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Provider NEWS

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Thank You to the Heroes in Health Care

Help Us Identify You as a Telemedicine Provider

Uniformed Services ID Cards May Expire

COVID-19 Convalescent Plasma Program

Specialty Visits after Urgent Care

Outpatient Referrals and Authorizations Extended

Right of First Refusal

Policy Changes Due to COVID-19

Understanding Audio-Only Telehealth

Physical and Occupational Therapy Assistants Allowed as TRICARE-Authorized Providers

Dedicated Call Center Option for Fetal Surgery Referrals

Real-Time Prescription Benefit Tool

Authorization Reminder: 3-D Mammograms/PRP Injections

TENS Treatment Excluded for Lower Back Pain

Home Health Agency PDGM Claims

Choosing Wisely®

Clear and Legible Report Basics

TRICARE®

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Help Us Identify You as a Telemedicine ProviderOur online Network Provider Directory includes a telemedicine filter to help providers and patients connect via telemedicine. Go to www.tricare-west.com > Provider > Network Provider Directory and select “Telemedicine” at the start of your provider search.

To get listed as a telemedicine provider in our directory, use our TRICARE Provider Group Roster Template to let us know which providers in your practice offer video telemedicine services. Go to www.tricare-west.com > Provider > Forms > Network Providers. If you use a different template, please indicate on it who offers telemedicine services.

Find complete benefit details at www.tricare-west.com > Provider > Benefits A–Z > Telemedicine. TRICARE policy outside of COVID-19 can be found in the TRICARE Policy Manual, Chapter 7, Section 22.1.

While TRICARE is temporarily allowing for audio-only telehealth during the COVID-19 pandemic, at this time, directory search results will only include providers who offer video telemedicine services. As such, please only identify on your roster those providers who offer video telehealth.

Uniformed Services ID Cards May Expire

Thank You to the Heroes in Health CareTo all of the heroes in health care who have been working tirelessly on the frontlines during the COVID-19 pandemic, thank you. Your sacrifice during this uncertain time has our deepest gratitude and appreciation.

We know through all that you face, you continue to put our West Region TRICARE beneficiaries first. You are making a difference in their lives.

We truly value your willingness to adapt as the health care landscape evolves. Thank you for supporting the Military Health System’s response to COVID-19. We’re proud to be your partner!

Due to restrictions in access to military installations and therefore Uniformed Services identification (USID) card renewal services, the Department of Defense is allowing beneficiaries to use USID cards that expired on or after Jan. 1, 2020 through Sept. 30, 2020. As such, you may encounter expired USID cards. The Defense Enrollment Eligibility Reporting System (DEERS) continues to be the source of TRICARE eligibility. Our Eligibility & Deductible tool at www.tricare-west.com > Provider offers real-time DEERS eligibility verification.

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COVID-19 Convalescent Plasma Program

Specialty Visits after Urgent Care

The Defense Health Agency (DHA) is leading an effort to collect up to 10,000

COVID-19 convalescent plasma (CCP) units by Sept. 30, 2020. Collected CCP will be

available for treatment of COVID-positive patients in military hospitals that meet established criteria

and in accordance with approved protocols. This effort is designed to increase operational readiness of our

combat forces and will help our nation study the use of CCP as a treatment.

You likely have patients you diagnosed or treated for COVID-19 who are now recovered and symptom free. If you are near one of the Armed Services Blood Program collection centers listed below, on behalf of DHA, we ask you actively reach out to any TRICARE beneficiary you treated for COVID-19 and encourage these patients to donate to DHA’s Convalescent Plasma Program.

Eligibility requirements for the Convalescent Plasma Program include:

• Must be at least 17 years of age, weigh at least 110 pounds and be in good health. Other travel/medical requirements may also apply.

• Have a prior diagnosis of coronavirus AND meet specific laboratory criteria.

• Be symptom-free for 14 days or more.

• Note: Patients who have ever been pregnant will need additional testing to determine if HLA antibodies are present.

