2.1 Regulatory
Background
TRICARE
supplements the availability of health care in military hospitals
and clinics. Services and items allowable as TRICARE benefits must
be obtained from TRICARE-authorized civilian providers to be considered
for payment. The Code of Federal Regulations (CFR),
32
CFR 199.6 along with the TRICARE Policy Manual (TPM),
establishes the specific requirements for institutional and professional
providers recognized for payment under the program. These requirements
have been used to ensure that providers possess licensing/credentials
and/or meet recognized standards unique to their provider status,
profession, or field of medicine. In the past, TRICARE has only
recognized three classes of providers; i.e., 1) an institutional
provider class consisting of hospitals and other categories of similar
facilities; 2) an individual professional provider class including
physicians and other categories of licensed individuals who render
professional services independently, and certain allied health and
extra medical providers that must function under physician orders
and supervision; and 3) a class of providers consisting of suppliers
of items and supplies of an ancillary or supplemental nature, such
as Durable Equipment (DE)/Durable Medical Equipment (DME). However,
since the CFR and policy provisions were first established, the
manner in which medical services are delivered has changed. TRICARE
beneficiaries, like other health care consumers, now have access
to a wide array of health care delivery systems that were not initially
recognized or reimbursed under the Program. As a result, a fourth
class of TRICARE provider has been established consisting of freestanding corporations
and foundations that render principally professional, ambulatory
or in-home care and technical diagnostic procedures. The addition
of the corporate class recognizes the current range of providers
with today’s health care delivery structure, and gives beneficiaries
access to another segment of the health care delivery industry.
2.2 Scope of Coverage/Reimbursement
2.2.1 Out-of-System/Non-Network Reimbursement.
The intent of this provider class expansion (recognition of CSPs
as authorized providers under TRICARE) is not to create additional
benefits that ordinarily would not be covered under TRICARE if provided
by a more traditional health care delivery system (i.e., care traditionally
offered in a hospital setting), but rather to allow those services
which would otherwise be allowed except for an individual provider’s
affiliation with a freestanding corporate entity. A provider qualifying
for CSP status under TRICARE would be allowed payment for the following
services and supplies:
2.2.1.1 Otherwise covered professional
services provided by TRICARE-authorized individual providers employed
by or under contract with a freestanding corporate entity will be
paid under the CHAMPUS Maximum Allowable Charge (CMAC) reimbursement
system, subject to any restrictions and limitations as may be prescribed under
existing TRICARE policy.
2.2.1.2 Payment will also be allowed
for supplies used by a TRICARE authorized individual provider employed
by or contracted with a CSP in the direct treatment of a TRICARE
eligible beneficiary. Allowable supplies will be reimbursed in accordance
with TRICARE allowable charge methodology as described in TRICARE Reimbursement
Manual (TRM),
Chapter 5, Section 1.
2.2.1.3 Reimbursement of covered professional
services and supplies will be made directly to the TRICARE authorized
CSP under its own tax identification number.
2.2.1.4 Payment will be allowable for
services rendered in the authorized CSP’s place of business, or
in the beneficiary’s home, under such circumstances as the contractor
determines to be needed for the efficient delivery of such in-home
services.
2.2.2 Alternative
Network (In-System/Network) Reimbursement Systems. There are regulatory
and contractual provisions currently in place that grant contractors
the authority to establish alternative network reimbursement systems
as long as they don’t exceed what would have otherwise been allowed
under Standard TRICARE payment methodologies as described in the
TRM.
2.2.2.1 Establishment of alternative
reimbursement systems for CSPs will allow contractors and TRICARE beneficiaries
access to a wide source of competitive ambulatory and in-home services
while at the same time maintaining budget neutrality; i.e., there
should be no increases in benefit costs since the services would
have otherwise been provided in an institutional setting on either
an inpatient or outpatient basis.
2.2.2.2 Since it is assumed that ambulatory
services will be less expensive than when provided in an institutional
setting, it is expected that the contractor will be able to establish
rates which will result in significant savings to the Government.
