The new TRICARE Reserve Select

Transcription

1 Second Quarter 2005 A Q U A RTERLY PUBLICATION FOR TRICARE PROVIDERS New TRICARE Reserve Select Health Plan Launched April 26 Understanding Your Role The new TRICARE Reserve Select health plan that started on April 26, 2005, provides some Reserve Component members 1 and their families continued access to TRICARE. Reserve Component members called or ordered to active duty for more than 30 days in support of a contingency operation now have 180 days of health care coverage under the Transitional Assistance Management Program (TAMP) upon separation from duty and may also purchase further coverage under the new TRICARE Reserve Select health plan. What Is the Coverage? Individuals who purchase TRICARE Reserve Select receive comprehensive coverage similar to the coverage available through TRICARE Standard and TRICARE Extra for active duty family members, including such TRICAREcovered services as: Urgent and emergency care, including ambulance services Family health care Obstetrics, gynecology and maternity services Clinical preventive services, including health screening and immunizations Behavioral health care, including partial hospitalization and residential treatment Annual eye examinations Durable medical equipment (DME) and supplies continued on page 2 From the Desk of the CMO Pedro N. Rivera, MD Chief Medical Officer Health Net Federal Services In the previous newsletter, I addressed the first 90 days of North Region operations and the progress we were making in the areas of referrals, authorizations and correspondence. I am pleased to report that we continue to improve and refine our processes, enhance our technological capabilities and increase our staffing in an effort to facilitate our daily operations and improve our services to you and our TRICARE beneficiaries. This time, I would like to draw attention to provider credentialing, an area of significant importance to Health Net Federal Services, Inc. (Health Net), network providers and the Department of Defense (DoD). A prerequisite for participation as a TRICARE network provider, credentialing is a tool used to ensure that provider qualifications, education, licensure, etc., are in compliance with the requirements of the program. Credentialing is a complex process culminating in the presentation of required documentation to the Health Net Credentials Committee for final approval and acceptance into the network. The Credentials Committee, which is comprised of Health Net Medical Directors, DoD members and network providers, meets monthly in Arlington, Va. For me, the experience has been both educational and rewarding, providing the opportunity to interact with key members of the TRICARE team and to share and understand each other s point of view. We welcome increased network provider membership on our Credentialing Committee. We are currently seeking providers from Virginia, Washington, D.C., and Maryland. The committee meets on the second Thursday of each month at 6 p.m., with dinner provided. If you are interested in joining, the committee please contact me at pedro.n.rivera@healthnet.com. I look forward to hearing from you. NE310202PRN0405I

2 New TRICARE Reserve Select Health Plan Launched April 26 continued from page 1 Ancillary services, such as laboratory and radiology Prescription drug coverage They may receive care from any civilian TRICARE certified/authorized providers, TRICARE network or non-network. Care may also be accessed from an MTF on a space-available basis only. They also can fill prescription medications through MTF pharmacies, the TRICARE Mail Order Pharmacy (TMOP) program or at TRICARE retail network and non-network pharmacies. For more information about covered services, refer to the TRICARE Reserve Select Handbook on the TRICARE Web site at Enrolled beneficiaries will be issued a TRICARE Reserve Select card that should be provided to you at the time of care to confirm eligibility. The TRICARE Reserve Select card looks very similar to a TRICARE Prime card. Look for TRICARE Reserve Select at the top of the card. Make a copy of the card for the patient s file as proof of eligibility. TRICARE Reserve Select requires that you collect the appropriate cost-share from the beneficiary at the time of the visit. What Services under TRICARE Reserve Select Require Prior Authorization? TRICARE Reserve Select beneficiaries require prior authorization from Health Net for the following services: Adjunctive dental care Home health care services Hospice All non-emergent inpatient admissions for substance abuse or behavioral health Psychiatric Psychotherapy after the initial eight (8) visits and Psychoanalysis Transplants All solid organ and stem cell transplants (excludes corneal) Where Do I Submit TRICARE Reserve Select Claims? TRICARE Reserve Select beneficiary claims should be submitted to PGBA in the same manner as TRICARE Standard/Extra beneficiary claims. The claims address for submitting TRICARE Reserve Select claims is: Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE P.O. Box Surfside Beach, SC TRICARE network providers should submit claims to Health Net/PGBA using their current methodologies. Where Should I Direct Questions? Health Net administers TRICARE Reserve Select in the TRICARE North Region and provides customer service, including plan enrollment and claims payment. You may contact Health Net through the dedicated TRICARE Reserve Select customer service line at or visit if you have questions or need additional information. You may also refer to the TRICARE Web site at for more information on coverage offered by TRICARE Reserve Select. 