Patient Administration - Army Publishing Directorate - U.S. Army
Patient Administration - Army Publishing Directorate - U.S. Army Patient Administration - Army Publishing Directorate - U.S. Army
TPCP office will file TPCP health insurance claims for the specific high cost ancillary rate as authorized by the applicable Federal register. g. TRICARE contracts specify that the MTF commander and managed care contractor can negotiate a resources sharing arrangement where the contractor hires an individual or individuals to work in the MTF. When a TRICARE contract is implemented, existing partnership agreements expire. When that occurs the MTF must bill the full amount, that is, the appropriate ambulatory, surgical, or outpatient visit rate for patients treated by a resources sharing TRICARE partner provider/practitioner. This includes the professional component of the DOD rate. h. According to 32 CFR 220, paragraph 220.8(d), for insured Family members and retirees, the usual medical services or subsistence charge will not be collected from the patient to the extent that payment received from the payer equals or exceeds the medical service or subsistence charge. The staff must consider these amounts to be included in the amount payable by the plan. If a claim has been resolved and no payment is received or expected from the third party payer, the TPCP office must refer the invoice to the MSAO to bill the patient for the subsistence amount. i. Claims must be filed with health maintenance organizations (HMOs). HMOs pay for urgent, emergent, and out-ofservice area care, and pay according to any point-of-service provisions. MTFs are expected to— (1) Identify patients with HMO coverage; (2) Certify admissions, file, and pursue all claims with HMOs (inpatient and outpatient); (3) Certify all admissions for emergent, urgent, and out-of-service area admissions; and (4) Identify all outpatient treatment for emergency, urgent, and out-of-service area care. j. The TPCP office must prepare separate claims for the mother and baby in an inpatient delivery case. k. The TPCP office will apply a separate charge for multiple outpatient visits on the same day to different clinics. Multiple visits on the same day to the same clinic must result in only one charge. l. The MTF has a statutory (or constructive) assignment of benefits and providers/practitioners must pay MTFs directly. The MTF has no responsibility and must not attempt to collect from a patient any amounts erroneously paid to the patient by a third party payer. m. MTFs will use the Medicare supplemental claims procedures outlined in the current CFRs. n. 10 USC 1095 collection authority includes automobile liability and no-fault insurance policies. Authority to collect extends to AD Soldiers for automobile liability and no-fault insurance policies. (Chap 12 and DOD 6010.15-M contain additional information.) The RJA is responsible for the submission and collection of these claims. Medical affirmative claims are commonly referred to as Federal Medical Care Recovery Act claims and were formerly referred to as Third Party Liability Claims. These claims are pursued by the RJA according to applicable regulations. 14–9. Collection activities a. Follow-up claims inquiries. If reimbursement is not received within 60 days of the initial filing, either a written or telephonic follow-up is conducted. There should be at least one additional follow-up 90 days after the initial filing. Follow-up must include the following: (1) MTFs included in a follow-up contract must refer disputed and/or delinquent TPCP claims to the follow-up contractor in accordance with provisions of the contract and written USAMEDCOM guidance. Follow-up will include transfer of current disputed claims and/or delinquent claims to the Regional Claims Settlement Office (RCSO) not later than the following: outpatient claims: 187 days after date of claim; inpatient claims: 217 days after date of claim. (2) MTFs not included in a follow-up contract must refer all disputed and/or delinquent claims to the Regional Claims Settlement Office (RCSO) not later than 180 days from date of claim. (3) Upon identification of a disputed payment trend, MTFs must report the payer dispute to the RCSO for early legal intervention. b. Deposits. TPCP collection deposits will be according to procedures delineated in the DOD 6010.15-M. 14–10. Minimum internal controls a. Management/internal controls are described in AR 11-2 and appendix C of this regulation. b. The MTF commander must ensure that appropriate separation of duties is maintained to minimize the risk of misappropriation of funds. The individual responsible for producing and filing claims must not receive, post, and deposit funds. Separate accounting records should be maintained for both the TPCP and the treasurer offices to provide adequate audit trails. c. Neither the TPCP manager nor any other person can perform all of the noted duties. There must be a clear delineation of duties for effective internal control. The patient administrator will ensure— (1) Appropriate separation of duties involving a minimum of three individuals; (2) That separate individuals prepare and mail claims; receive, post, deposit checks, and validate payments; and reconcile TPCP accounting or reporting records; and (3) That MSA/TPCP mail is opened in a central area and all checks are immediately placed in an MSA bag for further processing. d. The MSAO will— 88 AR 40–400 27 January 2010
