Tricare Claim Policy for RP Update

Posted: October 8, 2011 in Uncategorized
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WPS maintains separate lists of authorized and denied Tricare providers for the Philippines. The authorized list is available at http://www.tricare.mil/tma/pacific/pacificcertifiedproviders.aspx. The denied list is not available on their website. If a claimant submits a claim having used a provider who has been denied or decertified, WPS is forbidden to pay the claim if that provider appears on the list. This means that the retiree cannot be paid, even though he did not have any way to know that the provider was on the denied list. The only person that can request a re-certification of a denied provider is the provider. The beneficiary is not allowed to make that request. The only exception is if the provider was denied based on the fact that a claim had not been filed using the provider for a period of two years. In those cases the retiree/beneficiary can request a re-certification.
The Yahoo Group U.S. Military Retirees in the Philippines (USMRoP) over the last three years has attempted to get TRICARE Management Activity (TMA) to post a current and frequently updated ‗Denied Provider‘ list in order to assist retirees in the Philippines to avoid claim denials if they use a provider that is on the list. They made their request under the provisions of DODI 6000.14, (Patient Bill of Rights and Responsibilities in the Military Health System (MHS), which states in part;
 E3.2.2.1. Information Disclosure. MHS patients have the right to receive accurate, easily understood information and assistance in making informed healthcare decisions about their health plans, providers, and facilities. DoD facilities will promote quality and efficient healthcare through the use of health information technology; transparency regarding healthcare quality and price; and better incentives for beneficiaries, enrollees, and providers consistent with Executive Order 13410 (Reference (f)) and in accordance with specifications established by the ASD(HA).
 E3.2.2.1.1. MHS beneficiaries shall be provided accurate, understandable, and timely information about the TRICARE program (section 199.17 of Reference (e)) including details of the covered health benefit, the various health plan options, and applicable cost-sharing arrangements.
TRICARE Management Activity (TMA) appears adamant in their refusal to post this ‗Denied Provider‘ list on their TAO-P website http://www.tricare.mil/tma/pacific or any other readily available source. Their reasoning is apparently some restriction which prohibits disclosing who these providers are. By paying a $1056 fee required by the FOIA law and assessed by TMA for the cost of their research efforts to provide the info, the USRP Group through the Freedom of Information Act acquired a AUG 2010 Master list with updates through 13 SEP 2011. It can be viewed at http://db.tt/qoSmNzEO. This 113 page alphabetical listing of almost 4,000 decertified Philippine providers is updated weekly by ISOS. A previous denied list was obtained from an enclosure in the TMA 2008 Request for Bid on the current Tricare Overseas Program contract, (TOP), and contained denied providers from 2001-2007. That enclosure showed that the majority, more than 99%, of the providers denied certification were for reasons other than that the provider was not licensed or fraud. Rather they were denied because the International SOS (ISOS) contractor claimed they could not find their office, were reluctant to travel to the location or the provider refused to be certified. Some were decertified because a claim had not been filed for 2 years.
USMRoP recommends beneficiaries seeking a provider first check the Certified Provider List by learning how to determine the multiple ‗City‘ names used to find providers in their area. For example in Angeles City a beneficiary would need to check for ―Angeles City‖, ―ANGELES CITY 2009‖, ―Angeles City Pampan‖, ―ANGELES CITY PAMPANGA‖, ―ANGELES CITY,PAMPANGA‖ (comma added), ―Angeles Mac Arthur‖, ―PAMPANGA‖, ―PAMPANGA ANGELES CITY‖, ―Pamapanga‖ and ―Quezon City‖. Once you have determined there is no provider with the specialty you need on the Certified Provider List and decide to use an uncertified provider then check their name against the ‗Denied Provider List‘ at http://db.tt/qoSmNzEO. If their name appears it is likely you will need to take additional action such as addressing with the provider the need for them to request to be recertified for your benefit. If they will not
you may want to consider finding yet another provider or be prepared to pay for the cost of your care in full. [Source: USMRoP James Houtsma & Kenneth Fournier input 25 Sep 2011 ++]

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