1.0 SCOPE AND PURPOSE
1.1This
section specifies which individuals and entities may, or in some
cases must will,
be excluded from the TRICARE program Program.
It outlines the authority given to the Department of Health and
Human Services/Office of Inspector General (DHHS/OIG) to impose
exclusions from all Federal health care programs, including the TRICARE Program.
1.2 This section
also outlines the Defense Health Agency (DHA) authority for exclusions
and terminations.
1.3 In addition,
this section states the effect of exclusion, factors considered
in determining the length of exclusion, and provisions governing
notices, determinations, and appeals.
1.4 This section
also outlines procedures and protocol for suspension of claims processing,
conflict of interest, Voluntary Self-Disclosure protocol, and provider
self-reported refunds.
1.1 The Uniform Services
Family Health Plan (USFHP) is exempt from this requirement.
1.2 The Accountable Care
Organization (ACO) is partially exempt as follows:1.2.1 All claims where care
is provided and paid by the ACO are exempt from this requirement.
These claims are reported to DHA using the Batch TRICARE Encounter
Data (TED) Record(s) process.
1.2.2 All claims where the
costs are shared by the ACO and Government or are paid entirely
by the Government are subject to the requirements specified in this
section. These claims are reported to DHA using the Voucher TED
Record(s) process. All transactions related to these claims, to
include reimbursement by the ACO, shall be held in temporary suspense,
in accordance with the provisions outlined in this section.
1.3 Future Health Care Programs
Funded Under A Capitation AgreementAll health care claims
where the health care services provided are 100% covered under a
capitation (https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf)
agreement are exempt from this requirement. All health care claims
not 100% covered under a capitation agreement (to include shared
costs) are subject to the temporary suspension requirements outlined
in this section.
2.0 DHA AUTHORITY FOR
TEMPORARY SUSPENSION
OF CLAIM
(S
) PROCESSING PAYMENTS
2.2 The Director,
DHA or designee
may temporarily suspend
s claim
(s
) processing payments without
prior notification
to notifying the provider
,
pharmacy, entity, or
client beneficiary
of
the intent to suspend payments to protect
the public fisc.
The Government will advise
the provider, pharmacy, entity within 30 days of claims payment suspension
that a temporary suspension has been ordered with a statement of
the basis of the decision to suspend payment.2.2.1 Within 30 calendar
days of the claims suspension, DHA will provide written notice advising
the beneficiary or provider that a temporary suspension has been
ordered and a statement of the basis of the decision to suspend
payment.
2.2.2 The
suspension of claims processing will be for a temporary period pending
the completion of investigation and any ensuing legal or administrative
proceedings, unless sooner terminated by the Director, DHA or designee.
See 32
CFR 199.9 for additional
guidance.
2.2.3 DHA
Program Integrity Office (PI) is responsible for advising the contractor
of any suspension of claims processing.
2.2.4 The contractor
shall then issue special notifications. (Addendum
A, Figure 13.A-6, Figure
13.A-7, and Figure
13.A-8.)
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 claims 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 the amount owed by the client beneficiary to the temporarily
suspended provider during the suspension period.
2.4 The claims payment suspension
is for a temporary period pending the completion of investigation,
to include an ensuing any legal or administrative proceedings, unless
sooner determined by the Director, DHA or designee. See 32 CFR 199.9(h) for
additional guidance.Note: Both the Government
and the contractor are sending out temporary suspension notifications.
The contractor shall send out the standard temporary suspension
notification (Addendum A, Figure 13.A-6 and Figure 13.A-7 as appropriate)
in lieu of sending and EOB. The letters notify the provider or client
beneficiary the claims was received but not paid at Government direction.
The Government will send out the letter advising the provider why payments
were suspended and how to proceed to remove the claim(s) from suspension.