(1) Receive and open mail including checks or payments. (2) Ensure checks are posted (recorded) and deposited within 1 day of receipt. Checks received on a weekend or holiday must be posted and deposited the next working day. e. The TPCP officer/manager will— (1) Ensure collections are recorded accurately. (2) Ensure the insurance documents indicating amounts collected equals amounts deposited; ensure that the TPCP records are reconciled with the MSA TPCP deposits; and that the TPCP reports reconcile with the finance and accounting financial records, monthly. (3) Reconcile insurance documents indicating amounts paid with total charges to validate payment of the full amount, less appropriate deductibles and coinsurance. (4) Ensure insurance payments are validated according to current guidance regarding claim closure and procedures for disputed claims. 14–11. Third Party Collection Program reports a. Quarterly reports. Quarterly, each MTF must complete and forward the cumulative TPCP Report on program results to the Commander, USAMEDCOM, ATTN: MCHO-CL-P, 2050 Worth Road, Fort Sam Houston, TX 78234- 6010. DD Form 2571 (Third Party Collection Program—Aging Schedule) will be provided to the supporting regional claim settlement legal office or Commander, USAMEDCOM, ATTN: MCJA, 2050 Worth Road, Fort Sam Houston, TX 78234-6000 upon request. MTFs must submit quarterly reports on the proper DD Form 2570 (Third Party Collection Program-Report on Program Results) (may be submitted in electronic form), signed by the administrator or responsible official, and explaining any significant variation from prior quarters. Separate DD Forms 2570 must be completed for inpatient and outpatient billing and collection activities. For the purposes of these reports, dollars collected are reported against the year in which the medical service was rendered. The RCS number DD-HA(Q) 1752 and the MTF Defense Medical Information System ID number must be annotated on each MTF quarterly report. b. Additional reports. DOD 6010.15-M provides requirements related to additional reports. c. Annual report. Each MTF must forward a narrative report to the Commander, USAMEDCOM, ATTN: MCHO- CL-P, 2050 Worth Road, Fort Sam Houston, TX 78234-6010 annually. The report will include the cost of collections and how the collections were spent for the enhancement of health care. A sample format is in DOD 6010.15-M. 14–12. Disposition of claims files Third-party health plan reimbursable MTF claims may be disposed of when they reach 6 years, 3 months from the date of billing. Do not dispose of claims without release from the RCSO. In addition, prior to destroying claims files, written certification must be obtained from the local Records Retention Officer. This ensures that claims files are not part of a destruction freeze, or that for any other reason they should not be destroyed. Chapter 15 Patient Administration Systems and Biostatistics Activity 15–1. Authority AMEDD medical information systems program offices are authorized by this regulation and by the Director, Patient Administration Systems and Biostatistics Activity (PASBA), USAMEDCOM to maintain and prepare functional documentation (functional descriptions, users’ manuals, and so forth). Data on inpatients in the Military Health System will be reported to the OASD(HA) according to DODI 6015.23. 15–2. Standard Inpatient Data Record/Standard Ambulatory Data Record AMEDD personnel process patient records using various automated systems. The Standard Inpatient Data Record (SIDR) and the Standard Ambulatory Data Record (SADR), two systems frequently used by AMEDD personnel, are discussed below. a. Standard data sets and codes are utilized in the SIDR. Files will be created and transmitted according to current procedures developed by the MTF, CHCS systems contractors, and PASBA. Records will be submitted twice each month and will be submitted on the scheduled transmittal dates. Transmittals should not be delayed to await late records that will be forwarded on the next transmittal. The mid-month transmittal is due no later than the 20th of the current month and the end-of-month transmittal is due no later than the 5th of the succeeding month. b. Standard data sets and codes are also utilized in the SADR. It is the responsibility of the Patient Administration Division (PAD) and the Information Management Division of the MTF to ensure that complete and timely SADRs are transmitted to the PASBA. Files will be created and transmitted according to current procedures developed by the MTF, CHCS systems contractors, and PASBA. Records will be submitted daily to PASBA. AR 40–400 27 January 2010 89
- Page 47 and 48: Kingdom, and the United States The
- Page 49 and 50: f. The MTF commander who starts act
- Page 51 and 52: (1) Attempt to arrange transfer to
- Page 53 and 54: (3) Patients who are being or have
- Page 55 and 56: personal decisions will be assisted
- Page 57 and 58: authorities, to the sponsor or NOK.
