1.0 RM PROGRAM
1.1 The contractor
shall establish and maintain a RM program as outlined in this Chapter.
1.2 The contractor shall review
the referral request in accordance with
Chapter 1, Section 3,
to determine:
• That the provider to whom the
patient is referred meets applicable authorized provider and network
provider requirements;
• That the services being requested
are a TRICARE covered benefit and are requested in a covered setting;
and
• Whether any specific services
requested as part of the referral also require preauthorization.
1.2.1 The contractor shall provide
a response to referrals and authorizations, as part of the process
to completion (PTC).
1.2.2 The contractor
shall send the response and updates to the referring provider, beneficiary
and referred to provider and when applicable to the Markets/Military
Medical Treatment Facilities (MTFs).
1.3 The contractor shall develop
and provide a Health Insurance Portability and Accountability Act
(HIPAA)-compliant web-based RM system that the Markets/MTFs can
use to view referral details (to include but not limited to eligibility
check information) and track Market/MTF referred care to and from
private sector care and allows the Market/MTF to ascertain whether
each referral resulted in beneficiary care. The system should be
refreshed at a minimum of every 24 hours.
1.3.1 The contractor’s
system shall, at a minimum, provide the status of all referrals,
including ‘drill down’ detailed data at the individual referral
level, and search functions using multiple parameters including
but not limited to beneficiary, date range, provider, Market/MTF,
specialty and Referral Case Number/Unique Identifier Number (UIN).
1.3.2 The contractor shall link claims
data to the appropriate referral within its web-based system.
1.3.3 The contractor’s system shall
allow for multiple file types to be uploaded from the Market/MTF
to themselves, which includes, but is not limited to, Portable Document
Format (PDF), Word, and imaging files.
1.3.4 The contractor’s
RM system/portal shall include all authorization and denial correspondence
to beneficiary and providers and be viewable by the Government.
1.4 The contractor shall collaborate
with the Government to develop a table of acceptable secondary referrals
that will allow identified specialty-to-specialty referrals within
the same Episode of Care (EOC) for TRICARE Prime beneficiaries.
The contractor may recommend or the Government may direct adding
or deleting specialties from this table semiannually.
1.5 The contractor shall coordinate
with other TRICARE Private Sector Care Contractors (PSCCs) (continental United
States (CONUS) only) to ensure that all determinations about whether
a referral, treatment, or service is a TRICARE covered benefit,
is in a covered setting, and whether services that require preauthorization
and specialty-to-specialty referrals are consistent, regardless
of the beneficiary’s geographic location (within CONUS) and which PSCC
the beneficiary is enrolled to.
1.6 The contractor
shall utilize the Market/MTF Capability and Capacity tables to identify
referrals and authorizations for TRICARE Prime beneficiaries to
receive care at the MTF to meet Market/MTF Knowledge, Skills and
Abilities (KSAs) to maintain readiness.
1.7 The contractor
shall identify authorizations for TRICARE Select beneficiaries and
offer TRICARE Select beneficiaries the choice to receive care at
the MTF to meet Market/MTF KSAs to maintain readiness.
1.8 The contractor shall utilize
automation in processing referral and authorization, EOCs, procedure
and diagnosis coding.
1.9 The contractor
shall conduct all referral communications with the Market/MTF using
Department of Defense (DoD) system(s) approved electronic HIPAA
secure transactions as outlined in TRICARE Systems Manual (TSM),
Chapter 1, Section 1.1.
1.10 The contractor shall provide
reports on all unactivated network referrals by specialty for all
TRICARE Prime members enrolled to the government for all beneficiary
categories. For reporting requirements, see DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract.
Note: The UIN
is specific to the Composite Health Care System (CHCS)/Armed Forces
Health Longitudinal Technology Application (AHLTA) which is the
legacy Military Health System (MHS) Electronic Health Record (EHR) and
the legacy Referral Management Suite (RMS). As the MHS phases out
legacy CHCS/AHLTA and legacy RMS and moves to MHS Genesis as the
new EHR, the UIN will no longer be used. MHS Genesis produces the
“Referral ID” thus the UIN and Referral ID may be used interchangeably
in this Section.
