2.5 Requirements for continued payment
of ICMP-PEC authorized services:
2.5.1 Eligibility. The beneficiary must be TRICARE
eligible.
2.5.2 Authorized
Beneficiaries. Only those beneficiaries authorized services under
the ICMP-PEC upon its termination on December 28, 2001, are eligible
for continued coverage.
2.5.3 Authorized Services. Only those services
authorized under the ICMP-PEC upon its termination on December 28,
2001, are eligible for continued coverage.
2.5.4 Custodial Care. Beneficiaries must
continue to meet the TRICARE definition of custodial care in effect
prior to December 28, 2001, that is, custodial care is care rendered
to a patient who:
• Is disabled
mentally or physically and such disability is expected to continue
and be prolonged; and
• Requires a protected, monitored, or controlled
environment whether in an institution or in the home; and
• Requires assistance to support the essentials
of daily living; and
• Is not under active and specific medical,
surgical, or psychiatric treatment that will reduce the disability
to the extent necessary to enable the patient to function outside the
protected, monitored, or controlled environment.
2.5.5 Beneficiaries
covered under
paragraphs 2.1 or
2.2 must have a primary
caregiver in the home.
2.5.6 Reassessment. Continuation of receipt
of services requires reassessment on a regular basis. The contractors
will provide supporting clinical documentation of all authorized
participant’s medically necessary skilled needs, to include a plan
of care signed by the attending physician. Each letter of authorization
for continued coverage issued by the DHA Clinical Operations, Chief
Medical Officer, or designee, will include a statement regarding
the frequency of a periodic reassessment of the beneficiary. Generally,
periodic reassessment will occur annually, but will be based on
the needs of the beneficiary. Contractors shall provide a complete
clinical documentation update and recommendation for continuation
of coverage at the same level or indicate if either an increase
or decrease in services is indicated by the beneficiary’s current
needs. DHA will provide a courtesy reminder when a periodic reassessment
is due for a beneficiary. Once DHA reviews the reassessment and
updated recommendations of the contractor, a revised or updated
authorization letter will be issued to the contractor.
2.5.7 Revisions.
If at any time a contractor determines a need for a change in authorized
funding for a beneficiary (e.g., due to a change in CMAC rates,
a change in patient condition, such as a need for more or fewer
covered hours, change in HHA, etc.), then the contractor must submit
a written request for such change to the DHA Clinical Operations,
Chief Medical Officer, or designee, that includes a detailed explanation
of why the change is required. The DHA Clinical Operations, Chief
Medical Officer, or designee, will evaluate each request and provide
a written decision to the contractor.
2.5.8 Cost-shares. Cost-shares shall not
be applied to services authorized under the ICMP-PEC prior to December
28, 2001 nor to those services provided under this policy. Cost-shares
will continue to apply to all other TRICARE benefits.
2.5.9 Appeals.
Appeals should be made directly to the DHA Office of General Counsel
(OGC). There are three appealable issues related to the ICMP-PEC:
2.5.9.1 A custodial
care determination;
2.5.9.2 A determination
by the contractor that ICMP-PEC does not apply;
2.5.9.3 The types
and extent of services authorized for a beneficiary by DHA. The
following language is to be included in subsequent determination
of custodial care letters and notification of benefits related to
ICMP-PEC:
“Should you disagree with this initial
determination, you have the right to appeal and request a formal
review. Appealable issues include the types and extent of the services
and supplies authorized under the ICMP-PEC and the determination
that the care is custodial. The request must be in writing, be signed,
and must be postmarked or received by DHA OGC, within 90 days from the
date of this determination. For the purposes of TRICARE, a postmark
is a cancellation mark issued by the United States Postal Service.
Additional documentation in support
of the appeal may be submitted. However, because a request for a
formal review must be received within 90 days of the date of the
initial determination, a request for formal review should not be
delayed pending the acquisition of any additional documentation.
If additional documentation is to be submitted at a later date,
the letter requesting the formal review must include a statement
that additional documentation will be submitted and the expected
date of the submission.”
2.5.10 Claims Processing.
Contractors are to use the special processing code “CM” in addition
to the appropriate branch of service code for all claims for care
and services authorized under this policy. Contractors are to use
the special processing code “E” in addition to the special processing
code “CM” for claims for services authorized for those beneficiaries
indicated in
paragraph 2.3 Claims for services not provided
in accordance with
paragraphs 2.1,
2.2, or
2.3 (i.e.,
acute outpatient and inpatient care and services, including Durable
Medical Equipment (DME)) must be processed in accordance with the
TOM, the TRICARE Reimbursement Manual (TRM), and the TRICARE Systems
Manual (TSM), and without the use of the special processing codes
“E” and “CM”.
2.5.11 Contractors
shall notify the DHA Clinical Operations, Chief Medical Officer,
or designee upon any of the following changes to any beneficiary
who is covered by
paragraphs 2.1,
2.2, or
2.3.
• Death;
• Eligibility status, including becoming
a Transitional Survivor or a Survivor as those terms are used in
Chapter 10, Section 7.1;
• Residential relocation (pending or completed);
• Custodial care status;
• Inpatient admission;
• Requests for disengagement.