1.0 REQUIREMENTS FOR REQUESTING
RECONSIDERATION
1.1 Must Be In Writing (To Include
Email)
1.2 Must
Be Made By A Proper Appealing Party
1.2.1 The contractor
or the TRICARE Quality Monitoring Contract (TQMC) contractor shall
advise the proper appealing party in plain writing (see
Addendum A, Figure 12.A-4) with a copy to
the improper appealing party. A blank Appointment of Representative
form shall be enclosed with the letter to the proper appealing party
(see
Addendum A, Figure 12.A-1).
1.2.2 The contractor
or the TQMC contractor shall treat a request for reconsideration
from a person who is not authorized to participate in the appeal
as a routine correspondence and add the request to the claim file.
The proper appealing party shall be told that an appeal must be
filed within 20 calendar days of the date of the contractor’s or
the TQMC contractor’s letter or by the expiration of the appeal
filing deadline, whichever is later.
Note: A network provider is never
a proper appealing party. Disputes between a network provider and
the contractor concerning authorization of services are not subject
to the appeal process. Because non-network, nonparticipating providers
are not proper appealing parties, non-network, nonparticipating
provider disputes regarding waiver of liability determinations are
addressed as allowable charge reviews rather than reconsideration reviews.
1.3 Must
Include An Appealable Issue
1.3.1 Appealable Issues
1.3.1.1 A TRICARE beneficiary making
use of the authorization process who requests authorization to receive services
and such authorization is denied by the contractor, may appeal even
though no care has been provided and no claim submitted (refer to
paragraph 7.2 and
Section 4, for additional information relating
to preadmission or pre-procedure denials).
1.3.1.2 The decision by the contractor
to cost-share services under the Point of Service (POS) option is
not appealable, with the exception of the issue of whether services
were related to an emergency and, therefore, exempt from the requirement
for referral and authorization.
1.3.1.2.1 The TRICARE Prime enrollee
must demonstrate that the care would qualify as an emergency under the
criteria for emergency care set forth in
32
CFR 199.4. Should the beneficiary prevail the amount cost-shared would
be the difference between the amount cost-shared under the POS option
and the amount that would have been cost-shared had the beneficiary
received the care from a network provider.
1.3.1.2.2 A determination by the contractor
that services received under the point-of-service option are not a
TRICARE benefit would be appealable as a medical necessity or factual
denial determination.
1.3.1.3 The decision by a contractor
to deny a request by the Primary Care Manager (PCM) to refer a beneficiary
to a specialist is an appealable issue, if the reason for the denial
is a determination by the contractor that a referral is not needed.
1.3.1.4 Concurrent review authorizations
granting 48 hours or less of additional services beyond the previous
authorization when the provider has requested more than 48 hours
of additional services. If the concurrent review authorization grants
more than 48 hours of additional services beyond the previous authorization,
but less than the period requested by the provider, an appeal does
not exist.
1.3.1.5 In such a case, the letter
authorizing the additional period would inform the provider that
a subsequent concurrent review will be conducted within 48 hours
prior to the expiration of the newly authorized period.
1.3.2 Non-appealable
Issues
The following
issues are not appealable and shall not be accepted for reconsideration.
They should be counted as correspondence for both workload reporting
and processing purposes.
1.3.2.1 Allowable Charge
1.3.2.1.1 The amount of the TRICARE-determined
allowable cost or charge for services or supplies is not appealable.
One example involving an allowable charge issue would be the contractor’s
decision to pay benefits under the POS option (absent any claim
that the care was emergency in nature and was, therefore, exempt
from the requirement for referral and authorization).
1.3.2.1.2 In cases involving contractor
cutbacks or downcoding of diagnoses or procedure codes, there is
no issue with respect to the medical necessity of the services provided
and therefore, no appealable issue (i.e., the contractor does not
determine that the services are not a benefit under TRICARE). The
sole issue in these cases is the level of payment for the medically
necessary services - an allowable charge issue. If, however, the
contractor cutback or downcoding results in the non-coverage of
a furnished service, then an appealable issue would exist.
1.3.2.2 Eligibility
Determination of a person’s
eligibility as a TRICARE beneficiary is not appealable since this
determination is the responsibility of the Uniformed Services, see
the TRICARE Policy Manual (TPM),
Chapter 10, Section 1.1.
