1.0 TIME LIMITATIONS ON FILING
TRICARE CLAIMS
1.1 The contractor shall process
all claims for benefits that are filed no later than one year after
the date the services were provided or one year from the date of
discharge for an inpatient admission for facility charges billed by
the facility. The contractor shall process claims for inpatient
facility professional services claims within one year from the date
of service. The contractor shall deny claims that don’t meet the
filing deadline unless they meet one of the exceptions described
below.
Example:
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DATE OF SERVICE OR DISCHARGE
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MUST BE RECEIVED BY THE CONTRACTOR
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March 22, 2022
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No later than March 22, 2023
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December 31, 2022
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No later than December 31, 2023
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1.2 The contractor
shall accept any written request, whether or not on a claim form,
for benefits for determining if the claim was filed on a timely
basis.
1.3 The contractor shall notify
the claimant in writing that only an approved TRICARE claim form
is acceptable for processing a claim for benefits, when the contractor
receives an other than approved claim form.
1.4 The contractor shall inform the
claimant in writing that in order to be considered for benefits, the claimant
must submit an approved TRICARE claim form and any additional information
(if required) and it must be received by the contractor no later
than one year from the date of service, date of discharge, or 90
calendar days from the date they were notified by the contractor,
whichever is later.
1.5 The claimant
should submit claims on either the Centers for Medicare and Medicaid
Services (CMS) 1500 Claim Form, the CMS 1450 UB-04, or the Defense
Department (DD) Form 2642 as appropriate.
2.0 EXCEPTIONS TO FILING DEADLINE
2.1 Retroactive Eligibility/Preauthorization
Determinations
2.1.1 In order for an exception to
be granted based on a retroactive eligibility or preauthorization determination,
the contractor shall ensure the provider or beneficiary has obtained
or been issued a retroactive determination after the timely filing
period elapsed. Absent an Explanation of Benefits (EOB), the contractor
shall require proof that beneficiaries received medical care for
a covered service (or waived service). The contractor shall not
accept a bill as such proof. If the provider or beneficiary obtains
or is issued a retroactive determination within one year from the
date of service or discharge, the contractor shall apply the one
year timely filing limit.
(See Chapter
8 or, for the TRICARE Overseas Program (TOP), Chapter 24, Section 9, for complete claims
processing requirements.)
2.1.2 The contractor
shall process all claims resulting from retroactive eligibility
(i.e., equitable relief and the Civilian Health and Medical
Program of the Department of Veterans Affairs (CHAMPVA) claims).
2.1.3 The contractor
shall consider payment of ADSM retroactive claims as a specific
exception to the filing deadline. See
Section 5 and
Chapter 17, Section 3.
2.2 Administrative Error
2.2.1 The contractor shall grant
an exception to the claims filing deadline if an administrative
error is alleged, only if there is a basis for belief that the claimant
had been prevented from timely filing due to misrepresentation, mistake
or other accountable action of an officer or employee of Defense
Health Agency (DHA) (including the TRICARE
Overseas Program (TOP)) or a contractor,
performing functions under TRICARE and acting within the scope of
that individual’s authority.
2.2.2 The contractor
shall ensure the necessary evidence includes a statement from the
claimant, regarding the nature and effect of the error, how he or
she learned of the error, when it was corrected, and if the claim
was filed previously, when it was filed, as well as one of the following:
• A written report based on agency
records (DHA or contractor) describing how the error caused failure
to file within the usual time limit; or
• Copies of an agency letter
or written notice reflecting the error.
Note: The contractor shall not require
a claimant statement if the other evidence establishes that the
claimant’s failure to file within the usual time limit resulted
from administrative error, and that the claimant filed a claim within 90
calendar days after they were notified of the error. The contractor
shall ensure a clear and direct relationship between the administrative
error and the late filing of the claim before granting the waiver.
If the evidence is in the contractor’s own records, the contractor
shall annotate the claim file to that effect.
