TRICARE West Region - South Dakota Medical Group ... · PDF fileTRICARE West Region Customer...

TRICARE West Region Medical/Surgical

Basics for the Provider

TRICARE West Region Customer Service: 877-988-9378(WEST) - UHCMilitaryWest.com. “TRICARE,” “TRICARE Prime,” “TRICARE Reserve Select,” and “TRICARE Retired Reserve” are registered trademarks

of the Defense Health Agency. All Rights Reserved. This presentation reflects the program as of the date delivered and is subject to change. Administrative guides and the Provider Handbook should be consulted

regarding policies and procedures.

2 Doc#: PCA12480_20140428

Presentation Outline

• Introduction to TRICARE

• Eligibility

• Referral and Authorizations

• Programs and Benefits

• Clinical Programs

• Provider Types and Access Standards

• Claims and Reimbursement

• Provider Resources

• Behavioral Health

• Updates and Highlights

• DME Updates and Prescription

• Premium Designation

Introduction to TRICARE




4 Doc#: PCA12480_20140428

What is TRICARE?

TRICARE is …

the health care program for active duty service members, National Guard and

Reserve members, retirees, family members, young adults, survivors and certain

former spouses worldwide.

a network of Military Health System resources and civilian health care

professionals working together to foster, protect, sustain, and restore health for

those entrusted to their care.




5 Doc#: PCA12480_20140428

TRICARE is available worldwide and managed regionally.

Humana Military

Healthcare Services

South Region

TRICARE West Region

UnitedHealthcare

Military & Veterans

West Region

HealthNet Federal Services

North Region




6 Doc#: PCA12480_20140428

TRICARE West Region Contractor

UnitedHealth Group

• National, diversified health and well-being company dedicated to making the health

care system work better

UnitedHealthcare Military & Veterans

• A division of UnitedHealth Group

• An administrator/managed care support contractor for the Department of Defense

(DOD)

• Behavioral health and specialty networks provided through our vendor OptumHealth




7 Doc#: PCA12480_20140428

Military Treatment Facilities

• Military Treatment Facilities (MTFs) provide care for Active Duty Service

Members and other beneficiaries depending on available space.

• MTFs vary from large teaching facilities, such as Naval Medical Center San

Diego, to smaller primary care clinics with no specialty care.

• TRICARE network providers augment the care available at the MTFs.




8 Doc#: PCA12480_20140428

Behavioral Health and PT/OT/ST

Strong, specialized network in the 21 West Region states

• Behavioral health clinicians and facilities contracted through Optum/UnitedHealthcare

• Physical therapy, occupational therapy and speech therapy free-standing clinics

• Serves beneficiary and provider needs

TRICARE Eligibility




10 Doc#: PCA12480_20140428

10 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Eligible TRICARE Populations

Active Duty Service Member (ADSM) & family (ADFM)

Retired Service Member and dependents

Young adult up to age 26

Activated National Guard/Reserve and family

Retired National Guard/Reserve (age 60+) and family

Medal of Honor recipient and family

Other eligible beneficiaries

• survivors

• eligible former spouses

• eligible National Oceanic and Atmospheric Administration (NOAA)




11 Doc#: PCA12480_20140428

This presentation reflects the program as of the date delivered and is subject to change. Administrative guides and the Provider Handbook should be consulted regarding policies and procedures.

TRICARE Eligibility

Verify Patient Status

• Check Military ID or Common Access Card (CAC) on Date of Service

• Use sponsor’s social security number (SSN) or unique Defense benefit number

(DBN) located on back of the ID card

• Validate benefits and eligibility

• Check expiration date

Resources • UnitedHealthcare Military & Veterans

• Provider service: 877-988-9378

• Secure website* UHCMilitaryWest.com

• PGBA Claims Administrator

• Secure website* www.mytricare.com

*Secure portion requires registration




12 Doc#: PCA12480_20140428

Transition from SSN to DBN Newly formatted military and family member ID cards

• 11-digit DoD Benefits Number (DBN) replaces 9-digit Social Security Number (SSN)

• 10-digit DOD ID Number is not used for claims billing

H65 edit alert (invalid Member ID)

• numbers with 10 digits or dashes

12

Doc#: UHC2146v.2_20130725

TRICARE Referrals and Authorizations




14 Doc#: PCA12480_20140428

Referrals and Authorizations - defined

Referral: The process of sending a patient to another professional provider for a

consultation or health care service.

