1.0 BENEFICIARY,
PARENT/GUARDIAN
1.1 The contractor shall provide
an EOB through electronic means, including but not limited to a
web based secure online portal for beneficiaries (including parents
or legal guardians of minors) to retrieve electronic EOBs that appropriately
describe(s) the action taken for each claim processed to a final
determination.
1.2 Beneficiaries
(including parents and legal guardians) shall be given the option
to opt-in for summary paper EOBs mailed to them on a monthly basis
(if care is received).
1.3 The contractor
shall:
• Provide beneficiaries with
multiple EOB status alerts and notification options, including email,
text, web-portal and hardcopy letters (based on means the beneficiary
chooses).
• Educate beneficiaries on options
to receive EOBs and notifications.
• Make a copy of the EOB electronically
accessible and printable to the beneficiary in the contractor’s
portal regardless of which alert and notification option the beneficiary
chooses.
• Allow the beneficiary to opt
in to hard copy, mailed EOBs.
• Note what preference a beneficiary
chooses, hard copy or electronic, as the means of providing Monthly Summary
EOBs and change preference upon beneficiary request.
2.0 NON-PARTICIPATING PROVIDER
2.1 The contractor shall provide
a secure online portal for non-participating providers to retrieve
electronic EOBs. Non-participating providers shall be given the
opportunity to opt-in for mailed paper EOBs. The EOB shall include
the amount allowed so that the provider can determine what amount
may be billed to the beneficiary under the balance billing provision
(115% of the TRICARE allowable charge).
2.2 The contractor
shall provide the non-participating provider with information where
there is only a “need to know.” This means that if other information
appears on the EOB that does not pertain to the non-participating provider,
the TRICARE contractor shall suppress printing or remove it before
sending the EOB to the non-participating provider.
2.3 The non-participating provider
will receive only the EOB and the beneficiary will receive the TRICARE payment.
3.0 NETWORK AND PARTICIPATING PROVIDERS
3.1 The contractor shall provide
a secure on-line portal for network and participating providers
to retrieve electronic EOBs. Network and participating providers
shall be given the opportunity to opt-in for mailed paper EOBs.
3.1.1 The contractor shall issue
an EOB to network and participating providers or issue summary vouchers covering
multiple claims and beneficiaries in lieu of issuing multiple EOBs.
3.1.2 The contractor shall issue
a summary voucher at least monthly (electronic or paper).
3.2 Sufficient information must
be included on the vouchers to identify each beneficiary and explain
the payment for each line item on each claim.
3.3 The contractor shall include
adequate identification of the fiscal year involved applicable to
the various charges listed on the EOB to help keep the deductible
information clear to the beneficiary.
3.4 If the
provider submits the claim electronically, a Health Insurance Portability
and Accountability Act (HIPAA)-compliant Electronic Remittance Advice
(ERA) shall be returned to the provider.
3.5 The contractor
shall send Electronic Funds Transfers (EFTs) and ERA to the provider
in HIPAA standard format as specified in the
Chapter 19, Section 2.
4.0 STATE MEDICAID AGENCY
4.1 The contractor shall include
the same information on the copy sent to the state as it normally
sends to participating providers if the claim is from a state Medicaid
agency.
4.2 The contractor shall, if the
state has a claims data need which cannot be accommodated except
at extra expense, negotiate with the state, and if the state is
willing to pay for the accommodation.
5.0 EOB ISSUANCE EXCEPTIONS
5.1 The contractor shall not issue
an EOB to beneficiaries (parents or guardians of minors or incompetents) when
claims involve services related to any of the following diagnoses:
• Abortion
• Acquired Immune Deficiency
Syndrome (AIDS)/Human Immunodeficiency Virus (HIV)
• Alcoholism
• Pregnancy
• Substance Abuse
• Sexually Transmitted Diseases
(STDs)
• Sexual Assault or Domestic
Violence
5.2 The contractor
shall issue an EOB to participating providers, except as noted above.
5.2.1 The contractor shall provide
a paper EOB to a beneficiary upon request.
5.2.2 When a
request is made for a normally suppressed EOB, the copy provided
may be a facsimile or a hand-produced copy. It must, however, include
the required data and be certified by the contractor.
5.3 The contractor shall send,
when a service(s) is denied due to an abortion, a letter of explanation
but only when the denial is questioned by the beneficiary.
5.3.1 The explanation
shall be provided only to the beneficiary and participating provider.
5.3.2 The special denial letter shall
be sent in an envelope marked “personal”.
5.3.3 It is
EMPHASIZED that using an EOB is NOT acceptable for denial of abortion
services. Only an approved letter may be used.
5.5 In lieu of an EOB, the
contractor shall send the Temporary Payment Suspension notifications
specified in Chapter 13, Addendum A, Figure 13.A-6 or Figure 13.A-7 (as appropriate)
until the payment suspension is lifted.
6.0 PROCEDURES FOR INFORMING THE
BENEFICIARY OF CLAIM ACTION
6.1 The contractor
shall provide beneficiaries with multiple claims action status alerts
and notification options, including email, text, web portal and
hard copy letters (based on means the beneficiary chooses).