- Page 59 and 60: (2) Enabling care (EC). AD patients
- Page 61 and 62: patients in absent sick status, cha
- Page 63 and 64: date the packet is mailed to the PE
- Page 65 and 66: (4) A complete, current report of m
- Page 67 and 68: Table 7-1 Distribution of medical b
- Page 69 and 70: d. Instructions for the preparation
- Page 71 and 72: . After approval by the Service rev
- Page 73 and 74: . Soldiers who are in initial entry
- Page 75 and 76: a. The following information will b
- Page 77 and 78: c. Civilians interned by the Army.
- Page 79 and 80: a. Members of the Army, RC, and app
- Page 81 and 82: medical documents by submitting DD
- Page 83 and 84: 11-10. Audit and review The MSA is
- Page 85 and 86: lost. The MSA must have the interna
- Page 87 and 88: Figure 11-2. Sample memorandum form
- Page 89 and 90: Chapter 12 Patients’ Trust Fund 1
- Page 91 and 92: (2) Deposits and requests for check
- Page 93 and 94: whom administrative responsibility
- Page 95 and 96: 13-7. Concurrent medical affirmativ
- Page 97: (4) Establish a process whereby all
- Page 101 and 102: d. Patient administrators of deploy
- Page 103 and 104: AR 215-1 (not cited) Military Moral
- Page 105 and 106: AR 36-2 Audit Services in the Depar
- Page 107 and 108: VASRD Veteran’s Administration Sc
- Page 109 and 110: DA Form 5009 Medical Record-Release
- Page 111 and 112: Appendix B Persons authorized care
- Page 113 and 114: Table B-1 Persons authorized care a
- Page 115 and 116: Table B-1 Persons authorized care a
- Page 117 and 118: Table B-1 Persons authorized care a
- Page 119 and 120: Table B-1 Persons authorized care a
- Page 121 and 122: Table B-1 Persons authorized care a
- Page 123 and 124: Table B-1 Persons authorized care a
- Page 125 and 126: Table B-1 Persons authorized care a
- Page 127 and 128: (3) Is there a procedure in place t
- Page 129 and 130: Glossary Section I Abbreviations AA
- Page 131 and 132: EIN employee identification number
- Page 133 and 134: MPRJ military personnel records jac
- Page 135 and 136: REP 63 Reserve Enlistment Program o
- Page 137 and 138: VA Veterans Affairs VARO Veterans A
- Page 139 and 140: Disability separation Temporary or
- Page 141 and 142: Maximum hospital benefit That point
- Page 143 and 144: standard CHAMPUS cost shares apply.
