The TMEP contractor shall comply
with all TRICARE requirements noted in
Chapter
7 regarding MM, UUM, and QM unless specifically changed,
waived, or superseded by this section (as indicated below), the
TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM),
TRICARE Systems Manual (TSM), or TMEP contract.
1.0 Medical
Management/Utilization Management (MM/UM)
1.2 Regions
specific UM provisions do not apply to the TMEP contractor.
2.0 Preauthorization
2.1 The TMEP
contractor shall comply with the requirements in
Chapter 7, Section 2. The special authorization/preauthorization
services outlined in this section and in the TRICARE Policy Manual (TPM),
Chapter 1, Section 6.1 require preauthorization,
and if necessary, review of waivers of the day limits when TRICARE
is primary payer. As secondary payer, TRICARE will rely on and not
replicate Medicare’s determination of medical necessity and appropriateness
in all circumstances where Medicare is primary payer.
2.2 In the
event that TRICARE is primary payer for these services and preauthorization
was not obtained, the contractor shall obtain the necessary information
and perform a retrospective review.