Patient Administration - Army Publishing Directorate - U.S. Army

(4) Establish a process whereby all patients not having other health insurance are queried about their other health
insurance status upon discharge. Annually, thereafter, the patient must update and sign a new form on their first visit or
admission in each 12 month period.
d. For beneficiaries with coverage, the insurance company name and policy ID information-including employer
name, address, and phone number, policy and group number, and member ID-will be obtained. Insurance information
obtained during admission, discharge, or visit-including negative responses-should be entered on DD Form 2569.
(DOD 6010.15-M contains instructions for the use of this form.)
e. Patient interviews regarding health insurance coverage will be conducted according to instructions in the current
DOD 6010.15-M. The patient should be asked if their admission/visit is due to an injury sustained in an accident
(when, where, and type (for example, automobile, slip and fall, medical malpractice, work related, defective products,
homeowners’/renters’, boat and airplane, etc.)). In addition, relevant accident insurance information (policy holder
name, ID number and insurer name, address, phone number, etc.) and complete employment information should be
obtained. The goal of the interview is to obtain employment, insurance, and accident information.
14–6. Mandatory compliance by health insurance carriers
a. Insurance companies and other health insurance plans must abide by the provisions of Public Law 99-272
(incorporated into 10 USC 1095). Insurance companies cannot deny claims nor reduce payment on claims based on the
fact that care was rendered in a Government facility. Claims reduced or denied for these and other invalid reasons will
be referred to the appropriate Regional Claims Settlement Legal Office or designated legal office. Payment is not
contingent upon the military facility entering into a participation or other agreement with the insurance entity. The
current CFR also serves as a guide for the identification and documentation of payment denials for valid reasons.
b. MTFs may reach an understanding with third party payers on claims procedures and other administrative matters
if the understanding is not a precondition to complying with State and local statutory and regulatory requirements.
14–7. Authorization to release medical information in support of the Third Party Collection Program
a. MTFs must make available, upon request by third party payers, applicable health care records of the patients for
whom payment is sought. This applies only to those records necessary to verify the services provided and that
permissible terms and conditions of the plan were met. In these instances, the MTF must not charge payers for copying
these records.
b. TPCP personnel must inform patients, at the time insurance information is collected, that medical information
relevant to an episode of care being billed must be provided to third party payers if requested. A specific authorization
is required for release of alcohol and/or drug abuse, acquired immune deficiency syndrome, and sickle cell medical
records. (See AR 40-66.)
14–8. Claims activities
a. Financial accounting for claims, collections, and the disposition of third party claims will be according to DOD
7000.14-R, Volume 4.
b. MTFs that generate third party claims will establish and maintain a claims action log. As a minimum, the data
noted on the claims action log will include—
(1) Documentation of all action taken on the claim. This includes but is not limited to the date of each action, names
and phone numbers of persons contacted, and a brief summary of conversations.
(2) Amount of claim.
(3) Amount collected.
(4) Reason(s) for invalid payment. An explanation of the reason for the invalid payment or disputed amount stating
why the insurance company’s payment or denial is not a valid denial.
(5) Disputed unpaid amount.
(6) Final account disposition.
c. The TPCP personnel must accurately prepare and submit claims to third party payers. The MTF must use the UB-
04 or the CMS Form 1500.
d. To the extent practical, there should be compliance with the data elements and code specifications of the National
Uniform Billing Committee and the Uniform Claim Forms Task Force for submitting claims to third party payers.
TPCP personnel must prepare and forward inpatient claims to the third party payer within 10 business days following
completion of the medical record and outpatient claims within 7 business days after the outpatient service. The TPCP
manager (or representative) should coordinate with the patient administrator or medical records administrator to ensure
that medical records are coded within 30 days following the patient’s discharge from the MTF. In situations involving
long-term hospitalization of beneficiaries, interim claims should be prepared on a periodic basis, not to exceed 90 day
intervals.
e. Claims processing and reporting will be performed according to the current DOD 6010.15-M.
f. If an MTF provides certain high cost ancillary services or prescription drugs based on a request from a source
other than a Uniformed Services facility and not incident to an outpatient visit or inpatient service at the MTF, the
AR 40–400 27 January 2010/RAR 15 September 2011
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