2.0 POLICY
2.1 The
contractor may cost-share otherwise covered medically necessary
services and supplies rendered in emergency situations by an unauthorized
provider. Medically necessary inpatient emergency service are those
that are necessary to prevent the death or serious impairment of
the health of the patient, and that because of the threat to the
life or health of the patient, necessitate the use of the most accessible
hospital available that is equipped to furnish the services. In
the case of inpatient psychiatric emergencies, payment will be extended
when the patient is determined to be at immediate risk of serious
harm to self or others as a result of a mental disorder and requires
immediate continuous skilled observation at the acute level of care.
2.2 When a case qualifies as an
emergency at the time of admission to an unauthorized institutional
provider and the provider notifies the contractor of the admission,
payment can be extended for medically necessary and appropriate
care until a transfer is medically feasible (i.e., coverage will
be extended up to the point of discharge or until a medically appropriate
and legally authorized transfer can be initiated). The timing of
the transfer will be based upon the
availability of authorized facility beds.
2.3 Conditions
for reimbursement of emergency inpatient admissions to unauthorized
facilities.
2.3.1 At the time of admission to
an unauthorized institutional provider, the beneficiary’s condition
must meet the definition of medical or psychiatric emergency as
prescribed in
32 CFR 199.2.
2.3.2 The contractor must be notified
as soon as possible after the emergency admission (preferably within
24 hours) so that arrangements can be made to transfer the beneficiary
once the emergency no longer exists, or until such time as a medically
appropriate and legally authorized transfer
can be initiated.
2.3.3 The provider
must submit the necessary medical records and other documentation required
in the processing and payment of emergency inpatient admissions.
These records are essential in substantiating that an emergency
condition did exist at the time of the admission and that care provided
to the beneficiary after the emergency no longer existed, but before
a medically appropriate transfer could be initiated, was medically
necessary. Refusal to submit the appropriate medical documentation
will result in the denial of payment for the entire stay in the
facility, including the emergency portion of the patient’s care.
2.3.4 A determination must also be
made that treatment was received at the most accessible (closest)
hospital available that was equipped to furnish the medically necessary
care.
2.4 Reimbursement
guidelines for emergency inpatient admissions to unauthorized facilities.
2.4.1 Billed charges will be paid
for all medically necessary care up until such time as an appropriate
or
legally authorized transfer can be initiated by the contractor.
Payment will only be made if there was a true medical/psychiatric
emergency as defined in
32 CFR 199.2,
at the time of admission and only for that care extending beyond
stabilization of the patient (care extending beyond the emergency
treatment of the patient), as long as it was deemed medically necessary
and appropriate.
2.4.2 The copayment/cost-share
for an inpatient emergency admission to an unauthorized facility
is dependent on the eligibility and enrollment status of the beneficiary
at the time the services are rendered. Refer to
Chapter 2, Sections 1 and 2,
for inpatient beneficiary copayments/cost-shares.
2.4.3 Conditions for direct payment
to an unauthorized facility.
2.4.3.1 The signature-on-file procedure
may be used as a means of ensuring patient confidentiality, while
at the same time allowing direct payment to the facility. This procedure
involves incorporating the following language into the permanent
records of TRICARE beneficiaries for whom the facility is seeking
payment under emergency provision
32 CFR 199.6(a)(2).
“I request payment of authorized
benefits to me or on my behalf for any services furnished me by (Name
of Provider), including physician services. I authorize any
holder of medical or other information about me to release that
information in accordance with the provisions of The Alcohol, Drug
Abuse and Mental Health Administration Reorganization Act, Public
Law 102-321 and Privacy Act of 1974.”
2.4.3.2 Professional providers who
submit claims on the basis of an institution’s signature on file should
include the name of the institutional provider that maintains the
signature on file. The Centers for Medicare and Medicaid Services
(CMS) 1450 UB-04 instructions shall be followed for certifying signature
on file, except that the permanent hospital record containing a
release statement will be recognized. The unauthorized facility
will ensure that the beneficiary’s
signature is on file, attesting to the above language as soon as
possible after the emergency crisis has passed (i.e., after patient stabilization).
2.4.4 If the signature-on-file procedure
is not utilized by the unauthorized provider, payment must be made
directly to the beneficiary.