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WEEKEND MAINTENANCE: The maintenance outage is scheduled for June 22nd at 6:00am EST ending NLT Sunday, June 23rd at 11:59pm Eastern EST. The TRICARE Manuals web site may be available intermittently during this period but it's usage is not recommended.

TRICARE Operations Manual 6010.59-M, April 1, 2015
Program Integrity
Chapter 13
Section 6
Provider Reinstatements
Revision:  
1.0  Providers or pharmacies Sanctioned By TRICARE
32 CFR 199.9 provides that the Director, Defense Health Agency (DHA) or a designee, shall have the authority to reinstate providers, pharmacies, or entities previously excluded or terminated under TRICARE. For providers sanctioned by Department of Health and Human Services (DHHS), see paragraph 3.0.
1.1  DHHS/Office of Inspector General (OIG) will advise on the monthly listing if and when a previously excluded provider, pharmacy, or entity is reinstated. Before initiating reinstatement action, the contractor must first verify that the provider, pharmacy, or entity meets TRICARE requirements as an authorized provider, pharmacy or entity under 32 CFR 199.6.
1.2  If no funds have been paid for services by the provider, pharmacy, or entity while excluded or are otherwise owed the Government for claims paid prior to the exclusion, the contractor shall certify the provider, pharmacy or entity as an authorized provider, and determine the effective date of the reinstatement.
1.3  The contractor shall advise the provider, pharmacy, or entity in writing of the reinstatement date.
2.0  Contractor Responsibilities Following Requests For Reinstatements From Providers Excluded Or Terminated By DHA
2.1  The contractor will send a provider certification package to the provider to ensure that the provider meets the requirements to be an authorized TRICARE provider. The exclusion or suspension remains in effect until the provider completes and returns the certification package and is determined by the contractor to meet the requirements.
2.2  If the provider is determined to meet the requirements of an authorized provider, the contractor shall advise the provider of the reinstatement date as determined by DHA or designee.
2.3  If the provider does not meet the requirements of an authorized provider, the contractor shall advise the provider as to why he/she does not meet them and offer appeal rights. A copy of the letter shall be provided to the DHA Program Integrity Office (PI).
2.4  The contractor shall advise the same Beneficiary Counseling and Assistance Coordinators (BCACs) located within the provider’s service area that were initially advised of the exclusion or suspension.
2.5  For pharmacies, the contractor shall verify that the pharmacy has all required state licenses necessary to operate as a pharmacy. The exclusion or suspension remains in effect until the contractor has determined that the pharmacy has obtained the required state licenses.
2.6  If the pharmacy has met the state licensing requirements, the contractor shall advise the pharmacy of the date it is eligible to negotiate a new network agreement with the contractor, as determined by DHA.
2.7  If the pharmacy does not have the required state licenses, the contractor shall advise the pharmacy as to why it is not eligible to be a network pharmacy and offer appeal rights. A copy of the letter shall be provided to the DHA PI.
3.0  Contractor Responsibilities Following Requests For Reinstatement From Providers Excluded By DHHS
3.1  DHHS/OIG will advise on the monthly listing if and when a previously excluded provider, pharmacy, or entity is reinstated. Before initiating reinstatement action, the contractor must first verify that the provider, pharmacy, or entity meets TRICARE requirements as an authorized provider, pharmacy or entity under 32 CFR 199.6.
3.2  If no funds have been paid for services by the provider, pharmacy, or entity while excluded or are otherwise owed the Government for claims paid prior to the exclusion, the contractor shall certify the provider, pharmacy or entity as an authorized provider, and determine the effective date of the reinstatement.
3.3  The contractor shall advise the provider, pharmacy, or entity in writing of the reinstatement date.
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