2.0 URGENT CARE REFERRALS
2.1 Active Duty Service Members
(ADSMs) enrolled in TRICARE Prime require a referral which they
will obtain from the MTF provider or through the Nurse Advice Line
(NAL). ADSMs enrolled to the TRICARE Overseas Program (TOP) or in
TRICARE Prime Remote (TPR) will not be held to any urgent care referral
requirement, but they are still held to applicable DoD and Service
requirements concerning authorization for private sector care. Point
of Service (POS) does not apply to ADSM private sector care.
2.2 Active Duty Family Members
(ADFMs) enrolled in TRICARE Prime may self-refer for urgent care
from a TRICARE network provider or a TRICARE-authorized (network
or non-network) Urgent Care Center (UCC) or Convenience Clinic (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.
2.3 ADFMs enrolled in TRICARE Prime
Remote Active Duty Family Member (TPRADFM) with an assigned Primary
Care Manager (PCM) are required to seek urgent care from a TRICARE
network provider or a TRICARE-authorized (network or non-network)
UCC or CC to avoid POS.
2.3.1 ADFM in
TPRADFM without an assigned PCM may utilize any local TRICARE participating
or authorized provider for primary care services (to include urgent
care services).
2.3.2 ADFMs
and ADSMs enrolled to TOP Prime or TOP Prime Remote enrollees need
to contact the TOP contractor to obtain an authorization in order
to ensure their urgent care visit will be cashless and claimless. Without
this authorization, overseas providers may request payment upfront
and the enrollee will then have to submit a claim for reimbursement.
2.3.2.1 ADSMs enrolled to TOP Prime
or TOP Prime Remote requiring urgent care while Temporary Duty (TDY)
or on leave, in the 50 United States (US) and the District of Columbia,
will not be held to any urgent care referral requirements, but they
are still held to applicable DoD and Service regulations concerning
ADSM care outside Markets/MTFs. The usual ADSM POS exception applies.
2.3.2.2 ADFMs enrolled to TOP Prime
or TOP Prime Remote traveling in the 50 US and the District of Columbia,
may access urgent care without a referral or an authorization, but
POS deductibles and cost shares shall apply for claims when urgent
care is not provided by a TRICARE network provider or a TRICARE-authorized (network
or non-network) UCC.
2.4 If urgent
treatment is required by a TRICARE Prime enrollee after hours, while
traveling away from their residence, or whose PCM is otherwise unavailable,
the enrollee may contact the NAL, their PSCC, TOP contractor, Designated
Provider (DP) for assistance finding an appropriate facility and
provider before receiving non-emergent care from a provider other
than the PCM. If an enrollee is traveling overseas, he or she may
call the TOP Regional Call Center for the region in which he or
she is traveling to coordinate urgent care.
2.5 The contractor shall provide
beneficiary and network provider education on obtaining an after
hour appointment or UCC care to include information on how to contact
the NAL, how to schedule follow-up appointments, and how to coordinate
care.
2.6 When contacted by the beneficiary,
the contractor shall encourage TRICARE Prime enrollees to notify their
PCM of any urgent and acute care visits to providers, other than
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, or to get a referral from the PCM for additional
specialty care.
2.7 Urgent
care can be 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
• UCC or CCs
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.
3.0 Mental Health (MH) and Substance
Use Disorder (SUD) Referrals
3.1 The contractor
shall require a PCM referral for non-office based, outpatient (e.g.,
Partial Hospitalization Program (PHP), Intensive Outpatient Program
(IOP) and Opioid Treatment Program (OTP)) MH services. However,
if the non-office based, outpatient MH provider is a network provider,
a request for preauthorization from the network provider to the
contractor may be accepted in lieu of the PCM referral.
