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TRICARE Operations Manual 6010.62-M, April 2021
Claims Processing Procedures
Chapter 8
Section 8
ExplanationOf Benefits (EOB)
Revision:
1.0BENEFICIARY,PARENT/GUARDIAN
1.1The contractor shall providean EOB through electronic means, including but not limited to aweb based secure online portal for beneficiaries (including parentsor legal guardians of minors) to retrieve electronic EOBs that appropriatelydescribe(s) the action taken for each claim processed to a finaldetermination.
1.2Beneficiaries(including parents and legal guardians) shall be given the optionto opt-in for summary paper EOBs mailed to them on a monthly basis(if care is received).
1.3The contractorshall:
•Provide beneficiaries withmultiple EOB status alerts and notification options, including email,text, web-portal and hardcopy letters (based on means the beneficiarychooses).
•Educate beneficiaries on optionsto receive EOBs and notifications.
•Make a copy of the EOB electronicallyaccessible and printable to the beneficiary in the contractor’sportal regardless of which alert and notification option the beneficiarychooses.
•Allow the beneficiary to optin to hard copy, mailed EOBs.
•Note what preference a beneficiarychooses, hard copy or electronic, as the means of providing Monthly SummaryEOBs and change preference upon beneficiary request.
2.0NON-PARTICIPATING PROVIDER
2.1The contractor shall providea secure online portal for non-participating providers to retrieveelectronic EOBs. Non-participating providers shall be given theopportunity to opt-in for mailed paper EOBs. The EOB shall includethe amount allowed so that the provider can determine what amountmay be billed to the beneficiary under the balance billing provision(115% of the TRICARE allowable charge).
2.2The contractorshall provide the non-participating provider with information wherethere is only a “need to know.” This means that if other informationappears on the EOB that does not pertain to the non-participating provider,the TRICARE contractor shall suppress printing or remove it beforesending the EOB to the non-participating provider.
2.3The non-participating providerwill receive only the EOB and the beneficiary will receive the TRICARE payment.
3.0NETWORK AND PARTICIPATING PROVIDERS
3.1The contractor shall providea secure on-line portal for network and participating providersto retrieve electronic EOBs. Network and participating providersshall be given the opportunity to opt-in for mailed paper EOBs.
3.1.1The contractor shall issuean EOB to network and participating providers or issue summary vouchers coveringmultiple claims and beneficiaries in lieu of issuing multiple EOBs.
3.1.2The contractor shall issuea summary voucher at least monthly (electronic or paper).
3.2Sufficient information mustbe included on the vouchers to identify each beneficiary and explainthe payment for each line item on each claim.
3.3The contractor shall includeadequate identification of the fiscal year involved applicable tothe various charges listed on the EOB to help keep the deductibleinformation clear to the beneficiary.
3.4If theprovider submits the claim electronically, a Health Insurance Portabilityand Accountability Act (HIPAA)-compliant Electronic Remittance Advice(ERA) shall be returned to the provider.
3.5The contractorshall send Electronic Funds Transfers (EFTs) and ERA to the providerin HIPAA standard format as specified in the Chapter 19, Section 2.
4.0STATE MEDICAID AGENCY
4.1The contractor shall includethe same information on the copy sent to the state as it normallysends to participating providers if the claim is from a state Medicaidagency.
4.2The contractor shall, if thestate has a claims data need which cannot be accommodated exceptat extra expense, negotiate with the state, and if the state iswilling to pay for the accommodation.
5.0EOB ISSUANCE EXCEPTIONS
5.1The contractor shall not issuean EOB to beneficiaries (parents or guardians of minors or incompetents) whenclaims involve services related to any of the following diagnoses:
•Abortion
•Acquired Immune DeficiencySyndrome (AIDS)/Human Immunodeficiency Virus (HIV)
•Alcoholism
•Substance Abuse
•Sexually Transmitted Diseases(STDs)
•Sexual Assault or DomesticViolence
5.2The contractorshall issue an EOB to participating providers, except as noted above.
5.2.1The contractor shall providea paper EOB to a beneficiary upon request.
5.2.2When arequest is made for a normally suppressed EOB, the copy providedmay be a facsimile or a hand-produced copy. It must, however, includethe required data and be certified by the contractor.
5.3The contractor shall send,when a service(s) is denied due to an abortion, a letter of explanationbut only when the denial is questioned by the beneficiary.
Note:Addendum A, Figure 8.A-3 provides suggestedwording for abortion claims that are denied.
5.3.1The explanationshall be provided only to the beneficiary and participating provider.
5.3.2The special denial letter shallbe sent in an envelope marked “personal”.
5.3.3It isEMPHASIZED that using an EOB is NOT acceptable for denial of abortionservices. Only an approved letter may be used.
6.0PROCEDURES FOR INFORMING THEBENEFICIARY OF CLAIM ACTION
6.1The contractorshall provide beneficiaries with multiple claims action status alertsand notification options, including email, text, web portal andhard copy letters (based on means the beneficiary chooses).
