Tricare Philippines Newsletter 12006
Outpatient Claim Filing Considerations
First insure you comply with the guidance, previously discussed in Newsletter 12005, Basic Claim Filing Rules for the Philippines, which can be seen by clicking the link.
Use a provider listed on the latest Certified Provider list.
One of the most common reasons for denial of outpatient claims is Claims Processing Reasons 018 PROVIDER NOT TRICARE AUTHORIZED FOR THIS SERVICE and 135 PROVIDER IS NOT TRICARE AUTHORIZED. REQUESTED PROVIDER CERTIFICATION INFORMATION NOT RECEIVED.
If you must use a provider that is not certified discuss the need for certification with the provider when you see them. Indicate that a company known as International SOS (ISOS) will be contacting them in a few months to obtain some information. Make sure to tell them there is no charge for this certification. (More detailed information on what these mean and how to avoid or overcome them will be discussed in a later newsletter.) Certified Provider List
Receipt from Provider
Insure the receipt includes the full name and address of the provider as well as his specialty. If specialty is missing add it to the narrative. The date of care should be present and clear as should the amount paid. A short description of services provided should be included. In most cases local providers show something like “Professional Services”, Professional Fee” or “Prof Fee”. Insure the provider’s clerk signs the receipt. Example of a typical Receipt.
Detailed description of the care on the narrative
Under most circumstances simply including the description as “Outpatient Visit” will be sufficient. The way to determine this is to compare the actual fee, converted to dollars, against the normal approved amount that WPS will pay. Because of the CMAC, WPS will have to compare the billed amount against a procedure on the CMAC to determine how much is allowed. Generally there are five procedures used for new patients and five for established patients which are most often used in the U.S. The most common code used by TMA and WPS is 99213, the middle established patient code, on claims from the Philippines.[i] This code is used unless they receive information that justifies a higher code and currently carries a maximum allowed amount on the CMAC of $35.86. The Philippine CMAC can be seen by following the instructions at this website: Philippine CMAC.
Presently most Philippine outpatient visits run between Php300 and Php700. At an exchange rate of Php40 they would equate to $7.50 and $17.50.[ii] So as you can see for the vast majority of outpatient visit claims simply stating “Outpatient Visit” as the description will cause it to be paid within the allowed amount. This also clearly demonstrates how the CMAC is poorly designed for Philippine medical billing practices as addressed in Newsletter 20120410, Issues with the TRICARE CHAMPUS Maximum Allowable Charge (CMAC) Table, which can be seen by clicking the link.
What if the cost of your visit exceeds the CMAC rate for 99213?
While, at present, it is unlikely the charges will exceed the peso examples above. The most likely cause would be your provider is trying to overcharge you because he sees you as someone that doesn’t know the local system and is dishonest. This is probably more common in areas where there are large concentrations of expats and where Health Visions and other similar defrauders operated. If you are in one of these areas or suspect the provider it is always best to confirm his fees before seeing him.
In some instances where a provider my do a number of other procedures, in addition to just seeing you or your dependent, the fees could be higher and even exceed the CMAC maximum allowable amount for 99213. Although at present most doctors don’t charge more when they perform some of these procedures. Some examples of typical procedures performed by a physician in their office; suture removal, suturing of a wound, applying or removing casts, rectal prostate exam, vaginal exam, obtaining specimen for lab tests, biopsy, removal of cyst and many more. If the fee is increased due to one or more of these procedures it is important to insure whoever completes the receipt includes, in addition to the typical “Prof Fee” description, a description of the additional procedure(s) performed and ask them to break out the fees by visit and the procedures. An alternative is to take the OHI Form with you and use it as a method to have the provider list all procedures and then mark N/A as instructed. When N/A is used the rest of the form is not needed; include a copy with your claim and list the procedures and costs on you narrative. If they will not do that you will have to determine how much to charge against the visit and the procedure; charge to much to one and you will risk exceeding the CMAC maximum allowed charge. One way to do this is to look up the procedure on the Philippine CMAC but to do this you will have to determine the appropriate CPT code. (In a later newsletter we will detail some approaches that can be used to do this.)
