AllThe
TMEP contractor shall comply with all TRICARE requirements
noted in
Chapter 8 regarding
claims processing
shall apply to the TMEP unless
specifically changed, waived, or superseded by this section (as
indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement
Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.
1.0 General
1.1 The
provisions
of TMEP contractor shall comply with the
requirements in Chapter 8, Section 1 are applicable
to TMEP.
1.2 In general,
TRICARE pays secondary to Medicare and any other coverage.
1.3 SpecialThe
contractor shall use special double coverage procedures
shall
be used for all claims for beneficiaries who are
eligible for Medicare, including active duty dependents who are
age 65 and over as well as those beneficiaries under age 65 who
are eligible for Medicare for any reason. For specific instructions,
refer to the TRM,
Chapter 4, Section 4.
3.0 Claims
Filing Deadline
3.1 The
provisions
of TMEP contractor shall comply with the
requirements in Chapter 8, Section 3 are applicable
to TMEP.
3.2 In addition, the contractor
shall date stamp all claims with an Internal Control Number (ICN).
The contractor shall count the actual date of receipt as day one.
The ICN uniquely identifies each claim, includes the actual date
received in the contractor’s custody, and permits aging and counting
of the claim for workload reporting purposes at specific system
locations at any time during its processing. The contractor shall
provide procedures to ensure the actual date of receipt is entered
into the ICN and all required claims aging and inventory controls
are applied for paperless claims.
4.0 Signature
Requirements
4.1 The
provisions
of TMEP contractor shall comply with the
requirements in Chapter 8, Section 4,
are applicable
to TMEP, except the requirements for financially
underwritten TRICARE claims.
4.2 Electronic
“cross over” claims received from Medicare after Medicare completes
its claims processing do not need a beneficiary or provider signature.
For paper claims, when TRICARE is secondary payer to Medicare and
a Medicare Explanation of Benefits (EOB) is attached, the TMEP contractor
does not need to develop for provider or beneficiary signature.
5.0 TRICARE
Prime and TRICARE Select Referrals/Preauthorization/Authorizations
5.2 TMEP Prime-enrolled
beneficiaries, to the extent practicable, should follow all TRICARE
Prime requirements for Primary Care Manager (PCM) assignment, referrals
and authorizations. The TMEP contractor is not responsible to obtaining
or verifying that a TMEP Prime enrolled beneficiary has a referral
for care not provided by their PCM. The contractor shall
not subject TMEP Prime enrolled beneficiaries are
not subject to Point of Service (POS) cost-sharing.
5.3 TMEP beneficiaries
can contact a regional Managed Care Support Contractor (MCSC) for
assistance in locating a network provider. The MSCS shall provide
the TRICARE/Medicare beneficiary with the name, telephone number,
and address of network providers of the appropriate clinical specialty
located within the beneficiary’s geographic area. The MCSC is not
required to make appointments with network providers.
5.4 The
TMEP contractor
shall issue notification of preauthorization when requested for
primary pay services in accordance with
Chapter 7, Section 2 and
TPM,
Chapter 1, Section 7.1.
Notification
may be made The contractor may make notification in
writing by letter, or on a form developed by the contractor. These
forms and letters are all referred to as TRICARE authorization forms.
6.0 Claim
Development
6.2 TMEP claims
which TRICARE processes after Medicare, do not need to be developed
to the individual provider level for home health or group practice
claims.
6.3 Civilian claims for TMEP beneficiaries
shall be processed by Medicare first without consideration of the Supplemental
Health Care Program (SHCP).
6.4 The TMEP
contractor shall not process a claims from any civilian provider
in a Market/Military Medical Treatment Facility (MTF) under the
Resource Sharing or Clinical Support Agreements (CSA) programs.
7.0 Application
of Deductible and Cost-Sharing
7.1 The
provisions
of TMEP contractor shall comply with the
requirements in Chapter 8, Section 7 are applicable
to TMEP.
7.2 The TMEP contractor
shall apply TRICARE cost-shares and deductible are applied
when TRICARE is the primary payer on TMEP beneficiary claims.
The
contractor shall base TMEP beneficiary cost-shares on the following when
TRICARE is the primary payer:7.2.1 TMEP beneficiary
cost-shares shall be based on the following when TRICARE is the
primary payer. If the services were received by a
TRICARE Prime enrollee (as indicated in Defense Enrollment Eligibility
Reporting System (DEERS)), the TMEP contractor shall calculate the
Prime copayments applicable on the date services were received.
7.2.2 For a beneficiary who is not
a Prime enroll, if a provider is known to be a network provider
(e.g., Veterans Health Administration (VHA) medical facility) the
TRICARE Extra cost-shares shall be applied to services received
prior to January 1, 2018; if the provider is not a known network
provider, the TRICARE Standard cost-share shall be applied.
7.2.3 For a beneficiary who is a TRICARE
Select enrollee, services received from a known network provider
on or after January 1, 2018, will have the
contractor shall apply the TRICARE Select network copayments applied;
if the provider is not a known network provider, the
contractor shall apply the TRICARE Select out-of-network
cost-share shall be applied.
7.2.4 For a TRICARE For Life (TFL)
beneficiary who is not a TRICARE Prime enrollee,
the
contractor shall apply standard copays for services
received on or after January 1, 2018,
shall have the
TRICARE Standard copayment (see TRM,
Chapter 2, Section 1)
applied as
if TRICARE Standard were still being implemented.
7.3 OnlyThe
contractor shall count only the actual beneficiary out-of-pocket
liability remaining after TRICARE payments will be
counted for purposes of the annual catastrophic loss
protection.
8.0 EOB
8.1 The
provisions
of TMEP contractor shall comply with the
requirements in Chapter 8, Section 8 are applicable
to TMEP.
8.2 The
provisions
of requirements in Chapter 8, Section 8, paragraph 1.0 paragraphs
1.0 through 1.2 is are superseded
by the following: The contractor shall issue and mail an appropriate
and easily understood EOB to the beneficiary (parent/guardian for
minors or incompetents) that appropriately describes the action
taken for each clam processed to a final determination. The
EOB contractor shall
be mail
ed
in a hardcopy
EOB,
unless the beneficiary has provided written agreement to receive
the EOB electronically. The contractor may elect to provide a monthly
summary EOB in lieu of an EOB for each individual claim processed
by the contractor. The
mailed EOB contractor shall
include instructions regarding how to read
your the EOB
in
the mailed EOB.
8.3 The
provisions
of TMEP contractor shall comply with the
requirements in Chapter 8, Section 8, paragraphs 8.09.0 and
9.010.0 are applicable
to TMEP with the exception of the specific location
(front or back) of the required information. The
contractor
shall provide the information required on the EOB
shall
be provided in a clear easily understood layout.