10 U.S. Code § 1095c - TRICARE program: facilitation of processing of claims

(a) Reduction of Processing Time.—

(1) With respect to claims for payment for medical care provided under the TRICARE program, the Secretary of Defense shall implement a system for processing of claims under which—

(A) 95 percent of all clean claims must be processed not later than 30 days after the date that such claims are submitted to the claims processor; and

(B) 100 percent of all clean claims must be processed not later than 100 days after the date that such claims are submitted to the claims processor.

(2) The Secretary may, under the system required by paragraph (1) and consistent with the provisions in chapter 39 of title 31 (commonly referred to as the “Prompt Payment Act”), require that interest be paid on clean claims that are not processed within 30 days.

(3) For purposes of this subsection, the term “clean claim” means a claim that has no defect, impropriety (including a lack of any required substantiating documentation), or particular circumstance requiring special treatment that prevents timely payment on the claim under this section.

(b) Requirement to Provide Start-Up Time For Certain Contractors.—

(1) Except as provided in paragraph (3), the Secretary of Defense shall not require that a contractor described in paragraph (2) begin to provide managed care support pursuant to a contract to provide such support under the TRICARE program until at least nine months after the date of the award of the contract, but in no case later than one year after the date of such award.

(2) A contractor under this paragraph is a contractor who is awarded a contract to provide managed care support under the TRICARE program—

(A) who has not previously been awarded such a contract by the Department of Defense; or

(B) who has previously been awarded such a contract by the Department of Defense but for whom the subcontractors have not previously been awarded the subcontracts for such a contract.

(3) The Secretary may reduce the nine-month start-up period required under paragraph (1) if—

(A) the Secretary—

(i) determines that a shorter period is sufficient to ensure effective implementation of all contract requirements; and

(ii) submits notification to the Committees on Armed Services of the House of Representatives and the Senate of the Secretary’s intent to reduce the nine-month start-up period; and

(B) 60 days have elapsed since the date of such notification.

(c) Incentives for Electronic Processing.—

The Secretary of Defense shall require that new contracts for managed care support under the TRICARE program provide that the contractor be permitted to provide financial incentives to health care providers who file claims for payment electronically.

(d) Correspondence to Medicare Claims Information Requirements.—

The Secretary of Defense, in consultation with the other administering Secretaries, shall limit the information required in support of claims for payment for health care items and services provided under the TRICARE program to that information that is identical to the information that would be required for claims for reimbursement for those items and services under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) except for that information, if any, that is uniquely required by the TRICARE program. The Secretary of Defense shall report to the Committee on Armed Services of the Senate and the Committee on Armed Services of the House of Representatives any information that is excepted under this provision, and the justification for that exception.

(Added Pub. L. 106–65, div. A, title VII, § 713(a)(1), Oct. 5, 1999, 113 Stat. 688; amended Pub. L. 107–107, div. A, title VII, § 708(b), Dec. 28, 2001, 115 Stat. 1164; Pub. L. 107–314, div. A, title VII, § 711(a), Dec. 2, 2002, 116 Stat. 2588.)

Editorial Notes

References in Text

The Social Security Act, referred to in subsec. (d), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Title XVIII of the Act is classified generally to subchapter XVIII (§ 1395 et seq.) of chapter 7 of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables.

Amendments

2002—Subsec. (d). Pub. L. 107–314 added subsec. (d).

2001—Subsec. (b)(1). Pub. L. 107–107, § 708(b)(1), substituted “Except as provided in paragraph (3), the Secretary” for “The Secretary” and struck out “contract. In such case the contractor may begin to provide managed care support pursuant to the contract as soon as practicable after the award of the” before “contract, but in no case”.

Subsec. (b)(3). Pub. L. 107–107, § 708(b)(2), added par. (3).

Statutory Notes and Related Subsidiaries

Effective Date

Pub. L. 106–65, div. A, title VII, § 713(d), Oct. 5, 1999, 113 Stat. 689, provided that:

“Section 1095c(b) of title 10, United States Code (as added by subsection (a)), shall apply with respect to any contract to provide managed care support under the TRICARE program negotiated after the date of the enactment of this Act [Oct. 5, 1999].”

