TRICARE West Region Authorizations and Referrals

Transcription

1 TRICARE West Region Authorizations and Referrals March 2018 last updated March 19, 2018 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. 1

2 Welcome Health Net Federal Services, LLC (HNFS) is pleased to offer you information about our TRICARE West Region authorization and referral process. Today you will: Become familiar with TRICARE and HNFS referral requirements. Understand how to look up prior authorization and referral requirements, submit requests and check status. Become familiar with online tools available to you. 2

3 Health Net Federal Services As a TRICARE managed care support contractor, Health Net Federal Services, LLC (HNFS) must adhere to program manuals to administer the TRICARE benefit. However, contractors are allowed some discretion as to when an authorization or referral may be required, and if required, how those requests are processed. In addition to TRICARE benefit and program changes that took effect Jan. 1, 2018, you may have noticed some differences in HNFS approval requirements from the previous TRICARE West Region contractor, UnitedHealthcare Military & Veterans. The following information is to help providers become familiar with HNFS processes. 3

4 TRICARE Basics 4

5 Types of Beneficiaries Active Duty Service Members(ADSM) A person currently serving in one of the seven uniformed services* of the United States; this includes National Guard and Reserve members who have been activated for a period of 30 consecutive days or more. Active Duty Family Members (ADFM) A family member of an active duty service member; this includes Transitional Assistance Management Program (TAMP) and transitional survivors (spouses and children of service members killed while on active duty). Retired Service Members A former active duty service member who qualifies for benefits after retiring from service (has served 20 or more years); includes members of the retired National Guard and Reserve age 60 or over. Retired Family Members A family member of a retired service member; includes former spouses, family members of retired National Guard and Reserve members age 60 and over and survivors (spouses of service members killed while on active duty more than three years ago). *Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Services, NOAA 5

6 TRICARE Plans TRICARE Prime A managed care program similar to a health maintenance organization; only available in specific geographic areas. Active duty service members must enroll in TRICARE Prime or TRICARE Prime Remote. TRICARE Prime Remote(TPR) Similar to TRICARE Prime; available for active duty service members living and working in remote locations and their eligible family members residing with the service member. TRICARE Select A preferred provider option available to non-active duty beneficiaries throughout the United States. The most flexible of the TRICARE plan options; however, cost for care is typically slightly higher than the TRICARE Prime and TRICARE Prime Remote options. TRICARE Reserve Select (TRS) A premium-based health care plan with benefits similar to TRICARE Select that qualified National Guard and Reserve members may purchase. TRICARE Retired Reserve (TRR) A premium-based health care plan with benefits similar to TRICARE Select that retired Reserve members may purchase. TRICARE Young Adult (TYA) A premium-based health care plan that qualified young adults may purchase. TRICARE Young Adult Select and TRICARE Young Adult Prime are available. TRICARE For Life TRICARE s Medicare-wraparound coverage. Visit TRICARE Overseas (TOP) A TRICARE Prime program available for active duty families living in TRICARE Eurasia-Africa, TRICARE Pacific, and TRICARE Latin America and Canada. Contracted by International SOS. For more information, visit 6

7 Referrals 7

8 TRICARE Prime Referral Waiver Jan. 1 March 31, 2018 The Defense Health Agency has issued a temporary waiver which allows TRICARE West Region beneficiaries enrolled in a TRICARE Prime plan to bypass the HNFS review and approval process when referred by their provider for most specialty outpatient care. This waiver applies to most outpatient TRICARE-covered services provided as a result of referrals and authorizations issued Jan. 1 March 31, The exceptions to this waiver are inpatient care, and applied behavior analysis, laboratory developed test and Extended Health Care Option (ECHO) services. Requests for these exceptions must still be submitted to and approved by HNFS prior to care being rendered. 8

