February 2015 - Health Net Federal Services

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TR IC ARE ®
Provider News
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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)
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Healthy People 2020 Corner
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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
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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.

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