TRICARE Manuals - Display Chap 2 Sect 7 (Change 5, May 16, 2024) (2024)

TRICARE Operations Manual 6010.62-M, April 2021

Transitions

Chapter 2

Section 7

CriticalProcesses (CPs) - Referral Management (RM)

Revision:

1.0RM

1.1The incomingcontractor shall establish an automated RM process in accordancewith Section C of the contract and Chapter 7, Section 5 nolater than the 90 calendar days prior to the start of health caredelivery (SHCD).

1.2The incomingcontractor shall implement an electronic RM system that integrateswith the Government’s electronic RM system no later than 60 calendardays prior to the SHCD.

1.3The incomingcontractor’s RM system shall interface with the Uniformed ServicesRM process and/or system(s) at each Military Medical Treatment Facility(MTF), United States Coast Guard (USCG) clinics, and Markets nolater than 60 calendar days prior to the SHCD.

1.4The incoming contractor’s RMsystem shall include the ability to capture referrals and authorizationsfrom civilian providers into the Markets/MTFs and other businessprocesses as necessary to ensure that inbound and outbound referralsare processed accurately and timely in accordance with Chapter 1, Section 3, with a focus on thosereferrals with high value Knowledge, Skills and Abilities (KSAs)as defined by the Government.

1.5The incomingcontractor shall phase in referral processing as follows:

Day 1 of health care delivery(HCD) - The contractor shall process Active Duty Service Member(ADSM) and TRICARE Prime Remote (TPR) ADSM and Active Duty FamilyMember (ADFM) referrals only.

Day 31 of HCD - The contractorshall include in its referral processing TRICARE Prime beneficiariesenrolled to MTF Primary Care Managers (PCMs).Day 61 of HCD - Thecontractor shall include in its referral processing TRICARE Primebeneficiaries enrolled to a network PCM.Day 91 of HCD - The contractorshall include any other beneficiary category that requires a referral.

1.5.1A PCMreferral waiver and/or Point of Service (POS) waiver will be implementedwith this phased-in approach of referrals.

1.5.2The contractorshall submit a Daily Authorization Inventory Report and a DailyRolling Referral Inventory Report to the Government. For reportingrequirements, see DD Form 1423, Contract Data Requirements List(CDRL), located in Section J of the applicable contract.

2.0PERFORMANCE READINESS VALIDATION(PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)

During transition, the incomingcontractor’s performance readiness status regarding RM will be subjectto PRV/PRAV reviews as described below.

2.1RMPRV

2.1.1The incoming contractor shallvalidate its RM system can interface with the Government’s RM systems (MHSGenesis and RM Suite (375)).

2.1.2The incomingcontractor shall validate its interface meets two criteria:

2.1.2.1Markets/MTFs can send and receivereferrals with priority to those with a high KSA value with no technicalproblems, and

2.1.2.2The contractor sends referralsand authorizations in accordance with the Market/MTF Capability Tablewith 95% accuracy, as listed in paragraph 2.1.9.2.

2.1.3The incoming contractor shallvalidate its RM systems can effectively interface with the Government’s RMsystem(s), Defense Enrollment Eligibility Reporting System (DEERS),contractor’s claims systems, network provider directory, and thesystem network providers utilize to submit referrals and authorizationno later than 60 calendar days prior to the SHCD.

2.1.4The incoming contractor shalltest, validate, and produce connectivity test results on all interfaces.

2.1.5The incoming contractor shallvalidate all aspects of its referral, authorization and commandapproval (overseas only) processes by utilizing test scenarios whichinclude referrals to Market/MTF and network providers and referralsfrom contractor to Market/MTF no later than 60 calendar days priorto the SHCD.

2.1.6The incoming contractor’s processvalidation shall encompass all beneficiary categories and will use livedata from the Government’s RM system as part of the validation.

2.1.7The incoming contractor shallvalidate that its system can timely and accurately communicate referral, authorizationdeterminations with beneficiaries, network providers, Governmentsystems and claims systems without technical problems.

2.1.8The incoming contractor shallvalidate its ability to communicate with beneficiaries with multiple referralstatus alerts and notification options, including email, text, web-portaland hardcopy letters, to include beneficiary view and print capabilities.

2.1.9The incoming contractor’s validationshall demonstrate their RM system’s ability to accurately process 90%of all requests within one business day and 100% within two businessdays.

2.1.9.1The contractor shall validateits RM system (e.g., approval/denial letters) is accessible by the Government,beneficiaries, and providers.

