|
Tricare Philippines Newsletter
12005
Basic Claim
Filing Rules for the Philippines
There are any number of sites on the web that will provide you with the
TRICARE Management Activity (TMA) standard response on what is required
to file a claim.
The official version:[i]
Required Claim Information Professional Providers
Source: 32 Code of Federal Regulations 199.7
Required Patient Treatment information includes:
- Provider - by name and
professional status
- Date of Service
- Procedure code or narrative
description of each service for each date
- Individual charge for each
item of service
- Detailed description of any
unusual complicating circumstances
- Diagnosis – code or narrative
description
- Full name of source of care
- Full address of source of care
- Name of Attending Physician
- Referring Physician
- Patient Status – inpatient /
outpatient
This is a typical response one will get from the TRICARE Overseas
Program (TOP) contractor, International SOS (ISOS) help desk if you ask
for help in filing a claim.
· Completed DD Form
2642
· Itemized bill from
the provider on their letterhead
· Receipt or proof of
payment
If you question them further about how does one obtain this required
itemized bill when Philippine providers do not provide itemized bills,
you will be told to ask their medical coders to do it. If you further
explain that they have no medical coders you generally will not get a
response or one that continues to talk around the issue but provides no
real assistance in filing claims in the Philippines. Even if you
are able to break out the procedures the providers don’t understand the
nuances of the unique system of detailing procedures, bundling or
unbundling[ii], and have no ability to itemize their
cost, because they never bill that way and have no idea how much to
assign to each procedure.[iii]
The requirement for itemized bills is overlooked by the
TMA claims contractor, Wisconsin Physicians Service (WPS), in other
overseas areas because they pay billed charges. This means that they
have to only identify one or two procedures and assign the entire
global bill to those procedures and fully reimburse the beneficiary the
expected 75% of billed charges and the reason beneficiaries in other
countries don’t experience the problems we do.
Since neither TMA nor ISOS provide good information to beneficiaries on
how to file claims in the unique Philippine TRICARE system we will
attempt to provide some basic information that applies to all claims.
In following newsletters we will provide more specific information on
how to file specific types of claims including outpatient visits,
pharmacy, laboratory, radiology and inpatient care.
The average beneficiary, following the general and specific rules,
should have few problems in getting the claim accepted and processed
and most of the time the excepted reimbursement. The one exception is
professional fees for inpatient care which has and continues to be a
significant problem and also addressed later.
The following discussion will
address items and information required or suggested for all claims
regardless of type.
DD Form 2642 – TRICARE Medical
Claim This document must accompany every claim.[iv]
Below is an extract from the instructions contained on the
form with some additional caveats added for clarity or as applicable to
the Philippines.
1. Enter patient's last name, first
name and middle initial as it appears on the military ID Card. Do
not use nicknames. (Be sure not to place the sponsor’s
name here unless they are the patient. If
the
beneficiary does not have a current ID card use their name as it
appears in DEERS. A current ID card is not required to be eligible for
TRICARE but active enrollment in DEERS is.)
2. Enter the patient’s daytime
telephone number and evening telephone number to include the area code.
(This can be the same number and can include local cell
phone numbers. This is not required but helpful if WPS wants to call
and ask questions about the claim.)
3. Enter the complete address of
the patient's place of residence at the time of service (street number,
street name, apartment number, city, state, ZIP Code).
Do not use a Post Office Box Number except for Rural Routes and
numbers.
Do not use an APO/FPO address
unless the patient was actually residing
overseas when care was provided. (The simple answer for
those residing in the Philippines
is to use either your local physical address or your FPO address. Using
local addresses will result in all correspondence on the claim being
sent via international and Philippine mail including requests for
additional information, EOBs and checks.
Generally this will also increase the time it takes to get any
correspondence and may increase its chances of not arriving.
Non-receipt of a request for additional information will result in the
denial of the claim. Loss of checks will require six or more weeks to
obtain a replacement. So make this choice wisely.)
