OCFO : MC&FS :
Tricare Home OCFO Home
Management Control & Financial Studies Division
Financial Studies Financial Systems Management Control Data Quality Management Control MEPRS UBO

UBO

UBO Learning Center : UBO 101

UBO 101
Welcome to UBO 101: Your hub to discover and learn UBO basics.
This page can be viewed using any Internet browser; however, some interactive
features are only available when using Internet Explorer 5.5 or higher. Internet Explorer
Hover cursor Hover your cursor over acronyms or images for explanatory text.
Tell us what you think! Help us to improve UBO 101 by providing feedback.

UBO 101 is an interactive Learning Center page for those new to the UBO. It is designed for self-paced, on-demand learning: each section below provides an overview of a topic and has links to more information, such as another web page, a presentation, or a useful form. In addition to the content of this web page, MTF personnel must follow their Service-specific requirements and guidelines. Please check with your Service UBO Program Manager for that information. Please direct other questions to UBO.Helpdesk@altarum.org

The Uniform Business Office

MTF UBOs are responsible for recovering the cost of health care provided to patients seen in MTFs. The DHA UBO Program Office is responsible for developing health care reimbursement rates, setting policy, and providing program oversight for the health care cost recovery programs: MSA, TPC, and MAC. Descriptions of the three programs are in the table below. The Services and NCR Medical Directorate establish and operate UBOs at DHP fixed MTFs throughout the world and administer these programs with the overall goal of optimizing health care cost recovery. The UBO focus is to ensure that billable services are identified, payer information is available, accurate and complete claims are generated, and appropriate collections are received.

The funds collected return directly to the operation and maintenance budget of the MTF where the care was delivered and are used to improve the quality of healthcare. Often the funds allow the continuation of programs or purchasing of equipment at the facilities for which there would otherwise not be funding.

UBO Health Care Cost Recovery Programs
Medical Services Account

MSA activities involve billing and collecting funds for medical, cosmetic, and dental treatment and services provided in DHP fixed MTFs and DTFs from:
  • Other government agencies (e.g., VA, USCG, NOAA, and PHS)
  • DoD beneficiaries
  • DoD civilians and contractors
  • NAF employees
  • Authorized foreign military members
  • DoD Dependent School employees
  • AAFES employees
  • Secretarial Designees
  • Civilian emergency patients
  • Other non-DoD beneficiary patients authorized to receive treatment in the MTF
Authority:
10 USC 1071-1110
32 CFR 199
FMR DoD 7000.14-R
Third Party Collections

TPC activities involve billing third-party payers, such as commercial health insurance carriers, on behalf of eligible DoD beneficiaries, excluding active duty, for treatment and services provided in DHP fixed MTFs.

Authority:
10 USC 1095
32 CFR 220
Medical Affirmative Claims

MAC activities involve recovering the cost of furnishing health care to DoD beneficiaries, including active duty members, who are injured or suffer an illness caused by a third party. MAC involves billing all areas of liability insurance, such as automobile, general casualty, homeowner's and renter's, medical malpractice (by civilian providers), and workers compensation (for persons other than federal employees).

Authority:
37 USC 3711-3720A
28 CFR 43


Policy and Guidance
The DHA UBO Program Office creates and publishes policies and guidance to ensure compliance with federal laws and DoD regulations and to assist MTF UBOs in administration of the three health care cost recovery programs. Current DHA policy letters, UBO Manual, and the UBO User Guide are available on the Policy/Guidance page.

The UBO Manual prescribes uniform billing procedures and accounting practices for the management and follow-up of patient accounts including: collecting, depositing, posting, and reconciliation. It summarizes information from relevant federal laws and regulations, the DoD FMR, and HA policy memorandums by UBO program and function. The UBO Manual may be supplemented by Service-specific guidance.

The UBO User Guide supplements the UBO Manual by providing additional detail and functional guidance on specific MTF data collection and billing procedures.

Additional Resources
DoD Issuances

UBO Compliance Program
A compliance program consists of an internal control review process within an MTF that uses checks and balances to monitor and ensure application of laws and rules relating to the MTF's billing and collection process. Implementation of an effective UBO compliance program supports the MHS's overall mission of providing quality health care and the prevention of health care billing fraud, waste, abuse, or mismanagement of government resources by identifying risks and implementing tools to mitigate the risks. Each MTF is responsible for implementation, maintenance, and oversight of an active compliance program. Click on the links below for further information; also contact your Service UBO Program Manager for Service-specific requirements and guidelines.

