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May 2018

TRICARE®

Provider NewsW

TRICARE Prime Waiver Period Ends

Submitting Authorization and Referral Requests to HNFSOnline-only submissions

With the waiver lifted, TRICARE Prime enrollees must follow Prime referral and authorization guidelines for any specialty services referred by their providers for new referrals issued post-waiver, or Point of Service charges may apply.

As of April 16, 2018, providers must submit outpatient referral and authorizations requests to HNFS through the online tools at www.tricare-west.com*. Should we require additional medical documentation, we will notify you and provide submittal instructions. Requests submitted via fax on or after April 16, 2018, will not be processed. We realize if you previously submitted requests via fax this is a change for you.

Please review the following steps on how to submit requests to HNFS:

1. Get registered. If you haven’t already registered at www.tricare-west.com, we encourage you to do so. Registration gives you access to CareAffiliate®, our comprehensive online submission tool. CareAffiliate allows for inpatient and outpatient requests, attachments and the ability to create “frequently used” lists to expedite submissions.

2. Not yet registered? We offer a Web Authorization Referral Form (WARF) tool that does not require website registration.

3. Verify requirements. It’s important to verify requirements before you submit. Go to www.tricare-west.com > Provider > Is Approval Needed to verify referral and authorization requirements before submitting a request to HNFS. Remember, not all specialty care referrals require HNFS review. Take the guesswork out of what needs an approval – and what doesn’t – by always verifying requirements online first.

4. Submit online. Every time. As of April 16, 2018, all requests must be submitted online at www.tricare-west.com.

We encourage you to visit www.tricare-west.com to learn about our online submission tools. See page 2 of this newsletter for additional online submission tips.

*Providers in Alaska may submit via fax, if needed.

The TRICARE Prime referral waiver period, which allowed TRICARE West Region beneficiaries enrolled in a TRICARE Prime plan to bypass the Health Net Federal Services, LLC (HNFS) review and approval process for most referred specialty outpatient care, ended for care from military providers on April 1, 2018 , and for care from civilian providers on April 15, 2018.

Referrals for covered outpatient services issued to TRICARE Prime patients during the waiver period remain valid through June 30, 2018, or for obstetrical care, through the patient’s postpartum period. These will not show in our online authorization and referral tools; however, the TRICARE West Region Referral/Authorization Waiver Approval Letter is your verification of approval.

As a reminder, the waiver excluded inpatient care, and applied behavior analysis, laboratory developed test and Extended Health Care Option (ECHO) services.

If you referred a beneficiary for care during the waiver period, you only need to request a new approval from HNFS if that care extends past June 30, 2018 (or through postpartum care). We also ask you not resubmit requests for services that are already covered under an active HNFS approval. Your cooperation with these guidelines can help reduce the amount of unnecessary requests received and expedite beneficiaries’ access to care.

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Get Registered!Registration gives you access to CareAffiliate®, our comprehensive online submission tool. While we do offer an online submission option for those providers not registered, CareAffiliate is the preferred method, as it can be used for inpatient and outpatient requests, allows for attachments and gives users the ability to create “frequently used” lists to expedite submissions. We offer a step-by-step guide to using CareAffiliate® at www.tricare-west.com > Provider > Quick Reference Charts to help walk you through the online submission process.

Referral and Authorization Submission TipsIn addition to TRICARE benefit and program changes that took effect Jan. 1, 2018, you may have noticed some differences in HNFS’ approval requirements from the previous TRICARE West Region contractor, UnitedHealthcare Military & Veterans. We encourage you to review the following tips to help streamline the submission process:

1. It’s important to verify requirements online before you submit. Go to www.tricare-west.com > Provider > Is Approval Needed to verify referral and authorization requirements before submitting a request to HNFS.

2. Active duty service members continue to require a referral for most care. Active duty service members require a referral for all care, except for emergency inpatient admissions and chemical dependency detoxification. Note: Active duty service members enrolled in TRICARE Prime Remote do not require a referral for urgent care due to their remote location.

3. TRICARE implemented changes to its urgent care benefit. As of Jan. 1, 2018, most TRICARE Prime beneficiaries no longer require a referral when seeking urgent care from a network primary care provider or a network/non-network (TRICARE-authorized) urgent care center. Review updated benefit details at www.tricare-west.com > Provider > Benefits A–Z.

4. Applied behavior analysis (ABA) services always require a referral. This applies to TRICARE Prime and TRICARE Select beneficiaries.

5. Outpatient mental health visits with a licensed pastoral counselor, licensed professional counselor or mental health counselor always require a referral and physician oversight.

