Authority - TRICARE Operations Manual

TRICARE Operations Manual 6010.56-M, February 1, 2008
Appeals And Hearings

Chapter 12

Addendum A

Figures
FIGURE 12.A-1

APPOINTMENT OF REPRESENTATIVE AND AUTHORIZATION TO DISCLOSE
INFORMATION
(Reproduce Locally)

SAMPLE FORMAT
I appoint (Print/Type Name and Address of Representative) to act as my representative in
connection with my appeal under 32 CFR 199.10, Appeal and Hearing Procedures. To avoid the
possibility of a conflict of interest, I understand that an officer or employee of the United States, to
include an employee or member of a Uniformed Service, an employee of a Uniformed Service legal
office, an MTF Provider or a Health Benefits Advisor, is not eligible to serve as a representative. An
exception to this is made when an employee of the United States or member of a Uniformed
Service is representing an immediate family member.
I authorize the TRICARE Management Activity (TMA) to release to said representative,
information related to my medical treatment, and if necessary, photocopies of any medical records
which may be required for adjudication of my claim for TRICARE benefits.
I understand that the representative shall have the same authority as the party to the appeal
and notice given to the representative shall constitute notice to the party.
This consent will expire upon the issuance of the final agency decision regarding my appeal;
however, I reserve the right to withdraw this authorization at any time.
________________________
(Date)

___________________________________________
(Signature of Person Giving Consent)

Prohibition on redisclosure:
Further disclosure of information by the appointed representative may only be made in accordance
with the provisions of the Privacy Act of 1974, the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), and other applicable Federal law.

1

TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-2

APPEAL SUMMARY LOG, TMA FORM 607
APPEAL SUMMARY LOG

PART I. TO BE COMPLETED BY MANAGED CARE SUPPORT CONTRACTOR
APPEALING PARTY

❏ PROVIDER

CONTRACTOR’S CASE IDENTIFICATION NO.

❏ BENEFICIARY

BENEFICIARY

❏ REPRESENTATIVE

SPONSOR SSN

❏ ACTIVE DUTY

DATE OF BIRTH

❏ TRICARE ENROLLEE
❏ TRICARE STANDARD

APPEALING PARTY’S ADDRESS
SPONSOR

❏ RETIRED

NO
❏
❏
❏
❏
❏
❏
❏
❏

❏ TRICARE EXTRA

REPRESENTATIVE’S NAME (IF APPLICABLE)
BENEFICIARY’S RELATIONSHIP TO SPONSOR

❏ DECEASED

PROVIDER’S INFORMATION (LIST ADDITIONAL PROVIDERS IN COMMENT SECTION)
NAME(S) (ALL PROVIDERS)
1.
❏ NON-NETWORK
2,
❏ NON-NETWORK
3.
❏ NON-NETWORK
4.
❏ NON-NETWORK
5.
❏ NON-NETWORK
YES
❏
❏
❏
❏
❏
❏
❏
❏

DATE PREPARED

BENEFICIARY HELD HARMLESS
❏ YES
❏ NO
❏ YES
❏ NO
❏ YES
❏ NO
❏ YES
❏ NO
❏ YES
❏ NO

❏ NETWORK
❏ NETWORK
❏ NETWORK
❏ NETWORK
❏ NETWORK

MEDICAL NECESSITY DETERMINATION ❏
FACTUAL DETERMINATION ❏
PROPER APPEALING PARTY?
BENEFICIARY ELIGIBILITY ESTABLISHED?
DOUBLE COVERAGE? (IF YES, NAME OF OTHER PLAN) _________________________________________________________________
MEDICAID COVERAGE?
PARTICIPATING PROVIDER? (IF NON-NETWORK)
NONAVAILABILITY STATEMENT REQUIRED?
TIMELY FILED? (IF YES, DATE MAILED/RECEIVED)
_________________________________________________________________
WAIVER OF LIABILITY APPLICABLE?
AMOUNT IN DISPUTE DATA (IF ADDITIONAL CLAIMS, LIST ON ADDITIONAL SHEETS)
(See reverse for instructions)
AMOUNT PAID BY

Date Of
Service

(a)
Initial)
Determination
Date

(b)
ICN(s)
Of Claims
Appealed

(c)

(d)

(e)

(f )

