TRICARE Manuals - Display Chap 8 Sect 1 (Change 16, Sep 20, 2024)

Claims Processing Procedures

Chapter 8

Section 1

General

Revision: C-16, September 20, 2024

1.0 PURPOSE

1.1 The contractor shall ensure that all claims for care received by TRICARE beneficiaries are processed in accordance with TRICARE processing standards (Chapter 1, Section 3) and that Government-furnished funds are expended only for those services or supplies authorized by law and Regulation. All claims must be supported by the following, but are not limited to:

• 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.

• That the claim contains sufficient information to determine the allowable amount for each service or supply.

• Double coverage or Other Health Insurance (OHI). See the TRICARE Reimbursement Manual (TRM), Chapter 4, Section 2.

1.2 Claims Processing System Certifications

1.2.1 The contractor shall maintain the most current International Standards Organization (ISO) 9001 certification during the entire duration of the contract period.

1.2.2 The contractor shall maintain, at minimum, Capability Maturity Model Integration (CMMI) Level 4 during the entire duration of the contract.

2.0 WHO MAY FILE A CLAIM

2.1 Beneficiary/Provider

2.1.1 Any TRICARE eligible beneficiary may file a claim.

2.1.2 Any institutional or individual professional provider certified under TRICARE may file a claim on a participating basis for services or supplies provided to a beneficiary and receive payment directly from TRICARE.

2.1.3 The contractor shall deny any charge imposed by the provider relating to completing and submitting the applicable claim form (or any other related information). Such charges shall not be billed separately to the beneficiary by the provider nor shall the beneficiary pay the provider for such charges. These charges are to be reported as non-covered charges and denied as such.

2.2 State Agency

A state agency who administers the Medicaid Program may submit a claim, if there has been an agreement signed between the agency and Defense Health Agency (DHA). (Refer to the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 20.)

2.3 Participating Provider - Agency Agreement With A Third Party

2.3.1 Occasionally, a participating provider may enter into an agency agreement with a third party to act on its behalf in the submission and the monitoring of third party claims, including TRICARE claims.

2.3.1.1 Such arrangements are permissible as long as the third party is not acting simply as a collection agency.

2.3.1.2 There must be an agency relationship established in which the agent is reimbursed for the submission and monitoring of claims, but the claim remains that of the provider and the proceeds of any third party payments, including TRICARE payments, are paid to the provider.

2.3.1.3 The contractor may interact with these agents in much the same manner as it interacts with the provider’s accounts receivable department. However, such an entity is not the provider of care and cannot act on behalf of the provider in the filing of an appeal unless specifically designated as the appealing party’s representative in the individual case under appeal.

2.3.1.4 Questions relating to the qualifications of any such business entity should be referred to the DHA Office of General Counsel (OGC), through the Contracting Officer (CO), for resolution.

2.3.2 On a monthly basis, DHA’s Program Integrity Office (PI) provides each contractor with an updated data file of excluded third party billing agents. This list is available online through Department of Health and Human Services (DHHS)/Office of Inspector General (OIG) at https://oig.hhs.gov/exclusions/index.asp.

2.3.2.1 The contractor shall not accept any claims from excluded third party billing agents based on the DHA PI file.

2.3.2.2 The contractor shall return any claim received from an excluded third party billing agent to the provider, instructing the provider that the submission of a valid claim cannot be done through a sanctioned entity, and to resubmit the claim directly, or through an approved third party billing agent.

2.3.2.3 The contractor shall inform the provider that the third party billing agent has been excluded by Health and Human Services (HHS)/Centers for Medicare and Medicaid Services (CMS) and that no claims will be accepted from the third party billing agent until it has been reinstated.

2.3.2.4 The contractor shall also provide notification to the third party billing agent that no claims will be accepted from it until it has been reinstated by HHS/CMS.

3.0 TRICARE CLAIM FORMS

3.1 Acceptable Claim Forms

3.1.1 A properly completed acceptable claim form must be submitted to the contractor before payment may be considered.

3.1.1.1 The contractor shall, for paper claims, accept the latest mandated version of the following claim forms for TRICARE benefits: the DoD Document (DD) Form 2642, the CMS 1500 Claim Form, and the CMS 1450 UB-04. The American Dental Association (ADA) claim forms may be used in the processing and payment of adjunctive dental claims.

