TRICARE Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 5
ReferralManagement (RM)
Revision:
1.0RM PROGRAM
1.1The contractorshall establish and maintain a RM program as outlined in this Chapter.
1.2The contractor shall reviewthe referral request in accordance with Chapter 1, Section 3,to determine:
•That the provider to whom thepatient is referred meets applicable authorized provider and networkprovider requirements;
•That the services being requestedare a TRICARE covered benefit and are requested in a covered setting;and
•Whether any specific servicesrequested as part of the referral also require preauthorization.
1.2.1The contractor shall providea response to referrals and authorizations, as part of the processto completion (PTC).
1.2.2The contractorshall send the response and updates to the referring provider, beneficiaryand referred to provider and when applicable to the Markets/MilitaryMedical Treatment Facilities (MTFs).
1.3The contractor shall developand provide a Health Insurance Portability and Accountability Act(HIPAA)-compliant web-based RM system that the Markets/MTFs canuse to view referral details (to include but not limited to eligibilitycheck information) and track Market/MTF referred care to and fromprivate sector care and allows the Market/MTF to ascertain whethereach referral resulted in beneficiary care. The system should berefreshed at a minimum of every 24 hours.
1.3.1The contractor’ssystem shall, at a minimum, provide the status of all referrals,including ‘drill down’ detailed data at the individual referrallevel, and search functions using multiple parameters includingbut not limited to beneficiary, date range, provider, Market/MTF,specialty and Referral Case Number/Unique Identifier Number (UIN).
1.3.2The contractor shall link claimsdata to the appropriate referral within its web-based system.
1.3.3The contractor’s system shallallow for multiple file types to be uploaded from the Market/MTFto themselves, which includes, but is not limited to, Portable DocumentFormat (PDF), Word, and imaging files.
1.3.4The contractor’sRM system/portal shall include all authorization and denial correspondenceto beneficiary and providers and be viewable by the Government.
1.4The contractor shall collaboratewith the Government to develop a table of acceptable secondary referralsthat will allow identified specialty-to-specialty referrals withinthe same Episode of Care (EOC) for TRICARE Prime beneficiaries.The contractor may recommend or the Government may direct addingor deleting specialties from this table semiannually.
1.5The contractor shall coordinatewith other TRICARE Private Sector Care Contractors (PSCCs) (continental UnitedStates (CONUS) only) to ensure that all determinations about whethera referral, treatment, or service is a TRICARE covered benefit,is in a covered setting, and whether services that require preauthorizationand specialty-to-specialty referrals are consistent, regardlessof the beneficiary’s geographic location (within CONUS) and which PSCCthe beneficiary is enrolled to.
1.6The contractorshall utilize the Market/MTF Capability and Capacity tables to identifyreferrals and authorizations for TRICARE Prime beneficiaries toreceive care at the MTF to meet Market/MTF Knowledge, Skills andAbilities (KSAs) to maintain readiness.
1.7The contractorshall identify authorizations for TRICARE Select beneficiaries andoffer TRICARE Select beneficiaries the choice to receive care atthe MTF to meet Market/MTF KSAs to maintain readiness.
1.8The contractor shall utilizeautomation in processing referral and authorization, EOCs, procedureand diagnosis coding.
1.9The contractorshall conduct all referral communications with the Market/MTF usingDepartment of Defense (DoD) system(s) approved electronic HIPAAsecure transactions as outlined in TRICARE Systems Manual (TSM), Chapter 1, Section 1.1.
1.10The contractor shall providereports on all unactivated network referrals by specialty for allTRICARE Prime members enrolled to the government for all beneficiarycategories. For reporting requirements, see DD Form 1423, ContractData Requirements List (CDRL), located in Section J of the applicablecontract.
Note:The UINis specific to the Composite Health Care System (CHCS)/Armed ForcesHealth Longitudinal Technology Application (AHLTA) which is thelegacy Military Health System (MHS) Electronic Health Record (EHR) andthe legacy Referral Management Suite (RMS). As the MHS phases outlegacy CHCS/AHLTA and legacy RMS and moves to MHS Genesis as thenew EHR, the UIN will no longer be used. MHS Genesis produces the“Referral ID” thus the UIN and Referral ID may be used interchangeablyin this Section.