(g)

(h)

(i)

Billed
Charges

Allowable
Charges

Amount
Denied

Deductible
Amount

Other
INS

TRICARE

Cost
Share

Comments (Identify Service):

Managed Care Support Contractor Point of Contact:

PART II. TO BE COMPLETED BY NATIONAL QUALITY MONITOR CONTRACTOR (IF APPLICABLE)
SECOND RECONSIDERATION Determination
YES
❏
❏
❏
❏

NO
❏
❏
❏
❏

PROPER APPEALING PARTY?
TIMELY FILED? (IF YES, DATE MAILED/RECEIVED)
WAIVER OF LIABILITY APPLICABLE?
AMOUNT IN DISPUTE REMAINS $900 OR MORE?

_________________________________________________________________

TQMC Point of Contact

DATE PREPARED

TMA FORM 607
REV. JAN. 88

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TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-2

APPEAL SUMMARY LOG, TMA FORM 607 (CONTINUED)

PREPARATION OF AMOUNT IN DISPUTE DATA
a. Initial determination date............................................................Enter date of the initial determination, which is usually
the TRICARE Explanation of Benefits (EOB) date.
b. ICN(s) of claims appealed.............................................................Enter the ICN of each claim being appealed.
c. Billed charges...................................................................................Enter total amount billed for this (these) claims(s).
d. Allowable charges.......................................................................... Enter total allowable amount. For purposes of determining
“amount in dispute,” include the amount which would have
been “allowable” if the service/supply denied would have
been payable.
e. Amount denied............................................................................... Enter the amount of the “allowable charges,” which were
denied. Do not include any “allowable charge” reductions.
f. Deductible amount........................................................................Enter amount of deductible, if any, applied to this (these)
claim(s).
g. Amount paid by other insurance..............................................Enter amount of other insurance payment applicable.
h. Amount paid by TRICARE.............................................................Enter amount actually paid by TRICARE on this (these)
claims(s).
i. Amount paid by cost-share.........................................................Enter amount actually to be paid by the beneficiary/sponsor.
If other insurance covers the entire cost-share, enter ø.

TMA FORM 607
REV. JAN. 88

3

TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-3

PROFESSIONAL QUALIFICATIONS, TMA FORM 780
Form Approved
OMB No.: 0720-0005
Expires: 31 May 07

PROFESSIONAL QUALIFICATIONS
MEDICAL/PEER REVIEWERS
The Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington
Headquarters Services, Directorate for Information Operations and Reports (0720-0005), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302.
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.

Privacy Act Statement
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USE:
DISCLOSURE:

10 U.S.C. 1079, 1086 and 1092
To solicit the professional qualifications of medical specialists and their credentials for Medical/Peer
Reviewers positions. Individuals selected will review medical documentation contained in appeal or
hearing case files.
None.
Voluntary. No effect on respondents for not providing requested information.

Physician’s/Reviewer’s Name:

Year of Birth:

Address:

Medical Education
State:

Year of Degree:

School:

Year of License:

American Specialty Boards:

Specialties:

Type of Practice:

National Scientific Medical Societies:

CHAMPUS Form 780
May 2004

Previous editions are obsolete

4

TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-3

PROFESSIONAL QUALIFICATIONS, TMA FORM 780 (CONTINUED)
PROFESSIONAL APPOINTMENTS

State:

School:

Title and Current status
Other Information:

SOURCES OF INFORMATION
(PROFESSIONAL LISTING)
Name of Directory:
Year:

Edition:

Page:

Other Sources:

CHAMPUS Form 780
May 2004

Previous editions are obsolete

5

TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-4

LETTER TO PROPER APPEALING PARTY WHEN REVIEW HAS BEEN
REQUESTED BY AN IMPROPER APPEALING PARTY

An appeal in your behalf has been received from (Name of Person who requested Appeal).
Under 32 CFR 199.10, (Name of Person), is not an appropriate appealing party, and, consequently,
the request cannot be accepted as an appeal.
The TRICARE case file does not indicate that you have appointed anyone as representative to
act in your behalf. Therefore, if you wish to appeal you have the following options:
a. Appeal in your behalf.
b. Appoint a representative who may request an appeal in your behalf.
If you intend to appeal in your own behalf or through a duly-appointed representative, the
appeal must be received within 20 days of the date of this letter or by the appeal deadline set forth
in the initial determination notice (whichever is later).
An Appointment of Representative form is enclosed for your convenience should you wish to
appoint a representative. Your correspondence should be addressed to:
(Contractor’s Name And Address)
Signature
cc:
Improper Appealing Party

