South Region HumanaMilitary.com 2015 Provider2015 Handbook ® ®

TRICARE® Provider Handbook Your guide to TRICARE programs, policies and procedures

2015 TRICARE Provider Handbook — South Region An important note about TRICARE Program information

The TRICARE Provider Handbook will assist you in delivering TRICARE benefits and services. The handbook must be read in light of governing statutes and regulations and is not a substitute for legal advice from qualified counsel, as appropriate. It is important to remember that TRICARE policies and benefits are governed by public law and federal regulations. Changes to TRICARE programs are continually made as public law and/or federal regulations are amended.

TRICARE providers are obligated to abide by the rules, procedures, policies and program requirements as specified in this TRICARE Provider Handbook and the TRICARE regulations and manual requirements related to the program. TRICARE regulations are available on the TRICARE website at TRICARE.mil

“TRICARE” is a registered trademark of the Defense Health Agency (DHA). All rights reserved. 2015 Provider Handbook South Region

HumanaMilitary.com

® Table of Contents 1. Welcome to TRICARE and the South Region. 6 What is TRICARE? ...... 6 Your regional contractor ...... 7 Humana Military network subcontractors and vendors. 7 HumanaMilitary.com...... 7 Interactive Voice Response ...... 7 TRICARE policy resources and manuals ...... 8 Provider Education ...... 8 Self -Service for providers ...... 9 Provider resources . 12 2. Important provider information . 15 Healthy People 2020 ...... 15 HEDIS® performance measures ...... 15 Health Insurance Portability and Accountability Act of 1996 (HIPPA) ...... 15 What is a TRICARE provider?...... 16 Provider certification and credentialing . 17 Right to appeal ...... 18 Provider responsibilities . 19 Balance billing ...... 20 Hold-harmless policy for network providers . 20 Clearly legible reports . 21 3. TRICARE eligibility . 22 Eligibility for TRICARE and Veterans Affairs benefits ...... 22 Verifying eligibility . 22 Verifying coverage...... 22 Military identification cards ...... 23 4. TRICARE program options. 24 TRICARE Prime Coverage Options...... 24 TRICARE Standard and TRICARE Extra. 25 Supplemental Health Care Program . 25 Warrior Navigation and Assistance Program . 26 TRICARE For Life ...... 26 TRICARE for the National Guard and Reserve ...... 27 TRICARE Young Adult Program . 28 Transitional health care benefits. 28 TRICARE Pharmacy Program...... 29 TRICARE Extended Care Health Option...... 31 TRICARE Dental Options. 32 5. Medical coverage and healthcare management . 33 Covered benefits and services . 33 Clinical preventive services...... 35 Maternity care...... 36 Durable medical equipment ...... 37 Home health care . 38 Infusion therapy . 39 Hospitalization ...... 39 Hospice care . 39 Laboratory Developed Test (LDT) ...... 40 Referrals and authorizations . 45 Right of First Refusal (ROFR) ...... 46

4 –TRICARE Provider Handbook Discharge planning ...... 47 Case management ...... 47 Clinical quality management ...... 47 Peer review organization agreement . 48 Appealing a decision ...... 50 6. Mental health care services ...... 51 Mental health care providers . 51 Referral and authorization requirements ...... 51 Telemental health services . 52 Case management ...... 52 Discharge planning ...... 52 Incident reporting requirements ...... 52 Limitations and exclusions (mental health) . 52 Eating disorder programs ...... 52 Outpatient services...... 52 Applied Behavior Analysis (ABA) . 59 7. Claims information ...... 60 Claims processing standards ...... 60 Processing out-of-region care ...... 60 Claims using Medicare and TRICARE. 61 Claims for NATO beneficiaries ...... 61 Claims for CHAMPVA ...... 62 Claims for Continued Health Care Benefit Program . 62 Claims for Extended Care Health Option ...... 62 TRICARE network providers ...... 62 Non-network TRICARE-authorized providers ...... 62 OHI: requiring TRICARE prior authorization ...... 63 Fraud and abuse . 65 TRICARE electronic claims filing . 66 TRICARE claims and billing tips. 66 8. TRICARE reimbursement methodologies ...... 71 Reimbursement limitations . 71 Anesthesia claims and reimbursement ...... 72 Ambulatory surgery grouper rates ...... 72 Diagnosis-related group reimbursement . 72 Bonus payments in health professional shortage areas...... 73 Home health agency pricing...... 74 Skilled nursing facility pricing. 74 Durable medical equipment, prosthetics, orthotics and supplies pricing. 75 Home infusion drug pricing. 75 Modifiers ...... 75 Assistant surgeon services . 75 Surgeon’s services for multiple surgeries . 76 Outpatient prospective payment system. 76 Hospice pricing ...... 77 Updates to TRICARE rates and weights . 77 9. Provider tools . 78 Acronyms . 78 Glossary of terms ...... 79 10. List of figures...... 81 11. Index ...... 82

TRICARE Provider Handbook – 5 Welcome to TRICARE and the South Region

What is TRICARE? TRICARE brings together military and civilian health care professionals and resources to provide high-quality health care services. TRICARE is TRICARE is the Department of Defense’s (DoD’s) worldwide health managed in three stateside regions — TRICARE North, TRICARE South care program available to eligible beneficiaries in any of the seven and TRICARE West. uniformed services — the U.S. Army, the U.S. Navy, the U.S. Air Force, In these U.S. regions, TRICARE is managed by the Defense Health the U.S. Marine Corps, the U.S. Coast Guard, the Commissioned Corps Agency (DHA) and has contracted with civilian regional contractors of the U.S. Public Health Service and the Commissioned Corps of the in the North, South and West regions to assist TRICARE regional National Oceanic and Atmospheric Administration. directors and military hospital commanders in operating an TRICARE-eligible beneficiaries may include Active Duty Service integrated health care delivery system. Members (ADSMs) and their families, retired service members and their families, National Guard and Reserve members and their families, survivors, certain former spouses and others.

Figure 1.1 TRICARE Regions

NORTH REGION: SOUTH REGION: WEST REGION: Health Net Federal Services, LLC Humana Military UnitedHealth Military & Veterans Services HNFS.net HumanaMilitary.com UHCMilitaryWest.com Customer Service Line: Customer Service Line: 1-800-444-5445 Customer Service Line: 1-877-TRICARE (1-877-874-2273) 1-877-988-WEST (1-877-988-9378)

6 –TRICARE Provider Handbook Your regional contractor • PGBA, LLC is Humana Military’s claims processing contractor in the TRICARE South Region. PGBA is one of the largest subsidiaries Humana Military, a division of Humana Government Business, of BlueCross BlueShield of South Carolina. Inc., administers the TRICARE program in the South Region, which includes Alabama, Arkansas, Florida, Georgia, Kentucky (the Fort Campbell area only), Louisiana, Mississippi, Oklahoma, South HumanaMilitary.com Carolina, Tennessee and Texas (excluding the El Paso area). Humana Military’s website hosts a full array of interactive services Humana Military is committed to preserving the integrity, designed to save providers time and money. The provider portal features flexibility and durability of the Military Health System (MHS) by pages customized for providers and Primary Care Managers (PCMs). offering beneficiaries access to the finest health care services available, thereby contributing to the continued superiority of Visit HumanaMilitary.com to: U.S. combat readiness. • Learn about TRICARE programs and coverage. • Access forms and tutorials. Figure 1.1 displays a map of the three TRICARE regions in the • Learn about provider education opportunities. United States. Figure 1.2 on the following page shows the TRICARE • Get billing guidelines. South Region. • Locate TRICARE providers using the Find a Provider tool. • Access Self-Service for Providers, Humana Military’s secure self- Humana Military network subcontractors and service portal. vendors

Humana Military administers the TRICARE contract and utilizes Interactive Voice Response (IVR) partnerships for certain services: Providers that do not have Internet access can take advantage of • ValueOptions® Federal Services is Humana Military’s Humana Military’s Interactive Voice Response (IVR) system through mental health care contractor in the TRICARE South Region. our toll-free service line, 1-800-444-5445. This line is available 24 ValueOptions® Federal Services is the largest privately held hours a day, seven days a week. mental health managed care company in the nation.

Figure 1.2 TRICARE South Region

TRICARE Provider Handbook – 7 The IVR system responds to your natural speech patterns or touch- location addresses and phone/fax numbers are as current as possible tone responses. It is an easy way to get answers to routine questions, and display within 30 days of any change to that information. such as verifying beneficiary eligibility, checking the status of claims Lack of accurate information can impact the beneficiary selection and reviewing the status of referral and prior authorization requests. of a Primary Care Manager, specialty selection for a referral, and adequacy of the network in a geographic area. Please be sure to You can use Humana Military’s IVR to: provide updates and changes as soon as they are known. • Look up procedure codes. • Check the status of claims. • Determine eligibility and covered benefits. • Check the status of referrals, authorizations and mental health referrals.

TRICARE policy resources and manuals:

manuals.tricare.osd.mil

The DHA provides Humana Military with guidance — as issued by the DoD — for administering TRICARE-related laws. The DoD issues this direction through modifications to the Code of Federal Regulations (CFR).

The TRICARE Operations Manual, TRICARE Reimbursement Manual and TRICARE Policy Manual are continually updated to reflect changes in the CFR. Depending on the complexity of the law and federal funding, it can take a year or longer before the DoD provides direction for administering new policy.

Note: TRICARE-related statutes can be found in Chapter 55 of Title 10 of the United States Code, which contains all statutes regarding the armed forces. Unless specified otherwise, federal laws generally supersede state laws.

This TRICARE Provider Handbook provides an overview of the TRICARE program regulations and requirements contained in the TRICARE Policy Manual, TRICARE Operations Manual and TRICARE Reimbursement Manual. To view the complete manuals and other TRICARE policies, visit manuals.tricare.osd.mil

Refer to these TRICARE manuals as well as to the TRICARE Provider News publication and HumanaMilitary.com for current information about policy changes, time lines and implementation guidance.

Provider education and locator at Humana Military’s unsecured portal

The Provider portal at HumanaMilitary.com is available to all providers with internet access. The Provider page contains current information and explanations to educate providers in support of the TRICARE program. The list of Provider Education options and downloadable items includes: • Provider Handbook • Provider Forms • Provider Resources and Claims information • TRICARE Provider Education Powerpoints

The locator is the electronic version of a Network Provider Directory. URAC is the accrediting body for our Locator. Business rules for display are defined by URAC’s credentialing oversight.. TRICARE requires Humana Military to maintain the accuracy of the locator. It is important that all network providers, specialties/services available,

8 –TRICARE Provider Handbook Self-Service for providers Figure 1.3

The secure Self-Service for Providers offers many features that will save you time, ensure patient privacy and help manage your office more efficiently. It’s simple, secure and available 24 hours a day, seven days a week for registered providers.

With Self-Service for Providers, you can quickly and easily: • Verify patient eligibility/benefits/claims • Create and update referral and authorization requests • Check claim status • Manage your profile • Look up codes

Registration is fast and easy for providers. Just go to HumanaMilitary.com, select Provider and click the register for self- service button in the green box. Follow the prompts to complete your registration!

Need assistance with registering, logging in, resetting a password, verifying eligibility or another self-service task?

Check out our Guide to Self-Service for Providers to learn how to take advantage of our secure self-service tool. Search for Self-Service Guide at HumanaMilitary.com

Major features includes:

TRICARE patient profile Referrals and authorizations • Multiple eligibility checks and up to five eligibility checks at a time • Build referral/authorization request — in real time! • Updating existing referrals and authorizations • Cost-share/copay information beneficiary eligibility history • Adding visits and services to referrals • Other Health Insurance (OHI) information • Updating admission and discharge dates for inpatient hospital stays • Program information • Extending the coverage period • Referral by patient status • Adding procedure codes (Most types of service have procedures • Claims by patient status already identified) Code lookup • Accessing code lookup messages about procedures and diagnoses, shown in red (for example, “No referral required” or • Access CPT and Diagnosis code lookup about covered procedures “Noncovered service”) and service messaging that assist in determining referral or • Selecting a provider authorization needs: • Entering up to five lines of pertinent clinical information that will be • Limitations and Exclusions transmitted to the referred-to provider • Exempt from PRIME referrals • Many approvals and updates display immediately, saving you time • Non-covered service

TRICARE Provider Handbook – 9 Self-Service for providers

10 –TRICARE Provider Handbook Self-Service for providers

Individual Primary Care Managers can:

• View and update address information • Check count of patient panel and view individual TRICARE beneficiary information

Group information by TIN or EIN a group can now:

• Select the location under the Base TIN to work from • View the specialties available at that location • View the Types of Services available at that location • View the list of professional providers affiliated to that location, and view those professional providers with re-credentialing dates approaching

The facility information includes:

• View of location and also offers the ability to select other locations • Specialties available • Inpatient and Outpatient Services available • *Coming soon Facility Credentialing Status

TRICARE Provider Handbook – 11 Self-Service for providers

Gaining Access to Self-Service for Providers

When registering for Self-Service for Providers, providers have four different options for gaining access: • Site administrator express code: Providers may use an express code from a local site administrator responsible for the provider ID they want to access. • Existing referral information: Providers may enter the Auth/Order number and key code shown on a received Humana Military—TRICARE Referral/Authorization fax. The provider ID that they are requesting access for must be associated with the Auth/Order number entered. • Onsite Humana Military provider representative validation: The provider representative must enter several key codes to grant a provider immediate access to Self-Service for Providers. • Manual approval: If the previous options are unavailable, providers may submit an approval request to a local site administrator (usually a person who works for the provider) for the provider ID they want to access. If a local site administrator does not exist, a Humana Military provider representative will review the request and confirm or deny the right to obtain access.

Trusted site information

If you’re concerned about misuse of Internet access in your office, you can always designateHumanaMilitary.com as a trusted site. A trusted site is a website that you trust not to damage your computer. If the security level of your Internet Explorer browser is High, you may be unable to access a specific website that you trust. To access the website, add the URL to your Trusted Sites list or change your security level to Medium or lower. When using a High security level, you need to add the Web application URLs to your Trusted Sites list.

To add a trusted site in Internet Explorer, follow these steps: • Click the Sites button. • In the Add this website to the zone field, type the URL for the • From the Internet Explorer Tools menu, click Internet Options. trusted website. • On the Security tab, click Trusted Sites. • Deselect Require server verification for all sites in this zone • In the Security level for this zone box, you may need to do one of and then click Close. In the Internet Options dialog box, click OK. the following: • If it is set to High, use the slider to change it to a lower Note: Mozilla Firefox does not specifically offer a trusted sites security level. setting. However, you can set allowed sites for the limited purpose of • If it is set to Custom, click Default Level and use the slider installing cookies and add-ons. From the Tools menu, select Options to change the security level. and go to the Security tab.

Note: If you are running Windows Vista, verify that Enable Protected Mode is not selected.

Interactive Voice Response (IVR)

Providers that do not have Internet access can take advantage of Humana Military’s Interactive Voice Response (IVR) system through our toll-free service line, 1-800-444-5445. This line is available 24 hours a day, seven days a week. The IVR system responds to your natural speech patterns or touch-tone responses. It is an easy way to get answers to routine questions, such as verifying beneficiary eligibility, checking the status of claims and reviewing the status of referral and prior authorization requests. You can use Humana Military’s IVR to: • Look up procedure codes. • Check the status of claims. • Determine eligibility and covered benefits. • Check the status of referrals, authorizations and mental health referrals.

12 –TRICARE Provider Handbook TRICARE provider resources

Figure 1.4

Humana Military resources Resource/contact information Services provided HumanaMilitary.com (Access secure features via the Self- Secure services Non-secure services Services for Providers portal.) • Verify patient eligibility • Learn about TRICARE programs and • Create referrals and authorizations coverage • Review referrals and authorizations • Access forms and tutorials • Check claim status • Learn about provider education • Manage your profile opportunities • Access pharmacy data by patient • Get billing guidelines • Look up codes • Locate TRICARE providers using the Find a Provider tool • Access the TRICARE Provider Handbook and editions of TRICARE Provider News

Humana Military Interactive Voice Response (IVR) Line • Look up procedure codes 1-800-444-5445 • Check the status of claims • Determine eligibility and covered benefits • Check the status of referrals, authorizations and mental health referrals

PGBA Electronic Data Interchange (EDI) Help Desk • Get assistance with issues related to TRICARE Electronic Media Claims (EMC) 1-800-325-5920 submissions myTRICARE.com • Identify yourself as a TRICARE provider

Additional South Region resources Resource Contact information Mental health care partner: ValueOptions® Federal ValueOptions® Federal Services Services, Inc. P.O. Box 551188 Jacksonville, FL 32255-1188 1-800-700-8646 HumanaMilitary.com

PGBA provider data management updates TRICARE South Region Data Management Dept. P.O. Box 7031 Camden, SC 9021-7031 Fax: 1-803-462-3993 Fraud and abuse hotline 1-800-333-1620 HumanaMilitary.com

Claims: PGBA, LLC 1-800-403-3950 myTRICARE.com

National resources Resource Contact information TRICARE website TRICARE.mil TRICARE manuals online manuals.tricare.osd.mil Defense Health Agency- Great Lakes Defense Health Agency- Great Lakes 2834 Green Bay Road, Suite 304 North Chicago, IL 60064-3091 1-888-MHS-MMSO (1-888-647-6676)

TRICARE Provider Handbook – 13 TRICARE provider resources

TRICARE Pharmacy Resources Resource Contact information TRICARE Pharmacy Program: Express Scripts, Inc. Express Scripts, Inc. P.O. Box 52150 Phoenix, AZ 85072 Phone: 1-877-363-1303 Fax: 1-877-895-1900 express-scripts.com/TRICARE

TRICARE formulary search tool pec.ha.osd.mil/formulary_search.php Pharmacy prior authorization information and forms TRICARE.mil/pharmacy Prior Authorization Provider Line: 1-866-684-4488 Medical necessity forms and criteria for non-formulary pec.ha.osd.mil/forms_criteria.php medications

Online reimbursement rate calculators (Tricare.mil) Access these online tools via the websites listed below. The Web Posting Date indicates when the information was last updated. Rates are updated at least annually or at other intervals at the discretion of TRICARE Management Activity. Calculator resource Online access Ambulatory surgery grouper rates TRICARE.mil/ambulatory Anesthesia procedure pricing TRICARE.mil/anesthesia TRICARE allowable charges TRICARE.mil/CMAC Diagnosis-related group rates TRICARE.mil/DRGrates TRICARE outpatient prospective payment system TRICARE.mil/OPPS

Other program resources Resource Contact information Civilian Health and Medical Program of the Department va.gov/purchasedcare/programs/dependents/champva of Veterans Affairs (CHAMPVA) VA Health Administration Center CHAMPVA P.O. Box 469063 Denver, CO 80246-9063 1-800-733-8387 TRICARE For Life (TFL) TRICARE4U.com WPS/TDEFIC Wisconsin Physicians Service/TRICARE Dual Eligible Fiscal P.O. Box 7889 Intermediary Contract (WPS/TDEFIC) Madison, WI 53707-7889 (General correspondence only, no claims) 1-866-773-0404 1-866-773-0405 (TDD)

14 –TRICARE Provider Handbook Important provider information

TRICARE providers must abide by the rules, procedures, policies and providers, institutional providers such as hospitals, their workforce program requirements specified in this TRICARE Provider Handbook members and their contractors to use and disclose Protected Health and TRICARE regulations and requirements related to the TRICARE Information (PHI) only as permitted or required by the HIPAA Privacy program. Please read this handbook in light of governing statutes and Rule. PHI is individually identifiable health information, which includes regulations; it is not a substitute for legal advice from qualified counsel, demographic and payment information created and obtained by as appropriate. For more information, visit HumanaMilitary.com providers who deliver health services to patients.

Healthy People 2020 The HIPAA Privacy Rule permits providers to use and disclose PHI without a patient’s written authorization for purposes of treatment, payment In December 2010, the Department of Health and Human Services and health care operations. The HIPAA Privacy Rule also permits uses launched Healthy People 2020, the latest incarnation of a 30-year and disclosures of PHI without a patient’s authorization in various initiative to increase the health and wellness of the U.S. population. situations not involving treatment, payment and health care operations. Healthy People provides 10-year national objectives for improving the health of all Americans. In the Military Health System (MHS), one of the most important exceptions to the authorization requirement is the military command Please consider Healthy People initiatives and their LHIs for overall exception. This permits limited disclosures of PHI about Active Duty health, wellness and prevention for our beneficiaries by implementing Service Members (ADSMs) to their military commanders to determine prevention education and ensuring wellness care programs. fitness for duty or certain other purposes. Similarly, PHI of service The Healthy People 2020 program seeks interested providers to members separating from the armed forces may be disclosed to the participate and receive materials. U.S. Department of Veterans Affairs (VA).

For more information on Healthy People 2020, search for Healthy For more detailed guidance and information on the HIPAA Privacy People 2010-2020 at HumanaMilitary.com Rule, search for Privacy at HumanaMilitary.com

HEDIS performance measures Providers must establish administrative, physical and technical safeguards. Actual or possible unauthorized use or disclosure The Healthcare Effectiveness Data and Information Set (HEDIS) is of PHI (i.e., a breach) may require notifying affected individuals a widely used set of performance measures in the managed care and reporting to TMA and other government entities. For more industry, developed and maintained by the National Committee for information on responding to privacy breaches, visit Quality Assurance (NCQA). TRICARE.mil/TMA/privacy/breach.aspx

NCQA designed HEDIS to allow consumers to compare their health plan’s performance to other plans and to national or regional Military health system notice of privacy practices benchmarks. Although not originally intended for trending, HEDIS and other information sources results are increasingly used to track year-to-year performance as well. The Military Health System Notice of Privacy Practices form informs The DHA has challenged Humana Military to collaborate with its beneficiaries about their rights regarding PHI and explains how network providers to improve the HEDIS scores of TRICARE beneficiaries. PHI may be used or disclosed, who can access PHI and how PHI is protected. The notice is published in 11 languages. Braille and audio Improving HEDIS scores is another element of Humana Military’s versions are also available. ongoing efforts to help TRICARE beneficiaries improve their health and better manage chronic health conditions. This goal also supports Visit TRICARE.mil/TMA/privacy/HIPAA-NOPP.aspx to download copies the Population Health segment of the TMA’s Quadruple Aim. of the Military Health System Notice of Privacy Practices.

This segment seeks to reduce generators of ill health by encouraging They serve as beneficiary advocates for privacy issues and respond to healthy behaviors and decreasing likelihood of illness through beneficiary inquiries about PHI and privacy rights. focused prevention and increased resilience. For more information about privacy practices and other HIPAA Search for more information on HEDIS at HumanaMilitary.com requirements, visit TRICARE.mil/HIPAA. Beneficiaries and providers may also e-mail inquiries to [email protected]

Health Insurance Portability and Accountability For additional questions about the HIPAA Privacy Rule and TRICARE, Act of 1996 (HIPAA) visit TRICARE.mil/tma/privacy or HHS.gov/ocr/privacy

The HIPAA Privacy Rule generally requires individual health care

TRICARE Provider Handbook – 15 What Is a TRICARE Provider?

TRICARE defines a provider as a person, business or institution that provides health care. Providers must be authorized under TRICARE regulations in order for TRICARE beneficiaries to cost-share claimed services. Humana Military contracts with network providers in the South Region to deliver health care to TRICARE beneficiaries.

Figure 2.1 TRICARE-certified providers vs. TRICARE network providers TRICARE-authorized providers • TRICARE-authorized providers meet state licensing and certification requirements and are certified by TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers include doctors, hospitals, ancillary providers (nurse practitioners, physician assistants and physical therapists), laboratory and radiology providers, and pharmacies. Beneficiaries are responsible for the full cost of care if they see providers who are not TRICARE-authorized. • TRICARE covers services delivered by qualified TRICARE-authorized mental health care providers and ABA practicing within the scope of their licenses to diagnose and/or treat covered mental health components of an otherwise diagnosed medical or psychological condition. • There are two types of TRICARE-authorized providers: network and non-network. Network providers1 Non-network providers2 Regional contractors have established Non-network providers do not have agreements with Humana Military or ValueOptions® Federal networks, within a forty mile radius of Services and are therefore considered non-network. the military hospitals or clinics. There are two types of non-network providers: participating and nonparticipating. TRICARE network providers: Participating providers Nonparticipating providers • Have agreements with Humana • May choose to participate on a • Do not agree to accept the TRICARE allowable charge Military to provide care. For mental claim-by-claim basis or file claims for TRICARE beneficiaries health services, agreements are with • Agree to accept payment directly • Have the legal right to charge beneficiaries up to 15 ValueOptions® Federal Services. from TRICARE and accept the percent above the TRICARE allowable charge for services • Agree to file claims and handle other TRICARE allowable charge as paperwork for TRICARE beneficiaries. payment in full for their services

1. Network providers must have malpractice insurance. 2. To inquire about becoming a network provider, search for Join the Network at HumanaMilitary.com. (Information about mental health network participation is available from the same Web page.)

Military hospitals or clinics • Internal medicine physicians • Nurse practitioners A military hospital or clinic is a healthcare facility usually located • Pediatricians on or near a military base. The civilian TRICARE provider network • Obstetricians and gynecologists (Gender restrictions apply.) supplements military hospital or clinic resources and may work closely with military hospitals or clinics to ensure patients get the care they See PCM’s Role later in this section for more information about need. To locate a military hospital or clinic, visit TRICARE.mil/MTF PCM roles and responsibilities.

Primary Care Managers (PCMs) Corporate Services Provider (CSP) class

PCMs coordinate all care for their patients and provide non-emergency The CSP class consists of institutional-based or freestanding care whenever possible. PCMs also maintain patient medical records corporations and foundations that provide professional, and refer patients for specialty care that they cannot provide. ambulatory or in-home care, as well as technical diagnostic procedures. Some of the provider types in this category may When required, PCMs work with Humana Military to obtain referrals include: and prior authorizations. See the Health Care Management and • Cardiac catheterization clinics Administration section for more information about referral and • Comprehensive outpatient rehabilitation facilities authorization requirements. • Diabetic outpatient self-management education programs PCMs can be military hospitals or clinics or civilian TRICARE network (American Diabetes Association® accreditation required) providers. The following provider specialties may serve as TRICARE PCMs: • Freestanding bone-marrow transplant centers • Freestanding kidney dialysis centers • Family practitioners • Freestanding Magnetic Resonance Imaging (MRI) centers • General practitioners • Freestanding sleep-disorder diagnostic centers

16 –TRICARE Provider Handbook • Home health agencies (pediatric or maternity management TRICARE credentialing required) • Home infusion (Accreditation Commission for Health Care To join the TRICARE network, a TRICARE-authorized provider must accreditation required) complete the credentialing process and sign a contract with Humana • Independent physiological laboratories Military and ValueOptions® Federal Services for mental health. • Radiation therapy programs Humana Military’s credentialing process requires primary-source/ acceptable source verification of the provider’s education/training, Non-network CSPs must apply to become TRICARE-authorized. Qualified board certification, license, professional and criminal background, non-network providers can download the Application for TRICARE- malpractice history and other pertinent data. Provider Status/Corporate Services Provider at myTRICARE.com. Only after receiving the CSP’s application can Humana Military then To meet the minimum credentialing criteria established by Humana network the CSP. Military, individuals must: • Have graduated from a school appropriate to their profession CSPs who deliver home health care are exempt from prospective and completed postgraduate training appropriate to their payment system billing rules. For more information about CSP practicing specialty coverage and reimbursement, refer to the TRICARE Policy Manual, • Have a current, valid, unrestricted and un-probated professional Chapter 11, Section 12.1 at manuals.tricare.osd.mil state license* in the state(s) they practice within • Have a current, valid, unrestricted and un-probated Drug Provider certification and credentialing TRICARE Enforcement Agency (DEA) registration, if applicable to their certification practicing specialty • Have a current, valid, unrestricted and un-probated State TRICARE only reimburses appropriate covered services for eligible Controlled Dangerous Substance registration, if applicable to beneficiaries provided by TRICARE-authorized providers. TRICARE- their practicing specialty and the state they practice within authorized providers must meet TRICARE licensing and certification • Have current professional liability insurance or meet the state/ standards and must comply with regulations specific to their health local guidelines care areas. • Be able to participate in federal health care programs. • Not have been convicted of a felony related to controlled Certified providers are considered non-network TRICARE-authorized substances, health care fraud, or a child or patient abuse providers. Non-network providers may also choose to “accept • Not have any physical or mental health condition that cannot be assignment” (i.e., participate) on a case-by-case basis. accommodated without undue hardship or without reasonable accommodation If a non-network provider accepts assignment, he or she is • Not have untreated chemical/substance dependency considered a participating non-network provider and agrees to accept • Not have any unexplained gaps of six months or more in their the TRICARE allowable charge as payment in full for covered services. work history during the past five years Nonparticipating non-network providers do not have to accept the TRICARE allowable charge or file claims for beneficiaries. *See the TRICARE Policy Manual 6010.54-M, AUGUST 1, 2008, Chapter 11, Section 3.2, State Licensure and Certification Policy. Providers All providers must submit certification forms to PGBA to become a requiring credentialing include: TRICARE-certified provider. To download the forms, visit myTRICARE.com and search for Provider Forms South. • Medical Doctors (MDs) (if not hospital-based, active duty, urgent care or VA) In addition, freestanding Partial Hospitalization Programs (PHPs), • Doctors of Osteopathic Medicine (DOs) (if not hospital-based, Residential Treatment Centers (RTCs), and Substance Use Disorder active duty, urgent care or VA) Rehabilitation Facilities (SUDRFs) must first be certified by KePRO, the • Doctors of Dental Medicine (DMDs) (must practice oral and TRICARE Quality Monitoring Contractor (TQMC). Call KePRO at 1-877- maxillofacial surgery) 841-6413 to speak with TRICARE certification representatives and • Doctors of Dental Surgery (DDSs) (must practice oral and request information. maxillofacial surgery) • Doctors of Podiatric Medicine (DPMs) Once KePRO certifies the facility, the provider must complete the • Doctors of Optometry (ODs) ValueOptions® Federal Services contracting process. Contact • Nurse Practitioners (NPs) ValueOptions® Federal Services by e-mail at provhelptricare@jax. valueoptions.com or by phone at 1-800-700-8646 for more information. Credentialing is also required for acute inpatient facilities, freestanding surgical centers, home health agencies and Skilled Note: Separate TRICARE certification of hospital-based PHPs is not Nursing Facilities (SNFs). required. When a hospital is a TRICARE-authorized provider, the hospital’s PHP is also considered a TRICARE-authorized provider. To meet the minimum credentialing criteria established by Humana However, freestanding PHPs must be certified and enter into a Military, facilities must: participation agreement with TRICARE and obtain the required • Have a current signature and date on the application authorization prior to admitting patients. • Have a current, valid, unrestricted and un-probated state license • Have current acceptable liability insurance • Be able to participate in federal health care programs, including

TRICARE Provider Handbook – 17 Medicare, Medicaid and all other plans and programs that TRICARE program rules and regulations and Humana Military policies provide health benefits funded directly or indirectly by the United and procedures. Visit HumanaMilitary.com for more information States (other than the Federal Employees Health Benefits Plan) about provider responsibilities. as reported by the Office of the Inspector General (OIG) or the General Services Administration (GSA) Missed appointments • Have acceptable accreditation status appropriate to the facility TRICARE regulations do not prohibit providers from charging missed The provider must wait to receive final notification of contract appointment fees. TRICARE providers are within their rights to enforce execution and credentialing approval from Humana Military before practice standards, as stipulated in clinic policies and procedures providing care to TRICARE beneficiaries as a network provider. that require beneficiaries to sign agreements to accept financial Humana Military monitors each network provider’s quality of care and responsibility for missed appointments. TRICARE does not reimburse adherence to DoD, TRICARE and Humana Military policies. Network beneficiaries for missed appointment fees. providers must be re-credentialed at least every three years.

Right to appeal Nondiscrimination policy All TRICARE-authorized providers agree not to discriminate against Humana Military has established minimum credentialing/eligibility any TRICARE beneficiary on the basis of his or her race, color, national criteria for inclusion in the provider network. Failure to meet origin or any other basis recognized in applicable laws or regulations. the minimum credentialing/eligibility criteria established by the To access the full TRICARE policy, refer to the TRICARE Operations Credentialing Committee is not reportable to any external agency Manual, Chapter 1, Section 5 at manuals.tricare.osd.mil (i.e. the NPDB).

