2.5 Requirements for continued
payment of ICMP-PEC authorized services:
2.5.1 Eligibility.
The beneficiary must be TRICARE eligible.
2.5.2 Authorized
Beneficiaries. Only those beneficiaries authorized services under
the ICMP-PEC upon its termination on December 28, 2001, are eligible
for continued coverage.
2.5.3 Authorized
Services. Only those services authorized under the ICMP-PEC upon
its termination on December 28, 2001, are eligible for continued
coverage.
2.5.4 Custodial Care. Beneficiaries
must continue to meet the TRICARE definition of custodial care in
effect prior to December 28, 2001, that is, custodial care is care
rendered to a patient who:
• Is disabled mentally or physically
and such disability is expected to continue and be prolonged; and
• Requires a protected, monitored,
or controlled environment whether in an institution or in the home;
and
• Requires assistance to support
the essentials of daily living; and
• Is not under active and specific
medical, surgical, or psychiatric treatment that will reduce the disability
to the extent necessary to enable the patient to function outside
the protected, monitored, or controlled environment.
2.5.5 Beneficiaries covered under
paragraphs 2.1 or
2.2 must
have a primary caregiver in the home.
2.5.6 Reassessment.
Continuation of receipt of services requires reassessment on a regular
basis. The contractors will provide supporting clinical documentation
of all authorized participant’s medically necessary skilled needs,
to include a plan of care signed by the attending physician. Each
letter of authorization for continued coverage issued by the DHA
Clinical Operations, Chief Medical Officer, or designee, will include
a statement regarding the frequency of a periodic reassessment of
the beneficiary. Generally, periodic reassessment will occur annually,
but will be based on the needs of the beneficiary. Contractors shall
provide a complete clinical documentation update and recommendation for
continuation of coverage at the same level or indicate if either
an increase or decrease in services is indicated by the beneficiary’s
current needs. DHA will provide a courtesy reminder when a periodic reassessment
is due for a beneficiary. Once DHA reviews the reassessment and
updated recommendations of the contractor, a revised or updated
authorization letter will be issued to the contractor.
2.5.7 Revisions. If at any time a
contractor determines a need for a change in authorized funding for
a beneficiary (e.g., due to a change in CMAC rates, a change in
patient condition, such as a need for more or fewer covered hours,
change in HHA, etc.), then the contractor must submit a written
request for such change to the DHA Clinical Operations, Chief Medical
Officer, or designee, that includes a detailed explanation of why
the change is required. The DHA Clinical Operations, Chief Medical
Officer, or designee, will evaluate each request and provide a written
decision to the contractor.
2.5.8 Cost-shares.
Cost-shares shall not be applied to services authorized under the
ICMP-PEC prior to December 28, 2001 nor to those services provided
under this policy. Cost-shares will continue to apply to all other
TRICARE benefits.
2.5.9 Appeals.
Appeals should be made directly to the DHA Office of General Counsel
(OGC). There are three appealable issues related to the ICMP-PEC:
2.5.9.1 A custodial care determination;
2.5.9.2 A determination by the contractor
that ICMP-PEC does not apply;
2.5.9.3 The types and extent of services
authorized for a beneficiary by DHA. The following language is to
be included in subsequent determination of custodial care letters
and notification of benefits related to ICMP-PEC:
“Should you disagree with this
initial determination, you have the right to appeal and request
a formal review. Appealable issues include the types and extent
of the services and supplies authorized under the ICMP-PEC and the
determination that the care is custodial. The request must be in
writing, be signed, and must be postmarked or received by DHA OGC,
within 90 days from the date of this determination. For the purposes
of TRICARE, a postmark is a cancellation mark issued by the United States
Postal Service.
Additional documentation in
support of the appeal may be submitted. However, because a request
for a formal review must be received within 90 days of the date
of the initial determination, a request for formal review should
not be delayed pending the acquisition of any additional documentation.
If additional documentation is to be submitted at a later date,
the letter requesting the formal review must include a statement
that additional documentation will be submitted and the expected
date of the submission.”
2.5.10 Claims Processing. Contractors
are to use the special processing code “CM” in addition to the appropriate
branch of service code for all claims for care and services authorized
under this policy. Contractors are to use the special processing
code “E” in addition to the special processing code “CM” for claims
for services authorized for those beneficiaries indicated in
paragraph 2.3 Claims
for services not provided in accordance with
paragraphs 2.1,
2.2,
or
2.3 (i.e., acute outpatient and inpatient
care and services, including Durable Medical Equipment (DME)) must
be processed in accordance with the TOM, the TRICARE Reimbursement
Manual (TRM), and the TRICARE Systems Manual (TSM), and without
the use of the special processing codes “E” and “CM”.
2.5.11 Contractors shall notify the
DHA Clinical Operations, Chief Medical Officer, or designee upon
any of the following changes to any beneficiary who is covered by
paragraphs 2.1,
2.2,
or
2.3.
• Death;
• Eligibility status, including
becoming a Transitional Survivor or a Survivor as those terms are
used in
Chapter 10, Section 7.1;
• Residential relocation (pending
or completed);
• Custodial care status;
• Inpatient admission;
• Requests for disengagement.