The following Armed Services Blood Program collection centers are located in the TRICARE West Region:

• California:

o Naval Medical Center San Diego/Camp Pendleton Blood Donor Center (619) 532-6650; 34800 Bob Wilson Dr., San Diego, CA 92134-5000

o Camp Pendleton (619) 279-0526; 200 Mercy Circle, Camp Pendleton, CA 92055

• Hawaii: Tripler Army Medical Center Blood Donor Center (808) 433-6699; 1 Jarrett White Road, Room 2A207, Tripler AMC, HI 96859-5000

• Missouri: Fort Leonard Wood Blood Donor Center – (573) 596-5385, Building 822, 6656 Colorado Avenue, Fort Leonard Wood, MO 65473

• Texas: Fort Bliss Blood Donor Center (915) 742-5365; 2489 Ricker Road, Fort Bliss, Texas 79916

• Washington: Joint Base Lewis/McChord – Armed Services Blood Bank Center – Pacific Northwest (253) 968-1903; 9904 East Johnson Street, Tacoma, WA 98431

Donors living near a center should contact them directly before going in to donate. You can share the above-listed phone numbers with patients who have questions on plasma donation/collections. More information is at www.militaryblood.dod.mil.

DHA’s efforts are focused on collecting convalescent plasma at military blood donation centers; however, if you or your patients aren’t near a blood donation center, information on how to donate can be found here: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/donate-covid-19-plasma.

Except for active duty service members, TRICARE beneficiaries enrolled in TRICARE Prime do not need a referral for urgent care when seeing a network or non-network urgent care center or a network primary care type provider. However, should a TRICARE Prime patient need follow-up care with a specialist, that care must be coordinated with the patient’s primary care manager (PCM). It is the PCM’s responsibility to submit specialty referral requests to HNFS, when required. Without a PCM referral on file, TRICARE Prime patients may be subject to Point of Service costs for specialty care, even if that care was requested by the urgent care provider.

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Outpatient Referrals and Authorizations ExtendedIn an effort to support patient access to care and reduce administrative burden for your staff during the COVID-19 pandemic, we have automatically extended certain outpatient referrals and authorizations an additional 180 days. No action is required on your part. HNFS is not issuing new approval notices; however, you can find revised approval details in our Authorization Status tool at www.tricare-west.com. We encourage you to share this information with your TRICARE patients.

How to view updated authorization details: 1. Go to www.tricare-west.com > Provider.

2. Click on “Authorization Status” in the Secure Tools box (log in required).

3. Search for the specific authorization.

4. If you click on the “View authorization letter” link and the service dates don’t match the new status details, scroll to the bottom of the page and click on the “Print” button.

Whether you submit requests using CareAffiliate® or our Web Authorization Referral Form (WARF), you can use the Authorization Status tool to view authorization status and details. HNFS offers a step-by-step Authorization Status Tool Guide at www.tricare-west.com > Provider > Education/Quick Reference Charts.

Extension ExclusionsThe following outpatient care types are excluded from the 180-day extension:

Active Duty SHCP waivers

Ambulance

Audiology/hearing aids

Autism Care Demonstration

Behavioral/mental health care

Breastfeeding counseling

DVA/DoD MOA

Donor breast milk

Durable medical equipment

Extended Care Health Option

Electroconvulsive therapy

Emergency medicine/urgent

care/observation

Fetal monitor/non-stress test

Global OB/maternity care

Hemodialysis

Home health care

Hospice

Infusion/medication that requires coordination with Express Scripts

In-vitro fertilization for active duty Category II or III illness or injury

Intensive outpatient programs

Line of Duty

Orthotics or prosthetics

Partial hospitalization programs

Stem cell transplant

Substance use disorder

Right of First Refusal As a TRICARE requirement, when a TRICARE Prime beneficiary is referred for specialty care, HNFS will first attempt to coordinate care at a military hospital or clinic, even if the beneficiary is enrolled to a civilian primary care manager. This process is known as TRICARE’s right of first refusal. Providers should include as much clinical documentation or details as possible when submitting referrals to HNFS in order for the military hospital or clinic to reasonably determine if they have the ability to effectively treat the beneficiary.

Be sure to review the details of determination letters issued by HNFS with your TRICARE patients. Each determination letter issued by HNFS will specify the approved specialty provider. If a beneficiary sees a different specialty provider, Point of Service charges may apply.

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Policy Changes Due to COVID-19The TRICARE benefit has changed in response to COVID-19. Please take a moment to review key updates. Find complete benefit details at www.tricare-west.com. For TRICARE-specific COVID-19 updates, go to www.tricare-west.com/go/COVID-19 and www.health.mil/coronavirus.

Response to Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES) Act

TRICARE Benefit/Policy

Description Effective Dates

COVID-19 testing

Coverage of COVID-19 testing and medically-necessary antibody (serology) testing; cost-share/copayment waiver for covered testing and associated outpatient visit/services.