- Page 145 and 146: Convalescent leave, 5-1 Cosmetic su
- Page 147 and 148: Civilian participants in Army-spons
TPCP office will file TPCP health insurance claims for the specific high cost ancillary rate as authorized by the<br />
applicable Federal register.<br />
g. TRICARE contracts specify that the MTF commander and managed care contractor can negotiate a resources<br />
sharing arrangement where the contractor hires an individual or individuals to work in the MTF. When a TRICARE<br />
contract is implemented, existing partnership agreements expire. When that occurs the MTF must bill the full amount,<br />
that is, the appropriate ambulatory, surgical, or outpatient visit rate for patients treated by a resources sharing<br />
TRICARE partner provider/practitioner. This includes the professional component of the DOD rate.<br />
h. According to 32 CFR 220, paragraph 220.8(d), for insured Family members and retirees, the usual medical<br />
services or subsistence charge will not be collected from the patient to the extent that payment received from the payer<br />
equals or exceeds the medical service or subsistence charge. The staff must consider these amounts to be included in<br />
the amount payable by the plan. If a claim has been resolved and no payment is received or expected from the third<br />
party payer, the TPCP office must refer the invoice to the MSAO to bill the patient for the subsistence amount.<br />
i. Claims must be filed with health maintenance organizations (HMOs). HMOs pay for urgent, emergent, and out-ofservice<br />
area care, and pay according to any point-of-service provisions. MTFs are expected to—<br />
(1) Identify patients with HMO coverage;<br />
(2) Certify admissions, file, and pursue all claims with HMOs (inpatient and outpatient);<br />
(3) Certify all admissions for emergent, urgent, and out-of-service area admissions; and<br />
(4) Identify all outpatient treatment for emergency, urgent, and out-of-service area care.<br />
j. The TPCP office must prepare separate claims for the mother and baby in an inpatient delivery case.<br />
k. The TPCP office will apply a separate charge for multiple outpatient visits on the same day to different clinics.<br />
Multiple visits on the same day to the same clinic must result in only one charge.<br />
l. The MTF has a statutory (or constructive) assignment of benefits and providers/practitioners must pay MTFs<br />
directly. The MTF has no responsibility and must not attempt to collect from a patient any amounts erroneously paid to<br />
the patient by a third party payer.<br />
m. MTFs will use the Medicare supplemental claims procedures outlined in the current CFRs.<br />
n. 10 USC 1095 collection authority includes automobile liability and no-fault insurance policies. Authority to<br />
collect extends to AD Soldiers for automobile liability and no-fault insurance policies. (Chap 12 and DOD 6010.15-M<br />
contain additional information.) The RJA is responsible for the submission and collection of these claims. Medical<br />
affirmative claims are commonly referred to as Federal Medical Care Recovery Act claims and were formerly referred<br />
to as Third Party Liability Claims. These claims are pursued by the RJA according to applicable regulations.<br />
14–9. Collection activities<br />
a. Follow-up claims inquiries. If reimbursement is not received within 60 days of the initial filing, either a written<br />
or telephonic follow-up is conducted. There should be at least one additional follow-up 90 days after the initial filing.<br />
Follow-up must include the following:<br />
(1) MTFs included in a follow-up contract must refer disputed and/or delinquent TPCP claims to the follow-up<br />
contractor in accordance with provisions of the contract and written USAMEDCOM guidance. Follow-up will include<br />
transfer of current disputed claims and/or delinquent claims to the Regional Claims Settlement Office (RCSO) not later<br />
than the following: outpatient claims: 187 days after date of claim; inpatient claims: 217 days after date of claim.<br />
(2) MTFs not included in a follow-up contract must refer all disputed and/or delinquent claims to the Regional<br />
Claims Settlement Office (RCSO) not later than 180 days from date of claim.<br />
(3) Upon identification of a disputed payment trend, MTFs must report the payer dispute to the RCSO for early<br />
legal intervention.<br />
b. Deposits. TPCP collection deposits will be according to procedures delineated in the DOD 6010.15-M.<br />
14–10. Minimum internal controls<br />
a. Management/internal controls are described in AR 11-2 and appendix C of this regulation.<br />
b. The MTF commander must ensure that appropriate separation of duties is maintained to minimize the risk of<br />
misappropriation of funds. The individual responsible for producing and filing claims must not receive, post, and<br />
deposit funds. Separate accounting records should be maintained for both the TPCP and the treasurer offices to provide<br />
adequate audit trails.<br />
c. Neither the TPCP manager nor any other person can perform all of the noted duties. There must be a clear<br />
delineation of duties for effective internal control. The patient administrator will ensure—<br />
(1) Appropriate separation of duties involving a minimum of three individuals;<br />
(2) That separate individuals prepare and mail claims; receive, post, deposit checks, and validate payments; and<br />
reconcile TPCP accounting or reporting records; and<br />
(3) That MSA/TPCP mail is opened in a central area and all checks are immediately placed in an MSA bag for<br />
further processing.<br />
d. The MSAO will—<br />
88 AR 40–400 27 January 2010