TRICARE Manuals - Display Chap 3 Sect 1 (Change 8, Jun 13, 2024)

Financial Administration

Chapter 3

Section 5

Quarterly and Annual Claims Payment and Data Accuracy Reviews

Revision:

1.0 INTRODUCTION

1.1 The Government will conduct Quarterly and/or Annual Claims Payment Accuracy Reviews, and TRICARE Encounter Data System (TEDS) Error Occurrence Reviews as specified in each contract.

1.2 The Government will use an independent external claims review service to perform these reviews under the TRICARE Claims Review Services (TCRS) contract.

1.3 The Government will generate a random sample of claims for the quarterly and annual reviews, dependent on the contract requirements. TED records will be stratified by paid amount.

1.4 The Government will forward the listing of TEDs Individual Control Numbers (ICN) for the claims in the sample to the contractor. The sample may include non-denied, as well as denied claims for review, specific to the contract.

1.5 The contractor shall compile all pertinent claims processing documentation related to the claims in the sample and forward to the TCRS contractor within 45 calendar days from the date of the Defense Health Agency (DHA) letter containing the ICN listing. The format of the documentation shall be in accordance with the Memorandum of Understanding (MOU) established between the contractor and the TCRS contractor as specified in the contract.

1.6 The contractor shall provide to the Government and the TCRS contractor its description of data elements by field position in family history file files and field definitions for pricing, Other Health Insurance (OHI), authorization and/or referral screens, current claims adjudication guidelines used by processors.

1.6.1 The contractor shall include any unique internal procedure codes with narrative and cross-reference to approved TRICARE codes and pricing manuals used in claims processing.

1.6.2 The contractor shall submit the initial submission of documentation to the Government by the commencement of claims processing with the submission of revisions as they occur, but not later than the fifth work day of the month following the change.

1.7 The Government will conduct the following types of reviews, depending on the specifications of the contract:

• Quarterly Claims Payment Accuracy Reviews

• Quarterly TEDS Occurrence Reviews

• Quarterly Denied Claims Compliance Reviews

• Annual Underwritten Unallowable Healthcare Cost Compliance Reviews

• Annual Low Dollar Focus Study

2.0 REQUIRED DOCUMENTATION

2.1 The contractor shall submit the required documentation for each claim selected by the Government:

2.1.1 One legible copy of each claim (e.g., CMS 1500, UB 92/04, etc.).

2.1.2 All claim-related correspondence when attached to claim or related to the adjudication action (status inquiries, written and/or telephone, development records, and other telephone conversation records, etc.).

2.1.3 The provider’s medical record and patient history supporting the claim submitted (when specified within the contract).

2.1.4 Other claim-related documentation to include:

• Medical reports

• Medical review records

• Coding sheets

• All authorization and referral forms/records (including supporting documentation)

• Referrals for civilian medical care (e.g., SF Form 513 or DD 2161, or equivalent)

• Other Health Insurance (OHI) or Third Party Liability (TPL) documentation

• Discounted Rate Agreements to include:

• Provider name and National Provider Identifier (NPI)/identification number

• Effective and termination dates of agreements

• Negotiated rate(s), per diem rate(s), state prevailing fee(s) or fee schedule(s)

• Diagnosis Related Group (DRG)

• Hospital Outpatient Prospective Payment System (OPPS)

• Skilled Nursing Facility (SNF) rates

• Any and all other pricing information and other documents required to support the reimbursement action(s) taken on the claim

• Copy of the Explanation of Benefits (EOB) for each claim selected

• Documentation to support the Government or contractor approved beneficiary participation in any TRICARE demonstration program

2.1.5 Documentation for any claim selected with adjustment transactions completed prior to the date of the sample must include the documentation to indicate both initial and adjustment processing actions to include claims EOBs, and pricing information.

