2.3 The contractor
shall send the temporary suspension of payment notification (
Addendum A, Figure 13.A-6 or
Figure 13.A-7 as
appropriate) to the provider, pharmacy, entity, or client beneficiary
in lieu of sending an Explanation of Benefits (EOB) or other claim
settlement notifications of a claim(s) payment suspension
2.3.1 The contractor
shall not send out claim(s) payment temporary suspension notifications above
normal claim(s) settlement notifications.
2.3.2 The contractor
shall not send out any document (EOB, etc.) to the client beneficiary
stating an amount owed by the client beneficiary to the temporarily
suspended provider during the suspension period.
2.5 Contractor
Responsibilities
2.5.1 Upon notification from DHA
to temporarily suspend claim(s) payments to specific providers,
pharmacies, entities, or client beneficiaries, the contractor shall
take the following six actions:
2.5.1.1 Cancel all pending non-underwritten
and underwritten payments where funds have not been mailed or electronically
transmitted, and the contractor can stop the release of funds in accordance
with
paragraph 2.5.2.
2.5.1.2 Follow Government direction in
regard to underwritten debt. If instructed to convert debt from
underwritten to non-underwritten, then submit an invoice in accordance
with
paragraph 2.5.3. This paragraph does not apply
to the TRICARE Overseas Program (TOP), TRICARE Pharmacy (TPharm) and
TRICARE
Medicare Eligible
Program (
TMEP)
contracts.
2.5.1.3 Cease all further collection
of non-underwritten debt related to the temporarily suspended provider,
pharmacy, entity, and client beneficiary in accordance with
paragraph 2.5.4.
2.5.1.4 Temporarily suspend the processing
of updates to all non-underwritten and underwritten claims received
and paid prior to receiving the notice of suspension in accordance
with paragraph 2.5.5.
2.5.1.5 Process all new non-underwritten
and underwritten claims received after the notification of temporary
suspension in accordance with
paragraph 2.5.6.
2.5.1.6 Forward all funds received
after the notice of temporary suspension from or on behalf of the
suspended providers, pharmacies or entities to DHA, Contract Resource
Management (CRM) in accordance with
paragraph 2.5.7.
2.5.2 Attempt To Withhold The Release
Of Payments Where Funds Have Not Been Mailed Or Electronically Transmitted
At The Time Of Temporary Suspension Notice
Where reasonably possible,
the contractor shall try to prevent the release of Government payments
to a temporary suspended provider when notified of the provider’s
suspension. This requirement does not apply to all payments pending
release. The Government understands there is a stage in the disbursement
process where, though the payments have not been mailed or transmitted,
they have progressed to a point where they cannot be stopped without
significant effort and cost.
2.5.2.1 The contractor shall determine
the point, if any, where the release of payments for claims received
prior to receiving the notice of temporary suspension can be stopped.
2.5.2.2 The contractor shall, for all
payments intercepted prior to release and reported as paid to DHA
on a TED Record(s), update (usually Cancel) previously reported
TED Record(s) (contractor report of payment) to show no payment
occurred.
2.5.2.3 The contractor shall not cancel
or issue a stop payment order on any Electronic Funds Transfers
(EFTs) or checks where the wire transfer has already been sent,
where the check has been mailed, or where payment was not intercepted.
2.5.2.4 The contractor shall, for any
payment that is returned, or becomes stale-dated, or is on the refund
file (in the process of crediting back), process claims in accordance
with
paragraph 2.6.
2.5.2.5 The contractor shall process
all collections received prior to the notice of suspension from or
on behalf of any temporarily suspended provider, pharmacy, or entity
in accordance with
paragraph 2.6.
2.5.2.6 Pharmacy contractor only. The
contractor shall process all pending reversals up to the date of
temporary suspension notification. All reversals received on or
after receipt of the notice of suspension shall be held by the contractor
unless notified by DHA, PI to process the reversals.
2.5.3 Procedure For Converting Underwritten
Debt To Non-Underwritten Debt (Excludes TOP, TPharm, And
TMEP Contracts)
At the Government’s discretion,
the Government will require the contractor to convert its underwritten debt
to non-underwritten debt. The conversion of debt (underwritten to
non-underwritten) shall not involve the temporarily suspended provider(s),
pharmacy(s) or entity(s); the debt conversion is an administrative
transaction between the contractor and the Government. If required
to convert debt from underwritten to non-underwritten the contractor
shall:
2.5.3.1 Submit an invoice billing the
Government for the debt owed to the contractor by the temporarily
suspended provider, pharmacy, or entity. The supporting documentation
shall include the amount owed by TED Record(s) Indicator (TRICARE
Systems Manual (TSM),
Chapter 2, Section 2.9).