9 TRICARE Prime Referral Waiver continued How to Initiate Care during Waiver Period through March 31, 2018 If you refer a TRICARE Prime-enrolled patient for covered outpatient specialty care between Jan. 1, 2018 and March 31, 2018, HNFS does not need to receive, review or approve the request. TRICARE Prime beneficiaries may seek covered outpatient services from any TRICARE-authorized provider (network or non-network) with the following documentation: A written referral or order for covered procedures, services or equipment from the beneficiary's provider dated between Jan. 1, 2018 and March 31, A copy of the TRICARE West Region Referral/Authorization Waiver Approval Letter, available at > Provider > Forms > Authorizations. The TRICARE West Region Referral/Authorization Waiver Approval Letter is your verification of approval. HNFS will not be issuing separate approval letters for services covered under the waiver. Find complete details, including answers to frequently asked questions at > Provider. 9

10 TRICARE Prime Referral Waiver continued The TRICARE West Region Referral/Authorization Waiver Approval Letter allows for care through June 30, 2018 (or through postpartum care for outpatient maternity referrals. For care referred during the waiver period that extends beyond June 30, 2018, providers must submit a request to HNFS for approval. After March 31, 2018, the waiver period will end and TRICARE Prime enrollees must follow Prime referral and authorization guidelines for any new specialty services referred by their providers, or Point of Service charges may apply. If you referred a beneficiary for care during the waiver period, you ONLY need to request a new approval from HNFS if that care extends past June 30, 2018 (see maternity care exception above). We ask you not resubmit requests for services that are already covered under an active HNFS approval. Your cooperation with these guidelines can help reduce the amount of unnecessary requests received and expedite beneficiaries access to care. HNFS will resume accepting referral and authorization requests for TRICARE Prime patients beginning April 1, If you previously submitted requests via fax, please note we will only accept online requests once the waiver period ends. 10

11 What Is a Referral? Referrals are for services that are not considered primary care. An example of a referral is when a primary care manager (PCM) sends a patient to see a cardiologist to evaluate a possible heart problem. Referrals may be either: Evaluation only These referrals are for the initial evaluation of the patient, to include required diagnostic services, but not treatment. This type of referral also includes requests for second opinions. Evaluation and treatment These referrals are for the initial evaluation, required diagnostic services and treatment related to a specific medical condition. 11

12 Who Needs a Referral TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime* beneficiaries must have a referral from their PCM before seeking most specialty care from other professional or individual paramedical providers. Without an approved referral (when required), beneficiaries in TRICARE Prime plans are subject to Point of Service charges. *Does not apply during waiver period, except for inpatient, ABA. LDT and ECHO services. 12

13 Who Does NOT Need a Referral In general, TRICARE Select, TRICARE Reserve Select, TRICARE Retired Reserve and TRICARE Young Adult Select beneficiaries do not require a referral for specialty care. The exception being applied behavior analysis services require a referral. TRICARE dual-eligible beneficiaries do not require a referral for specialty care. Beneficiaries with other health insurance (OHI) only require authorization for applied behavior analysis services. (Active duty service members cannot use OHI.) 13

14 Point of Service The Point of Service (POS) option allows most TRICARE Prime beneficiaries to self-refer to any TRICARE network or non-network provider for medical/surgical or mental health services without referrals from their PCMs or HNFS. Beneficiaries who use the POS option will pay a deductible and have higher cost-shares for services. The POS option does not apply to active duty service members, so they may be responsible for the entire cost of self-referred care The POS option does not apply for services that do not require a referral. (see slide 13). 14

15 Active Duty Service Members Active duty service members require a referral for all care*, except: emergency inpatient admissions chemical dependency detoxification Note: Active duty service members enrolled in TRICARE Prime Remote do not require a referral for urgent care due to their remote location. *Does not apply during waiver period, except for inpatient, ABA, LDT and ECHO services. 15

16 Non-Active Duty Prime Enrollees Non-active duty TRICARE Prime/TRICARE Prime Remote beneficiaries require a referral for most, but not all, specialty care.* The exceptions include: urgent care ancillary services (such as laboratory, radiology and pulmonary function tests); Based upon location, some radiology services require authorization. outpatient behavioral health services (some services require authorization) preventive care services from network providers emergency services *Does not apply during waiver period, except for inpatient, ABA, LDT and ECHO services. 16