2.0URGENT CARE REFERRALS
2.1Active Duty Service Members(ADSMs) enrolled in TRICARE Prime require a referral which theywill obtain from the MTF provider or through the Nurse Advice Line(NAL). ADSMs enrolled to the TRICARE Overseas Program (TOP) or inTRICARE Prime Remote (TPR) will not be held to any urgent care referralrequirement, but they are still held to applicable DoD and Servicerequirements concerning authorization for private sector care. Pointof Service (POS) does not apply to ADSM private sector care.
2.2Active Duty Family Members(ADFMs) enrolled in TRICARE Prime may self-refer for urgent carefrom a TRICARE network provider or a TRICARE-authorized (networkor non-network) Urgent Care Center (UCC) or Convenience Clinic (CC).If the enrollee seeks care from a non-network provider (except aTRICARE-authorized UCC or CC), the usual POS deductible and cost-sharesshall apply.
2.3ADFMs enrolled in TRICARE PrimeRemote Active Duty Family Member (TPRADFM) with an assigned PrimaryCare Manager (PCM) are required to seek urgent care from a TRICAREnetwork provider or a TRICARE-authorized (network or non-network)UCC or CC to avoid POS.
2.3.1ADFM inTPRADFM without an assigned PCM may utilize any local TRICARE participatingor authorized provider for primary care services (to include urgentcare services).
2.3.2 ADFMsand ADSMs enrolled to TOP Prime or TOP Prime Remote enrollees needto contact the TOP contractor to obtain an authorization in orderto ensure their urgent care visit will be cashless and claimless. Withoutthis authorization, overseas providers may request payment upfrontand the enrollee will then have to submit a claim for reimbursem*nt.
2.3.2.1ADSMs enrolled to TOP Primeor TOP Prime Remote requiring urgent care while Temporary Duty (TDY)or on leave, in the 50 United States (US) and the District of Columbia,will not be held to any urgent care referral requirements, but theyare still held to applicable DoD and Service regulations concerningADSM care outside Markets/MTFs. The usual ADSM POS exception applies.
2.3.2.2ADFMs enrolled to TOP Primeor TOP Prime Remote traveling in the 50 US and the District of Columbia,may access urgent care without a referral or an authorization, butPOS deductibles and cost shares shall apply for claims when urgentcare is not provided by a TRICARE network provider or a TRICARE-authorized (networkor non-network) UCC.
2.4If urgenttreatment is required by a TRICARE Prime enrollee after hours, whiletraveling away from their residence, or whose PCM is otherwise unavailable,the enrollee may contact the NAL, their PSCC, TOP contractor, DesignatedProvider (DP) for assistance finding an appropriate facility andprovider before receiving non-emergent care from a provider otherthan the PCM. If an enrollee is traveling overseas, he or she maycall the TOP Regional Call Center for the region in which he orshe is traveling to coordinate urgent care.
2.5The contractor shall providebeneficiary and network provider education on obtaining an afterhour appointment or UCC care to include information on how to contactthe NAL, how to schedule follow-up appointments, and how to coordinatecare.
2.6When contacted by the beneficiary,the contractor shall encourage TRICARE Prime enrollees to notify theirPCM of any urgent and acute care visits to providers, other thanthe PCM within 24 hours of the visit, or the first business dayfollowing the visit and to schedule follow-up treatment, if indicated,with their PCM, or to get a referral from the PCM for additionalspecialty care.
2.7Urgentcare can be rendered by a TRICARE network provider or TRICARE-authorizedUCC. Providers must have one of the following primary specialtydesignations:
•Family Practice
•Internal Medicine; GeneralPractice
•Pediatrician
•UCC or CCs
Note:In accordance with TPM, Chapter 1, Section 7.1, Obstetricians/Gynecologists(OB/GYNs), Physician Assistants (PAs), Nurse Practitioners (NPs),and Certified Nurse Midwives (CNMs) can be considered Primary Care Providers(PCPs) and may also be designated PCMs.
