Claims Appeals by zlf68208

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									                                 TRICARE Fundamentals Course


                                   Claims & Appeals




                                        13
                                         Participant Guide




References
32 CFR §§ 199.7, 199.10
OPM Part III, Chapter 13
TRICARE Operations Manual 6010.51-M, August 2002, Chapter 8
TRICARE Reimbursement Manual, 6010.53, March 15, 2002, Chap 2, Addendum A
http://www.military.com/benefits/tricare/tricare-standard/non-availability-statements
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                  Each of the 8 items below is a separate puzzle.
                           How many can you figure out?


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5.               6.                      7.                         8.
dice             Dribble                 GROUND                     FRIENDS STANDING
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    TRICARE Fundamentals Course
    13) Claims & Appeals




        Explain who can file claims and where claims should be submitted
        Describe how to resolve claims issues
        Identify three reasons why a claim may be denied
        Distinguish between what can and cannot be appealed




    Disclaimer: The content in this module only applies to claims for health care services, not to
    pharmacy or dental claims



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13) Claims & Appeals

1.0 What are Claims?
    Claims are filed to issue payment for services or supplies provided by civilian sources of
     medical care which may include, but are not limited to:
       o Physicians
       o Hospitals
       o Skilled nursing facilities
       o Pharmacies
       o Medical suppliers
       o Ambulance companies
       o Laboratories
       o Physical therapy
       o Vendor pharmacies
       o Veterans Affairs treatment facilities
       o Other TRICARE authorized providers.

2.0 Who Files the Claim?
The person who submits the claim is either the provider of services or supplies, or the beneficiary

2.1 Provider
    An authorized provider is one approved under TRICARE for services or supplies provided to a
     beneficiary and receive payment directly from TRICARE
       o Institutional providers include hospitals and nursing facilities
       o Professional providers include an independent provider or group practice
Note: TRICARE denies claims from non-authorized providers

2.2 Beneficiary
    Any TRICARE-eligible beneficiary
       o A spouse, parent, or legal guardian of a minor (under age 18) or incompetent beneficiary
         submits a claim on behalf of the beneficiary, unless otherwise specified



3.0 Submitting Claims
    Claims are submitted to the claims processor responsible for the region where the beneficiary
     lives
    There are two major TRICARE claims processors:


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       o Palmetto Government Benefits Administration (PGBA) processes claims for the North
         and South regions
       o Wisconsin Physicians Service (WPS) processes claims for the West and Overseas
         regions, as well TRICARE for Life claims (regardless of stateside region)
    If beneficiaries send claims to the regional contractor instead of the regional claims processor,
     the contractor forwards them to the appropriate processor
       o If a claim is sent to the wrong claims processor, the claim is either forwarded to the
         correct processor or returned to either the provider or beneficiary
    TRICARE-eligible beneficiaries are responsible for making sure their providers, as well as
     DEERS, have current personal contact information so claims go to the correct claims
     processor and related payment information can be sent to the beneficiary

4.0 Claims Processing Procedures
    TRICARE processes claims using specific procedures to ensure:
       o All claims are processed in a timely manner
       o Government-furnished funds are expended only for those services or supplies authorized
         by law and regulation

4.1 Processing Criteria
    Claims processors verify the following criteria in this order:
       o The beneficiary is eligible
       o The beneficiary/provider filed the claim within the given time limits
       o The provider of services or supplies is TRICARE authorized
       o The service or supply provided is a benefit
       o The service or supply provided is medically necessary and appropriate or is an approved
         TRICARE clinical preventive service
       o The beneficiary is legally obligated to pay for the service or supply, when appropriate
       o The claim contains sufficient information to determine the TRICARE maximum allowable
         charge (TMAC) for each service or supply
Note: The beneficiary is ultimately responsible for making sure claims are filed

5.0 Resolving Claims Issues
    The first action beneficiaries should take to resolve claims issues is to call the regional
     contractor’s toll-free number and pick the option for claims assistance, or visit a local TRICARE
     Service Center (TSC)
    If the claim issue remains unresolved, the beneficiary may contact a military treatment facility
     (MTF) or a TRICARE Regional Office Beneficiary Counseling and Assistance Coordinators
     (BCAC)

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    If the unresolved debt results in a collection action, the beneficiary should contact the regional
     contractor or MTF/a TRICARE Regional Office Debt Collection Assistance Officer
     (DCAO)/TRICARE Regional Office/TRICARE Area Office
    BCACs and DCAOs can also request access to the regional claims processors online system
     (mytricare.com or tricare4u.com) through their TRICARE Regional Office (TRO)

5.1 Questions to ask the Beneficiary
The following list should be considered when conducting an initial claim inquiry with and for the
beneficiary:
    Did the beneficiary contact the claims processor for their region or plan? If so, what was the
     result?
    Did the beneficiary bring in his or her explanation of benefits (EOB), summary payment
     voucher, or bill?
       o If the beneficiary states that he or she never received an EOB, he or she can look up
         claims information on the Web (if requested and granted access), or call the claims
         processor (PGBA or WPS) to find out if the provider submitted a claim
       o If not, contact the provider to determine if and/or when the claim was forwarded to the
         claims processor
    When was the date of service? What was the beneficiary’s eligibility status or category at the
     time of service?
    What type of service did the beneficiary receive (i.e. medical appointment, hospitalization,
     medications administered in a provider’s office, supplies)?
    Was this an inpatient or outpatient service?
    If the EOB is available, study the notes to determine how and why the claim processed as
     such (for example):
       o Point of Service [POS]
       o No authorization on file
       o Beneficiary is no longer eligible/Social Security Number [SSN] is no longer eligible
       o Not a TRICARE benefit

5.2 Working with Claims Processors
BCACs and DCAOs should try to work consistently with one key claims processor staff member to
build rapport and maintain consistency in the communication process when researching/resolving
beneficiaries’ claim(s) issues

6.0 Who is Responsible for Filing the Claim?
Beneficiaries are ultimately responsible for ensuring the submission of claims to TRICARE for
payment


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13) Claims & Appeals
6.1 Network
If the beneficiary sees a network provider, the provider is responsible for filing the claim, but the
beneficiary can still be held liable if the network provider fails to file.

