1.0 Purpose
The purpose of the Pilot is
to meet requirements set forth in the National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 2016, Section 725 and to determine
if the elimination of the requirement to obtain a referral or preauthorization
for urgent care visits improves access to urgent care, helps enrollees
to choose the most appropriate source for the health care they need
(such as a TRICARE-authorized Urgent Care Center (UCC) rather than
the Emergency Room (ER)), potentially lowers health care costs for
the Department of Defense (DoD) and/or improves patient satisfaction.
2.0 Background
2.1 Access
to primary health care for acute episodic primary care continues
to be in high demand by TRICARE Prime enrollees. The TRICARE manual
guidance and the process by which Prime enrollees currently access
primary health care is defined under the
32
CFR 199.17 and the TRICARE Policy Manual (TPM),
Chapter 1, Section 7.1. Historically, the
Defense Health Agency (DHA) has required that Prime enrollees obtain
a referral for primary or urgent care if they seek that care from
someone other than their Primary Care Manager (PCM). As a result,
when an enrollee needs urgent care after hours or when the PCM in
the Military Treatment Facility (MTF)/Enhanced Multi-Service Market
(eMSM) does not have available appointments, they have been seeking
care from civilian sources such as the ER or with a UCC, including
Convenience Clinics (CCs).
2.2 In an
effort to avoid overuse of ER care and meet the demand for acute
primary care, many facilities have expanded acute care hours within
the MTFs/eMSMs or worked with the contractors to utilize provider
groups or UCCs in their network. However, these visits outside the
MTF/eMSM require an authorization. Seeking emergency care in an
ER does not require authorization. Additionally, the cost of care
in a civilian ER for non-emergent reasons is higher than any other
source of care.
3.0 Policy and Eligibility
3.1 Under the Pilot, Service members
who are enrolled in TRICARE Prime Remote (TPR), Active Duty Family
Members (ADFMs) who are enrolled in TRICARE Prime, TRICARE Young
Adult (TYA) Prime, or TRICARE Prime Remote for Active Duty Family
Members (TPRADFM), retirees and their family members who are enrolled
in Prime or TYA Prime within the 50 United States or the District
of Columbia and TRICARE Overseas Program (TOP) enrollees traveling/seeking
stateside care will be allowed to self-refer, without an authorization,
to a TRICARE network provider or TRICARE-authorized UCC provider,
for urgent care. All the aforementioned categories, except overseas,
will be allowed two unauthorized urgent care visits per FY, per
individual, including services provided when the enrollee is out
of their enrollment area. Overseas enrollees seeking stateside urgent
care will not be held to the two visit cap. For the allowed unmanaged
visits, no referral from their PCM or authorization by a Health
Care Finder (HCF) will be required and no Point of Service (POS)
deductibles and cost shares shall apply. Referral requirements for
specialty care and inpatient authorizations shall remain as currently
required by
Chapter 8, Section 5.
3.2 Enrollees are encouraged to
notify their PCM of any urgent/acute care visits outside the PCM within
24 hours of the visit or the first business day following the visit
and to schedule follow-up treatment, if indicated, with their PCM.
The contractor shall provide beneficiary and provider information
on this process, to include information on how to schedule follow-up
appointments, and how to coordinate care.
3.3 If more
than the two visits allowed under this Pilot are used or if the
enrollee seeks care from a non-network provider (except a TRICARE-authorized
UCC), the usual POS deductible and cost-shares shall apply. The
usual POS exceptions are still applicable and include:
• Emergency care;
• Service members (in accordance
with
Chapters 16 and
17);
• Newborns and adopted children
during the first 60 days (120 days, if overseas) after birth or adoption;
• TRICARE Prime clinical preventive
services received from a network provider (in accordance with TPM,
Chapter 7, Section 2.2);
• TRICARE Prime enrollees who
obtain outpatient mental health care from a network provider without
a referral from their PCM (in accordance with TPM,
Chapter 7, Section 3.8); and
• Enrollees with Other Health
Insurance (OHI).
3.4 The Pilot
shall encourage and incentivize the use of the Nurse Advise Line
(NAL) to direct enrollees to the source of the most appropriate
level of health care required to treat the medical conditions of
the enrollee. The NAL will provide advice to all enrollees and will
facilitate referrals for Direct Care (DC) enrollees who receive
an urgent care recommendation. For incentive purposes, urgent care
accessed via a NAL recommendation that leads to a PCM referral shall
not be counted against the allowable self-referred visits provided
under the Pilot.
