2.0 POLICY
In the case of a provider’s failure to obtain
a required preauthorization, the provider’s payment shall be reduced
by 10% of the amount otherwise allowable. Under the managed care
contracts, a network provider’s payment can be subject to a greater
than 10% reduction or a denial if the network provider has agreed
to such a reduction or denial in the agreement.
2.1 Types of
Care Subject to Payment Reduction
For a provider’s
failure to obtain a required preauthorization or preadmission authorization,
the provider’s payment will be reduced in connection with the following
types of care:
2.1.1 All non-emergency mental health admissions
to hospitals.
2.1.2 All admissions for psychiatric residential
treatment for children, and
inpatient/residential Substance Use Disorder (SUD)
detoxification and rehabilitation, and psychiatric
partial hospitalization (Partial Hospitalization Program
(PHP) care prior to June 13, 2017). None of these
can be considered emergency care.
2.1.3 Psychoanalysis. It cannot
be considered as an emergency service.
2.1.4 Adjunctive dental care.
2.1.5 Organ and
stem cell transplants.
2.1.6 Skilled Nursing Facility (SNF)
care received in the U.S. and U.S. territories for TRICARE dual eligible
beneficiaries once TRICARE is primary payer.
2.1.7 Infusion
drug therapy delivered in the home.
2.1.8 Additional
procedures and services as prescribed by the contractors except
when the beneficiary has “other insurance” as provided in the TRICARE
Policy Manual (TPM),
Chapter 1, Section 6.1, paragraph 1.12, Note.
2.2 Applicability
of Payment Reduction
This section shall apply
to participating (including network providers and participating Department
of Veterans Affairs (DVA) facilities) and nonparticipating providers.
For a provider’s failure to obtain the required preauthorization,
the payment reduction shall be subject to the policy in this section.
2.2.1 In the
case of an admission to a hospital, inpatient/residential Substance
Use Disorder Rehabilitation Facility (SUDRF), or Residential
Treatment Center (RTC), or a PHP (PHP care prior to
June 13, 2017) (or a SNF) when applicable, for network
providers the payment reduction shall apply to the institutional
charges and any associated professional charges of the attending
or admitting provider. Services of other providers shall be subject
to the payment reduction as provided under the network provider
agreements, but not less than 10%.
2.2.2 The amount of the reduction
for non-network providers shall be 10% of the amount otherwise allowable
(consistent with
paragraphs 2.3,
2.4, and
2.5)
for services for which preauthorization should have been obtained,
but was not obtained.
2.2.3 The amount of the reduction
for network providers shall be in accordance with the provider’s
contract with the respective contractor, but not less than 10%.
2.2.4 The payment
reduction shall apply under the Point of Service (POS) option.
2.3
Diagnosis Related
Group (DRG) Reimbursed Facilities
In the
case of admissions reimbursed under the DRG-based payment system,
the reduction shall be taken against the percentage (between 0 and
100%) of the total reimbursement equal to the number of days of
care provided without preauthorization, divided by the total Length-Of-Stay
(LOS) for the admission. See the example in
Chapter 3, Section 4.
2.4
Non-DRG
Facilities/Units (Includes RTCs
and Mental
Health Per Diem Hospitals)
In the case of
admissions to non-DRG facilities/units, the reduction shall be taken
only against the days of care provided without preauthorization.
See the example in
Chapter 3, Section 4.
2.5
Care
Paid on Per-Service Basis
For the care for
which payment is on a per-service basis, e.g., outpatient adjunctive
dental care, the reduction shall be taken only against the amount
that relates to the services provided without prospective authorization.
See the example in
Chapter 3, Section 4.
2.6 Determination
of Days/Services Subject to Payment Reduction
For
purposes of determining the days/services which will be subject
to the payment reduction, the following shall apply:
2.6.1 When the
request for authorization is made prior to the admission but is
not received by the contractor until after the admission occurred,
the days for payment reduction shall be counted from the date of
admission to the date of receipt of the request by the contractor
(not counting the date of receipt). This includes alleged emergency
care subsequently found not to meet the emergency criteria.