6.2 Non-Network
    Non-network providers can choose to participate (accept TRICARE payment as payment in
     full) or not on a case-by-case basis.
       o Participating: Provider accepts TRICARE payment (beneficiary and provider pay 100% of
         the allowable charge) as payment in full/accepts assignment from TRICARE
              These providers may submit claims for beneficiaries; the beneficiary is responsible to
               make sure the claim is filed.
       o Non- Participating: The provider receives TRICARE payment (beneficiary and provider
         pay 100% of the allowable charge), plus bills the beneficiary an additional 15 percent
         (Balance Billing).
              The provider is not required or may choose not to file a claim; it is ultimately the
               beneficiary’s responsibility to make sure claims get filed in a timely manner; the
               beneficiary is responsible to make sure the claim is filed.

6.3 Filing Deadlines
    The filing deadline is within one (1) year of the date of service.
    Beneficiaries should file or check on a claim filing status as soon as possible.
    Beneficiaries should ask their civilian providers to file the claim.

7.0 Other Health Insurance (OHI)
    Special circumstances exist when beneficiaries have other health insurance (OHI).
    If a beneficiary has OHI, the beneficiary or the provider must file a claim with that health
     insurance plan before filing with TRICARE.
    After it has been processed by the OHI, a claim can then be filed with TRICARE along with a
     copy of:
       o The other health plan’s payment determination
       o The itemized charges (bill)
    Beneficiaries should notify their Regional Contractor or the claims processor about their OHI
     and any changes to it to avoid delays in claims processing or possible denials.

8.0 Claim Forms
    Beneficiaries cannot combine different types of claims; they should send a separate claim and
     claim form for each visit to a provider’s office or for each service provided by different
     providers.


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    Beneficiaries must submit a separate claim for each family member despite the fact they all
     may have visited the same provider on the same day.

8.1 Sent in by Beneficiaries or Family Members
    Beneficiaries or family members should submit a claim using a DD Form 2642, “TRICARE
     DoD / CHAMPUS Medical Claim - Patient’s Request For Medical Payment.”
    The DD Form 2642 is submitted for services or supplies provided by civilian sources of
     medical care.
       o If submitted by a provider, the form will be returned to the provider unless he/she is an
         overseas provider.
    The DD Form 2642 can be downloaded from:
       o The TRICARE Web site: www.tricare.mil/claims/Dd2642.pdf,
       o PGBA’s Web site: www.mytricare.com or
       o WPS Web site: www.tricare4u.com.
    The DD Form 2642 can be requested by calling the regional contractor’s toll-free number, or
     visiting a local TRICARE Service Center (TSC), if one is available.
    As a last resort, beneficiaries may also get claim forms by writing to TRICARE Management
     Activity, 16401 E. Centretech Parkway, Aurora, Colorado 80011-9066.

8.2 Sent in by Providers
    Professional providers should submit a claim using the CMS 1500, “Health Insurance Claim
     Form.”
    The CMS 1500 is available:
       o By downloading from:
              The TRICARE Web site: www.tricare.mil/claims/1500-90.pdf
              PGBA’s Web site: www.mytricare.com
              WPS’ Web site: www.tricare4u.com
       o By hardcopy at most TSCs or from BCACs/Health Benefit Advisors (HBAs)
    Institutional providers should submit a claim using the UB–04 form.
       o The UB-04 is used for inpatient or outpatient care from hospitals and other institutes.
    The UB-04 can be downloaded from:
       o The WPS Web site: www.tricare4u.com/apps/tricare2/pdfs/h1450.pdf
       o The PGBA Web site: http://www.cms.hhs.gov/providers/edi/h1450.pdf
    The UB-04 is not readily available at TSCs.




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8.3 Overseas: Care Received Overseas
    Beneficiary may submit a DD Form 2642.
    Overseas providers may submit a DD Form 2642 or the CMS 1500, depending on the region in
     which care was received.

8.4 Items That May Need to be Submitted with A Claim
If a beneficiary is required to file the claim, the following may have to accompany the claim:
    A Non-availability Statement (NAS) Authorization Number
       o A NAS is a certification from an MTF stating that it cannot provide needed non-
         emergency inpatient mental health care services.
              If the beneficiary does not get a NAS before they receive inpatient behavioral care
               from a civilian source, TRICARE may not share the costs.
    An Itemized list of charges for each service or supply; must be on the provider’s letterhead or
     standard form
    An Itemized list of charges from the pharmacy; must be on the pharmacy’s letterhead or billing
     form
    Other health insurance claim forms: the health plan’s payment determination or denial/EOB
    A DD Form 2527 “Statement of Personal Injury—Possible Third-Party Liability”
       o Required to be submitted with DD Form 2642 when filing in instances in which a
         beneficiary’s condition is accident-related, work-related, or both.
       o If the beneficiary does not submit a DD Form 2527 initially, the claim processor has
         certain procedural or diagnostic codes that indicate there may be third party liability
         involved and sends the form to the beneficiary for processing.
       o Beneficiaries’ claims are pended and/or denied if they do not submit the third party liability
         form within the time frame specified.
       o Beneficiaries can send this form after initial claim is submitted or as requested by the
         regional claims processor.
       o Request a DD Form 2527 by calling the regional contractor’s toll-free line or by visiting a
         local TSC.
       o The DD Form 2527 can be downloaded from:
              The TRICARE Web site: www.tricare.mil/claims/Dd_2527.pdf
              PGBA’s Web site: www.mytricare.com
              WPS’ Web site: www.tricare4u.com
              Also available from TSC, BCAC, or HBA




