Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 42Utilization Management Version 3.0Medical Management GuideTRICARE OPERATIONS MANUALReferrals/Preauthorizations/AuthorizationsRequired Data ElementRequest Date/TimeRequest PriorityDescription/Purpose/UseDDMMYY/hhmmSTAT/24-hour/ASAP/Today/72-hour/RoutineRequester• Referring Provider NAME• Referring Provider NPI• Referring TF• Referring MT NPIName of PCM/MTF individual provider making requestHIPAA National Provider Identifier (NPI) — Type 1 (individual)Name of Military Treatment Facility (MTF)HIPAA National Provider Identifier (NPI) — Type 2 (organizational)Patient InformationSponsor SSNPatient IDPatient NamePatient DOBPatient GenderPatient AddressPatient Telephone NumberPatient Primary Provisional DiagnosisReason for RequestEDI_PN (from DEERS), if availableFull name of patient (if no EDI_PN available)Date of birth (required if patient not on DEERS)Full address of beneficiary (including zip code)Telephone number (including area code), if availableClinical InformationDescriptionSufficient clinical info to perform MNRServiceService1 — ProviderSpecialty of service providerService 1 — Provider Sub-specialtyService 1 — By Name ProviderRequest if Applicable — First and Last NameService 1 — Service TypeAdditional sub-specialist Info, if needed (free text clarifying info entered,with reason for request — e.g., Pediatric Nephrologist)Optional info regarding preferred specialist provider (free text)Inpatient, specialty referral, DM purchase/rental, other health service, etc.DME provider to do CMNService 1 — Service Quantity (optional)Number of visits, units, etc.CHCS Generated Order Number(DMIS-YYMMDD-XXXXX)Unique Identifier Number (UIN) — The DMIS of the referring facilityidentified in the “Referring MTF” field on this request(Date in format indicated — consult order number from CHCS)Source: TRICARE Operations Manual 6010.51-M, Chapter 8, Section 5, (Aug. 1, 2002)Fig. 10 – TRICARE Referrals/Preauthorizations/Authorizations
Medical Management GuideVersion 3.0Utilization ManagementPage 43Communication between MTFs and MCSCs• There will be a single RM POC at the MTF withone phone and fax number.• MTF staff will fax referrals to the MCSC (someMTFs may be using e-fax to perform thisfunction).• MTF staff will not be responsible for coding thediagnosis or procedure(s).• MTF staff must implement the use of Englishlanguagetext.Patient Clinical Information• Referring providers will include pertinent clinicalinformation in the referral.• The referring provider and/or the RMC personnelhave primary responsibility in coordinatingthe transfer of information to the civilianprovider(s).Medical Necessity and Covered BenefitDeterminations• The MCSC will review all referrals to the networkfor medical necessity and covered benefitdeterminations, including the associatedappeals processes within the PCS. However, theMTF is responsible for all referrals for ADSMsand for the MTF appeal process.• No preauthorization is needed for the first eightvisits of non-ADSM patients who seek mentalhealth care with network providers. There is norequirement for MTFs to manage the care ofpatients who self-refer. Mental health care forADSMs needs to be preauthorized.Utilizing Military Treatment Facility Capabilityand Right of First Refusal ReportsMTF staff must:1. Provide the MCSC with accurate, current listingsof the MTF’s capabilities so ROFR reports can beforwarded for MTF care, as appropriate.o MTF staff will regularly update MCSCcapability listings.2. Review all incoming referrals before the closeof the following business day for routine ROFRrequests.o Urgent ROFRs will include personaltelephone contact initiated by MCSCsand near-immediate (not to exceed 30minutes) acceptance or declination by MTFrepresentatives.MTFs must notify the MCSC of receipt of a routinereferral within one business day when the referralhas been accepted. However, if the MTF does notrespond to an ROFR, either negatively or positively,the MCSC will assume an implied declinationand the patient will be appointed to the network(TMA Memorandum, Policy Guidance for ReferralManagement, 2004). It is the MTF’s responsibilityto provide clinical feedback to the referring civilianprovider within 10 business days.Additional InformationThe MCSC does not provide referral services forTRICARE Standard, TRICARE Plus (T-Plus) TRICAREfor Life (TFL), or North Atlantic Treaty Organization(NATO) patients, or for those covered by otherhealth insurance (OHI). The RMC is responsible forassisting with these referral requirements.
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Medical Management Guide, 2009, Version 3.0 - Tricare

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