1.3.2.3 Provider
Or Entity Sanction
1.3.2.3.1 If the decision to disqualify
or exclude a provider or entity because of a determination against
that provider or entity resulting from abuse or fraudulent practices
or procedures under another Federal or Federally-funded program
is not appealable, the provider or entity is limited to exhausting
administrative appeal rights offered under the federal or federally-funded
program that made the initial determination.
1.3.2.3.2 A determination to sanction
a provider or entity because of abuse or fraudulent practices or procedures
under TRICARE is an initial determination which is appealable under
32 CFR 199, see
Chapter 13. A sanction
imposed pursuant to
32 CFR 199.15(m) is appealable as described
in
32 CFR 199.15(m)(3).
1.3.2.4 Network
Provider Or Entity And Contractor Disputes
Disputes between a network
provider or entity and the contractor concerning payment for services
provided by the network provider are not appealable.
Note: Network pharmacies are not
subject to hold harmless provisions, and, therefore, beneficiary
liability and appeal rights arise from a denial issued at a network
pharmacy. The beneficiary may appeal such a denial.
1.3.2.5 Provider
Not Authorized
The denial
of services or supplies received from a provider not authorized
to provide care under TRICARE is not appealable.
1.3.2.6 Denial
Of A Treatment Plan
The denial
of a treatment plan when an alternative treatment plan is selected
is not appealable. Peer to peer dialogue resulting in selection
and approval of another treatment option is not a denial of care.
1.3.2.7 Denial
Of Services By A PCM
The refusal
of a PCM to provide services or to refer a beneficiary to a specialist
is not an appealable issue. A beneficiary who has been refused services
or a referral by a PCM may file a grievance under
Chapter 11, Section 8. The decision by the
contractor to deny a PCM’s request to refer a beneficiary to a specialist
is an appealable issue and is addressed in
paragraph 1.3.1.3.
1.3.2.8 Designation
Of Providers
The contractor’s
designation of a particular network or non-network provider to perform
requested services is not appealable.
1.3.2.9 Point
Of Service (POS)
The decision
by the contractor to cost-share services under the POS option is
not appealable, with the exception of the issue of whether the services
were related to an emergency and are therefore exempt from the requirement
for referral and authorization.
1.4 Must
Be Filed Timely
1.4.1 The contractor or TQMC contractor
shall treat an untimely request for reconsideration as routine correspondence,
and add the request to the claim file.
1.4.2 An appeal
must be filed before the expiration of the appeal filing deadline
or within 20 calendar days of the date of the contractor’s letter,
referenced in
paragraph 1.2. In calculating the number of
days elapsed, the day following the date of the previous determination
is counted as day “one” with the count progressing through actual
calendar days including the date the request is filed.
1.5 By
Mail
1.5.1 The contractor shall, if the
appeal is not filed in a timely manner, advise the appealing party
that the appeal cannot be accepted since the time limit for filing
was exceeded, based on the receipt date of the appeal request or
the postmark date on the envelope.
1.5.2 For the
purposes of TRICARE, a postmark is a cancellation mark issued by
the United States Postal Service (USPS) (i.e., private mail carriers
do not issue postmarks). If there is no postmark or the date of
the postmark is illegible, the date of receipt by the contractor
shall be used to determine timeliness of filing.
1.6 By
Facsimile
A request
for reconsideration submitted by facsimile (fax) is considered filed
on the date the fax is received by the contractor.
1.7 By
Electronic Mail (Email)
A request
for reconsideration submitted by email is considered filed on the
date the email is received by the contractor.
1.8 Must
State The Issue In Dispute And Include Previous Determination
1.8.1 The contractor
or the TQMC contractor shall supply a copy of the previous denial
determination notice from its files or shall initiate communication
with the appealing party to clarify the specific issue in dispute,
as appropriate.
1.8.2 The request should state the
specific issue in dispute and be accompanied by a copy of the previous denial
determination notice.
2.0 EXTENSION OF APPEAL FILING
DEADLINE
The contractor
or the TQMC contractor shall accept a request for reconsideration
notwithstanding the failure of the appealing party to provide a
copy of the previous denial determination notice or to state the
specific issue in dispute.
2.1 Extraordinary
Circumstances Are Limited To:
2.1.1 Administrative Error
2.1.1.1 Administrative error (e.g.,
misrepresentation, mistake or other accountable action) of an employee
of the contractor performing functions under TRICARE and acting
within the scope of that individual’s authority.
