US Family Health Plan Provider Manual

Transcription

US Family
Health Plan
Provider Manual
TABLE OF CONTENTS
TITLE
PAGE
IMPORTANT PHONE NUMBERS
AND ADDRESSES
GLOSSARY OF TERMS
INTRODUCTION
1
PROVIDER PARTICIPATING REQUIREMENTS
2
PRACTITIONER PARTICIPATION CRITERIA
FACILITY PARTICIPATION CRITERIA
FACILITY APPLICATION REQUIREMENTS
PROVIDER, FACILITY AND ANCILLARY CONTRACTUAL
REQUIREMENTS
PROVIDER RIGHTS
APPOINTMENT WAIT TIME
ACCESS STANDARDS
2
2
2
3
COVERING PHYSICIANS
MEDICAL RECORDS
24/7 NURSE TRIAGE LINE
PATIENT NO SHOW
OTHER PROVIDER INFORMATION
National Disaster Medical System (NDMS)
President’s Advisory Commission On Consumer P rotection
and Quality in the Healthcare Industry
5
5
6
6
7
7
7
PROVIDER COMPLAINTS and APPEALS
8
ADMINISTRATIVE DISPUTES RELATED TO CLAIMS
ADMINISTRATIVE DISPUTES NOT RELATED TO CLAIMS
PROFESSIONAL COMPETENCE OR CONDUCT DISPUTES
8
8
9
4
4
4
TITLE
MEMBER ELIGIBILITY
SELECTING A PCP
CATASTROPHIC CAPITATION
MEMBER DISENROLLMENT AND CHANGES
MEMBER GRIEVANCES AND COMPLAINTS
COVERED and NON-COVERED SERVICES
PAGE
11
11
11
12
13
14
FAMILY PLANNING
14
BEHAVIORAL HEALTH
14
MEDICARE
END STAGE RENAL DISEASE
COORDINATION OF BENEFITS / THIRD PARTY LIABILITY
14
15
15
COPAYMENTS FOR COVERED SERVICES
SERVICES NOT COVERED UNDER THE US FAMILY HEALTH PLAN
INFORMING MEMBERS ABOUT NON – COVERED SERVICES
Hold Harmless Policy for Network Providers
PREVENTATIVE HEALTH GUIDELINES
GUIDELINE LINKS
16
20
20
20
22
22
REFERRAL/AUTHORIZATION GUIDELINES
23
PCP SELECTION
SELF-REFERRALS
PCP REFERRAL TO NETWORK SPECIALISTS
PRIOR-AUTHORIZATION GUIDELINES
UTILIZATION MANAGEMENT COMPONENTS
UTILIZATION MANAGEMENT NOTIFICATION REQUIREMENTS
AUTHORIZATION PROCESS
REQUESTS TO OUT-OF-NETWORK PROVIDERS
REQUESTS FOR CASE MANAGEMENT
APPEALS PROCESS
23
23
23
23
24
25
25
26
26
27
SERVICES REQUIRING PRIOR AUTHORIZATION
28
TITLE
PHARMACY SERVICES
PHARMACY BENEFIT – TRICARE FORMULARY
PRESCRIPTIONS
DRUG DENIAL APPEALS
MAIL ORDER INFORMATION
PHARMACY BENEFIT LIMITATIONS AND EXCLUSIONS
CLINICAL QUALITY MANAGEMENT PROGRAM
QUALITY REFERRALS
PROCEDURE FOR UNUSUAL PROVIDER PRACTICE PATTERNS
SENTINEL EVENT REVIEW PROCESS
HEALTHY PEOPLE 2020
TEAMSTEPPS
NATIONAL DISASTER MEDICAL SYSTEM (NDMS)
PAGE
29
29
30
30
30
31
32
32
33
33
34
35
35
CLAIMS, ENCOUNTERS AND EDI TRANSACTIONS
36
CLAIM SUBMISSIONS
EDI TRANSACTIONS
36
36
REIMBURSEMENT METHODOLOGIES
38
FEE-FOR-SERVICE (PROFESSIONAL SERVICES)
INSTITUTIONAL SERVICES
COPAYMENTS
CATASTROPHIC CAP PROTECTION
INTEGRITY/COMPLIANCE
SAFETY
QUALITY CARE
ACCURATE RECORDING AND REPORTING
ACCURATE AND APPROPRIATE CLAIMS
PROTECTION OF PRIVACY
ETHICAL PRACTICES
FRAUD AND ABUSE
IMPORTANT STATUTES
38
39
39
39
40
40
40
40
41
41
41
42
42
US FAMILY HEALTH PLAN
IMPORTANT PHONE NUMBERS AND ADDRESSES
BILLING ADDRESS
P.O. Box 169001
Irving, TX 75016-9001
Attention: Claims
EDI SPECIALIST
(469) 282-3066
Fax: (469) 282-3013
MEMBER SERVICES
1 (800) 678-7347
Fax: (469) 282-3013
PROVIDER RELATIONS
1 (800) 678-7347
Fax: (469) 282-3012
UTILIZATION MANAGEMENT
1 (800) 446-1730
Fax: (800) 277-4926
TRICARE FORMULARY
http://pec.ha.osd.mil/formulary_search.php
PHARMACY
Mail Order: 1-866-408-2459
See provider directory for list of local
participating pharmacies
BEHAVIORAL HEALTH
APS Healthcare
1-800-406-0022
FAMILY PLANNING
Meritain Health Inc.
P.O.Box 27083
Lansing, MI 48909-7083
1-888-627-8889
WEBSITE
www.usfamilyhealthplan.org
http://christus.usfhp.com
GLOSSARY OF TERMS
The following terms are intended to provide a brief description of the more important
concepts and provisions found in the US Family Health Plan Provider Manual They are
further intended to provide a point of reference when the terms appear in this manual.
Adverse Action: The adverse determination, i.e., denial, of a requested covered service,
including the type or level of service which includes:
 Denial in whole of the service;
 Denial in part of a service, i.e., has been limited, reduced, suspended, or terminated;
 Denial in whole or part of payment for a covered service;
 Failure by the health plan to provide a service in a timely manner as defined by federal
and/or state regulations; and
 Failure to act within timeframes for the health plan’s Prior Authorization review
process.
Appeal: The formal process by which a member or his/her authorized representative request
a review of health plan’s or delegated contractor’s adverse determination of a covered
service due to lack of medical necessity. The appeal consists of a review of the evidence and
findings upon which it was based, and any other evidence the parties submit or the health
plan or regulatory agency obtains. A standard appeal resolution is made within (30)
calendar days of receiving the request for the appeal.
Benefit: The amount payable by an insurer to a claimant, assignee, or beneficiary under each
coverage in the group contract.
Clean Claim: A claim submitted by a physician or provider for medical care or health care
services rendered to a Member, with the data necessary for the Managed Care Organization
(MCO) or subcontracted claims processor to adjudicate and accurately report the claim. A
Clean Claim must meet all requirements for accurate and complete data as defined in the
appropriate 837- (claim type) encounter guides as follows:
 837 Professional Combined Implementation Guide;
 837 Institutional Combined Implementation Guide;
 837 Professional Companion Guide; and
 837 Institutional Companion Guide.
 National Council for Prescription Drug Programs (NCPDP) Companion Guide.
Complaint (Grievance): Any dispute or expressed level of dissatisfaction, either verbally or in
writing, by the member or the member’s authorized representative with the health plan
or a delegated contractor’s processes other than an action associated with the disposition
of a claim, i.e., adverse determination of a benefit.
Copayment: An out-of-pocket dollar amount or percentage of charges a member pays to the
provider for specified covered services.
Covered Services: Health care services and items the Enrollee is entitled to receive under
the DoD Managed Care Contract except for those services inconsistent with the Ethical and
Religious Directives for Catholic Health Care, as published from time to time.
Deductible: The amount of covered expenses which must be paid by the member before
benefits are payable by the insurance company.
DoD: The United States Department of Defense.
DoD Managed Care Contract: The contract between the US Family Health Plan and the DoD
under which certain Covered Services are to be provided to or arranged for
Enrollees/Beneficiaries.
Emergency Medical Condition: A medical condition manifesting itself by acute symptoms
of sufficient severity, including but not limited to severe pain, that would lead a prudent
layperson possessing an average knowledge of medicine and health to believe that his or
her condition, sickness, or injury is of such a nature that failure to get immediate medical
care to evaluate and/or stabilize the condition could result in:
 Placing the patient’s health in serious jeopardy
 Serious impairment to bodily functions
 Serious dysfunction of any bodily organ or part
 Serious disfigurement or as in the case of a pregnant woman, serious jeopardy to the
health of the fetus.
Expedited Appeals: A request to do a more time sensitive medical necessity review of a
denied urgent pre-service or urgent concurrent service when the standard appeal time
periods could seriously jeopardize the member’s life, health or the ability to attain,
maintain or regain maximum function, or in the opinion of the treating provider member’s
condition cannot be adequately managed without the urgent care or services. An expedited
appeal resolution is made within seventy two (72) hours, or sooner if the member’s condition
warrants.
Medical Necessity: Services sufficient in amount, duration, and scope to reasonably achieve
their purpose, are in accordance with accepted standards of practice in the medical
community of the area in which the services are rendered and are furnished in the most
appropriate setting. A service is medically necessary when it (1) prevents, diagnoses, or
treats a physical or behavioral health injury; (2) is necessary to achieve age appropriate
growth and development; (3) minimizes the progress of disability; or (4) is necessary to
attain, maintain, or regain functional capacity. A service is not considered reasonable and
medically necessary if it can be omitted without adversely affecting the member’s condition
or the quality of medical care rendered.
MM/QI Committees: Committees composed of physicians, the medical director, and other
healthcare professionals that provide a mechanism for physician participation,
communication and development and administration of the US Family Health Plan.
National Accrediting Standards: URAC standards and any and all accrediting standards
that the US Family Health Plan is required to meet.
Participating Provider: A physician who has signed an agreement to provide US Family
Health Plan covered services to its members.
Preadmission Review: A function performed by the US Family Health Plan to review and
authorize hospitalizations to determine medical necessity.
Primary Care Physician:
Any US Family Health Plan Physician who is practicing medicine in the area of internal
medicine, family practice, general practice or pediatrics, who is deemed by US Family
Health Plan to be a Primary Care Physician, and who upon selection or assignment, shall
be responsible for providing initial and primary care, maintaining the continuity of care,
and initiating referrals for care of Members who have selected or been assigned to such
Primary Care Physician.
Provider: An entity that performs or furnishes a medical, behavioral health, and/or dental
service/treatment to members AND is recognized under Section 1866(e) of the Social
Security Act.
Referral: An authorization granted by the Participating Physician/Primary Care Physician
for use of another provider.
Specialty Care Physician: A US Family Health Plan Physician who is not a Primary Care
Physician.
Third Party Liability: Recovery of the reasonable value of care and treatment furnished or to
be furnished by or for the government to persons entitled to such care and treatment when
such persons suffer injury or disease under circumstances which create tort or contractual
liability on third parties, including insurance companies, to pay damages.
TRICARE: formerly known as the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS), is a health care program of the United States Department of
Defense Military Health System that provides civilian health benefits for military
personnel, military retirees and their dependents, including some members of the Reserve
Component.
INTRODUCTION
In 1981, CHRISTUS Health began caring for military beneficiaries as a part of the
Uniformed Service Treatment Facilities. In 1993, US Family Health Plan, along with other
programs around the country, became the first government-sponsored managed care
plan – the US Family Health Plan. Through this plan, we serve:
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Active Duty Dependents such as children and spouses
Retired Military 64 years and younger and their dependents
Retired Military over 65 years of age and their dependents, with some exceptions.
Members of the US Family Health Plan receive services as part of healthcare benefits
managed by the Primary Care Physician (PCP). Benefits are available only through the
exclusive use of participating physicians, hospitals, medical centers, pharmacies, home
health agencies, and other health care providers. No benefits are provided for use of
nonparticipating providers (except in the case of emergencies, and when authorized in
advance, for services not available from participating providers). A list of participating
providers is f o u n d o n t he plan’s website at http://christus.usfhp.com, which is updated on
a monthly basis.
As a provider for the US Family Health Plan, providers have agreed to follow and adhere to
“Rules & Regulations,” which include, but are not limited to, all quality improvement,
utilization management, credentialing, peer review, grievance, National Quality Monitoring
Contract (“NQMC”) program, and other policies and procedures established and revised by
US Family Health Plan or the Department of Defense (DoD) and the US Family Health Plan
Provider Manual, as amended from time to time. Further, the policies and procedures set
forth herein may be altered, amended, or discontinued by CHRISTUS Health or the US
Family Health Plan at any time upon notice to the provider.
This manual and the policies and procedures contained herein do not constitute a contract
and cannot be considered or relied upon as such. Further, the policies and procedures set
forth herein may be altered, amended, or discontinued by CHRISTUS Health or US Family
Health Plan at any time upon notice to the physician. The most up-to-date version of the
Provider Manual is located on the Plan’s website at http://christus.usfhp.com. All terms and
statements used in this manual will have the meaning ascribed to them by the US
Family Health Plan and CHRISTUS Health and shall be interpreted by US Family Health
Plan and CHRISTUS Health in its sole discretion.
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PROVIDER PARTICIPATING REQUIREMENTS
US Family Health Plan (USFHP) credentials practitioners and certain facilities (hospitals,
ambulatory surgery centers, home health agencies and skilled nursing facilities) prior to
participation. Practitioners and facilities are re-credentialed, at a minimum, every three (3)
years. The credentialing/re-credentialing process consists of the provider application process,
verification of credentials with primary sources (excludes facilities), if required, and a review
by the credentialing committee.
PRACTITIONER PARTICIPATION CRITERIA
•
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•
•
•
Completed USFHP Provider Application.
Current license to practice medicine or operate facility without limitation, suspension,
restriction
Current DEA/CDS certificate (if applicable)
Current malpractice insurance coverage: minimum $200,000/600,000
Board Certification or completed appropriate training in the requested specialty
Ability to meet USFHP Access and Availability standards
Must be eligible to become a TRICARE Authorized Provider
No current Medicare/TRICARE sanctions
Network Need
FACILITY PARTICIPATION CRITERIA**
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Completed USFHP Facility/Ancillary Application
Current operating certificate
Current Accreditation (JCAHO Accreditation if applicable)
Current malpractice insurance coverage: minimum $200,000/600,000 or consistent
with state minimum standards
Ability to meet USFHP Access and Availability standards
Must be eligible to become a TRICARE Authorized Provider
No Medicare sanctions
Network need
** Facility credentialing is limited to hospitals, skilled nursing facilities, home health
agencies, and ambulatory surgery centers.
PROVIDER, FACILITY AND ANCILLARY CONTRACTUAL REQUIREMENTS
At a minimum, language in the contract includes the following conditions or programs to
which the provider agrees to comply:
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
Provide continuous 24-hour, 7 day a week access to care
Arrange for another physician (the "Covering Physician") to provide patient care or
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referral services to a member in the event that a participating provider is
temporarily unavailable
 Utilize the US Family Health Plan's participating physicians and facilities when
services are available and can meet the patient's needs
 Not discriminate on the basis of age, sex, handicap, race, color, religion or national
origin
 Accept patients transferring from out-of-network care to in-network facilities
 Not balance bill a member for providing services that are covered by the US
Family Health Plan. You may only bill members for applicable deductibles, copayments, and/or cost-sharing amounts
 Not bill for charges which exceed contractually allowed reimbursement rates. May
bill a member for a service or procedure that is not a covered benefit
 Prepare and complete medical and other related records in a timely fashion and
maintain contemporaneous clinical records that substantiate the clinical rationale
for each course of treatment, periodic evaluation of the efficacy of treatment, and
the outcome at completion or discontinuation of treatment.
 Provide clearly legible specialty care consultation or referral reports, operative
reports, and discharge summaries to the member’s PCP within 30 business days
of the member’s visit with the specialist
 Maintain medical records for five (5) years or 60 months from the last date in which
service was provided to the member
 Transfer medical records within 10 business days or sooner if requested by a
treating physician, after a member in your panel changes to another PCP
 Allow access to medical records for review by appropriate committees of the US
Family Health Plan and, upon request, provide the medical records to
representatives of the Federal Government and/or their contracted agencies
 Inform the US Family Health Plan within twenty-four hours, in writing, of any
revocation or suspension of the physician’s Drug Enforcement Agency (DEA)
number, certificate or other legal credential authorizing the physician to practice
in the state of Texas, or any other state. Failure to comply with the above could
result in termination from the Plan
 Inform the US Family Health Plan immediately, in writing, of changes in
licensure status, tax identification numbers, phone numbers, addresses, status at
participating hospitals, loss of liability insurance, and any other change, which would
affect practicing status with the US Family Health Plan
 Provide or assist the US Family Health Plan in obtaining Coordination of
Benefits/Third Party Liability Information
 Participate in the US Family Health Plan's quality improvement, utilization
management, credentialing, peer review, grievance, National Quality Monitoring
Contract (“NQMC”) programs, and other policies and procedures established and
revised by US Family Health Plan or the DOD which also includes participation in
evidence-based patient safety programs
 Abide by the US Family Health Plan rules and regulations, and also by all other
lawful standards, policies, rules and regulations of the CHRISTUS Health System.
Note: All subcontractor agreements are subject to the contract requirements above. If
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provider performs a delegated function (“Delegated Activities”) on behalf of the Plan via
their contract with the Plan, the provider shall not delegate, assign, or otherwise
transfer the performance of any of the Delegated Activities to any person or entity
without the prior written consent of US Family Health Plan. Any further delegation,
assignment, or transfer shall not release provider from liability for performance under
the delegated activities and shall be in writing and shall subject the person or entity
to whom tasks are further delegated, assigned, or transferred to the identical terms
contained within the provider’s agreement with the Plan and shall be further subject
to any and all accrediting standards that the Plan is required to meet.
PROVIDER RIGHTS
Providers have certain rights as participating providers of the US Family Health Plan. These
rights include:
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Ask to have any adjudicated claim reconsidered if they feel it was not paid
appropriately
Appeal any action taken by US Family Health Plan that affects their status with the
network and/or that is related to professional competency or conduct
Request that the US Family Health Plan remove a member from their care if an
acceptable patient-physician relationship cannot be established with a US Family
Health Plan member who has selected them as his/her physician.
Request to serve on the Quality Management Committees or other committees that
may be formed by the US Family Health Plan
Provide feedback and suggestions on how service may be improved for providers
and for members through written correspondence, the Plan’s annual Provider
Satisfaction Survey, or via the Physician Advisory Committee.
APPOINTMENT WAIT TIME
Wait times in any physician’s office should not exceed 30 minutes for non-emergent visits.
ACCESS STANDARDS
Primary Care Physician:
Members must have access to a primary care physician within a 30 minute drive time from
their residence.
Specialty Care Provider or Ancillary Provider:
Members must have access to a specialist within a 60-minute drive time from their residence.
US Family Health Plan defines access standards as the timeliness within which a
Member can obtain available services, in accordance with the Department of Defense’s access
and availability requirements. When a member calls to make an appointment, it must be
made within the following guidelines:
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Service
Well visits (Preventive
Health Services)
ACCESS STANDARDS
Definition
Health care services designed for
the prevention and early
detection of illness in
asymptomatic people, generally
including well woman exams,
physical examinations, routine
eye exams and immunizations
Standard
Within four (4) weeks
Routine Care
Non-urgent care for
symptomatic conditions
As soon as possible; no
later than one week
Urgent Care (Acute)
Acute but not life or limbthreatening
Less than 24 hours
Emergency Care
Life or limb-threatening illness
or accident potentially leading
to permanent disability or
seriously jeopardizing health.
Symptoms requiring immediate
medical attention
Care, provision for care, or
direction of care by the provider
during non- office hours
Immediately
Care, provision for care, or
direction of care, by the specialty
provider
Within four (4) weeks
After Hours Care
Specialty Consultation
or Procedure
24-hours-per-day 7 daysper-week
COVERING PHYSICIANS
Covering physicians will be reimbursed according to the contracted provider’s
reimbursement rates. Covering physicians are responsible for urgent care only. Follow-up
treatment should always occur with the member’s PCP. It is the responsibility of the
contracted PCP to have his/her covering physician provide care according to the benefit and
access guidelines outlined in this Provider Manual, whether or not the covering physician is
affiliated with US Family Health Plan. A covering physician may not make routine
referrals.
MEDICAL RECORDS
There may be times when a member’s medical record needs to be transferred from one PCP
to another in the Plan. This may occur when members change PCPs or if a PCP leaves
the plan. All medical records must be transferred to the new PCP within 10 business days
or sooner if requested by the treating physician. Medical records for US Family Health Plan
members must be maintained for 5 years (60 months) from the last date of service provided.
Federal/TRICARE regulations require that the following information should be included in
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every individual patient record:
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Patient Identification
Personal Data
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Allergies
Chronic/Significant Problem List
Chronic/Continuing Medication List
Immunization History
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Informed Consent
Provider Signature/Name, Each Entry
Patient’s Signature on File
Growth Chart (14 years of age and under)
Initial Relevant History
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Smoking Status (12 years and older)
Alcohol or Substance Use/Abuse (12 years and older)
Date of Each Visit
Chief Complaint
Physical Exam Relevant to Chief Complaint
Diagnosis/Impression for Chief Complaint
Appropriate Use of Consultants
Treatment/Therapy Plan
Results discussed with Patient
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MD Review of Diagnostic Studies
Results of Consultations
Date of Next Visit
Hospital Records

