1.0 SCOPE AND PURPOSE
This section specifies which
individuals and entities may, or in some cases will, be excluded
from the TRICARE Program. It outlines the authority given to the
Department of Health and Human Services/Office of Inspector General
(DHHS/OIG) to impose exclusions from all Federal health care programs,
including the TRICARE Program.
1.1 The Uniform
Services Family Health Plan (USFHP) is exempt from this requirement.
1.2 The Accountable
Care Organization (ACO) is partially exempt as follows:
1.2.1 All claims
where care is provided and paid by the ACO are exempt from this
requirement. These claims are reported to DHA using the Batch TRICARE
Encounter Data (TED) Record(s) process.
1.2.2 All claims
where the costs are shared by the ACO and Government or are paid
entirely by the Government are subject to the requirements specified
in this section. These claims are reported to DHA using the Voucher
TED Record(s) process. All transactions related to these claims,
to include reimbursement by the ACO, shall be held in temporary
suspense, in accordance with the provisions outlined in this section.
1.3 Future
Health Care Programs Funded Under A Capitation Agreement
All health care claims where the
health care services provided are 100% covered under a capitation
(
https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf)
agreement are exempt from this requirement. All health care claims
not 100% covered under a capitation agreement (to include shared
costs) are subject to the temporary suspension requirements outlined
in this section.
2.0 DHA AUTHORITY FOR TEMPORARY SUSPENSION
OF CLAIM(S) PAYMENTS
2.2 The Director,
DHA or designee temporarily suspends claim(s) payments without notifying
the provider, pharmacy, entity, or client beneficiary to protect
the public fisc. The Government will advise the provider, pharmacy,
entity within 30 days of claims payment suspension that a temporary
suspension has been ordered with a statement of the basis of the
decision to suspend payment.
2.3 The contractor
shall send the temporary suspension of payment notification (
Addendum A, Figure 13.A-6 or
Figure 13.A-7 as
appropriate) to the provider, pharmacy, entity or client beneficiary
in lieu of sending an Explanation of Benefits (EOB) or other claims
settlement notifications of a claim(s) payment suspension.
2.3.1 The contractor
shall not send out claim(s) payment temporary suspension notifications
above normal claim(s) settlement notifications.
2.3.2 The contractor
shall not send out any document (EOB, etc.) to the client beneficiary
stating the amount owed by the client beneficiary to the temporarily
suspended provider during the suspension period.
2.4 The claims
payment suspension is for a temporary period pending the completion
of investigation, to include an ensuing any legal or administrative
proceedings, unless sooner determined by the Director, DHA or designee.
See
32 CFR 199.9(h) for additional guidance.
Note: Both the Government and the contractor
are sending out temporary suspension notifications. The contractor
shall send out the standard temporary suspension notification (
Addendum A, Figure 13.A-6 and
Figure 13.A-7 as
appropriate) in lieu of sending and EOB. The letters notify the
provider or client beneficiary the claims was received but not paid
at Government direction. The Government will send out the letter
advising the provider why payments were suspended and how to proceed
to remove the claim(s) from suspension.
2.5 Contractor
Responsibilities
2.5.1 Upon notification from DHA to temporarily
suspend claim(s) payments to specific providers, pharmacies, entities,
or client beneficiaries, the contractor shall take the following
six actions:
2.5.1.1 Cancel all pending non-underwritten
and underwritten payments where funds have not been mailed or electronically
transmitted, and the contractor can stop the release of funds in
accordance with
paragraph 2.5.2.
2.5.1.2 Follow Government direction in
regard to underwritten debt. If instructed to convert debt from underwritten
to non-underwritten, then submit and invoice in accordance with
paragraph 2.5.3.
This paragraph does not apply to the TRICARE Overseas Program (TOP),
TRICARE Pharmacy (TPHARM) and TRICARE Medicare Eligible Program
(TMEP) contracts.
2.5.1.3 Cease all current collection of
non-underwritten debt related to the temporary suspended provider, pharmacy,
entity, or client beneficiary, in accordance with
paragraph 2.5.4.
2.5.1.4 Temporarily suspend the processing
of updates to all non-underwritten and underwritten claims received
and paid prior to receiving the notice of suspension in accordance
with
paragraph 2.5.5.
2.5.1.5 Process all new non-underwritten
and underwritten claims received after the notification of temporary
suspension in accordance with
paragraph 2.5.6.
2.5.1.6 Forward all funds received after
the notice of temporary suspension from or on behalf of the suspended
providers, pharmacies, or entities to DHA, Contract Resource Management
(CRM) in accordance with
paragraph 2.5.7.
2.5.2 Attempt To Withhold Release of
Payments Where Funds Have Not Been Mailed Or Electronically Transmitted
At The Time Of Temporary Suspension Notice
Where reasonably possible, the
contract shall try to prevent the release of Government payments
to the suspended provider when notified of the provider’s suspension.
This requirement does not apply to all payments pending release.
The Government understands there is a stage in the disbursement
process where, though the payments have not been mailed or transmitted,
they have progressed to a point where they cannot be stopped without significant
effort and cost.
2.5.2.1 The contractor shall determine
the point, if any, where the release of payment for claims received prior
to receiving the notice of temporary suspension can be stopped.
2.5.2.2 The contractor shall, for all payments
intercepted prior to release and reported as paid to DHA on a TED
Record(s), update (usually Cancel) previously reported TED Record(s)
(contractor report of payment) to show no payment occurred.
2.5.2.3 The contractor shall not cancel
or issue a stop payment order on any Electronic Funds Transfer (EFTs) or
checks where the wire transfer has already been sent, where the
check has been mailed, or where the payment was not intercepted.
2.5.2.4 The contractor shall, for any payment
that is returned, or becomes stale-dated, or is on the refund file (in
the process of being crediting back), process claims in accordance
with
paragraph 2.6.
2.5.2.5 The contractor shall process all
collections received prior to the notice of suspension from or on behalf
of any temporarily suspended provider, pharmacy, or entity in accordance
with
paragraph 2.6.