Prior Authorization: A request for services, procedures or admission to a hospital or facility that is

obtained before a service is provided. Prior authorization is not required for

emergencies.

Resources

• Prior Authorization List UHCMilitaryWest.com

• No Government Pay Procedure Code List www.tricare.mil/nogovernmentpay/

14 Doc#: UHC2146v.2_20130725

http://www.tricare.mil/nogovernmentpay/

http://www.tricare.mil/nogovernmentpay/




15 Doc#: PCA12480_20140428

Referrals and Authorizations (non-behavioral)

Active Duty Service Member (ADSM):

Referrals and authorizations are required for all inpatient and outpatient services

Referrals are necessary for:

TRICARE Prime (Active Duty or Retired)

TRICARE Prime Remote (Active Duty and Family)

TRICARE Young Adult (TYA) Prime (AD/Retired)

Authorizations are needed for:

• Any procedure on the Prior Authorization List (all program options)

• All care provided under the Extended Care Health Option (ECHO)

Authorization requests must include supporting clinical information

15 Doc#: UHC2146v.2_20130725




16 Doc#: PCA12480_20140428

Prior Authorization List

Important references to determine if authorization is required:

Narrative Prior Authorization List

Questionable Services List

UHCMilitaryWest.com > Providers > Referrals and Prior Authorizations

• Scroll to end of page for Information links

No Government Pay List - codes excluded from TRICARE coverage and

not payable

• http://tricare.mil/nogovernmentpay/

Referral/Authorization approval is required before providing services.

http://tricare.mil/nogovernmentpay/




17 Doc#: PCA12480_20140428


Primary Care Managers and Specialists can submit referral and

authorization requests.

• Select a network/contracted provider from the provider directory at

UHCMilitaryWest.com or leave the field blank (TRICARE will select a

network provider)

• Network provider selection benefits the beneficiary by:

• Avoiding Prime and Prime Remote Point of Service (POS) billing

issues

• Reduces standard out-of-pocket expenses




18 Doc#: PCA12480_20140428


What is Urgent Care? Medically necessary services (i.e. a sprain, sore throat, or rising temperature) that are required for illness or injury that would not result in further disability or death if not treated immediately.

Requires professional attention, and has the potential to develop into such a threat if treatment is delayed longer than 24 hours

Referral needed for the Prime beneficiary

• TRICARE Prime beneficiaries must receive referrals from their PCMs or UnitedHealthcare Military & Veterans before receiving urgent care

• A claim without a referral could be paid under Point Of Service (POS).




19 Doc#: PCA12480_20140428 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.


Inpatient Notification

• fax 877-578-2738

• needs cover sheet with medical, surgical, and maternity notification

(OB requires authorizations for both global physician care and the hospital stay)

• is required for any scheduled non-emergent admission

• is not required for outpatient observation

Emergency care “In the event of a medical, maternity or psychiatric condition leading to life, limb, or eyesight threatening emergency, the beneficiary should go, or be taken, to the nearest emergency room or appropriate medical facility”

• Notify within 24 hours of an emergency admission (including weekend notifications)

• Certain medical/surgical/behavioral health care services are reviewed for medical necessity and appropriateness of care prior to services being rendered or within 24 hours of an emergency admission




20 Doc#: PCA12480_20140428

Submit Referral and Authorization - Fax

Fax Referral and Authorization requests

877-578-2738 Inpatient admission face sheets

877-890-8203 Urgent requests (care required within 24-72 hours)

