2.5 Requirements
for continued payment of ICMP-PEC authorized services:
2.5.1 Eligibility. The beneficiary
must be TRICARE eligible.
2.5.2 Authorized
Beneficiaries. Only those beneficiaries authorized services under
the ICMP-PEC upon its termination on December 28, 2001, are eligible
for continued coverage.
2.5.3 Authorized
Services. Only those services authorized under the ICMP-PEC upon
its termination on December 28, 2001, are eligible for continued
coverage.
2.5.4 Custodial Care. Beneficiaries
must continue to meet the TRICARE definition of custodial care in
effect prior to December 28, 2001, that is, custodial care is care
rendered to a patient who:
• Is disabled mentally or physically
and such disability is expected to continue and be prolonged; and
• Requires a protected, monitored,
or controlled environment whether in an institution or in the home;
and
• Requires assistance to support
the essentials of daily living; and
• Is not under active and specific
medical, surgical, or psychiatric treatment that will reduce the
disability to the extent necessary to enable the patient to function
outside the protected, monitored, or controlled environment.
2.5.5 Beneficiaries covered under
paragraphs 2.1 or
2.2 must
have a primary caregiver in the home.
2.5.6 Reassessment.
Continuation of receipt of services requires reassessment on a regular
basis. The contractor shall provide supporting clinical documentation
of all authorized participant’s medically necessary skilled needs,
to include a plan of care signed by the attending physician. Each
letter of authorization for continued coverage issued by the DHA
will include a statement regarding the frequency of a periodic reassessment
of the beneficiary. Generally, periodic reassessment will occur
annually, but will be based on the needs of the beneficiary.
2.5.7 The contractor shall provide
a complete clinical documentation update and recommendation for continuation
of coverage at the same level or indicate if either an increase
or decrease in services is indicated by the beneficiary’s current
needs. DHA will provide a courtesy reminder when a periodic reassessment
is due for a beneficiary. Once DHA reviews the reassessment and
updated recommendations of the contractor, a revised or updated
authorization letter will be issued to the contractor.
2.5.8 Revisions. The contractor shall
submit a written request to the Government Designated Authority (GDA)
that includes a detailed explanation of why the change is required,
any time a contractor determines a need for a change in authorized
funding for a beneficiary (e.g., due to a change in CHAMPUS Maximum
Allowable Charge (CMAC) rates, a change in patient condition, such
as a need for more or fewer covered hours, change in HHA). The GDA
will evaluate each request and provide a written decision to the
contractor.
2.5.9 Cost-shares. Cost-shares shall
not be applied to services authorized under the ICMP-PEC prior to December
28, 2001 nor to those services provided under this policy. Cost-shares
will continue to apply to all other TRICARE benefits.
2.5.10 Appeals. Appeals should be
made directly to the DHA Office of General Counsel (OGC). There
are three appealable issues related to the ICMP-PEC:
2.5.10.1 A custodial care determination;
2.5.10.2 A determination by the contractor
that ICMP-PEC does not apply;
2.5.10.3 The types and extent of services
authorized for a beneficiary by DHA. The following language is to
be included in subsequent determination of custodial care letters
and notification of benefits related to ICMP-PEC:
“Should you disagree with this
initial determination, you have the right to appeal and request
a formal review. Appealable issues include the types and extent
of the services and supplies authorized under the ICMP-PEC and the
determination that the care is custodial. The request must be in
writing, be signed, and must be postmarked or received by DHA OGC,
within 90 calendar days from the date of this determination. For
the purposes of TRICARE, a postmark is a cancellation mark issued
by the United States Postal Service.
Additional documentation in
support of the appeal may be submitted. However, because a request for
a formal review must be received within 90 calendar days of the
date of the initial determination, a request for formal review should
not be delayed pending the acquisition of any additional documentation.
If additional documentation is to be submitted at a later date,
the letter requesting the formal review must include a statement
that additional documentation will be submitted and the expected
date of the submission.”
2.5.11 Claims Processing. The contractor
shall use the Special Processing Code (SPC) CM in addition
to the appropriate Branch Of Service Code for all claims for care
and services authorized under this policy.
2.5.12 The contractor shall use the
SPC
E in addition to the SPC
CM for claims
for services authorized for those beneficiaries indicated in
paragraph 2.3.
Claims for services not provided in accordance with
paragraphs 2.1,
2.2,
or
2.3 (i.e., acute outpatient and inpatient
care and services, including Durable Medical Equipment (DME)) must
be processed in accordance with the TOM, the TRICARE Reimbursement
Manual (TRM), and the TRICARE Systems Manual (TSM), and without
the use of the SPCs
E and
CM.
2.5.13 The contractor shall notify
the GDA upon any of the following changes to any beneficiary who
is covered by
paragraphs 2.1,
2.2, or
2.3.
• Death;
• Eligibility status, including
becoming a Transitional Survivor or a Survivor as those terms are
used in
Chapter 10, Section 7.1;
• Residential relocation (pending
or completed);
• Custodial care status;
• Inpatient admission;
• Requests for disengagement.