TRICARE Provider News JUNE 2011 TRICARE Referral and Prior Authorization Changes As a reminder, referral and prior authorization requirements for TRICARE patients changed with the start of Health Net s new TRICARE contract. The following clarifications are effective as of April 19, 2011. You can visit www.hnfs.com for complete information regarding the referral and prior authorization requirements. Some of the changes include: Specialty Care Referrals Health Net referrals are required for most specialty services for TRICARE Prime beneficiaries regardless of where they live. Durable Medical Equipment To ensure TRICARE Prime and TRICARE Prime Remote (TPR) beneficiaries have immediate access to durable medical equipment (DME), Health Net does not require a referral for DME items with a purchase price of less than $2,000 when they are provided by a network provider. All DME items with a purchase price equal to or greater than $2,000, as well as DME from a non-network provider, require prior authorization. When they bill under their own tax identification number (TIN) and the purchase price is less than $2,000, primary care managers (PCMs) and specialists may provide DME items directly to beneficiaries. If the beneficiary is referred to a DME company or vendor for an item with a purchase price of less than $2,000, then the referring provider must write a physician s order or prescription for the required item. The physician s order may be faxed to PGBA at 888-377-4191 to facilitate claims payment. Urgent Care All Prime beneficiaries require a Health Net approved referral for urgent care. Occupational Therapy/Physical Therapy/Speech Therapy To create consistency for specialty services, all TRICARE Prime and TPR beneficiaries needing physical, occupational and speech therapy services will require an approved Health Net referral submitted by their PCMs or specialists. Remember, the following beneficiaries require a prior authorization for all inpatient admissions and outpatient facility care: Active duty service members (ADSMs) TRICARE Prime Remote active duty service members (TPRADSMs) Network and non-network provider claims submitted for services rendered without required prior authorizations will receive a 10 percent payment reduction during claims processing. Therefore, please be sure to confirm prior authorization and referral requirements before providing care. We understand these requirements may incur additional coordination effort for network and non-network providers and we appreciate your compliance with these requirements. For a complete list of referral and authorization requirements, visit our website at www.hnfs.com.
Removal of Social Security Numbers from TRICARE Beneficiary Identification Cards The Department of Defense (DoD) has started the process of removing Social Security numbers (SSNs) from identification (ID) cards. This change is part of the continued effort to protect the privacy and security of TRICARE beneficiaries, and is designed to reduce the risk of identity theft. SSNs are being replaced with DoD Benefits Numbers (DBNs) 11-digit numbers used to determine TRICARE eligibility. The first nine digits of the DBN are common to the sponsor. The last two digits identify the specific beneficiary. The DBN will be printed on every new ID card. TRICARE beneficiaries will receive a new card upon expiration of their current card. It will be approximately four years until all cards are updated. Until all beneficiary ID cards have the new DBN, beneficiaries can be identified and claims can be filed using either the SSN or the new DBN. In order to verify TRICARE eligibility, you may still ask a TRICARE beneficiary to provide his or her sponsor s SSN verbally or in writing as required by your office protocol. For beneficiaries unable to provide the sponsor s SSN, providers have the following options to confirm beneficiary eligibility: Check eligibility on www.hnfs.com, using the first nine digits of the DBN. Check eligibility on PGBA s website, www.mytricare.com, using the first nine digits of the DBN. Check eligibility by calling 877-TRICARE (877-874-2273) and follow the interactive voice response prompts. If you have questions, please visit www.hnfs.com or www.tricare.mil/ssn. TRICARE Young Adult A new program, TRICARE Young Adult, extends TRICARE coverage to eligible dependent children until age 26. This premium-based health care coverage is a result of the National Defense Authorization Act (NDAA) of 2011. With TRICARE Young Adult, eligible beneficiaries purchase TRICARE Standard coverage. Coverage may be retroactive to January 1, 2011 if the enrollee chooses to pay premiums back to that date. TRICARE Young Adult includes medical and pharmacy benefits, but excludes dental coverage. Enrollees may get care at a military treatment facility on a space-available basis. This plan is available only for individuals and is not offered as a family plan. For more information, visit www.hnfs.com or www.tricare.mil/tya. Registration on the new www.hnfs.com is now available. Previously registered users of www.hnfs.com will need to re-register. Learn more about registering at www.hnfs.com today! Registry on PGBA s website, www.mytricare.com remains unchanged. 2
Patient Safety Corner Follow-Up Care after an Inpatient Hospitalization for Mental Illness In the U.S., one in four adults will develop a mental disorder at some point in their life. According to the National Institute of Mental Health, mental illness is the leading cause of disability, affecting nearly 60 million people and costing more than $300 billion annually. During 2007, there were 2.4 million hospitalizations for mental disorders in the U.S. 1 As a psychiatric hospitalization is generally reserved for patients whose illnesses are complicated or whose symptoms are dangerously acute (such as suicidal urges), appropriate follow-up care after discharge is vital. In 2009, however, only 39 percent of TRICARE North Region beneficiaries had a follow-up outpatient visit with a behavioral health practitioner within seven days of discharge. Nationally, more than 58 percent of patients in commercial health maintenance organizations (HMOs) received this necessary care. Appropriate