17 Change to Urgent Care TRICARE implemented changes to its urgent care benefit on Jan. 1, TRICARE guidelines now allow most beneficiaries enrolled in a TRICARE Prime plan to seek urgent care without a referral and without visit limits. TRICARE Prime plans (does not apply during waiver period) Except for active duty service members enrolled in TRICARE Prime, beneficiaries enrolled in a TRICARE Prime plan do not need a referral for urgent care and Point of Service will not apply when seeking urgent care from the following: any network or non-network urgent care center (must be TRICARE-authorized) any network primary care type provider (family practice, general practice, internal medicine, pediatrics, OB/GYN, physician assistant, nurse practitioner, or certified nurse midwife) Active duty service members enrolled in TRICARE Prime still require a referral for urgent care; however, active duty service members enrolled in TRICARE Prime Remote do not require a referral due to their remote location. All other plans There is no referral requirement for urgent care, and care may be rendered by any TRICARE-authorized (network or non-network) provider. Note: TRICARE Overseas Program enrollees who are traveling and seeking stateside urgent care do not require a referral. 17

18 Authorizations 18

19 What Is an Authorization? Authorizations are for certain services and/or procedures that require HNFS review and approval, prior to being provided. Some services and/or procedures that require approval include certain mental health care, hospitalization, surgical, and therapeutic procedures. 19

20 Requirements 20

21 Don t Guess. Go Online. We realize TRICARE referral and authorization guidelines can be complicated, so we offer an online tool to help simplify the process. It s important to verify requirements online before you submit! Go to > Provider > Is Approval Needed to verify referral and authorization requirements before submitting a request to HNFS. (This tool is also available on our secure portal.) 21

22 West Region Transition 22

23 UnitedHealthcare to HNFS HNFS is honoring active prior authorizations and referrals approved by UnitedHealthcare Military & Veterans (UnitedHealthcare) that extend beyond January 2018, through their expiration date, even if the approval is to a non-network provider. Active UnitedHealthcare authorizations are loaded in our system for accurate claims processing and visible through our online authorization tools. TRICARE Prime beneficiaries who choose to see a different civilian provider than the one authorized by UnitedHealthcare, may see any network or non-network provider of that specialty. Point of Service charges will apply after March 31, 2018, should the beneficiary choose a non-network provider. We are only issuing authorization letters for services approved by HNFS on or after Jan. 1, There may be rare cases where HNFS must update an authorization. In those cases, the provider and beneficiary will be notified. All referral or authorizations inquiries should be directed to HNFS, even if the beneficiary is in the middle of an episode of care previously authorized by UnitedHealthcare. 23

24 Submitting Requests 24

25 Submitting Online HNFS requires providers to submit referral and authorization requests online. Should we require additional medical documentation, we will notify you and provide submittal instructions. When you submit When creating your online request, be sure to complete all required fields, and be clear and concise in the clinical information provided (for example, include diagnoses, presenting problem, symptoms). If requesting a specific provider, you must complete all required fields, including the provider s NPI, first and last name, phone/fax number, and address. The attachment feature in our secure online submission tool (CareAffiliate ) is now available. We offer a step-by-step guide to using CareAffiliate at > Provider > Education/Quick Reference Charts. 25

26 Routine, Urgent or Emergent? Routine: A routine request is when care is needed within the four-week TRICARE specialty care access standards. Nearly all referral requests are routine unless the patient needs care in less than 72 hours. Urgent: A medically urgent request is when care is needed within hours. Emergent: A medically emergent request is when care is needed within 24 hours or less. Please include as much clinical information as possible when submitting requests. 26

27 Processing Time Frames HNFS processes routine requests within 2 5 business days and medically urgent requests in an expedited manner; however, we are currently experiencing an inventory and processing backlog. While we work diligently to reduce the inventory, please do not re-submit your request. Additionally, unless asked by HNFS, it is not necessary to fax additional clinical information to HNFS after submitting a request. If after receiving and reviewing the request HNFS determines additional information is needed, an HNFS team member will notify the requesting provider. Please remind your patients to not schedule appointments if they are still awaiting a response on new requests submitted to HNFS. 27