6. When creating your online request, be sure to complete all required fields, and be clear and concise in the clinical information provided (for example, include diagnoses, presenting problem, symptoms).

7. If requesting a specific provider, you must include his or her first and last name, and address.

8. Unless asked by HNFS, it is not necessary to submit additional clinical information to HNFS after submitting a request. If after receiving and reviewing the request HNFS determines additional information is needed, an HNFS team member will notify the requesting provider.

9. Please remind your patients to not schedule appointments if they are still awaiting a response on new requests submitted to HNFS.

10. To check the status of your request, log in at www.tricare-west.com and click on “Check Authorization Status” in the Secure Tools box. For providers not registered, we also offer a check status option on our public portal at www.tricare-west.com > Provider > Authorizations > Check Status.

For additional information on TRICARE West Region authorizations, visit www.tricare-west.com > Provider > Authorizations.

Understanding HNFS Referral and Authorization Approvals Part of the HNFS referral and authorization approval process is the use of standard request profiles. Request profiles allow us to authorize CPT® codes or ranges of codes based on the service requested. The request profiles loaded into our online authorization and referral tools automatically populate information when selected (for example, CPT® codes, number of visits and duration of the authorization).

Certain request profiles include multiple CPT® codes that cover a range of services. By issuing a standard range of pre-authorized codes, HNFS gives providers the flexibility to provide services that specifically match the totality of care needed.

If the approval letter received from HNFS includes a range of codes, all services provided within that range are considered authorized by HNFS. Keep in mind, not all services require prior authorization. HNFS may not specify related codes are approved in our letters, if those codes on their own do not require HNFS review and approval.

If using the Web Authorization/Referral Form (WARF) at www.tricare-west.com to submit requests, we offer a WARF Request Profile Guide that lists the code ranges for each request profile. This guide is accessible at www.tricare-west.com > Provider > Authorizations > Submit a Request, and within the WARF tool itself.

TRICARE Billing RemindersTRICARE Prohibits Waiver of Copayments, Cost-Shares or DeductiblesSome providers may routinely reduce the cost of care to a patient by waiving or forgiving a copayment, cost-share or deductible. However, waiving patient out-of-pocket costs for TRICARE beneficiaries is a violation of Title 10, United States Code, Section 1079 and 1086. Doing so is considered fraud and abuse, which can result in fines and other legal action. With the exception of uncollectible bad debt, only the Director of the Defense Health Agency can determine if a provider may waive beneficiary copayment, cost-share or deductible amounts.

Waiving beneficiary copayments, cost-shares or deductibles may result in TRICARE refusing to pay the claim, removal of the provider from the network and suspension of authorized provider status under TRICARE.

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Website RegistrationYour access to the secure portal at www.tricare-west.comIf you have not already completed registration at www.tricare-west.com, we invite you to register to ensure access to all the online self-service tools HNFS offers.

We offer two registration methods. We strongly encourage you to use the instant registration method using claims or authorization data, as it is the fastest and easiest way for you to register and gain instant access to a suite of self-service tools:

1. Instant registration: Uses TRICARE West authorization or claim numbers and related patient information. This process allows for instant access.

2. Secure key code registration: Requires we mail a letter to the office location you select during registration. This process may take a few weeks to complete depending on the U.S. postal system and the routing of postal mail within your location.

Secure portal vs. public portalThe online tools at www.tricare-west.com > Provider can help providers and staff quickly complete transactions for TRICARE patients. We offer online resources that take you from eligibility verification to claims payment … all fax, postage and envelope free! We require registration

for tools on our secure portal, while tools and content on our public portal can be accessed without logging in. Secure Portal Public Portal

• Patient eligibility• Prior Authorization and Benefit Tool (Is Approval

Needed?) – complete version• CareAffiliate® (to submit authorization/referral requests)• Authorization status• Claims submission and status• Document upload• Claims data reports• Provider remits• EFT/ERA registration• Recoupments• TRICARE Provider Connect (medication lists and

patient view) • Credentialing status• PCM Enrollee Roster• Preventive services history• Secure Inbox• Ask Us

• Benefits A–Z • Copays and cost-shares• Prior Authorization and Benefit Tool (Is Approval

Needed?) – basic version• Web Authorization/Referral Form (WARF) (to submit

requests without website registration)• Authorization status – basic version• Network and non-network provider directories*• Handbooks, quick reference charts and additional

reference materials• Webinar schedule and presentations• FAQs

*HNFS continues to build its West Region network. Many provider contracts are in process and will be added to our directory soon. We are aware of duplicate or incorrect entries in the directory and are working to correct these issues.