4. Check the box to indicate
patient’s relationship to sponsor. If "Other" is checked,
indicate how related to the sponsor; e.g., parent.
5. Enter patient's date of birth
(YYYYMMDD).
6. Check the box for either male or
female (patient).
7. Check box to indicate if
patient's condition is accident related, work related or both. If
accident or work related, the patient is required to complete DD Form
2527, "Statement of Personal Injury - Possible Third Party
Liability TRICARE Management Activity." The form may be
obtained from the claims processor, BCAC, or TRICARE Management
Activity. (This form should be completed when appropriate
or claims processing maybe delayed.)
8. (a)Describe
patient's condition for which treatment was provided, e.g., broken arm,
appendicitis, eye infection. If patient's condition is the result of an
injury, report how it happened, e.g., fell on stairs at work, car
accident. (Provide a brief description. If you know the exact
terminology for the condition, include it.)
(b)Check the box to indicate where the care was given.
9. Enter the Sponsor's or Former
Spouse's last name, first name and middle initial as it appears on the
military ID Card. If the sponsor and patient are the same, enter
"same." (If the patient, listed in 1 above,
is not the sponsor, generally the military retiree, include their full
name here as indicated.)
10. Enter the Sponsor's or Former Spouse's Social Security
Number (SSN). (This should always be the SSN of the
sponsor and not the patient, dependent, even if they have one.
Eligibility is always based on the sponsor’s status and SSN.)
11. By law, you must report if the patient is covered by
any other health insurance to include health coverage available through
other family members. If the patient has supplemental TRICARE/CHAMPUS
insurance, do not report. You must, however, report Medicare
supplemental coverage. Block 11 allows space to report two insurance coverages. If there are additional insurances,
report the information as required by Block 11 on a separate sheet of
paper and attach to the claim. NOTE: All other health insurances except
Medicaid and TRICARE/CHAMPUS supplemental plans must pay before
TRICARE/CHAMPUS will pay. With the exception of Medicaid and CHAMPUS
supplemental plans, you must first submit the claim to the other health
insurer and after that insurance has determined their payment, attach
the other insurance Explanation of Benefits (EOB) or work sheet to this
claim. The claims processor cannot process claims until you provide the
other health insurance information. (Supplemental insurance
typically pays TRICARE copays or pays a fixed
amount, usually referred to as supplemental income and includes a
clause that it pays only after your primary insurance pays. Most, if
not all of these, typically offered by service organizations do not
cover care overseas, are cost prohibitive compared to local costs and
do not cover those who have TFL. Other health insurance (OHI) on the
other hand pays directly for medical expenses, as defined by the
policy, and can be anything from a private policy to one obtained
through employment or a retirement benefit from a civilian employer or
obtained due to employment of a spouse. Most often in the Philippines
OHI would be PhilHealth. See Newsletter
20120402 for more information on how to overcome
the OHI EOB requirements and the form approved by TMA to replace them
for PhilHealth.)
12. The patient or other authorized person must sign the
claim. If the patient is under 18 years old, either parent may sign
unless the services are confidential and then the patient should sign
the claim. If the patient is 18 years or older, but cannot sign
the claim, the person who signs must be either the legal guardian, or
in the absence of a legal guardian, a spouse or parent of the patient.