Preventive Health Education
24/7 NURSE TRIAGE LINE
The Plan has a 24/7 Nurse Triage line. Members can access this service toll free for medical
guidance/triage 24 hours a day, 7 days per week. Members are instructed based on
nationally recognized triage protocols. This service does not replace the provider’s afterhours coverage commitment.
PATIENT NO SHOW
The patient’s PCP must review each chart for patients who fail to keep their scheduled
appointments. A patient “No Show” should be documented in the patient’s medical record.
Continual failure to keep appointments without notice of cancellation may be grounds for
member disenrollment.
OTHER PROVIDER INFORMATION
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National Disaster Medical System (NDMS)
All acute-care medical and/or surgical hospitals are encouraged to become members of the
National Disaster Medical System (NDMS). For more information, please visit:
http://www.phe.gov/Preparedness/responders/ndms/Pages/default.aspx.
Providers and members are encouraged to use Medline Plus® a web site developed and
maintained by the U.S. National Library of Medicine (NLM) and the National Institutes of
Health (NIH). This site provides information on diseases and conditions, clinical trials, drugs,
and the latest health information. The use of this site is not intended to be a substitute for
health care information, but may be used as a resource. See the Medline Plus® site:
http://medlineplus.gov.
President’s Advisory Commission On Consumer P rotection and Quality in the Healthcare
Industry
As part of the contractual obligations to DoD, the US Family Health Plan is committed to
the principles contained in a document released on March 12, 1998: entitled “Quality First:
Better Health Care for All Americans.” Developed by the Presidential Advisory
Commission, this document recommends steps to provide a “national commitment to
improving health care quality.” The Commission’s final report also included its
recommendations for a Consumer Bill of Rights and Responsibilities in health care.
The Commission states that a Consumer Bill of Rights and Responsibilities “can help to
establish a stronger relationship of trust among consumers, health care professionals,
health care institutions, and health plans by helping sort out the responsibilities of
each of these participants in a system that promotes quality improvement. Physicians
desiring more information about the Consumer’s report or the Consumer Bill of Rights
and Responsibilities can access the documents online from the Commission’s Website at
http://www.hcqualitycommission.gov.
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PROVIDER COMPLAINTS and APPEALS
All participating providers have agreed to comply with the plan’s dispute resolution process
by signing the provider agreement. The provider complaint process is available to any
participating provider to resolve disputes with the Plan. The Plan distinguishes disputes by
the following categories: 1) Administrative Disputes related to claims or claims payment; 2)
Administrative Disputes not related to claims payment; and 3) Disputes Concerning
Professional Competence and Conduct.
1. Administrative Disputes Related to Claims:
May include, but are not limited to, a participating provider’s written notice to the US
Family Health Plan challenging, appealing or requesting reconsideration of a claim denial
or payment.
 A provider may submit a written request for reconsideration within 90 days of an
action taken or decision made by US Family Health Plan.
 For any dispute involving the payment or denial of a claim, the 90-day period begins
on the date of the US Family Health Plan remittance reflecting the disputed payment
or denial. For any dispute related to a claim audit, the 90-day period begins on the
date of the notice to the provider.
 For any dispute involving the payment or denial of a claim, US Family Health Plan
forwards the provider reconsideration to the appropriate person in the Claims
Department for research and resolution.
 Providers will receive a payment or written response generally within thirty (30)
calendar days (can take up to 90 days), describing how their request was resolved.
 Please note that providers cannot appeal the rules and regulations of the Plan or
TRICARE policy, but may send a formal complaint/grievance if they think an error in
the interpretation of the policy has occurred. Grievances are handled in a like manner
to appeals.
2. Administrative Disputes Not Related to Claims:
May include a participating provider’s written notice to the US Family Health Plan
challenging, appealing or requesting reconsideration of a factual determination made by
Utilization Management and/or contractual concerns.

