Outpatient Physical, Occupational and Speech Therapy ...

Outpatient Physical, Occupational a
TRICARE Provider Orientation

2014

and Speech Therapy

Doc#: UHCMV1106_07032014

Outpatient Physical, Occup
Speech Therapy Services

• Outpatient physical, occupational and speech
therapy providers contracted with Optum™ may
find all the key terms and conditions of their
TRICARE relationship on the Optum -
UnitedHealthcare Military & Veterans Fact Sheet.

• The Fact Sheet is sent to all providers upon
joining the TRICARE network, and also is
available at
www.myoptumhealthphysicalhealth.com > Plan
Summaries & Fee Schedules.

• For questions about the Fact Sheet or their
TRICARE contract terms and conditions,
providers may call Optum at (800) 873-4575 and
ask to speak with their Optum Contract Manager.

2

This presentation reflects the program as of the date delivered and is subject to change. Administra

pation and

ative guides and the Provider Handbook should be consulted regarding policies and procedures.

TRICARE Outpatient Thera
Authorizations

• Beneficiaries must have a referral from the
before outpatient physical, occupational or

• Referrals can be made only by MDs, DOs,

• Referral requests are made by the PCM or
&Veterans. It typically takes 2-5 days to pro
authorization is then sent to the requesting

• Completed referrals/authorizations are sen
www.uhcmilitarywest.com > Providers > Se
Authorizations.

• Authorizations are required for all Active Du
TRICARE programs, including: TRICARE P
Prime Remote Active Duty Family Member
TRICARE Reserve Select, TRICARE Retir
Extended Care Health Option (ECHO).

• Military Treatment Facilities (MTFs) have th
outpatient therapy services before referring

• The Optum utilization review process/clinic

apy Referrals/

eir primary care manager (PCM) or a specialist
speech therapists can provide services.
PAs & NPs.
r specialist to UnitedHealthcare Military
ocess the request; a determination/

g provider, therapist and beneficiary.
nt via mail and are also available online at
ecure Content > Search Referrals and Prior

uty Service Members (ADSM) and most
Prime, TRICARE Prime Remote, TRICARE
r, TRICARE Standard, TRICARE Extra,
red Select, TRICARE Young Adult and

he right of first refusal (ROFR) to provide
g outside of the MTF.
cal submission form is not required.

TRICARE Outpatient Thera
Referrals/Authorizations &

• The duration of the authorization is indica

• The referral/authorization letter includes a

• If you bill services outside of those on the

• To request authorization for additional se
to www.uhcmilitarywest.com > Providers
Surgical Referrals and Authorizations from
and send in the form per the instructions.
the request on line by going to Providers
Authorization Request.

• Durable Medical Equipment >$150 requir
for therapy services.

• For a complete list of services requiring p
TRICARE Provider Handbook at www.uh
Resources/Provider Handbook. Please s

• Before providing services, confirm Benefi
call UnitedHealthcare Military & Veterans

apy
Eligibility

ated on the referral/authorization letter.

a code range covered by the authorization.

e authorization, those services may be denied.

ervices beyond what is initially authorized, go
> Resources/Find a Form > Select Medical-
m Form Category drop down box; complete
. If you are registered, you may also submit
> Secure Content > Submit Referral or

res an authorization beyond the authorization

prior authorization, please refer to the
hcmilitarywest.com > Providers >
select the appropriate version.

iciary eligibility at www.uhcmilitarywest.com or
s provider services at (877) 988-9378.

Search Referrals and Prior Aut

Click on Search Referrals and Prior Authorizat
referrals and prior authorizations by:
• Single Patient
• Reference Number
• All Patients

Office Managers can only view referrals and authorizations of pat
they are logged in as on the portal.
To view referrals and authorizations for all providers on the accou
to view each provider individually.

thorizations

tions in the secure content navigation to search

t

tients for the specific provider
unt, click Switch Provider

Search Referrals and Prior Aut
by Reference Number

To Search by Reference Number:
• Select Reference Number
• Enter the Reference Number
• Click on Search

thorizations

Search Referrals and Prior Aut
by All Patients

To Search by All Patients:
• Select All Patients
• Choose an Activity Timeframe

• Last 30, 60 or 90 Days
OR

• Enter Start Date
and End Date

• Click on Search

thorizations

Search Referrals and Prior Aut
Search Results Details

Referral and
Prior Authorization
details include:

• Reference Number
• Servicing Provider
• Diagnosis
• Service Description
• Service Dates
• Visits
• Status
• Date Received
• Beneficiary Information

thorizations –

Referral or Authorization Requests will
appear as “Pending” until processed.

TRICARE Claims

• Submitting claims electronically is preferred; it

• Check claims status online at www.uhcmilitaryw

be registered on uhcmilitarywest.com) > Claim

• You may also inquire about the status of a claim
Veterans at (877) 988-9378 (WEST).

• Claims must be received within one year from t
denied.

