6.1 The
contractor and the TQMC contractor shall inform the appealing party
(or the representative, if a representative has been appointed)
of the reconsideration determination in plain writing in accordance
with the timeliness standards set forth in
Chapter 1, Section 3.
6.1.1 The
reconsideration determination shall be typewritten or computer-printed
in its entirety. At the request of the appealing party, a reconsideration
determination may be sent by facsimile or by email, followed by mailing
a hardcopy. All claims that relate to the same incident of care,
or the same type of service to the beneficiary shall be addressed
in a single reconsideration determination.
6.1.2 The
contractor shall provide a copy for the reconsideration determination
to the beneficiary in accordance with the timeliness standards set
forth in
Chapter 1, Section 3 if the appealing party
is a non-network participating provider. Conversely, the non-network
participating providers shall be furnished copies of the determination
if the beneficiary filed the appeal.
6.1.3 The
notice shall include a caption identifying:
• The beneficiary (including
what plan the beneficiary is covered under);
• The sponsor;
• The last four digits of sponsor’s
Social Security Number (SSN);
• The type of care (e.g., Residential
Treatment Center (RTC) care, outpatient psychotherapy, mammography, substance
abuse, dental);
• The date(s) of service, the
date(s) of service in dispute;
• Whether the appeal was processed
as a preauthorization, concurrent review, or retrospective review;
• The providers (identifying
each provider as network or non-network participating, or non-network nonparticipating).
6.2 The
notice shall include the following headings:
6.2.1 Statement
Of Issues
The
contractor and the TQMC contractor shall summarize the issue or
issues under appeal and shall be clear and concise. All issues shall
be addressed; for example, a reconsideration determination in all
cases requiring preadmission authorization shall address the requirement
for preadmission authorization of the care as well as whether the
requirement was met.
6.2.2 Applicable Authority
6.2.2.1 The contractor and the TQMC
contractor shall briefly discuss the relevant provisions of law, regulation,
TRICARE policy, or TRICARE guidelines on which the determination
was made. Include pertinent specific citations and quotations of
applicable text.
6.2.2.2 The
contractor shall omit authority that is not applicable to the case
under review (e.g., when citing cosmetic surgery policy, the contractor
need not include a listing of all procedures considered by TRICARE
to constitute cosmetic surgery, but should quote only the procedure(s)
applicable to the case under review).
6.2.3 Discussion
6.2.3.1 The contractor and the TQMC
contractor shall address the original and any added information relevant
to the issue(s) under appeal, clearly and concisely, and shall state
the patient’s condition, including symptoms. One or two paragraphs
will suffice unless the issues are complex.
6.2.3.2 The contractor and the TQMC
contractor shall include a discussion of any secondary issues raised
by the appealing party or which may have been discovered during
the reconsideration process.
6.2.4 Decision
6.2.4.1 The contractor and the TQMC
contractor shall state the decision and whether the reconsideration upholds
or reverses the original decision in whole or in part, and clearly
and concisely state the rationale for the decision (i.e., fully
state the reasons that were the basis for the approval or denial
of TRICARE benefits). If specific TRICARE benefit criteria must
be met, the patient’s medical condition must be related to each
criterion and a finding made concerning whether each criterion is
met.
6.2.4.2 The
contractor and the TQMC contractor shall state the amount in dispute
remaining as a result of the decision and how the amount in dispute
was determined (calculated), and also state whether payments are
to be recouped.
6.2.5 Waiver Of Liability
6.2.5.1 The contractor and the TQMC
contractor shall include a statement explaining waiver of liability determination
as applied to the beneficiary and to each provider, including the
rationale for each decision.
6.2.5.2 Waiver of Liability provisions
are only applicable to denials as described in Section
4 for applicable cases.
6.2.5.3 A beneficiary found not to
be liable for the entire EOC will not be offered further appeal
rights. Refer to the TPM, Chapter 1, Section 4.1 for
information relating to waiver of liability.
6.2.6 Hold
Harmless
6.2.6.1 The contractor and the TQMC
contractor shall include, in applicable cases, a statement explaining hold
harmless, including how the provision is waived, the beneficiary’s
right to a refund, the method by which a beneficiary can request
a refund, and must provide information regarding from what entity
a refund can be requested (see Chapter 5, Section 1).
Hold harmless provisions are applied only to care provided by a
network provider.
6.2.6.2 Suggested wording for inclusion
in a reconsideration determination when the provider is a network provider
is provided at Addendum A, Figure 12.A-11.
6.2.7 Point
Of Service (POS)
6.2.7.1 The
contractor and the TQMC contractor shall provide beneficiaries who
enroll in TRICARE Prime full and fair disclosure of any restrictions
on freedom of choice that may be applicable to beneficiaries, including
the POS option.
6.2.7.1.1 The
contractor and the TQMC contractor shall explain the right of the
beneficiary to exercise the POS option and its effect on the payment
of benefits for services determined to be medically necessary (additional information
about the POS option can be found in the TRM, Chapter
2, Section 3).
6.2.7.1.2 The POS option is available
to TRICARE Prime beneficiaries who seek or receive non-emergency specialty
or inpatient care, either within or outside the network which is
neither provided by the beneficiary’s PCM nor referred by the PCM,
nor authorized by the contractor.
6.2.7.2 The contractor and the TQMC
contractor shall include the following language in a reconsideration determination
where the beneficiary is TRICARE Prime:
“Should you, as a TRICARE Prime
beneficiary, elect to proceed with this service and the service
is provided by a non-network provider, and provided the service
is found upon appeal to have been medically necessary, benefits
will be payable under the deductible and cost-share amounts for Point-of-Service
claims and your out-of-pocket expenses will be higher than they
would be had you received the service from a network provider. No
more than 50% of the allowable charge can be paid by the Government
for care provided under the Point-of-Service option.”