Response within 24 hours

877-890-9309 Routine requests

Response within 3-5 business days

877-581-1590 Behavioral Health urgent and routine requests

TRICARE Patient Referral/Authorization Form (Blank and “Type & Print”)

• UHCMilitaryWest.com > Medical/Surgical Referral/Authorization > Find a Form




21 Doc#: PCA12480_20140428

Submit Referral and Authorization- Online

Register for the website and then submit requests online

• Available to UnitedHealthcare Military & Veterans network providers

• Log in to your account at UHCMilitaryWest.com

• Use the Submit Referral or Authorization Request link

Recently added features:

• Send attachments

• Select an Episode of Care (EOC)




22 Doc#: PCA12480_20140428

Supporting Documents

Supporting documentation, such as clinical notes, can be added to the request.

Here are some simple rules:

• You may attach up to 10 documents.

• Each document can be no larger than 25 MB.

Several file formats are supported, including: .txt, .pdf, .doc, .docx, .xls, and .xlsx.

Picture formats are also supported and include: .gif, .jpeg, and .tif.




23 Doc#: PCA12480_20140428

Episode of Care (EOC)

• Select an EOC from the drop down menu.

• Click on View CPT Code Description to see the CPT codes associated with the selected EOC.

• Additional CPT Codes may be added in the box for CPT Code/HCPCS Code.




24 Doc#: PCA12480_20140428

Procedure(s)/Service(s)

Click the Add Additional

Procedure/Service link if you

have more CPT/HCPCS Codes to

enter.




25 Doc#: PCA12480_20140428


Right of First Refusal (ROFR)

ROFR is given when a MTF has the specialty capability and available appointment

times to care for the Prime beneficiary.

• MTF directs ALL care for ADSMs

• MTF is always the primary source of care for Prime beneficiaries living within the

Prime Service Area (PSA)

• ROFR does not apply to seeking care at MTFs for TRICARE Prime Remote,

TRICARE Prime Remote Active Duty Family Member and TRICARE Standard

• Additional referrals/authorizations may be denied if the MTF has capacity for

specialty services




26 Doc#: PCA12480_20140428


Referral/Authorization Appointment Process

Beneficiary is notified via letter, email, or text message to schedule an appointment and notify UnitedHealthcare Military & Veterans of the appointment date by calling 877-988-9378 (WEST)

Requesting specialist and facility receive a copy of the beneficiary letter and approved referral/authorization. Approvals are sent by mail, however, the rendering providers who are enrolled in the fax notification program will receive a faxed approval.

• Call 877-644-4315 if a rendering provider is interested in the fax notification program

Providers may check status at UHCMilitaryWest.com after registration

Providers may request additional services by submitting Referral/Authorization form online or by fax

Specialty referrals valid up to a 180 day max

• exception: obstetrician (OB) is covered for 312 days




27 Doc#: PCA12480_20140428

Search Referrals and Prior Authorizations

After submitting a Referral or Authorization Request, you can then search for

the request to view its status.

• If you are not already logged-in, log in to your UHCMilitaryWest.com

account.

• From the left navigation, click on the Search Referral and Prior

Authorizations link.




28 Doc#: PCA12480_20140428

Search Results

Referral or Authorization Requests submitted online will appear in “Pending” status until they

are processed.

To view the details of the Referral or Authorization,

click on the Reference Number Link.

Office Managers will only be able to view referrals and authorizations

of patients for the specific provider they are logged-in as on the portal.

To view referrals and authorizations for all providers on the account, click

the Switch Provider link in the header to view each Provider individually.