To appeal a decision, Humana Military must receive notification Office and appointment access standards of the appeal within 14 calendar days of the provider’s notification that minimum credentialing/eligibility was not met. TRICARE access standards ensure that beneficiaries receive timely All documentation must be included to support the appeal. The care within a reasonable distance from their homes. Emergency appeal and documentation will be reviewed by the First Level services must be available 24 hours a day, seven days a week. Review Panel. Notification of outcome will be in writing. Failure Network and military hospital and clinic providers must adhere to the to comply with the time frame constitutes a waiver of the right following access standards for non-emergency care: to appeal. • Preventive care appointment: Four weeks (28 days) • Routine care appointment: One week (seven days) Note: The TRICARE Policy Manual 6010.57-M, February 1, 2008, • Specialty care appointment: Four weeks (28 days) Chapter 11, Section 3.2, State Licensure and Certification Policy • Urgent care or acute illness appointment: One day (24 hours) states, “A. State Licensure/Certification. Otherwise covered serves shall be cost-shared only if the individual professional provider Office wait times for non-emergency care appointments shall holds a current, valid license or certification to practice his or not exceed 30 minutes except when the provider’s normal her profession in the state where service is rendered. Licensure/ appointment schedule is interrupted due to an emergency. certification in a profession other than that for which the Providers that are running behind schedule should notify the provider is seeking authorization is not acceptable. The licensure/ patient of the cause and anticipated length of the delay, and offer certification must be at the full clinical level of practice. Full clinical to reschedule the appointment. The patient may choose to keep practice level is defined as an unrestricted license that is not the scheduled appointment. subject to limitations on the scope of practice ordinarily granted all other applicants for similar specialty in the granting jurisdiction. Individual placed on probation or whose license has otherwise PCM’s role been restricted are not considered to be practicing at the full TRICARE Prime beneficiaries agree to initially seek all non-emergency clinical practice level. services from their PCM. PCMs are specified providers selected for Mental health care providers — including freestanding PHPs, RTCs primary care services at the time of enrollment. The PCM is an and SUDRFs — must also be credentialed by ValueOptions® Federal individual provider within a military or civilian setting. Services. For credentialing criteria and to download a writable PDF Here is an overview of the PCM’s roles and responsibilities: application for behavioral health providers, see the Mental Health Care Services section of this handbook, or search Join the Network at • Primary care services are typically, although not exclusively, HumanaMilitary.com. provided by internal medicine physicians, family practitioners, pediatricians, general practitioners and, nurse Provider responsibilities practitioners • When a provider signs a contractual agreement to become Network providers have contracts with Humana Military and must a PCM, he or she must follow TRICARE procedures and comply with all TRICARE program rules and regulations and Humana requirements for obtaining specialty referrals and prior Military policies. authorizations for non-emergency inpatient and certain outpatient services This handbook is not all-inclusive and provides an overview of • In the event the assigned PCM cannot provide the full range of

18 –TRICARE Provider Handbook primary care functions necessary, the PCM must ensure access Humana Military/ValueOptions® Federal Services is required for to the necessary health care services, as well as any specialty certain services requirements • Active Duty Family Members (ADFMs): PCMs should refer • PCMs are required to provide access to care 24 hours a day, patients to military hospitals and clinics or network providers seven days a week, including after-hours and urgent care whenever possible. ADFMs must obtain PCM and/or Humana services, or arrange for on-call coverage by another provider Military referrals for any care they receive from providers other than their PCMs, except for preventive care services from Note: The on-call provider must be a certified network network providers, mental health care visits for medically provider who is also a PCM. The PCM or on-call provider will necessary treatment for covered conditions by network determine the level of care needed: providers who are authorized under TRICARE regulations • Routine care: The PCM or on-call provider instructs the to see patients independently or when using the Point-Of- TRICARE Prime beneficiary to contact the PCM’s office on Service (POS) option. In addition, prior authorization from the next business day for an appointment Humana Military/ValueOptions® Federal Services is required • Urgent care: The PCM or on-call provider coordinates for certain services timely care for the TRICARE Prime beneficiary • TRICARE Standard: Beneficiaries may self-refer to TRICARE- • The on-call physician should contact the PCM authorized specialty care providers. However, prior authorization within 24 hours of an inpatient admission to ensure from Humana Military/ValueOptions® Federal Services is required continuity of care for certain services • TRICARE For Life: Beneficiaries may self-refer to Medicare- • PCMs referring patients for specialty care may need to certified providers. However, prior authorization from coordinate the referral with Humana Military Humana Military/ValueOptions® Federal Services is required • ADSMs must have referrals for all care outside of military for certain services hospitals and clinics (except for emergencies or as provided in TRICARE Prime Remote [TPR] regulations, if applicable), including Providers should request referrals and prior authorizations via all mental health care services. If the ADSM has an assigned the secure Self-Service for Providers portal at HumanaMilitary. civilian PCM under TRICARE Prime or TPR, all specialty referral and com. Humana Military/ValueOptions® Federal Services only authorization guidelines must be followed accepts requests via fax if the provider is not able to submit electronically.

Specialty care responsibilities If a civilian specialty provider refers a TRICARE patient to a sub- specialist, the specialty provider must contact the patient’s PCM when Specialty care may require prior authorization from Humana Military subspecialty care is outside of the scope of the initial referral and/or as well as referrals from PCMs (for TRICARE Prime enrollees) and/or prior authorization. If required, the PCM must request a new referral Humana Military. and/or authorization from Humana Military. TRICARE Prime beneficiaries who live within a 60-minute drive time If active (i.e., already approved) referrals and/or prior authorizations of a military hospital or clinic may be required to first seek specialty are in place, specialists can request additional visits or services care, ancillary services and physical therapy at the military facility directly from Humana Military. Refer to the Health Care Management based on it’s Right Of First Refusal (ROFR). and Administration section for more information about referral and PCMs and/or specialty care providers must coordinate with Humana prior authorization requirements. Military to obtain referrals and prior authorizations. A network Note: If the PCM refers a patient for a consultation only, Humana provider who submits a claim for an unauthorized service is subject Military issues a referral for an initial consultation and one follow- to a penalty of up to 50 percent of the TRICARE allowable charge. up visit. Specialists cannot request additional visits or services for Network mental health care providers have agreements with consult-only authorizations. The beneficiary must coordinate further ValueOptions® Federal Services to follow rules and procedures care with his or her PCM. If additional services beyond the scope regarding mental health care. Although a PCM referral is not of the initial referral are required, the specialist must send another required for mental health care services (except for ADSMs), request to Humana Military to ensure continuity of care. prior authorization may be required from ValueOptions® Federal Services. Department of Veterans Affairs (VA) health Care rendered without prior authorization will be reviewed care facilities retrospectively and may result in a penalty of up to 50 percent. The cost of this penalty will be borne by the provider, and the beneficiary On a case-by-case basis, the VA may contact a TRICARE network is held harmless. provider to request care for a VA patient or a Civilian Health and Medical Program of the Department of Veterans Affairs Specialty care referral requirements vary by TRICARE beneficiary type (CHAMPVA) beneficiary. and program option: CHAMPVA is the federal health benefits program for eligible family • TRICARE Prime: ADSMs: PCM and/or Humana members of 100 percent totally and permanently disabled Veterans. Military/ValueOptions® Federal Services referrals are required for Administered by the VA, CHAMPVA is a separate federal program from all civilian specialty care. In addition, prior authorization from

TRICARE Provider Handbook – 19 TRICARE. For questions regarding CHAMPVA, call 1-800-733-8387 or If a TRICARE beneficiary has Other Health Insurance (OHI), the e-mail [email protected]. provider must bill the OHI first. After the OHI pays, TRICARE pays the remaining billed amount up to the TRICARE allowable charge For VA patients, the provider works with the referring VA Medical for covered services. Providers may not collect more than the billed Center (VAMC) to coordinate health care services, medical charge from the OHI (the primary payer) and TRICARE combined. OHI documentation and reimbursement. The VA patient must give the and TRICARE payments may not exceed the beneficiary’s liability. TRICARE provider VAMC referral information and reimbursement instructions at the time of service. For more information or Medicare’s balance billing limitations apply to TRICARE. assistance, call Humana Military at 1-800-444-5445. Noncompliance with balance billing requirements may affect a provider’s TRICARE and/or Medicare status. Balance billing limitations DVA and CHAMPVA only apply to TRICARE-covered services. Providers may not bill beneficiaries for administrative expenses, A facility understands that, through this network agreement, it including collection fees, to collect TRICARE payment. In addition, agrees to being reported to the Department of Veterans Affairs network and participating non-network providers cannot bill (DVA) and to Civilian Health and Medical Program of the Veterans beneficiaries for noncovered services unless the beneficiary agrees Administration (CHAMPVA) as a TRICARE network provider. This in advance and in writing to pay for these services up front. At that agreement will give the DVA the right to directly contact Facility and point the provider is not obligated to file a claim to TRICARE if the request care on a case by case basis for VA patients or CHAMPVA TRICARE specific waiver is in place and the non-covered service is beneficiaries if the facility availability allows. The facility understands confirmed prior to the date of service. that it is not required to meet access standards for CHAMPVA beneficiaries, but is encouraged to do so. The facility understands that CHAMPVA beneficiaries are not to receive preferential Noncovered services appointment scheduling over a TRICARE beneficiary. Before delivering care, network providers must notify TRICARE patients if services are not covered. Noncovered services include: Emergency care responsibilities • Services that appear on the No Government Pay Procedure Code To avoid penalties, providers must notify Humana Military of any List, available at TRICARE.mil/NoGovernmentPay emergency admission. Notification is available 24 hours a day, 7 days • Services outside of the scope of TRICARE-covered services a week on HumanaMilitary.com, by calling the Interactive Voice • Services that currently have a temporary code or are still Response (IVR) line at 1-800-444-5445 or by faxing the information considered experimental to 1-877-548-1547. Note: Denied or rejected claims with services in the scope of coverage Humana Military reviews admission information and authorizes are not considered noncovered services continued care, if necessary. If TRICARE Prime enrollees seek non- ADSMs may be covered for the above non-covered services on emergency care without required referrals and/or authorizations, they Note: a case-by-case basis as long as there is a valid authorization from are responsible for paying POS fees. their military hospital or clinic.

Urgent care The beneficiary must agree in advance and in writing to receive and accept financial responsibility for noncovered services. The TRICARE Prime beneficiaries must obtain referrals from their PCMs agreement must document the specific services, dates, estimated or Humana Military for urgent care. If a TRICARE Prime beneficiary costs and other information. does not receive a referral, the claim will be paid under the Point-Of- Service (POS) option. Network providers must use the TRICARE Noncovered Services Waiver form to satisfy these requirements. A general agreement to pay, such as one signed by the beneficiary at the time of admission, is not sufficient Balance billing to prove that a beneficiary was properly informed or agreed to pay. A TRICARE network provider agrees to accept the rates and terms of If the beneficiary does not sign a TRICARE Noncovered Services Waiver payment specified in its agreement with Humana Military as payment form, the provider is financially responsible for the cost of noncovered for a covered service. Participating non-network provider agrees to services he or she delivers. See the Medical Coverage section for a accept the TRICARE allowable charge as payment in full for a covered summary of TRICARE-covered and noncovered services and benefits. service. These providers may not bill TRICARE beneficiaries more than this amount for covered services. Both network and non-network To download the form, search for TRICARE Noncovered Services providers can seek applicable co-pays and cost-shares directly from Waiver at HumanaMilitary.com. Network providers should keep the beneficiaries. copies of the TRICARE Noncovered Services Waiver form in their offices.

Non-network nonparticipating providers do not have to accept the TRICARE allowable charge and may bill patients for up to 15 percent Hold-harmless policy for network providers above the TRICARE allowable charge. If the billed amount is less than A network provider may not bill a TRICARE beneficiary for excluded or the TRICARE allowable charge, TRICARE reimburses the billed amount. excludable services (i.e., the beneficiary is held harmless), except in

20 –TRICARE Provider Handbook the following circumstances: Tips for Returning Consult Reports • If the beneficiary did not inform the provider that he or she was • Requested consult reports must be returned on TRICARE patients a TRICARE beneficiary within 10 days following the patient’s appointment unless an • If the beneficiary was informed that services were excluded urgent situation exists or excludable and agreed in advance and in writing to pay for • For urgent consults, contact the referring provider by phone the services within 24 hours, and follow up by faxing the formal consult report to the specified military hospital or clinic number within A TRICARE beneficiary is held harmless from financial liability for 10 days of the appointment date noncovered services. If the beneficiary has agreed in writing (using the • If you have programmed the Humana Military TRICARE TRICARE Noncovered Services Waiver form) in advance of the service/ consult fax number in your fax machine, please update it to care being performed, the provider may bill the beneficiary directly. the military hospital or clinic number shown on the referral If there is not a TRICARE waiver on file for the patient and the • Remember to check the fax number periodically and confirm it is specified date of service and care, then the network provider has no the correct fax number for consult reports recourse and must uphold the hold harmless provision according to • If your office uses a transcription service that sends consult Title 10 of the Code of Federal Regulations on TRICARE. reports directly to the referring physician, please inform them of the new fax number for TRICARE patient consults and the 10 TRICARE network providers must file patients’ claims, even when the day requirement patient has Other Health Insurance (OHI). • Please be sure Humana Military is notified if you change your office or referral fax line An Important Message from TRICARE form Consult Report Fax Cover Sheet Referred-to specialists receive an Auto Fax Confirmation Sheet for Inpatient facilities are required to provide each TRICARE beneficiary TRICARE patients referred by Humana Military on all approved re- with a copy of the An Important Message from TRICARE form. ferrals. This includes details about the referral request, the referred This document details the beneficiary’s rights and obligations on patient and the fax number for the consult report when it is a admission to a hospital. TRICARE patient referred from the military treatment facility.

The signed document must be kept in the beneficiary’s file. A new document must be provided for each admission.

To download the form, search for Important Message at HumanaMilitary.com.

Clearly legible reports

For care referred by an military hospital or clinic, network providers must provide Clearly Legible Reports (CLRs), which include consultation reports, operative reports and discharge summaries to the military hospital or clinic within seven business days of care delivery. Mental health care network providers must submit brief initial assessments within seven to 10 business days.

Providers must send preliminary reports for urgent and emergency specialty care consultations to the referring provider within 24 hours (unless best medical practices dictate less time is required for a preliminary report). Network providers must follow the instructions included on the referral/authorization confirmation from Humana Military.

TRICARE Provider Handbook – 21 TRICARE eligibility

Identification cards for family members age 75 TRICARE beneficiaries with Medicare Part A and Part B are covered by TFL, TRICARE’s Medicare-wraparound coverage. Under TFL, Medicare acts as and older the primary insurance, and TRICARE acts as the secondary payer.

All eligible family members and survivors age 75 or older are issued VA care is not covered by Medicare, so if beneficiaries seek care from permanent ID cards. These cards should read INDEF (i.e., indefinite) in a VA provider while they are using their TRICARE benefit, TFL pays the Expiration Date box. first, and Medicare pays nothing. In this situation, beneficiaries pay • ADFMs remain eligible for TRICARE Prime and TRICARE the TRICARE Standard Fiscal Year (FY) deductible, cost-shares and Standard/TRICARE Extra while the sponsor is on active duty. remaining billed charges. However, once the sponsor retires from active duty, the sponsor and his or her family members who are entitled to premium-free Alternatively, they may choose to use their VA benefit when seeing Medicare Part A must also have Medicare Part B to keep their VA providers. For beneficiaries to minimize their out-of-pocket costs TRICARE benefits once they are covered by TFL, they should seek care from providers • TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), who participate in both TRICARE and Medicare. CHCBP and US Family Health Plan (USFHP) beneficiaries are not required to have Medicare Part B to remain covered under Verifying eligibility these programs • Civilian: Check the ID card to verify eligibility for TRICARE civilian TRICARE beneficiaries should present their military ID card at the time care. The Civilian box should read YES. A TRICARE For Life (TFL) of service to assist with eligibility verification. Providers may verify beneficiary with an ID card that reads NO in this block may still TRICARE Prime or TRICARE Standard/TRICARE Extra eligibility in one of use TFL if he or she has both Medicare Part A and Medicare Part the following ways: B coverage • HumanaMilitary.com: The secure Self-Service for Providers portal’s check eligibility feature shows a patient’s current status Eligibility for TRICARE and Veterans Affairs benefits along with information about the TRICARE copay, cost-share, Other Health Insurance (OHI) and catastrophic cap Certain beneficiaries are eligible for both TRICARE and U.S. • myTRICARE.com: Access PGBA’s secured portal to check eligibility Department of Veterans Affairs (VA) benefits programs, and they may • Availity.com: This option is currently available in Texas, Oklahoma choose which benefits they want to use. Further, a beneficiary can and Florida seek TRICARE-covered services even if he or she received treatment • Call Humana Military’s Interactive Voice Response (IVR) line at through the VA for the same medical condition during a previous 1-800-444-5445. Access the Provider Main Menu, and press # for episode of care. eligibility and benefits

However, TRICARE does not duplicate payments made or authorized Providers have the right to collect out-of-pocket costs from by VA for service-connected disability care. Eligibility for VA health care beneficiaries prior to seeing the TRICARE patient, or they can file the for service-connected disabilities is not considered double coverage. claim first if it’s easier. Both the patient’s Explanation Of Benefits (EOB) and the provider remittance will include copay or cost-share amounts owed. Veterans Affairs benefits as Other Health Insurance (OHI) Verifying coverage If beneficiaries are entitled to Department of Veterans Affairs (VA) Humana Military encourages providers to use the Self-Service for benefits, they may choose whether to see a TRICARE or VA provider. Providers portal’s code lookup feature at HumanaMilitary.com. By If they are not Medicare-eligible, VA coverage is considered OHI and looking up the service or procedure code, you can determine whether TRICARE pays second to any out-of-pocket costs for VA services. the service requires a referral or is exempt from referral requirements If beneficiaries are entitled to Medicare Part A due to age or another if you are seeing a TRICARE Prime member. The code lookup feature reason, they are considered Medicare-eligible and must have also identifies noncovered services and procedures or ones that Medicare Part B to keep their TRICARE benefit. (Certain beneficiaries may be on the No Government Pay Procedure Code List available at may not need Medicare Part B to keep their TRICARE benefit. For more TRICARE.mil/NoGovernmentPay information, visit TRICARE.mil/TFL) If you do not have access to HumanaMilitary.com, our 1-800-444- 5445 IVR line can provide the same coverage information by code or service/procedure description.

22 –TRICARE Provider Handbook TRICARE eligibility continued

Military identification cards Figure 3.1

Active Duty Service Members (ADSMs), family members over age 10, retirees and family members will have one of two valid military ID cards displayed below. Providers should ensure patients have a valid military ID card or authorization letter of eligibility. Be sure to check the expiration date and make a copy of both sides of the ID card for your patient files. An ID alone is not proof of eligibility. See the Verifying Eligibility section below for more information. • DOD Benefits Number (DBN)/member ID or Social Security Number (SSN) or sponsor SSN: Providers may verify the beneficiary’s eligibility using the information supplied on the card. As new military ID cards are issued, a new member ID will replace the sponsor SSN. This new member ID can still be used to verify eligibility. Humana Military’s Web-based eligibility check option allows you to use either the sponsor SSN or the new member ID to verify eligibility • Expiration Date: Check the date in the EXPIRATION DATE box on the ID card. If expired, the beneficiary must update his or her information in the Defense Enrollment Eligibility Reporting System (DEERS) and be issued a valid card • Civilian: Check the back of the ID card to verify eligibility for TRICARE civilian care. The center section of the card should read YES in the CIVILIAN box

Note: Beneficiaries who are dual-eligible will have Medicare Part A and Part B and TRICARE. Military ID cards will be similar. An eligibility check will verify TRICARE coverage as secondary.

TRICARE cannot accept or cross-walk a 10-digit number in the Member ID field, which causes claims to reject. Numbers containing dashes also generate an error. Here’s a list of possible ID numbers you may encounter: • SSN — a nine-digit number no longer on ID cards, which is acceptable for claims submissions • DoD ID number — a 10-digit number on the front of ID cards, which is not acceptable for claims submissions • DBN — an 11-digit number on the back of some ID cards, which is acceptable for claims submissions (Do not include any dashes)

If the ID card does not include a 9-digit sponsor SSN or an 11-digit DBN, ask the beneficiary to provide the two numbers.

Please review your systems to ensure that your claims submissions contain the appropriately formatted nine-digit SSN or 11-digit DBN. If you have any questions, please call PGBA’s Electronic Data Interchange (EDI) Help Desk at 1-800-325-5920, menu option 2.

TRICARE Provider Handbook – 23 TRICARE program options

TRICARE offers comprehensive medical benefits to all TRICARE Military hospital or clinic staff members review the referral to beneficiaries, as well as pharmacy and dental benefits. Depending determine if they can provide care within access standards. If the on a beneficiary’s status and location, he or she may be eligible service is not available within access standards, the military hospital for different program options. This section provides information on or clinic refers the beneficiary to a TRICARE network provider. TRICARE program options, including the TRICARE Pharmacy Program and the TRICARE Dental Program (TDP) options. TRICARE Prime Remote and TRICARE Prime Remote for Active Duty Family Members TRICARE Prime coverage options TPR and TPRADFM provide TRICARE Prime coverage to ADSMs and TRICARE Prime, TRICARE Prime Remote (TPR) and TRICARE Prime Remote the family members who live with them in remote locations through for Active Duty Family Members (TPRADFM) are managed care a network of civilian TRICARE-authorized providers, institutions and options offering the most affordable and comprehensive coverage. suppliers (network or non-network). ADSMs and their families who While Active Duty Service Members (ADSMs) must enroll in a TRICARE live and work more than 50 miles or a one-hour drive time from the Prime option, Active Duty Family Members (ADFMs), retirees and nearest military hospital or clinic designated as adequate to provide their families, and others may choose to enroll in TRICARE Prime or primary care may be eligible to enroll in TPR or TPRADFM. use TRICARE Standard/TRICARE Extra. ADSMs receive care at Military Treatment Facilities (military hospitals and clinics). If civilian network care Each TPR or TPRADFM enrollee is assigned a PCM. Whenever possible, is required, the military hospitals and clinics will provide a referral. Active a TRICARE network PCM is assigned, but a non-network TRICARE- Duty Service members cannot be treated outside of the military hospitals authorized PCM may be assigned if a network provider is not available. and clinics without a valid referral, including preventive services. TPR and TPRADFM beneficiaries should always seek non-emergency In the TRICARE South Region, TRICARE Prime, TPR and TPRADFM care from their PCMs unless they’re using the POS option. In most require enrollment with Humana Military. See the TRICARE Eligibility cases, a TPR or TPRADFM enrollee must obtain a referral and/or prior section for instructions on verifying patient eligibility. authorization to receive non-emergency care from another provider who is not his or her PCM.

TRICARE Prime TPR ADSMs do not need referrals, prior authorizations or fitness- for-duty reviews to receive primary care. Specialty and inpatient TRICARE Prime is a managed care option available in TRICARE Prime services require referrals and prior authorizations from Humana Service Areas (PSAs). A PSA is a geographic area where TRICARE Prime Military/ValueOptions® Federal Services and the Military Medical benefits are offered. It is typically an area around a military hospital Support Office (MMSO) Service Point Of Contact (SPOC). The SPOC or clinic or other predetermined area. determines referral management for fitness-for-duty care.

ADFMs and other eligible beneficiaries may enroll in TRICARE Prime or To determine if a particular ZIP code falls within a TPR coverage area, use TRICARE Standard/TRICARE Extra. Each TRICARE Prime enrollee is use the ZIP code lookup tool at TRICARE.mil/TPRZipCode assigned a Primary Care Manager (PCM).

Whenever possible, a PCM located at a military hospital or clinic is TRICARE Prime Point-Of-Service (POS) Option assigned, but a TRICARE network PCM may be assigned if a military hospital or clinic PCM is not available. The POS option allows non-ADSMs enrolled in TRICARE Prime, TPR or TPRADFM to seek non-emergency health care services from any In most cases, a TRICARE Prime enrollee must obtain a referral and/or TRICARE-authorized provider without referrals. prior authorization to receive non-emergency care from a provider other than his or her PCM. All TRICARE Prime enrollees (except ADSMs) can self- The POS cost-share applies when: refer to a network provider who is authorized under TRICARE regulations • The patient receives care from a civilian TRICARE-authorized to see patients independently for mental health care services. provider without an appropriate referral/authorization • The patient self-refers to a network specialty care provider after A military hospital or clinic has the Right Of First Refusal (ROFR) for Humana Military authorizes a referral to see a military hospital or TRICARE Prime referrals within their catchment area for inpatient clinic specialty care provider admissions, specialty appointments and procedures requiring prior • The patient enrolled at a military hospital or clinic self-refers to a authorization, provided the military hospital or clinic is able to civilian provider, other than his or her PCM, for routine care deliver the service requested by the beneficiary’s civilian provider. • The patient self-refers for non-emergency mental health care This means TRICARE Prime enrollees must first try to obtain care at from a non-network behavioral provider. (The POS option applies Military hospitals and clinics. to all non-emergency mental health care from non-network providers. Prior authorization requirements may still apply) 24 –TRICARE Provider Handbook The POS option does not apply to the following: Supplemental Health Care Program (SHCP) • ADSMs TRICARE is derived from the Civilian Health and Medical Program of the • Newborns and newly adopted children in the first 60 days after Uniformed Services (CHAMPUS), which technically does not cover ADSMs birth or adoption (or National Guard and Reserve members on active duty). However, • Emergency care similar to TRICARE, the Supplemental Health Care Program (SHCP) provides • Clinical preventive care received from a network provider coverage for ADSMs (except those enrolled in TPR) and non-active • Mental health care outpatient visits to a network provider duty individuals under treatment for Line-Of-Duty (LOD) conditions. for medically necessary treatment for covered conditions by network providers who are authorized under TRICARE regulations SHCP also covers health care services ordered by a military hospital to see patients independently or clinic provider for a non-ADSM military hospital or clinic patient for • Beneficiaries with Other Health Insurance (OHI) whom the military hospital or clinic provider maintains responsibility. Although the Department of Defense (DoD) funds SHCP, it is separate When using the POS option, beneficiaries must pay a deductible and from TRICARE and follows different rules. 50 percent of the TRICARE allowable charge. POS costs do not apply to the catastrophic cap. Only the following individuals are eligible for SHCP: Please note that the POS option does not affect provider • ADSMs assigned to military hospitals or clinics reimbursement; the beneficiary pays a larger portion of the total • ADSMs on travel status (e.g., leave, temporary assignment to TRICARE allowable charge. Providers should note referral end dates duty or permanent change of station) and advise beneficiaries when additional referrals are required. For • Navy and Marine Corps service members enrolled to deployable specific inpatient costs, visit TRICARE.mil/costs units and referred by the unit PCM (non-military hospital or clinic) • National Guard and Reserve members on active duty Note: ADSMs may not use the POS option and must always obtain • National Guard and Reserve members (LOD care only, unless referrals and/or authorization for civilian care. If an ADSM receives member is on active federal service) care without a required referral or prior authorization, the claim is • National Oceanic and Atmospheric Administration personnel, forwarded to the SPOC for payment determination. U.S. Public Health Service personnel, cadets or midshipmen, and eligible foreign military personnel If the SPOC approves the care, the ADSM does not have to pay the bill. • Non-active duty beneficiaries when they are inpatients in a If the SPOC does not approve, the ADSM is responsible for the entire military hospital or clinic and are referred to civilian facilities for cost of care. tests or procedures unavailable at the military hospital or clinic, provided the military hospital or clinic maintains continuity of TRICARE Standard and TRICARE Extra care over the inpatient and the beneficiary is not discharged from the military hospital or clinic prior to receiving services TRICARE Standard/TRICARE Extra is available to any TRICARE-eligible • Comprehensive Clinical Evaluation Program participants beneficiary with an active military ID who has not enrolled in TRICARE • Beneficiaries on the Temporary Disability Retirement List required Prime. Beneficiaries can seek care from any TRICARE-authorized to obtain periodic physical examinations provider with no referral. • Medically retired former members of the armed services enrolled in the Federal Recovery Coordination Program TRICARE Standard/TRICARE Extra involves cost-shares and deductibles. TRICARE Standard patients who see network providers Providers can verify SHCP patient eligibility via Humana Military’s for their care use the TRICARE Extra benefit, which lowers out-of- secure Self-Service for Providers at HumanaMilitary.com or via pocket costs. Humana Military’s toll-free Interactive Voice Response (IVR) line at 1-800-444-5445. Seeing TRICARE Standard/TRICARE Extra beneficiaries involves no drawbacks for network providers. Network providers file claims SHCP covers care referred or authorized by the military hospital or for TRICARE Standard/TRICARE Extra in the same way as for clinic and/or the MMSO. When SHCP beneficiaries need care, the TRICARE Prime. military hospital or clinic (if available) or the MMSO refers ADSMs and certain other patients to civilian providers. TRICARE Standard beneficiaries do not have PCMs and may self-refer to any TRICARE-authorized provider. However, certain If services are unavailable at the military hospital or clinic, the services (e.g., inpatient admissions for substance abuse disorders Referral for Civilian Medical Care form (DD Form 2161) is sent to and mental health, adjunctive dental care, home health services) Humana Military before the patient receives specialty care. (The form require prior authorization from Humana Military/ValueOptions® may vary by military hospital or clinic site.) Humana Military and the Federal Services. military hospital or clinic, as appropriate, identify a civilian provider and notify the patient. For non-military hospital or clinic referred See the Health Care Management and Administration section or care, the SPOC determines if the ADSM receives care from a military the Mental Health Care Services section for more information about hospital or clinic or civilian provider. referral and authorization requirements. SHCP beneficiaries are not responsible for cost-shares, co-pays or See the TRICARE Program Options Costs chart, included with this deductibles. See the Claims Processing and Billing Information section handbook, for specific cost information. For more cost information, for SHCP claims submission information. visit TRICARE.mil/costs

TRICARE Provider Handbook – 25 Warrior Navigation and Assistance Program If a beneficiary returns to work and his or her Social Security disability payments are suspended, his or her Medicare Humana Military created the Warrior Navigation and Assistance entitlement continues for up to eight years and six months. Program (WNAP) to support ADSMs and National Guard and Reserve When disability payments are suspended, beneficiaries receive a members, their families and their providers. The program provides bill every three months for Medicare Part B premiums and must information and assistance to help combat veterans — ADSMs, continue to pay Medicare Part B premiums to remain eligible for National Guard and Reserve members, and medically retired service TRICARE coverage. members — navigate military health care systems, the Department Note: The term dual-eligible refers to TRICARE and Medicare dual- of Veterans Affairs (VA) health systems, community resources and eligibility and should not be confused with Medicare-Medicaid the civilian health care sector. dual-eligibility. WNAP offers person-to-person guidance and access to an advocacy TFL provides comprehensive health care coverage. Beneficiaries have unit specially trained to handle the unique challenges many the freedom to seek care from any Medicare-participating provider, wounded, ill and injured warriors face in accessing care. The program from military hospitals and clinics on a space-available basis or from provides warriors and their families with resources that can help VA facilities (if eligible). them return to healthy and productive lives. Medicare cannot pay for services received from the VA. Therefore, For more information, visit HumanaMilitary.com or call TRICARE is the primary payer for VA claims, and the beneficiary will be 1-888-4GO-WNAP (1-888-446-9627). responsible for the TRICARE annual deductible and cost-shares.

TRICARE For Life Alternatively, the beneficiary may choose to use his or her VA benefit. Neither TRICARE nor Medicare will reimburse costs not TRICARE For Life (TFL) is Medicare-wraparound coverage for dual- covered by the VA. eligible TRICARE beneficiaries. Regardless of age, beneficiaries are considered dual-eligible if they are entitled to premium-free Medicare Medicare-participating providers file claims with Medicare first. After Part A and eligible for TRICARE because they also have Medicare Part paying its portion, Medicare automatically forwards the claim to B coverage. TFL for processing (unless the beneficiary has OHI). TFL pays after Medicare and any OHI for covered health care services. However, the following beneficiaries, entitled to Medicare Part A, are not required to have Medicare Part B to remain TRICARE-eligible: All beneficiaries should sign up for Medicare Part B as soon as they become eligible to avoid a break in TRICARE coverage. ADFMs remain eligible for TRICARE Prime and TRICARE Standard/ TRICARE Extra while the sponsor is on active duty. However, once the TFL beneficiaries must present valid uniformed services sponsor retires from active duty, the sponsor and his or her family identification (ID) cards and Medicare cards prior to receiving members who are entitled to premium-free Medicare Part A must services. If a TFL beneficiary’s uniformed services ID card reads NO also have Medicare Part B to keep their TRICARE benefits. under the Civilian box, he or she is still eligible to use TFL if he or she has both Medicare Part A and Part B. Copy both sides of the cards TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), CHCBP and retain the copies for files. and US Family Health Plan (USFHP) beneficiaries are not required to have Medicare Part B to remain covered under these programs. There is no separate TFL enrollment card. To verify TFL eligibility, call the TFL contractor, Wisconsin Physicians Service/TRICARE Dual Eligible Note: TRICARE advises beneficiaries to sign up for Medicare Part B Fiscal Intermediary Contract (WPS/TDEFIC), at 1-866-773-0404. when first eligible to avoid a break in TRICARE coverage. Beneficiaries Call the Social Security Administration (SSA) at 1-800-772-1213 to who sign up later may have to pay a premium surcharge for as long confirm a patient’s Medicare status. as they have Part B. The Medicare Part B surcharge is 10 percent for each 12-month period that a beneficiary was eligible to enroll in Part Note: Beneficiaries age 65 and older who are not eligible for B but did not enroll. premium-free Medicare Part A may remain eligible for TRICARE Prime (if residing in PSAs) or TRICARE Standard/TRICARE Extra. After turning 65, beneficiaries who are not eligible for premium-free Medicare Part A on their own or their current, former or deceased See TRICARE and Medicare Eligibility in the TRICARE Eligibility section spouse’s record may remain eligible for TRICARE Prime or TRICARE for more information. Standard/TRICARE Extra. They must take the Notices of Award and/or Notices of Disapproved Claim they received from the Social Security How TRICARE for Life works Administration (SSA) to the nearest uniformed services ID card- issuing facility to update DEERS and get new ID cards. Because Medicare is the primary payer, referrals and prior authorizations from Humana Military are usually not required. Beneficiaries who receive disability benefits from the SSA are entitled However, dual-eligible beneficiaries may need an authorization from to Medicare in the 25th month of receiving disability payments. Humana Military/ValueOptions® Federal Services if Medicare benefits The Centers for Medicare and Medicaid Services (CMS) notifies are exhausted or for care covered by TRICARE but not Medicare. See beneficiaries of their Medicare entitlement date. the Health Care Management and Administration section for more information about TRICARE referral and authorization requirements.

