1.0 BACKGROUND
Section 714 of the Fiscal Year
(FY) 2019 National Defense Authorization Act (NDAA) requires a streamlined
approach to referrals in TRICARE. Specifically, it requires that:
“(1)
The referral process shall model best industry practices for referrals
from primary care managers to specialty care providers;
(2)
The process shall limit administrative requirements for enrolled
beneficiaries;
(3) Beneficiary preferences
for communications relating to appointment referrals using state-of-the-art
information technology shall be used to expedite the process; and
(4)
There shall be effective and efficient processes to determine the
availability of appointments at military medical treatment facilities
and, when unavailable, referrals to network providers under the
TRICARE program.”
Consistent with this requirement,
TRICARE is implementing a pilot to use appointing and referral centers
to simplify the process of receiving referrals for care and making
appointments.
2.0 DESCRIPTION
AND OVERVIEW
The
Government will create a referral and appointing center located
at one pilot site to be detailed in the contract modification.
2.1 The
RAC will serve as a “one number” center for all specialty care appointing
for TRICARE Prime patients when the referral is generated by a provider
at a Market/Military Treatment Facility (MTF) in the pilot Prime
Service Area (PSA).
2.2 These
requirements apply only to the managed care support contract(s)
Managed Care Support Contractors (MCSC). Impact on Market/Military
Treatment Facility (MTF) local contracts will be addressed by the
Market/MTF.
2.3 The
pilot will be eight weeks in length. The Government may negotiate
additional time with the contractor at a future date.
3.0 Policy
3.1 The
RACs will receive all TRICARE Prime referrals written by providers
at MTFs in the pilot PSA. The appointing and referral center will
determine whether the specialty care will be provided at a direct care
facility or will be referred to the TRICARE network. If the care
is referred to the TRICARE network, the RAC will transmit the referral
to the contractor using existing systems (Referral Management System
(RMS) or MHS Genesis).
3.2 For
referrals received by the contractor by 1500 hours local time (local
time is based on the pilot PSA), the contractor shall process and
authorize the referral by 0700 hours local time the next business day.
If the referral is received after 1500 hours or on a non-business
day, the contractor shall process and authorize the referral by
0700 hours on the second business day after the referral is received.
For example, if the referral is received on Saturday, the contractor
shall process and authorize the referral no later than 0700 the
following Tuesday (assuming Monday is not a federal holiday). If
the referral does not have enough information for the contractor
to process, the contractor shall communicate that fact back to the
Market/MTF along with what information is needed for the contractor
to complete the authorization and approval letter. For referrals
sent by 1500 hours local time, the contractor shall accomplish said
communication to the RAC by 0700 hours the next business day. For
referrals sent after 1500 hours, the contractor shall accomplish
communication to the RAC by 0700 hours the second business day.
The contractor shall process referral requests in accordance with
pilot guidelines when DEERS or any other required Government system
is unavailable. The Government expects referrals during down time
to meet pilot process timelines once the system(s) returns online
and the contractor becomes aware of the referral or authorization
request. The contractor shall notify the Government when it encounters
outages or disruptions.
3.3 The
contractor shall generate an authorization and/or approval letter.
In the letter, the contractor shall identify at least one and up
to three network providers (when available) who have the capability
to provide the service required by the referral. The contractor
shall upload the authorization and/or letter into the Government-MCSC
interfacing system, using established referral management processes.
See
Chapter 8, Section 5. When the contractors
Medical Management System architecture is such that only one servicing
provider can be added to the initial approval letter or uploaded
to the interfacing portal, the contractor is permitted to develop
workarounds with the Government that would meet the requirement
to identify three providers.
3.4 The
contractor shall upload the approval letter, authorization and identified
network providers to the MCSC portal, consistent with established
processes.
3.5 The
referring Market/MTF provider will direct the beneficiary to call
the RAC to schedule an appointment. The RAC will call the first
provider listed on the approval letter and determine if the provider
has the capacity to provide the care within TRICARE access standards.
If so, the RAC will then perform a warm hand off with the beneficiary
and the provider’s office. If the first provider on the list is not
able to provide the needed care within access standards, the RAC
will call the second, and if needed, third provider on the list.
3.6 If
none of the providers listed has the capacity, the RAC will contact
the contractor and request additional network providers (or if no
network providers are available, a non-network provider consistent
with existing policy) to assist the beneficiary in making an appointment.
The contractor shall provide additional providers within one business
day of receiving the request from the RAC. If the contractor is
unable to provide additional providers within one business day the
contractor shall communicate this to the Government and notify the
Government as soon as it becomes aware of appropriate additional
providers. The RAC may use the provider directory when the contractor
cannot provide additional providers. The contractor shall identity
and submit up to three non-network providers in lieu of network
providers, when network providers lack capacity or capability.
3.7 The
RAC will collect data to measure pilot success. These will include:
• Availability
of network providers of the requested type;
• Which providers accepts TRICARE
and which provide care within access standards;
• Number of un-activated referrals
(when the beneficiary fails to make or keep an appointment and no
claim is associated with the approved referral);
• Beneficiary satisfaction;
• Costs;
• Processing times;
• Completeness and appropriateness
of referrals; and
• Return of clear and legible
reports.
3.8 The Government
reserves the right to add additional pilot sites in the future.
5.0 Exclusions
• Referral
and authorization requests for current pilots and demonstrations
including the Comprehensive Autism Care Demonstration and Intensive
Outpatient Program (IOP) Pilot To Address Behavioral Health Sequelae
of Sexual Trauma.
• Referrals for beneficiaries
not enrolled in TRICARE Prime.
• Referrals
for beneficiaries with Other Health Insurance (OHI).
• Directed
referrals to non-network providers >100 miles.
• Retroactive
referrals.
• Retroactive referrals for emergency
room and urgent care.
• Renewed
referrals such as for continuity of care.
• Referrals
for evaluation of plastic surgery.
• Referrals
for gender dysphoria, including endocrinology evaluation and treat
for gender dysphoria.
• Dental
office visits for adult and pediatric, including dental requiring
sedation.
• Prosthetic referrals.
• Referrals
needing second level review.
• Duplicate
referrals.
• Behavior Health referrals (non-office
based that requires benefit review and medical necessity review
such as IOP, Transcranial Magnetic Stimulation, Electroconvulsive treatment
and Partial Hospitalization Program).
• Referrals
for Home Care, Hospice and Home Infusion.
• Referrals
for evaluation and treatment of pediatric congenital heart defects.
• Faxed
referrals (i.e. non-electronic referrals and authorizations).