Utilization Management

    TRICARE and CSMV Logo

    TRICARE Prime® Demo by CareSource Military & Veterans™ is committed to maintaining the quality and appropriateness of health care services provided to our beneficiaries. The Utilization Management (UM) department performs all UM activities including prior authorization, concurrent review, discharge planning and other activities.

    We make our UM criteria available in writing by mail, fax and online through the Provider Portal, as follows:

    • Mail: TRICARE Prime Demo

    ATTN: Medical Management Department
    P.O. Box 1598 
    Dayton, OH 45401

    • Fax: 1-844-824-5582
    • Sick Newborn Fax: 1-937-396-3499 

    Prior Authorization  

    TRICARE Prime Demo understands that you may have questions about prior authorization. Learn more about Prior Authorization. 

    Medical Necessity Criteria  

    We utilize nationally recognized criteria to determine medical necessity and appropriateness of inpatient hospital, rehabilitation and skilled nursing facility admissions. These criteria are designed to assist health care partners in identifying the most efficient quality care practices in use today. They are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about individual patients. We default to all applicable state and federal guidelines regarding criteria for authorization of covered services. TRICARE Prime Demo also has policies developed to supplement nationally recognized criteria. If a patient’s clinical information does not meet the criteria, the case is forwarded to a Medical Director for further review and determination. Physician reviewers from TRICARE Prime Demo are available to discuss individual cases with attending physicians upon request. 

    Utilization review determinations are based only on appropriateness of care and service and existence of coverage. We do not reward health care partners or our own staff for denying coverage or services. There are no financial incentives for our staff beneficiaries that encourage them to make decisions that result in underutilization. 

    Our beneficiaries’ health is always our number one priority. Upon request, we will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing the TRICARE Prime Demo Utilization Management Department. You can reach us by phone at 1-800-488-0134. 

    Access to Staff  

    To request authorization for an inpatient admission or ask a question about post-stabilization services, please call Provider Services at 1-833-230-2170. When calling, tell our IVR system that you are requesting post-stabilization. Your call will be answered by our UM department. If calling after regular business hours, the call will be answered by CSMV Nurse Advice Line. Authorization requests are completed within the time frames noted below:

    Authorization Type

    Decision

    Extension

    Urgent Concurrent

    48 hours from receipt of request

    Extensions are not allowed for urgent concurrent decisions for TRICARE Prime Demo

    Urgent Preservice

    One business day

    If an urgent pre-service request is incomplete and requires additional information, CareSource Military & Veterans must request the additional information within 2 business days.

    Health care providers then have 48 hours to respond to the request.

    Standard Preservice

    Five business days

    CareSource Military & Veterans may extend the time frame once, by up to 15 calendar days if the CareSource Military & Veterans asks the beneficiary to allow the extension before the decision timeframe because we need additional time to get more information, and we give at least 45 calendar days to provide the information.

    Retro (Post service)

    30 calendar days

    CareSource Military & Veterans may extend the time frame once, by up to 15 calendar days if the CareSource Military & Veterans asks the beneficiary to allow the extension before the decision timeframe because we need additional time to get more information, and we give at least 45 calendar days to provide the information.

    Providers may call 1-833-230-2170 to contact Utilization Medical Management staff with any UM questions. 

    • Staff members are available from 8 a.m. to 5 p.m. Eastern Time (ET), Monday through Friday, for inbound calls regarding UM issues. 
    • Staff members can receive inbound communication regarding UM issues after normal business hours. 
    • Providers may leave voice mail messages on these telephone lines after business hours, 24 hours a day, 7 days a week. 
    • Medical necessity determination requests can be submitted 24 hours a day, seven days a week via a dedicated fax line and the provider portal. 
    • Staff members can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon. 
    • Staff members are identified by name, title and organization name when initiating or returning calls regarding UM issues. 
    • Staff members are available to accept collect calls regarding UM issues. 
    • Staff members are accessible to callers who have questions about the UM process. 
    • TTY and language assistance services are available to callers who need them.

    In the best interest of our beneficiaries and to promote their positive health care outcomes, TRICARE Prime Demo supports and encourages continuity of care and coordination of care between medical health care partners as well as between behavioral health care partners.