CHANGE 5 6010.59-M AUGUST 28, 2017 REMOVE PAGE(S) INSERT PAGE(S) Master Table of Contents, pages 1 and 2 Master Table of Contents, pages 1 and 2 CHAPTER 7 Section 2, pages 1 and 2 Section 2, pages 1 and 2 2
Revision: C-5, August 28, 2017 Foreword Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 - Administration - Transitions - Financial Administration - Provider Certification And Credentialing - Provider Networks - Enrollment - Medical Management (MM), Utilization Management (UM), And Quality Management (QM) - Claims Processing Procedures - Records Management (RM) Chapter 10 - Claims Adjustments And Recoupments Chapter 11 - Beneficiary Education and Support (BE&S) Chapter 12 - Appeals And Hearings Chapter 13 - Program Integrity Chapter 14 - Reports Chapter 15 - TRICARE Regional Offices (TROs)/Military Treatment Facility (MTF)/ Enhanced Multi-Service Market (emsm) and Contractor Interfaces Chapter 16 - TRICARE Prime Remote (TPR) Program Chapter 17 - Supplemental Health Care Program (SHCP) Chapter 18 - Demonstrations And Pilot Projects Chapter 19 - Health Insurance Portability and Accountability Act (HIPAA) of 1996 Chapter 20 - TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) 1 C-5, August 28, 2017
Chapter 21 - TRICARE Alaska Chapter 22 - Reserve Component Health Coverage Plans Chapter 23 - TRICARE Pharmacy (TPharm) Chapter 24 - TRICARE Overseas Program (TOP) Chapter 25 - TRICARE Young Adult (TYA) Chapter 26 - Continued Health Care Benefit Program (CHCBP) Chapter 27 - Prime Service Area (PSA) Reduction Policies And Effective Dates Appendix A - Definitions Index 2 C-5, August 28, 2017
Medical Management (MM), Utilization Management (UM), And Quality Management (QM) Chapter 7 Section 2 Preauthorizations Revision: C-5, August 28, 2017 1.0 GENERAL Preauthorization review shall be performed for all care and procedures listed below. The contractor may propose additional authorization reviews. (See Section 1 for additional guidance.) The admissions/procedures are subject to change over time based upon the Government s assessment of the efficacy of the review. The changes will include adding and/or removing admissions/procedures. When the beneficiary has other insurance that provides primary coverage, exception to the preauthorization requirements shall apply as provided in the TRICARE Policy Manual (TPM), Chapter 1, Section 6.1, paragraph 1.12. When the contractor is acting as a secondary payor any medically necessary reviews shall be performed on a retrospective basis. THE FOLLOWING INPATIENT ADMISSIONS SHALL BE PREAUTHORIZED: Adjunctive Dental Mental Health Substance Abuse Skilled Nursing Facility (SNF) care for dual eligible beneficiaries Note: Effective for dates of service June 1, 2010, SNF care received in the U.S. and U.S. territories must be preauthorized for TRICARE dual eligible beneficiaries. The TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) contractor shall preauthorize SNF care beginning on day 101, when TRICARE becomes primary payer. Organ and Stem Cell Transplants THE FOLLOWING OUTPATIENT SERVICES SHALL BE PREAUTHORIZED: Adjunctive Dental Mental Health Care after the eighth visit each fiscal year. Primary Care Manager (PCM) referral is not required; however, the contractor shall steer all beneficiaries who contact them to the Military Treatment Facility (MTF)/Enhanced Multi-Service Market (emsm) or appropriate network provider. Additionally, the contractor shall expound upon the benefits of using the MTF/eMSM and network providers during all appropriate beneficiary and provider briefings. Note: Service members require preauthorization before receiving mental health services. The contractor shall comply with the provisions of Chapters 16 and 17 when processing requests for active duty personnel. 1
Chapter 7, Section 2 Preauthorizations THE FOLLOWING SERVICES WILL BE PREAUTHORIZED IN ANY SETTING: Extended Care Health Option (ECHO) Services Hospice Provisional Coverage for Emerging Services and Supplies (see the TPM, Chapter 13, Section 1.1.) Low Protein Modified Foods (LPMF) for the treatment of Inborn Errors of Metabolism (IEM) (see the TPM, Chapter 8, Section 7.2) Psychiatric Residential Treatment Center (RTC) Care Dental Anesthesia and Institutional Benefits 2.0 INPATIENT MENTAL HEALTH AND RTC CARE As indicated above, inpatient mental health and RTC requires preauthorization. However, in the event that services were not preauthorized, the contractor shall obtain the necessary information and complete a retrospective review. Penalties for failing to obtain preauthorization apply (see 32 CFR 199.15). 3.0 EFFECTIVE AND EXPIRATION DATES The preauthorization shall have an effective date and an expiration date. For organ and stem cell transplants, the preauthorization shall remain in effect as long as the beneficiary continues to meet the specific transplant criteria set forth in the TPM, or until the approved transplant occurs. - END - 2 C-5, August 28, 2017