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TRICARE Operations Manual 6010.59-M, April 1, 2015
Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Chapter 7
Addendum A
An Important Message From TRICARE
Revision:  
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
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