1 The Reserve Component (RC) includes the Army National Guard, the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air National Guard, the Air Force Reserve, and the U.S. Coast Guard Reserve. Who Is Eligible for TRICARE Reserve Select? Reserve Component members who meet the following qualifications may be eligible for the TRICARE Reserve Select program: 1. The member is called or ordered in support of a contingency operation under Title 10 for a period of greater than 30 days. (This is retroactive to Reserve Component members who were called to active duty in support of a contingency operation on or after Sept. 11, 2001.) 2. The member must have served continuously on active duty for 90 days or more under such call or order* the length of time served determines the maximum period of coverage you may purchase under TRICARE Reserve Select. * If the Reserve Component member is otherwise eligible, but did not serve continuously on active duty for 90 days under that call-up due to an injury, illness or disease incurred or aggravated while they were activated, they may be eligible for one year of coverage. 3. The member agrees to serve in the Selected Reserve for a length of time (in whole years) equal to or less than the period of eligibility for TRICARE Reserve Select. a. If the member separated from qualifying active duty service after April 26, 2005, the member must (1) enter into a Service Agreement by the last day of active duty, (2) execute the Service Agreement with the Service/Reserve Component and (3) submit a completed enrollment form and initial premium payment to Health Net so they receive it 30 days before the end of TAMP. b. If the member separated from qualifying active duty service on or before April 26, 2005, the member and the Service/Reserve Component must execute a Service Agreement no later than October 28, Second Quarter 2005

3 HIPAA National Provider Identifier Simplifies Communication One Unique Identifier for Providers Nationwide Will Make Coordinating Benefits Faster, Easier One of the benefits of the electronic age is the speed at which data can be exchanged and transactions completed. But in the health care industry, progress has been hampered by the lack of industry-wide standards and the lack of a single, unique identifier for each health care provider. Until now, any health plan that providers work with could assign them an ID number to use with that health plan, explains Sherry McKenzie, chief of operational architecture and HIPAA electronic standards for TRICARE s Information Management Division. Not only did that mean providers had to keep track of multiple ID numbers, but it also made coordinating benefits and exchanging information across health plans more difficult and expensive. The new National Provider Identifier (NPI) program, called for in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), will ease that complexity. Slated to begin May 23, 2005, the program gives providers a twoyear window to apply for their unique NPI. About NPI The NPI is a 10-digit number that identifies a provider and will be required in all HIPAA-standard transactions. Each NPI will be assigned and managed by the National Plan and Provider Enumeration System (NPPES), a newly created federal registry, and will stay with the provider for life. Providers who must participate include individuals (physicians, dentists, nurses, pharmacists, physical therapists, etc.), as well as organizations (hospitals, clinics, HMOs, laboratories, pharmacies, etc.) that provide health care. McKenzie notes that the NPI is an important step toward making the health care industry more efficient. We are behind some other industries in being able to use electronic transactions for various administrative purposes. For example, the financial industry does almost everything electronically. Now, having this standard national identifier will help us to implement transactions and move the health care industry further into the electronic world. A Practical Approach The NPI number itself does not contain built-in intelligence, such as the type of provider or the state where the provider is located. The information required to apply for an NPI is similar to what