10 U.S.C. § 1095b — TRICARE program: contractor payment

Page 1144 TITLE 10—ARMED FORCES § 1095a by subsection (a) [amending this section] shall apply with respect to health care services provided in a med- ical facility of the uniformed services after the date of the enactment of this Act [Nov. 5, 1990], but not with respect to collection under any insurance, medical service, or health plan agreement entered into before the date of the enactment of this Act that the Sec- retary of Defense determines clearly excludes payment for such services. Such an exception shall apply until the amendment or renewal of such agreement after that date.’’ EFFECTIVE DATE OF 1989 AMENDMENT Pub. L. 101–189, div. A, title VII, § 727(b), Nov. 29, 1989, 103 Stat. 1480, provided that: ‘‘The amendment made by this section [amending this section] shall take effect on October 1, 1989, and shall apply to amounts collected under section 1095 of title 10, United States Code, on or after that date.’’ EFFECTIVE DATE Pub. L. 99–272, title II, § 2001(b), Apr. 7, 1986, 100 Stat. 101, provided that: ‘‘Section 1095 of title 10, United States Code, as added by subsection (a), shall apply with respect to inpatient hospital care provided after September 30, 1986, but only with respect to an insur- ance, medical service, or health plan agreement en- tered into, amended, or renewed on or after the date of the enactment of this Act [Apr. 7, 1986].’’ PILOT PROGRAM ON INCREASED THIRD-PARTY COLLEC- TION REIMBURSEMENTS IN MILITARY MEDICAL TREAT- MENT FACILITIES Pub. L. 113–66, div. A, title VII, § 712, Dec. 26, 2013, 127 Stat. 793, required the Secretary of Defense, in coordi- nation with the Secretaries of the military depart- ments, to conduct a three-year pilot program to dem- onstrate and assess the feasibility of implementing commercially available enhanced recovery practices to increase reimbursement from third-party payers in military medical treatment facilities and report the re- sults to Congress not later than 180 days after the pro- gram’s completion. § 1095a. Medical care: members held as captives and their dependents (a) Under regulations prescribed by the Presi- dent, the Secretary concerned shall pay (by ad- vancement or reimbursement) any person who is a former captive, and any dependent of that per- son or of a person who is in a captive status, for health care and other expenses related to such care, to the extent that such care— (1) is incident to the captive status; and (2) is not covered— (A) by any other Government medical or health program; or (B) by insurance. (b) In the case of any person who is eligible for medical care under section 1074 or 1076 of this title, such regulations shall require that, when- ever practicable, such care be provided in a fa- cility of the uniformed services. (c) In this section: (1) The terms ‘‘captive status’’ and ‘‘former captive’’ have the meanings given those terms in section 559 of title 37. (2) The term ‘‘dependent’’ has the meaning given that term in section 551 of that title. (Added Pub. L. 99–399, title VIII, § 806(c)(1), Aug. 27, 1986, 100 Stat. 886, § 1095; renumbered § 1095a, Pub. L. 100–26, § 7(e)(2), Apr. 21, 1987, 101 Stat. 281; amended Pub. L. 100–526, title I, § 106(b)(1), Oct. 24, 1988, 102 Stat. 2625.) Editorial Notes AMENDMENTS 1988—Subsec. (c). Pub. L. 100–526 substituted ‘‘The terms ‘captive status’ ’’ for ‘‘ ‘Captive status’ ’’ in par. (1), and ‘‘The term ‘dependent’ ’’ for ‘‘ ‘Dependent’ ’’ in par. (2). Statutory Notes and Related Subsidiaries EFFECTIVE DATE; REGULATIONS Pub. L. 99–399, title VIII, § 806(c)(3), Aug. 27, 1986, 100 Stat. 886, provided that: ‘‘(A) Section 1095 [now 1095a] of title 10, United States Code, as added by paragraph (1), shall apply with re- spect to any person whose captive status begins after January 21, 1981. ‘‘(B) The President shall prescribe specific regula- tions regarding the carrying out of such section with respect to persons whose captive status begins during the period beginning on January 21, 1981, and ending on the effective date of that section [Aug. 27, 1986].’’ Executive Documents DELEGATION OF FUNCTIONS Functions of President under this section delegated to Secretary of Defense, see section 3 of Ex. Ord. No. 12598, June 17, 1987, 52 F.R. 23421, set out as a note under section 5569 of Title 5, Government Organization and Employees. § 1095b. TRICARE program: contractor payment of certain claims (a) PAYMENT OF CLAIMS.—(1) The Secretary of Defense may authorize a contractor under the TRICARE program to pay a claim described in paragraph (2) before seeking to recover from a third-party payer the costs incurred by the con- tractor to provide health care services that are the basis of the claim to a beneficiary under such program. (2) A claim under this paragraph is a claim— (A) that is submitted to the contractor by a provider under the TRICARE program for pay- ment for services for health care provided to a covered beneficiary; and (B) that is identified by the contractor as a claim for which a third-party payer may be liable. (b) RECOVERY FROM THIRD-PARTY PAYERS.