TRICARE Operations Manual 6010.59-M, April 1, 2015
Claims Processing Procedures
Chapter 8
Section 1
General
Revision:C-120, June 12, 2023
1.0Purpose
The purpose of the TRICAREclaims processing procedures is to help ensure that all claims forcare received by TRICARE beneficiaries are processed in a timelyand consistent manner and that Government-furnished funds are expendedonly for those services or supplies authorized by law and Regulation.The contractor shall review all claims submitted and accept HealthInsurance Portability and Accountability Act (HIPAA) transactionand code sets. The review must ensure that sufficient informationis submitted to determine:
•The patient is eligible.
•The provider of services orsupplies is authorized under the TRICARE Program.
•The service or supply providedis a benefit.
•The service or supply providedis medically necessary and appropriate or is an approved TRICARE preventivecare service.
•The beneficiary is legallyobligated to pay for the service or supply.
•That the claim contains sufficientinformation to determine the allowable amount for each service orsupply.
2.0Who MayFile A Claim
2.1Beneficiary/Provider
Any TRICARE eligible beneficiarymay file a claim. Any institutional or individual professional provider certifiedunder TRICARE may file a claim on a participating basis for servicesor supplies provided to a beneficiary and receive payment directlyfrom TRICARE. The contractor shall deny any charge imposed by theprovider relating to completing and submitting the applicable claimform (or any other related information). Such charges shall notbe billed separately to the beneficiary by the provider nor shallthe beneficiary pay the provider for such charges. These chargesare to be reported as noncovered charges and denied as such.
2.2StateAgency
A stateagency who administers the Medicaid Program may submit a claim,if there has been an agreement signed between the agency and DefenseHealth Agency (DHA). (Refer to the TRICARE Reimbursem*nt Manual(TRM), Chapter 1, Section 20.)
2.3ParticipatingProvider - Agency Agreement With A Third Party
2.3.1Occasionally,a participating provider may enter into an agency agreement witha third party to act on its behalf in the submission and the monitoringof third party claims, including TRICARE claims. Such arrangementsare permissible as long as the third party is not acting simplyas a collection agency. There must be an agency relationship establishedin which the agent is reimbursed for the submission and monitoringof claims, but the claim remains that of the provider and the proceedsof any third party payments, including TRICARE payments, are paidto the provider. The contractor may interact with these agents inmuch the same manner as it interacts with the provider’s accounts receivabledepartment. However, such an entity is not the provider of careand cannot act on behalf of the provider in the filing of an appealunless specifically designated as the appealing party’s representativein the individual case under appeal. Questions relating to the qualificationsof any such business entity should be referred to the DHA Officeof General Counsel (OGC), through the Contracting Officer (CO),for resolution.
2.3.2On a monthlybasis, DHA’s Office of Program Integrity (PI) provides each contractorwith an updated data file of excluded third party billing agents.Based on this file, the contractor shall not accept any claims fromexcluded third party billing agents. Any claim received from anexcluded third party billing agent shall be returned to the provider,instructing the provider that the submission of a valid claim cannotbe done through a sanctioned entity, and to resubmit the claim directly,or through an approved third party billing agent. The contractorshall inform the provider that the third party billing agent hasbeen excluded by Health and Human Services (HHS)/Centers for Medicareand Medicaid Services (CMS) and that no claims will be acceptedfrom the third party billing agent until it has been reinstated.The contractor shall also provide notification to the third partybilling agent that no claims will be accepted from it until it hasbeen reinstated by HHS/CMS.
3.0TRICARE Claim Forms
3.1AcceptableClaim Forms
3.1.1A properly completed acceptableclaim form must be submitted to the contractor before payment maybe considered. For paper claims, the contractor shall accept thelatest mandated version of the following claim forms for TRICAREbenefits: the DoD Document (DD) Form 2642, the CMS 1500 Claim Form,and the CMS 1450 UB-04. The American Dental Association (ADA) claimforms may be used in the processing and payment of adjunctive dentalclaims. Electronic claims shall be accepted in HIPAA-compliant standardizedelectronic transactions (see Chapter19).
3.1.2The DDForm 2642, “Patient’s Request For Medical Payment” (http://www.dtic.mil/whs/directives/forms/eforms/dd2642.pdf)is for beneficiary use only and is for submitting a claim requesting paymentfor services or supplies provided by civilian sources of medicalcare to include physicians, medical suppliers, medical equipmentsuppliers, ambulance companies, laboratories, Extended Care HealthOption (ECHO) providers, or other authorized providers. See Appendix A fora definition of “medical.” If a DD Form 2642 is identified as beingsubmitted by a provider for payment of services, the form shallbe returned to the provider with an explanation that the DD Form2642 is for beneficiary use only and that the claim must be resubmittedusing either the CMS 1500 Claim Form or the CMS 1450 UB-04, whicheveris appropriate. The form may be used for services provided in aforeign country but only when submitted by the beneficiary. Contactthe DHA Administrative Office to order the DD Form 2642.
3.1.3Electronic Claim Forms
When submitting an electronicclaim form, the physician, supplier, pharmacy, or their representativeis attesting to the same information as provided on the back ofa CMS 1500 claim form and a CMS 1450 UB-04.
4.0ClaimsReceipt And Control
All claimsshall be controlled and retrievable. The face of each hardcopy TRICAREclaim shall be stamped with an individual Internal Control Number(ICN), and entered into the automated system within five workdaysof actual receipt. For both hardcopy and Electronic Media Claim(EMC), the ICN shall contain the Julian date indicating the actualdate of receipt. The Julian date of receipt shall remain the sameeven if additional ICNs are required to process the claim. If aclaim is returned, the date of the receipt of the resubmission shallbe entered as the new date of receipt. All claims not processedto completion and supporting documentation shall be retrievableby beneficiary name, sponsor’s Social Security Number (SSN), DefenseEnrollment Eligibility Reporting System (DEERS) family ID, or ICN within15 calendar days following receipt.