How to Access TRICARE Claims Information Claims data at myTRICARE.com no longer availableAs of May 1, 2018, TRICARE West Region claims information for dates of service on or before Dec. 31, 2017, is no longer available on PGBA, LLC’s myTRICARE.com website. While PGBA remains the TRICARE claims subcontractor for HNFS, West Region providers should use www.tricare-west.com as their online resource.

Active UnitedHealthcare authorization information will be available at myTRICARE.com through June 30, 2018, although the option to print previously issued approval letters is no longer available.

Did you know? Health Net Federal Services transitioned two years of UnitedHealthcare claims data beginning with dates of service Jan. 1, 2016, to its systems. These, along with current claims can be viewed at www.tricare-west.com.

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Point of Service Deviation ExtensionIn order to allow managed care support contractors sufficient time to process enrollments and assign primary care managers after the government-issued enrollment freeze late last year, the Defense Health Agency (DHA) implemented a waiver of Point of Service fees for TRICARE Prime-enrolled beneficiaries who sought care from non-network providers. Recently, DHA extended the period in which Point of Service charges will not apply from Jan 1–March 31, 2018, to Jan 1–June 30, 2018.

The Point of Service waiver applies to the following:

• Primary care manager (PCM) assignments: TRICARE Prime beneficiaries whose PCMs from UnitedHealthcare Military & Veterans (UnitedHealthcare) are not in the HNFS West Region Network Directory, or who have not yet been assigned a PCM, can see any TRICARE-authorized PCM through June 30, 2018, and Point of Service charges will not apply. Providers should continue to submit referrals for specialty care to HNFS, as appropriate.

• UnitedHealthcare authorizations: HNFS continues to honor referrals and authorizations issued by UnitedHealthcare through their 2018 expiration dates, even if the servicing provider is not a part of the HNFS West Region network. TRICARE Prime beneficiaries who choose to see a different civilian provider than the one authorized by UnitedHealthcare, may see any TRICARE-authorized provider of that specialty. Point of Service charges will only apply after June 30, 2018, should the beneficiary choose a non-network provider.

Point of Service only applies to TRICARE Prime plans. Point of Service does NOT apply to:

• Active duty service members

• Beneficiaries using non-Prime plans. Beneficiaries enrolled in TRICARE Select plans, TRICARE Reserve Select and TRICARE Retired Reserve can see any TRICARE-authorized provider (network or non-network); however, out-of-pocket costs will vary based on the provider's network status.

• Newborn or adopted children until enrolled in TRICARE Prime. Children are covered by TRICARE Prime for 90 days (120 days overseas) after birth or adoption as long as one other family member is enrolled.

• Beneficiaries with other health insurance, such as Medicare or an employer-sponsored health insurance.

• The following types of care:

o Emergency care

o Preventive care from a network provider in your region

Online Education for TRICARE ProvidersIn a busy office setting, it can be difficult for health care providers to find time to train new and existing staff about the TRICARE program. That’s why HNFS provides online webinars, available to providers for viewing from the office or home. Registration isn’t required for the webinars – simply click on the “Join Now” link and call in to the listed telephone number. For system requirements and schedules, visit www.tricare-west.com > Provider > Education > TRICARE webinars.

Additionally, The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) offer a free monthly webinar series for providers focusing on active duty military, their beneficiaries and veterans’ psychological health and traumatic brain injury. The monthly DCoE webinars are designed to help foster better understanding of pioneering medical research, familiarize health care professionals with the unique needs of our active military and their families, and to allow providers an opportunity to earn required continuing education credits conveniently. Visit http://dcoe.cds.pesgce.com to view the schedule and sign up for a DCoE webinar.

The Importance of Clear and Legible ReportsClear and legible reports (CLRs) are necessary to ensure information is recorded accurately and to avoid untimely disruptions in care for TRICARE beneficiaries. Network providers must provide CLRs – which include consultation reports, operative reports, and discharge summaries – to the referring military hospital or clinic within the specified time frame listed below. Network urgent care centers should submit CLRs to the beneficiary’s assigned military hospital or clinic, as there may not be a referring provider. (Obtain beneficiary authorization when necessary before releasing sensitive information such as alcohol and drug abuse patient records, as required by law.)

Our online CLR Fax Matrix lists all TRICARE West Region secure military hospital or clinic fax numbers and a local CLR mailing address should you prefer to mail the CLR. This matrix is subject to change. Always confirm fax numbers before sending reports.

