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.