West Region Provider Handbook

TRICARE?

West Region Provider Handbook

Your guide to TRICARE programs, policies and procedures

January 1?December 31, 2020

An Important Note about TRICARE Program Information

This TRICARE West Region Provider Handbook will assist you in delivering TRICARE benefits and services. At the time of publication, January 1, 2020, the information in this handbook is current. It is important to remember that TRICARE policies and benefits are governed by public law, federal regulation and the Government's amendments to Health Net Federal Services, LLC's (HNFS') managed care support (MCS) contract. Changes to TRICARE programs are continually made as public law, federal regulation and HNFS' MCS contract are amended. For up-to-date information, visit tricare-. Contracted TRICARE providers are obligated to abide by the rules, procedures, policies and program requirements as specified in this TRICARE West Region Provider Handbook, which is a summary of the TRICARE regulations and manual requirements related to the program. TRICARE regulations are available on the Defense Health Agency (DHA) website at tricare.mil. If there are any discrepancies between the TRICARE West Region Provider Handbook and TRICARE manuals (Manuals), the Manuals take precedence.

Using This TRICARE West Region Provider Handbook

This TRICARE West Region Provider Handbook has been developed to provide you and your staff with important information about TRICARE, emphasizing key operational aspects of the program and program options. This handbook will assist you in coordinating care for TRICARE beneficiaries. It contains information about specific TRICARE programs, policies and procedures. TRICARE program changes and updates may be communicated periodically through TRICARE Provider News and the online publications. The TRICARE West Region Provider Handbook is updated annually and as required. Thank you for your service to America's heroes and their families.

TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

Photos courtesy of

HH1119x012 (10/20)

Table of Contents

SECTION 1

Welcome to TRICARE? and the West Region

What Is TRICARE?...........................................................................................................................................................1 Your Regional Contractor................................................................................................................................................1 TRICARE Regions.............................................................................................................................................................1 HNFS TRICARE Contract Administration.........................................................................................................................1 HNFS Website.................................................................................................................................................................2 Online Network Provider Directory................................................................................................................................2 HNFS Customer Service Line...........................................................................................................................................4 Provider Relations Representatives................................................................................................................................4 TRICARE Provider News..................................................................................................................................................4 Choosing Wisely?............................................................................................................................................................6 Healthcare Effectiveness Data and Information Set (HEDIS)..........................................................................................6 National Disaster Medical System (NDMS).....................................................................................................................7

SECTION 2

Important Provider Information

TRICARE Policy Resources...............................................................................................................................................8 Health Insurance Portability and Accountability Act of 1996.........................................................................................8 TRICARE Provider Types................................................................................................................................................10 Accepting Patients from the U.S. Department of Veterans Affairs...............................................................................11 Military Hospitals and Clinics .......................................................................................................................................11 Urgent Care..................................................................................................................................................................11 Emergency Care............................................................................................................................................................12 Corporate Services Provider Class................................................................................................................................12 Managing the Network.................................................................................................................................................13 Provider Certification and Credentialing......................................................................................................................13 Value-Based Incentives.................................................................................................................................................15 Network Provider Responsibilities................................................................................................................................15 Updating Provider Information.....................................................................................................................................20 Beneficiary Rights and Responsibilities........................................................................................................................20 An Important Message from TRICARE..........................................................................................................................21

SECTION 3

TRICARE Eligibility

Verifying Eligibility........................................................................................................................................................22 Same-Sex Spouses........................................................................................................................................................24 TRICARE and Medicare Eligibility..................................................................................................................................24 Eligibility for TRICARE and Veterans Affairs Benefits....................................................................................................24 TRICARE Health Care Program Options........................................................................................................................24