2.6.2 When the
request for authorization is made to the contractor after the admission
occurred, the days for payment reduction shall be counted from the
date of admission to the date of approval of the request by the
contractor (not counting the date of approval).
2.6.3 For the
care paid on a per-service basis, e.g., outpatient adjunctive dental
care, payment reduction shall apply to those services/sessions provided
prior to receipt of the authorization request by the contractor.
2.7 Other Health
Insurance (OHI) and Beneficiary Cost-Share
2.7.1 When a beneficiary has OHI
that provides primary coverage, certain services shall not be subject
to payment reduction. See
paragraph 2.1.8.
2.7.2 The reduction of payment is
calculated based on the otherwise allowable amount (consistent with
paragraphs 2.3,
2.4,
and
2.5) before the application of deductible,
beneficiary cost-share, and OHI.
2.7.3 The beneficiary is still required
to pay a cost-share for the days or services for which the payment
is reduced. The beneficiary cost-share shall be calculated applying
the normal cost-share rules before the reduction is taken.
2.7.4 The amount
applied/credited toward the deductible cannot be greater than the
amount for which the beneficiary remains liable after the Government
payment.
2.8 Preauthorization
Process
2.8.1 Preauthorization may be requested from a contractor
in person, by telephone, fax, or mail. The date of receipt of a
request shall be the date (business day) on which a contractor receives
the request to authorize the medical necessity and appropriateness
of care for which it has jurisdiction.
Note: The date a preauthorization request is mailed
to the contractor and postmarked shall determine the date the request
was made (not received). If a request for preauthorization does
not have a postmark, it shall be deemed made on the date received
by the contractor.
2.8.2 In general, the decision regarding
the preauthorization shall be issued by the contractor within one
business day of the receipt of a request from the provider, and
shall be followed with a written confirmation (if initial notice
is verbal).
2.8.3 A preauthorization is valid for the period
of time, appropriate to the type of care involved. It shall state
the number of days/type of care for which it is valid. In general,
preauthorizations will be valid for 30 days. If the services are
not obtained within the number of days specified, a new preauthorization
request is required. For organ and stem cell transplants the preauthorization
shall remain in effect as long as the beneficiary continues to meet
the specific transplant criteria set forth in the TPM, or until
the approved transplant occurs.
2.9 Patient Not Liable
The patient (or the patient’s family) may not
be billed for the amount of the payment reduction due to the provider’s
noncompliance with preauthorization requirements.
2.10 Emergency
Admissions/Services
2.10.1 Payment reductions shall not be applied in
connection with bona fide emergency admissions or services. The
authorization required for a continuation of services in connection
with bona fide emergency admission will not be subject to payment
reduction.
2.10.2 Contractor having jurisdiction for the medical
review of the admission is required to review for emergency when
requested by the provider. In addition to the review of alleged
emergency admissions, the contractor is required to issue an initial
determination providing the review decision which is appealable.
Note: Psychoanalysis and all admissions for psychiatric residential
treatment for children or inpatient/residential SUD
detoxification and rehabilitation are the types of
services/admissions requiring preauthorization that cannot be considered
as emergencies.
2.11 Waiver of Payment Reduction
2.11.1 The contractor
may waive the payment reduction only when a provider could not have known
that the patient was a TRICARE beneficiary, e.g., when there is
a retroactive eligibility determination by a Uniformed Service,
or when the patient does not disclose eligibility to the provider.
2.11.2 The criteria
for determining when a provider could have been expected to know
of the preauthorization requirements shall be the same as applied
under the Waiver of Liability provisions.
2.11.3 If at any
time a payment reduction is revised after claims processing, claim
processors will follow existing procedures for processing any resulting
payment adjustments.
2.12 Appeal Rights
2.12.1 The days/services
for which the provider’s payment is reduced are approved days/services and
not subject to appeal.
2.12.2 The denial
of a waiver request and clerical/calculation errors in connection
with the payment reduction are not subject to appeal but are subject
to administrative review by the contractor upon request.
2.12.3 Adverse
decisions regarding alleged emergency admissions/services are appealable
in cases involving payment reductions following the normal appeal
procedures.