The TMEP contractor shall comply
with all TRICARE requirements noted in
Chapter
8 regarding claims processing unless specifically changed,
waived, or superseded by this section (as indicated below), the TRICARE
Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE
Systems Manual (TSM), or TMEP contract.
1.0 General
1.2 In general,
TRICARE pays secondary to Medicare and any other coverage.
1.3 The contractor
shall use special double coverage procedures for all claims for
beneficiaries who are eligible for Medicare, including active duty
dependents who are age 65 and over as well as those beneficiaries
under age 65 who are eligible for Medicare for any reason. For specific
instructions, refer to the TRM,
Chapter 4, Section 4.
3.0 Claims
Filing Deadline
3.2 In addition,
the contractor shall date stamp all claims with an Internal Control
Number (ICN). The contractor shall count the actual date of receipt
as day one. The ICN uniquely identifies each claim, includes the
actual date received in the contractor’s custody, and permits aging
and counting of the claim for workload reporting purposes at specific
system locations at any time during its processing. The contractor
shall provide procedures to ensure the actual date of receipt is
entered into the ICN and all required claims aging and inventory
controls are applied for paperless claims.
4.0 Signature Requirements
4.1 The TMEP
contractor shall comply with the requirements in
Chapter 8, Section 4, except the requirements
for financially underwritten TRICARE claims.
4.2 Electronic “cross over” claims
received from Medicare after Medicare completes its claims processing
do not need a beneficiary or provider signature. For paper claims,
when TRICARE is secondary payer to Medicare and a Medicare EOB is
attached, the TMEP contractor does not need to develop for provider
or beneficiary signature.
5.0 TRICARE
Prime and Select Referrals/Preauthorization/Authorizations
5.2 TMEP Prime-enrolled
beneficiaries, to the extent practicable, should follow all TRICARE
Prime requirements for Primary Care Manager (PCM) assignment, referrals
and authorizations. The TMEP contractor is not responsible to obtain
or verify that a TMEP Prime enrolled beneficiary has a referral
for care not provided by their PCM. The contractor shall not subject
TMEP Prime enrolled beneficiaries to Point of Service (POS) cost-sharing.
5.3 TMEP beneficiaries
can contact a regional Managed Care Support Contractor (MCSC) for assistance
in locating a network provider. The MCSCs shall provide the TRICARE/Medicare
beneficiary with the name, telephone number, and address of network
providers of the appropriate clinical specialty located within the
beneficiary’s geographic area. The MCSC is not required to make appointments
with network providers.
5.4 The TMEP contractor shall issue
notification of preauthorization when requested for primary pay
services in accordance with
Chapter 7, Section 2 and
TPM,
Chapter 1, Section 7.1. The contractor may
make notification in writing by letter, or on a form developed by
the contractor. These forms and letters are all referred to as TRICARE
authorization forms.
6.0 Claim
Development
6.2 TMEP claims
which TRICARE processes after Medicare, do not need to be developed
to the individual provider level for home health or group practice
claims.
6.3 Civilian claims for TMEP beneficiaries
referred from a Market/MTF as an inpatient are processed first by
Medicare without consideration of the Supplemental Health Care Program
(SHCP) in accordance with
Chapter 17, Section 3.
6.4 The TMEP
contractor shall not process a claims from any civilian provider
in a Market/MTF under the Resource Sharing or Clinical Support Agreements
(CSA) programs.
7.0 Application
of Deductible and Cost-Sharing
7.2 The TMEP
contractor shall apply TRICARE cost-shares and deductible when TRICARE
is the primary payer on TMEP beneficiary claims. The contractor
shall base TMEP beneficiary cost-shares on the following when TRICARE
is the primary payer:
7.2.1 If the
services were received by a TRICARE Prime enrollee (as indicated
in DEERS), the TMEP contractor shall calculate the TRICARE Prime
copayments applicable on the date services were received.
7.2.2 For a beneficiary who is not
a TRICARE Prime enrollee, if a provider is known to be a network
provider (e.g., Department of Veterans Affairs Medical Center (VAMC))
the contractor shall apply TRICARE Extra cost-shares to services
received prior to January 1, 2018; if the provider is not a known
network provider, the contractor shall apply TRICARE Standard cost-shares.
7.2.3 For a beneficiary who is a
TRICARE Select enrollee, services received from a known network provider
on or after January 1, 2018, the contractor shall apply TRICARE
Select network copayments; if the provider is not a known network
provider, the contractor shall apply TRICARE Select out-of-network cost-shares.
7.2.4 For a TFL beneficiary who is
not a TRICARE Prime enrollee, the contractor shall apply TRICARE
Standard copays for services received on or after January 1, 2018,
(see TRM,
Chapter 2, Section 1) as if TRICARE Standard
were still being implemented.
7.3 The contractor shall count
only the actual beneficiary out-of-pocket liability remaining after TRICARE
payments for purposes of the annual catastrophic loss protection.
8.0 Explanation
of Benefits (EOB)
8.2 The requirements
in
Chapter 8, Section 8, paragraph 1.0 are superseded
by the following: The contractor shall issue and mail an appropriate
and easily understood EOB to the beneficiary (parent/guardian for
minors or incompetents) that appropriately describes the action
taken for each clam processed to a final determination. The contractor
shall mail a hardcopy EOB unless the beneficiary has provided written
agreement to receive the EOB electronically. The contractor may
elect to provide a monthly summary EOB in lieu of an EOB for each
individual claim processed by the contractor. The contractor shall
include instructions regarding how to read the EOB in the mailed
EOB.
8.3 The TMEP contractor shall comply
with the requirements in
Chapter 20, Section 8, paragraphs 9.0 and
10.0 with
the exception of the specific location (front or back) of the required
information. The contractor shall provide the information required
on the EOB in a clear and easily understood layout.