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
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.
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.
The next issues will address specific considerations when filing outpatient visits followed by pharmacy.
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[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.