2.5 Contractor Responsibilities2.5.1 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 and 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 current collection
of non-underwritten debt related to the temporary suspended provider, pharmacy,
entity, or 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
Release of Payments Where Funds Have Not Been Mailed Or Electronically Transmitted
At The Time Of Temporary Suspension NoticeWhere reasonably possible,
the contract shall try to prevent the release of Government payments
to the 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 payment 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
Transfer (EFTs) or checks where the wire transfer has already been
sent, where the check has been mailed, or where the 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 being 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, Program Integrity (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 document 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
(A/R) entry into 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 to 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 SuspensionDuring 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 any 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 all applicable
reporting requirements related to A/R 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 relate 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 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 Notice2.5.5.1 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 NoticeThe contractor shall
process all new claim 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 Date 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,
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.
Shall not cite Override Code = NP when submitting
Vouchers.
2.5.7 Procedure For Processing
Debt Payments And Unsolicited/Voluntary Refunds Received Temporary
After Suspension NoticeAll funds received from
or on behalf of the temporarily suspended provider(s), pharmacy(s),
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 the US Treasury, ALC 97000012. Funds collected
in accordance with paragraph 2.6 are
accepted.
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-9).
2.6 TED Record(s) Processing
Exceptions Processing For ClaimsThe following TED Record(s)
updates shall not require approval from DHA, PI and TED Record(s)
updates are processed in accordance with the TSM.
2.6.1 The contractor shall
supply 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 reconciliation.
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 SuspensionDuring 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
removed claims from a ‘do-not-process’ status to ‘process’ status
based upon date of receipt are embedded in the Internal Control Number
(ICN) (TSM, Chapter 13, Section 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) process
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: 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, 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
listed 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 corresponding
Batch TED Record(s) citing Override Code NP -
‘Payment to the 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’ 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, entity’s TED Record(s) debit
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 the 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 fund 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
new aged-based date for potential transfer to DHA if the claim(s)
return 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 SuspensionUpon notification of
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 initiated debt collection activities.
The date of demand in accordance with 42 CFR § 30.11 is used as
the new debt aging date.
2.9 Other Instructions To
The Contractor2.9.1 On contracts where the
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 UNDERWRITEN 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) towards 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 contract 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 Chapter 2, Section 10, paragraph 1.0.
2.9.5 Debt Transferred To
DHA And Returned To The ContractorWhen 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 suspension or partial release of suspension (Process
Status), any debt falling with in the suspension 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 A/R 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 within 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 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
OnlyDeposit
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 under written
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.
3.0 DHA AUTHORITY FOR EXCLUSIONS
AND TERMINATIONS
3.1 DHA
may exclude exclusion
of any individual or entity
is based
on
32 CFR 199.9(h) provisions.
3.2 The contractor
shall provide written notice to DHA PI within 10 calendar days of
any situation involving a TRICARE provider, pharmacy, or entity
whose actions warrant exclusion under DHA authority related to fraudulent or
abusive behavior.
3.3 The Director, DHA or designee,
has the authority to exclude an authorized TRICARE provider, pharmacy, or
entity. The period of exclusion is at the discretion of DHA. (See
32
CFR 199.9.)
3.4 DHA PI is responsible
for coordinating will coordinate and issuing issue notification
of exclusion action. DHA PI will send written notice to the provider
of the proposed exclusion, and the potential effect thereof. The individual
or entity may submit evidence and written argument regarding the
proposed exclusion.
3.5 DHA PI
has sole authority to issue an Initial Determination of Exclusion.
Written notice of this decision will include the basis for the exclusion,
the length of the exclusion, as well as the effect of the exclusion.
The determination also outlines the earliest date on which DHA PI
will consider a request for reinstatement, the requirements for
reinstatement, and appeal rights available.
3.5.1 DHA PI
will notify appropriate agencies, including contractors, of all
DHA exclusion actions taken.
3.5.2 DHA PI will be
responsible for initiating initiate action
based upon reversed or vacated decisions. Exclusion
of a provider, pharmacy, or entity will be effective 15 calendar
days from the date of the initial determination.
3.5.3 The Director,
DHA or designee has sole authority for approval of any request for
reinstatement.
4.0 CONTRACTOR
ACTIONS UNDER TRICARE EXCLUSION AUTHORITY -
32
CFR 199.94.1 The contractor shall provide
supporting documentation to DHA PI within 10 calendar days when recommending
any provider exclusion.
