Tricare Philippines Newsletter 12007
Pharmacy, Pathology and Radiology Claim Filing Considerations
While the title indicates Pharmacy, Pathology and Radiology we will also briefly discuss durable medical equipment. These guidelines can also apply to other ancillary services.
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 ancillary claims is Claims Processing Reasons
018 PROVIDER NOT TRICARE AUTHORIZED FOR THIS SERVICE
135 PROVIDER IS NOT TRICARE AUTHORIZED REQUESTED PROVIDER CERTIFICATION INFORMATION NOT RECEIVED
Note: We were finally successful in getting the TRICARE Management Activity (TMA) to certify pharmacies at the corporate level and as of this newsletter Mercury Drug and Rose Pharmacy have been certified this way which means beneficiaries can use any of these drugstores. However both Manson Drug and South Star Pharmacy have made it clear to TMA that they want nothing to do with TRICARE and asked that all their pharmacies be decertified. So any claims for prescriptions from these pharmacies, after the dates indicated on the certified provider web page, will be denied.
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
Prescription or Procedure Request Document
You will need a document from your physician ordering the prescription, lab, x-ray or other procedure. The most common document used is the physician’s prescription form for all of these. Insure the letter head includes provider’s full name, specialty and address. Under current practice Wisconsin Physicians Service (WPS) will honor and process claims for pharmacy and ancillary services written by non-certified providers.[i] What this means is if you see a non-certified provider and also have prescriptions or ancillary services as a result of your visit do not combine them into one claim. Doing so will cause all the individual claims to be held pending certification of the physician. Instead submit two claims with two claim forms, DD2642, one for the physician and one for the other services. They can even be mailed in the same envelope, just staple the pertinent documents to the appropriate DD2642.
Receipt from Provider of Services
Whether you are filing a claim for a prescription or other ancillary service a receipt, itemized to the extent possible, should be obtained from the provider. Insure the receipt includes the full name and address of the provider. The date of care should be present and clear as should the amount paid. A short description of services provided should be included if possible.
Pharmacy Specific Considerations
Many drug store receipts, Mercury in particular, are on thermal paper which can fade quickly. So it is wise to make a copy for your files early. Some cash register receipts list the medication name, quantity and price, while others do not. If they are not listed you should print or type the name of the medication, quantity and price on the copy you submit with your claim. An alternative is to ask for a hand written Official Receipt from the pharmacy which includes that information. If the medication is not a prescription drug, such as an over the counter item such as cough syrup, WPS will deny that item.
If all the information for the claim is straight forward and doesn’t require any additional explanations a narrative is not normally required, however it never will hurt to include one. Example of a cash register receipt with annotation. Example of an Official Receipt.
Because the TRICARE Management Activity (TMA) set the Pharmacy CMAC at the U.S. rates most claims will be paid in full and in general there are few problems with pharmacy claims if these instructions are followed.
Laboratory and Radiology Specific Considerations
1. Some of these procedures can be a problem when trying to file claims. The issue is created by the CMAC that is designed for U.S. standards. For our purposes in this area the problem exists where Philippine medical industry practice groups two or more procedures under one procedure for the purposes of billing. If only the listed procedure is claimed in most cases a significant portion of the billed amount will be denied as exceeding the CMAC. To overcome this the beneficiary has to understand what the individual procedures are and list them in the narrative along with a pricing breakout for each one identified. One way to determine if the local procedure includes multiple sub-procedures is to do an internet search on the procedure. Generally the best results are obtained by searching the procedure name preceded by “billing for”. For example “billing for urine culture”. For some examples see endnote.[ii]
2. The second issue is also caused by the CMAC that was developed for the U.S. standards and then not adjusted for inflation and exchange rate changes. When the CMAC was implemented, more than 4 years ago, the ancillary rates were high enough that procedures done in high cost urban areas were just covered. With the loss of value of the CMAC, many of the higher cost procedures done in an urban setting are no longer covered in full. Even some procedures done in rural areas are now bumping the maximum allowable charges. What this means is TMA will refuse to pay the full, local, fair and reasonable charge. So the beneficiary is required to pay the amount that exceeds the maximum allowable charge plus their normal copay. Attempts to obtain relief from TMA on these issues have been ignored.
Insure your receipts are clear and identify the procedure if possible. It is also a good idea to annotate the information on the copy being sent with the claim in case the information on the receipt is not clear or if the terminology is somewhat different. You can do this on the receipt or in a narrative but it is important to make it clear to the claims processor what was done, using U.S. medical claims terminology, and the cost. Remember, you may know what happened and what was done but the claims processor only has the documents you submit to go on. So make it as clear as possible and include a description if you feel it will help them with the claim.
