1.0 GENERAL
1.1 Pursuant
to National Defense Authorization Act for Fiscal Year 2007 (NDAA
FY 2007), Section 731(b)(2) where services are covered by both Medicare
and TRICARE, and medical necessity documentation is required for claims
processing.
1.1.1 The contractor shall require
only the documentation as specified by the Medicare Indemnity Program, for
example, the Centers for Medicare and Medicaid Services (CMS)-Certificates
of Medical Necessity (CMNs).
1.1.2 No additional
documentation for medical necessity is generally required if the
care has been preauthorized.
1.2 The contractor
shall retain all claims that contain sufficient information to allow
processing to completion.
1.2.1 The contractor
shall retain all claims that have missing information that can be
obtained from in-house sources, including Defense Enrollment Eligibility
Reporting System (DEERS) and contractor operated or maintained systems
or files (both electronic and paper).
1.2.2 The contractor
shall either return the claim to the sender or retain the claim
and develop for the missing information from external sources (e.g.,
beneficiary or provider) if the claim has missing information that cannot
be obtained from in-house sources.
1.2.3 The contractor
shall return the claim to the sender with a letter stating that
the claim is being returned, stating the reason and requesting the
missing or required information and documentation.
1.2.4 The contractor shall identify
the claim as returned not denied in the claims processing system.
1.2.5 The contractor shall not report
returned claims on TRICARE Encounter Data (TED) records.
1.2.6 The contractor shall retain
sufficient information on returned claims in the event that the
Government invokes the right to audit returned claims.
1.3 The contractor shall contact
a beneficiary to determine how he or she wishes to provide the missing information
on a claim that is to be returned to a beneficiary who is under
18 years of age and involves venereal diseases, substance or alcohol
abuse, reproductive health, or abortion. See
Section 8 regarding
possible contact procedures and the need for both sensitivity and
use of good judgment in the protection of patient privacy.
1.4 The contractor shall not initiate
mail development on this type of claim without consent of the beneficiary
irrespective of whether it is a network or non-network claim.
2.0 AGREEMENT TO PARTICIPATE
2.1 If the provider has agreed
to participate, payment to the full extent of program liability
will be paid directly to the provider, but the payment to the provider
from program and beneficiary sources must not exceed the contractor
determined allowable charge except as provided in payments which
include other health insurance which is primary.
2.2 In such a case, the provisions
of
32 CFR 199.8 and
the TRICARE Reimbursement Manual (TRM),
Chapter
4 will apply.
2.3 The contractor
shall appropriately disburse the payment in all cases in which the
documented knowledge of payment by the beneficiary or other party,
including, when necessary, splitting payment. (See the TRM for cases
where double coverage is also involved.)
2.3.1 The contractor
shall reissue an adjustment check to the beneficiary or sponsor
if the provider returns an adjustment check to the contractor indicating
that payment had been made in full.
2.3.2 The contractor
shall, if the non-network provider is clearly not participating
or the intent cannot be determined, pay the beneficiary (parent
or legal guardian).
3.0 CLAIMS FOR CERTAIN ANCILLARY
SERVICES
3.1 The contractor shall approve
arrangements for laboratory work submitted by network physicians,
if laboratory tests billed by a non-network provider were performed
outside the office of the non-network provider, the place where
the laboratory tests were performed must be provided.
3.2 The services, to be covered,
must have been ordered by a Doctor of Medicine (MD) or Doctor of Osteopathy
(DO) and the laboratory must meet the requirements to provide the
services as required under the 32 CFR 199, and Defense Health Agency
(DHA) instructions.
4.0 INTERNATIONAL
CLASSIFICATION OF DISEASES, 9TH REVISION, CLINICAL MODIFICATION
(ICD-9-CM) “V” CODES
4.1 The ICD-9-CM codes listed in
the Supplementary Classification of Factors Influencing Health Status
and Contact with Health Services, otherwise known as
V codes,
deal with circumstances other than disease or injury classifiable
to the ICD-9-CM categories 001-999.
V codes are acceptable
as primary diagnoses on outpatient claims (rarely on inpatient claims)
to the extent that they describe the reason for a beneficiary’s
encountering the health care system.
4.1.1 Claims
with dates of service or dates of discharge provided before the
mandated date, as directed by Health and Human Services (HHS), for
International Classification of Diseases, 10th Revision (ICD-10) implementation,
with V codes as the primary diagnoses are to be processed
as follows in the paragraphs below without development.