2.1.1.2 For example, an administrative
error would occur when a request for reconsideration was filed with the
contractor before the expiration of the appeal filing deadline but
the envelope containing the reconsideration request was misplaced
by the contractor. In such a case, the misplacement of the envelope
by the contractor would constitute an extraordinary circumstance
over which the appealing party had no practical control, thereby permitting
late filing of the appeal, unless it could be determined that:
• The letter requesting the reconsideration
was dated after the reconsideration filing deadline; or
• Other circumstances would lead
to the conclusion that the reconsideration request could not have
been postmarked on or before the reconsideration filing deadline
(for example, the reconsideration request was received by the contractor
30 calendar days after the reconsideration filing deadline).
2.1.2 Mental
Or Physical Incapacity Of The Beneficiary
Mental or physical incapacity
of the beneficiary causing an inability to communicate when the
beneficiary is the appealing party.
2.2 Requests
For Extension
The contractor
and the TQMC contractor shall return all requests for extension
of the appeals filing deadline to the requesting party that the
request for extension may not be considered until a request for
reconsideration has been received. There must have been a denial
of an appeal, due to lack of timely filing, before an extension
can be considered.
3.0 RECEIPT
AND CONTROL OF APPEALS
3.1 Date Stamp
The contractor shall stamp
all reconsideration requests with the actual date of receipt within
three business days of receipt.
3.2 Control
3.2.1 The contractor
shall establish a single centralized appeals department and establish
and maintain a single automated system for the control, location,
and tracking time lines of appeals received. Appeals may be processed
at more than one location but all appeals shall be managed and controlled
by the centralized appeals department.
3.2.2 The contractor
shall respond to inquiries on a timely basis determined n from the
actual date of receipt by the contractor, rather than the date the
inquiry was received or imaged by the appropriate responding department.
3.3 Acknowledgment
Of Receipt Of Request For Reconsideration
3.3.1 The contractor
shall provide an interim written response for all reconsiderations
not processed to completion in accordance with
Chapter 1, Section 3, advising the appealing
party of the estimated date of issuance of the reconsideration determination.
3.3.2 A preprinted
postcard may be used if information covered by the Privacy Act and
the Health Insurance Portability and Accountability Act (HIPAA)
is not disclosed.
3.3.3 Email and facsimile may be
used to respond to the appealing party, provided the contractor
first obtains written permission from the appealing party to use
email or facsimile for communicating information regarding his or
her appeal.
3.4 Timeliness Standards
3.4.1 Sections 4,
5, and
6 include
standards relating to timely issuance of reconsideration determinations
and timely submission of appeals case files to the TQMC contractor
and to the Appeals and Hearings Division.
3.4.2 Standards
are expressed in either calendar days or business days. To determine
whether timeliness has been met relating to a standard expressed
in business days, the first business day following receipt by the contractor
or TQMC contractor of the request for reconsideration, or request
for the appeal file, is counted as day one of the timeliness requirement.
3.4.3 To determine
whether timeliness has been met relating to a standard expressed
in calendar days, the first calendar day following receipt by the
contractor or TQMC contractor of the request for reconsideration
is counted as day one of the timeliness requirement.
4.0 RECONSIDERATION
REVIEWER QUALIFICATIONS AND ADMINISTRATIVE REQUIREMENTS
4.1 Reviewer
Qualifications
If the
reconsideration determination is based on lack of medical necessity
or other reason relative to reasonableness, necessity, or appropriateness,
the reconsideration reviewer must be someone who is:
4.1.2 Not the
individual who made the initial denial determination; and
4.1.3 A peer
of the provider of services under review.
Exception: A reconsideration
determination fully overturning the initial denial determination
can be made by the reviewer who issued the initial denial determination.
4.2 Administrative Requirements
4.2.1 Each review
shall be dated and include the signature, legibly printed name,
clinical specialty, and credentials of the reviewer.
4.2.2 Each reviewer
shall include rationale for his or her decision (i.e., a complete
statement of the evidence and the reasons for the decision). In
addition, the name and title of the individual issuing the reconsideration determination
shall be included in the Appeal Summary Log (
Addendum A, Figure 12.A-2).
4.2.3 If the
appeal file is forwarded to Defense Health Agency (DHA), a completed
Professional Qualifications form (
Addendum A, Figure 12.A-3) must be included
in the file for each reviewer.
4.3 Additional
Documentation
4.3.1 The contractor and the TQMC
contractor shall request and make every reasonable effort to obtain
any documentation required to arrive at a proper reconsideration
determination. This includes follow-up letters or documented telephone
calls if requested information is not received.