26 –TRICARE Provider Handbook File TFL claims first with Medicare. Medicare pays its portion and TRICARE Retired Reserve (TRR) electronically forwards the claim to WPS/TDEFIC (unless the beneficiary has OHI). WPS/TDEFIC sends its payment for TRICARE- TRR is a premium-based health plan that members of the Retired covered services directly to the provider. Beneficiaries receive Reserve may qualify to purchase. TRR provides comprehensive health Medicare Summary Notices and TRICARE Explanations Of Benefits care coverage and patient cost-shares and deductibles similar to (EOBs) indicating the amounts paid: TRICARE Standard/TRICARE Extra, but TRR beneficiaries must pay monthly premiums. • For services covered by both TRICARE and Medicare: Medicare pays first and TRICARE pays its share of the remaining expenses TRR members may self-refer to any TRICARE-authorized second (unless the beneficiary has OHI). provider; however, certain services (e.g., inpatient admissions • For services covered by TRICARE but not by Medicare: TRICARE for substance use disorders and mental health care, adjunctive processes the claim as the primary payer. The beneficiary is dental care, home health services) require prior authorization responsible for the applicable TFL deductible and cost-share. from Humana Military. See the Health Care Management and • For services covered by Medicare but not by TRICARE: Medicare is Administration section for more information about referral and the primary payer and TRICARE pays nothing. The beneficiary is authorization requirements. responsible for the applicable Medicare deductible and cost-share. • For services not covered by Medicare or TRICARE: the beneficiary After purchasing either member-only or member-and-family TRR is responsible for the entire bill. coverage, TRR members receive TRR enrollment cards. These cards include important contact information but are not required to See the Claims Processing and Billing Information section for obtain care. information about TFL claims and coordinating with OHI. For more information about TFL, call WPS/TDEFIC at 1-866-773-0404 or visit Although beneficiaries should expect to present their cards at the TRICARE4u.com time of service, enrollment cards do not verify TRICARE eligibility. Copy both sides of the cards and retain the copies for files. See the TRICARE TRICARE for the National Guard and Reserve Eligibility section for information on verifying patient eligibility. For more information, visit the TRR website at TRICARE.mil/TRR or call The seven National Guard and Reserve components include: 1-877-298-3408, menu option 1. • Army National Guard • Army Reserve • Marine Corps Reserve Line-Of-Duty (LOD) care for National Guard and • Navy Reserve Reserve members • Air Force Reserve An LOD condition is determined by the military service and • Air National Guard includes any injury, illness or disease incurred or aggravated • U.S. Coast Guard Reserve while the National Guard or Reserve member is in a duty status, either inactive duty (such as reserve drill) or active duty status. TRICARE Reserve Select (TRS) This includes the time period when the member is traveling directly to or from the location where he or she performs TRS is a premium-based health plan that members of the Selected military duty. The National Guard or Reserve member’s service Reserve of the Ready Reserve may qualify to purchase. TRS provides determines eligibility for LOD care, and the member receives a comprehensive health care coverage and patient cost-shares and written authorization that specifies the LOD condition and terms deductibles similar to TRICARE Standard/TRICARE Extra, but TRS of coverage. beneficiaries must pay monthly premiums. Note: The Defense Enrollment Eligibility Reporting System (DEERS) TRS members may self-refer to any TRICARE-authorized provider; does not show eligibility for LOD care. however, certain services (e.g., inpatient admissions for substance use disorders and mental health care, adjunctive dental care, home LOD coverage is separate from any other TRICARE coverage in effect, health services) require prior authorization from Humana Military. See such as: the Health Care Management and Administration section for more • Transitional health care coverage under the Transitional information about referral and authorization requirements. Assistance Management Program (TAMP) or Transitional Care for Service-Related Conditions (TCSRC) program After purchasing either member-only or member-and-family TRS • Coverage under the TRS program option coverage, TRS members receive TRS enrollment cards. These cards include important contact information but are not required to obtain care. Whenever possible, military hospitals and clinics provide care to National Guard and Reserve members with LOD conditions. Although beneficiaries should expect to present their cards at the Military hospitals and clinics may refer National Guard and time of service, enrollment cards do not verify TRICARE eligibility. Copy Reserve members to civilian TRICARE providers. If there is no both sides of the cards and retain the copies for files. See the TRICARE military hospital or clinic nearby to deliver or coordinate care, the Eligibility section for information on verifying patient eligibility. MMSO may coordinate non-emergency care with any TRICARE- For more information, visit the TRS website at TRICARE.mil/TRS or call authorized civilian provider. 1-877-298-3408, menu option 1.

TRICARE Provider Handbook – 27 Humana Military forwards any claim not referred by a military • Not eligible to enroll in an employer-sponsored health plan as hospital or clinic or preapproved by the MMSO to the MMSO for defined in TYA regulations approval or denial. The provider should submit medical claims • Not otherwise eligible for TRICARE program coverage directly to Humana Military unless otherwise specified in the LOD written authorization or requested by the National Guard or Reserve Transitional health care benefits member’s medical department representative. When submitting claims for a National Guard or Reserve member with an LOD TRICARE offers three program options for beneficiaries separating condition, the services listed on the claim must be directly related to from active duty: the Transitional Assistance Management the condition documented in the LOD written authorization. Program (TAMP), the Transitional Care for Service-Related Conditions (TCSRC) program and the Continued Health Care If the MMSO denies a claim for eligibility reasons, the provider’s office Benefits Program (CHCBP). should bill the beneficiary. The MMSO may approve payment once the appropriate eligibility documentation is submitted. It is the National Guard or Reserve member’s responsibility to ensure that his or her Transitional Assistance Management Program unit submits appropriate eligibility documentation to the MMSO and (TAMP) that the MMSO authorizes all follow-up care. TAMP provides 180 days of transitional health care benefits to help certain armed services members and their families transition to Coverage when activated for more than 30 civilian life after separating from active duty service. consecutive days Qualifying beneficiaries may enroll in TRICARE Prime if they reside in National Guard and Reserve members with activation orders for more a PSA, or they are automatically covered under TRICARE Standard/ than 30 consecutive days in support of a contingency operation may TRICARE Extra. Rules and processes for these programs apply, and be TRICARE-eligible for 180 days prior to mobilization and until either beneficiaries are responsible for ADFM costs. deactivation prior to mobilization or until 180 days after deactivation TAMP beneficiaries must present valid uniformed services ID cards post-mobilization. They are considered ADSMs during the active duty or CACs at the time of service. See the TRICARE Eligibility section for period when on orders. Service members should not enroll in TRICARE information about verifying eligibility. Prime or TPR during the early eligibility period, but they must enroll (following command guidance and depending on location) when For more information, visit TRICARE.mil/TAMP they reach their final duty stations. Note: TAMP does not cover LOD care. See Line-Of-Duty Care for Family members of National Guard and Reserve members may also National Guard and Reserve Members earlier in this section. become eligible for TRICARE if the National Guard or Reserve member (sponsor) is called to active duty for more than 30 consecutive days. These family members may enroll in TRICARE Prime or TPRADFM, depending Transitional Care for Service-Related on location, or they may use TRICARE Standard/TRICARE Extra. They are Conditions Program also eligible for dental coverage through TDP. Sponsors must register their family members in DEERS to establish TRICARE eligibility. The Transitional Care for Service-Related Conditions (TCSRC) program extends TRICARE coverage for qualified former ADSMs TRICARE Young Adult program diagnosed with service-related conditions during their 180-day TAMP period. The TRICARE Young Adult (TYA) program is a premium-based To qualify for TCSRC, a TAMP-eligible member’s medical condition health care plan available for purchase by qualified dependents. must be: Beneficiaries who are adult-age dependents may purchase TYA coverage based on the eligibility established by their uniformed • Service-related services sponsor and where they live. TYA includes medical and • Newly discovered or diagnosed during the 180-day TAMP period pharmacy benefits, but excludes dental coverage. • Able to be resolved within 180 days • Validated by a DoD physician Special eligibility conditions may exist. Beneficiaries may purchase TYA coverage if they meet all of the following conditions: The TCSRC benefit covers care only for the specific service-related condition. Preventive and health maintenance care is not covered. • A dependent of an eligible uniformed services sponsor (If the beneficiary is an adult child of a nonactivated member of the TCSRC beneficiaries may seek care at military hospitals or clinics Selected Reserve of the Ready Reserve or of the Retired Reserve, or from TRICARE-authorized civilian providers if military hospital or his or her sponsor must be enrolled in TRS or TRR to be eligible to clinic care is not available. There are no co-pays or cost-shares under purchase TYA coverage) TCSRC, and providers must submit claims to Humana Military. The • Unmarried TCSRC benefit is available worldwide. • At least age 21 (or age 23 if enrolled in a full-time course of study at an approved institution of higher learning and if the For more information, visit TRICARE.mil/TCSRC sponsor provides more than 50 percent of the financial support) but have not yet reached age 26

28 –TRICARE Provider Handbook Continued Health Care Benefit Program (CHCBP) All prescriptions filled through TRICARE Pharmacy Home Delivery must have the prescriber’s handwritten signature. For more CHCBP is a premium-based health care program administered by information about benefits and costs, visit TRICARE.mil/pharmacy Humana Military. CHCBP offers temporary transitional health care or express-scripts.com/TRICARE, or call Express Scripts at coverage (18 to 36 months) after TRICARE eligibility ends. 1-877-363-1303.

CHCBP acts as a bridge between military health care benefits and Note: US Family Health Plan (USFHP) participants may only use the the beneficiary’s new civilian health care plan. CHCBP benefits are pharmacy benefits provided under that program. comparable to TRICARE Standard/TRICARE Extra, but differences do exist.

The main difference is that beneficiaries must pay quarterly Member choice center premiums. In addition, under CHCBP, providers are not required to use The Member Choice Center helps TRICARE beneficiaries transfer or coordinate with military hospitals or clinics. their current retail and MTF pharmacy maintenance medication Providers must coordinate with Humana Military to obtain referrals prescriptions to home delivery. If one of a provider’s patients uses the and authorizations for CHCBP beneficiaries. Providers must seek Member Choice Center, an Express Scripts patient-care advocate may authorization for care that is deemed medically necessary. Medical contact the provider for patient and prescription information. necessity rules for CHCBP beneficiaries follow TRICARE Standard/ To learn more about the Member Choice Center, call Express TRICARE Extra guidelines. Scripts at 1-877-363-1303, or visit TRICARE.mil/pharmacy or For more information about CHCBP, including eligibility verification, express-scripts.com/TRICARE search for CHCBP at HumanaMilitary.com or call 1-800-444-5445. Generic drug use policy To coordinate CHCBP referrals and authorizations, call Humana Military at 1-800-444-5445 or fax information to 1-877-270- It is a DoD policy to use generic medications instead of brand- 9113. For mental health CHCBP referrals and authorizations, name medications whenever possible. A brand-name drug with contact ValueOptions® Federal Services at 1-800-700-8646 or fax a generic equivalent may be dispensed only after the prescribing information to 1-866-811-4422. physician completes a clinical assessment that indicates the brand-name drug is medically necessary and after Express Scripts TRICARE pharmacy program grants approval.

TRICARE offers comprehensive prescription drug coverage and several If a patient requires a brand-name medication that has a options for filling prescriptions. All TRICARE beneficiaries are eligible generic equivalent, the provider must obtain prior authorization. for the TRICARE Pharmacy Program, administered by Express Scripts, Otherwise, the patient may be responsible for the entire cost of Inc. To fill prescriptions, beneficiaries need written prescriptions and the medication. valid uniformed services ID cards or Common Access Cards (CACs). If a generic-equivalent drug does not exist, the brand-name drug is TRICARE beneficiaries have the following options for filling prescriptions: dispensed at the brand-name cost. • Military hospital or clinic pharmacies: Using a military pharmacy is the least expensive option, but formularies may Quantity limits vary by military pharmacy location. Contact the local MTF pharmacy to check availability before prescribing a medication TRICARE has established quantity limits on certain medications, which means the DoD only pays for up to a specified, limited amount • E-Prescribe: Military pharmacies have electronic prescribing capability across their system of clinics and hospitals. TRICARE of medication each time the beneficiary fills a prescription. Quantity civilian network providers can send prescriptions electronically limits are often applied to ensure medications are safely and to military pharmacies. For information visit the Defense Health appropriately used. Agency Pharmacoeconomic Branch Exceptions to established quantity limits may be made if (pec.ha.osd.mil/eRx.php?submenuheader=2) website. the prescribing provider is able to justify medical necessity. • TRICARE Pharmacy Home Delivery: TRICARE Pharmacy Home Visit pec.ha.osd.mil/formulary_search.php for a general list of Delivery (formerly TRICARE Mail Order Pharmacy) is the preferred TRICARE-covered prescription drugs that have quantity limits. method when not using a military pharmacy • TRICARE retail network pharmacies: Beneficiaries can access a network of approximately 60,000 retail pharmacies in the United Prior authorizations States and U.S. territories (American Samoa,* Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands). Some drugs require prior authorization from Express Scripts. Medications requiring prior authorization may include, but are not • Non-network retail pharmacies: Filling prescriptions at a non- network retail pharmacy is the most expensive option and is not limited to, prescription drugs specified by the DoD Pharmacy and recommended to beneficiaries Therapeutics Committee, brand-name medications with generic equivalents, medications with age limitations and medications * Currently, there are no TRICARE retail network pharmacies in prescribed for quantities exceeding normal limits. American Samoa.

TRICARE Provider Handbook – 29 For a general list of TRICARE-covered prescription drugs requiring Pharmacy benefits for medicare-eligible prior authorization and to access prior authorization and medical beneficiaries necessity criteria forms for retail network pharmacy and home delivery prescriptions, visit pec.ha.osd.mil/formulary_search.php. TRICARE beneficiaries who were entitled to Medicare Part A prior Military pharmacies may follow different procedures. At the top of to April 1, 2001, remain eligible for TRICARE pharmacy benefits each form, there is information on where to send the completed without the requirement to have Medicare Part B. Medicare-eligible form. For assistance, call 1-877-363-1303. beneficiaries are able to use the TRICARE Pharmacy Program if they • ADSMs: If medical necessity is approved, ADSMs may receive are entitled to Medicare Part A and have Part B. non-formulary medications through TRICARE Pharmacy Home If they do not have Medicare Part B, they may only access pharmacy Delivery or at retail network pharmacies at no cost. benefits at military hospital or clinic. (Exceptions exist for certain • All other eligible beneficiaries: If medical necessity is approved, beneficiaries, including ADSMs and ADFMs. Please see TRICARE For Life the beneficiary may receive the non-formulary medication at the earlier in this section for more information.) formulary cost through TRICARE Pharmacy Home Delivery or at retail network pharmacies. Medicare-eligible beneficiaries are also eligible for Medicare Part D prescription drug plans. However, beneficiaries do not need to enroll in a For medical necessity to be established, at least one of the following Medicare Part D plan to keep their TRICARE Pharmacy Program benefits. criteria must be met for each available formulary alternative: • Use of the formulary alternative is contraindicated Providers can direct eligible beneficiaries who inquire about Medicare • The patient experiences, or is likely to experience, Part D coverage to visit the TRICARE website at TRICARE.mil/MedicarePartD. significant adverse effects from the formulary alternative, For the most up-to-date information on the Medicare Part D and the patient is reasonably expected to tolerate the non- prescription drug benefit, beneficiaries should call Medicare at formulary medication 1-800-MEDICARE (1-800-633-4227) or visit medicare.gov • The formulary alternative results in therapeutic failure, and the patient is reasonably expected to respond to the non- Specialty medication care management formulary medication • The patient previously responded to a non-formulary Specialty medications are usually high-cost; self-administered; medication, and changing to a formulary alternative would incur injectable, oral or infused drugs that treat serious chronic conditions unacceptable clinical risk (e.g., multiple sclerosis, rheumatoid arthritis, hepatitis C). These drugs • There is no formulary alternative typically require special storage and handling and are not readily available at local pharmacies. Call Express Scripts at 1-877-363-1303 or visit pec.ha.osd.mil/forms_criteria.php for forms and medical necessity Specialty medications may also have side effects that require criteria. To learn more about medications and common drug pharmacist and/or nurse monitoring. The Specialty Medication Care interactions, check for generic equivalents or determine if a drug Management program is structured to improve the beneficiary’s is classified as a non-formulary medication, visit the TRICARE health through continuous health evaluation, ongoing monitoring, Formulary Search Tool at pec.ha.osd.mil/formulary_search.php assessment of educational needs and management of medication use. This program provides: Step therapy • Access to proactive, clinically based services for specific diseases designed to help beneficiaries get the most benefit from their Step therapy involves prescribing a safe, clinically effective and cost- medications effective medication as the first step in treating a medical condition. • Monthly refill reminder calls The preferred medication is often a generic medication that offers • Scheduled deliveries to beneficiaries’ specified locations the best overall value in terms of safety, effectiveness and cost. • Specialty consultation with a nurse or pharmacist at any point Nonpreferred drugs are only prescribed if the preferred medication is during therapy ineffective or poorly tolerated. These services are provided to beneficiaries at no additional cost Drugs subject to step therapy will only be approved for first-time when they receive their medications through TRICARE Pharmacy users after they have tried one of the preferred agents on the DoD Home Delivery, and participation is voluntary. If a patient orders a uniform formulary (e.g., a patient must try omeprazole or Nexium® specialty medication from TRICARE Pharmacy Home Delivery, Express prior to using any other proton pump inhibitor). Scripts sends the patient additional information about the Specialty Medication Care Management program and how to get started. Note: If a beneficiary filled a prescription for a step therapy drug within 180 days prior to step therapy implementation, the beneficiary Beneficiaries enrolled in the Specialty Medication Care Management will not be affected by step therapy requirements and will not be program have access to pharmacists 24 hours a day, seven days required to switch medications. a week. The specialty clinical team contacts the beneficiaries’ physicians, as needed, to address beneficiary issues such as side effects or disease exacerbations. If any patients currently fill specialty medication prescriptions at retail pharmacies, the specialty clinical team will provide brochures detailing the program as well as pre- populated enrollment forms.

30 –TRICARE Provider Handbook If a patient requires specialty pharmacy medications, fax the prescription (PCM or specialist) can inform the patient’s sponsor about the to TRICARE Pharmacy Home Delivery at 1-877-895-1900. TRICARE ECHO benefit. Pharmacy Home Delivery ships medications to the beneficiary’s home. Faxed prescriptions must include the following ID information: patient’s Refer patients to Humana Military for assistance with eligibility full name, date of birth, address and ID number. determination and ECHO registration. This ensures that the beneficiary and provider have a complete understanding of Note: Some specialty medications may not be available through the benefit and have taken the necessary steps for efficient TRICARE Pharmacy Home Delivery because the manufacturer claims processing. limits the drug’s distribution to specific pharmacies. If providers submit a prescription for a limited-distribution medication, Providers must obtain prior authorization for all ECHO services, TRICARE Pharmacy Home Delivery either forwards the and they may be requested to provide medical records or assist prescription to a pharmacy of the patient’s choice that can fill it beneficiaries with completing EFMP documents. Network and or provides the patient with instructions about where to send the participating non-network providers must submit ECHO claims to prescription. To determine if a specialty medication is available PGBA, Humana Military’s claims processing partner. through TRICARE Pharmacy Home Delivery, visit pec.ha.osd.mil/formulary_search.php ECHO benefits

TRICARE Extended Care Health Option (ECHO) ECHO provides coverage for the following products and services: • ABA and other services that are not available through schools or The TRICARE Extended Care Health Option (ECHO) provides other local community resources services to ADFMs who qualify based on specific mental or • Assistive services (e.g., those from a qualified interpreter or physical disabilities. It offers beneficiaries an integrated set of translator) services and supplies beyond those offered by the basic TRICARE • Durable equipment, including adaptation and maintenance health benefit programs (e.g., TRICARE Prime, TPRADFM, TRICARE • Expanded in-home medical services through TRICARE ECHO Standard/TRICARE Extra). Home Health Care (EHHC) • Rehabilitative services Potential ECHO beneficiaries must be ADFMs, have qualifying • Respite care (during any month when at least one other ECHO conditions and be registered in the Exceptional Family Member benefit is received and limited to the United States, Guam, Program (EFMP). Each service branch has its own EFMP and Puerto Rico and the U.S. Virgin Islands): enrollment process. • ECHO respite care: up to 16 hours of care Under certain circumstances, this requirement may be waived. • EHHC respite care: up to eight hours per day, five days per week To learn more, contact the beneficiary’s service branch’s EFMP representative or visit TRICARE.mil. A record of ECHO registration is • Training to use special education and assistive technology devices stored with the beneficiary’s DEERS information. • Institutional care when a residential environment is required • Transportation under certain limited circumstances (i.e., to and Conditions qualifying an ADFM for ECHO coverage may include, but from institutions or facilities to receive otherwise-allowable are not limited to: ECHO benefits) • Moderate or severe mental retardation TRICARE may pay for “hands-on” ABA services provided by TRICARE- • Serious physical disability authorized providers. However, TRICARE does not pay for services • Extraordinary physical or psychological condition of such provided by family members, trainers or other individuals who are not complexity that the beneficiary is homebound TRICARE-authorized. • Diagnosis of a neuromuscular developmental condition or other condition in an infant or toddler (under age 3) that is expected Note: All ECHO services require prior authorization from Humana to precede a diagnosis of moderate or severe mental retardation Military/ValueOptions® Federal Services. See the Health Care or a serious physical disability Management and Administration section for information about ECHO • Multiple disabilities, which may qualify if there are two or more prior authorization requirements in the South Region. disabilities affecting separate body systems

Note: Active duty sponsors with family members seeking ECHO ECHO costs registration must enroll in their service branch’s EFMP — unless The government’s limit for the cost of ECHO services combined waived in specific situations — and register to be eligible for (excluding EHHC) is $36,000 per beneficiary per Fiscal Year (FY). ECHO benefits. There is no retroactive registration for the ECHO Beneficiaries are responsible for ECHO cost-shares in addition to program. Visit militaryonesource.mil/efmp/TRICARE for more cost-shares for basic TRICARE benefits (e.g., under TRICARE Prime, information about EFMP. TPRADFM, TRICARE Standard/TRICARE Extra).

ECHO provider responsibilities ECHO cost-shares do not count toward the catastrophic cap. EHHC costs do not count toward ECHO yearly maximum cost-shares. TRICARE providers, especially PCMs, are responsible for managing care for TRICARE beneficiaries. Any TRICARE provider For more information about ECHO, refer to the TRICARE Policy Manual,

TRICARE Provider Handbook – 31 Chapter 9 at manuals.TRICARE.osd.mil, visit TRICARE.mil/ECHO, visit TRICARE Retiree Dental Program (TRDP) HumanaMilitary.com or call Humana Military at 1-800-444-5445. Delta Dental is the TRICARE Retiree Dental Program contractor. The To learn more about ECHO benefits contact a local ECHO case manager: TRICARE Retiree Dental Program is a voluntary dental insurance plan For ECHO Medical Services: for: retired service members, family members of a retired service member, retired guard/reserve members, family members of retired • Arkansas, Louisiana, Oklahoma, Texas (except the El Paso area guard/reserve member, Medal of Honor recipients, family members of and the Florida Panhandle): 1-800-615-7332 Medal of Honor recipient and survivors. To learn more visit: • Florida (except the Florida Panhandle), Georgia, South Carolina, tricare.mil/CoveredServices/Dental/TRDP.aspx Mississippi. Alabama, Tennessee: 1-877-411-9796

For ECHO Mental Health Services: • All States: 1-866-323-7155

TRICARE dental options

The TRICARE health care benefit covers adjunctive dental care (i.e., dental care that is medically necessary to treat a covered medical condition). However, several non-adjunctive dental care options are available to eligible beneficiaries.

ADSMs receive dental care at military Dental Treatment Facilities (DTFs) or from civilian providers through the TRICARE Active Duty Dental Program (ADDP) if necessary. For all other beneficiaries, TRICARE offers two premium-based dental programs: the TRICARE Dental Program (TDP) or the TRICARE Retiree Dental Program (TRDP). Each program is administered by a separate dental contractor and has its own monthly premiums and cost-shares.

Note: TRICARE may cover some medically necessary services in conjunction with noncovered or non-adjunctive dental treatment for patients with developmental, mental or physical disabilities and for children age 5 years and younger. See the Medical Coverage section for more details.

TRICARE Active Duty Dental Program (ADDP)

United Concordia Companies, Inc. administers ADDP and provides civilian dental care to ADSMs who are referred for care by a military DTF or who serve on active duty and reside more than 50 miles from a DTF. Visit ADDP-UCCI.com or TRICARE.mil/dental for more information.

TRICARE Dental Program (TDP)

TDP, administered by Metropolitan Life Insurance Company (MetLife), is a voluntary dental insurance program available to eligible ADFMs and National Guard and Reserve and Individual Ready Reserve members and their eligible family members.

ADSMs (and National Guard and Reserve members called to active duty for a period of more than 30 consecutive days are eligible for the preactivation benefit up to 180 days prior to their report date) are not eligible for TDP. They receive dental care at military DTFs or through ADDP.

For more information, visit mybenefits.metlife.com/TRICARE or call MetLife at 1-855-MET-TDP1 (1-855-638-8371).

32 –TRICARE Provider Handbook Medical coverage and health care management

Introduction

TRICARE beneficiaries are instructed to receive all routine care, when possible, from network providers in their designated regions.

TRICARE covers most medically necessary inpatient and outpatient care. This section provides an overview of the special rules and limits for TRICARE-covered benefits and services. The Specified Authorization Service (SAS) may authorize services for Active Duty Service Members (ADSMs) that are not regular TRICARE benefits. This overview is not all-inclusive. For additional details, visitHumanaMilitary.com or call 1-800-444-5445.

TRICARE covers office visits; outpatient, office-based medical and surgical care; consultation, diagnosis and treatment by a specialist; allergy tests and treatment; osteopathic manipulation; rehabilitation services (e.g., physical and occupational therapy, speech pathology services); and medical supplies used within the office.

In general, TRICARE excludes services and supplies not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury or for the diagnosis and treatment of pregnancy or well-child care. All services and supplies (including inpatient institutional costs) related to a non-covered condition or treatment, or provided by an unauthorized provider, are excluded.

Before delivering care, network providers must notify TRICARE patients if services are not covered. The beneficiary must agree in advance and in writing to receive and accept financial responsibility for non-covered services by signing the TRICARE Non-covered Services Waiver form.

To determine if a specific service is a covered benefit or if coverage is limited, check the current list of non-covered services on the No Government Pay Procedure Code List at TRICARE.mil/NoGovernmentPay or check the Code Look Up using the secure Self-Services for Providers portal at HumanaMilitary.com

The information contained in this section is not all-inclusive. See the Mental Health Care Services section for a list of mental health care limitations and exclusions.

TRICARE covered benefits and services Figure 5.1 TRICARE covers most medically necessary inpatient and outpatient care. This chart provides an overview of the special rules and limits for TRICARE-covered benefits and services. This overview isnot all-inclusive. For additional details visit HumanaMilitary.com or call 1-800-444-5445.

Covered outpatient and inpatient services Service Coverage details Prior authorization requirements1 Adjunctive • Covered when medically necessary to treat a covered medical • Required Dental Care (not dental) condition, is an integral part of the treatment • Emergency adjunctive care does not require prior of such medical condition or is required in preparation for, or authorization as the result of, dental trauma that may be or is caused by medically necessary treatment of an injury or disease • Acute anxiety, mental health issues, need for extensive treatment or need for sedation/anesthesia does not alone qualify a patient for adjunctive dental care coverage

Durable • Covers medical equipment or supplies needed by a patient in • A prescription requesting DMEPOS signed by the medical order to arrest or reduce functional loss beneficiary’s physician is required for rental or equipment, • Must be ordered by a physician purchase of DMEPOS. Prescriptions must specify prosthetics, the beneficiary’s diagnosis, the particular type of orthotics equipment needed, the reason it is needed and the and supplies duration for which it will be needed. A Certificate of (DMEPOS Medical Necessity (CMN) may be accepted in place of a prescription

TRICARE Provider Handbook – 33 TRICARE covered benefits and services (continued)

Service Coverage details Prior authorization requirements1 Emergency • Covered for qualified medical, maternity and • In all emergency situations, the TRICARE Prime care/urgent psychiatric conditions beneficiary must notify his or her Primary Care Manager care • Ambulance services covered for emergency situations. (PCM) or Humana Military of any emergency inpatient Non-emergency medical transportation is only covered admission within 24 hours or the next business day when provided by an ambulance service and is medically so ongoing care can be coordinated. Requests for necessary in connection with otherwise covered services authorizations may be entered at HumanaMilitary.com or and supplies and a covered medical condition faxed to 1-877-548-1547 • Urgent care is not the same as emergency care but may • TRICARE Prime beneficiaries must obtain referrals from be needed to treat a condition that doesn’t threaten life, their PCMs or Humana Military for urgent care. If a limb or eyesight but attention before it becomes a serious TRICARE Prime beneficiary does not receive a referral, the risk to health claim will be paid under the Point-Of-Service (POS) option

Home • Covers a limited number of hours per week of either part- • All home health services require prior authorization from health care time or intermittent services Humana Military and must be renewed every 60 days (provided by • Patient must be confined to the home and under the • Home infusion has limited coverage. The type of participating care of a physician medication used in home infusion determines whether home health • Urgent care is not the same as emergency care but may the benefit will pay under the medical benefit or the care agencies) be needed to treat a condition that doesn’t threaten life, pharmacy benefit limb or eyesight but attention before it becomes a serious • Prior authorization is required to ensure medications risk to health are received from the correct TRICARE source and any • Respite care for ADSMs who are homebound as a result of required nursing visits and DME are approved. a serious injury or illness incurred while serving on active • Prior authorization from Humana Military and the ADSM’s duty may be covered if the ADSM’s plan of care includes approving authority for respite care for ADSM frequent interventions by the primary caregiver

Hospice care Provided in three benefit periods: • Required for all hospice care • If patient does not meet criteria for admission for hospice • First two benefit periods: 90 days each, begin on the day services, the provider cannot bill TRICARE that the beneficiary signs the hospice election statement and both the attending physician and the hospice medical director sign the physician’s certificate of terminal illness • Final benefit period: Unlimited number of 60-day periods, each of which requires recertification of the terminal illness

Hospitalization • Covered services include: General nursing; hospital; physician • Notify Humana Military of inpatient admission at (semiprivate and surgical services; meals (including special diets); drugs/ HumanaMilitary.com or by faxing 1-877-548-1547 room/special medications; operating/recovery room care; anesthesia; within 24 hours or the next business day care units laboratory tests; X-rays/other radiology services; medical when medically supplies and appliances; and blood and blood products necessary) • Surgical procedures considered inpatient only may only be covered when performed in an inpatient setting • Semiprivate rooms and special care units may be covered if medically necessary

Maternity care • Covers medical services related to prenatal care, labor • Required for obstetric (inpatient and outpatient) care for and delivery, and postpartum care TRICARE Prime, TRICARE Prime Remote (TPR) and TRICARE • Eligible beneficiaries can receive maternity care from the Prime Remote for Active Duty Family Members (TPRADFM) first obstetric visit through up to six weeks after the birth of beneficiaries. (Obtain authorization at mother’s first the child pregnancy-related appointment with the PCM or provider) • Maternity inpatient stays require additional prior authorization

Skilled Nursing • TRICARE-participating SNFs in semiprivate rooms for • All admissions or transfers to an SNF require prior Facility (SNF) patients with qualifying medical conditions treated in authorization care hospitals for at least three consecutive days (not including • TRICARE only covers care at Medicare-certified the day of discharge) or if the patient is admitted to the SNF within 30 days of his or her discharge from the hospital

34 –TRICARE Provider Handbook Covered clinical preventive services

Figure 5.2

Service Procedures and frequency limitations Cancer Colonoscopy: Individuals at average risk for colon cancer are covered once every 10 years beginning at age 50. Screenings For individuals with increased risk, a colonoscopy is performed every two years beginning at age 25 or five years younger than the earliest age of diagnosis of colorectal cancer, whichever is earlier. Screenings are performed annually after age 40 for individuals with hereditary non-polyposis colorectal cancer syndrome. Individuals with familial risk of sporadic colorectal cancer (i.e., individuals with first-degree relatives with sporadic colorectal cancer or adenomas before age 60 or multiple first-degree relatives with colorectal cancer or adenomas) may receive a colonoscopy every three to five years beginning at an age 10 years earlier than the youngest affected relative.

