1.0 POLICY
1.1 Except
as provided in
paragraph 1.2, the contractor will provide
the required authorization for requested services and items under
the Extended Care Health Option (ECHO).
1.2 In
the case of beneficiaries residing outside the 50 United States
(U.S.) and the District of Columbia, the TRICARE Overseas Program
(TOP) contractor is responsible for authorizing ECHO benefits. The
TOP contractor shall notify the appropriate TRICARE Area Office
(TAO) Director of all ECHO benefit authorizations or authorization
waivers.
1.3 The
authorization is based upon the following:
1.3.1 The beneficiary is registered in the ECHO;
and
1.3.2 The
requested service or item is allowable as a ECHO benefit; and
1.3.3 The requested
service or item meets the public facility use requirements when
applicable.
1.4 The authorization shall specify
the services by type, scope, frequency, duration, dates, amounts, requirements,
limitations, provider name and address, and all other information
necessary to provide exact identification of approved benefits.
Claims can not be adjudicated without this information.
1.5 The authorization
shall remain in effect until such time as the contractor or TOP
contractor determines that:
1.5.1 The beneficiary is no longer eligible for
the ECHO; or
1.5.2 The
authorized ECHO service or item is no longer appropriate or required
by the beneficiary; or
1.5.3 The authorized ECHO service or item becomes
a benefit through the TRICARE Basic Program.
1.6 The contractor
or TOP contractor may waive the required written authorization for
rendered services and items that, except for the absence of the
written authorization, would be allowable as an ECHO benefit.
1.7 The contractor
or TOP contractor may waive the required public facility use certification
when such waiver is appropriate. See
Section 5.1.