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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Duplicate Claims System (DCS) - TRICARE Encounter Data (TED) Version
Chapter 4
Section 1.3
Multi-Contractor Claim Sets
Revision:  C-14, May 30, 2018
On occasion, two different contractors will pay for the same billed services. These types of duplicate payments are a result of jurisdictional processing errors. To ensure that this type of duplicate payment is addressed in the Duplicate Claims System (DCS), special data fields and procedures have been incorporated.
1.0  Description Of A Multi-Contractor Claim Set
1.1  A multi-contractor claim set contains potential duplicate claims processed by two or more contractors. A multi-contractor set, consisting of Responsible FIs 50 and 55, is shown in Figure 4.1.3-1. The resolution of multi-contractor claim sets requires coordination between/among the contractors involved. Multi-contractor sets always involve an erroneous payment because only one contractor is responsible for processing and paying for services within a jurisdiction at any given time. When two different contractors pay for the same billed service, it means that one or more of the claims in the set were erroneously processed and paid by a contractor who did not have processing jurisdiction.
Figure 4.1.3-1  Sample Multi-Contractor Claim Set
Description for Figure 4.1.6-1 - This is a screen shot of a Multi-Contractor Claim Set. The description of what is on this screen follows.
1.2  As with all other potential duplicate claim sets, the DCS assigns ownership of each set, i.e., responsibility for resolving the set, to the contractor who submitted the claim with the latest processed to completion (PTC) date. This contractor becomes the Owner FI, who must research the claims in the set to determine if they had jurisdiction for the billed services. If the assigned Owner FI determines that they did not have processing jurisdiction for the claims in the set and, therefore, paid the claims in error, the Owner FI must resolve the duplicate situation. This means that the Owner FI must remain as the Owner FI, indicate that a duplicate condition exists in the set, initiate recoupment of the overpayments, ensure receipt of the refunds/offsets, submit appropriate TRICARE DCS-TRICARE Encounter Data (TED) Version adjustments, verify that these adjustments are reflected in the TED database, and resolve the set.
1.3  If, however, the Owner FI determines that they did have processing jurisdiction for the claims in the set and, therefore, the other contractor paid the claim(s) in the set in error, the current Owner FI must change ownership of the set to the other contractor for resolution.
1.4  Changing set ownership (i.e., the Owner FI field) is a function limited to multi-contractor sets. Ownership of other duplicate claim sets cannot be changed by a contractor. Only multi-contractor sets can be changed. The Owner FI change is restricted to the contractors (Responsible FIs) that processed claims in the set or are responsible for claims transferred in a contract transition.
1.5  When ownership of a multi-contractor claim set is changed, the set is moved from the view of the old Owner FI to the new Owner FI. The new Owner FI becomes the new “owner” of the set and assumes responsibility for resolving the duplicate situation in the set. The old Owner FI uses the Modify function on the menu bar to re-assign ownership of the claim set to the other contractor.
1.6  The system uses three fields to manage the assignment of responsibility for resolving duplicate claims in multi-contractor claim sets. By default, the system assigns the Owner FI field to the contractor that processed the claim with the latest PTC date. Multi-contractor claim sets appear along with all other claim sets assigned to the same Owner FI. Other contractors will not have access to these sets.
1.7  The Responsible FI field is used to identify the contractor who is currently responsible for a claim. This field is shown for each claim listed on the CLAIM SET SCREEN and the CLAIM DETAIL SCREEN. The Processing FI field is used to identify the contractor that paid the claim. This field is shown on the CLAIM DETAIL SCREEN. These fields are described below.
1.7.1  Owner FI Field
This field is assigned by the DCS to each claim set. The Owner FI field designates the contractor responsible for resolving the claim set.
1.7.2  Responsible FI Field
This field is assigned by the DCS to each claim in a set to identify the contractor responsible for correcting any errors in the claim and for recouping any overpayments of actual duplicate payments. The Responsible FI of the claim with the latest PTC date is also assigned as the Owner FI of the set. During a contract transition, the system looks at all claims belonging to the outgoing contractor and determines if the Responsible FI field should be changed to the incoming contractor. If the claim is included in the transition plan, the system will change the Responsible FI field to the incoming contractor or to the inactive designation of FI 99. The FI 99 designation will appear on the screen in red. If the claim is not included in the transition plan, the system will leave the field unchanged. See paragraph 5.0, for additional information.