Additional Resources
Sept 2011 UBO Webinar - UBO Compliance Program UBO Compliance Program Sept 2011 UBO Webinar - UBO Compliance Program UBO Policy Update Anti-Fraud Program Anti-Fraud Program


PHI/PII
HIPAA is the Federal Law that protects a patient's health information and privacy. PII is information about an individual which identifies, links, relates, is unique to, or describes him or her. This includes information which can be used to distinguish or trace an individual's identity and any other personal information which is linked or linkable to a specified individual. PHI is PII linked to an individual's physical or mental health records. The use and disclosure of PHI and PII is governed by U.S. privacy laws, DoD privacy and security regulations, and your MTF's policies and procedures. MTF personnel are responsible for complying with these laws, regulations, policies and procedures.

For further information, visit the DHA Privacy and Civil Liberties Office web site and the DHA UBO HIPAA resources page. For questions and further clarification of your responsibilities, contact your UBO Service Program Manager.

UBO's Role in the MHS Revenue Cycle

Patient Administration, UBO, UBU, MEPRS, and DQ staff perform the coding, data quality, and billing functions for the MHS. Understanding how these activities are connected will increase the potential for positive financial outcomes and patient satisfaction for individual MTFs and the entire MHS.

The MHS Revenue Cycle consists of multiple activities that impact the function of the UBO. The revenue cycle is categorized into three basic areas:
  • Access Management - Registration (capture of patient and insurance information)
    • Provided by patient administration and UBO
  • Medical Management - Clinical Care and Documentation (accurate capture of health care services through documentation and coding)
    • Provided by healthcare provider and UBU
  • Financial Services - Billing and Payment Collection
    • Provided by UBO

NOTE: Each Military Service may have a unique process flow and Service-specific guidelines for some or all of the functions depicted.

MHS Revenue Cycle

Hover cursor Hover your cursor over the revenue cycle steps for a brief description.
Click a step to jump to the corresponding section in the text.

Revenue Cycle Process (color)
PAD staff verify eligibility, site enrollment, and PATCAT. Schedule appointment At patient check-in, staff validate ID card and verify other health insurance (DD 2569). Insurance validated and insurance information is entered into PII screen in CHCS Healthcare provider performs the clinical encounter. Healthcare provider documents the clinical encounter. Coding staff apply appropriate codes to patient record based on provider documentation. Automated billing process is completed in CHCS or TPOCS. CHCS and TPOCS  generate claims for submission to the payer. Biller reviews the status of payment and follows up with the payer, if necessary. Biller identifies and resolves denied, rejected, or pending claims with payer. Payment received and applied to account in either CHCS or TPOCS. Each MTF must have real-time data to measure itself on performance both for internal management purposes and for external measurement. Access Management - Patient Administration (PAD) and Uniform Business Office (UBO) Medical Management – Healthcare providers and Unified Biostatistical Utilities (UBU) Financial Services -  Uniform Business Office (UBO) Data Quality affects all aspects of the Revenue Cycle.

Data Quality

Every phase of the revenue cycle depends on the completeness and accuracy of the data collected. Starting from the beginning of the revenue cycle, every data point is passed along to the next step. An error in one step affects the whole cycle and ultimately affects reimbursement for the MTF. The Data Quality Management Control program is the driving force and conduit for ensuring effective and efficient operations. DHA manages data quality via the Data Quality Management Control Program. For more information, click on the link to the presentation below.

Additional Resources


Data Quality: UBO and the Revenue Cycle height=Data Quality: UBO and the Revenue Cycle




Step 1: Scheduling

Eligibility

When a patient schedules an appointment, patient administration personnel verify the patient's eligibility for care by using CHCS to run a DEERS eligibility check. DEERS is a DoD data system of military sponsors and families who are eligible for care in an MTF. Once eligibility is verified, patient administration personnel confirm or assign a PATCAT in CHCS for that episode of care and schedule the appointment. No payment is collected at this time.

