TRICARE Manuals - Display Chap 18 Sect 9 (Change 3, Apr 26, 2024) (2024)

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TRICARE Operations Manual 6010.62-M, April 2021

Demonstrations, Pilot Projects, and Value-Based Initiatives

Chapter 18

Section 9

ReferralAnd Appointing Center (RAC) Pilot

Revision:

1.0BACKGROUND

Section 714 of the Fiscal Year(FY) 2019 National Defense Authorization Act (NDAA) requires a streamlined approachto referrals in TRICARE. Specifically, it requires that:

“(1) The referral process shallmodel best industry practices for referrals from primary care managersto specialty care providers;

(2) The process shall limitadministrative requirements for enrolled beneficiaries;

(3) Beneficiary preferencesfor communications relating to appointment referrals using state-of-the-artinformation technology shall be used to expedite the process; and

(4) There shall be effectiveand efficient processes to determine the availability of appointmentsat military medical treatment facilities and, when unavailable,referrals to network providers under the TRICARE program.”

Consistent with this requirement,TRICARE is implementing a pilot to use appointing and referral centersto simplify the process of receiving referrals for care and makingappointments.

2.0DESCRIPTIONAND OVERVIEW

The Governmentwill create a RAC located at one pilot site to be detailed in thecontract modification.

2.1The RAC will serve as a “onenumber” center for all specialty care appointing for TRICARE Primepatients when the referral is generated by a provider at a Market/MilitaryMedical Treatment Facility (MTF) in the pilot Prime Service Area(PSA).

2.2 These requirements apply onlyto the managed care support contract(s) Managed Care Support Contractors(MCSCs). Impact on Market/MTF local contracts will be addressedby the Market/MTF.

2.3The pilot will be eight weeksin length. The Government may negotiate additional time with the contractorat a future date.

3.0Policy

3.1The RACswill receive all TRICARE Prime referrals written by providers atMTFs in the pilot PSA. The RAC will determine whether the specialtycare will be provided at a direct care facility or will be referredto the TRICARE network. If the care is referred to the TRICARE network,the RAC will transmit the referral to the contractor using existingsystems (Referral Management System (RMS) or MHS GENESIS).

3.2For referralsreceived by the contractor by 1500 hours local time (local timeis based on the pilot PSA), the contractor shall process and authorizethe referral by 0700 hours local time the next business day. Ifthe referral is received after 1500 hours or on a non-business day,the contractor shall process and authorize the referral by 0700 hourson the second business day after the referral is received. For example,if the referral is received on Saturday, the contractor shall processand authorize the referral no later than 0700 the following Tuesday(assuming Monday is not a Federal holiday). If the referral doesnot have enough information for the contractor to process, the contractorshall communicate that fact back to the Market/MTF along with whatinformation is needed for the contractor to complete the authorizationand approval letter. For referrals sent by 1500 hours local time,the contractor shall accomplish said communication to the RAC by0700 hours the next business day. For referrals sent after 1500hours, the contractor shall accomplish communication to the RACby 0700 hours the second business day. The contractor shall processreferral requests in accordance with pilot guidelines when DEERSor any other required Government system is unavailable. The Governmentexpects referrals during down time to meet pilot process timelinesonce the system(s) returns on-line and the contractor becomes awareof the referral or authorization request. The contractor shall notifythe Government when it encounters outages or disruptions.

3.3The contractorshall generate an authorization and/or approval letter. In the letter,the contractor shall identify at least one and up to three networkproviders (when available) who have the capability to provide the servicerequired by the referral. The contractor shall upload the authorizationand/or letter into the Government-MCSC interfacing system, usingestablished referral management processes. See Chapter 8, Section 5. When the contractorsMedical Management System architecture is such that only one servicingprovider can be added to the initial approval letter or uploadedto the interfacing portal, the contractor is permitted to developworkarounds with the Government that would meet the requirementto identify three providers.

3.4The contractorshall upload the approval letter, authorization and identified networkproviders to the MCSC portal, consistent with established processes.

3.5The referringMarket/MTF provider will direct the beneficiary to call the RACto schedule an appointment. The RAC will call the first providerlisted on the approval letter and determine if the provider hasthe capacity to provide the care within TRICARE access standards.If so, the RAC will then perform a warm hand off with the beneficiaryand the provider’s office. If the first provider on the list isnot able to provide the needed care within access standards, theRAC will call the second, and if needed, third provider on the list.

3.6If noneof the providers listed has the capacity, the RAC will contact thecontractor and request additional network providers (or if no networkproviders are available, a non-network provider consistent withexisting policy) to assist the beneficiary in making an appointment.The contractor shall provide additional providers within one businessday of receiving the request from the RAC. If the contractor isunable to provide additional providers within one business day thecontractor shall communicate this to the Government and notify theGovernment as soon as it becomes aware of appropriate additionalproviders. The RAC may use the provider directory when the contractorcannot provide additional providers. The contractor shall identityand submit up to three non-network providers in lieu of networkproviders, when network providers lack capacity or capability.

3.7The RACwill collect data to measure pilot success. These will include:

Availability of network providersof the requested type;

Which providers accepts TRICAREand which provide care within access standards;

Number of un-activated referrals(when the beneficiary fails to make or keep an appointment and noclaim is associated with the approved referral);

Beneficiary satisfaction;

Costs;

Processing times;

Completeness and appropriatenessof referrals; and

Return of clear and legiblereports.

3.8The Governmentreserves the right to add additional pilot sites in the future.

4.0EFFECTIVE DATE

The pilot will be effectiveon February 1, 2021. The Government will determine the exact startdate in February in conjunction with the contractor and includethe information in the contract modification.

5.0Exclusions

Referral and authorizationrequests for current pilots and demonstrations including the ComprehensiveAutism Care Demonstration (ACD) and Intensive Outpatient Program(IOP) Pilot To Address Behavioral Health Sequelae of Sexual Trauma.

Referrals for beneficiariesnot enrolled in TRICARE Prime.

Referrals for beneficiarieswith Other Health Insurance (OHI).

Directed referrals to non-networkproviders >100 miles.

Retroactive referrals.

Retroactive referrals for emergencyroom and urgent care.

Renewed referrals such as forcontinuity of care.

Referrals for evaluation ofplastic surgery.

Referrals for gender dysphoria,including endocrinology evaluation and treat for gender dysphoria.

Dental office visits for adultand pediatric, including dental requiring sedation.

Prosthetic referrals.

Referrals needing second levelreview.

Duplicate referrals.

Behavior Health referrals (non-officebased that requires benefit review and medical necessity reviewsuch as IOP, Transcranial Magnetic Stimulation, Electroconvulsivetreatment and Partial Hospitalization Program (PMP)).

Referrals for Home Care, Hospice,and Home Infusion.

Referrals for evaluation andtreatment of pediatric congenital heart defects.

Faxed referrals (i.e., non-electronicreferrals and authorizations).

- END -

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TRICARE Manuals - Display Chap 18 Sect 9 (Change 3, Apr 26, 2024) (2024)
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