1.0 Purpose
The purpose of the Pilot is to meet requirements
set forth in the National Defense Authorization Act (NDAA) for Fiscal
Year (FY) 2016, Section 725 and to determine if the elimination
of the requirement to obtain a referral or preauthorization for
urgent care visits improves access to urgent care, helps enrollees
to choose the most appropriate source for the health care they need
(such as a TRICARE-authorized Urgent Care Center (UCC) rather than
the Emergency Room (ER)), potentially lowers health care costs for
the Department of Defense (DoD) and/or improves patient satisfaction.
2.0 Background
2.1 Access
to primary health care for acute episodic primary care continues
to be in high demand by TRICARE Prime enrollees. The TRICARE manual
guidance and the process by which Prime enrollees currently access
primary health care is defined under the
32 CFR 199.17 and the TRICARE Policy Manual (TPM),
Chapter 1, Section 7.1. Historically, the
Defense Health Agency (DHA) has required that Prime enrollees obtain
a referral for primary or urgent care if they seek that care from
someone other than their Primary Care Manager (PCM). As a result,
when an enrollee needs urgent care after hours or when the PCM in
the Military Treatment Facility (MTF)/Enhanced Multi-Service Market
(eMSM) does not have available appointments, they have been seeking
care from civilian sources such as the ER or with a UCC, including
Convenience Clinics (CCs).
2.2 In an effort to avoid overuse
of ER care and meet the demand for acute primary care, many facilities
have expanded acute care hours within the MTFs/eMSMs or worked with
the contractors to utilize provider groups or UCCs in their network.
However, these visits outside the MTF/eMSM require an authorization.
Seeking emergency care in an ER does not require authorization.
Additionally, the cost of care in a civilian ER for non-emergent
reasons is higher than any other source of care.
3.0 Policy
and Eligibility
3.1 Under the Pilot, Service members who are enrolled
in TRICARE Prime Remote (TPR), Active Duty Family Members (ADFMs)
who are enrolled in TRICARE Prime, TRICARE Young Adult (TYA) Prime,
or TRICARE Prime Remote for Active Duty Family Members (TPRADFM),
retirees and their family members who are enrolled in Prime or TYA
Prime within the 50 United States or the District of Columbia and TRICARE
Overseas Program (TOP) enrollees traveling/seeking stateside care
will be allowed to self-refer, without an authorization, to a TRICARE
network provider or TRICARE-authorized UCC provider, for urgent
care. All the aforementioned categories, except overseas, will be
allowed two unauthorized urgent care visits per FY, per individual,
including services provided when the enrollee is out of their enrollment
area. Overseas enrollees seeking stateside urgent care will not
be held to the two visit cap. For the allowed unmanaged visits,
no referral from their PCM or authorization by a Health Care Finder (HCF)
will be required and no Point of Service (POS) deductibles and cost
shares shall apply. Referral requirements for specialty care and
inpatient authorizations shall remain as currently required by
Chapter 8, Section 5.
3.2 Enrollees
are encouraged to notify their PCM of any urgent/acute care visits
outside the PCM within 24 hours of the visit or the first business
day following the visit and to schedule follow-up treatment, if
indicated, with their PCM. The contractor shall provide beneficiary
and provider information on this process, to include information
on how to schedule follow-up appointments, and how to coordinate
care.
3.3 If more than the two visits allowed under this
Pilot are used or if the enrollee seeks care from a non-network
provider (except a TRICARE-authorized UCC), the usual POS deductible
and cost-shares shall apply. The usual POS exceptions are still
applicable and include:
• Emergency care;
• Service members (in
accordance with
Chapters 16 and
17);
• Newborns and adopted
children during the first 60 days (120 days, if overseas) after
birth or adoption;
• TRICARE
Prime clinical preventive services received from a network provider
(in accordance with TPM,
Chapter 7, Section 2.2);
• TRICARE Prime enrollees
who obtain outpatient mental health care from a network provider
without a referral from their PCM (in accordance with TPM,
Chapter 7, Section 3.8); and
• Enrollees with Other
Health Insurance (OHI).
3.4 The Pilot
shall encourage and incentivize the use of the Nurse Advise Line
(NAL) to direct enrollees to the source of the most appropriate
level of health care required to treat the medical conditions of
the enrollee. The NAL will provide advice to all enrollees and will
facilitate referrals for Direct Care (DC) enrollees who receive
an urgent care recommendation. For incentive purposes, urgent care
accessed via a NAL recommendation that leads to a PCM referral shall
not be counted against the allowable self-referred visits provided
under the Pilot.