1.7.3  Processing FI Field
This field is a claim-level data element that is extracted from the TED. It contains the FI number of the contractor that originally processed the claim. The Processing FI field cannot be changed in the DCS.
2.0  System Features Unique To Multi-Contractor Claim Sets
The layout of the data and the screens available for viewing and entering data in multi-contractor claim sets is the same as the layout of single contractor claim sets. In multi-contractor sets, though, the contractor who is designated the Owner FI can change the Owner FI field to designate the other contractor as the Owner FI. This process is initiated as follows:
2.1  Click on the Modify function on the menu bar.
2.2  Click on the Owner FI option from the drop-down menu.
2.3  The system displays the FI number(s) of the other contractor(s) in the set. Click on the contractor to be designated as the new Owner FI.
2.4  This feature also requires the current Owner FI to document contact with the contractor to which the set will be transferred and provide an explanation for why ownership of and responsibility for resolving the set is being changed. When a new Owner FI is assigned, the Owner Region field changes to <to be assigned>. The new Owner FI subsequently can click on the Modify function, Owner Region option, and select the appropriate Owner Region.
•  A system feature unique to multi-contractor sets is the rule for changing the status of a set to Pending. In effect, the system ignores the claims in the set in which the Responsible FI is not the Owner FI. It allows an Owner FI to move a set to a Pending status if there is one BASE claim and all of the Owner FI’s claims meet the general conditions for Pending status. That is, all Owner FI claims must have a dupeflag and reason code, there must be a Y claim, and every Y claim must have an identified recoupment amount greater than $0.00. According to this rule, the status of a multi-contractor set may change as the Owner FI changes. For example, if the Owner FI identifies all of their claims as actual duplicates and enters a Y in the Dupe? fields, selects reason codes and enters amounts identified for recoupment, and leaves the other contractor’s claim as the BASE claim, and clicks the UPDATE CHANGES button, the status of the set will move to Pending. However, if the Owner FI changes the Owner FI field to the other contractor that has only the BASE claim, the new Owner FI will receive the set in Open status. According to the rules, the new Owner FI does not have actual duplicate claims with associated amounts identified for recoupment. Since Pending status means pending recoupment and since the new Owner FI’s claim is the BASE claim and is not one of the duplicates, the set cannot be pending recoupment for the new Owner FI. The set would be in Pending status for the old Owner FI not the new Owner FI.
2.5  Another system feature unique to multi-contractor claim sets is the special logic invoked for multi-contractor appended sets. When a new claim is identified during the monthly extract as a potential duplicate of a claim in an existing set, the set is called an appended set. In appending a new claim to a set, the system applies the general rule of assigning the Owner FI to the Responsible FI of the claim with the latest PTC date if the status of the set is Open or Closed. If the status of the set is Pending or Validate, the system ignores this rule and leaves the current assignment of the Owner FI. The system also applies special logic to determine the status of multi-contractor appended sets. The status of multi-contractor sets with an appended claim is determined as follows:
•  Open sets will remain Open because recoupment had not been initiated on the set prior to the new claim being appended.
•  Pending sets will remain Pending to allow the Owner FI to complete recoupment of actual duplicate payments prior to determining if additional research is required or if the set should be transferred to another contractor.
•  Validate sets will be changed to Pending to allow the Owner FI to determine if the appended claim changes the Validate situation prior to determining if additional research is required or if the set should be transferred to another contractor.
•  Closed sets will be changed to Open to allow the Owner FI to determine if the appended claim requires additional research or if the set should immediately be transferred to another contractor.
3.0  Coordination Requirements When Working With Multi-Contractor Sets
Resolution of multi-contractor claim sets requires close coordination between the contractors involved to ensure that research efforts and resolution activities are conducted efficiently, appropriately, and in a timely manner. When researching a multi-contractor set, the Owner FI must coordinate with the other contractor(s) involved to determine who is responsible for the duplicate payment(s) and for recouping the overpayment(s). The method of coordination must be negotiated between contractors and may take whatever form is agreeable, i.e., by telephone, fax, e-mail, or combination thereof. This coordination is a courtesy among contractors and should prevent indiscriminate transfers of sets back and forth. If the current Owner FI is not responsible for the duplicate payment, the current Owner FI should contact the other contractor to advise them of the set, its upcoming transfer, and to discuss or describe the circumstances involved. Ownership of the set must not be changed to another contractor until the receiving contractor has been consulted and an explanation has been entered into the system justifying the switch. The explanation entered into the system must contain:
•  The date the other contractor was contacted.
