1.0 DEFENSE ENROLLMENT ELIGIBILITY
REPORTING SYSTEM (DEERS) CATASTROPHIC CAP AND DEDUCTIBLE DATA (CCDD)
1.1 The contractor shall apply
cost-share and deductible amounts for non-network TRICARE claims
toward the catastrophic cap as the claims are processed for each
fiscal year.
1.2 The contractor shall apply
amounts toward he catastrophic cap as the claims are processed for
each calendar year, beginning January 1, 2018.
1.3 The contractor shall apply
all beneficiary cost-shares and deductibles specified in the contract
toward the cap, including nominal copayments for outpatient care
for TRICARE Prime, TRICARE Standard/Extra, and TRICARE Select claims.
1.4 The amount applied toward the
cap on the current claim and the family’s cumulative total must
be reflected on the Explanation of Benefits (EOB), except on complete
denials.
1.5 Once the maximum individual
or family catastrophic cap liability is met for the fiscal year
(prior to January 1, 2018) or calendar year (starting January 1,
2018), cost-shares and deductibles will no longer apply and the TRICARE-determined
allowable amount will be paid in full for all covered services and
supplies under the Basic Program through the end of that fiscal
year or calendar year.
1.6 Calendar
year 2017 was an exception as TRICARE converted from a fiscal year
basis to a calendar year basis. October, November and December 2017
were added to the 2017 fiscal year. Beginning January 1, 2018, all TRICARE
plans were converted to a calendar year basis for enrollment, catastrophic
cap, and deductible transactions.
1.7 To assist
the contractor with determining if changes to the CCDD need to be
made, a monthly Claims Reprocessing Alert Report will be made available
by the Government to facilitate adjustments of cost-share amounts
and enrollment fee payments.
1.7.1 This report
will identify beneficiaries that may need claim and/or fee payment
adjustments based on catastrophic cap activity.
1.7.2 When a total amount exceeds
the fiscal (effective January 1, 2018, calendar) year limit, a review
of recent activity is required to ensure proper processing has occurred.
1.7.3 The report will identify policies
where the catastrophic cap limit has been exceeded as a result of applying
claim and/or enrollment fee amounts. The report will also identify
policies where the catastrophic cap limit is reduced for any reason,
resulting in the total going under the annual limit.
1.7.4 The contractor shall correct
all accounts identified as exceeding the catastrophic cap limit.
1.7.5 The contractor shall determine
if any previously waived/reduced cost-shares or enrollment fee payments
are now due from the beneficiary.
2.0 CLAIM ORDER FOR APPLYING DEDUCTIBLE
2.1 The contractor shall apply
the outpatient deductible amounts as the claims are processed.
2.2 The contractor shall apply
the deductible based upon the date the claim was initially processed,
not the date the claim was subsequently adjusted. See the TRICARE
Reimbursement Manual (TRM),
Chapter 2, Section 1.
3.0 DEDUCTIBLE DOCUMENTATION
3.1 The contractor shall furnish
a deductible certificate or show the status of the deductible on
the EOB except on complete denials.
3.2 For complete
denials the contractor does not query any internal or external catastrophic
cap and deductible files and is not required to send deductible
information or catastrophic cap information on the denial notice.
3.3 The contractor shall obtain
the amount met toward the deductible from the CCDD, for claims processed for
years included in CCDD.
3.4 The contractor
shall query CCDD and apply deductible and cap as directed by the
CCDD query response, when a claim is adjusted.
3.5 The contractor shall not review
any intervening claims processed between the initial claim and the adjustment
for the purpose of adjusting deductible or cap amounts.
3.6 The contractor shall determine
from their deductible record, and/or EOBs from other contractors submitted
by the beneficiary, the amount the contractor has to apply to the
CCDD.
3.6.1 For services in prior years,
the beneficiary may request in writing the application of deductibles
and cost-shares taken by other contractors or paid by Other Health
Insurance (OHI).
3.6.2 The contractor
shall adjust the claim when a beneficiary subsequently documents
an excess deductible, based on the order in which claims were processed.
3.6.3 The contractor shall determine
which services are creditable toward the catastrophic cap by reference to
the TRM,
Chapter 2, Section 3.
3.7 For purposes of catastrophic
loss protection, a TRICARE claim must be submitted along with an
EOB from OHI in order for the beneficiary to receive credit for
any amount paid by OHI, even if the OHI paid the bill in total.
3.8 Normal double coverage rules
remain in effect after the cap has been reached; the beneficiary
must submit a claim to the OHI before submitting a claim to the
TRICARE contractor.
4.0 AUDIT TRAIL AND HISTORY FILE
4.1 The contractor shall ensure
that the history file accurately reflects all transactions pertaining
to care received, cost-shares, deductible, copayments, and adjustments.
4.2 The contractor shall maintain
the integrity of the audit trail and protect the confidentiality
and integrity of the files.
5.0 ADJUSTMENTS AND RECOUPMENTS
5.1 The contractor shall adjust
the CCDD to reflect the amount as an outstanding deductible if the
contractor is required to recoup a benefit payment.
5.2 Any other credited deductible
amount resulting from an individual claim adjustment will be offset
from future claims received for the beneficiary.
5.3 The Government has determined
that it is not cost effective to collect any outstanding deductible amounts
at the close of the timely filing period.