Provider Handbook

Previous Page          Table of Contents          Next Page

Debt Collection Assistance Officers (DCAOs) are located at each TRICARE Regional Office and  MTF to assist TRICARE beneficiaries in determining the validity of collection agent claims and/or negative credit reports received for debts incurred as a result of receiving health care* under the TRICARE Program. DCAOs will take all measures necessary to resolve the issues presented. Beneficiaries must bring or submit documentation associated with a collection action or adverse credit rating to the DCAO. This includes debt collection letters, TRICARE EOBs, and health care bills from providers. The more information the beneficiary provides, the faster it will be to determine the cause of the problem. The DCAO will research the beneficiary’s claim with the appropriate claims processor or other agency points of contact and provide the beneficiary with a written resolution to the collection problem. The collection agency will be notified by the DCAO that action is being taken to resolve the issue.

DCAOs cannot provide beneficiaries with legal advice or fix their credit rating, but DCAOs can help the beneficiary through the debt collection process by providing documentation for the collection or credit-reporting agency in explaining the circumstances relating to the debt.

The DCAO directory is available online.

* “Health care” includes medical and adjunctive dental care under TRICARE.

Back to Top

Prepayment review of medical necessity or appropriate level of care is reviewed by Humana Military upon written request. Providers may request reconsideration of a review within 90 days of the initial claim determination by PGBA at the following address:
 

TRICARE South Region
Appeals Department
P.O. Box 202002
Florence, SC 29502-2002

Back to Top

• Network provider claim appeals: Network providers who are dissatisfied with the denial of a claim can appeal under the administrative review process. The process for administrative review and general claim appeals are similar and require the same information to process your request.
• Non-network provider and beneficiary claim appeals: Non-network, participating providers (those who accept assignment) and beneficiaries can appeal a TRICARE claim.
• Claim adjustments: An allowable charge review can be requested by a provider or beneficiary if either party disagrees with reimbursement allowed on a claim. This includes appeals for “By Report” or unlisted procedures where a provider can request an appeal.

Refer to Figures 8.9 and 8.10 for details about the appropriate types of appeal requests, time frames for submitting an appeal request, addresses, and the information to include with the request. By following the rules and timelines for requesting reviews, you can help to achieve prompt resolution to your request.

After your request is submitted, Humana Military will notify you in writing or by telephone of the outcome.

Section 1869/1878 Social Security Act—Appeals Determination

• APC groups and rates
• Periodic adjustments
• Conversion factors
• Fixed dollar amount
• Marginal cost amount
• Determination of initial and new groups

Back to Top