Fecal Occult Blood Testing (FOBT): Individuals are covered once every 12 months (either guaiac-based testing or immunochemical-based testing) beginning at age 50. At least 11 months must pass following the month of the last covered FOBT.

Mammograms: Women over age 39 are covered for annual screening mammograms. High-risk women (i.e., family history of breast cancer in a first-degree relative) can receive a baseline mammogram at age 35 and then annually.

Magnetic Resonance Imaging (MRI) breast screenings: Asymptomatic women age 30 or older considered to be at high risk of developing breast cancer per the guidelines of the American Cancer Society (ACS) may receive an MRI breast screening annually. These guidelines include women who meet one of the following conditions: • A known BRCA1 or BRCA2 gene mutation • A first-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation who have not had genetic testing themselves • History of radiation to the chest between the ages of 10 and 30 • History of Li-Fraumeni, Cowden or Hereditary Diffuse Gastric Cancer Syndrome or a first-degree relative with a history of one of these syndromes

Proctosigmoidoscopy or sigmoidoscopy: Beneficiaries are covered once every three to five years beginning at age 50.

Prostate cancer: All men are covered for an annual digital rectal examination beginning at age 50. Annual exams are also covered for men with a family history of prostate cancer in at least one other family member beginning at age 45, all African-American men regardless of family history beginning at age 45 and men with a family history of prostate cancer in two or more other family members beginning at age 40.

An annual Prostate Specific Antigen (PSA) screening is covered for all men beginning at age 50, men with a family history of prostate cancer in at least one other family member beginning at age 45, all African-American men regardless of family history beginning at age 45 and men with a family history of prostate cancer in two or more other family members beginning at age 40.

Routine Pap smears: Women are covered annually beginning at age 18 (or younger if sexually active) until three consecutive satisfactory normal annual examinations. Frequency may then decrease at the discretion of the patient and clinician, but not less frequently than every three years.

Skin cancer: Individuals with a family or personal history of skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions should receive regular skin examinations.

Cardiovascular Blood pressure screenings: Children ages 3 to 6 should receive annual screenings. Children over age 6 and adults should receive screenings at a minimum of every two years.

Cholesterol test: TRICARE covers age-specific periodic lipid panels as recommended by the National Heart, Lung, and Blood Institute (NHLBI). Refer to NHLBI’s website for current recommendations: nhlbi.nih.gov/health-pro/guidelines/current

Abdominal Aortic Aneurysm (AAA): Men ages 65 to 75 who have ever smoked may receive a one-time AAA screening by ultrasonography.

The information contained in these charts is not all-inclusive.

TRICARE Provider Handbook – 35 Covered clinical preventive services (continued)

Service Procedures and frequency limitations Hearing All high-risk neonates (as defined by the Joint Committee on Infant Hearing) should undergo audiology screening before leaving the hospital. If not tested at birth, high-risk children should be screened before 3 months of age. Evaluate hearing of all children as part of routine examinations, and refer those with possible hearing impairment as appropriate.

Immunizations TRICARE covers age-appropriate doses of vaccines recommended and adopted by the Advisory Committee on Immunization Practices (ACIP) and accepted by the Director of the Centers for Disease Control and Prevention (CDC) and the Secretary of Health and Human Services (HHS) and published in a CDC Morbidity and Mortality Weekly Report (MMWR). Refer to the CDC’s website for the current schedule of CDC-recommended vaccines: CDC.gov

Immunizations required for ADFMs whose sponsors have permanent change of station orders to overseas locations are also covered.

Infectious Tuberculosis screening: TRICARE covers annual screenings, regardless of age, for all high-risk individuals (as defined by Disease CDC) using Mantoux tests. Screening Rubella antibodies: TRICARE covers a one-time screening for females ages 12 to 18, unless there’s a documented history of adequate rubella vaccination with at least one dose of rubella vaccine on or after the first birthday.

Hepatitis B screening: Screen pregnant women for HBsAG during the prenatal period. Vision TRICARE may cover routine and comprehensive eye exams not related to another medical or surgical condition. Vision Coverage coverage varies based on beneficiary status, program option and age. Other: Pediatric blood lead: TRICARE covers assessment of risk for lead exposure by structured questionnaire based on the CDC’s Preventing Lead Poisoning in Young Children (October 1991) during each well-child visit from age 6 months through 6 years. TRICARE covers screenings by blood lead level determination for all children at high risk for lead exposure per CDC guidelines.

The information contained in these charts is not all-inclusive.

Maternity care

Maternity care includes medical services related to prenatal care, • TRICARE does not cover ultrasounds for routine screening or to labor and delivery, and postpartum care. determine the sex of the baby • In the absence of other qualifying conditions, pain associated Eligibility with pregnancy or incipient birth after the 34th week of • TRICARE covers maternity care for a TRICARE-eligible dependent gestation when associated with a pregnancy is not an daughter of an ADSM or retired service member emergency condition for adjudication purposes • TRICARE does not cover care for the newborn grandchild unless the newborn is otherwise eligible as an adopted child or the child Referral and authorization requriements of another eligible sponsor • A newborn is covered as a TRICARE Prime or TPR beneficiary • The PCM for a beneficiary who becomes pregnant must submit for the first 60 days following birth or adoption as long as one a referral request prior to the mother’s first pregnancy-related additional family member is enrolled in TRICARE Prime or TPR. If appointment with an obstetrician the child is not enrolled in TRICARE Prime or TPR within 60 days, • The referral begins with the first prenatal visit and remains valid coverage will revert to the TRICARE Standard program option until 42 days after birth • Prior to the delivery, the PCM must obtain a prior authorization for the civilian (non-military hospital or clinic) inpatient facility or Coverage birthing center where the beneficiary plans to deliver • Maternity care includes medical services related to prenatal care, • The inpatient length of stay cannot be restricted to less than 48 labor and delivery, and postpartum care hours following a normal vaginal delivery or 96 hours following a • TRICARE covers professional and technical components of medically cesarean section necessary fetal ultrasounds as well as the maternity global fee • Notify Humana Military if the mother is hospitalized or placed in • A maternal ultrasound is covered only with diagnosis and observation during the pregnancy for any reason other than delivery management of conditions that constitute a high-risk pregnancy • If a newborn remains in the hospital after the mother is discharged, a separate inpatient authorization is required for the newborn

36 –TRICARE Provider Handbook Durable Medical Equipment (DME) for TRICARE

DME refers to durable medical equipment and/ or supplies that Military website. are necessary for the treatment, habilitation, or rehabilitation of a beneficiary. The equipment should provide the medically appropriate Referral/authorization guidelines for DME level of performance and quality for the medical condition present.

Note: Some durable medical equipment, prosthetics, orthotics and All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult medical supplies (DMEPOS) are a limited benefit. Prime beneficiaries require a referral for any DME billed under code E1399 or for any other miscellaneous code. Billed charge is the Certificate of Medical Necessity (CMN) is a document signed by the charge amount or negotiated amount submitted on the claim. E1399 prescribing provider containing clinical information that supports the should only be used for special and/or customized equipment for need for each item/services/supplies requested for a beneficiary. which no other HCPCS code has been assigned. A physician order or prescription itself can take the place of the CMN • Active duty service members require an authorization for all as long as it includes the necessary elements and signature. It is very DMEPOS items important that the CMN or physician order be complete and current • Pre-determination is available for non-prime beneficiaries for the services/supplies/equipment to be covered. A copy of the CMN or order must be submitted with the claim. Be sure to keep the CMN To determine if a specific DMEPOS is covered, or if a referral or au- on file for at least one year. thorization is required, go to the Code Look Up feature available to providers on the secured portal at HumanaMilitary.com. At a minimum, the CMN must include: • Type of equipment An approved authorization does not take the place of a certificate of • Diagnosis or reason medical necessity (CMN) or physician’s order. • Length of need* A completed and current CMN or physician’s order is required to • Beginning date submit with the claim. • Physician signature (nurse practitioner and physician assistant signatures are accepted) Referrals and authorizations are generally considered valid for one year. The beneficiary should return to his or her PCM annually for *Length of Need -- A length of need should not exceed a 12 month assessment of his or her condition and ongoing treatment/needs and period. For prescriptions/orders that exceed 12 months, the beneficiary obtain a new referral, if needed. should return to his or her PCM annually for assessment of his or her condition and ongoing treatment/needs and obtain a new prescription/ CMN. Length of need can be more than 12 months in the case of life- Rental vs. Purchase time use. (An example of lifetime use would be oxygen. In most cases, if you have a prescription for oxygen you are going to have it for life.) Depending on which is the least expensive for TRICARE, DMEPOS may be leased or purchased. When receiving claims for extended rentals, If there is no length of need on the CMN, the claim will be rejected for TRICARE evaluates the cost benefit of purchasing the equipment and missing information. will pay only up to the allowable purchase amount.

Any time there is a change in the prescription, the physician must Repairs: Benefits are allowed for repair of beneficiary owned DME provide an updated or new prescription or CMN for the DME to be when it is necessary to make the equipment serviceable. This in- submitted for claims. cludes the use of a temporary replacement item provided during the period of repair. (Deluxe, Luxury, Immaterial features) Upgraded DME Replacements: Benefits are allowed for replacement of beneficiary owned DME when the DME is not serviceable due to normal wear, TRICARE will only cover Deluxe, Luxury, or Immaterial features for ADSMs. accidental damage, a change in the beneficiary’s condition, or the All other TRICARE beneficiaries who choose to upgrade from a device has been declared adulterated by the FDA. Exceptions exist for covered DME item to a deluxe, luxury, or immaterial feature for prosthetic devices. comfort or convenience will need to be responsible for the added Modifications: A wheelchair, or an approved alternative, which is nec- cost. (Reference TRICARE Operations Manual-Chapter 8, Section essary to provide basic mobility, including reasonable additional cost 2.1 at TRICARE.mil) to accommodate a particular disability, is covered. DME providers must obtain a TRICARE specific non-covered service A duplicate item of DME which otherwise meets the DME benefit re- waiver form signed by the beneficiary in advance in order to quirement that is essential to provide a fail-safe in-home life-support collect from the beneficiary without fear of holding the beneficiary system is covered. harmless for the additional cost due to upgrading. You can find a copy of the non-covered services waiver form on the Humana

TRICARE Provider Handbook – 37 MUE vs DUTs and date spans with as much clinical support as possible. Please follow the “reconsideration process” instructions. The coversheet and tips MUE stands for a Medically Unlikely Edit. This edit indicates that for filing a reconsideration are also available under the FORMS it is unlikely that more than X number of an item would be used section of the provider portal at HumanaMilitary.com. Please in a DAY. This causes confusion as so many items are ordered do not confuse this with the initial claim filing and supporting on a 30 day or even a 90 day basis. DHA has a list of MUEs at documentation. This is a reconsideration process after claims TRICARE.mil. It is important to note that not all codes have a have been denied. DHA determined MUE. Supplies should be filed using the date of service, not a date span, and should indicate the DUTs. DUT Billing guidelines regarding upgraded DME stands for Day Units Time. (Code A7033 billed with 90 DUTs) Providers need to verify all information on TRICARE.mil before Effective 03/03/2013, TRICARE allows the GA and GK modifiers sending to claims processing. This field represents the number of for DME claims processing. This change allows for the units of an item you are submitting. recognition, but not payment of, upgraded DME items, except under certain circumstances. Providers are to bill codes with For example, in the observation world 1 unit = 1 hour. the GA and GK modifiers to indicate which service is the actual Note: Do not file claims with future dates. equipment ordered and the updgraded equipment ordered.

Not all service units represent the same measure. Please be sure GA: this is the modifier to indicate the upgraded equipment you know what, if any, units are associated with the code you are GK: this is the modifier to indicate the actual equipment. submitting on a claim. If the patient is not an ADSM, there MUST BE BOTH a ‘GA’ AND a’ There are specific supplies that are distributed in a measure greater GK’ modifier on the claim to indicate which service is the actual than a daily supply. These items are date spanned. There are equipment and which service is the upgraded equipment. Providers very few of these and you should check before submitting a date will only be paid for the actual equipment. spanned claim. (Example: Date span 01/01/14 - 01/31/14 for code Note: This change in policy affects all DME including eyeglasses and B4035, and 31 as the DUT). hearing aids.

DME reimbursement / claims tips & guidelines If only one modifier is present the line will deny as needing both modifiers.

DMEPOS Fee Schedule: TRICARE uses the reimbursement rates If both modifiers are present then we will issue payment on the line established by the Centers for Medicare and Medicaid Services with the GK modifier as we normally do, and reject the line with the (CMS) or the CMAC state prevailing price for items of Durable GA modifier indicating it is not medically necessary. This information Medical Equipment, Prosthetics, Orthotics, and Supplies. CMS will also be seen on the EOB and remit. updates these rates quarterly during the year. Inclusion or If the patient is an ADSM and there is an authorization the claim will exclusion of a reimbursement rate does not imply TRICARE process as it does today, even if the GA modifier is present. Cost for coverage. repairs for upgraded items that TRICARE did not purchase are also Note: If submitting claims electronically, you can fax the the responsibility of the patient. supporting documentation (CMN and or physician order) using the supporting documentation coversheet and send through the Home health care DME dedicated Faxgate number at 803-462-3982. The supporting documentation will be matched to the claim. Please be sure The benefit includes coverage of medical equipment, to send in within two to four days of submitting the claim. The supplies, certain therapies and nursing care to homebound supporting documentation fax cover sheet, with the fax numbers patients whose conditions make home visits necessary. to PGBA, can be found under the FORMS section of the provider While a beneficiary does not need to be bedridden, his or her portal at HumanaMilitary.com condition should be such that there exists a normal inability to leave home and leaving home would require a considerable If you submit on paper, you may include the supporting documen- and taxing effort. Short-term absences from the home for tation with the claim; however, there is no guarantee the docu- nonmedical purposes are permitted. mentation will be kept with the claim once it arrives in the mail room at PGBA. Assistance with daily living activities (e.g., laundry, cleaning dishes, etc.) is not part of the home health care benefit.

Claims denied/rejected due to exceeding MUE/ Respite care for ADSMs who are homebound as a result of a serious DUT limitations injury or illness incurred while serving on active duty may be covered if the ADSM’s plan of care includes frequent interventions by the Requests for Reconsideration are an option for providers when primary caregiver. It requires prior authorization from Humana services or supplies are denied or rejected due to units or Military and the ADSM’s approving authority (i.e., MMSO or the services exceeding the daily limit. Reconsideration will not be referring military hospital or clinic). considered for luxury or upgraded DME items . Reconsiderations must include documentation, that supports the units billed, Refer to the TRICARE manuals at manuals.TRICARE.osd.mil

38 –TRICARE Provider Handbook For information about home health care, refer to the TRICARE Laboratory and x-ray services Reimbursement Manual, Chapter 12. TRICARE generally covers laboratory and X-ray services if prescribed by For information about home health care benefits related to the a physician. However, some exceptions apply (e.g., chemo-sensitivity TRICARE ECHO program, refer to the TRICARE Policy Manual, Chapter assays, bone density X-ray studies for routine osteoporosis screening). 9, Section 15.1. The TRICARE Demonstration Project for Approved Laboratory Developed Tests (LDTs)is covered for TRICARE beneficiaries (including For information about ADSM respite care coverage, refer to the ADSMs). These tests may require prior authorization. For more TRICARE Operations Manual, Chapter 18, Section 3 and Addendum C. information, search for Genetic Testing at HumanaMilitary.com. (See chart on next page.) Infusion therapy

Infusion therapy delivered in the home may include: • Skilled nursing services to administer the drug • The drug and associated compounding services • Medical supplies and Durable Medical Equipment (DME)

The TRICARE medical benefit covers the skilled nursing services, medical supplies, DME and the first five doses of the drug. After the first five doses, the therapy is considered long-term, and the drug is covered under the pharmacy benefit.

For information about home infusion benefits, refer to the TRICARE Policy Manual, Chapter 8, Section 20.1. at manuals.TRICARE.osd.mil

Hospitalization

TRICARE covers hospitalization services, including general nursing; hospital, physician and surgical services; meals (including special diets); drugs and medications; operating and recovery room care; anesthesia; laboratory tests; X-rays and other radiology services; medical supplies and appliances; and blood and blood products. TRICARE may cover semiprivate rooms and special care units if medically necessary. TRICARE may only cover surgical procedures designated as “inpatient only” when performed in an inpatient setting.Skilled Nursing Facility (SNF) care

All admissions or transfers to a SNF require prior authorization. TRICARE only covers care at Medicare-certified, TRICARE- participating SNFs in semiprivate rooms for patients with qualifying medical conditions treated in hospitals for at least three consecutive days (not including the day of discharge) or if the patient is admitted to the SNF within 30 days of his or her discharge from the hospital.

Hospice care

The TRICARE hospice benefit is designed to provide palliative care to individuals with a prognosis of less than six months to live if the terminal illness runs its normal course. TRICARE has adopted most of the provisions currently set out in Medicare’s hospice coverage benefit guidelines, reimbursement methodologies and certification criteria for participation in the hospice program.

For more information about TRICARE’s hospice coverage, refer to the TRICARE Reimbursement Manual, Chapter 11 at manuals.TRICARE.osd.mil

TRICARE Provider Handbook – 39 TRICARE guidelines for Laboratory Developed Test (LDT)

Figure 5.3

Laboratories performing LDTs must have CLIA accreditation or certificate of compliance.

LDT (alphabetical Specific order) codes Covered for the following: BCR/ABL1 81206 • Diagnostic assessment of patients with suspected Chronic Myelogenous Leukemia (CML) by 81207 quantitative RT-PCR (RQ-PCR) 81208 • Diagnostic assessment of patients with suspected CML by qualitative RT- PCR • Monitoring response to Tyrosine Kinase Inhibitor (TKI) therapy, such as imatinib, in patients with CML by RQ-PCR • Testing for the presence of the BCR/ABL1 p.Thr315Ile variant in CML patients to guide treatment selection following resistance to first-line imatinib therapy • Testing for the presence of BCR/ABL1 variants other than p.Thr315Ile in CML patients to guide treatment selection following resistance to first-line imatinib therapy BMPR1A 81479 • To clarify the diagnosis of patients with Juvenile Polyposis Syndrome (JPS) • If a known SMAD4 mutation is in the family, genetic testing should be performed in the first six months of life due to hereditary hemorrhagic telangiectasia risk BRAF 81210 • To predict response to vemurafenib therapy in patients with a positive cobas 4800 BRAF mutation test result 81406 • For patients with indeterminate thyroid Fine-Needle Aspiration (FNA) biopsy cytology for diagnosis of papillary thyroid carcinoma BRACAnalysis 81211 • Bene from families transmitting a known BRCA1/2 variant 81212 • Bene with a history breast cancer and at least one of the following: 81213 (not • Breast cancer diagnosed ≤ 45 years of age covered as a BRAC1/BRAC2 • Breast cancer diagnosed ≤ 50 years of age and a close family member with breast cancer ≤ 45 stand alone years of age or ovarian cancer at any age test) • Two breast primaries with one diagnosed at or before age 50 81214 • A diagnosis of triple negative breast cancer at or before age 60 81215 • Breast cancer diagnosed at any age and at least one close relative with breast cancer before age 81216 50 and/or epithelial ovarian cancer at any age 81217 • Breast cancer diagnosed at any age and at least two close relatives diagnosed with breast, pancreatic, and/or prostate (Gleason ≥ 7) cancer at any age • A close male relative with breast cancer • An ethnic background associated with a higher frequency of BRCA1/2 variants (i.e., Ashkenazi Jewish)

• Bene with a personal history of epithelial ovarian cancer • Bene with male breast cancer • Bene with a personal history of pancreatic or prostate (Gleason ≥ 7) cancer and at least two close relatives with breast, ovarian, prostate (Gleason ≥ 7), and/or pancreatic cancer • Unaffected bene (with no personal history of cancer) who have one of the following: • A first- or second-degree relative satisfying the above criteria • A third-degree relative with breast and/or ovarian cancer and at least two more relatives with breast cancer (at least one diagnosed before age 50) and/or ovarian cancer

Note: One must have 3 relatives with breast or ovarian cancer. One must be a third degree relative (A third- degree relative is defined as a blood relative which includes the individual’s first-cousins, great-grandpar- ents or great grandchildren). The other two may be more distantly related with breast or ovarian cancer. If the other two include breast cancer, one breast cancer patient must have been diagnosed before 50. The words “at least one diagnosed before age 50” apply to “two or more relatives” who have had breast cancer. •• Detection of large genomic rearrangements (e.g., BRACAnalysis® Large Rearrangement Test (BART)) is considered medically necessary for patients who meet the testing criteria for BRCA1/ BRCA2, have no known familial BRCA1/BRCA2 mutations, and the original BRACAnalysis® test was negative. BART is not covered as a stand-alone test

40 –TRICARE Provider Handbook TRICARE guidelines for Laboratory Developed Test (LDT)

LDT Specific (alphabetical order) codes Covered for the following: CEBPA 81403 • To guide the treatment decisions for patients with Acute Myeloid Leukemia (AML) CF testing 81220 • As part of a newborn screening panel included in well-child care (TPM Chapter 7, Sec 2.5) - (Cystic Fibrosis) 81221 handled under the authorization for the delivery. It does not require a separate authorization 81222 • Confirmation of diagnosis in patients showing clinical symptoms of Cystic Fibrosis (CF) or having 81223 a high sweat chloride level 81224 • Identification of newborns who are affected with CF • Identification of patients with the p.Gly551Asp variant who will respond to treatment with Ivacaftor. • Male infertility testing and treatment • Preconception and prenatal carrier screening in accordance with the most current ACOG guidelines Colaris® for Lynch 81292 Bene who has or has had colorectal or endometrial cancer and meets one of the following criteria: 81293 Syndrome 1. Amsterdam II Criteria for Lynch syndrome genetic testing: 81294 MLH1, MSH2, MSH6, 81295 • At least two close blood relatives of the affected beneficiary must have or have had a cancer MSI, PMS2 and EPCAM 81296 associated with Lynch syndrome; and all of the following criteria must be present: 81297 • One must be a first-degree blood relative of the other two 81298 • At least two successive generations must be affected 81299 • At least one of the blood relatives or the beneficiary with cancer associated with HNPCC 81300 should be diagnosed before the age 50 years 81301 • Familial Adenomatous Polyposis (FAP) should be excluded in the colorectal cancer case(s) (if 81317 any) 81318 • Histologic diagnosis of tumors should be verified whenever possible 81319 81403 2. Revised Bethesda guidelines: • Colorectal cancer diagnosed in a bene at less than 50 years of age • Presence of synchronous or metachronous Lynch syndrome- associated cancers, regard less of age • Colorectal cancer with the MSI-H histology diagnosed in a bene who is less than 60 years of age • Colorectal cancer with one or more first-degree blood relatives with a Lynch syndrome- associated cancer, with one of the cancers being diagnosed under age 50 years • Colorectal cancer with two or more first- or second-degree blood relatives with Lynch syndrome-associated cancers, regardless of age

3. Bene has a blood relative with a known Lynch syndrome related gene mutation

4. Endometrial cancer diagnosed in a bene at less than 50 years of age

5. If any of the revised Bethesda guidelines are met, Microsatellite Instability (MSI) and/or Immuno histochemistry (IHC) testing on the colon cancer tissue may be clinically appropriate. If the tumor is MSI positive or mutation of one of the mismatch repair genes is indicated by failure of IHC stain- ing, then genetic testing should be undertaken. Further unnecessary testing can often be avoided by performance of IHC prior to any MSI testing

Colaris® testing is covered for symptomatic or asymptomatic patients > 18 years of age who are at risk of having a known familial sequence variant in a Mismatch Repair (MMR) gene.

TRICARE Provider Handbook – 41 TRICARE guidelines for Laboratory Developed Test (LDT)

LDT Specific (alphabetical order) codes Covered for the following: Colaris AP® for 81201 Colaris AP testing is not covered for prenatal diagnosis or Pre-implantation Genetic Diagnosis (PGD) in detection mutations in 81202 couples affected with, or at-risk for, FAP. the APC and 81203 MUTYH -MYH genes 81401 Other than prenatal diagnosis or PGD, testing is covered: 81403 • For genetic testing for APC variants in patients with clinical symptoms consistent with FAP 81406 • For genetic testing for APC variants in patients with clinical symptoms consistent with AFAP • For genetic testing for APC variants in patients with clinical symptoms consistent with Turcot’s or Gardner’s syndromes • For testing patients with an APC-associated polyposis syndrome for the purpose of identifying a variant that may be used to screen at- risk relatives

For the presymptomatic testing of at-risk relatives for a known familial variant. • NOT COVERED for prenatal testing or PGD in couples at risk for FAP

MYH gene testing may be performed in patients with colorectal polyposis of unknown etiology, and in the siblings and offspring of known MYH- Associated Polyposis (MAP) patients: • For the diagnosis of MAP in APC-negative polyposis patients, or in polyposis patients who have a family history consistent with autosomal recessive inheritance • For the diagnosis of MAP in asymptomatic siblings of patients with known MYH variants • For the testing of offspring or asymptomatic siblings of known MAP patients in order to provide an accurate recurrence risk to offspring Cytogenomic Constitu- 81228 • Diagnostic evaluation of patients suspected of having a genetic syndrome (i.e., have congenital tional Microarry 81229 anomalies, dysmorphic features, Developmental Delay (DD), and/or intellectual disability Analysis (CCMA) 81406 • Diagnostic evaluation of patients with Autism Spectrum Disorder (ASD), including autism, Asperger syndrome, and pervasive developmental disorder EGFR 81235 • To help guide administration of Epidermal Growth Factor Receptor (EGFR) TKIs in the first-line treatment of non-small cell lung cancer FMR1 81243 FMR1 gene testing is covered for the following indications: 81244 • Testing for CGG repeat length for diagnosis of patients of either sex with mental retardation, intellectual disability, developmental delay, or autism

FMR1 gene testing for Fragile X-Associated Tremor/Ataxia Syndrome is covered for the following individuals: • Males and females older than age 50 years who have progressive cerebellar ataxia and intention tremor with or without a positive family history of FMR1-related disorders in whom other common causes of ataxia have been excluded • Women with unexplained Premature Ovarian Insufficiency (POI) F2 81240 • Diagnostic evaluation of patients with a prior Venous Thromboembolism (VTE) during pregnancy 81400 or puerperium • For patients with VTE with a personal or family history of recurrent VTE (more than two in the same person) • For patients with their first VTE before age 50 with no precipitating factors • For venous thrombosis at unusual sites such as the cerebral, mesenteric, portal, or hepatic veins • For VTE associated with the use of estrogen-containing oral contraceptives, Selective Estrogen Receptor Modulators (SERMs), or Hormone Replacement Therapy (HRT) • To diagnose an inherited thrombophilia in female family members of patients with an inherited thrombophilia if the female family member is pregnant or considering pregnancy or oral contraceptive use

42 –TRICARE Provider Handbook TRICARE guidelines for Laboratory Developed Test (LDT)

LDT Specific (alphabetical order) codes Covered for the following: F5 81241 • Diagnostic evaluation of patients with a prior VTE during pregnancy or puerperium.For patients 81240 with VTE with a personal or family history of recurrent VTE (more than two in the same person) • For patients with their first VTE before age 50 with no precipitating factors • For venous thrombosis at unusual sites such as the cerebral, mesenteric, portal, or hepatic veins • For VTE associated with the use of estrogen-containing oral contraceptives, Selective Estrogen Receptor Modulators (SERMs), or Hormone Replacement Therapy (HRT) • To diagnose an inherited thrombophilia in female family members of patients with an inherited thrombophilia if the female family member is pregnant or considering pregnancy or oral contraceptive use HBA1/HBA2 81257 • To confirm the diagnosis of alpha-thalassemia in a symptomatic bene 81404 • To confirm the diagnosis in a pregnant woman with low hemoglobin when alpha-thalassemia 81405 is suspected HEXA 81255 • As an adjunct to biochemical testing in patients with low hexosaminidase A levels in blood. 81406 When patients are identified with apparent deficiency of hexosaminidase A enzymatic activity, targeted mutation analysis can then be used to distinguish pseudodeficiency alleles from disease- causing alleles HLA 81370 • To determine histocompatibility of tissue between organ and bone marrow donors and recipients 81371 prior to transplant 81372 • For platelet transfusion for patients refractory to treatment due to alloimmunization 81373 • Diagnosis of celiac disease in symptomatic patients with equivocal results on small bowel biopsy 81374 and serology, or in previously symptomatic patients who are asymptomatic while on a gluten- 81375 free diet 81376 • Testing for the HLA-B*1502 allele prior to initiating treatment with carbamazepine in patients 81377 from high-risk ethnic groups 81378 • Testing for the HLA-B*5701 allele for hypersensitivity reactions in patients prior to initiation or 81379 reinitiation with treatments containing abacavir 81380 • Testing for the HLA-B*58:01 allele in patients prior to initiating treatment with allopurinol 81381 81382 81383 HFE 81256 • Diagnosis of patients with or without symptoms of iron overload with a serum transferrin saturation >45% and/or elevated serum ferritin JAK2 81270 • Diagnostic evaluation of patients presenting with clinical, laboratory, or pathological findings 81403 suggesting classic forms of myeloproliferative neoplasms (MPN), that is, Polycythemia Vera (PV), Essential Thrombocythemia (ET), or Primary Myelofibrosis (PMF) • Diagnostic evaluation of PV through JAK2 Exon 12 variant detection in JAK2 p.Val617Phe negative patients KRAS 81275 • To help guide administration of anti-EGFR monoclonal antibodies MECP2 81302 • Testing for MECP2 sequence variants in patients who meet established clinical diagnostic criteria 81303 for classic or variant Rett Syndrome (RS) 81304 • Testing for MECP2 sequence variants in patients who have symptoms of RS, but do not meet established clinical diagnostic criteria MPL 81310 • Diagnostic evaluation of Myeloproliferative Leukemia (MPL) variants to include Trp515Leu and Trp515Lys in JAK2 p.Val617Phe-negative patients showing symptoms NPM1 81310 • To guide treatment decisions for patients with Acut myeloid leukemia (AML) Oncotype DX® Breast S3854 • Estrogen Receptor (ER) positive (+), lymph node (N) negative (-) breast cancer who are considering Cancer Assay whether to use adjuvant chemotherapy in addition to hormonal therapy (Oncotype DX®) • ER+ (or progesterone receptor +), N–, human epidermal growth factor receptor 2 negative (HER2–) women with stage I or II breast cancer who are considering whether to have adjuvant chemotherapy

TRICARE Provider Handbook – 43 TRICARE guidelines for Laboratory Developed Test (LDT)

LDT Specific (alphabetical order) codes Covered for the following: PAX8 81401 • For patients with indeterminate thyroid FNA biopsy cytology for diagnosis of papillary thyroid carcinoma PML/RARalpha 81315 • Diagnostic assessment of patients with suspected acute promyelocytic leukemia (APL) by 81316 quantitative RT-PCR (RQ-PCR) • Diagnostic assessment of patients with suspected APL by qualitative RT- PCR • Monitoring response to treatment and disease progression in patients with APL by RQ-PCR PMP22 81324 • For the accurate diagnosis and classification of hereditary polyneuropathies 81325 81326 PTEN 81321 • For patients with Autism Spectrum Disorders (ASDs) and macrocephaly (Head circumference 81322 greater than 2 standard above the mean for age) 81323 • PTEN variant testing in patients suspected of being affected with Cowden Syndrome (CS) or Bannayan-Riley-Ruvalcaba Syndrome (BRRS) RET 81404 • Multiple endocrine neoplasia type 2 (MEN2) gene testing in patients with the clinical 81405 manifestations of MEN2A, MEN2B, or familial medullary thyroid carcinoma (FMTC), including those with apparently sporadic Medullary Thyroid Carcinoma (MTC) or pheochromocytoma • MEN2 gene testing to confirm a diagnosis in the at-risk relatives of genetically confirmed MEN2 patients SNRPN/UBE3A 81331 When a clinical diagnosis of Prader-Willi Syndrome (PWS) is suspected, the following findings justify genetic testing: • From birth to age two: Hypotonia with poor suck (neonatal period) • From age two to age six: Hypotonia with history of poor suck, global developmental delay • From age six to age 12: Hypotonia with history of poor suck, global developmental delay, excessive eating with central obesity if uncontrolled • From age 13 years to adulthood: Cognitive impairment, usually mild intellectual disability; excessive eating with central obesity if uncontrolled, hypothalamic hypogonadism and/or typical behavior problems

When a clinical diagnosis of Angelman Syndrome is suspected, the following findings justify genetic testing: • As part of the evaluation of patients with developmental delay, regardless of age • As part of the evaluation of patients with a balance or movement disorder such as ataxia of gait May not appear as frank ataxia but can be forward lurching, unsteadiness, clumsiness, or quick, jerky motions • As part of the evaluation of patients with uniqueness of behavior: any combination of frequent laughter/smiling; apparent happy demeanor; easily excitable personality, often with uplifted hand-flapping or waving movements; hypermotoric behavior • Speech impairment, none or minimal use of words; receptive and non-verbal communication skills higher than verbal ones STK11 81404 • To confirm a diagnosis of Peutz-Jeghers Syndrome (PJS) in proband patients with a presumptive 81405 or probable diagnosis of PJS TP53 81404 • Diagnosis of patients satisfying the criteria for classic Li-Fraumeni Syndrome (LFS) or Li- 81405 Fraumeni-Like Syndrome (LFLS), or the Chompret criteria for TP53 gene testing. TRG 81342 • Diagnosis and treatment of T-cell neoplasms. VHL 81403 • Diagnosis of Von Hippel-Lindau (VHL) syndrome in patients presenting with pheochromocytoma, 81404 paraganglioma, or central nervous system hemangioblastoma. • Confirmation of diagnosis in patients with symptoms consistent with VHL syndrome.