3.2 The contractor shall comply
with the provisions of
Chapters 16 and
17 when
processing requests for active duty personnel. See
Chapter 16, Sections 2 and
6 for
referral requirements under the TPR program. ADSMs require referral
and preauthorization before receiving all MH and SUD services.
3.3 The contractor shall process
outpatient MH and SUD referrals to the subspecialty level in accordance
with
Chapter 1, Section 3 when submitted by a Market/MTF.
3.4 The contractor shall indicate
in their portal whether the processed referral was approved or denied.
4.0 REFERRAL AND AUTHORIZATION
PROCESSING
4.1 The contractor shall process
referrals in accordance with Utilization Management (UM),
Section 4, and the following:
4.2 The contractor shall select
the provider priority for referral in the following sequence:
4.2.1 Market/MTF via Capability And
Capacity (aka KSA) tables and processes as outlined in the Memorandum
of Understanding (MOU) between the Government and the contractor.
4.2.2 Network provider within Access
To Care (ATC) standards.
4.2.3 Non-network
provider within ATC standards.
4.2.4 Closest
network provider outside of ATC standards, but within 100 miles.
4.2.5 Closest non-network provider
outside of ATC standards, but within 100 miles.
4.2.6 Closest network provider outside
100 miles.
4.2.7 Closest non-network provider
outside 100 miles.
4.2.9 Out of
Region when the care requested is of such a special nature that
it cannot be rendered within the region and medical necessity warrants
the care. This is expected to occur rarely.
4.3 Centralized Appointing Centers
(Integrated Referral Management Appointing Centers (IRMACs)/Referral
Appointing Centers (RACs))
4.3.1 The contractor
shall collaborate with the Government to coordinate urgent and routine
Direct Care System (DCS) referrals through the IRMACs/RACs (where
available) to make prompt referrals to network providers under the
TRICARE program.
4.3.2 The contractor
shall provide up to 1,500 IRMAC/RAC personnel with read only access
to its RM system.
4.3.3 The contractor
shall send the DCS enrolled beneficiary a message through the beneficiary’s
primary means of communication (telephone, email, text, app) as
soon as a referral has been approved and instruct them to contact
the IRMAC/RAC to schedule an appointment.
4.4 Referrals from the Market/MTF
to the Contractor
4.4.1 The contractor shall translate
the narrative descriptions for a referral into standard diagnosis
and procedure codes.
4.4.2 The contractor
shall authorize care in their network and retain responsibility
for managing requests for additional services or inpatient concurrent
stay reviews associated with the original referral, as well as changes
to the specialty provider identified to deliver the care.
4.4.2.1 The contractor shall apply
the Market/MTF capability and capacity tables described in
paragraph 4.6.1 and
the secondary referral table described in
paragraph 1.4 when determining
and authorizing care for additional services that are requested
beyond the initial referral within the same EOC.
4.4.2.2 The contractor authorizing
the care shall forward the referral and authorization information, including
the range of codes authorized (i.e., EOC), the name, the National
Provider Identifier (NPI), and demographic information of the specialty
provider to the contractor for the region to which the patient is
enrolled, as well as the Market/MTF where enrolled, if applicable.
4.4.2.3 The contractor shall provide
the same service and information required above to the TOP contractor, if
the patient is enrolled overseas.
4.4.2.4 The contractor shall forward
the authorization information to the TOP contractor to ensure appropriate
adjudication of the claim, if a CONUS Prime retiree or retiree family
member receives authorization to obtain care overseas from a contractor.
4.4.2.5 The contractor shall provide
a report of all referrals and authorizations transferred from one contractor
to another. For reporting requirements, see DD Form 1423, CDRL,
located in Section J of the applicable contract.
4.4.3 The contractor shall provide
a text explanation of why a referral was returned and rejected in
a HIPAA-compliant 278 transaction within 24 hours to the Market/MTF
(if enrolled to a Market/MTF). The returned and rejected standard
nomenclature will be provided by the Government. The return of a
referral to the Market/MTF is considered processed to completion.