2.5.3.2 The Government will issue payment
to the contractor and record an Accounts Receivable entry in the
accounting system under the temporarily suspended provider, pharmacy,
or entity name. The Government will not attempt collection during
the suspension period.
2.5.3.3 At the Government’s discretion,
debt converted from underwritten to non-underwritten will be returned
to the contractor as non-underwritten debt in accordance with
paragraph 2.9.5.
2.5.4 Procedure For Existing Debt
At The Time Of Temporary Suspension
During the temporary suspension
period and while the TED Record(s) Debt is in a “do-not process” status
the contractor shall:
2.5.4.1 Upon receipt of notification
of temporary suspension, cease all non-underwritten debt collection
efforts.
2.5.4.2 Not bill for Other Health Insurance
(OHI), transfer debt to DHA or conduct any additional claims processing.
2.5.4.3 Not update any TED Record(s).
Any DHA-directed action to collect debt or correct claims processing
errors, to include: Duplicate Claims System (DCS), OHI, Ineligibles,
or beneficiary copay adjustments, Tax Levy, Payment offset, etc.
(this is not an all-inclusive list), will be approved by DHA, PI prior
to taking any action.
2.5.4.4 Forward all funds collected
after receipt of the notice of temporary suspension from or on behalf
of the suspended provider, pharmacy, or entity in accordance with
paragraph 2.5.7.
2.5.4.5 Comply with applicable reporting
requirements related to Accounts Receivable by separately reporting
Temporarily Suspended Fiscal Intermediary (FI) Receivable debt for
each suspended provider, pharmacy, or entity by the following two
categories:
• FI Receivable debt by temporarily
suspended providers in a “do-not process” (do-not-pursue collection)
status.
• FI Receivable debt related
to temporarily suspended providers in a “process” (actively pursuing collection)
status (see
paragraph 2.7).
Continue to age and include
temporarily suspended debt on the monthly FI Receivable report.
Note: Temporarily Suspended FI Receivable
debt shall only relates to TED Record(s) data submitted on Vouchers.
The TED Record(s) data submitted on Batches was not paid and therefore
there is no associated debt. Details for reporting suspended A/R
for temporarily suspended providers are identified in DD Form 1423,
Contract Data Requirements List (CDRL), located in Section J of
the applicable contract.
2.5.4.6 Regional contractors only:
If underwritten debt existed prior to the notice of temporary suspension
and the Government did not convert the debt to non-underwritten
in accordance with
paragraph 2.5.3, the contractor may continue
to pursue its underwritten debt collection efforts against the suspended
provider, pharmacy, entity, or client beneficiary. All unsolicited/voluntary
refunds (underwritten and non-underwritten) shall be processed in
accordance with
paragraph 2.5.7.
2.5.4.7 Claims
Processing and Payment Exceptions for
paragraph 2.5.4Contractor shall not bill for
Other Health Insurance (OHI), transfer debt to DHA or conduct any additional
claims processing unless:
2.5.4.7.1 Authorized by DHA, PI;
2.5.5 Procedure For Processing Updates
To Claims Received Prior To Temporary Suspension Notice
2.5.5.1 All proceeds received prior
to the temporary suspension notice are applied to the suspended
provider’s TED Record(s) Debt in accordance with
paragraph 2.6.
2.5.5.2 All proceeds received after
the notice of temporary suspension are forwarded by EFT, check,
or special endorsement to DHA, CRM in accordance with
paragraph 2.5.7.
2.5.5.3 All updates (positive or negative),
received after the notice of temporary suspension, to previously
paid claims (claims received and paid prior to the notice of suspension)
are held in suspense by the contractor. No TED Record(s) updates
(Batch or Voucher) are done.
Note: TED Record updates received
prior to the notice of temporary suspension pending submission to
DHA shall be processed to completion and sent to DHA after receiving
the notice of suspension. The contractor shall stop updates resulting
in payments if possible.