TRICARE Programs




30 Doc#: PCA12480_20140428

TRICARE Programs (product types)

TRICARE Prime

Managed care option

Offered in Prime Service Areas (PSAs) within a 40 mile radius of a MTF

Beneficiary enrolled to Primary Care Manager (PCM) at the MTF or network provider

Referrals made to network specialty providers

Authorizations required if on the Prior Authorization List

Lowest out-of-pocket costs

Point of Service (POS) option

• Deductible: $300 individual, $600 family

• 50 percent cost share




31 Doc#: PCA12480_20140428


TRICARE Prime Remote (TPR) Managed care option

Similar to Prime, TRICARE Prime Remote (TPR) is for the ADSM and the Active Duty Family Member (TPRADFM)

Prime Remote is for ADSMs:

• While assigned to remote US duty stations

• Who live and work more than 50 miles or one hour drive from an MTF

• National Guard/Reserve called to Active Duty Status and their families may be eligible

http://www.google.com/imgres?sa=X&rls=com.microsoft:en-US&biw=1280&bih=849&tbm=isch&tbnid=Rg-O-gDJzNQF6M:&imgrefurl=http://bamc.armylive.dodlive.mil/tag/bamc-doctors/&docid=vTUsWB8hbFzjEM&imgurl=http://bamc.armylive.dodlive.mil/files/2013/03/DSC_0050.jpg&w=3216&h=2136&ei=2OQVU9DwM6PmyQG_04GoDg&zoom=1&iact=rc&dur=884&page=2&start=20&ndsp=27&ved=0CM0BEK0DMCQ




32 Doc#: PCA12480_20140428


TRICARE Standard and TRICARE Extra

TRICARE Standard (like a traditional fee-for-service option)

• Care from a TRICARE-authorized non-network provider

• Most expensive out-of-pocket fiscal year (FY) deductible and cost-shares

TRICARE Extra (like a preferred provider option)

• Care from a network provider

• Reduced five percent FY deductibles and cost shares

No PCM enrollment required

No referrals required

Prior authorization required before performing services on the Prior Authorization List




33 Doc#: PCA12480_20140428


TRICARE Young Adult (TYA)

Similar to TRICARE Standard/Extra/Prime

Eligible dependent age 21 (or 23 if full time student), up to age 26

Need to meet specific criteria to be eligible

Premium-based health plan




34 Doc#: PCA12480_20140428


TRICARE Reserve Select (TRS)

Similar to TRICARE Standard/Extra (deductible and cost share)

TRS coverage for National Guard/Reserve eligible members

Premium-based health plan

Authorizations required for services listed on the Prior Authorization List

Prior authorizations required before performing

services on the Prior Authorization List

http://www.google.com/imgres?sa=X&rls=com.microsoft:en-US&biw=1280&bih=849&tbm=isch&tbnid=53Ydg2uMUobC_M:&imgrefurl=http://www.dosomething.org/tipsandtools/background-military-families&docid=n4VGhcGX5VX8wM&imgurl=http://www.dosomething.org/files/styles/blog_landscape/public/pictures/114161547 (1).jpg?itok=o9L4VHUE&w=550&h=368&ei=-eMVU_uyAsLWyQGQiYDoCw&zoom=1&iact=rc&dur=465&page=4&start=72&ndsp=24&ved=0CL8CEK0DMEo




35 Doc#: PCA12480_20140428


TRICARE Retired Reserve (TRR)

Similar to TRICARE Reserve Select (deductible and cost share)

Premium-base health plan

Specific criteria for eligible Retired Reservist

Prior authorization required for services on the Prior Authorization list




36 Doc#: PCA12480_20140428


TRICARE for Life (TFL) NOT Administered by UnitedHealthcare

TRICARE’s Medicare-wraparound coverage

Available to all TRICARE and Medicare (Part A & B) dual-eligible beneficiaries

Contact Wisconsin Physicians Service (WPS)

866-773-0404 or www.tricare4u.com for

• Benefits

• Claims

• Requirements

Claims filed with Medicare are electronically forwarded to WPS/TFL

http://www.tricare4u.com/




37 Doc#: PCA12480_20140428

Extended Care Health Option (ECHO)