behavioral health follow-up care helps reduce the risk of a repeat hospitalization and identifies patients in need of additional interventions before they reach a crisis point. One of the following behavioral health aftercare options offers a greater chance for a speedy recovery: Structured behavioral health outpatient program (day or evening) Outpatient medication visit with a psychiatrist Outpatient psychotherapy (individual, family or group) Primary care managers (PCMs) and specialists can help improve continuity of care for TRICARE North Region beneficiaries after discharge from a psychiatric hospitalization by: Encouraging beneficiaries, who may call you after a psychiatric inpatient hospitalization, to see a behavioral health practitioner within one week of leaving the hospital. Encouraging beneficiaries to adhere to their medication and clinical treatment plan. Expressing interest in the behavioral health treatment plan. Asking beneficiaries to have their behavioral health practitioner share clinical information with you. Reminding beneficiaries they can call 877-TRICARE (877-874-2273) or visit www.hnfs.com or www.members.mhn.com to find psychiatrists, psychologists or other behavioral health practitioners. Your support during and after a psychiatric hospitalization has a powerful impact on the overall health of our beneficiaries. 1 Hall, M.; DeFrances, C., Williams, S., Golosinskiy, A., & Schwartzman, A. (2010). National hospital discharge survey: 2007 summary. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr029.pdf Third Party Billing List of Excluded Individuals/Entities Every month, TRICARE Management Activity s (TMA) Office of Program Integrity provides Health Net with an up-to-date list of excluded entities which can include third party billing agents (clearinghouses). This list comes from the U.S. Department of Health and Human Services (DHHS) List of Excluded Individuals/Entities. What does this mean for providers? As of April 1, 2011, any provider who uses a sanctioned clearinghouse on the DHHS s List of Excluded Individuals/ Entities will have their claims returned, unprocessed. Providers can check the status of their clearinghouses by visiting the DHHS Office of Inspector General website. Enter part of the name or the entire name of the clearinghouse in the Business Name section to check the status of your current clearinghouse or clearinghouse you are considering using in the future. 3
Healthy People 2020 Corner Men s Health Screenings Compared to women, men are more likely to smoke and drink, make unhealthy or risky choices, and put off regular checkups and medical care. Many men have the philosophy, If it s not broken, it doesn t need fixing, not realizing part of maintaining a healthy body is preventive maintenance. In this month s Healthy People (HP) 2020 Corner we address the objectives supporting men s health screenings. The two leading causes of death among men are heart disease and cancer. Advice from a health care provider about getting blood pressure, cholesterol, diabetes and cancer screenings, as well as providing information on reducing controllable risk factors, such as smoking, physical inactivity and obesity, can make a positive impact toward meeting HP objectives. Each HP objective has a baseline, and a target toward which the nation is trying to achieve. Here are a few objectives: HDS 4: Increase the proportion of adults who have had their blood pressure measured within the preceding two years and can state whether their blood pressure was normal or high. HDS 6: Increase the proportion of adults who have had their blood cholesterol checked within the preceding five years. NWS 6: Increase the proportion of physician office visits that include counseling or education related to nutrition or weight. D 15: Increase the proportion of persons with diabetes whose condition has been diagnosed. PA 11: Increase the proportion of physician office visits that include counseling or education related to physical activity. C 18: Increase the proportion of adults who were counseled about cancer screenings consistent with current guidelines. C 19: Increase the proportion of men who have discussed with their health care provider whether or not to have a prostate-specific antigen (PSA) test to screen for prostate cancer. TU 10: Increase tobacco cessation counseling in health care settings. Take every advantage to encourage your male patients to get timely health screenings and to practice healthy behaviors that help prevent heart disease and cancer. The health of every patient affects the health of our nation. Visit www.healthypeople.gov to learn more about the national objectives and find resources to support your practice. Health Net s website, www.hnfs.com, also has a variety of resources for you and your patients. Access health education toolkits within the Wellness section of the Resources tab of the provider portal. Sources: healthypeople.gov, cdc.gov (USCS), National Cancer Institute (USCS) U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999 2006 Incidence and Mortality Web-based Report pre-release data. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2010. 4
Changes to Clearly Legible Report Submission Fax Numbers Many clearly legible report (CLR) fax numbers changed with the start of Health Net s new TRICARE contract on April 1, 2011. These changes allow for a swifter return of CLRs to the referring military treatment facility (MTF) provider and assist in meeting Joint Commission requirements. Health Net requests network providers fax all CLRs directly to the secure fax line of the requesting MTF. Visit our website (www.hnfs.com) to view the CLR Fax Matrix, which lists the confidential MTF fax number you will need to use. The CLR Fax Matrix lists all TRICARE North Region MTF secure fax numbers, contains a local point of contact telephone number and a local CLR mailing address should you prefer to mail the CLR. Note: The requirement to submit CLRs to the MTF only applies to care referred from an MTF. Upon receipt of an approved referral or authorization from Health Net, providers will receive a letter that contains the secure fax number for coordinating the CLR with the MTF. For