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TRICARE Acts to Fix Claim Denials Called to Its Attention by NHIA

(August 19, 2009)

Over the past 21 months, the National Home Infusion Association (NHIA) has communicated with the Department of Defense (DoD) about a number of issues on the effectiveness and efficiencies of coverage for home and alternate-site infusion therapies by TRICARE. TRICARE is the military’s health care program that covers care outside of military facilities when needed by members of and retirees from the uniformed services, their families and survivors. We are pleased to announce some positive developments which have resulted from this effort.

Last winter, NHIA requested resolution of two “hot issue” claim denial situations experienced by home infusion pharmacies and brought forward to NHIA by our members:

Claim Denial Issue #1: When infusion supplies are billed on same date of service as a nursing visit, the supply billings have been denied since October 1, 2008. This resulted from an update of a claim editor used by the TRICARE contractors.

Claim Denial Issue #2: The TRICARE For Life plan, which covers health care claims secondary to Medicare, has been automatically rejecting claims for home infusion therapy denied by Medicare as not medically necessary—a technical denial based on Medicare statute and coverage policy that hardly ever means the therapy is medically unnecessary.

The DoD’s TRICARE Management Activity (TMA) group, which administers the program, has communicated to NHIA that both issues of claim denial will be resolved in the future.