TRICARE Overseas Program Claims August 5, 2010 TRICARE Overseas Claims WPS Health Insurance Filing and Processing Claims • Jurisdiction Rules change to “Place of Service” for care delivered in Overseas locations. Remain the same for Stateside services for TOP beneficiaries. • Traveling Beneficiaries – No stated restriction that the care be urgent or emergent – Mechanism to check for services requiring authorizations after a certain number of services – Health Care Finder services available to assist with finding a provider and obtaining an authorization if needed • Centralized Authorizations through International SOS loaded to WPS. Filing and Processing Claims • Claims will transition based on date received, not date of service. • SuperBill being designed, tested and introduced as a means to increase speed and accuracy of Overseas provider claims. • Standard Claim Forms Required – CMS 1500, UB-04, DD2642*. *6-month phase in approved. Claims received March 1, 2011 and later will be on the appropriate claim form. • Internet Based Claims Processing (IBCP) being offered. Proof of Payment • Operations and Program Integrity Concerns • DD-2642 Beneficiary Submitted claims • Non-participating provider claims • High dollar reimbursements • Policy will be forthcoming on proof of payment requirements – Still in development – Dollar threshold? – Location? – Presence on prepayment review for either Beneficiary or Provider? Timely Filing • Will continue to follow one year from the date of service. • Waivers allowed include – Retroactive eligibility – Administrative error – Mental Incompetency – Delays by other health insurance – Waivers granted by TMA through C&CS TRICARE For Life (TFL) • Claims jurisdiction is based on Place of Service. • Care received in the U.S. and its Territories are TFL claims. • Claims outside of these locations are TOP claims. • Enrollment in Medicare Parts A & B required for eligibility Other Health Insurance • In most cases primary to TRICARE • State Assistance (Medicaid) and approved TRICARE Supplemental Coverage are secondary pay. • Host Nation National Health Insurance is primary to TRICARE and administrative requirements must be followed. Pharmacy Claims • Stateside and territories must use the TPharm Contractor, Express Scripts International, for pharmacy claims. • TPharm Mail Order Pharmacy benefits available to APO, FPO, DPM for prescription from a U.S. credentialed provider • Specialty medications may be provided directly from International SOS. • TOP pharmacy claims require name, strength, quantity, prescribing physician and price on the receipt.