For complete CLR submission instructions and to access the CLR Fax Matrix, visit www.tricare-west.com > Provider > Take Me To…Clear and Legible Reports.

Contacting HNFS Customer ServiceWhile HNFS offers many self-service tools at www.tricare-west.com, we realize there are times when a phone call is required. If you need to contact our customer service department, please keep in mind our highest call volume days are Mondays and Tuesdays, and our busiest times tend to be in the late morning to early afternoon. If possible, we recommend waiting until later in the day and later in the week to call.

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Benefit Corner

Mental Health Clinical Documentation RequirementsAdequate medical documentation provides the means for measuring the type, frequency and duration of care provided. Under TRICARE, providers are required to keep sufficient clinical records to substantiate that care provided was actually and appropriately furnished and medically or psychologically necessary. TRICARE requires the following mental health provider types must, at a minimum, maintain medical records in accordance with The Joint Commission, the Commission on the Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (CoA) or an accrediting organization approved by the Director, Defense Health Agency (DHA).

• Acute care psychiatric hospitals

• Intensive outpatient programs

• Inpatient/residential substance use disorder rehabilitation facilities

• Opioid treatment programs

Clinical documentation should include, but is not limited to, psychiatric and psychological evaluations, physician orders, treatment plans, physician and/or integrated progress notes, and discharge summaries (refer to TRICARE Operations Manual, Appendix A, Definitions).

Baseline assessment of psychiatric admissionsIn addition, all psychiatric admissions require an evaluation report, to include baseline assessments using standardized measures, for the diagnosis of post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD) and major depressive disorder (MDD). The qualifying standardized measures, to be performed at 60–120 day intervals and at discharge, include:

• PTSD: PTSD Checklist (PCL)

• GAD: GAD-7 and

• MDD: Patient Health Questionnaire – 8 (PHQ-8)

State Vaccine ProgramAs of April 1, 2018, TRICARE will allow State Vaccine Programs (SVPs) that agree to reimburse on a per capita assessment to be certified as TRICARE-authorized providers without executing a participation agreement. TRICARE defines per capita SVPs as those that are reimbursed for purchased vaccines based on the proportional allocation of state vaccine-eligible children and adults covered under TRICARE. This policy applies to SVPs located within the continental U.S. to include Alaska and Hawaii, the Commonwealth of Puerto Rico, and all U.S. territories. Please refer to the TRICARE Policy Manual, Chapter 11, Section 9.2 for additional information.

No-Transport Ambulance Services for Active DutyTRICARE does not cover services or supplies provided by ambulance personnel if there is no transport, except when services are provided by ambulance personnel while awaiting the arrival of a more urgent means of transport, such as air ambulance. Under the Department of Defense’s Supplemental Health Care Plan, as of March 2, 2018, active duty service members (ADSMs) may request a DHA waiver for denied no-transport or treat-and-release ambulance services that occurred prior to April 21, 2018. HNFS includes instructions on the DHA waiver process on denial notices issued to ADSMs. We also offer information on our beneficiary portal at www.tricare-west.com > Beneficiary > Authorizations > Appeals > Supplemental Health Care Plan. No-transport ambulance services for ADSMs that occur on or after April 21, 2018, are covered under SHCP without a waiver.

• Outpatient mental health and substance use disorder treatment

• Partial hospitalization programs

• Psychiatric residential treatment centers

• Psychiatric units within acute care institutions

Claims and Appeals: Submit to HNFS As of May 1, 2018, all TRICARE West Region claims and appeals must be submitted to HNFS, and not UnitedHealthcare, regardless of the date of service.

This includes any corrections, reconsideration requests or follow-up correspondence to claims and appeals previously submitted to or processed by UnitedHealthcare.

We offer complete submittal instructions at www.tricare-west.com > Provider > Claims.

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Resources for Implementing Choosing Wisely®

Do you ever find yourself concerned that you or your colleagues are providing tests or treatments that are unnecessary or have limited benefit? Choosing Wisely® is an initiative of the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports that aims to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. Learn more about Choosing Wisely at www.tricare-west.com/go/cwprov.

