2015 Provider Handbook South Region HumanaMilitary.com ® ® 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..