44 –TRICARE Provider Handbook TRICARE referrals and prior authorizations

Humana Military issues a referral when a TRICARE Prime beneficiary Tips for hospital admission notifications needs specialized medical services from a civilian professional or ancillary provider only if the requested services are not available Submitting the notification online atHumanaMilitary.com is the quickest at a military hospital/clinic or at the Primary Care Manager’s and most convenient way to notify Humana Military of a hospital (PCM’s) office. A prior authorization is issued for requested services, admission. In many cases, the admission is immediately approved. procedures or admissions that require medical necessity review prior Entering a new hospital admission notification is easy. Sign in to Self-Service to services being rendered. for Providers, select New request for referral or authorization, including hospital admission and follow the simple steps to complete the request. Referral and authorization submission options Submit continued stay reviews and notify Humana Military of a Submit online for quickest response via the Self-Service for Providers patient’s discharge online. It is important to notify Humana Military portal at HumanaMilitary.com when a patient is discharged. This allows the authorization to be completed and the claim to be properly processed. Fax Patient Referral Authorization Form 1-877-548-1547 For mental health care admissions, submit notification online at Submit by phone HumanaMilitary.com. This is the quickest and most convenient way 1-800-444-5445 to notify ValueOptions® Federal Services of a hospital admission. Facilities unable to access the Web can fax the TRICARE Higher Level Mental health care referrals and authorizations via the Self-Service of Care Treatment Report form, available at HumanaMilitary.com, to for Providers portal at HumanaMilitary.com ValueOptions® Federal Services at 1-866-811-4422. Fax Outpatient Treatment Report (OTR): 1-866-811-4422 For questions: 1-800-700-8646 Specialist-to-specialist referrals for the same Via the Self-Service for Provider portal at HumanaMilitary.com episode of care

Some referrals may be authorized from one specialty care provider to Tips for making referrals and authorizations another, bypassing the need to get another PCM referral. Specialist-to-specialist referrals: Submitting a request online at HumanaMilitary.com is the quickest and most convenient way to obtain a referral or authorization. • Apply only when a valid Evaluate and Treat referral from the PCM was previously authorized for the same episode of care • All network PCM and specialist-to-specialist referral requests • Do not apply to Active Duty Service Members (ADSMs) will be directed to system-selected providers or to providers the • Are subject to the military hospital or clinic ROFR policy beneficiary has seen in the preceding six months • The choice of up to five providers will reflect the optimal options in If you are a specialist referring your patient to another specialist, terms of quality of care, accessibility (e.g., appointment availability), please keep in mind: affordability and drive time from the beneficiary’s address • You, the receiving specialist and the PCM will be notified of all • If the beneficiary resides within a military hospital’s catchment such referrals by automatic fax, keeping the entire care team area, the services requested may be subject to redirection to the aware of these clinical contacts military hospital - known as the Right Of First Refusal (ROFR) • Not all specialist-to-specialist referrals will be authorized • When completing the referral, always include the sponsor’s • If a pediatric patient age 5 or younger or a patient with a TRICARE ID, diagnosis and clinical data explaining the reason for developmental, mental or physical disability requires dental the referral procedures under general anesthesia, the request for prior • If the patient needs services beyond the referral’s scope, the authorization may be submitted by the dentist PCM must approve additional services • Check the status of the referral or authorization at HumanaMilitary.com or by phone at 1-800-444-5445 Services requiring prior authorization in the • Humana Military will notify the beneficiary and providers of an approved referral or authorization south region • For urgent referrals and authorizations, call 1-800-444-5445, press 2 to access the Provider Main Menu and press 3 Procedures and services • Adjunctive dental care • Advanced life support air ambulance in conjunction with stem cell transplantation • Bariatric surgery • Applied Behavior Analysis (ABA) • Extended Care Health Option (ECHO) services

TRICARE Provider Handbook – 45 • Home health services, including home infusion If the military hospital or clinic cannot provide the services or care • Hospice requested, the patient will be referred to a civilian network provider. • Lab Developed Tests (LDTs) The important thing to understand is even if a provider has already • Transplants (solid organ and stem cell, not corneal transplant been selected, the local military hospital or clinic may review and override that referral by exercising its Right Of First Refusal. *Approved to military hospitals or clinic for available service or approved to civilian Inpatient hospital stays provider if military hospital or clinic service is not available. • Acute care admissions (Notification of acute care admission is In accordance with the TRICARE Operations Manual (Chapter 8, Sec- required by the next working day tion 5, 6.2.2), “The referral request for beneficiaries residing within the • Admissions or transfers to Skilled Nursing Facilities (SNFs), PRIME Service Area shall follow the Right Of First Refusal allowing the rehabilitation and Long-Term Acute Care (LTAC) local military hospital or clinic priority. Access standards, enrollment • Discharge notification category, available specialty, as well as diagnosis and requested services/procedures are considered affording the military hospital the Mental health opportunity to see the patient….”

• Non-emergency admissions to inpatient hospitals for psychiatric and substance use disorders Tips for ensuring the ROFR process is working in • Partial Hospitalization Programs (PHPs) for psychiatric and your office substance use disorders • Residential Treatment Centers (RTCs) • Build/request referrals using the options available to your • Outpatient mental health care visits exceeding the initial eight office (online atHumanaMilitary.com ) or by faxing a referral/ visits each Fiscal Year (October 1 to September 30 authorization request using the Patient Referral Authorization • Psychoanalysis Form (PRAF) • Understand that even if you select a provider to refer to, the local military hospital or clinic may review and override the Right of First Refusal referral selection, applying the Right Of First Refusal • Ensure the beneficiary is aware the military hospital or clinic may Military hospitals and clinics have the Right Of First Refusal (ROFR) to take precedence on the referral selection provide care for a TRICARE beneficiary. When a TRICARE Prime beneficiary’s civilian network provider is unable to provide a special- Military hospitals and clinics and ROFRS ized medical service, the network provider must contact Humana Military to request a referral. Military hospitals and clinics are located on most military posts, bases and installations. Their primary focus is active duty readiness The ROFR Process for military contingency operations. The military hospital or clinic is also responsible for TRICARE families and may choose to have PRIME After it is determined that a beneficiary needs to be referred for spe- referred services delivered within the military hospital or clinic for a cialty care, the requesting provider will contact Humana Military for number of reasons: a referral or authorization. We will then send the request to the local • To enhance the military graduate medical education program military hospital or clinic for review. • To hone the skills of military providers rotating through the military hospital or clinic nearest you Many times the military hospital or clinic will have the specialized • To ensure military hospital and clinic optimization, which helps services available. In this scenario, the military hospital or clinic will to contain health care cost for TRICARE beneficiaries notify us, usually within one business day, and the beneficiary will • To assist in determining prevalent military hospital and be referred to the military hospital or clinic. The military hospital or clinic specialty access and adequacy needs for a particular clinic may contact the beneficiary to schedule an appointment, and TRICARE population Humana Military will provide the beneficiary with the information for contacting the military hospital or clinic.

Figure 5.4 Response Referral Review by military Military Request hospital or clinic Decision* hospital or clinic

Civilian Provider

46 –TRICARE Provider Handbook Autofax confirmation Discharge planning

The PCM and the referred-to provider will receive an automatic Discharge planning begins on admission review and continues fax when care is authorized. Authorization is not a guarantee for throughout the hospital stay. Activities include arranging for payment. Figure 5.1 shows an example of this confirmation. services such as home health and DME needed after discharge and coordinating transfers to lower levels of care to minimize The automatic fax will specify the services authorized, the number inappropriate use of hospital resources. of visits and the time frame in which the visits must occur. The beneficiary will also receive a letter notifying him or her of the To help facilitate beneficiary reintegration following inpatient services approved referral or authorization. and prevent hospital readmissions, Humana Military nurses conduct post-discharge calls to beneficiaries with traumatic injuries, burns, Providers should program their office/referral fax number into their high-risk obstetrics, back surgery, hip and knee replacements, and fax machine to ensure the number appears on their referral requests. prolonged hospitalization of more than 20 days.

Case management IMPORTANT Return Discharge Summary or Operative Report/Consultation to the referring clinician fax # Humana Military nurses provide case management services for FAX: (xxx) xxx-xxxxx AUTH/ORDER # xxxxxxxxxxxxx listed below.

DATE: Include this form as a TRICARE beneficiaries with complex health needs. The following coversheet for your fax.

DR. JOHN SMITH conditions warrant mandatory referral to case management: 123 MAIN STREET PHONE: (xxx) xxx-xxxx JACKSONVILLE, FL 12345 FAX#: (xxx) xxx-xxxx • Transplant evaluation or procedure (solid organ or bone marrow/ HUMANA MILITARY --- TRICARE REFERRAL/AUTHORIZATION You’ve been approved to provide the services described below. If an appointment is required to provide these services, the peripheral stem cell) beneficiary will contact you. Please schedule the appointment within the TRICARE access standard. Wait time for specialty care appointments is based on the nature of the care required, but should not exceed four weeks. Units shown below are the • Ventilator dependence total number of visits or procedures covered by this authorization number. Routine ancillary lab, skin biopsy, and radiology diagnostic tests do not require specific authorization. This authorization does not guarantee payment. Payment is based on TRICARE eligibility and compliance with TRICARE policy. If further information about this authorization is required, please • Acute inpatient rehabilitation (not skilled facility with contact Humana Military at (800)444-5445).Inpatient care requires notification by the hospital and separate authorization. therapy only) BENEFICIARY INFORMATION: HELEN SMITH SPONSOR ID: last 4 digits • Traumatic brain injury, spinal cord injury, stroke, new blindness PHONE: (xxx) xxx-xxxx FACILITY: • New quadriplegia or paraplegia AUTHORIZED SERVICES: UNITS: BETWEEN DATES: OFFICE CONSULT NEW OR EXTABLISHED PT 1 xx/xx/xxxx – xx/xx/xxxx • Premature infant: ventilator-dependent more than 24 hours OFFICE OR OP VISIT ESTABLISHED PATIENT 1 xx/xx/xxxx – xx/xx/xxxx and/or weight less than 1,500 grams [FAX NOTES] • Planned Long-Term Acute Care (LTAC) admission • Catastrophic illness or injury, amputation, multiple trauma REASON FOR REFERRAL: • Pregnancy with significant identified risks To improve coordination of care, TRICARE requires a report of this referral to be provided to the Primary Care Manager (PCM)/referring provider within 10 days of the visit. The fax number is listed below. • Hourly nursing care more than four hours per day

REFERRING CLINICIAN: Name and Address PHONE: (xxx) xxx-xxxx FAX #: (xxx) xxx-xxxx • Burn injury requiring a burn unit ORDERING PROVIDER: • Unplanned admissions to acute hospital three times or more Log on to MyHMHS at HumanaMilitary.com. Enter the auth/order number listed above and this key code for immediate access: XXXX within 90 days with the same diagnosis  Eligibility, referral status and prescription history for the patient  Submit requests for new referrals and authorizations, often with immediate approval • Chronic condition resulting in high resource consumption (e.g., hemophilia, Gaucher’s disease) This transmittal is intended only for the use of the individual or entity to which it is addressed and contains Protected Health Information, which is CONFIDENTIAL. This information may only be used or disclosed in accordance with federal law, which contains penalties for misuse. If you are not the intended recipient of this transmission, you may not otherwise use or disclose the information contained in this transmission. If you receive this • ECHO requests transmission in error, please return the transmission to Humana Military at 1-888-385-4565 and delete or destroy this information. Thank you. • Transfer to a military hospital or clinic or network facility Figure 5.5 This list is not all-inclusive and is subject to change. Beneficiaries with a complex case who may benefit from case management are eligible for an evaluation, and providers should refer them to Humana Military. Concurrent review

Concurrent review is the review of a continued inpatient stay to Clinical quality management determine medical necessity, quality of care and appropriateness of the level of care being provided. Concurrent review ensures The Humana Military Quality Management Department is responsible appropriate, efficient and effective utilization of medical resources. for oversight of clinical care provided to TRICARE beneficiaries. TRICARE providers must agree to participate in clinical quality studies and to When approving inpatient admissions, an approved number of make their medical records available for review for quality purposes. days are assigned, and the last covered date is set. If a facility does TRICARE Prime beneficiaries and PCMs receive reminder postcards from not request an extension, there is no further review. If the patient the Humana Military Quality Management Department to promote remains hospitalized beyond the approved number of days, a provider awareness of recommended preventive care services. penalty will be applied to the additional days.

Retrospective review

Retrospective review is conducted when a certain procedure or service requires a medical necessity review but was not previously authorized.

TRICARE Provider Handbook – 47 TRICARE Quality Monitoring Contractor • Providing copies of medical records • Providing accurate information on patients’ conditions KePRO is the TRICARE Quality Monitoring Contractor (TQMC) and assists • Informing patients of their rights and responsibilities DoD Health Affairs, Defense Health Agency (DHA), military hospitals • Providing other assistance that may be required for Humana or clinic market managers and the TRICARE Regional Offices by Military to conduct comprehensive utilization and quality providing the government with an independent, impartial evaluation management programs for care of MHS beneficiaries who are of the care provided to beneficiaries within the Military Health patients of the facility System (MHS). The TQMC reviews care provided by TRICARE network providers and subcontractors on a limited basis. The TQMC is part of TRICARE’s Quality and Utilization Peer Review Organization Program, in accordance with 32 Code of Federal Regulations (CFR) 199.15.

To facilitate TQMC reviews, providers’ medical records may be requested by Humana Military on a monthly basis to comply with requirements detailed in the TRICARE Operations Manual, Chapter 7, Section 3 at manuals.TRICARE.osd.mil. Providers may be required to submit records to Humana Military to comply with requests for medical records submitted by KePRO to Humana Military.

Providers that receive requests for medical records are required to submit the requested medical record in its entirety to Humana Military. Failure to do so will result in recoupment of payment for the hospitalization and/or any other services in accordance with 32 CFR 199.4(a)(5).

Medical records documentation

Humana Military may review a provider’s medical records on a random basis to evaluate patterns of care and compliance with performance standards. Policies and procedures should be in place to help ensure that a beneficiary’s medical record is kept organized and confidential. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis and describe the patient’s progress and response to medications and services.

Peer review organization agreement

Humana Military has review authority over health care services provided in civilian facilities to MHS beneficiaries in the TRICARE South Region.

To participate in the care of TRICARE beneficiaries, facilities must establish a Peer Review Organization (PRO) Agreement with Humana Military in accordance with 32 CFR 199.15(g). For more information, refer to the TRICARE Operations Manual, Chapter 7, Section 1 at manuals.TRICARE.osd.mil

The PRO Agreement is separate from a network contract and network and non-network facilities are required to sign one. The agreement is a signed acknowledgement that Humana Military is the PRO for the TRICARE South Region.

If a corporation has multiple facilities, one signed agreement may cover all the facilities. Please attach a list that includes each facility and its respective tax ID.

The PRO Agreement confirms that the facility will cooperate with Humana Military and its subcontractors by:

48 –TRICARE Provider Handbook Peer review organization agreement for institutional providers

Figure 5.6

For beneficiaries of the military health system

The institution will cooperate with Humana Government Business (HGB) and its subcontractors by providing copies of medical records; providing accurate information on patient’s conditions; informing patients of their rights and responsibilities; and providing other assistance that may be required for HGB to conduct comprehensive utilization and quality management programs for care of Military Health Systems (MHS) beneficiaries who are patients of the institution.

The institution will provide adequate space for conducting on-site review or provide review information telephonically or electronically to HGB or its subcontractors. The institution will deliver to HGB or its subcontractors, within 30 days of receipt of written request, copies of information required for off-site review of care provided by the institution to beneficiaries who are patients of the institution. Reimbursement for the costs of photocopying and postage will be the same reimbursement as Medicare, as amended from time to time.

The institution will provide all MHS beneficiary patients written information on their rights and responsibilities (e.g. “An Important Message from TRICARE”) and, when appropriate, a proper hospital issued notice of noncoverage.

The institution will reasonable efforts to inform HGB at 1-800-334-5612 within three (3) business days when the institution issues a notice that a MHS beneficiary patient no longer needs inpatient care.

The institution will use reasonable efforts to ensure that all cases requiring review are reviewed and approved by HGB or its subcontractors. The institution will accept full financial liability for care provided to MHS beneficiaries if all of the following are true: 1. The care required pre-authorization 2. Pre-authorization was not received 3. The care is subsequently found to be a medically unnecessary or provided at an inappropriate level (reference 32 Code of Federal Regulations 199.15 [g])

The institution acknowledges that HGB has provided it with detailed information on the utilization and quality review processes and criteria used and the potential financial liability incurred by failing to obtain pre-authorization when required.

______Signature Institution Name

______Title Tax ID Number

______Date Address

______Suite or Building

______City/State/Zip

Return to: Utilization Management, Humana Government Business, P.O. Box 740044 Louisville, KY 40201-7444 or fax to 1-502-322-8895.

TRICARE Provider Handbook – 49 Appealing a decision Figure 5.7

TRICARE beneficiaries have the right to appeal decisions made by DHA or Humana Military. All initial and appeal denials explain how, where and by when to file the next level of appeal.

Where to send appeals for denied referrals or authorizations

Prior authorization appeals Humana Military Attn: Utilization Management P.O. Box 740044 Louisville, KY 40201-9973

Mental health care appeals ValueOptions® Federal Services Mental Health Attn: Appeals and Reconsideration Department P.O. Box 551138 Jacksonville, FL 32255-1138 Medical necessity determinations Medical necessity determinations are based on whether, from a medical point of view, the suggested care is appropriate, reasonable and adequate for the beneficiary’s condition. If an expedited appeal is available, the initial and appeal denial decisions will fully explain how to file an expedited appeal. Factual determinations Factual determinations involve issues other than medical necessity. Some examples of factual determinations include coverage issues (i.e., determining whether the service is covered under TRICARE policy or regulation), all foreign claims determinations and denial of a provider’s request for approval as a TRICARE-authorized provider. Proper appealing parties • A TRICARE beneficiary (including minors) • A non-network participating provider • A provider who has been denied approval as a TRICARE- authorized provider or who has been terminated, excluded, suspended or otherwise sanctioned • A person who has been appointed in writing by the beneficiary to represent him or her in the appeal • An attorney filing on behalf of a beneficiary • A custodial parent or guardian of a beneficiary under 18 years of age

A network provider is never an appropriate appealing party unless the beneficiary has appointed the provider, in writing, to represent him or her for the purpose of the appeal. To avoid a possible conflict of interest, an officer or employee of the U.S. government is not eligible to serve as a representative unless the beneficiary is an immediate family member.

Non-appealable issues notifications Certain issues are considered non-appealable. Non-appealable issues include the following:

• POS determinations, with the exception of whether services were related to an emergency and are, therefore, exempt from the requirement for referral and authorization • Allowable charges (The TRICARE allowable charge for services or supplies is established by regulation.) • A beneficiary’s eligibility (This determination is the responsibility of the uniformed services.) • Provider sanction (The provider is limited to exhausting administrative appeal rights.) • Network provider/contractor disputes • Denial of services from an unauthorized provider • Denial of a treatment plan when an alternative treatment plan is selected • Denial of services by a PCM

50 –TRICARE Provider Handbook Mental health care services

ValueOptions® Federal Services is the mental health care contractor ValueOptions® Federal Services credentials the following types for Humana Military for the TRICARE South Region. ValueOptions® of facilities and health care delivery organizations: administers the TRICARE mental health care benefit and manages • General hospitals with psychiatric services the mental health care provider network. • Acute freestanding psychiatric hospitals • RTCs ValueOptions® Federal Services reviews clinical information to • SUDRFs determine if mental health care is medically or psychologically • PHPs necessary. In certain circumstances, TRICARE waives mental health care benefit limits for medically or psychologically necessary services. Referral and authorization requirements ValueOptions® Federal Services provider relations representatives are TRICARE mental health care referral and authorization available to answer nonclinical questions, address concerns or assist requirements vary according to several factors, including, but with requests for additional information Monday through Friday, not limited to, beneficiary status, program option and type of excluding federal holidays, at 1-800-700-8646. care. Referral and prior authorization requirements for specific To determine if a specific service is a covered benefit or if coverage services can be found on the following pages. Active Duty Service is limited, check the current list of non-covered services on the No Members require MTF referral for all behavioral health services. Government Pay Procedure Code List at TRICARE.mil/NoGovernmentPay Active Duty Service Members require a military hospital or clinic or check the Code Look Up using the secure Self-Services for Providers referral for all mental health services. portal at HumanaMilitary.com NOTE: Physician referrals (i.e., MDs or DOs seeing the patient, The information contained in this section is not all-inclusive. See the performing an evaluation and making an initial diagnosis before following pages for a list of mental health care limitations and exclusions. referring the patient) and ongoing communication with referring physicians are required for all visits (including the first eight) to licensed or certified mental health and pastoral counselors. Mental health care providers

TRICARE covers services delivered by qualified, TRICARE-authorized Obtaining referrals and prior authorizations mental health care providers practicing within the scope of their license to diagnose or treat covered mental health disorders. TRICARE Providers are required to submit all referrals and requests for encourages beneficiaries to receive mental health care at military authorization through the Self-Services for Providers portal at hospitals or clinics, but beneficiaries may be referred to network HumanaMilitary.com providers if military hospital or clinic care is not available. • Psychiatrists and addictionologists Initial evaluations • Psychologists • Prescriptive privileges for psychologists (PhD): In select states One initial evaluation — either a psychiatric diagnostic within the United States, licensed clinical psychologists can examination (Current Procedural Terminology [CPT®] obtain prescriptive privileges code 90791) or a psychiatric diagnostic examination with • Nurse practitioners medical services (CPT code 90792) — is allowed per FY. This • Psychiatric nurses initial evaluation counts toward the first eight self-referred • Social workers outpatient visits. • Marriage and family therapists • Pastoral counselors Additional evaluations in the same FY require prior authorization • Applied Behavior Analysis (ABA; BCBA and BCBA-D) from ValueOptions® Federal Services, regardless of whether • TRICARE certified MHCs and other clinicians the first eight visits have occurred. Submit requests for prior authorizations for additional evaluations using the secure Self- The TRICARE mental health care inpatient network consists of Service for Providers portal at HumanaMilitary.com hospitals, inpatient psychiatric units, Partial Hospitalization Programs (PHPs), Residential Treatment Centers (RTCs) and Substance Use Disorder Rehabilitation Facilities (SUDRFs). See the Join the Network section of HumanaMilitary.com for networking criteria. (HumanaMilitary.com /provider/mental-health/join-network)

TRICARE Provider Handbook – 51 Telemental health services Reportable occurrences as defined by TRICARE include: • Life-threatening accident Telemental health services involve using secure, two-way audiovisual • Patient death conferencing to connect stateside TRICARE beneficiaries with offsite • Patient elopement TRICARE network providers. Telemental health provides medically and • Suicide attempt psychologically necessary mental health care services, including: • Cruel or abusive treatment • Clinical consultation • Physical or sexual abuse • Individual psychotherapy • Any equally dangerous situation • Psychiatric, diagnostic interview examination • Medication management The point of contact for TRICARE incident reporting is the TQMC. See the Important Provider Information section for more information. Beneficiaries can access telemental health services at TRICARE- authorized telemental health-participating facilities by using a telecommunications system to contact TRICARE network providers Limitations and exclusions (Mental health) at remote locations. Services rendered from a beneficiary’s home are not covered by TRICARE. For a complete list of Mental Health care services that are generally not covered under TRICARE or are covered with significant limitations, Mental health care limitations, authorization requirements, visit TRICARE.mil deductibles and cost-shares apply. For more information, visit tricare.mil/CoveredServices/IsItCovered/TelementalHealth.aspx Eating disorder programs

Case management An eating disorder program provided within an institutional facility that meets the requirements to be certified as a TRICARE-authorized Certain beneficiaries require more intensive care management and institutional provider is covered. coordination. These high-risk beneficiaries may be eligible for case management through ValueOptions® Federal Services. Eating disorder services rendered in a freestanding eating disorder program that fails to meet the certification requirements of one of Case management identifies links and provides intensive coordination the institutional provider categories are excluded from coverage. of mental health care and substance use disorder services to help beneficiaries maintain clinical stability. Case managers link beneficiaries with TRICARE resources, military hospitals or clinics, Outpatient services and state, federal and local community resources, and they teach TRICARE covers medically and psychologically necessary behavioral beneficiaries to be proactive about accessing care. health care services, for Substance Use Disorders, Mental Disorders To refer a patient for a case management evaluation, call and Behavioral Disturbances in Inpatient and Outpatient settings. ValueOptions® Federal Services at 1-800-700-8646 or submit the Substance use covered services include inpatient detoxification, Case Management Mental Health Referral Form. inpatient rehabilitation, partial hospitalization and outpatient If ValueOptions® Federal Services accepts the case for management services. services, a case manager will contact the beneficiary. Psychiatric hospital levels of care include inpatient, partial hospitalization and residential treatment center services. Discharge planning Outpatient services include outpatient psychotherapy, psychological Discharge planning begins on admission review and continues testing and assessment, Applied Behavior Analysis (ABA), throughout the hospital stay. Activities include arranging for electroconvulsive therapy (ECT) and telemental health services. outpatient services after discharge or coordinating transfers to lower See the charts on the following pages for additional details. levels of care to minimize inappropriate use of hospital resources.

To help facilitate beneficiary reintegration following inpatient services and prevent hospital readmissions, ValueOptions® Federal Service nurses conduct post-discharge calls to beneficiaries with affective disorders with psychosis and prolonged hospitalization of more than 20 days.

Incident reporting requirements

Any serious occurrence involving a TRICARE beneficiary while receiving services at a TRICARE-authorized treatment program (e.g., RTC, freestanding PHP or SUDRF) must be reported to ValueOptions® Federal Services and the TQMC within one business day. TRICARE participation agreements outline specific requirements.

52 –TRICARE Provider Handbook Covered services information Figure 6.1

Noncovered behavioral health care services2

• Aversion therapy (including electric shock • Court-ordered treatment that is not • Services and supplies not medically or and the use of chemicals for alcoholism, otherwise medically necessary is excluded psychologically necessary for the diagnosis except for Antabuse® [disulfiram], which from coverage. and treatment of a covered condition is covered for the treatment of alcoholism) • Custodial nursing care • Services for V-code or Z-code diagnoses • Behavioral health care services and • Diagnostic admissions • Sexual dysfunction therapy supplies related solely to obesity and/or • Educational programs • Surgery performed primarily for weight reduction • Experimental procedures psychological reasons (e.g., psychogenic) • Biofeedback for psychosomatic conditions • Marathon therapy • Therapy for developmental disorders, such • Counseling services not medically • Megavitamin or orthomolecular therapy as dyslexia, developmental mathematics necessary in the treatment of a diagnosed • Psychosurgery (Surgery for the relief disorders, developmental language disorders medical condition (e.g., educational of movement disorders, electroshock and developmental articulation disorders counseling, vocational counseling, treatments and surgery to interrupt • Unproven drugs, devices and medical nutritional counseling, stress management, the transmission of pain along treatments or procedures marital therapy or lifestyle modifications) sensory pathways are not considered psychosurgery)

Outpatient mental health care covered services

Service Coverage details Prior authorization Frequency limitations

Psychiatric diagnostic • Initial evaluation counts toward the • Not required (unless more • One per beneficiary, per FY interview examination initial eight outpatient visits each than one session requested Fiscal Year (FY). Active Duty Service within same FY [October 1 to Members (ADSMs) require referrals September 30]

Outpatient psychotherapy Covered sessions include: • Required after initial eight • A provider cannot bill for ( visits per beneficiary, per FY. more than two sessions physician referral and • Psychotherapy (individual up to 60 • ADSMs must have a referral or per calendar week without ongoing communication minutes, family or conjoint up to 90 authorization before receiving prior authorization from required when seeing minutes, group up to 90 minutes) any care outside of a military ValueOptions® Federal licensed or certified • Crisis intervention (individual up to hospital or clinic Services mental health and 120 minutes, family or conjoint up • Required for psychoanalysis • Multiple sessions of the same pastoral counselors and to 180 minutes) type cannot be billed on the similar non-independent • Collateral visits same day providers.) • Psychoanalysis

Psychological and • Covered when medical necessity exists • Required after the first six • Psychological testing is neuropsychological testing and performed in conjunction with sessions per FY generally limited to six hours otherwise-covered psychotherapy per FY, but ValueOptions® Federal Services may approve more hours on a case-by- case basis

Medication • Covered when provided as an • Requires prior authorization • A provider cannot bill for management independent procedure and rendered from ValueOptions® Federal more than two sessions by a provider who is authorized to Services per calendar week without prescribe the medication • ADSMs must have a referral or prior authorization from authorization before receiving ValueOptions® Federal any care outside of a military Services hospital or clinic

Electroconvulsive therapy • May be covered when medically • Not required. • None necessary and must be rendered by a qualified provider

TRICARE Provider Handbook – 53 Covered services information

Inpatient mental health care covered services Service Coverage details Prior authorization1 Frequency limitations

Acute inpatient • For stabilization of a life- • Required for all mental • Patients age 19 and older: 30 days per psychiatric care threatening or severely disabling health admissions FY or in any single admission mental health condition • Notify ValueOptions® • Patients age 18 and under: 45 days • Psychiatric emergency admissions Federal Services within per FY or in any single admission are required when, based on 24 hours of emergency • Inpatient admissions for substance use a psychiatric evaluation, the admission and no more disorder detoxification and rehabilitation beneficiary is at immediate risk of than 72 hours after count toward 30- or 45-day limit serious harm to self or others and admission • ValueOptions® Federal Services may requires immediate, continuous, approve additional days, as appropriate, skilled observation based on medical necessity

Residential Treatment • Covered for children and • Required • Up to 150 days per FY or for a single Center (RTC) adolescents (up to age 21) with admission (must be TRICARE- psychological disorders who • ValueOptions® Federal Services may authorized by KePRO, Inc.) require continued treatment in a approve additional days, as appropriate, therapeutic environment based on medical necessity

Partial Hospitalization • For stabilization or treatment of • Requires referral and • Up to 60 treatment days (full- or half- Program (PHP) partially stabilized mental health prior authorization from day program) per FY or for any single (Freestanding PHPs must disorders ValueOptions® Federal admission be TRICARE-authorized by • Serves as a transition from Services • Does not count toward 30- or 45- day KePRO, Inc.) an inpatient program when mental health care inpatient limit medically necessary • Appropriate for crisis stabilization\ Does not require 24 hour-a-day care in an inpatient setting

Substance use disorder covered services Service Coverage details Prior authorization Frequency limitations

Inpatient detoxification • Covered when medically • Required for all inpatient • Up to seven days per episode in a necessary for active medical detoxification admissions TRICARE-authorized facility treatment of acute phases without exception Notify • Counts toward 30- or 45- day of substance use withdrawal ValueOptions® Federal inpatient behavioral health care (detoxification) when the patient’s Services within 24 hours limit Does not count toward 21-day condition requires the personnel of emergency admission rehabilitation limit and facilities of a hospital and no more than 72 hours after admission

Inpatient rehabilitation • Follows the detoxification period • Required • Up to 21 days of rehabilitation per • Care must occur in an inpatient year, per benefit period or PHP setting. (See PHP • Up to three benefit treatment requirements below) episodes per lifetime • Counts toward 30- or 45-day inpatient behavioral health care limit

Outpatient care • Outpatient care must be provided • Required • 60 individual or group therapy visits by an approved Substance Use per benefit period Disorder Rehabilitation Facility • 15 family therapy visits per benefit (SUDRF) period

Partial Hospitalization • May be used alone or as a step- • Required • Up to 21 treatment days (full- or Program (PHP) down from inpatient rehabilitation half-day program) per FY (Freestanding PHPs must • Must be a TRICARE-authorized • Counts toward 60-day limit per FY be TRICARE-authorized by SUDRF (freestanding or hospital KePRO, Inc.) based)

54 –TRICARE Provider Handbook Mental health disorder information for PCMs

Figure 6.2 PTSD, TBI, suicide risk

Military life, especially the stress of deployments or mobilizations, can present challenges to service members and their families that are both unique and difficult. Primary Care Managers (PCMs) are the frontline of support for our military families and play a critical role in early detection and intervention of mental health disorders. Please be aware of the risks and symptoms of Posttraumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI) and suicide. Many times primary care is a patient’s only source for mental health treatment.