Provides additional healthcare coverage benefits to ADFMs with special needs

Beneficiaries must qualify based on specific mental or physical disabilities and

register with their military branch Exceptional Family Member Plan (EFMP)

Offers integrated set of services and supplies beyond basic TRICARE benefits

Requires prior authorizations for all services





38 Doc#: PCA12480_20140428

Other DOD Health Care Programs

Supplemental Health Care Program (SHCP):

• ADSM and Guard/Reserve with valid Line of Duty injuries may be referred to the network

Transitional Health Care Benefits (TAMP and TCSRC):

• TAMP is transitional coverage for ADSM and family upon separation from Active Duty

• TCSRC is Transitional coverage for the ADSM only

Continued Health Care Benefit Program (CHCBP):

• Transitional coverage (possibly 18–36 months) to former service members and their families, eligible non-remarried former spouses and emancipated children living on their own. Enrollment required with quarterly premiums.

• DoD contracted Humana Military Healthcare Services, Inc. to administer program

US Family Health Plan: (Active Duty Service Members are ineligible)

• A TRICARE Prime Option available in six service areas across the country

TRICARE Dental Programs:

• NOT administered by UnitedHealthcare Military & Veterans




39 Doc#: PCA12480_20140428

TRICARE Programs

TRICARE Pharmacy Benefits

MTF pharmacies are the least expensive option

• Availability may vary by MTF pharmacy location

TRICARE Pharmacy Home Delivery (formerly TRICARE Mail Order Pharmacy)

• Preferred method when not using an MTF pharmacy

• Contractor is Express Scripts: www.express-scripts.com/TRICARE

TRICARE retail network pharmacies

• Network of approximately 60,000 retail pharmacies

Non-network retail pharmacies (most expensive option)

http://www.express-scripts.com/TRICARE




TRICARE

Clinical Programs




41 Doc#: PCA12480_20140428

TRICARE Clinical Programs

Condition (Disease) Management

UnitedHealthcare Military & Veterans covers medical, surgical and behavioral health

management for the following conditions:

• Asthma (adult and children)

• Chronic Heart Failure

• Chronic Obstructive Pulmonary Disease (COPD)

• Cancer Screening

• Diabetes

• Depression

• Anxiety Disorder




42 Doc#: PCA12480_20140428

TRICARE Clinical Programs

Case Management

Programs include:

• Medical, surgical and behavior health case management

Specialty programs

• Extended Care Health Option (ECHO/Autism Demonstration)

• Extended Home Health Care (EHHC)

• Custodial Care Transition Policy (CCTP)

• Transplants, cancer clinical trials, etc.

• Warrior Advocate Program (high risk/cost, seriously ill ADSMs)

Referring a TRICARE beneficiary to Case Management

• Download Case Management Patient Referral Form UHCMilitaryWest.com > Provider > Find a Form > Med-Surg. Referrals & Auths

• Call UnitedHealthcare Military & Veterans: 877-988-9378 (WEST)

TRICARE Provider Types




44 Doc#: PCA12480_20140428

TRICARE Provider Types

All authorized providers meet state licensing and TRICARE certification requirements

e.g., physicians, hospitals, ancillary providers, pharmacies, et al.

Network Providers have signed a TRICARE agreement to accept assignment, file claims and other paperwork for TRICARE beneficiaries

• Participating Non-Network Providers

• participate on claim-by-claim basis

• accept allowable charge and direct payment from TRICARE

Non-Network Providers (out of network) have not signed a TRICARE agreement

• Non-participating Non-Network Providers

• do not accept TRICARE allowable charge or file claims for beneficiaries

• can legally charge up to 15 percent above TRICARE allowable charges




45 Doc#: PCA12480_20140428

TRICARE Network Providers

Network providers may only bill a beneficiary for:

• deductible

• cost-share

• copayment

Network providers may not bill the beneficiary for:

• charges that exceed contracted rates

Network Provider Hold Harmless Policy

Payment is not required for any non-covered services except when:

• beneficiary did not inform provider of TRICARE status

• beneficiary informed the services were non-covered, agreed in advance to pay for specific services, and signed TRICARE Waiver of Non-Covered Services

TRICARE Waiver of Non-Covered Services form

• available at UHCMilitaryWest.com > Find A Form

TRICARE Provider Resources




47 Doc#: PCA12480_20140428

Provider Resources – TRICARE

UnitedHealthcare Military & Veterans:

877-988-9378 (WEST)

Extended hours 7 a.m. to 7 p.m. for all time zones

• Have your tax ID number ready when calling

Routine answers for:

• Claims

• Benefits and eligibility

• Contracting

• Provider data updates




48 Doc#: PCA12480_20140428

Provider Resources – TRICARE

UHCMilitaryWest.com

• Network Provider Directory

• TRICARE program updates and UnitedHealthcare Military & Veterans processes

• Link to TRICARE Manuals and policy information

• TRICARE Provider Handbook

• Downloadable forms

• Prior Authorization List

• Secure website information

Check Status of:

• Claims

• Referrals and Authorizations

• Eligibility

Now Submit online:

• Referrals with Episodes of Care

• Authorizations with attachments

:




49 Doc#: PCA12480_20140428

myTRICARE.com Features

Access available to all TRICARE providers

• Network and non-network

• Hospitals, facilities and providers

Resources available (secure site registration required):

• Verify eligibility (including primary care manager, program and other

health insurance information)

• Check referral/authorization status

• Check claim status

• View and print remits

• Pull claim data reports

• Validate provider file demographics

• Validate/submit NPI numbers

• Submit claims via XPressClaim

• Email PGBA directly and confidentially using the “Ask Us” feature




50 Doc#: PCA12480_20140428

myTRICARE.com Features

PGBA website navigation tutorials

mytricare.com > Provider > myTRICARE help > Tutorials • http://www.mytricare.com/internet/tric/tri/mtc_wprov.nsf/sectionmap/myTRCRHlp_VdTtrls

“Ask Us” – secure and confidential email directly to PGBA

Log in to your myTRICARE.com account

• From home page, click on myTRICARE Help/Tools – “Ask Us”

or

• Select a claim and click “Ask Us” at the bottom of page

http://www.mytricare.com/internet/tric/tri/mtc_wprov.nsf/sectionmap/myTRCRHlp_VdTtrls

TRICARE Behavioral Health




52 Doc#: PCA12480_20140428

TRICARE and Behavioral Health

Behavioral Health Program and Resources

UHCMilitaryWest.com > Beneficiaries > Behavioral Health Programs

• General information on topics such as anxiety, depression, autism, PTSD,

substance abuse and suicide prevention

• Behavioral Health Care Services Brochure and Fact Sheet

• Military OneSource

• Live and Work Well

• Quick Links include the Behavioral Health Clinician Search Tool

52

TRICARE Updates and Highlights




54 Doc#: PCA12480_20140428

UnitedHealthcare Military & Veterans Website

Registration Options: Provider or Office Manager

Provider Registration

• Office personnel can register in place of an individual provider

• This option accommodates an unlimited number of registrants

Office Manager Registration

• Office personnel can create one account and add an unlimited

number of provider/professional tax IDs to the account

• There can be multiple Office Manager accounts with the same

provider/professional tax ID

• Both a provider and office manager can register with the same

provider/professional tax ID




55 Doc#: PCA12480_20140428

TRICARE Service Center Walk-In Service Closure

TRICARE Service Center

• Developed 20 years ago to assist beneficiaries with understanding their TRICARE benefit

• Primarily located at Military Treatment Facilities and clinics

Changes

• Beneficiaries increasingly access electronic, internet and toll-free customer service features

• The need for walk-in customer service has decreased and is no longer offered

Quality customer service

TRICARE beneficiaries can manage their benefits and seek assistance:

• 877-988-9378

• UHCMilitaryWest.com

• www.myTRICARE.com

• www.tricare.mil




56 Doc#: PCA12480_20140428

TRICARE and HealthyPeople.gov

UnitedHealthcare Military & Veterans supports the Department of Health and

Human Services’ National Healthy People Program goals of health-promotion and

disease-prevention.