4.3.2 An appeal
involving inpatient admission or Length-Of-Stay (LOS) may require
obtaining the entire hospital record. Whenever records are required,
the contractor or the TQMC contractor shall request such records directly
from the provider. Written or verbal statements made by beneficiaries
regarding their medical conditions are not a substitute for medical
records.
4.3.3 The TQMC contractor may make
the determination on the information available in its records if
there are no extenuating circumstances alleged and no added information
furnished or referenced.
4.3.4 Improperly developed or incomplete
appeal files received by DHA may be returned to the contractor or the
TQMC contractor for additional development, completion, and, if
appropriate, issuance of a revised reconsideration determination.
4.3.5 Due to
the time constraints involved in expedited preadmission or pre-procedure
appeals, fully documenting a case file may not be possible. Requirements
for documenting case files for expedited preadmission or pre-procedure
appeals is addressed in
Section 4.
4.4 File
Documentation (In Other Than Provider Termination Cases)
4.4.1 The contractor
and the TQMC contractor shall carefully review the initial determination
and all pertinent evidence and documentation obtained at reconsideration
in light of the applicable provisions of 32 CFR 199, this manual,
the TPM, the TRICARE Reimbursement Manual (TRM) and all other relevant
guidelines and instructions issued by DHA.
4.4.2 The reconsideration
determination shall be based on the facts of the case as shown in
the evidence and shall be supported by appropriate citations from
32 CFR 199, which shall be cited in the reconsideration determination.
4.5 File
Content, Requirements, And Structure
4.5.1 The contractor
and the TQMC contractor shall document all determinations made at
the reconsideration level in sufficient detail so that, if the next
level of appeal is pursued, a subsequent reviewer shall be provided
with a clear and complete picture of all actions taken on the case
to that point.
4.5.1.1 All material related to the
reconsideration shall be made part of the permanent claim file.
4.5.1.2 The copy of the appeal file
provided by the contractor to the TQMC contractor or DHA must be complete,
including the Appeal Summary Log (
Addendum A, Figure 12.A-2) and the Professional
Qualifications form (
Addendum A, Figure 12.A-3). Likewise, the
copy of the appeal file provided by the TQMC contractor to DHA must
be complete and include the file received by the TQMC contractor
from the contractor. In addition, the TQMC contractor must complete
and include its portion of the Appeal Summary Log.
4.5.2 The contractor
and the TQMC contractor shall retain and completely document the
file or files for all claims involved in the appeal.
4.5.2.1 The contractor may establish
a separate appeal file containing all documents related to the appeal,
or can gather all documents related to the appeal, including the
completed Appeal Summary Log and Professional Qualifications Statement,
into an appeal file when the file is requested by the TQMC contractor
or DHA.
4.5.2.2 The contractor and the TQMC
contractor, irrespective of the method, shall be responsible for furnishing
the required appeal file to the entity performing the next level
of appeal within required time periods, if an appeal request is
filed.
4.5.3 Appeal
Case File
4.5.3.1 The contractor shall assemble
and forward case files to the office conducting the next level of
appeal in the format described herein. Failure to comply may result
in return of the case file for assembly consistent with this paragraph.
Case files shall consist of:
• A table of contents shall be
the first page of the case file and will describe the contents of
each tabbed section and subsection.
• All documents within sections
shall be arranged in chronological order based on document date,
not date of receipt.
• Summary Explanations of Benefits
(EOBs) shall be redacted to remove information not associated with
the beneficiary relevant to the appeal.
Note: All documents shall be complete
and legible. Tabbed sections for electronic files may be substituted
with cover pages containing headings to distinguish required sections.
Note: Documents in landscape orientation
shall be assembled with the heading on the left and case file shall not
contain duplicate copies of documents. However, it may be necessary
to copy documents to ensure each section contains a complete set
of relevant documents. For example, at times, documents such as
claims or EOBs contain handwritten notes. A copy or copies should
be made of such documents, originals returned to the appropriate
sections (such as the claims or EOB sections), and the copy or copies
placed in the section(s) appropriate for the notes. Likewise if
a document contains an attachment or enclosure, if the attachment
or enclosure falls within the category of documents under a separately
tabbed section or sections, the document shall be copied and the
copies placed in the appropriate sections, ensuring originals remain
with the document to which they were attached or enclosed.
4.5.3.2 The contractor shall ensure
the documents within the appeal case file be organized by the following tabbed
sections, as applicable. Tabbed sections for electronic files may
be substituted with cover pages containing headings to distinguish
required sections.
