Provider Contract Provisions
The following provisions are applicable to services rendered pursuant to the TRICARE/CHAMPUS program requirements as administered by TriWest and will be incorporated by reference into the Provider’s contract as fully set forth therein. The Spanish version of the Provider Handbook is provided for convenience only; the English version of all contractual documents between TriWest and the provider, including but not limited to the TRICARE Provider Handbook, shall be exclusively used for legal interpretation. For avoidance of doubt, in the event of any ambiguity or disagreement between the terms of the Spanish version of the Provider Handbook and the original English version, the English version shall take precedence and control.
Definitions
| Term | Definition |
|---|---|
| Adequate Medical Documentation, Medical Treatment Records | Adequate medical documentation contains sufficient information to justify the diagnosis, the treatment plan, and the services and supplies furnished. Under TRICARE/CHAMPUS, it is required that adequate and sufficient clinical records be kept by health care provider(s) to substantiate that specific care was actually and appropriately furnished, was medically necessary and appropriate, and to identify the individual(s) who provided the care. All procedures billed must be documented in the records. In determining whether medical records are adequate, the records will be reviewed under the generally acceptable standards such as the applicable Joint Commission (formally Accreditation of Healthcare Organizations) standards, the Peer Review Organization (PRO) standards (and the provider’s state or local licensing requirements) and other requirements specified by TRICARE Requirements. In general, the documentation requirements for a professional provider are not less in the outpatient setting than the inpatient setting. |
| Authorized Provider | A hospital or institutional provider, physician, or other individual professional provider, or other provider of services or supplies specifically authorized to provide benefits under CHAMPUS pursuant to TRICARE Requirements. Provider shall be an Authorized Provider. |
| Balance Billing | A provider seeking any payment, other than any payment relating to applicable deductible and cost sharing amounts, from a beneficiary for TRICARE/CHAMPUS covered services for any amount in excess of the applicable TRICARE/CHAMPUS allowable cost or charge. Balance billing is prohibited. |
| Beneficiary Liability | The legal obligation of a beneficiary, his or her estate, or responsible family member to pay for the costs of medical care or treatment received. Specifically, for the purposes of services and supplies covered by TRICARE, beneficiary liability includes any annual deductible amount or cost-sharing amounts. Beneficiary liability also includes any expenses for medical or related services and supplies not covered by TRICARE. |
| Civilian Health and Medical Program of the Uniformed Services (“CHAMPUS”) | A term also used for TRICARE and as referenced by the relevant authorities, including TRICARE Requirements. TRICARE and CHAMPUS shall be considered synonymous and interchangeable terms for the purpose of this TRICARE Provider Handbook. |
| CHAMPUS Maximum Allowable Charge (“CMAC”) | CMAC is a nationally determined allowable charge level that is adjusted by locality indices and generally, but not always, is equal to or greater than the Medicare Fee Schedule amount. |
| Defense Health Agency (“DHA”) | A joint, integrated combat support agency that enables the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to combatant commands in both peacetime and wartime. DHA is considered part of the government. |
| Director | The Director of the Defense Health Agency, Director, TRICARE Management Activity, or Director, Office of CHAMPUS. Any references to the Director, Office of CHAMPUS, or OCHAMPUS, or TRICARE Management Activity, shall mean the Director, Defense Health Agency (DHA). Any reference to Director shall also include any person designated by the Director to carry out a particular authority. In addition, any authority of the Director may be exercised by the Assistant Secretary of Defense (Health Affairs). |
| Department of Defense (“DOD”) | The Department of Defense is responsible for providing the military forces of the United States of America needed to deter war and protect the security of the country. DOD is also considered part of the government. |
| Medically (or Psychologically) Necessary Preauthorization | A pre (or prior) authorization for payment for medical/surgical or psychological services based upon criteria that are generally accepted by qualified professionals to be reasonable for diagnosis and treatment of an illness, injury, pregnancy, and mental disorder. Provider reimbursement may be reduced or claims denied if services were provided without appropriate Preauthorization. |
| Military Health System (“MHS”) | Means the system that is operated by the United States Department of Defense and is responsible for providing health services through both Military Treatment Facilities and private sector care to TRICARE eligible beneficiaries, composed of uniformed service members, military retirees, and family members. MHS is also considered part of the government. |
| Military Treatment Facility (“MTF”) | Means a military facility that operate within the Military Health System provide and direct care of TRICARE Beneficiaries. MTFs are also considered part of the government. |
