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TRICARE Operations Manual 6010.59-M, April 1, 2015
Supplemental Health Care Program (SHCP)
Chapter 17
Addendum B
Specified Authorization Staff (SAS) Review For Authorization: Protocols And Procedures
Revision:  C-58, September 20, 2019
1.0  Interconnectivity Between The Contractor And Defense Health Agency-Great Lakes (DHA-GL) (The SAS For Army, Air Force, Navy, Marine Corps, And Coast Guard)
1.1  Automated Data Processing (ADP) Protocols
1.1.1  For those Government staff who will remotely access the contractor’s system from the DHA-GL location, the contractor shall provide access for entry and edit of referrals into the contractor’s systems. The contractor shall include a status code indicating that SAS review is required.
1.1.2  The contractor shall submit a standard management report which provides the number of deferred claims that SAS staff reviewed and processed during each month. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
1.1.3  The contractor shall provide the capability to edit the status and entry of a 16 digit disposition code indicating if the referral was approved for civilian network treatment (see paragraph 1.2). This disposition code may be used during the claims adjudication process.
1.1.4  The contractor shall provide the logic to automatically approve the referral if the SAS determination is not received within two work days of referral entry.
1.1.5  The contractor shall provide the telecommunications, hardware, and software necessary for data entry and report printing from the SAS location. The contractor shall provide application training and support to the SAS staff who utilize the contractor’s referral system.
1.1.6  The contractor shall provide a data dictionary of available data elements to be sent to the SAS automated information system. The contractor shall send all care referral records to the SAS in a tab delimited data flat file. The method of transfer shall be File Transfer Protocol (FTP) or a secure, password-protected e-mail attachment.
1.1.7  The contractor shall provide the SAS with read-only access to their subcontractor’s claims history database. The contractor shall provide the necessary training to the SAS staff in order to access the claims history database.
1.2  SAS Referral Data
1.2.1  The format of the referral number shall be DMISYYJJJNNNS where:
1.2.1.1  DMIS = the DMIS ID Code of the issuing facility (5203 = SAS);
1.2.1.2  YY = the last two digits of the year in which the referral number was issued;
1.2.1.3  JJJ = the Julian date on which the referral number was issued;
1.2.1.4  NNN = the Facility Sequence Number;
1.2.1.5  S = Status (the type of provider)
•  C = Civilian Care (refer to Chapter 16, Section 2, paragraph 5.3.1.2 for referral requirements)
•  M = Military Care (medical Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) or clinic)
•  V = Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA) Care (DVA/VHA hospital or medical facility)
•  P = Care rendered under the Department of Defense/Department of Veterans Affairs (DoD/VA) Memorandum of Agreement (MOA) for “Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services” (refer to Section 2, paragraph 3.1 for referral requirements).
1.2.2  The format of the effective date is YYYYMMDD where:
•  YYYY = the year in which the SAS referral is effective;
•  MM = the month in which the SAS referral is effective; and
•  DD = the day on which the SAS referral is effective. A retroactive authorization is indicated by an effective date prior to the issue date.
1.2.3  The format of the expiration date is YYYYMMDD where:
•  YYYY = the year in which the SAS referral expires;
•  MM = the month in which the SAS referral expires; and
•  DD = the day on which the SAS referral expires.
1.3  Data Elements
The following data elements are the minimum elements required by SAS for determining whether to authorize civilian care. The SAS will return the data elements furnished by the contractor when responding to a request for authorization determination.
Data Element
Contractor To SAS
SAS To Contractor
Patient Name
X
X
Patient’s DOB
X
X
Patient’s Sex
X
X
Contact Date (for retroactive authorizations)
X
X
Service Member SSN
X
X
Service Member Branch of Service
X
X
Duty Status
X
X
PCM Location Code
X
X
DMIS-ID
X
X
Contractor’s Authorization Number
X
X
Effective Date of Authorization
X
X
*Not a Benefit
*If applicable
**Not Medically Necessary
**If applicable
***Provider Not Authorized
***If applicable
SAS Fitness-for-Duty Referral Number or Benefit Determination Number
X
Effective Date of SAS Referral
X
Expiration Date of SAS Referral
Status of Authorization (may be embedded number)
X
Number/Frequency of Services Requested for SAS Referral
X
X
Diagnosis
X
X
Procedure Code Range
X
X
Type of Service
X
X
Place of Service
X
X
Free Text (for available clinical information)
X
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