March 18, 2020 through expiration of Public Health Emergency period

Outpatient authorization extension

HNFS extended certain already-approved physical health outpatient referrals and authorizations 180 days. Exceptions apply.

Referrals/authorizations that expired between March 1, 2020 and June 30, 2020

Telemedicine

Applied behavior analysis parent/caregiver guidance via telehealth.

March 31, 2020 through expiration of President’s national emergency period

Audio-only telehealth allowed for medically or psychologically necessary office visits.

May 12, 2020 through expiration of President’s national emergency period

Waiver of cost-shares/copayments for covered telehealth services rendered by network providers.

May 12, 2020 through expiration of President’s national emergency period

Intensive outpatient programs (IOPs), opioid treatment programs (OTPs) and medication assistance treatment (MAT) allowed via telehealth. Partial hospitalization programs (PHPs) not allowed via telehealth except for ½ day PHP when billed and authorized as an IOP.

March 13, 2020 through expiration of President’s national emergency period

Recognition of temporary licenses issued in states that have declared a state of emergency.

TRICARE-authorized providers who have been issued a temporary license in response to the COVID-19 pandemic may render telehealth across state lines (must comply with state guidelines).

Valid while state is in declared state of emergency

May 12, 2020 through expiration of President’s national emergency period

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Understanding Audio-Only Telehealth

Physical and Occupational Therapy Assistants Allowed as TRICARE®-Authorized Providers

Per the Interim Final Rule (IFR) – TRICARE Coverage and Payment for Certain Services in Response to the COVID-19 Pandemic, TRICARE is temporarily allowing for audio-only telehealth. Please review these frequently asked questions.

How will a physician know if the telemedicine services are considered medically necessary? TRICARE defines medically necessity as appropriate, reasonable and adequate care for the patient’s condition (as defined in Regulation 32 CFR 199). Providers should document in the medical records why audio only was chosen in lieu of an audio/video combination. Audio-only telehealth should not be used for care that normally requires a physical examination or a visual evaluation. Administrative services such as making appointments or verifying prescriptions are not separately reimbursable.

How do physicians bill for audio-only visits? Current coding manuals include CPT codes 99441–43, 98966–68 and HCPCS code G2012 as audio-only telehealth. Telemedicine services billed on either a CMS 1500 professional or UB04 claim form must contain the applicable GT, GQ or 95 modifier.

Why is the physician required to document when it’s an audio-only visit? The language in the IFR reads, “If the decision to provide care via a traditional audio/visual method is chosen, the reasons for that decision should be documented as well. For recurring care, the rationale for choosing audio-only or audio and visual should be documented only at the initiation of remote care, or upon any change in modality."

Will audio-only telehealth claims be reimbursed using the CMAC rates posted by locality on health.mil?Yes, claims will be reimbursed at CMACs published on www.health.mil.

Are audio-only services covered under the Autism Care Demonstration?Audio-only services are not allowed under the Autism Care Demonstration. Parent/caregiver guidance performed via telemedicine must be rendered using audio AND video platforms. Go to www.tricare-west.com > Provider > Benefits A – Z > Applied Behavior Analysis for additional benefit details.

TRICARE now allows physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) to be TRICARE-authorized providers. This rule aligns TRICARE with Medicare’s policy, which permits PTAs or OTAs to provide physical or occupational therapy when supervised by a licensed, registered physical therapist or occupational therapist.

Services rendered by PTAs and OTAs must be billed under the licensed physical or occupational therapist. Use a CQ modifier when submitting claims for services performed by a PTA; use a CO modifier when submitting claims for services performed by an OTA.

Per TRICARE guidelines, PTAs and OTAs may not:

• Provide an initial examination.

• Provide an evaluation.

• Provide a re-evaluation and assessment.

• Establish a diagnosis.

• Establish a plan of care.

For more information, view TRICARE Policy Manual, Chapter 11, Section 3 and our physical and occupational therapy benefit details at www.tricare-west.com > Provider > Benefits A–Z.

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Real-Time Prescription Benefit ToolThe Real-Time Prescription Benefit tool is available to civilian providers who see TRICARE beneficiaries. This tool delivers patient specific TRICARE pharmacy benefit information directly to the provider so the best and most cost-effective treatment can be provided to the beneficiary.

How does it work? All providers who enable this in their Electronic Health Record will have access. Simply enter the prescription and the patient’s pharmacy into the tool and Express Scripts will review and provide data about coverage and costs for therapeutic options. This tool can assist you in answering patients’ questions about drug coverage and available alternatives.