4.0 General Description of Administrative
Process
4.1 Referral (authorization) requirements
for up to two urgent care visits per FY, per individual, shall be
waived for Service members who are enrolled in TPR, ADFMs who are
enrolled in TRICARE Prime, TPRADFM, or TYA Prime and retirees and
their family members who are enrolled in Prime within the 50 United
States or the District of Columbia. Referral (authorization) requirements
are also waived for an uncapped number of visits for TOP enrollees
traveling/seeking care in the Continental United States (CONUS)
when services are rendered by a TRICARE network provider or TRICARE-authorized
UCC. Providers must have one of the following primary specialty
designations:
• Family Practice;
• Internal Medicine; General
Practice;
• Pediatrician; and
• UCC or Convenience
Clinic (CC).
Note: In accordance with TPM,
Chapter 1, Section 7.1, Obstetricians/Gynecologists
(OB/GYNs), Physician Assistants (PAs), Nurse Practitioners (NPs),
and Certified Nurse Midwives (CNMs) can be considered Primary Care
Providers (PCPs) and may also be designated PCMs.
4.2 All claims shall be vouchered
and paid as prescribed by existing policy for both underwritten and
non-underwritten care. The unauthorized urgent care visits permitted
under this pilot shall be considered “authorized care” for purposes
of
Chapter 8, Section 5, paragraph 2.6.
5.0 Policy Considerations
The inclusion of Service member
in TPR does not limit/change their overall TPR benefit (as specified
in
Chapter 16).
6.0 Contractor Responsibilities
6.1 The contractors shall verify
the TRICARE eligibility of the patient on the Defense Enrollment Eligibility
Reporting System (DEERS).
6.2 The contractors
shall search for any submitted urgent care referral and when an
urgent care referral is identified the contractor shall not count
the urgent care visit against the allowable self-referred visits
provided under the Pilot.
6.3 The contractors
shall develop a process to track the number of unmanaged urgent
care visits used per enrollee/per FY. This process shall incorporate
a means to share that number with other contractors when enrollment
transfers occur.
6.4 DHA Communications
will provide all educational materials regarding the pilot to contractors. The
educational materials will encourage enrollees seeking access to
care to use the MTF/eMSM first and to use the NAL to guide them
to the source of the most appropriate level of healthcare required
to treat their medical condition.
6.5 The contractors
shall ensure that pilot information is made available on their primary
Internet web sites.
6.6 TRICARE
Encounter Data (TED) Record Special Processing Code (SPC) “UC-Urgent
Care Pilot” shall be coded on all TED records where one of the two
self-referred authorizations allowed under this Pilot is used. If
the TED SPC is implemented in the contractor’s system after May
23, 2016, the contractor shall search for previously processed Urgent
Care Pilot TED records and adjust those records to show SPC UC.
7.0 Applicability
This Pilot is limited to Service
members who are enrolled in TPR; and ADFMs who are enrolled in TRICARE
Prime; TYA Prime; or TPRADFM; retirees and their family members
who are enrolled in Prime or TYA Prime within the 50 United States
or the District of Columbia; and TOP enrollees traveling/seeking stateside
care.
8.0 Exclusions
This Pilot does not apply to
referral requirements for specialty care and inpatient authorizations
as currently required by
Chapter 8, Section 5.
This Pilot excludes TOP Prime enrollees unless they are traveling
stateside. This pilot excludes Uniformed Services Family Health
Plan (USFHP) enrollees.
9.0 Effective date
s9.1 Per requirements set forth
in the NDAA FY 2016, Section 725, the
Secretary is required to carry out the Pilot Program for a period
of three years. Implementation is to commence no later than 180 days
after the date of the enactment of the Act, and hence the Pilot
will begin May 23, 2016, and will continue until May 23, 2019.
9.2 The NDAA FY 2017,
Section 704, authorized the Director, DHA to establish the TRICARE
Prime referral requirement for urgent care visits for TRICARE Prime
enrollees other than Active Duty Service Members (ADSMs) enrolled
to an MTF/eMSM. TRICARE policy (Chapter 8, Section 5) was changed
to allow unlimited self-referred urgent care visits for all TRICARE
Prime enrollees (other than most ADSMs enrolled to an MTF/eMSM)
with an effective date of January 1, 2018. No POS deductibles and
cost shares shall apply when urgent care is provided by a TRICARE
network provider or a TRICARE-authorized (network or non-network)
UCC or CC. If the enrollee seeks care from a non-network provider (except
a TRICARE-authorized UCC or CC), the usual POS deductible and cost-shares
shall apply. The aforementioned policy change effectively made this
pilot obsolete with an end date of December 31, 2017.