CurrentDHAPolicy 6010.61-M

State Agency Billing and Medicaid Coordination of Benefits

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Governs reimbursement procedures when a TRICARE beneficiary is also eligible for Medicaid and a state agency has paid claims on the beneficiary’s behalf.

Policy Summary

PayerDHA

PolicyState Agency Billing and Medicaid Coordination of Benefits

Policy CodePolicy 6010.61-M

Change TypeAdministrative clarificationno material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionArrange coordination-of-benefits procedures with states that have current executed state agency billing agreements.

SourceLink

POLICY UPDATE CHANGES

Administrative clarification; no material clinical or coverage changes.

TRICAREPrimary payer when eligible alongside Medicaid

2Signature options for claims

State agencyPayment recipient

1 yearMaximum state filing period

35 days

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CurrentDHAPolicy 6010.61-M

State Agency Billing and Medicaid Coordination of Benefits

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Get alerted when Policy 6010.61-M changes without checking for updates manually.

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Governs reimbursement procedures when a TRICARE beneficiary is also eligible for Medicaid and a state agency has paid claims on the beneficiary’s behalf.

Policy Summary

PayerDHA

PolicyState Agency Billing and Medicaid Coordination of Benefits

Policy CodePolicy 6010.61-M

Change TypeAdministrative clarificationno material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionArrange coordination-of-benefits procedures with states that have current executed state agency billing agreements.

SourceLink

POLICY UPDATE CHANGES

Administrative clarification; no material clinical or coverage changes.

TRICAREPrimary payer when eligible alongside Medicaid

2Signature options for claims

State agencyPayment recipient

1 yearMaximum state filing period

35 days

Lesser of twoReimbursement limit

State Agency Reimbursement Eligibility

State Agency Reimbursement Conditions

State agency reimbursement is available only when the following conditions are met:

ALL of the following

The beneficiary is eligible for both TRICARE and Medicaid.
TRICARE is treated as the primary payor under 32 CFR 199.8.
The state has a current executed state agency billing agreement with the contractor establishing Coordination of Benefits (COB) procedures.
Claims are signed by the recipient/beneficiary or by a designated state official on the patient's behalf. A state official may sign each claim individually or attach one signed statement to each batch.
Disbursement is made directly to the state agency, or to a contractor acting as the state agency's agent, under established TRICARE claims processing guidelines and requirements.
Claim signatures are verified under the same rules and criteria used for provider facsimile or authorized representative signatures.
Medicaid claims satisfy normal claims-processing requirements for establishing eligibility.

State Agency Claim Reimbursement Criteria

State agency claims are reimbursable only when all applicable submission, adjudication, documentation, eligibility, and payment requirements below are satisfied.

ALL of the following

Acceptable submission and certification
- The state agency submits the claim on an acceptable claim form and attaches a computer printout of the agency's service records and/or copies of the original bills.
- All required processing data is submitted in an acceptable format. If electronic exchange is available, the electronic claims-processing arrangement is defined in the agreement between the contractor (including a TRICARE or TRICARE Pharmacy contractor) and the state agency.
- Each batch in which claims are not individually signed is certified by an authorized state official, and a signed transmittal identifying the claims covered by the certification accompanies the batch.
- For electronic claims, a securely transmitted encrypted or password-protected email with the authorized official's electronic signature and identifying information either accompanies the claims or is sent before submission; a subsequent email provides the access password when that method is used.

Claim Coding and Filing Requirements

Inpatient room revenue codingRevenue

12X	Revenue Code category to report when inpatient hospital bills lack evidence establishing another room type; charges may be assumed to be for a semi-private room.

Example procedure codingCPT

90050

Example CPT procedure code used to illustrate estimation of service frequency when service detail is missing.

Permitted missing-diagnosis codesmixed

799.9	ICD-9-CM code to use for services provided on or before September 30, 2015 when a correct diagnosis code is absent and the policy permits waiver.
R69	ICD-10-CM code identified for use after the mandated ICD-10 implementation date when a correct diagnosis code is absent and the policy permits waiver.
R99	Alternative ICD-10-CM code identified for use after the mandated ICD-10 implementation date when a correct diagnosis code is absent and the policy permits waiver.

State Claim Timely Filing Limit

Filing deadlineClaims must be filed no later than one year after the applicable filing date.

Applicable filing datesThe period is measured from the date of service, prescription fill, inpatient discharge, or receipt of the annual DMDC/DEERS data-match results.

WaiversAuthorized waivers are addressed in the TRICARE Operations Manual, Chapter 8, Section 3, paragraph 2.0.