TRICARE Prime Coverage Options................................................................................................................................24 TRICARE Select..............................................................................................................................................................26 TRICARE Young Adult....................................................................................................................................................26 Direct-Care Only...........................................................................................................................................................26 TRICARE For Life...........................................................................................................................................................26 TRICARE for the National Guard and Reserve...............................................................................................................27 TRICARE Pharmacy Program.........................................................................................................................................28 TRICARE Dental Options...............................................................................................................................................31 Cancer Clinical Trials.....................................................................................................................................................31 TRICARE Extended Care Health Option........................................................................................................................32 Supplemental Health Care Program.............................................................................................................................33 Transitional Health Care Benefits.................................................................................................................................34

SECTION 4

Medical Coverage

Network Utilization ......................................................................................................................................................36 Covered Services..........................................................................................................................................................37 Cancer Clinical Trials.....................................................................................................................................................42 Eye Examinations..........................................................................................................................................................42 Laboratory Developed Tests.........................................................................................................................................44 Maternity Care..............................................................................................................................................................44 Provisional Coverage Program......................................................................................................................................46 Telemedicine.................................................................................................................................................................46 Exclusions.....................................................................................................................................................................46

SECTION 5

Mental Health Care Services

Mental Health Care Providers.......................................................................................................................................51 Prior Authorization and Referral Requirements ..........................................................................................................52 Clinical Documentation for Mental Health Services.....................................................................................................53 Outpatient Services......................................................................................................................................................53 Inpatient Services.........................................................................................................................................................55 Substance Use Disorder Services..................................................................................................................................55 Telemedicine Services...................................................................................................................................................56 Non-Covered Mental Health Care Services..................................................................................................................56

SECTION 6

Health Care Management and Administration

Advance Directives.......................................................................................................................................................58 Network Utilization ......................................................................................................................................................58 Referral Process............................................................................................................................................................58 Prior Authorization Process..........................................................................................................................................60 Providing Care to Beneficiaries from Other Regions and Overseas..............................................................................64

Medical Records Documentation.................................................................................................................................65 Utilization Management...............................................................................................................................................67 Clinical Quality Management.......................................................................................................................................70 Credentialing and Certification.....................................................................................................................................70 Fraud and Abuse...........................................................................................................................................................72 Grievances....................................................................................................................................................................73

SECTION 7

Claims Processing and Billing Information

West Region Claims Processor......................................................................................................................................74 Claims Processing Standards and Guidelines................................................................................................................74 Important Billing Tips...................................................................................................................................................74 Mental Health Care Claim Tips ....................................................................................................................................77 HIPAA Transaction Standards and Code Sets for Mental Health Claims ......................................................................77 Proper Billing for Multiple Procedures.........................................................................................................................77 Medically Unlikely Edit .................................................................................................................................................77 Duplicate Claims...........................................................................................................................................................77 Electronic Claims Submission.......................................................................................................................................78 Electronic Funds Transfer .............................................................................................................................................78 Claims Submission Addresses.......................................................................................................................................78 Hospital and Facility Billing...........................................................................................................................................79 Proper Treatment and Observation Room Billing.........................................................................................................79 Billing with ICD-10 Z Codes...........................................................................................................................................79 Allergy Testing and Treatment Claims...........................................................................................................................81 Eye Exam Claims...........................................................................................................................................................81 Global Maternity Claims...............................................................................................................................................82 Claims for Mutually Exclusive Procedures....................................................................................................................82 Physician-Administered Drug and Vaccine Claim Filing................................................................................................82 Processing Claims for Out-of-Region Care....................................................................................................................83 Claims for Beneficiaries Assigned to US Family Health Plan Designated Providers......................................................83 TRICARE Overseas/Foreign Claims................................................................................................................................83 Claims for Beneficiaries Using Medicare and TRICARE For Life....................................................................................84 Claims for Foreign Military Beneficiaries......................................................................................................................84 Claims for Civilian Health and Medical Program of the Department of Veterans Affairs.............................................85 Claims for the Continued Health Care Benefit Program...............................................................................................85 Claims for the Extended Care Health Option................................................................................................................85 Comprehensive Autism Care Demonstration Billing.....................................................................................................86 Claims for TRICARE Reserve Select, TRICARE Retired Reserve and TRICARE Young Adult............................................86 Supplemental Health Care Program Claims..................................................................................................................86 TRICARE and Other Health Insurance...........................................................................................................................87 TRICARE and Third-Party Liability Insurance.................................................................................................................88 TRICARE and Workers' Compensation..........................................................................................................................88 Avoiding Collection Activities.......................................................................................................................................88 TRICARE Claim Disputes................................................................................................................................................89

