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TRICARE Operations Manual 6010.59-M, April 1, 2015
Demonstrations And Pilot Projects (Except Value-Based Initiatives)
Chapter 18
Section 10
Referral And Appointing Center (RAC) Pilot
Revision:  C-81, December 29, 2020
1.0  BACKGROUND
Section 714 of the Fiscal Year (FY) 2019 National Defense Authorization Act (NDAA) requires a streamlined approach to referrals in TRICARE. Specifically, it requires that:
“(1) The referral process shall model best industry practices for referrals from primary care managers to specialty care providers;
(2) The process shall limit administrative requirements for enrolled beneficiaries;
(3) Beneficiary preferences for communications relating to appointment referrals using state-of-the-art information technology shall be used to expedite the process; and
(4) There shall be effective and efficient processes to determine the availability of appointments at military medical treatment facilities and, when unavailable, referrals to network providers under the TRICARE program.”
Consistent with this requirement, TRICARE is implementing a pilot to use appointing and referral centers to simplify the process of receiving referrals for care and making appointments.
2.0  DESCRIPTION AND OVERVIEW
The Government will create a referral and appointing center located at one pilot site to be detailed in the contract modification.
2.1  The RAC will serve as a “one number” center for all specialty care appointing for TRICARE Prime patients when the referral is generated by a provider at a Market/Military Treatment Facility (MTF) in the pilot Prime Service Area (PSA).
2.2   These requirements apply only to the managed care support contract(s) Managed Care Support Contractors (MCSC). Impact on Market/Military Treatment Facility (MTF) local contracts will be addressed by the Market/MTF.
2.3  The pilot will be eight weeks in length. The Government may negotiate additional time with the contractor at a future date.
3.0  Policy
3.1  The RACs will receive all TRICARE Prime referrals written by providers at MTFs in the pilot PSA. The appointing and referral center will determine whether the specialty care will be provided at a direct care facility or will be referred to the TRICARE network. If the care is referred to the TRICARE network, the RAC will transmit the referral to the contractor using existing systems (Referral Management System (RMS) or MHS Genesis).
3.2  For referrals received by the contractor by 1500 hours local time (local time is based on the pilot PSA), the contractor shall process and authorize the referral by 0700 hours local time the next business day. If the referral is received after 1500 hours or on a non-business day, the contractor shall process and authorize the referral by 0700 hours on the second business day after the referral is received. For example, if the referral is received on Saturday, the contractor shall process and authorize the referral no later than 0700 the following Tuesday (assuming Monday is not a federal holiday). If the referral does not have enough information for the contractor to process, the contractor shall communicate that fact back to the Market/MTF along with what information is needed for the contractor to complete the authorization and approval letter. For referrals sent by 1500 hours local time, the contractor shall accomplish said communication to the RAC by 0700 hours the next business day. For referrals sent after 1500 hours, the contractor shall accomplish communication to the RAC by 0700 hours the second business day. The contractor shall process referral requests in accordance with pilot guidelines when DEERS or any other required Government system is unavailable. The Government expects referrals during down time to meet pilot process timelines once the system(s) returns online and the contractor becomes aware of the referral or authorization request. The contractor shall notify the Government when it encounters outages or disruptions.
3.3  The contractor shall generate an authorization and/or approval letter. In the letter, the contractor shall identify at least one and up to three network providers (when available) who have the capability to provide the service required by the referral. The contractor shall upload the authorization and/or letter into the Government-MCSC interfacing system, using established referral management processes. See Chapter 8, Section 5. When the contractors Medical Management System architecture is such that only one servicing provider can be added to the initial approval letter or uploaded to the interfacing portal, the contractor is permitted to develop workarounds with the Government that would meet the requirement to identify three providers.
3.4  The contractor shall upload the approval letter, authorization and identified network providers to the MCSC portal, consistent with established processes.
3.5  The referring Market/MTF provider will direct the beneficiary to call the RAC to schedule an appointment. The RAC will call the first provider listed on the approval letter and determine if the provider has the capacity to provide the care within TRICARE access standards. If so, the RAC will then perform a warm hand off with the beneficiary and the provider’s office. If the first provider on the list is not able to provide the needed care within access standards, the RAC will call the second, and if needed, third provider on the list.
3.6  If none of the providers listed has the capacity, the RAC will contact the contractor and request additional network providers (or if no network providers are available, a non-network provider consistent with existing policy) to assist the beneficiary in making an appointment. The contractor shall provide additional providers within one business day of receiving the request from the RAC. If the contractor is unable to provide additional providers within one business day the contractor shall communicate this to the Government and notify the Government as soon as it becomes aware of appropriate additional providers. The RAC may use the provider directory when the contractor cannot provide additional providers. The contractor shall identity and submit up to three non-network providers in lieu of network providers, when network providers lack capacity or capability.
3.7  The RAC will collect data to measure pilot success. These will include:
•  Availability of network providers of the requested type;
•  Which providers accepts TRICARE and which provide care within access standards;
•  Number of un-activated referrals (when the beneficiary fails to make or keep an appointment and no claim is associated with the approved referral);
•  Beneficiary satisfaction;
•  Costs;
•  Processing times;
•  Completeness and appropriateness of referrals; and
•  Return of clear and legible reports.
3.8  The Government reserves the right to add additional pilot sites in the future.
4.0  EFFECTIVE DATE
The pilot will be effective on February 1, 2021. The Government will determine the exact start date in February in conjunction with the contractor and include the information in the contract modification.
5.0  Exclusions
•  Referral and authorization requests for current pilots and demonstrations including the Comprehensive Autism Care Demonstration and Intensive Outpatient Program (IOP) Pilot To Address Behavioral Health Sequelae of Sexual Trauma.
•  Referrals for beneficiaries not enrolled in TRICARE Prime.
•  Referrals for beneficiaries with Other Health Insurance (OHI).
•  Directed referrals to non-network providers >100 miles.
•  Retroactive referrals.
•  Retroactive referrals for emergency room and urgent care.
•  Renewed referrals such as for continuity of care.
•  Referrals for evaluation of plastic surgery.
•  Referrals for gender dysphoria, including endocrinology evaluation and treat for gender dysphoria.
•  Dental office visits for adult and pediatric, including dental requiring sedation.
•  Prosthetic referrals.
•  Referrals needing second level review.
•  Duplicate referrals.
•  Behavior Health referrals (non-office based that requires benefit review and medical necessity review such as IOP, Transcranial Magnetic Stimulation, Electroconvulsive treatment and Partial Hospitalization Program).
•  Referrals for Home Care, Hospice and Home Infusion.
•  Referrals for evaluation and treatment of pediatric congenital heart defects.
•  Faxed referrals (i.e. non-electronic referrals and authorizations).
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