| Network Subcontractor | Means the health plans with whom TriWest contracts to include providers in the TriWest provider network. |
| Preauthorization | A decision issued in writing, or electronically by the Director, TRICARE Management Activity, TriWest, or a designee, that TRICARE benefits are payable for certain services that a beneficiary has not yet received. The term prior authorization is commonly substituted for preauthorization and has the same meaning. Provider reimbursement may be reduced or claims denied if services were provided without appropriate Preauthorization. Preauthorization is not a guarantee of payment of a claim. |
| TRICARE Beneficiary/Beneficiaries/MHS Eligible Beneficiary | An individual who has been determined to be eligible for TRICARE/CHAMPUS benefits as set forth in TRICARE Requirements. TRICARE Beneficiary programs include TRICARE Prime and TRICARE Select. |
| TRICARE/TRICARE Program | A component of the Military Health System (MHS). The TRICARE Program is the means by which managed care activities designed to improve the delivery and financing of health care services in MHS are carried out. |
| TRICARE Covered Services | Services, items and supplies for which benefits are available to TRICARE Beneficiaries in accordance with the rules, regulations, policies and instructions of DHA and DOD. |
| TRICARE Requirements | Title 10, United States Code, Chapter 55; 32 CFR Part 199; TRICARE Policy Manual (TPM); TRICARE Reimbursement Manual (TRM); TRICARE Operations Manual (TOM); and TriWest TRICARE Provider Handbook and TriWest Policies and Procedures. As of the Effective Date of these TRICARE Terms and Conditions, TRICARE Manuals may be found at: https://manuals.health.mil/. |
Exclusions and Terminations
TriWest and Network Subcontractor have the right to immediately terminate Provider Agreements upon written notice to the provider for any of the events listed below:
- Provider’s state or federal license or authorization to do business is reduced, restricted, suspended, or terminated (either voluntarily or involuntarily), placed on probation, or provider’s other applicable license or accreditation is reduced, restricted, suspended, or terminated (either voluntarily or involuntarily)
- Provider’s professional liability coverage as required under Provider’s Agreement is reduced below required amounts or is no longer in effect
- Provider fails to meet TriWest’s or Network Subcontractor’s credentialing, re-credentialing, quality management or utilization management criteria, or fails to comply with quality management or utilization management processes
- Provider fails to provide material information or provides erroneous information on Provider’s credentialing application or re-credentialing application
- Provider is no longer Medicare-eligible, Medicaid-eligible, or is not eligible to participate in another government program
- Provider or any of its officers is arrested or indicted on felony charges that directly or indirectly relate to provisions of services under Provider’s Agreement, and TriWest and Network Subcontractor makes a reasonable and good faith determination that the nature of the charges are such that termination or necessary to avoid unnecessary risk or harm to Beneficiaries that could occur during the pendency of the criminal proceedings
- The Director, DHA, or designee may exclude any provider based on 32 CFR § 199.9 provisions (fraud, abuse and conflict of interest). The period of exclusion is at the discretion of DHA. DHA Program Integrity will send written notice to the Provider of the proposed exclusion, and the potential effect thereof. Provider may submit evidence and written argument regarding the proposed exclusion. DHA Program Integrity has sole authority to issue an Initial Determination of Exclusion. Written notice of this decision will include the basis for the exclusion, the length of the exclusion, as well as the effect of the exclusion. The determination also outlines the earliest date on which DHA Program Integrity will consider a request for reinstatement, the requirements for reinstatement, and appeal rights available. Exclusion of a Provider will be effective fifteen (15) calendar days from the date of the initial determination. The Director, DHA or designee has sole authority for approval of any request for reinstatement. Within fifteen (15) business days of DHA Program Integrity notifying TriWest of an exclusion action, TriWest will provide written notice, sent by certified mail, return receipt requested, that the Provider’s agreement has been cancelled.
- TriWest will initiate termination action based on a finding that Provider fails to meet the qualifications to be an authorized TRICARE/CHAMPUS provider. The period of termination will be indefinite and will end only after Provider has successfully met the established qualifications for authorized status under TRICARE and has been reinstated as outlined in TOM Ch. 13 Section 5 Subsection 10.0
- TriWest will initiate termination action based on a finding that the provider fails to meet the qualifications to be an authorized TRICARE/CHAMPUS provider. The period of termination will be indefinite and will end only after Provider has successfully met the established qualifications for authorized status under TRICARE and has been reinstated as outlined in TOM Ch. 13 Section 5 Subsection 10.0.
