All TRICARE requirements noted
in
Chapter 7 regarding
MM, UM, and QM shall apply to the TMEP unless specifically changed,
waived, or superseded by this section (as indicated below), the
TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM),
TRICARE Systems Manual (TSM), or TMEP contract.
2.0 Preauthorization
2.1 The provisions of
Chapter 7, Section 4 are applicable to TMEP.
The special authorization/preauthorization services outlined in
this section and in the TPM,
Chapter 1, Section 6.1 require preauthorization,
and if necessary, review of waivers of the day limits when TRICARE
is primary payer. As secondary payer, TRICARE will rely on and not replicate
Medicare’s determination of medical necessity and appropriateness
in all circumstances where Medicare is primary payer.
2.2 In the
event that TRICARE is primary payer for these services and preauthorization
was not obtained, the contractor shall obtain the necessary information
and perform a retrospective review.