3.0Mental Health (MH) and SubstanceUse Disorder (SUD) Referrals
3.1The contractorshall require a PCM referral for non-office based, outpatient (e.g.,Partial Hospitalization Program (PHP), Intensive Outpatient Program(IOP) and Opioid Treatment Program (OTP)) MH services. However,if the non-office based, outpatient MH provider is a network provider,a request for preauthorization from the network provider to thecontractor may be accepted in lieu of the PCM referral.
3.2The contractor shall complywith the provisions of Chapters 16 and 17 whenprocessing requests for active duty personnel. See Chapter 16, Sections 2 and 6 forreferral requirements under the TPR program. ADSMs require referraland preauthorization before receiving all MH and SUD services.
3.3The contractor shall processoutpatient MH and SUD referrals to the subspecialty level in accordancewith Chapter 1, Section 3 when submitted by a Market/MTF.
3.4The contractor shall indicatein their portal whether the processed referral was approved or denied.
4.0REFERRAL AND AUTHORIZATIONPROCESSING
4.1The contractor shall processreferrals in accordance with Utilization Management (UM), Section 4, and the following:The contractorshall select the provider priority for referral in the followingsequence:
4.2.1Market/MTF via Capability AndCapacity (aka KSA) tables and processes as outlined in the Memorandumof Understanding (MOU) between the Government and the contractor.
4.2.2Network provider within AccessTo Care (ATC) standards.
4.2.3Non-networkprovider within ATC standards.
4.2.4Closestnetwork provider outside of ATC standards, but within 100 miles.
4.2.5Closest non-network provideroutside of ATC standards, but within 100 miles.
4.2.6Closest network provider outside100 miles.
4.2.7Closest non-network provideroutside 100 miles.
4.2.8 Whencontinuity of care is a consideration. See https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf forthe definition of continuity of care.
4.2.9Out ofRegion when the care requested is of such a special nature thatit cannot be rendered within the region and medical necessity warrantsthe care. This is expected to occur rarely.
4.3Centralized Appointing Centers(Integrated Referral Management Appointing Centers (IRMACs)/ReferralAppointing Centers (RACs))
4.3.1The contractorshall collaborate with the Government to coordinate urgent and routineDirect Care System (DCS) referrals through the IRMACs/RACs (whereavailable) to make prompt referrals to network providers under theTRICARE program.
4.3.2The contractorshall provide up to 1,500 IRMAC/RAC personnel with read only accessto its RM system. The contractor shall send the DCS enrolled beneficiarya message through the beneficiary’s primary means of communication(telephone, email, text, app) as soon as a referral has been approvedand instruct them to contact the IRMAC/RAC to schedule an appointment.
4.4Referrals from the Market/MTFto the Contractor
4.4.1 The contractor shall translatethe narrative descriptions for a referral into standard diagnosisand procedure codes.
4.4.2The contractorshall authorize care in their network and retain responsibilityfor managing requests for additional services or inpatient concurrentstay reviews associated with the original referral, as well as changesto the specialty provider identified to deliver the care.
4.4.2.1The contractor shall applythe Market/MTF capability and capacity tables described in paragraph 4.6.1 andthe secondary referral table described in paragraph 1.4 when determiningand authorizing care for additional services that are requestedbeyond the initial referral within the same EOC.
4.4.2.2The contractor authorizingthe care shall forward the referral and authorization information, includingthe range of codes authorized (i.e., EOC), the name, the NationalProvider Identifier (NPI), and demographic information of the specialtyprovider to the contractor for the region to which the patient isenrolled, as well as the Market/MTF where enrolled, if applicable.
4.4.2.3The contractor shall providethe same service and information required above to the TOP contractor, ifthe patient is enrolled overseas.
4.4.2.4The contractor shall forwardthe authorization information to the TOP contractor to ensure appropriateadjudication of the claim, if a CONUS Prime retiree or retiree familymember receives authorization to obtain care overseas from a contractor.