2.1.6 Patient history, when required, per the MOU between the contractor and the TCRS contractor.

2.2 Claim Adjustment History

The contractor shall send documentation for any claim selected with adjustment transactions completed prior to the date of the sample and must include the documentation to indicate both initial and adjustment processing actions to include claims EOBs and pricing information.

3.0 PAYMENT ERROR DETERMINATIONS

The Government will determine payment errors based on the claim information available and those processing actions taken up to the time the compliance review sample is generated.

3.1 The Government will assess payment errors for claims for which the contractor cannot produce the claim or the claim provided is not auditable. For TEDs that do not represent a legitimate condition requiring submission of a record as defined in the TRICARE Systems Manual (TSM), a 100% error will be assessed. This condition is considered to be an unsupported TED. The payment error amount(s) will be based on either the institutional TEDs data field -Amount Paid by Government Contractor (TOTAL) or the non-institutional TEDs data field - Amount Paid by Government Contractor by Procedure Code, as submitted by the contractor.

3.2 The Government will consider Total Amount Billed to be the actual amount billed on the claims, as stated on the TED record. This applies to treatment encounters for which no per diem, negotiated rate or DRG based amount applies.

4.0 ERROR CODES

4.1 The Government will assess errors using the codes listed in the following tables:

TED AUDIT (TA) PAYMENT ERROR CODES
K	01K	AUTHORIZATION/PREAUTHORIZATION NEEDED
K	02K	BENEFIT DETERMINATION UNSUPPORTED
K	03K	BILLED AMOUNT INCORRECT
K	04K	COST-SHARE/DEDUCTIBLE ERROR
K	05K	DEVELOPMENT CLAIM DENIED PREMATURELY
K	06K	DEVELOPMENT REQUIRED
K	07K	DUPLICATE SERVICES PAID
K	08K	ELIGIBILITY DETERMINATION - PATIENT
K	09K	ELIGIBILITY DETERMINATION - PROVIDER
K	10K	MEDICAL EMERGENCY NOT SUBSTANTIATED
K	11K	MEDICAL NECESSITY NOT EVIDENT
K	13K	OHI - GOVERNMENT PAY MISCALCULATED
K	14K	OHI PAYMENT OMITTED
K	15K	PAYEE WRONG - SPONSOR/PATIENT
K	16K	PAYEE WRONG - PROVIDER
K	17K	PARTICIPATING/NONPARTICIPATING ERROR
K	18K	PRICING INCORRECT - OTHER
K	19K	PROCEDURE CODE INCORRECT
K	20K	SIGNATURE ERROR
K	21K	TIMELY FILING ERROR
K	22K	DRG REIMBURSEMENT ERROR
K	23K	CONTRACT JURISDICTION ERROR
K	24K	BENEFIT DETERMINATION WRONG
K	25K	CLAIM NOT PROVIDED
K	26K	CLAIM NOT AUDITABLE
