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Situation
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TRICARE Timely Filing Rules
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TRICARE Operations Manual
Ch 8-Sec 3
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| Submission of initial/new professional claim |
Claim must be submitted within one year after the date of service |
1.2
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| Submission of initial/new institutional claim |
Claim must be submitted within one year from date of hospital discharge |
1.2
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| Claimant submits written request for payment without submitting proper, approved claim form |
Within one year after the date of service/date of discharge OR 90 days after date of letter from us stating the service must be billed on the appropriate claim form, whichever is later |
1.3
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| Retroactive eligibility determination after timely filing deadline has been exceeded (Note: this request and decision can be made only by Uniformed Services or Dept. of Veterans Affairs) |
Timely filing waived back to effective date of retroactive authorization or retroactive change of eligibility. However, claims past the timely filing deadline must be filed within 180 days after the date the retroactive determination is issued. |
2.1.2
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| Claimant alleges that an administrative error was made by TRICARE processor on a previously processed (or denied) claim (Request for correction is received by processor within 90 days of claim settlement) |
Claimant must make the request within 90 calendar days of the claim’s settlement date (which is the date on the EOB and provider remit for the claim in question) |
2.2.1, 2.2.2
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| Claimant alleges that an administrative error was made by TRICARE processor on a previously processed (or denied) claim (Request for correction is received by processor 90 days after claim settlement or after one year following date of service/hospital discharge, whichever is later) |
-Claimant must submit written documentation describing basis for belief that they were prevented from timely filing due to misrepresentation, mistake or other accountable action by TMA or contractor. Necessary evidence must include statement from claimant regarding the nature and effect of the error, how he/she learned about the error, when it was corrected, and when the claim was previously filed (if it was previously filed) or provide a copy of an agency letter reflecting the error.
-Copies of claimant’s previous correspondence must be sent to us proving the correction was originally requested within 90 days |
2.2.2
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| Claimant alleges mental incompetency or inability to communicate prevented timely filing |
-Claimant must submit physician’s statement (including dates, diagnoses, and treatment) showing that the beneficiary’s mental incompetence or inability to communicate prevented timely filing.
-If no legal guardian was appointed before the timely filing deadline, an exception can be granted based on the physician’s statement.
-If legal guardian was appointed before the timely filing deadline, no exception for mental competence will be granted. |
2.3.1, 2.3.2
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| Claimant states he/she submitted claim after timely filing deadline because patient’s other health insurance (OHI) carrier delayed processing and their ability to get their claim to you |
-Claimant must submit written documentation that proves they sent the claim to the OHI carrier BEFORE the TRICARE timely filing deadline
-Claimant must submit documentation of when OHI resolved their payment, including EOB
-Claimant must submit claim with OHI EOB to us within 90 days of OHI’s EOB date |
2.5
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| Claim or request for corrections submitted 6 years after date of service/date of hospital discharge/date of correction report |
- All requests received will be answered with message stating request is denied
- All claims submitted will be denied |
3.1
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