SECTION 8

TRICARE Reimbursement Methodologies

Reimbursement Limit...................................................................................................................................................91 TRICARE CHAMPUS Maximum Allowable Charge.........................................................................................................91 TRICARE Allowable Charge...........................................................................................................................................92 State Prevailing Rates...................................................................................................................................................92 Ambulance Rates..........................................................................................................................................................92 Ambulatory Surgery Grouper Rates..............................................................................................................................94 Anesthesia Claims and Reimbursement.......................................................................................................................94 Applied Behavior Analysis............................................................................................................................................95 Assistant Surgeon Services...........................................................................................................................................95 Banked Donor Milk.......................................................................................................................................................96 Breast Pumps and Supplies..........................................................................................................................................96 Diagnosis-Related Group Reimbursement....................................................................................................................96 Capital and Direct Medical Education Cost Reimbursement........................................................................................97 Drug Testing..................................................................................................................................................................97 Durable Medical Equipment, Prosthetics, Orthotics and Supplies Pricing...................................................................98 Health Professional Shortage Areas Bonus Payments..................................................................................................98 Home Health Agency Pricing........................................................................................................................................98 Home Infusion Drug Pricing..........................................................................................................................................99 Hospice Pricing...........................................................................................................................................................100 Long-Term Care Hospitals Inpatient Rehabilitation Facilities......................................................................................100 Modifiers....................................................................................................................................................................101 Outpatient Prospective Payment System...................................................................................................................101 Skilled Nursing Facility Pricing....................................................................................................................................102 Sole Community Hospitals..........................................................................................................................................103 Surgeon's Services for Multiple Surgeries...................................................................................................................103 Updates to TRICARE Rates and Weights.....................................................................................................................103

SECTION 9

Provider Resources

Acronyms....................................................................................................................................................................104 Glossary of Terms.......................................................................................................................................................106 Forms..........................................................................................................................................................................112 Health Insurance Claim Form (1500) Instructions......................................................................................................112 1500 Claim Form Place of Service Codes....................................................................................................................113 West Region Service Codes.........................................................................................................................................113 Uniform Bill Form (UB-04) Instructions......................................................................................................................114 Condition Codes.........................................................................................................................................................115 Occurrence Span Codes..............................................................................................................................................116 Value Codes and Amounts..........................................................................................................................................116

SECTION 1

Welcome to TRICARE? and the West Region

Thank you for supporting our service members and their families in the TRICARE West Region as a TRICARE network provider. TRICARE covers a wide range of health care benefits you help deliver as we carry on the vital mission of the TRICARE program. Together, we can continue to provide health care excellence for our nation's best.

What Is TRICARE?

TRICARE is the worldwide health care program available to eligible beneficiaries of the seven uniformed services ? the Army, U.S. Navy, U.S. Air Force, U.S. Marine Corps, U.S. Coast Guard, Commissioned Corps of the U.S. Public Health Service, and the Commissioned Corps of the National Oceanic and Atmospheric Administration. TRICARE-eligible beneficiaries may include active duty service members and their families, retired service members and their families, National Guard and Reserve members and their families, survivors, certain former spouses, and others.

TRICARE brings together military and civilian health care professionals and resources to provide high-quality health care services. TRICARE is managed in two stateside regions in the U.S ? TRICARE East and TRICARE West. In these U.S. regions, TRICARE is jointly managed by the Defense Health Agency (DHA) and the TRICARE Health Plan. The DHA has partnered with civilian regional contractors in the East and West regions to assist TRICARE regional directors, and military hospital and clinic commanders in operating an integrated health care delivery system.