K	28K	POINT OF SERVICE MISCALCULATED/OMITTED
K	50K	PRICING INCORRECT - CPT/HCPCS/CMAC/Fee Schedule Allowed Amount Miscalculated
K	51K	PRICING INCORRECT - OPPS Reimbursement Rate Miscalculation
K	52K	PRICING INCORRECT - HHS Reimbursement Rate Miscalculation
K	53K	PRICING INCORRECT - Critical Access Hospital Reimbursement Rate Miscalculated
K	54K	PRICING INCORRECT - Residential Treatment Center (RTC) Per-Diem Rate Miscalculated
K	55K	PRICING INCORRECT - Long Term Care Facility Per-Diem Rate Miscalculated
K	56K	PRICING INCORRECT - Substance Abuse Treatment Facility Per-Diem Rate Miscalculated
K	57K	PRICING INCORRECT - Skilled Nursing Facility (SNF) Per-Diem Rate Miscalculated
K	58K	PRICING INCORRECT - Hospice Per-Diem Rate (Inpatient) Miscalculated
K	59K	PRICING INCORRECT - Hospice Per-Diem Rate (Outpatient) Miscalculated
K	60K	PRICING INCORRECT - Professional/Technical Component Rate Miscalculated
K	61K	PRICING INCORRECT - Provider Discount Rate Miscalculated/Not Applied
K	62K	PRICING INCORRECT - Blended Rate Allowed Amount Miscalculated/Not Applied
K	63K	PRICING INCORRECT - Locality Based Waiver Miscalculated/Not Applied
K	64K	PRICING INCORRECT - Claim Incorrectly Paid as Billed (PAB)
K	65K	PRICING INCORRECT - DMEPOS Fee Schedule - Incorrect rate/information used
K	66K	PRICING INCORRECT - Number/Units of Service Miscalculated
K	67K	PRICING INCORRECT - Multiple Procedure/Surgery Discount Miscalculated/Not Applied
K	68K	PRICING INCORRECT - Inpatient Psych Hospital Per-Diem Rate Miscalculated/Not Applied
K	69K	PRICING INCORRECT - Reimbursement Rate for SCH Miscalculated/Not Applied
K	70K	PRICING INCORRECT - AMBi Surg Miscalculated
K	71K	PRICING INCORRECT - Overseas Exchange Rate Miscalculated/Not Applied
K	72K	PRICING INCORRECT - Lesser Of Reimbursement Logic Miscalculated/Not Applied
K	73K	PRICING INCORRECT - Outpatient Hospital Claim Incorrectly Processed
K	74K	PRICING INCORRECT - Ambulance Service (Air/Ground) - Reimbursement Rate Miscalculated
K	75K	PRICING INCORRECT - Anesthesia Pricing Miscalculated
K	76K	PRICING INCORRECT - Pharmacy Pricing Methodology (i.e., AWP, U&C, billed discount) Incorrectly Applied and/or Miscalculated
K	77K	PRICING INCORRECT - Pharmacy Compound Drug Pricing Miscalculation
K	78K	PRICING INCORRECT - Pharmacy Specialty Drug Rate Miscalculated
K	79K	PRICING INCORRECT - Pharmacy Discount Miscalculated/Not Applied
K	80K	PRICING INCORRECT - Pharmacy Dispensing Fee Miscalculated/Not Applied
K	99K	OTHER - SEE REMARKS

