Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Your Rights While A TRICARE
Hospital Patient
You have the right to receive all the hospital
care that is necessary for the proper diagnosis and treatment of
your illness or injury. According to Federal law, your
discharge date must be determined solely by your medical needs,
not by “Diagnosis Related Groups (DRGs)” or by TRICARE payments.
You have the right to be fully informed about
decisions affecting your TRICARE coverage and payment of your hospital
stay and any post-hospital services.
You have the right to request a review by a
TRICARE Regional Review Authority (RRA) of any written notice of
noncoverage that you may receive from the hospital stating that
TRICARE will no longer pay for your hospital care. RRAs employ groups
of doctors under contract by the Federal Government to review medical
necessity, appropriateness and quality of hospital treatment furnished
to TRICARE patients. The phone number and address of the RRA for
your area are:
Contractor's Address
Contractor's Toll-Free Telephone
Number
Talk To Your Doctor About Your Stay In
The Hospital
You and your doctor know more about your condition
and your health needs than anyone else. Decisions about your medical
treatment should be made between you and your doctor. If
you have any questions about your medical treatment, your need for
continued hospital care, your discharge, your need for possible
post-hospital care, don’t hesitate to ask your doctor.
The hospital’s patient representative or social worker will also
help you with your questions and concerns about hospital services.
If You Think You Are Being Asked To Leave
The Hospital Too Soon
Ask a hospital representative for a written
notice of explanation immediately, if you have not already received
one. This notice is called a “notice of noncoverage.” You must have
this notice of noncoverage if you wish to exercise your right to
request a review by the RRA.
The notice of noncoverage will state whether
your doctor or the RRA agrees with the hospital’s decision that
TRICARE should no longer pay for your hospital care.
• If the
hospital and your doctor agree, the RRA does not review your case
before a notice of noncoverage is issued. But the RRA will respond
to your request for a review of your Notice of Noncoverage and seek
your opinion. You cannot be made to pay for your hospital care until
the RRA makes its decision if you request the review by
noon of the first workday after you receive the notice of noncoverage.
• If the hospital and your doctor disagree,
the hospital may request the RRA to review your case. If it does
make such a request, the hospital is required to send you a notice
to that effect. In this situation, the RRA must agree with the hospital
or the hospital cannot issue a notice of noncoverage. You may request
that the RRA reconsider your case after you receive a notice of noncoverage,
but since the RRA has already reviewed your case once, you may have
to pay for at least one day of hospital care before the RRA completes
this reconsideration.
IF YOU DO NOT REQUEST A REVIEW, THE HOSPITAL
MAY BILL YOU FOR ALL THE COSTS OF YOUR STAY BEGINNING WITH THE THIRD
DAY AFTER YOU RECEIVE THE NOTICE OF NONCOVERAGE. THE HOSPITAL, HOWEVER,
CANNOT CHARGE YOU FOR CARE UNLESS IT PROVIDES YOU WITH A NOTICE
OF NONCOVERAGE.
How To Request A Review Of The Notice
Of Noncoverage
If the notice of noncoverage states that your physician
agrees with the hospital’s decision:
• You must
make your request for review to the RRA by noon of the
first work day after you receive the notice of noncoverage
by contacting the RRA by phone or in writing.
• The RRA must ask for your views about your
case before making its decision. The RRA will inform you by phone
and in writing of its decision on the review.
• If the RRA agrees with the notice of noncoverage,
you may be billed for all costs of your stay beginning at noon of
the day after you receive the RRA’s decision.
• Thus, you will not be responsible for the
cost of hospital care before you receive the RRA decision.
If the notice of noncoverage states that the RRA
agrees with the hospital’s decision:
• You should
make your request for reconsideration to
the RRA immediately upon receipt of the notice of noncoverage
by contacting the RRA in writing.
• The RRA can take up to three working days
from receipt of your request to complete a review. The RRA will
inform you in writing of its decision on the review.
• Since the RRA has already reviewed your case
once prior to the issuance of the notice of noncoverage, the hospital
is permitted to begin billing you for the cost of your stay beginning with
the third calendar day after you receive your notice of noncoverage, even
if the RRA has not completed its review.
• Thus, if the RRA continues to agree with the
notice of noncoverage, you may have to pay for at least
one day of hospital care.
Note: The process described above is called “immediate
review.” If you miss the deadline for this immediate review while
you are in the hospital, you may still request a review of the TRICARE
decision to no longer pay for your care at any point during your
hospital stay or after you have left the hospital. The notice of
noncoverage will tell you how to request this review.
Post-Hospital Care
When your doctor determines that you no longer
need all the specialized services provided in a hospital, but you
still require medical care, he or she may discharge you to a skilled
nursing facility or to home care. The discharge planner at the hospital
will help arrange for the services you may need after your discharge.
TRICARE and supplemental insurance policies have limited coverage
for skilled nursing facility care and home health care. Therefore,
you should find out which services will or will not be covered and
how payment will be made. Consult with your doctor, hospital discharge
planner, Beneficiary Counseling and Assistance Coordinator
(BCAC), patient representative and your family in making
preparations for care after you leave the hospital. Don’t
hesitate to ask questions.
Questions involving billing or specific benefit
coverage issues should be addressed to your TRICARE claims processor
which is:
Contractor's Address
Contractor's Toll-Free Telephone
Number
Acknowledgment Of Receipt
My signature only acknowledges my receipt of
this message from (Name of Hospital) on (Date) and does
not waive any of my rights to request a review or make me liable
for any payment.
___________________________________________
Signature Of Beneficiary Or Person Acting On
Behalf Of The Beneficiary
___________________________________________
Date Signed