TRICARE Manuals - Display Chap 16 Addendum B (Change 58, Sep 20, 2019)

TRICARE Prime Remote (TPR) Program

Chapter 16

Addendum B

Specified Authorization Staff (SAS) Review: Protocols And Procedures

Revision: C-58, September 20, 2019

1.0 Interconnectivity Between The Contractor And SAS

1.1 ADP Protocols

1.1.1 The contractor shall provide the capability to edit the status and entry of a 13 digit disposition code indicating if the referral was approved for Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) or civilian network treatment (see paragraph 1.2). This disposition code may be used during the claims adjudication process.

1.1.2 The contractor shall provide the logic to automatically approve the referral if the SAS determination is not received within two work days of referral entry.

1.1.3 The contractor shall provide the telecommunications, hardware, and software necessary for data entry and report printing from the SAS location. The contractor shall provide initial and ongoing application training and support on an “as needed” basis.

1.1.4 The contractor shall provide a data dictionary of available data elements to be sent to the SAS automated information system. The contractor shall send all care referral records to the SAS in a tab delimited data flat file. The method of transfer can be File Transfer Protocol (FTP) or an e-mail attachment.

1.1.5 The contractors shall provide the SAS read only access to their subcontractor’s claims history database. The contractors shall provide the necessary training to the SAS staff in order to access the claims history database.

1.2 SAS Referral Data

1.2.1 The format of the referral number will be DMISYYJJJNNNS where:

1.2.1.1 DMIS = the DMIS ID Code of the issuing facility--(5203 = SAS);

1.2.1.2 YY = the year in which the referral number was issued;

1.2.1.3 JJJ = the Julian date on which the referral number was issued;

1.2.1.4 NNN = the Facility Sequence Number;

1.2.1.5 S = Status (the type of provider)

• C = Civilian Care (refer to Section 2, paragraph 5.3.1.2 for referral requirements)

• M = Military Care (military MTF/eMSM or clinic)

• V = Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) Care (DVA/VHA hospital or medical facility)

• P = Care rendered under the Department of Defense/Department of Veterans Affairs (DoD/VA) Memorandum of Agreement (MOA) for “Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services” (refer to Section 4, paragraph 2.2 for referral requirements).

1.2.2 The format of the effective date is YYYYMMDD where:

• YYYY = the year in which the SAS referral is effective;

• MM = the month in which the SAS referral is effective; and

• DD = the day on which the SAS referral is effective. A retroactive authorization is indicated by an effective date prior to the issue date.

1.2.3 The format of the expiration date is YYYYMMDD where:

• YYYY = the year in which the SAS referral expires;

• MM = the month in which the SAS referral expires; and

• DD = the day on which the SAS referral expires.

1.3 Data Elements

The following data elements are the minimum elements required by SAS for determining fitness-for-duty and for determining if care not covered under TRICARE Prime will be covered under TPR. The SAS will return the data elements furnished by the contractor when responding to a request for a fitness-for-duty or coverage/benefit determination. If the contractor is asking for a coverage/benefit determination, the contractor shall include the applicable elements marked with asterisks (*) below. If, for example, the contractor cannot authorize the care it is not a covered benefit under TRICARE, the contractor will include *Not a benefit. If the contractor cannot authorize the care because the care is not medically necessary, the contractor will include **Not medically necessary. If the contractor cannot authorize the care because the provider is not an authorized provider, the contractor shall include ***Provider not authorized.

Data Element	Contractor To SAS	SAS To Contractor
Patient Name	X	X
Patient’s DOB	X	X
Patient’s Sex	X	X
Contact Date (for retroactive authorizations	X	X
Service Member SSN	X	X
Service Member Branch of Service	X	X
Duty Status	X	X
PCM Location Code	X	X
DMIS-ID	X	X
Contractor’s Authorization Number	X	X
Effective Date of Authorization	X	X
*Not a Benefit	*If applicable
**Not Medically Necessary	**If applicable
***Provider Not Authorized	***If applicable
SAS Fitness-for-Duty Referral Number or Benefit Determination Number		X
Effective Date of SAS Referral		X
Expiration Date of SAS Referral		X
Status of Authorization (may be imbedded number)		X
Number/Frequency of Services Requested for SAS Referral	X	X
Diagnosis	X	X
Procedure Code Range	X	X
Type of Service	X	X
Place of Service	X	X
Free Text (for available clinical information)	X

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