1.0 General
All TRICARE requirements regarding Utilization
Management (UM) and Quality Management (QM) shall apply to the TRICARE
Overseas Program (TOP) unless specifically changed, waived, or superseded
by the provisions of this section; the TRICARE Policy Manual (TPM),
Chapter 12; or the TRICARE contract for health
care support services outside the 50 United States (U.S.) and the
District of Columbia (hereinafter referred to as the “TOP contract”).
See
Chapter 7 for additional instructions. Language
in
Chapter 7 that has no direct application to
the TOP contract does not apply (e.g., Diagnosis Related Group (DRG)
validation reviews which are not applicable in any overseas location
except Puerto Rico).
2.0 Utilization
Management
2.1 The contractor shall establish a Medical Management
(MM)/UM Plan for care received by TRICARE beneficiaries.
2.1.1 The contractor’s MM/UM Plan
shall recognize that the Military Treatment Facility (MTF) Primary
Care Manager (PCM) retains clinical oversight for TOP Prime enrollees.
As such, the enrolling MTF will determine medical and psychological necessity
and issue all referrals for TOP Prime enrollees, and provide UM
and all case management services for the MTF-enrolled population.
The contractor shall ensure that MTF-issued referrals and appropriate
authorizations are entered into all applicable contractor systems
to ensure accurate, timely customer service and claims adjudication.
The contractor shall perform certain UM activities to assist the
MTF with the medical management of TOP Prime inpatients as described
in
paragraph 8.0.
The contractor shall provide notification to the MTF Commander Manager
or designee whenever an MTF enrollee is admitted to an inpatient
facility (including mental health admissions), regardless of location.
Note: Newborns/adoptees who are deemed enrolled in TOP
Prime (based on the sponsor’s MTF enrollment) shall receive clinical
oversight from the MTF.
2.1.2 The contractor shall determine
medical and psychological necessity, conduct covered benefit review,
and issue authorizations for specialty care for TOP Prime Remote
enrollees and all Service members who are on Temporary Duty/Temporary
Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed
on liberty in a remote overseas location. The contractor shall provide
notification of cases to the appropriate TRICARE Area Office (TAO)
for reviews involving remote Service member requests for specialty
care, and whenever hospital admissions have occurred for any beneficiary
not enrolled to a TOP MTF (including mental health admissions),
regardless of location.
Note: Newborns/adoptees
who are deemed enrolled in TOP Prime (based on the sponsor’s TOP Prime
Remote enrollment) shall receive clinical oversight from the TOP
contractor.
2.1.3 The contractor shall review
and authorize urgent specialty care for beneficiaries enrolled to a
stateside contractor who are traveling outside of the 50 U.S. and
the District of Columbia.
2.2 The MM/UM Plan shall recognize
that purchased care sector network providers (except for TOP Partnership
Providers) are the responsibility of the TOP contractor and the
contractor shall ensure that any adverse finding related to purchased
care sector provider care is forwarded within five calendar days
of identification to the appropriate TAO.
2.3 The MM/UM Plan shall include
a process for identifying high utilization/high cost patients and locations.
2.3.1 At a minimum,
this process shall include the identification of patients exceeding
the frequency and/or cost thresholds established in the TOP contract.
These thresholds apply to all TOP beneficiaries, including TOP Prime,
TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE
Select (starting January 1, 2018), and TOP TRICARE For Life (TFL).
2.3.2 The TOP
contractor shall review these claims for appropriateness of care,
and shall propose interventions to reduce overutilization or contain
costs whenever possible. Proposed interventions to cost and/or overutilization
shall be forwarded to the Government for review prior to contractor implementation.
2.4 The MM/UM Plan
shall integrate efforts to identify potential fraud/abuse. Any cases
identified as possible fraud/abuse shall be referred directly and
exclusively to the Defense Health Agency (DHA) Program Integrity
(PI) Office in accordance with
Section 14.
2.5 The TOP
contractor shall provide case management services as outlined in
the contract with DHA. Specific case management processes shall
be addressed in the Statements Of Responsibilities (SORs) between
the contractor, MTF Commanders, and the TAO Directors.
2.6 The TOP
contractor shall closely monitor requests for inpatient care or
medical evacuation services to ensure that services are medically or
psychologically necessary and appropriate for the patient’s condition.
Beneficiaries will not be assigned to a particular facility or medically
evacuated to a particular geographic location based solely on personal
preference, but will be transported to the closest medical facility
capable of providing appropriate stabilization and/or treatment.
2.7 Inpatient
stays that exceed the standard Length-Of-Stay (LOS) for a local
area in a purchased care sector country or U.S. commonwealth/territory
shall be identified and reviewed for medical or psychological necessity.
Unless a different standard has been identified by the government,
the contractor shall use best business practices to determine the
standard LOS for a particular overseas location. Upon Government
request, the TOP contractor shall provide supporting documentation related
to LOS determinations.
5.0
Referral/Authorization/Health
Care Finder (HCF) Requirements
5.1 The TOP contractor shall develop
procedures for processing referrals for TOP Prime and TOP Prime
Remote enrollees in accordance with the TOP contract;
Chapter 8, Section 5; and this chapter. The
TOP contractor shall conduct related authorization and HCF activities.
