Productively Billing and Collecting from TRICARE

Transcription

1 Productively Billing and Collecting from TRICARE

2 Top 5 Things to Know for CE: 1. Make sure your BADGE IS SCANNED each time you enter a session, to record your attendance. 2. Carry the Evaluation Packet you received on registration with you to EVERY session. 3. If you re not applying for CE, we still want to hear from you! Your opinions about our conference are very valuable. 4. Pharmacists and Nurses need to track their hours on the Statement of Continuing Education Certificate form as they go. 5. FOR CE: At your last session, total the hours and sign your Statement of Continuing Education Certificate form. Keep the PINK copy for your records. Place the YELLOW and WHITE copies in your Evaluation packet Make sure an evaluation form from each session you attended is completed and in your Evaluation packet Put your name on the outside of the packet, seal it, and drop it in the drop boxes in the NHIA registration area at the convention center

3 Objectives Define TMA TRICARE Benefits TRICARE Claiming and Reimbursement Appeals and Overpayments Advocacy Efforts

4 TRICARE Management Activity TMA

5 Tricare Management Activity (TMA) Since 1998 TMA leadership has managed the TRICARE health care program The Office of Champus is now understood to be the TMA The TMA operates under the authority of the Assistant Secretary of Defense for Health Affairs

6 Tricare Management Activity (TMA) Two Operational offices: Falls Church, VA and Aurora, CO Six geographic regions/areas Three US health service regions each with its own Regional Office and Regional Director Three overseas health service regions managed by Tricare Area Offices

7 TRICARE Department of Defense healthcare program for: Active Duty Service Members Retirees Family of Active Duty and Retirees Survivors & Certain Former Spouses TRICARE integrates military and civilian resources to provide comprehensive healthcare

8 TRICARE Regional Offices (TRO) TRICARE Regional Office North TRICARE Regional Office South TRICARE Regional Office West TRO s are responsible for managing the three US regional contractors TRO guidance comes from the TMA

9 Managed Care Service Contractor (MCSC) Each TRICARE region has a MCSC Also known as a Regional Contractor The MCSC s role is to support and augment healthcare services Overall guidance comes from the TMA

10 Tricare West TriWest Healthcare Alliance Corporation remains the MCSC for the West Region

11 Tricare South Humana Military Healthcare Services July 2009 UnitedHealth Military & Veteran Services was selected as the new MCSC Transition has not yet occurred

12 Tricare North Health Net Federal Services, LLC In July 2009 Aetna Government Health Plans was selected to provide Managed Care Support (MCSC) Transition has not yet occurred

13 Military Treatment Facilities (MTF) MTF s may provide the following services to eligible beneficiaries In/Out Patient Care Ambulatory Care MTF care capability can vary Capabilities are augmented by civilian TRICARE authorized providers

14 Authorized Providers Network Agrees to file claims and accepts the TRICARE allowable charge as payment in full Non-Network providers May or may not choose to file claims Participating Agrees to accept the TRICARE allowable charge as payment in full Non-Participating May charge the beneficiary 15% more than the TRICARE allowable charge

15 Authorized Providers Authorized TRICARE providers Must have a state license & be accredited by a national organization Medicare-certified providers are considered TRICARE-authorized providers Regional Contractors are responsible for verifying a providers authorized status

16 WHAT ABOUT CHAMPUS?

17 Champus Reform Initiative (CRI) 1988 the CRI was introduced - it offered more healthcare choices to the military Successfully tested in CA & HI for 5 years 1993 the DoD extended & improved the CRI, and renamed it TRICARE Three plan options were introduced: TRICARE Prime TRICARE Extra TRICARE Standard

18 TRICARE Benefits Plans and Coverage

19 TRICARE Plan Options TRICARE Standard Fee for Service (FFS) TRICARE Extra Managed Care TRICARE Prime Preferred Provider Option (PPO) DEERS registration is required for all three plans

20 Defense Enrollment Eligibility Reporting System (DEERS) DEERS is a centralized DoD database of personal and medical data Serves as the database of record for: Eligibility Enrollment Primary Care Manager assignment Catastrophic caps and Deductibles Enrollment is required in order to receive TRICARE benefits or care

21 TRICARE Service Centers (TSC) Responsible for explaining TRICARE enrollment, benefits, and eligibility information to beneficiaries Assists with Prime enrollment Selects Primary Care Managers (PCM) Supplies network provider information Assists members with claim issues

22 TRICARE Standard Highest out of pocket cost Freedom to choose from any TRICARE authorized provider for covered services MTF access is limited to space availability Prior Authorization is not required for most covered services TRICARE Standard is not available to Active Duty Service Members No enrollment fees

23 TRICARE Standard

24 TRICARE Extra When TRICARE Standard beneficiaries receive care from an in-network provider they are using the TRICARE Extra option for that period of care TRICARE Standard Beneficiaries receive a 5% discount off their cost share if a network provider is used

25 TRICARE Extra

26 Not available to: TRICARE Extra Active Duty Service Members Dependent parents Dependent parents-in-law MTF access is limited to space availability No enrollment fees

