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TAOP TRICARE Advanced Course 2010 Claims - PowerPoint PPT Presentation


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TAOP TRICARE Advanced Course 2010 Claims. Claims Objectives. Assisting Beneficiaries Assisting Providers Timely Filing Waivers Appeals. Claims. Assisting Beneficiaries If it happens…. Claims Assisting Beneficiaries. DD Form 2642 ‘Patient’s Request for Medical Reimbursement’

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claims objectives
ClaimsObjectives
  • Assisting Beneficiaries
  • Assisting Providers
  • Timely Filing Waivers
  • Appeals
claims
Claims

Assisting Beneficiaries

If it happens…

claims assisting beneficiaries
ClaimsAssisting Beneficiaries
  • DD Form 2642 ‘Patient’s Request for Medical Reimbursement’
    • http://tricare.mil/mybenefit/Download/Forms/dd2642.pdf
  • Required Supporting Documentation:
    • Itemized invoice, statement or bill from the provider
    • Receipts showing any payments made by the beneficiary
    • Script from provider when claiming medications
  • Timely Filing Limit
    • Within 1 year from DOS or date of discharge from a hospital
    • Independently billed professional fees – 1 year from DOS
claims assisting beneficiaries6
ClaimsAssisting Beneficiaries

DD Form 2642 – Key Points

  • (7) If the answer is yes to either of these questions, have the beneficiary complete a Third Party Liability (DD Form 2527) form and submit it along with their claim.
    • https://www.tricare4u.com/apps-portal/tricareapps-app/static/pdf/dd2527.pdf
  • (8a) Make sure that the beneficiary has annotated the reason for receiving the medical care.
  • (12a.) Verify that the beneficiary/authorized person has applied their handwritten signature. Signatures cannot be typed.
  • (13) Verify that the beneficiary has annotated whether they want to be reimbursed in the local currency or in US dollars
claims8
Claims

Assisting Providers

claims mailing addresses
ClaimsMailing Addresses
  • ADSM:

WPS-Active Duty Overseas

P.O. Box 7968

Madison, WI 53707-7968

  • ADFM/Ret/RetFM:

WPS-Foreign Claims

P.O. Box 7985

Madison, WI 53707-7985

claims11
Claims

Timely Filing Waivers

If it happens…

claims timely filing waivers
ClaimsTimely Filing Waivers
  • For claims not filed w/in the 1 year timely filing limit
  • TMA may grant timely filing waiver for
    • Retroactive determinations
    • Administrative errors
    • Inability to communicate & mental incompetency
    • Provider change from non-participating to participating
    • OHI
    • Dual eligibility w/ Medicare
  • Required for requesting a waiver
    • Written/typed request
    • Copy of original claim & supporting documentation
    • A copy of the EOB
claims timely filing waivers13
ClaimsTimely Filing Waivers
  • Send requests to:

TRICARE Management Activity

Beneficiary & Provider Services (BPS)

16401 East Centretech Parkway

Aurora, CO 80011-9066

  • For more information
    • TRICARE Operations Manual, “Claims Filing Deadline”, Chapter 8, Section 3

Follow Instructions in Letter

claims14
Claims

Appeals

claims appeals
ClaimsAppeals
  • 2 types of appeals:
    • Medical Necessity Appeals
      • From a medical point of view, the care is appropriate, reasonable and adequate for the condition.
    • Factual Appeals
      • Other than medical necessity; i.e. whether or not covered under TRICARE policy/regulation
  • Must be mailed NLT 90 days from date on EOB or determination letter from WPS
  • Required for submitting an appeal:
    • Signed written or typed request
    • Copy of EOB
    • Any documentation supporting the beneficiary’s position
claims appeals16
ClaimsAppeals
  • Send appeal to:

WPS TRICARE

ATTN: Appeals

P.O. Box 7992

Madison, WI 53707-7992

  • If the beneficiary is not satisfied with WPS’ determination, they can appeal the decision to TMA
    • See EOB and/or determination letter from WPS for instructions/guidelines for submitting appeals to TMA
claims things to remember
ClaimsThings to Remember
  • Check DEERS to determine eligibility/appropriate claims address
  • Checks for claims submitted by a POC will be sent to the POC
  • Only POCs can fax claims to WPS
  • Translation of supporting documents is not required
  • Remind beneficiaries to keep copies of all documents
  • Beneficiaries w/ OHI must submit a claim to their OHI first; then the OHI EOB (equivalent) needs to be sent w/ claim to TRICARE
  • 21 days: Approx time WPS takes to process a claim
  • 6-8 weeks: Approx time it takes a Beneficiary to receive correspondence/checks from WPS starting from the time the claim was initially sent in the mail to WPS
claims assisting providers19
ClaimsAssisting Providers
  • HCFA-1500 “Health Insurance Claim Form”
    • Most commonly used provider claim form
    • Can be found by doing a simple internet search
    • May also be found at your MTF’s Cashier’s Cage/Billing Office
  • Required Supporting Documentation:
    • Itemized invoice, bill or statement
  • Timely Filing Limit is same as beneficiary-submitted claims
  • Electronic Funds Transfer (EFT)
    • EFT form only needs to be submitted once
    • Not available in the Philippines and South Korea
    • Provider responsible for all banking charges
claims assisting providers21
ClaimsAssisting Providers

HCFA 1500 – Key Points

  • (12) Beneficiary must sign the HCFA-1500 or WPS will not process the claim.
  • (27) In order for WPS to issue reimbursement check directly to provider, provider must accept assignment
  • (31) A signature needs to be affixed to the HCFA 1500 or WPS may not process the claim
  • (33) Check that the provider is using the address that they want to receive the reimbursement check