§1095c. TRICARE program: facilitation of processing of claims

(a) Reduction of Processing Time.-(1) With respect to claims for payment for medical care provided under the TRICARE program, the Secretary of Defense shall implement a system for processing of claims under which-

(A) 95 percent of all clean claims must be processed not later than 30 days after the date that such claims are submitted to the claims processor; and

(B) 100 percent of all clean claims must be processed not later than 100 days after the date that such claims are submitted to the claims processor.

(2) The Secretary may, under the system required by paragraph (1) and consistent with the provisions in chapter 39 of title 31 (commonly referred to as the "Prompt Payment Act"), require that interest be paid on clean claims that are not processed within 30 days.

(3) For purposes of this subsection, the term "clean claim" means a claim that has no defect, impropriety (including a lack of any required substantiating documentation), or particular circumstance requiring special treatment that prevents timely payment on the claim under this section.

(b) Requirement to Provide Start-Up Time For Certain Contractors.-(1) The Secretary of Defense shall not require that a contractor described in paragraph (2) begin to provide managed care support pursuant to a contract to provide such support under the TRICARE program until at least nine months after the date of the award of the contract. In such case the contractor may begin to provide managed care support pursuant to the contract as soon as practicable after the award of the contract, but in no case later than one year after the date of such award.

(2) A contractor under this paragraph is a contractor who is awarded a contract to provide managed care support under the TRICARE program-

(A) who has not previously been awarded such a contract by the Department of Defense; or

(B) who has previously been awarded such a contract by the Department of Defense but for whom the subcontractors have not previously been awarded the subcontracts for such a contract.

(c) Incentives for Electronic Processing.-The Secretary of Defense shall require that new contracts for managed care support under the TRICARE program provide that the contractor be permitted to provide financial incentives to health care providers who file claims for payment electronically.

(Added Pub. L. 106–65, div. A, title VII, §713(a)(1), Oct. 5, 1999, 113 Stat. 688 .)

Effective Date

Pub. L. 106–65, div. A, title VII, §713(d), Oct. 5, 1999, 113 Stat. 689 , provided that: "Section 1095c(b) of title 10, United States Code (as added by subsection (a)), shall apply with respect to any contract to provide managed care support under the TRICARE program negotiated after the date of the enactment of this Act [Oct. 5, 1999]."

Claims Processing Improvements

Pub. L. 106–398, §1 [[div. A], title VII, §727], Oct. 30, 2000, 114 Stat. 1654 , 1654A-188, provided that: "Beginning on the date of the enactment of this Act [Oct. 30, 2000], the Secretary of Defense shall, to the maximum extent practicable, take all necessary actions to implement the following improvements with respect to processing of claims under the TRICARE program:

"(1) Use of the TRICARE encounter data information system rather than the health care service record in maintaining information on covered beneficiaries under chapter 55 of title 10, United States Code.

"(2) Elimination of all delays in payment of claims to health care providers that may result from the development of the health care service record or TRICARE encounter data information.

"(3) Requiring all health care providers under the TRICARE program that the Secretary determines are high-volume providers to submit claims electronically.

"(4) Processing 50 percent of all claims by health care providers and institutions under the TRICARE program by electronic means.

"(5) Authorizing managed care support contractors under the TRICARE program to require providers to access information on the status of claims through the use of telephone automated voice response units."

Deadline for Implementation

Pub. L. 106–65, div. A, title VII, §713(c), Oct. 5, 1999, 113 Stat. 689 , provided that: "The system for processing claims required under section 1095c(a) of title 10, United States Code (as added by subsection (a)), shall be implemented not later than 6 months after the date of the enactment of this Act [Oct. 5, 1999]."