Tricare Philippines Newsletter 13002
Alert: TRICARE Wrongly Denies Claims if You Pay Less than Double under the Demonstration and File a Claim
Because providers are charging as much as 113% above their normal fees and as they have told us, because they were told they should by ISOS, we advised beneficiaries to consider agreeing to pay the normal local fees offered by these same providers if one does not demand care under the demonstration. Many, if not all, providers will revert from the P1,066 fee to their normal P500 fee if the beneficiary denounces TRICARE and pays like normal local patients, even PPO patients, and we recommended beneficiaries use this approach to save over half the cost over the demonstration care charges, see newsletter, Alert: Deliberate Overcharges under the Demonstration (Closed Network)
A beneficiary who followed this advice and filed a claim had it denied under denial code 259, Must be submitted by approved demo provider.
It seems the TRICARE Management Activity wants to make sure that everyone pays the higher fees regardless of their own Operations Manual as they are now denying legitimate claims paid in full and with a receipt from Approved providers and in direct violation of their posted and stated policy.
Specifically the TRICARE Operations Manual (TOM) Chapter 18, Section 12 at Paragraph 4.4 states at the last sentence; “Beneficiary-submitted claims for services provided by an approved demonstration provider in an approved demonstration area shall be denied unless it is submitted with proof of payment showing that the beneficiary has paid for the service(s).”
The full text of Paragraph 4.4 is below:
“TRICARE Standard beneficiaries who reside in the Philippines, in accordance with paragraph
4.2, and receive care in designated demonstration area(s) must receive all care from approved demonstration providers, unless a specific waiver has been granted (see paragraphs 4.8 and 4.9). If these beneficiaries receive care from a non-approved demonstration provider without a waiver,
TRICARE will not cost-share the claim and the beneficiary will be responsible for 100% of the charges. Normal TRICARE cost-shares and deductibles apply to care rendered to eligible beneficiaries by approved providers under the terms of the demonstration. Additionally, when a beneficiary receives care from an approved provider in a designated demonstration area, the provider will file the claim on the beneficiary’s behalf, and the provider will collect only applicable cost shares and deductibles after receipt of the TOP EOB. The beneficiary will be held harmless for denied charges rendered by an approved demonstration provider unless the beneficiary was notified in writing that the care provided was not a covered benefit prior to receiving the care. Beneficiary-submitted claims for services provided by an approved demonstration provider in an approved demonstration area shall be denied unless it is submitted with proof of payment showing that the beneficiary has paid for the service(s).”
See the full text of the TOM Chapter 18, Section 12
Given what appears as an attempt to force beneficiaries into paying much higher costs than they should, recommend everyone include the following statement with all claims filed for care by Approved providers where you paid the full amount.
I certify I paid in full the equal lower fee offered by the Approved Provider for not using the TRICARE Demonstration and this claim is submitted in accordance with the provisions of the TRICARE Operations Manual (TOM) Chapter 18, Section 12 at Paragraph 4.4 which states as the last sentence; “Beneficiary-submitted claims for services provided by an approved demonstration provider in an approved demonstration area shall be denied unless it is submitted with proof of payment showing that the beneficiary has paid for the service(s).” See attached Official Receipt from the provider.
As we gather more information from TMA, the contractor and beneficiaries we will continue to send out newsletters but generally not more than once a month.
What we are seeing is rapidly put together policy that then changes within a few days only to be changed once again. These in turn raise new issues or other unforeseen problem surface. To keep up with these we will post shorter topic specific updates and notices on our blog, TRICARE Overseas Philippines Blog. Recommend those interested in keeping informed on the experiment check it frequently or alternately add your email address and click “Follow” about midway down the front page and on the right. This will automatically email you a link to each new entry.
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