3.1.1.2 The contractor shall accept electronic claims in Health Insurance Portability and Accountability Act (HIPAA)-compliant standardized electronic transactions (see Chapter 19).

3.1.2 The DD Form 2642, “Patient’s Request For Medical Payment” (http://www.dtic.mil/whs/directives/forms/eforms/dd2642.pdf) is for beneficiary use only and is for submitting a claim requesting payment for services or supplies provided by civilian sources of medical care to include physicians, medical suppliers, medical equipment suppliers, ambulance companies, laboratories, Extended Care Health Option (ECHO) providers, or other authorized providers.

3.1.2.1 See https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf for a definition of “medical.”

3.1.2.2 The contractor shall, if a DD Form 2642 is identified as being submitted by a provider for payment of services, return the claim form to the provider with an explanation that the DD Form 2642 is for beneficiary use only and that the claim must be resubmitted using either the CMS 1500 Claim Form or the CMS 1450 UB-04, whichever is appropriate.

3.1.2.3 The form may be used for services provided in a foreign country but only when submitted by the beneficiary.

3.2 Electronic Claim Forms

When submitting an electronic claim for reimbursement, the provider, supplier, pharmacy, or their representative is attesting to:

3.2.1 The same requirements as listed on the back of claim form CMS 1500 Claim Form and UB-04/UB92 (CMS 1450).

3.2.2 The claims are accurate and complete.

3.2.3 Has complied with TRICARE program requirements, contractual and licensure requirements, laws, and regulations of various state and federal agencies, and conditions that would allow the provider to participate in and receive reimbursement under the TRICARE program for which the claim is made.

4.0 CLAIMS RECEIPT AND CONTROL

4.1 The contractor shall ensure that all claims are controlled and retrievable.

4.2 The contractor shall stamp the face of each hardcopy TRICARE claim with an individual Internal Control Number (ICN), and enter into its automated system within five business days of actual receipt.

4.2.1 For both hardcopy and Electronic Media Claim (EMC), the ICN shall contain the Julian date indicating the actual date of receipt.

4.2.2 The Julian date of receipt shall remain the same even if additional ICNs are required to process the claim.

4.2.3 If a claim is returned, the date of the receipt of the resubmission shall be entered as the new date of receipt.

4.2.4 The contractor shall ensure that all claims not processed to completion with supporting documentation be retrievable by beneficiary name, sponsor’s Social Security Number (SSN), Defense Enrollment Eligibility Reporting System (DEERS) family ID, or ICN within 15 calendar days following receipt.

5.0 NEWBORN CLAIMS - BEFORE JANUARY 1, 2018

5.1 The contractor shall process claims for newborns without eligibility on DEERS as long as:

• The newborn date of birth is within 365 calendar days of the contractor’s eligibility query; and

• The sponsor was eligible for TRICARE for the dates of care on the newborn claim.

5.2 A newborn or adoptee will be deemed to be enrolled in TRICARE Prime as of the date of birth or adoption if one family member is already enrolled in TRICARE Prime.

5.2.1 A responsible representative has 60 calendar days to officially enroll the child to the TRICARE Prime option.

5.2.2 If the newborn or adoptee is formally enrolled in TRICARE Prime within the 60 calendar day period, the effective date of enrollment will be the first of the month following the date of birth or adoption. (The 20th of the month enrollment rule is waived, if necessary.)

5.2.3 If the newborn or adoptee is not formally enrolled during the 60 calendar day period, the newborn or adoptee will revert to a non-enrolled beneficiary effective the 61st day.

5.2.4 If the decision is made to continue TRICARE Prime coverage, an official enrollment request (enrollment form, the Government furnished web-based self-service enrollment system/application transaction, or telephonic request) must be completed on behalf of the child.

5.2.5 For retirees or their family members or survivors who decide to continue enrollment for the child, the unused portion (prorated on a monthly basis) of the single enrollment fee they paid will be applied toward a new family enrollment period. For newborns and newly adopted children enrolled under this provision, Point of Service (POS) cost-sharing does not apply through the 60th day or the effective date of enrollment, whichever is earlier.

