2.0 POLICY
In the case of a provider’s failure
to obtain a required preauthorization, the provider’s payment shall
be reduced by 10% of the amount otherwise allowable. Under the managed
care contracts, a network provider’s payment can be subject to a
greater than 10% reduction or a denial if the network provider has
agreed to such a reduction or denial in the agreement.
2.1 Types of
Care Subject to Payment Reduction
For a provider’s
failure to obtain a required preauthorization or preadmission authorization,
the provider’s payment will be reduced in connection with the following
types of care:
2.1.1 All
non-emergency mental health admissions to hospitals.
2.1.2 All admissions
for psychiatric residential treatment for children, and inpatient/residential Substance
Use Disorder (SUD) detoxification and rehabilitation, and psychiatric
partial hospitalization (Partial Hospitalization Program (PHP) care
prior to June 13, 2017). None of these can be considered emergency
care.
2.1.3 Psychoanalysis.
It cannot be considered as an emergency service.
2.1.4 Adjunctive dental
care.
2.1.5 Organ
and stem cell transplants.
2.1.6 Skilled Nursing Facility (SNF) care received
in the U.S. and U.S. territories for TRICARE dual eligible beneficiaries
once TRICARE is primary payer.
2.1.7 Infusion drug therapy delivered in the
home.
2.1.8 Additional
procedures and services as prescribed by the contractors except
when the beneficiary has “other insurance” as provided in the TRICARE
Policy Manual (TPM),
Chapter 1, Section 6.1, paragraph 1.12, Note.
2.2 Applicability
of Payment Reduction
This section shall apply to participating
(including network providers and participating Department of Veterans
Affairs (DVA)/Veterans Health Administration (VHA) facilities)
and nonparticipating providers. For a provider’s failure to obtain
the required preauthorization, the payment reduction shall be subject
to the policy in this section.
2.2.1 In the case of an admission to a
hospital, inpatient/residential Substance Use Disorder Rehabilitation
Facility (SUDRF), or Residential Treatment Center (RTC), or a PHP
(PHP care prior to June 13, 2017) (or a SNF) when applicable, for
network providers the payment reduction shall apply to the institutional
charges and any associated professional charges of the attending
or admitting provider. Services of other providers shall be subject
to the payment reduction as provided under the network provider
agreements, but not less than 10%.
2.2.2 The amount of the reduction for
non-network providers shall be 10% of the amount otherwise allowable
(consistent with
paragraphs 2.3,
2.4, and
2.5)
for services for which preauthorization should have been obtained,
but was not obtained.
2.2.3 The amount of the reduction for
network providers shall be in accordance with the provider’s contract
with the respective contractor, but not less than 10%.
2.2.4 The payment
reduction shall apply under the Point of Service (POS) option.
2.3
Diagnosis
Related Group (DRG) Reimbursed Facilities
In the
case of admissions reimbursed under the DRG-based payment system,
the reduction shall be taken against the percentage (between 0 and
100%) of the total reimbursement equal to the number of days of
care provided without preauthorization, divided by the total Length-Of-Stay
(LOS) for the admission. See the example in
Chapter 3, Section 4.
2.4
Non-DRG
Facilities/Units (Includes RTCs and Mental Health Per Diem Hospitals)
In the case of admissions to non-DRG
facilities/units, the reduction shall be taken only against the
days of care provided without preauthorization. See the example
in
Chapter 3, Section 4.
2.5
Care
Paid on Per-Service Basis
For the
care for which payment is on a per-service basis, e.g., outpatient
adjunctive dental care, the reduction shall be taken only against
the amount that relates to the services provided without prospective
authorization. See the example in
Chapter 3, Section 4.
2.6 Determination
of Days/Services Subject to Payment Reduction
For purposes
of determining the days/services which will be subject to the payment
reduction, the following shall apply:
2.6.1 When the request for authorization
is made prior to the admission but is not received by the contractor
until after the admission occurred, the days for payment reduction
shall be counted from the date of admission to the date of receipt
of the request by the contractor (not counting the date of receipt).
This includes alleged emergency care subsequently found not to meet
the emergency criteria.