2.5.2.6 Pharmacy contractor only. The contractor
shall process all pending reversals up to the date of temporary
suspension notification. All reversals received on or after receipt
of the notice of suspension shall be held by the contractor unless
notified by DHA, Program Integrity (PI) to process the reversals.
2.5.3 Procedure For Converting Underwritten
Debt To Non-Underwritten Debt (Excludes TOP, TPharm, and TMEP Contracts)
At the Government’s discretion,
the Government will require the contractor to convert its underwritten
debt to non-underwritten debt. The conversion of debt (underwritten
to non-underwritten) shall not involve the temporarily suspended
provider(s), pharmacy(s), or entity(s); the debt conversion is an
administrative transaction between the contractor and the Government.
If required to convert debt from underwritten to non-underwritten the
contractor shall:
2.5.3.1 Submit an invoice billing the Government
for the debt owed to the contractor by the temporarily suspended
provider, pharmacy, or entity. The supporting document shall include
the amount owed by TED Record(s) Indicator (TRICARE Systems Manual
(TSM),
Chapter 2, Section 2.9).
2.5.3.2 The Government will issue payment
to the contractor and record an Accounts Receivable (A/R) entry into
the accounting system under the temporarily suspended provider,
pharmacy, or entity name. The Government will
not attempt collection during the suspension period.
2.5.3.3 At the Government’s discretion,
debt converted to underwritten to non-underwritten will be returned
to the contractor as non-underwritten debt in accordance with
paragraph 2.9.5.
2.5.4 Procedure For Existing Debt At
The Time Of Temporary Suspension
During the temporary suspension
period and while the TED Record(s) Debt is in a ‘do-not process’
status the contractor shall:
2.5.4.1 Upon receipt of notification of
temporary suspension, cease all non-underwritten debt collection efforts.
2.5.4.2 Not bill for Other Health Insurance
(OHI), transfer debt to DHA or conduct any additional claims processing.
2.5.4.3 Not update any TED Record(s). Any
DHA-directed action to collect debt or correct any claims processing
errors, to include: Duplicate Claims System (DCS), OHI, Ineligibles,
or beneficiary copay adjustments, Tax Levy, Payment offset, etc.,
(this is not an all-inclusive list) will be approved by DHA, PI
prior to taking any action.
2.5.4.4 Forward all funds collected after
receipt of the notice of temporary suspension from or on behalf
of the suspended provider, pharmacy, or entity in accordance with
paragraph 2.5.7.
2.5.4.5 Comply with all applicable reporting
requirements related to A/R by separately reporting Temporarily Suspended
Fiscal Intermediary (FI) Receivable debt for each suspended provider,
pharmacy, or entity by the following two categories:
• FI Receivable debt by temporarily
suspended providers in a ‘do-not process’ (do-not-pursue collection)
status.
• FI Receivable debt related to temporarily
suspended providers in a ‘process’ (actively pursuing collection) status
(see
paragraph 2.7).
Continue to age and include temporarily
suspended debt on the monthly FI Receivable report.
Note: Temporarily Suspended FI Receivable
debt shall only relate to TED Record(s) data submitted on Vouchers. The
TED Record(s) data submitted on Batches was not paid and therefore
there is no associated debt. Details for reporting suspended A/R
for temporarily suspended providers are identified in DD Form 1423,
Contract Data Requirements List (CDRL), located in Section J of
the applicable contract.
2.5.4.6 Regional contractors only: If underwritten
debt existed prior to the notice of temporary suspension and the
Government did not convert the debt to non-underwritten in accordance
with
paragraph 2.5.3, the contractor may continue
to pursue its underwritten debt collection efforts against the suspended
provider, pharmacy, entity, or client beneficiary. All unsolicited/voluntary
refunds (underwritten and non-underwritten) shall be processed in
accordance with
paragraph 2.5.7.
2.5.4.7 Claims
Processing and Payment Exceptions for
paragraph 2.5.4Contractor shall not bill for OHI,
transfer debt to DHA or conduct any additional claims processing
unless:
2.5.4.7.1 Authorized by DHA, PI:
2.5.5 Procedure For Processing Updates
To Claims Received Prior To Temporary Suspension Notice
2.5.5.1 All proceeds received prior to
the temporary suspension notice are applied to the suspended provider’s
TED Record(s) Debt in accordance with
paragraph 2.6.
2.5.5.2 All proceeds received after the
notice of temporary suspension are forwarded by EFT, check, or special
endorsement to DHA, CRM in accordance with
paragraph 2.5.7.
2.5.5.3 All updates (positive or negative),
received after the notice of temporary suspension, to previously paid
claims (claims received and paid prior to the notice of suspension)
are held in suspense by the contractor. No TED Record(s) updates
(Batch or Voucher) are done.
Note: TED Record updates received prior
to the notice of temporary suspension pending submission to DHA shall
be processed to completion and sent to DHA after receiving the notice
of suspension. The contractor shall stop updates resulting in payments
if possible.
2.5.6 Procedure
For Processing New Claims Received After Temporary Suspension Notice
The contractor shall process all
new claim submissions received after notice of temporary suspension
of a provider, pharmacy, entity, or client beneficiary as an initial
Batch TED Record then immediately place TED Record(s) in a ‘do-not
process’ status suspending the claim from further processing. The
contractor shall not make payments to the provider, pharmacy, entity,
or client beneficiary nor apply calculated payment amounts to the
provider’s, pharmacy’s, or entity’s TED Record(s) debt for any claim
processed as a Batch. To submit claims using the Batch process the
contractor shall:
2.5.6.1 Cite Header Type Indicator 0 (Batch
Header no claim rate) OR 9 (Batch Header claim rate
eligible) as appropriate (TSM Date Element 0-001);
2.5.6.2 Cite Contract Line Item Number/
Automated Standard Application for Payment (CLIN/ASAP) Account Number 00000000 (TSM
Data Element 0-025);
2.5.6.3 Cite Adjustment Key 0 (TSM
Data Element 1-035- or 2-035); and
2.5.6.4 Cite Override Code
NP -
Payment to provider, pharmacy, entity, or client beneficiary temporarily suspended
at the direction of DHA, PI (TSM Data Elements 1-160 and 2-095).