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A provider’s request must be in writing. The 90-day period begins on the date that
US Family Health Plan notifies the provider of the disputed action taken or decision
made by US Family Health Plan (e.g., denial of late authorization request).
When appropriate, the Medical Director will review the matter first, using appropriate
peer input. The review process may include third-party subject matter experts who
have not been previously involved with the issue. If an issue is referred to a thirdparty subject matter expert, the referral is documented in writing.
For any dispute not involving the payment or denial of a claim, US Family Health
Plan may convene a committee of appropriate cross-functional representatives to
review the written request for reconsideration and make a determination. At least
one authorized health plan representative not previously involved in the initial
decision will be included to review the issue.
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At the discretion of the committee, a meeting with the provider may be held or a
request for additional information may be submitted to the provider. If a meeting
takes place with the provider, or additional information is requested and received
from the provider, the 30-day timeframe for a determination is extended accordingly.
Determinations are made in writing or via denied claims or adjusted claims on the
provider remittance advice within 30 days of receipt of a written request. If US Family
Health Plan is unable to make a determination within 30 days, best efforts are made
to provide an update to the provider with an estimate on the timeframe for a
determination.
Administrative Dispute Appeal:
 Participating providers have the right to appeal their dispute to a panel consisting of
at least three qualified individuals, of which at least one must be a participating
provider who is not otherwise involved in network management and who is a clinical
peer of the participating provider that filed the dispute. In no case will panel members
be assigned who have been previously involved with the issue.
 The provider has the right to submit relevant information:
o The panel will discuss the dispute and make a decision. The decision will be
forwarded in writing, return receipt required, to the disputing provider
o The decision of panel is final. Its decision will also be transmitted in writing
 Providers will receive a payment or written response generally within thirty (30)
calendar days describing how their request was resolved.
3. Professional Competence Or Conduct Disputes:
May include non-administrative disputes that involve actions by the Plan that relate
to a participating provider’s status within the Plan’s provider network and any action
by the Plan related to a participating provider’s professional competency or conduct.
Professional Competence or Conduct Dispute Appeal:
 Participating providers have the right to appeal their dispute to two (2) separate panels
above the level of the Plan body involved in the dispute, each consisting of at least
three qualified individuals, of which at least one must be a participating provider who
is not otherwise involved in network management and who is a clinical peer of the
participating provider that filed the dispute. In no case will panel members be
assigned who have been previously involved with the issue.

At each level, the provider has the right to submit relevant information:
o When appropriate, the Medical Director will review the matter first, using
appropriate peer input; if not satisfactorily resolved, the dispute will be
referred to the first level panel
o The first level panel will discuss the dispute and make a decision. The decision
will be forwarded in writing, return receipt required, to the disputing provider,
and when necessary, the second level appeal rights, procedures, and
timeframes will be provided. The provider has the right to challenge the
findings of the decision
o The decision of the second level panel is final. Its decision will also be
transmitted in writing
o In order to maintain the right to use the dispute resolution process, a signed
2014-2015 Revision
9


