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Date
_______________
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Administrator
SNF Name
Address
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Effective
October 1, 2001, TRICARE (formerly known as CHAMPUS) became a secondary
payer to Medicare for approximately 1.5 million Medicare-eligible
Department of Defense (DoD) health care beneficiaries. On December
28, 2001, President Bush signed the National Defense Authorization
Act of Fiscal Year 2002 (NDAA FY 2002) (Public Law 107-107). This
legislation provided three important provisions for SNF providers:
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First,
with one exception, the legislation revised the TRICARE SNF benefit
so that it is identical to the Medicare SNF benefit. Like Medicare,
the TRICARE SNF benefit now requires a qualifying three-day prior
hospitalization. The skilled services must meet the Medicare coverage
rules and be for a medical condition that was either treated during
the qualifying three-day hospital stay, or started while the beneficiary
was already receiving Medicare-covered SNF care. The one exception
is that, unlike Medicare, the TRICARE benefit for a spell of illness
will be unlimited. After 100 days of the Medicare benefit, TRICARE
will become the primary payer if the beneficiary does not have other
health insurance.
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Second,
the legislation required that the TRICARE program adopt the Medicare
SNF Prospective Payment System (PPS) payment methods and rates,
including Minimum Data Set (MDS) assessments, Resource Utilization
Group (RUG)-III classifications, and Medicare weights and per diem
rates. Both of these provisions took effect for SNF admissions on
or after August 1, 2003. Children under age 10 on the date of SNF
admission are not subject to MDS assessments and SNF PPS. Critical
Access Hospital (CAH) swing beds are not subject to MDS assessments
and SNF PPS. Unless required by their Memorandum of Understanding (MOU)
or the Provider Agreement, Department of Veterans Affairs (DVA)/Veterans
Health Administration (VHA) facilities are not subject to MDS assessments
and SNF PPS. Facilities in Puerto Rico, Guam, the U.S. Virgin Islands,
and American Samoa are subject to MDS assessments and SNF PPS.
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Third,
the legislation required that SNF providers enter into a Participation
Agreement with TRICARE if they wish to be considered to be an authorized
TRICARE provider. This agreement will require that TRICARE-participating
SNFs are not charge a beneficiary any
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amount
above the TRICARE allowed amount. Beneficiaries are financially
responsible only for co-insurance amounts and services not covered
by TRICARE. SNFs are required to use the same certification forms
for TRICARE beneficiaries as they are required to use for Medicare
beneficiaries. SNFs will be in violation of their TRICARE participation
agreements if they discriminate against the TRICARE beneficiary
in their admission practices or in delivery of medically necessary
services due to the level of payment. Accordingly, attached with
this cover letter is a TRICARE SNF Participation Agreement for your
signature. Please sign and return this agreement within 15 calendar
days from the date of this letter to facilitate prompt claims processing.
All SNFs must sign and return this agreement if they wish to have
TRICARE pay for the care of TRICARE beneficiaries. Claims for non-authorized SNFs
will be denied.
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There
are four other changes for TRICARE SNF providers. First, SNFs must
use 21X bill type and Revenue Code 022 on all TRICARE SNF PPS claims.
Second, a Health Insurance Prospective Payment System (HIPPS) code
must also be put on the PPS claim. This is a five digit code. The
first three digits are an alpha/numeric code identifying the RUG
III classification. The last two digits are the indicators of the reason
for the MDS assessment. Up to 100 days, SNFs will use the same HIPPS
codes for TRICARE patients as used under Medicare. After the 100th
SNF day, for TRICARE patients, SNFs will use an appropriate three
digit RUG-III code with a TRICARE-specific two digit modifier that
makes up the HIPPS code. The TRICARE-specific two digit modifiers
are as follows:
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120-day
assessment
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8A
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150-day
assessment
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8B
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180-day
assessment
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8C
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210-day
assessment
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8D
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240-day
assessment
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8E
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270-day
assessment
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8F
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300-day
assessment
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8G
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330-day
assessment
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8H
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360-day
assessment
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8I
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Post
360-day assessments with 30-day interval
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8X
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Third,
under SNF PPS, all SNF claims (21X bill type) must contain a line
item listing (by revenue code) of all services rendered to the SNF
inpatient resident during the dates of service on the claim. As under
Medicare, SNFs are responsible for making payment to those contractors
who have provided services to their TRICARE beneficiaries. The SNF
must pay for any service provided to a TRICARE beneficiary by an
outside supplier unless that service is excluded from consolidated
billing by statue.
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Fourth,
under SNF PPS, SNFs will continue to be responsible for performing
the resident assessment every 30 days after the 90th day using the
MDS assessment form, for determining the medical necessity of services,
for contracting with outside suppliers, for managing Certificates
of Medical Necessity (CMN) from suppliers, and for making appropriate
payment to contractors for services rendered to SNF patients. The
‘Significant Change in Status Assessments’ or ‘Significant Correction
of Prior Assessments’ as applied under Medicare will also apply
to these assessments under TRICARE. The SNFs shall use the default
HIPPS rate code on the claim in case of an off-schedule or late
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TRICARE.
The SNFs shall use the default HIPPS rate code on the claim in case
of an off-schedule or late patient assessment. SNFs will provide
notices to TRICARE beneficiaries in the same manner as they provide
under Medicare.
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The
SNF benefit and PPS provisions will also apply to those TRICARE
beneficiaries who are not Medicare-eligible.
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If
you have any questions, please contact ______________, telephone
number __________.
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Name
Title
Contractor
Name
Address
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Enclosure:
SNF Participation Agreement
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