2.5.6.4.1 Override Code NP is
only used for new claims received after the notice of temporary,
processed as a Batch (informational TED Record(s)), and payment
is being held in accordance with the notice of suspension.
2.5.6.4.2 Updates to claims paid prior
to receiving the notice of temporary suspension are held in suspense (i.e.,
no TED Record(s) updates) in accordance with
paragraph 2.5.5. Shall not
cite Override Code =
NP when submitting Vouchers.
2.5.7 Procedure For Processing Debt Payments
And Unsolicited/Voluntary Refunds Received Temporary After Suspension
Notice
All funds
received from or on behalf of the temporarily suspended provider(s),
pharmacy(s), entity(s) for claims subject to the suspension are
forwarded (by EFT, check or special endorsement) to DHA, CRM and
are not applied as payment to the suspended provider’s, pharmacy’s,
or entity’s TED Record(s) Debt. All unsolicited/voluntary refunds
(underwritten and non-underwritten) are forwarded to DHA, CRM. The
funds are placed into a ‘Deposit Fund’ in accordance with the Department
of Defense (DoD) Financial Management Regulation (DoD 7000.14-R, Volume
12, Chapter 1, Paragraph 0108 & 010803) “Monies held by the
U.S. Government awaiting distribution on the basis of a legal determination
or investigation.” For all funds received after the notice of suspension
from or on behalf of the suspended provider, pharmacy, or entity,
the contractor shall:
2.5.7.1 Forward checks payable to the contractor
to DHA, CRM with the following Special Endorsement: “Pay to the
order of US Treasury, ALC 97000012”. The contractor shall endorse
the checks. If the remittance is deposited by the contractor, the
contractor shall remit the funds to DHA, CRM by check or EFT payable
to the US Treasury, ALC 97000012. Funds collected in accordance
with
paragraph 2.6 are accepted.
2.5.7.2 Not deposit proceeds received after
the notice of temporary suspension in its non-underwritten bank account.
2.5.7.3 Not create TED Record(s) updates
for any funds transferred to DHA, CRM to be placed in a ‘Deposit Fund’
on behalf of the temporarily suspended provider, pharmacy, or entity
pending the outcome of the suspension investigation.
2.5.7.4 Advise the payer using special
notification the funds received have been placed in a Government owned
‘Deposit Fund’ (
Addendum A, Figure 13.A-9).
2.6 TED Record(s) Processing Exceptions
Processing For Claims
The following
TED Record(s) updates shall not require approval from DHA, PI and
TED Record(s) updates are processed in accordance with the TSM.
2.6.1 The contractor
shall supply all collections received prior to the notice of temporary
suspension to the provider’s, pharmacy’s, or entity’s TED Record(s)
debt with corresponding TED Record(s) updates.
2.6.2 The contractor
shall, for any payment that is returned, becomes stale-dated, intercepted
in accordance with
paragraph 2.5.2, or is on a refund file (in
the process of crediting back) process claims as follows:
2.6.2.1 NOT reissue payment (even if a
request is received from the payee).
2.6.2.2 Submit the corresponding credit
TED Record(s) reporting non-payment of claim in accordance with
Chapter 3, Section 4.
2.6.2.3 Deposit the returned funds in the
CLIN/ASAP Account originally used to make payment (if applicable).
If the CLIN/ASAP Account originally used for payment is closed the
contractor shall deposit funds into the current Fiscal Year (FY)
CLIN/ASAP Account assigned for the same purpose.
2.6.2.4 Process TED Record(s) adjustments
(Vouchers) to temporarily suspended providers as necessary to ensure
the reported TED Record(s) payments (Amount Paid Government Contractor,
TSM,
Chapter 2, Section 2.4, Record Locator 1-140
or 2-205 equal actual amounts executed under the contract (payments
excluding offsets). If the contractor is not sure a TED Record(s)
update is needed or authorized for non-underwritten bank reconciliation or
underwritten cost reimbursement purposes during the suspension period,
contact DHA, CRM for reconciliation.
2.6.2.5 Process all TED Record(s) updates
as required under Section H.10. ANNUAL UNDERWRITTEN UNALLOWABLE
HEALTHCARE COST COMPLIANCE REVIEW Cost of Care audit requirements.
This requirement applies to TED Record(s) data submitted under a
Voucher header. TED Record(s) data submitted under a Batch header
is excluded from audit as the Batch TED Records are informational
records and no expenditure of Government funds occurred based upon
the TED Record(s) (TSM,
Chapter 2, Section 2.3).
2.7 Procedure For Partial Release Of
Payments During Temporary Suspension
During the temporary suspension
period (pending the completion of investigation, to include any
ensuing legal or administrative proceedings) the Government will,
at its discretion, instruct the contractor to move suspended provider,
pharmacy, entity, and client beneficiary TED Record(s) from a ‘do-not
process’ status to a ‘process’ status while retaining the suspension
on all remaining and future claims received. The Government will
removed claims from a ‘do-not-process’ status to ‘process’ status
based upon date of receipt are embedded in the Internal Control Number
(ICN) (TSM,
Chapter 13, Section 5). Claims will be released
using a date range on an oldest to newest basis. This action will
release some or all TED Record(s) process to-date under suspense
for a specific provider, pharmacy, entity or client beneficiary;
however it does not change the providers’, pharmacies’, or entities’
suspension status. The suspension remains in effect for all claims
not covered by the ‘process’ release and for all new claims received.
2.7.1 For all temporarily
suspended provider claims set to a ‘process’ status the contractor
shall:
2.7.1.1 Process the claims-to-date as a
Voucher citing Special Processing Code (SPC) NQ - ‘PI
Temporarily Suspended Provider, Pharmacy, Entity, or Client Beneficiary
claim in ‘PROCESS STATUS.’ Claim updates shall include but are not
limited to: DCS, OHI, Ineligibles, beneficiary copay adjustments,
Cost of Care audit findings, Tax Levy, Payment offset, etc., occurring
after the suspension date. All TED Records set to a ‘process’ status
while the provider, pharmacy, entity, remains suspended are submitted
as non-underwritten vouchers cite SPC NQ and remain
non-underwritten for the life of the claim. SPC NQ is
listed for all claims submitted and adjusted as a Voucher and paid
as non-underwritten during the temporary suspension release(s).
