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Double coverage and administrative remedies under CHAMPUS/TRICARE

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Governs how CHAMPUS/TRICARE coordinates benefits when beneficiaries have other insurance or third-party payers (double coverage), special rules for Medicare/Medicaid/Workers' Compensation/ECHO/MA-PD, and administrative remedies for fraud, abuse, and conflicts of interest; applies to TRICARE/CHAMPUS beneficiaries, providers, contractors, and employers referenced in the regulation.

Policy Summary

Payerhealthchoiceofoklahoma

PolicyDouble coverage and administrative remedies under CHAMPUS/TRICARE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewApr 9, 2010

Next Review DateN/A

Key ActionDirector may authorize advance payment pending adjudication by other plans and later recover costs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleMedicare, Medicaid, active duty dependents, retirees, survivors referenced

last payTRICARE payment position

primaryMedicare position

$5,000Max civil penalty

administrativeRemedies

Double Coverage and Coordination Rules

Double coverage adjudication criteria

Rules for adjudication and payment when double coverage exists.

TRICARE (CHAMPUS) is generally the secondary/last payer to other health benefit, insurance and third-party payer plans; benefits under other plans must be adjudicated before TRICARE pays, except as provided for advance payment authorization.

Advance payment/authorization

The Director, TRICARE Management Activity, or a designee may authorize payment of a claim in advance of adjudication by a double coverage plan and later recover TRICARE costs under §199.12.
Advance payment may be authorized only when the claim is for services furnished to a covered beneficiary and is identified as involving services for which a third-party payer other than a primary medical insurer may be liable.

A CHAMPUS beneficiary may not elect to waive benefits under a double coverage plan to use CHAMPUS; whenever double coverage exists, the provisions of this section apply.

Amounts denied by a double coverage plan solely because a claim was not timely filed or the beneficiary failed to meet other plan requirements cannot be paid by CHAMPUS unless the double coverage plan provides a statement indicating how much it would have paid; if such a statement is provided the CHAMPUS contractor may process the claim as if the other plan had paid that amount; if no statement is received, no CHAMPUS payment is authorized.

For beneficiaries eligible for both Medicare and CHAMPUS, Medicare is always the primary payer; CHAMPUS pays the beneficiary's actual out-of-pocket costs after Medicare and other third-party payers, subject to CHAMPUS payment limits (CHAMPUS payment may not exceed what would have been paid solely under CHAMPUS).

For purposes of advance payment rules, a 'primary medical insurer' is a plan or third-party payer whose primary purpose is to provide or pay for health care services, supplies, or equipment; certain payers (e.g., automobile liability, no-fault, workers' compensation, homeowners insurance) are excluded from this definition unless designated otherwise by the Director or designee.

Special payer interactions and exceptions (e.g., Medicaid, workers' compensation, ECHO, Medicare supplemental/medigap and employer-provided insurance) are addressed by the section's special-consideration rules and must be applied per the regulation's provisions.

Payer Hierarchy, Catastrophic Caps, and Code Notes

Payer hierarchy rulesmixed

No codes listed

Catastrophic cap counting (CHAMPUS/TRICARE)

Catastrophic cap countingOnly CHAMPUS payments determined consistent with paragraph (d)(1)(iii)(B) (i.e., CHAMPUS payment in non‑Medicare‑payable situations) count toward the annual catastrophic loss protection; actual beneficiary out‑of‑pocket liability remaining after those CHAMPUS payments is applied to the cap.

When cap metWhen a family has met the annual catastrophic cap, CHAMPUS will pay allowable amounts for remaining covered services through the end of that fiscal year.

ScopeThis counting rule applies only in cases where CHAMPUS payment is determined consistent with paragraph (d)(1)(iii)(B) (see Medicare‑related payment provisions).

Advance Payments, Implementing Instructions, and Administrative Remedies

Prior Authorization

Advance Payment Authorization — Director, TRICARE Management Activity may authorize advance payment

The Director, TRICARE Management Activity (or a designee) may authorize payment of a claim in advance of adjudication by a double coverage plan and later recover TRICARE costs under §199.12 when the claim is for services furnished to a covered beneficiary and the claim is identified as involving services for which a third‑party payer (other than a primary medical insurer) may be liable.

Advance payment may be authorized only for claims submitted for health care services furnished to a covered beneficiary.
Advance payment applies where the claim involves services for which a third‑party payer, other than a primary medical insurer, may be liable.
TRICARE may recover advance payments under §199.12.

Documentation Required

Implementing Instructions and Administrative Remedies — Director, OCHAMPUS to issue instructions; remedies may be invoked

The Director, OCHAMPUS (or a designee) shall issue implementing instructions, procedures, or guidelines as necessary to implement the intent of this section; administrative remedies for fraud, abuse, or conflict of interest may be invoked in addition to other remedies authorized by law or regulation.

Director, OCHAMPUS (or designee) must issue implementing instructions, procedures, or guidelines to implement the section.
Administrative remedies set forth may be applied in addition to other statutory or regulatory remedies.
Providers and CHAMPUS contractors have duties to comply with program requirements and report known fraud, abuse, or conflicts of interest.

