Remote Reserve Component Line of Duty (LOD) Care: Guidelines & Support | TMA MMSO Brief

1. TMA MMSO: Reserve Component Line of Duty Care in Remote Areas TRICARE Management Activity Military Medical Support Office (MMSO) One Team, Many Challenges, All Committed

2. Purpose • Provide information to attendees and address issues and questions which will allow us to work together more effectively supporting remote Reserve Component (RC) Line of Duty (LOD) care. • This brief is strictly related to LOD care in remote areas

3. RC and TMA MMSO Line of Duty Care • RC members on orders for 30 days or less are not eligible in DEERS as active duty • Unit Chain of Command/Service HQ determines LOD eligibility • TMA MMSO only authorizes Remote LOD care • Residing greater than 50 miles or 1 hour from an MTF • Non emergent/urgent civilian LOD care must be pre-authorized by either an MTF or TMA MMSO • Claims • Providers send to the regional contractor • Contractor defers medical claims for DEERS ineligible RC members without MTF authorization to TMA MMSO

4. MMSO Nurse Consultant (NC) authorization of RC Care • Unit coordinates directly with TMA MMSO LOD staff • “Authorization for care request” with supporting LOD eligibility documentation sent by fax or through MODS. No emails!!!!! • Army National Guard must use MODS. Effective 1 Oct 09, all Army Reserve requests must be via MODS. • TMA MMSO LOD staff: • Ensures requested care is within scope of LOD • Care is medically necessary and a covered service • Consults with SPOC, as needed, to determine if care should be deferred to an MTF • May require additional medical documentation • Internal TMA MMSO authorization is communicated to unit within 5-7 working days • TMA MMSO LOD authorizations are not in the MCSC systems, providers or members must contact MMSO directly to verify the authorizations

5. SPOC Authorization of Claims for RC LOD Care • MCSC defers all RC not eligible claims without an MTF authorization to TMA MMSO • SPOC checks for • TMA MMSO LOD auth • Eligibility Documentation • Care within scope of LOD • Claims without eligibility documentation on file are denied • RC unit is responsible for sending eligibility documentation to TMA MMSO • Orders/attendance roster/muster sheet • Good for initial emergent or urgent care only

6. RC Dual eligibility?! • Demobilized and enrolled in? • TRICARE Reserve Select Program (TRS) • Transitional Assistance Management Program (TAMP) • Continued Health Care Benefit Program (CHCBP) • Dependent of active duty member • And have service related LOD injuries? • Must contact the TMA MMSO or their MTF • TMA MMSO or MTF will direct MCSC to reprocess LOD related claim as active duty without cost share

7. Common Problems Delaying LOD Claim Payment • Incomplete/closed LOD • TMA MMSO not notified or involved in the case • No pre-authorization obtained • MTF did not properly authorize the care • Claim forms not sent to contractor by provider

8. Retail Pharmacy Reimbursement for RC with LOD injuries • Reimburses for RC Pharmacy Claims resulting from LOD injuries/illness • Collaboration between Express Scripts Inc. and TMA MMSO • TMA MMSO assists all service members with LOD pharmacy claims regardless of who is managing their care • Process can be found on the TMA MMSO website

9. Contact Information TRICARE Management Activity Military Medical Support Office DSN 792-3950 (847) 688-3950 http://www.tricare.mil/tma/MMSO/

10. FAQ • Question: How can I help a member who has unpaid claims problems? • Answer: If a member reports that a claim for LOD civilian care has not been paid • Primary reasons • No line of duty documentation on file at TMA MMSO • Claim never submitted to the MCSC • Resolutions • Make sure LOD documentation has been submitted to TMA MMSO (send to Health Care Support Services Office (FAX: 1-847-688-6137) • Contact TMA MMSO SPOC by telephone or fax to request a review of the case • If no EOB has been received, contact the provider to see if he/she has submitted the claim to the Managed Care Support Contractor Claims Processor

11. FAQ • Question: As TMA MMSO directs, we send a member to an MTF for LOD care but the MTF won’t see them or refuses an appointment, what can we do? • Answer: • 32 CFR 199.17 and HA Policy 01-015; RC members in need of LOD care have Active Duty (Priority 1) access • Call the Patient Administration Office at the MTF

12. FAQ • Question: How does a unit medical representative ensure that TMA MMSO approves their pre-authorization request for remote care as quickly as possible? • Answer: • FAX to the correct TMA MMSO number: 1-847-688-7394 • Army National Guard must submit requests via MODS • Make sure the “Authorization for care request” is completed and legible • Include LOD documentation • Appropriate clinical information is essential: ensure that requested care is within the scope of the LOD • Call the TMA MMSO LOD contact reps in advance of FAX to address any questions or specific issues 1-888-647-6676, Ext. 3367

13. QUESTIONS??? One Team, Many Challenges, All Committed