TRICARE and Third-Party Liability Insurance
The Federal Medical Care 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, required actions 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 8.9), 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. Claims will not be processed further until the beneficiary completes and submits a 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 8.9. Figure 8.9 Diagnosis Codes Exceptions/Exclusions
- 910.2-910.7
- 912.2-912.7
- 914.2-914.7
- 916.2-916.7
- 918.0
- 919.2-919.7
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- 911.2-911.7
- 913.2-913.7
- 915.2-915.7
- 917.2-917.7
- 918.2
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When the claim is received and appears to have possible third-party involvement as mentioned previously, the following process will occur:
- DD Form 2527 will be mailed to the beneficiary.
- The claim is pended for up to 35 calendar days. If DD Form 2527 is not received within that time period, 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 DD Form 2527. If the form is not returned, the claim will be denied, and the provider may bill the beneficiary.
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