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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyDHA TRICARE Filing Deadlines Policy Update | OpenP…
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    CurrentDHAPolicy 6010.59-M

    Claims Filing Deadline

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    Claims filing deadlines within DHA's TRICARE claims processing procedures, including standard deadlines and recognized exceptions.

    Policy Summary
    PayerDHA
    PolicyClaims Filing Deadline
    Policy CodePolicy 6010.59-M
    Change TypeClarification
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit all claims to the appropriate TRICARE contractor no later than one year after the date services were provided, or one year after inpatient discharge for facility charges.
    SourceLink
    POLICY UPDATE CHANGES

    Revision 127 added requirements for exceptions based on retroactive eligibility or preauthorization determinations.

    The policy clarifies that a retroactive eligibility or preauthorization determination issued within one year of service or discharge does not remove the ordinary one-year filing deadline.

    1 yearStandard claim filing deadline
    180 daysRetroactive determination deadline
    90 daysCommon exception filing period
    6 yearsException lookback period
    Policy Summary
    PayerDHA
    PolicyClaims Filing Deadline
    Policy CodePolicy 6010.59-M
    Change TypeClarification
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit all claims to the appropriate TRICARE contractor no later than one year after the date services were provided, or one year after inpatient discharge for facility charges.
    SourceLink
    On This Page
    Claims Filing Requirements and ExceptionsFiling Periods and Lookback LimitsProvider and Claims Administrator ActionsDefined Terms

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3
    Approved claim forms

    Claims Filing Requirements and Exceptions

    Standard filing requirements

    A claim is timely and processable when it meets one of the following filing pathways:

    ONE of

    • ALL of the following

      • ALL of the following

        • Claim is received by the appropriate TRICARE contractor within 1 year after the date services were provided, or within 1 year after inpatient discharge for facility charges billed by the facility.
        • Professional services billed by the facility are submitted within 1 year from the date of service.
      • Claim is submitted on an approved TRICARE claim form, such as CMS-1500, CMS-1450 UB-04, or DD Form 2642, with any additional information required for processing.

    • ALL of the following

      • A written request for benefits or a non-approved claim form was initially submitted and accepted for determining timely filing.
      • The approved TRICARE claim form and any required additional information are received by the contractor by the later of 1 year from the date of service or discharge, or 90 days from the date of contractor notification.

    Filing Periods and Lookback Limits

    Standard claims filing period
    Standard deadlineClaims must be filed no later than 1 year after the date services were provided.
    Inpatient facility chargesFacility-billed inpatient charges must be filed within 1 year after the date of discharge.
    Professional services billed by a facilityProfessional services billed by the facility remain subject to 1 year from the date of service.
    Alternative claim-form notification period
    Applicable deadlineThe approved claim form and required information must be received by the later of 1 year from the date of service or discharge, or 90 days from contractor notification.
    Initial written requestA written request for benefits is accepted for determining whether the claim was filed timely, even when it is not submitted on a claim form.

    Provider and Claims Administrator Actions

    Billing Rule

    Submit Claims Within the Filing Deadline

    Submit all TRICARE benefit claims to the appropriate TRICARE contractor within the applicable one-year filing deadline.

    • Facility-billed inpatient charges: submit within one year from the date of discharge.
    • Professional services billed by a facility: submit within one year from the date of service.
    • The claim must be received by the contractor by the deadline, not merely mailed by that date.
    Documentation Required

    Use Approved Claim Forms

    Use an approved TRICARE claim form and include all information required to process the claim. A written request or other submission may establish timely filing, but it is not sufficient for processing without the approved form.