Posttraumatic Stress Disorder PCMs should be aware of the symptoms of PTSD. PTSD can be detected and frequently managed in a (PTSD) Overview primary care setting. The onset is one month to several years (delayed onset) of a physical/emotional trau- matic event. PCMs should determine potential risk factors, such as: a) experience of a traumatic event; b) injured or experienced a near-death experience; c) survivor of lengthy or severe trauma; d) strong physical/ emotional response during event; e) little or no support following event; and f) have multiple stressors in current life situation. Symptoms of PTSD Cognitive Inattentiveness, intrusive memories, memory impairment, trouble concentrating and/or worry Behavioral and Angry outbursts, compulsive, repetitive acts, faintness, headaches, loss of control, Physiological hyperalertness, hyperventilation and/or being easily startled or frightened Affect/Mood Anger, crying, shame or guilt, irritability, low self-esteem, sadness and/or self-criticism Miscellaneous Isolative behaviors, anticipation of misfortune, distrust of others, avoidance of past recollections, flashbacks, feelings of inadequacy or unworthiness, sense of foreshort- ened or hopeless future, sense of pervasive unreality, and/or self-destructive behavior (substance abuse) Treatment • Required • Evaluate safety, suicide risk factors, potential to harm others • Determine level of functioning (social, occupational, interpersonal, self-care) and availability of basic care resources (e.g., safe housing, social support network, companion care, food, and clothing) • Diagnose co-morbid physical or psychiatric disorders, including depression, substance use, STDs • Re-evaluate if new symptoms emerge, destructive impulses, significant deterioration in functional status, or significant periods elapse without response to treatment • Treat co-morbid medical or psychiatric conditions in addition to evidence-based PTSD treatments • Refer for specialized mental health treatment, if necessary Medication SSRIs for depression and anxiety; Prazosin for nightmares and hypervigilance Psychotherapy Trauma-focused CBT, Prolonged Exposure Therapy, and possibly EMDR Suicide overview Primary care is where patients often present physical and emotional issues that signal distress. Studies indicate that many who commit suicide have seen a health care provider within the month prior to their death. In collaboration with the patient, the provider can enlist the support of the patient’s family and identify other immediate supports. Some service members may be reluctant to engage in treatment. It is important for providers to convey that others have experienced similar life events and there is help avail- able to deal with the present crisis. Ensuring safety and addressing the issues increasing risk are necessary key interventions prior to moving the patient to the next step of care. Warning signs Suicidal ideations, intent or plan require immediate and decisive action. A suicide risk assessment should also be undertaken when a provider observes substantial changes in demeanor, or the following signs and symptoms: extreme anxiety, appearing withdrawn and overwhelmed, depression, or when a patient discloses significant, recent losses (such as relationships, finances, status, and job). Importantly, suicide is not only associated with depression, but with a variety of risk factors – see next page.

TRICARE Provider Handbook – 55 Mental health disorder information for PCMs

Risk factors The following risk factors should lead the provider to expand their assessment and questioning about thoughts of self- harm: Current thoughts of suicide, hopelessness, worthlessness, male gender, past thoughts of suicide, severe anxiety, age (At risk are: young enlisted in the military and elderly and adolescents in the civilian world) past suicide at- tempts, impulsiveness, alcohol/substance abuse, lack of social support, access to firearms, widowed, divorce, single psychiatric diagnosis, family history of suicide; physical and chronic illnesses, such as pain syndromes, head trauma Traumatic Brain Injury Because of the widespread nature and prevalence of TBI, especially mild TBI (mTBI), primary care providers should (TBI) overview be alert to its potential presence and its implications for families. Symptoms of TBI Symptoms Immediately Dazed, confused, or “seeing stars,” loss of memory immediately before or after the After Injury injury, losing consciousness, alteration in mental state at the time of the accident, and/ or focal neurological deficits Symptoms Later On Motor Sensory Headaches, pain, dizziness, sleep disturbance, fatigue, seizures, spas- ticity, hydrocephalus, and/or sensory deficits - visual, verbal, strength and coordination Cognitive/ Irritability, liability, depression, substance abuse, impaired judgment, Emotional slower thinking, decreased concentration and focus, poor control over basic physical urges, disinhibited personality changes, physical ag- gression, impulsive/disruptive behavior, and/or no “filter” on thoughts or actions Medical evaluation Evaluate and treat physical complaints, document baseline neurological, cognitive and emotional state, assess the ability to return to everyday activities such as sports, work or operating motor vehicles. Treatment/ clinical Avoid medications (or use cautiously) that can cause dependence, or rebound headache or alter mood management Educate patients and families about treatment, setting expectations; avoid symptom aggravating substances (alcohol, caffeine). Use pharmacological assistance cautiously to re-establish sleep patterns on a short-term basis. Evaluate complaints of paresthesias or radiculopathy via MRI imaging of the appropriate region of the spine. Seek true cause of headaches and manage appropriately. Evaluate neuro-ophthalmologic complaints of visual blurring, double vision, difficulty reading, etc. Use physical therapy to increase flexibility, improve strength, endurance, and range of motion, decrease pain and treat vestibular hypersensitivity. Alter activities of daily living appropriately. Depression overview Depression, one of the most common and treatable mental disorders, often presents itself during a primary care visit. This can be in the form of unexplained fatigue or vague aches and pains. Primary care providers play an important role in early detection and intervention of mental disorders, which can often prevent and mitigate long- term health consequences. Unique military issues • Upon return from duty, a mental health screen called the PDHA (post-deployment health assessment) is for consideration administered 90-180 days after returning home • Mental health issues may or may not be related to an actual combat • Barriers to care include the availability of mental health resources (particularly to family members) at more remote military posts

Tools & resources Visit HumanaMilitary.com and find the Mental Health Resources page for a listing of mental health educational tools and resources for providers and patients, including: • Risk Assessment Forms • Tip sheets on PTSD, Suicide, TBI and Depression • Information and links concerning PTSD, Suicide, TBI and Depression

56 –TRICARE Provider Handbook Suicide risk assessment. Improving assessment and decreasing risk

A completed suicide is one of the most dreaded outcomes of mental illness and is an on-going focus in the military population. Humana Military and ValueOptions® Federal Services recognize that the primary care office is an important component in the prevention of suicides, and suicide risk screening is an established tool in preventive medicine.

Research on this topic provides us with a number of both predictive and associated factors that are commonly present in cases where there is a completed suicide. There is no algorithm or scoring tool which in and of itself can identify level of suicide risk in any consistent manner.

Determination of suicide risk is dependent on (1) the awareness and inclusion of identifying personal risk factors in the context of the biopsychosocial model, and (2) thoughtfully formulating an assessment of the potential risk for suicide in the near future.

In today’s environment, with time pressures, it may be a challenge to assess suicidality (including potential risk factors for suicide) in the course of completing a routine patient assessment. It is useful to identify what interventions may modify risk of a suicide. Some risk factors are not modifiable, such as gender, but many others may potentially be modified.

Your formulation will include clinical thinking and will help guide your treatment and disposition decisions. Your formulation should document both risk factors and protective factors. Describe your estimation of the patient’s risk for suicide in the near future (e.g., low, moderate or high), as well as necessary interventions to assure patient safety and facilitate stabilization.

It is essential to quality clinical practice to document identified risk factors, clinical formulation and treatment planning appropriate to decrease the risk of suicidal behavior.

Humana Military, in coordination with ValueOptions® Federal Services, is making available to primary care providers a brief suicide risk assessment (next page) tailored to the primary care practice setting. This form includes risk factors for suicide in one easy-to-use assessment tool with space for the clinical documentation of both level of risk and recommended interventions for modifiable risk factors.

Humana Military and ValueOptions® Federal Services encourage your office to utilize this tool as a component of your primary prevention and initial screening practices to support your quality suicide risk assessment and risk reduction.

If a mental health care referral is necessary, submit authorization requests using the secure Self-Service for Providers portal at HumanaMilitary.com

TRICARE Provider Handbook – 57 Sample primary care suicide risk assessment form

Patient name:______Date:______

Demographic factors Clinical factors continued

‰‰ Male ‰‰ Obsessive-Compulsive Disorder ‰‰ 65 years or older ‰‰ Schizophrenia ‰‰ Low socioeconomic status ‰‰ Personality Disorders ‰‰ Living alone ‰‰ Epilepsy ‰‰ Currently divorced ‰‰ Chronic Pain ‰‰ Caucasian or Native American ‰‰ More than one psychiatric diagnosis ‰‰ Unemployed ‰‰ Currently psychotic ‰‰ Access to/history of use of firearms ‰‰ Unstable or poor therapeutic relationship ‰‰ Lack of structured religion

Current mental status Cognitive features that contribute to risk

‰‰ Suicidal ideation by patient ‰‰ Loss of executive function ‰‰ Suicidal ideation by others ‰‰ Thought constriction (tunnel vision) ‰‰ Realistic plan in community ‰‰ Polarized thinking ‰‰ Suicidal intent alleged by others ‰‰ Closed-mindedness ‰‰ Suicidal intent expressed by patient

Clinical factors Historical factors

‰‰ Severe anxiety and/or agitation ‰‰ Prior suicide attempts ‰‰ Anorexia Nervosa ‰‰ Family history of suicide ‰‰ Bipolar Disorder ‰‰ Anniversary of important loss ‰‰ Depression ‰‰ Victim of physical or sexual abuse ‰‰ Post Partum Depression ‰‰ Domestic partner violence ‰‰ Alcohol/Substance Abuse/Dependence

Loss factors Risk assessment/disposition

‰‰ Decrease in vocational status ______‰‰ Loss of significant relationship ______‰‰ Decline in physical health ______

Signature:______

Download this assessment form: HumanaMilitary.com/provider/mental-health/forms

Adapted from the Cat-RAG(C) Suicide Risk Assessment Form from Catawba Hospital. Used with permission from Catawba Hospital.

58 –TRICARE Provider Handbook Applied Behavior Analysis (ABA)

Figure 6.3

The Comprehensive Autism Care Demonstration (CACD) covers Applied Behavior Analysis (ABA) services for all eligible beneficiaries with a diagnosed Autism Spectrum Disorder (ASD). The CACD includes one benefit with simplified diagnostic criteria. Authorizations cover one-to-one services and tiered delivery services, depending upon the unique needs of the beneficiary.

Applied Behavioral Analysis covered services (ABA)

Service Description Who conducts service Prior authorization

Initial aba assessement • Initial and semi-annual aba tp updates • BCBA or BCBA-D; BCaBA under • Required and treatment plan (tp) supervision of BCBA or BCBA-D Adaptive behavior • 1:1 aba intervention with beneficiary • Behavior Technician, BCaBA, BCBA or • Required treatment by protocol BCBA-D Supervised fieldwork • BCBA, BCBA-D or BCaBA • Required Adaptive behavior • Direct 1:1 time with beneficiary to • BCBA or BCBA-D; BCaBA under • Required treatment by protocol demonstrate new or modified protocol to supervision of BCBA or BCBA-D modification bt or parent/ caregiver Family adaptive • Teaching eligible parents/caregivers • BCBA, BCBA-D or BCaBA • Required behavior treatment to utilize aba tp protocols to reduce guidance maladaptive behavior, without beneficiary present

ECHO Dependents of Active Duty Family Members must be registered in the Extended Care Health Option (ECHO) to receive ABA under the CACD. A TRICARE-authorized BCBA/BCBA-D will be identified but families are free to choose any TRICARE-authorized ABA provider when the authorization is received.

More information Contact ValueOptions® Federal Services ABA Customer Assistance at 866-323-7155 with additional questions. Current information is posted at TRICARE.mil/aba

Criteria to recevie ABA Must have an ABA-specific referral from a TRICARE authorized: • P-PCM (including family practice, internal medicine and pediatric physicians) • Physician board-certified or board-eligible in behavioral developmental pediatrics • Neurodevelopmental pediatrics • Pediatric neurology or child or adult psychiatry • Doctoral-level licensed clinical psychologist working primarily with children

Assessment If referral was made by P-PCM, family has one year to either have an ADOS-2 done to verify diagnosis OR have beneficiary assessed by a specialized ASD provider

Limits CACD has no limits: $36,000 annual cap, no lifetime cap, and no minimum/maximum age

1. Submitting an authorization request online at HumanaMilitary.com is the quickest and most convenient way to obtain an authorization. Many times an authorization can be obtained immediately for the entire episode of care.

TRICARE Provider Handbook – 59 TRICARE claims information

South Region claims processor Signature on file requirements

PGBA, LLC Providers must keep a “signature on file” for TRICARE-eligible beneficiaries to protect patient privacy, release important information PGBA is the Humana Military contractor for claims processing in the and prevent fraud. A new signature is required for each admission for TRICARE South Region. Visit PGBA’s website at myTRICARE.com for claims submitted on a UB-04 claim form but only once each year for more information about PGBA and claims processing for TRICARE. professional claims submitted on a CMS-1500 claim form.

Payments made to network providers for medical services rendered Claims for diagnostic tests, test interpretations and certain other will not exceed 100 percent of the TRICARE allowable charge. Visit services do not require the beneficiary’s signature. Providers TRICARE.mil/CMAC to find the fee schedules. submitting these claims must indicate “patient not present” on the claim form.

Claims processing standards Mentally or physically disabled TRICARE beneficiaries age 18 or older who are incapable of providing signatures may have a legal guardian HIPAA National Provider Identifier Compliance appointed or a power of attorney issued on their behalf. This legal TRICARE requires providers to file claims electronically with the documentation must include the guardian’s signature, full name, appropriate Health Insurance Portability and Accountability Act of address, relationship to the patient and the reason the patient is 1996 (HIPAA)-compliant standard electronic claims format. Non- unable to sign. network providers submitting paper claims must use either a CMS-1500 The first claim a provider submits on behalf of the beneficiary (professional charges) or a UB-04 (institutional charges) claim form. must include the legal documentation establishing the guardian’s The National Provider Identifier (NPI) is a 10-digit number used to identify signature authority. Subsequent claims may be stamped with providers in standard electronic transactions. It is a HIPAA requirement. “signature on file” in the beneficiary signature box of the CMS-1500 or UB-04 claim form. Providers must submit the appropriate NPI on all HIPAA-standard electronic transactions. Both billing NPIs and rendering provider NPIs, If the beneficiary does not have legal representation, the provider when applicable, are required when filing claims. Providers treating must submit a written report with the claim to describe the patient’s TRICARE beneficiaries as a result of referrals should also include illness or degree of mental disability and should annotate in box the referring provider’s NPI on transactions, if available, per the 12 of the CMS-1500 claim form: “patient’s or authorized person’s implementation guide for the transaction. signature—unable to sign.” If the beneficiary’s illness was temporary, the signature waiver must specify the dates the illness began and Both individual providers (Type 1) and organizational providers ended. Providers should consult qualified legal counsel concerning (Type 2) should register all NPIs with Humana Military. The easiest signature requirements in particular circumstances involving mental way to do this is via the secure Self-Service for Providers portal at or physical incapacity. HumanaMilitary.com Processing claims for out-of-region care HIPAA transaction standards and code sets When providing health care services to a TRICARE beneficiary who is Providers must use the following HIPAA standard formats for TRICARE enrolled in a different region, the beneficiary will pay the applicable claims: ASC X12N 837—Health Care Claim: Professional, Version 5010 cost-share and providers must submit reports and claims information and Errata and ASC X12N 837—Health Care Claim: Institutional, to the region based on the TRICARE beneficiary’s enrollment address, Version 5010 and Errata not the region in which he or she received care.

TRICARE contractors and other health care payers are prohibited from For claims issue or questions regarding a TRICARE patient who accepting or issuing transactions that do not meet HIPAA standards. normally receives care in another TRICARE region, call the appropriate To avoid cash-flow disruptions, it is imperative that providers use the region-specific number for assistance. HIPAA-compliant claims formats. North Region 1-877-TRICARE (1-877-874-2273) For assistance with HIPAA standard formats for TRICARE, call PGBA’s TRICARE Electronic Data Interchange (EDI) Help Desk at 1-800-325- The North Region includes Connecticut, Delaware, the District of 5920, menu option 2. Columbia, Illinois, Indiana, Iowa (Rock Island Arsenal area only), Kentucky (excluding the Fort Campbell area), Maine, Maryland, Massachusetts, Michigan, Missouri (St. Louis area only), New

60 –TRICARE Provider Handbook Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Claims for beneficiaries using Medicare and Rhode Island, Vermont, Virginia, West Virginia and Wisconsin. TRICARE

West Region 1-877-988-WEST (1-877-988-9378) Wisconsin Physicians Service/TRICARE Dual Eligible Fiscal Intermediary Contract (WPS/TDEFIC) is the claims processor for all The West Region includes Alaska, Arizona, California, Colorado, TRICARE for Life (TFL) claims. Providers who currently submit claims Hawaii, Idaho, Iowa (excluding the Rock Island Arsenal area), Kansas, to Medicare on a patient’s behalf do not need to submit a claim to Minnesota, Missouri (excluding the St. Louis area), Montana, Claims for WPS/TDEFIC. WPS/TDEFIC has signed agreements with each Medicare Beneficiaries Assigned to US Family Health Plan Designated Providers carrier allowing direct, electronic transfer of TRICARE beneficiary Designated providers are facilities that have contracts with the DoD claims to WPS/TDEFIC. Beneficiaries and providers will receive EOBs to provide care to beneficiaries enrolled in the US Family Health Plan from WPS/TDEFIC after processing. (USFHP). USFHP is offered in six geographic regions in the United States. Note: Participating providers accept Medicare’s payment amount. Although it provides a TRICARE Prime-like benefit, USFHP is a Non-participating providers do not accept Medicare’s payment separately funded program that is distinct from the TRICARE amount and are permitted to charge up to 115 percent of the program administered by Humana Military. The designated provider Medicare-approved amount. Both participating and non-participating is responsible for all medical care for a USFHP enrollee, including providers may bill Medicare. pharmacy services, primary care and specialty care. When TRICARE is the primary payer, all TRICARE requirements If providing care to a USFHP enrollee outside of the network or in an apply. Refer to the TRICARE Reimbursement Manual, Chapter 13 at emergency situation, file claims with the appropriate designated manuals.TRICARE.osd.mil provider at one of the addresses listed.

Do not file USFHP claims with Humana Military. Claims for NATO beneficiaries For more information, visit USFHP.com TRICARE covers North Atlantic Treaty Organization (NATO) foreign nations’ armed forces members who are stationed in the United USFHP designated providers States or are in the United States at the invitation of the U.S. government. They receive the same benefits as American ADSMs, Brighton Marine Health Center including no out-of-pocket expenses for care if the care is directed by P.O. Box 9195 the military hospitals and clinics. Watertown, MA 02471-9195 1-800-818-8589 Eligible accompanying family members of ADSMs of NATO nations who are stationed in, or passing through, the United States in CHRISTUS Health connection with their official duties can receive outpatient services US Family Health Plan under TRICARE Standard/TRICARE Extra. A copy of the family ATTN: Claims member’s identification card will have a Foreign Identification P.O. Box 924708 Number or a Social Security Number (SSN) and indicate Outpatient Houston, TX 77292-4708 Services Only. 1-800-678-7347 NATO family members do not need military hospital or clinic referrals

prior to receiving outpatient services from civilian providers, follow Martin’s Point Health Care the same prior authorization requirements as TRICARE Standard/ P.O. Box 9746 TRICARE Extra beneficiaries and are responsible for TRICARE Standard Portland, ME 04104-9882 cost-shares and deductibles. 1-888-241-4556 To collect charges for services not covered by TRICARE, providers Pacific Medical Clinics must have the NATO beneficiary agree, in advance and in writing, US Family Health Plan to accept financial responsibility for any noncovered service by 1200 12th Avenue South, Quarters 8 & 9 signing the TRICARE Noncovered Services Waiver form. To download Seattle, WA 98144 the form, search for TRICARE Noncovered Services Waiver at 1-800-585-5883 HumanaMilitary.com. St. Vincent Catholic Medical Centers of New York TRICARE does not cover inpatient services for NATO beneficiaries. To US Family Health Plan at SVCMC be reimbursed for inpatient services, the NATO beneficiary must make P.O. Box 830745 the appropriate arrangements with the NATO nation embassy or Birmingham, AL 35283-0745 consulate in advance. 1-800-241-4848 NATO beneficiary eligibility is maintained in the Defense Enrollment Eligibility Reporting System (DEERS). Claims submission procedures are the same as for American ADFMs.

TRICARE Provider Handbook – 61 Claims for CHAMPVA Providers can file CHCBP claims electronically at myTRICARE.com or file paper claims at the address listed below. The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is not a TRICARE program. For questions CHCBP Behavioral Health Claims: or general correspondence, contact CHAMPVA using the information P.O. Box 7031 listed below. Camden, SC 29020-7031

Phone: 1-800-733-8387 Claims for the Extended Care Health Option Mail: VA Health Administration Center (ECHO) CHAMPVA P.O. Box 469064 All claims for ECHO and the DoD Enhanced Access to Comprehensive Denver, CO 80246-9064 Autism Care Demonstration must have a valid written authorization, and the beneficiary must show as enrolled in ECHO in DEERS. Website: va.gov/purchasedcare Claims for current treatment must be filed within 365 days of the All claims for ECHO-authorized care (including ECHO Home Health date of service. Providers may file health care claims electronically on Care and the DoD Comprehensive Autism Care Demonstration) that behalf of their patients. To file a paper health care claim, download have been authorized under ECHO must be billed on individual line CHAMPVA claim forms from the CHAMPVA website and file them items. Unauthorized ECHO care claims will be denied. within the one-year claim filing deadline. Send the claim to: ECHO claims will be reimbursed for the amount negotiated, the Fiscal VA Health Administration Center Year (FY) benefit limit or the TRICARE allowable charge, whichever CHAMPVA is lower. Each line item on an ECHO claim must correspond to a line P.O. Box 469064 item on the service authorization, or the claim may be denied or Denver, CO 80246-9064 delayed due to research and reconciliation.

Providers may request a written appeal if exceptional circumstances The billed amount for procedures must reflect the service, not the prevented them from filing a claim in a timely fashion. Send written applicable ECHO benefit limits. Pricing of ECHO services and items is appeals to: determined in accordance with the TRICARE Reimbursement Manual.

VA Health Administration Center Refer to the TRICARE Policy Manual, Chapter 9, Sections 4.1, 11.1, CHAMPVA 14.1 and 18.1 at manuals.TRICARE.osd.mil ATTN: Appeals P.O. Box 460948 Claims for TRICARE Reserve Select and TRICARE Retired Reserve Denver, CO 80246-0948 All individuals covered under TRICARE Reserve Select (TRS) should Note: Do not send appeals to the claims processing address. This will follow the applicable cost-shares, deductibles and catastrophic caps delay the appeal. for ADFMS covered under TRICARE Standard/TRICARE Extra.

If a CHAMPVA claim is misdirected to PGBA, PGBA will forward All individuals covered under TRICARE Retired Reserve (TRR) should it to the CHAMPVA Veterans Affairs (VA) Health Administration follow the applicable cost-shares, deductibles and catastrophic caps Center in Denver within 72 hours and will send a letter to the for retirees and eligible family members covered under TRICARE claimant informing him or her of the transfer. The letter includes Standard/TRICARE Extra. instructions on how to submit future CHAMPVA claims and to direct any correspondence for CHAMPVA beneficiaries to the VA Health TRICARE network providers Administration Center. File claims with PGBA electronically on behalf of TRS and TRR Claims for the Continued Health Care Benefit beneficiaries in the same manner as filing other TRICARE claims. Program (CHCBP) The cost-share for all TRS beneficiaries, including National Guard and Reserve members, is 15 percent of the negotiated fee for covered Humana Military is the contractor for the Continued Health Care services from TRICARE network providers. TRICARE will reimburse Benefit Program (CHCBP) and has partnered with PGBA to process all providers the remaining amount of the negotiated fee. CHCBP claims. CHCBP beneficiaries may request providers file medical claims on their behalf. For questions and assistance regarding CHCBP The cost-share for all TRR beneficiaries, including National Guard and claims, call PGBA at 1-800-403-3950. Reserve members, is 20 percent of the negotiated fee for covered services from TRICARE network providers. TRICARE will reimburse While PGBA is the South Region claims processor for TRICARE providers the remaining amount of the negotiated fee. programs, CHCBP claims are filed to a different address within PGBA. Filing claims correctly ensures timely and accurate claims payment. Non-network TRICARE-authorized providers Note: Send claims for CHCBP beneficiaries with Medicare to PGBA, not to WPS/TDEFIC. Participation with TRICARE (e.g., accepting assignment, filing claims

62 –TRICARE Provider Handbook and accepting the TRICARE allowable charge as payment in full) is require prior authorization even when OHI coverage exists. encouraged. Non-network providers should submit their TRICARE claims electronically. OHI: services requiring TRICARE prior The cost-share for all TRS beneficiaries is 20 percent of the TRICARE authorization allowable charge for covered services from participating non-network TRICARE-authorized providers. TRICARE will reimburse the remaining • Adjunctive dental care amount of the TRICARE allowable charge. • Mental health care services • All non-emergency inpatient admissions for substance use The cost-share for all TRR beneficiaries is 25 percent of the TRICARE disorder or mental health care services allowable charge for covered services from participating non-network • Partial Hospitalization Programs (PHPs) and residential TRICARE-authorized providers. TRICARE will reimburse the remaining treatment center (RTC) programs amount of the TRICARE allowable charge. • Psychoanalysis • Outpatient behavioral health visits exceeding eight visits in a If a non-network provider does not participate on a particular claim, Fiscal Year (October 1 to September 30) beneficiaries must file their own claims with TRICARE and then pay • Extended Care Health Option (ECHO) services the non-network provider. • Home health services Note: By federal law, if a non-network provider does not participate • Hospice services on a particular claim, the provider may not charge beneficiaries more • Solid organ and stem-cell transplants than 15 percent above the TRICARE allowable charge. If the OHI benefits are exhausted, TRICARE becomes the primary Visit TRICARE.mil/CMAC to find the fee schedules. payer, and additional referral/prior authorization requirements may apply. Since OHI status can change at any time, always ask all beneficiaries about OHI, including National Guard and Reserve Supplemental Health Care Program (SHCP) claims members and their families.

PGBA processes and pays claims for SHCP. Send all paper TRICARE If a beneficiary’s OHI status changes, update patient billing system claims to: records to avoid delays in claim payments. If a provider indicates that there is no OHI, but Humana Military’s files indicate otherwise, TRICARE South Region Claims Department a signed or verbal notice from the beneficiary will be required to P.O. Box 7031 inactivate the OHI record. Camden, SC 29020-7031 When a TRICARE-eligible beneficiary has OHI, submit a claim using The same balance-billing limitations applicable to TRICARE apply the guidelines found in figure 2.3. to SHCP. For more information, see Balance Billing in the Important Provider Information section. In some cases, the TRICARE Summary Payment Voucher/Remit will state, “Payment reduced due to OHI payment,” and there may be no payment and no beneficiary liability. The TRICARE cost-share (the TRICARE and third-party liability insurance amount of cost-share that would have been taken in the absence of primary insurance) is indicated on the TRICARE Summary Payment The Federal Medical Care Recovery Act allows the government to be Voucher/Remit only to document the amount credited to the reimbursed for costs associated with treating a TRICARE beneficiary beneficiary’s catastrophic cap. who has been injured in an accident caused by someone else. When a claim appears to have possible third-party involvement, required actions can affect total processing time. TRICARE and workers’ compensation

Inpatient claims submitted with diagnosis codes 800 to 999 (with TRICARE will not share costs for services for work-related illnesses or some exclusions, as listed in Figure 8.8), regardless of the billed injuries covered under workers’ compensation programs. amount, and outpatient professional claims that exceed a TRICARE liability of $500, which indicate an accident, injury or illness, will be pended for research. Claims will not be processed further until the Avoiding collection activities beneficiary completes and submits a Statement of Personal Injury— Both network and non-network providers are encouraged to explore Possible Third Party Liability (DD Form 2527). every possible means to resolve claims issues without involving debt-collection agencies. Before sending a beneficiary’s claim to a TRICARE and other health insurance collection agency, providers should do one or more of the following:

TRICARE is the secondary payer to all health benefits and insurance • Submit an administrative review request to PGBA plans, except for Medicaid, TRICARE supplements, the Indian Health • Request an adjustment on an allowable charge review from PGBA Service and other programs or plans as identified by DHA. TRICARE Please wait at least 45 days after submitting a claim before contacting beneficiaries who have OHI do not need referrals or prior authorizations Humana Military. Beneficiaries are responsible for their out-of-pocket for covered services except for those services listed below, which

TRICARE Provider Handbook – 63 expenses, unless the outstanding amount is the beneficiary’s deductible, • Claims denied as “Requested information was not received” cost-share or copay amount reflected on the provider remittance advice. • Coding issues • Claims denied because Nonavailability Statement (NAS) is not TRICARE’s debt collection assistance officer program in DEERS • Network provider disputes relating to contractual Debt Collection Assistance Officers (DCAOs) are located at TRICARE reimbursement amount. Regional Offices and military hospitals or clinics to assist TRICARE beneficiaries in determining the validity of collection agent claims If requesting an allowable charge review, providers must submit the and/or negative credit reports received for debts incurred as a result following information: of receiving health care under the TRICARE program. (“Health care” • A copy of the claim and the TRICARE EOB or TRICARE Summary includes medical and adjunctive dental care under TRICARE.) • Payment Voucher/Remit • Supporting medical records and any new information not DCAOs cannot provide beneficiaries with legal advice or fix their credit ratings, but DCAOs can help beneficiaries through the debt-collection process by providing documentation for the collection or credit- Appeals and administrative reviews of claims denials reporting agency in explaining the debt-inducing circumstances. The DCAO directory is available online at TRICARE.mil/BCACDCAO The following are considered appealable issues:

Beneficiaries must take or submit documentation associated with • Claims denied because the service is not covered under TRICARE a collection action or adverse credit rating to the DCAO (e.g., debt or exceeds policy limitations/coverage criteria collection letters, TRICARE EOBs and health care bills from providers). • Claims denied as not medically necessary The more information the beneficiary provides, the less time it will • Claims for assistant surgeon charges denied by the claims take to determine the cause of the problem. auditing tool • Claims processed as POS only when the reason for dispute is that The DCAO will research the beneficiary’s claim with the appropriate claims the service was for emergency care processor or other agency points of contact and provide the beneficiary with a written resolution to the collection problem. The DCAO will notify Note: Network providers must hold the beneficiary harmless for the collection agency that action is being taken to resolve the issue. noncovered care. Under the Hold-Harmless policy, the beneficiary has no financial liability and, therefore, has no appeal rights. However, if the beneficiary has waived his or her hold-harmless Section 1869/1878 Social Security Act—appeals rights, the beneficiary may be financially liable and may have further determination appeal rights. Appeal and administrative review requests must be postmarked or received within 90 calendar days of the date of the There shall be no administrative or judicial review under section 1869, denial. For TRICARE purposes, a postmark is a cancellation mark 1878, or otherwise, of the classification system, the relative weights, issued by the U.S. Postal Service. If the postmark on the envelope is payment amounts, and the geographic adjustment factor, if any, not legible, the date of receipt is deemed to be the date of the filing. under this subparagraph. Please mail requests to: TRICARE South Region Claims adjustments and allowable charge reviews Appeals Department P.O. Box 202002 A provider or a beneficiary can request an allowable charge review if Florence, SC 29502-2002 either party disagrees with the reimbursement allowed on a claim. This includes “By Report” or unlisted procedures where a provider can After a request is submitted, Humana Military will notify the provider request a review. in writing or by telephone of the outcome. When filing appeals, keep in mind the following: The following issues are considered reviewable: • All appeal and administrative review requests must be in • Allowable charge complaints writing and signed by the appealing party or the appealing • Charges denied as “Included in a paid service” party’s representative • Keying errors/corrected bills • All appeal and administrative review requests must state the • Eligibility denials/patient not in DEERS issue in dispute • Cost-share and deductible inquiries/disputes • Be certain to include a copy of the initial denial (EOB/provider • Claims denied because the provider is not a TRICARE- remittance advice) and any additional documentation in support authorized provider of the appeal • Claims auditing tool denials (except assistant surgeons) • If submitting supporting documentation, the timely filing • OHI denials/issues of the appeal should not be delayed while gathering the • Prescription drug coverage documentation • TPL denials/issues • If intending to obtain supporting documentation that is not • Claims denied or payments reduced due to lack of authorization readily available, file the appeal and state in the appeal letter • POS when reason for dispute is other than emergency care the intention to submit additional documentation and the • Claims denied due to late filing estimated date of submission • Charges denied as a duplicate charge

64 –TRICARE Provider Handbook • Providers must meet the 90-day filing deadline, or the request other than billed or claimed) for reconsideration will generally not be accepted • Practicing with an expired, revoked or restricted license (An expired or revoked license in any state or U.S. territory will result In addition, include the following information with an appeal: in a loss of authorized-provider status under TRICARE) • Sponsor’s SSN or patient’s DBN • Agreements or arrangements between the provider and the • Beneficiary’s/patient’s name beneficiary that result in billings or claims for unnecessary costs • Date(s) of service or charges to TRICARE • Provider’s address, telephone/fax numbers and email address, The Program Integrity Branch also reviews cases of potential if available abuse (i.e., practices inconsistent with sound fiscal, business or • Statement of the facts of the request medical procedures and services not considered to be reasonable Appeals must be requested by an appropriate appealing party and necessary). Such cases often result in inappropriate claims for persons or providers who may appeal are limited to: TRICARE payment.

