All TRICAREThe
TMEP contractor shall comply with the 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specifically changed, waived, or superseded by this section (as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.
1.0 Medical Management/Utilization
Management (MM/UM)
1.2 Regions-specific UM provisions
do not apply to TMEP contractor.
2.0 Preauthorization
2.1 The
provisions
of TMEP contractor shall comply with the
requirements in Chapter 7, Section 24
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.