5.0Newborn Claims- Before January 1, 2018
5.1Claims for newborns shall beprocessed without eligibility on DEERS as long as:
•The newborn date of birth iswithin 365 days of the contractor’s eligibility query; and
•The sponsor is/was eligiblefor TRICARE for the dates of care on the newborn claim.
5.2A newborn or adoptee will bedeemed to be enrolled in Prime as of the date of birth or adoptionif one family member is already enrolled in Prime. A responsiblerepresentative has 60 days to officially enroll the child to thePrime option. If the newborn or adoptee is formally enrolled inPrime within the 60 day period, the effective date of enrollmentwill be the first of the month following the date of birth or adoption.(The 20th of the month enrollment rule is waived, if necessary.)If the newborn or adoptee is not formally enrolled during the 60day calendar period, the newborn or adoptee will revert to a non-enrolledbeneficiary effective the 61st day. If the decision is made to continuePrime coverage, an official enrollment request (enrollment form, theGovernment furnished web-based self-service enrollment system/application transaction,or telephonic request) must be completed on behalf of the child.For retirees or their family members or survivors who decide to continueenrollment for the child, the unused portion (prorated on a monthlybasis) of the single enrollment fee they paid will be applied towarda new family enrollment period. For newborns and newly adopted childrenenrolled under this provision, Point of Service (POS) cost-sharingdoes not apply through the 60th day or the effective date of enrollment,whichever is earlier. All services shall be processed with the Primecopayment even in the absence of referrals or authorizations. TheDirector, TRICARE Regional Office (TRO) may extend the deemed periodup to 120 days, on a case-by-case or regional basis.
•Newborns/adoptees in overseaslocations are deemed to be enrolled for 120 days following birth/adoptionwhen one other family member, to include the sponsor, is enrolledin TRICARE Overseas Program (TOP) Prime or TOP Prime Remote.
•For additional informationon newborns under the TRICARE Reserve Select (TRS) program see Chapter 22, Section 1 and for TRICARE RetiredReserve (TRR) see Chapter 22, Section 2.
6.0NewbornClaims - On Or After January 1, 2018
See TRICARE Policy Manual (TPM), Chapter 10, Section 3.1.
7.0ClaimsProcessing Exemption During 2018 Calendar Year Enrollment Period- Effective January 1, 2018
7.1Policy
During the calendar year 2018enrollment grace period, an individual who is eligible to enrollin TRICARE Prime or TRICARE Select but does not elect to enrollin such programs will only be eligible for space-available careat military treatment facilities. If claims are received for theseindividuals that would otherwise be cost-shared under the TRICAREprogram, the claims will be cost shared by TRICARE for that initialEpisode Of Care (EOC) only. This exemption to established TRICAREclaims processing rules expires on December 31, 2018.
7.2ManagedCare Support Contractors (MCSCs), OverseasContractor, and TRICARE Medicare Eligible Program(TMEP) Contractor will:
7.2.1Use theDEERS eligibility response to determine which purchased care claim(s)apply to beneficiaries who are eligible for but have not enrolledin TRICARE Prime or TRICARE Select.
7.2.2ValidateHealth Care Delivery Program Code (HCDP) of beneficiary for DirectCare of 002, 004, 006, 008, 014, 016, or 30; and one of the following:
7.2.2.1If OGP type code A or B are bothpresent; route to the TMEP or overseascontractor (as applicable) for processing, or
7.2.2.2If the OGP type code does notindicate any form of Medicare coverage and the Member RelationshipCode is one of the following, process the claim as TRICARE Select:
•A=SELF,
•B=SPOUSE,
•C=CHILD/STEP CHILD,
•E=WARD,
•G=SURVIVING SPOUSE,
•H/I/J/K=FORMER SPOUSE, OR
•O=NEWBORN
7.2.2.3Otherwise, deny the claim andrespond with an explanation of benefits.
7.2.3Use bestbusiness practice to determine the claims that are applicable tothe episode of care.
7.2.4Process those claims at theTRICARE Select network or out-of-network rate, as applicable.
7.2.5Notifythe individual in writing within 10 business days with an explanationof benefits or similar correspondence, and include the following.
7.2.5.1Only claims related to thisinitial episode of purchased care services (as defined by the contractor,including a date range) will be cost-shared by TRICARE. The daterange must be specified in the written notification.
7.2.5.2Future claims not related tothe determined episode of care will be denied.
7.2.5.3If TRICARE Prime or TRICARESelect coverage is desired, he/she may enroll in such coverage atany time during calendar year 2018, and provide instructions onhow to enroll, and
7.2.5.4After December 31, 2018, he/shemay only enroll in TRICARE Prime or TRICARE Select during an annualopen enrollment period or if a member of the family experiencesa Qualifying Life Event (QLE).
7.3Pharmacycontractor will:
7.3.1Upon receipt of a TRICARE pharmacyclaim for retroactive reimbursem*nt that includes a copy of thewritten notification from a contractor listed above as requiredby paragraph 7.2.5, process the claim at thenetwork or out-of-network rate, as applicable, for the time framesas listed in the written notification.
Refills are limited to thetime frame specified in the notification letter.
7.3.2Notifythe individual in writing within 10 business days, and include thefollowing:
7.3.2.1Only pharmacy claims relatedto this initial episode of purchased care services will be cost-sharedby TRICARE.
7.3.2.2Future claims or refills notrelated to the determined episode of care will be denied until the individualis enrolled in TRICARE coverage.
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