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9.0 Explanation of Benefits (EOB)
    After submitting claims, the beneficiary and provider each receive an EOB from the claims
     processor, showing the services performed and the claim adjudication (or settlement of
     payments)
    The EOB is mailed or posted online on either www.tricare4u.com or www.myTRICARE.com,
     depending on the region

9.1 When to expect an EOB
    For the majority (95%) of claims processed, the beneficiary and the provider should each
     receive an EOB within 6 weeks of submitting a clean claim.
       o Some complex claims may take 60 days or more to complete.
       o To determine if a claim was received, check the claim’s processor Web site or call the
         claim’s processor.
    If the beneficiary lives in the South region, they will not receive an EOB if they are not liable for
     charges. However, the beneficiary is encouraged to review all claims information in
     www.myTRICARE.com for PGBA.
    The beneficiary should contact his/her provider if he/she doesn’t receive a TRICARE EOB
     within the six weeks of the date of service or if he/she cannot find the claim on the claims
     processor’s Web site.
       o This purpose is to determine if the provider has submitted the claim and find out what to
         do if not to avoid missing the timely filing deadline of one year from the date of service.
    The address beneficiaries put on their claim forms in the provider’s office or the address their
     provider has on file is the address used when processing claims.
       o Addresses on claim forms are considered the most recent and accurate information;
         DEERS is not the primary mailing source for EOBs/checks.
       o Beneficiaries should keep DEERS updated so that if information is undeliverable, the
         DEERS address may be checked and the letter/document forwarded.

9.2 Some reasons for a delay in processing a claim or receiving an EOB:
    The wrong address is provided
    The claim is incomplete
    Eligibility is being questioned/DEERS information inaccurate
    The diagnosis is missing or inconsistent with other services provided
    A Third-Party Liability form is required or has not been received
    Other health insurance forms are missing
    A claim is complex and requires an extensive review



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    There is a government directed delay, usually because the provider is being investigated or
     because of fraud
    The provider delayed submitting a claim
    There are duplicate charges — more than one claim has been submitted for the same service
    The service is non-authorized or there is no referral
    Medical necessity is not documented
    The provider’s Unique Provider Identification Number (UPIN) or National Provider Identification
     (NPI) is missing.

9.3 Important to review EOBs
    Beneficiaries should carefully check each EOB they receive to compare their bills from the
     provider or service against the EOB.
    Beneficiaries should contact their claims processor if they receive charges for a service they
     never received.
       o Incorrect charges can be due to a simple error in the provider’s billing, or can be an
         indication of fraud.

9.4 Notes
    The regional contractor/claims processor should be the first source of assistance for any
     questions pertaining to the EOB, via phone, Web or at the nearest TRICARE Service Center.
    The beneficiary may also seek assistance from the nearest MTF or regional BCAC/DCAO if
     unable to get a claims issue resolved through the regional contractor.
    Beneficiaries must pay their co-payment/cost share, deductibles, or point of service charges.

10.0 Learning to Read an Explanation of Benefits (EOB)
PGBA or WPS: PGBA or WPS processes all TRICARE health care claims, depending on the
region where you live.
Prime Contractor: The name and logo of the regional contractor that is responsible for the claim.
Date of Notice: The date the claims processor prepared the TRICARE EOB.
Mail to Name and Address: The address the TRICARE EOB is mailed to: the patient’s (or patient's
parent or guardian’s) address given on the claim. (HINT: Be sure to tell beneficiaries to update their
records with current address information.)
Claim Number: Each claim is assigned a unique number to track the claim as it is processed and
for reference if there are questions or concerns.
Sponsor SSN/Sponsor Name: Claims are processed using the Social Security Number of the
uniformed services service member (active duty, retired, or deceased) who is the TRICARE
sponsor.



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Beneficiary Name: The individual who received the service/procedure and for whom this claim was
filed.
Benefits Were Payable To: This field appears only if the provider accepts TRICARE assignment.
This means the doctor accepts the TRICARE Maximum Allowable Charge (TMAC) as payment in
full for the services you received.
Service Provided By/Date of Services: This section lists who provided the care, the number of
services and the procedure codes, and the date the beneficiary received the care.
Services Provided: This section describes the medical services received and how many services
are itemized (listed) on the claim by listing the specific procedure and diagnostic codes that
providers use to identify the specific medical services.
Amount Billed: The amount the provider charged for a particular service(s).
TRICARE Approved: This is the amount TRICARE approved for the services.
See Remarks: If you see a code or a number here, look at the Remarks section (17) for more
information about how the claim processed.
Claim Summary: A detailed explanation of the action taken by the claims processor. Here one
finds the following totals: amount billed, amount approved by TRICARE, non-covered amount,
amount (if any) that was already paid to the provider by the beneficiary, amount the other health
insurance paid, amount paid to the provider, and amount paid to the beneficiary. A Check Number
will appear here only if a check accompanies an EOB.
Beneficiary Liability Summary: The amount the beneficiary is responsible for paying –may be a
deductible, co-payment, cost share, point of service, or non-covered service charges.
Benefit Period Summary: This section shows how much of the individual and family annual
deductible and maximum out-of-pocket expense has been paid to date. Claims processors calculate
TRICARE Standard or Extra beneficiaries’ annual deductibles and maximum out-of-pocket
expenses by fiscal year. If a TRICARE Prime beneficiary, they calculate your maximum out-of-
pocket expense by enrollment and fiscal year. (Note: The enrollment year beginning will appear on
your EOB only if you are enrolled in TRICARE Prime.)
Remarks: Explanations of the codes or numbers listed in “See Remarks” appear here.
Toll-Free Telephone Number: The toll-free number for the claims processor for questions is on
the EOB.