SPC NQ allows DHA to identify all claims actually paid
and collected during the temporary suspension waiver.
2.7.1.2 Cancel corresponding Batch TED
Record(s) citing Override Code NP - ‘Payment to the
Provider, Pharmacy, Client Beneficiary or Entity Temporarily Suspended
at the Direction of DHA PI. Do not cite Override Code = NP when
submitting Vouchers.
Note: All TED Records set to a ‘process’
are submitted to DHA as non-underwritten Vouchers for the life of
the claim.
2.7.2 For all debt associated with TED
Records in a ‘process’ status, the contractor shall follow the recoupment
process as described in
Chapter 10, Section 4.
All funds recovered for TED Records set to a ‘process’ status are
applied to the provider’s, pharmacy’s, entity’s TED Record(s) debit
and are deposited by the contractor into the CLIN/ASAP Account originally
used for payment. If the CLIN/ASAP Account originally used for payment
is closed the contractor shall deposit the funds into the current
FY CLIN/ASAP Account assigned for the same purpose. The date Government
notification was received to set the TED Record(s) to ‘process’
and fund under the ‘process’ order (if any) held by DHA/CRM in a
‘Deposit Fund’ were returned to the contractor is the start date
to initiate debt collection activities. The date of demand in accordance
with 45 CFR 30.11 is used as the new debt aging date and is the
new aged-based date for potential transfer to DHA if the claim(s)
return uncollectable.
2.7.3 All amounts owed to the provider,
pharmacy, or entity for TED Records set to a ‘process’ status are
first applied to the provider’s, pharmacy’s, or entity’s active
debt (debt related to TED Records set to a ‘process’ status) and
any remaining amounts owed are paid to the provider, pharmacy, entity
or client beneficiary.
2.7.4 The contractor shall deposit any
funds applied to the provider’s, pharmacy’s, or entity’s debt into
its current FY non-underwritten bank account and submit a TED Record
‘cancellation’ showing the reduction in amount paid to the provider,
pharmacy, or entity. If the contractor is unable to submit a TED
Record Cancellation or Adjustment, the contractor shall report the
deposit(s) on the monthly Bank Reconciliation Report in accordance with
paragraph 2.9.5.5.
2.8 Procedure For Full Release Of Temporary
Suspension
Upon notification
of DHA PI that the provider, pharmacy, or entity is no longer under
suspension the contractor shall:
2.8.1 For all claims
received after notification by DHA PI the temporary suspension has
ended, receive specific guidance from DHA as to how to proceed.
2.8.2 If instructed
by DHA, PI to process temporarily suspended TED Record(s) data,
coordinate with DHA, CRM regarding the disposition of all pending
adjustments and cancellations to TED Record(s) paid prior to the notice
of suspension (in accordance with
paragraph 2.5.5) that remain
in a “do-not process’ status at the time of suspension release.
This coordination ensures the TED Record-based transactions submitted
by the contractor are recorded and paid correctly by the DHA financial
systems.
2.8.3 Receive specific instruction from
DHA, CRM regarding the disposition of all funds held in ‘Deposit
Fund’.
2.8.4 The contractor shall reset the
debt aging date to the date of temporary suspension release when directed
by DHA. The date Government notification was received to release
suspension of claims and the date funds (if any) held by DHA, CRM
in a ‘Deposit Fund’ were returned to the contractor is used as the
start date to initiated debt collection activities. The date of
demand in accordance with 42 CFR § 30.11 is used as the new debt aging
date.
2.9 Other Instructions To The Contractor
2.9.1 On contracts
where the TED Record(s)-based administrative (also known as claim
rate) payments are authorized, the contractor is authorized one
administrative payment for each new TED Record required by Government
direction (e.g., claims processed as a Batch and then changed to
a ‘process’ status or released from temporary suspension shall receive
one administrative payment for creating the original Batch TED Record
and a second administrative payment for creating the new Voucher
TED Record).
2.9.2 All claims being held based upon
the notice of temporary suspension are excluded from Section H audit
requirements except, in accordance with
paragraph 2.6.2.5, the Section
H.10 ANNUAL UNDERWRITEN UNALLOWABLE HEALTHCARE COST COMPLIANCE REVIEW
Cost of Care audit requirements.
2.9.3 The contractor
shall not apply the identified patient responsibility (applicable
cost-shares, copayments, deductibles) towards the catastrophic cap
for claims that are not fully processed. The contractor shall apply
the identified patient responsibility on claims fully processed
prior to the temporary suspension notice (and not intercepted,
paragraph 2.5.2)
or fully processed in accordance with
paragraphs 2.6,
2.7,
or
2.8.
2.9.4 At the end
of the contract and for all providers, pharmacies, entities, or
client beneficiaries that remain in temporary suspense, the contract
shall transfer all Batch and Voucher TED Record(s) data to the new
contractor in accordance with
Chapter 2, Section 8.
All additional materials being held in suspense related to the suspended Batch
and Voucher TED Record(s) data is transferred to the new contractor’s
Program Integrity (or equivalent) office in accordance
Chapter 2, Section 10, paragraph 1.0.
2.9.5 Debt Transferred To DHA And Returned
To The Contractor
When a provider,
pharmacy, or entity is under a temporary suspense order, all non-underwritten
debt collection efforts shall cease, to include collection efforts
related to debt previously transferred to DHA that remains uncollected.
Upon release of suspension or partial release of suspension (Process
Status), any debt falling with in the suspension release period
and transferred to DHA will be transferred back to the contractor
and the collection process shall start over. The contractor shall:
2.9.5.1 Reestablish the debt on its A/R
system within 30 days after receiving funds placed in ‘Deposit Fund’ and
debt information from the DHA, Office of General Counsel (OGC).
Regional Contractors: All debt returned to the contractor is non-underwritten
debt.
2.9.5.2 Issue a demand letter within 30
days after the debt has been reestablished using the date of demand as
the new debt aging date in accordance with 45 CFR § 30.11.
2.9.5.3 All interest and penalty timelines
shall start over within the date of demand as the aging start date
of debt.