Your Regional Contractor

As the managed care support contractor (MCSC) in the West Region, Health Net Federal Services, LLC (HNFS), a whollyowned subsidiary of Centene Corporation, administers the TRICARE program in Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except the Rock Island Arsenal area), Kansas, Minnesota, Missouri, (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (areas of western Texas only), Utah, Washington, and Wyoming.

As the longest serving managed care support contractor for TRICARE, we are dedicated to ensure the program is a successful experience for all beneficiaries and network providers.

TRICARE Regions

West Region Health Net Federal Services, LLC 1-844-866-WEST (1-844-866-9378) tricare-

East Region Humana Military 1-800-444-5445 tricare-

WEST Region

EAST Region

HNFS TRICARE Contract Administration

HNFS develops and maintains the medical/surgical network, and mental health network. Our partner, PGBA, LLC (PGBA), provides and maintains claims processing and claims customer service.

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HNFS Website

The HNFS website, tricare-, provides information about TRICARE benefits, processes, requirements, and operations in the West Region, as well as access to selfservice tools.

Visit the provider section of tricare- to:

? Verify a beneficiary's TRICARE eligibility, other health insurance status, and out-of-pocket expenses (deductibles, copayments, cost-shares).

? Check prior authorization and referral requirements.

? Quickly find and print information on benefits and costs.

? Access the Primary Care Manager (PCM) Enrollee Roster for a list of beneficiaries enrolled to a PCM.

? Submit and check the status of prior authorization and referral requests.

? Upload attachments such as forms and medical documentation.

? Submit and check the status of claims. ? Create claims data reports to view beneficiary claims

history, set up electronic funds transfer (EFT) and view remits. ? Update provider demographics. ? Use McKesson Risk Manager to access patient health information online. ? View the TRICARE West Region Provider Handbook quick reference charts and TRICARE Provider News. ? V iew/print forms. ? Read important updates about the TRICARE program and HNFS processes. ? Submit secure electronic mail questions using Ask Us.

This list is not all-inclusive.

Website Registration

Certain features at tricare- require website registration. Start by clicking on Log In or Register at the top of any web page. HNFS encourages website registration to streamline your web experience.

Electronic Claims

TRICARE requires network providers to submit claims electronically using the appropriate Health Insurance Portability and Accountability Act (HIPAA) compliant standard electronic claims format. Paper claims submitted by a network provider may be returned to the provider with directions to submit electronically. Exception: TRICARE network providers in Alaska are not required to submit claims electronically.

? Electronic Data Interchange (EDI) Payer ID: 99726

Benefits of filing claims electronically:

? improved cash flow ? on average, TRICARE processes electronic claims two to three weeks faster than paper claims

? reduced postage and paper-handling costs ? elimination of data entry errors

Providers registered at tricare- can file new and corrected claims through XPressClaim?. XPressClaim allows providers to submit 1500 and UB-04 claims and receive instant payment results for a majority of claims. Providers can also print a patient summary receipt while your patient is still in the office. There is no cost to use XPressClaim. Register at tricare- to begin using XPressClaim now.

Electronic Funds Transfer

You can sign up for electronic funds transfer (EFT) at tricare-. Registering for EFT requires having signature authority. This means you are authorized to disburse funds, sign checks and add, modify or terminate bank account information.

Online Network Provider Directory

HNFS' online Network Provider Directory makes it easy for beneficiaries and providers to locate TRICARE West Region network providers. Network providers must satisfy all applicable credentialing requirements and execute a Provider Participation Agreement in order to be eligible to be listed in the Network Provider Directory. Network Provider Directory information includes location, provider name, provider type, specialty, gender, accepting new patients status, office phone/ fax numbers and additional language(s).

Please visit the online Network Provider Directory to confirm your individual listing(s) is accurate. Keep in mind, certain specialties may be credentialed by HNFS at the individual level but only listed in the Network Provider Directory at the group level. Similarly, HNFS must credential all network nurse practitioners and physician assistants, but only those identified as primary care managers (PCMs) will display in the Network Provider Directory.

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