The MTF will conduct medical and psychological necessity reviews
for TOP MTF enrollees and determine that the requested care is not
available in the MTF prior to forwarding the referral to the contractor.
• The
contractor shall conduct covered benefit reviews to determine whether
the referred care is a covered TRICARE benefit. Medical or psychological necessity
notification to beneficiaries regarding covered benefit findings
shall follow the provisions of
Chapter 8, Section 5.
The contractor shall locate an appropriate network or non-network
purchased care sector provider for all authorized care and shall
provide the provider information to the beneficiary. Upon beneficiary
request, the contractor shall assist with scheduling an appointment
for the beneficiary. The contractor shall also implement guarantee
of payment or other business processes to ensure that TOP Prime
and TOP Prime Remote beneficiaries have access to authorized care
on a cashless, claimless basis.
Note: Although a referral/authorization is never required
for emergency care, TRICARE Prime/TRICARE Prime Remote (TPR) ADFMs
who require emergency care (including emergency medical evacuation,
if medically or psychologically necessary and appropriate) while
traveling outside the 50 U.S. and the District of Columbia will
be provided with emergency care on a cashless, claimless basis upon
notification to the TOP contractor before the services are rendered
(see
Sections 7 and
9).
5.2 The TOP
contractor shall develop procedures for the identification and tracking
of TOP enrollee claims submitted by a purchased care sector provider
or a beneficiary without preauthorization/authorization.
5.3 The TOP
contractor shall educate beneficiaries of the preauthorization/authorization requirements
and of the procedures for requesting preauthorization/authorization.
In MTF locations, these beneficiary education efforts may be conducted
in conjunction with MTF staff. In remote locations, the contractor
shall provide all beneficiary education. Although beneficiaries
are required to obtain authorization for care prior to receiving
payment for the care requiring TOP preauthorization/authorization,
retroactive authorization may be requested following the care from
the appropriate authority for issuing authorizations. Specifically,
TOP enrollees who seek urgent care from a purchased care sector
without obtaining authorization will be required to contact their
PCM within three business days so that a retroactive referral may
be submitted. Retroactive authorization requests shall not be accepted
by the TOP contractor after this initial time frame without higher
level approval (TAO or TOP Office). The contractor shall document
preauthorization/authorizations according to current contract requirements.
5.4 If medical
review is required to determine medical or psychological necessity
of a service rendered, the TOP contractor shall follow the requirements
outlined in
Chapter 7, Section 1 related to medical review
staff qualifications and review processes.
5.5 The TOP preauthorization/authorization
must be submitted with the claim or be available via internal contractor
systems designated to interface with the claims processing system.
5.6 The TOP
contractor shall maintain a preauthorization/authorization file.
5.7 When necessary,
clarification of discrepancies between authorization data and data
on the claims shall be made by the TOP contractor with the appropriate
authorizing authority.
5.8 Except for obstetrical care
or other long-term/chronic care authorizations, the TOP contractor shall
consider authorizations valid for 90 days (i.e., date of service
must be within 90 days of issue date). Authorizations may be granted
for 365 days for obstetrical care, or for any other long-term/chronic conditions
for which an extended care period is medically or psychologically necessary
and appropriate. Only services that are applicable to the care authorization
shall be covered under the authorization (i.e., a care authorization
for obstetrical care cannot be extended to cover specialty care that
is unrelated to the pregnancy).
5.9 Procedures for preauthorizations/authorizations
for TOP beneficiaries for inpatient mental health care rendered
in the 50 U.S. or the District of Columbia shall be developed by
the TOP contractor. The TOP contractor shall authorize/review all
stateside non-emergency inpatient mental health care (i.e., acute
hospitalization psychiatric care, psychiatric Residential Treatment
Center (RTC), Substance Use Disorder (SUD) inpatient/residential
detoxification and rehabilitation for TOP Prime/TOP Prime Remote
ADFMs, regardless of where the care is rendered. To perform this
requirement, the contractor shall at a minimum provide:
• Three
24-hour telephone lines: one stateside toll free, one commercial
and one fax for overseas inpatient mental health review requirement;
• Sample forms for use
by the referring physician when requesting preauthorization/authorization
for care; and
• A
system for notification of the contractor when care has been authorized.
Additionally, the TOP contractor shall:
5.9.1 Inform
the beneficiary/provider if a desired facility is not a TRICARE
authorized facility and offer the beneficiary/provider a choice
of alternative facilities and assist with identifying stateside facilities
for referring providers.
5.9.2 Upon request, either telephonically
or by fax, from a referring provider, the contractor shall initiate
preauthorization prior to admission for non-emergency inpatient
care, including RTC, Substance Use Disorder Rehabilitation Facility
(SUDRF), etc. (Essentially, all admissions defined by TPM,
Chapter 1, Section 6.1, as requiring preauthorization).
The TOP contractor shall arrange ongoing utilization review, as
indicated, for overseas beneficiaries admitted to any level of inpatient
mental health care.