Other Health Insurance (OHI)
As briefly discussed in Newsletter 20120402 there are certain additional requirements that must be met to insure the claim is approved for payment. If you have OHI you will have to note it on the claim form and provide an EOB to show how much was paid by the OHI with the claim. If you have PhilHealth as OHI then the OHI form needs to be completed and submitted with the claim. The most time effective approach is to bring a blank form along with you and complete it by printing the information on the form and having the provider or office clerk that signs the receipt also sign the form. The alternative is to return with a typed version but this entails an additional trip to the doctor’s office. Since PhilHealth doesn’t cover routine outpatient encounters completing the form should be quite simple. In some limited instances PhilHealth will cover some outpatient procedures in which case the form should indicate the amount the provider received or will receive. OHI payments are supposed to be credited towards the deductible, copay and catastrophic cap so when you receive your EOB from TRICARE insure you were given credit. If not use the secure email system, addressed in Newsletter 12005 under Personal TRICARE - Overseas Account to send WPS an email bringing the error to their attention. A new EOB should be produced and sent to show the corrections.
The last step
Once you have accomplished all the requirements described in Newsletter 12005, Basic Claim Filing Rules for the Philippines and those addressed above all that remains is to submit your claim. Be sure to follow the claim on your Personal TRICARE - Overseas Account, also described in the same Newsletter 120005.
The next newsletter will discuss the specific concerns when filing pharmacy, laboratory and radiology or similar ancillary services.
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[i] The established patient codes are:
99211 - OFFICE OR OTHER OUTPATIENT VISIT FOR EVAL & MGMT OF ESTABLISHED PATIENT, MAY NOT REQUIRE PHYSICIAN. PRESENTING PROBLEM(S) MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING SERVICES
99212 - OFFICE OR OTHER OUTPATIENT VISIT FOR EVAL & MGMT OF ESTABLISHED PATIENT, REQUIRES 2 OF 3: PROBLEM FOCUSED HISTORY; EXAM; MEDICAL DECISION MAKING. PROBLEM(S) ARE SELF LIMITED OR MINOR
99213 - OFFICE OR OTHER OUTPATIENT VISIT FOR EVAL & MGMT OF ESTABLISHED PATIENT, REQUIRES 2 OF 3: EXPANDED PROBLEM HISTORY; EXAM; MEDICAL DECISION MAKING LOW COMPLEXITY. PROBLEM(S) LOW TO MODERATE SEVERITY
99214 - OFFICE OR OTHER OUTPATIENT VISIT FOR EVAL & MGMT OF ESTABLISHED PATIENT, REQUIRES 2 OF 3: DETAILED HISTORY; EXAM; MEDICAL DECISION MAKING MODERATE COMPLEXITY. PROBLEM(S) MODERATE TO HIGH SEVERITY
99215 - OFFICE OR OTHER OUTPATIENT VISIT FOR EVAL & MGMT OF ESTABLISHED PATIENT, REQUIRES 2 OF 3: COMPREHENSIVE HISTORY; EXAM; MEDICAL DECISION MAKING HIGHCOMPLEXITY. PROBLEM(S) MODERATE TO HIGH SEVERITY
One significant issue with using these codes in the Philippines is that in the front of the American Medical Association CPT Coding manual, under Evaluation and Management codes is a listing of visit times used as one criteria to determine which of the above codes are used. The problem is that the times are based on U.S. medical standards and not Philippine medical standards so in reality have little bearing on which code to use. Having said that, it doesn’t appear TMA or WPS have taken this into consideration so time can be used as one approach to justifying a higher code if necessary. They are listed as Established Patient Visit Time: 99211 - 05 minutes, 99222 - 10 minutes, 99213 - 15 minutes, 99214 - 25 minutes, 99215 - 40 minutes. Because local providers tend to take more time with patients a typical visit will run 30 minutes which would place the code at 99214 and a higher rate of reimbursement but the typical and most common code used in the states is 99213 and the one used on almost all claims by WPS.
[ii] Php40 was used because the contract WPS has to operate under requires they use CiTi bank exchange rates at the time of care which generally run 2% below the actual exchange rate obtainable in the Philippines at the time of care.