state licensing boards require. The NPI will make that basic information about providers more accessible and easily exchanged among health plans, however. LCDR Stephanie Bardack of the DoD Patient Safety Office notes the practical nature of the NPI in today s world. In the past, when providers would spend their entire career practicing in one state, their information would be provided to the state, Bardack says. Today, many providers move about the country, and billing systems are much more complicated than they once were. Having a single number to identify a provider across the country just makes sense. What You Need to Do Providers have between May 23, 2005, and May 23, 2007, to apply for their NPI, either online or by completing a paper application. You are urged to apply as soon as possible. Once you receive your NPI, it will be yours for life and will not need to be renewed. You will be required to inform the NPPES of any changes to your information (such as a change of address) within 30 days. Under NPI guidelines, health plans may also choose to use the NPI in non-hipaa transactions to replace previously assigned ID numbers. To Learn More If you want to learn more about the NPI, visit TRICARE s Web site at If you have specific questions, TRICARE at hipaamail@tma.osd.mil. Second Quarter

4 Appealing Denied Claims If you should disagree with a Health Net claims decision, you have a number of recourses, depending on the situation. Administrative Review To appeal a medical claim with Health Net, network providers must go through an administrative review process. In requesting a review, you will have to state in writing what you disagree with in Health Net s handling of the claim. Providers can request administrative reviews for the following reasons 1) if a claim was denied as not medically necessary and 2) if a claim was denied because the service is not a TRICARE benefit. All written requests should include the sponsor s Social Security number, the patient s name, date of service and your contact information. Also include a statement of the facts involved in the request and documentation to support the claim. Medical necessity reviews will be sent to an independent peer reviewer. You must send written requests for reviews within 90 days of a claim s denial. Send administrative review requests to: Health Net Federal Services, Inc. c/o PGBA, LLC TRICARE Administrative Reviews P.O. Box Surfside Beach, SC Allowable Charge Review If you disagree with the reimbursement allowed on a claim, you can request an allowable charge review. Also, if a payment was reduced because no authorization was on file and extenuating circumstances prevented you from obtaining an authorization, you can request a review through the address below. These requests also must be made within 90 days, but providers can make them by telephone at and choosing the option for claims. Make sure you have a copy of the claim and the TRICARE Explanation of Benefits (EOB) or Summary Payment Voucher, as well as supporting medical records and any new information that was not originally submitted with the claim. Send administrative review requests to: Health Net Federal Services, Inc. c/o PGBA, LLC TRICARE Claims Corresponding P.O. Box Surfside Beach, SC Meeting Access Standards Your Obligations as a TRICARE Prime Provider TRICARE Prime beneficiaries should have access to providers within specific time frames and within certain drive times from their homes. The time and drive time access standards show how committed the Military Health System is to improving access for our members and how important it is to us that beneficiaries are seen as soon as possible, explains Gita Uppal, policy analyst for TRICARE. Appointment Wait Time TRICARE network providers servicing TRICARE Prime beneficiaries are obligated to meet the following access standards for appointments: For urgent care or acute illness, patients must not wait more than 24 hours for an appointment. For routine visits, patients must not wait more than one week for an appointment. For specialty care or wellness visits, patients must not wait more than four weeks (28 days). Once in the office, patient wait times in nonemergency situations must not exceed 30 minutes, except when you are providing emergency care to other patients and the normal schedule is interrupted. This exception offers some flexibility in emergency situations. You should notify patients of the cause for the delay and the length of delay anticipated, and then offer to reschedule the appointment. Patients may choose to stay and keep their scheduled appointment. Drive Time Primary care managers (PCMs) open for enrollment should understand that beneficiaries are entitled to a drive time that does not exceed 30 minutes from their home to your office under normal circumstances. When helping patients with referrals to specialists, PCMs should also be aware that TRICARE Prime beneficiaries do not have to travel more than an hour from their home to access specialty care. Verifying the Standards Meeting the TRICARE Prime appointment wait time access standards is an essential condition for network providers. Network providers must notify Health Net within 10 days of any change to demographic information, panel status, or their ability to meet the appointment standards. 4 Second Quarter 2005

