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TAOP TRICARE Advanced Course 2010 Claims

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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TAOP TRICARE Advanced Course 2010 Claims

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  1. TAOP TRICARE Advanced Course 2010 Claims

  2. ClaimsObjectives • Assisting Beneficiaries • Assisting Providers • Timely Filing Waivers • Appeals

  3. Claims Assisting Beneficiaries If it happens…

  4. 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

  5. ClaimsAssisting Beneficiaries

  6. 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

  7. ClaimsAssisting Beneficiaries

  8. Claims Assisting Providers

  9. ClaimsAssisting Providers Contact ISOS

  10. 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

  11. Claims Timely Filing Waivers If it happens…

  12. 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

  13. 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

  14. Claims Appeals

  15. 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

  16. 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

  17. 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

  18. ClaimsQuestions

  19. 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

  20. ClaimsAssisting Providers

  21. 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

  22. ClaimsAssisting Providers

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