4.4.4 The contractor shall provide
a report of all rejected/returned referrals. For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.4.5 The contractor shall advise
the patient, referring Market/MTF, and receiving provider of all
approved referrals and authorizations including, but not limited
to, the following:
• The Market/MTF single Point
of Contact (POC) shall be advised via HIPAA-compliant 278 response.
(The Market/MTF single POC may be an individual or a single office
with more than one telephone number.)
• The contractor shall provide
a response to the Market/MTF single POC via fax or other approved
Government system, if the Government’s or contractor’s HIPAA-compliant
278 system is not available.
• The notice to the beneficiary
shall contain the Referral Case Number or UIN and information necessary
to support obtaining ordered services or an appointment with the
referred to provider.
• The notice shall also provide
the beneficiary with instructions on how to change their provider,
if desired, and will instruct the beneficiary to notify the contractor
of the change.
4.4.5.1 The contractor shall make appropriate
modifications within their portal, if they are informed that the beneficiary
changed the provider listed on the referral.
4.4.5.2 The contractor shall make appropriate
modifications to the issued authorization, if the contractor is informed
that the beneficiary changed the provider listed on the referral
or authorization. The revised referral or authorization shall contain
the same level of data as the initial referral or authorization.
The revised authorization shall be issued to the beneficiary, the
provider beneficiary chose, referring provider and the Market/MTF.
4.4.5.3 The contractor shall not send
beneficiary notification letters for referrals marked “urgent.”
4.4.5.4 The contractor shall provide
a notification to beneficiaries that failure to adhere to a referral
will result in the care being subject to POS charges. In other cases,
a referral may be to the civilian provider network, and again, POS
charges would apply to a failure to follow the referral.
4.4.5.5 A major purpose of preauthorization
is to prevent unanticipated coverage determinations, which are sometimes
dependent on particular details regarding the patient’s condition
and circumstances.
4.4.6 The contractor
shall notify the patient by mail, if services are denied, and shall
advise the patient of their right to appeal consistent with the
TRICARE Operations Manual (TOM).
4.4.7 The contractor
shall also notify the referring provider and single Market/MTF POC
of the initial denial by HIPAA-compliant 278 response and by mail.
4.4.8 The contractor shall provide
the Market/MTF, by HIPAA-compliant 278 response, the updated authorization
and clinical information that served as the basis for the new authorization.
4.5 Directed Referrals (CONUS Only)
4.5.1 Directed referrals are expected
to be rare and will be reviewed according to
paragraph 1.2. The types of acceptable
directed care referrals will be in the best interest of the Government
for quality, affordable care and military readiness. The process
for submitting directed referrals for services will be contained
within the MOUs between the Government and the contractor.
4.5.2 Acceptable directed care special
situations include, but are not limited to, the following:
4.5.2.1 Clinically urgent/emergent
referrals (Administrative reasons should not be used as an “urgent” request
justification; although the contractor shall support PCM/Market/MTF
in expediting referrals for administrative reasons when needed).
4.5.2.2 Military operationally related
referral requests such as referrals to network providers who provide rapid
ATC for an ADSM for military operational issues.
4.5.2.3 Retrospective requests, including
UCC referrals and emergency department follow-up referrals for beneficiaries
while traveling.
4.5.2.4 Continuity of care considerations
along with referrals to providers who have special skill sets, an expertise
or access to devices or instruments that cannot be met by providers
who might otherwise be selected.
4.5.2.5 Beneficiaries have a right
to see any network provider and may chose a different network provider
by contacting the contractor to request a change to another network
provider within the same specialty requested by the referring PCM/Market/MTF.
4.5.2.6 MTF providers or network providers
may generate a directed referral for the purpose of obtaining a second
clinical opinion; a clinical visit such as this would not be part
of a continuity of care determination. Such a referral should be
written as an “evaluate only” request.
4.5.2.7 MTF to Veterans Health Administration
(VHA) referrals, Integrated Disability Evaluation System (IDES) referrals,
terminal leave for ADSM, Temporary Disability Retired List (TDRL),
demobilizing Reserve Component (RC) members and beneficiaries transferring
enrollment between regions and ADSMs or cadets/midshipmen on extended
convalescent leave.