Applicability

Pub. L. 107–314, div. A, title VII, § 711(b), Dec. 2, 2002, 116 Stat. 2588, provided that:

“The Secretary of Defense, in consultation with the other administering Secretaries referred to in section 1072(3) of title 10, United States Code, shall apply the limitations required under subsection (d) of section 1095c of such title (as added by subsection (a)) with respect to contracts entered into under the TRICARE program on or after October 1, 2002.”

Standardization of Claims Processing Under TRICARE Program and Medicare Program

Pub. L. 109–364, div. A, title VII, § 731, Oct. 17, 2006, 120 Stat. 2295, as amended by Pub. L. 112–81, div. A, title X, § 1062(d)(2), Dec. 31, 2011, 125 Stat. 1585, provided that:

“(a) In General.—

Effective beginning with the next contract option period for managed care support contracts under the TRICARE program, the claims processing requirements under the TRICARE program on the matters described in subsection (b) shall be identical to the claims processing requirements under the Medicare program on such matters.

“(b) Covered Matters.—

The matters described in this subsection are as follows:

“(1) The utilization of single or multiple provider identification numbers for purposes of the payment of health care claims by Department of Defense contractors.

“(2) The documentation required to substantiate medical necessity for items and services that are covered under both the TRICARE program and the Medicare program.

“(c) Report on Collection of Amounts Owed.—

Not later than March 1, 2007, the Secretary of Defense shall submit to the congressional defense committees [Committees on Armed Services and Appropriations of the Senate and the House of Representatives] a report setting forth a detailed description of the following:

“(1) All TRICARE policies and directives concerning collection of amounts owed to the United States pursuant to section 1095 of title 10, United States Code, from third party payers, including—

“(A) collection by military treatment facilities from third-party payers; and

“(B) collection by contractors providing managed care support under the TRICARE program from other insurers in cases of private insurance liability for health care costs of a TRICARE beneficiary.

“(2) An estimate of the outstanding amounts owed from third party payers in each of fiscal years 2002, 2003, and 2004.

“(3) The amounts collected from third party payers in each of fiscal years 2002, 2003, and 2004.

“(4) A plan of action to streamline the business practices that underlie the policies and directives described in paragraph (1).

“(5) A plan of action to accelerate and increase the collections or recoupments of amounts owed from third party payers.

“(d) Definitions.—

In this section:

“(1) The term ‘Medicare program’ means the program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

“(2) The term ‘TRICARE program’ has the meaning given that term in section 1072(7) of title 10, United States Code.”

Claims Processing Improvements

Pub. L. 106–398, § 1 [[div. A], title VII, § 727], Oct. 30, 2000, 114 Stat. 1654, 1654A–188, provided that:

“Beginning on the date of the enactment of this Act [Oct. 30, 2000], the Secretary of Defense shall, to the maximum extent practicable, take all necessary actions to implement the following improvements with respect to processing of claims under the TRICARE program:

“(1) Use of the TRICARE encounter data information system rather than the health care service record in maintaining information on covered beneficiaries under chapter 55 of title 10, United States Code.

“(2) Elimination of all delays in payment of claims to health care providers that may result from the development of the health care service record or TRICARE encounter data information.

“(3) Requiring all health care providers under the TRICARE program that the Secretary determines are high-volume providers to submit claims electronically.

“(4) Processing 50 percent of all claims by health care providers and institutions under the TRICARE program by electronic means.

“(5) Authorizing managed care support contractors under the TRICARE program to require providers to access information on the status of claims through the use of telephone automated voice response units.”

Deadline for Implementation

Pub. L. 106–65, div. A, title VII, § 713(c), Oct. 5, 1999, 113 Stat. 689, provided that the system for processing claims required under subsec. (a) of this section was to be implemented not later than 6 months after Oct. 5, 1999.