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11.0 Group Activity: Reading an EOB
All Groups: Look at the information on the EOB. Pay attention to how it provides the beneficiary
with information regarding services or care rendered by their provider.
    Using the first EOB provided on Jane Smith, answer the following questions:
       o Who are the sponsor and/or the beneficiary?
       o What is the date of notice on this EOB?
       o Who provided the care and how much was billed?
       o What type of provider was this?
       o What type of care was provided?
       o How much does TRICARE cover, and what is the term for this approved amount?
       o What amount was not covered?
       o Who is responsible for paying the co-payment?
       o What TRICARE option does Jane Smith use?
    Using the second EOB provided on John Doe, answer the following questions:
       o Where is the claim number printed on this EOB?
       o Who provided the care?
       o What type of visit was made to the provider?
       o How much was billed to TRICARE?
       o How much did TRICARE allow for the service?
       o How much is the cost share?
       o How much is the deductible?
       o Which TRICARE option is the beneficiary in?




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   PGBA, LLC                       TRICARE EXPLANATION OF BENEFITS
   TRICARE SOUTH REGION            This is a statement of the action taken on your TRICARE
                                   Claim.
   PO BOX 7032
                                   Keep this notice for your records.
   CAMDEN, SC, 29020-7032
                                    Date of Notice:      October 24, 2008
   HUMANA Military Healthcare
   Services                         Sponsor SSN:         ###-##-7845

                                    Sponsor Name:        JANE SMITH

                                    Beneficiary Name: JANE SMITH

                                   Benefits were payable to:

   JANE SMITH                      TRY CARE SOUTH
   123 S CHRISTMAS LANE            PO BOX 567
   AROUNDTHEBEND, SC               OVERTHEHILL, SC 203156
   203156


   Claim Number: 345678901-00-00



    Services Provided By      Services                             Amount TRICARE See
    Date of Services          Provided                             Billed Approved Remarks


   TRY CARE SOUTH

   10/9/2008           1       Office/outpatient      (99214)      $ 95.00   $ 60.00   1,2,3
                               visit, est

   Totals:                                                         $ 95.00   $ 60.00




    Claim                     Beneficiary Liability       Benefit Period
    Summary                   Summary                     Summary

                                                           Fiscal Year Beginning:




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   Amount billed:         95.00 Deductible $ 0.00         October 01, 2008

   TRICARE                60.00   Co-pay   $                          Individual Family
   Approved:                               12.00

   Non-Covered:           35.00 Cost Share $ 0.00       Deductible:      12.00    12.00

   Paid by Beneficiary: 0.00                            Catastrophic Cap: 12.00   12.00

   Other Insurance:        0.00                           Enrollment Year Beginning:

   Paid to Provider:      48.00                           October 01, 2008

   Paid to Beneficiary:    0.00

   Check Number:




    Remarks


   1 -- CHARGES ARE MORE THAN ALLOWABLE AMOUNT
   2 -- AMOUNT ALLOWED IS BASED ON DISCOUNT AGREEMENT
   3 -- $12.00 HAS BEEN APPLIED TOWARD THE CATASTROPHIC CAP OF $3,000.00




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   PGBA, LLC                         TRICARE EXPLANATION OF BENEFITS
   TRICARE NORTH REGION              This is a statement of the action taken on your TRICARE
                                     Claim.
   PO BOX 870140
                                     Keep this notice for your records.
   Surfside Beach, SC 29587
                                                         November 10,
                                      Date of Notice:
                                                         2008
   HealthNet Federal Services
                                      Sponsor SSN:       ###-##-1035

                                      Sponsor Name:      JACK DOE

                                      Beneficiary
                                                         JOHN DOE
                                      Name:

                                     Benefits were payable to:

   JOHN DOE                          Whats-Up DERMATOLOGY CLINIC
   123 25th ST                       PO BOX 1234
   WASHINGTON, DC 20123              WASHINGTON, DC 20113


   Claim Number:123456789-00-00



    Services Provided By       Services                             Amount TRICARE See
    Date of Services           Provided                             Billed Approved Remarks


   Whats-Up DERMATOLOGY CLINIC

   10/22/2008            001    Office visit            (99284)     $ 264.00 $ 84.09    1,2

   Totals:                                                          $ 264.00 $ 84.09




    Claim                      Beneficiary Liability       Benefit Period
    Summary                    Summary                     Summary




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                                                         Fiscal Year Beginning:

   Amount billed:        264.00 Deductible 84.09         October 01, 2008

   TRICARE               84.09 Co-pay      0.00                        Individual Family
   Approved:

   Non-Covered:          179.91 Cost Share 0.00          Deductible:   84.09      84.09