4.5.2.8 Coordination of care for a
Permanent Change of Station (PCS) move.
4.5.3 Directed referrals to DoD recognized
Centers of Excellence (CoEs) can be made by DC, network and non-network
providers for TRICARE Prime and TRICARE Select beneficiaries. The
Government will provide the contractor with a list of DoD recognized
CoEs.
4.5.4 Private sector
care and Market/MTF directed referrals for initial services to a
network or non-network provider greater than 100 miles from the
Market/MTF or private sector PCM, where specialized treatment, surgical procedure,
and inpatient admission is expected, or being requested, require
justification from the Market/MTF or private sector PCM to the contractor
and coordination between the contractor and TRICARE Health Plan
(THP) prior to approval by the contractor.The
contractor shall accomplish benefit and medical necessity review
as required by policy.4.5.4.1 This coordination
process is contained within the MOUs between the Markets/MTFs and
contractor. The MOU will also contain guidance on types of Market/MTF
directed referrals excluded from this policy.The contractor
may ask the Government for guidance on redirecting any Market/MTF
or network provider-directed referral that does not meet the intent
of this policy.
4.5.4.2 THP will conduct their
review and provide a response within two business days.
4.5.4.3 This coordination process is
contained within the provider agreement/handbook from the contractor.
The provider agreement/handbook will also contain guidance on the
types of directed referrals excluded from this policy.
4.5.5 The contractor
shall accomplish benefit review and medical necessity review, as
required by policy, and then coordinate with THP prior to completing
the referral and authorization.The contractor
shall make and document appropriate determinations considering the
justification provided by the Market/MTF for directed referrals
to non-network providers. For reporting requirements, see DD Form
1423, CDRL, located in Section J of the applicable contract.4.5.5.1 The contractor
may ask THP for guidance on any Market/MTF or network provider-directed
referral that meets the intent of this policy.
4.5.5.2 THP will conduct
their review and provide a response within two business days.
4.5.6 The contractor
shall make and document appropriate determinations considering the
justification provided by the Market/MTF for directed referrals
to non-network providers. For reporting requirements, see DD Form
1423, CDRL, located in Section J of the applicable contract.
4.6 Referrals from the Contractor
to the Market/MTF
4.6.1 The contractor
shall provide Market Directors/MTF Directors with web-based ability
to review and update their Capability and Capacity (KSA) tables
in real time. The Government defines “real time” in this instance as
providing the Markets/MTFs with access to view and update their
capability and capacity information 24 hours a day/seven days a
week (24/7), exclusive of scheduled system maintenance. For reporting
requirements, see DD Form 1423, CDRL, in Section J of the applicable
contract.
4.6.2 The contractor shall provide
a report of referrals from the contractor to the Market/MTF. For
reporting requirements, see DD Form 1423, CDRL, located in Section
J of the applicable contract.
4.7 TRICARE Prime
4.7.1 The contractor
shall process referrals from the civilian sector in accordance with
the following procedures:
4.7.1.1 The contractor shall send referrals
for TRICARE Prime beneficiaries who are enrolled to the network for
whom the Market/MTF has indicated the desire to receive referral
requests as indicated by the capability and capacity tables (except
for continuity of care, emergency admissions, and traveling out
of area).
4.7.1.2 The contractor shall provide
referrals to the Government prior to the contractor’s medical necessity and
covered benefit review.
4.7.1.3 The Government will provide
the contractor a list of Current Procedural Terminology (CPT) codes
or International Classification of Diseases, 10th Revision (ICD-10)
(or current edition) codes and will assign these a KSA value from 1 (low
KSA value) to 10 (highest KSA value). Diagnoses and
procedures not listed shall receive a default KSA value of 1.
4.7.1.4 The contractor shall prioritize
the highest KSA value referrals for TRICARE Prime patients for assignment
to the Market/MTF for care.
