The purpose of the TRICARE
claims processing procedures is to help ensure that all claims for
care received by TRICARE beneficiaries are processed in a timely
and consistent manner and that Government-furnished funds are expended
only for those services or supplies authorized by law and Regulation.
The contractor shall review all claims submitted and accept Health
Insurance Portability and Accountability Act (HIPAA) transaction
and code sets. The review must ensure that sufficient information
is submitted to determine:
• The patient is eligible.
• The provider of services or
supplies is authorized under the TRICARE Program.
• The service or supply provided
is a benefit.
• The service or supply provided
is medically necessary and appropriate or is an approved TRICARE preventive
care service.
• The beneficiary is legally
obligated to pay for the service or supply.
• Double coverage or Other
Health Insurance (OHI). See the TRICARE Reimbursement Manual (TRM), Chapter 4, Section 2.
• That the claim contains sufficient
information to determine the allowable amount for each service or
supply.