Claims Processing Procedures
Chapter 8
Section 5
TRICARE
Prime And TRICARE Select Referrals/Preauthorizations/Authorizations
Revision:
1.0 REFERRALS
The contractor shall ensure
that TRICARE network providers hold beneficiaries harmless “held
harmless” (i.e., considered not financially responsible for any
charges) in cases where the network provider fails to request a referral
and the contractor either denies payment or applies the Prime Point
of Service (POS) option.
2.0 The contractor shall maintain
an automated authorization file or an automated system of flagging
to ensure claims are processed consistent with authorizations.
Note: The Unique Identifier Number
(UIN) is specific to the Composite Health Care System (CHCS)/Armed Forces
Health Longitudinal Technology Application (AHLTA) which is the
legacy Military Health System (MHS) Electronic Health Record (EHR)
and the legacy Referral Management Suite (RMS). As the MHS phases
out legacy CHCS/AHLTA and legacy RMS and moves to MHS Genesis as
the new EHR, the UIN will no longer be used. MHS Genesis produces
the “Referral ID” thus the UIN and Referral ID may be used interchangeably
in this Section.
2.1 TRICARE
Prime enrollees receiving emergency care or authorized care from
non-network, non- participating providers shall be responsible for
only the Prime copayment.
2.1.1 The
contractor shall allow the amount the provider may collect under
TRICARE rules; i.e., if the charges on a claim are subject to the
balance billing limit (refer to the TRICARE Reimbursement Manual
(TRM),
Chapter 3, Section 1 for information on balance
billing limit), the contractor shall allow the lesser of the billed
charges or the balance billing limit (115% of allowable charge).
2.1.2 The
contractor shall, if the charges on a claim are exempt from the
balance billing limit, allow the billed charges. Refer to the TRM,
Chapter 2, Section 1 for information on claims
for certain ancillary services.
2.2 The
contractor shall implement National Provider Identifier (NPI) checks
or other business processes to ensure that authorizations are not
issued to Market/Military Medical Treatment Facility (MTF) providers
who are also providing services in private sector care.
3.0 FAILURE
TO COMPLY WITH PREAUTHORIZATION - PAYMENT REDUCTION
The contractor shall reduce
provider payments for failure to comply with the preauthorization
requirements for certain types of care. See the TRM,
Chapter 1, Section 28, for more information.
4.0 PSYCHIATRIC RESIDENTIAL TREATMENT
CENTERS (RTC
s)
4.1 The
contractor shall, if a claim for admission or extension to an RTC
is submitted and no authorization form is on file, deny the claim.
4.1.1 The contractor may, for network
claims, deny or develop in accordance with its agreements with network
providers.
4.1.2 The
contractor shall deny non-network claims.
4.2 The contractor shall, for any
claims submitted for inpatient care at other than the RTC, pay the
claim if the care was medically necessary.
4.2.1 The
contractor shall, for RTC care during the period of time the beneficiary
was receiving care from another inpatient facility, deny the claims.
4.2.2 The contractor shall, if the
RTC has been paid and a claim for inpatient hospital care is received
and the care was medically necessary, pay the inpatient hospital
claim and recover the payment from the RTC.
5.0 GRANDFATHERED CUSTODIAL CARE
CASES
5.1 A
list of the beneficiaries who qualified for custodial care benefits
prior to June 1, 1977 will be furnished to the contractor with instructions
to flag the file for those beneficiaries on the list who are within
its geographic area of responsibility. See
Section 2 for
transition-in requirements.
5.2 The
contractor shall suspend claims for which no authorization is on
file notify the appropriate Government Designated Authority (GDA).
Refer to
32 CFR 199.4.
6.0 REFERRAL AND AUTHORIZATION
PROCESS
The
contractor shall process referrals (from the Market/MTF to the contractor)
in accordance with the following:
6.1 The
contractor shall create a claims system that utilizes the UIN, at
a minimum, to match claims with referral authorizations.
6.2 The contractor shall modify
generated Market/MTF reports to accommodate the UIN and NPI.
6.3 The contractor shall provide
the Market/MTF a monthly adjudicated referral claim report which
shall include the UIN against each claim. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), in Section
J of the applicable contract.
6.4 The
contractor shall provide the same services and information required
above to the TRICARE Overseas Program (TOP) contractor if the patient
is enrolled overseas.
6.4.1 The
contractor shall forward the authorization information to the TOP
contractor to ensure appropriate adjudication of the claim.
6.4.2 The contractor or TOP contractor
shall process claims according to
Section 2.
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