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
date
s9.1 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.