Provider Handbook

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Balance Billing
Urgent and Emergency Care
Release of Patient Information
Release of Medical Records

Network providers may only bill TRICARE beneficiaries for applicable deductible, copayment, or cost-sharing amounts, but may not bill for charges that exceed contractually agreed upon payment rates. Because network providers have contractually agreed to adhere to these provisions, TRICARE beneficiaries will be referred first to a network provider. Any provider who is uncertain about the amount that may be billed to a TRICARE beneficiary may call Humana Military’s TRICARE Service Line at 1-800-444-5445. The beneficiary’s responsibility is reflected on the explanation of benefits (EOB) or the provider’s remittance advice. In the case of a network provider, the contractually negotiated amount is the TRICARE allowable charge.

Non-network providers who accept assignment are limited to collecting the TRICARE allowable charge. If the billed charge is less than the allowable charge, the billed charge becomes the billable amount to the beneficiary. Balance billing applies only to services covered by TRICARE. A general statement of financial liability does not meet TRICARE criteria.

When providers do not accept assignment on a claim, non-network, nonparticipating providers can collect applicable deductibles andor cost-shares and any outstanding amounts up to 15 percent above the TRICARE allowable charge (shown on the TRICARE EOB) from a TRICARE Standard beneficiary. If the billed charge is less than the TRICARE allowable charge, the billed charge is the allowable amount used to process the claim.

Balance billing applies only to services covered by TRICARE. TRICARE’s balance-billing limit also applies when other health insurance (OHI) is involved. Providers may not bill beneficiaries for administrative expenses, including collection fees, to collect TRICARE amounts.

Providers are limited to collecting the amount previously described, regardless of the beneficiary’s OHI financial responsibility. When OHI is involved, the provider of care may receive no more than the TRICARE allowable charge, or if a non-network, nonparticipating provider, 115 percent of the TRICARE allowable charge through payment by the other health insurer and TRICARE. Providers may not collect any amount from a beneficiary after payment of the claim unless TRICARE and the OHI combined have failed to pay the TRICARE allowable charge. In the case of a network provider, the contractually negotiated amount is the TRICARE allowable charge. Additionally, network providers cannot bill beneficiaries for non-covered services unless the beneficiary has agreed in advance and in writing to pay for these services. See “Hold Harmless Policy” later in this section.

Non-compliance with these balance-billing requirements by any TRICARE provider may affect that provider’s TRICARE and/or Medicare status. Additional information on this topic may be obtained by visiting the TRICARE Web site.

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• When a parent writes on behalf of a minor child (under 18 years old)
• When a guardian writes on behalf of a physically or mentally incompetent beneficiary

In responding to a parent or guardian in the above circumstances, the Privacy Act of 1974 precludes disclosure of sensitive information, which, if released, could have an adverse effect on the beneficiary.

Providers must not furnish information to the parents or guardians of minors or incompetents when services are related to the following diagnostic codes:
 

TRICARE-eligible beneficiaries must maintain a “signature on file” in the physician’s office to protect the patient’s privacy, for the release of important information, and to prevent fraud. A new signature is required every year for professional claims submitted on a CMS-1500 and every admission for claims submitted on a UB-04. Claims submitted for diagnostic tests, test interpretations, or other similar services do not require the beneficiary’s signature. Providers submitting these claims must indicate “patient not present” on the claim form.

Mentally incompetent or physically disabled TRICARE-eligible beneficiaries 18 years of age and older who are incapable of providing a signature may have a legal guardian appointed or a power of attorney issued on their behalf. This legal documentation must include the guardian’s signature, full name, address, relationship to patient, and reason the patient is unable to sign.

For civilian providers, the first claims submission on behalf of the beneficiary should include the legal documentation establishing the guardian’s signature authority. Subsequent claims may be stamped with “Signature on File” in the beneficiary signature box of the CMS-1500 or UB-04 claim form.
 

• If the beneficiary is without legal representation, the provider must submit a written report with the claims describing the patient’s illness or degree of mental competence, and should annotate in Box 12, “Patient’s or Authorized Representative’s Signature—Unable to Sign.”
• If the beneficiary’s illness is temporary, the signature waiver must specify the dates the illness began and ended.
• When the beneficiary is mentally competent but physically incapable of a signature, the representative may be issued a general or limited power of attorney by signing an “X” in the presence of a notary public.

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All providers are required to request that the TRICARE beneficiary sign a release of medical information at each office visit (unless a signed release is on file), to include ancillary services associated with each visit whereby the primary care manager (PCM) and/or the (MTF) commanders are designated as the recipients of the medical records. For an urgent care visit, the records should be given to the beneficiary at the time of the visit. Providers are required to submit beneficiary records for review upon request.

Under the TRICARE Prime Remote program (described in the TRICARE Program Options section), active duty service members will be instructed to sign annual medical release forms with the provider who manages their care much like a PCM to allow information to be forwarded to civilian and military providers. If an active duty service member is reassigned to a new location, the PCM should provide complete copies of medical records and specialty and ancillary care documentation to the service member within 30 calendar days of the request—prior to moving.

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