27 TRICARE Prime Managed Care program similar to a civilian HMO Primary Care Manager assigned to them either provides for, or manages the beneficiaries care May receive care at a MTF or from any civilian TRICARE network provider TRICARE Prime offers the lowest out of pocket costs compared to the other options

28 TRICARE Prime Available to the following beneficiaries: Active Duty Service Members (ADSM) & family Retirees & family, and eligible survivors Certain Guard/Reserve members & eligible family Medal of Honor recipients and their eligible members Enrollment is required Retirees & family pay annual enrollment fees Receive care priority at MTFs

29 TRICARE Prime

30 TRICARE Prime The following MUST enroll in TRICARE Prime: Active Duty Service Members National Guard Members on Federal active duty orders for more than 30 consecutive days Reservists when on active duty for more than 30 consecutive days

31 TRICARE for Life (TFL) TRICARE s Medicare-wraparound coverage available worldwide to TRICARE beneficiaries regardless of age Must be enrolled in Part A and Part B No enrollment fee, but must pay Medicare Part B premiums to remain TFL eligible Medicare entitled active duty service members are not required to purchase Part B until they retire Medicare entitled active duty family members are not required to purchase Part B until their active duty sponsor retires

32 Tricare For Life (TFL) Medicare is billed as primary If Medicare pays the claim it is forwarded to TFL for processing of PR amounts If the beneficiary has Other Health Insurance (OHI), OHI must be billed prior to TFL

33 Coordination of Benefits

34 Other Health Insurance (OHI) OHI must be filed prior to TRICARE After OHI has processed a claim may be submitted to TRICARE Should include the Explanation of Payment and an itemized bill TRICARE pays second to OHI except for: Medicaid Indian Health Services TRICARE supplements Other plans as determined by the TMA

35 Part D Enrollment in a Part D prescription drug plan is not required Some low income beneficiaries may choose to enroll in Part D

36 WHAT SERVICES CAN I PROVIDE AS A HOME INFUSION PROVIDER?

37 Home Infusion Therapy Services TPN and Enteral Therapy Statement of Medical Necessity Required Generally follows Medicare guidelines Will cover when ordered as Medically Necessary by the physician Infusion Drugs Pumps/supplies will follow Medicare caps and quantity limits

38 Home Infusion Therapy Specialty Drugs Services Changes made in November 2009 limited the ability to provide Specialty Drugs

39 Prior Authorization Home Infusion therapy services require prior authorization Prior Auth forms can be found at the MCSC s web site Most allow for on-line authorization A SMN (statement of Medical Necessity) may also be required A MTF has the first right of refusal to provide care to the TRICARE beneficiary

40 TRICARE CLAIMING & REIMBURSEMENT

41 Claiming Claims for home infusion drugs will be billed using the appropriate J-code along with a specific NDC for pricing TRICARE Reimbursement Manual Ch 1, Sct 15 J3490 should be used for NOC drugs The code description may also be helpful Drug Billing Unit should be NDC based NDC Unit Qualifier = N4 NDC Unit of Measure F2 International Unit ML Milliliter GR Gram UN Unit

42 Claiming HCPC coding should be used for pumps/supplies Pumps are capped A few definition reminders: A4221: Catheter Maintenance Supplies A4222: External drug infusion pump supplies A4223: Infusion supplies not used with external infusion pump Gravity, Injectables, Disposable Pumps A4223 should not be used to code nursing or drugs

43 Claiming TPN/Enteral should be billed using Medicare codes/modifiers When billing TPN remember to bill non-nutritional drugs as a separate line item A Statement of Medical Necessity (SMN) may be required & should include: Sponsor s Social Security number Patient s name Diagnosis Patient s date of birth Length of Need Description of services, including procedure codes

44 Claiming Nursing related to infusion is payable by TRICARE (0-2 hours) (each additional hour) Reimbursement rates can be found at Note that if the patient is TFL, nursing cannot be billed for denial to the DME MAC

45 Claiming Submit claims electronically Bill at List (Usual & Customary) Authorization should be noted in Box 23 EDI attachment capabilities may be available Corrected Claims should have the word corrected claim" written at the top It is helpful to note what the correction is

46 Reimbursement Home Infusion Drugs are drugs (including chemotherapy drugs) administered by means other than oral means, e.g., the drug must be administered either intramuscularly, subcutaneously, intravenously, or infused through a piece of DME

47 Reimbursement CMAC and TMAC what s the difference? CMAC for Home Infusion Drugs is AWP-5% The CMAC Drug listing on TRICARE s web site is ASP Based and should not be used for Home Infusion Drug pricing AWP-5% Drug Reimbursement Retroactive to April 1, 2005 If your contract states CMAC 5% then you should expect to be paid AWP-10%

48 Reimbursement TRICARE will reimburse the lesser of: Billed Charges Medicare Fee Schedule Maximum Allowable Charge State Prevailing Rates Prevailing rate is determined by placing all charges billed for the service in ascending order (min of 8 claims). The lowest charge that is high enough to include 80% of the cumulative charges becomes the prevailing charge Payments from the primary payer and TRICARE as the secondary may not collectively exceed the TRICARE-allowable charge