4.1.2 Claims with dates of service
or dates of discharge provided on or after the mandated date, as
directed by HHS, for ICD-10 implementation, are to be processed
in accordance with ICD-10-CM Z codes.
4.2 V codes which
provide descriptive information of the reason for the encounter
based on the single code, e.g., V03.X (Prophylactic vaccination
and inoculation against bacterial diseases), V20.2 (Routine infant
or child health check), V22.X (Supervision of normal pregnancy),
V23.X (Supervision of high-risk pregnancy), V25.2 (Sterilization),
are acceptable as primary diagnoses.
4.3 Claims
with these codes may be processed according to TRICARE benefit policy
without additional diagnostic information.
4.4 V codes
for outpatient visits or encounters involving only ancillary diagnostic
or therapeutic services are acceptable as the primary diagnosis
to describe the reason for the visit or encounter only if the diagnosis
or problem for which the ancillary service is being performed is
also provided. For example, a V code for radiologic exam,
V72.5, followed by the code for 786.07 (wheezing) or 786.50 (chest
pain) is acceptable.
4.5 If the
diagnosis or problem is not submitted with a claim for the V-coded
ancillary service and the diagnosis is not on file for the physician’s
office services, the claim is to be denied for insufficient diagnosis.
4.6 V codes for preventive
services due to a personal history of a medical condition or a family
history of a medical condition are acceptable as primary diagnoses
when medically appropriate due to the personal or family history
condition.
4.7 Claims with these codes may
be processed according to the TRICARE benefit policy without additional diagnostic
information. Specifically, the treatment areas are as follows:
• Diagnostic and Screening Mammography,
e.g., V76.11, V10.3, V15.89, and V163.0.
• Pap Smears, e.g., V72.3, V76.2,
and V15.89.
• Screening for Fecal Occult
Blood, e.g., V10.00, V10.05, and V10.06.
4.8 Claims with the only diagnoses
being V codes which do not fall into one of the above
of categories, e.g., codes indicating personal or family histories
of conditions, are to be returned for insufficient diagnosis. This includes
those V codes corresponding to the V codes
for “Conditions not Attributable to a Mental Disorder” in the Diagnostic
and Statistical Manual of Mental Disorders of the American
Psychiatric Association (APA).
5.0 ICD-10-CM
“Z” CODES
5.1 The codes listed in Chapter
XXI of ICD-10-CM - Factors Influencing Health Status and Contact
with Health Services (Z00-Z99), otherwise known as Z codes,
will become effective on the mandated date, as directed by HHS, for
ICD-10 implementation, and replace ICD-9-CM V codes.
These Z codes deal with circumstances other than disease
or injury classifiable to the ICD-10-CM categories A00-Y99. Z codes
are acceptable as primary diagnoses on outpatient claims (rarely
on inpatient claims) to the extent that they describe the reason
for a beneficiary encountering the health care system.
5.2 Claims with Z codes
as the primary diagnoses are to be processed as follows without
development.
5.3 Z codes which
provide descriptive information of the reason for the encounter
based on the single code, e.g., Z23 (Encounter for Immunization),
Z00.129 (Encounter for routine child health examination without
abnormal findings), Z34.00 (Encounter for supervision of normal
first pregnancy, unspecified trimester), Z30.011 (Encounter for
initial prescription of contraceptive pills), are acceptable as
primary diagnoses.
5.4 Claims
with these codes may be processed according to TRICARE benefit policy
without additional diagnostic information.
5.5 Z codes
for outpatient visits or encounters involving only ancillary diagnostic
or therapeutic services are acceptable as the primary diagnosis
to describe the reason for the visit or encounter only if the diagnosis
or problem for which the ancillary service is being performed is
also provided. For example, Z01.89, Encounter for the other specified
(radiologic not associated with procedure) special examinations,
followed by the code for R06.2 (wheezing) or R07.1 (chest pain on
breathing) is acceptable.
5.6 If the
diagnosis or problem is not submitted with a claim for the Z-coded
ancillary service and the diagnosis is not on file for the physician’s
office services, the claim is to be denied for insufficient diagnosis.
5.7 Z codes for preventive
services due to a personal history of a medical condition or a family
history of a medical condition are acceptable as primary diagnoses
when medically appropriate due to the personal or family history
condition.
5.8 Claims with these codes may
be processed according to the TRICARE benefit policy without additional diagnostic
information. Specifically, the treatment areas are as follows:
• Diagnostic and Screening Mammography,
e.g., Z12.31, Z85.3, Z86.000, Z80.3, and Z91.89.