4.7.1.5 The contractor shall notify
the beneficiary of the accepted referral to the Market/MTF and provide assistance
or instructions for obtaining an appointment in the Market/MTF.
4.7.1.6 The contractor shall send referrals
to the Market/MTF via a HIPAA-compliant 278, or other process as identified
by the Government.
4.7.1.6.1 The request shall contain the
minimum data set described in
paragraph 5.0 (with the exception of the Referral
Case Number/UIN) plus the referring civilian provider’s telephone
number, fax number, and mailing address.
4.7.1.6.2 This data set shall be provided
to the Market/MTF in plain text with diagnosis or procedure codes.
4.7.1.7 The contractor shall transmit
the referrals within one business day from date and time of receipt
of referral for “urgent priority” and “routine priority” referrals
(excluding MTF closures).
4.7.1.8 The Market/MTF will respond
and accept or decline to the contractor via HIPAA-compliant 278,
or other process as identified by the Government within one business
day from receipt of the request for “urgent priority” and “routine
priority” referrals. Referrals from the contractor to the Market/MTF
shall not be transmitted when the MTF is closed.
4.7.1.9 The contractor shall, and the
Government may, notify the beneficiary of the Market/MTF acceptance and
provide instructions for contacting the Market/MTF to obtain an
appointment in instances where the Market/MTF elects to accept the
patient.
4.7.1.10 The contractor shall process
the referral request as if the Market/MTF declined to see the patient, when
no response is received from the Market/MTF in response to the referral
request as defined above.
4.7.1.11 The contractor shall forward
all referrals for care based on the Capability And Capacity (KSA)
table and secondary referrals table (
paragraph 1.4), to the Market/MTF.
The only exception will be if the continuity of care criteria is
met.
4.7.2 The contractor
shall provide each Market/MTF with a monthly report. For reporting
requirements, see Contract Data Requirements List, DD Form 1423,
in Section J of the applicable contract.
4.8 TRICARE Select
4.8.1 The contractor
shall provide a process for TRICARE Select beneficiaries the choice
of where specialty care or a procedure is received, to include the
MTF with capability and capacity of the specialty care or procedure required;
based on when the case meets the needs of the Market/MTF provider’s
KSAs and where the capability and capacity table indicates the Market/MTF
has capacity to accept TRICARE Select beneficiaries.
4.8.1.1 The contractor shall offer
such beneficiaries the option of utilizing a Market/MTF when one
exists within ATC standards that has the capacity and capability
to provide the needed care. This shall include providing the beneficiary
with quality and outcomes data, average days to be seen, as well
as general information about out-of-pocket costs for comparable
MTF and network providers and facilities capable of providing the
service.
4.8.1.2 The contractor shall ensure
Select beneficiaries are aware of this program.
4.8.2 The contractor shall provide
the beneficiary with information to contact to the Government for
MTF appointments when the TRICARE Select beneficiary chooses to
obtain care at the MTF.
4.8.3 The contractor
shall notify the Government via HIPAA compliant 278 transaction
when a TRICARE Select enrollee elects to utilize the MTF within
24 hours of electing care at the MTF. Correspondences shall follow the
same procedures for the TRICARE Prime referrals from the network
to the Market/MTF as outlined in
paragraph 4.7.
4.8.4 The Market Director/MTF Director
will ensure that the Capability And Capacity (KSA) tables are continually
maintained and refreshed every business day. Referrals for high-value
KSAs must be accepted by the DCS in accordance with the capability
and capacity tables unless listed in contingency
paragraph 8.0.
4.9 Status of Referrals When Beneficiaries
Change Geographical Location
4.9.1 The contractor’s
referral process shall support continuity of referrals when beneficiaries
change geographical region. Changing of geographical region includes
both internal contract region and a change to the other T-5 region.
4.9.2 Referrals shall remain valid
when a beneficiary changes geographical region, so long as they
are still in a Prime Service Area (PSA) (or TPR or TPRADFM) at the
new location.
4.9.3 The gaining
contractor shall not require a new referral from a PCM in the gaining
location.