TPL Information Response Period

Response period35 days

Required actionProvide the necessary third-party-liability information within 35 days when the submitted data is inadequate.

State Claim Processing Actions

Billing Rule

Coordinate benefits with participating state agencies

Arrange coordination-of-benefits procedures with states that have current executed state agency billing agreements. These procedures support claim flow when TRICARE is primary to Medicaid.

Documentation Required

Obtain an authorized claim signature

Accept claims signed by the recipient or beneficiary, or by a designated state official on the patient’s behalf. The official may sign each claim individually or attach a signed statement to each batch of claims submitted for reimbursement.

Operational Terms

Coordination of Benefits (COB)

DefinitionCoordination of Benefits (COB) consists of procedures arranged between the contractor and state agencies to process claims when TRICARE is primary to Medicaid.

Primary payerTRICARE is the primary payor when a beneficiary is eligible for both TRICARE and Medicaid.

PurposeCOB procedures facilitate claim flow and help reimburse states for funds they erroneously disbursed on behalf of TRICARE-eligible beneficiaries.

Third-Party Liability (TPL)

DefinitionThird-Party Liability (TPL) is the potential liability of another payer for a claim.

Required informationState submissions must include sufficient information to establish or rule out TPL and identify any amount paid under TPL.

Policy Summary

PayerDHA

PolicyState Agency Billing and Medicaid Coordination of Benefits

Policy CodePolicy 6010.61-M

Change TypeAdministrative clarificationno material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionArrange coordination-of-benefits procedures with states that have current executed state agency billing agreements.

SourceLink

On This Page

The transmittal certification includes patient names and sponsor Social Security numbers (SSNs).

The contractor records the Julian calendar date of receipt on the transmittal and assigns that same date in the Internal Control Number (ICN) to every included claim.

Transmittal documents are retained in a readily accessible file or microcopied with the claims when the contractor microfilms claims at the front end of processing.

Adjudication, eligibility, and documentation

Except for stated exceptions, the claim satisfies all applicable TRICARE requirements, limitations, and definitions.
The claim includes sufficient diagnosis or other supporting information required for processing. For DME, information other than a diagnosis may support payment when it reasonably supports payment; an incomplete claim requiring a diagnosis is returned to the state for supporting information.
The state files the claim within the applicable one-year timely-filing period: one year after the date of service; one year after the prescription was filled; one year after discharge for services rendered during an inpatient admission; or one year after the state received the annual DMDC/DEERS data-match results. Applicable TOM waivers may apply.
The state provides the eligibility and other beneficiary data needed to process the claim. The contractor may develop information through DEERS or other in-house sources; if essential information cannot be located or the state fails to provide required data, the claim is denied.
Claims received for a state agency are reported on TRICARE Encounter Data (TED) with Special Processing Code 1, using the basic requirements for a participating claim with the state Medicaid agency as payee, and the Government-paid amount is reported in the Amount Paid by Government Contractor field.
The claim does not duplicate a payment. When service-type information is incomplete but duplication is apparent, the contractor attempts resolution using available in-house data; if unresolved, the claim is denied unless the state resubmits documentation refuting the duplication assumption.
If the same services were submitted directly to TRICARE by a beneficiary or provider and also sent to the state for Medicaid payment, the claim is returned to the state with notice that TRICARE has paid; potential fraud is considered and the contractor cooperates with a state investigation as permitted by TRICARE guidelines.
The provider is TRICARE-approved or TRICARE-eligible under the TOM. A provider absent from contractor files may be certified through normal procedures if the provider is in a normally acceptable category; a provider outside a certifiable category results in the claim being returned to the state.
ONE of the following TPL conditions
- No third-party liability (TPL) applies.
- If possible TPL applies, the state supplies adequate information, has exercised its subrogation rights, and its beneficiary claim file includes complete TPL data, including the amount paid under TPL.
- If TPL information is inadequate, the claim is returned to the state; if the state does not provide the required information within 35 days, the claim is denied.

Reimbursement determination and payment

The contractor reimburses the State Medicaid Agency directly for each submitted claim and provides an explanation of benefits (EOB) for each claim, unless an agreement permits a summary payment voucher.
No EOB or other notice is sent to the beneficiary or provider.
The allowance is based on the amount billed to the Medicaid Agency by the provider, and the contractor calculates the net amount TRICARE would have paid, including any applicable COB reduction, deductible, and cost-share.
The state is paid the lesser of the amount it actually paid or the amount TRICARE would have paid.
A Medicaid billing amount below the provider's customary charge is not included in determining area prevailing charges.
If a provider later bills for the difference between the Medicaid payment and the customary charge, the claim is denied as a duplicate and no additional payment is made.
If Medicaid denied a service that would be allowable under TRICARE and the provider subsequently submits the service, the charge is considered under the normal TRICARE claims process.

