Claims Processing Procedures
Chapter 8
Section 5
TRICARE
Prime And TRICARE Select Referrals/Preauthorizations/Authorizations
Revision:
1.0 REFERRALS
The contractor shall ensure
that TRICARE network providers hold beneficiaries harmless “held
harmless” (i.e., considered not financially responsible for any
charges) in cases where the network provider fails to request a referral
and the contractor either denies payment or applies the Prime Point
of Service (POS) option.
2.0 The contractor shall maintain
an automated authorization file or an automated system of flagging
to ensure claims are processed consistent with authorizations.
Note: The Unique Identifier Number
(UIN) is specific to the Composite Health Care System (CHCS)/Armed Forces
Health Longitudinal Technology Application (AHLTA) which is the
legacy Military Health System (MHS) Electronic Health Record (EHR)
and the legacy Referral Management Suite (RMS). As the MHS phases
out legacy CHCS/AHLTA and legacy RMS and moves to MHS Genesis as
the new EHR, the UIN will no longer be used. MHS Genesis produces
the “Referral ID” thus the UIN and Referral ID may be used interchangeably
in this Section.
2.1 TRICARE Prime enrollees receiving
emergency care or authorized care from non-network, non- participating
providers shall be responsible for only the Prime copayment.
2.1.1 The contractor
shall allow the amount the provider may collect under TRICARE rules;
i.e., if the charges on a claim are subject to the balance billing
limit (refer to the TRICARE Reimbursement Manual (TRM),
Chapter 3, Section 1 for information on balance
billing limit), the contractor shall allow the lesser of the billed
charges or the balance billing limit (115% of allowable charge).
2.1.2 The contractor
shall, if the charges on a claim are exempt from the balance billing
limit, allow the billed charges. Refer to the TRM,
Chapter 2, Section 1 for information on claims
for certain ancillary services.
2.2 The contractor
shall implement National Provider Identifier (NPI) checks or other
business processes to ensure that authorizations are not issued
to Market/Military Medical Treatment Facility (MTF) providers who
are also providing services in private sector care.
3.0 FAILURE TO COMPLY WITH PREAUTHORIZATION
- PAYMENT REDUCTION
The contractor
shall reduce provider payments for failure to comply with the preauthorization
requirements for certain types of care. See the TRM,
Chapter 1, Section 28, for more information.
4.0 PSYCHIATRIC
RESIDENTIAL TREATMENT CENTERS (RTC
s)
4.1 The contractor shall, if a
claim for admission or extension to an RTC is submitted and no authorization form
is on file, deny the claim.
4.1.1 The contractor
may, for network claims, deny or develop in accordance with its
agreements with network providers.
4.1.2 The contractor shall deny non-network
claims.
4.2 The contractor
shall, for any claims submitted for inpatient care at other than
the RTC, pay the claim if the care was medically necessary.
4.2.1 The contractor shall, for RTC
care during the period of time the beneficiary was receiving care
from another inpatient facility, deny the claims.
4.2.2 The contractor shall, if the
RTC has been paid and a claim for inpatient hospital care is received
and the care was medically necessary, pay the inpatient hospital
claim and recover the payment from the RTC.
5.0 GRANDFATHERED
CUSTODIAL CARE CASES
5.1 A list of the beneficiaries
who qualified for custodial care benefits prior to June 1, 1977
will be furnished to the contractor with instructions to flag the
file for those beneficiaries on the list who are within its geographic area
of responsibility. See
Section 2 for transition-in requirements.
5.2 The contractor shall suspend
claims for which no authorization is on file notify the appropriate Government
Designated Authority (GDA). Refer to
32
CFR 199.4.
6.0 REFERRAL AND AUTHORIZATION
PROCESS
The contractor
shall process referrals (from the Market/MTF to the contractor)
in accordance with the following:
6.1 The contractor shall create
a claims system that utilizes the UIN, at a minimum, to match claims
with referral authorizations.
6.2 The contractor
shall modify generated Market/MTF reports to accommodate the UIN
and NPI.
6.3 The contractor shall provide
the Market/MTF a monthly adjudicated referral claim report which
shall include the UIN against each claim. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), in Section
J of the applicable contract.
6.4 The contractor
shall provide the same services and information required above to
the TRICARE Overseas Program (TOP) contractor if the patient is
enrolled overseas.
6.4.1 The contractor shall forward
the authorization information to the TOP contractor to ensure appropriate adjudication
of the claim.
6.4.2 The contractor
or TOP contractor shall process claims according to
Section 2.
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