2.5.6 Procedure For Processing New
Claims Received After Temporary Suspension Notice
The contractor shall process
all new claims submissions received after notice of temporary suspension of
a provider, pharmacy, entity, or client beneficiary as an initial
Batch TED Record then immediately place TED Record(s) in a “do-not
process” status suspending the claim from further processing. The contractor
shall not make payments to the provider, pharmacy, entity, or client
beneficiary nor apply calculated payment amounts to the provider’s,
pharmacy’s, or entity’s TED Record(s) debt for any claim processed
as a Batch. To submit claims using the Batch process the contractor
shall:
2.5.6.1 Cite Header Type Indicator 0 (Batch
Header no claim rate) OR 9 (Batch Header claim rate eligible)
as appropriate (TSM Data Element 0-001);
2.5.6.2 Cite Contract Line Item Number/Automated
Standard Application for Payment (CLIN/ASAP) Account Number 00000000 (TSM
Data Element 0-025);
2.5.6.3 Cite Adjustment Key 0 (TSM
Data Element 1-035 or 2-035); and
2.5.6.4 Cite Override Code
NP -
Payment to provider, pharmacy, entity, or client beneficiary temporarily
suspended at the direction of DHA, PI (TSM Data Elements 1-160 and
2-095).
2.5.6.4.1 Override Code NP is
only used for new claims received after the notice of temporary suspension,
processed as a Batch (informational TED Record(s)), and payment
is being held in accordance with the notice of suspension.
2.5.6.4.2 Updates to claims paid prior
to receiving the notice of temporary suspension are held in suspense
(i.e., no TED Record(s) updates) in accordance with
paragraph 2.5.5.
Do not cite Override Code =
NP when submitting Vouchers.
2.5.7 Procedure For Processing Debt
Payments And Unsolicited/Voluntary Refunds Received Temporary After
Suspension Notice
All funds
received from or on behalf of the temporarily suspended provider(s),
pharmacy(s) or entity(s) for claims subject to the suspension are
forwarded (by EFT, check or special endorsement) to DHA, CRM and
are not applied as payment to the suspended provider’s, pharmacy’s,
or entity’s TED Record(s) Debt. All unsolicited/voluntary refunds
(underwritten and non-underwritten) are forwarded to DHA, CRM. The
funds are placed into a “Deposit Fund” in accordance with the Department
of Defense (DoD) Financial Management Regulation (DoD 7000.14-R,
Volume 12, Chapter 1, Paragraph 0108 & 010803) “Monies held
by the U.S. Government awaiting distribution on the basis of a legal
determination or investigation.” For all funds received after the
notice of suspension from or on behalf of the suspended provider,
pharmacy, or entity, the contractor shall:
2.5.7.1 Forward checks payable to the
contractor to DHA, CRM with the following Special Endorsement: “Pay
to the order of US Treasury, ALC 97000012”. The contractor shall
endorse the checks. If the remittance is deposited by the contractor,
the contractor shall remit the funds to DHA, CRM by check or EFT
payable to US Treasury, ALC 97000012. Funds collected in accordance
with
paragraph 2.6 are excepted.
2.5.7.2 Not deposit proceeds received
after the notice of temporary suspension in its non-underwritten
bank account.
2.5.7.3 Not create TED Record(s) updates
for any funds transferred to DHA, CRM to be placed in a “Deposit
Fund” on behalf of the temporarily suspended provider, pharmacy,
or entity pending the outcome of the suspension investigation.
2.5.7.4 Advise the payer using special
notification the funds received have been placed in a Government
owned “Deposit Fund” (
Addendum A, Figure 13.A-10).
2.6 TED Record(s) Processing Exceptions
For Claims
The following
TED Record(s) updates do not require approval from DHA, PI and TED
Record(s) updates are processed in accordance with the TSM.
2.6.1 The contractor
shall apply all collections received prior to the notice of temporary suspension
to the provider’s, pharmacy’s, or entity’s TED Record(s) debt with
corresponding TED Record(s) updates.
2.6.2 The contractor
shall, for any payment that is returned, becomes stale-dated, intercepted
in accordance with
paragraph 2.5.2, or is on a refund file (in
the process of crediting back), process claims as follows:
2.6.2.1 NOT reissue payment (even if
a request is received from the payee).
2.6.2.2 Submit the corresponding credit
TED Record(s) reporting non-payment of claim in accordance with
Chapter 3, Section 4.
2.6.2.3 Deposit the returned funds
in the CLIN/ASAP Account originally used to make payment (if applicable).
If the CLIN/ASAP Account originally used for payment is closed the
contractor shall deposit funds into the current Fiscal Year (FY)
CLIN/ASAP Account assigned for the same purpose.
2.6.2.4 Process TED Record(s) adjustments
(Vouchers) to temporarily suspended providers as necessary to ensure
the reported TED Record(s) payments (Amount Paid Government Contractor,
TSM,
Chapter 2, Section 2.4, Record Locator 1-140
or 2-205) equal actual amounts executed under the contract (payments
excluding offsets). If the contractor is not sure a TED Record(s)
update is needed or authorized for non-underwritten bank reconciliation
or underwritten cost reimbursement purposes during the suspension
period, contact DHA, CRM for resolution.
