TR IC ARE ® Provider News February 2015 Comprehensive Clinical Preventive Exam and Cancer Screenings Comprehensive clinical preventive exams are a limited benefit and are not always covered. colon cancer screening, or prostate cancer screening is required for claims payment. For TRICARE Standard beneficiaries, a comprehensive clinical preventive exam must include a cancer screening (Pap test, mammogram, colon cancer screening, or prostate cancer screening) or immunization, to be considered a covered service. Without a cancer screening, an annual exam may not be covered under TRICARE Standard. While routine cervical cancer screening guidelines now recommend testing every three years for women ages 21–65, TRICARE covers one routine Pap test every 12 months starting at age 18, or younger if sexually active. A Pap test is often performed during a comprehensive clinical preventive exam, also known as an annual well-woman exam or routine gynecological exam. It is important to note an annual/routine exam is not covered unless it includes a Pap test, cancer screening or immunization. TRICARE Prime beneficiaries have an additional benefit that covers one comprehensive clinical preventive exam without an immunization or cancer screening per age group (2–4, 5–11, 12–17, 18–39, and 40–64). Clinical preventive exam claims usually include a general medical examination diagnosis (V70 or V70.0). A separate diagnosis code for an immunization, screening Pap test, screening mammogram, For more information on preventive services, go to www.hnfs.com > I’m a Provider > Benefits & Copays > Benefits A-Z > Preventive Services > Preventive Services Details. Care Transition Program The Care Transition (CT) Program is designed to address the rate of avoidable hospital readmissions for an initial diagnosis, especially chronic conditions such as asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and pancreatitis. Under the supervision of Health Net Federal Services, LLC (Health Net), a registered nurse acts as the care manager and is assigned to work with a TRICARE beneficiary. Through CT, beneficiaries will learn self-management skills they can put into practice to help better manage their health condition. A care manager communicates by telephone with the patient and helps to ensure the beneficiary and family caregivers understand discharge instructions; how and when to take prescribed medications; dates and times for follow-up appointments with the primary health care provider or specialist; and whom to contact if they have problems. Additionally, the care manager will instruct the patient on the use of a personal health record to facilitate communication and ensure continuity of care across providers and settings. This is a free program and includes follow-up telephone calls from the care manager to help the beneficiary stay well and ensure a smooth transition from hospital to home. Provider Resources and Education Opportunities The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) serves as the principal integrator and authority on psychological health and traumatic brain injury (TBI) knowledge and standards for the Department of Defense. The DCoE offers a wide variety of products and services designed to improve knowledge, understanding and treatment of TBI, and psychological health conditions. The DCoE Resource Catalog contains summaries and hyperlinks to available resources for health care providers, service members, veterans, and military families. Product offerings span a wide variety of categories, to include: •clinical practice recommendations and clinical support tools •mobile applications for providers and patients Upcoming DCoE webinars: •educational materials Feb. 18 – Clinical Benefits of Technology in Behavioral Health Care •fact sheets Feb. 26 – Physical Symptoms and Mental Health •websites Remember, Health Net offers online provider education resources that allow you to attend live TRICARE briefings and view previously recorded sessions at your own pace. Attend webinars and take advantage of self-paced PowerPoint and video tutorials. To view our course description guide, visit www.hnfs.com > I’m a Provider > TRICARE Webinars. •programs The contents of this catalog can help impact the medical treatment, care and advocacy of service members and their families. Visit the DCoE Resources page (http://dcoe.mil/PsychologicalHealth/ Resources.aspx) to download the latest version of the catalog. The DCoE webinars are scheduled 1:00–2:30 p.m. (ET) on the day of the event and many provide continuing education credit. You must register in advance. For more information, to register and to view a complete list of webinars, visit the www.DCoE.mil/ Training/Monthly_Webinars. TRICARE Provides Limited Benefit for Breast Pumps As a reminder, breast pumps are considered a limited benefit. Heavy-duty hospital grade electric breast pumps are covered (including services and supplies related to the use of the pump) for the mother of a premature infant while the infant remains hospitalized during the immediate postpartum period. A physician must document the medical reason for an electric breast pump after the infant has been discharged. Please refer TRICARE beneficiaries to www.hnfs.com > I’m a Provider > Benefits > Alternative Health Care Resources. Behavioral Health Care Provider Qualifications Update - Extended to January 2017 The Department of Defense still plans to implement the TRICARE Certified Mental Health Counselor (TCMHC) provider type as a qualified mental health provider authorized to independently diagnose and treat TRICARE beneficiaries and receive reimbursement for services. However, the timeframe to complete education, examination and supervised clinical practice criteria to be considered for authorization as a TCMHC has been extended to January 1, 2017. Go to www.MHN.com and click on Join Our Network for questions about joining the behavioral health TRICARE network and the MHN credentialing process. 