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TRICARE Operations Manual 6010.59-M, April 1, 2015
Demonstrations And Pilot Projects (Except Value-Based Initiatives)
Chapter 18
Section 7
EXPIRED - Department of Defense (DoD) TRICARE Pilot Project To Redirect Uniformed Services Beneficiaries Identified For Inpatient Admission At Civilian Emergency Departments (EDs) For Admission To Designated Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs)
Revision:  C-70, September 4, 2020
1.0  Purpose
This TRICARE pilot project will evaluate the success of collaboration between Managed Care Support Contractors (MCSCs), network EDs, and inpatient MTFs to offer the opportunity to transfer clinically stable, qualified Uniformed Services beneficiaries from civilian EDs to an inpatient MTF/eMSM for inpatient care and treatment. The outcome of the pilot project would enable the Government to consider operational and financial changes necessary to further Military Health System (MHS) goals to optimize the capabilities of the Direct Care (DC) system and support medical readiness, enhance MTF/eMSM provider proficiency and graduate medical education programs, responsibly steward taxpayer dollars, reduce beneficiary costs, and enhance beneficiary satisfaction.
2.0  Eligibility Policy
2.1  Participating Beneficiary:
2.1.1  Any Uniformed Services beneficiary who shows as TRICARE eligible in Defense Enrollment Eligibility Reporting System (DEERS) except for beneficiaries not eligible for care in MTFs/eMSMs; and
2.1.2  Voluntarily elects transfer to a local inpatient MTF/eMSM once stabilized in a civilian ED. Parents, legal guardians, or authorized personal representatives may elect transfers on behalf of others.
2.2  EXCEPTION: If clinically stable, members on active duty greater than 30 days should be asked to agree to transfer, but may be ordered to transfer depending on the circumstances.
3.0  Ambulance Policy
3.1  A request by either a civilian ED or MTF/eMSM shall, for purposes of this Pilot, constitute an “order” under TRICARE Policy Manual (TPM), Chapter 8, Section 1.1, to serve as authority for TRICARE payment of a not-medically necessary transport to an MTF.
3.2  If Medicare is primary payer and the claim is denied by Medicare because the civilian facility has appropriate facilities to treat the patient, TRICARE will cost share on the claim. See TPM, Chapter 8, Section 1.1.
3.3  If Medicare is primary payer and the claim is denied by Medicare as not being medically necessary, TRICARE will cost-share on the claim so long as it is ordered by civilian or military personnel. See TRICARE Reimbursement Manual (TRM), Chapter 1, Section 14, paragraph 3.6.4.
4.0  Responsibilities
4.1  Participating MTFs/eMSMs
4.1.1  Collaborate with regional contractor to identify and educate civilian network facilities and their ED staff on the goals and benefits of participating in this pilot project.
4.1.2  Determine clinically appropriate MTF/eMSM capabilities and capacities to accept clinically stable beneficiaries for transfer.
4.1.3  Provide contractor and/or civilian EDs with information regarding MTF/eMSM clinical capabilities, MTF/eMSM patient transfer hotline information, MTF/eMSM patient transfer process, and beneficiary-focused educational materials including a written beneficiary/personal representative acknowledgment of cost-sharing and other financial obligations if they transfer to an MTF/eMSM versus admitted to a civilian facility, to be given to beneficiaries.
4.1.4  Staff a 24-hour patient transfer hotline to receive requests for patient transfers.
4.1.5  Respond to notifications of potential transfers from civilian EDs.  Confirm eligibility and determine inpatient clinical capability and capacity to accept the beneficiary for admission and treatment.  Provide a verbal response within 30 minutes of the notification from the civilian ED.  If MTF/eMSM inpatient capability and capacity exists and both the attending civilian physician and the accepting MTF/eMSM physician agree that the beneficiary is clinically stable and can be safely transported to the MTF/eMSM based on the medical status of the beneficiary and the clinical appropriateness of the transfer, the MTF/eMSM shall initiate a request to dispatch ambulance transportation within 30 minutes of the acceptance decision (when ambulance transport is clinically required). Based on local procedures, the civilian ED may request dispatch of the ambulance.  If no MTF/eMSM capability exists or the attending and receiving providers do not agree the beneficiary can be safely transported to the MTF/eMSM based on the medical status of the beneficiary and the clinical appropriateness of the transfer, the beneficiary remains the responsibility of the civilian ED to arrange appropriate care in a civilian facility.