4.2 DHA PI will notify the contractor
of an exclusion action.
4.3 The contractor shall:
4.3.1 Ensure that no payment is made
to an excluded provider, pharmacy, or entity for care provided on
or after the date of the DHA action (15 calendar days from the date
of the Initial Determination as noted in
paragraph 3.5). Neither the
provider, pharmacy, entity, nor the
patient will be client
beneficiary is entitled to TRICARE cost-sharing once
the exclusion is in effect.
4.3.2 Notify
DHA PI if a provider, pharmacy, or entity attempts to bill the program
after the effective date of exclusion.
4.3.3 Ensure
that an excluded provider, pharmacy, or entity is not included in
the network and provider directory.
4.3.3.1 The contractor shall ensure
that the network provider, pharmacy, or entity whose contract has
been canceled clearly understands his or her status if cancellation
of a network provider, pharmacy, or entity agreement is required.
4.3.3.2 Provide written notice within
15 business days, sent by certified mail, return receipt requested,
that the network provider’s or network pharmacy’s agreement has
been canceled.
4.3.3.3 Provide DHA PI a copy within
15 business days.
4.3.4 Notify,
in writing within 10 calendar days, the beneficiary who submitted
a claim that the provider has been excluded from the TRICARE program.
4.3.5 Ensure
the enforcement of all exclusion action taken, and notify appropriate
parties of the application of exclusions. For example, any claim
received from an excluded third party billing agent shall be returned
to the provider with instructions to resubmit the claim directly
or through another third party billing agent. The provider remains
entitled to reimbursement for covered services as long as they remain
an authorized TRICARE provider.
5.0 DHHS/OIG
APPLICATION OF SANCTION AUTHORITY
5.1 DHHS/OIG can excludes individuals
or entities from participation in any federal Federal health
care program to include the Department of Defense
(DoD) Military Health
System (MHS), and TRICARE. Authority and exclusion categories can
be found are on the DHHS/OIG
website.
5.2 DHHS/OIG has sole responsibility
for issuing a written notice of its intent to exclude a provider,
pharmacy, or entity, the basis for the exclusion, the effective
date, the period of exclusion, and the potential effect of exclusion.
5.3 DHHS/OIG
has sole authority for terminating an exclusion imposed under their its authority.
DHHS/OIG will handle notifications of approval or denial of a request
for reinstatement and are responsible for reversing or vacating
decisions.
5.4 DHHS/OIG exclusions and reinstatements
are issued on a monthly basis. DHHS/OIG will provide DHA PI with
immediate access to this information, which will be forwarded to
each contractor.
5.5 Exclusions taken by DHHS/OIG
are binding on Medicare, Medicaid, and all Federal health care programs with
the exception of the Federal Employee Health Benefit Program (FEHBP)
(42 USC 1320a-7b(f)). No payment
will be is made
for any item or service furnished on or after the effective date
of exclusion until an individual or entity is reinstated by DHHS/OIG,
and subsequently meets the requirements under
32
CFR 199.6.
6.0 CONTRACTOR
ACTIONS UNDER DHHS/OIG EXCLUSION AUTHORITY
6.1 DHA PI
will provide the contractor the monthly issuance of DHHS/OIG exclusion
and reinstatement actions.
6.2 The contractor shall ensure that
no payment is made to an excluded provider, network pharmacy, or entity
for care provided on or after the date of the DHHS/OIG action. The
provider, pharmacy, or entity, nor the
patient will
not be client beneficiary entitled
to TRICARE cost-sharing once the exclusion is effective.
6.2.1 The contractor
shall notify DHA PI should when a
provider, network pharmacy, or entity attempt to bill the program
or if payment has been issued after the effective date of exclusion.
6.2.2 It is
not necessary for the contractor to issue a separate letter notifying
the provider, network pharmacy, or entity of the exclusion action.
6.3 The contractor shall ensure
that an excluded provider, pharmacy, or entity is not included in
the network.
6.3.1 The contractor shall ensure that
the network provider or network pharmacy whose contract has been canceled
understands his or her their status,
if the cancellation of a network, or if applicable, participating
provider agreement is required.
