The contractor shall determine
that claims received are within its contractual jurisdiction using
the criteria below.
1.0 TRICARE
PRIME ENROLLEES
The contractor
shall use the Defense Enrollment Eligibility System (DEERS) to determine
a beneficiary’s enrollment status and shall process all TRICARE
Prime enrollee claims in its jurisdiction regardless of where the
services are received (except for care received overseas, see below),
and exchange provider category information (network vs. non-network)
with the contractor responsible for jurisdiction.
2.0 ALL
OTHER TRICARE BENEFICIARIES
The contractor shall process
claims for beneficiaries not enrolled in TRICARE Prime (using the
beneficiary’s home address on the claim to determine jurisdiction)
regardless of where the service was received and exchange provider
category information (network vs. non-network) with the contractor
responsible for jurisdiction. (See the TRICARE Systems Manual (TSM),
Chapter 3, Section 4.2, if the beneficiary’s
home address on the claim differs from the home address on DEERS).
3.0 CARE RECEIVED OVERSEAS
3.1 The TRICARE Overseas Program
(TOP) contractor shall process claims for beneficiaries who reside overseas
or who are enrolled in the TOP regardless of where the enrollee
receives the services.
3.2 The TOP
contractor shall process claims for Continental United States (CONUS)-based
beneficiaries who receive civilian health care while traveling or
visiting abroad regardless of where the beneficiary resides or where they
are enrolled. See
Chapter 24, Section 9,
for additional information.
4.0 TRICARE MEDICARE DUAL ELIGIBLES
The TRICARE Medicare Eligible
Program (TMEP) contractor shall process claims for services rendered
to TRICARE-Medicare dual eligibles within the 50 United States (US),
the District of Columbia, Puerto Rico, Guam, US Virgin Islands,
American Samoa, and the Northern Mariana Islands.
5.0 PHARMACY
CLAIMS
5.1 The TRICARE Pharmacy (TPharm)
contractor shall process all claims for pharmaceuticals dispensed
at a retail pharmacy or a Mail Order Pharmacy (MOP).
5.2 The Managed Care Support Contractor
(MCSC) shall process claims for pharmaceuticals (e.g., injectables) ordered
by and administered in a physician’s office or other place of practice
such as a clinic for enrollees and residents of their geographic
area of responsibility.
5.3 Claims
for pharmaceuticals dispensed by a provider who does not have a
National Council of Prescription Drug Plans (NCPDP) number are also
the responsibility of the appropriate non-TPharm contractor.
6.0 SUPPLYING
OUT-OF-AREA PROVIDER INFORMATION
6.1 The contractor
shall respond within five business days after receipt of an out-of-area
provider information request and shall designate a Point of Contact
(POC) for these requests.
6.2 The contractor shall verify
that the provider is TRICARE-authorized and whether or not the provider
is a network provider.
6.3 Contractor
Coordination On Out-Of-Jurisdiction Providers
The contractor shall first
search available provider files, including the Defense Health Agency
(DHA) supplied copy of the TRICARE centralized provider file before
requesting out of area provider information.
6.3.1 The servicing
contractor shall notify the DHA Contracting Officer’s Representative
(COR) if the certifying contractor does not provide the required
provider information and notification of the TRICARE Encounter Provider (TEPRV’s)
acceptance by DHA within 35 calendar days from the time of the initial
contact.
6.3.2 The servicing contractor shall,
after notifying the COR, continue to pend the claim until they:
6.3.2.1 Receive the required provider
information from the certifying contractor; or
6.3.2.2 Receive notification from the
COR on how to proceed.
6.4 Provider Correspondence
6.4.1 The contractor shall send any
provider correspondence which the servicing contractor forwards
for the certifying contractor’s action or information to the certifying
contractor’s POC to avoid misrouting.
6.4.2 The servicing
contractor shall, within seven calendar days after receipt, forward
for the certifying contractor’s action any correspondence or other
documentation received which indicates the need to perform a provider
file transaction. This includes, but is not limited to, such transactions
as address changes, adding or deleting members of clinics or group
practices, or changing a provider’s Taxpayer Identification Number
(TIN).