Patient Category

PATCATs are codes used to identify a patient's level of eligibility for care in an MTF. PATCATs identify and group patients by:

  • Sponsor Service
  • Beneficiary Category
  • Special Interest patient groups

PATCATs are directly linked to UBO billing and tell what reimbursable rate (if any) is applicable for the healthcare services provided, what billing forms are used, and which cost recovery program is responsible for billing the encounter. See the Cost Recovery Programs table above for MSA, TPC, and MAC areas of responsibility. For more information, click on the link to the online training module and presentation below.

Additional Resources

PATCAT Table

PATCAT Training Course PATCAT Training Course How to Assign and Use PATCATs How to Assign and Use PATCATs

PATCAT Finder Guide (updated 2013) pdf 4247.9 KB


Step 2: Registration

Upon arrival for care, the patient must present proof of eligibility for care in an MTF and complete or update a DD Form 2569, indicating whether or not the patient has OHI. If proof of eligibility for care in an MTF is not presented, the Temporary Authorization for Medical Care form must be completed and the patient must return with valid proof of eligibility within 30 days. If proof of eligibility is not provided within 30 days, the patient will be billed the full amount for the cost of care.

Additional Resources

How Registration Impacts Reimbursement How Registration Impacts Reimbursement

Other Health Insurance (OHI)

OHI is any health insurance policy other than TRICARE, TRICARE Supplemental plans, Medicare, Medicaid, and certain government sponsored programs, that a beneficiary may carry through an employer or private insurance company. Any OHI in addition to TRICARE coverage is considered to be the primary health insurance. OHI data collected includes the information about a patient's policy, such as the policy name and number, coverage type, patient relationship to the insured and effective dates. This information is used to properly route a health care claim sent to the OHI carrier for reimbursement.

The source of OHI information is the DD Form 2569, which is completed by patients during registration. All patients (excluding active duty) are required to complete or update a DD Form 2569 annually or whenever their OHI status changes.

DD 2569DD Form 2569












Additional Resources

SIT OHI WebinarSIT/OHI Webinar


SIT/OHI page

Return to MHS Revenue Cycle

Step 3: Insurance Validation and Entry

Standard Insurance Table (SIT)

The SIT centralized database is located in DEERS, which holds the master table of all HICs. It shares the information with CHCS, which contains the local SIT table for all MTFs to access. Once the patient's health insurance information has been received, the insurance company is contacted to validate the insurance information. Once validated, the insurance information is entered into the PII screen of CHCS. If this is not done, it "doesn't exist" for billing purposes. When entering the insurance carrier information, the SIT will display available options. The user selects the correct HIC ID from the SIT, and the information is imported to the CHCS PII screen. Once imported, the insurance information is connected to the patient's file.

Additional Resources

SIT OHI Webinar SIT/OHI Webinar


SIT/OHI page

Return to MHS Revenue Cycle

Step 4: Clinical Encounter

The clinical encounter may include: collection of patient history, a physical examination, and treatment as needed. Encounters must be documented by the healthcare provider in order to be coded, billed and paid. UBOs can only bill for services and treatments coded in the documentation. If corrections are required or information is missing, billers must ask the coders to update that information in the record. If documentation does not support a diagnosis or treatment, the claim will be denied.

Additional Resources

The Role of Medical Records in the Revenue Cycle The Role of Medical Records in the Revenue Cycle

Return to MHS Revenue Cycle

Step 5: Medical Records Documentation

The provider documents the examination for the clinical encounter, which includes, but is not limited to: detail of patient and family history, extent of physical exam, complexity of medical decision making, nature of patient’s problems, minutes of service, and any counseling.

Providers may use superbills or templates to assist with clinical encounter documentation. These templates are tailored to the provider's specialty. Correct documentation must provide a complete picture of the encounter for other health professionals to use in subsequent care. If there is insufficient documentation, an accurate bill cannot be generated.

Return to MHS Revenue Cycle

Step 6: Inpatient and Outpatient Coding

Based on the provider's encounter documentation, coding staff assign appropriate diagnosis and procedure codes (ICD-9-CM, CPT®, and HCPCS codes) to the patient record. Coders must adhere to official MHS coding guidelines that are developed and published by the UBU. For more information on coding guidelines, visit the UBU Web site.

