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Date _______________
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Administrator
SNF Name
Address
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Effective October 1, 2001,
TRICARE (formerly known as CHAMPUS) became a secondary payer to
Medicare for approximately 1.5 million Medicare-eligible Department
of Defense (DoD) health care beneficiaries. On December 28, 2001,
President Bush signed the National Defense Authorization Act of
Fiscal Year 2002 (NDAA FY 2002) (Public Law 107-107). This legislation
provided three important provisions for SNF providers:
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First, with one exception,
the legislation revised the TRICARE SNF benefit so that it is identical
to the Medicare SNF benefit. Like Medicare, the TRICARE SNF benefit
now requires a qualifying three-day prior hospitalization. The skilled
services must meet the Medicare coverage rules and be for a medical condition
that was either treated during the qualifying three-day hospital
stay, or started while the beneficiary was already receiving Medicare-covered
SNF care. The one exception is that, unlike Medicare, the TRICARE
benefit for a spell of illness will be unlimited. After 100 calendar
days of the Medicare benefit, TRICARE will become the primary payer
if the beneficiary does not have other health insurance.
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Second, the legislation required
that the TRICARE program adopt the Medicare SNF Prospective Payment System
(PPS) payment methods and rates, including Minimum Data Set (MDS)
assessments, Patient Driven Payment Model (PDPM) classifications,
and Medicare weights and per diem rates. Both of these provisions
took effect for SNF admissions on or after August 1, 2003. Children
under age 10 on the date of SNF admission are not subject to MDS
assessments and SNF PPS. Critical Access Hospital (CAH) swing beds
are not subject to MDS assessments and SNF PPS. Unless required
by their Memorandum of Understanding (MOU) or the Provider Agreement,
Department of Veterans Affairs (VA)/Veterans Health Administration
(VHA) facilities are not subject to MDS assessments and SNF PPS.
Facilities in Puerto Rico, Guam, the United States (US) Virgin Islands,
and American Samoa are subject to MDS assessments and SNF PPS.
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Third, the legislation required
that SNF providers enter into a Participation Agreement with TRICARE
if they wish to be considered to be an authorized TRICARE provider.
This agreement will require that TRICARE-participating SNFs are
not charge a beneficiary any amount above the TRICARE allowed amount.
Beneficiaries are financially responsible only for co-insurance
amounts and services not covered by TRICARE. SNFs are required to
use the same certification forms for TRICARE beneficiaries as they
are required to use for Medicare beneficiaries. SNFs will be in
violation of their TRICARE participation agreements if they discriminate
against the TRICARE beneficiary in their admission practices or
in delivery of medically necessary services due to the level of
payment. Accordingly, attached with this cover letter is a TRICARE
SNF Participation Agreement for your signature. Please sign and
return this agreement within 15 calendar days from the date of this
letter to facilitate prompt claims processing. All SNFs must sign
and return this agreement if they wish to have TRICARE pay for the
care of TRICARE beneficiaries. Claims for non-authorized SNFs will
be denied.
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There are four other changes
for TRICARE SNF providers. First, SNFs must use 21X bill type and
Revenue Code 022 on all TRICARE SNF PPS claims. Second,
a Health Insurance Prospective Payment System (HIPPS) code must
also be put on the PPS claim. This is a five digit code. The first
four digits are an alpha/numeric code identifying the PDPM classification.
The last digit is the Assessment Indicator (AI) of the reason for
the MDS assessment which is assigned per Medicare Policy.
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Third, under SNF PPS, all SNF
claims (21X bill type) must contain a line item listing (by revenue
code) of all services rendered to the SNF inpatient resident during
the dates of service on the claim. As under Medicare, SNFs are responsible
for making payment to those contractors who have provided services
to their TRICARE beneficiaries. The SNF must pay for any service
provided to a TRICARE beneficiary by an outside supplier unless
that service is excluded from consolidated billing by statue.
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Fourth, under SNF PPS, SNFs
will continue to be responsible for performing the resident assessment
if there is a change of clinical status past the initial five-day
assessment, for determining the medical necessity of services, for contracting
with outside suppliers, for managing Certificates of Medical Necessity
(CMN) from suppliers, and for making appropriate payment to contractors
for services rendered to SNF patients. The ‘Significant Change in
Status Assessments’ or ‘Significant Correction of Prior Assessments’
as applied under Medicare will also apply to these assessments under
TRICARE. The SNFs shall use the default HIPPS rate code of ZZZZZ on
the claim in case of an off-schedule or late patient assessment.
SNFs will provide notices to TRICARE beneficiaries in the same manner
as they provide under Medicare.
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The SNF benefit and PPS provisions
will also apply to those TRICARE beneficiaries who are not Medicare-eligible.
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If you have any questions,
please contact ______________, telephone number __________.
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Name
Title
Contractor Name
Address
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Enclosure:
SNF Participation Agreement
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