6.2 The contractor shall notify
the beneficiary, based on the means the beneficiary chooses, that
a claim has been paid or denied and that they can access the claims
information via the portal.
6.3 The contractor
shall take into account, where applicable, the following:
6.3.1 The special rules for alcohol
and drug abuse program patient records referenced in DoD 6025.18-R, C5.4
and C8.9;
6.3.2 The provisions on abuse, neglect
and endangerment situations in DoD 6025.18-R, C8.7.5;
6.3.3 The beneficiary’s right to
request restrictions on disclosure under DoD 6025.18-R, C10.1; and
6.3.4 The beneficiary’s right to
request confidential communications under DoD 6025.18-R, C10.2.
6.4 The processing of claims for
the diagnoses listed above requires sensitivity to the beneficiary’s
right to privacy.
6.5 Because
of the need for contractors to apply reasonable judgment on a case-by-case
basis, Defense Health Agency (DHA) has not prescribed specific procedures
except in the case of abortion claims.
6.6 For claims
involving services and supplies for the other diagnoses, a phone
call to the beneficiary may serve to obtain information on how the
beneficiary wishes to have the EOB handled in some instances.
6.7 In other cases, a request that
the provider serve as an intermediary, or a personal letter to the
beneficiary, using a plain envelope, may be appropriate.
6.8 The contractor shall take into
account the intent, as well as the letter, of the Privacy Act, the
HIPAA of 1996, and the DoD Health Information Privacy Regulation,
DoD 6025.18-R.
7.0 EOB FORMAT
7.1 The form
design of the EOB is not specifically prescribed.
7.2 The contractor shall design
the form to fit their individual equipment and system needs.
7.3 The contractor shall provide
their toll-free inquiry number on the EOB.
7.4 Only the
last four digits of the Social Security Number (SSN), or the DoD
Benefits Number (DBN) shall appear on the EOB.
8.0 REQUIRED INFORMATION ON THE
EOB
8.1 The following detailed information
shall be included on the EOB:
• Provider or Pharmacy Name
• Provider or Pharmacy Address
• Provider or Pharmacy Taxpayer
Identification Number (TIN)
• Check Number
• Voucher Date
• Patient Name
• Sponsor Name
• Last four digits of Sponsor
SSN or DBN
• Date(s) of Service/Date(s)
Prescription(s) Filled
• Pharmacy EOB - Prescription
Number
• Pharmacy EOB - Prescription
Name
• Billed Amount
• Reason Codes
• Allowed Covered Charges
• Deductible
• Cost-Share or Copayment Amount
• Total Paid by Other Health
Insurance (OHI)
• Catastrophic Cap
• Remarks
• Description(s) of Reason Code(s)
• Interest Paid
• Federal Tax Withheld
• Accumulated Toward Catastrophic
Cap
• Accumulated Toward Individual
Deductible
• Accumulated Toward Family Deductible
• Offset (In the event payment
is offset or partially offset and applied toward a debt.)
• Amount Paid (If payment was
not issued but money was withheld and applied towards another debt, information
regarding where the funds were applied).
8.2 In addition to the fields specified
in
paragraph 9.1, offset EOBs shall also contain
the following additional information:
• Total Amount Offset
• Amount Paid
• Statement:
“$ was offset from this remittance
and applied towards your outstanding overpayment listed below. You
may not seek reimbursement from the TRICARE beneficiary for whom
you rendered services. We will send you a letter providing detailed
claim information within five to seven business days. If you have
any questions, please contact our customer service department for assistance.”
• Information regarding where
the offset will be applied:
• Patient Name
• Claim
Number
• Date Repayment Requested
• Amount
Requested
• Offset Amount
• Collected
To Date
• Amount Outstanding
9.0 REVERSE
OF THE EOB FORM
The following
information shall be on the reverse of the EOB:
9.1 Beneficiary
Notice Regarding Services
9.1.1 Please
review the services/supplies shown on the front of your EOB. If
you find that TRICARE has paid for any services that you did not
receive or that you were charged by a health care professional you
did not see, please call the (Contractor’s Name) Fraud
and Abuse Hotline at (Toll-Free Number).
9.1.2 The contractor shall include,
on the TRICARE Provider Electronic Remittance Advice (ERA), a reminder
to providers of requirements to familiarize with, comply with TRICARE
program requirements, rules and responsibility for medically necessary
and appropriate care.
9.2 Right To Appeal
If you disagree with the determination
on your claim, you have the right to request a reconsideration.
Your signed written request must state the specific matter with
which you disagree and MUST be sent to the following address no
later than 90 calendar days from the date of this notice. If the
postmark on the envelope is not legible, then the date of receipt
is deemed the date of filing, unless proof of mailing, such as a
certified mail receipt documents a different date. Include a copy
of this notice. On receiving your request, all TRICARE claims for
the entire course of treatment will be reviewed.
(Contractor’s Address)