5.9.3 The review determination must
conclude in either authorization or denial of care. Review results
must be faxed to the beneficiary/provider within 24 hours of the
request. The review and denial process will follow, as applicable
the processes outlined in
Section 7.
5.9.4 The TOP
contractor shall provide an opportunity to discuss the proposed
initial denial determination with the patient’s attending physician
AND referring physician (if different providers). The purpose of
this discussion is to allow further explanation of the nature of
the beneficiary’s need for health care support services, including
all factors which preclude treatment of the patient as an outpatient
or in an alternative level of inpatient care. This is important
in those beneficiaries designated to return overseas, where supporting
alternative level of care may be limited, as well as support for intensive
outpatient treatment. If the referring provider does not agree with
the denial determination, then the contractor shall contact the
appropriate overseas TAO Medical Director to discuss the case. The
TAO Director shall provide the schedule and contact information
for all overseas TAO mental health advisors. The final decision
on whether or not to issue a denial will be made by the TOP contractor.
5.9.5 The TOP
contractor shall notify the referring provider if the patient is
returning to ensure coordination of appropriate after-care arrangements,
as well as facilitate discussion with the attending provider to
ensure continuity of care is considered with the proposed after-care
treatment plan.
5.9.6 The TOP contractor shall adhere
to the appeals process outlined in
Section 13.
5.10 The required
data elements for MTF referrals prescribed in
Chapter 8, Section 5, paragraph 6.1 may be
altered to accommodate the delivery of health care overseas with
the permission of the Government.
Note: Any alteration
to the referral data elements prescribed in
Chapter 8, Section 5, paragraph 6.1 must be
approved in writing by the DHA Contracting Officer (CO) prior to
implementation.
6.0 MEDICAL
TRAVEL
6.1 TOP Prime
Enrollees and MTF-Referred Transient Beneficiaries
If the TOP contractor’s HCF determines that
appropriate medical or psychological care is not available in the
beneficiary’s local service area, the TOP contractor shall provide a Notification
of Case (NOC) Report to the appropriate TAO per
the medical travel requirements. Details
for reporting are identified in DD Form 1423, Contract
Data Requirements List (CDRL), located in Section
J of the applicable contract. The NOC Report shall
identify the nearest purchased care sector provider or facility that
can provide adequate specialty care. The TOP contractor shall issue
a care authorization upon MTF’s request (as documented in the MTF’s
response to the NOC Report).
6.2 TOP Prime
Remote and Self-Referred Transient Beneficiaries
If
the TOP contractor’s HCF determines that appropriate medical or
psychological care is not available in the beneficiary’s local service
area, the TOP contractor shall provide a NOC Report to
the appropriate TAO per the medical travel requirements.
Details for reporting are identified in DD Form 1423, CDRL,
located in Section J of the applicable contract.
The NOC Report shall identify the nearest purchased
care sector provider or facility that can provide adequate specialty
care. The TOP contractor shall issue a care authorization upon TAO’s
request (as documented in the TAO’s response to the NOC Report).
7.0 Case
Management
The TOP contractor shall establish
and operate a case management program to identify and manage the
health care of individuals with high-cost conditions or with specific
diseases or conditions for which evidence-based clinical management
guidelines exist. This program shall be available to all TOP beneficiaries
(both enrolled and non-enrolled) except TRICARE-Medicare dual eligible
beneficiaries who receive care in the Commonwealth of Puerto Rico,
Guam, American Samoa, the Northern Marianas, and the U.S. Virgin
Islands. MTF retain primary responsibility for case management for
MTF enrollees; however, the contractor shall assist the MTF by identifying
MTF enrollees who might benefit from case management, and by coordinating
care for these individuals with the MTF clinical staff as well as
the purchased care sector civilian provider staff. The contractor
shall submit a Case Management Program and patient selection criteria
and shall provide annual updates in accordance with the provisions
of the TOP contract.
8.0
Medical
Management for Prime inpatients
The contractor
shall assist the MTFs with the medical management to TOP Prime enrollees
who are hospitalized in a purchased care sector facility (regardless
of location). Based on the contractor’s role as a Peer Review Organization
(PRO), their knowledge of TRICARE benefit policy, and their expertise
regarding purchased sector health care, the contractor shall perform
concurrent review/continued stay reviews for all TOP Prime enrollees
during the entire inpatient Episode Of Care (EOC). These reviews
shall assess the patient’s continued need for treatment and the
appropriateness of current and proposed treatment (including, but
not limited to, an assessment of the appropriateness of care setting).
Based on these reviews, if changes to the treatment plan (as proposed
by the inpatient facility) are indicated, the contractor shall intervene
with the treating facility to make the appropriate changes. The
contractor shall interface with the MTF PCM through the duration
of the inpatient stay and shall provide status updates discharge
summaries, and follow-up care recommendations to the MTF. Upon discharge
from the inpatient facility and transfer of the discharge summary/follow-up
care recommendations, the contractor shall relinquish all medical
management responsibilities to the MTF PCM.