4.5.3.2.1 Appeal Summary Log
4.5.3.2.2 Determinations
Include requests for preadmission
or pre-procedure authorization, if any. Include requests for reconsideration
and the envelope in which they were delivered. Include acknowledgments
of requests for reconsideration.
• Initial
• Reconsideration
• TQMC contractor reconsideration
4.5.3.2.3 Peer
reviews
Signed
peer review opinions as referenced in
paragraph 4.2. Include requests
for peer review. Attach the professional qualifications of each
peer reviewer (see
Addendum A, Figure 12.A-3).
• Initial
• Reconsideration
• TQMC contractor reconsideration
4.5.3.2.4 Documentation
Do not add claims, EOB forms,
or medical records to this section. Documents appropriate for this
section include, but are not limited to, records of telephone contacts,
requests for medical and other documentation received or obtained
prior to rendering the initial or reconsideration determination,
other documentation received or obtained prior to rendering the
initial or reconsideration determination, requests for additional
evidence and information from the appealing party, and additional
evidence or information submitted by the appealing party.
4.5.3.2.5 Claims related to the Episode
of Care (EOC), with attachments (in chronological order with no duplicates).
4.5.3.2.6 EOB forms (in chronological
order with no duplicates).
4.5.3.2.7 Medical records (in chronological
order with no duplicates).
4.6 File
Documentation For A Provider Termination Case
The contractor shall follow
the file documentation requirements in provider termination cases,
see
Chapter 13, Section 5.
6.0 NOTICE
TO APPEALING PARTY OF RESULTS OF RECONSIDERATION
6.1 The contractor
and the TQMC contractor shall inform the appealing party (or the
representative, if a representative has been appointed) of the reconsideration
determination in plain writing in accordance with the timeliness
standards set forth in
Chapter 1, Section 3.
6.1.1 The reconsideration
determination shall be typewritten or computer-printed in its entirety.
At the request of the appealing party, a reconsideration determination
may be sent by facsimile or by email, followed by mailing a hardcopy.
All claims that relate to the same incident of care, or the same
type of service to the beneficiary shall be addressed in a single
reconsideration determination.
6.1.2 The contractor
shall provide a copy for the reconsideration determination to the
beneficiary in accordance with the timeliness standards set forth
in
Chapter 1, Section 3 if the appealing party
is a non-network participating provider. Conversely, the non-network
participating providers shall be furnished copies of the determination
if the beneficiary filed the appeal.
6.1.3 The notice
shall include a caption identifying:
• The beneficiary (including
what plan the beneficiary is covered under);
• The sponsor;
• The last four digits of sponsor’s
Social Security Number (SSN);
• The type of care (e.g., Residential
Treatment Center (RTC) care, outpatient psychotherapy, mammography, substance
abuse, dental);
• The date(s) of service, the
date(s) of service in dispute;
• Whether the appeal was processed
as a preauthorization, concurrent review, or retrospective review;
• The providers (identifying
each provider as network or non-network participating, or non-network nonparticipating).
6.2 The notice
shall include the following headings:
6.2.1 Statement
Of Issues
The contractor
and the TQMC contractor shall summarize the issue or issues under
appeal and shall be clear and concise. All issues shall be addressed;
for example, a reconsideration determination in all cases requiring preadmission
authorization shall address the requirement for preadmission authorization
of the care as well as whether the requirement was met.
6.2.2 Applicable
Authority
6.2.2.1 The contractor and the TQMC
contractor shall briefly discuss the relevant provisions of law, regulation,
TRICARE policy, or TRICARE guidelines on which the determination
was made. Include pertinent specific citations and quotations of
applicable text.
6.2.2.2 The contractor shall omit authority
that is not applicable to the case under review (e.g., when citing cosmetic
surgery policy, the contractor need not include a listing of all
procedures considered by TRICARE to constitute cosmetic surgery,
but should quote only the procedure(s) applicable to the case under
review).
6.2.3 Discussion
6.2.3.1 The contractor and the TQMC
contractor shall address the original and any added information relevant
to the issue(s) under appeal, clearly and concisely, and shall state
the patient’s condition, including symptoms. One or two paragraphs
will suffice unless the issues are complex.
6.2.3.2 The contractor and the TQMC
contractor shall include a discussion of any secondary issues raised
by the appealing party or which may have been discovered during
the reconsideration process.
6.2.4 Decision
6.2.4.1 The contractor and the TQMC
contractor shall state the decision and whether the reconsideration upholds
or reverses the original decision in whole or in part, and clearly
and concisely state the rationale for the decision (i.e., fully
state the reasons that were the basis for the approval or denial
of TRICARE benefits). If specific TRICARE benefit criteria must
be met, the patient’s medical condition must be related to each
criterion and a finding made concerning whether each criterion is
met.