written appeal from the participating provider must be received within 30
calendar days from the date the letter was received. Unless otherwise
indicated, delivery will be assumed to have occurred 5 days after mailing
o The provider has the right to challenge the findings of the decision and to
present relevant documentation and information in support of his/her dispute
or appeal.
A panel will be convened within 60 days of the request and the decision will be returned
to the participating provider within 30 days of the closure of the panel. When an
adverse action is taken or if the provider voluntarily relinquishes participation while
undergoing investigation and/or peer review, it is noted in the Credentialing File and
reported if required by law.
The following actions are required to be reported to the National Practitioner Data
Bank (NPDB): terminations resulting from serious quality deficiencies, providers who
terminate themselves while under investigation and providers who terminate
themselves with an action plan in place.
2014-2015 Revision
10
MEMBER ELIGIBILITY
SELECTING A PCP
Upon enrollment, the Plan member and the member’s eligible family members select a
Primary Care Physician (PCP). Members will only be assigned to PCPs with open panels
(those currently accepting new members). Physicians may establish, ahead of time, a
limit on the number of US Family Health Plan members to be accepted into his or her panel.
Physician panels can be opened and closed as necessary by the physician via written
notification to the Provider Relations Department.
A sample Member ID Card is shown below. Members are to present their Member ID card to
providers at the time of service.
EXAMPLE:
CATASTROPHIC CAPITATION
The Department of Defense requires the US Family Health Plan to discontinue collecting
any copays, deductibles or enrollment fee payments once an individual and/or family reach
their out-of-pocket maximum for any plan year (October 1 thru September 30). The outof-pocket maximum for retirees and/or family members is $3,000 per policy year and the
limit for Active Duty service family members is $1,000 per policy year.
Members will receive a new membership card after the maximum dollar amount has been
reached. The new card will indicate a $0 copay in the copay section. Copayments are
reinstated at the beginning of the next plan year, on October 1st, as the accrual of catastrophic
maximum resets.
No copays, including pharmacy, should be collected from a member who presents to the
office with a copy of their TEMPORARY card. The card will indicate that the member
has no copays and it will also include an “end effective date” that regular cards do not
contain.
2014-2015 Revision
11
TEMPORARY CARD
Member ID: 123456789*01
Pat ID:
Name:
DOB:
Sex :
Status:
Region: St. John
9876543210 Fam ID: 123456789 Bene ID: 1
MARY ELIZABETH TOWN
09/30/1801
FEMALE
Group ID #: RETMEDB2
End Effective Date: 9/30/2009
Catastrophic Maximum
No Copays or Deductibles are Required
Verify Coverage:
1-800-678-7347
Emergency Info:
1-800-455-9355
This card is not a guarantee of coverage
MEMBER DISENROLLMENT AND CHANGES
General Disenrollment
Members may become ineligible for US Family Health Plan benefits for many reasons,
including the following:
1. The Military identification card expires or the Department of Defense eligibility system
indicates the member is ineligible
2. Member makes a permanent move out of the service area
3. A determination can be made that the member has provided false information to the
Plan, committed fraud with respect to the Plan or permitted someone else to do so with
respect to the Plan
4. Member fails to pay an applicable enrollment fee
5. Members use other healthcare services in the Military Health System or the Medicare
program without prior approval of the US Family Health Plan.
Voluntary Disenrollment
Members may elect to disenroll anytime without cause. The effective date of disenrollment
from the Plan is based on medical necessity and/or date the request is received. Members
may choose to disenroll prior to completing 12 continuous months of enrollment if they
have made a permanent move out of the service area. US Family Health Plan may consider
and may approve other requests for disenrollment on a case-by-case basis.
Members who require the services provided under TRICARE Standard’s Program For
Persons With Disabilities (PFPWD) will be disenrolled at the request of the member or
the member’s guardian.
MEMBER GRIEVANCES AND COMPLAINTS
2014-2015 Revision
12
The Plan encourages members to resolve individual inquiries and concerns or problems at
the point of service. In the event their request for assistance is not settled at the point of
service, members should contact a Member Services Representative, who will work with
members to resolve their concerns and issues.
In the event that a member’s grievance/complaint/inquiry has not been settled at the
informal level and the member is dissatisfied, he or she may file a formal grievance.
Providers are required to respond in writing to any formal grievance made regarding the
provider, the provider’s staff, the provider’s facility/office, or the services provided within 10
days of the receipt of the grievance.
2014-2015 Revision
13
COVERED and NON-COVERED SERVICES
US Family Health Plan provides covered medical benefits to its members. Following is a list
of covered and non-covered services, although it is not all inclusive. A copayment may be
required for an office visit, hospital admissions, prescribed medications, emergency room visit
if not admitted, purchase or lease of durable medical equipment and other services as
indicated. Members are responsible for payment for all services determined not to be
medically necessary and not authorized by the physician.
FAMILY PLANNING
Family planning services are covered as a part of the US Family Health Plan package of
benefits. However, since this benefit is inconsistent with the Ethical and Religious
Directives for Catholic Health Care, and is not provided by CHRISTUS Health owned
entities, Meritain Health, Inc. administers the family planning benefit for US Family Health
Plan members. Meritain Health, Inc. is not affiliated with CHRISTUS Health.
Family Planning services provided are paid directly through Meritain Health, Inc.
Providers who have questions should contact Meritain directly at (888) 627-8889. Claims
for family planning should be submitted to the address provided under “Important Phone
Number and Addresses.”
BEHAVIORAL HEALTH
US Family Health Plan has contracted with APS HealthCare to manage behavioral health
services, including all Mental Health services, treatment for alcoholism, substance abuse,
drug addiction and chemical dependency. APS Health Integrated behavioral health staff is
available 24 hours per day/7 days per week at 1-800-406-0022. Providers should use this
phone number to identify participating behavioral health providers, request pre
authorization for inpatient admissions and outpatient services after the initial 8 visits and
continued stay reviews. Members may self‐refer for the initial 8 visits to a participating
behavioral health provider.
MEDICARE
A provider may not bill Medicare for US Family Health Plan covered benefits provided
to a US Family Health Plan member. Should a provider bill Medicare for US Family Health
Plan covered services, the US Family Health Plan is required to investigate and if
appropriate, disenroll the member from the Plan. Should a member possessing Medicare
benefits disenroll from the plan, their Medicare benefits are automatically reinstated.
2014-2015 Revision
14
END STAGE RENAL DISEASE
Special rules apply for the coverage and payment for maintenance kidney dialysis.
Members, regardless of age, diagnosed with End Stage Renal Disease (ESRD), become
eligible and must apply for Medicare coverage. US Family Health Plan will provide full
coverage for ESRD patients until Medicare coverage is obtained (typically up to the first
90 days of dialysis depending on the method of dialysis). Once Medicare coverage is
obtained by the member, Medicare replaces US Family Health Plan as the primary
insurance for all health care. US Family Health Plan becomes secondary to Medicare
thereafter, and covers coinsurance charges for which patients would otherwise be
responsible. However, services provided to ESRD patients must continue to be authorized
by the Plan in order to be reimbursable. Claims submitted for services provided to ESRD
patients will require the submission of a Medicare EOB in addition to the claim.
ESRD patients who do not obtain Part B insurance, will lose their US Family Health
Plan benefit, and will be responsible for all charges related to ESRD.
COORDINATION OF BENEFITS / THIRD PARTY LIABILITY
The US Family Health Plan will coordinate benefits for those provided services which
are also covered by Workers' Compensation or other third party carriers. Third Party
Liability occurs when a US Family Health Plan patient suffers injury or illness that was
caused by the negligence of or intentional act of a third party. Examples of third party
liabilities are automobile insurance, workers' compensation, homeowners' liability, etc.
Benefits will also be coordinated with a "no-fault" auto insurance carrier if allowable
under the specific state law. It is the responsibility of the physician to provide or assist
the US Family Health Plan in obtaining Coordination of Benefits/Third Party Liability
information.
Provider shall accept payment from US Family Health Plan, plus any copayments as
payment in full for all covered services provided to members, and will not attempt to bill
any other person, insurer, payor, or other entity for such services. Providers must provide
to US Family Health Plan information upon request about a member's other insurance
coverage(s). Providers assign to US Family Health Plan all of provider's rights to any
other benefits that may be payable in respect to a member and agrees to use their best
efforts to determine other benefit coverage assisting US Family Health Plan’s collection of
other such benefits. Providers will be required to provide patient information updates upon
request to allow US Family Health Plan to update records or other information.
2014-2015 Revision
15
Active Duty
Family
Members
Retirees and
Retirees and
Eligible Family Eligible Family
Members with
Members
Medicare Part
without
B*
Medicare Part B
OUTPATIENT SERVICES
Alcohol & Substance Abuse Treatment (Partial
Hospitalization)
Up to 21 days for rehabilitative treatment on a limited hour
per day basis. Does not count toward the limits for days of
the mental health partial hospital limits.
Ambulance Services
(Per Occurrence)
CT/MRI
Durable Medical Equipment, Prosthetic Devices and
Medical Supplies
When prescribed by your physician and secured through
USFHP contracted providers.
Emergency Care
Emergency care obtained on an outpatient basis, network and
non-network. Copayment (if applicable) is waived if admitted to
hospital.
Eye Examinations
One routine eye exam per plan year. *Note: The Retiree eye
exam is provided by CHRISTUS Health and is not a DoD
covered benefit.
Family Planning Services
Provided by Meritain Health, Inc.
Home Health Care
When medically necessary.
$0 per day
$0 per day
$40 per day/
$25 minimum
$0
$0
$0
$0
$0
$0
0%
of contracted
rate
0%
of contracted
rate
20%
of contracted rate
$0
$0
$30
$0
$0
$0
Physician Visit:
$0
Physician Visit:
$0
Physician Visit:
$12
$0 per visit
$0 per visit
$0 per visit
Hospice
$0
$0
$0
Immunizations for Required Overseas Travel
No copayment is required if part of an office visit.
$0
Not covered
Not covered
Laboratory and X-Ray Services
No additional copayment will be required if provided as a part
of an office visit in which a USFHP copayment (if required)
was collected even if the services are performed separate
from the office visit (i.e. different location or time). No
copayment will be collected when these services are billed
and provided as preventative services.
$0
$0
$0
$0 per visit
$0 per visit
$0 per visit
Maternity Care
Prenatal and postnatal visits.
2014-2015 Revision
16
Active Duty
Family
Members
Retirees and
Retirees and
Eligible Family
Eligible Family
Members with Members without
Medicare Part B * Medicare Part B
OUTPATIENT SERVICES
Outpatient Mental Health (Individual)
One hour of therapy, no more than two times each week
when medically necessary.
Beneficiaries enrolled may seek mental healthcare from a
network mental health provider, for up to eight visits per
enrollment year, without a referral from their PCP. However,
the network mental health provider must obtain a
preauthorization from the Plan
Outpatient Mental Health (Group)
One hour of therapy, no more than two times each week
when medically necessary.
Beneficiaries enrolled may seek mental healthcare from a
network mental health provider, for up to eight visits per
enrollment year, without a referral from their PCP. However,
the network mental health provider must obtain a
preauthorization from the Plan.
$0 per visit
$0 per visit
$25 per visit
$0 per visit
$0 per visit
$17 per visit
Outpatient Surgery (Procedures Performed in a Hospital
Facility)
Copayment (if applicable) is applied to facility performing
procedure.
$0
$0
$25
Outpatient Surgery (Procedures Performed in a Doctor’s
Office)
Regular office visit copay (if applicable) applies. No
additional copayment beyond the regular physician office
visit can be charged.
$0
$0
$12
Physical/Occupational Therapy
When medically necessary. When provided in home, any
applicable copayment for home health care applies.
$0 per visit
$0 per visit
$12 per visit
Physicians Services
Office visits; outpatient office-based medical and surgical
care; consultation; diagnosis and treatment by a specialist;
allergy tests and treatment; osteopathic manipulation; medical
supplies used within the office including casts, dressings and
splints.
Prescriptions (On-Site)
Up to a 30-day supply or smaller obtained directly from plan
pharmacy.
$0 per visit
$0 per visit
$12 p er visit
2014-2015 Revision
$5 Generic
$17 Name
Brand up to a
30-day supply
$44 nonformulary
brand and
generic drugs
$5 Generic
$5 Generic
$17 Name Brand $17 Name Brand up
up to a 30-day
to a 30-day supply
supply
$44 non-formulary
$44non-formulary
brand and
brand and
generic drugs
generic drugs
17
Active Duty
Family
Members
Retirees and
Retirees and
Eligible Family
Eligible Family
Members with Members without
Medicare Part
Medicare Part B
B*
OUTPATIENT SERVICES
Prescriptions (Mail Order Pharmacy)
Up to a 90-day supply or smaller obtained through the USFHP
Maxor Mail Order Pharmacy when authorized; includes
prescriptions for nursing home patients.
$0 Generic
$13 Name Brand
up to a 90-day
supply*
$43 nonformulary
brand/generic
drugs
$0 Generic
$13 Name
Brand up to a
90-day supply*
$43 nonformulary
brand/generic
drugs
$0Generic
$13 Name Brand up
to a 90-day supply*
$0
$0
$0
Residential Treatment Centers
$0 per day
$0 per day
$0 per day
Speech Therapy
When medically necessary. When provided in home, the
copayment for home health care applies.
Well-Child Care
Up to 6 years of age, except as a preventative service.
$0 per visit
$0 per visit
$12 per visit
$0 per visit
$0 per visit
$0 per visit
Periodic Preventative Screenings
Age and gender appropriate screening tests for the early
detection of disease and/or disease risk factors including:
Cancer Screening- mammography, pap smears, sigmoid and
colonoscopy, and fecal occult blood testing; Infectious Disease
Screening-Tuberculosis, Rubella, and Hepatitis;
Cardiovascular- Cholesterol and Blood Pressure; Other-vision
screening, lead toxicity, hearing (as part of annual physical).
$0
$0
$0
Education and Counseling Services
The following education/counseling services can be part of any
visit to your PCP dietary assessment & nutrition; physical
activity & exercise; cancer surveillance; tobacco, alcohol &
substance abuse; accident & injury prevention; promotion
dental health; stress and bereavement.
Annual Physicals or Well Woman Exams Refer to the
Preventive Health Services section to determine the age
appropriate screenings you could be provided. (Presenting to
your PCP’s office with medical problems during a well visit will
be viewed as a regular office visit.)
$0
$0
$0
$0
$0
$0
Immunizations
Age appropriate immunizations are provided for vaccine
preventable diseases according to guidelines set forth by the
Centers for Disease Control.
Enhancement Seminars, Community Health Services, and
Community Resource Coordination
$0
$0
$0
No charge
No charge
No charge
No charge
No charge
No charge
*Name Brand up to a 90-day supply when physician
authorized
Radiation Therapy
$43 non-formulary
brand/generic
drugs
PREVENTATIVE SERVICES
24-hour Nurse/Health Information Library
2014-2015 Revision
18
Active Duty
Family
Members
Retirees and
Retirees and
Eligible Family
Eligible Family
Members with
Members without
Medicare Part B * Medicare Part B
INPATIENT SERVICES
Alcohol & Substance Abuse Treatment
(Inpatient)
7 days for detoxification and 21 days for rehabilitation per
plan year. Maximum of one rehabilitation program per plan
year and three per lifetime. Detoxification and rehabilitation
days count toward limit for mental health benefits.
$0 per day
$0 per day
$40 per day/
$25 minimum
Hospitalization
Semiprivate room (and when medically necessary, special
care units), general nursing, and hospital services. Includes
inpatient physician and their surgical services, meals
(including special diets), drugs and medications while an
inpatient, operating and recovery room, anesthesia,
laboratory tests, X-ray and other radiology services,
necessary medical supplies and appliances, blood and blood
products. Unlimited services with authorization, as medically
necessary.
Inpatient Mental Health Treatment
Up to 30 days per plan year for ages 19 and older, up to 45
days per plan year for ages 18 and under, and up to 150
days per fiscal year for Residential Treatment Centers (as
medically necessary). For partial hospitalization up to 60
days with authorization per plan year (minimum of 3 hours
per day of the therapeutic services).
$0 per day
$0 per day
$11 per day or $25,
whichever is
greater
$0 per day
$0 per day
$40 per day/
$25 minimum
Maternity
Hospital and professional services (prenatal, postnatal).
Unlimited services with authorization, as medically
necessary.
$0 per day
$0 per day
$11 per day or $25,
whichever is
greater
Skilled Nursing Facility Care
Semiprivate room, regular nursing services, meals including
special diets, physical occupational and speech therapy
drugs furnished by the facility, necessary medical supplies
and appliances. Unlimited services with authorization, as
medically necessary.
$0 per day
$0 per day
$11 per day or $25,
whichever is
greater
2014-2015 Revision
19
SERVICES NOT COVERED UNDER THE US FAMILY HEALTH PLAN



