For example, under non-network (out-of-system) reimbursement methodologies, freestanding
bone marrow transplant centers will be restricted solely to payment
of professional services and related supplies which account for
only 10% to 20% of the total program charges for autologous bone
marrow transplants. The remaining 70% to 80% of the charges will
be attributable to technical and/or facilities fees. The services
will include but are not limited to: 1) laboratory charges; 2) pre-conditioning
chemotherapy; 3) growth factor; 4) home health; 5) catheter placement;
6) blood products; and 7) recovery post discharge. Under the above alternative
reimbursement provisions, contractors will be given the flexibility
of negotiating with network providers (i.e., freestanding outpatient
bone marrow transplant centers who agree to become network providers) for
outpatient bone marrow transplants at rates below those performed
in a hospital setting, which would include CMAC rates for professional
fees plus the Diagnosis Related Group (DRG) amount.
2.2.2.3 The contractor shall adhere
to the following minimal requirements in the establishment of alternative reimbursement
methodologies for in-system/network CSPs in order to ensure quality
of care and fiscal accountability:
2.2.2.3.1 Alternative reimbursement methodologies
may include and/or be a combination of fee schedules, discounts
from usual and customary fees or CMAC, flat fee arrangements (negotiated
all inclusive rates), capitation arrangements, discounts off of
DRGs, per diems; or such other method as is mutually agreed upon,
provided such alternative payments do not exceed what would have
otherwise been allowed under Standard TRICARE payment methodologies
in another setting (e.g., comparable services rendered in a hospital
inpatient or outpatient setting).
2.2.2.3.2 Payments in full (e.g., negotiated
flat fees, all-inclusive global fees, captitation arrangements, discounts
off of DRGs and per diems) are prospective reimbursement systems
which may include items related or incidental to the treatment of
the patient but for which coverage is not normally extended under
TRICARE. These incidental services are to be included in the negotiated
prospective payment rate; i.e., they can neither be billed to the
beneficiary or deducted from the negotiated global rate.
2.2.3 All billing for CSPs should
be submitted on a Centers for Medicare and Medicaid Services (CMS)
1500 Claim Form. Defense Health Agency (DHA) will assign Pricing
Rate Codes (e.g., assigning a Pricing Rate Code GP for non-institutional
per diem rates) to accommodate approved alternative reimbursement
systems.
2.2.4 The contractor shall designate
the coding that it wants to use as part of the alternative reimbursement request
submitted to the DHA or designee for review and approval.
2.2.5 The contractor shall determine
the appropriate procedural category of a qualified organization
and may change the category based upon the provider’s TRICARE claim
characteristics. The category determination is conclusive and may
not be appealed.
2.2.6 The corporate
entity will not be allowed additional facility charges that are
not already incorporated into the professional services fee structure
(i.e., facility charges that are not already included in the overhead
and malpractice cost indices used in establishing locally-adjusted
CMAC rates).
2.2.7 While the expanded provider
category will allow coverage of professional services for corporate entities
qualifying for provider authorization status under the provisions
of this policy, it will at the same time restrict coverage of professional
services for those corporate entities which cannot meet the criteria
for CSP status under TRICARE.
2.3
Conditions
for Coverage/Authorization
2.3.1 Be a corporation
or a foundation, but not a professional corporation or professional
association;
2.3.2 Be institution-affiliated or
freestanding;
2.3.3 Provide
services and related supplies of a type rendered by TRICARE individual
professional providers employed directly or contractually by a corporation,
or diagnostic technical services and related supplies of a type which
requires direct patient contact and a technologist who is licensed
by the state in which the procedure is rendered or who is certified
by a Qualified Accreditation Organization;
2.3.4 Provide
the level of care that does not necessitate that the beneficiary
be provided with on-site sleeping accommodations and food in conjunction
with the delivery of the services except for sleep disorder diagnostic
centers in which on-site sleeping accommodations are an integral
part of the diagnostic evaluation process.
