|
Date _______________
|
|
|
|
Administrator
SNF
Name
Address
|
|
|
|
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:
|
|
|
|
|
|
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.
|
|
|
|
|
|
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, Patient Driven Payment
Model (PDPM) 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 (VA)/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.
|
|
|
|
|
|
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
|
|
|
|
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.
|
|
|
|
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
four digits are an alpha/numeric code identifying the PDPM classification.
The last digit is the Assessment Indicator (AI) of the reason for
the MDS assessment which is assigned per Medicare Policy.
|
|
|
|
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.
|
|
|
|
Fourth,
under SNF PPS, SNFs will continue to be responsible for performing
the resident assessment if there is a change of clinical status
past the initial five-day assessment, 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 of ZZZZZ 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.
|
|
The SNF
benefit and PPS provisions will also apply to those TRICARE beneficiaries
who are not Medicare-eligible.
|
|
|
|
If you have
any questions, please contact ______________, telephone number __________.
|
|
|
|
|
Name
Title
Contractor
Name
Address
|
|
|
|
Enclosure:
SNF
Participation Agreement
|