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TRICARE Operations Manual 6010.59-M, April 1, 2015
Demonstrations And Pilot Projects (Except Value-Based Initiatives)
Chapter 18
Section 5
EXPIRED As Of January 1, 2018 - Pilot Program On Urgent Care For TRICARE Prime/TRICARE Prime Remote (TPR) Beneficiaries
Revision:  C-28, June 15, 2018
1.0  Purpose
The purpose of the Pilot is to meet requirements set forth in the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2016, Section 725 and to determine if the elimination of the requirement to obtain a referral or preauthorization for urgent care visits improves access to urgent care, helps enrollees to choose the most appropriate source for the health care they need (such as a TRICARE-authorized Urgent Care Center (UCC) rather than the Emergency Room (ER)), potentially lowers health care costs for the Department of Defense (DoD) and/or improves patient satisfaction.
2.0  Background
2.1  Access to primary health care for acute episodic primary care continues to be in high demand by TRICARE Prime enrollees. The TRICARE manual guidance and the process by which Prime enrollees currently access primary health care is defined under the 32 CFR 199.17 and the TRICARE Policy Manual (TPM), Chapter 1, Section 7.1. Historically, the Defense Health Agency (DHA) has required that Prime enrollees obtain a referral for primary or urgent care if they seek that care from someone other than their Primary Care Manager (PCM). As a result, when an enrollee needs urgent care after hours or when the PCM in the Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) does not have available appointments, they have been seeking care from civilian sources such as the ER or with a UCC, including Convenience Clinics (CCs).
2.2  In an effort to avoid overuse of ER care and meet the demand for acute primary care, many facilities have expanded acute care hours within the MTFs/eMSMs or worked with the contractors to utilize provider groups or UCCs in their network. However, these visits outside the MTF/eMSM require an authorization. Seeking emergency care in an ER does not require authorization. Additionally, the cost of care in a civilian ER for non-emergent reasons is higher than any other source of care.
3.0  Policy and Eligibility
3.1  Under the Pilot, Service members who are enrolled in TRICARE Prime Remote (TPR), Active Duty Family Members (ADFMs) who are enrolled in TRICARE Prime, TRICARE Young Adult (TYA) Prime, or TRICARE Prime Remote for Active Duty Family Members (TPRADFM), retirees and their family members who are enrolled in Prime or TYA Prime within the 50 United States or the District of Columbia and TRICARE Overseas Program (TOP) enrollees traveling/seeking stateside care will be allowed to self-refer, without an authorization, to a TRICARE network provider or TRICARE-authorized UCC provider, for urgent care. All the aforementioned categories, except overseas, will be allowed two unauthorized urgent care visits per FY, per individual, including services provided when the enrollee is out of their enrollment area. Overseas enrollees seeking stateside urgent care will not be held to the two visit cap. For the allowed unmanaged visits, no referral from their PCM or authorization by a Health Care Finder (HCF) will be required and no Point of Service (POS) deductibles and cost shares shall apply. Referral requirements for specialty care and inpatient authorizations shall remain as currently required by Chapter 8, Section 5.
3.2  Enrollees are encouraged to notify their PCM of any urgent/acute care visits outside the PCM within 24 hours of the visit or the first business day following the visit and to schedule follow-up treatment, if indicated, with their PCM. The contractor shall provide beneficiary and provider information on this process, to include information on how to schedule follow-up appointments, and how to coordinate care.
3.3  If more than the two visits allowed under this Pilot are used or if the enrollee seeks care from a non-network provider (except a TRICARE-authorized UCC), the usual POS deductible and cost-shares shall apply. The usual POS exceptions are still applicable and include:
•  Emergency care;
•  Service members (in accordance with Chapters 16 and 17);
•  Newborns and adopted children during the first 60 days (120 days, if overseas) after birth or adoption;
•  TRICARE Prime clinical preventive services received from a network provider (in accordance with TPM, Chapter 7, Section 2.2);
•  TRICARE Prime enrollees who obtain outpatient mental health care from a network provider without a referral from their PCM (in accordance with TPM, Chapter 7, Section 3.8); and
•  Enrollees with Other Health Insurance (OHI).
3.4  The Pilot shall encourage and incentivize the use of the Nurse Advise Line (NAL) to direct enrollees to the source of the most appropriate level of health care required to treat the medical conditions of the enrollee. The NAL will provide advice to all enrollees and will facilitate referrals for Direct Care (DC) enrollees who receive an urgent care recommendation. For incentive purposes, urgent care accessed via a NAL recommendation that leads to a PCM referral shall not be counted against the allowable self-referred visits provided under the Pilot.