    Defined Terms

    Mental incompetency
    DefinitionFor claims filing deadline exceptions, mental incompetency includes inability to communicate.
    Physical disabilityThe inability to communicate qualifies even when it results from a physical disability.
    Required documentationA physician's statement with dates, diagnoses, and treatment must accompany each claim submitted under this exception.
    Retroactive eligibility or preauthorization determination
    DefinitionA retroactive eligibility or preauthorization determination is issued after the normal timely filing period and establishes retroactive eligibility or authorizes coverage.
    Covered servicesThe determination may authorize services such as ECHO, adjunctive dental care, or surgical procedures requiring preauthorization.
    Approved form requirementAn approved TRICARE claim form is required for processing after an initial submission made on another form or without a claim form.
    Retroactive determination filing period
    Filing periodPast-due claims must be filed within 180 calendar days after the retroactive determination is issued.
    Applicable determinationThe exception applies to a retroactive eligibility or preauthorization determination obtained or issued after the timely filing period elapsed.
    Early determination ruleWhen the retroactive determination is issued within 1 year from the date of service or discharge, the 1-year timely filing period remains binding.
    Administrative error notification period
    Notification periodThe claim must be filed within 90 calendar days after notification of the administrative error when the claimant statement is not required.
    Evidence basisAgency records or a written agency notice must establish that the administrative error caused the failure to file within the usual time limit.
    Causation requirementThere must be a clear and direct relationship between the administrative error and the late filing.
    OHI exception filing period
    Filing periodThe claim form must be submitted within 90 days from the date of OHI adjudication.
    Prior OHI submissionThe claim must have been sent to the primary OHI before the TRICARE filing deadline, or timely filed with TRICARE and returned or denied pending OHI processing.
    Supporting recordsThe submission must include the original OHI submission date, adjudication date, relevant correspondence, and an Explanation of Benefits or similar statement.
    Medicare exception filing period
    Filing periodThe claim must be submitted within 90 calendar days from the date of Medicare adjudication.
    Timely Medicare acceptanceMedicare must have accepted the claim as timely for an exception to be considered.
    Who may submitThe claim may be submitted by Medicare or by the beneficiary.
    Exception lookback limit
    Lookback periodAfter an exception is granted, only services or supplies received during the 6 years immediately preceding receipt of the exception request may be considered.
    Older services or suppliesServices or supplies received more than 6 years before receipt of the request must be denied.
    Request timingThere is no stipulated time limit for submitting a written exception request before a claim has been submitted.
    • Use the CMS-1500 Claim Form, CMS-1450 UB-04, or DD Form 2642, as appropriate.
    • Submit any required supporting information with the claim.
    • The approved form and required information must be received by the contractor within one year from the date of service or discharge, or within 90 days after contractor notification, whichever is later.
    Billing Rule

    Process Filing-Deadline Exceptions

    Evaluate and document any request to waive the filing deadline under an authorized exception. If an exception is granted, apply the category-specific submission deadline and other limits before considering payment.

    • Retroactive eligibility or preauthorization: verify that the determination was issued after the timely filing period, obtain the decision, and waive filing back to the effective date; a late claim must be filed within 180 calendar days after the determination is issued. A determination issued within the one-year period does not extend the ordinary deadline. Only the Uniformed Services or DVA/VHA may determine retroactive eligibility. ADSM retroactive claims are a specific exception governed by applicable referenced procedures.
    • Administrative error: grant an exception only when DHA, TRICARE Overseas, or a contractor, acting within authority, misrepresented, made a mistake, or otherwise caused the late filing. The error must have a clear and direct relationship to the late claim; when supported by contractor records, annotate the claim file.
    • Inability to communicate or mental incompetency: determine whether the condition prevented timely filing. An exception is unavailable when a legal guardian was appointed before the filing deadline and the deadline was missed.
    • Other health insurance (OHI): consider an exception when the claim was timely submitted to primary insurance, or timely filed with TRICARE and returned or denied pending OHI processing. Submit the TRICARE claim within 90 days after OHI adjudication.
    • Medicare: consider a waiver when Medicare accepted the claim as timely. Medicare or the beneficiary must submit the claim within 90 calendar days after Medicare adjudication.
    • There is no stated deadline for a written exception request made before a claim is submitted. After a completed claim is submitted and an exception is granted, consider only services or supplies received during the six years immediately preceding receipt of the request; older services or supplies must be denied.
    Documentation Required

    Collect Exception Evidence

    Require evidence that establishes the applicable exception and its relationship to the late filing; a bill alone is not sufficient proof of receipt of covered care when an EOB is unavailable.

    • Retroactive eligibility or preauthorization: obtain the retroactive decision or authorization, and, absent an EOB, proof that the beneficiary received medical care for a covered or waived service.
    • Administrative error: obtain the claimant's statement describing the error's nature and effect, how and when the claimant learned of it, when it was corrected, and any prior filing date, plus either an agency or contractor records-based report or an agency letter or written notice reflecting the error. The claimant statement may be omitted when other evidence establishes the error and the claim was filed within 90 calendar days after notification.
    • Mental incompetency or inability to communicate: require a physician's statement for each claim, including dates, diagnoses, and treatment, addressing the condition and whether it prevented timely filing. If a spouse or parent paid the charges, obtain evidence identifying the payer and payment.
    • OHI: require a statement showing the original submission date and adjudication date, relevant correspondence, and the OHI Explanation of Benefits or similar statement.
    • Medicare: document Medicare's timely acceptance and the date of Medicare adjudication.
    Documentation Required

    Handle Incomplete Exception Requests

    If an exception request is received without a completed approved claim form, do not process benefits until the claimant completes and resubmits the form with supporting documentation.

    • Notify the claimant that an approved TRICARE claim form is required before benefits may be considered.
    • Provide the appropriate claim form, such as CMS-1500, CMS-1450 UB-04, or DD Form 2642, as applicable.
    • Advise that the completed claim and supporting documentation must be resubmitted within 90 calendar days from the date of the contractor's letter.
    • A written request submitted before a claim may establish that the request was timely, but the completed approved claim form remains necessary for processing.
    Effect of authorizationFor retroactive preauthorization, timely filing requirements are waived back to the effective date of the retroactive authorization.