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Your Rights While A TRICARE
Hospital Patient
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You have the right to receive
all the hospital care that is necessary for the proper diagnosis
and treatment of your illness or injury. According to Federal law, your
discharge date must be determined solely by your medical needs, not
by “Diagnosis Related Groups (DRGs)” or by TRICARE payments.
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You have the right to be fully
informed about decisions affecting your TRICARE coverage and payment
of your hospital stay and any post-hospital services.
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You have the right to request
a review by a TRICARE Regional Review Authority (RRA) of any written
notice of noncoverage that you may receive from the hospital stating
that TRICARE will no longer pay for your hospital care. RRAs employ
groups of doctors under contract by the Federal Government to review
medical necessity, appropriateness and quality of hospital treatment
furnished to TRICARE patients. The phone number and address of the
RRA for your area are:
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Contractor’s Address
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Contractor's Toll-Free
Telephone Number
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Talk To Your Doctor About
Your Stay In The Hospital
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You and your doctor know more
about your condition and your health needs than anyone else. Decisions
about your medical treatment should be made between you and your
doctor. If you have any questions about your medical
treatment, your need for continued hospital care, your discharge,
your need for possible post-hospital care, don’t hesitate to ask
your doctor. The hospital’s patient representative
or social worker will also help you with your questions and concerns
about hospital services.
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If You Think You Are
Being Asked To Leave The Hospital Too Soon
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Ask a hospital representative
for a written notice of explanation immediately, if you have not
already received one. This notice is called a “notice of noncoverage.”
You must have this notice of noncoverage if you wish to exercise your
right to request a review by the RRA.
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The notice of noncoverage will
state whether your doctor or the RRA agrees with the hospital’s
decision that TRICARE should no longer pay for your hospital care.
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• If the hospital and your doctor
agree, the RRA does not review your case before a notice of noncoverage
is issued. But the RRA will respond to your request for a review
of your Notice of Noncoverage and seek your opinion. You cannot
be made to pay for your hospital care until the RRA makes its decision
if you request the review by noon of the first business
day after you receive the notice of noncoverage.
• If the hospital and your doctor
disagree, the hospital may request the RRA to review your case.
If it does make such a request, the hospital is required to send
you a notice to that effect. In this situation, the RRA must agree with
the hospital or the hospital cannot issue a notice of noncoverage.
You may request that the RRA reconsider your case after you receive
a notice of noncoverage, but since the RRA has already reviewed
your case once, you may have to pay for at least one day of hospital
care before the RRA completes this reconsideration.
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IF YOU DO NOT REQUEST A REVIEW,
THE HOSPITAL MAY BILL YOU FOR ALL THE COSTS OF YOUR STAY BEGINNING WITH
THE THIRD DAY AFTER YOU RECEIVE THE NOTICE OF NONCOVERAGE. THE HOSPITAL,
HOWEVER, CANNOT CHARGE YOU FOR CARE UNLESS IT PROVIDES YOU WITH
A NOTICE OF NONCOVERAGE.
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How To Request A Review
Of The Notice Of Noncoverage
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If the notice of noncoverage
states that your physician agrees with
the hospital’s decision:
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• You must make your request
for review to the RRA by noon of the first business
day after you receive the notice of noncoverage by
contacting the RRA by phone or in writing.
• The RRA must ask for your views
about your case before making its decision. The RRA will inform
you by phone and in writing of its decision on the review.
• If the RRA agrees with the
notice of noncoverage, you may be billed for all costs of your stay
beginning at noon of the day after you
receive the RRA’s decision.
• Thus, you will not be responsible
for the cost of hospital care before you receive the RRA decision.
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If the notice of noncoverage
states that the RRA agrees with the hospital’s
decision:
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• You should make your request
for reconsideration to the RRA immediately
upon receipt of the notice of noncoverage by contacting the RRA
in writing.
• The RRA can take up to three
business days from receipt of your request to complete a review.
The RRA will inform you in writing of its decision on the review.
• Since the RRA has already reviewed
your case once prior to the issuance of the notice of noncoverage,
the hospital is permitted to begin billing you for the cost of your
stay beginning with the third calendar day after you receive your
notice of noncoverage, even if the RRA has not completed
its review.
• Thus, if the RRA continues
to agree with the notice of noncoverage, you may have
to pay for at least one day of hospital care.
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Note: The process described above
is called “immediate review.” If you miss the deadline for this
immediate review while you are in the hospital, you may still request
a review of the TRICARE decision to no longer pay for your care
at any point during your hospital stay or after you have left the
hospital. The notice of noncoverage will tell you how to request
this review.
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Post-Hospital Care
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When your doctor determines
that you no longer need all the specialized services provided in
a hospital, but you still require medical care, he or she may discharge
you to a skilled nursing facility or to home care. The discharge planner
at the hospital will help arrange for the services you may need
after your discharge. TRICARE and supplemental insurance policies
have limited coverage for skilled nursing facility care and home
health care. Therefore, you should find out which services will
or will not be covered and how payment will be made. Consult with
your doctor, hospital discharge planner, Beneficiary
Counseling and Assistance Coordinator (BCAC), patient representative
and your family in making preparations for care after you leave
the hospital. Don’t hesitate to ask questions.
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Questions involving billing
or specific benefit coverage issues should be addressed to your
TRICARE claims processor which is:
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Contractor’s Address
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Contractor’s Toll-Free
Telephone Number
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Acknowledgment Of Receipt
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My signature only acknowledges
my receipt of this message from (Name of Hospital) on (Date) and
does not waive any of my rights to request a review or make me liable
for any payment.
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_______________________________________
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Signature Of Beneficiary Or
Person Acting On Behalf Of The Beneficiary
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_______________________________________
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Date Signed
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