2.5 Requirements for continued
payment of ICMP-PEC authorized services:
2.5.1 Eligibility. The beneficiary
must be TRICARE eligible.
2.5.2 Authorized Beneficiaries.
Only those beneficiaries authorized services under the ICMP-PEC upon
its termination on December 28, 2001, are eligible for continued
coverage.
2.5.3 Authorized Services. Only those services authorized
under the ICMP-PEC upon its termination on December 28, 2001, are
eligible for continued coverage.
2.5.4 Custodial Care. Beneficiaries
must continue to meet the TRICARE definition of custodial care in
effect prior to December 28, 2001, that is, custodial care is care
rendered to a patient who:
• Is disabled mentally
or physically and such disability is expected to continue and be prolonged;
and
• Requires
a protected, monitored, or controlled environment whether in an
institution or in the home; and
• Requires assistance
to support the essentials of daily living; and
• Is not under active
and specific medical, surgical, or psychiatric treatment that will reduce
the disability to the extent necessary to enable the patient to
function outside the protected, monitored, or controlled environment.
2.5.5 Beneficiaries
covered under
paragraphs 2.1 or
2.2 must have a primary
caregiver in the home.
2.5.6 Reassessment. Continuation
of receipt of services requires reassessment on a regular basis. The
contractors will provide supporting clinical documentation of all
authorized participant’s medically necessary skilled needs, to include
a plan of care signed by the attending physician. Each letter of authorization
for continued coverage issued by the DHA Clinical Operations, Chief
Medical Officer, or designee, will include a statement regarding
the frequency of a periodic reassessment of the beneficiary. Generally,
periodic reassessment will occur annually, but will be based on
the needs of the beneficiary. Contractors shall provide a complete
clinical documentation update and recommendation for continuation
of coverage at the same level or indicate if either an increase
or decrease in services is indicated by the beneficiary’s current
needs. DHA will provide a courtesy reminder when a periodic reassessment
is due for a beneficiary. Once DHA reviews the reassessment and
updated recommendations of the contractor, a revised or updated
authorization letter will be issued to the contractor.
2.5.7 Revisions.
If at any time a contractor determines a need for a change in authorized
funding for a beneficiary (e.g., due to a change in CMAC rates,
a change in patient condition, such as a need for more or fewer
covered hours, change in HHA, etc.), then the contractor must submit
a written request for such change to the DHA Clinical Operations,
Chief Medical Officer, or designee, that includes a detailed explanation
of why the change is required. The DHA Clinical Operations, Chief
Medical Officer, or designee, will evaluate each request and provide
a written decision to the contractor.
2.5.8 Cost-shares. Cost-shares shall
not be applied to services authorized under the ICMP-PEC prior to
December 28, 2001 nor to those services provided under this policy.
Cost-shares will continue to apply to all other TRICARE benefits.
2.5.9 Appeals.
Appeals should be made directly to the DHA Office of General Counsel
(OGC). There are three appealable issues related to the ICMP-PEC:
2.5.9.1 A custodial
care determination;
2.5.9.2 A determination
by the contractor that ICMP-PEC does not apply;
2.5.9.3 The types
and extent of services authorized for a beneficiary by DHA. The
following language is to be included in subsequent determination
of custodial care letters and notification of benefits related to
ICMP-PEC:
“Should you disagree
with this initial determination, you have the right to appeal and
request a formal review. Appealable issues include the types and extent
of the services and supplies authorized under the ICMP-PEC and the determination
that the care is custodial. The request must be in writing, be signed,
and must be postmarked or received by DHA OGC, within 90 days from the
date of this determination. For the purposes of TRICARE, a postmark
is a cancellation mark issued by the United States Postal Service.
Additional documentation in support of
the appeal may be submitted. However, because a request for a formal
review must be received within 90 days of the date of the initial
determination, a request for formal review should not be delayed
pending the acquisition of any additional documentation. If additional
documentation is to be submitted at a later date, the letter requesting
the formal review must include a statement that additional documentation
will be submitted and the expected date of the submission.”
2.5.10 Claims
Processing. Contractors are to use the special processing code “CM”
in addition to the appropriate branch of service code for all claims
for care and services authorized under this policy. Contractors
are to use the special processing code “E” in addition to the special
processing code “CM” for claims for services authorized for those
beneficiaries indicated in
paragraph 2.3 Claims for services not provided
in accordance with
paragraphs 2.1,
2.2, or
2.3 (i.e.,
acute outpatient and inpatient care and services, including Durable
Medical Equipment (DME)) must be processed in accordance with the
TOM, the TRICARE Reimbursement Manual (TRM), and the TRICARE Systems
Manual (TSM), and without the use of the special processing codes
“E” and “CM”.
2.5.11 Contractors
shall notify the DHA Clinical Operations, Chief Medical Officer,
or designee upon any of the following changes to any beneficiary
who is covered by
paragraphs 2.1,
2.2, or
2.3.
• Death;
• Eligibility status,
including becoming a Transitional Survivor or a Survivor as those terms
are used in
Chapter 10, Section 7.1;
• Residential relocation
(pending or completed);
• Custodial care status;
• Inpatient admission;
• Requests for disengagement.