Visit www.militaryrx.express-scripts.com/healthcare-professionals for more information.

Dedicated Call Center Option for Fetal Surgery ReferralsBeginning Aug. 7, 2020, pregnant TRICARE beneficiaries, who have a fetal condition or suspected fetal condition, and their providers will have access to a dedicated call center option to request an expedited referral for fetal surgery. Call the Health Net Federal Services, LLC (HNFS) Case/Care Support line at 1-844-524-3578 and choose option 4 for maternity fetal support.

Fetal surgery performed by a perinatal or pediatric specialist is a covered TRICARE benefit. Specific benefit criteria applies and prior authorization is required. We will issue a determination on fetal surgery requests within three business days.

Fetal surgery counseling rendered during an office visit prior to the surgery is an expected component of good clinical practice and not separately reimbursable. Mental health care received separately (for example, psychotherapy) is reimbursable when rendered in accordance with TRICARE policy.

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Benefit Corner

Authorization Reminder: 3-D Mammograms/PRP Injections

TENS Treatment Excluded for Lower Back PainAs of June 1, 2020, TRICARE no longer covers transcutaneous electrical nerve stimulation (TENS) for the treatment of acute, subacute and chronic low back pain. If you have not already, please discuss alternate treatments with your TRICARE patients who were receiving TENS treatment for low back pain.

In addition to the device, the following also will not be covered:

• Supplies for TENS units prescribed for low back pain

• Physical therapy visits, where the sole treatment provided is TENS for low back pain

• Charges for TENS treatment for low back pain that is performed during an otherwise-covered physical therapy visit

For complete benefit details, visit www.tricare-west.com > Provider > Benefits & Copays > Benefits A–Z > TENS.

Dry Needling ReminderDry needling remains a non-covered benefit when it is the sole purpose of a visit. If a physical therapist provides dry needling in the course of an otherwise-covered physical therapy session, the visit itself may be covered, but dry needling is not separately reimbursable. When billing for dry needling in conjunction with another covered service, use of the following Current Procedural Terminology® (CPT) codes will help avoid claims processing delays: 20552, 20553, 20560, 20561, 97039, 97139 and/or 97799. Using one of these codes for the coverage of only dry needling will result in the claim denying.

Vitamin D ScreeningTRICARE no longer covers vitamin D screenings performed as a preventive measure. This includes vitamin D screenings performed on asymptomatic patients, the general population and/or during examinations when there is no clinical indication for the screening.

Please refer to TRICARE Policy Manual, Chapter 6, Section 1.1. We also offer Vitamin D screening benefit details at www.tricare-west.com > Provider > Benefits & Copays > Benefits A–Z > Vitamin D Screening.

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Except for active duty service members, TRICARE no longer requires prior authorization for 3-D mammograms or platelet rich plasma (PRP) injections. For an overview of each of these benefits, visit www.tricare-west.com > Provider > Benefits A–Z.

Learn more about TRICARE’s Provisional Coverage Program in the TRICARE Policy Manual, Chapter 13, Section 1.1.

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Home Health Agency PDGM ClaimsEarlier this year, DHA updated the TRICARE manuals to include a Patient-Driven Groupings Model (PDGM) for home health agency reimbursement. TRICARE’s PDGM reimbursement is effective retroactive to Jan. 1, 2020, for periods of care that begin on or after Jan 1. We appreciate your patience as we work through system updates required to implement this complex change. We anticipate releasing held PDGM-reimbursed home health agency (HHA) claims by the end of August 2020.

For details on TRICARE’s PDGM reimbursement model, visit www.tricare-west.com > Provider > Claims > Review Billing Tips > Home Health Billing.

Coding Update for CPAP BillingLast year, the Defense Health Agency (DHA) expanded the Continuous Positive Airway Pressure (CPAP) benefit under the Supplemental Health Care Program to allow active duty service members (ADSMs) who meet specific criteria to get portable CPAP machines when authorized. ADSMs require prior authorization for all CPAP devices. Health Net Federal Services, LLC (HNFS) has been issuing approvals for portable CPAP units using E0601, the Healthcare Common Procedure Coding System (HCPCS) code for a standard CPAP, and accepting E0601 on claims, due to the absence of a portable CPAP code.