4.1.6  Collect and report on project workload and financial data as required by the Defense Health Agency (DHA) Project Manager.
4.2  Regional Contractor (East and West Regions Only)
4.2.1  Collaborate with MTF/eMSM pilot sites to identify and educate civilian network facility staff on the goals and benefits of participating in this demonstration.
4.2.2  Establish processes with or within civilian network facilities to:  Identify eligible and stable Uniform Services beneficiaries seen in EDs that require inpatient admission.  Inform eligible beneficiaries of the opportunity to be admitted to a nearby MTF/eMSM for further treatment as an inpatient.  Share MTF-provided educational materials to the beneficiary, to include full disclosure and patient/personal representative written acknowledgment of their cost-sharing and other financial obligations related to both remaining at their present facility and transferring to an MTF. All educational materials will be coordinated with DHA Communications Office.  If the beneficiary desires to participate in the pilot project, notify the appropriate MTF.  If both the attending civilian ED physician and the accepting MTF/eMSM physician determine the beneficiary can be safely transported to the MTF/eMSM based on the medical status of the beneficiary and the clinical appropriateness of the transfer, the civilian ED shall prepare the beneficiary for transfer to the MTF/eMSM and provide appropriate transfer clinical and administrative medical documentation. Based on local procedures, either the MTF/eMSM or the civilian ED may request dispatch of an ambulance when clinically necessary.  If there is no concurrence between the providers for safe transfer or the MTF/eMSM declines the transfer, the beneficiary remains the responsibility of the civilian ED to arrange appropriate care in a civilian setting.
5.0  Pilot Project Service Areas
5.1  Army: Puget Sound eMSM - Madigan Army Medical Center, Tacoma, WA and Naval Hospital Bremerton, WA; Womack Army Medical Center, Fort Bragg, NC; San Antonio MHS e-MSM, San Antonio Military Medical Center, Joint Base San Antonio, TX.
5.2  Navy: Naval Hospital Jacksonville, FL; Tidewater eMSM - Naval Medical Center Portsmouth, VA and 633rd Medical Group, Joint Base Langley-Eustis, VA.
5.3  Air Force: 60th Medical Group, David Grant Medical Center, Travis Air Force Base (AFB), CA; 99th Medical Group, Mike O’Callaghan Federal Medical Center, Nellis AFB, NV; 88th Medical Group, Wright-Patterson Medical Center, Wright-Patterson AFB, OH; and 96th Medical Group, Eglin AFB, FL.
5.4  National Capital Region eMSM: Walter Reed National Military Medical Center, Bethesda, MD.
6.0  Beneficiary Cost Liability
6.1  Beneficiaries shall be responsible for all required TRICARE cost-shares or MTF/eMSM fees.
6.2  See paragraph 3.0 for ambulance related cost-shares and the potential for denied Medicare claims.
7.0  Pilot Cost Avoidance
7.1  Government and Contractor. Monetary cost avoidance occurs as MTF/eMSM admissions eliminate the Government cost of inpatient TRICARE claims (facility and professional fees). This is offset by costs to the Government for ambulance transfers to the MTF/eMSM and the marginal costs of MTF/eMSM inpatient admissions.
7.2  Beneficiary. Eliminates beneficiary cost-sharing of an inpatient TRICARE claim but adds potential for cost-shares or denied claims relating to ambulance transfers. See the TPM, Chapter 8, Section 1.1 and the TRM, Chapter 4, Section 4.
8.0  Applicability
This pilot is limited geographically to those eMSMs and inpatient MTFs/eMSMs as identified in paragraph 5.0.
9.0  Effective And Termination Dates
This pilot project is effective for elective patient transfer requests from civilian EDs to designated inpatient MTFs/eMSMs as of July 25, 2016. The pilot project shall terminate on the last day of a Region’s current contract, or two years from the start of the pilot project, whichever comes first.
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