2.9.5.4 If the debt remains uncollectable
it is transferred back to DHA, OGC in accordance with
Chapter 10, Section 4 using the date of demand
after the debt was transferred back as the aging start date.
2.9.5.5 Regional Contractors Only
Deposit all collections of converted
debt into the current FY non-underwritten bank account assigned
to them. Because TED Record(s) credit data submissions shall have
already been sent to DHA for all under written debt converted to
non-underwritten debt, the monthly deposits of converted debt will
create an out-of-balance on the bank reconciliation report. The
contractor shall separately report on its monthly bank reconciliation
report (in summary) all collections for converted debt. Details
for reporting are identified in DD Form 1423, CDRL, located in Section
J of the applicable contract.
3.0 DHA AUTHORITY FOR EXCLUSIONS
AND TERMINATIONS
3.1 DHA exclusion of any individual
or entity is based on
32 CFR 199.9(h) provisions.
3.2 The contractor
shall provide written notice to DHA PI within 10 calendar days of
any situation involving a TRICARE provider, pharmacy, or entity
whose actions warrant exclusion under DHA authority related to fraudulent or
abusive behavior.
3.3 The Director, DHA or designee,
has the authority to exclude an authorized TRICARE provider, pharmacy, or
entity. The period of exclusion is at the discretion of DHA. (See
32
CFR 199.9.)
3.4 DHA PI will coordinate and issue
notification of exclusion action. DHA PI will send written notice
to the provider of the proposed exclusion, and the potential effect
thereof. The individual or entity may submit evidence and written
argument regarding the proposed exclusion.
3.5 DHA PI has sole authority to
issue an Initial Determination of Exclusion. Written notice of this
decision will include the basis for the exclusion, the length of
the exclusion, as well as the effect of the exclusion. The determination
also outlines the earliest date on which DHA PI will consider a
request for reinstatement, the requirements for reinstatement, and
appeal rights available.
3.5.1 DHA PI will notify appropriate
agencies, including contractors, of all DHA exclusion actions taken.
3.5.2 DHA PI will
initiate action based upon reversed or vacated decisions. Exclusion
of a provider, pharmacy, or entity will be effective 15 calendar
days from the date of the initial determination.
3.5.3 The Director,
DHA or designee has sole authority for approval of any request for
reinstatement.
4.0 CONTRACTOR
ACTIONS UNDER TRICARE EXCLUSION AUTHORITY -
32
CFR 199.94.1 The contractor shall provide
supporting documentation to DHA PI within 10 calendar days when recommending
any provider exclusion.
4.2 DHA PI
will notify the contractor of an exclusion action.
4.3 The contractor shall:
4.3.1 Ensure that no payment is made
to an excluded provider, pharmacy, or entity for care provided on
or after the date of the DHA action (15 calendar days from the date
of the Initial Determination as noted in
paragraph 3.5). Neither the
provider, pharmacy, entity, nor the client beneficiary is entitled
to TRICARE cost-sharing once the exclusion is in effect.
4.3.2 Notify
DHA PI if a provider, pharmacy, or entity attempts to bill the program
after the effective date of exclusion.
4.3.3 Ensure that an excluded provider,
pharmacy, or entity is not included in the network and provider directory.
4.3.3.1 The contractor shall ensure
that the network provider, pharmacy, or entity whose contract has
been canceled clearly understands his or her status if cancellation
of a network provider, pharmacy, or entity agreement is required.
4.3.3.2 Provide written notice within
15 business days, sent by certified mail, return receipt requested,
that the network provider’s or network pharmacy’s agreement has
been canceled.
4.3.3.3 Provide DHA PI a copy within
15 business days.
4.3.4 Notify,
in writing within 10 calendar days, the beneficiary who submitted
a claim that the provider has been excluded from the TRICARE program.
4.3.5 Ensure
the enforcement of all exclusion action taken, and notify appropriate
parties of the application of exclusions. For example, any claim
received from an excluded third party billing agent shall be returned
to the provider with instructions to resubmit the claim directly
or through another third party billing agent. The provider remains
entitled to reimbursement for covered services as long as they remain
an authorized TRICARE provider.
5.0 DHHS/OIG
APPLICATION OF SANCTION AUTHORITY
5.1 DHHS/OIG excludes individuals
or entities from participation in any Federal health care program
to include the DoD Military Health System (MHS), and TRICARE. Authority
and exclusion categories are on the DHHS/OIG website.
5.2 DHHS/OIG
has sole responsibility for issuing a written notice of its intent
to exclude a provider, pharmacy, or entity, the basis for the exclusion,
the effective date, the period of exclusion, and the potential effect
of exclusion.
5.3 DHHS/OIG has sole authority for
terminating an exclusion imposed under its authority. DHHS/OIG will handle
notifications of approval or denial of a request for reinstatement
and are responsible for reversing or vacating decisions.
5.4 DHHS/OIG
exclusions and reinstatements are issued on a monthly basis. DHHS/OIG
will provide DHA PI with immediate access to this information, which
will be forwarded to each contractor.
5.5 Exclusions
taken by DHHS/OIG are binding on Medicare, Medicaid, and all Federal
health care programs with the exception of the Federal Employee
Health Benefit Program (FEHBP) (42
United States Code
(USC
) 1320a-7b(f)). No payment
is made for any item or service furnished on or after the effective
date of exclusion until an individual or entity is reinstated by
DHHS/OIG, and subsequently meets the requirements under
32
CFR 199.6.
6.0 CONTRACTOR
ACTIONS UNDER DHHS/OIG EXCLUSION AUTHORITY
6.1 DHA PI
will provide the contractor the monthly issuance of DHHS/OIG exclusion
and reinstatement actions.
6.2 The contractor shall ensure that
no payment is made to an excluded provider, network pharmacy, or entity
for care provided on or after the date of the DHHS/OIG action. The
provider, pharmacy, or entity, nor the client beneficiary entitled
to TRICARE cost-sharing once the exclusion is effective.
6.2.1 The contractor
shall notify DHA PI when a provider, network pharmacy, or entity
attempt to bill the program or if payment has been issued after
the effective date of exclusion.
6.2.2 It is
not necessary for the contractor to issue a separate letter notifying
the provider, network pharmacy, or entity of the exclusion action.