4.0 General
Description of Administrative Process
4.1 Referral (authorization) requirements
for up to two urgent care visits per FY, per individual, shall be
waived for Service members who are enrolled in TPR, ADFMs who are
enrolled in TRICARE Prime, TPRADFM, or TYA Prime and retirees and
their family members who are enrolled in Prime within the 50 United
States or the District of Columbia. Referral (authorization) requirements
are also waived for an uncapped number of visits for TOP enrollees
traveling/seeking care in the Continental United States (CONUS)
when services are rendered by a TRICARE network provider or TRICARE-authorized
UCC. Providers must have one of the following primary specialty
designations:
• Family Practice;
• Internal Medicine;
General Practice;
• Pediatrician; and
• UCC or Convenience
Clinic (CC).
Note: In accordance with TPM,
Chapter 1, Section 7.1, Obstetricians/Gynecologists
(OB/GYNs), Physician Assistants (PAs), Nurse Practitioners (NPs),
and Certified Nurse Midwives (CNMs) can be considered Primary Care
Providers (PCPs) and may also be designated PCMs.
4.2 All claims
shall be vouchered and paid as prescribed by existing policy for
both underwritten and non-underwritten care. The unauthorized urgent
care visits permitted under this pilot shall be considered “authorized
care” for purposes of
Chapter 8, Section 5, paragraph 2.6.
5.0 Policy
Considerations
The inclusion of Service member
in TPR does not limit/change their overall TPR benefit (as specified
in
Chapter 16).
6.0 Contractor
Responsibilities
6.1 The contractors shall verify the TRICARE eligibility
of the patient on the Defense Enrollment Eligibility Reporting System
(DEERS).
6.2 The contractors shall search for any submitted
urgent care referral and when an urgent care referral is identified
the contractor shall not count the urgent care visit against the
allowable self-referred visits provided under the Pilot.
6.3 The contractors
shall develop a process to track the number of unmanaged urgent
care visits used per enrollee/per FY. This process shall incorporate
a means to share that number with other contractors when enrollment
transfers occur.
6.4 DHA Communications will provide
all educational materials regarding the pilot to contractors. The
educational materials will encourage enrollees seeking access to
care to use the MTF/eMSM first and to use the NAL to guide them
to the source of the most appropriate level of healthcare required
to treat their medical condition.
6.5 The contractors shall ensure
that pilot information is made available on their primary Internet web
sites.
6.6 TRICARE Encounter Data (TED) Record Special
Processing Code (SPC) “UC-Urgent Care Pilot” shall be coded on all
TED records where one of the two self-referred authorizations allowed
under this Pilot is used. If the TED SPC is implemented in the contractor’s
system after May 23, 2016, the contractor shall search for previously
processed Urgent Care Pilot TED records and adjust those records
to show SPC UC.
7.0 Applicability
This Pilot is limited to Service members who
are enrolled in TPR; and ADFMs who are enrolled in TRICARE Prime;
TYA Prime; or TPRADFM; retirees and their family members who are
enrolled in Prime or TYA Prime within the 50 United States or the
District of Columbia; and TOP enrollees traveling/seeking stateside
care.
8.0 Exclusions
This Pilot does not apply to referral requirements
for specialty care and inpatient authorizations as currently required
by
Chapter 8, Section 5. This Pilot excludes
TOP Prime enrollees unless they are traveling stateside. This pilot
excludes Uniformed Services Family Health Plan (USFHP) enrollees.
9.0 Effective
date
s9.1 Per requirements
set forth in the NDAA FY 2016, Section
725, the Secretary is required to carry out the Pilot Program for
a period of three years. Implementation is to commence no later
than 180 days after the date of the enactment of the Act, and hence
the Pilot will begin May 23, 2016, and will continue until May 23,
2019.
9.2 The
NDAA FY 2017, Section 704, authorized the Director, DHA to establish
the TRICARE Prime referral requirement for urgent care visits for
TRICARE Prime enrollees other than Active Duty Service Members (ADSMs)
enrolled to an MTF/eMSM. TRICARE policy (Chapter 8, Section 5) was changed
to allow unlimited self-referred urgent care visits for all TRICARE
Prime enrollees (other than most ADSMs enrolled to an MTF/eMSM)
with an effective date of January 1, 2018. No POS deductibles and
cost shares shall apply when urgent care is provided by a TRICARE
network provider or a TRICARE-authorized (network or non-network)
UCC or CC. If the enrollee seeks care from a non-network provider (except
a TRICARE-authorized UCC or CC), the usual POS deductible and cost-shares
shall apply. The aforementioned policy change effectively made this
pilot obsolete with an end date of December 31, 2017.