2.2.3 The contractor shall waive
recoupment of erroneous payments or reprocess recovered claims based
on full reconciliation caused by administrative error under the
TRICARE program that has been granted Equitable Relief (EQR) by
DHA in accordance with National Defense Authorization Act (NDAA)
for Fiscal Year (FY) 2016, Section 711, (a); 1095g.
2.2.4 The contractor shall collect
all TRICARE premiums, if applicable, before processing or reprocessing
EQR claims in accordance with
32
CFR 199.4 and
199.5, the TRICARE
Policy Manual (TPM), TRICARE Operations Manual (TOM), and TRICARE
Reimbursement Manual (TRM).
2.3 Inability To Communicate And
Mental Incompetency
2.3.1 For purposes
of granting an exception to the claims filing deadline, ‘mental
incompetency’ includes the inability to communicate even if it is
the result of a physical disability. The contractor shall require
a physician’s statement, which includes dates, diagnosis(es) and
treatment, attesting to the beneficiary’s mental incompetency with each
claim submitted.
2.3.2 The contractor
shall review each statement for reasonable likelihood that mental
incompetency prevented the person from timely filing.
2.3.3 The contractor shall grant
an exception to the claims filing deadline based on the required
physician statement (
paragraph 2.3.1) due the beneficiary’s mental
incompetency and the lack of a legal guardian being appointed during
the period of time in question.
2.3.4 The contractor
shall request evidence from the spouse or parent that the claim
was paid and by whom if the charges were paid by someone else, i.e.,
legal guardian, spouse or parent.
2.3.5 The contractor
shall, when the required evidence is received, make payment to the
signer of the claim, with the check made out: “Pay to the order
of (legal guardian, spouse’s or parent’s name) for the use and benefit
of (beneficiary’s name).”
2.3.6 If a legal
guardian was appointed prior to the timely filing deadline and the
claims filing deadline was not met, the contractor shall not grant an
exception due to mental incompetency of the beneficiary.
2.4 Other Health Insurance (OHI)
2.4.1 The contractor shall grant
exceptions to the claims filing deadline requirements if the provider
or beneficiary submitted a claim to a primary health insurance,
i.e., double coverage, and the OHI delayed adjudication past the
TRICARE deadline.
2.4.2 The contractor
shall ensure the claims were originally sent to the OHI prior to
the TRICARE filing deadline or filed with a TRICARE contractor prior
to the deadline but returned or denied pending processing by the OHI.
2.4.3 The contractor shall require
the provider or beneficiary to submit with the claim a statement
indicating the original date of submission to the OHI, and date
of adjudication, together with any relevant correspondence and an
Explanation of Benefits (EOB) or similar statement.
2.4.4 The contractor shall require
the provider or beneficiary to submit the claim form to the contractor within
90 calendar days from the date of the OHI adjudication.
2.5 Dual Eligibility With Medicare
2.5.1 The contractor shall grant
exceptions to the claims filing deadline if Medicare accepted the
claim as timely.
2.5.2 The contractor
shall process claims submitted by Medicare or by the beneficiary,
within 90 calendar days from the date of Medicare’s adjudication.
3.0 TIME LIMITATIONS FOR EXCEPTIONS
The contractor shall not apply time
limit for submitting written requests for exceptions to the claims
filing deadline before a claim has been submitted.
Note: The contractor shall not apply
time limitations for exceptions to the processing of retroactive
eligibility claims.
3.1 The contractor
shall consider for benefits only those services or supplies received
during the six years immediately preceding the receipt of the request.
3.2 The contractor shall deny claims
for any services or supplies more than six years immediately preceding the
receipt of the request.
3.3 The contractor
shall, upon receipt of a request for an exception to the filing
deadline without the completed claim form enclosed:
• Inform the claimant of the requirement to
complete and submit an approved TRICARE claim form before benefits
may be considered;
• Advise the claimant that the
claim and supporting documentation must be resubmitted within 90
calendar days from the date of the contractor’s letter; and
• Provide the beneficiary with
appropriate forms.