6.3 The contractor shall ensure
that an excluded provider, pharmacy, or entity is not included in
the network.
6.3.1 The contractor shall ensure that
the network provider or network pharmacy whose contract has been canceled
understands their status, if the cancellation of a network, or if
applicable, participating provider agreement is required.
6.3.2 The contractor
shall accomplish this by providing written notice, within seven
calendar days, sent by certified mail, return receipt requested,
stating the network provider’s or network pharmacy’s agreement has
been canceled. The contractor shall send a copy to DHA PI.
7.0 CONTRACTOR
APPLICATION OF SANCTION AUTHORITY
7.1 The contractor shall ensure the
enforcement of all sanction action(s) taken, and
notify appropriate parties of the application of sanctions. For
example, any claim received from an excluded third party billing
agent is returned to the provider with instructions to resubmit
the claim directly or through another third party billing agent.
7.2 The provider
remains entitled to reimbursement for covered services as long as
they remain an authorized TRICARE provider.
8.0 PROVIDER,
NETWORK PHARMACY, OR ENTITY TERMINATION OF AUTHORIZED PROVIDER STATUS
8.1 The contractor
shall terminate the authorized provider status of any provider,
network pharmacy, or entity determined not to meet program requirements.
The request for reinstatement shall be processed under the procedures
established for initial requests for authorized provider or network
pharmacy status. See
paragraph 10.0 for further information.
8.2 Other
Listings
The contractor
shall ensure receipt of the appropriate state board listings of
actions affecting provider authorization status (i.e., Federation
of State Medical Boards of the United States (US)). A provider who
has licenses to practice in two or more jurisdictions and has one
or more licenses suspended or revoked shall be terminated as a TRICARE
provider in all jurisdictions.
9.0 CONTRACTOR
REQUIREMENTS FOR TERMINATION
9.1 The contractor shall initiate
termination action based upon a finding that the provider, pharmacy,
or entity does not meet the qualifications to be an authorized provider
when status as an authorized provider, authorized network pharmacy
or authorized entity is ended.
9.2 Separate
termination action by the contractor is not required for a provider,
pharmacy, or entity sanctioned under the exclusion authority granted
DHHS/OIG.
9.3 The period of termination will
be indefinite and will end only after the provider, pharmacy, or
entity has successfully met the established qualifications for authorized
status under the TRICARE Program and has been reinstated as outlined
in
paragraph 10.0.
9.4 The contractor
shall notify the provider, pharmacy, or entity in writing of the
proposed action to terminate them.
9.4.1 The Government
will direct the contractor to notify the provider, pharmacy, or
entity of the proposed action to terminate their status as an authorized
TRICARE provider when the provider, pharmacy, or entity falls within
the contractor’s certifying responsibility and the provider, pharmacy,
or entity fails to meet the requirements of
32
CFR 199.6 (
Addendum A, Figure 13.A-8).
9.4.2 The notice
will offer the provider, pharmacy, or entity an opportunity to respond
within 30 calendar days from the date of the notice. An extension
to 60 calendar days may be granted if a written request is received during
the 30 calendar days showing good cause.
9.4.3 The provider,
pharmacy, or entity may respond with either documentary evidence
and written argument contesting the proposed action or a written
request to present in person evidence or argument to DHA, PI. Expenses
incurred by the provider, pharmacy, or entity are their responsibility.
9.4.4 Once the
notice of proposed action to terminate is sent, the provider’s claims
are temporarily suspended from claims processing until an Initial
Determination is issued. The provider, pharmacy, or entity is notified
via the proposed notice that the claims are suspended from claims
processing.
9.4.5 For pharmacy claims, once the
notice of proposed action to terminate is sent, the pharmacy’s claims
are not processed as network claims until an Initial Determination
is issued.
9.4.5.1 The pharmacy is notified via
the notice that the claims will not be processed as network claims.
9.4.5.2 Beneficiaries are advised by
the pharmacy that it is no longer a network pharmacy and that any prescription
filled there requires submittal of a claim for reimbursement by
the beneficiary.
9.5 Initial
Determination
9.5.1 The Government will invoke an
administrative remedy of termination by directing the contractor
to issue a written notice of the Initial Determination via certified
mail.
9.5.2 The contractor shall include
the following in the Initial Determination written notice:
9.5.2.1 A Unique Identification Number
(UIN) indicating the FY of the Initial Determination, a consecutive number
within that FY and the contractor’s name. A sample letter is found
at
Addendum A, Figure 13.A-9.
9.5.2.2 A statement of the action being
invoked and the effective date of the action. The effective date
will be the date the provider, pharmacy, or entity no longer meets
the regulatory requirements. If there is no documentation the provider
ever met the requirements, the effective date will be either June
10, 1977 (the effective date of the Regulation) or the date on which
the provider, pharmacy, or entity was first
approved, whichever date is later. In the case of a pharmacy, it
is the date on which the pharmacy first became part of the network.
9.5.2.3 A statement of the facts, circumstances,
or actions that form the basis for the termination and a discussion
of any information submitted by the provider, pharmacy, or entity
relevant to the termination.
9.5.2.4 A statement of the provider’s,
pharmacies, or entity’s right to appeal.
9.5.2.5 The requirements and procedures
for reinstatement.
9.6 Providers
Failing To Return Recertification Documentation
9.6.1 Upon notification
from the Government the providers, pharmacies, or entities who failed
to return recertification documentation, the contractor shall terminate
but shall place the providers, pharmacies, and entities on the inactive
provider listing.
9.6.2 The contractor shall first
verify that the recertification package was mailed to the correct
address and was not returned by the US Postal Service (USPS).
9.6.3 The contractor
shall ensure that no claims are paid and shall deny claims for services
regardless of who submits the claim.
9.6.4 The Government
will notify the provider, pharmacy, or entity their TRICARE claims
will be denied for failing to return their recertification documentation.
9.7 Requirement
To Recoup Erroneous Payments
9.7.1 The contractor shall, after
the Initial Determination letter has been issued, initiate recoupment
in accordance with
Chapter 10, Section 2 for
any claims cost-shared, paid for services, or supplies furnished
by the provider (including pharmacies) on or after the effective
date of termination, even when the effective date is retroactive,
unless a specified exception is provided by 32 CFR 199. This also
applies to claims processed by previous contractor(s).
