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:
|
For Service Or Discharge
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Must Be Received By The Contractor
|
|
March 22, 2015
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No later than March 22, 2016
|
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December 31, 2015
|
No later than December 31,
2016
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1.2 Any written
request for benefits, whether or not on a claim form, shall be accepted
for determining if the “claim” was filed on a timely basis. However,
when other than an approved claim form is first submitted, the claimant
shall be notified that only an approved TRICARE claim form is acceptable
for processing a claim for benefits. 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 days
from the date they were notified by the contractor, whichever is later.
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/preauthorization determination,
the retroactive determination must have been obtained/issued after
the timely filing period elapsed. Absent an Explanation of Benefits
(EOB), contractors must have proof that beneficiaries received medical
care for a covered service (or waived service). A bill
alone does
not suffice as such proof. If a retroactive determination is obtained/issued
within one year from the date of service/discharge, the one year
timely filing period is still binding.
(See Chapter
8 or, for the TRICARE Overseas Program (TOP), Chapter 24, Section 9, for complete claims
processing requirements.)
2.1.2 Only the
Uniformed Services or the Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) may determine retroactive eligibility.
Once a retroactive eligibility determination is made, an exception
to the claims filing deadline shall be granted. A copy of the retroactive
eligibility decision must be provided. In any case where a retroactive
“preauthorization” determination is made to cover such services
as the Extended Care Health Option (ECHO), adjunctive dental care,
surgical procedures requiring preauthorization, etc., the timely
filing requirements shall be waived back to the effective date of
the retroactive authorization. Claims which are past the filing
deadline must; however, be filed not more than 180 calendar days
after the date of issue of the retroactive determination.
2.2 Administrative Error
2.2.1 If an administrative error
is alleged, the contractor shall grant an exception to the claims filing
deadline 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.
2.3 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. Review each statement for
reasonable likelihood that mental incompetency prevented the person
from timely filing.
2.3.2 If the
failure to timely file was due to the beneficiary’s mental incompetency
and a legal guardian had not been appointed during the period of
time in question, the contractor shall grant an exception to the
claims filing deadline based on the required physician’s statement.
(See above.) If the charges were paid by someone else, i.e., legal
guardian, spouse or parent, request evidence from the spouse or
parent that the claim was paid and by whom. 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).”
2.3.3 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 may 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.
2.4.2 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 days from the date of the OHI adjudication.
2.5 Dual Eligibility With Medicare
2.5.1 The contractor may 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
3.1 There is no time limit stipulated
for submitting written requests for exceptions to the claims filing
deadline before a claim has been submitted. However, after the proper
claim has been submitted and an exception to the claims filing deadline
granted, the contractor is authorized to consider for benefits only
those services or supplies received during the six years immediately
preceding the receipt of the request. Services or supplies claimed
for more than six years immediately preceding the receipt of the
request shall be denied.
3.2 If a contractor
receives a request for an exception to the filing deadline, but
a completed claim form is not enclosed, the contractor shall:
• 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.