Military Health System

5.3.1.1  The requesting provider shall follow the contractor’s referral procedures and shall contact the contractor for an authorization. Upon receipt of a civilian provider referral, the contractor shall perform a covered service review. If an authorization is required, the contractor shall enter the information in Addendum B, required by the SAS for a fitness-for-duty review (paragraph 5.3). SAS will respond to the contractor within two business days. When a SAS referral directs evaluation or treatment of a condition, as opposed to directing a specific service(s), the contractor shall use its best business practices in determining the services encompassed within the Episode Of Care (EOC), indicated by the referral. A SAS authorization for health care includes authorization for any TRICARE covered ancillary or diagnostic services related to the health care authorized (i.e., associated with the EOC). The contractor shall not communicate to the provider or patient that the care has been authorized until the SAS review process has been completed. The contractor shall use the same best business practices as used for other TRICARE Prime enrollees in determining EOC when claims are received with lines of care that contain both referred and non-referred lines. Laboratory tests, radiology tests, echocardiogram, holter monitors, pulmonary function tests, and routine treadmill tests logically associated with the original EOC may be considered part of the originally requested services and do not need to come back to the PCM (if assigned) or Primary Care Provider (PCP) for approval.

5.3.1.2  If the SAS determines that the Service member may receive the care from a civilian source, the SAS will enter the appropriate code into the authorization/referral system. The contractor shall notify the Service member of approved referrals. The Service member may receive the specialty care from a Market/Military Treatment Facility (MTF), a network provider, or a non-network provider according to TRICARE access standards, where possible. In areas where providers are not available within TRICARE access standards, community norms shall apply. (A Service member may always choose to receive care at a Market/MTF even when the SAS has authorized a civilian source of care and even if the care at the Market/MTF cannot be arranged within the TRICARE Prime access standards subject to the member’s unit commander [or supervisor] approval.) If the appointment is with a non-network provider, the contractor shall instruct the provider on payment requirements for Service members (e.g., no deductible or cost-share) and on other issues affecting claim payment (e.g., the balance billing prohibition). The contractor shall follow Chapter 8, Section 5 when there are additional requests by a Market/MTF for Civilian Health Care (CHC) needs. The contractor shall adjudicate claims for additional Market/MTF requested civilian care in accordance with Chapter 8, Sections 2 and 5.

5.3.1.3  If the contractor does not receive the SAS’s response or request for an extension within two business days, the contractor shall, within one business day after the end of the two business day waiting period, enter the contractor’s authorization code into the contractor’s claims processing system. The contractor shall document in the contractor’s system each step of the effort to obtain a review decision from the SAS. The first choice for civilian care is with a network provider; if a network provider is not available within TRICARE Prime access standards, the contractor may authorize the care with a TRICARE-authorized provider. The contractor shall help the Service member locate an authorized provider.

5.3.1.4  If the SAS directs the care to a military source, the SAS will manage the EOC. If the Service member disagrees with a SAS determination that the care must be provided by a military source, the Service member may appeal only through the SAS who will coordinate the appeal as appropriate; the contractor shall refer all appeals and inquiries concerning the SAS’s fitness-for-duty determination to the SAS.

5.3.1.5  If the Service member’s PCM determines that a specialty referral or test is required on an urgent basis (less than 48 hours from the time of the PCM office visit) the PCM shall contact the contractor for a referral and send required information to the SAS for a fitness for duty review. The Service member shall receive the care as needed without waiting for the SAS determination, and the contractor shall adjudicate the claim according to TRICARE Prime provisions. If further specialty care is warranted, the PCM shall request a referral to specialty care. The contractor shall contact the SAS with a request for an additional SAS review for the specialty care.

5.3.2.1  The contractor may receive claims for care that require referral, authorization, and SAS review, that have not been authorized or reviewed. If the claim involves care covered under TRICARE policy, the contractor shall pend the claim and supply the required information (Addendum B) to the SAS for review. If the SAS does not notify the contractor of the review determination or ask for an extension for further review within two business days after submitting the request for coverage determination, the contractor shall then authorize the care. The contractor shall then release the claim for payment, and apply any overrides necessary to ensure that the claim is paid with no fees assessed to the Service member. However, the contractor shall not make claims payments to sanctioned or suspended providers (see Chapter 13, Section 5).

5.3.2.2  If the contractor determines that the requested service, supply, or equipment is not covered by TRICARE policy (including Chapter 17, Section 3) and no Defense Health Agency (DHA) approved waiver is provided, the contractor shall decline to file an authorization and shall deny any received claims accordingly. The contractor shall notify the civilian provider and the remote Service member/non-enrolled Service member of the declined authorization with explanation of the reason. The contractor shall ensure the notification to a civilian provider and the remote Service member/non-enrolled Service member explains the waiver process and provide contact information for the applicable Uniformed Services Headquarters Point of Contact (POC)/Service Project Officers as listed in Addendum A. The contractor is not required to notify the SAS.