5 Providing Clearly Legible Reports in Seven Business Days What Network Providers Need to Know To assist in the facilitation of patient care referred from a military treatment facility (MTF), network providers need to provide clearly legible consultation reports, operative reports, discharge summaries and rehabilitation therapy progress notes in a timely manner. Network providers must submit these clearly legible reports to Health Net Federal Services, Inc. (Health Net) within seven business days of the date of service. Health Net will facilitate sending the report back to the referring MTF through the process explained below. Note that this requirement only applies to care referred from an MTF. For self-referred care or care referred by a non-mtf provider (civilian network or non-network providers), reports do not have to be coordinated with Health Net. However, the servicing provider should still send the same reports to the requesting provider in the usual, timely manner. How To Coordinate Reports Here is the process for coordinating clearly legible reports with Health Net: 1. Prior to the service, the MTF should supply the patient (or the rendering network provider directly) with the necessary medical documentation (e.g., X-rays, photos, etc.) for the specialty appointment, outpatient service or inpatient visit. 2. The network provider renders the care. 3. Within seven business days following the care, the network provider faxes the clearly legible report to Health Net s reports fax line at Note that this is a different fax number than the number used for referral and prior authorization fax requests. 4. Once the report is received, Health Net will electronically forward the report to the MTF in a secure manner. If the network provider prefers to send a written report or call results directly to the referring MTF provider, please be sure to also fax a copy to Health Net for completion of electronic records. Urgent and Emergency Care In urgent and emergency situations, a preliminary report of a specialty consultation shall be submitted by the network provider to Health Net within 24 hours. The same process should be followed for coordination of these reports but using a 24-hour time frame. Telephone reports to the MTF can be coordinated based upon the urgency of the condition, but please be sure to fax the report to Health Net, as well, for completion of electronic records. Release of Medical Information Providers must have TRICARE beneficiaries sign a release of medical information. You can use your standard patient release of medical information form for this purpose. If the patient is not an active duty service member (ADSM) and does not authorize release of their medical records, please fax Health Net a copy of the documentation stating that the patient did not agree to release the records. ADSMs will be instructed to sign annual medical release forms to allow information to be forwarded to civilian and military providers. Release of Behavioral Health Information Behavioral health network providers need to submit a brief initial assessment within the seven business day standard. There are circumstances when the patient does not want information relayed back to the MTF. For ADSM referrals, report coordination by network providers is required. However, for other TRICARE beneficiary referrals, the network provider may have the patient sign a waiver to prevent the release of information. The Behavioral Health Waiver of Specialty Consultation Report Form can be used to notify Health Net that the behavioral health information will not be released. This form is available through the Provider Portal of the Health Net Web site at by clicking on the Authorizations tab. A signature will be valid for the time frame noted on the form. This waiver form should be submitted to Health Net s reports fax line at Second Quarter