5.2.6 The contractor shall process all services with the TRICARE Prime copayment even in the absence of referrals or authorizations.

5.2.7 The Government Designated Authority (GDA) may extend the deemed period up to 120 calendar days, on a case-by-case or geographic area of responsibility basis.

5.2.7.1 Newborns/adoptees in overseas locations are deemed to be enrolled for 120 calendar days following birth/adoption when one other family member, to include the sponsor, is enrolled in TRICARE Overseas Program (TOP) Prime or TOP Prime Remote.

5.2.7.2 For additional information on newborns under the TRICARE Reserve Select (TRS) program, see Chapter 22, Section 1, and for TRICARE Retired Reserve (TRR), see Chapter 22, Section 2.

6.0 NEWBORN CLAIMS - ON OR AFTER JANUARY 1, 2018

See the TRICARE Policy Manual (TPM), Chapter 10, Section 3.1.

7.0 CLAIMS PROCESSING EXEMPTION DURING 2018 CALENDAR YEAR ENROLLMENT PERIOD - EFFECTIVE JANUARY 1, 2018

7.1 Policy

7.1.1 During the Calendar Year (CY) 2018 enrollment grace period, an individual who is eligible to enroll in TRICARE Prime or TRICARE Select but does not elect to enroll in such programs will only be eligible for space-available care at Markets/Military Medical Treatment Facilities (MTFs).

7.1.2 If claims are received for these individuals that would otherwise be cost-shared under the TRICARE Program, the claims will be cost shared by TRICARE for that initial Episode Of Care (EOC) only. This exemption to existing TRICARE claims processing rules expires on December 31, 2018.

7.2 The Managed Care Support Contractor (MCSC), TOP contractor, and TRICARE Medicare Eligible Program (TMEP) contractor shall:

7.2.1 Use the DEERS eligibility response to determine which purchased care claim(s) apply to beneficiaries who are eligible for but have not enrolled in TRICARE Prime or TRICARE Select.

7.2.2 Validate Health Care Delivery Program Code (HCDP) of beneficiary for Direct Care (DC) of 002, 004, 006, 008, 014, 016, or 30; and one of the following:

7.2.2.1 If Other Government Program (OGP) type code A or B are both present; route to the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) or overseas contractor (as applicable) for processing, or

7.2.2.2 If the OGP type code does not indicate any form of Medicare coverage and the Member Relationship Code is one of the following, process the claim as TRICARE Select:

• A = Self,

• B = Spouse,

• C = Child/Stepchild,

• E = Ward,

• G = Surviving Spouse,

• H / I / J / K = Former Spouse, or

• O = Newborn

7.2.2.3 Otherwise, deny the claim and respond with an explanation of benefits.

7.2.3 The contractor shall determine the claims that are applicable to the EOC.

7.2.4 Process those claims at the TRICARE Select network or out-of-network rate, as applicable.

7.2.5 Notify the individual in writing within 10 business days with an explanation of benefits or similar correspondence, and include the following.

7.2.5.1 Only claims related to this initial episode of purchased care services (as defined by the contractor, including a date range) will be cost-shared by TRICARE. The date range must be specified in the written notification.

7.2.5.2 Future claims not related to the determined EOC will be denied.

7.2.5.3 If TRICARE Prime or TRICARE Select coverage is desired, he or she may enroll in such coverage at any time during CY 2018, and provide instructions on how to enroll, and

7.2.5.4 After December 31, 2018, he or she may only enroll in TRICARE Prime or TRICARE Select during an annual open enrollment period or if a member of the family experiences a Qualifying Life Event (QLE).

7.3 The pharmacy contractor shall:

7.3.1 Upon receipt of a TRICARE pharmacy claim for retroactive reimbursement that includes a copy of the written notification from a contractor listed above as required by paragraph 7.2.5, process the claim at the network or out-of-network rate, as applicable, for the time frames as listed in the written notification.

7.3.2 Refills are limited to the time frame specified in the notification letter.

7.3.3 Notify the individual in writing within 10 business days, and include the following:

7.3.3.1 Only pharmacy claims related to this initial episode of purchased care services will be cost-shared by TRICARE.

7.3.3.2 Future claims or refills not related to the determined EOC will be denied until the individual is enrolled in TRICARE coverage.

- END -

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

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.