• Allow at least 30 days to receive payment or a

claims. Remember to check claim status online

• See the TRICARE Provider Handbook for a co
policies. Go to www.uhcmilitarywest.com > Pro
of the Provider Handbook for the Claims Proce

• Claims Submission (see Fact Sheet):

 Send Electronic claims to: Emdeon® Payer ID: 99
 For providers with less than 150 claims per month

www.mytricare.com.
 Paper Claims Filing: If you are unable to submit cl
 For EDI Support contact: (800) 325-5920

• Claims Inquiry:

 To inquire about the status of a claim, contact Unit
988-9378 (WEST)

minimizes errors and expedites payment.

west.com > Providers > Secure Content (you must

ms.
m by contacting UnitedHealthcare Military &

the service date. Late claim submissions may be

provider remittance advice before resubmitting
e (see above) before resubmitting.
omplete description of billing and claims payment
oviders > Resources; select the appropriate version
essing and Billing Information section.

9726
h, claims can be submitted directly on PGBA’s website at:

laims electronically, please call (877) 988-9378.

tedHealthcare Military and Veteran’s provider service at (877)

TRICARE Reimbursement

• Outpatient therapy reimbursement is base
Rate, which is based on CHAMPUS Maxim

• The percent you are reimbursed is noted i
Provider Appendix.

• The TRICARE Maximum Rate is solely de
Defense and is subject to change by the T

• To determine a rate for a specific CPT cod
website. For example, if a Seattle, Washin
determine the reimbursement rate for CPT

 Go to www.tricare.mil/CMAC/home.aspx.
 Choose CMAC Procedure Pricing option an
 In this example, the locality code is 385; the
 Enter 97001 into “procedure code” and pre
 The correct value is reflected as “CMAC for

the TRICARE Maximum Rate.
 Multiply $81.13 by your percent of TRICAR

Optum TRICARE Provider Appendix. This

ed on a percent (%) of the TRICARE Maximum
mum Allowable Charge (CMAC).
in the Payment Appendix of your TRICARE

etermined by the United States Department of
TMA.
des, you will need to access the TRICARE
ngton-based physical therapist wants to
T 97001:

nd follow the instructions to select a locality code.
en press “search”
ess “show pricing information”
r Category 2”. In this case, it’s $81.13. This value is

RE maximum rate in the Payment Appendix of your
s is the provider’s allowed rate for CPT code 97001.

TRICARE: Your Optum Re

• Optum manages your contractual rel
& Veterans in support of TRICARE.

• Key areas managed by Optum:

 Questions or issues with your TRIC
language and expectations

 Demographic changes - it is critica
change to clinic location, TIN, prov
incorrect referral or claims process

o Submit demographic changes (inc
changes) via one of the following
Web: www.myoptumhealthphysic
Fax: (888) 626-1701
Mail: OptumHealth Provider Data
Minneapolis, MN 55440-1459

• Call your Optum Contract Manager for an
standard resolution channels outlined in th

• For questions about your TRICARE cont
Optum at (800) 873-4575 and ask to spea

elationship

lationship with UnitedHealthcare Military

CARE provider agreement/addendum

ally important to keep Optum apprised of any
vider, address, etc.; it reduces the risk of
sing.

cluding relocation and tax identification number
methods:
calhealth.com

a Mgmt., P.O. Box 1459, MN010-W120,

ny escalated issues not resolved through
he prior slides (e.g., claims, referrals, etc.).
tract terms and conditions, you may call
ak with your Optum Contract Manager.

Optum Physical Health
Contract Manager Contact

WA MT ND
SD
OR ID WY NE

NV UT CO KS
CA AZ NM

AK TX

HI

El Paso Only

ts by State

MN

IA
MO

Kurt Le Van (303) 690-9152
Email: [email protected]

Dawn Becker (952) 205-2856
Email: [email protected]

Wes Doolittle (763) 797-5804
Email: [email protected]

Niels Neve (763) 595-3430

Email: [email protected]

Non-Optum: Lease Markets

TRICARE: Contact Summar

Beneficiary Eligibility

• www.uhcmilitarywest.com or calling UnitedHealthcare Mil

TRICARE Provider Handbook

• www.uhcmilitarywest.com > Providers > Resources (le

Authorizations/Referral Status

• Completed referrals/authorizations are sent via mail an
Providers > Secure Content > Search Referrals and Pr

Authorizations for Additional Services beyond I

• To request authorization for additional services beyond
> Providers > Resources/Find a Form > Select Medica
Category drop down box; complete and send in the form
accomplished through Secure Content > Submit Referr

Claims Submission

• Send Electronic claims to: Emdeon® Payer ID: 99726

Claims Inquiry

• To inquire about the status of a claim, contact UnitedHealthc
(WEST)

Demographic Changes (TIN, address, etc).

• Submit demographic changes to Optum at www.myopt

Optum-TRICARE Contract Terms and Condition

• For questions about your TRICARE contract terms an
speak with your Optum Contract Manager.

ry

litary & Veterans provider services at (877) 988-9378 (WEST).

eft-hand side of page)

nd are also available online at www.uhcmilitarywest.com >
rior Authorizations.

Initial Authorization

d what is initially authorized, go to www.uhcmilitarywest.com
al-Surgical Referrals and Authorizations from the Form
m per the instructions. If you are registered, this also be
ral or Authorization Request?

care Military & Veterans provider service at (877) 988-9378

tumhealthphysicalhealth.com or fax to (888) 626-1701

ns

nd conditions, call Optum at (800) 873-4575 and ask to