If other than the patient, the signer should print or type his/her name
in Block 12a and sign the claim. Attach a statement to the claim giving
the signer's full name and address, relationship to the patient and the
reason the patient is unable to sign. Include documentation of the
signer's appointment as legal guardian, or provide your statement that
no legal guardian has been appointed. If a power of attorney has been
issued, provide a copy. (The easiest solution
here is to have the patient sign the claim form. If someone other than
the patient signs the form WPS will look very closely at the claim and
there maybe issues with the processing. Where a legal guardian has been
appointed include a copy of the appointment. If the patient wants
someone else to sign the claim or wants someone else to discuss the
claim with WPS a power of attorney/medical release is required and
should be submitted with the claim. In the past WPS provided a link to
their preferred medical release form but since ISOS became the prime
contractor and replaced their website with their own it has
disappeared. However we have a copy that can be obtained at Medical
Release Form. If you have any questions
concerning someone else signing the claim form or dealing directly with
WPS on someone else’s claim it is best to contact them directly by
phone or by secure email through your personal “Tricare-Overseas
account” How to obtain an account is discussed below. The direct phone
number to WPS, toll free in the U.S. and when using Skype,
is 877-451-8659, select option 2. Customer service representatives are
available from 2 am - 7 pm Central time.)
13. If this is a claim for care received overseas, indicate
if you want payment in the local currency. NOTE: Payment
available only in some local currencies. (You can be paid
in Philippine Pesos. Past experience tells us if you fail to check this
block you will be paid in dollars.)
DD Form 2642 is available as a fillable pdf file so can be completed on your computer and
then printed and signed. Those with the expertise can add an image of
the appropriate signatures to the form so it can be used without printing
for filing claims by email or internet fax.
Both forms, DD 2642 and DD 2527, are available for download at Claim
Forms.
Itemized bill from the provider on
their letterhead: Since local providers seldom provide an
itemized bill you will have to use the standard global bill, if a bill
is provided at all. The notable exception is the inpatient portion of a
hospital claim where there is an itemized bill. In many instances such
as outpatient visits, pharmacy prescriptions and laboratory or
radiology procedures the receipt will serve this purpose. Just insure
the provider’s name and address is included on the receipt and
preprinted, if available. If filing a claim for a prescription,
laboratory or radiology the doctor’s prescription/order should also be
included. (Never submit the originals, only copies. Insure the patients
name is visible and add the sponsor’s SSN to each document.)
Receipt or proof of payment:
Because local providers don’t generally provide a bill and receipt, the
receipt is accepted for both by WPS. Try to insure your receipts
contain preprinted identifying information regarding the provider
including name and address as this will be what is used to determine if
the provider is certified or the claim needs to be held pending a
request for certification is processed. All information on the receipt
should be clearly visible and legible. Attempt to obtain the original
of the receipt if possible to aid in this. If the receipt is one like
many Mercury Drug stores issue that fades over time get good copies or
scan it before it becomes illegible. (Never submit the originals,
copies only. Insure the patients name is visible and add the sponsor’s
SSN to each document.)
Narrative: Not normally
mentioned but a very good idea is to include a narrative, typewritten
if possible and signed by the same person that signs the claim form.
Future newsletters, dealing with specific types of claims will address
specific information that should be included. Keep in mind the claims
processors have limited knowledge about the patient’s condition and
treatments but have to use that information to determine the level of
care received which directly translates into the amount that will be
approved for reimbursement. So the more pertinent information you
provide the better outcome you can expect. Narratives should contain
the following:
- Full name of the patient,
followed by the sponsor’s SSN.
- Type of care – Outpatient
visit, inpatient, pharmacy, laboratory, radiology, durable medical
equipment, etc.
- Diagnosis or description of
the problem that required the care or service.
- Full name and address of the
provider. If the provider is not certified at the location of care
but at another location include that information along with the
address where they are certified.
- Detailed description of the
care. (The type of information and detail required will vary based
on the type of claim which will be addressed in newsletters
dealing with each type of claim.)
- Signature block including name
and address and sign.
Personal TRICARE - Overseas
Account
Anyone that intends to submit claims should set up their personal
account with ISOS/WPS. This allows the beneficiary to monitor their
individual claims as they go through the claims process and access EOBs as soon as the claim processing is complete.
It also allows beneficiaries to send secure emails and receive
responses from WPS and claims can also be submitted by email using the
secure email system. Because of the privacy laws and issues with
identity theft they are not allowed to use normal email when discussing
medical information or personal information such as SSNs.