- TriWest and Network Subcontractor, in their sole discretion, have the right to immediately terminate or pursue other administrative action upon TriWest learning that Provider had not been credentialed in compliance with the TriWest Credentialing Committee Policy & Procedure.
Notification
All notices and other communications to a Party must be in writing, hand delivered, delivered by prepaid commercial courier services with tracking capabilities, faxed, or delivered by the U.S. mail to the address listed on the signature page of the Provider’s Agreement. The Parties may change the address of record by notifying the other Party of the new address. Notice shall be complete upon the earlier of actual receipt or five (5) days after being deposited into the U.S. mail. Notices and other communications in writing need not be mailed either by registered or certified mail, although a signed return receipt received through the U.S. Post Office shall be conclusive proof between the Parties of delivery of any notice or communication and of the date of such delivery.
Provider shall notify TriWest or Network Subcontractor in writing immediately upon learning of any action, policies, determinations or internal or external developments that may have a direct impact on Provider’s ability to perform its obligations under the Provider’s Agreement. Such matters shall include, but are not limited to:
- Any change in ownership, specialty services provided, Medicare designation (including but not limited to sole community, critical access, etc.) or location of facilities
- Action against or lapse of Provider’s license, certification, accreditation or certificate of authority
- Loss of hospital privileges
- Arrest or indictment
- Reduction in insurance coverage below the required limits set forth for the applicable Program, or termination of insurance coverage
- Any activity that compromises the confidentiality and security of the medical records of Beneficiaries
- Exclusion or any other penalty from Medicare, Medicaid, or any other federal health care program
- Provider shall complete TRICARE required training that will be determined at a later date and reflected in the next version of the TriWest TRICARE Provider Handbook
Provider Directory
TriWest may periodically include the provider’s name, sex, work address, work fax number, work telephone number, whether the provider is accepting new patients, specialty and sub-specialty and willingness to accept beneficiaries in a directory of network providers. The provider is responsible for notifying TriWest or network subcontractor of any changes of address, phone or fax number, or specialty services rendered within 10 business days.
Compliance
Providers must comply with all applicable state and federal laws as well as regulations and all rules, policies and procedures of the applicable program including without limitation to credentialing, peer review, referrals, utilization review/management, clinical practice guidelines, case management and quality assurance programs and procedures established by TriWest or the applicable health care program including submission of information concerning provider and compliance with Preauthorization requirements, care approvals, pharmacy, dental and Durable Medical Equipment (DME) utilization requirements, care approvals, concurrent reviews, retrospective reviews, discharge planning for inpatient admissions, critical event notifications, quality of care audits, return of medical records and preauthorization of referrals.
Ancillary Providers
If laboratory tests billed by a non-network provider were performed outside the office of the non-network provider, the place where the laboratory tests were performed must be provided for TriWest to approve arrangements for laboratory work submitted by network providers.
The services, to be covered, must have been ordered by a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) and the laboratory must meet the requirements to provide the services as required under the 32 CFR § 199 and Defense Health Agency instructions.
For TRICARE Prime beneficiaries, ancillary services must be ordered by the PCM.
Credentialing Requirements
Providers cannot have had any state license termed for cause, have relinquished any state license after being notified in writing by that state of potential termination for cause or have relinquished any state license for any reason that would violate TRICARE requirements (as defined in the Provider TRICARE Terms and Conditions) whether or not provider had been notified by that state of potential termination for cause.
Providers who have not submitted a claim or whose services have not been submitted on a claim within the past two years may be moved from the active file to the inactive file. However, even if the provider remains on the active file, if a claim is received from a provider who has not submitted a claim or whose services have not been submitted on a claim within the past two years, the provider must be fully recertified. Providers who have been terminated or suspended shall not be deleted. Suspended or terminated, or excluded providers shall remain on the file as flagged providers indefinitely or until the flag is dropped because the suspended provider has been reinstated.
Professional Liability Coverage
Providers must provide and maintain professional liability insurance in an amount in accordance with the laws of the state in which the care is provided and TRICARE Requirements, including TriWest TRICARE Terms and Conditions.
DRAFT — pending DHA approval. Submitted for review on 2/15/24.