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 maintain
the OHI record on DEERS coverage
type 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.