2.3.5 Render
services for which direct or indirect payment is expected to be
made by TRICARE only after obtaining written authorization (i.e.,
comply with applicable TRICARE authorization requirements before
rendering designated services or items for which TRICARE cost-share/copayment
may be expected);
2.3.6 Comply
with all applicable organizational and individual licensing or certification
requirements that exist in the state, county, municipality, or other
political jurisdiction in which the corporate entity provides services;
2.3.7 Maintain Medicare approval
for payment when the contractor determines that a category, or type,
of provider is substantially comparable to a provider or supplier
for which Medicare has regulatory conditions of participation or
conditions of coverage, or when Medicare approved status is not
required, be accredited by a qualified accreditation organization,
as defined in
Section 12.2; and
2.3.8 Has entered
into a negotiated provider contract with a network provider or a
participation agreement with a non-network provider which at least
complies with the minimum participation agreement requirements set forth
in
Section 12.3. The participation agreement
will accompany the application form (Application for TRICARE-Provider
Status: CORPORATE SERVICES PROVIDER) sent out as part of the initial
authorization process for non-network providers as described below.
2.4 Application Process
2.4.1 The contractor shall use the
information collected on the “Application for TRICARE-Provider Status: CORPORATE
SERVICES PROVIDERS” (i.e., the information collection form for which
the provider is seeking TRICARE authorization status) in determining
whether the provider meets the criteria for authorization as a CSP
under the TRICARE program (refer to
Addendum C for
a copy of the CSP application form).
2.4.2 The application
will be sent out and information collected when a:
2.4.2.1 Provider requests permission
to become a TRICARE provider;
2.4.2.2 Claim is filed for care received
from a provider who is not listed on the contractor’s provider file;
or
2.4.2.3 Formerly TRICARE authorized
provider requests reinstatement.
2.4.3 The contractor
shall verify that the provider meets TRICARE authorization criteria
through the collection and review of applicable Medicare, the Joint
Commission (TJC), and state and national board certificates/licenses
requests on the CSP application form.
2.4.4 The authorization
process is streamlined (simplified) in that the individual authorization
of professional providers employed by or under contract with a corporate
entity will not be required as part of the authorization process.
2.4.4.1 Instead, the responsibility
for ensuring all individuals meet TRICARE requirements is placed
on the corporate entity itself.
2.4.4.2 This assurance is further strengthened
by requiring Medicare approval for payment as a condition of authorization
under TRICARE, since Medicare also relies on the delegation of certification
of individual professional and allied health care providers to the
corporate entity.
2.4.4.3 Although the actual provider
of care will still have to be identified on the claim form, verification
of the qualifications of employed and contracted individual providers
will not be required by the contractors. In the case where the individual
(e.g., technician) providing the service does not have a National
Provider Identifier (NPI), the NPI of the ordering/supervising physician,
non-physician practitioner, or billing entity is required on the
claim form.
2.4.4.4 Reliance on Medicare approval
for payment - or when Medicare approved status is not required, accreditation
by a qualified accrediting organization - is administratively expeditious
and cost effective for both TRICARE and providers qualifying for
authorization under the new provider category.
2.4.5 The effective date of authorization
will be the date the provider met the “Conditions for Coverage/Authorization”
as prescribed in
paragraph 2.3 or June 8, 1999, whichever is
later. Retroactive authorization will apply to both network providers
(providers that have entered into negotiated network contracts)
and non-network providers (those providers authorized under the
application process) subject to the effective date of June 8, 1999, appearing
in the CSP Final Rule published in the
Federal Register on
March 10, 1999.
2.5 Approval
Process For New Provider Categories Seeking Authorization Under
the CSP Class
2.5.1 While the contractor shall
use the “Conditions for Coverage/Authorization” under
paragraph 2.3 for initial
review/screening of all new provider categories seeking authorization
status under the CSP class, final approval will be reserved for
DHA.
2.5.2 The contractor shall only submit
those provider categories who on initial analysis appear to meet
the criteria for inclusion under the CSP class. The submission should
include all supporting documentation, along with the contractor’s
rationale for recommending authorization status under the CSP class.
2.5.3 If DHA concurs with the contractor’s
recommendation, a new provider specialty code will be added.
2.5.4 A notice of the agency’s determination,
along with supporting documentation (a copy of the package seeking
final approval status of the provider category), will be sent out
to all the contractors for appropriate action.
2.5.5 Requests for final approval
status should be submitted to the Government Designated Authority
(GDA).