4.4.2.5The contractor shall providea report of all referrals and authorizations transferred from one contractorto another. For reporting requirements, see DD Form 1423, CDRL,located in Section J of the applicable contract.
4.4.3The contractor shall providea text explanation of why a referral was returned and rejected ina HIPAA-compliant 278 transaction within 24 hours to the Market/MTF(if enrolled to a Market/MTF). The returned and rejected standardnomenclature will be provided by the Government. The return of areferral to the Market/MTF is considered processed to completion.
4.4.4The contractor shall providea report of all rejected/returned referrals. For reporting requirements,see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.4.5The contractor shall advisethe patient, referring Market/MTF, and receiving provider of allapproved referrals and authorizations including, but not limitedto, the following:
•The Market/MTF single Pointof Contact (POC) shall be advised via HIPAA-compliant 278 response.(The Market/MTF single POC may be an individual or a single officewith more than one telephone number.)
•The contractor shall providea response to the Market/MTF single POC via fax or other approvedGovernment system, if the Government’s or contractor’s HIPAA-compliant278 system is not available.
•The notice to the beneficiaryshall contain the Referral Case Number or UIN and information necessaryto support obtaining ordered services or an appointment with thereferred to provider.
•The notice shall also providethe beneficiary with instructions on how to change their provider,if desired, and will instruct the beneficiary to notify the contractorof the change.
4.4.5.1The contractor shall make appropriatemodifications within their portal, if they are informed that the beneficiarychanged the provider listed on the referral.
4.4.5.2The contractor shall make appropriatemodifications to the issued authorization, if the contractor is informedthat the beneficiary changed the provider listed on the referralor authorization. The revised referral or authorization shall containthe same level of data as the initial referral or authorization.The revised authorization shall be issued to the beneficiary, theprovider beneficiary chose, referring provider and the Market/MTF.
4.4.5.3The contractor shall not sendbeneficiary notification letters for referrals marked “urgent.”
4.4.5.4The contractor shall providea notification to beneficiaries that failure to adhere to a referralwill result in the care being subject to POS charges. In other cases,a referral may be to the civilian provider network, and again, POScharges would apply to a failure to follow the referral.
4.4.5.5A major purpose of preauthorizationis to prevent unanticipated coverage determinations, which are sometimesdependent on particular details regarding the patient’s conditionand circ*mstances.
4.4.6The contractorshall notify the patient by mail, if services are denied, and shalladvise the patient of their right to appeal consistent with theTRICARE Operations Manual (TOM).
4.4.7The contractorshall also notify the referring provider and single Market/MTF POCof the initial denial by HIPAA-compliant 278 response and by mail.
4.4.8The contractor shall providethe Market/MTF, by HIPAA-compliant 278 response, the updated authorizationand clinical information that served as the basis for the new authorization.
4.5Directed Referrals (CONUS Only)
4.5.1Directed referrals are expectedto be rare and will be reviewed according to paragraph 1.2. The types of acceptabledirected care referrals will be in the best interest of the Governmentfor quality, affordable care and military readiness. The processfor submitting directed referrals for services will be containedwithin the MOUs between the Government and the contractor.
4.5.2Acceptable directed care specialsituations include, but are not limited to, the following:
4.5.2.1Clinically urgent/emergentreferrals (Administrative reasons should not be used as an “urgent” requestjustification; although the contractor shall support PCM/Market/MTFin expediting referrals for administrative reasons when needed).
4.5.2.2Military operationally relatedreferral requests such as referrals to network providers who provide rapidATC for an ADSM for military operational issues.
4.5.2.3Retrospective requests, includingUCC referrals and emergency department follow-up referrals for beneficiarieswhile traveling.
4.5.2.4Continuity of care considerationsalong with referrals to providers who have special skill sets, an expertiseor access to devices or instruments that cannot be met by providerswho might otherwise be selected.
4.5.2.5Beneficiaries have a rightto see any network provider and may chose a different network providerby contacting the contractor to request a change to another networkprovider within the same specialty requested by the referring PCM/Market/MTF.