Organ transplants considered to be experimental or investigational
Convenience and personal care items which are billed separately such as telephone,
television or radio
Charges for care and supplies not ordered by a physician
A stay at an inpatient skilled nursing facility, unless deemed medically necessary
by the member's physician and authorized by the plan
Cosmetic or plastic surgery except as may be necessary to correct a severe
disfigurement, or to correct the disorder of a normal bodily function
Custodial care
Non-medically necessary transportation costs
Experimental/investigational procedures
Acupuncture or acupressure
Lodging costs during outpatient dialysis treatment
Wages lost to the care giver and the dialysis assistant during self-training
Homemaker services
Chiropractic or Naturopath services
Meals delivered to the home
Private duty nurses and nursing care on a full-time basis in the home
Services performed by immediate relatives or members of the household
Services for which neither the member nor another party acting on the member's
behalf has a legal obligation to pay. Note: Under the US Family Health Plan, the
member is covered only for services authorized or arranged by the Primary Care
Physician (PCP). Care outside of the Plan will not be paid for by the US Family
Health Plan, except in emergency situations. Non-pre-approved urgently needed
care is a covered benefit only when the member is traveling outside of the 48
contiguous states.
Services related to education, elective travel, employment, licensing, or other
administrative reasons
Services related to the treatment of End Stage Renal Disease (ESRD). Special rules
apply for the coverage and payment for maintenance kidney dialysis.
INFORMING MEMBERS ABOUT NON – COVERED SERVICES
As part of usual good business practice, providers are expected to notify US Family Health
Plan beneficiaries when a service is not covered. TRICARE policy includes a specific “hold
harmless” policy for network providers and recommends that out of network providers also
follow a similar process to document beneficiary notification.
Hold Harmless Policy for Network Providers
A network provider may not require payment from a beneficiary for any excluded or
excludable services that the beneficiary received from the participating provider except in the
following situations:
2014-2015 Revision
20
•
If the member did not inform the provider that he or she was a US Family Health Plan
member, the provider may bill the beneficiary for services rendered.
•
If the member was informed that the service was excluded or excludable and he or she
agreed in advance to pay for that service, the provider may bill the member.
US Family Health Plan members must be properly informed in advance and in writing of
specific services or procedures that are excluded before the service is provided. If the member
chooses to be financially responsible for the non‐covered service, the member should be asked
to sign a waiver agreeing to pay for the non‐covered service. A member’s agreement to pay for
a non‐covered service must be evidenced by written records. Examples of acceptable written
records include:
•
•
Provider office or medical record documentation written prior to receipt of the services
demonstrating that the US Family Health Plan member was informed that the
services were excluded or excludable and the beneficiary agreed to pay for them.
A statement or letter written by the beneficiary prior to receipt of the service,
acknowledging that the service is excluded or excludable and agreeing to pay.
If the participating provider does not obtain a signed waiver, and the service is not authorized
by US Family Health Plan, the provider is expected to accept full financial liability for the
cost of the care. It is important to note that a waiver signed by a member after the care is
rendered is not valid under DoD regulations.
For a US Family Health Plan member to be considered fully informed, DoD regulations
require that:
• The agreement is documented prior to the non‐covered service being rendered.
• The agreement is in writing – a verbal agreement is not valid under DoD policy.
• The specific service, date of service and estimated cost of service is documented in
writing.
• General agreements to pay, such as those routinely signed by patients, are not
evidence that the US Family Health Plan member knew specific services were
excluded.
Caution: Providers should be aware that there have been situations when a US Family
Health Plan member has agreed to pay in full for non‐covered services without signing a
waiver. The provider rendered the care in good faith without prior written waiver and the
beneficiary was not held financially responsible. Without a signed advance waiver, the
provider was denied reimbursement and could not bill the member.
2014-2015 Revision
21
PREVENTATIVE HEALTH GUIDELINES
US Family Health plan views preventive health as the foundation of services for its
members. The plan covers a variety of periodic health examinations and other services
such immunizations, disease specific screening, cancer screening, annual physicals, school
physicals, counseling services, mammograms, cholesterol screenings, blood pressure checks
and health screenings that conform to the recommendations of the TRICARE Policy
Manual and the United States Preventive Services Task Force. There is no specific
definition of “periodic” as referenced in the standard for preventive services, so this
judgment will be made by the Primary Care Physician, based on each individual case.
Each US Family Health Plan member is entitled to an annual physical and women are
entitled to one self-referring, well-woman exam performed by a network
Obstetrician/Gynecology specialist. Each US Family Health Plan member is entitled to an
annual eye exam performed by a network Optometrist/Ophthalmologist without PCP
referral.
Well-child care is covered for beneficiaries from birth to age six and includes routine
newborn care, health supervision examinations, routine immunizations, periodic health
screening, and developmental assessment in accordance with the American Academy of
Pediatrics (AAP) guidelines.
Note: No copay can be collected for preventive health services. Services provided should
not be unbundled in order to collect a copayment.
GUIDELINE LINKS
Preventive clinical preventive services policy for Tricare can be accessed at:
http://manuals.tricare.osd.mil/DisplayManualFile.aspx?Manual=TP08&Change=112
&Type=AsOf&Filename=C7S2_2.PDF&highlight=xml%3dhttp%3a%2f%2fmanuals.t
ricare.osd.mil%2fPdfHighlighter.aspx%3fDocId%3d32795%26Index%3dD%253a%25
5cIndex%255cTP08%26HitCount%3d17%26hits%3d12%2b2c%2b3a%2b9c%2b178%2
b1a0%2b1f4%2b218%2b2f8%2b374%2b3e6%2b530%2b6bf%2b85d%2b89b%2ba3a%2
bbff%2b
USPTF guidelines can be accessed at:
http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/guide/section1.html
Recommendations on Preventive Pediatric Health care from AAP can be accessed at:
http://www.aap.org/en-us/professional-resources/practicesupport/Periodicity/Periodicity%20Schedule_FINAL.pdf
2014-2015 Revision
22
REFERRAL/AUTHORIZATION GUIDELINES
PCP SELECTION
US Family Health Plan members are required to select a Primary Care Physician (PCP).
The PCP is responsible for providing and/or coordinating all health care for all covered family
members who have selected him/her as their Primary Care Physician:




PCPs refer members to US Family Health Plan network specialists
PCPs arrange for hospitalization and authorize urgent care, X‐rays, lab work and other
medical services when necessary
PCPs see members for routine care, preventive and annual physicals
PCPs initiate and coordinate authorization requests.
Members may access specialty and ancillary services a s coordinated by their PCP.
Specialists may not refer to other specialists without prior approval.
SELF-REFERRALS
Members may self-refer for annual well-woman exams and annual eye exams. Members may
seek outpatient mental health services through their PCP or they may self-refer to a
network mental health provider for up to eight (8) visits without a referral. Referrals are
made by calling APS at 800-406-0022. In those cases where a member self-refers, the
network mental health provider shall notify the PCP of the self-referral.
PCP REFERRAL TO NETWORK SPECIALISTS
PCP does not need prior/referral authorization to refer the member to an in-network
specialist. Participating providers are listed in the provider directory, US Family Health Plan
website (www. usfamilyhealthplan.org) or providers may call member services to verify innetwork participation.
Specialists may not refer to other specialists. If a specialist determines that a member needs
to be seen by another specialist, the member’s PCP is to be contacted for initiation of referral
and coordination of care.
PRIOR-AUTHORIZATION GUIDELINES
The PCP must complete the US Family Health Plan Referral/Authorization Form in its
entirety and either:


Contact the UM/CM Department at 1-800-446-1730 for an urgent or emergent request,
or
Fax a routine request to 1-800-277-4926.
2014-2015 Revision
23
The following information will be requested from the provider:










Provider name, address, and telephone number
Patient name, ID number, and date of birth
Diagnosis/ICD-9
Procedure(s), if applicable
Procedure code (CPT)
Name of facility
Date of admission/procedure
Indications for admission/procedure
Requested length of stay
Pertinent clinical information
Completed referrals containing all necessary information and supporting documentation
will be processed by the UM/CM Department.
UTILIZATION MANAGEMENT COMPONENTS
Preadmission Review: The process of authorizing non-emergency medical and surgical
hospitalizations.
Admission Notification: The physician and/or hospital notifies UM/CM when a US Family
Health Plan member is admitted to the hospital.
Continued Stay Review: (Concurrent Review) is a process that assures the length of stay
in the hospital is appropriate for the member’s medical condition, whether admitted for
non-emergency or emergency treatment.
Discharge Planning: The Plan’s Care Manager is responsible for coordinating a member’s
care and will work with the patient and the provider to assist in arranging for the member’s
discharge needs. The Plan’s Care Manager will assist in discharge planning by arranging
for any home care services, skilled nursing care, or medical equipment that is required
after leaving the hospital. This process helps assure that every member is provided with
appropriate care, both in the hospital and post discharge.
Retrospective Review: The process of review that occurs before payment of any claims for
which Precertification/Authorization did not occur. The review will consist of assessing the
medical necessity of all services not previously approved. Clinical information will be
reviewed for appropriateness using InterQual® Criteria, Plan Protocols, and TRICARE
coverage, as appropriate.
Ambulatory/Outpatient Review: The process of authorizing non-emergency
diagnostic and surgical outpatient procedures.
selected
Skilled Nursing, Long Term Acute Care and Rehabilitation Facility Authorization: Skilled
Nursing Facilities (SNF), Long Term Acute Care facilities (LTAC) and Rehabilitation
Facilities are specially qualified facilities or designated units in a hospital which have the
staff and equipment to provide acute care, skilled nursing care or rehabilitation services
2014-2015 Revision
24
and other related health services. US Family Health Plan coverage includes, as a benefit,
inpatient care in a participating SNF, LTAC or Rehabilitation Facility. Custodial care is
a non-covered benefit. Prior authorization is required.
Home Health Care: A Home Health Agency is a public or private agency that specializes in
providing skilled nursing services and other therapeutic services, such as physical
therapy in the home. The Home Health Care program provides skilled professional
services to members upon receiving prior orders by the attending physician and
authorization by the UM/CM Department. Requests for continuation of services will be
reviewed on an ongoing basis to determine medical necessity. Custodial care is a noncovered benefit.
Durable Medical Equipment: Durable medical equipment (DME) is used primarily and
customarily for a medical purpose, rather than primarily for transportation, comfort
or convenience. It can withstand repeated use and improves the function of a malformed,
diseased or injured body part or retards further deterioration of the patient’s physical
condition. Specific DME items require prior authorization (see Services Requiring Prior
Authorization). DME must be obtained through US Family Health Plan contracted
providers.
UTILIZATION MANAGEMENT NOTIFICATION REQUIREMENTS
There are specific notification requirements that apply to the services evaluated in each of
the review components, in order to ensure payment. The provider must call the Plan
regarding proposed treatment and service.
Treatment/Service
Notification Requirement
Urgent admissions/ observations
Elective admissions/
observations/surgical procedures/
outpatient procedures
With 48 hours of admission to the facility
5 business days prior to the requested date of
service
SNF/ Rehab/ Home health /Hospice
Initiation – 2 business days prior to requested
date of admission
Continuation – 7 days prior to requested date of
service
7 business days prior to requested date of
services
Diagnostic services/DME/ other
procedures requiring authorization
AUTHORIZATION PROCESS
Information received either via phone or electronic means in the UM/CM
Department will be reviewed for coverage and benefits. Appropriateness and medical
necessity will be reviewed using InterQual® Criteria, Plan Clinical Protocols and TRICARE
benefits and coverage.
2014-2015 Revision
25
Upon approval of authorization, the system generated authorization sheet is faxed to the
requesting provider and servicing provider.
Requests that do not meet the medical necessity or coverage guidelines are forwarded to
the Medical Reviewer for determination regarding medical necessity or benefit coverage.
If the Medical Reviewer determines that medical necessity or benefit coverage is not
established, notification is made to the requesting provider that will include the physician
reviewer’s determination to deny authorization. A denial letter will be sent to requesting
provider in two (2) business days of the determination.
REQUESTS TO OUT-OF-NETWORK PROVIDERS
Requests for services to non-participating or out-of-network providers may only be made:



For emergencies experienced in or out of the service area
In urgent situations experienced outside the 48 contiguous states
When other medically necessary services are unavailable from participating network
providers.
Most out of network requests for services will be sent to medical review and may require
service negotiations, which could potentially delay the request.
REQUESTS FOR CASE MANAGEMENT
The Case management program plans and manages care of members with catastrophic,
chronic needs and those whose needs are acute, episodic or short term in nature. The goals
of case management are the provision of quality care, enhancement of member’s quality of
life and management of health care costs for short term and long term. Disease Management
is Case Management for members with Specific chronic diseases.
Potential participants for Case management may be identified by the following
·
Physician referral
·
Facility admission/ Concurrent review process
·
Retrospective analysis
·
Member request
·
Case Management criteria per the Case Management assessment policy.
Providers can refer members for case management evaluation by calling the UM Department
at 1-800-446-1730.
2014-2015 Revision
26
APPEALS PROCESS
Level 1 Appeal-
Written requests for reconsideration-appeal of initial denial
determination may be submitted by the provider or member
Appeal of Initial Denial within the following time frames:
Determinations
 Concurrent review request for reconsideration must be
submitted by noon of the day following the day of receipt
of the initial denial determination.
 Expedited reconsideration of a preadmission/pre-procedure
denial must be filed within three (3) calendar days after
the date of the receipt of the denial determination.
 All other requests for reconsideration must be filed within
ninety (90) days after the date of the initial denial
determination.
 All appeals should be in writing
 The TriCare Quality Monitoring Contractor (TQMC) is
responsible for reviewing requests (Level 2 Appeals) from
providers for an appeal of reconsideration when a contractor
Appeal of Reconsideration
upholds an initial determination on reconsideration. The
Determination
TQMC will make a determination of the reconsideration
request within the following time frames:
Members/providers
request an appeal of
o Three (3) working days for expedited reconsideration
reconsideration when US
appealed by a member.
Family Health Plan
o Thirty
(30) days after receipt of the required
upholds an initial denial
documentation for review of reconsideration denial of
determination on
cases not identified as an expedited reconsideration.
reconsideration.
 The TQMC will notify all parties to the determination of
appeal of US Family Health Plan’s reconsideration
Level 2 Appeal-
All appeals of reconsideration decisions made by TQMC are final and binding. Additional
information about Tricare policy on appeals can be found in the TRICARE Operations
Manual 6010.56-M, Chapter 12 at http://manuals.tricare.osd.mil.
All appeals should be sent in writing to the following:
By Mail:
US Family Health Plan Medical Appeals Department
P.O. Box 169001
Irving, TX 75016-9001
By Fax:
US Family Health Plan
Attn: Medical Appeals
F a x : 1-800-277-4926
2014-2015 Revision
27
SERVICES REQUIRING PRIOR AUTHORIZATION
For Eligibility and Benefits, please contact Member Services at 800-678-7347
For Family Planning Assistance, please contact Meritain Health, Inc. at 888-627-8889
For Mental Health Assistance, please contact APS Healthcare at 800-406-0022
ALL OUT-OF-NETWORK SERVICES REQUIRE AUTHORIZATION
Durable Medical Equipment
Authorization Required
-
Alternating pressure pad/mattress
Bone growth stimulator
Compression/lymphedema sleeve and pump
CPAP/BiPAP
Continuous passive motion device (CPM)
Customized splints
Diabetic shoes/inserts
Dialysis equipment
Electric wheelchair/scooter (includes accessories, lifts
and modifications
-
Orthotics
Authorization not required for orthotics with a cost of $300
or less when furnished by a Network Provider, except:
- AS590 – AS513 (Diabetic Shoes, Fitting and
Modification), and
- L3000 – L3649 (Orthopedic Shoes) require
authorization
Prosthetics
Authorization not required for prosthetics with a cost of
$300 or less when furnished by a Network Provider.
Inpatient Authorization Required
All elective and urgent admissions/ observation stays to
acute care hospitals, hospice, long-term acute care,
rehabilitation, skilled nursing facilities and pre-operative
admissions.
Hospital Bed and Accessories
Hoyer Lift
Insulin Pump
Oxygen and Equipment
Standard Wheelchair
Traction Equipment
Ventilator and Supplies
Implanted Neuromuscular Stimulator
Specialty Drugs Authorization Requirements
(Not All Inclusive)
-
Activase (Alteplese
Aranesp (Darbepoetin)
Botox (Botulinum Toxin Type A)
Desferal (Deferoxamine)
Enbrel (Etanercept)*
Growth Hormone (Somatropin)*
Interferon (Avonex)
IVIG (Immune/Human Gamma Globulin)
Lucentis (Raniblzumab)
Maeugen (Pegaptnnib Sodium)
Neulasta (Pegfilgrastim)
Remicade (Infliximab)*
Vantas (Histrelin Implant
* Authorization required if not dispensed
through US Family Health Plan Network
Pharmacy.
Authorization Required
Outpatient Office/Facility/Home
- Chemotherapy
- Dialysis
- Home Health (Physician Review Required for Aide Requests)
- Radiation Therapy
- Rehabilitation Therapy (physical, occupational, speech, cardiac)
- Hospice-Outpatient and Continuous Care
- Selected Outpatient surgical/diagnostic procedures
- Clinical Trials
- Hyperbaric Oxyten Therapy
- Bariatric Surgery
- All out-of-network services
2014-2015 Revision
Diagnostic Services
- Cardiac Catheterization
(scheduled)
- PET Scan
- MRI/MRA
- SPECT
- Sleep Studies
- Genetic Testing
- Nuclear Medicine
- Stress Test (must be performed in
outpatient hospital setting)
28
PHARMACY SERVICES
PHARMACY BENEFIT – TRICARE FORMULARY
Prescription drugs are covered by US Family Health Plan when ordered by a licensed
provider. US Family Health Plan covers medically necessary FDA-approved prescription
drugs that are included on the TRICARE Formulary.
The TRICARE Formulary covers most US Food and Drug Administration (FDA) approved
prescriptions. In general, for a medication to be covered under the US Family Health Plan
pharmacy benefit it must:
 Be a prescription medication approved by the FDA
 Not be covered under the medical benefit, and
 Be prescribed in accordance with good medical practice and established
national standards of quality care.
Medications that are not medically necessary for the diagnosis or treatment of an
illness are not covered by US Family Health Plan.
If a brand name medication has a generic equivalent, it is the Department of Defense
(DoD) policy to dispense the generic equivalent instead of the brand name medication.
The brand name medication will be dispensed only if the medical director determines
that it is clinically required after careful review of clinical information provided by the
prescriber.
Some prescription medications may have pre-authorization, quantity limitations and/or
step therapy requirements as identified by the DoD Pharmacy and Therapeutics (P&T)
Committee.
An updated list of drugs requiring pre-authorization from the TRICARE Formulary is
located on the web at: http://pec.ha.osd.mil/formulary_search.php
DoD quantity limitations are in place for some drugs. TRICARE Quantity limits
information can be found on the web at: http://pec.ha.osd.mil/formulary_search.php
Step therapy involves prescribing a safe, cost-effective medication as the first step in
treating a medical condition. The preferred medication is often a generic that offers the
best value in terms of safety, effectiveness and cost. Non-preferred drugs are covered if
the preferred medication is ineffective or poorly tolerated. New prescriptions subject to
step therapy will not be covered unless the member has tried and failed the first line
drug in the past 180 days. An updated list of TRICARE step therapy drugs can be
found on the web at:
http://www.tricareformularysearch.org/dod/medicationcenter/default.aspx
2014-2015 Revision
29
PRESCRIPTIONS
Prescriptions can be filled at a local Maxor Pharmacy (designated provider), a network
pharmacy or the Maxor mail order pharmacy. CVS Pharmacies nationwide can be used for
first time and urgent care fills only. Prescriptions filled at a local Maxor pharmacy or other
network pharmacy are limited to a maximum of 30-day supply. A ninety (90) day supply
can only be obtained by Maxor Mail Order Pharmacy.
The member is responsible for a copayment to the pharmacy for each prescription filled or
refilled. There is no copayment for drugs administered by a healthcare professional. The
table below outlines member’s copayments according to the type of pharmacy and
formulary status:
Type of Pharmacy
Formulary Drugs
Generic
Brand Name
Tier 1
Tier 2
Non-Formulary
Tier 3
In-Network (up to a
30-day supply)
$5
$17
$44
MAXOR Mail Order
(up to 90-day supply)
$0
$13
$43
Out-of-Network (Up
to a 30-day supply)
50% of total cost
applies after POS
deductible met
50% of total cost
applies after POS
deductible met
50% of total cost
applies after POS
deductible met
If a member needs a medication that requires pre-authorization, the pharmacy clinical
department will fax a request for medical information (including diagnosis). This form
must be filled out entirely and returned by fax. The form will also be used to contact
the physician if the drug is subject to step therapy to switch to the first line drug or
provide additional clinical information.
If the request is denied or needs additional information, the clinical department will
notify the physician’s office by fax.
DRUG DENIAL APPEALS
Administrative and Clinical Drug denial letters are issued along with the instructions on the
procedure to appeal the decision.
MAIL ORDER INFORMATION
US Family Health Plan requires that maintenance medication prescriptions routinely be
filled via mail order through Maxor Pharmacy Mail Order. In order to facilitate the mail
order process, the following process must be used:
2014-2015 Revision
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
When issuing a first-time prescription for a maintenance medication, please write
two prescriptions: one for a 30-day initial supply and one for a 90-day
maintenance supply. The initial 30-day prescription will be filled at any of their
affiliated walk-in Plan pharmacies. The 90-day prescription will be filled through
Maxor Mail Order. Prescriptions can be mailed, faxed, e-prescribed or called into
the pharmacy.
The mail order pharmacy is limited to filling 30-day supply on control substances, with
the exception of ADHD and seizure medications.
Maxor Mail Order Pharmacy
P.O. Box 32050, Amarillo, TX 79120
Phone: 1-866-408-249
Fax: 1-866-589-7656
(Must be faxed directly from the physician’s office)
PHARMACY BENEFIT LIMITATIONS AND EXCLUSIONS
Due to TRICARE restrictions, the US Family Health Plan pharmacy benefit excludes:








drugs prescribed for cosmetic purposes including but not limited to drugs used for
hair growth or wrinkle reduction
food supplements
homeopathic and herbal preparations
multivitamins (except prenatal vitamins for pregnant women)
over –the-counter (OTC) products or any pharmacy product purchased
without a prescription except insulin and related diabetic supplies
smoking cessation products (approved only if member is participating in a
program)
weight reduction products
any prescription refilled before 75% of a previous filling has been used
2014-2015 Revision
31
CLINICAL QUALITY MANAGEMENT PROGRAM
The US Family Health Plan has a comprehensive Quality Management Program. The goal
of the Clinical Quality Management Program is to ensure that every member receives
quality care in a timely and accessible fashion and to provide a mechanism for evaluating
the appropriateness of member care. The purpose of the Clinical Quality Management
Program serves to assure timely identification, assessment and resolution of known or
suspected problems/trends by continuous monitoring and evaluation of care and services
provided. The Quality Improvement Program includes, but is not limited to, the following
topics:














Access and availability of provider/services
Accreditation and Compliance
Appeals
Complaints and Grievances
Credentialing
Disease Management
Improvement of member and provider satisfaction
Medical record review at physician offices. Types of medical record reviews include
continuity of care and other focused reviews.
Patient Safety
Pharmacy Services Effectiveness
Preventative Health Services
Timely Credentialing of providers and adequacy of the provider network
Timely resolution of complaints and appeals
Utilization Management
All participating providers are required to comply with US Family Health Plan’s policies and
procedures including complying with, participating in, and implementing Quality
Management Projects including Patient Safety Programs. This includes but is not limited to
implementing activities necessary and required to comply with external accreditation by the
NQMC, JCAHO, URAC or other similar accrediting bodies selected by the Plan. In addition,
all participating providers are required to comply with the terms of this Provider Manual as
well as Medical Management and Quality Management Programs.
Reviews are conducted periodically by an independent organization contracted by the
Department of Defense (DoD). These reviews are conducted to assure that appropriateness
of care, medical necessity, reasonableness of care and intensity of services occur. When
requests for review are made, all clinical documentation is required. This includes all UM
information as well as facility and physician records.
QUALITY REFERRALS
Any stakeholder may refer a matter for review as a potential quality issue. The Quality
Manager may direct qualified personnel to screen the review for potential quality issues.
The Director of Quality Services or designee may refer cases to the Medical Director for
review and recommendations. The Medical Director’s review may result in such
2014-2015 Revision
32
determinations as:



No quality issue exists
Potential quality concerns exist
Actual quality concerns exist
The Medical Director will recommend action as appropriate to the event, in keeping with
CHRISTUS US Family Health Plans CQMP, CHRISTUS US Family Health Plan Policies
and Procedures, contractual requirements of the plan, requirements under the terms of the
plans contract with the Department of Defense and other relevant federal, state or local
regulatory requirements.
PROCEDURE FOR UNUSUAL PROVIDER PRACTICE PATTERNS
Whenever a concern regarding the clinical quality of care and services provided arises,
all available records and related correspondence are screened by the Clinical Quality
Improvement Department. The concerns are then forwarded to the Medical Director for
review and determination of any potential quality issues.
Individual concerns that do not represent a pattern of behavior or do not seriously
jeopardize patient care/welfare may be individually addressed by the Medical Director and
summarized to the QIC Committee at its next regularly scheduled meeting. The QIC
Committee may accept the Medical Director’s assessment and follow up actions, or it may
recommend another course of action based upon the information presented. When individual
concerns represent a pattern of behavior, the Medical Director shall ensure that the
matter is addressed through the QIC Committee.
Note: When a situation occurs that is deemed to pose an immediate threat to the health
and safety of beneficiaries, the Medical Director may, on behalf of US Family Health
Plan, the Quality Improvement Committee and the Credentialing Committee, act to
immediately revoke, limit or suspend the privileges of a participating provider. The affected
provider will be immediately notified as will other affected parties (i.e., Provider
Relations, Utilization Management, Quality Management, Plan Administration). In such
an event, the QIC Committee will be assembled at the earliest possible time to hear the
situation and support or override the Medical Director’s decision.
The Sanctioning Process of the Plan will follow the Healthcare Quality Improvement
Act of 1986. The US Family Health Plan has a policy and process for conducting the required
due process. The provider may request a copy of the policy at any time by contacting the
Medical Director or the Quality Department.
SENTINEL EVENT REVIEW PROCESS
US Family Health Plan complies with the contractual requirements of sentinel event
detection and reporting in accordance with the terms of its contract with the Department
of Defense. The Health Plan has a series of audit processes, screening elements and
reporting procedures that facilitate the detection of sentinel events. When a Sentinel Event
is identified to the Health Plan or by the Health Plan, it will be investigated in accordance
2014-2015 Revision
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with the standards as set forth the National Quality Forum’s Report on Sentinel Events.
US Family Health Plan will conduct its activities in such a manner as to comply with the
Health Care Portability and Accountability Act of 1996 and the Quality Improvement Act
of 1986. US Family Health Plan will retain the privilege of protection and confidentiality
afforded under this act. Communication will be point to point under the auspices of the QIC
Committee, a Quality Assurance Committee of the Medical Staff. US Family Health Plan
will require that information provided in compliance with mandatory releases of
information will not compromise the protected and privileged nature of the information.
HEALTHY PEOPLE 2020
CHRISTUS US Family Health Plan is contractually obligated to the Department of Defense
to educate providers on the precepts of Healthy People 2020, with the goal of improving
the quality of healthcare of all members.
Healthy People 2010 is a set of health objectives for the nation to achieve over the first decade
of the new century. US Family Health Plan encourages all participating providers to
undertake activities to further the health of all members of our health plan. Health care
providers can motivate their patients to pursue healthier lifestyles and to participate in
community‐based programs.
Each objective represents an important public health area. The Leading Health Indicators
are a limited set of objectives designed to encourage wide participation in improving health in
the next decade. They represent the major health concerns in the United States.
The Leading Health Indicators are:
 Physical Activity
 Overweight and Obesity
 Tobacco Use
 Substance Abuse
 Responsible Sexual Behavior
 Mental Health
 Injury and violence
 Environmental Quality
 Immunization
 Access to Health Care
For more information please contact the Healthy People Information line at 800‐367‐4725 or
visit: www.healthypeople.gov .
2014-2015 Revision
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TEAMSTEPPS
TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes
by improving communication and other teamwork skills among healthcare professionals.
This training system was developed by the Department of Defense (DoD) Patient Safety
Program, in collaboration with the Agency for Healthcare Research and Quality (AHRQ).
Research has shown that teams of individuals that communicate effectively and back each
other up to reduce the consequences of inevitable human error will have increased patient
safety and improved performance.
Patient Safety experts agree that communication and other teamwork skills are essential
for the provision of quality healthcare and the prevention of errors that may result in patient
harm. Most healthcare training lacks teamwork training despite its known importance to
medical outcomes. Teamwork skills are not innate, but must be learned and put into practice.
Providers can view the Fundamentals Course at:
http://www.ahrq.gov/.
The Team STEPPS Primary Care Version can be viewed at:
http://teamstepps.ahrq.gov/abouttoolsmaterials.htm.
NATIONAL DISASTER MEDICAL SYSTEM (NDMS)
All participating US Family Health Plan acute‐care, medical/surgical hospitals are
encouraged to become members of NDMS. The National Disaster Medical System (NDMS) is
a cooperative asset‐sharing program among Federal government agencies, state and local
governments, and the private businesses and civilian volunteers to ensure resources are
available to provide medical services following a disaster that overwhelms the local health
care resources.
The National Disaster Medical System (NDMS) is a federally coordinated system that
augments the Nation's emergency medical response capability. The overall purpose of the
NDMS is to establish a single, integrated national medical response capability for assisting
state and local authorities in dealing with the medical and health effects of major peacetime
disasters and providing support to the military and Veterans Health Administration medical
systems in caring for casualties evacuated back to the U.S. from overseas armed conflicts.
Visit the NDMS website at:
http://ndms.dhhs.gov/NDMS/ndms.html.
All information above is quoted from the National Disaster Medical System website at:
http://ndms.dhhs.gov/NDMS/ndms.html.
2014-2015 Revision
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CLAIMS, ENCOUNTERS AND EDI TRANSACTIONS
CLAIM SUBMISSIONS
Unless indicated otherwise by your agreement, clean claims are to:

Be submitted within 365 days following the original date of service or date of
discharge. The US Family Health Plan will bear no liability to pay claims received
after the 365 days and members cannot be balanced billed for provider’s failure to
submit claims within 365 days.
Include AMA-developed procedural coding.
Include ICD-9 diagnosis coding to the highest specification.
Have separate charges listed on separate lines. Charges should always be itemized.
Be submitted on original red and white CMS 1500 or UB-04 forms when filing paper
claims. (Black and white copies or faxes will not be accepted).
Not be handwritten.
Be mailed to the following address when submitting paper claims:
P.O. Box 169001
Irving, Texas 75016-9001
Attn: Claims






The following Allied Health Providers are required to bill under the supervising or
employing physician:
 Anesthesiology Assistants (AA)
 Advance Practice Nurse (APN)
 Certified First Assistant (CFA)
 Certified Surgical Assistants (CSA)
 Licensed Surgical Assistants (LSA)
 Physician Assistant (PA)
 Physician Assistant Certified (PAC)
 Registered Nurse (RN)
 Registered Nurse First Assistant (RNFA)
EDI TRANSACTIONS
The Plan’s EDI transactions are performed via the clearinghouse, Availity. The
following provides information regarding each type of transaction and what is
required in order to perform these transactions with the US Family Health Plan.
Contact your clearinghouse or billing entity to ensure that you are set-up to interact
with Availity prior to performing any EDI transactions involving the US Family
Health Plan.
Electronic Claims Submissions (837)


For submission of 837s, providers are to use Payor ID: USFHP. The Plan is listed
as US Family Health Plan (Texas and Louisiana).
Ensure you have a valid NPI on file with the health plan.
2014-2015 Revision
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Electronic Provider Remittance Advice (835)
 In order to receive electronic remittance advice (835) from the Plan, providers need
to follow the instructions on the EDI Form. The form should be completed sent to
[email protected]
 For group providers, a form must be submitted for each physician associated with
the group.
 For ancillary providers or facilities, a form must be submitted for each location.
 Once set up, the provider’s billing service/clearinghouse will receive notification
via e-mail.
Electronic Enrollment Status (270/271)
Providers do not need to contact the Plan to be set up for this service. Providers only
need to contact Availity and choose this transaction. You will be able to obtain the
following information electronically via Availity:








Member Name
Subscriber ID
Address
Group/Plan/Product Number
Eligibility Time Frame
Status (Active or Inactive)
DOB
Insurance Type




Gender
Home Phone Number
Co-pay (Office and ER)
Pharmacy (Maxor) Contact
Number
PCP Name
PCP NPI
PCP Contact Number



Electronic Claim Status (276/277)
Providers can obtain electronic claims status (276/277) through Availity. Contact the
health plan to ensure that both your NPI 1 and NPI 2 (if applicable) are captured in the
plan’s system. You can obtain the following information via Availity:






Member Name
Subscriber ID
Servicing Provider
Servicing Provider NPI
Date of Service (from and to)
Claim Number