• Pap Smears, e.g., Z12.72, Z12.4,
Z11.51, Z86.001, and Z91.89.
• Screening for Fecal Occult
Blood, e.g., Z85.00 (Personal history of malignant).
5.9 Claims with the only diagnoses
being Z codes which do not fall into one of the above
of categories, e.g., codes indicating personal or family histories
of conditions, are to be returned for insufficient diagnosis. This includes
those Z codes corresponding to the Z codes
for “Conditions not Attributable to a Mental Disorder” in the Diagnostic
and Statistical Manual of Mental Disorders of the APA.
6.0 INDIVIDUAL PROVIDER SERVICES
Claims for individual providers
(including claims for ambulatory surgery) usually require materially
more detailed itemization than institutional claims. The claim must
show the following detail:
• Identification of the provider
of care;
• Dates of services;
• Place of service, if not evident
from the service description or code, e.g., office, home, hospital,
Skilled Nursing Facility (SNF), etc.;
• Charge for each service;
• Description of each service
and/or a clearly identifiable/acceptable procedure code; and
• The number/frequency of each
service.
7.0 UNDELIVERABLE/RETURNED MAIL
The contractor shall void the
check when a provider’s or beneficiary’s Electronic Remittance Advice
(ERA)/Explanation of Benefits (EOB) and check, or letter is returned
as undeliverable.
8.0 TED DETAIL LINE ITEM - COMBINED
CHARGES
8.1 Combining charges for the same
procedures having the same billed charges under the contractor’s “financially
underwritten” operation, for TED records, is optional with the contractor
if the same action is taken with all.
8.2 However,
for example, if the claim itemizes services and charges for daily
inpatient hospital visits from March 25, 2015 to April 15, 2015
and surgery was performed on April 8, 2015, some of the visits may
be denied as included in the surgical fee (post-op follow-up).
8.3 The denied charges, if combined,
would have to be detailed into a separate line item from those being allowed
for payment. Similarly, the identical services provided between
March 25th and March 31st, inclusive, would be separately coded
from those rendered in April.
8.4 The option
to combine like services shall be applied to those services rendered
the same calendar month.
9.0 CLAIMS SPLITTING
A claim shall only be split
under the following conditions. All services included on the claim
shall be processed together and reported on one TED record unless
a claim meets one of the following conditions. Unless a claim meets
one of the following conditions, all services included on the claim
shall be processed together and reported on one TED record.
9.1 A claim covering services and
supplies for more than one beneficiary (other than conjoint therapy,
etc.) should be split into separate claims, each covering services
and supplies for a specific beneficiary. This must be split under
TEDs for different beneficiaries.
9.2 A claim
for the lease or purchase of Durable Equipment (DE) and Durable
Medical Equipment (DME) that is paid by separately submitted monthly
installments will be split into one claim for each monthly installment.
The monthly installment will exclude any approved accumulation of
past installments (to be reimbursed as one claim) due on the initial
claim. These must be split under TEDs.
9.3 A claim
that contains services, supplies or equipment covering more than
one contractor’s jurisdiction shall be split. See
Section 2, for
information on transferring partially out-of- jurisdiction claims.
9.4 An inpatient maternity claim
which is subject to the TRICARE Diagnosis Related Group (DRG)-based payment
system and which contains charges for the mother and the newborn
shall be split, only when there are no nursery/room charges for
the newborn. See the TRM,
Chapter 1, Section 31.
9.5 Hospice claims that contain
both institutional and physician services shall be split for reporting
purposes. Institutional services (i.e., routine home care-651, continuous
home care-652, inpatient respite care-655, and general inpatient
care-656) shall be reported on an institutional claim format while
hospice physician services (Revenue code
657 and accompanying
Current Procedural Terminology (CPT) codes) shall be reported on
a non-institutional format. See the TRM,
Chapter 11, Section 4.
9.6 A claim for ambulatory surgery
services submitted by an ambulatory surgery facility (either freestanding or
hospital-based) may be split into separate claims for:
• Charges for services which
are included in the prospective group payment rate;
• Charges for services which
are not included in the prospective group payment rate and are separately allowable;
and
• Physician’s fees which are
allowable in addition to the facility charges. See the TRM,
Chapter 9, Section 1.
9.7 The contractor shall split
a claim submitted with both non-financially underwritten and financially underwritten
charges.
