Provider Handbook

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The Federal Medical Recovery Act allows the Government to be reimbursed for costs associated with treating a TRICARE beneficiary who has been injured in an accident caused by someone else. When a claim appears to have possible third-party involvement, certain actions must be taken that can affect total processing time. Humana Military is responsible for identifying and investigating all potential third-party recovery claims. Inpatient claims submitted with diagnosis codes 800–999 (with some exclusions, as listed in Figure 8.8), regardless of the billed amount, and claims for professional services that exceed a TRICARE liability of $500, which indicate an accidental injury or illness will be pended for research. These claims will not be processed further until the beneficiary completes and submits a DD Form 2527 Statement of Personal Injury—Possible Third Party Liability Form.

There are certain diagnosis codes that are exceptions. A third-party liability form is not required for the codes listed in Figure 8.8. 
 

Fig. 8.8

• The DD Form 2527 Statement of Personal Injury will be mailed to the beneficiary.
• The claim is pended for up to 35 calendar days. If the DD Form 2527 is not received, the claim will be denied.
• The claim will be reprocessed when the DD Form 2527 is completed and returned by the beneficiary. Encourage the beneficiary to fill out the form within the 35 calendar days to avoid payment delays.
• If the illness or injury was not caused by a third party, but the diagnosis code(s) still falls between 800 and 999, the beneficiary may still be responsible to fill out the form. If the form is not returned, the claim will be denied. If the claim is denied due to lack of submission of the DD Form 2527 by the beneficiary, the provider may bill the beneficiary.

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TRICARE will not share costs for services for work-related illnesses or injuries that are covered under workers’ compensation programs.

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• Submit an administrative review request
• Request an adjustment on an Allowable Charge Review
• Contact Humana Military at 1-800-444-5445 to view the status of a claim.

Please wait at least 45 days after submitting a claim before contacting Humana Military. If the problem is still not resolved, providers should contact their local network representative and non-network providers should contact PGBA at 1-800-403-3950 for assistance.

Beneficiaries are responsible for their out-of-pocket expenses. A beneficiary should not be sent to collections before the non-network provider contacts his or her local network representative, unless the only amount outstanding is the beneficiary’s deductible, cost-share, or copayment amount reflected on the Provider Remittance Advice.

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