Additional Resources
2011 MHS Revenue Cycle Conference - Bridging the Gap -- Coding and BillingCoding and Billing- Bridging the Gap

Return to MHS Revenue Cycle

Step 7: Charge Capture

MHS systems capture both institutional and professional services and items and pharmaceuticals provided for both inpatient admissions and outpatient visits. MHS billing systems include CHCS (inpatient and outpatient MSA, inpatient TPC) and TPOCS (outpatient TPC). For each service or supply documented in the encounter record, MHS billing systems generate a charge using published and effective DHA UBO rates.

Most diagnostic and procedural codes have a corresponding billing rate. The DHA UBO Program Office develops and publishes Direct Care Inpatient ASAs, Outpatient, and pharmacy rates for care and services provided in MTFs. These rates are used by the three MHS health care cost recovery programs to submit claims for reimbursement. Outpatient rates are revised annually, typically effective on 1 July; ASA rates are revised annually, typically effective 1 October; and pharmacy rates are revised biannually, typically effective in February and August.

For MAC billing, ASA and Outpatient rates must be approved by the Office of Management and Budget and published in the federal register before they are effective.

Additional Resources

MHS Systems

CHCS Process Management for Reimbursement
CHCS Process Management for Reimbursement
Webinar
TPOCS Updates: Impacts to Billers of HIPAA
TPOCS Updates: Impacts to Billers of HIPAA

Return to MHS Revenue Cycle

Step 8: Claim Generation and Submission

Billing claims may be generated automatically from CHCS (inpatient and outpatient MSA, inpatient TPC) and TPOCS (outpatient TPC) or manually for submission to the payer in either electronic or paper format. Each cost recovery program has different methods for generating and submitting bills.

MSA
MSA is responsible for billing patients in categories noted in the Cost Recovery Programs table above. The billing method varies depending on the person or entity billed. For example, the VA and USCG have unique billing requirements.

MSA billing forms:
SF 1080

An SF 1080 form is
used by one government agency
to bill another government agency.
After submission, funds are
transferred between agencies.

DD 7

DD Form 7 (inpatient) and
DD Form 7A (outpatient)
are used as monthly reports
to bill government agencies
for medical charges for
employees of certain
non-DoD federal agencies
or foreign governments.

DD 

7A

Sample Invoice and Receipt

Invoice & Receipt
The I&R form is used for IAR or FRR
depending on the PATCAT. The I&R
is also used when the patient
is responsible for payment.

Additional Resources

MSA Services Panel MSA Services Panel

VA-DoD BillingFY14 VA-DoD Billing

TPC
TPC bills third parties(e.g., insurance companies) using two standard paper claim forms. The UB-04 is for institutional services, and the CMS 1500 for professional services. Claims may also be submitted electronically using the 837 Health Care Claim: Institutional (837I) and the 837 Health Care Claim: Professional (837P) transactions. All bills submitted electronically must comply with HIPAA standard electronic transaction standards.

  • UB 04 - Institutional Charges UB-04 - The UB-04 form is the
    claim form used to bill
    for institutional services.


  • CMS 1500 - The CMS 1500
    is the claim form used to
    bill for professional services.
    The CMS 1500 is required by Medicare
    and generally used by private
    insurance companies and managed care plans.

Additional TPC Resources
Data and Billing in Sync: 1500 (02/12)/837PData and Billing in Sync: 1500 (02/12)/837P Online Training Course

Data and Billing in Sync: UB-04/837i Data and Billing In Sync: UB-04/837i Online Training Course

MAC
If medical care is necessary due to the fault of a third party, a MAC claim can be generated from data in CHCS and TPOCS. Billing personnel work with the RJA to identify services and care related to the accident or injury. Follow Service-specific guidelines for MAC billing.

Additional MAC Resources
How to: MAC Billing How to: MAC Billing
Additional Resources

For more information, visit the DHA UBO Billing web page.

Deciphering Your TPOCS Error Report
Deciphering Your TPOCS Error Report
Webinar

CHCS Process Management for Reimbursement
CHCS Process Management for Reimbursement
Webinar


Return to MHS Revenue Cycle

Step 9: Payer Follow up

Once a claim is generated and submitted, the biller reviews the status of the claim and if not paid, follows up with the payer, as necessary. Follow up methods vary depending on the cost recovery program.