6.3.2 The contractor
shall accomplish this by providing written notice, within seven
calendar days, sent by certified mail, return receipt requested, that stating the
network provider’s or network pharmacy’s agreement has been canceled. The
contractor shall send a copy to DHA PI.
6.3.3 The contractor
shall send a copy to DHA PI within seven calendar days.
7.0 CONTRACTOR
APPLICATION OF SANCTION AUTHORITY
7.1 The contractor shall ensure the
enforcement of all sanction action(s) taken, and notify appropriate
parties of the application of sanctions. For example, any claim
received from an excluded third party billing agent shall
be is returned to the provider
with instructions to resubmit the claim directly or through another
third party billing agent.
7.2 The provider remains entitled
to reimbursement for covered services as long as they remain an authorized
TRICARE provider.
8.0 PROVIDER,
NETWORK PHARMACY, OR ENTITY TERMINATION OF AUTHORIZED PROVIDER STATUS
8.1 The contractor
shall terminate the authorized provider status of any provider,
network pharmacy, or entity determined not to meet program requirements.
The request for reinstatement
will shall be
processed under the procedures established for initial requests
for authorized provider or network pharmacy status. See
paragraph 10.0 for
further information.
8.2 Other Listings
OtherThe
contractor shall ensure receipt of the appropriate state board listings
of actions affecting provider authorization status (e.g.i.e.,
Federation of State Medical Boards of the United States (US)) will
be sent to each contractor. A provider who has licenses
to practice in two or more jurisdictions and has one or more licenses suspended
or revoked shall be terminated as a TRICARE provider in all jurisdictions.
9.0 CONTRACTOR
REQUIREMENTS FOR TERMINATION
9.1 The contractor shall initiate
termination action based upon a finding that
the provider, pharmacy, or entity does not meet the qualifications
to be an authorized provider when status as an authorized provider, authorized
network pharmacy or authorized entity is ended.
9.2 Separate
termination action by the contractor is not required for a provider,
pharmacy, or entity sanctioned under the exclusion authority granted
DHHS/OIG.
9.3 The period of termination will
be indefinite and will end only after the provider, pharmacy, or
entity has successfully met the established qualifications for authorized
status under
the TRICARE
Program and
has been reinstated as outlined in
paragraph 10.0.
9.4 The contractor
shall notify the provider, pharmacy, or entity in writing of the
proposed action to terminate them.
9.4.1 The
contractor
shall specifically Government will direct
the contractor to notify the provider, pharmacy, or
entity of the proposed action to terminate their status as an authorized
TRICARE provider when the provider, pharmacy, or entity falls within
the contractor’s certifying responsibility and the provider, pharmacy,
or entity fails to meet the requirements of
32
CFR 199.6 (
Addendum A, Figure 13.A-9Addendum A, Figure 13.A-8).
9.4.1.1 The contractor
shall not terminate the provider, pharmacy, or entity when he or
she fails to return certification packets but flag the provider
as ‘inactive’.
9.4.1.2 The contractor
is not required to send a copy of the notice to DHA PI.
9.4.1.3 The contractor
shall send the notice to the provider’s, pharmacy’s or entity’s
last known business or office address.
9.4.2 The pharmacy
contractor shall notify the pharmacy in writing of the proposed
action to terminate the pharmacy status as a network pharmacy when
it is not in compliance with its agreement and the pharmacy fails
to meet the requirements of 32
CFR 199.6 (Addendum A, Figure
13.A-9).
9.4.3 The
notice shall state that the provider, pharmacy, or entity will be
terminated as of the effective date of the termination notice.
9.4.4 The notice shall
also inform the provider, pharmacy, or entity of the situation(s)
or action(s) which form the basis for the proposed termination.
9.4.5 For network
providers, the notice shall inform the provider that his or her
patients will be referred to another provider pending final action.
9.4.6 For a network
pharmacy, the notice shall inform the pharmacy that beneficiary
prescriptions may not be filled and any claims submitted will be
denied.
9.4.2 The notice shall will offer
the provider, pharmacy, or entity an opportunity to respond within
30 calendar days from the date of the notice. An extension to 60
calendar days may be granted if a written request is received during
the 30 calendar days showing good cause.