6 Are You a Network or Non-network Provider? Although you might have been providing care for TRICARE beneficiaries for some time now, you may not know for certain whether you are a TRICARE network or non-network provider. The Basics: Network and Non-Network Providers, Defined Network providers are civilian providers with signed contract agreements to be part of the network of providers who participate in the TRICARE program. As part of these contracts, network providers accept the negotiated rate as payment in full for the services they provide. These providers typically administer care to TRICARE Prime beneficiaries and those TRICARE Standard beneficiaries using TRICARE Extra in fact, network providers have become the civilian providers of choice for all TRICARE beneficiaries, resulting in higher TRICARE patient volume than non-network providers. Non-network providers do not have a contractual relationship to provide care to TRICARE beneficiaries. They are, however, certified to provide care, as payment cannot be made to non-certified providers. For this reason, non-network providers are often referred to as TRICARE-certified providers. There are two types of non-network providers participating and non-participating. Participating/certified providers accept assignment, meaning they agree to accept the TRICARE-determined allowable costs or charges as the total charge for services as full fees for care. These are also known as TRICAREallowable charges. Non-network, individual providers may choose to participate on a case-by-case basis, and they may seek applicable copayments or cost-shares and deductibles from beneficiaries. Non-participating/certified providers are providers who have not signed a contract and do not agree to accept assignment, but still render services and care to TRICARE beneficiaries. For non-participating provider care, the TRICARE beneficiary usually submits the claim and TRICARE pays the beneficiary for the health care service. The non-participating provider must collect payment for the services from the beneficiary. What Does It Mean to Be Certified? Certified for non-network providers refers to the successful outcome of a verification process by TRICARE Management Activity (TMA), PGBA and/or Health Net to satisfy that the provider meets various standards. Certified providers are approved to provide care to TRICARE beneficiaries and to receive government payment for services rendered. Network providers sign contact agreements and complete a credentialing process that includes review of qualifications and other criteria as discussed below. If I Am a Non-network Provider, How Can I Become A Network Provider? To become a network provider, call Health Net at and choose the option for contracting and credentialing and request a contracting packet. Once Health Net has completed its initial review to determine if you meet the minimum criteria for network participation, you will complete an application form and participate in a stringent review of your qualifications, education, licensure, malpractice coverage and other criteria in a credentialing process. Once you become a network provider, you must maintain credentialing requirements. A re-credentialing review will be conducted every three years. You will be required to complete a short renewal form with updated information on your qualifications and related matters. A Quick Way to Be Certain... Chances are that if you were an existing network provider under TRICARE s former contracts with Humana or Sierra, you re still a TRICARE network provider under the Health Net contract. If you are a new TRICARE network provider, you signed your contract agreement with Health Net or MHN. 6 Second Quarter 2005

7 Tips for Working with Dual-Eligible Beneficiaries Transition to Nationwide Claims Processor Complete After the transition period, providers across all three TRICARE regions should now be working with a single, nationwide claims processing contractor Wisconsin Physicians Service TRICARE For Life (WPS-TFL) for all dual-eligible beneficiary claims. Dual-eligible beneficiaries are TRICARE beneficiaries who also receive Medicare. Now that the transition to WPS-TFL is complete, here is some good information to know about dual-eligible claims processing. Dual-Eligible Beneficiaries Can Be either Under Age 65 or Age 65 and Over While most dual-eligible beneficiaries will be age 65 and over, entitled to Medicare Part A and enrolled in Medicare Part B, it s important to remember that some may be younger. For instance, patients under the age of 65 may be dual-eligible if they are entitled to Medicare Part A due to a disability or end-stage renal disease and if they have purchased Part B (active duty family members do not have to purchase Part B). How to Identify Your Dual-Eligible Patients Each dual-eligible patient must present a valid uniformed services or military identification card, as well as a Medicare card prior to receiving services. You should copy both sides of the cards and retain them for your files. If you have a question about a patient s eligibility, you can call Health Net at or visit to confirm TRICARE status and to confirm a patient s Medicare status. How to Process Claims All TRICARE dual-eligible claims are processed by WPS-TFL. Since Medicare is the primary payer to TRICARE, you should continue to follow Medicare rules for claims processing and submit your dualeligible claims to Medicare first. To ease claims processing for your patients, Medicare will electronically transfer these claims directly to WPS-TFL, including those for your TRICARE patients who are under the age of 65 and Medicare-eligible. If you have questions, WPS-TFL can be reached toll-free at You can also visit WPS online at Patients Bill of Rights and Responsibilities Patients enrolled in TRICARE have rights and responsibilities pertaining to their health care. To obtain more information, refer patients to the Healthy Living page at and click on the Bill of Rights link on the left navigation bar. Second Quarter