9.7.2 The contractor
shall transfer all monies recouped, including those paid by previous
contractor(s), to DHA CRM in accordance with
Chapter
3.
9.8 File Requirements For A Terminated
Provider, Pharmacy, Or Entity
The contractor shall include
the following in the Initial Determination file for the provider,
pharmacy, or entity:
9.8.1 Initial Determination of Termination
Action as well as Proposed Notice to Terminate;
9.8.2 Provider/pharmacy/entity
certification file (i.e., the documentation upon which the original certification
of the provider/pharmacy/entity was based) or network pharmacy agreement;
9.8.3 All correspondence
and documentation relating to the termination. Copies of the enclosures
are attached to the copy of the original correspondence;
9.8.4 Documentation
that the contractor considered or relied upon in issuing the determination.
9.9 Special
Action or Notice Requirements When An Institution Is Terminated
9.9.1 The contractor
shall take appropriate action when a DHA determination is made that
an institutional provider does not meet qualifications or standards
to be an authorized TRICARE provider.
9.9.2 Provider
And Client Beneficiary Notification
9.9.3 The Government
will:
9.9.3.1 Instruct the institution by certified
mail to immediately give written notice of the termination to any TRICARE
client beneficiary (or beneficiary’s parent, guardian, or other
representative) admitted to or receiving care at the institution
on or after the effective date of the termination.
9.9.3.2 Notify any client beneficiary
(or beneficiary’s parent, guardian, or other representative) admitted prior
to the date of the termination by certified mail that TRICARE cost-sharing
ended as of the termination date when the termination effective
date is after the date of the initial determination.
9.9.3.3 Advise the client beneficiary
(or beneficiary’s parent, guardian, or other representative) of
the client beneficiary’s financial liability.
9.9.3.4 Use a fast, effective means
of notice (e.g., phone, fax, express mail, or regular mail, depending
on the circumstances).
9.9.3.5 Notify any client beneficiary
(or beneficiary’s parent, guardian, or other representative) admitted prior
to the grace period of the violation that TRICARE cost-sharing of
covered care continues during that period. Cost-sharing continues
through the last day of the month following the month in which the
institution is terminated if an institution is granted a grace period
to effect correction of a minor violation.
9.9.3.6 Notify any client beneficiary
(or beneficiary’s parent, guardian, or other representative) admitted prior
to a grace period of the institution’s corrective action, when such
has been determined to have occurred, and the continuation of the
institution as an authorized TRICARE provider.
9.9.4 Cost-Sharing
Actions
9.9.5 The contractor shall deny cost-sharing
for any:
9.9.5.1 New patient admitted after
the effective date of the termination;
9.9.5.2 Beneficiary admitted during
a grace period granted an institution involved in a minor violation;
9.9.5.3 Beneficiary already in an institution
involved in a major violation beginning with the effective date
of the termination;
9.9.5.4 The contractor shall cost-share
covered care for those beneficiaries admitted prior to a grace period.
10.0 PROVIDER REINSTATEMENTS
10.1 Reinstatement
of an excluded individual or entity is not automatic once the specified
period of exclusion ends.
10.2 The individual or entity will
apply for reinstatement and receive written notice from DHA that reinstatement
has been granted.
10.3 32
CFR 199.9 provides that the Director, DHA or a designee,
will have the authority to reinstate providers, pharmacies, or entities
previously excluded or terminated under TRICARE. For providers sanctioned
by DHHS, see
paragraph 3.0.
10.4 DHHS/OIG
provides monthly updates for reinstated providers, individuals,
pharmacies, and entities. The information includes exclusion date
and reinstatement date when a previously excluded provider, pharmacy,
or entity is reinstated by DHHS/OIG.
10.5 The contractor
shall, before initiating reinstatement action:
10.5.1 Determine if any erroneous
payments have been made to provider, pharmacy
, or
entity during period of sanction.
10.5.1.1 The contractor shall certify
the provider, pharmacy, or entity as an authorized
provider, and determine the effective date of the reinstatement
if no funds have been paid for services to the provider while excluded
or are otherwise owed the Government for claims paid prior to the
exclusion.
10.5.1.2 If erroneous payments have
been made to a provider, pharmacy, or entity during the period of exclusion,
restitution of the payments shall be made before a request for reinstatement
will be considered.
10.5.1.3 The contractor shall determine,
if any payments have been made, and initiate restitution of the payments.
10.5.2 The contractor shall send the
certification package to the provider, entity, or pharmacy for completion to
ensure that the provider meets the requirements to be an authorized
TRICARE provider under
32 CFR 199.6.
10.5.3 Verify that pharmacies has
all required state licenses to operate as a pharmacy.
10.5.4 Ensure the exclusion or suspension
shall remain in effect until the provider completes and returns
the certification package and the determination is made by the contractor
that the provider meets the requirements of an authorized TRICARE
provider under
32 CFR 199.6.
10.5.5 Provide in writing of the reinstatement
date, once the determination is made that the provider meets the
requirements of a TRICARE Authorized provider under
32
CFR 199.6.
10.5.6 If pharmacy, provide in writing
that the pharmacy has met the state licensing requirements and advise the
pharmacy of the date it is eligible to negotiate a new network agreement
with the contractor, as determined by DHA.
10.6 The contractor
shall notify the provider in writing with an explanation on why
the provider did not meet the requirements and advise the provider
of their appeal rights if the provider does not meet the requirements
of a TRICARE Authorized Provider under
32
CFR 199.6.
10.6.1 The contractor shall provide
DHA PI a copy of the letter within seven calendar days.
10.6.2 The contractor shall provide
in writing to the pharmacy within seven calendar days, that the
pharmacy does not have the required state licenses and provide notification
to the pharmacy why the pharmacy is not eligible to be a network
pharmacy and advise pharmacy of appeal rights.
10.6.3 A copy of the letter shall
be provided to the DHA PI within seven calendar days.