Consequence of nonresponseThe claim shall be denied if the required information is not provided within 35 days.

Pay the state agency directly

Disburse reimbursement directly to the state agency or to a contractor acting as the state agency’s agent, following established TRICARE claims processing guidelines and requirements.

Documentation Required

Verify signatures and eligibility

Verify state-official signatures using the same rules and criteria used for provider facsimile or authorized representative signatures. Apply normal claims processing requirements to establish Medicaid claim eligibility.

Billing Rule

Coordinate state Medicaid claims

Establish coordination-of-benefits procedures with states that have executed state agency billing agreements. Ensure claims are properly signed, verify signatures under applicable TRICARE rules, and pay the state agency or its designated contractor directly.

Documentation Required

Require acceptable claim submissions

Require the state agency to submit an acceptable claim form with a computer printout of its service record or copies of the original bills. All required processing data must be submitted in an acceptable format; electronic exchange requirements must be included in the agreement when applicable.

Documentation Required

Certify claim batches

For batches in which claims are not individually signed, require certification by an authorized state official and a signed transmittal identifying the claims covered by the certification. Electronic batches require secure transmission and an electronic signature.

Include patient names and sponsor Social Security Numbers on the transmittal certification.
Record the Julian receipt date on the transmittal and the same date in the Internal Control Number for each included claim.

Documentation Required

Retain transmittal documentation

Retain transmittal documents in a readily accessible file, or microcopy them with the claims when front-end claim microfilming is used.

Billing Rule

Apply state-claim processing exceptions

Apply the authorized exceptions for missing prescriptions, diagnoses, claim detail, drug quantity or strength, and inpatient billing detail. Develop or return claims when supporting information is required, and use permitted assumptions or coding procedures when the policy authorizes a waiver.

For missing inpatient detail, require beginning and ending dates and sufficient detail to determine the Revenue Code major category.
For missing diagnosis, apply the permitted waiver or return claims requiring diagnosis and supporting information.

Denial Risk

Enforce timely filing

Require the state to file each claim no later than one year after the applicable filing trigger.

Date of service
Prescription fill date
Inpatient discharge date
Receipt of annual DMDC/DEERS data-match results

Billing Rule

Report state claims on TEDs

Process claims received from state agencies with Special Processing Code 1 on TRICARE Encounter Data and report the government contractor payment amount in the Amount Paid by Government Contractor field.

Denial Risk

Develop missing claim data

Obtain eligibility and other beneficiary information from the state, or develop missing information through DEERS or other in-house sources. Deny the claim when essential required information cannot be located.

Denial Risk

Check for duplicate claims

Take precautions to prevent duplicate payments and attempt to resolve apparent duplication using available information. If the matter cannot be resolved, assume duplication and deny the claim; the state may resubmit documentation refuting that assumption.

Denial Risk

Validate provider eligibility

Confirm that providers are TRICARE-approved or TRICARE-eligible. Follow normal certification procedures when an otherwise acceptable provider is not yet listed in contractor files; return the claim when the provider is not in a certifiable category.

Denial Risk

Develop third-party liability

Require adequate third-party-liability information for claims requiring development. Return inadequate submissions to the state, and deny the claim if the required information is not provided within 35 days.

Billing Rule

Issue state-agency reimbursement

Reimburse the State Medicaid Agency directly and provide an explanation of benefits for each claim, unless an agreed summary payment voucher arrangement applies. Do not send an explanation of benefits or other notice to the beneficiary or provider.

Billing Rule

Calculate reimbursement limit

Calculate the net amount that would have been payable by TRICARE, including any applicable coordination-of-benefits reduction, deductible, and cost-share. Pay the lesser of the amount Medicaid actually paid or the amount TRICARE would have paid.

Insufficient informationInadequate TPL information is returned to the state; the claim is denied if the required information is not provided within 35 days.

TRICARE Encounter Data (TED)

DefinitionTRICARE Encounter Data (TED) is the data reporting system used for state-agency claims.

Special Processing CodeState-agency claims are processed with Special Processing Code 1 on TEDs.

Payment reportingThe amount paid by the government contractor is reported in the Amount Paid by Government Contractor field.

Transmittal Certification

DefinitionA transmittal certification is a document or secure electronic transmission signed by an authorized state official that identifies and certifies a batch of claims that are not individually signed.

Required contentsThe certification includes the claims covered and the patient names and sponsor Social Security Numbers.

Electronic submissionElectronic batches require secure transmission and an electronic signature from an authorized state official.