   Paid by Beneficiary: 0.00                             Catastrophic Cap: 84.09           84.09

   Other Insurance:      0.00                            Enrollment Year Beginning:

   Paid to Provider:     0.00                            October 01, 2008

   Paid to Beneficiary: 0.00

   Check Number:




    Remarks


   1 – CHARGES ARE MORE THAN ALLOWABLE AMOUNT
   2 - $84.09 HAS BEEN APPLIED TOWARD THE FISCAL YEAR CATASTROPHIC CAP OF
   $1,000.00




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11.1 Explanation of Benefits Guide (TriWest Healthcare Alliance Beneficiary EOB)
    Section 1: Identifies the name and mailing address of the beneficiary
    Section 2: List’s the contact information for the contractor
    Section 3: Defines the explanation of benefits
    Section 4: Identifies the Date the claim processed and the EOB was printed
    Section 5: Identifies the sponsor’s SSN
    Section 6: Identifies the sponsor’s name
    Section 7: Identifies the patient/beneficiary’s name
    Section 8: List the claim number also known as internal control number
    Section 9: Identifies the provider 18 digit tax id number
    Section 10: List the name of the provider or facility who rendered the service
    Section 11: Identifies who provided the service
    Section12: Identifies the date(s) of the service
    Section 13: Shows the amount billed by the provider of the service
    Section 14: Shows what the TRICARE allowable charge is
    Section 15: This is the remark code applied by the processor describing how the claim
     processed. Always read the remarks at the bottom of the Explanation of Benefits for a
     description of the remark codes
    Section 16: The Claim Summary section identifies the following: Amount billed, amount
     TRICARE approved and paid out, Non-covered service(s) listed based on dollar amount, how
     much was paid by the beneficiary if applicable, what OHI has paid if any, what was paid to the
     provider and/or the beneficiary, and the check number if the beneficiary is paid directly by
     TRICARE
    Section 17: The Beneficiary Share section shows what the beneficiary has paid or liable to pay
     to include deductible, co-pay, cost share, and patient responsibility. If the beneficiary owes
     money to the provider, the provider will directly bill the beneficiary. It is always best for the
     beneficiary to wait for the EOB to ensure the correct amount was paid by TRICARE before
     paying any outstanding directly to the provider.
    Section 18: The out of pocket expense indicates the catastrophic cap, the deductible and how
     much has been/was met depending on the fiscal year. Amount listed are for the current fiscal
     year as well as 2 previous years,(Remember Active Duty Sponsor Cat Cap is $1,000 and
     Retired Sponsor is $3,000)
    Section 19: Description of the remark code applied from # 15
    Section 20: Identifies who the check was mailed to regarding the claim. If the beneficiary is
     mailed the check, a check number will appear in the claim summary section


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    Section 21: Indicates the amount of the check from TRICARE
    Section 22: Shows the amount the patient owes to the provider
    Section 23: Contractor Logo




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12.0 Appeals
To appeal means to ask the TRICARE contractor or TRICARE Management Activity (TMA) for a
review of an authorization or claims denial.
    The appeals process varies, depending on whether the denial involves:
       o Medical Necessity
       o Factual Determination
       o Dual – Eligible beneficiary (Medicare-TRICARE eligible beneficiaries)
       o Provider Sanction
    All initial denials and appeal denials explain how, where, and by when to file the next level of
     review.

13.0 Who is Able to Appeal?
    The appealing party must be able to prove he/she is eligible for TRICARE benefits including:
       o Any TRICARE beneficiary, or a parent or guardian of a beneficiary who is under 18 years
         of age,
       o The guardian of a beneficiary who is not competent to act in his or her own behalf,
       o A health care provider who has been:
              Denied approval or
              Suspended, excluded, or terminated as a TRICARE-authorized provider
       o Providers who participate in TRICARE and accept the TRICARE-allowable charge as
         their full fee
       o A representative appointed in writing by a beneficiary or provider
    Certain individuals may not serve as beneficiary representatives due to a conflict of interest
     including:
              An officer (member of a uniformed services legal office),
              Beneficiary Counseling and Assistance Coordinator (BCAC)/Health Benefits Advisor
               (HBA),
              Employee of the United States (employee of a uniformed services legal office or an
               BCAC/HBA),
              Exception: That person is representing an immediate family member.
Note: Providers who do not participate in TRICARE and network providers cannot file appeals.

14.0 What Can Be Appealed?
    The facts of the beneficiary’s case can be appealed including:
       o The diagnosis


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       o The necessity to be an inpatient
       o The denial of preauthorization for services, including mental health
       o The termination of treatments or services that have been previously authorized
       o The denial of TRICARE payment for services or supplies received
       o The termination of TRICARE payment for continuation of services or supplies that were
         previously authorized and
       o The denial of a provider’s request for approval as a TRICARE-authorized provider or
         expelling a provider from TRICARE

15.0 What Cannot Be Appealed?
The following are examples of what cannot be appealed:
    The amount of the TRICARE determined costs or charges for a particular medical service
       o The beneficiary may ask the TRICARE contractor for an allowable charge review, but
         cannot file an appeal.
    The decision by TRICARE, or its contractors, to ask the beneficiary for more information before
     taking action on the beneficiary’s claim or appeal request
    Beneficiaries cannot appeal decisions relating to the status of TRICARE providers
    Although a beneficiary may want to receive care, or already received care from a particular
     provider, the beneficiary cannot appeal a decision that denies the provider authorization to be
     a TRICARE provider, or a decision that suspends, excludes, or terminates the provider.
       o The provider in question may appeal in his or her own behalf.
    The decisions relating to eligibility as a TRICARE beneficiary cannot be appealed
       o The branch of Service determines eligibility and DEERS reports eligibility.
       o Beneficiaries must appeal decisions regarding their eligibility through their branch of
         Service.