9.4.3 The provider, pharmacy, or entity
may respond with either documentary evidence and written argument
contesting the proposed action or a written request to present in
person evidence or argument to a contractor’s designee
at the contractor’s location DHA, PI.
Expenses incurred by the provider, pharmacy, or entity are their
responsibility.
9.4.4 Once the notice of proposed action
to terminate is sent, the provider’s claims will be are
temporarily suspended from claims processing until an
Initial Determination is issued. The provider, pharmacy, or entity will
be is notified via the proposed
notice that the claims will be are suspended
from claims processing. However, beneficiaries will
not be notified of the suspension.
9.4.5 For pharmacy claims, once the
notice of proposed action to terminate is sent, the pharmacy’s claims
will are not
be processed
as network claims until an Initial Determination is issued.
9.4.5.1 The pharmacy will
be is notified via the notice
that the claims will not be processed as network claims.
9.4.5.2 Beneficiaries will
be are advised by the pharmacy
that it is no longer a network pharmacy and that any prescription
filled there will requires submittal
of a claim for reimbursement by the beneficiary.
9.5 Initial
Determination
9.5.1 The contractor
shall Government will invoke
an administrative remedy of termination if after the provider,
pharmacy, or entity has exhausted, or failed to comply with the
procedures for appealing the proposed termination and the decision
to terminate remains unchanged by directing
the contractor to issue a written notice of the Initial Determination
via certified mail.
9.5.2 The contractor
shall accomplish this by issuing a written notice of the Initial
Determination via certified mail to the effective entity.
9.5.3 The contractor
shall send a copy of the Initial Determination to DHA PI along with
supporting documentation within seven calendar days.
9.5.2 The contractor shall include
the following in the Initial Determination written notice:
9.5.2.1 A Unique Identification Number
(UIN) indicating the
fiscal year FY of
the Initial Determination, a consecutive number within that
fiscal
year FY and the contractor’s
name. A sample letter is found at
Addendum A, Figure
13.A-10 Addendum A, Figure 13.A-9.
9.5.2.2 A statement of the action being
invoked and the effective date of the action. The effective date shall will be
the date the provider, pharmacy, or entity no longer meets the regulatory
requirements. If there is no documentation the provider ever met
the requirements, the effective date will be either June 10, 1977
(the effective date of the Regulation) or the date on which the
provider, pharmacy or entity was first approved, whichever date
is later. In the case of a pharmacy, it would be is the
date on which the pharmacy first became part of the network.
9.5.2.3 A statement of the facts, circumstances,
or actions that form the basis for the termination and a discussion
of any information submitted by the provider, pharmacy, or entity
relevant to the termination.
9.5.2.4 A statement of the provider’s,
pharmacies, or entity’s right to appeal.
9.5.2.5 The requirements and procedures
for reinstatement.
9.6 Providers
Failing To Return Recertification Documentation
9.6.1 The
contractor shall not terminateUpon notification
from the Government the providers, pharmacy pharmacies,
or entity failing entities
who failed to return recertification documentation,
the contractor shall terminate but shall be placed the
providers, pharmacies, and entities on the inactive
provider listing.
9.6.2 The contractor shall first
verify that the recertification package was mailed to the correct
address and was not returned by the US Postal Service (USPS).
9.6.3 The contractor
shall ensure that no claims are paid and shall deny claims for services
regardless of who submits the claim.
9.6.4 The contractor
shall advise Government will notify the
provider, pharmacy, or entity shall be advised that
such action will be taken within 15 calendar days their
TRICARE claims will be denied for failing to return their recertification
documentation.
9.7 Requirement
To Recoup Erroneous Payments
9.7.1 The contractor shall, after
the Initial Determination letter has been issued, initiate recoupment
in accordance with
Chapter 10, Section 2 for
any claims cost-shared, paid for services, or supplies furnished
by the provider (including pharmacies) on or after the effective
date of termination, even when the effective date is retroactive,
unless a specified exception is provided by 32 CFR 199. This also
applies to claims processed by previous contractor(s).