We recently received direction from DHA to accept HCPCS E1399 instead of E0601 for portable CPAP claims with dates of service on or after May 20, 2020. We also have established a new modifier – “XI” – to use with the unlisted E1399 code. Providers can continue to use HCPCS E0601 on claims for standard CPAP machines.

Under the Supplemental Health Care Program, active duty service members can be authorized to receive a portable CPAP device if they meet specific benefit criteria. Prior authorization is required. HNFS approves CPAPs as a capped rental item for purchase, per DHA and Centers for Medicare and Medicare (CMS) guidelines. Reimbursement for these items is either paid monthly as a rental with the total purchase price spread over 15 months or as a purchase spread over 13 months. We do not issue lump sum payments for CPAP machines.

For CPAP benefit details, please visit www.tricare-west.com > Provider > Benefits A–Z > Continuous Positive Airway Pressure (CPAP) Machine.

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Skilled Nursing Facility Interrupted Stay PolicyTRICARE has adopted Medicare’s interrupted stay policy for skilled nursing facility (SNF) admissions. An interrupted SNF stay is one in where a patient is discharged from an SNF and subsequently readmitted to the same SNF within three days.

The three-day interruption or leave of absence window begins on the first non-covered day following the SNF stay and ends at 11:59 p.m. on the third consecutive non-covered day. Follow Medicare guidelines when billing:

• Use revenue code 018x and occurrence span code 74,

• Indicate the interruption “from” and “through” dates and

• Put the number of non-covered days as units.

The interrupted stay policy does not apply if:

• The patient is readmitted to the same SNF outside the three-day interruption window.

• The patient is admitted to a different SNF (regardless of the length of time between stays).

All SNF stays require prior approval. Find additional benefit details at www.tricare-west.com > Provider > Benefits A–Z > Skilled Nursing Facility Care and in the TRICARE Reimbursement Manual, Chapter 8, Section 2.

Breast Milk Storage Bags Billing As of April 1, HNFS only accepts Healthcare Common Procedure Coding System (HCPCS) code K1005 on claims for breast milk storage bags with dates of service on or after Jan. 1, 2020. Claims received on or after April 1 with the unlisted HCPCS code A9900 or A9999 and modifier XH will be denied.

Providers must bill for the number of bags provided and not the number of boxes. When using unlisted HCPCS codes A9900 or A9999 for other covered breast pump supplies, modifiers are still required. Find current modifiers specific to breast pump supplies at www.tricare-west.com > Provider > Claims > How Do I … > Review Billing Tips > Breast Pumps and Supplies Billing.

Claims Tips

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

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

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

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

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Provider NEWS

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Choosing Wisely®

It’s Never too Early to Talk About Advance Care PlanningVarious studies suggest only about a quarter of all adults have engaged in advance care planning. As a provider, you have direct access to influence your patients. Providers are encouraged to do their own advanced care planning, let their patients know about it and discuss the benefits of completing it early.

Key messages your patients should know:

• Advance care planning isn’t difficult. There are a variety of free tools available for different populations to help them start and structure their conversation with loved ones at https://theconverstationproject.org/starter-kits.

• You do not need a lawyer to create an advance directive (living will, health care power of attorney, etc.) Every hospital and most medical offices have advanced care directives, or patients can create, store and share an online version of their wishes at www.mydirectives.com.

• Completing an advance directive is not about encouraging patients to seek aggressive care. It’s about discussing and documenting their wishes so they get the right care for any event where they may not be able to speak for themselves.

Please visit https://www.theconversationproject.org/starter-kits/ for free information and tools to assist with thoughtful reflection on health care choices and ideas on how to get involved.

Access additional end-of-life planning information and resources, as well as health promotion materials, at www.tricare-west.com > Provider > Resources > Wellness > Provider Toolkits > Life Care Planning.

Clear and Legible Report Basics TRICARE network providers are required to submit clear and legible reports – which includes consultation reports, operative reports and discharge summaries – to the referring military hospital or clinic within specified time frames.* The requirement to submit CLRs applies to care referred by a military hospital or clinic, and to care received at an urgent care center.

Why send CLRs? • It is a requirement of your TRICARE contract.

• They help expedite treatment and ensure continuity of care for your TRICARE patients.

• They meet The Joint Commission standards.

Find CLR submission details, including submittal time frames and our CLR Fax Matrix at

www.tricare-west.com > Provider > Take Me To … Clear and Legible Reports.

* Network urgent care centers should submit CLRs to the beneficiary’s assigned military hospital or clinic, as there may not be a referring provider.