MSA
The MSA office must follow up in writing sixty (60) and ninety (90) calendar days after inpatient hospital discharge or outpatient date of service or within Service-specific guidelines.

TPC
TPC staff should conduct either a written or telephone follow up if reimbursement is not received within sixty (60) days of the clinical encounter and again at ninety (90) days, or within Service-specific guidelines. See the UBO Manual for more information on collection activities and for follow-up claims inquiries.

MAC
UBO does not follow up on MAC claims. MAC claims are handled by each Service's legal office.

Additional Resources
Payments and ?Refunds Payments and Refunds

Return to MHS Revenue Cycle

Step 10: Denials Management and Appeals

For denials management, the biller identifies and resolves denied, rejected, or pending claims with the payer. The biller may request the payer to reconsider denial, rejection, and additional payments.

MSA
For MSA insurance claim denials, follow Service-specific guidance.

How to Manage MSA Insurance DenialsHow to Manage MSA Insurance Denials

TPC
For TPC insurance claim denials, follow Service-specific guidance.

MAC
MAC insurance claim denials are not a UBO function. Follow Service-specific guidance.

Additional Resources
Denial Management- Tools, Tips, and Solutions
Denial Management- Tools, Tips, and Solutions
JAG Support for UBO Billing
JAG Support for UBO Billing
Webinar


Return to MHS Revenue Cycle

Step 11: Payment Posting

Once payment is received, the payment is applied to the patient's account in either CHCS (inpatient and outpatient MSA, inpatient TPC) or TPOCS (outpatient TPC). This step should be performed immediately after payment is received. Follow Service-specific guidelines.

Return to MHS Revenue Cycle

Step 12: Performance Measurements

The UBO's overarching goal is to maximize authorized collections in accordance with applicable laws and policies. Performance measurements help assess progress toward that goal. Each MTF must have tangible, real-time data to measure performance both for internal management purposes and for external measurement in relation to peers, competitors, and the community.

MSA
MSA collections reporting is performed based on Service-specific requirements.

    Go to UBOMetrics.org

TPC
The DHA UBO Metrics.org site (login required) is the performance measurement tool used for TPC quarterly reporting. The MTFs take the DD-2570 reports from CHCS (inpatient) and TPOCS (outpatient) and enter it into the UBO Metrics Report web site.

Additional Resources
Metrics Reporting System Upgrade Update Metrics Reporting System Upgrade Update

How to Pull DD 2570 Data and Combine for Accuracy How to Pull DD 2570 Data and Combine for Accuracy

View the Performance Measurements page for more information.

MAC
MAC collections reporting is performed based on Service-specific reporting requirements.

UBO 101 glossary of terms Need help with terms and acronyms? Check out the UBO 101 Glossary of Terms.

Check Your Knowledge

This functionality is designed for use in Internet Explorer. Internet Explorer

If a biller was to submit an electronic bill for institutional services from the TPC program, they would use:
CMS 1500
837i
837p

True or False: Active duty Service members must fill out the DD 2569.
True
False

This is an automated database of military sponsors, their family members, and others worldwide who are entitled under law to TRICARE benefits:
DEERS
CHCS

Which statement about the DD 7 is untrue?
It is used to bill outpatient services to other government agencies.
It is used to bill inpatient services to other government agencies.
It is used as a monthly report to bill other government agencies for medical charges provided to their employees.

The Federal Law that protects a patient's health information and privacy is:
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Health Confidentiality Act (HCA)

What are the standard follow-up guidelines for both TPC and MSA?
If unpaid, follow-up with payer within 60 and again at 90 days after discharge or date of service
If unpaid, follow-up with payer within 90 and again at 180 days after discharge or date of service
Don't follow-up with the payer

How frequently is the DHA UBOmetrics.org tool used for reporting TPC performance measurements?
Bi-monthly
Annually
Quarterly


Your feedback is important to us and will help improve future Learning Center training.
Click on the icon below to begin the survey.

UBO 101 survey

Questions or comments? E-mail us at UBO.LearningCenter@altarum.org

Viewing or printing the PDF documents found on this site requires the use of Adobe Acrobat Reader, which you may download here. Get Adobe Reader