9.7.2 The contractor
shall transfer all monies recouped, including those paid by previous
contractor(s), to DHA
Contract Resource Management
(CRM
) in accordance
with
Chapter 3.
9.8 File
Requirements For A Terminated Provider, Pharmacy, Or Entity
The contractor shall include
the following in the Initial Determination file for the provider,
pharmacy, or entity:
9.8.1 Initial Determination of Termination
Action as well as Proposed Notice to Terminate.;
9.8.2 Provider/pharmacy/entity certification
file (i.e., the documentation upon which the original certification
of the provider/pharmacy/entity was based)
or network pharmacy agreement.;
9.8.3 All correspondence
and documentation relating to the termination. (copies Copies of
the enclosures must be are attached
to the copy of the original correspondence).;
9.8.4 Documentation
that the contractor considered or relied upon for in issuing
the determination.
9.9 Special Action or Notice Requirements
When An Institution Is Terminated
9.9.1 The contractor shall take appropriate
action when a DHA determination is made that an institutional provider
does not meet qualifications or standards to be an authorized TRICARE
provider.
9.9.2 Provider And Client Beneficiary
Notification
9.9.3 The
contractor
shall Government will:
9.9.3.1 Instruct the institution by certified
mail to immediately give written notice of the termination to any TRICARE client beneficiary
(or his or her beneficiary’s parent,
guardian, or other representative) admitted to or receiving care
at the institution on or after the effective date of the termination.
9.9.3.2 Notify any client beneficiary
(or their beneficiary’s parent,
guardian, or other representative) admitted prior to the date of
the termination by certified mail that TRICARE cost-sharing ended
as of the termination date when the termination effective date is
after the date of the initial determination.
9.9.3.3 Advise the client beneficiary
(or their beneficiary’s parent,
guardian, or other representative) of their the
client beneficiary’s financial liability.
9.9.3.4 Use a fast, effective means
of notice (e.g., phone, fax, express mail, or regular mail, depending
on the circumstances).
9.9.3.5 Notify any client beneficiary
(or his or her beneficiary’s parent,
guardian, or other representative) admitted prior to the grace period
of the violation that TRICARE cost-sharing of covered care will continues during that
period. Cost-sharing is to continues through
the last day of the month following the month in which the institution
is terminated if an institution is granted a grace period to effect
correction of a minor violation.
9.9.3.6 Notify any client beneficiary
(or their beneficiary’s parent,
guardian, or other representative) admitted prior to a grace period
of the institution’s corrective action, when such has been determined
to have occurred, and the continuation of the institution as an
authorized TRICARE provider.
9.9.4 Cost-Sharing
Actions
9.9.5 The contractor shall deny cost-sharing
for any:
9.9.5.1 New patient admitted after
the effective date of the termination.;
9.9.5.2 Beneficiary admitted during
a grace period granted an institution involved in a minor violation.;
9.9.5.3 Beneficiary already in an institution
involved in a major violation beginning with the effective date
of the termination.;
9.9.5.4 The contractor shall
cost-share covered care for those beneficiaries admitted prior to
a grace period.
10.0 PROVIDER REINSTATEMENTS
10.1 Reinstatement
of an excluded individual or entity is not automatic once the specified
period of exclusion ends.
10.2 The individual or entity must will apply
for reinstatement and receive written notice from DHA that reinstatement
has been granted.
10.3 32
CFR 199.9 provides that the Director, DHA or a designee,
will 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.
10.4 DHHS/OIG
provides monthly updates for reinstated providers, individuals,
pharmacies, and entities. The information includes exclusion date
and reinstatement date when a previously excluded provider, pharmacy,
or entity is reinstated by DHHS/OIG.
10.5 The contractor
shall, before initiating reinstatement action:
10.5.1 Determine if any erroneous
payments have been made to provider, pharmacy or entity during period of
sanction.
10.5.1.1 The contractor shall certify
the provider, pharmacy or entity as an authorized provider, and
determine the effective date of the reinstatement if no funds have
been paid for services to the provider while excluded or are otherwise
owed the Government for claims paid prior to the exclusion.