6.2.4.2 The contractor and the TQMC
contractor shall state the amount in dispute remaining as a result
of the decision and how the amount in dispute was determined (calculated),
and also state whether payments are to be recouped.
6.2.5 Waiver
Of Liability
6.2.5.1 The contractor and the TQMC
contractor shall include a statement explaining waiver of liability determination
as applied to the beneficiary and to each provider, including the
rationale for each decision.
6.2.5.2 Waiver of Liability provisions
are only applicable to denials as described in
Section 4 for
applicable cases.
6.2.5.3 A beneficiary found not to
be liable for the entire EOC will not be offered further appeal
rights. Refer to the TPM,
Chapter 1, Section 4.1 for information relating
to waiver of liability.
6.2.6 Hold
Harmless
6.2.6.1 The contractor and the TQMC
contractor shall include, in applicable cases, a statement explaining hold
harmless, including how the provision is waived, the beneficiary’s
right to a refund, the method by which a beneficiary can request
a refund, and must provide information regarding from what entity
a refund can be requested (see
Chapter 5, Section 1). Hold harmless provisions
are applied only to care provided by a network provider.
6.2.6.2 Suggested wording for inclusion
in a reconsideration determination when the provider is a network provider
is provided at
Addendum A, Figure 12.A-11.
6.2.7 Point
Of Service (POS)
6.2.7.1 The contractor and the TQMC
contractor shall provide beneficiaries who enroll in TRICARE Prime
full and fair disclosure of any restrictions on freedom of choice
that may be applicable to beneficiaries, including the POS option.
6.2.7.1.1 The contractor and the TQMC
contractor shall explain the right of the beneficiary to exercise
the POS option and its effect on the payment of benefits for services
determined to be medically necessary (additional information about
the POS option can be found in the TRM,
Chapter 2, Section 3).
6.2.7.1.2 The POS option is available
to TRICARE Prime beneficiaries who seek or receive non-emergency specialty
or inpatient care, either within or outside the network which is
neither provided by the beneficiary’s PCM nor referred by the PCM,
nor authorized by the contractor.
6.2.7.2 The contractor and the TQMC
contractor shall include the following language in a reconsideration determination
where the beneficiary is TRICARE Prime:
“Should you, as a TRICARE Prime
beneficiary, elect to proceed with this service and the service
is provided by a non-network provider, and provided the service
is found upon appeal to have been medically necessary, benefits
will be payable under the deductible and cost-share amounts for Point-of-Service
claims and your out-of-pocket expenses will be higher than they
would be had you received the service from a network provider. No
more than 50% of the allowable charge can be paid by the Government
for care provided under the Point-of-Service option.”
6.2.8 Appeal
Rights
The contractor
and the TQMC contractor shall state whether further appeal rights
are available if the determination is denied in whole or in part.
6.2.8.1 Contractor
Medical Necessity Reconsideration Determinations
The contractor shall include
a statement explaining the right of the beneficiary (or representative)
and the non-network participating provider to request an appeal
to the TQMC contractor for a second reconsideration if the contractor
reconsideration determination is denied in whole or in part, and
$50 or more remains in dispute. The contractor statement shall include
the time frames to file an appeal of the contractor reconsideration determination
are as follows:
6.2.8.2 Expedited Preadmission or Pre-procedure
Reconsiderations
6.2.8.2.1 The contractor shall notify
the beneficiary to file the appeal request with the TQMC contractor within
three calendar days after the date of receipt of the initial reconsideration
determination.
6.2.8.2.2 The date of receipt of the
appeal request by the TQMC contractor will be considered to be five calendar
days after the date of mailing, unless the receipt date is documented.
6.2.8.2.3 A request for reconsideration
filed with the TQMC contractor by the beneficiary more than three calendar
days after the date of receipt but within 90 calendar days from
the date of the initial reconsideration determination will be addressed
as a non-expedited reconsideration.
6.2.8.3 Non-expedited
Reconsiderations
The contractor
shall notify the beneficiary or non-network participating provider
to file the appeal request with the TQMC contractor within 90 calendar
days after the date of the initial reconsideration determination.
Note: Refer to
Section 4 for
the appeal process in concurrent review cases.