10.6.4 The contractor shall provide
notification to Beneficiary Counseling and Assistance Coordinators (BCACs)
at Markets/Military Medical Treatment Facilities (MTFs) within the
provider’s service area of provider status within seven calendar
days.
11.0 CONFLICT
OF INTEREST
11.1 The contractor shall document
and refer suspected violations of conflict of interest to the DHA
PI within 15 calendar days.
11.1.1 Conflict of interest includes
any situation where an active duty member of the Services (including
a reserve member while on active duty, active duty for training,
or inactive duty training) or civilian employee (which includes
employees of the Department of Veterans Affairs/Veterans Health
Administration (DVA/VHA)) of the US Government, through an official
federal position has the apparent or actual opportunity to exert,
directly or indirectly, any influence on the referral of beneficiaries
to himself or herself or others with some potential for personal
gain or the appearance of impropriety.
11.1.2 Although individuals under
contract to the Uniformed Services are not considered employees,
such individuals are subject to conflict of interest provisions
by express terms of their contracts and, for purposes of the
32
CFR 199.9 may be considered to be involved in conflict
of interest situations as a result of their contract positions.
11.1.3 In any situation involving
potential conflict of interest of a Uniformed Service employee,
the Director, DHA, or a designee, may refer the case to the Uniformed
Service concerned for review and action.
11.2 Federal
Employees And Active Duty Military
11.2.1 32
CFR 199.6 prohibits active duty members of the Uniformed
Services or employees (including part-time or intermittent), appointed
in the civil service of the US Government, from authorized TRICARE
provider status.
11.2.2 This prohibition applies to
TRICARE payments for care furnished to TRICARE beneficiaries by
active duty members of the Uniformed Services or civilian employees
of the Government.
11.2.3 The prohibition does not apply
to individuals under contract to the Uniformed Services or the Government.
11.3 Exceptions
11.3.1 National
Health Service Corps
TRICARE
payment may be made for services furnished by organizations to which
physicians of the National Health Service Corps (NHSC) are assigned.
However, direct payments to the NHSC physician are prohibited by
the dual compensation provisions.
11.3.2 Emergency
Rooms
11.3.2.1 Any off-duty Government medical
personnel employed in an emergency room of an acute care hospital
will be presumed not to have had the opportunity to exert, directly
or indirectly, any influence on the referral of TRICARE beneficiaries;
therefore, TRICARE payments may be made to the employing hospital
provided the medical care was not furnished directly by the off-duty
Government medical personnel in violation of dual compensation provisions.
11.3.2.2 The contractor shall not cost-share
professional services by the provider since they cannot be recognized
as TRICARE-authorized providers.
11.3.3 Reserves
Generally Exempt
11.3.3.1 Conflict of interest provisions
shall not apply to medical personnel who are Reserve members of
the Uniformed Services or who are employed by the Uniformed Services
through personal services contracts, including contract surgeons.
11.3.3.2 Although Reserve members, not
on active duty, and personal service contract medical personnel
are subject to certain conflict of interest provisions by express
terms of their membership or contract with the Uniformed Services,
resolution of any apparent conflict of interest issues which concern
such medical personnel is the responsibility of the Uniformed Services,
not the DHA.
11.3.3.3 National Guard and reservists
on active duty are not exempt during the period of their active
duty commitment.
11.3.4 Part-Time Physician Employees
Of The US Government
11.3.5 Referrals
From Uniformed Services Facilities
11.3.5.1 Referrals from Uniformed Services
facilities to individual civilian providers should, in every practical instance,
be made to participating providers. However, referrals of TRICARE
beneficiaries by Uniformed Services personnel to selected individual
providers in the civilian community when other similar participating
providers are available may involve a conflict of interest.
11.3.5.2 The contractor shall document
any apparent problem of this nature and refer the case to the DHA
PI for investigation.
11.3.5.3 In any situation involving
potential conflict of interest of a Uniformed Service employee,
the Director, DHA, or a designee, may refer the case to the Uniformed
Service concerned for review and action.
12.0 REPORTING
PROVIDER REFUNDS - PROVIDER REFUNDS (SINGLE CLAIM AND MULTIPLE CLAIMS)
12.1 Providers
have a requirement to return overpayments to the TRICARE program
(voluntary or requested). Possible reasons for provider refunds
(single or multiple claims) may include: OHI, Third Party Liability
(TPL), Payment sent to incorrect provider, Duplicate Payment, Provider
Billing Error, or TRICARE overpaid.
12.2 The contractor
shall notify DHA PI within 30 business days of receiving reported
refund when a Provider Billing Error refund is made to the contractor
(single or multiple).
12.3 For reporting submission requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
13.0 VOLUNTARY
SELF-DISCLOSURE
13.1 Congress through the Fraud
Enforcement and Recovery Act of 2009 (FERA) amended the False Claims
Act (FCA) to cover the identification and return of overpayments
to federal programs. Specifically, FERA expanded the scope of the
FCA to provide liability for “knowingly” retaining an overpayment.
Accordingly, the FCA now imposes liability on any provider who received
overpayments (accidentally or otherwise) and then knowingly fails
to return the overpayment to the Government. The amended statute
allows for knowingly retaining an overpayment to be the sole allegation
of a complaint under the FCA. Additionally, failure to timely report
and return an overpayment under the amended FCA exposes a provider
to liability. This includes TRICARE claims and payments.
13.2 Individuals
or entities who wish to voluntarily disclose self-discovered potential
fraud to DHA-PI may do so under the Self-Disclosure Program (SDP).
Disclosing parties may report by sending to DHA PI or may also report online.
13.3 Non-health
care matters, should be reported to the DHA OIG Hotline, or if military,
to the DoD OIG Hotline or the respective military service OIG Hotline.
13.4 Disclosing
parties already subject to a Government inquiry (including investigations,
audits, or other oversight activities) are not automatically precluded
from using the SDP. The disclosure, however, will be made in good
faith and will not be an attempt to circumvent any ongoing inquiry.
Disclosing parties under Corporate Integrity Agreements (CIA) with
DHA may also use the SDP in addition to making any reports required
in the CIA.
13.5 Disclosing parties are advised
that the self-disclosure may be shared with other Federal agencies.