1.0 POLICY
1.1 Except
as provided in
paragraph 1.2, the contractor will provide
the required authorization for requested services and items under
the Extended Care Health Option (ECHO).
1.2 In
the case of beneficiaries residing outside the 50 United States
(U.S.) and the District of Columbia, the TRICARE Overseas Program
(TOP) contractor is responsible for authorizing ECHO benefits. The
TOP contractor shall notify the appropriate TRICARE Area Office
(TAO) Executive Director of all ECHO
benefit authorizations or authorization waivers.
1.3 The authorization is based
upon the following:
1.3.1 The beneficiary is registered
in the ECHO; and
1.3.2 The requested
service or item is allowable as an ECHO
benefit; and
1.3.3 The requested service or item
meets the public facility use requirements when applicable.
1.4 The authorization shall specify
the services by type, scope, frequency, duration, dates, amounts, requirements,
limitations, provider name and address, and all other information
necessary to provide exact identification of approved benefits.
Claims can not be adjudicated without this information.
1.5 The authorization shall remain
in effect until such time as the contractor or TOP contractor determines
that:
1.5.1 The beneficiary is no longer
eligible for the ECHO; or
1.5.2 The authorized
ECHO service or item is no longer appropriate or required by the beneficiary;
or
1.5.3 The authorized ECHO service
or item becomes a benefit through the TRICARE Basic Program.
1.6 The contractor or TOP contractor
may waive the required written authorization for rendered services
and items that, except for the absence of the written authorization,
would be allowable as an ECHO benefit.
1.7 The contractor
or TOP contractor may waive the required public facility use certification
when such waiver is appropriate. See
Section 5.1.