Providers may encourage TRICARE beneficiaries to the “Healthy People”

webpage for health and wellness tips, updates and resources to maintain or adopt

healthy lifestyle habits.

http://www.healthypeople.gov/2020/default.aspx



TRICARE DME Updates and Prescriptions




58 Doc#: PCA12480_20140428

Durable Medical Equipment Changes

Durable Medical Equipment (DME)

Pricing Criteria as of Feb. 15, 2014

DME Information • Detailed DME information can be found at UHCMilitaryWest.com > Providers > Claims >

Durable Medical Equipment Claims Filing Tip Sheet

Authorization is needed for all DME greater than $150

All DME authorization requests must include: • patient’s name

• procedure code(s)

• diagnosis code(s)

• beginning and ending dates equipment is needed

• physician’s statement of prognosis

• valid physician signature – cannot be a certified Nurse Practioner or Physician

Assistant




59 Doc#: PCA12480_20140428

Durable Medical Equipment Changes

Pricing Criteria

Authorizations satisfy Certification of Medical Necessity (CMN)

requirements if DME item costs $150 - $2000 • Exceptions: five items require additional clinical information through submission of the

appropriate CMS form http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html

Proof of Medical Necessity is required for authorization if DME item

costs more than $2000 Be sure to include:

• “required item list” (patient name, diagnosis codes, procedure codes, etc.)

• supporting clinical information justifying the need

CMS

FORM

ITEMS ADDRESSED

484 Oxygen

846 Pneumatic Compression Devices

847 Osteogenesis Stimulators (Bone Growth Stimulators)

848 Transcutaneous Electrical Nerve Stimulators (TENS Units)

849 Seat Lift Mechanisms

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html












60 Doc#: PCA12480_20140428

DME Upgrade When Medically Necessary

DME upgrade is covered when medically necessary if:

• Item otherwise meets the DME benefit requirement

• Prescription specifically states the medical reason why upgrade is

necessary

(e.g. the beneficiary does not have the physical strength or balance

required to lift a standard walker and, therefore, one with wheels is

required)




61 Doc#: PCA12480_20140428

DME Upgrade: Beneficiary Preference

DME upgrade for deluxe, luxury, or immaterial feature device

when it is a beneficiary preference that is not medically

necessary: • TRICARE-allowed amount for base model may be applied to the upgraded equipment if item

otherwise meets DME benefit requirement

• The beneficiary will be solely responsible for the difference between the base model/standard

equipment allowed amount and provider’s billed charges

• Upgrade must be within the range of services appropriate for the medical condition

(e.g.: with no medical objection from physician, beneficiary can upgrade from standard manual

wheelchair to power wheelchair - not from walker to wheelchair)

When a beneficiary prefers to upgrade: Provider may collect charges that exceed the cost the government would pay for the standard

equipment only when:

• Beneficiary is given written notice the upgrade has been (or may be) denied

• Beneficiary agrees in writing to be financially liable for the difference between charges

for the upgraded item and the charges for the standard item

• DME providers need to identify non-payable upgrades to DME using the appropriate

HCPCS/CPT modifiers




62 Doc#: PCA12480_20140428

DME Upgrade Reimbursement

DME item upgraded by beneficiary

• Beneficiary cost-shares and deductible will apply to the basic DME

• Upgrade is not managed by TRICARE but is calculated by the provider/supplier

issuing the equipment

• Upgraded charges and clerical/calculation errors in connection with the

upgraded equipment:

• are not subject to appeal

• are subject to administrative review by UnitedHealthcare Military &

Veterans upon beneficiary request

The upgrade charge is the difference between the provider/supplier charge for the

deluxe or upgraded item and the allowable charge amount for the covered item.

