1.0 Causes Of Underpayments
An underpayment adjustment
may be required as a result of any one or more of a number of circumstances,
such as reimbursement based on an incomplete billing, reversal of
a previous coverage or eligibility based denial of benefits, or
correction of an erroneous payment to an incorrect party.
2.0 Procedures For Disposition
Of Underpayment Cases
The correction
of most underpayments is readily handled by determining the correction
required, calculating the added amount, making appropriate changes
to the Beneficiary History file, the TRICARE Encounter Data (TEDs)
and issuing a check, if necessary, and a revised Explanation of
Benefits (EOB). For correction of reports of non-receipt of payment,
see
paragraph 3.0.
3.0
Disposition
Of Non-Receipt Of Payment Reports
3.1 If the
contractor is made aware that a payee has not received payment,
the contractor shall determine if the check has been negotiated,
voided, or stale dated. If payment was negotiated by other than
the appropriate payee, and the report of non-receipt was received
by the contractor within six years of the date the services or supplies
were provided, and it is a contractor financially underwritten case,
the contractor shall reissue payment to the appropriate payee and
handle the case as a possible forgery in accordance with
Chapter
13.
3.2 If the check has not been negotiated
the contractor shall take immediate steps to replace the check if
more than 30 days have elapsed since the issue date.
3.3 If it is not a contractor issued
check, refer the case to the contractor handling the case, or if there
is no appropriate contractor, refer the case to Office of General
Counsel (OGC) in Aurora, Colorado. Notify the sender of the action
being taken, sending a copy of the notice with all available information
to the contractor.
3.4 If the
check is stale dated, the contractor shall reissue the check to
the appropriate payee, if notice of non-receipt was received within
six years following the date of service or delivery of supply.
3.5 If the check has been returned
as undeliverable and voided, the contractor shall reissue payment
whenever new information; e.g., corrected address, is received which
has the potential for leading to the successful delivery. The reissue
must be accomplished within six years from the date the services
or supplies were provided.