10.5.1.2 If erroneous payments have
been made to a provider, pharmacy, or entity during the period of exclusion,
restitution of the payments shall be made before a request for reinstatement
will be considered.
10.5.1.3 The contractor shall determine,
if any payments have been made, and initiate restitution of the payments.
10.5.2 The contractor shall send the
certification package to the provider, entity, or pharmacy for completion to
ensure that the provider meets the requirements to be an authorized
TRICARE provider under
32 CFR 199.6.
10.5.3 Verify that pharmacies has
all required state licenses to operate as a pharmacy.
10.5.4 Ensure the exclusion or suspension
shall remain in effect until the provider completes and returns
the certification package and the determination is made by the contractor
that the provider meets the requirements of an authorized TRICARE
provider under
32 CFR 199.6.
10.5.5 Provide in writing of the reinstatement
date, once the determination is made that the provider meets the
requirements of a TRICARE Authorized provider under
32
CFR 199.6.
10.5.6 If pharmacy, provide in writing
that the pharmacy has met the state licensing requirements and advise the
pharmacy of the date it is eligible to negotiate a new network agreement
with the contractor, as determined by DHA.
10.6 The contractor
shall notify the provider in writing with an explanation on why
the provider did not meet the requirements and advise the provider
of their appeal rights if the provider does not meet the requirements
of a TRICARE Authorized Provider under
32
CFR 199.6.
10.6.1 The contractor shall provide
DHA PI a copy of the letter within seven calendar days.
10.6.2 The contractor shall provide
in writing to the pharmacy within seven calendar days, that the
pharmacy does not have the required state licenses and provide notification
to the pharmacy why the pharmacy is not eligible to be a network
pharmacy and advise pharmacy of appeal rights.
10.6.3 A copy of the letter shall
be provided to the DHA PI within seven calendar days.
10.6.4 The contractor shall provide
notification to Beneficiary Counseling and Assistance Coordinators (BCACs)
at Markets/Military Medical Treatment Facilities (MTFs) within the
provider’s service area of provider status within seven calendar
days.
11.0 CONFLICT
OF INTEREST
11.1 The contractor shall document
and refer suspected violations of conflict of interest to the DHA
PI within 15 calendar days.
11.1.1 Conflict of interest includes
any situation where an active duty member of the Uniformed Services (including
a reserve member while on active duty, active duty for training,
or inactive duty training) or civilian employee (which includes
employees of the Department of Veterans Affairs/Veterans Health
Administration (DVA/VHA)) of the US Government, through an official
federal position has the apparent or actual opportunity to exert, directly
or indirectly, any influence on the referral of beneficiaries to
himself or herself or others with some potential for personal gain
or the appearance of impropriety.
11.1.2 Although individuals under
contract to the Uniformed Services are not considered employees,
such individuals are subject to conflict of interest provisions
by express terms of their contracts and, for purposes of the
32
CFR 199.9 may be considered to be involved in conflict
of interest situations as a result of their contract positions.
11.1.3 In any situation involving
potential conflict of interest of a Uniformed Service employee,
the Director, DHA, or a designee, may refer the case to the Uniformed
Service concerned for review and action.
11.2 Federal
Employees And Active Duty Military
11.2.1 32
CFR 199.6 prohibits active duty members of the Uniformed
Services or employees (including part-time or intermittent), appointed
in the civil service of the US Government, from authorized TRICARE
provider status.
11.2.2 This prohibition applies to
TRICARE payments for care furnished to TRICARE beneficiaries by
active duty members of the Uniformed Services or civilian employees
of the Government.
11.2.3 The prohibition does not apply
to individuals under contract to the Uniformed Services or the Government.
11.3 Exceptions
11.3.1 National
Health Service Corps
TRICARE
payment may be made for services furnished by organizations to which
physicians of the National Health Service Corps (NHSC) are assigned.
However, direct payments to the NHSC physician are prohibited by
the dual compensation provisions.
11.3.2 Emergency
Rooms
11.3.2.1 Any off-duty Government medical
personnel employed in an emergency room of an acute care hospital
will be presumed not to have had the opportunity to exert, directly
or indirectly, any influence on the referral of TRICARE beneficiaries;
therefore, TRICARE payments may be made to the employing hospital
provided the medical care was not furnished directly by the off-duty
Government medical personnel in violation of dual compensation provisions.