6.2.8 Appeal
Rights
The
contractor and the TQMC contractor shall state whether further appeal
rights are available if the determination is denied in whole or
in part.
6.2.8.1 Contractor Medical Necessity
Reconsideration Determinations
The contractor shall include
a statement explaining the right of the beneficiary (or representative)
and the non-network participating provider to request an appeal
to the TQMC contractor for a second reconsideration if the contractor
reconsideration determination is denied in whole or in part, and
$50 or more remains in dispute. The contractor statement shall include
the time frames to file an appeal of the contractor reconsideration determination
are as follows:
6.2.8.2 Expedited Preadmission or Pre-procedure
Reconsiderations
6.2.8.2.1 The
contractor shall notify the beneficiary to file the appeal request
with the TQMC contractor within three calendar days after the date
of receipt of the initial reconsideration determination.
6.2.8.2.2 The date of receipt of the
appeal request by the TQMC contractor will be considered to be five calendar
days after the date of mailing, unless the receipt date is documented.
6.2.8.2.3 A request for reconsideration
filed with the TQMC contractor by the beneficiary more than three calendar
days after the date of receipt but within 90 calendar days from
the date of the initial reconsideration determination will be addressed
as a non-expedited reconsideration.
6.2.8.3 Non-expedited
Reconsiderations
The
contractor shall notify the beneficiary or non-network participating
provider to file the appeal request with the TQMC contractor within
90 calendar days after the date of the initial reconsideration determination.
Note: Refer to Section
4 for the appeal process in concurrent review cases.
6.2.8.4 Factual
Reconsideration Determination Based on Statute or Regulation
6.2.8.4.1 If the reconsideration determination
upholds the denial based on a statutory or regulatory exclusion,
further appeal shall not be offered to challenge the statutory or
regulatory exclusion. Further appeal is available, however, to challenge
whether the exclusion was appropriately applied.
6.2.8.4.2 The contractor shall include
the following language for the appeal rights section of reconsideration determinations
upholding denials based on statutory or regulatory exclusions:
“An administrative reconsideration
review is available under the TRICARE appeal process when a denial
is based on a requirement of law or regulation. However, because
disputes challenging a requirement of law or regulation do not present
an appealable issue, they are ineligible for appeal to a formal
review or hearing. Since the disputed care in this case is excluded
by law or regulation, further appeal is not authorized. This reconsideration
determination completes the administrative appeal process under 32
CFR 199.10, and no further administrative appeal is
available.
Although disputes challenging
a requirement of law or regulation are not appealable to a formal review
or hearing, further appeal to a formal review or hearing is available
to dispute whether the law or regulation was properly applied if
other requirements are satisfied, such as the requisite amount in
dispute. For example, services and supplies related to treating
obesity are excluded by law and regulation when obesity is the only
or the major condition being treated. If a service or supply was
provided to treat hypertension, but the obesity exclusion was erroneously
applied, an appeal may be filed to challenge the erroneous application
of the obesity exclusion. As a further example, if law or regulation
excludes durable medical equipment, but the actual service provided was
for a prosthetic device, an appeal may be filed on the grounds that
the durable medical equipment exclusion was incorrectly applied
to the prosthetic device coverage determination.”
6.2.8.5 Reconsideration
Determinations Issued By The TQMC Contractor
6.2.8.5.1 The TQMC contractor shall include
a statement explaining the right of the beneficiary (or representative)
and the non-network participating provider to file a request for
hearing with DHA, if the reconsideration determination issued by
the TQMC contractor is denied in whole or in part and $300 or more remains
in dispute.
6.2.8.5.2 A request for hearing must
be postmarked or received by DHA within 60 calendar days from the date
of the notice on the reconsideration determination issued by the
TQMC contractor. Refer to
paragraph 7.2 regarding hearings in preadmission
or pre-procedure cases in which the requested service(s) have not commenced.
6.2.8.6 When
the Amount Required to File an Appeal Remains in Dispute
Section 2 contains
the requirements for the amount in dispute.
6.2.8.6.1 Non-Expedited
Reconsideration Determination
Suggested wording for a non-expedited
reconsideration can be found at Addendum A, Figure 12.A-12.
6.2.8.6.2 Expedited
Preadmission or Preprocedure Reconsideration Determination (include
in addition to
Addendum A, Figure 12.A-12)
“The TRICARE beneficiary, or
the appointed representative of the beneficiary, has the alternative
of requesting an expedited reconsideration. The request must be
in writing, be signed and must be received by (insert the TQMC name,
postal address, email address, and fax number) within three business
days after the receipt of this denial determination, and must include
a copy of this denial determination. A request for an expedited
reconsideration filed after the three day appeal filing deadline
will be accepted as a non-expedited request for reconsideration.
It is recommended that any additional documentation you may wish
to submit be submitted with the request for expedited reconsideration.
Upon receiving your request, all TRICARE claims related to the entire
course of treatment will be reviewed.”
6.2.8.7 Amount
In Dispute Less Than The Amount Required To File An Appeal
The contractor or the TQMC
contractor shall notify the appealing party or representative that
the reconsideration determination is final and no further administrative
appeal is available for those cases in which the amount in dispute
is less than the amount required to file an appeal (refer to
Section
2 for required amount in dispute). The following is
suggested wording:
“Because the amount in dispute
is less than (insert required amount in dispute), this reconsideration
determination is final and there are no further appeal rights available.”