4.5.2.6MTF providers or network providersmay generate a directed referral for the purpose of obtaining a secondclinical opinion; a clinical visit such as this would not be partof a continuity of care determination. Such a referral should bewritten as an “evaluate only” request.
4.5.2.7MTF to Veterans Health Administration(VHA) referrals, Integrated Disability Evaluation System (IDES) referrals,terminal leave for ADSM, Temporary Disability Retired List (TDRL),demobilizing Reserve Component (RC) members and beneficiaries transferringenrollment between regions and ADSMs or cadets/midshipmen on extendedconvalescent leave.
4.5.2.8Coordination of care for aPermanent Change of Station (PCS) move.
4.5.3Directed referrals to DoD recognizedCenters of Excellence (CoEs) can be made by DC, network and non-networkproviders for TRICARE Prime and TRICARE Select beneficiaries. TheGovernment will provide the contractor with a list of DoD recognizedCoEs.
4.5.4Private sector care and Market/MTFdirected referrals for initial services to a network or non-network providergreater than 100 miles from the Market/MTF or private sector PCM,where specialized treatment, surgical procedure, and inpatient admissionis expected, or being requested, require justification from theMarket/MTF or private sector PCM to the contractor and coordinationbetween the contractor and TRICARE Health Plan (THP) prior to approvalby the contractor.
4.5.4.1This coordination process iscontained within the MOUs between the Markets/MTFs and contractor. TheMOU will also contain guidance on types of Market/MTF directed referralsexcluded from this policy.
4.5.4.2This coordination process iscontained within the provider agreement/handbook from the contractor.The provider agreement/handbook will also contain guidance on thetypes of directed referrals excluded from this policy.
4.5.5The contractor shall accomplishbenefit review and medical necessity review, as required by policy,and then coordinate with THP prior to completing the referral andauthorization.
4.5.5.1The contractor may ask THPfor guidance on any Market/MTF or network provider-directed referral thatmeets the intent of this policy.
4.5.5.2THP will conduct their reviewand provide a response within two business days.
4.5.6The contractor shall make anddocument appropriate determinations considering the justification providedby the Market/MTF for directed referrals to non-network providers.For reporting requirements, see DD Form 1423, CDRL, located in SectionJ of the applicable contract.
4.6Referralsfrom the Contractor to the Market/MTF
4.6.1The contractor shall provideMarket Directors/MTF Directors with web-based ability to reviewand update their Capability and Capacity (KSA) tables in real time.The Government defines “real time” in this instance as providingthe Markets/MTFs with access to view and update their capabilityand capacity information 24 hours a day/seven days a week (24/7),exclusive of scheduled system maintenance. For reporting requirements,see DD Form 1423, CDRL, in Section J of the applicable contract.
4.6.2The contractor shall providea report of referrals from the contractor to the Market/MTF. Forreporting requirements, see DD Form 1423, CDRL, located in SectionJ of the applicable contract.
4.7TRICARE Prime
4.7.1The contractorshall process referrals from the civilian sector in accordance withthe following procedures:
4.7.1.1The contractor shall send referralsfor TRICARE Prime beneficiaries who are enrolled to the network forwhom the Market/MTF has indicated the desire to receive referralrequests as indicated by the capability and capacity tables (exceptfor continuity of care, emergency admissions, and traveling outof area).
4.7.1.2The contractor shall providereferrals to the Government prior to the contractor’s medical necessity andcovered benefit review.
4.7.1.3The Government will providethe contractor a list of Current Procedural Terminology (CPT) codesor International Classification of Diseases, 10th Revision (ICD-10)(or current edition) codes and will assign these a KSA value from 1 (lowKSA value) to 10 (highest KSA value). Diagnoses andprocedures not listed shall receive a default KSA value of 1.
4.7.1.4The contractor shall prioritizethe highest KSA value referrals for TRICARE Prime patients for assignmentto the Market/MTF for care.
4.7.1.5The contractor shall notifythe beneficiary of the accepted referral to the Market/MTF and provide assistanceor instructions for obtaining an appointment in the Market/MTF.
4.7.1.6The contractor shall send referralsto the Market/MTF via a HIPAA-compliant 278, or other process as identifiedby the Government.