Repairs

Beneficiary is liable for repairs on the upgraded item/features.




63 Doc#: PCA12480_20140428

Prescriptions

Compound Medications

• Effective Feb. 1, 2014, compound medications containing ingredients not approved by the

FDA will no longer be covered by the TRICARE Pharmacy Program

• TRICARE will continue to pay claims for compound medications containing FDA-approved

ingredients

• Details available at www.express-scripts.com/TRICARE

Please encourage beneficiaries to:

• use the MTF as the least expensive option

• suggest the Express Scripts Home Delivery option

Express Scripts mobile app

• Refill, renew, and track prescription orders through TRICARE Pharmacy Home Delivery

• Set medication reminders

• Locate the nearest retail pharmacy

• Search for drug information and more




UnitedHealth Premium® Designation

Program and TRICARE




65 Doc#: PCA12480_20140428

UnitedHealth Premium® Designation Program

To help members make more informed choices about their health care, the

UnitedHealth Premium Designation program recognizes doctors who meet

quality and cost efficiency guidelines. The provider directory identifies

physicians who have met the criteria at UHCMilitaryWest.com.

“Triple Aim”

1. Improve patient experience of care

2. Improve population health

3. Reduce the per capita cost of health care

Doc#: UHC2146v.2_20130725

Better Health Outcomes, Better Care, Lower Cost




66 Doc#: PCA12480_20140428

Military Health System Quadruple Aim

Doc#: UHC2146v.2_20130725

Increased Readiness

• Ensure the total military force is medically ready to

deploy and that the medical force is ready to deliver health care

Better Health

• Reduce frequency of visits by encouraging health behaviors

and focusing on prevention

Better Care

• Provide a care experience that is safe, timely, effective

and patient centric

Lower Cost

• Consider the total cost of care over time and create value by focusing on quality,

eliminating waste and reducing unwarranted variation

(Source: Military Health System Mission, Evaluation of the TRICARE Program FY 2013)




67 Doc#: PCA12480_20140428

Premium Designation Specialties

25 specialties account for more than

80 percent of total health care costs for services delivered

Primary Care Family Medicine Obstetrics & Gynecology

Pediatrics Internal Medicine

Specialists Allergy Orthopaedics-General

Cardiology Orthopaedics-Foot/Ankle

Cardiology-Electrophysiology Orthopaedics-Hand

Cardiology- Interventional Orthopaedics-Hip/Knee

Endocrinology Orthopaedics-Shoulder/Elbow

General Surgery Orthopaedics-Spine

General Surgery–Colon/Rectal Orthopaedics-Sports Medicine

Nephrology Pulmonology

Neurology Rheumatology

Neurosurgery-Spine Urology

Ophthalmology

Premium Designation information is given for physicians who participate with both

UnitedHealthcare commercial health plan networks and TRICARE networks. Information is not

given for physicians who participate only with the TRICARE network.




68 Doc#: PCA12480_20140428

Premium Designation Availability by State

CT

RI

MA

DE

MD

NJ

AL

AR AZ

FL

IA

IL

MO

LA

MI

MS

TN

SC

PA NE

NY

TX

UT

WI

VA

CO

MN

NC

OH IN NV

NM

ND

OK

OR

WA

GA

SD

HI

VT NH

Available

ID

KS

DC

* Illinois: Not available in Southwest Illinois

Michigan: Not available in Upper Michigan

Pennsylvania: Not available Philadelphia

Missouri: Not available in St. Louis, St. Joseph and Jefferson City

Partial Availability*

Not Available

68

ME

AK

CA

WY

MT

Thank You!

TRICARE West Region - South Dakota Medical Group ... · PDF fileTRICARE West Region Customer...

Documents

Transcript of TRICARE West Region - South Dakota Medical Group ... · PDF fileTRICARE West Region Customer...