6

TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-5

TRICARE APPEALS PROCESS - MEDICAL NECESSITY DENIALS
PROPOSED INITIAL
DENIAL DETERMINATION
OPPORTUNITY FOR PROVIDER
TO DISCUSS PROPOSED
DENIAL DET
INITIAL DENIAL DETERMINATION

RECON OF CONCURRENT REVIEW
INITIAL DENIAL DET
BENE ENCOURAGED TO FILE
RECON REQUEST WITH MCSC BY
NOON OF THE DAY AFTER DAY OF
RECEIPT OF INITIAL DET, BUT MUST
FILE W/IN 90 CALENDAR DAYS OF
THE DATE OF INITIAL DET
AND
BENE MUST BE IN THE FACILITY
WHEN THE RECON REQUEST IS
RECEIVED BY MCSC
MCSC AUTOMATICALLY
OVERNIGHTS RECON REQUEST
AND COMPLETE MEDICAL RECORD
TO TQMC
W/IN 2 WORKDAYS OF RECEIPT OF
RECON REQUEST BY TQMC, TQMC
MAKES RECONSIDERATION DET

W/IN 3 WORKDAYS OF RECEIPT OF
RECON REQUEST BY TQMC, TQMC
NOTIFIES MCSC OF RECON DET
AND ISSUES RECON DET TO
BENEFICIARY AND PROVIDER

60 CALENDAR DAYS FROM DATE
OF RECONSIDERATION DET FOR
BENEFICIARY TO REQUEST
HEARING IF $300 OR MORE IN
DISPUTE

EXPEDITED RECON OF
PREADMISSION/
PREPROCEDURE INITIAL
DENIAL DET
BENE MUST FILE RECON
REQUEST W/IN 3 CALENDAR
DAYS OF RECEIPT OF INITIAL
DET
MCSC PROVIDES ADVANCE
NOTICE OF DATE OF RECON
AND GIVES PARTIES
OPPORTUNITY TO REVIEW
APPEAL FILE AND SUBMIT
ADDITIONAL DOCS
W/IN 3 WORKDAYS OF
RECEIPT OF RECON REQUEST,
MCSC MUST ISSUE RECON
UNLESS MCSC RESCHEDULES
RECON AT REQUEST OF
APPEALING PARTY

NONEXPEDITED RECON OF INITIAL
DENIAL DET
BENE OR NON-NETWORK
PROVIDER MUST FILE RECON
REQUEST W/IN 90 CALENDAR DAYS
OF THE DATE OF INITIAL DET
MCSC PROVIDES NOTICE OF DATE
OF RECON AND GIVES PARTIES
OPPORTUNITY TO REVIEW APPEAL
FILE AND SUBMIT ADDITIONAL
DOCS
W/IN 30 CALENDAR DAYS OF
RECEIPT OF RECON REQUEST, MCSC
MUST ISSUE RECON UNLESS MCSC
RESCHEDULES RECON AT REQUEST
OF APPEALING PARTY

RECON IS FINAL IF LESS THAN
$50 REMAINS IN DISPUTE
W/IN 3 CALENDAR DAYS OF
RECEIPT OF RECON DET, BENE
MUST FILE REQUEST FOR
EXPEDITED SECOND RECON
W/ TQMC
W/IN 3 WORKING DAYS OF
RECEIPT OF RECON REQUEST,
TQMC ISSUES SECOND RECON

W/IN 90 CALENDAR DAYS OF THE
DATE OF RECON DET, BENE OR
PROVIDER MUST FILE REQUEST FOR
SECOND RECON W/ TQMC
W/IN 30 CALENDAR DAYS OF
RECEIPT OF RECON REQUEST, TQMC
ISSUES SECOND RECON

IF OTHER THAN A PREADMISSION/PREPROCEDURE APPEAL, 60
CALENDAR DAYS FROM DATE OF SECOND RECONSIDERATION DET FOR
BENEFICIARY TO REQUEST HEARING ON ISSUES OF MEDICAL NECESSITY
AND WOL IF $300 OR MORE IN DISPUTE. (THE PROVIDER’S HEARING IS
LIMITED TO THE WOL DETERMINATION IN THE TQMC RECON DET)
WAIVER OF LIABILITY
RETROSPECTIVE DETERMINATIONS ISSUED BY THE MCSC AND THE TQMC MUST ADDRESS WAIVER OF LIABILITY AS SET
FORTH IN 32 CFR 199.4(h), AND THE TRICARE POLICY MANUAL (TPM), Chapter 1, Section 4.1.