Check Date
Check Number
Total Claim Charge Amount
Total Claim Payment Amount
Claim Status (paid, pended, voided
etc.)
Should you have any questions regarding EDI transactions with the Plan, please feel free
to contact the Plan’s EDI Specialist at 281-936-7095 or you can send your questions in an
e-mail to [email protected].
ENCOUNTER DATA
Capitated providers are required to submit their encounter data on a monthly basis.
Encounter data should be submitted on an original red and white CMS 1500 or UB-04
form. Faxes and black and white copies are not permitted.
2014-2015 Revision
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REIMBURSEMENT METHODOLOGIES
FEE-FOR-SERVICE (PROFESSIONAL SERVICES)
Professional services provided under a fee-for-service contractual arrangement are
reimbursed from the tiered fee schedule which appears below. During the pricing of
claims, the Plan verifies whether there is an applicable rate configured at each level for the
rendering provider for any given service before dropping to a subsequent level.
Level
Level I
Fee Schedule
The specific carve-out fee schedule based on the
provider’s contract with the Plan
Medicare allowable fee schedule
Level II
The Medicare fee schedule can be obtained free of charge from
the website of the Centers for Medicare and Medicaid Services
(CMS) at http://www.cms.gov. The fee schedule can also be
obtained from the website of TrailBlazer Health Enterprises,
LLC, a CMS Contracted Intermediary/Carrier at
https://www.novitas-solutions.com
TRICARE/CHAMPUS allowable fee schedule.
Level III
The TRICARE/CHAMPUS fee schedule is also available for free
from the website of TRICARE Military Health System at
www.tricare.osd.mil.
Usual and Customary (UCR) schedule of billed charges
per zip code.
Level IV
Level V
The charges are stratified into a percentile of submitted claims
developed by Ingenix ©.
In year 2004, the US Family Health Plan added an additional
level, that includes codes that do not fall in any of the above fee
schedules and are paid at a percentage of billed charges
The Plan updates fee schedules in coordination with updated releases of new fee
schedules from Medicare and CHAMPUS.
2014-2015 Revision
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INSTITUTIONAL SERVICES
Unless otherwise indicated by the provider’s agreement, the US Family Health Plan
reimburses inpatient institutional services rendered by contracted providers at the
TRICARE/CHAMPUS
DRG
rate.
The
rates
may
be
obtained
from
www.tricare.osd.mil/drgrates. These rates are updated annually, and the Plan processes
claims accordingly by date of service.
The US Family Health Plan reimburses outpatient institutional services rendered by
contracted providers at a contractually agreed upon amount. Please refer to the provider’s
agreement with the health plan for specific details.
COPAYMENTS
It is the responsibility of the provider’s office to collect the basic office visit copayment
at the time of the member's visit. If the copayment is NOT collected from the member, the
provider’s office will NOT be reimbursed by the US Family Health Plan for that payment
amount.
The US Family Health Plan would like to be notified of those members who routinely do
not pay their copayment. Failure to make the required copayment is grounds for possible
termination of the member from the plan. The copayment is a legal debt, owed by the
member to the provider, and can be collected as such.
CATASTROPHIC CAP PROTECTION
US Family Health Plan offers members the reassurance of a “catastrophic cap” which limits
the amount of money members are required to pay out of pocket in one year for deductibles
and co-insurance in a plan year (October 1 – September 30). After the maximum dollar
limit is reached, US Family Health Plan members will not pay any additional cost-share
or deductibles for allowable healthcare services received during the remainder of the fiscal
year.
For Active Duty family members, the maximum family liability (Catastrophic Cap
Benefit) is $1000. For all other beneficiary families, the fiscal year cap is $3,000.
Members will receive a new membership card after the maximum dollar amount has been
reached. The new card will indicate a $0 copay in the copay section. Copayments are
reinstated at the beginning of the next plan year, on October 1st, as the accrual of catastrophic
maximum resets.
2014-2015 Revision
39
INTEGRITY/COMPLIANCE
As an affiliate of CHRISTUS Health and as a contracted provider for the DoD, the US
Family Health Plan adheres to a corporate strategy that underlines its commitment to
health care integrity. The US Family Health Plan is responsible for ensuring that
medically necessary services are provided only to eligible beneficiaries by authorized
providers under existing law, regulation and TRICARE Management Activity (TMA)
instructions. Furthermore, the US Family Health Plan is responsible for the evaluation of
quality care and for ensuring that payment is made for care which is in keeping with
generally accepted standards of medical practice.
The US Family Health Plan is dedicated to the CHRISTUS “Core Values” of Dignity,
Integrity, Excellence, Compassion and Stewardship, and we hold contracted physicians and
providers to the same standards. As a participating provider in the US Family Health Plan,
providers are expected to:
SAFETY


Strive to provide a safe, secure and hazard-free environment consistent with national
standards and established federal, state and local regulations
Strictly follow all laws and regulations governing the disposal of hazardous waste and
radioactive materials.
QUALITY CARE



Provide quality care to all members by performing duties to the best of their abilities
Attempt to anticipate and understand member needs while meeting their expectations
Employ professionals with proper credentials and recognize that members and their
personal representatives have the right to access information regarding the identity and
licensure of their caregivers.
ACCURATE RECORDING AND REPORTING


Prepare and maintain all member and organizational data, records and reports
accurately and truthfully and adhere to applicable standards in maintaining all
records
Strive to maintain complete and accurate medical records of each member and protect
this information from breach of confidentiality or loss.
ACCURATE AND APPROPRIATE CLAIMS
2014-2015 Revision
40



Submit claims for payment or reimbursement only for services actually rendered and
make sure that claims submitted for payment or reimbursement are for services
that are medically necessary
Submit claims for payment or reimbursement which are not knowingly false,
fraudulent or otherwise incorrect. Establish an audit function to validate accuracy of
claims submission
Strive to make sure that all submitted claims are properly coded and documented,
and filed according to all applicable laws and regulations.
PROTECTION OF PRIVACY
 Protect and maintain the confidentiality of all member records as required by
applicable laws and regulations
 Maintain knowledge of information protection standards affecting job function
recognizing that confidential information is valuable, sensitive, and protected by law.
 Maintain the appropriate confidentiality and privacy of all members.
ETHICAL PRACTICES





Not mislead members or the public or cause them to request services they do not
reasonably need
Treat all members with dignity, respect, and compassion
Respect and support the rights of all members
Strive for excellence in quality of care and service provided to all served, regardless of
race, color, religion, gender, orientation, disability, age or national origin
Clearly explain care, treatment and services to the member and family so that
informed consent can be obtained. Explanation of treatment must include:
o Potential benefits and drawbacks
o Potential problems related to recovery
o Likelihood of success
o Possible results of non-treatment; and
o Significant alternatives.
FRAUD AND ABUSE
Fraud and abuse includes deception or misrepresentation by a provider, or any person or
entity acting on behalf of a provider in relation to a US Family Health Plan claim.
Examples of potential fraud (the intent to deceive or misrepresent to secure unlawful
gain) include:

Billing for items or services not rendered or not provided as claimed
2014-2015 Revision
41







Submitting claims for equipment, medical supplies and services that are not
reasonable and necessary
Double billing resulting in duplicate payment
Billing for non-covered services as if covered
Unbundling (billing for each component of the service instead of billing or using an
all-inclusive code)
Failure to properly use coding modifiers
Clustering, and
Up-coding the level of service provided.
Examples of potential abuse (practices inconsistent with sound fiscal, business, or
medical procedures and services not considered to be reasonable and necessary) include:




A pattern of claims for services that are not medically necessary, or if necessary, not to
the extent rendered
Care of inferior quality (does not meet accepted standards of care)
Failure to maintain adequate clinical or financial records, or
Refusal to furnish or allow access to records.
In addition, unbundling, fragmenting or code gaming to manipulate the Physician’s
Current Procedural Terminology (CPT) codes as a means of increasing reimbursement is
considered an improper billing practice and a misrepresentation of the services rendered.
Such a practice can be considered fraudulent and abusive.
As a provider, it is important to note that it is considered a crime to knowingly and
willfully execute (or attempt to execute) a scheme to defraud a health care benefit
program, or to obtain money or property from a health care benefit program through
false representations.
IMPORTANT STATUTES
We hope that you find this information helpful, however, if you would like more
information regarding compliance programs, please visit OIG’s web site at
www.oig.hhs.gov Whistleblower – Sarbanes/Oxley Act
False Claims Act
Imposes civil liability on any person/entity submitting false claims to the US government.
Criminal Investigation of Health Care Offenses
Imposes criminal penalties for any person willfully obstructing such investigation(s), for
example, withholding medical records
Mail and Wire Fraud
Imposes criminal penalties for any scheme to defraud another of money or property by using
mail, private courier, telephone, fax or computer. Notably each offense is considered a
2014-2015 Revision
42
separate crime.
Social Security Act
A broad statute with civil and criminal penalties that covers many fraudulent and abusive
activities including:
 Upcoding
 Providing services not medically necessary
 Unlicensed providers
 Offering kickbacks/bribes/rebates to influence the beneficiary to seek services from a
provider excluded from participation with the Federal government
There are a limited number of exceptions to the Social Security law known as “safe harbors,”
which provide immunity from criminal prosecution.
Federal Anti‐Referral Law (Stark Laws)
Providers are prohibited from referring patients to health entities. In which they have an
ownership relationship. Any health service receiving a “prohibited referral” is prohibited from
billing for it. Health services include:
• Lab and radiology
• Physical Therapy and Occupational Therapy
• DME equipment and supplies
• Intravenous and enteral (tube feeding) nutrients and supplies
• Orthotic and Prosthetic devices and supplies
• Home Health services, inpatient and outpatient hospital services
• Outpatient prescription drugs
There are specific exceptions to the Stark laws, some related to Stocks and Bonds, and some
related to certain physician services. The Sherman Antitrust Act‐prohibits any ventures which
result in a monopoly or combination of restraint of interstate trade.
Emergency Medical Treatment and Active Labor Act‐(EMTALA)
Prohibits hospitals that receive Medicare funds from transferring out patients in their ERs
based solely on their inability to pay for services.
Civil Rights Act of 1964
Prohibits any federally funded program from discriminating on the basis of race, creed, color,
or national origin.
Rehabilitation Act of 1973
Prohibits qualified handicapped individuals from being discriminated against in any
program or activity receiving federal funds. Individuals protected are those with:
• Physical or mental impairment which substantially limits one or more major activities
of daily living
• Has a record of such an impairment or has it currently
• Blind/visual impairment or deaf/hearing impairment
• Cerebral Palsy, epilepsy or seizure disorder
• Drug/Alcohol addiction
• Mental retardation and Psychiatric disorders
• Orthopedic handicap, spinal cord/traumatic brain injury
• Specific learning disability, and certain speech disorders
2014-2015 Revision
43
•
Chronic diseases including AIDS, arthritis, cancer and diabetes
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Mandates that security and confidentiality of individually identifiable protected health
information (PHI) must be stored and transmitted securely, patients must be notified of
their rights, and where to submit complaints, and patients must have access to their medical
records.
Alcohol Drug Abuse and Mental Health Administration Reorganization Act
Specifies that alcohol and drug abuse records are kept confidential and requires certain
court orders.
Confidentiality and Disclosure Requirements Table 10
Requires that quality assurance documentation be kept confidential in DoD programs.
The Freedom of Information Act
Enacted to reach a balance between the right of the public to know, and the needs of
government to keep information private. The DoD has specific procedures by which
information is made available to the public that requires a written request.
2014-2015 Revision
44

US Family Health Plan Provider Manual

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