8 TRICARE, Health Net Resources Save You Time The staff at Health Net knows just how busy your workday can be, so we ve compiled the following list of useful telephone, fax and Web resources that can lessen time spent on office duties and increase time spent on patient care. The chart, listed alphabetically, includes both national and regional resources. When calling toll-free customer service telephone numbers, be sure to listen to the automated choices and select the appropriate option in order to expedite you call and receive faster service. New Online Features The Health Net Web site at offers you three new tools to support your TRICARE referral and prior authorization requests: The Referral and Prior Authorization Status Tool allows providers and beneficiaries to view the status of their referral or prior authorization request with Health Net. Data range options also allow users to view referral and prior authorizations for dates of service within the last 12 months. The Referral Decision Tool saves you from having to call Health Net to determine if a Health Net referral is required. Enter the beneficiary s TRICARE health care plan option and their ZIP code and find out if a referral is needed. The Prior Authorization Determination and Code Look-up Tool allows you to identify if a service requires a prior authorization and also lets you verify that you are using appropriate code designations for the procedure description. Resource Description Contact Information Benefits and Patient Responsibility Inquire about TRICARE covered and non-covered benefits and patient financial responsibility for TRICARE Reserve Select Claims Information For all claims-related questions CPT Procedural Coding Manual To obtain copies or if you need assistance American Medical Association P.O. Box Chicago, IL Electronic Claims For questions concerning the electronic data interface (EDI) EDI-CLAIM ( ) Eligibility Information Verify TRICARE patient eligibility Fraud and Abuse Hotline To report suspected fraud or abuse Health Care Finders (Provider Locator Services) Health Net Customer Service Line Representatives who help locate TRICARE providers and applicable community/state/federal health care resources for beneficiaries who require benefits and services beyond TRICARE TRICARE benefits, patient responsibility, claims status, eligibility inquiries, referrals, authorizations and allowable charge rates ICD-9 Diagnosis Coding Manual and HCPCS Procedure Coding Manual To obtain copies or if you need assistance Ingenix 5225 Wiley Post Way, Suite 500 Salt Lake City, UT Second Quarter 2005

9 TRICARE, Health Net Resources Save You Time (continued) Resource Description Contact Information Military Medical Support Office (MMSO) National Oceanic and Atmospheric Administration (NOAA) and U.S. Public Health Services (USPHS) Prior Authorization Information Prior Authorization and Referral Requests Prior Authorization and Referral Status Check Provider Status Verification and Updates Registered Nurse Services TRICARE For Life Claims (Be sure to submit claims to Medicare first) TRICARE Mail Order Pharmacy Program TRICARE Maximum Allowable Charge Rates TRICARE Provider Web Site, National TRICARE Retail Pharmacy Program For written or phone inquiries to Army, Navy, Air Force, Marine Corps, Coast Guard and National Guard For written or telephone inquiries to NOAA or USPHS For inpatient and select outpatient procedures requiring approval prior to receiving care Request a prior authorization or referral from Health Net by completing and faxing a TRICARE Service Request/Notification Form For immediate status updates on prior authorization and referral requests For network and non-network civilian provider contracting and certification status inquiries, as well as demographic and tax identification number updates Registered nurses provide clinical review for prior authorizations, quality and coordination of care/referrals For questions or assistance concerning TRICARE For Life (TFL) claims For questions concerning TRICARE Mail Order Pharmacy (TMOP) Program View TRICARE maximum allowable charge rates To obtain national TRICARE information, including links to TRICARE regulatory guidance, policies and procedures; TRICARE program options and features; and the latest news and events For questions about the TRICARE retail pharmacy network, as well as questions about pharmacy claims and prior authorizations (insert branch of service) Point of Contact Military Medical Service Office P.O. Box Great Lakes, IL NOAA/USPHS Point of Contact Medical Affairs Branch Beneficiary Medical Program 5600 Fishers Lane, Room 4C-06 Rockville, MD Fax: Fax: TDD DoD-TMOP ( ) DoD-TRRx ( ) Second Quarter