Each authorized family member must have their own account. In addition
from this account you can check TRICARE eligibility information on
yourself and your dependents. From the account the beneficiary can
grant permission for other family members to see their claims data
through their account. OHI information can be verified and updated as
well and one can opt for paperless EOBs among
other things.
To create an account, go to TRICARE
Account then go to the window about half way
down the left side of the page and click on “Register” and follow the
instructions.
Filing Claims
The final step in the process is to actually file your claim and there
are three methods; mail, fax and email. Copies, not originals, of all
documents associated with the claim should be included, with the DD
2642 first followed by the narrative and then the rest of the
documents.
The most basic and probably most common method is mailing. You can use
international or FPO mail. The primary advantage is simplicity but time
is lost while the claim is in transit. Claims should be mailed
to:
TRICARE Overseas Program
P.O. Box 7985
Madison, WI 53707-7985
The second method is faxing. However, faxing using local facilities may
not get through due to poor landline connections. The best and most
reliable faxing method is to use an internet fax facility. This does
require a decent internet connection to upload the claim however and
knowledge of how to scan and compile claims. A detailed discussion of
how to compile and fax claims online will be the subject of a future
newsletter. Fax numbers: Claims Filing (608) 301-2251, Correspondence
pertaining to claims (608) 301-2250.
The third option is through secure email via the Personal TRICARE -
Overseas Account. One caveat with this system is secure email normally
does not get accessed by the WPS customer service for about two to
three weeks after the email is posted and under current rules the
claims processing time requirements will not start until then. Many of
the same issues involved in faxing claims along with a few others have
to be considered if using this system and will be included in the
future newsletter that deals with faxed claims.
What’s next?
The next issues will address specific considerations when filing
outpatient visits followed by pharmacy.
Share this newsletter with other
beneficiaries
Forward this newsletter to others you feel might benefit from them so
they can sign up as well. If you represent an RAO or service
organization let your members know so they can sign up. Sign
up link
If you are on Facebook share this newsletter with your
friends.
[i]
This quote from the Code of Federal Regulations was
extracted from a brief by Wisconsin Physicians Service (WPS).
[ii] The
standards that TMA expects local providers to use for TRICARE billing
are a system that is unique to the U.S. and nowhere else in
the world. In the U.S.
providers hire medical coding and billing staff or contract with a
commercial billing service and the cost of this is reflected in the
higher cost of care in the states. While local providers will have
knowledge of some procedure terminology they don’t see procedures in
the same way. For example they don’t see individual patient visits on
the ward as procedures nor do they see each process accomplished during
a surgical procedure as individual, billable, procedures that have to
be identified and costed. Another significant
issue is a process in the U.S. system known as
bundling. In the U.S.
system some procedures are grouped together for billing purposes, you
list only one of 2 – 5 procedures, while others require that each step
be identified and coded. These rules change annually as well. This is
why you will find that TMA routinely claims that local providers are
defrauding them through a process of unbundling and use this excuse as
a basis to justify the draconian measures put into place. On the other
had many local procedures are seen as one process, bundled, so if they
try to identify procedures for TRICARE claims and list the one
procedure instead of all the underlying procedures as required in the U.S.
system TMA doesn’t claim fraud and happily pays for the one procedure
disallowing a significant portion of the real local cost. Laboratory
and other ancillary procedures have many examples of this. This is one
of the reasons a growing number of providers are refusing to be
certified by TRICARE as they are tired of being falsely accused of
fraud and underpaid at the same time.
[iii] TMA
is well aware of this issue and how they created it through the
implementation of a CMAC that was not fully thought through. We have
continued to address this issue to TMA for years but generally are
ignored or told the sacrifice is unavoidable because of massive fraud
like the bundling issue.
[iv] The
current and latest version of the form is dated Apr 2007 and shows that
its OMB approval expires August 31, 2009. As of this date this is the
most current form available.
|