9.8 The contractor shall split
a non-institutional financially underwritten claim where Begin Date
of Care (TRICARE Systems Manual (TSM) Data Element 2-150) crosses
contract option periods. See the TSM,
Chapter 2, Section 1.1, paragraph 6.0.
9.9 A claim that contains both
institutional and professional services may be split into separate
claims for:
• Charges for services included
in the Outpatient Prospective Payment System (OPPS); and
• Charges for professional services
which are not included in the OPPS and are separately allowable.
9.10 The contractor shall process
claims which include services covered by NDAA for FY 2008, Section
1637, Transitional Care for Service-Related Conditions (TCSRC),
in accordance with
Chapter 17, Section 3.
9.11 Outpatient claims with dates
of service that cross the mandated date, as directed by HHS, for
ICD-10 implementation, the date for ICD-10-CM coding implementation,
must be split to accommodate the new coding regulations.
9.11.1 A separate claim shall be submitted
for services provided before the mandated date, as directed by HHS,
for ICD-10 implementation, and be coded in accordance with the ICD-9-CM,
as appropriate.
9.11.2 Claims for services provided
on or after the mandated date, as directed by HHS, for ICD-10 implementation,
shall be submitted and coded with the ICD-10-CM as appropriate.
9.12 West Region Only. Buckley Prime
Service Area (PSA) Pilot. The contractor shall split outpatient
claims which include services covered by the Buckley PSA Pilot and
services not covered under the Buckley PSA Pilot into separate claims
for:
• Charges for services provided
on dates of service covered under the Buckley PSA Pilot; and
• Charges for services provided
on dates of service which are not covered under the Buckley PSA
Pilot.
9.13 Claims for outpatient
services rendered in children’s or cancer hospitals when service
dates span September 30, 2023 to October 2, 2023. Claims that include
multiple service dates spanning September 30, 2023 and October 1,
2023 shall be separated by the contractor, and the policy in effect
on the date the service was rendered shall be utilized to price
the claim. The date of service for an emergency room encounter,
observation stay, or other encounter which spans multiple service
dates will be the date the service begins; for all other services related
to that encounter (e.g., lab, radiology, etc.) payment shall be
made on the basis of the policy in force on the date the service
was rendered.
10.0 PROVIDER NUMBERS
10.1 The contractor
shall process claims received from covered entities with the provider’s
National Provider Identifier (NPI) (individual and organizational)
using the NPI.
10.2 The contractor
shall deny electronic claim transactions received from covered entities
without the requisite NPIs in accordance with Implementation Guide
for the ASC X12N 837 transaction. See
Chapter 19, Section 4 for
further information.
10.3 The contractor
shall not return claims received (electronic, paper, or other acceptable
medium) with provider’s Medicare Provider Number (institutional
and non-institutional) to the provider to obtain the TRICARE Provider
Number.
10.4 The contractor shall accept
the claim for processing, develop the provider number internally,
and report the TRICARE Provider Number as required by the TSM,
Chapter
2, on the TED records.
11.0 TRANSGENDERED
BENEFICIARIES
The contractor
shall flag that patient’s file and defer claims for medical review
when there is a discrepancy between the patient’s gender and the
procedure, diagnosis (see Note), ICD-9-CM surgical procedure code
(for procedures before the mandated date, as directed by HHS, for
ICD-10 implementation), or ICD-10-Procedure Coding System (PCS)
surgical procedure code (for procedures on or after the mandated
date, as directed by HHS, for ICD-10 implementation), if a beneficiary
or provider notifies the contractor of the beneficiary’s status
as a transgender individual (either prospectively or through an
appeal).
11.1 The contractor shall override
any edit identifying a discrepancy between the procedure and the
patient’s gender for care that the review determines to be medically
necessary and appropriate.
11.2 TED record
data for claims made by a transgender individual must reflect the
Person Sex as downloaded from DEERS (TSM,
Chapter 2, Section 2.7) and the appropriate
override code.
Note: The edition of the ICD, CM
reference to be used is determined by the date of service for outpatient services
or date of discharge for inpatient services. Diagnoses coding for
dates of service or dates of discharge prior to ICD-10 implementation
shall be consistent with the ICD-9-CM. Diagnoses coding for dates
of service or dates of discharge on or after the mandated date,
as directed by HHS, for ICD-10 implementation, shall be consistent
with ICD-10-CM.
12.0 DRUG SEEKING BENEFICIARIES
Refer to
Chapter
28 for current claims review and restriction program.