— The United States shall have the same right to collect charges related to claims described in subsection (a) as charges for claims under sec- tion 1095 of this title. (c) DEFINITION OF THIRD-PARTY PAYER.—In this section, the term ‘‘third-party payer’’ has the meaning given that term in section 1095(h) of this title, except that such term excludes pri- mary medical insurers. (Added Pub. L. 105–261, div. A, title VII, § 711(a)(1), Oct. 17, 1998, 112 Stat. 2058; amended Pub. L. 106–65, div. A, title VII, § 716(c)(2), Oct. 5, 1999, 113 Stat. 692.) Editorial Notes AMENDMENTS 1999—Subsec. (b). Pub. L. 106–65 substituted ‘‘The United States shall have the same right to collect charges related to claims described in subsection (a) as charges for claims under section 1095 of this title.’’ for ‘‘A contractor for the provision of health care services Page 1145 TITLE 10—ARMED FORCES § 1095c under the TRICARE program that pays a claim de- scribed in subsection (a)(2) shall have the right to col- lect from the third-party payer the costs incurred by such contractor on behalf of the covered beneficiary. The contractor shall have the same right to collect such costs under this subsection as the right of the United States to collect costs under section 1095 of this title.’’ § 1095c. TRICARE program: facilitation of proc- essing of claims (a) REDUCTION OF PROCESSING TIME.—(1) With respect to claims for payment for medical care provided under the TRICARE program, the Sec- retary 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 re- quired by paragraph (1) and consistent with the provisions in chapter 39 of title 31 (commonly referred to as the ‘‘Prompt Payment Act’’), re- quire 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) Except as pro- vided in paragraph (3), 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, but in no case later than one year after the date of such award. (2) A contractor under this paragraph is a con- tractor who is awarded a contract to provide managed care support under the TRICARE pro- gram— (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 con- tract. (3) The Secretary may reduce the nine-month start-up period required under paragraph (1) if— (A) the Secretary— (i) determines that a shorter period is suf- ficient to ensure effective implementation of all contract requirements; and (ii) submits notification to the Commit- tees on Armed Services of the House of Rep- resentatives and the Senate of the Sec- retary’s intent to reduce the nine-month start-up period; and (B) 60 days have elapsed since the date of such notification. (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 pay- ment electronically. (d) CORRESPONDENCE TO MEDICARE CLAIMS IN- FORMATION REQUIREMENTS.—The Secretary of Defense, in consultation with the other admin- istering Secretaries, shall limit the information required in support of claims for payment for health care items and services provided under the TRICARE program to that information that is identical to the information that would be re- quired for claims for reimbursement for those items and services under title XVIII of the So- cial Security Act (42 U.S.C. 1395 et seq.) except for that information, if any, that is uniquely re- quired by the TRICARE program. The Secretary of Defense shall report to the Committee on Armed Services of the Senate and the Com- mittee on Armed Services of the House of Rep- resentatives any information that is excepted under this provision, and the justification for that exception. (Added Pub. L. 106–65, div. A, title VII, § 713(a)(1), Oct. 5, 1999, 113 Stat. 688; amended Pub. L. 107–107, div. A, title VII, § 708(b), Dec. 28, 2001, 115 Stat. 1164; Pub. L. 107–314, div. A, title VII, § 711(a), Dec. 2, 2002, 116 Stat. 2588.) Editorial Notes REFERENCES IN TEXT The Social Security Act, referred to in subsec. (d), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Title XVIII of the Act is classified generally to subchapter XVIII (§ 1395 et seq.) of chapter 7 of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables. AMENDMENTS 2002—Subsec. (d). Pub. L. 107–314 added subsec. (d). 2001—Subsec. (b)(1). Pub. L. 107–107, § 708(b)(1), sub- stituted ‘‘Except as provided in paragraph (3), the Sec- retary’’ for ‘‘The Secretary’’ and struck out ‘‘contract. In such case the contractor may begin to provide man- aged care support pursuant to the contract as soon as practicable after the award of the’’ before ‘‘contract, but in no case’’. Subsec. (b)(3). Pub. L. 107–107, § 708(b)(2), added par. (3). Statutory Notes and Related Subsidiaries 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].’’ APPLICABILITY Pub. L. 107–314, div. A, title VII, § 711(b), Dec. 2, 2002, 116 Stat. 2588, provided that: ‘‘The Secretary of De- fense, in consultation with the other administering Secretaries referred to in section 1072(3) of title 10, United States Code, shall apply the limitations re- quired under subsection (d) of section 1095c of such title (as added by subsection (a)) with respect to contracts entered into under the TRICARE program on or after October 1, 2002.’’