6.2.8.4 Factual
Reconsideration Determination Based on Statute or Regulation
6.2.8.4.1 If the reconsideration determination
upholds the denial based on a statutory or regulatory exclusion,
further appeal shall not be offered to challenge the statutory or
regulatory exclusion. Further appeal is available, however, to challenge
whether the exclusion was appropriately applied.
6.2.8.4.2 The contractor shall include
the following language for the appeal rights section of reconsideration determinations
upholding denials based on statutory or regulatory exclusions:
“An administrative reconsideration
review is available under the TRICARE appeal process when a denial
is based on a requirement of law or regulation. However, because
disputes challenging a requirement of law or regulation do not present
an appealable issue, they are ineligible for appeal to a formal
review or hearing. Since the disputed care in this case is excluded
by law or regulation, further appeal is not authorized. This reconsideration
determination completes the administrative appeal process under
32
CFR 199.10, and no further administrative appeal is available.
Although disputes challenging
a requirement of law or regulation are not appealable to a formal review
or hearing, further appeal to a formal review or hearing is available
to dispute whether the law or regulation was properly applied if
other requirements are satisfied, such as the requisite amount in
dispute. For example, services and supplies related to treating
obesity are excluded by law and regulation when obesity is the only
or the major condition being treated. If a service or supply was
provided to treat hypertension, but the obesity exclusion was erroneously
applied, an appeal may be filed to challenge the erroneous application
of the obesity exclusion. As a further example, if law or regulation
excludes durable medical equipment, but the actual service provided was
for a prosthetic device, an appeal may be filed on the grounds that
the durable medical equipment exclusion was incorrectly applied
to the prosthetic device coverage determination.”
6.2.8.5 Reconsideration
Determinations Issued By The TQMC Contractor
6.2.8.5.1 The TQMC contractor shall include
a statement explaining the right of the beneficiary (or representative)
and the non-network participating provider to file a request for
hearing with DHA, if the reconsideration determination issued by
the TQMC contractor is denied in whole or in part and $300 or more remains
in dispute.
6.2.8.5.2 A request for hearing must
be postmarked or received by DHA within 60 calendar days from the date
of the notice on the reconsideration determination issued by the
TQMC contractor. Refer to
paragraph 7.2 regarding hearings in preadmission
or pre-procedure cases in which the requested service(s) have not commenced.
6.2.8.6 When
the Amount Required to File an Appeal Remains in Dispute
Section 2 contains
the requirements for the amount in dispute.
6.2.8.6.1 Non-Expedited
Reconsideration Determination
Suggested wording for a non-expedited
reconsideration can be found at
Addendum A, Figure 12.A-12.
6.2.8.6.2 Expedited
Preadmission or Preprocedure Reconsideration Determination (include
in addition to
Addendum A, Figure 12.A-12)
“The TRICARE beneficiary, or
the appointed representative of the beneficiary, has the alternative
of requesting an expedited reconsideration. The request must be
in writing, be signed and must be received by (insert the TQMC name,
postal address, email address, and fax number) within three business
days after the receipt of this denial determination, and must include
a copy of this denial determination. A request for an expedited
reconsideration filed after the three day appeal filing deadline
will be accepted as a non-expedited request for reconsideration.
It is recommended that any additional documentation you may wish
to submit be submitted with the request for expedited reconsideration.
Upon receiving your request, all TRICARE claims related to the entire
course of treatment will be reviewed.”
6.2.8.7 Amount
In Dispute Less Than The Amount Required To File An Appeal
The contractor or the TQMC
contractor shall notify the appealing party or representative that
the reconsideration determination is final and no further administrative
appeal is available for those cases in which the amount in dispute
is less than the amount required to file an appeal (refer to
Section 2 for required amount in dispute).
The following is suggested wording:
“Because the amount in dispute
is less than (insert required amount in dispute), this reconsideration
determination is final and there are no further appeal rights available.”