6.5 Provider Certification Appeals
6.5.1 Requests for reconsideration
of a contractor’s adverse determination of a provider’s TRICARE certification
status are processed by the certifying contractor.
6.5.1.1 Any such requests received
by the servicing contractor are to be forwarded to the certifying contractor
within five business days of receipt and the appealing party notified
of this action and the reason for the transfer.
6.5.1.2 The certifying contractor shall
follow standard appeal procedures including aging the appeal from the
date of receipt by the certifying contractor.
6.5.1.2.1 The contractor shall, if the
reconsideration decision is favorable, notify the provider to resubmit
any claims denied for lack of TRICARE certification to the servicing
contractor with a copy of the reconsideration response.
6.5.1.2.2 The contractor shall ensure
a TEPRV for this provider is accepted by DHA within seven calendar days
from the date of the appeal decision.
6.5.2 The servicing contractor shall
forward to the certifying contractor within five business days of
receipt any provider requests for review of claims denied because
the certifying contractor was unable to complete the certification
process.
6.5.2.1 The servicing contractor shall
notify the provider of the transfer with an explanation of the requirement
to complete the certification process with the certifying contractor.
6.5.2.2 The certifying contractor shall,
upon receipt of the provider’s request, follow its regular TRICARE provider
certification procedures. In this case, no basis for an appeal exists.
If the provider is determined to meet the certification requirements,
the special provider notification and TEPRV submittal requirements
apply.
7.0 OUT-OF-JURISDICTION TRICARE
CLAIMS
7.1 The contractor shall, when
the contractor receives an electronic claim with no services or
supplies within its jurisdiction, transfer the claim to the appropriate
jurisdictional contractor (including TPharm, TOP, TMEP) via a Health
Insurance Portability and Accountability Act (HIPAA)-compliant
837 transaction within 72-hours of identifying out-of-jurisdiction
on a claim.
7.2 The contractor
shall, when it receives a paper claim that is identified as out-of-jurisdiction,
transfer the paper claim (and any supporting documents) to the appropriate
contractor.
7.3 Partially
Out-of-Jurisdiction. The contractor shall process the claim for
which services or supplies are within its jurisdiction.
8.0 NON-TRICARE
CLAIMS
The contractor
shall return claims submitted on other than approved TRICARE claim
forms to the sender or transfer to other lines of business, if appropriate.
8.1 Civilian
Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA) Claims
The contractor
shall return a claim identified as a CHAMPVA claim to the sender
with a letter advising them of the CHAMPVA program’s toll-free telephone
number, 1-800-733-8387, and instructing them to send the claim and
all future CHAMPVA claims to:
Chief, Business Office Purchased
Care
CHAMPVA
P.O. Box 469064
Denver, CO 80246-9064
8.2 Provider Moonlighting and Claims
8.2.1 Active duty military providers
and General Schedule (GS) civil service providers employed full-time
by the Department of Defense (DoD) may be permitted to moonlight
in the civilian sector with Commander approval. However,
32
CFR 199.6, Title 32 “Dual Compensation/Conflict of Interest”
and
Chapter 4, Sections 1.0 and
2.1 strictly prohibit
these providers from treating TRICARE beneficiaries, while moonlighting,
and bill for such services. This includes civilian health care entities
who employ moonlighting providers and knowingly bill TRICARE for beneficiaries
seen by active duty military or GS civil service providers. There
are limited circumstances where moonlighting providers are permitted
to treat TRICARE beneficiaries including emergency services.
8.2.2 The contractor shall implement
processes to screen claims to identify for active duty military
or GS civil service moonlighting providers and shall deny such claims.
Processes shall include, but not limited to, flagging the provider
in its provider management system and its claims processing system
and revalidating that the active duty military or GS civil service
provider is still employed full time by the DoD.
8.2.3 The contractor shall, if it
is made known to them that a claim is from a DoD moonlighting provider,
take necessary action to deny the claim/s and educate the moonlighting
provider’s civilian employer.
8.2.4 The contractor
shall include information on moonlighting providers and billing
TRICARE in its provider education materials and briefings.
8.2.5 The contractor shall report
to the Government on a monthly basis all claims discovered and denied
as moonlighting. For reporting requirements see DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract.