Patient Administration - Army Publishing Directorate - U.S. Army

10–6. Authorization for civilian medical care
a. . Except as indicated in c, below, personnel will not obtain care from civilian agencies without obtaining prior
authorization for payment from the designated approving authority.
b. In TRICARE Prime areas, procedures for obtaining prior authorization for all non-emergent medical care will be
provided by the PCM. Direct contact with the approving authority may be necessary to obtain prompt approval for time
sensitive medical care. If requested medical care is authorized, coordination of that care will be maintained by the
Army MTF for the patient. (See chap 8.)
c. Individuals may obtain civilian medical care without the prior authorization of the designated approving authority
under the following conditions:
(1) In emergencies when the urgency of the situation does not permit obtaining such prior authorization as defined
in e below.
(2) When the individual is serving OCONUS.
(3) When an AWOL individual is undergoing emergency civilian care as specified in paragraph 10-3.
(4) For remotely stationed Soldiers as defined in e below.
d. When civilian medical care is obtained without prior authorization, the patient’s immediate commander will
advise the appropriate approving authority without delay that such care is being or has been obtained so that the
approving authority may further coordinate the Soldier’s medical needs. When a Soldier is hospitalized in a civilian
MTF while on leave, pass, PCS, or TDY from their station, it is the individual Soldier’s responsibility to notify (or to
have someone notify in their behalf) the nearest Army MTF or their commander who must notify the appropriate Army
MTF.
e. In areas designated as eligible for the TRICARE Prime Remote Program, active duty and RC Soldiers in an active
duty status for more than 30 days may obtain medical care through the TRICARE Prime Remote Program. For
procedures regarding program eligibility, enrollment, and obtaining medical care, see the instructions at the TRICARE
Prime Remote Web site (http://www.tricare.osd.mil/tpr) or call 1-888-DOD-CARE (363-2273) or 1-888-MHS-MMSO
(676-6676).
f. In areas designated as remote, eligible RC Soldiers, as specified in paragraph 3–2, will obtain approval of medical
care and payment of claims at the Military Medical Support Office (MMSO) http://mmso.med.navy.mil or call 1-888-
MHS-MMSO (676-6676). In areas not designated as remote and near an MTF, eligible RC Soldiers, as specified in
paragraph 3–2, will obtain medical care at the MTF or for civilian medical care with MTF approval.
10–7. Dental care in civilian facilities for active duty personnel
Instructions for requesting dental care in civilian facilities for active duty personnel can be found at the Military
Medical Support Office Web site (http://mmso.med.navy.mil) or call 1-888-MHS-MMSO (676-6676).
10–8. Autopsies
The commander or the surgeon of an installation or command may authorize autopsies to be performed by civilian
physicians, civilian laboratories, or at civilian MTFs to determine the true cause of death and to secure information for
the completion of military records.
10–9. Rates of compensation
The rates of compensation paid for outpatient claims are at the CHAMPUS maximum allowable charge (CMAC). AD
inpatient claims are priced using DRG methodology. When Soldiers have paid the billed amount for properly
authorized care, reimbursement will be for the amount paid. In cases where the civilian provider seeks reimbursement
from the Soldier for any excess unpaid by the MCS contractor, exceptions to the CMAC/DRG based pricing may be
made. TRICARE managed support contractors establish rates for payment of civilian medical claims within their areas
of responsibility.
10–10. Medical records and reports
a. When an AD Soldier receives inpatient care at a civilian facility, the patient will be accounted for as “absent
sick” by the MTF having geographic responsibility for the area in which the patient is hospitalized. The ITR and
HREC entries will be made according to AR 40-66. For patients whose medical records are maintained at another MTF
(for example, for Soldiers traveling on leave, TDY, etc.), the HREC documentation will be forwarded to the
responsible MTF by the MTF carrying the patient as “absent sick.”
b. Reasonable charges may be paid to civilian physicians or civilian MTFs for furnishing copies of medical records,
reports, and studies when such services have been requested by the patient administrator.
c. The AD Soldiers can request medical documents/records from hospitals and/or providers on an ongoing basis or
as a single request prior to their transfer to a new permanent duty location. The TRICARE contractor will pay the
claim for copying and related mailing charges. Hospitals and provider offices should submit the charges for copying
and mailing on a CMS 1500 (Health Insurance Claim Form) as well as a UB-04 form—to the TRICARE contractor.
Claim filing addresses are at www.tricare.osd.mil/claims. Soldiers may be reimbursed copying and mailing charges for
70 AR 40–400 27 January 2010/RAR 15 September 2011