1.0 PROVIDER
CERTIFICATION CRITERIA
1.1 The contractor shall ensure
all providers are TRICARE certified in accordance with
32
CFR 199.6 and the TRICARE Policy Manual (TPM),
Chapters
1 and
11.
1.2 The contractor shall ensure
network providers are credentialed in accordance with nationally
accepted credentialing standards adopted by a national accrediting
body.
1.3 If a beneficiary submits a
claim for services provided by a non-participating individual professional provider
who is known to be legally practicing and is eligible for TRICARE-authorization,
the provider shall be certified and payment shall be made to the
beneficiary. In no case shall a provider who refuses to provide
proper Social Security Number (SSN) and Employer Identification
Number (EIN) identification be paid directly.
2.0 PROVIDER APPROVALS
2.1 The contractor shall accurately
authorize all providers of care using a single, centralized authorization process.
2.2 The contractor shall ensure
that all providers of care for whom a billing is made or claim submitted
under TRICARE meet all conditions, limitations or exclusions specified
or enumerated in 32 CFR 199, the TPM, and the TRICARE Operations
Manual (TOM).
2.3 The contractor shall maintain
separate institutional and non-institutional provider files. Additions, deletions,
and changes to these files, shall be reported to Defense Health
Agency (DHA) as specified in the TRICARE Systems Manual (TSM).
2.4 The contractor shall contact
the provider, the state licensing board, the appropriate national
or professional association, or other sources to determine that
the provider meets certification requirements, upon receipt of a
claim or request for provider certification information involving
a provider practicing in the contractor’s jurisdiction, but not
on the TRICARE Encounter Provider (TEPRV) file.
2.5 The contractor may establish
eligibility for certification by any of these means. Documentation
may be a copy of the page from the most recent state licensor listings,
screen print from on-line access to state board licensing files,
or other methods that show proof that the provider meets the certification
requirements.
2.6 The contractor shall, if certification
cannot be accomplished, deny all pending and subsequent claims for services
from that provider.
2.6.1 The contractor may, if the
provider is later determined to be authorized based on receipt of
the required documentation, reopen and reprocess the claim/s if
requested by the provider or beneficiary.
2.6.2 Services
delivered by any provider must be within the scope of the license
or other legal authorization.
2.7 The contractor
shall maintain a current computer listing of all certified providers,
including, at a minimum, the data required by the TSM,
Chapter 2, Section 2.10.
2.8 If the provider was initially
certified by the contractor, the certification shall be supported
by a documented and readily accessible hardcopy or electronic file
documenting each provider’s qualifications. A hardcopy or electronic
file documenting the provider’s existence on the TEPRV shall be
maintained for all other providers.
2.9 The contractor
shall remove from the active file any provider who has not submitted
a claim or whose services have not been submitted on a claim within
the past two years.
2.9.1 The contractor shall recertify
a provider who remains on the active file, if a claim is received
from a provider who has not submitted a claim or whose services
have not been submitted on a claim within the past two years.
2.9.2 The contractor shall not delete
providers who have been terminated or suspended.
2.9.3 Suspended, or terminated,
or excluded providers shall remain on the file as flagged providers indefinitely
or until the flag is dropped because the suspended provider has
been reinstated.
2.9.4 The contractor
shall review all providers that have been flagged to ensure the
flags are working at a minimum of once each year.
2.9.5 The contractor shall maintain
records of all suspended and terminated providers and audit the
provider file flags and, as necessary, test to ensure they are operational.
2.10 The contractor shall accept
the Medicare certification of individual professional providers
who have a like class of individual professional providers under
TRICARE without further authorization, unless there is information indicating
Medicare, TRICARE, or other federal health care program integrity
violations by the physician or other health care practitioner.
2.11 The contractor shall deny certification
of individual professional providers without a like class (e.g., chiropractors)
under TRICARE.
3.0 PART-TIME PHYSICIAN EMPLOYEES
OF THE DEPARTMENT OF VETERANS AFFAIRS/VETERANS HEALTH ADMINISTRATION
(DVA/VHA)
3.1 The Director, DHA, has authorized
an exception, on a case-by-case basis, to the TRICARE policy which excludes
any civilian employee of the DVA/VHA from certification as a TRICARE
provider. This exception is for part-time physician/Medical
Doctor (MD) employees only who file claims for service
furnished in their private, non-DVA/VHA employment practice.
3.2 In order to be considered as
a certified provider, the DVA/VHA facility administrator must send
a request for an exception to the appropriate contractor (
Addendum A, Figure 4.A-1) along with a Part-Time
Physician Employee Provider Certification Form (
Addendum A, Figure 4.A-2) signed by the physician.