4.7.1.6.1The request shall contain theminimum data set described in paragraph 5.0 (with the exception of the ReferralCase Number/UIN) plus the referring civilian provider’s telephonenumber, fax number, and mailing address.
4.7.1.6.2This data set shall be providedto the Market/MTF in plain text with diagnosis or procedure codes.
4.7.1.7The contractor shall transmitthe referrals within one business day from date and time of receiptof referral for “urgent priority” and “routine priority” referrals(excluding MTF closures).
4.7.1.8The Market/MTF will respondand accept or decline to the contractor via HIPAA-compliant 278,or other process as identified by the Government within one businessday from receipt of the request for “urgent priority” and “routinepriority” referrals. Referrals from the contractor to the Market/MTFshall not be transmitted when the MTF is closed.
4.7.1.9The contractor shall, and theGovernment may, notify the beneficiary of the Market/MTF acceptance andprovide instructions for contacting the Market/MTF to obtain anappointment in instances where the Market/MTF elects to accept thepatient.
4.7.1.10The contractor shall processthe referral request as if the Market/MTF declined to see the patient, whenno response is received from the Market/MTF in response to the referralrequest as defined above.
4.7.1.11The contractor shall forwardall referrals for care based on the Capability And Capacity (KSA)table and secondary referrals table (paragraph 1.4), to the Market/MTF.The only exception will be if the continuity of care criteria ismet.
4.7.2The contractorshall provide each Market/MTF with a monthly report. For reportingrequirements, see Contract Data Requirements List, DD Form 1423,in Section J of the applicable contract.
4.8TRICARE Select
4.8.1The contractorshall provide a process for TRICARE Select beneficiaries the choiceof where specialty care or a procedure is received, to include theMTF with capability and capacity of the specialty care or procedure required;based on when the case meets the needs of the Market/MTF provider’sKSAs and where the capability and capacity table indicates the Market/MTFhas capacity to accept TRICARE Select beneficiaries.
4.8.1.1The contractor shall offersuch beneficiaries the option of utilizing a Market/MTF when oneexists within ATC standards that has the capacity and capabilityto provide the needed care. This shall include providing the beneficiarywith quality and outcomes data, average days to be seen, as wellas general information about out-of-pocket costs for comparableMTF and network providers and facilities capable of providing theservice.
4.8.1.2The contractor shall ensureSelect beneficiaries are aware of this program.
4.8.2The contractor shall providethe beneficiary with information to contact to the Government forMTF appointments when the TRICARE Select beneficiary chooses toobtain care at the MTF.
4.8.3The contractorshall notify the Government via HIPAA compliant 278 transactionwhen a TRICARE Select enrollee elects to utilize the MTF within24 hours of electing care at the MTF. Correspondences shall follow thesame procedures for the TRICARE Prime referrals from the networkto the Market/MTF as outlined in paragraph 4.7.
4.8.4The Market Director/MTF Directorwill ensure that the Capability And Capacity (KSA) tables are continuallymaintained and refreshed every business day. Referrals for high-valueKSAs must be accepted by the DCS in accordance with the capabilityand capacity tables unless listed in contingency paragraph 8.0.
4.9Status of Referrals When BeneficiariesChange Geographical Location
4.9.1The contractor’sreferral process shall support continuity of referrals when beneficiarieschange geographical region. Changing of geographical region includesboth internal contract region and a change to the other T-5 region.
4.9.2Referrals shall remain validwhen a beneficiary changes geographical region, so long as theyare still in a Prime Service Area (PSA) (or TPR or TPRADFM) at thenew location.
4.9.3The gainingcontractor shall not require a new referral from a PCM in the gaininglocation.
4.9.4The contractorshall assist the beneficiary (or IRMAC/RAC) in finding a qualifiedprovider and arranging an appointment with that provider in thenew location with the goal of the beneficiary not having disruptionsor waiting for care in the new location.
4.9.5At beneficiary (or the beneficiary’sprovider) request, the contractor shall assist with requirementsof paragraph 4.9.4, prior to the beneficiarymoving.