10 DoD Generics Policy What You Need to Know One year ago this June, Express Scripts, Inc. began administering the new, nationwide TRICARE Retail Pharmacy (TRRx) program. Thanks to this program, TRICARE beneficiaries can travel anywhere across the U.S. or its territories and have their prescriptions filled easily at any of 53,000 network retail pharmacy locations. The TRRx program has also meant that the Department of Defense s (DoD) 10-year-old, mandatory generic drug program is now being enforced more consistently across the nation. This program requires that prescriptions be filled with the generic product, if one is available, at the generic copayment. If a generic equivalent does not exist, the brand-name drug is dispensed at the brand-name copayment. Saving Millions DoD s long standing mandatory generic policy has saved our beneficiaries and taxpayers countless millions of dollars while providing quality pharmaceutical products, explains Col. James Young, director of DoD Pharmacy Programs for the Office of the Assistant Secretary of Defense. We encourage you to prescribe generic products whenever possible. In doing so, you help us conserve valuable resources that enable us to continue our commitment to provide the best pharmaceutical care to all our beneficiaries, continues Col. Young. It is estimated that the use of generics saves DoD almost $50 million per year, and it is a tribute to you that this process is working so well. Generic medications work the same as their brand-name counterparts in dosage, strength, performance and use. They must meet the same Food and Drug Administration (FDA) quality and safety standards. Prescribing Brand Name Instead If you feel that a brand-name drug (for which a generic equivalent is available) is medically necessary for a beneficiary, it is recommended that you receive authorization from Express Scripts prior to writing the prescription. Otherwise, the beneficiary may be responsible for the entire cost of the medication. Medical necessity waivers are approved if one or more of the following situations exist: The patient must experience, or would be likely to experience, significant adverse effects from the generic medication. The generic medication has resulted in, or is likely to result in, therapeutic failure. The patient has previously responded to the brand-name medication, and changing to the generic medication would incur an unacceptable clinical risk. To obtain a medical necessity waiver, call the TRRx Prior Authorization Line at You will be asked to complete and submit a Prior Authorization Request Form (also available in the frequently asked questions (FAQs) portion of the Express Scripts Web site Getting More Information Once Express Scripts has approved the request, you will receive a letter of medical necessity, which the beneficiary must present with the prescription at the pharmacy. At that time, the pharmacist will provide the beneficiary with the brand-name medication at the brand-name copayment. For more information about the safety and reliability of generic medications, visit the FDA Web site at To learn more about medical necessity waivers or the TRRx program, visit or call DoD-TRRx. 10 Second Quarter 2005

11 Healthy Choices for Life Motivating Patients to Adopt Healthy Living Habits Doctors aren t the only ones who understand the critical importance of healthy living. But often they are the ones who hold the keys to change. Whether patients need to lose weight, adopt a healthy eating plan or quit smoking, you can play a critical role particularly when patients are undergoing periods of relapse. Dr. Bruce Berger, professor at Auburn University, Ala., suggests an approach called motivational interviewing, a method of communication used to encourage individuals to change. When it comes to behavioral change, ambivalence is a common reaction, Dr. Berger said at a recent TRICARE conference. In fact, 70 percent of people who are faced with change do not feel ready to comply. Dr. Berger suggests taking three to five minutes during patient visits to apply motivational interviewing techniques that can help individuals move past feelings of resistance and through several stages of change (see chart). The object is to move patients from one stage to the next rather than directly to action. Once each stage is achieved, action can occur and maintenance of the new behavior can be sustained. Such motivational interviewing techniques include the following: 1. Assess the patient s readiness to adhere to a prescribed regimen. This can be achieved by discussing the good things and the less good things. Discover what the patient likes and dislikes about the proposed changes. Discuss if the patient Stages of Change believes he or she can do what is asked, what will help, and what might be potential barriers. 