28 How to Submit Using CareAffiliate 28

29 Getting Started If you have not done so already, register at Registration provides you access to all the self-service tools on our website. We offer two registration methods. We strongly encourage you to use the instant registration method using claims or authorization data, as it is the fastest and easiest way for you to register and gain instant access to a suite of self-service tools: Instant registration: Uses TRICARE West authorization or claim numbers and related patient information. This process allows for instant access. Secure key code registration: Requires we mail a letter to the office location you select during registration. This process may take a few weeks to complete depending on the U.S. postal system and the routing of postal mail within your location. Click on Log In/Register at the top of any page at to get started. 29

30 Authorization Submission We offer two online submission tools at > Provider. If not already logged in, click on Submit a Request from the drop-down menu. You will see two options. Requires Login (the preferred method, and what we ll focus on today) Does Not Require Login 30

31 Authorization Submission continued While both the online submission options allow you to submit requests and receive immediate responses, there are advantages to using the Login option (CareAffiliate): Key features of this option include: available for outpatient and inpatient requests create frequently used providers, request profiles and diagnosis lists add attachments 31

32 Resource Guide We offer a step-by-step guide to using CareAffiliate at > Provider > Education/Quick Reference Charts. 32

33 Submission Tips 1. Use Chrome for best results. It helps to clear all cookies/website data. 2. Use the lookup feature (magnifying glass icon). You ll notice this in multiple places throughout the CareAffiliate submission tool. 3. We are updating the Member Search fields to make it easier to search. Current: New (around Feb. 15, 2018): 33

34 Submission Tips continued 4. The associated CPT code(s), number of visits, and duration of the authorization will populate based on the request type selected. 5. If you do not have a specific servicing provider in mind, enter the provider specialty and HNFS will locate one. 34

35 How We Approve Our online authorization and referral tools use request profiles for different services. Request profiles automatically populate information when selected (for example, CPT codes, number of visits and duration of the authorization. In many of the standard request profiles, HNFS will authorize a range of codes. In these instances, codes that fall within that range are also authorized. Certain request profiles have one or more single codes populated on a service line. In these instances, HNFS will only authorize the single code. HNFS will include the consultation code range when approving specialty referral requests for evaluation and treatment. HNFS may conduct postpayment audits on claims submitted with consultation codes to verify accuracy of coding. 35

36 How We Approve continued What won t be on HNFS approval letters? On HNFS approval letters, we will NOT include codes for all possible scenarios related to the requested services. When billing, as long as the codes are: 1. For services covered by TRICARE, 2. not on the Government No-Pay List and 3. do not require separate prior authorization, we will accept the claim. In other words, your approval letter from HNFS will only specify those codes that DO require our approval. 36

37 Right of First Refusal Optimization of military hospital or clinic resources: Requests for specialty care, inpatient admissions or procedures requiring prior authorization will be directed to the military hospital or clinic first, followed by TRICARE network providers if the services are not available at the military hospital or clinic. 37

38 Status To check status, go to > Provider > Authorizations. We encourage you to log back in the website to access this feature through our secure portal. 38

39 Status continued To check status in CareAffiliate, from the Authorizations tab, click on Search Existing Records. 39

40 Active Referrals A referral is considered active if it is less than 180 days old for an active duty service member (ADSM), or less than 365 days old for a non-adsm. A military hospital or clinic may specify a longer duration for ADSMs, not to exceed one year. Referrals are valid for the time frame specified and only for the number of visits specified. Specialty care received outside the scope of a referral may be denied or processed as Point of Service. Note: The active referral 180/365 day duration is calculated from the receipt date of the last military or civilian PCM referral. 40

41 Provider Resources 41

42 Online Resources Find the TRICARE West Region Provider Handbook, quick reference charts, the TRICARE provider newsletter, answers to frequently asked questions, contact information and more at 42

43 Customer Service WEST ( ), Monday through Friday, 5:00 a.m. 9:00 p.m. (Pacific time). As a reminder, all referral or authorizations inquiries should be directed to HNFS, even if the beneficiary is in the middle of an episode of care previously authorized by UnitedHealthcare. We offer a TRICARE West Region Inquiries Guide to help you determine which contractor, UnitedHealthcare or HNFS you should contact based on the topic, date of service/incident and date of contact. Visit > Provider > Education/Quick Reference Charts. 43

44 Questions and Answers 44