1.0 TIME LIMITATIONS ON FILING
TRICARE CLAIMS
1.1 AllThe
contractor shall process all claims for benefits
must
be that are 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 The
contractor shall process claims for inpatient facility professional services
billed
by the facility must be submitted claims within
one year from the date of service.
The contractor shall
deny claims that don’t meet the filing deadline unless they meet
one of the exceptions described below.
Example:
|
FOR DATE
OF SERVICE OR DISCHARGE
|
MUST BE RECEIVED BY THE CONTRACTOR
|
|
March 22, 2015 2022
|
No later than March 22, 2016 2023
|
|
December 31, 2015 2022
|
No later than December 31, 2016 2023
|
1.2 The contractor
shall accept any written request, whether or not on a
claim form, for benefits for determining if the claim was filed
on a timely basis.
1.3 The contractor
shall notify the claimant in writing that only an approved TRICARE
claim form is acceptable for processing a claim for benefits, when
the contractor receives an other than approved claim form.
1.4 The contractor shall inform the
claimant in writing that in order to be considered for benefits, the claimant
must submit an approved TRICARE claim form and any additional
information (if required) must be submitted and it
must be received by the contractor no later than one
year from the date of service, or date
of discharge, or 90 calendar days from the date they were notified
by the contractor, whichever is later.
1.5 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 or preauthorization determination,
the contractor shall ensure the provider or beneficiary
has obtained or been issued a retroactive determination must
have been obtained or issued after the timely filing
period elapsed. Absent an Explanation of Benefits (EOB),
the contractor shall require proof that beneficiaries received medical
care for a covered service (or waived service). The contractor shall
not accept a bill as such proof. If the provider
or beneficiary obtains or is issued a retroactive determination is
obtained or issued within one year from the date
of service or discharge, the contractor shall apply the one
year timely filing period is still binding limit.
2.1.2 The contractor shall process
all claims resulting from retroactive eligibility (i.e., equitable
relief and CHAMPVA claims).
2.1.3 The contractor shall
consider payment of ADSM retroactive claims as a specific exception
to the filing deadline. See Section 5 and Chapter 17, Section 3.
2.2 Administrative Error
2.2.1 The contractor shall grant
an exception to the claims filing deadline if an administrative
error is alleged, 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
contractor
shall ensure the necessary evidence
shall include
s 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 contractor shall
not require a claimant statement of the
claimant is not essential if the other evidence establishes
that his or her the claimant’s failure
to file within the usual time limit resulted from administrative
error, and that he or she the
claimant filed a claim within 90 calendar days after he
or she was they were notified
of the error. There must be The
contractor shall ensure a clear and direct relationship
between the administrative error and the late filing of the claim before
granting the waiver. If the evidence is in the contractor’s
own records, the contractor shall annotate the claim
file shall be annotated to that effect.
2.2.3 The contractor shall waive
recoupment of erroneous payments or reprocess recovered claims based
on full reconciliation caused by administrative error under the
TRICARE program that has been granted Equitable Relief (EQR) by
DHA in accordance with National Defense Authorization Act (NDAA)
for Fiscal Year (FY) 2016, Section 711, (a); 1095g.
2.2.4 The contractor shall collect
all TRICARE premiums, if applicable, before processing or reprocessing
EQR claims in accordance with
32
CFR 199.4 and
199.5, the TRICARE
Policy Manual (TPM), TRICARE Operations Manual (TOM), and TRICARE
Reimbursement Manual (TRM).
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 The
contractor shall require a physician’s statement, which
includes dates, diagnosis(es) and treatment, attesting to the beneficiary’s
mental incompetency shall accompany with each
claim submitted.
2.3.2 The contractor
shall review each statement for reasonable likelihood that mental
incompetency prevented the person from timely filing.
2.3.3 The contractor shall grant
an exception to the claims filing deadline based on the required
physician statement (
paragraph 2.3.1) due the beneficiary’s mental
incompetency and the lack of a legal guardian being appointed during
the period of time in question.
2.3.4 The contractor
shall request evidence from the spouse or parent that the claim
was paid and by whom if the charges were paid by someone else, i.e.,
legal guardian, spouse or parent.
2.3.5 The contractor
shall, 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).”
2.3.6 If a legal
guardian was appointed prior to the timely filing deadline and the
claims filing deadline was not met, the contractor shall
not grant an exception cannot be granted due
to mental incompetency of the beneficiary.
2.4 Other Health Insurance (OHI)
2.4.1 The contractor shall grant
exceptions to the claims filing deadline requirements if the provider
or 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 The
contractor shall ensure the claims must
have been were 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 contractor shall
require the provider or beneficiary must to 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 contractor shall
require the provider or beneficiary to submit the claim
form must be submitted to the contractor
within 90 calendar days from the date of the OHI adjudication.
2.5 Dual Eligibility With Medicare
2.5.1 The contractor shall grant
exceptions to the claims filing deadline if Medicare accepted the
claim as timely.
2.5.2 The claim
must be contractor shall process claims 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
There is noThe
contractor shall not apply time limit stipulated for
submitting written requests for exceptions to the claims filing
deadline before a claim has been submitted.
Note: TimeThe
contractor shall not apply time limitations for exceptions does
not apply to the processing of retroactive eligibility
claims.
3.1 The contractor shall consider
for benefits only those services or supplies received during the
six years immediately preceding the receipt of the request.
3.2 The contractor shall deny claims
for any services or supplies claimed for more
than six years immediately preceding the receipt of the request.
3.3 The contractor shall, upon
receipt of a request for an exception to the filing deadline without
the completed claim form enclosed:
• Inform the claimant of the requirement that to
complete and submit 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.