1.0 BACKGROUND
Section 714 of the Fiscal Year
(FY) 2019 National Defense Authorization Act (NDAA) requires a streamlined approach
to referrals in TRICARE. Specifically, it requires that:
“(1) The referral process shall
model best industry practices for referrals from primary care managers
to specialty care providers;
(2) The process shall limit
administrative requirements for enrolled beneficiaries;
(3) Beneficiary preferences
for communications relating to appointment referrals using state-of-the-art
information technology shall be used to expedite the process; and
(4) There shall be effective
and efficient processes to determine the availability of appointments
at military medical treatment facilities and, when unavailable,
referrals to network providers under the TRICARE program.”
Consistent with this requirement,
TRICARE is implementing a pilot to use appointing and referral centers
to simplify the process of receiving referrals for care and making
appointments.
2.0 DESCRIPTION
AND OVERVIEW
The Government
will create a RAC located at one pilot site to be detailed in the
contract modification.
2.1 The RAC will serve as a “one
number” center for all specialty care appointing for TRICARE Prime
patients when the referral is generated by a provider at a Market/Military
Medical Treatment Facility (MTF) in the pilot Prime Service Area
(PSA).
2.2 These requirements apply only
to the managed care support contract(s) Managed Care Support Contractors
(MCSCs). Impact on Market/MTF local contracts will be addressed
by the Market/MTF.
2.3 The pilot will be eight weeks
in length. The Government may negotiate additional time with the contractor
at a future date.
3.0 Policy
3.1 The RACs
will receive all TRICARE Prime referrals written by providers at
MTFs in the pilot PSA. The RAC will determine whether the specialty
care will be provided at a direct care facility or will be referred
to the TRICARE network. If the care is referred to the TRICARE network,
the RAC will transmit the referral to the contractor using existing
systems (Referral Management System (RMS) or MHS GENESIS).
3.2 For referrals
received by the contractor by 1500 hours local time (local time
is based on the pilot PSA), the contractor shall process and authorize
the referral by 0700 hours local time the next business day. If
the referral is received after 1500 hours or on a non-business day,
the contractor shall process and authorize the referral by 0700 hours
on the second business day after the referral is received. For example,
if the referral is received on Saturday, the contractor shall process
and authorize the referral no later than 0700 the following Tuesday
(assuming Monday is not a Federal holiday). If the referral does
not have enough information for the contractor to process, the contractor
shall communicate that fact back to the Market/MTF along with what
information is needed for the contractor to complete the authorization
and approval letter. For referrals sent by 1500 hours local time,
the contractor shall accomplish said communication to the RAC by
0700 hours the next business day. For referrals sent after 1500
hours, the contractor shall accomplish communication to the RAC
by 0700 hours the second business day. The contractor shall process
referral requests in accordance with pilot guidelines when DEERS
or any other required Government system is unavailable. The Government
expects referrals during down time to meet pilot process timelines
once the system(s) returns on-line and the contractor becomes aware
of the referral or authorization request. The contractor shall notify
the Government when it encounters outages or disruptions.
3.3 The contractor
shall generate an authorization and/or approval letter. In the letter,
the contractor shall identify at least one and up to three network
providers (when available) who have the capability to provide the service
required by the referral. The contractor shall upload the authorization
and/or letter into the Government-MCSC interfacing system, using
established referral management processes. See
Chapter 8, Section 5. When the contractors
Medical Management System architecture is such that only one servicing
provider can be added to the initial approval letter or uploaded
to the interfacing portal, the contractor is permitted to develop
workarounds with the Government that would meet the requirement
to identify three providers.
3.4 The contractor
shall upload the approval letter, authorization and identified network
providers to the MCSC portal, consistent with established processes.
3.5 The referring
Market/MTF provider will direct the beneficiary to call the RAC
to schedule an appointment. The RAC will call the first provider
listed on the approval letter and determine if the provider has
the capacity to provide the care within TRICARE access standards.
If so, the RAC will then perform a warm hand off with the beneficiary
and the provider’s office. If the first provider on the list is
not able to provide the needed care within access standards, the
RAC will call the second, and if needed, third provider on the list.
3.6 If none
of the providers listed has the capacity, the RAC will contact the
contractor and request additional network providers (or if no network
providers are available, a non-network provider consistent with
existing policy) to assist the beneficiary in making an appointment.
The contractor shall provide additional providers within one business
day of receiving the request from the RAC. If the contractor is
unable to provide additional providers within one business day the
contractor shall communicate this to the Government and notify the
Government as soon as it becomes aware of appropriate additional
providers. The RAC may use the provider directory when the contractor
cannot provide additional providers. The contractor shall identity
and submit up to three non-network providers in lieu of network
providers, when network providers lack capacity or capability.
3.7 The RAC
will collect data to measure pilot success. These will include:
• Availability of network providers
of the requested type;
• Which providers accepts TRICARE
and which provide care within access standards;
• Number of un-activated referrals
(when the beneficiary fails to make or keep an appointment and no
claim is associated with the approved referral);
• Beneficiary satisfaction;
• Costs;
• Processing times;
• Completeness and appropriateness
of referrals; and
• Return of clear and legible
reports.
3.8 The Government
reserves the right to add additional pilot sites in the future.
5.0 Exclusions
• Referral and authorization requests
for current pilots and demonstrations including the Comprehensive
Autism Care Demonstration (ACD) and Intensive Outpatient
Program (IOP) Pilot To Address Behavioral Health Sequelae of Sexual
Trauma.
• Referrals for beneficiaries
not enrolled in TRICARE Prime.
• Referrals for beneficiaries
with Other Health Insurance (OHI).
• Directed referrals to non-network
providers >100 miles.
• Retroactive referrals.
• Retroactive referrals for emergency
room and urgent care.
• Renewed referrals such as for
continuity of care.
• Referrals for evaluation of
plastic surgery.
• Referrals for gender dysphoria,
including endocrinology evaluation and treat for gender dysphoria.
• Dental office visits for adult
and pediatric, including dental requiring sedation.
• Prosthetic referrals.
• Referrals needing second level
review.
• Duplicate referrals.
• Behavior Health referrals (non-office
based that requires benefit review and medical necessity review
such as IOP, Transcranial Magnetic Stimulation, Electroconvulsive
treatment and Partial Hospitalization Program (PMP)).
• Referrals for Home Care, Hospice,
and Home Infusion.
• Referrals for evaluation and
treatment of pediatric congenital heart defects.
• Faxed referrals (i.e., non-electronic
referrals and authorizations).