• TRICARE beneficiaries (including minors) Some examples of abuse include: • Participating non-network TRICARE-authorized providers • A pattern of waiver of beneficiary (patient) cost-share or deductible • A custodial parent or guardian of a minor beneficiary • Charging TRICARE beneficiaries rates for services and supplies • A provider denied approval as a TRICARE-authorized provider that are in excess of those charged to the general public, such as • A provider who has been terminated, excluded or suspended by commercial insurance carriers or other federal health benefit • A representative appointed by a proper appealing party entitlement programs Examples of representatives are: • A pattern of claims for services that are not medically necessary or, if necessary, not to the extent rendered • Parents of a minor (If the patient is a minor, his or her • Care of inferior quality (i.e., does not meet accepted standards of care) custodial parent is presumed to have been appointed his or her • Failure to maintain adequate clinical or financial records representative in the appeal.) • Unauthorized use of the TRICARE® term in private business • An attorney • Refusal to furnish or allow access to records • A network provider Providers are cautioned that unbundling, fragmenting or code- Administrative reviews must be requested by the network provider. gaming to manipulate the Current Procedural Technology (CPT®) codes as a means of increasing reimbursement is considered an Fraud and abuse improper billing practice and a misrepresentation of the services rendered. Such practices can be considered fraudulent and abusive. Program integrity is a comprehensive approach to detecting and preventing fraud and abuse. Prevention and detection are results Fraudulent actions can result in criminal or civil penalties. Fraudulent of functions of the prepayment control system, the post payment or abusive activities may result in administrative sanctions, including evaluation system, quality assurance activities, reports from beneficiaries suspension or termination as a TRICARE-authorized provider. and identification by a provider’s employees or Humana Military staff. The DHA Office of General Counsel works in conjunction with the TMA oversees the fraud and abuse program for TRICARE. The Program Program Integrity Branch to deal with fraud and abuse. The DoD Office Integrity Branch analyzes and reviews cases of potential fraud (i.e., of Inspector General and other agencies investigate TRICARE fraud. the intent to deceive or misrepresent to secure unlawful gain). To report suspected fraud and/or abuse, call the Humana Military Some examples of fraud include: Fraud and Abuse Hotline at 1-800-333-1620. • Billing for services, supplies or equipment not furnished or used by the beneficiary • Billing for costs of noncovered or nonchargeable services, supplies or equipment disguised as covered items • Violating the participation agreement, resulting in the beneficiary being billed for amounts that exceed the TRICARE allowable charge or cost • Duplicate billings (e.g., billing more than once for the same service, billing TRICARE and the beneficiary for the same services, submitting claims to both TRICARE and other third parties without making full disclosure of relevant facts or immediate full refunds in the case of overpayment by TRICARE) • Misrepresentations of dates, frequency, duration or description of services rendered or misrepresentations of the identity of the recipient of the service or who provided the service • Reciprocal billing (i.e., billing or claiming services furnished by another provider or furnished by the billing provider in a capacity

TRICARE Provider Handbook – 65 TRICARE electronic claims filing

Figure 7.1

Electronic claims submission and claims filing information are available at HumanaMilitary.com and myTRICARE.com Electronic claims filing responsibilities • Network providers should file TRICARE claims electronically within 90 days of the date care was provided • Non-network providers are encouraged to take advantage of one of the electronic claims submission options

Electronic media claims (emc) submission options

XPressClaim® Providers can submit secure TRICARE CMS-1500 and UB-04 claims and receive instant payment results. They can also print a patient summary receipt while the patient is still in the office. There is no cost to use XPressClaim. To sign up, go to and search for XPressClaim. eZ TRICARE Network providers can upload batches of claims directly from their practice management system. There is no Claims software to install, no data entry and no cost to file TRICARE claims for network providers. eZ TRICARE Claims can accept a variety of claims formats, including National Standard Format, ASC X12 837, and CMS-1500 or UB-04 print files. To sign up for eZ TRICARE Claims, log in to the secure Self-Service for Providers portal atHumanaMilitary.com Electronic Data For providers who have systems that can create HIPAA-compliant claims formats and who prefer to send claims Interchange (EDI) directly to the payer, PGBA’s EDI Gateway may be the right option. The communications protocols supported are Gateway Asynchronous Dial-up, File Transfer Protocol (FTP) and CONNECT: Direct/NDM. To enroll or learn more about the EDI Gateway, contact the TRICARE EDI Help Desk at 1-800-325-5920, menu option 2. Claims Humana Military receives TRICARE claims from a large number of EMC clearinghouses. Providers should contact their Clearinghouse clearinghouse to find out what they need to do to send TRICARE claims to PGBA. Depending on the clearinghouse, Humana Military’s payer listing could be Humana Military, Humana Military Healthcare Services, PGBA or TRICARE South. The information contained in these charts is not all-inclusive.

Contact information For questions or concerns about claims issues, call PGBA. 1-800-403-3950 For assistance with electronic claims, call PGBA’s EDI Help Desk. 1-800-325-5920, option 2

TRICARE claims and billing tips Figure 7.2

Claims filing information

Claims processing PGBA, LLC is the Humana Military contractor for claims processing in the TRICARE South Region. TRICARE requires claims to be filed electronically with the appropriate Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant standard electronic claims format. For assistance, call PGBA at 1-800-403-3950. For electronic claims assistance, call 1-800-325-5920, menu option 2. Claims deadlines All TRICARE provider claims must be submitted to PGBA for payment within one year of the date the service was rendered.

Claims status Providers can check the status of claims using the secure Self-Service for Providers portal at HumanaMilitary.com. They can also log in to myTRICARE.com or call PGBA’s Interactive Voice Response (IVR) line at 1-800-403-3950. IVR is available 24 hours a day, seven days a week. HIPAA National Provider Providers must submit the appropriate NPI on all HIPAA-standard electronic transactions. Both billing NPIs Identifier (NPI) Compliance and rendering provider NPIs, when applicable, are required when filing claims. Providers treating TRICARE beneficiaries as a result of referrals should also include the referring provider’s NPI on transactions, if available, per the implementation guide for the transaction.

Outpatient Prospective TRICARE OPPS is mandatory for both network and non-network providers and applies to all hospitals Payment System (OPPS) participating in the Medicare program with some exceptions. TRICARE OPPS also applies to hospital-based Partial Hospitalization Programs (PHPs) subject to TRICARE’s prior authorization requirements.

66 –TRICARE Provider Handbook TRICARE claims and billing tips

Tips for filing claims Supporting documentation Use the EDI Support Documentation form to ensure documentation is correctly matched to the claim. Search for EDI Support Documentation at HumanaMilitary.com to download the form. The form lists the dedicated fax numbers.

HIPAA transaction Providers must use the following HIPAA standard formats for TRICARE claims: standards and code sets • ASC X12N 837—Health Care Claim: Professional, Version 5010 and Errata • ASC X12N 837—Health Care Claim: Institutional, Version 5010 and Errata

Provider signature The National Uniform Billing Committee has designated FL 80 (Remarks) as the location for the non- network provider signature if signature-on-file requirements do not apply to the claim. The TRICARE South Region has implemented a signature-on-file capability for non-network providers. Contact PGBA for details.

To ensure TRICARE has the appropriate signature authorization forms on file, refer to the TRICARE Operations Manual, Chapter 8, Section 4 at manuals.tricare.osd.mil

Other Health Insurance (OHI)

Submitting OHI claims If TRICARE is the secondary payer, submit the claim to the primary payer first. If the claim processor’s records indicate that the beneficiary has one or more primary insurance policies, submit EOB information from other insurers along with the TRICARE claim. Humana Military will coordinate benefits when a claim has all the necessary information (e.g., billed charges, beneficiary’s copay and OHI payment).

Identifying OHI in the Submit OHI benefit information in Boxes 4, 9, 11 and 29 on the CMS-1500 claim form or FL 34, 39, 50, 54 claim form and 58 of the UB-04 claim form, or submit an EOB statement from the OHI carrier with the TRICARE claim if submitting a paper claim.

OHI status Since OHI status can change at any time, always ask all beneficiaries about OHI, including National Guard and Reserve members and their families.

Payment guidelines Payments from OHI and TRICARE may not exceed the total charges. Providers may not collect any amount from a beneficiary after payment of the claim unless TRICARE and the OHI combined have failed to pay the TRICARE allowable charge (if network or accepting assignment) or 115 percent of the TRICARE allowable charge (if not accepting assignment). In the case of a network provider, the negotiated rate is the TRICARE allowable charge.

Second payer TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service and other programs or plans as identified by the Defense Health Agency (DHA).

Point-Of-Service (POS) POS cost-sharing and deductible amounts do not apply if a TRICARE Prime beneficiary has OHI. However, the Option beneficiary must have prior authorization for certain covered services regardless of whether he or she has OHI.

Third-party liability insurance

TRICARE and Third-Party When a received claim appears to have possible third-party involvement, the following process will occur: Liability (TPL) Insurance 1. A copy of DD Form 2527 will be mailed to the beneficiary 2. The claim is pended for up to 35 calendar days. If DD Form 2527 is not received within that time period, the claim will be denied 3. The claim will be reprocessed when DD Form 2527 is completed and returned by the beneficiary. (Encourage the beneficiary to fill out the form within the 35 calendar days to avoid payment delays) 4. If the illness or injury was not caused by a third party, the beneficiary is still responsible for completing the DD Form 2527 when the ICD-9-CM diagnosis falls between 800 and 999 or the ICD-10-CM diagnosis code(s) falls between S00.00 and T88.9 with a seventh character of A, B or C (indicating initial encounters). If the form is not returned, the claim will be denied, and the provider may bill the beneficiary

TRICARE Provider Handbook – 67 TRICARE claims and billing tips (continued)

Billing with ICD-9-V codes (use the correct v code for dates of service prior to October 1, 2015)

Generic V Codes For ancillary diagnostic or therapeutic services, do not use a generic V code as a primary diagnosis unless the diagnosis or problem for which the ancillary service being performed is also reported. For example, a V code for a radiologic exam (V72.5) followed by the code for wheezing (786.07) or chest pain (786.50) is acceptable.

Preventive services For preventive services, a V code describing a personal or family history of a medical condition is sufficient as a primary diagnosis without the need for additional diagnostic information. Examples are a mammography, Pap smear or Fecal Occult Blood Test (FOBT) screening.

Descriptive V Codes For V codes providing descriptive information as the reason for the patient encounter, designate that as the primary diagnosis. An example of a descriptive V code is a routine infant or child health visit, which is designated as V20.2.

Billing with ICD-10-Z codes (use the correct Z code for dates of service on or after October 1, 2015) Generic Z Codes For ancillary diagnostic or therapeutic services, do not use a generic Z code as a primary diagnosis unless the diagnosis or problem for which the ancillary service being performed is also reported. For example, using the Z code Z01.89 (Encounter for the other specified [radiologic not associated with procedure] special examinations) followed by the code for wheezing (R06.2) or chest pain on breathing (R07.1) is acceptable.

Preventive services For preventive services, a Z code describing a personal or family history of a medical condition is sufficient as a primary diagnosis without the need for additional diagnostic information. Examples are a mammography, Pap smear or FOBT screening.

Descriptive Z Codes For Z codes providing descriptive information as the reason for the patient visit, designate that description as the primary diagnosis. An example of a descriptive Z code is a routine infant or child health visit, which is designated as Z00.121, Z00.129, Z00.2, Z00.70 or Z00.71.

South Region claims resources

Resource Contact information Continued Health Care Benefit Program

Claims: PGBA PGBA South Region Claims Department For questions and assistance regarding Continued Health Care Benefit P.O. Box 7031 Program (CHCBP) claims, call PGBA at 1-800-403-3950. Camden, SC 29020-7031 • File CHCBP claims electronically at myTRICARE.com 1-800-403-3950 • File all corresponding paper claims at one of the following:

CHCBP Behavioral Health Claims All Other CHCBP Claims P.O. Box 7034 P.O. Box 7031 Camden, SC 29021-7034 Camden, SC 29020-7031

TRICARE For Life WPS/TDEFIC Claims Information P.O. Box 7889 Madison, WI 53707-7889 1-866-773-0404 1-866-773-0405 (TDD)

Out-of-Region Claims North Health Net Federal Services, LLC West PGBA, LLC Overseas See Section 8 of the Region c/o PGBA, LLC/TRICARE Region TRICARE WEST REGION Region TRICARE Provider Handbook P.O. Box 870140 P.O. Box 7064 for details on filing claims Surfside Beach, SC 29587-9740 Camden, SC 29020-7064 for overseas beneficiaries. 1-877-TRICARE 1-877-988-WEST hnfs.net

68 –TRICARE Provider Handbook TRICARE claims and billing tips (continued)

Medicare and TRICARE Claims Wisconsin Physicians Service/TRICARE Dual Eligible Fiscal Intermediary Contract (WPS/TDEFIC) is the claims processor for all TFL claims. Providers who currently submit claims to Medicare on a patient’s behalf do not need to submit a claim to WPS/TDEFIC.

Appeals WPS/TRICARE For Life Refunds WPS/TRICARE For Life Attn: Appeals Attn: Refunds P.O. Box 7490 P.O. Box 7928 Madison, WI 53707-7490 Madison, WI 53707-7928 Claims submission WPS/TRICARE For Life Third-Party Liability WPS/TRICARE For Life (note: submit claims to P.O. Box 7890 Attn: TPL medicare first.) Madison, WI 53707-7890 P.O. Box 7897 Madison, WI 53707-7897 Customer service WPS/TRICARE For Life Toll-free telephone 1-866-773-0404 P.O. Box 7889 Madison, WI 53707-7889 Online TRICARE4u.com Toll-free TDD 1-866-773-0405 Program Integrity WPS/TRICARE For Life Attn: Program Integrity P.O. Box 7516 Madison, WI 53707-7516 The information contained in these charts is not all-inclusive.

TRICARE claims auditing

The TRICARE South Region uses a claims auditing tool to review claims on a prepayment basis. This auditing tool is an automated clinical tool that contains specific auditing logic designed to evaluate provider billing for CPT coding appropriateness and to eliminate overpayment on professional and outpatient hospital service claims. Humana Military updates the claims auditing tool periodically with new coding based on current industry standards.

Edits

Follow CPT coding guidelines to prevent claims auditing editing from resulting in claim denials. Claims auditing edits will be explained by a message code on the remittance advice.

The auditing tool also includes, but is not limited to, the following edit categories: 1 • Age conflicts • Incidental procedures • Alternate code replacements • Modifier auditing • Assistant surgeon requirements • Mutually exclusive procedures • Cosmetic procedures • Preoperative and postoperative auditing billed • Duplicate and bilateral procedures • Procedure unbundling • Duplicate services • Unlisted procedures • Gender conflicts 1 The complete set of code edits is proprietary and, as such, cannot be released to the general public.

Review of provider claims

Humana Military checks claims for consistency and new visit frequency through the codes specified. To avoid unnecessary claim line rejections, assign a diagnosis code that represents the reason the procedure is performed, as well as any diagnoses that will impact treatment.

TRICARE Provider Handbook – 69 Claims reconsiderations • The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copay, cost-share, deductible, etc.) Participating providers may have claims reconsidered through medical review for issues including: With non-network providers that do not accept TRICARE assignment, providers may only bill the beneficiary up to 115 percent of the • Requests for verification that the edit was appropriately entered TRICARE allowable charge. If the OHI paid more than 115 percent of for the claim the allowed amount, then no TRICARE payment is authorized, the • Situations in which the provider submits additional documentation charge is considered paid in full and the provider may not bill the substantiating that unusual circumstances existed beneficiary. If the service is considered noncovered by TRICARE, the If a line on a claim is rejected, first review the medical beneficiary may be liable for these charges. documentation for any additional diagnosis and, if found, submit it With all other providers, TRICARE pays the lesser of: on a corrected claim. If other diagnoses are not found after review, providers may request a reconsideration. For questions regarding this • 115 percent of the allowed amount minus the OHI payment editing function, contact PGBA at 1-800-403-3950. • The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copay, cost-share, deductible, etc.) Send supporting medical record information to: TRICARE South Correspondence When working with OHI, all TRICARE providers should keep in mind: P.O. Box 7032 • TRICARE will not pay more as a secondary payer than it would as Camden, SC 29020-7032 a primary payer. • Point-Of-Service (POS) cost-sharing and deductible amounts do Providers are not permitted to bill TRICARE beneficiaries for services not apply if a TRICARE Prime beneficiary has OHI. However, the rejected by claims auditing. beneficiary must have prior authorization for certain covered services, regardless of whether he or she has OHI.

Identify OHI in the claim form Note: Requests must be postmarked or received within 90 calendar To identify OHI in the claim form: days of the date of the TRICARE EOB.

• Mark Yes in Box 11d (CMS-1500) or FL 34 (UB-04) Send all requests to: • Indicate the primary payer in Box 9 (CMS-1500) or FL 50 (UB-04) TRICARE South Region Customer Service Department • Indicate the amount paid by the other carrier in Box 29 (CMS P.O. Box 7032 1500) or FL 54 (UB-04) Camden, SC 29020-7032 • Indicate insured’s name in Box 4 (CMS-1500) or FL 58 (UB-04) • Indicate the allowed amount of the OHI in FL 39 (UB-04) using value code 44 and entering the dollar amount

Payment guidelines

If TRICARE is the secondary payer, submit the claim to the primary payer first. If the claim processor’s records indicate that the beneficiary has one or more primary insurance policies, submit EOB information from other insurers along with the TRICARE claim.

Humana Military will coordinate benefits when a claim has all necessary information (e.g., billed charges, beneficiary’s copay and OHI payment). In order for Humana Military to coordinate benefits, the EOB must reflect the patient’s liability (copay and/or cost-share), the original billed amount, the allowed amount and/or any discounts. If the EOB indicates that a primary carrier has denied a claim due to failure to follow plan guidelines or use network providers, TRICARE will also deny the claim.

TRICARE does not always pay the beneficiary’s copay or the balance remaining after the OHI payment. However, the beneficiary liability is usually eliminated. The beneficiary should not be charged the cost- share when the TRICARE EOB shows no patient responsibility. Payment calculations differ by provider status as detailed below.

With TRICARE network providers and non-network providers that accept TRICARE assignment, TRICARE pays the lesser of: • The billed amount minus the OHI payment

70 –TRICARE Provider Handbook Reimbursement methodologies

Reimbursement rates and methodologies are subject to change per For example: Department of Defense (DoD) guidelines. For more information, refer to • If the TRICARE allowable charge for a service from a non- the TRICARE Reimbursement Manual at manuals.TRICARE.osd.mil network provider is $90 and the billed charge is $50, TRICARE will allow $50 (the lower of the two charges) Reimbursement limitations • If the TRICARE allowable charge for a service from a non- network provider is $90, and the billed charge is $100, TRICARE Payments made to network and non-network providers for medical will allow $90 (the lower of the two charges) services rendered to beneficiaries shall not exceed 100 percent of the In the case of inpatient hospital services from a non-network TRICARE allowable charge for the services. Visit TRICARE.mil/CMAC to provider, the specific hospital reimbursement method applies. For find the TRICARE allowable charges. example, the Diagnosis-Related Group (DRG) rate is the TRICARE The TRICARE allowable charge is the maximum amount TRICARE will allowable charge for inpatient hospital services. authorize for medical and other services furnished in an inpatient or In the case of outpatient hospital claims subject to the TRICARE outpatient setting. For non-network providers, TRICARE will reimburse Outpatient Prospective Payment System (OPPS), services will be subject the lesser of the TRICARE allowable charge or the provider’s billed to OPPS Ambulatory Payment Classifications (APCs) where applicable. charge for the service. Non-network nonparticipating providers have the legal right to Figure 8.1 lists TRICARE provider categories. charge beneficiaries up to 115 percent of the TRICARE allowable charge for services.

Figure 8.1 TRICARE provider categories

Category Provider type Facility type Category 1 Medical Doctors (MDs), Doctors of Osteopathic Medicine (DOs), optometrists, podiatrists, psychologists, Services provided in oral surgeons, occupational therapists, speech therapists, physical therapists, audiologists, Certified a facility1 Nurse Midwives (CNMs) and applicable outpatient hospital services (See Chapter 5 of the TRICARE Reimbursement Manual.) Category 2 MDs, DOs, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech Services provided in therapists, physical therapists, audiologists, CNMs and applicable outpatient hospital services a nonfacility2 Category 3 All provider types not found in Category 1 Facility setting

Category 4 All provider types not found in Category 2 Nonfacility setting

1. A facility includes the following: ambulances, Ambulatory Surgery Centers (ASCs), community mental health centers, hospices, hospitals (both inpatient and outpatient where the hospital generates a revenue bill; i.e., revenue code 510), military hospitals or clinics, psychiatric facilities, Residential Treatment Centers (RTCs) and Skilled Nursing Facilities (SNFs). 2. A nonfacility includes the following: home settings, provider offices and other nonfacility settings.

State-prevailing rates For the latest details concerning prevailing rates, see the TRICARE Reimbursement Manual, Chapter 5, Section 13 at manuals.TRICARE.osd.mil State-prevailing rates are established for codes that have no current available TRICARE allowable charge pricing. Prevailing rates are those charges that fall within the range of charges most frequently used in Ambulance Fee Schedule (AFS) for TRICARE a state for a particular procedure or service. The TRICARE Policy Manual Chapter 8, Section 1.1 and TRICARE When no fee schedule is available, a prevailing charge is developed Reimbursement Manual Chapter 1, Section 14 and Chapter 5, Section for the state in which the service or procedure is provided. In lieu of a 1-3 includes the change to AFS and provides detail on Ground/ specific exception, prevailing profiles are developed on: Air Ambulance services, transfers, and appropriate claim filing information. TRICARE manuals can be found at TRICARE.mil • A statewide basis (Localities within states are not used, nor are prevailing profiles developed for any area larger than individual states) • A nonspecialty basis

TRICARE Provider Handbook – 71 Anesthesia claims and reimbursement Conversion factor: the sum of the time units and RVUs is multiplied by a conversion factor. Conversion factors differ between physician and non- Professional anesthesia claims must be submitted using the Current physician providers and vary by state, based on local wage indexes. Procedural Terminology (CPT®) anesthesia codes. If applicable, the claim must also be billed with the appropriate physical-status For more specific information on anesthesia reimbursement modifier and, if needed, other optional modifiers. calculation and methodologies, refer to the TRICARE Reimbursement Manual at manuals.TRICARE.osd.mil An anesthesia claim must specify who provided the anesthesia. In cases where a portion of the anesthesia service is provided by an anesthesiologist and a non-physician anesthetist performs the Anesthesia procedure pricing calculator remainder, the claim must identify exactly which services were For an anesthesia rate calculator, go to TRICARE.mil/anesthesia and provided by each type of provider. This distinction may be made by follow the online prompts. the use of modifiers.

Ambulatory surgery grouper rates Calculating anesthesia reimbursement rates Only non-OPPS providers are reimbursed under this methodology. TRICARE calculates anesthesia reimbursement rates using the Hospital-based surgery procedures are reimbursed under OPPS. number of time units, the Medicare Relative Value Units (RVUs) and the anesthesia conversion factor. Ambulatory surgery facility payments fall into one of 11 TRICARE grouper rates. All procedures identified by the TRICARE Management The following formula is used to calculate the TRICARE anesthesia Activity (TMA) for reimbursement under this methodology can reimbursement: be found at manuals.TRICARE.osd.mil. TRICARE payment rates (Time Units + RVUs) established under this system apply only to the facility charges for × ambulatory surgery. Conversion Factor Ambulatory surgery providers may view reimbursements, Base Unit: TRICARE anesthesia reimbursement is determined ambulatory surgery rates and grouper assignments by visiting by calculating a base unit, derived from the Medicare Anesthesia TRICARE.mil/ambulatory Relative Value Guide, plus an amount for each unit of time the anesthesiologist is in attendance (in the beneficiary’s presence). Ambulatory surgery center charges A base unit includes reimbursement for: All hospitals or freestanding Ambulatory Surgery Centers (ASCs) • Preoperative examination of the beneficiary must submit claims for surgery procedures on a UB-04 claim form. • Administration of fluids and/or blood products incident to the Hospital-based ASC providers must use Type of Bill 13X. anesthesia care • Interpretation of noninvasive monitoring (e.g., electrocardiogram, temperature, blood pressure, oximetry, Diagnosis-related group reimbursement capnography and mass spectrometry) • Determination of the required dosage/method of anesthesia DRG reimbursement is a reimbursement system for inpatient charges • Induction of anesthesia from facilities. This system assigns payment levels to each DRG based • Follow-up care for possible postoperative effects of anesthesia on the average cost of treating all TRICARE beneficiaries in a given on the beneficiary DRG. The TRICARE DRG-based payment system is modeled on the Medicare inpatient Prospective Payment System (PPS). A grouper Services not included in the base unit include: placement of arterial, program classifies each case into the appropriate DRG. central venous and pulmonary artery catheters and the use of transesophageal echocardiography. When multiple surgeries are The grouper used for the TRICARE DRG-based payment system is performed, only the RVUs for the primary surgical procedure are the same as the Medicare grouper with some modifications, such considered, while the time units should include the entire surgical session. as neonate DRGs. For more details, see the TRICARE Reimbursement Manual at manuals.TRICARE.osd.mil Note: This does not apply to continuous epidural analgesia. TRICARE uses the TRICARE Severity DRG payment system, which is Time unit: Time units are measured in 15-minute increments, and modeled on the Medical Severity DRG payment system. any fraction of a unit is considered a whole unit. Anesthesia time starts when the anesthesiologist begins to prepare the beneficiary for anesthesia care in the operating room or in an equivalent area. It Present-on-admission indicator ends when the anesthesiologist is no longer in personal attendance Inpatient acute care hospitals paid under the TRICARE DRG-based and the beneficiary may be safely placed under postanesthesia payment system are required to report a Present-On-Admission (POA) supervision. Providers must indicate the number of time units in indicator for both primary and secondary diagnoses on inpatient column 24G of the CMS-1500 form. acute care hospital claims. POA is defined as present at the time the order for inpatient admission occurs.

72 –TRICARE Provider Handbook Conditions that develop during an outpatient encounter, including Capital and direct medical education cost emergency department, observation or outpatient surgery, are considered POA. Any hospital-acquired conditions, as identified reimbursement by Medicare, will not be reimbursed. A list of hospital-acquired Facilities may request capital and direct medical education cost conditions can be found at TRICARE.mil/DRGrates reimbursement. Capital items, such as property, structures and Any claim that does not report a valid POA indicator for each equipment, usually cost more than $500 and can depreciate under diagnosis on the claim will be denied. Figure 8.2 describes the five tax laws. Direct medical education is defined as formally organized or valid POA codes. planned programs of study in which providers engage to enhance the quality of care at an institution. Figure 8.2 POA code descriptions Submit reimbursement requests for capital and direct medical education costs to Humana Military and PGBA, Humana Military’s POA code Description claims processor, on or before the last day of the 12th month Y Indicates that the condition was present on admission. following the close of the hospital’s cost-reporting period. The request should cover the one-year period corresponding with the hospital’s W Affirms that the provider has determined, based on Medicare cost-reporting period. This applies to hospitals (except data and clinical judgment, that it is not possible to children’s hospitals) subject to the TRICARE DRG-based system. document when the onset of the condition occurred. N Indicates that the condition was not present on When submitting initial requests for capital and direct medical admission. education reimbursement, providers should include the following: U Indicates that the documentation is insufficient to • Hospital name determine whether the condition was present at • Hospital address the time of admission. • Hospital Tax Identification Number • Hospital Medicare provider number 1 Prior to Fiscal Year (FY) 2011, signified exemption • Time period covered (must correspond with the hospital’s from POA reporting. The Centers for Medicare & Medicare cost-reporting period) Medicaid Services (CMS) established this code as • Total inpatient days provided to all beneficiaries in units subject a workaround to blank reporting on the electronic to DRG-based payment 4010A1. A list of exempt ICD-9-CM diagnosis • Total TRICARE inpatient days, provided in “allowed” units, subject codes is available in the ICD-9-CM Official Coding to DRG-based payment (excluding non-medically necessary Guidelines. This exemption to POA reporting is not inpatient days) available for reporting on the electronic 5010. • Total inpatient days provided to Active Duty Service Members (ADSMs) in units subject to DRG-based payment As of FY 2011, signifies unreported/not used. • Total allowable capital costs (must correspond with the Exempt from POA reporting. (This code is equivalent applicable pages from the Medicare cost report) to a blank on the CMS 1450 UB-04; however, it • Total allowable direct medical education costs (must correspond was determined that blanks are undesirable when with the applicable pages from the Medicare cost report) submitting this data via 4010A.) • Total full-time equivalents for residents and interns • Total inpatient beds as of the end of the cost-reporting period The following hospitals are exempt from POA reporting for TRICARE: • Title of official signing the report • Critical Access Hospitals (CAHs) • Reporting date • Long-term care hospitals • Maryland waiver hospitals The submission must include a statement certifying that any • Cancer hospitals changes, if applicable, were made as a result of a review, audit or • Children’s inpatient hospitals appeal of the provider’s Medicare cost report. Report any changes to • Inpatient rehabilitation hospitals Humana Military and PGBA within 30 days of the date the hospital • Psychiatric hospitals and psychiatric units is notified of the change. In addition, the provider’s officer or • Sole community hospitals administrator must certify all cost reports. • U.S. Department of Veterans Affairs (VA) hospitals Bonus payments in health professional shortage areas Diagnosis-related group calculator Network and non-network physicians — MDs, DOs, podiatrists, The DRG calculator is available at TRICARE.mil/DRGrates oral surgeons and optometrists — who qualify for Medicare bonus Providers can locate the Indirect Medical Education (IDME) factor (for payments in Health Professional Shortage Areas (HPSAs) may be teaching hospitals only) and wage index information using the Wage eligible for a 10 percent bonus payment for claims submitted to Indexes and IDME Factors File that are also available on the DRG Web TRICARE. The only mental health care providers who are eligible page. If a hospital is not listed in the Wage Indexes and IDME Factors for HPSA bonuses are MDs and DOs. Non-physicians (PhDs, social File, use the ZIP to Wage Index File to obtain the wage index for that workers, counselors, psychiatric nurse practitioners and marriage area by ZIP code. therapists) are not eligible.