3.2.1 The contractor shall approve
the physician as a TRICARE provider for services furnished by this
provider in his private practice, upon receipt of these two documents.
The effective date is the date the contractor approves the waiver.
3.2.2 The contractor shall notify
the physician and requesting DVA/VHA facility by letter of the approval
and the effective date. No retroactive approval dates shall be allowed.
3.2.3 All claims from these providers
shall be annotated on the signature block of the claim form, “additional certification
on file”.
5.0 TRICARE PROVIDER FILE
5.1 The TRICARE provider file is
created from contractor submissions of TEPRVs as required in the
TSM,
Chapter 2, Section 1.2 and is a singular database
which is added to or changed through contractors’ reporting activity.
5.1.1 The concept of the TRICARE
centralized provider file is based on the agency’s commitment to
a singular database which operates on the premise of accountability.
5.1.2 The contractor having contractual
authority for provider certification in a given region has accountability
for the TEPRVs for providers in that region and is responsible for
ensuring these TEPRVs pass the TRICARE edits and for performing
all maintenance transactions. This responsibility extends to those
TEPRVs submitted in support of the claims processing by another
contractor, except the Pharmacy contractor.
5.2 Due to the various methods
in use for defining contractor claims processing jurisdictions,
a contractor having claims processing responsibility may not be
the contractor having accountability for the TEPRV (i.e., having provider
certification responsibility) for the provider rendering the service(s)
on a claim. In this case, the servicing contractor (i.e., the claims
processor) may have to obtain provider data from the certifying
contractor. See
Chapter 8, Section 2 for
instructions regarding development of out-of-jurisdiction provider
certification information.
6.0 PROVIDER FILE AUDITS
6.1 The contractor shall conduct
an annual provider file audit prior to the start of each option
period, of a statistically valid sample, of all TRICARE Prime contractors’
and subcontractors’ individual network provider credentialing and
privileging files to ensure that information is appropriately verified.
For reporting requirements, see DD Form 1423, Contract Data Requirements
List (CDRL), located in Section J of the applicable contract.
6.2 The contractor shall invite
the Government Designated Authority (GDA) to observe the contractor’s
audit no later than 30 calendar days prior to the scheduled audit.
At the time of the audit, the Government will identify the provider
and facility type of files to be audited. Not less than 95% of the
audited files shall be in full compliance with all provider file
requirements.
6.3 The contractor shall submit
a written Corrective Action Plan (CAP) within five business days
of the completion of the audit, which addresses all credentialing
and privileging file deficiencies. Within 30 calendar days after
completion of the audit, the incomplete or incorrect files shall
be corrected to full compliance.
6.4 The contractor
shall provide a report detailed the corrections made and submit
thorough e-Commerce. For reporting requirements, see DD Form 1423,
CDRL, located in Section J of the applicable contract.
7.0 CRIMINAL HISTORY BACKGROUND
CHECKS (CHBC
s)
7.2 The background checks are required
by Criminal Control (CC) Act, Public Law 101-647, Section 231 (CC Act
1990, 42 United States Code (USC) Section 13041) and shall be completed
by the contractor. The contractor may not accept background checks
completed by other agencies.
7.4 The contractor shall furnish
the completed documentation, for individuals who require background checks
but not clinical privileges, to the Market Director/MTF Director
prior to employment at, or assignment to, the Market/MTF.
8.0 CRIMINAL HISTORY REVIEWS
8.1 The contractor shall perform
criminal history reviews on certain physician (see
paragraph 8.2)
and non-physician (
paragraph 8.4) network providers.
8.1.1 A criminal history review is
not required during the recredentialing process.
8.1.2 The contractor may search federal,
state, and county public records in performing criminal history checks.
8.1.3 The contractor may subcontract
for these services; for example, MEDI-NET, Inc., provides physician screening
services, and ADREM Profiles, Inc., performs criminal history checks.
8.1.4 The contractor shall document,
in a form of the contractors’ choosing, the American Medical Association
(AMA) screen and the results of all criminal history checks.
8.2 The contractor shall screen
their TRICARE network physicians’ licensure and discipline histories
using the AMA’s master file.
8.3 The contractor
shall check the criminal histories of all physicians with anomalies
in their licensure history (i.e., who have four or more active or
expired licesnses licenses)
or who have been disciplined.
8.4 The contractor shall perform
criminal history reviews on all non-physician providers who practice independently
and who are not supervised by a physician (refer to
32 CFR 199.6(c)(3) for types of providers).
8.5 The contractor shall maintain
a copy of all background check documentation with the provider certification
files.
8.6 The contractor shall be financially
responsible for all credentialing requirements, including background reviews.