Provider Handbook

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Important
Provider
Information

Provisions of the U.S. Constitution authorize Congress to make laws by passing an “Act” (e.g., Defense Appropriations Act of 1999). When an act is passed, it becomes a federal law, which generally supercedes any state law (unless it specifies that a state law may apply). An act can be codified in a number of statutes. These statutes are classified and coded in the United States Code. Title 10 of the United States Code houses all statutes regarding the armed forces.

When an act relevant to TRICARE becomes law, the Department of Defense (DoD) directs Humana Military Healthcare Services, Inc., (Humana Military) on the manner in which that law should be administered. This direction comes through modifications to federal regulations (e.g., the Code of Federal Regulations [CFR], the TRICARE Operations Manual, TRICARE Reimbursement Manual, and theTRICARE Policy Manual ). Depending on the complexity of the law, it can take a year or more before direction from the DoD is given and Humana Military can begin administration of the new policy.

For the most current information about TRICARE policy changes, refer to the TRICARE manuals, as well as the TRICARE Provider News publications that include articles featuring policy changes and how and when they should be implemented.

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The Health Insurance Portability and Accountability Act (HIPAA) was enacted on August 21, 1996, to combat waste, fraud, and abuse; improve portability of health insurance coverage; and simplify health care administration. All health plans, health care clearinghouses, and health care providers who conduct certain financial and administrative transactions electronically must comply with HIPAA. The TRICARE health plan, military treatment facilities (MTFs), providers, TRICARE contractors, subcontractors, clearinghouses, and other business associates fall within these categories.

In compliance with the portability portion of HIPAA, the Military Health System (MHS), through the Defense Manpower Data Center Support Office, issues Certificates of Creditable Coverage automatically to beneficiaries who lose TRICARE coverage.

Under the Administrative Simplification portion of HIPAA, the Department of Health and Human Services (HHS) has published five rules for HIPAA compliance:
    

• Transactions and Code Sets Rule
  Published: August 17, 2000
  Compliance date: October 16, 2003
  
• Privacy Rule
  Published: December 28, 2000
  Compliance date: April 14, 2003
  
• Employer Identifier Rule
  Published: May 31, 2002
  Compliance date: July 30, 2004
  
• Security Rule
  Published: February 20, 2003
  Compliance date: April 21, 2005
  
• National Provider Identifier Rule
  Published: January 23, 2004
  Compliance date: May 23, 2007

Effective April 14, 2003, the HIPAA Privacy Rule provisions were implemented nationwide and all covered entities, including providers, were required to be in full compliance with the Privacy Rule. 

Effective October 16, 2003, HIPAA standard electronic transactions were implemented within the MHS.

Effective July 30, 2004, the Employer Identifier Rule provisions were implemented nationwide and all covered entities, including providers, were required to be in full compliance with the Employer Identifier Rule.

Effective April 21, 2005, the HIPAA Security Rule provisions were implemented nationwide and all covered entities, including providers, were required to be in full compliance with the Security Rule.

On April 2, 2007, the Centers for Medicare and Medicaid (CMS) published guidance to the health care industry regarding National Provider Identifier (NPI) contingency planning. CMS’ NPI contingency plan guidance allows providers, vendors, clearinghouses, and health plans (“covered entities”) that demonstrate “good faith efforts” a maximum of 12 additional months (i.e., May 23, 2008) to achieve NPI compliance without financial penalty.

CMS encouraged covered entities to assess the readiness of their communities and determine the need to implement contingency plans to maintain the flow of payments, while continuing to work toward compliance.

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