6.2The contractor shall notifythe beneficiary, based on the means the beneficiary chooses, thata claim has been paid or denied and that they can access the claimsinformation via the portal.
6.3 The contractorshall take into account, where applicable, the following:
6.3.1 The special rules for alcoholand drug abuse program patient records referenced in DoD 6025.18-R, C5.4and C8.9;
6.3.2The provisions on abuse, neglectand endangerment situations in DoD 6025.18-R, C8.7.5;
6.3.3The beneficiary’s right torequest restrictions on disclosure under DoD 6025.18-R, C10.1; and
6.3.4The beneficiary’s right torequest confidential communications under DoD 6025.18-R, C10.2.
6.4The processing of claims forthe diagnoses listed above requires sensitivity to the beneficiary’sright to privacy.
6.5 Becauseof the need for contractors to apply reasonable judgment on a case-by-casebasis, Defense Health Agency (DHA) has not prescribed specific proceduresexcept in the case of abortion claims.
6.6For claimsinvolving services and supplies for the other diagnoses, a phonecall to the beneficiary may serve to obtain information on how thebeneficiary wishes to have the EOB handled in some instances.
6.7In other cases, a request thatthe provider serve as an intermediary, or a personal letter to thebeneficiary, using a plain envelope, may be appropriate.
6.8The contractor shall take intoaccount the intent, as well as the letter, of the Privacy Act, theHIPAA of 1996, and the DoD Health Information Privacy Regulation,DoD 6025.18-R.
7.0EOB FORMAT
7.1The formdesign of the EOB is not specifically prescribed.
7.2The contractor shall designthe form to fit their individual equipment and system needs.
7.3The contractor shall providetheir toll-free inquiry number on the EOB.
7.4Only thelast four digits of the Social Security Number (SSN), or the DoDBenefits Number (DBN) shall appear on the EOB.
8.0REQUIRED INFORMATION ON THEEOB
8.1The following detailed informationshall be included on the EOB:
•Provider or Pharmacy Name
•Provider or Pharmacy Address
•Provider or Pharmacy TaxpayerIdentification Number (TIN)
•Check Number
•Voucher Date
•Patient Name
•Sponsor Name
•Last four digits of SponsorSSN or DBN
•Date(s) of Service/Date(s)Prescription(s) Filled
•Pharmacy EOB - PrescriptionNumber
•Pharmacy EOB - PrescriptionName
•Billed Amount
•Reason Codes
•Allowed Covered Charges
•Deductible
•Cost-Share or Copayment Amount
•Total Paid by Other HealthInsurance (OHI)
•Catastrophic Cap
•Remarks
•Description(s) of Reason Code(s)
•Interest Paid
•Federal Tax Withheld
•Accumulated Toward CatastrophicCap
•Accumulated Toward IndividualDeductible
•Accumulated Toward Family Deductible
•Offset (In the event paymentis offset or partially offset and applied toward a debt.)
•Amount Paid (If payment wasnot issued but money was withheld and applied towards another debt, informationregarding where the funds were applied).
8.2In addition to the fields specifiedin paragraph 9.1, offset EOBs shall also containthe following additional information:
•Total Amount Offset
•Amount Paid
•Statement:
“$ was offset from this remittanceand applied towards your outstanding overpayment listed below. Youmay not seek reimbursem*nt from the TRICARE beneficiary for whomyou rendered services. We will send you a letter providing detailedclaim information within five to seven business days. If you haveany questions, please contact our customer service department for assistance.”
•Information regarding wherethe offset will be applied:
•Patient Name
•ClaimNumber
•Date Repayment Requested
•AmountRequested
•Offset Amount
•CollectedTo Date
•Amount Outstanding
9.0REVERSEOF THE EOB FORM
The followinginformation shall be on the reverse of the EOB:
9.1BeneficiaryNotice Regarding Services
9.1.1Pleasereview the services/supplies shown on the front of your EOB. Ifyou find that TRICARE has paid for any services that you did notreceive or that you were charged by a health care professional youdid not see, please call the (Contractor’s Name) Fraudand Abuse Hotline at (Toll-Free Number).
9.1.2The contractor shall include,on the TRICARE Provider Electronic Remittance Advice (ERA), a reminderto providers of requirements to familiarize with, comply with TRICAREprogram requirements, rules and responsibility for medically necessaryand appropriate care.
9.2Right To Appeal
If you disagree with the determinationon your claim, you have the right to request a reconsideration.Your signed written request must state the specific matter withwhich you disagree and MUST be sent to the following address nolater than 90 calendar days from the date of this notice. If thepostmark on the envelope is not legible, then the date of receiptis deemed the date of filing, unless proof of mailing, such as acertified mail receipt documents a different date. Include a copyof this notice. On receiving your request, all TRICARE claims forthe entire course of treatment will be reviewed.
(Contractor’s Address)
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