care referred by a non-mtf (civilian) provider, reports should not be sent to the local secure fax line. Follow your normal office protocol and forward non-mtf referred consultation reports to the requesting civilian provider within the seven (7) business days standard. Urgent and Emergent Care In urgent and emergency situations, a preliminary report of a specialty consultation should be provided to the referring provider by telephone or the secure fax line within 24 hours of the urgent or emergent care. Telephonic preliminary reports should be followed up with a CLR sent to the local secure fax line within seven (7) business days of the urgent or emergent care. Protect Patient Information These CLR fax number changes require you reprogram your fax machines with the correct, updated fax numbers for CLRs. Please reprogram your fax machine and double check that your fax is being sent to the correct, corresponding fax number for the MTF on the CLR fax matrix. Proper Coordination of CLRs What Specialty care consultation/referral reports, operative reports and discharge summaries for patients referred from an MTF When MTFs expect to receive CLRs within seven (7), but no later than 30 days of the date of service Where Forward CLRs to the referring MTF provider How Fax CLRs to the local secure fax number as indicated on the referral/authorization letter or in the CLR Fax Matrix Note: The CLR secure fax number is different than the fax number used to submit TRICARE Service Request/Notification Forms for referral and authorization requests. 5
Making Health Information Technology Work for Your Practice and Clinical Health (HITECH) Act made available significant funding to help providers large and small make the transition. The Community College Consortia is just one of the many programs that may be able to help you! continued on page 7 Health information technology makes it possible for health care providers to better manage patient care through secure use and sharing of health information. For example, the use of electronic health records (EHRs) instead of paper medical records may allow providers to identify all patients with diabetes in need of a blood test, or all women who are overdue for mammography. Now, more than ever, hospitals, clinics and practices alike are making the switch to electronic systems. Whether you re thinking about implementing a new EHR in your practice, or if you re simply looking to improve your current medical management processes by applying information technology, some additional technical training can help. Implementing health information technology can be a complex process that involves many moving parts. Fortunately, the Health Information Technology for Economic TRICARE Webinars June Schedule Health Net now offers online interactive webinars to allow you to attend live TRICARE sessions and view previously recorded sessions from your office or location of your choosing. Whether you choose to attend a live webinar presented by one of our TRICARE representatives or watch one of the recorded sessions, we hope you take advantage of the ease and convenience of online learning. Health Net offers live TRICARE webinars twice a month. Topics will vary. Registration is required. A registration link is provided in the Provider Learning/TRICARE Webinars section of www.hnfs.com. Space is limited to the first 35 participants. June Webinar Schedule Topic Date Time TRICARE 101 Wed., June 8, 2011 11 a.m. (ET) TRICARE 101 Wed., June 22, 2011 2 p.m. (ET) 6
Making Health Information Technology Work for Your Practice continued from page 6 What Is the Community College Consortia? The Community College Consortia to Educate Health Information Professionals is a free non-degree training program for providers, clinicians and office staff alike to learn more about incorporating health information technology into their practices. More than 70 community colleges in all 50 states received grants to develop or improve non-degree health information technology training programs that can be completed in six months or less. These training programs will also be part of the first effort to help physicians incorporate meaningful use into their EHRs, and ultimately improve quality and patient care. Who Should Attend the Community College Consortia? Classes will be taught in six job-specific tracks. These programs will incorporate hard technical skills as well as soft skills such as problem solving, decision making, time management, etc. Many programs offer both campus-based and distance education courses, and include both evening and weekend scheduling. TRACK Practice workflow and information management redesign specialists Clinician/practitioner consultants Implementation support specialists Implementation managers Technical/software support staff Trainers DESCRIPTION This transition will require the ability to assess workflows in a practice, suggest changes to increase the quality and efficiency of care and facilitate reporting. Licensed health professionals will need to apply their specialized clinical knowledge to select hardware/software and work to ensure that clinical goals are met. Specialists will be needed to install and test health IT systems in clinical settings to ensure systems are easy and effective to use. Those who have administrative or managerial experience in health or IT environments may seek additional training to oversee and manage the transition to health IT for providers. Providers will need ongoing support to diagnose IT problems, develop solutions and keep systems running smoothly and securely. Practice staff will have to be trained on new systems and upgrades. New staff will have to be trained as they come on board. How to Get Your Practice Involved! To learn more about this program as well as other funding opportunities, please visit http://healthit.hhs.gov. To locate your nearest participating community college visit: http://healthit.hhs.gov/portal/server.pt/community/healthit_ hhs_gov community_college_program/1804. For questions related to the Community College Consortia or the Health IT Workforce Development Program, please email HITEducation@hhs.gov 7
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