2.6.2.5 Process all TED Record(s) updates
as required under Section H.10. ANNUAL UNDERWRITTEN UNALLOWABLE
HEALTHCARE COST COMPLIANCE REVIEW Cost of Care audit requirements.
This requirement applies to TED Record(s) data submitted under a
Voucher header. TED Record(s) data submitted under a Batch header
is excluded from audit as the Batch TED Records are informational records
and no expenditure of Government funds occurred based upon the TED
Record(s) (TSM,
Chapter 2, Section 2.3).
2.7 Procedure For Partial Release
Of Payments During Temporary Suspension
During the temporary suspension
period (pending the completion of investigation, to include any ensuing
legal or administrative proceedings) the Government will, at its
discretion, instruct the contractor to move suspended provider,
pharmacy, entity, and client beneficiary TED Record(s) from a “do-not
process” status to a “process” status while retaining the suspension
on all remaining and future claims received. The Government will
move claims from a “do-not-process” status to a “process” status based
upon date of receipt found embedded in the Internal Control Number
(ICN) (TSM,
Chapter 2, Section 2.5). Claims will be released
using a date range on an oldest to newest basis. This action will release
some or all TED Record(s) processed to-date under suspense for a
specific provider, pharmacy, entity, or client beneficiary; however,
it does not change the providers’, pharmacies’, or entities’ suspension
status. The suspension remains in effect for all claims not covered
by the “process” release and for all new claims received.
2.7.1 For all
temporarily suspended provider claims set to a “process” status
the contractor shall:
2.7.1.1 Process the claims to-date
as a Voucher citing Special Processing Code (SPC) NQ -
“PI Temporarily Suspended Provider, Pharmacy, Entity, or Client
Beneficiary claim in ‘PROCESS STATUS’.” Claim updates shall include,
but are not limited to: Duplicate Claims System (DCS), OHI, Ineligibles, beneficiary
copay adjustments, Cost of Care audit findings, Tax Levy, Payment
offset, etc., occurring after the suspension date. All TED Records
set to a “process” status while the provider, pharmacy, or entity
remains suspended are submitted as non-underwritten vouchers, cite
SPC NQ and remain non-underwritten for the life of
the claim. SPC NQ is used for all claims submitted
and adjusted as a Voucher and paid as non-underwritten during the
temporary suspension release(s). SPC NQ allows DHA
to identify all claims actually paid and collected during the temporary
suspension waiver.
2.7.1.2 Cancel the corresponding Batch
TED Record(s) citing Override Code NP - “Payment to Provider,
Pharmacy, Client Beneficiary or Entity Temporarily Suspended at
the Direction of DHA, PI.” Do not cite Override Code = NP when
submitting Vouchers.
Note: All TED Records set to a “process”
status are submitted to DHA as non-underwritten Vouchers for the
life of the claim.
2.7.2 For all
debt associated with TED Records in a “process” status, the contractor
shall follow the recoupment process as described in
Chapter 10, Section 4. All funds recovered
for TED Records set to a “process” status are applied to the provider’s,
pharmacy’s, or entity’s TED Record(s) debt and are deposited by
the contractor into the CLIN/ASAP Account originally used for payment.
If the CLIN/ASAP Account originally used for payment is closed the
contractor shall deposit funds into the current FY CLIN/ASAP Account
assigned for the same purpose. The date Government notification
was received to set the TED Record(s) to “process” and funds covered
under the “process” order (if any) held by DHA, CRM in a “Deposit
Fund” were returned to the contractor is the start date to initiate
debt collection activities. The date of demand in accordance with
45 CFR § 30.11 is used as the new debt aging date and is the age-based
date for potential transfer to DHA if the claim(s) remain uncollectable.
2.7.3 All amounts
owed to the provider, pharmacy, or entity for TED Records set to
a “process” status are first applied to the provider’s, pharmacy’s,
or entity’s active debt (debt related to TED Records set to a “process”
status) and any remaining amounts owed are paid to the provider,
pharmacy, entity, or client beneficiary.
2.7.4 The contractor
shall deposit any funds applied to the provider’s, pharmacy’s, or
entity’s debt into its current FY non-underwritten bank account
and submit a TED Record “cancellation” showing the reduction in
amount paid to the provider, pharmacy, or entity. If the contractor
is unable to submit a TED Record Cancellation or Adjustment, the
contractor shall report the deposit(s) on the monthly Bank Reconciliation
Report in accordance with
paragraph 2.9.5.5.