2 Patient Safety Corner Empathy and Patient Safety Empathy goes hand in hand with patient safety but is often overlooked in clinical practices. Recently, a growing body of national and international policies and patient initiatives are focusing on empathy and patient-centered care.1 Evidence suggests a lack of empathy by caregivers can act as a barrier to a patient’s willingness to fully disclose their medical issues, which can lead to negative outcomes, such as missed diagnosis, medical errors, compromised patient safety, liability consequences, and missed opportunities for meaningful and effective clinical encounters.2 Conversely, empathetic and patient-centered care is associated with positive patient health outcomes, enablement and satisfaction.3 Key steps that can help ensure effective, empathetic communication with your patients include the following:4 •Recognize how the patient may be feeling in the clinical setting (for example, afraid or angry). Was your patient redirected to a military hospital or clinic? If you submit a prior authorization or referral request for a TRICARE Prime beneficiary, he or she may be referred to a military hospital or clinic for care, regardless of whether a civilian network provider is requested. If the military hospital or clinic determines it can provide the service, Health Net will complete the request and advise the beneficiary to contact the military hospital or clinic to schedule an appointment. If the services are not available at the military hospital or clinic, Health Net will coordinate the services with a TRICARE network provider. This process is known as the right of first refusal. In order to reduce any confusion as to who will render specialty care, please remind your patients each approval will contain the selected source of care, which may be a military hospital or clinic. Referral information will be provided to the patient and servicing providers. In limited circumstances, a TRICARE Prime beneficiary may see a non-network provider with Health Net’s approval and only if no other providers are available. To learn more, visit www.hnfs.com. •Pause to imagine how the patient might be feeling. •State your perception of the patient’s feeling. •Legitimize the patient’s feeling. •Respect the patient’s effort to cope with the situation. •Offer support and partnership. Fostering a culture of empathy in your primary care setting can lead to more satisfying patient experiences, minimize risks to patient safety, and can help put the care back in health care. For more information, visit the Cleveland Clinic’s Empathy and Innovation Summit website at www.empathyandinnovation.com. 1 Niamh Fitzgerald et al. “Enhancing empathy in healthcare: mixed-method evaluation of a pilot project implementing the CARE Approach in primary and community care settings in Scotland,” Journal of Compassionate Health Care 1 (2014):6, accessed on December 15, 2014, http://www.jcompassionatehc.com/content/1/1/6. 2 Chochinov, H. “Dignity in Care: Time to Take Action,” Journal of Pain Symptom Management 46 (2013): 756-9, accessed December 15, 2014, http://www.jpsmjournal. com/article/S0885-3924(13)00452-1/pdf. 3 Fitzgerald, 1. 4 Strategies for Chronic Care, “Exhibiting Empathy and Patient Sensitivity in Provider-Patient Communication,” accessed on December 15, 2014, http://www. strategiesforchroniccare.com/resources/detail/exhibiting-empathy-and-sensitivity-inpatient-communication. Routine Requests Timelines Routine prior authorization or referral requests should be submitted when care is needed within the four-week TRICARE specialty care access standards. For routine requests, submit your request through the online authorization and referral submission tool or complete the TRICARE Service Request/Notification Form a minimum of seven days prior to the anticipated date of service. Complete each section of the form so we have all of the information to process your request and be sure to include clinical history, any previous treatment and supporting test results. Routine prior authorization and referral requests are processed within 2–5 business days of receiving the request from the provider. Determination letters for routine requests will be delivered to beneficiaries within 7–10 business days after the request has been processed. Processing time may be delayed if sufficient information is not provided. 3 Health Net Federal Services, LLC P.O. Box 2890 Rancho Cordova, CA 95741 HN1214x010 (01/15) Healthy People 2020 Corner T R IC A R E ® Provider News Contacts Health Net Customer Service 1-877-TRICARE (1-877-874-2273) www.hnfs.com PGBA, LLC Electronic claims, EFT set up 1-877-EDI-CLAIM (1-877-334-2524) myTRICARE.com Express Scripts, Inc. Pharmacy inquiries 1-877-363-1303 www.express-scripts.com/TRICARE Visit us at www.hnfs.com and Facebook 42 Prevent and Manage Heart Disease with Good Health Habits Heart disease is the leading cause of death and one of the most widespread and costly health problems in the United States today.1 The good news is most of the risk factors contributing to heart disease are preventable. Nutrition, Physical Activity, and Obesity is one of the Healthy People 2020 Leading Health Indicator topics. Eating healthy, being physically active, and achieving and maintaining a healthy weight reduce a person’s risk for developing some of the other risk factors for heart disease, including high blood pressure, cholesterol and diabetes. They are also vital to managing health conditions so they don’t worsen over time, and are essential parts of a person’s overall health and well-being. Help reduce heart disease and obesity rates by educating patients on preventing risk factors and encouraging them to change poor eating and physical activity habits. Health Net offers online programs and telephone-based classes focused on successful behavior change, weight management, heart healthy living, and diabetes management. Refer your patients to www.hnfs.com/go/learningcenter for more information. Visit www.healthypeople.gov for more information on the Leading Health Indicators and objectives for heart disease and stroke. 1 Xu J, Kochanek KD et al., Division of Vital Statistics, Deaths: Preliminary Data for 2009 (National Vital Statistics Reports, Volume 59, Number 4, March 16, 2011), page 51. TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
© Copyright 2016 ExploreDoc