7.0 EFFECT
OF THE RECONSIDERATION DETERMINATION
7.1 The reconsideration determination
is final and binding upon all parties unless:
7.1.1 The amount
in dispute meets the jurisdictional requirements required to file
an appeal (refer to
Section 2 regarding requirements for an amount
in dispute), appeal rights were offered in the notice of denial
at the reconsideration (or second reconsideration) level, and a
request for a second reconsideration, formal review, or hearing,
as applicable, is either postmarked or received by the appeal filing
deadline; or
7.1.2 The contractor’s reconsideration
(or TQMC contractor’s second reconsideration) decision is reopened and
revised by the contractor or the TQMC contractor, either on its
own motion or at the request of a party, within one year from the
date of the reconsidered determination; or
7.1.3 The contractor’s
reconsideration (or the TQMC contractor’s second reconsideration)
is reopened and revised by the contractor or the TQMC contractor,
after one year but within four years, because: new and material evidence
is received; a clerical error in the reconsideration determination
is discovered; the contractor or the TQMC contractor erred in an
interpretation or application of TRICARE coverage policy; or an
error is apparent on the face of the evidence upon which the reconsideration
(or second reconsideration) determination was based; or
7.1.4 The contractor’s
reconsideration (or the TQMC contractor’s second reconsideration)
is reopened and revised by the contractor or the TQMC contractor
at any time, if the reconsideration (or second reconsideration) determination
was obtained through fraud or an abusive practice, e.g., describing
services in such a way that a wrong conclusion is reached; or
7.1.5 The contractor’s
reconsideration (or the TQMC contractor’s second reconsideration)
is reversed upon appeal at a hearing in accordance with the provisions
of
32 CFR 199.10 and
199.15.
7.1.5.1 Beneficiaries may appeal a
TQMC contractor reconsideration determination to DHA and obtain
a hearing on such appeal to the extent allowed under the procedures
in
32 CFR 199.10(d).
7.1.5.2 A non-network participating
provider may appeal a TQMC contractor reconsideration determination to
DHA and obtain a hearing on such appeal to the extent allowed under
the procedures in
32 CFR 199.10(d). The issue in a hearing requested
by a provider is limited to waiver of liability (i.e., whether the
provider knew or could reasonably have been expected to know that
the services were excludable) (refer to
Section 4. Because
waiver of liability applies only to services retrospectively determined
to be potentially excludable, waiver of liability will not apply
in concurrent review or preadmission or pre-procedure cases (i.e.,
non-network participating providers may request hearings only in
cases involving retrospective determinations with the issue being
limited to waiver of liability).
7.2 Further appeal of a preadmission
or pre-procedure denial to the hearing level is not permitted unless
the requested services have commenced.
7.2.1 An appeal
to a hearing where the services have not commenced is not allowed
because there would not be an adequate remedy should the hearing
final decision hold in favor of the beneficiary. This is because
the issue at hearing would be whether the medical documentation
at the time of the request for preadmission or pre-procedure demonstrated
medical necessity for the services requested.
7.2.2 A final
decision issued as a result of the hearing process (which may take
several months to complete) holding that the beneficiary met the
requirements for preadmission or pre-procedure on the date the preadmission
or pre-procedure request was made could not be implemented as the
circumstances that warranted the services at the time of the initial
request would unquestionably have changed.
8.0 CASES
REMANDED AT DHA’S DISCRETION
8.1 At the discretion of DHA, appeal
cases may be returned to the contractor for processing without the issuance
of a formal review or hearing decision. These cases will normally
involve instances in which a processing error has resulted in a
denial or partial denial of a claim; instances in which the contractor
has failed to obtain additional documentation as required by
paragraph 4.3;
instances in which the contractor has failed to address the entire
EOC; instances in which the contractor has erroneously identified
a medical necessity issue as a factual issue and vice-versa; instances
in which the contractor has failed to complete the Appeal Summary
Log; and instances in which the contractor has failed to offer appropriate
appeal rights. Also, DHA, in reviewing the appeal, may obtain information
that resolves the issues without further review by DHA. If the case
is returned for reprocessing, for record purposes the case will
be treated as a new request for reconsideration (
Chapter 1, Section 3 will apply and the returned
case will be reported for workload purposes).
8.2 The contractor
shall, if necessary, develop for additional documentation and issue
a revised reconsideration determination based on the merits of the
claim.
8.3 The contractor shall offer
additional appeal rights, if applicable.
The contractor shall maintain
the record of its reconsideration determinations in accordance with
the requirements of
Chapter 9, Section 2.
10.0 CONTRACTOR
PARTICIPATION IN THE FORMAL REVIEW AND HEARING
10.1 The contractor
shall participate in formal reviews and hearings as requested by
DHA, to include but not limited to submission of written documentation,
and serving as a witness.
10.2 The contractor shall provide
all documentation within 10 calendar days after DHA notification.
10.3 The contractor
shall participate as a witness in hearings upon notification by
DHA. DHA will advise the contractor of the time and place of the
hearing.
10.4 The contractor and the TQMC
contractor shall notify DHA of the receipt of any additional claims
or documentation and submit copies to DHA within 10 calendar days.