2. Help the patient move forward in the stage continuum by using stagespecific, tailored questioning. Gauge the patient s lifestyle and how he or she views it. Asking the patient to describe a typical day s routine will help you to identify dietary needs/ problems and exercise habits. Posing questions such as What is making it difficult to [insert behavioral change]? or What would have to happen in order to implement the change? enable patients to create their own resolutions. It is essential that patients recognize the benefits that will come from engaging in the changed behavior. Ask openended questions to determine how they believe they will benefit. If they don t know, or if they don t list all of the results, it is appropriate to share information to help them see the rewards that will likely come. Dr. Berger suggests the following during motivational interviews: When gathering information and assessing patients needs: listen carefully, express empathy, help patients make their own decisions, roll resistance, avoid argumentation, develop discrepancy and support self-efficacy. When eliciting change talk: ask evocative questions, explore readiness, explore the decisional balance, elaborate, query extremes, look back/look forward and explore goals and values. He also offers an acronym, GAWPOW, as a guide to help health care providers communicate and motivate change: Goals Discuss what the new regimen will do for the patient. Action Learn what actions are required to achieve results. When Establish a start date. People Discuss whether individuals or things can offer motivation. Obstacles Encourage the patient to be honest and realistic in removing barriers. What Establish what the patient will use to measure his or her success. For more information about motivational interviewing and the stages of change, you can view the presentation Dr. Berger gave to Military Health System providers at the 2005 TRICARE Conference online at the link below. Additional information can also be found in the June 2004 ACP Observer article, Strategies to help patients change their behavior, at the link listed below. Dr. Berger s presentation: ACP Observer article: Pre-contemplation Contemplation Preparation Action Maintenance Second Quarter

12 Health Net Federal Services, Inc. P.O. Box 2890 Rancho Cordova, CA CONTACTS Health Net Customer Service PGBA (Electronic claims set up) EDI-CLAIM WPS TFL (Dual-eligible claims) TDD Express Scripts (Pharmacy inquiries) DoD-TRRx DoD-TMOP CMAC Payments Now Based on Site of Services TRICARE CHAMPUS Maximum Allowable Charge (CMAC) changes for 2005 are effective for services rendered on or after April 1, The most significant changes to the CMAC include payments based on site of services as TRICARE will now implement similar payment methodologies utilized by Medicare. Although payment based on site of service is a new concept to TRICARE, it is already used by Medicare to distinguish between services rendered in a facility setting as opposed to a non-facility setting. Previous CMAC pricing by provider class will be superseded by the following four categories: Category 1 Services of M.D.s, D.O.s, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, and audiologists provided in a facility, including hospitals (both inpatient and outpatient where the hospital is generating a revenue bill, e.g., revenue code 510), residential treatment centers, ambulances, hospices, military treatment facilities, psychiatric facilities, community mental health centers, skilled nursing facilities, ambulatory surgical centers, etc. Category 2 Services of M.D.s, D.O.s, optometrists, podiatrists, psychologists, oral surgeons, occupational therapists, speech therapists, physical therapists, and audiologists provided in a non-facility, including provider offices, home settings, and all other non-facility settings. Category 3 Services, of all other providers not found in category 1, provided in a facility, including hospitals (both inpatient and outpatient where the hospital is generating a revenue bill, e.g., revenue code 510), residential treatment centers, ambulances, hospices, military treatment facilities, psychiatric facilities, community mental health centers, skilled nursing facilities, ambulatory surgical centers, etc. Category 4 Services of all other providers, not found in category 2, provided in a non-facility, including provider offices, home settings, and all other non-facility settings. Note: Services and procedure codes not affected by payment based on site of service include anesthesia services, laboratory services, component pricing services, such as radiology and J codes. Access the CMAC rates portion of the TRICARE Web site at to determine the new CMAC rates based on site of service. 12 Second Quarter 2005