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Health Plan and Policy Billing Guidelines

There are several health coverage policies and plans eligible for cost recovery programs to submit claims. Claim formats that are used in the Military Health System (MHS) are based on encounter services provided, payer requirements, and Service and NCR MD billing policies. The U.S. government may not collect more than the total charge of medical care from any one source or combination of sources. If total payment received exceeds the amount billed, the military treatment facility (MTF) must refund the overage to the payer(s). The table below details the claim format guidelines for each UBO cost recovery program.

  • Institutional- Hospital charges (routine service charges associated with hospital stay or ancillary hospital services)
  • Professional- Provider charges (professional services provided by a physician or other provider)
Health Plan/Policy Institutional Bill format Professional Bill format Cost Recovery Program
Private insurance  Yes 8371/UB-04 Yes 837/CMS1500 TPC, MSA, MAC
Employer Group Health Plan Yes 8371/UB-04 Yes 837/CMS1500 TPC, MSA, MAC
High Deductible Health Plan (HDHP) Yes 8371/UB-04  Yes 837/CMS1500 N/A
Health Savings Account (HSA) No N/A No N/A N/A
Health Reimbursement Account (HRA) No N/A No N/A N/A
Flexible Spending Account (FSA) No N/A No N/A N/A
Association or Organization Health Plan Yes 8371/UB-04 Yes 837/CMS1500 MAC
No fault automobile insurance Yes 8371/UB-04 Yes 837/CMS1500 MAC
Third party automobile liability Yes 8371/UB-04 Yes 837/CMS1500 MSA
Medicare Supplemental Plan Yes 8371/UB-04 Yes 837/CMS1500 MSA
Workers' Compensation Plan (non-federal employee) Yes 8371/UB-04 Yes 837/CMS1500 MSA
Workers' Compensation Plan (federal employee) No DD7/DD7A No DD7/DD7A MSA
Workers' Compensation Plan (DoD employee) No N/A No N/A N/A
TRICARE Supplement No N/A No N/A N/A
Income (wage) Supplement Yes N/A No N/A N/A
Other/Special Coverage Group Yes 8371/UB-04 Yes 837P/CMS1500 TPC, MSA, MAC
None (pay patient) Yes Invoice/receipt Yes Invoice/receipt TPC, MAC

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