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TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-6

TRICARE APPEALS PROCESS - FACTUAL DETERMINATIONS

FACTUAL DETERMINATION
(PROVIDER SANCTION CASES)

FACTUAL DETERMINATION (OTHER
THAN PROVIDER SANCTION CASES)

MCSC ISSUES NOTICE OF PROPOSED
SANCTION TO PROVIDER AND SUSPENDS
CLAIMS PROCESSING

MCSC ISSUES INITIAL
DETERMINATION

APPEALING PARTY MUST FILE RECON
REQUEST W/MCSC W/IN 90
CALENDAR DAYS FROM THE DATE OF THE
INITIAL DET

PROVIDER MAY W/IN 30 DAYS (60
DAYS FOR GOOD CAUSE) SUBMIT
DOCUMENTS AND WRITTEN ARGUMENT
OR SUBMIT A WRITTEN REQUEST TO
PRESENT IN PERSON TO THE MCSC,
WRITTEN EVIDENCE OR ARGUMENT
RECON IS FINAL IF LESS THAN $50
REMAINS IN DISPUTE

W/IN 60 CALENDAR DAYS OF RECEIPT OF
RECON REQUEST, MCSC ISSUES
RECON DET

MCSC ISSUES INITIAL
DETERMINATION
APPEALING PARTY MUST FILE
FORMAL REVIEW REQUEST WITH TMA W/
IN 60 CALENDAR DAYS FROM THE DATE
OF THE RECON DET

FORMAL REVIEW IS FINAL IF LESS THAN
$300 REMAINS IN DISPUTE

APPEALING PARTY MUST FILE
HEARING REQUEST WITH TMA W/IN
60 CALENDAR DAYS FROM THE DATE
OF THE INITIAL DET

W/IN 90 CALENDAR DAYS OF RECEIPT OF
FORMAL REVIEW REQUEST, TMA ISSUES
FORMAL REVIEW DET

APPEALING PARTY MUST FILE
HEARING REQUEST WITH TMA W/IN
60 CALENDAR DAYS FROM THE DATE
OF THE FORMAL REVIEW DET

8

TRICARE Operations Manual 6010.56-M, February 1, 2008
Chapter 12, Addendum A
Figures
FIGURE 12.A-7

TRICARE/MEDICARE DUAL ELIGIBLE APPEAL PROCESS - MEDICARE
PROCESSES CLAIM

TRICARE/MEDICARE DUAL ELIGIBLE APPEALS PROCESS - MEDICARE PROCESSES CLAIM

CLAIM IS DENIED BY
MEDICARE - NEVER A
MEDICARE BENEFIT

CLAIM CROSSES OVER TO
TRICARE

TRICARE
PAYS AS
PRIMARY
PAYER

SERVICE OR
SUPPLY DENIED
- NOT A TRICARE
BENEFIT

CLAIM IS DENIED BY MEDICARE MEDICARE PROGRAM BENEFIT BUT
PATIENT-SPECIFIC DENIAL

CLAIM CROSSES
CROSSES
CLAIM
OVER TO TRICARE
OVER TO
AND IS REJECTED
TRICARE AND IS
REJECTED

CLAIM IS PAID BY
MEDICARE

CLAIM CROSSES
OVER TO TRICARE

CLAIM APPEALED
THROUGH
MEDICARE APPEAL
PROCESS

CLAIM IS DENIED BY
MEDICARE - MEDICARE
DECISION FINAL

Chapter 12,
APPEAL PROCESS APPLIES

- END -

9

TRICARE
PAYS
REMAINING
LIABILITY

SERVICE OR
SUPPLY DENIED
- NOT A TRICARE
BENEFIT