2.1.9.2The incoming contractor shallvalidate that referrals processed meet contract requirements witha 95% accuracy rate. To be considered accurate, processed referralshall include:

Correct beneficiary

Correct beneficiary demographics

To include sponsor’s last fourdigits of the Social Security Number (SSN) or Department of Defense(DoD) ID Number

Date of Birth (DOB)

Unique Identifier Number (UIN)is present if Market/MTF generated request

Correct Servicing Provider

Correct Servicing Specialty

Correct Episode of Care (EOC)

Evaluate and Treat

Evaluate only

Number of visits

Length of authorization

Range of Current ProceduralTerminology (CPT) codes

2.2RM PRAV

2.2.1The incomingcontractor shall comply with the Government’s approach for assessmentand verification of the contractor’s performance readiness regardingenrollment activities as described above.

2.2.2The incomingcontractor shall submit a detailed mitigation plan no later than10 business days following the Government’s findings if, after review,the Government finds the contractor’s performance readiness forenrollment processing to be deficient. Specific PRAV activities,assessment techniques, and performance readiness thresholds willbe identified by the Government during the Transition Specifications(TRANSPEC) Meeting.

- END -

TRICARE Manuals - Display Chap 2 Sect 7 (Change 5, May 16, 2024) (2024)

FAQs

How to get a TRICARE for Life handbook? ›

It describes how Medicare and TRICARE work together, provider options, costs, claims, and more. Want to order a hard copy of the TRICARE For Life Handbook? Call Wisconsin Physicians Service (WPS) at 1-866-773-0404.

How do you update your address with TRICARE? ›

You can update your home address, email address or phone number(s) by:
  1. Logging in to milConnect.
  2. Calling 1-800-538-9552 (TTY/TDD: 1-866-363-2883)
  3. You can also fax or mail your changes. >> Learn More.
Feb 6, 2024

Is North Dakota TRICARE east or west? ›

West Region. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (southwestern corner including El Paso), Utah, Washington and Wyoming.

How to apply for TRICARE for Life? ›

You don't have to enroll to use TRICARE For Life—coverage is automatic as long as you are registered in the Defense Enrollment Eligibility Reporting System and have Medicare Part A & B.

Do all military retirees get TRICARE for Life? ›

If you retire from the National Guard or reserves, you can purchase Tricare Retired Reserve until age 60. At that time, you get the same options as retired active-duty members. At age 65, you are no longer eligible for those programs. You can then purchase Medicare and Tricare for Life.

What is the monthly cost for TRICARE for Life? ›

There are no enrollment fees or monthly premiums with this TRICARE retiree plan, because it provides “wraparound” coverage to Medicare benefits. Medicare is the primary payer. However, you must have Medicare Part A and B to qualify and pay Part B premiums, which are based on your income.

What company owns TRICARE? ›

Tricare (styled TRICARE) is a health care program of the United States Department of Defense Military Health System.

What is the difference between TRICARE and TRICARE West? ›

In short, TRICARE covers active duty service members, retirees, and their family members. TriWest covers veterans and certain members of the National Guard and Reserves. This difference can become confusing because people sometimes mistake “retiree” for meaning the same thing as “veteran”.

What is TRICARE East called now? ›

Committed to creating better health outcomes and simplified experiences. Humana Military is dedicated to offering the finest healthcare available, with a simplified approach to service and care. Self-service empowers your experience with quicker and more efficient options.

Do I lose TRICARE at age 65? ›

TRICARE and Medicare beneficiaries who are age 65 must have Medicare Part A and Part B to remain TRICARE-eligible and be able to use TFL. TRICARE beneficiaries who aren't eligible for premium-free Medicare Part A at age 65 on their own work history or their spouse's work history remain eligible to enroll in USFHP.

Who is not eligible for TRICARE for life? ›

Dependent parents and parents-in-law are not eligible for TFL. When TRICARE beneficiaries become entitled to Medicare Part A and B (1) on the basis of age (65), (2) disability, or (3) end-stage renal disease, they are eligible for TFL.

Is TRICARE for Life still free? ›

TRICARE For Life is available worldwide. To learn more, visit the TRICARE For Life page. Costs: There are no enrollment fees but you must pay the Medicare Part B monthly premium.

How do you prove you have TRICARE for life? ›

For most people with TRICARE, you'll need to show your Uniformed Services ID card to your provider as proof of TRICARE eligibility. If you're an active duty service member, you'll need to show your Common Access Card.

Is there a difference between TRICARE and TRICARE for Life? ›

TRICARE is a health insurance program provided by the federal government to active duty and retired military personnel and their family members. There are many different TRICARE programs. TRICARE for Life (TFL), a program for Medicare-eligible military retirees and their dependents, acts as a supplement to Medicare.

Is there a card for TRICARE for Life? ›

There isn't a TRICARE For Life card. When you go to the doctor, you need to show your valid uniformed services identification (ID) card and your Medicare card. If you don't have a uniformed services ID card, or it's expired, visit your nearest ID Card Office.

Does TRICARE for Life pay for gym membership? ›

No. By law, TRICARE can't pay for exercise programs. This includes (but not limited to): SilverSneakers® Fitness program.

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