Key Definitions for Coordination of Benefits

Double coverage plan (definition)

DefinitionDouble coverage plan: an insurance plan, a medical service or health plan, or a third‑party payer that provides coverage for medical services and supplies; includes plans with premiums paid by beneficiary or entitlement through employment/association.

ExclusionsExcludes plans administered under title XIX (Medicaid) from the general double coverage rule (Medicaid treated specially).

Waiver of benefitsA CHAMPUS beneficiary may not elect to waive benefits under a double coverage plan and use CHAMPUS; when double coverage exists the double coverage provisions apply.

Primary medical insurer (definition and scope)

DefinitionPrimary medical insurer: an insurance plan, medical service or health plan, or third‑party payer whose primary or sole purpose is to provide or pay for health care services, supplies, or equipment.

ExclusionsDoes not include automobile liability, no‑fault, workers' compensation programs or plans, homeowners insurance, or similar third‑party payers as may be designated by the Director/ designee in policy guidance.

Role in advance paymentFor advance payment authorization purposes, a primary medical insurer is distinguished from other third‑party payers when identifying claims for which TRICARE may make an advance payment pending adjudication by other plans.

Employer / plan terms relevant to prohibited incentives

EmployerThe term 'employer' includes any State or unit of local government (and other employers as defined for paragraph (d)(6) enforcement).

Group health planGroup health plan: the employer‑sponsored health benefit arrangement referenced in the prohibition on offering alternatives to employer primary plans (subject to exceptions).

Similarly situated & documentationExceptions (e.g., cafeteria plan conditions) require the employer to maintain certification in employer files and provide it to DoD upon request to qualify for exclusion from the prohibition.

Policy Summary

Payerhealthchoiceofoklahoma

PolicyDouble coverage and administrative remedies under CHAMPUS/TRICARE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewApr 9, 2010

Next Review DateN/A

Key ActionDirector may authorize advance payment pending adjudication by other plans and later recover costs.

SourceLink

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Double coverage and administrative remedies under CHAMPUS/TRICARE

Customize your policy alerts

Sign up for all healthchoiceofoklahoma policy alerts

Know when healthchoiceofoklahoma releases new policies or updates existing guidance.

Monitor payer policy activity

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Double Coverage and Coordination Rules

Double coverage adjudication criteria

Rules for adjudication and payment when double coverage exists.

Advance payment/authorization

The Director, TRICARE Management Activity, or a designee may authorize payment of a claim in advance of adjudication by a double coverage plan and later recover TRICARE costs under §199.12.
Advance payment may be authorized only when the claim is for services furnished to a covered beneficiary and is identified as involving services for which a third-party payer other than a primary medical insurer may be liable.

A CHAMPUS beneficiary may not elect to waive benefits under a double coverage plan to use CHAMPUS; whenever double coverage exists, the provisions of this section apply.

Payer Hierarchy, Catastrophic Caps, and Code Notes

Payer hierarchy rulesmixed

No codes listed

Catastrophic cap counting (CHAMPUS/TRICARE)

When cap metWhen a family has met the annual catastrophic cap, CHAMPUS will pay allowable amounts for remaining covered services through the end of that fiscal year.

ScopeThis counting rule applies only in cases where CHAMPUS payment is determined consistent with paragraph (d)(1)(iii)(B) (see Medicare‑related payment provisions).

Advance Payments, Implementing Instructions, and Administrative Remedies

Prior Authorization

Advance Payment Authorization — Director, TRICARE Management Activity may authorize advance payment

Advance payment may be authorized only for claims submitted for health care services furnished to a covered beneficiary.
Advance payment applies where the claim involves services for which a third‑party payer, other than a primary medical insurer, may be liable.
TRICARE may recover advance payments under §199.12.

Documentation Required

Implementing Instructions and Administrative Remedies — Director, OCHAMPUS to issue instructions; remedies may be invoked

Director, OCHAMPUS (or designee) must issue implementing instructions, procedures, or guidelines to implement the section.
Administrative remedies set forth may be applied in addition to other statutory or regulatory remedies.
Providers and CHAMPUS contractors have duties to comply with program requirements and report known fraud, abuse, or conflicts of interest.

Key Definitions for Coordination of Benefits

Double coverage plan (definition)

ExclusionsExcludes plans administered under title XIX (Medicaid) from the general double coverage rule (Medicaid treated specially).

Waiver of benefitsA CHAMPUS beneficiary may not elect to waive benefits under a double coverage plan and use CHAMPUS; when double coverage exists the double coverage provisions apply.

Primary medical insurer (definition and scope)

Employer / plan terms relevant to prohibited incentives

EmployerThe term 'employer' includes any State or unit of local government (and other employers as defined for paragraph (d)(6) enforcement).

Group health planGroup health plan: the employer‑sponsored health benefit arrangement referenced in the prohibition on offering alternatives to employer primary plans (subject to exceptions).