2.0 POLICY
2.1 The
contractor may cost-share otherwise covered medically necessary
services and supplies rendered in emergency situations by an unauthorized
provider. Medically necessary inpatient emergency service are those
that are necessary to prevent the death or serious impairment of
the health of the patient, and that because of the threat to the
life or health of the patient, necessitate the use of the most accessible
hospital available that is equipped to furnish the services. In
the case of inpatient psychiatric emergencies, payment will be extended
when the patient is determined to be at immediate risk of serious
harm to self or others as a result of a mental disorder and requires
immediate continuous skilled observation at the acute level of care.
2.2 When a
case qualifies as an emergency at the time of admission to an unauthorized institutional
provider and the provider notifies the contractor of the admission,
payment can be extended for medically necessary and appropriate
care until a transfer is medically feasible (i.e., coverage will
be extended up to the point of discharge or until a medically appropriate
and legally authorized transfer can be initiated). The timing of
the transfer will be based on the availability of authorized facility
beds.
2.3 Conditions for reimbursement of emergency
inpatient admissions to unauthorized facilities.
2.3.1 At the time of admission to an unauthorized
institutional provider, the beneficiary’s condition must meet the
definition of medical or psychiatric emergency as prescribed in
32 CFR 199.2.
2.3.2 The contractor must be notified as soon
as possible after the emergency admission (preferably within 24
hours) so that arrangements can be made to transfer the beneficiary
once the emergency no longer exists, or until such time as a medically
appropriate and/or legally authorized transfer can be initiated.
2.3.3 The provider
must submit the necessary medical records and other documentation required
in the processing and payment of emergency inpatient admissions.
These records are essential in substantiating that an emergency
condition did exist at the time of the admission and that care provided
to the beneficiary after the emergency no longer existed, but before
a medically appropriate transfer could be initiated, was medically
necessary. Refusal to submit the appropriate medical documentation
will result in the denial of payment for the entire stay in the
facility, including the emergency portion of the patient’s care.
2.3.4 A determination
must also be made that treatment was received at the most accessible (closest)
hospital available that was equipped to furnish the medically necessary
care.
2.4 Reimbursement guidelines for emergency
inpatient admissions to unauthorized facilities.
2.4.1 Billed charges will be paid for all
medically necessary care up until such time as an appropriate and/or
legally authorized transfer can be initiated by the contractor.
Payment will only be made if there was a true medical/psychiatric
emergency as defined in
32 CFR 199.2,
at the time of admission and only for that care extending beyond
stabilization of the patient (care extending beyond the emergency
treatment of the patient), as long as it was deemed medically necessary
and appropriate.
2.4.2 The copayment/cost-share for an inpatient
emergency admission to an unauthorized facility is dependent on
the eligibility and enrollment status of the beneficiary at the
time the services are rendered. Refer to
Chapter 2, Section 1,
for inpatient beneficiary copayments/cost-shares.
2.4.3 Conditions
for direct payment to an unauthorized facility.
2.4.3.1 The signature-on-file
procedure may be used as a means of ensuring patient confidentiality,
while at the same time allowing direct payment to the facility.
This procedure involves incorporating the following language into
the permanent records of TRICARE beneficiaries for whom the facility
is seeking payment under emergency provision
32 CFR 199.6(a)(2).
“I request payment of authorized benefits
to me or on my behalf for any services furnished me by (Name
of Provider), including physician services. I authorize any
holder of medical or other information about me to release that information
in accordance with the provisions of The Alcohol, Drug Abuse and Mental
Health Administration Reorganization Act, Public Law 102-321 and Privacy
Act of 1974.”
2.4.3.2 Professional
providers who submit claims on the basis of an institution’s signature
on file should include the name of the institutional provider that
maintains the signature on file. The Centers for Medicare and Medicaid
Services (CMS) 1450 UB-04 instructions shall be followed for certifying signature
on file, except that the permanent hospital record containing a
release statement will be recognized. The unauthorized facility
will be responsible for ensuring that the beneficiary’s signature
is on file, attesting to the above language as soon as possible
after the emergency crisis has passed (i.e., after patient stabilization).
2.4.4 If the signature-on-file
procedure is not utilized by the unauthorized provider, payment must
be made directly to the beneficiary.