•  The name and telephone number of the person making the contact from the current Owner FI.
•  The name and telephone number of the person contacted at the contractor to which ownership of the set is being changed.
•  A brief explanation for the change of ownership (e.g., “This claim falls within the jurisdiction of the West Region. Contractor for the East Region 14 paid claim in error and is responsible for recoupment of the overpayment.”).
4.0  Resolving Multi-Contractor Claim Sets
Multi-contractor claim sets are resolved in the same manner as all other claim sets in the DCS.
4.1  When the initial Owner FI conducts research and determines that they were responsible for the duplicate payment, the contractor can initiate recoupment and resolve the claim set in accordance with the rules of resolution.
4.2  When the initial Owner FI determines that the duplicate payment belongs to a different contractor, the current Owner FI must contact the other (receiving) contractor and discuss or describe the situation before the current Owner FI can change ownership. The current Owner FI must document the contact and the reason for the change in set ownership. Although the current Owner FI may enter a Y in the Dupe? field of the other contractor’s claim, it is recommended that this action be reserved for the Responsible FI of the claim. The Owner FI transferring the set may not enter an amount identified for recoupment for the other contractor’s claims.
4.3  After documenting the contact and agreement to change set ownership, the current Owner FI may change ownership to the other (receiving) contractor. Once ownership is changed in the system, the receiving contractor (the new Owner FI) can view the set, initiate recoupment action, and resolve the claim set in accordance with the rules of resolution. Multi-contractor sets must not be resolved without communication and coordination among the involved contractors. The only exceptions to this are multi-contractor sets in which the only other contractor involved is FI 99.
4.4  If a multi-contractor set contains a BASE claim and two or more additional claims processed by different contractors, ownership must be transferred to each contractor responsible for the non-BASE claims in order to resolve the set. Each contractor is responsible for identifying their duplicate payments, initiating recoupments, and submitting TED adjustments corresponding to their refunds and offsets. The set cannot be resolved unless all resolution requirements have been met.
4.5  Ownership of multi-contractor sets may switch back and forth between contractors as research is conducted and determinations about jurisdictional responsibility are made. When a set changes ownership, only the current Owner FI can view the set, including all adjustments. The current Owner FI is never permitted to enter recoupment amounts in the other contractor’s claim. The current Owner FI is, however, permitted to flag an adjustment submitted by another contractor to facilitate resolution.
5.0  Resolving Claim Sets Containing Inactive FI 99 Claims
5.1  The transition plan will determine if an outgoing contractor’s claim should be transferred to the incoming contractor or to an inactive status of FI 99. If a claim in a multi-contractor set is transferred to FI 99, special logic is applied to the resolution of the set. The system will not permit a multi-contractor set to have an Owner FI of 99. Therefore, if the Responsible FI on the claim with the latest PTC date is FI 99, the Owner FI will be assigned to another Responsible FI.
5.2  The resolution of multi-contractor sets normally requires Owner FIs to identify at least one actual duplicate claim in the set. However, special logic is applied to multi-contractor sets containing an inactive FI 99 claim. If there are no other active contractors in the set, the Owner FI can resolve the set without identifying an actual duplicate claim. In other words, if the Owner FI is the Responsible FI of one claim in the set and the other claim has a Responsible FI of 99, the Owner FI can identify both claims as non-duplicates and resolve the set to a Closed status. The Owner FI also can resolve sets containing FI 99s according to the general rules of resolution in which actual duplicates are identified, recoupments are received, and adjustments are processed.
5.3  Sets with FI 99 claims are simply another type of multi-contractor set. When confronted with an FI 99 set, the Owner FI needs to determine if it had jurisdiction for the claim(s) it paid. For FI 99 sets the Owner FI should enter an N in the Dupe? fields and enter either BASE or N300 in the Reason Code fields of the FI 99 claims. For the Owner FI’s claims, an N or a Y may be entered in the Dupe? field and a valid reason code should be entered.
Note:  An Owner FI claim may be designated as the BASE claim. If the Owner FI determines that it did not have jurisdiction for the claim(s) it paid, then it must put a Y in the Dupe? field(s) of its claim(s).
6.0  Determining Jurisdiction For Claim Sets
Duplicate claim sets assign jurisdiction in accordance with TRICARE Operations Manual (TOM), Chapter 8.
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