TED AUDIT (TA) DOCUMENTATION/INCORRECT PROCEDURE ERROR CODES
L	01L	AUDIT DOCUMENTATION INCOMPLETE
L	02L	AUDIT DOCUMENTATION ILLEGIBLE
L	03L	DOCUMENTATION SUBMITTED LATE
L	04L	EOB INCORRECT
L	06L	ERROR IN CLAIM HISTORY
L	10L	ADJUSTMENT - NO AUTHORIZING OFFICIAL
L	11L	CONTRACT JURISDICTION ERROR

TED AUDIT (TA) PROCESS ERROR CODES
P	01P	AUTHORIZATION/PRE-AUTHORIZATION NEEDED (PFTH AND ADJUNCTIVE DENTAL AUTHORIZATIONS)
P	02P	UNSUPPORTED BENEFIT DETERMINATION
P	05P	DEVELOPMENT CLAIM DENIED PREMATURELY
P	06P	DEVELOPMENT REQUIRED
P	10P	MEDICAL EMERGENCY NOT SUBSTANTIATED
P	11P	MEDICAL NECESSITY/REVIEW NOT EVIDENT
P	21P	TIMELY FILING ERROR
P	23P	CONTRACT JURISDICTION ERROR
P	99P	OTHER

MEDICAL RECORD REVIEW DOCUMENTATION ERROR CODES
M	MR1	NO DOCUMENTATION: The provider did not respond to the request for records within the required timeframe.
M	MR2	Insufficient Documentation: There is not enough documentation to support the service. (Specify what documentation is missing.)
M	MR3	PROCEDURE CODING ERROR: The procedure was performed but billed using an incorrect procedure code and the result affected the payment amount.
M	MR4	DIAGNOSIS CODING ERROR: According to the medical record, the diagnosis was incorrect and resulted in a payment error - as in a DRG error (e.g., the diagnosis was not supported by the medical record).
M	MR5	UNBUNDLING: The provider separately billed and was paid for the separate components of a procedure code when only one inclusive procedure code should have been billed and paid.
M	MR6	NUMBER OF UNIT(S) ERROR: The incorrect number of units was billed for a particular procedure/service, National Drug Code (NDC) units, or revenue code. This does not include claims where the provider billed for less than the allowable amount, as provided for in written TRICARE policy.
M	MR7	POLICY VIOLATION: A policy is in place regarding the service or procedure performed (e.g., reimbursement methodology, benefit determination, documentation requirements, etc.) and medical review indicates that the services or procedure is not in agreement with TRICARE policy.
M	MR8	ADMINISTRATIVE/OTHER MEDICAL REVIEW ERROR: A payment error was determined by the medical review but does not fit into one of the other medical review error categories, including program-specific, non-covered services.
M	MTD	MEDICAL TECHNICAL DEFICIENCY: A deficiency was found during medical review that did not result in a payment error.
M	C1	NO ERROR: The claim was reviewed and no errors or deficiencies were found.

4.2 For Active Duty Dental Program (ADDP) contract and TRICARE Pharmacy (TPharm) contract, refer to specific error codes included within the respective contracts.

4.3 TED Record Occurrence Compliance Reviews

4.3.1 The Government will, for contracts that contain a performance requirement for Occurrence Compliance Reviews, conduct quarterly reviews to assess the contractor’s compliance with TEDS record coding requirements as stipulated in TSM, Chapter 2, Section 2.2. Results from this review will be used to assess contractor claims processing performance.

4.3.2 The Government may, for contracts that do not contain a performance requirement for Occurrence Compliance Reviews, request Occurrence Compliance Reviews to assess the contractor’s compliance with TEDS record coding requirements.

TED Audit (TA) OCCURRENCE ERROR CODES
J	01J	UNLIKE PROCEDURES COMBINED (NON-INST)
J	02J	UNLIKE REVENUE CODES COMBINED (INST)
J	03J	SERVICES SHOULD BE COMBINED
J	04J	MISSING NON-INST UTILIZATION DATA SET
J	05J	EXTRA NON-INST UTILIZATION DATA SET
J	06J	MISSING INST REVENUE CODE SET
J	07J	EXTRA INST REVENUE CODE SET
J	08J	INCORRECT RECORD TYPE
J	09J	SEPARATE HCSR’S/TED’S REQUIRED
J	10J	CLAIM NOT PROVIDED FOR AUDIT
J	11J	CLAIM NOT AUDITABLE
J	12J	UNSUPPORTED TED TRANSACTION

5.0 COMPLIANCE REVIEW REBUTTAL PROCEDURES

5.1 The contractor shall submit rebuttals of initial payment error findings to the TCRS contractor within 30 calendar days of the date of the Government’s letter containing the initial audit results. Rebuttal comments not received by the TCRS contractor within 30 calendar days from the date of the Government’s letter will be excluded from further consideration.

5.2 The Government will allow one rebuttal per erred claim. Subsequent rebuttals of a previously addressed error will not be considered.

5.3 The Government may allow an additional rebuttal to claims that are assessed a new payment error after receipt of documentation not originally submitted in the initial audit review. Subsequent rebuttals of a previously addressed error will not be considered.

5.4 The contractor’s rebuttal responses to new payment errors must be received by the TCRS contractor within 30 calendar days of the Government’s letter containing the rebuttal audit results. Rebuttal comments to new payment errors not submitted within 30 calendar days from the date of the Government’s letter will be excluded from further consideration.

5.5 The Government’s error determinations are considered final.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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