of the files.
5.0  Adjustments And Recoupments
If the contractor is required to recoup a benefit payment any deductible amount applied to the claim to be recouped must be adjusted on the CCDD to reflect that amount as an outstanding deductible. Any other credited deductible amount resulting from an individual claim adjustment will be offset from future claims received for the beneficiary. The Government has determined that it is not cost effective to collect any outstanding deductible amounts at the close of the timely filing period.
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