Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Your
Rights While A TRICARE Hospital Patient
You
have the right to receive all the hospital care that is necessary
for the proper diagnosis and treatment of your illness or injury.
According to Federal law, your discharge date must be
determined solely by your medical needs, not by “Diagnosis
Related Groups (DRGs)” or by TRICARE payments.
You
have the right to be fully informed about decisions affecting your
TRICARE coverage and payment of your hospital stay and any post-hospital
services.
You have the right to request a review
by a TRICARE Regional Review Authority (RRA) of any written notice
of noncoverage that you may receive from the hospital stating that
TRICARE will no longer pay for your hospital care. RRAs employ groups
of doctors under contract by the Federal Government to review medical
necessity, appropriateness and quality of hospital treatment furnished
to TRICARE patients. The phone number and address of the RRA for
your area are:
Contractor's
Address
Contractor's
Toll-Free Telephone Number
Talk
To Your Doctor About Your Stay In The Hospital
You and your doctor know more about
your condition and your health needs than anyone else. Decisions
about your medical treatment should be made between you and your
doctor. If you have any questions about your medical
treatment, your need for continued hospital care, your discharge,
your need for possible post-hospital care, don’t hesitate to ask
your doctor. The hospital’s patient representative
or social worker will also help you with your questions and concerns
about hospital services.
If
You Think You Are Being Asked To Leave The Hospital Too Soon
Ask
a hospital representative for a written notice of explanation immediately,
if you have not already received one. This notice is called a “notice
of noncoverage.” You must have this notice of noncoverage if you
wish to exercise your right to request a review by the RRA.
The notice of noncoverage will state
whether your doctor or the RRA agrees with the hospital’s decision that
TRICARE should no longer pay for your hospital care.
• If the hospital and your doctor agree,
the RRA does not review your case before a notice of noncoverage
is issued. But the RRA will respond to your request for a review
of your Notice of Noncoverage and seek your opinion. You cannot
be made to pay for your hospital care until the RRA makes its decision
if you request the review by noon of the first workday
after you receive the notice of noncoverage.
• If
the hospital and your doctor disagree, the hospital may request
the RRA to review your case. If it does make such a request, the
hospital is required to send you a notice to that effect. In this situation,
the RRA must agree with the hospital or the hospital cannot issue
a notice of noncoverage. You may request that the RRA reconsider
your case after you receive a notice of noncoverage, but since the
RRA has already reviewed your case once, you may have to pay for at
least one day of hospital care before the RRA completes this reconsideration.
IF
YOU DO NOT REQUEST A REVIEW, THE HOSPITAL MAY BILL YOU FOR ALL THE
COSTS OF YOUR STAY BEGINNING WITH THE THIRD DAY AFTER YOU RECEIVE
THE NOTICE OF NONCOVERAGE. THE HOSPITAL, HOWEVER, CANNOT CHARGE
YOU FOR CARE UNLESS IT PROVIDES YOU WITH A NOTICE OF NONCOVERAGE.
How
To Request A Review Of The Notice Of Noncoverage
If
the notice of noncoverage states that your physician
agrees with the hospital’s decision:
• You
must make your request for review to the RRA by noon
of the first work day after you receive the notice
of noncoverage by contacting the RRA by phone or in writing.
• The RRA must ask for your views about
your case before making its decision. The RRA will inform you by
phone and in writing of its decision on the review.
• If
the RRA agrees with the notice of noncoverage, you may be billed
for all costs of your stay beginning at noon of the day after you
receive the RRA’s decision.
• Thus, you will not be responsible
for the cost of hospital care before you receive the RRA decision.
If
the notice of noncoverage states that the RRA agrees with
the hospital’s decision:
• You
should make your request for reconsideration to
the RRA immediately upon receipt of the notice of noncoverage
by contacting the RRA in writing.
• The RRA can take up to three working
days from receipt of your request to complete a review. The RRA
will inform you in writing of its decision on the review.
• Since
the RRA has already reviewed your case once prior to the issuance
of the notice of noncoverage, the hospital is permitted to begin
billing you for the cost of your stay beginning with the third calendar
day after you receive your notice of noncoverage, even
if the RRA has not completed its review.
• Thus,
if the RRA continues to agree with the notice of noncoverage, you
may have to pay for at least one day of hospital care.
Note: The
process described above is called “immediate review.” If you miss
the deadline for this immediate review while you are in the hospital,
you may still request a review of the TRICARE decision to no longer
pay for your care at any point during your hospital stay or after
you have left the hospital. The notice of noncoverage will tell
you how to request this review.
Post-Hospital
Care
When your doctor determines that you
no longer need all the specialized services provided in a hospital,
but you still require medical care, he or she may discharge you
to a skilled nursing facility or to home care. The discharge planner
at the hospital will help arrange for the services you may need
after your discharge. TRICARE and supplemental insurance policies
have limited coverage for skilled nursing facility care and home
health care. Therefore, you should find out which services will
or will not be covered and how payment will be made. Consult with
your doctor, hospital discharge planner, Beneficiary
Counseling and Assistance Coordinator (BCAC), patient
representative and your family in making preparations for care after
you leave the hospital. Don’t hesitate to ask questions.
Questions
involving billing or specific benefit coverage issues should be
addressed to your TRICARE claims processor which is:
Contractor's
Address
Contractor's
Toll-Free Telephone Number
Acknowledgment
Of Receipt
My
signature only acknowledges my receipt of this message from (Name
of Hospital) on (Date) and does not waive any
of my rights to request a review or make me liable for any payment.
___________________________________________
Signature
Of Beneficiary Or Person Acting On Behalf Of The Beneficiary
___________________________________________
Date
Signed