4.9.6In the event of a regionalchange:
4.9.6.1The gaining contractor shallnot require a new referral from a PCM in the gaining location.
4.9.6.2The gaining contractor shallcomplete requirements of paragraphs 4.9.4 and 4.9.5.
4.9.6.3The losing contractor shallretain responsibility for the beneficiary referrals during the periodof the move until the beneficiary changes their enrollment to anothercontractor and coverage becomes effective in the new location.
4.9.6.4The losing contractor shallensure the beneficiary has access to urgent care utilizing virtualhealth during their move, if this service is not offered by thelosing Market/MTF.
4.9.6.5The losing contractor shallforward approved referrals to the gaining contractor when requested(in phone or writing) by the beneficiary or gaining contractor.The information forwarded shall include, but is not limited to,the number of authorized visits and approved diagnostic/treatmentcodes.
4.9.6.6The contractor with which thebeneficiary is enrolled at the time the referral is activated shallensure claims are processed appropriately.
5.0RETURNED/REJECTED/PROCESSEDREFERRALS
The contractorshall provide a response why a referral was returned/rejected ina HIPAA-compliant 278 transaction. The returned/rejected standardnomenclature will be provided by the Government.
6.0NOTIFICATIONS
6.1The contractorshall provide beneficiaries with multiple referral status alertsand notification options, including email, text, web-portal andhard-copy letters (based on means the beneficiary chooses), to promoteATC. The contractor shall educate beneficiaries on options to receivereferral, authorizations and notifications.
6.2.1The contractorshall make a copy of the referral, consult and the authorizationletter electronically accessible and printable to the beneficiaryin the contractor’s portal regardless of which alert and notification optionthe beneficiary chooses.
6.2.2The contractorshall allow the beneficiary to opt in to hard copy, mailed authorizationsand notifications on referrals.
6.2.3The contractorshall note what preference a beneficiary chooses, hard copy or electronic,as the means of providing authorization and denial letters and changepreference upon beneficiary request.
6.2.4The contractorshall mail all denial letters to the referring provider and beneficiary.
7.0REPORTS
7.1The contractorshall locate related referrals, authorizations and claims usingthe Referral Case Number/UIN.
7.2The contractorshall modify generated Market/MTF reports to accommodate the ReferralCase Number/UIN and NPI. The Referral Case Number/UIN shall alsobe used for all related customer service inquiries. Referral CaseNumbers/UINs and NPIs will be attached to all Market/MTF referralsand will be portable across all regions of care. The Referral CaseNumber/UIN will be used to match claims to a Market/MTF-generatedreferral.
7.3The contractor shall capturethe NPIs from the referral transmission report and forward the NPIand corresponding Referral Case Number/UIN to the referred to provideron all referrals.
7.4The contractorshall provide a report on all specialty referrals. For reportingrequirements, see DD Form 1423, CDRL, located in Section J of theapplicable contract.
8.0CONTINGENCYOPERATIONS (OPS) WHEN SYSTEMS ARE DOWN
The contractor shall developa contingency process for transmitting referrals and authorizationswhen its RM system is inoperable.
8.1The contingencyprocess will be mutually agreed upon by the Government and the contractor.
8.2The Government will submitreferrals and authorizations utilizing manual fax or the contractor’sportal when the Government RM systems are inoperable. When boththe Government’s referral management system and the contractor’sreferral management system, simultaneously are inoperable, manualfax shall be used as a last option.
8.2.1The contractorshall enter referral received via manual fax into its RM system.
8.2.2Urgent referrals may be transmittedto the contractor immediately during Government RM system downtime.
8.2.3Markets/MTFs will hold routinereferrals and authorizations for two business days when Government RMsystem is inoperable.
8.3The contractorshall provide training on submitting referrals within their portalto Markets/MTFs to facilitate referral processing during Governmentsystem outages.
9.0VHA REFERRALS
9.1The contractorshall comply with requirements pertaining to VHA medical facilitiesas specified in the TPM, Chapter 1, Section 8.1.
9.2The contractor shall processDoD to VHA referrals regardless of facility design.
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