49 Claiming - TFL Billing Medicare for Denial will be necessary Infusion via an External Infusion Pump Obtain an appropriate ABN Obtain a Written Order and DIF Bill Medicare using a GA modifier Once the Medicare EOB is received Ensure that a PR is on each claim line Pump, supplies and drug are billed with the same codes billed to Medicare The TFL claim must have the NDC listed

50 Claiming - TFL When no Infusion External Infusion Pump A4223 may require an itemized invoice A4221 catheter maintenance Note A4222 would not be used Once the Medicare EOB is received Ensure that a PR is on each claim line The TFL claim must have the NDC listed Medicare EOB is required with the TFL Claim Crossover claims may pay at list in error

51 Reimbursement - TFL For services payable by both Medicare & TFL Medicare pays first, OHI Second, then TFL For services payable by TFL, but not Medicare Beneficiaries are responsible for Tricare deductibles and cost share PR denial may be required For services payable by Medicare, and not TFL beneficiaries are responsible for the Medicare copays and deductibles

52 Reimbursement - TFL Drug reimbursement is AWP-5% Medicare Fee Schedule State Prevailing Rate A4223 no fee schedule Charges exceeding $1000 may require an itemized invoice

53 Ambulatory Infusion Suites (AIS) Reimbursement You may see a patient in the AIS Place of Service is 11 SS Modifier should be used TRICARE does not consider AIS patients as being seen in the home, therefore Drug pricing is ASP + 6% in the AIS CMAC Fee Schedule based reimbursement

54 TRICARE Claims Processing Palmetto Government Benefits Administration (PGBA) Processes claims for North and South Wisconsin Physician Service (WPS) Processes claims for West & Overseas regions and TFL (regardless of region) Claims sent to the wrong processor may either be forwarded or returned

55 TRICARE Claims Processing Network Providers Responsible for filing claims Non-Network (Participating & Non) Not required to submit claims Beneficiaries are responsible for ensuring claims are submitted & processed no matter who actually submits the claim Timely Filing is 1 year from service date

56 CHAMPVA

57 CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs Administered by the Department of Veterans Affairs CHAMPVA & TRICARE are separate programs A provider s TRICARE contract with a MCSC does not apply to CHAMPVA

58 CHAMPVA Home infusion drugs will pay the lesser of: The billed amount The AWP plus a $3.00 dispensing fee The negotiated price Claims for home infusion drugs will be billed using the appropriate J-code along with a specific NDC for pricing

59 CHAMPVA OHI: payment will not exceed that which would have been paid in the absence of OHI After deductibles have been met, the CHAMPVA payment usually covers all of the beneficiaries OHI co-payment requirements CHAMPVA is secondary to Medicare If the beneficiary does not enroll in Part D, CHAMPVA becomes the primary payer for pharmacy coverage Filing Limit is 1 year CHAMPVA Policy Manual Chapter 3 section 5.11

60 CHAMPVA Claim Filing VA Health Administration Center CHAMPVA P.O. Box Denver, CO Fax: Appeals VA Health Administration Center CHAMPVA ATTN: Appeals P.O. Box Denver, CO General Info Phone

61 TFL and the VA If a beneficiary is eligible for benefits under both TRICARE and the VA program he/she may choose to use the TRICARE benefit at a VA medical facility as long as: The service is covered under TRICARE and, Isn t for a service-connected condition The VA facility is in the TRICARE network Since the VA can bill TRICARE but cannot bill Medicare, the beneficiary is responsible for TRICARE cost shares and the deductible

62 Appeals and Overpayments

63 TRICARE Claim Appeals Appeal Filing Limit is 90 days Allowable charge complaints Charges denied as Included in a paid service Keying errors/corrected bills Claims denied due to no authorization Late filing Charges denied as a duplicate charge Denied as Requested information was not received Coding issues

64 TRICARE Claim Appeals Medical Necessity Appeal Requirements: Appeal requests must be in writing and must be signed Must state the issue in dispute Must include a copy of the initial denial and any additional documentation in support of the appeal Sponsor s SSN Beneficiary/patient name Dates) of service Provider s address, phone/fax, and *Appeals must be requested by an appropriate party

65 Health Net TRICARE North Region P.O. Box TRICARE Claim Appeals Surfside, Beach, SC TriWest Wisconsin Physicians Service P.O. Box Madison, WI

66 TRICARE Claim Appeals TFL WPS TRICARE For Life ATTN: Appeals P.O. Box 7490 Madison, WI Humana TRICARE South Region Customer Service Department P.O. Box 7032 Camden, SC

67 On-Line Resources TRICARE National Website TMA View, print, download copies of handbooks, brochures, etc.

68 On-Line Resources TriWest Health Alliance Health Net Federal Services Humana TFL providers/

69 NHIA ADVOCACY UPDATE

70 QUESTION & ANSWER