11.3.2.2 The contractor shall not cost-share
professional services by the provider since they cannot be recognized
as TRICARE-authorized providers.
11.3.3 Reserves
Generally Exempt
11.3.3.1 Conflict of interest provisions do shall not
apply to medical personnel who are Reserve members of the Uniformed
Services or who are employed by the Uniformed Services through personal
services contracts, including contract surgeons.
11.3.3.2 Although Reserve members, not
on active duty, and personal service contract medical personnel
are subject to certain conflict of interest provisions by express
terms of their membership or contract with the Uniformed Services,
resolution of any apparent conflict of interest issues which concern
such medical personnel is the responsibility of the Uniformed Services,
not the DHA.
11.3.3.3 National Guard and reservists
on active duty are not exempt during the period of their active
duty commitment.
11.3.4 Part-Time Physician Employees
Of The US Government
11.3.5 Referrals
From Uniformed Services Facilities
11.3.5.1 Referrals from Uniformed Services
facilities to individual civilian providers should, in every practical instance,
be made to participating providers. However, referrals of TRICARE
beneficiaries by Uniformed Services personnel to selected individual
providers in the civilian community when other similar participating
providers are available may involve a conflict of interest.
11.3.5.2 The contractor shall document
any apparent problem of this nature and refer the case to the DHA
PI for investigation.
11.3.5.3 In any situation involving
potential conflict of interest of a Uniformed Service employee,
the Director, DHA, or a designee, may refer the case to the Uniformed
Service concerned for review and action.
12.0 REPORTING
PROVIDER REFUNDS - PROVIDER REFUNDS (SINGLE CLAIM AND MULTIPLE CLAIMS)
12.1 Providers
have a requirement to return overpayments to the TRICARE program
(voluntary or requested). Possible reasons for provider refunds
(single or multiple claims) may include: Other Health
Insurance (OHI), Third Party
Liability (TPL), Payment sent to incorrect provider, Duplicate Payment,
Provider Billing Error, or TRICARE overpaid.
12.2 The contractor
shall notify DHA PI within 30 business days of receiving reported
refund when a Provider Billing Error refund is made to the contractor
(single or multiple).
12.3 For reporting submission requirements,
see DD Form 1423, Contract Data Requirements List
(CDRL), located in Section
J of the applicable contract.
13.0 VOLUNTARY
SELF-DISCLOSURE
13.1 Congress through the Fraud
Enforcement and Recovery Act of 2009 (FERA) amended the False Claims
Act (FCA) to cover the identification and return of overpayments
to federal programs. Specifically, FERA expanded the scope of the
FCA to provide liability for “knowingly” retaining an overpayment.
Accordingly, the FCA now imposes liability on any provider who received
overpayments (accidentally or otherwise) and then knowingly fails
to return the overpayment to the Government. The amended statute
allows for knowingly retaining an overpayment to be the sole allegation
of a complaint under the FCA. Additionally, failure to timely report
and return an overpayment under the amended FCA exposes a provider
to liability. This includes TRICARE claims and payments.
13.2 Individuals
or entities who wish to voluntarily disclose self-discovered potential
fraud to DHA-PI may do so under the Self-Disclosure Program (SDP).
Disclosing parties may report by sending to DHA PI or may also report online.
13.3 Non-health
care matters, should be reported to the DHA Office
of Inspector General (OIG) Hotline,
or if military, to the DoD OIG Hotline or the respective military
service OIG Hotline.
13.4 Disclosing parties already subject
to a Government inquiry (including investigations, audits, or other oversight
activities) are not automatically precluded from using the SDP.
The disclosure, however, must will be made
in good faith and must will not
be an attempt to circumvent any ongoing inquiry. Disclosing parties
under Corporate Integrity Agreements (CIA) with DHA may also use
the SDP in addition to making any reports required in the CIA.
13.5 Disclosing
parties are advised that the self-disclosure may be shared with
other Federal agencies.