Not sure where to start, or looking for ideas to advance your Choosing Wisely efforts? Find a variety of guides and toolkits at www.choosingwisely.org > Getting Started > How Can I Implement Choosing Wisely in My Practice or Health System? to help you plan and implement Choosing Wisely in your practice, including:

• The American Medical Association’s module to help physicians advance Choosing Wisely;

• Consumer Reports step-by-step guide that helps clinicians, health systems, employers, and community organizations implement a consumer-facing campaign;

• The American Society for Clinical Pathology’s online toolkit, which includes blog posts, implementation guides, handouts, and posters you can download;

• Maine Quality Counts’ toolkit which includes practice workflow scripting and easy ways for a practice to empower patient through Choosing Wisely;

• ABIM Foundation and Robert Wood Johnson’s “Advancing the Choosing Wisely campaign in Clinical Practices and Communities”, which details the stories of successes and lessons learned from the first round of Choosing Wisely grantees;

• And much more!

You can become a Choosing Wisely champion today.

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Patient Safety Corner

Insights from AviationHealth care and aviation are both complex industries, involving technology and time-constrained situations, where individual lives are at risk. Both rely on highly skilled, trained professionals to work collaboratively with each other to achieve safe outcomes. Known for its success in safety, here are some key aspects in aviation that can be evaluated in health care to improve patient safety.

Checklists Checklists are widely used in aviation and proven to be effective. Dr. Atul Gawande, renowned author of The Checklist Manifesto, learned at Boeing, the “pilot’s checklist” is crucial, not just for how to handle takeoff and landing in normal circumstances, but how to handle a “crisis emergency” when there is only a few minutes to make a critical decision. He introduced a simple surgical checklist in eight hospitals and the death rate fell 47 percent.1 Dr. Peter Pronovost created a checklist for reducing bloodstream infections that saved 1,500 lives and $100 million.

Culture of safety Captain Chelsey “Sully”, the pilot who successfully landed Flight 1549 in the Hudson River described how there is a culture shift in aviation from a “blame-based” to a “learning-based” system. Feeling comfortable providing information on errors and safety issues is crucial to early detection and allows for the opportunity to learn from them. When introductions were made before a surgery, Dr. Gawande found that the average number of complications and deaths decreased by 35 percent. He explains, "The person, having gotten a chance to voice their name, let speak in the room, was much more likely to speak up later if they saw a problem."

Systematic reporting and investigation

Aircraft accidents are highly visible and improvements are readily integrated into practice. The National Transportation Safety Board (NTSB) independently investigates these accidents to understand the system-wide causes and then disseminates recommendations to any relevant organization, not just the airline. Although, there are no health care agencies comparable to NTSB, improvements are underway for a more standardized reporting and investigation, such as The Joint Commission’s Root Cause Analysis and Action Plan.

Understanding the successes and lessons learned in one industry, like aviation, can be insightful and lead towards improvements in patient safety.

1 Gawande, A. (2010). The checklist manifesto: How to get things right. New York:

Metropolitan Books.

Performance Based Maternity Payment PilotValue-based initiatives, authorized by the National Defense Authorization Act for Fiscal Year 2016, seek to reward better health outcomes, enhance beneficiaries’ experience of care, and reduce health care costs over time. TRICARE will soon implement the Performance Based Maternity Payment Pilot, a value-based initiative that seeks to improve health outcomes for mothers and babies through an increased emphasis on maternity care quality in the TRICARE networks.

The initial phase of the pilot focuses on updating our network provider directory to identify those providers who have been assigned a performance rating of “Fully Meets the Standard” by The Leapfrog Group, a national nonprofit organization established to drive improvements in health care quality and safety.

The Leapfrog Group conducts an annual hospital survey and compares reported hospital performance against nationally-recognized benchmarks for five maternity care measures (early elective deliveries, C-sections, episiotomies, maternity care processes, and high-risk deliveries). Applicable providers will be awarded a rating (Value, High Value and High-Risk Deliveries) based upon the most current survey data posted by The Leapfrog Group on its public website.

HNFS will use these ratings to then indicate Value, High Value and High-Risk Delivery providers in the West Region network provider directory, no later than June 5, 2018.

Participation in The Leapfrog Group’s survey is voluntary, and the lack of a quality designation in the West Region network provider directory does not mean that hospital provides low-quality care. All network providers must meet TRICARE’s and HNFS’ stringent quality and credentials requirements. To learn more about The Leapfrog Group and survey participation, scoring and results, please visit www.leapfroggroup.org.

Health Net Federal Services, LLCPO Box 2890Rancho Cordova, CA 95741

HN0418x010 (04/18)

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Contacts Health Net Federal Services, LLC 1-844-866-WEST (1-844-866-9378) www.tricare-west.com

PGBA, LLC EDI/EFT Help Desk 1-800-259-0264

Express Scripts, Inc. Pharmacy inquiries 1-877-363-1303 www.express-scripts.com/TRICARE

Visit us at www.tricare-west.com and Facebook

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