TRICARE Overseas Program Provider Manual

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TRICARE overseas Program Provider Manual Authorization Forms International SOS will send an Authorization Form to you and the referring MTF along with a pre-populated Claim Form (see Section 5). The Authorization Form will include your contact information (as the Network Provider), the patient’s name, date of birth, and instructions regarding the scope and validity of the authorization. The Authorization Form will also include the name of the MTF referring the care. A sample TRICARE Authorization Form is included on the following page, as well as in Section 7 of this TOP Provider Manual. A specific Authorization Form will be issued depending on whether a beneficiary is a TOP Prime or TOP Prime Remote patient. Authorization Forms will also vary depending on whether the beneficiary is receiving inpatient or outpatient care. A separate Authorization Form will be needed for TOP Prime Remote ADSM before receiving dental care. Below is a brief description about the fields you will find on an International SOS Authorization Form. You will need this information before delivering health care services. ■ Priority Care — this will either state ‘Urgent’ or ‘Routine’ — Urgent: An appointment must be provided within 24 hours of the beneficiary’s request for care. Note: For urgent care, medical results and any consult notes must be sent to the referring party, either the MTF or International SOS, within 24 hours. The referring party’s contact details are indicated on the Authorization Form. — Routine: An appointment must be provided within 1 week of the beneficiary’s request for routine care and within 4 weeks of the beneficiary’s request for specialty care. Note: For routine care, medical results and any consult notes must be sent to the referring party, either the MTF, the assigned Primary Care Manager (in Puerto Rico) or International SOS, within 10 days. ■ Specialty required ■ Preliminary diagnosis from referring physician ■ Scope of care – this will either state ‘Evaluate’ or ‘Evaluate and Treat’ — Evaluate: You are authorized to evaluate only, using diagnostic tools such as laboratory tests, consultation, X-rays (to determine appropriate treatment). — Evaluate and Treat: You are authorized to both evaluate and treat the patient. A separate Authorization Form will be provided for surgical procedures and inpatient care, if admission is required as part of the treatment. Please notify the MTF or International SOS if this is the case. ■ Detailed Instructions ■ Inclusions Note: If you have any questions about the medical care that is being authorized, please call International SOS before delivering service. Note: The authorization will indicate how long it is valid. Authorizations are typically valid for 90 days. If your treatment dates exceed the time the Authorization Form is valid, please contact International SOS or your local MTF to obtain a new Authorization Form. Note: To access the full terms and conditions of the Authorization Form, please visit www.tricare-overseas.com. You may also contact your International SOS TOP Regional Call Center and press option #5 to request a copy of the terms and conditions. 30
TRICARE overseas Program Provider Manual TRICARE AUTHORIZATION FORM FOR OUTPATIENT CARE TRICARE PRIME BENEFICIARY To: Tel: Fax: Authorization Number: Date: 14 April 2010 Pages: 1 SERVICE(S) REQUEST IN RESPECT OF: This is to confirm the Authorization for the above patient at for outpatient care. This Authorization is only valid between and . Priority Specialty Preliminary Diagnosis Number of Visits Scope Instructions: As per referral Inclusions: Further to medical information received, International SOS authorizes all reasonable, customary and necessary medical expenses within the scope of the approved authorization. Medical Reports: Please send a written medical report and discharge summary to the below addressee after this patient’s episode of care / procedure. Please follow any special arrangements you may have between you and the Military Treatment Facility (MTF). , Fax: SECTIoN 4 Authorizations and Seeing TRICARE Patients Priority: For urgent medical appointments please return a copy of medical results within 24 hours. For routine appointments please return a copy of medical results within 10 calendar days. Important: An authorization is issued for requested services, procedures, or admissions that require medical necessity review prior to services being rendered. The terms of this Authorization are only applicable to the specific service provider indicated above and to this instance of service requested. Billing Instructions: If the Beneficiary has "other" healthcare coverage in addition to TRICARE, the "other" healthcare coverage is the Primary Insurer. All invoices must reach us within 12 calendar months from date of service to avoid denial of settlement. An itemized invoice accompanied with a duly completed Claim Form and a copy of this Authorization Form is to be sent to the following address. : For full terms and conditions of this Authorization Form, please refer to www.tricare-overseas.com . Alternatively, you may contact our office for a copy of the terms and conditions. Yours sincerely TRICARE Department 31
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TRICARE Overseas Program Provider Manual

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