2.6.2 When the request for authorization
is made to the contractor after the admission occurred, the days
for payment reduction shall be counted from the date of admission
to the date of approval of the request by the contractor (not counting
the date of approval).
2.6.3 For the care paid on a per-service
basis, e.g., outpatient adjunctive dental care, payment reduction
shall apply to those services/sessions provided prior to receipt
of the authorization request by the contractor.
2.7 Other Health
Insurance (OHI) and Beneficiary Cost-Share
2.7.1 When a beneficiary has OHI that
provides primary coverage, certain services shall not be subject
to payment reduction. See
paragraph 2.1.8.
2.7.2 The reduction of payment is calculated
based on the otherwise allowable amount (consistent with
paragraphs 2.3,
2.4,
and
2.5) before the application of deductible,
beneficiary cost-share, and OHI.
2.7.3 The beneficiary is still required
to pay a cost-share for the days or services for which the payment
is reduced. The beneficiary cost-share shall be calculated applying
the normal cost-share rules before the reduction is taken.
2.7.4 The amount applied/credited
toward the deductible cannot be greater than the amount for which
the beneficiary remains liable after the Government payment.
2.8 Preauthorization
Process
2.8.1 Preauthorization may be requested
from a contractor in person, by telephone, fax, or mail. The date
of receipt of a request shall be the date (business day) on which
a contractor receives the request to authorize the medical necessity
and appropriateness of care for which it has jurisdiction.
Note: The
date a preauthorization request is mailed to the contractor and
postmarked shall determine the date the request was made (not received).
If a request for preauthorization does not have a postmark, it shall
be deemed made on the date received by the contractor.
2.8.2 In general,
the decision regarding the preauthorization shall be issued by the
contractor within one business day of the receipt of a request from
the provider, and shall be followed with a written confirmation
(if initial notice is verbal).
2.8.3 A preauthorization is valid for
the period of time, appropriate to the type of care involved. It shall
state the number of days/type of care for which it is valid. In
general, preauthorizations will be valid for 30 days. If the services
are not obtained within the number of days specified, a new preauthorization
request is required. For organ and stem cell transplants the preauthorization
shall remain in effect as long as the beneficiary continues to meet
the specific transplant criteria set forth in the TPM, or until
the approved transplant occurs.
2.9 Patient Not Liable
The patient
(or the patient’s family) may not be billed for the amount of the
payment reduction due to the provider’s noncompliance with preauthorization
requirements.
2.10 Emergency Admissions/Services
2.10.1 Payment
reductions shall not be applied in connection with bona fide emergency admissions
or services. The authorization required for a continuation of services
in connection with bona fide emergency admission will not be subject
to payment reduction.
2.10.2 Contractor having
jurisdiction for the medical review of the admission is required
to review for emergency when requested by the provider. In addition
to the review of alleged emergency admissions, the contractor is
required to issue an initial determination providing the review
decision which is appealable.
Note: Psychoanalysis
and all admissions for psychiatric residential treatment for children
or inpatient/residential SUD detoxification and rehabilitation are
the types of services/admissions requiring preauthorization that
cannot be considered as emergencies.
2.11 Waiver of
Payment Reduction
2.11.1 The
contractor may waive the payment reduction only when a provider
could not have known that the patient was a TRICARE beneficiary,
e.g., when there is a retroactive eligibility determination by a
Uniformed Service, or when the patient does not disclose eligibility
to the provider.
2.11.2 The criteria
for determining when a provider could have been expected to know
of the preauthorization requirements shall be the same as applied
under the Waiver of Liability provisions.
2.11.3 If at any
time a payment reduction is revised after claims processing, claim
processors will follow existing procedures for processing any resulting
payment adjustments.
2.12 Appeal Rights
2.12.1 The days/services
for which the provider’s payment is reduced are approved days/services and
not subject to appeal.
2.12.2 The denial of
a waiver request and clerical/calculation errors in connection with
the payment reduction are not subject to appeal but are subject
to administrative review by the contractor upon request.
2.12.3 Adverse decisions
regarding alleged emergency admissions/services are appealable in cases
involving payment reductions following the normal appeal procedures.