With the exceptions noted in
paragraph 1.0,
the contractor shall have proof of any double coverage payments
prior to adjudication of the claim.
2.1 No
Evidence Of Double Coverage
If there is no information
to suggest the claim could be covered by another health insurance
plan or there is no information on the claim to suggest that the
charges have been submitted to or paid by other insurance, the claim
shall be processed.
2.2 Double
Coverage Is Known
2.2.1 Whether it is a network or
non-network claim, payment must be obtained from the primary insurance
coverages or plans. The contractor shall include procedures to ensure
this requirement is met in all agreements with its network providers
of care. If the provider of care is owned or operated by the contractor
or is in a clinic or other facility operated by the contractor as
an employee or subcontractor, the Other Health Insurance (OHI) shall
also be collected by the contractor or its designee. If the claim indicates
no OHI coverage, but the Defense Enrollment Eligibility Reporting
System (DEERS) or contractor’s file indicates otherwise, a signed
statement or verbal notice from the beneficiary or sponsor furnishing
the termination date of the other coverage will be necessary for
the contractor to inactivate the positive OHI record. The contractor
shall have acceptable evidence of processing by the double coverage
plan prior to processing the claim. If there is no such evidence
submitted with the claim, the contractor shall deny the claim and
send an Explanation of Benefits (EOB) to the beneficiary and to
the provider.
2.2.2 The contractor
shall take appropriate action to ensure that a sample of all Electronic
Media Claims (EMC) is audited on a no less than annual basis with
verification obtained from the provider to corroborate the submission
of a zero OHI payment amount. In addition, no less than annually,
the contractor shall audit past EMC submissions to identify all
providers who may show a pattern of submissions with OHI payment
amounts of zero or of a nominal amount (e.g., $.01, $1.00, $5.00,
etc.). All EMC providers who demonstrate a possible pattern of “plugging”
nominal OHI payment amounts shall be referred to the contractor’s
Program Integrity staff for further investigation.
2.2.3 Except for EMC claims, when
Medicare is the primary payer, an Explanation of Medicare Benefits
(EOMB) is required. This will enable the contractor to determine
whether the provider accepted assignment under Medicare; if the
provider accepts assignment, the provider cannot bill for any difference
between the billed charge and the Medicare allowed amount. In addition,
it will identify cost-share and deductible amounts as well as any
allowable charge reductions.
2.2.4 For double
coverage situations which do not involve the routine issuance of
an EOB, the following
shall be accepted
in lieu of an EOB:
• Documentation that the beneficiary
belongs to the plan;
• Documentation that there is
a liability beyond the amounts paid by the primary payor;
• Documentation that the liability
is specified in the plan contract; and
• Documentation of total liability
on the claim.
2.2.5 If a contractor
becomes aware of the possible existence of OHI through means other
than the adjudication of a pending claim (e.g., a provider returns
all or a part of TRICARE payment because of payment by OHI), the
contractor shall establish an OHI record on DEERS for the patient
and request completion of a double coverage questionnaire. Depending
upon the circumstances of the individual occurrence, reopening and
adjustment of prior claims and/or a Program Integrity referral may
also be appropriate. All affected claims shall be adjusted appropriately,
although adjustment action may be temporarily deferred at the request
of Program Integrity staff if such adjustment would compromise their
investigation.
2.3 DRG-Based
System
The contractor
shall be able to identify OHI payments for all separately-billable
components of the inpatient services on a claim. If the OHI EOB
does not adequately identify the payments for each separately-billable
component, or if claims for their charges are not received, the
entire OHI payment is to be applied to the inpatient operating costs.
This also applies to claims from higher volume mental health hospitals
and units subject to the TRICARE Inpatient Mental Health Per Diem
Payment System that are authorized to bill for institution-based
professional services.
2.4 Medicare
Claims
Claims
processed on which Medicare is primary payer require review for
possible double coverage. Contractors shall be required to build
other health insurance files on these beneficiaries that identify coverages
(primarily Medicare supplements) that may be primary to TRICARE.
Contractors shall use any reasonably reliable indicator to identify
other coverages including crossover claims received from Medicare
carriers and fiscal intermediaries, crossover files received from
Medicare carriers and fiscal intermediaries, paper claims, information
resulting from refunds, information from providers, etc. Also, contractors
shall ensure that providers are aware that if they receive any TRICARE
payments that duplicate payments made by another coverage, they
shall return the TRICARE payment. Since TRICARE remains secondary
payer to all other coverages, contractors shall recover all payments
that they subsequently identify as duplicating a payment made by
any coverage, including Medicare supplements, that is primary to
TRICARE.
2.5 Skilled Nursing Facility (SNF)
Prospective Payment System (PPS)
Payment under the SNF PPS is
dependent upon the PPS-specific information submitted by the provider with
the TRICARE Claim (see
Chapter 8, Section 1).
However, if the beneficiary has OHI which has processed the claim
as primary payer, it is likely that the information necessary to
determine the TRICARE PPS payment amount will not be available.
Therefore, special procedures have been established for processing
SNF claims involving OHI. These claims will not be processed as
PPS claims. Such claims will be allowed as billed unless there is
a provider discount agreement. TRICARE payment will be the difference
between the billed charge and the OHI payment. The only exception
to this is cases when there is evidence on the face of the claim
that the beneficiary’s liability is limited to less than the billed
charge (e.g., the OHI has a discount agreement with the provider
under which the provider agrees to accept a percentage of the billed
charge as payment in full). In such cases, the TRICARE payment is
to be the difference between the limited amount established by the
OHI and the OHI payment.