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Clarifying the Referral and Prior Authorization Process January/February 2012.

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Presentation on theme: "Clarifying the Referral and Prior Authorization Process January/February 2012."— Presentation transcript:

1 Clarifying the Referral and Prior Authorization Process January/February 2012

2 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Welcome Health Net is honored to continue our service to nearly three million beneficiaries in the TRICARE North Region. We thank you for caring for and supporting our nations heroes.

3 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Learning Objectives Upon completion of todays presentation, you should: 1)Become familiar with TRICARE and Health Net referral requirements. 2)Understand how to look up prior authorization and referral requirements, submit requests and check status. 3)Become familiar with the available online tools.

4 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Types of Beneficiaries ACTIVE DUTY SERVICE MEMBER (ADSM) – A person currently serving in one of the seven uniformed services* of the United States under a call or order for a period of 30 consecutive days or more. ACTIVE DUTY FAMILY MEMBER (ADFM) – 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 MEMBER – A former active duty service member who qualifies for benefits after leaving the service (e.g., has served 20 or more years); includes members of the retired National Guard and Reserve age 60 or over. RETIRED FAMILY MEMBER – 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 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Types of Beneficiaries NATIONAL GUARD AND RESERVE MEMBER – A member of one of the seven inactive uniformed services** who is not on active duty orders. These members may purchase coverage, depending on the sponsor's status, with benefits similar to active duty family members or retiree family members. National Guard and Reserve members on active duty more than 30 consecutive days are treated as ADSMs. NATIONAL GUARD AND RESERVE FAMILY MEMBER – Family member of a National Guard and Reserve member; benefits are based on sponsors status and if he or she purchased coverage. DUAL-ELIGIBLE BENEFICIARY – Eligible for TRICARE and Medicare. YOUNG ADULT – Family member of an eligible uniformed service sponsor, under the age of 26, who is eligible for the TRICARE Young Adult program (includes TRICARE Young Adult Standard and TRICARE Young Adult Prime). **Army National Guard, Army Reserve, Navy Reserve, Marine Corps Reserve, Air National Guard, Air Force Reserve or U.S. Coast Guard Reserve

6 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x TRICARE Plans TRICARE PRIME – A managed care program similar to a health maintenance organization; only available in specific geographic areas. 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 STANDARD/EXTRA – The basic TRICARE health care plan 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 Standard/Extra that qualified National Guard and Reserve members may purchase. TRICARE RETIRED RESERVE (TRR) – A premium-based health care plan with benefits similar to TRICARE Standard/Extra 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 Standard and TRICARE Young Adult Prime are available. TRICARE FOR LIFE – TRICAREs Medicare-wraparound coverage.

7 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Primary Care Managers Depending on the beneficiary category and plan type, TRICARE beneficiaries may choose or be assigned: A military primary care manager. A civilian primary care manager. No primary care manager (as in TRICARE Standard/Extra, TYA Standard and in some cases, TRICARE Prime Remote).

8 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x The Right of First Refusal Optimization of military treatment facility (MTF) resources: Requests for specialty care, inpatient admissions or procedures requiring prior authorization will be directed to the MTF first, followed by TRICARE network providers if the services are not available at the MTF.

9 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Clearly Legible Reports Proper Medical Record Reporting – Help Our Military Hospitals Comply with Joint Commission Standards Timely medical record documentation is an important standard in the Joint Commission accreditation process for our military hospitals. TRICARE network providers must continue to provide clearly legible reports (CLRs) to the referring military treatment facility (MTF) provider. CLR Basics 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) days, but no later than 30 days of the date of service; in urgent and emergency situations, a preliminary report should be given to the referring provider by telephone or secure fax line within 24 hours. 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, which contains fax numbers for each MTF. The CLR Fax Matrix is located on Be sure to include patient name and date of birth at a minimum.www.hnfs.com

10 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Clearly Legible Reports To ensure CLRs are linked to the correct patient, and for the safety of patient treatment, please include at least two sources of identification for each patient. For example: First name, middle initial, last name and date of birth. First name, middle initial, last name and last four numbers of the Social Security number. It is important to promptly submit these required reports to the MTF in order for timely facilitation of TRICARE beneficiary care and to meet the Joint Commission accreditation requirements. Please review the Clearly Legible Reports page on our website for further details on this process.Clearly Legible Reports

11 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Referrals and Prior Authorizations Referral: Referrals are for services that are not considered primary care. Health Net utilizes referrals to document when a primary care manager (PCM) obtains consultation, care and services for his or her patients from other providers (e.g., medical/surgical specialists, physical therapists or psychologists). An example of a referral is when a PCM sends a patient to see a cardiologist to evaluate a possible heart problem. Prior Authorization: Certain services or procedures require Health Net review and approval, known as a prior authorization, prior to being provided. Some services and procedures requiring prior authorization include certain behavioral health care, hospitalization, surgical and therapeutic procedures.

12 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Who Needs a Referral? Active duty service members (ADSMs) require a Health Net referral for nearly all civilian network or non-network provider care. ADSM referral exceptions: –Ancillary services. –Emergency care services. –Preventive care services for TPR ADSMs. All TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime beneficiaries (excluding ADSMs), regardless of where they live, require a Health Net referral to civilian specialty providers. Services received without the required referral will process under the point-of-service option.