16.0 Appeals of Medical Necessity Determinations
    “Medical Necessity” is based on whether, from a medical point of view, the care is appropriate,
     reasonable, and adequate for the beneficiary’s condition, to include decisions on custodial and
     mental health care services.
    It may be necessary to show medical necessity for inpatient, outpatient, and specialty care.
    There are two kinds of medical necessity determination appeals:
       o Expedited and
       o Non-Expedited
Note: Most appeals are non-expedited.



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16.1 Expedited Appeal
    An expedited appeal should only be submitted to reconsider approval of inpatient stays or prior
     authorization of services.
    A request for an expedited reconsideration of a preadmission/pre-procedure denial must be
     filed by the beneficiary within three calendar days after the date of the receipt of the initial
     denial determination.
Note: Beneficiaries will be notified of a decision within 3 working days of the contractor receiving
the request.

16.2 Non-Expedited Appeal
    To file this type of appeal, the beneficiary sends a letter to the regional contractor at the
     address specified in the notice of the beneficiary’s right to appeal, included on their EOB or
     other notification.
    The letter must be postmarked or received within 90 days of the date on the EOB or initial
     determination.

16.3 Contractor Expedited and Non-Expedited Reconsideration Review
    The packet should include a cover letter with relevant case information, a copy of the denial
     letter, any associated EOBs/claims/bills, documents the beneficiary feels supports overturning
     the denial decision.
    If beneficiaries cannot get all of the supporting documents in on time, they should send the
     appeal anyway and state in the letter their intention to submit additional information in the near
     future.
    The beneficiary should keep copies of all paperwork related to the appeal.
    The regional contractor reviews the case and issues a reconsideration review determination-
     either supporting or overturning the denial.
    If the amount is less than $50, the decision is final.
    If the denial is again upheld, the beneficiary can appeal to TRICARE Management Activity via
     the National Quality Monitoring Contractor (NQMC).

16.4 National Quality Monitoring Contractor (NQMC) Reconsideration Review (Second-level
Review)
    As above, if the regional contractor reviews the case and upholds the denial determination on
     second review, the next level of appeal is to NQMC.
    The beneficiary sends a letter to the NQMC.
       o The letter must be postmarked or received within 90 days of the date on the contractor’s
         reconsideration decision.
       o A copy of the reconsideration decision and any supporting documents not previously
         submitted must be included with the letter.


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              If the beneficiary does not have all of the supporting documents, it should state in the
               letter that the beneficiary intends to submit additional information.
       o The beneficiary should keep copies of all paperwork.
    The NQMC reviews the case and issues a second reconsideration decision.
       o If the amount is less than $300, the NQMC decision is final.
       o If the beneficiary disagrees, and the disputed services are $300 or more, the beneficiary
         can request TRICARE Management Activity to schedule an independent hearing.
              The address for filing this request is:
                                    TRICARE Management Activity
                           Appeals, Hearings, and Claims Collection Division
                                     16401 E. Centretech Parkway
                                    Aurora, Colorado 80011-9066
    An independent hearing officer then conducts the hearing at a location convenient to both the
     requesting party and the government.
       o The hearing officer will issue a recommended decision and the TMA director (or
         designee) or the Assistant Secretary of Defense for Health Affairs issues the final
         decision.

17.0 Appeals of Factual Determinations
Factual determinations involve issues other than medical necessity, such as coverage issues,
provider authorization (status) requests, hospice care, foreign claims, and denial of a provider’s
request for approval as a TRICARE authorized provider.
Medical or peer review may be necessary to reach a factual determination.

17.1 Factual Determination Appeal Process
    To file a factual determination appeal the beneficiary submits the same kind of packet he/she
     would submit for a non-expedited medical necessity appeal (see section 13.2).
    The reconsideration letter must be postmarked or received within 90 days of the date on the
     EOB or initial determination.
    The contractor issues a reconsideration determination within 60 days of the beneficiary’s
     request.
       o If the beneficiary appeals an amount less than $50, the TRICARE regional contractor's
         reconsideration (second) determination is final.
       o If appealing an amount greater than $50, the contractor issues a determination and if the
         denial is upheld, instructs the beneficiary to file a formal review request with TRICARE
         Management Activity.
    To request a formal review, they must send a letter to TMA within 60 days (postmarked or
     received) of the date on the initial determination or reconsideration decision and include copies
     of the decision along with additional supporting documents.

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    TMA will issue a formal review decision within 90 days.
       o If the disputed amount is less than $300, TMA's decision is final.
       o If the disputed amount is more than $300, the beneficiary can request an independent
         hearing.
    To request an independent hearing, the beneficiary must send a request to TMA-Aurora within
     60 days (postmarked or received) from the date of TMA’s formal review determination.
       o The beneficiary should include a copy of the formal review determination and any
         supporting documents not previously submitted.
    An independent hearing officer then conducts the hearing at a location convenient to both the
     requesting party and the government.
    The hearing officer will issue a recommended decision and the TMA director (or designee) or
     the Assistant Secretary of Defense for Health Affairs issues the final decision.
    Appeals and appeal correspondence for the TMA should be addressed to:
                                 TRICARE Management Activity
                         Appeals, Hearings and Claims Collection Division
                                  16401 E. Centretech Parkway
                                    Aurora, CO 80011-9066



18.0 Appeals for Dual Eligibility Determinations
    Dual-eligibility refers to beneficiaries who are eligible for both TRICARE and Medicare.
    When Medicare and TRICARE have both denied a claim and the beneficiary has successfully
     appealed the Medicare claim (Medicare has paid the claim), the beneficiary can appeal the
     TRICARE denial through the factual claim process above.




