5.3.2 Referred Care
5.3.2.1 The contractor shall perform
a covered benefits review for requested services from a provider.
The requesting provider shall follow the contractor’s referral procedures
and contact the contractor for an authorization.
5.3.2.2 The contractor shall enter
any required referral data in Addendum B as required by the SAS
for a fitness-for-duty review (
paragraph 5.3).
5.3.2.3 The SAS will respond to the
contractor within two business days.
5.3.2.4 The contractor shall determine
the services encompassed within the Episode Of Care (EOC), indicated by
the referral when a SAS referral directs evaluation or treatment
of a condition, as opposed to directing a specific service(s).
5.3.2.4.1 A SAS authorization for health
care includes authorization for any TRICARE covered ancillary or diagnostic
services related to the health care authorized (i.e., associated
with the EOC).
5.3.2.4.2 The contractor shall not communicate
to the provider or patient that the care has been authorized until
the SAS review process has been completed.
5.3.2.4.3 The contractor shall use the
processes as used for other TRICARE Prime enrollees in determining EOC
when claims are received with lines of care that contain both referred
and non-referred lines.
5.3.2.4.4 Laboratory tests, radiology
tests, echocardiogram, Holter monitors, pulmonary function tests,
and routine treadmill tests logically associated with the original
EOC may be considered part of the originally requested services
and do not need to come back to the PCM (if assigned) or Primary
Care Provider (PCP) for approval.
5.3.2.5 If the SAS determines that
the ADSM may receive the care from a civilian source, the SAS will
enter the appropriate code into the authorization or referral system.
5.3.2.5.1 The contractor shall notify
the ADSM of approved referrals.
5.3.2.5.2 The ADSM may receive the specialty
care from a Market/MTF, a network provider, or a non-network provider
according to TRICARE access standards, where possible.
5.3.2.5.3 The contractor shall ensure
in areas where providers are not available within TRICARE access standards,
community norms apply. (An ADSM may always choose to receive care
at a Market/MTF even when the SAS has authorized a civilian source
of care and even if the care at the Market/MTF cannot be arranged
within the Prime access standards subject to the ADSM’s unit commander
[or supervisor] approval.)
5.3.2.5.4 The contractor shall instruct
the provider on payment requirements for ADSMs (e.g., no deductible or
cost-share) and on other issues affecting claim payment (e.g., the
balance billing prohibition) if the appointment is with a non-network
provider.
5.3.2.5.5 The contractor shall follow
Chapter 7, Section 5 when there are additional
requests by a Market/MTF for Civilian Health Care (CHC) needs.
5.3.2.6 The contractor shall, within
one business day after the end of the two business day waiting period, enter
the contractor’s authorization code into the contractor’s claims
processing system if the contractor does not receive the SAS’s response
or request for an extension within two business days.
5.3.2.7 The contractor shall document
each attempt to obtain a review decision from the SAS.
5.3.2.8 The contractor shall refer
civilian care to a network provider as the first option if a network
provider is not available within Prime access standards.
5.3.2.9 The contractor shall assist
the ADSM in locating a TRICARE-authorized provider.
5.3.2.10 If the SAS directs the care
to a military source, the SAS will manage the EOC.
5.3.2.11 If the ADSM disagrees that
the care must be provided by a military source, the ADSM may appeal through
the SAS who will coordinate the appeal as appropriate.
5.3.2.12 The contractor shall refer
all appeals and inquiries concerning the SAS’s military source determination to
the SAS.
5.3.2.13 If the ADSM’s PCM determines
that a specialty referral or test is required on an urgent basis
(less than 48 hours from the time of the PCM office visit) the PCM
should submit a referral to the contractor.
5.3.2.14 The contractor shall send all
requested information to the SAS for a fitness for duty review.
5.3.2.15 The ADSM can receive the care
as needed without waiting for the SAS determination.
5.3.2.16 The contractor shall adjudicate
the claim according to TRICARE Prime provisions.
5.3.2.17 If further specialty care is
warranted, the PCM should request a referral to specialty care.
5.3.2.18 The contractor shall contact
the SAS with a request for an additional SAS review for the specialty
care.
5.3.3 Care Received With No Authorization
or Referral
5.3.3.1 The contractor shall pend claims
for care which require referral, authorization, and SAS review,
but which have not been authorized or reviewed.
5.3.3.2 The contractor shall pend the
claim and supply the required information (TRICARE Systems Manual (TSM),
Chapter 1, Section 1.1, paragraph 11.0) to
the SAS for review, if the claim involves care covered under TRICARE
policy.
5.3.3.3 The contractor shall authorize
the care, release the claim for payment, and apply any overrides necessary
to ensure that the claim is paid with no fees assessed to the ADSM,
if the SAS does not notify the contractor of the review determination
or ask for an extension for further review within two business days
after submitting the request for coverage determination.
5.3.3.4 The contractor shall not make
claims payments to sanctioned or suspended providers (see
Chapter 13, Section 5).
Note: Claims for care provided under
the National DoD/DVA/VHA MOA for Payment for Processing Disability Compensation
and Pension Examinations (DCPE) in the Integrated Disability Evaluation
System (IDES) shall follow the routing requirements specified in
Chapter 17, Section 2.
5.3.3.5 The contractor shall decline
to file an authorization and deny any received claims if the contractor determines
that the requested service, supply, or equipment is not covered
by TRICARE policy (including
Chapter 17, Section 3)
and no Defense Health Agency (DHA) approved waiver is provided.
5.3.3.6 The contractor shall notify
the civilian provider and the remote ADSM or non-enrolled ADSM of
the declined authorization with explanation of the reason.
5.3.3.7 The contractor’s notification
to a civilian provider and the ADSM or non-enrolled ADSM shall explain the
waiver process and provide contact information for the applicable
Uniformed Services Headquarters Point of Contact (POC) or Service
Project Officers as listed in
Addendum A.
No notification to the SAS is required.
Note: The contractor shall initiate
recoupment actions according to
Chapter 10, Section 4 if
the SAS retroactively determines that the payment should not have
been made.