TRICARE Provider Handbook – 73 Providers can determine if they are in an HPSA using the U.S. SNF admissions for children under age 10 and CAH swing beds Department of Health and Human Services Health Resources and are exempt from SNF PPS and are reimbursed based on DRG or Services Administration’s HPSA search tool at hpsafind.hrsa.gov. contracted rates. The Centers for Medicare and Medicaid Services (CMS) provides HPSA designations along with bonus payment information For information about SNF PPS, refer to the TRICARE Reimbursement at cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ Manual, Chapter 8, Section 2 at manuals.TRICARE.osd.mil HPSAPSAPhysicianBonuses Sole Community Hospitals (SCH) Bonus payments calculations A hospital that meets the requirements to be an SCH as determined For providers who are eligible and located in an HPSA, PGBA will by the Centers for Medicare and Medicaid Services is considered to be calculate a quarterly 10 percent bonus payment from the total paid an SCH under TRICARE. amount for TRICARE Prime, TRICARE Prime Remote (TPR), TRICARE SCHs include hospitals that are: Geographically isolated, serving a Prime Remote for Active Duty Family Members (TPRADFM), TRICARE population relying on that hospital for most inpatient care, certain small Standard/TRICARE Extra, TRICARE Reserve Select (TRS) and TRICARE hospitals Isolated by local topography or periods of extreme weather. Retired Reserve (TRR) claims and the amount paid by the government on Other Health Insurance (OHI) claims. In general, an SCH is:

Please keep in mind the following: • At least 35 miles or more from another “like” hospital; or • Between 25 and 35 miles from another “like” hospital, and • The bonus payment is based on the zip code of the location meets other criteria such as bed-size and a certain number of where the service is actually performed, which must be in an inpatient admissions HPSA, rather than the zip code of the billing office or other location. The TRICARE program Sole Community Hospital Reimbursement • As of October 1, 2013, the AQ modifier is no longer required Policy can be found in TRM, Chapter 14, Section 1 located at except in those instances where zip codes do not fall entirely TRICARE.mil within a full county HPSA. • When calculating bonus payment for services containing both a professional and technical component, only the professional Tips for filing a request for anticipated payment component will be used. When filing a Request for Anticipated Payment (RAP), keep in mind the following: For information about Bonus Payments, refer to the TRICARE Reimbursement Manual, Chapter 1,Section 33 at manuals.tricare.osd.mil • The bill type in Form Locator (FL) 4 of the UB-04 is always 322 or 332 • The To date and the From date in FL 6 must be the same and must match the date in FL 45 Home health agency pricing • FL 39 must contain code 61 and the Core-Based Statistical Area code of the beneficiary’s residence address TRICARE pays Medicare-certified Home Health Agencies (HHAs) • There must be only one line on the RAP, and it must contain using a PPS modeled on Medicare’s plan. Medicare-certified billing revenue code 023 and 0 dollars. On this line, FL 44 must contain is handled in 60-day care episodes, allowing HHAs to receive two the Health Insurance PPS code payments of 60 percent and 40 percent, respectively, per 60-day • The quantity in FL 46 must be 0 or 1 cycle. This two-part payment process is repeated with every new • FL 63 must contain the treatment authorization code assigned cycle, following the patient’s initial 60 days of home health care. by the Outcome Assessment Information Set All home health services require prior authorization from Humana Note: This is not Humana Military’s prior authorization number. Military and must be renewed every 60 days. To receive private duty nursing or additional nursing services/shift nursing, the TRICARE beneficiary may be enrolled in an alternative TMA-approved special Tips for a final claim program, and a case manager must manage his or her progress. • Network home health care providers must submit TRICARE claims electronically. The bill type in FL 4 must always be 329 or 339 Skilled Nursing Facility (SNF) pricing • In addition to the blocks noted for the RAP above, each actual service performed with the appropriate revenue code must be TRICARE pays Skilled Nursing Facilities (SNFs) using the Medicare PPS listed on the claim form lines and consolidated billing. SNF PPS rates cover all routine, ancillary and • The claim must contain a minimum of five lines to be processed capital costs of covered SNF services. as a final RAP SNFs are required to perform resident assessments using the • The dates in FL 6 must be a range from the first day of the Minimum Data Set. SNF admissions require authorizations when episode plus 59 days TRICARE is the primary payer. • Dates on all of the lines must fall between the dates in FL 6

74 –TRICARE Provider Handbook Durable medical equipment, prosthetics, Providers may use modifiers to indicate one of the following: orthotics and supplies pricing • A service or procedure has both a professional and technical component Durable Medical Equipment, Prosthetics, Orthotics and Supplies • A service or procedure was performed by more than one (DMEPOS) prices are established by using the Medicare fee schedules, physician and/or in more than one location reasonable charges or state-prevailing rates. Most Durable Medical • A service or procedure has been increased or reduced Equipment (DME) payments are based on the fee schedule • Only part of a service, an adjunctive service or a bilateral established for each DMEPOS item by state. The services and/or service was performed supplies are coded using CMS Healthcare Common Procedure Coding • A service or procedure was provided more than once System (HCPCS) Level II codes that begin with the following letters: • Unusual events occurred during the service • A procedure was terminated prior to completion • A (medical and surgical supplies) • B (enteral and parenteral therapy) Providers should use applicable modifiers that fit the description • E (DME) of the service, and the claim will be processed accordingly. The • K (temporary codes) CPT and HCPCS publications contain lists of modifiers available • L (orthotics and prosthetic procedures) for describing services. • V (vision services and hearing aids)

Inclusion or exclusion of a fee schedule amount for an item or service Assistant surgeon services does not imply TRICARE coverage or noncoverage. TRICARE policy defines an assistant surgeon as any physician, Use the following modifiers to identify repair and replacement of an item: dentist, podiatrist, certified Physician Assistant (PA), Nurse • RA (replacement of an item): The RA modifier on claims denotes Practitioner (NP) or CNM acting within the scope of his or her instances where an item is furnished as a replacement for the license who actively assists the operating surgeon with a same item that has been lost, stolen or irreparably damaged covered surgical service. • RB (replacement of a part of DME furnished as part of a repair): TRICARE covers assistant surgeon services when the services are The RB modifier indicates replacement parts of an item furnished considered medically necessary and meet the following criteria: as part of the service of repairing the item •• The complexity of the surgical procedure warrants an DMEPOS pricing information is available at TRICARE.mil/DMEPOS assistant surgeon rather than a surgical nurse or other operating room personnel Luxury/upgraded DME that does not have supporting documentation •• Interns, residents or other hospital staff are unavailable for medical necessity will be the responsibility of the beneficiary to at the time of the surgery pay the difference. Please be sure to have a non-covered service waiver form on file in order to bill the beneficiary for the cost above When billing for assistant surgeon services, please note: the approved DME item. •• All assistant surgeon claims are subject to medical review and medical necessity verification. Home infusion drug pricing •• Standby assistant surgeon services are not reimbursed when the assistant surgeon does not actively participate Home infusion drugs are those drugs (including chemotherapy drugs) in the surgery that cannot be taken orally and are administered in the home by •• The PA or NP must actively assist the operating surgeon other means: intramuscularly, subcutaneously, intravenously or as an assistant surgeon and perform services that are infused through a piece of DME. DME verification is not required. authorized as a TRICARE benefit •• When billing for a procedure or service performed by a Home infusion drugs are reimbursed according to TRICARE policy. PA, the supervising or employing physician must bill the These drugs must be billed using an appropriate HCPCS code along procedure or service as a separately identified line item with a specific National Drug Code (NDC) for pricing. (e.g., PA office visit) and use the PA’s provider number. The supervising or employing physician of a PA must be a Claims for home infusion will be identified by the place of service TRICARE-authorized provider and the CMS HCPCS National Level II Medicare codes, along with the •• Supervising authorized providers that employ NPs may specific NDC number, drug units and quantity of the administered drug. bill as noted for the PA, or the NP may bill on his or her own behalf and use his or her NP provider number for Modifiers procedures or services performed Providers should use the modifier that best describes the Industry-standard modifiers are often used with procedure codes assistant surgeon services provided in column 24D on the CMS- to clarify the circumstances under which medical services were 1500 claim form: performed. Modifiers allow the reporting physician to indicate that a service or procedure has been altered by some specific circumstance • Modifier 80 indicates that the assistant surgeon provided but has not been changed in definition or code. services in a facility without a teaching program

TRICARE Provider Handbook – 75 • Modifier 81 is used for Minimum Assistant Surgeon when the •• Freestanding end-stage renal disease facilities services are only required for a short period during the procedure •• Freestanding PHPs (psychiatric facilities and Substance Use • Modifier 82 is used by the assistant surgeon when a qualified Disorder Rehabilitation Facilities [SUDRFs]) resident surgeon is not available •• HHAs • Modifier AS is used to designate an assistant at surgery. •• Hospice programs •• Other corporate services providers (e.g., freestanding Note: Modifiers 80 and 81 are applicable modifiers to use; however, cardiac catheterization and sleep disorder diagnostic PGBA will most likely wait for medical review to validate the medical centers) necessity for surgical assistance, and medical records may be •• SNFs requested. During this process, the claim also will be reviewed to •• Residential Treatment Centers (RTCs) validate that the facility has (or does not have) residents and interns on staff (e.g., small community hospitals). TRICARE allowable charge /CMAC fee schedule pricing, including injectable rates on payable claim lines not grouped to an APC, are updated on a quarterly basis. Annual TRICARE allowable charge / Surgeon’s services for multiple surgeries CMAC rates generally available and effective February 1 have a two- month lag under OPPS (i.e., April 1 instead of February 1). Multiple surgical procedures have specific reimbursement requirements. When multiple surgical procedures are performed, For more information on TRICARE OPPS implementation, refer to the the primary surgical procedure (i.e., the surgical procedure with the TRICARE Reimbursement Manual, Chapter 13 at manuals.TRICARE.osd.mil highest allowable rate) will be paid at 100 percent of the contracted or visit TRICARE.mil/OPPS rate. Any additional covered procedures performed during the same surgical session will be allowed at 50 percent of the contracted rate. Temporary military contingency payment An incidental surgical procedure is one that is performed at the same adjustments time as a more complex primary surgical procedure. However, the incidental procedure requires little additional physician resources Network hospitals that have received OPPS payments of $1.5 million and/or is clinically integral to the performance of the primary or more for care provided to ADSMs and Active Duty Family Members procedure. Payment for the incidental procedure is considered to be (ADFMs) during an OPPS year (May 1 through April 30) will be given included in the payment of the primary procedure. a Temporary Military Contingency Payment Adjustment (TMCPA). Hospitals that qualified for a TMCPA received a 20 percent increase Certain codes are considered add-ons or modifier 51 exempt. in the total OPPS payments for the initial year of OPPS (May 1, 2009 Procedures for non-OPPS professional and facility claims should not through April 30, 2010). Subsequent adjustments have been reduced apply a reduction as a secondary procedure. by 5 percent each year until the OPPS payment levels are reached in year five (i.e., 15 percent in year two, 10 percent in year three and 5 Outpatient Prospective Payment System percent in year four).

TRICARE OPPS is mandatory for both network and non-network providers and applies to all hospitals participating in the Medicare program with Filing claims for PHP charges some exceptions (e.g., CAHs, cancer hospitals and children’s hospitals). The TRICARE OPPS pays claims filed for hospital outpatient services, TRICARE OPPS also applies to hospital-based Partial Hospitalization including hospital-based PHPs (psychiatric and SUDRFs) subject to Programs (PHPs) subject to TRICARE’s prior authorization requirements TRICARE’s prior authorization requirements. The outpatient code and hospitals (or distinct parts thereof) that are excluded from the editor logic requires that hospital-based PHPs provide a minimum of inpatient DRG-based payment system to the extent the hospital (or three units of service per day in order to receive PHP payment. distinct part thereof) furnishes outpatient services. TRICARE has adopted Medicare’s PHP reimbursement methodology Several organizations, as defined by TRICARE policy, are exempt for hospital-based PHPs. There are two separate APC payment rates from OPPS: under this reimbursement methodology: • CAHs • APC 0172: For days with three services • Certain hospitals in Maryland that qualify for payment under the • APC 0173: For days with four or more services state’s cost containment waiver • Hospitals located outside one of the 50 United States, In addition, TRICARE allows physicians, clinical psychologists, clinical Washington, D.C. and Puerto Rico nurse specialists, NPs and PAs to bill separately for their professional • Indian Health Service hospitals that provide outpatient services services delivered in a PHP. The only professional services included in the • Specialty care providers, including: PHP per diem payment are those furnished by clinical social workers, •• Cancer and children’s hospitals occupational therapists, and alcohol and addiction counselors. •• Community mental health centers The claim must include a mental health diagnosis and an authorization •• Comprehensive outpatient rehabilitation facilities on file for each day of service. Since there is no HCPCS code that specifies •• VA hospitals a partial hospitalization-related service, partial hospitalizations are •• Freestanding ASCs identified by a particular bill type and condition code. •• Freestanding birthing centers

76 –TRICARE Provider Handbook For more information about how OPPS affects TRICARE PHPs and Figure 8.3 for a complete listing of applicable revenue and HCPCS codes, refer TTPA Percentages for APC Codes 604 to 609 and to the TRICARE Reimbursement Manual, Chapter 13, Section 2 at manuals.TRICARE.osd.mil 613 to 616 Network1 Non-Network2 Transition Hospital Hospital Hospice pricing Period ER ER Clinic Clinic Hospice programs are not eligible for TRICARE reimbursement unless Year 1 200% 175% 140% 140% they enter into an agreement with TRICARE. National Medicare hospice rates will be used for reimbursement of each of the following Year 2 175% 150% 125% 125% levels of care provided by, or under arrangement with, a Medicare- Year 3 150% 130% 110% 110% approved hospice program: Year 4 130% 115% 100% 100% • Routine home care Year 5 100% 100% 100% 100% • Continuous home care 1. The transition period for network hospitals is four years. In year five, TRICARE’s • Inpatient respite care payment level will be the same as Medicare’s (i.e., 100 percent). • General inpatient care 2. The transition period for non-network hospitals is three years. In year four, TRICARE’s payment level will be the same as Medicare’s (i.e., 100 percent). The national Medicare payment rates are designed to reimburse the hospice for the costs of all covered services related to the treatment of the beneficiary’s terminal illness, including the administrative and general supervisory activities performed by physicians who Figure 8.4 are employees of, or working under arrangements made with, TRICARE rates update schedule the hospice. The only amounts that will be allowed outside of the Update frequency Rates scheduled to change locally adjusted national payment rates and not considered hospice services will be for direct patient-care services rendered by either an Variable at TMA’s TRICARE allowable charge, also known independent attending physician or a physician under contract with discretion as the CHAMPUS Maximum Allowable the hospice program. Charge (CMAC) (Allowable profiles are typically updated at least once per year, When billing, hospices should keep in mind the following: usually in the first quarter of the year.) • Bill for physician charges/services (physicians under contract Anesthesia with the hospice program) on a UB-04 claim form using the Injectables and immunizations appropriate revenue code of 657 and the appropriate CPT codes • Payments for hospice-based physician services will be paid at April 1 Birthing centers 100 percent of the TRICARE allowable charge and will be subject October 1 Diagnosis-Related Group (DRG) to the hospice cap amount (calculated into the total hospice payments made during the cap period) Residential Treatment Center (RTC) • Bill independent attending physician services or patient-care Mental health per diem services rendered by a physician not under contract with or Skilled Nursing Facility (SNF) employed by the hospice on a CMS-1500 claim form using the appropriate CPT codes. These services will be subject to standard Prospective Payment System (may TRICARE reimbursement and cost-sharing/deductible provisions, be adjusted quarterly) and will not be included in the cap amount calculations Inpatient hospital co-pays and cost shares Hospice Temporary transitional payment adjustments November 1 Ambulatory surgery grouper December 1 Critical Access Hospital (CAH) Temporary Transitional Payment Adjustments (TTPAs) are in place for all hospitals, both network and non-network, to buffer the initial Quarterly Durable Medical Equipment, Prosthetics, decline in payments upon implementation of TRICARE OPPS. For (January, April, July, Orthotics and Supplies (DMEPOS) network hospitals, the TTPAs cover a four-year period. October) Home Health Prospective Payment System (PPS) The four-year transition sets higher payment percentages for the 10 APC codes for Emergency Room (ER) and hospital clinic visits (APC Outpatient Prospective Payment codes 604 to 609 and 613 to 616), with reductions in each transition System (OPPS) year. For non-network hospitals, the TTPAs cover a three-year period, with reductions in each transition year.

Figure 8.3 shows the TTPA percentages for APC codes 604 to 609 and 613 to 616 during the four-year network hospital and three-year non-network hospital transition periods.

TRICARE Provider Handbook – 77 Provider tools

Acronyms PCM Primary Care Manager

ABA Applied Behavior Analysis PHP Partial Hospitalization Program

ADDP Active Duty Dental Program POS Point Of Service

ADFM Active Duty Family Member PRAF Patient Referral Authorization Form

ADSM Active Duty Service Member RTC Residential Treatment Center

CAC Common Access Card SUDRF Substance Use Disorder Rehabilitation Facility

CHAMPUS Civilian Health and Medical Program of the SHCP Supplemental Health Care Program Uniformed Services SPOC Service Point Of Contact CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs TAMP Transitional Assistance Management Program

CHCBP Continued Health Care Benefit Program TCSRC Transitional Care for Service-Related Conditions

CMAC CHAMPUS Maximum Allowable Charge TDP TRICARE Dental Program

DCAO Debt Collection Assistance Officer TFL TRICARE For Life

DEERS Defense Enrollment Eligibility Reporting System TMA TRICARE Management Activity

DHA Defense Health Agency TMCPA Temporary Military Contingency Payment Adjustment

DoD Department of Defense TOP TRICARE Overseas Program

DTF Dental Treatment Facility TPR TRICARE Prime Remote

ECHO Extended Care Health Option TPRADFM TRICARE Prime Remote for Active Duty Family Members

EFMP Exceptional Family Member Program TQMC TRICARE Quality Monitoring Contractor

EHHC ECHO Home Health Care TRDP TRICARE Retiree Dental Program

FY Fiscal Year TRIAP TRICARE Assistance Program

HPSA Health Professional Shortage Area TRR TRICARE Retired Reserve

IVR Interactive Voice Response TRS TRICARE Reserve Select

LOD Line Of Duty TSC TRICARE Service Center

LDT Laboratory Developed Test TTPA Temporary Transitional Payment Adjustment

MCSC Managed Care Support Contractor TYA TRICARE Young Adult

MHS Military Health System USFHP US Family Health Plan

MMSO Military Medical Support Office USPHS U.S. Public Health Service

NAS Nonavailability Statement VA Department of Veterans Affairs

NPI National Provider Identifier VAMC VA Medical Center

NPPES National Plan and Provider Enumeration System WNAP Warrior Navigation and Assistance Program

OPPS Outpatient Prospective Payment System

78 –TRICARE Provider Handbook Glossary of Terms Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Accepting assignment The federal health benefits program for eligible family members of Those instances when a provider agrees to accept the TRICARE 100 percent totally and permanently disabled veterans. CHAMPVA allowable charge. is administered by the Department of Veterans Affairs and is a separate federal program from the Department of Defense TRICARE Authorization for care program. For question regarding CHAMPVA, call 1-800-733-8387 or email [email protected] The determination that the requested treatment is medically necessary, delivered in the appropriate setting, a TRICARE benefit and that the treatment will be cost-shared by the Department of Defense. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

Base Realignment and Closure Commission (BRAC) Site The health care program established to provide purchased health care coverage for ADFMs and retired service members and their A military base that has been closed or targeted for closure by the family members outside the military’s direct care system. TMA was government BRAC. organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. The purchased care benefits Beneficiary authorized under the CHAMPUS law and regulations are now covered under TRICARE Standard. A person who is eligible for TRICARE benefits. Beneficiaries include ADFMs and retired service members and their families. Family members include spouses and unmarried children, adopted children Corporate Services Provider (CSP) or stepchildren up to the age of 21 (or 23 if full-time students at A class of TRICARE-authorized providers consisting of institutional-based approved institutions of higher learning and the sponsor provides or freestanding corporations and foundations that render professional at least 50 percent of the financial support). Other beneficiary ambulatory or in-home care and technical diagnostic procedures. categories are listed in the TRICARE Eligibility section.

Credentialing Beneficiary Counseling and Assistance Coordinators (BCACs) The process by which providers are allowed to participate in the Persons at military hospitals or clinics and TRICARE Regional Offices TRICARE network. This includes a review of the provider’s training, who are available to answer questions, help solve health care-related educational degrees, licensure, practice history, etc. problems and assist beneficiaries in obtaining medical care through TRICARE. BCACs were previously known as Health Benefits Advisors (HBAs). To locate a BCAC, visit TRICARE.mil/BCACDCAO Defense Enrollment Eligibility Reporting System (DEERS) A database of uniformed services members (sponsors), family Catastrophic cap members and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS The maximum out-of-pocket expenses for which TRICARE updated. Refer to the TRICARE Eligibility section for more information. beneficiaries are responsible in a given Fiscal Year (October 1 to September 30). Point-Of-Service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap. Designated Provider (DP) Under the US Family Health Plan (USFHP), DPs (formerly known as Catchment area uniformed services treatment facilities) are selected civilian medical facilities around the United States assigned to provide care to eligible Geographic areas determined by the Assistant Secretary of Defense and enrolled USFHP beneficiaries — including those who are age 65 (Health Affairs) that are defined by a set of five-digit ZIP codes, and older — who live within the DP area. At these DPs, the USFHP usually within an approximate 40-mile radius of a military inpatient provides TRICARE Prime benefits and cost-shares for eligible persons treatment facility. who enroll in USFHP, including those who are Medicare-eligible.

Note: Humana Military — and all other contractors responsible for administering TRICARE — is required to offer TRICARE Prime in each Disease management catchment area. A prospective, disease-specific approach to improving health care outcomes by providing education to beneficiaries through non- CHAMPUS Maximum Allowable Charge (CMAC) physician practitioners who specialize in targeted diseases. The CHAMPUS (Civilian Health and Medicaid Program of the Uniformed Services) Maximum Allowable Charge is the maximum amount Extended Care Health Option (ECHO) TRICARE will reimburse for nationally established procedure coding A supplemental program to the TRICARE basic program. It provides (i.e., codes for professional services). CMAC is the TRICARE allowable eligible and enrolled ADFMs with additional benefits for an integrated charge for covered services set of services and supplies designed to assist in the treatment and/

TRICARE Provider Handbook – 79 or reduction of the disabling effects of the beneficiary’s qualifying deductibles and cost-shares even after the enrollment/Fiscal Year condition. Qualifying conditions may include moderate or severe mental catastrophic cap has been met. The POS option is not available to retardation, a serious physical disability or an extraordinary physical ADSMs. or psychological condition such that the beneficiary is homebound.

Primary Care Manager (PCM) Foreign Identification Number (FIN) A military hospital or clinic provider, team of providers or a network A permanent identification number assigned to a North Atlantic provider to whom a beneficiary is assigned for primary care services Treaty Organization (NATO) beneficiary by the appropriate national at the time of enrollment in TRICARE Prime. Enrolled beneficiaries embassy. The number resembles a Social Security Number and most agree to initially seek all non-emergency, non-mental health care often starts with 6 or 9. TRICARE will not issue an authorization for services from their PCMs. treatment or services to NATO beneficiaries without a valid FIN.

Split enrollment Laboratory Developed Test (LDT) Split enrollment refers to multiple family members enrolled in A term used to refer to a certain class of in vitro diagnostics (IVDs). TRICARE Prime under different TRICARE regions or MCSCs.

Managed Care Support Contractor (MCSC) Sponsor A civilian health care contractor of the Military Health System (MHS) The ADSM, retiree or deceased service member or former service that administers TRICARE in one of the TRICARE regions. Humana member through whom family members are eligible for TRICARE. Military is an MCSC. An MCSC helps combine the service available at military hospitals or clinics with those offered by the TRICARE network Supplemental Health Care Program (SHCP) of civilian hospitals and providers to meet the health care needs of the TRICARE beneficiaries. A program for eligible uniformed services members and other designated patients who require medical care that is not available at the military hospital or clinic upon the approval of the cognizant National Provider Identifier (NPI) military hospital or clinic commander or the TMA director, as required, A 10-digit number used to identify providers in standard electronic to be purchased from civilian providers under TRICARE payment rules. transactions. It is a requirement of the Health Insurance Portability and Accountability Act of 1996. The National Plan and Provider Transitional Assistance Management Program (TAMP) Enumeration System (NPPES) assigns NPIs to providers. A program that provides 180 days of transitional health care benefits to help certain uniformed services members and their families Nonavailability Statement (NAS) transition to civilian life. A certification by a commander (or a designee) of a uniformed services medical hospital or clinic recorded in DEERS, generally for Transitional Care the reason that the needed medical care being requested by a non- TRICARE Prime enrolled beneficiary cannot be provided at the facility Designed for all beneficiaries to ensure a coordinated approach takes concerned because the necessary resources are not available in the place across the continuum of care. time frame needed.

Outpatient Prospective Payment System (OPPS) TRICARE OPPS is used to pay claims for hospital outpatient services. TRICARE OPPS is based on nationally established Ambulatory Payment Classification amounts and standardized for geographic wage differences that include operating and capital-related costs, which are directly related and integral to performing a procedure or furnishing a service in a hospital outpatient department. TRICARE OPPS became effective May 1, 2009.

Point Of Service (POS) The option under TRICARE Prime that allows enrollees to self-refer for non-emergency health care services to any TRICARE-authorized civilian provider, in or out of the network. When Prime enrollees choose to use the POS option (i.e., to obtain non-emergency health care services from other than their PCMs or without a referral from their PCMs), all requirements applicable to TRICARE Standard apply except the requirement for a NAS. POS claims are subject to

80 –TRICARE Provider Handbook Provider tools

Figure 1.1 TRICARE Regions . 6

Figure 1.2 TRICARE South Region ...... 7

Figure 1.3 Self-Service for providers ...... 9

Figure 1.4 Provider Resources...... 13

Figure 2.1 What is a TRICARE Provider. 16

Figure 3.1 Military identification cards. 23

Figure 5.1 Covered benefits and services...... 33

Figure 5.2 Covered clinical preventive services...... 35

Figure 5.3 Labatory Developed Test...... 40

Figure 5.4 Right of First Refusal ...... 46

Figure 5.5 Autofax confirmation...... 47

Figure 5.6 Peer review organzation agreement...... 49

Figure 5.7 Appealing a decision ...... 50

Figure 6.1 Mental health care covered services...... 53

Figure 6.2 Mental health disorder information for PCMs...... 55

Figure 6.3 Applied Behavior Anaylsis...... 59

Figure 7.1 Electronic claims filing...... 66

Figure 7.2 TRICARE claims and billing tips. 66

Figure 8.1 TRICARE provider categories . 71

Figure 8.2 POA code descriptions...... 73

Figure 8.3 TTPA percentages for APC codes 604 to 609 and 613 to 616...... 77

Figure 8.4 TRICARE rates update schedule ...... 77

TRICARE Provider Handbook – 81 Index

A Abuse 13, 17, 25, 52, 53, 55, 56, 58, 65 D Defense Enrollment Eligibility Reporting System (DEERS) 23, 27, 61, 79 Active Duty Dental Program (ADDP) 32 Denial 28, 50, 64, 69 Acute care 46, 47, 72 Detoxification 52, 54 Adjunctive dental 25, 27, 32, 33, 45, 63, 64 Diabetes 16 Ambulatory surgery 14, 71, 72, 77 Diabetic outpatient self-management 16 Anesthesia 14, 33, 72 Diagnosis-Related Group (DRG) 14, 71, 77 Appeal 18, 50, 62, 64, 65, 69, 73 Disability 22, 25, 26, 37, 42, 44, 60, 79 Applied Behavior Analysis (ABA) 45, 51, 52, 59 Discharge notification 46 Authorizations 8, 9, 16, 18, 19, 20, 24, 26, 29, 34, 45, 50, 63, 74 Discharge planning 47, 52 Autism 42, 44, 59, 62 DoD Enhanced Access to Autism Services Demonstration 62 Autofax 47 DRG calculator 73 B Durable Medical Equipment (DME) 33, 37, 38, 39, 75 Balance billing 20, 63 Bariatric surgery 45 E ECHO Home Health Care (EHHC) 31, 62 Billing 7, 13, 17, 25, 38, 60, 65, 66, 67, 68, 74, 75, 77 Electronic Data Interchange (EDI) 13, 23, 60, 66 Birth 25, 31, 34, 36, 44, 77 Eligibility 8, 9, 12, 13, 18, 22, 23, 24, 26, 27, 28, 29, 61, 64 Blood 34, 35, 39, 41, 43, 68 Emergency 18, 20, 25, 33, 34, 54, 64, 77 Blood pressure 35, 72 Exceptional Family Member Program (EFMP) 31 Braille 15 Exclusions 9, 33, 51, 52, 63 Breast cancer 35, 40, 43 Extended Care Health Option (ECHO) 31, 39, 45, 47, 59, 62 C Cardiac catheterization clinics 16 F Fraud 13, 17, 60, 65 Case management 47, 52 Centers for Medicare and Medicaid Services (CMS) 26, 38, 74 H Certification 16, 17, 18, 39, 52 Healthcare Common Procedure Coding System (HCPCS) 75 CHAMPUS Maximum Allowable Charge (CMAC) 77 Health Insurance Portability and Accountability Act of 1996 (HIPAA) Civilian Health and Medical Program of the Department of Veterans 15 Affairs (CHAMPVA) 14, 19, 20, 25, 62 Healthy People 2020 15 Clinical Evaluation Program 25 Hearing 36 Clinical preventive services 35, 36 Hearing aids 38, 75 Compliance 48 Hepatitis 30, 36 Comprehensive Clinical Evaluation Program 25 Home infusion 17, 34, 46, 75 Concurrent review 47 Hospice 34, 39, 46, 63, 71, 76, 77 Continued Health Care Benefit Program (CHCBP) 28, 62, 68 Humana Military Quality Management Department 47 Corneal 46 Critical Access Hospital (CAH) 73, 77

82 –TRICARE Provider Handbook I Pediatric 16, 18, 36, 45, 59 Peer Review Organization 48, 49 Immunization 36, 77 PGBA 7, 13, 17, 22, 31, 60, 62, 66, 68, 70, 76 Indian Health Service 63, 67, 76 Pharmacy Home Delivery 29, 30 Individual Ready Reserve 32 Postpartum 34, 36 Infant 31, 36, 47, 68 Pregnancy 33, 36, 42, 43, 47 Injectables 77 Premature infant 47 L Preoperative 69, 72 Licensure 17, 18, 79 Prepayment 65, 69 Prescription 29, 30, 31, 33, 37, 65 M Preventive care 18, 19, 47 Magnetic Resonance Imaging (MRI) 16, 35 Primary Care Manager (PCM) 11, 16, 24, 34, 45, 55 Maternity care 34, 36 Prime Service Area (PSA) 24, 46 Medicaid 18, 26, 38, 63, 67, 74 Prior authorization 14, 16, 19, 38, 45, 53, 54, 61, 63, 66, 70 Medical necessity 14, 29, 33, 37, 45, 50, 53, 54, 75 Program Integrity Branch 65, 69 Medicare 20, 22, 27, 61, 69, 72, 73, 74, 76, 77, Protected Health Information (PHI) 15 Medication management 52 Psychoanalysis 46, 53 Member Choice Center 29 Psychological testing 53 Mental health care 16, 24, 25, 27, 33, 45, 46, 50, 51, 52, 53, 57, 63, 73 Psychotherapy 52, 53, 55, 581 Military Medical Support Office (MMSO) 24 Modifier 38, 69, 72, 75, 76 R Radiation therapy 17 N Reconsideration 38, 65, 70 National Guard and Reserve 25, 26, 27, 62, 63, 67 Referrals 13, 18, 19, 47, 50, 63 National Provider Identifier (NPI) 60 Rehabilitation 16, 33, 37, 46, 51, 54, 73 NATO beneficiaries 61 Reimbursement 8, 14, 25,38, 49, 71, 73, 76 Network provider 15, 16, 17, 19, 20, 24, 31, 46, 48, 60, 63, 65, 67, 70, Residential Treatment Center (RTC) 17, 46, 51, 71, 76, 77 71 Respite care 31, 34, 39 No Government Pay Procedure Code List 20, 22, 33, 51 Retrospective review 47 Noncompliance 20 Right Of First Refusal (ROFR) 19, 24, 46 Noncovered services 20, 21 Routine care 18, 19, 24, 33 Non-network provider 17, 20, 24, 60, 63, 66, 70, 76 Notice of Privacy Practices 15 S Notices of Award 26 Service Point Of Contact (SPOC) 24 Notices of Disapproved Claim 26 Skilled Nursing Facility (SNF) 34, 39, 74, 77 Social Security Number (SSN) 23, 61 O Specialist 19, 45 Obesity 44, 53 Specialty care 16, 18, 21, 24, 25, Orthotics 33, 38, 75, 77 Sponsor 22, 23, 36, 45, 65 Other Health Insurance (OHI) 9, 20, 22, 25, 63, 67, 74 Supplemental Health Care Program (SHCP) 25, 63 Outpatient mental health care 46, 53 Surgeon 64, 69, 71, 73, 75, 76 Outpatient Prospective Payment System (OPPS) 14, 66, 71, 76 T P Telemental health 48, 52 Patient Referral Authorization Form (PRAF) 45, 46

TRICARE Provider Handbook – 83 Third-Party Liability (TPL) 63 Transitional Assistance Management Program (TAMP) 27, 28 Transplant 16, 43, 46, 47 TRICARE allowable charge 14, 16, 25, 70, 71, 76 TRICARE-authorized provider 16, 24 TRICARE Dental Program (TDP) 24, 32 TRICARE Extra 24, 25, 26, 27, 31 TRICARE For Life (TFL) 14, 19, 22, 26, 61, 68, 69 TRICARE Operations Manual 8, 18, 37, 39, 46, 48, 67 TRICARE Pharmacy Program 24, 29 TRICARE Policy Manual 8 TRICARE Prime 22, 24 TRICARE Prime Remote for Active Duty Family Members (TPRADFM) 24 TRICARE Prime Remote (TPR) 24 TRICARE Quality Monitoring Contractor (TQMC) 48 TRICARE Reimbursement Manual 61, 71 TRICARE Reserve Select (TRS) 26, 27, 62 TRICARE Retired Reserve (TRR) 27 TRICARE Retiree Dental Program (TRDP) 32 TRICARE Standard 24, 25, 26 TRICARE Young Adult Program 28

U Urgent care 20 US Family Health Plan (USFHP) 22, 26, 61

V ValueOptions® Federal Services 13, 16, 17, 18, 25, 26, 45, 51, 53, 54, 57 Veterans Affairs (VA) 22, 26, 73

W Warrior Navigation and Assistance Program (WNAP) 26

X X-ray 34, 39

84 –TRICARE Provider Handbook Notes

85 –TRICARE Provider Handbook Notes

86 –TRICARE Provider Handbook

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