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13) Claims & Appeals

                 TRICARE/Medicare Dual Eligible Appeals Process – Medicare Processes Claim



  Claim is denied by Medicare –      Claim is denied by Medicare –
  Never a Medicare benefit                                                    Claim is paid by Medicare
                                     Medicare Program benefit but
                                     patient-specific denial



 Claim crosses over to TRICARE                                                Claim crosses over to
                                      Claim             Claim
                                                                              TRICARE
                                      crosses           appealed
                                      over to           through
                                      TRICARE           Medicare
                                      and is            appeal
                                      rejected          process                               Service
     TRICARE            Service                                              TRICARE          or supply
     Pays as            or supply                                            pays             denied –
     Primary            denied –                                             remaining        not a
     payer              Not a                                                                 TRICARE
                        TRICARE                                              liability        benefit
                        benefit
                                                   Claim is denied
                                                   by Medicare –
                                                   Medicare
                                                   decision final




                           Source: TOM, Chapter 13, Appeal Process Applies




19.0 Provider Sanction Determinations
A provider that has been denied approval as an authorized TRICARE provider or who has been
terminated, excluded, suspended, or otherwise sanctioned.
      Providers may be sanctioned by TRICARE because of the following:
        o Failure to maintain credentials
        o Provider fraud
        o Abuse
        o Conflict of interest or other reasons
      Only the provider or his or her representative can appeal.
      If the provider appeals the sanction, an independent hearing officer conducts a hearing
       administered by the TMA Appeals, Hearings, and Claims Collection Division in Aurora,
       Colorado.




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20.0 TRICARE Prime Remote Appeals
    If an active duty service member (ADSM) does not receive authorization for specialty care:
       o The ADSM may appeal by first contacting the Military Medical Support Office (MMSO)
         Service Point of Contact (SPOC).
       o ADSMs, their primary care manager, or other provider (if they do not have a primary care
         manager) may send additional written information or documentation to the SPOC to
         support the ADSM’s appeal request.
    If the request is denied on appeal, the ADSM may then appeal to his/her Surgeon General or
     the senior medical officer of his/her respective Service.
       o The address for this second appeal will be provided to the ADSM upon denial of the first
         appeal.

20.1 Service Points of Contact/Military Medical Support Office
    Active duty service members (ADSMs) from the Army, Navy, Air Force, and Marine Corps may
     contact their SPOC at 1-888-MHS-MMSO (1-888-647-6676). Send written inquires to:
                              (Insert branch of Service) Point of Contact
                                Military Medical Support Office (MMSO)
                                           P.O. Box 886999
                                      Great Lakes, IL 60088-6999
    United States Public Health Service (USPHS) and National Oceanic and Atmospheric
     Administration (NOAA) members may contact their Beneficiary Medical Program SPOC at
     1-800-368-2777 option 2.
    Coast Guard members may call 1-800-9HBA-HBA (1-800-942-2422).

21.0 Program Integrity
    The TRICARE Management Activity Office of Program Integrity:
       o Is the investigative arm of TRICARE,
       o Provides management of the TMA anti-fraud program,
       o Is responsible for national coordination and control of cases through their work with
         contractors, the Department of Justice, and investigative agencies and
       o Provides oversight to all contractor program integrity units to ensure compliance in the
         area of anti-fraud activities.
    Program Integrity is responsible for deterring fraud, waste, and abuse through:
       o Prevention
       o Detection
       o Coordination and
       o Enforcement


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21.1 What is Fraud?
    Fraud is any intentional deception or misrepresentation that an individual or entity does which
     could result in an unauthorized TRICARE benefit or payment.
    TRICARE considers the following fraudulent acts under the program:
       o Submitting claims for services not rendered or used
       o Falsified claims or medical records
       o Misrepresentation of dates, frequency, duration, or description of services rendered
       o Billing for services at a higher level than provided or necessary
       o Over-utilization of services
       o Breach of provider participation agreement

21.2 Who Commits Fraud?
    Dishonest physicians and other health care professionals commit the majority of fraud.
       o Examples: Physicians, dentists, labs, hospitals, psychiatrists, ambulance companies, and
         clinics
    A lesser percent is attributed to patient fraud and abuse.
    Fraud is also committed by contractors and employees.

21.3 Common TRICARE Referral-Related Fraud/Abuse
    Billing for services and/or supplies not rendered
    Billing for excessive services in a 24 hour period
    Misrepresentation of services provided, provider of care, or beneficiary
    Billing for higher level of service than actually rendered
    Billing for unnecessary services or supplies

21.4 Fraud Indicators
    Excessive charges by provider
    Claims with excessive or vague documentation
    Correspondence for rapid adjudication
    Reluctance of provider to submit records
    Diagnosis or treatment inconsistent with patient’s age or sex
    Provider who uses post office boxes for the remit to address
    Claims with misused or misspelled medical terms
    Erasures, cross-outs, or white out


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    Providers routinely billing the same procedures to each patient regardless of diagnosis
    Claims handwritten in the same ink for both beneficiary and provider portion of claim
    Provider is not in the same geographic area as the beneficiary, particularly when patterns
     occur
    Excessive billing by provider for low cost items or services
    High volume of treatment for a particular condition or diagnosis
    Overlapping services on the same date
    Too many providers for same date of service
    Conflicting dates of service
    Illogical places of service

21.5 Potential outcome of cases referred to TRICARE
    Criminal conviction
    Civil settlement
    Administrative action by contractor
    Termination action
    Exclusion action—removal from the TRICARE program

21.6 Where to report potential fraud cases:
TRICARE Region North
Health Net Federal Services
(800) 977-6761


TRICARE Region South
Humana Military Healthcare Services
(800) 333-1620


TRICARE Region West
TriWest Healthcare Alliance
(888) 584-9378


TRICARE Overseas
Wisconsin Physicians Service
(888) 777-8343




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Express Scripts, Inc.
(800) 332-5455, ext. 67079
United Concordia
(877) 968-7455
TRICARE Management Activity Program Integrity Office
16401 East Centretech Parkway
Aurora, CO 80011
Phone: (303) 676-3824Fax: (303) 676-3981

22.0 Where to Get Additional Information for Beneficiaries
If you cannot answer beneficiaries’ questions about their denials, direct them to the following:
    Regional TRICARE contractor or claims processor
    National Guard/Reserve members should contact:
       o The nearest military treatment facility (MTF),
       o Or a BCAC at the TRICARE Regional Office (TRO) or TRICARE Area Office (TAO)
    The local TRICARE Service Center (TSC)

22.1 Beneficiaries must:
    Meet all the required deadlines
    Send appeals in writing with signatures
    Include copies of all supporting documents in their appeal.
       o If they do not have the paperwork available, they should send their letter within the
         deadline and note that more information will be sent
    Keep copies of everything

23.0 Claims Processors

North Region

Location                      Name       Address City         State ZIP           Telephone

Connecticut,                  PGBA       PO BOX Surfside SC          29587-9740 877-874-
Delaware,                                870140 Beach                           2273

District of Columbia,
Florida
Georgia



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Illinois,
Indiana,
Kentucky,
Maine,
Maryland,
Massachusetts,
Michigan,
Missouri (St. Louis area),
New Hampshire,
New Jersey,
New York,
North Carolina,
Ohio,
Pennsylvania,
Rhode Island,
South Carolina
Tennessee (only those
counties in Tennessee
surrounding Ft. Campbell),
Vermont,
Virginia,
West Virginia,
Wisconsin




South Region



Location                      Name Address    City    State ZIP     Telephone

Alabama,                      PGBA PO BOX     Camden SC    29020-   800-403-
                                   7031                    7031     3950
Arkansas,



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Florida,
Georgia,
Louisiana,
Mississippi,
Oklahoma,
South Carolina
Tennessee (excluding the
Ft. Campbell area),
Texas (except William
Beaumont catchment area
in El Paso and Cannon
AFB, NM service are ZIP
codes that fall in Texas)




West Region

Location                   Name   Address    City    State ZIP       Telephone

Alaska                     WPS    PO BOX     Madison WI   53707-7028 888-915-
                                  77028                              4001
Arizona,
California,
Colorado,
Hawaii,
Idaho,
Iowa,
Kansas,
Minnesota,
Missouri
(except St. Louis area),
Montana,
Nebraska,
Nevada,
New Mexico,


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North Dakota,
Oregon,
South Dakota,
Utah,
Washington,
Wyoming




TRICARE Europe



 Location                Name   Address     City     State ZIP          Telephone

 Europe, Africa,         WPS    PO BOX 8976 Madison WI        53708-    (608) 224-
 Middle East                                                  8976      2727




TRICARE Pacific



 Location                Name   Address     City      State ZIP          Telephone

 Western Pacific         WPS    PO BOX 7985 Madison WI        53707-     (608) 301-2310
 (Japan, Guam,                                                7985
 Korea, Thailand,
 etc.)

TRICARE Latin America, Canada, Puerto Rico & Virgin Islands



 Location                Name Address       City      State ZIP          Telephone

 All of Latin America,    WPS PO BOX 7985   Madison WI        53707-7985 (608)301-2311
 Canada, Bermuda,
 Virgin Islands


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 Puerto Rico             WPS PO BOX 7985         Madison WI      53707-7985 (800) 700-7104


TRICARE For Life

    Department                  Address                    Phone              Web site

    Claims Submission           WPS/TRICARE For Life       (866) 773-0404 www.tricare4u.com
                                PO Box 7890            TDD (866) 773-
                                Madison, WI 53707-7890 0405



    Appeals                     WPS/TRICARE For Life       (866) 773-0404 www.tricare4u.com
                                Attn: Appeals              TDD (866) 773-
                                                           0405
                                PO Box 7490
                                Madison, WI 53707-7490

Pharmacy

    Department Address                          Phone              Web site

    TMOP          Express Scripts               (866) 363-8667     www.express-scripts.com
                  P.O. Box 66518,
                  St. Louis, MO 63166-6518



    Retail        Express Scripts               (866) 363-8779     www.express-scripts.com
                  P.O. Box 66518,
                  St. Louis, MO 63166-6518




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    TRICARE Fundamentals Course
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        Explain who can file claims and where claims should be submitted
        Describe how to resolve claims issues
        Identify three reasons why a claim may be denied
        Distinguish between what can and cannot be appealed




         Participant Guide                 TFC Q2 2010                      32
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Appendix 1: Claim Form DD 2642
DD 2642: Updated April 2007




     Participant Guide           TFC Q2 2010   33

								
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