2.8 Procedure For Full Release
Of Temporary Suspension
Upon notification
from DHA PI that the provider, pharmacy or entity is no longer under
suspension the contractor shall:
2.8.1 For all
claims received after notification by DHA PI the temporary suspension
has ended, receive specific guidance from DHA as to how to proceed.
2.8.2 If instructed
by DHA, PI to process temporarily suspended TED Record(s) data,
coordinate with DHA, CRM regarding the disposition of all pending
adjustments and cancellations to TED Record(s) paid prior to the
notice of suspension (in accordance with
paragraph 2.5.5) that remain
in a “do-not process” status at the time of suspension release.
This coordination ensures the TED Record-based transactions submitted
by the contractor are recorded and paid correctly by the DHA financial systems.
2.8.3 Receive
specific instruction from DHA, CRM regarding the disposition of
all funds held in “Deposit Fund.”
2.8.4 The contractor
shall reset the debt aging date to the date of temporary suspension
release when directed by DHA. The date Government notification was
received to release suspension of claims and the date funds (if
any) held by DHA, CRM in a “Deposit Fund” were returned to the contractor
is used as the start date to initiate debt collection activities.
The date of demand in accordance with 45 CFR § 30.11 is used as
the new debt aging date.
2.9 Other
Instructions To The Contractor
2.9.1 On contracts where TED Record(s)-based
administrative (also known as claim rate) payments are authorized,
the contractor is authorized one administrative payment for each
new TED Record required by Government direction (e.g., claims processed
as a Batch and then changed to a “process” status or released from
temporary suspension shall receive one administrative payment for creating
the original Batch TED Record and a second administrative payment
for creating the new Voucher TED Record).
2.9.2 All claims
being held based upon the notice of temporary suspension are excluded
from Section H audit requirements except, in accordance with
paragraph 2.6.2.5, the Section H.10 ANNUAL UNDERWRITTEN
UNALLOWABLE HEALTHCARE COST COMPLIANCE REVIEW Cost of Care audit requirements.
2.9.3 The contractor
shall not apply the identified patient responsibility (applicable
cost-shares, copayments, deductibles) toward the catastrophic cap
for claims that are not fully processed. The contractor shall apply
the identified patient responsibility on claims fully processed
prior to the temporary suspension notice (and not intercepted,
paragraph 2.5.2)
or fully processed in accordance with
paragraphs 2.6,
2.7,
or
2.8.
2.9.4 At the
end of the contract and for all providers, pharmacies, entities,
or client beneficiaries that remain in temporary suspense, the contractor
shall transfer all Batch and Voucher TED Record(s) data to the new
contractor in accordance with
Chapter 2, Section 8.
All additional materials being held in suspense related to the suspended
Batch and Voucher TED Record(s) data is transferred to the new contractor’s
Program Integrity (or equivalent) office in accordance with
Chapter 2, Section 10, paragraph 1.0.
2.9.5 Debt Transferred To DHA And
Returned To The Contractor
When a provider, pharmacy,
or entity is under a temporary suspense order, all non-underwritten
debt collection efforts shall cease, to include collection efforts
related to debt previously transferred to DHA that remains uncollected.
Upon release of suspense or partial release of suspense (Process
Status), any debt falling within the suspense release period and
transferred to DHA will be transferred back to the contractor and
the collection process shall start over. The contractor shall:
2.9.5.1 Reestablish the debt on its
Accounts Receivable system within 30 days after receiving funds placed
in “Deposit Fund” and debt information from the DHA, Office of General
Counsel (OGC). Regional contractors: All debt returned to the contractor
is non-underwritten debt.
2.9.5.2 Issue a demand letter within
30 days after the debt has been reestablished using the date of
demand as the new debt aging date in accordance with 45 CFR § 30.11.
2.9.5.3 All interest and penalty timelines
shall start over with the date of demand as the aging start date
of debt.
2.9.5.4 If the debt remains uncollectable
it is transferred back to the DHA, OGC in accordance with
Chapter 10, Section 4 using the date of demand
after the debt was transferred back as the aging start date.
2.9.5.5 Regional contractors only:
Deposit all collections of converted debt into the current FY non-underwritten
bank account assigned to them. Because TED Record(s) credit data
submissions shall have already been sent to DHA for all underwritten
debt converted to non-underwritten debt, the monthly deposits of
converted debt will create an out-of-balance on the bank reconciliation
report. The contractor shall separately report on its monthly bank
reconciliation report (in summary) all collections for converted
debt. Details for reporting are identified in DD Form 1423, CDRL,
located in Section J of the applicable contract.