Examples of laboratory and radiology documents for claims submission
Laboratory test (Note that the receipt does not include the full procedure description as ordered and the print is light. To overcome these the procedure description and price were typed on the copy and an arrow used to point to the appropriate local description.)
CT Scan (Note more detailed description of procedure below the receipt.)
Ultra Sound (Note typed description of procedure on the doctor’s order to better clarify the hard to read written one. Also multiple comments with arrows were added to the receipt to clarify the procedure name and the amount paid because the signature partially covered the original)
Urine Culture with breakout (In this example note the short procedure description on the doctor’s order and the receipt. In this case in the Philippines they see this as a single procedure while in the U.S. it is considered three procedures. So to be properly paid one must identify the three procedures and price them within the CMAC amounts. Failure to do this will result in TMA paying the claim on the basis of only the first procedure listed and half the billed amount will be disallowed.)
Laboratory test with extensive breakout (This example shows the extreme, but not all that uncommon, example where the receipt description shows something like “Executive Panel B” but in reality 29 separate reported results were obtained through 27 distinct laboratory tests each of which has to be identified with individual costs before TMA will approve the claim for payment. It should also be noted that the tests were done in a low cost area so the charges were lower than the CMAC. If these same tests had been done in a high cost area like Manila, the costs would have exceeded the CMAC in many instances. )
Durable Medical Equipment (DME) Considerations
As some of you may have encountered in the past the TRICARE Management Activity (TMA) has denied claims because durable medical equipment authorized by the program and even authorized in the Philippines was not purchased at a pharmacy. We know that local pharmacies don’t generally offer many items of DME and you have to find a store, usually a retail store, which is willing to order it for you.
The TRICARE Policy Manual actually authorizes the purchase of DME from, in their term, “Any civilian retail store”. So that means those of you that purchased DME from local hardware stores can now file a claim and hope to be paid. Be sure to inform the owner of the store that ISOS will visit them for certification and review the guidance we provided on what to do to assist in the certification of your provider. With the recent change to policy where claims can be filed for up to 3 years after the care is received, those that previously had DME claims denied because they were not purchased at a pharmacy may want to consider refilling following this guidance.
Be sure to include the references, below, in your narrative submitted with the claim as well as the doctor’s prescription for the item and the receipt showing the actual item purchased, price, date and business identification data including address.
TRICARE Policy Manual 6010.57-M, February 1, 2008 Providers, Chapter 11, Section 9.1
2.2 Vendors of medical supplies, Durable Medical Equipment (DME), or Durable Equipment (DE) which are covered as a Basic Program or Extended Care Health Option (ECHO) benefit.
2.2.1 The types of vendors which may be approved for medical supplies, DME, or DE includes, but is not limited to, the following:
188.8.131.52 Any firm, supplier, or provider that is authorized under Medicare.
184.108.40.206 Any commissary under the jurisdiction of the Defense Commissary Agency.
220.127.116.11 Any Post Exchange, Base Exchange, or Station Exchange under the jurisdiction of:
• The Army/Air Force Exchange Service (AAFES); or
• The Department of the Navy; or
• The United States Marine Corps; or
• The United States Coast Guard.
18.104.22.168 Any civilian retail store.
22.214.171.124 Any civilian retail pharmacy.
Detailed description of the care on the narrative
The more information about a laboratory or radiology or DME purchase included in the narrative to assist the claims processors in determining the U.S. equivalent the better your chances of getting properly reimbursed.
Other Health Insurance (OHI)
As briefly discussed in Newsletter 20120402 and 12006 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 to send WPS an email bringing the error to their attention. A new EOB should be produced and sent to show the corrections.
The next newsletter will discuss the Current understanding of the Provider Certification process including how to increase the chances your provider is certified and your claim paid.
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[i] We have not found any content in the TRICARE manuals that specifically authorize this but we know from a long history of past practice that this is true. However, because it is apparently not documented, it could change at any time.
[ii] Urine Culture
One example of many typical locally bundled procedures: A Urine Culture and Sensitivity lab test is billed and paid as one procedure. The U.S. billing system doesn’t bundle this test but requires it to be unbundled into the following three procedures for payment, 87086 CULT,BACT;QUANTITCOLONY COUNT, 87088 CULT,BACT; ISOLAT& PRESUM, URINE, 87184 SUSPT STD,DISK METH,PR PLT. Failure on the part of the beneficiary or provider to understand and do this when filing a claim will and has resulted in a significant underpayment. Another example is what many local laboratories call an executive panel usually followed by a letter such as “Executive Panel B”. These panels can be made up of 25 or more individual procedures that the U.S. billing system requires to be individually identified and costed. Failure to do this results in significant underpayment if not complete denial.