4.0  General Description of Administrative Process
4.1  Referral (authorization) requirements for up to two urgent care visits per FY, per individual, shall be waived for Service members who are enrolled in TPR, ADFMs who are enrolled in TRICARE Prime, TPRADFM, or TYA Prime and retirees and their family members who are enrolled in Prime within the 50 United States or the District of Columbia. Referral (authorization) requirements are also waived for an uncapped number of visits for TOP enrollees traveling/seeking care in the Continental United States (CONUS) when services are rendered by a TRICARE network provider or TRICARE-authorized UCC. Providers must have one of the following primary specialty designations:
•  Family Practice;
•  Internal Medicine; General Practice;
•  Pediatrician; and
•  UCC or Convenience Clinic (CC).
Note:  In accordance with TPM, Chapter 1, Section 7.1, Obstetricians/Gynecologists (OB/GYNs), Physician Assistants (PAs), Nurse Practitioners (NPs), and Certified Nurse Midwives (CNMs) can be considered Primary Care Providers (PCPs) and may also be designated PCMs.
4.2  All claims shall be vouchered and paid as prescribed by existing policy for both underwritten and non-underwritten care. The unauthorized urgent care visits permitted under this pilot shall be considered “authorized care” for purposes of Chapter 8, Section 5, paragraph 2.6.
5.0  Policy Considerations
The inclusion of Service member in TPR does not limit/change their overall TPR benefit (as specified in Chapter 16).
6.0  Contractor Responsibilities
6.1  The contractors shall verify the TRICARE eligibility of the patient on the Defense Enrollment Eligibility Reporting System (DEERS).
6.2  The contractors shall search for any submitted urgent care referral and when an urgent care referral is identified the contractor shall not count the urgent care visit against the allowable self-referred visits provided under the Pilot.
6.3  The contractors shall develop a process to track the number of unmanaged urgent care visits used per enrollee/per FY. This process shall incorporate a means to share that number with other contractors when enrollment transfers occur.
6.4  DHA Communications will provide all educational materials regarding the pilot to contractors. The educational materials will encourage enrollees seeking access to care to use the MTF/eMSM first and to use the NAL to guide them to the source of the most appropriate level of healthcare required to treat their medical condition.
6.5  The contractors shall ensure that pilot information is made available on their primary Internet web sites.
6.6  TRICARE Encounter Data (TED) Record Special Processing Code (SPC) “UC-Urgent Care Pilot” shall be coded on all TED records where one of the two self-referred authorizations allowed under this Pilot is used. If the TED SPC is implemented in the contractor’s system after May 23, 2016, the contractor shall search for previously processed Urgent Care Pilot TED records and adjust those records to show SPC UC.
7.0  Applicability
This Pilot is limited to Service members who are enrolled in TPR; and ADFMs who are enrolled in TRICARE Prime; TYA Prime; or TPRADFM; retirees and their family members who are enrolled in Prime or TYA Prime within the 50 United States or the District of Columbia; and TOP enrollees traveling/seeking stateside care.
8.0  Exclusions
This Pilot does not apply to referral requirements for specialty care and inpatient authorizations as currently required by Chapter 8, Section 5. This Pilot excludes TOP Prime enrollees unless they are traveling stateside. This pilot excludes Uniformed Services Family Health Plan (USFHP) enrollees.
9.0  Effective dates
9.1  Per requirements set forth in the NDAA FY 2016, Section 725, the Secretary is required to carry out the Pilot Program for a period of three years. Implementation is to commence no later than 180 days after the date of the enactment of the Act, and hence the Pilot will begin May 23, 2016, and will continue until May 23, 2019.
9.2  The NDAA FY 2017, Section 704, authorized the Director, DHA to establish the TRICARE Prime referral requirement for urgent care visits for TRICARE Prime enrollees other than Active Duty Service Members (ADSMs) enrolled to an MTF/eMSM. TRICARE policy (Chapter 8, Section 5) was changed to allow unlimited self-referred urgent care visits for all TRICARE Prime enrollees (other than most ADSMs enrolled to an MTF/eMSM) with an effective date of January 1, 2018. No POS deductibles and cost shares shall apply when urgent care is provided by a TRICARE network provider or a TRICARE-authorized (network or non-network) UCC or CC. If the enrollee seeks care from a non-network provider (except a TRICARE-authorized UCC or CC), the usual POS deductible and cost-shares shall apply. The aforementioned policy change effectively made this pilot obsolete with an end date of December 31, 2017.
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