4.9.4 The contractor
shall assist the beneficiary (or IRMAC/RAC) in finding a qualified
provider and arranging an appointment with that provider in the
new location with the goal of the beneficiary not having disruptions
or waiting for care in the new location.
4.9.5 At beneficiary (or the beneficiary’s
provider) request, the contractor shall assist with requirements
of
paragraph 4.9.4, prior to the beneficiary
moving.
4.9.6 In the event of a regional
change:
4.9.6.1 The gaining contractor shall
not require a new referral from a PCM in the gaining location.
4.9.6.3 The losing contractor shall
retain responsibility for the beneficiary referrals during the period
of the move until the beneficiary changes their enrollment to another
contractor and coverage becomes effective in the new location.
4.9.6.4 The losing contractor shall
ensure the beneficiary has access to urgent care utilizing virtual
health during their move, if this service is not offered by the
losing Market/MTF.
4.9.6.5 The losing contractor shall
forward approved referrals to the gaining contractor when requested
(in phone or writing) by the beneficiary or gaining contractor.
The information forwarded shall include, but is not limited to,
the number of authorized visits and approved diagnostic/treatment
codes.
4.9.6.6 The contractor with which the
beneficiary is enrolled at the time the referral is activated shall
ensure claims are processed appropriately.
6.0 NOTIFICATIONS
6.1 The contractor
shall provide beneficiaries with multiple referral status alerts
and notification options, including email, text, web-portal and
hard-copy letters (based on means the beneficiary chooses), to promote
ATC. The contractor shall educate beneficiaries on options to receive
referral, authorizations and notifications.
6.2.1 The contractor
shall make a copy of the referral, consult and the authorization
letter electronically accessible and printable to the beneficiary
in the contractor’s portal regardless of which alert and notification option
the beneficiary chooses.
6.2.2 The contractor
shall allow the beneficiary to opt in to hard copy, mailed authorizations
and notifications on referrals.
6.2.3 The contractor
shall note what preference a beneficiary chooses, hard copy or electronic,
as the means of providing authorization and denial letters and change
preference upon beneficiary request.
6.2.4 The contractor
shall mail all denial letters to the referring provider and beneficiary.
7.0 REPORTS
7.1 The contractor
shall locate related referrals, authorizations and claims using
the Referral Case Number/UIN.
7.2 The contractor
shall modify generated Market/MTF reports to accommodate the Referral
Case Number/UIN and NPI. The Referral Case Number/UIN shall also
be used for all related customer service inquiries. Referral Case
Numbers/UINs and NPIs will be attached to all Market/MTF referrals
and will be portable across all regions of care. The Referral Case
Number/UIN will be used to match claims to a Market/MTF-generated
referral.
7.3 The contractor shall capture
the NPIs from the referral transmission report and forward the NPI
and corresponding Referral Case Number/UIN to the referred to provider
on all referrals.
7.4 The contractor
shall provide a report on all specialty referrals. For reporting
requirements, see DD Form 1423, CDRL, located in Section J of the
applicable contract.
8.0 CONTINGENCY
OPERATIONS (OPS) WHEN SYSTEMS ARE DOWN
The contractor shall develop
a contingency process for transmitting referrals and authorizations
when its RM system is inoperable.
8.1 The contingency
process will be mutually agreed upon by the Government and the contractor.
8.2 The Government will submit
referrals and authorizations utilizing manual fax or the contractor’s
portal when the Government RM systems are inoperable. When both
the Government’s referral management system and the contractor’s
referral management system, simultaneously are inoperable, manual
fax shall be used as a last option.
8.2.1 The contractor
shall enter referral received via manual fax into its RM system.
8.2.2 Urgent referrals may be transmitted
to the contractor immediately during Government RM system downtime.
8.2.3 Markets/MTFs will hold routine
referrals and authorizations for two business days when Government RM
system is inoperable.
8.3 The contractor
shall provide training on submitting referrals within their portal
to Markets/MTFs to facilitate referral processing during Government
system outages.