13 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Who does NOT need a referral? TRICARE STANDARD, TRICARE RESERVE SELECT, TRICARE RETIRED RESERVE and TRICARE YOUNG ADULT STANDARD beneficiaries do not require a Health Net referral. TRICARE DUAL-ELIGIBLE beneficiaries do not require a Health Net referral for specialty care. BENEFICIARIES WITH OTHER HEALTH INSURANCE – Beneficiaries with any non-TRICARE health insurance that is not considered a supplement to TRICARE do not require a Health Net referral for specialty care.

14 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x TRICARE Prime and TRICARE Prime Remote Active Duty Family MembersReferral Exceptions There are some exceptions where TRICARE Prime and TRICARE Prime Remote (TPR)* active duty family member beneficiaries do not require a Health Net referral. These include: An initial consultation and the initial eight outpatient behavioral health therapy visits from network providers. Preventive care services from network providers. Ancillary services from network or non-network providers/facilities. Durable medical equipment from network providers with a purchase price of less than $2000. Emergency care services from network or non-network facilities (beneficiary asked to contact PCM within 24 hours to report the care). *Exceptions to these referral requirements may apply if the beneficiary is a TPR active duty family member without an assigned primary care manager.

15 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Key Changes * The point-of-service option does not apply for active duty service members. For a complete listing of referral and prior authorization requirements, visit As of April 1, 2011 Specialty Care Referrals All TRICARE Prime beneficiaries, regardless of where they live, require a Health Net referral for most specialty services. Claims received without the proper referral will process under the point-of- service option*. Urgent Care All TRICARE Prime beneficiaries require a Health Net referral for urgent care. Claims received without the proper referral will process under the point-of- service option*. (See next slide for urgent care initiative exception.) Inpatient Admissions Health Net requires notification of inpatient admission (face sheet) and discharge dates by the next business day following the admission and discharge.

16 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Urgent Care Referrals TRICARE Prime beneficiaries require a Health Net referral for urgent care. TRICARE Urgent Care Initiative: TRICARE Prime beneficiaries enrolled to Joint Base-McGuire-Dix-Lakehurst (87th Medical Group), Fort Lee (Kenner Army Health Clinic) and Patuxent River Naval Health Clinic, who need urgent care: after hours, weekends, holidays or while traveling outside of their Prime Service Area should contact 877-TRICARE ( ) for a Health Net referral.

17 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Therapy Requirements PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY: To create consistency for specialty services, all TRICARE Prime and TRICARE Prime Remote beneficiaries require a Health Net referral. Primary care managers, or specialists with a Health Net referral, may submit a request for these services. Note: TRICARE Policy restricts non-physician ordering and prescribing authority for some service types. For provider types who are not able to order or prescribe under TRICARE, proper documentation of physician orders must be submitted with the claim to avoid claim denials, regardless of prior authorization requirements. The physician's order may be faxed to PGBA at to facilitate claims payment.

18 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Durable Medical Equipment Prior Authorization Health Net does not require a referral for durable medical equipment (DME) items with a purchase price under $2000* when provided by a network provider. For TRICARE Prime, TPR and TYA Prime, all DME items with a purchase price of $2000* or more, and any non-network DME providers require prior authorization (excluding ADSMs). *Note: Active duty service members must have a Health Net authorization for all civilian DME, regardless of the cost of the DME.

19 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Skilled Nursing Prior Authorization Retroactive to June 1, 2010, skilled nursing facility care requires prior authorization for TRICARE dual- eligible beneficiaries. Since Medicare is the primary payer for TRICARE dual- eligible beneficiaries, no prior authorization or referral is required from Health Net or TRICARE for skilled nursing facility admissions. However, when TRICARE becomes primary payer on day 101 of the inpatient stay, prior authorization from TRICARE is required. Authorization requests must be submitted to Wisconsin Physicians Service (WPS) for approval.

20 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Referral and Prior Authorizations– Requirements, Submissions and Status Visit for:www.hnfs.com Requirements: Prior Authorization, Referral and Benefit Tool. Submissions: Online Authorization and Referral Submission tool. Status: Requires a myTRICARE.com login and password.

21 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x P rior Authorization, Referral and Benefit Tool Use the Prior Authorization, Referral and Benefit Tool on to determine prior authorization and referral requirements for your TRICARE patients. Printer- friendly tables are also available.www.hnfs.com Please note: This tool only identifies if a Health Net referral or prior authorization is needed. It does not provide the approval.

22 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Referral and Prior Authorization Guide To view prior authorization and referral requirements in a printer- friendly format, providers may also view our Referral, Prior Authorization and Inpatient Notification Requirements Guide.

23 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Referral and Prior Authorization Guide

24 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Submissions Located under Tools section. Two ways to submit requests.

25 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Status A myTRICARE.com login and password are required.

26 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Customer Service for 24/7 access to up-to-date information.www.hnfs.com 877-TRICARE ( ) –Call Center hours: Monday-Friday 7 a.m.-7 p.m. (EST) Interactive Voice Response (IVR) features added allowing the convenience of support on a 24x7 basis.

27 TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved. HS0910x004x Questions


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