Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
1.0 mm/UM
Program Plan
The Defense Health Agency (DHA)
defines MM as an integrated managed care model that promotes UM,
Case Management (CM), and chronic care/Disease Management (DM) programs
as a hybrid approach to managing patient care. MM integrates evidence-based
and outcome-oriented programs into the MM processes.
1.1 These requirements
are applicable to utilization and quality review of all health care
services delivered to all beneficiaries living within the region,
to all beneficiaries receiving care in the Region regardless of
their place of residence, and to all providers delivering care within
the region. Additional requirements for enrollees (such as authorizations
for specialty care are found throughout 32 CFR 199 and the TRICARE
Manuals) and network providers (such as qualifications to be network
providers are further identified in
Chapter 5 and
the TRICARE Policy Manual (TPM)). All providers shall be subject
to the same review standards and criteria. The contractor shall
be considered a multi-function Peer Review Organization (PRO) under
this contract.
1.2 The contractor shall fully describe in a written
MM/UM Plan all processes, procedures, criteria, staff and staff
qualifications, and information and data collection activities and
requirements the contractor shall use in conducting MM/UM activities.
Details
for
providing this plan are
identified
by DD Form 1423, Contract Data Requirements List
(CDRL)
, located in Section J of the applicable contract.
1.2.1 The DHA
Program Office (Clinical Operations Division (COD)/TRICARE Overseas
Program Office) will review the plan and make recommendations
for revision if necessary within 45 calendar days or provide written
approval through the Contracting Officer (CO). In the absence of MM/UM staff in
the Uniformed Services Family Health Plan Program
Office (USFHP PO), the DHA Clinical
Support Division (CSD) will review the plans submitted and
provide recommendations for revision or written acceptance within
45 days.
1.2.2 The contractor shall provide a revised plan
addressing the recommendations within 15 business days to the appropriate
reviewing office which, will provide written approval of the plan through
the appropriate CO within 45 calendar days if there are no recommendations
or upon receipt of a revised plan which addresses the recommendations.
1.2.3 The contractor
shall participate in DHA sponsored medical management training as requested,
to include coordination of training schedules and the development
of the agenda and training schedules and the development of the
agenda and training materials. Each contractor shall participate
in two four-day training sessions per year in their respective region.
The location of the training will be designated by DHA.
2.0 Notification
Of Review Requirements
The contractor is
responsible for education and training to providers and beneficiaries
on the requirements of the MM/UM programs. The contractor shall
describe fully the process for notification, in a timely manner
(but not less than 30 calendar days prior to commencement of review),
of all providers, both network and non-network, of all review requirements
such as:
• Preauthorization;
• Concurrent review;
• Retrospective review
(including the fiscal penalties for failing to obtain review authorizations);
and
• Review
criteria to be used, and requirements for CM.
3.0
Reviewer
qualifications and participation
3.1 Peer Review By Physicians
3.1.1 Except
as provided in
paragraph 3.1.2, each person who makes an
initial
or reconsideration denial determination
or standard of care determination about services furnished or proposed
to be furnished by a licensed doctor of medicine or osteopathy or
by a doctor of dentistry must be another licensed doctor of medicine
in a like specialty, or osteopathy in a like specialty, or
dentistry
with an active clinical practice in the PRO area, if the initial,
reconsideration, or standard of care determination is based on lack
of medical necessity or other reason relative to reasonableness,
necessity, or appropriateness.
3.1.2 If
a PRO determines that peers are not available, then
a nationally accredited external independent review organization
shall be used to make the determinations.
3.2 Peer Review
By Health Care Practitioners Other Than Physicians
Health care practitioners other than physicians
may review services and/or make standard of care determinations for
services furnished by other practitioners in the
same professional field and specialty.
3.3 Diagnosis Related Group (DRG)
Validation Review
3.3.1 Decisions about procedural
and diagnostic information must be made by physicians.
3.3.2 Technical coding issues must be reviewed by
individuals with training and experience in International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding
(for outpatient services with dates of service or inpatient services
with dates of discharge provided before the mandated date, as directed
by Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation) and in ICD-10-CM
coding (for outpatient services with dates of service or inpatient
services with dates of discharge provided on or after the mandated date,
as directed by HHS, for ICD-10 implementation, or International
Classification of Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS) for inpatient services with dates of discharge provided
on or after the mandated date, as directed by HHS, for ICD-10 implementation).
3.4 Persons Excluded
From Review
3.4.1 A person may not review health care services
or make initial denial determinations or changes as a result of
DRG validations if he or she, or a member of his or her family:
• Participated
in developing or executing the beneficiary’s treatment plan;
• Is a member of the
beneficiary’s family; or
• Is a governing body
member, officer, partner, 5% or more owner, or managing employee
in the health care facility where the services were or are to be
furnished.
3.4.2 A member of a reviewer’s family
is a spouse (other than a spouse who is legally separated under
a decree of divorce or separate maintenance), child (including a
legally adopted child), grandchild, parent, or grandparent.
3.5 Administrative
Requirements
Each review shall be dated and
include the signature, legibly printed name, clinical specialty, and
credentials of the reviewer. Each reviewer shall include rationale
for his or her decision (i.e., a complete statement of the evidence
and the reasons for the decision).
4.0
Written
Agreements With Institutional Providers
The
contractor shall establish written agreements with each institutional
provider over which the contractor has review authority. These agreements
shall be maintained throughout health care delivery. Agreements
must specify that:
• Institutional providers
will cooperate with the contractor in the assumption and conduct
of review activities.
• Institutional providers
will allocate adequate space for the conduct of on-site review.
• Institutional providers
will deliver to the contractor a paper or electronic copy of all required
information within 30 calendar days of a request for off-site review.
• Institutional providers
will provide all beneficiaries, in writing, their rights and responsibilities
(e.g., “An Important Message from TRICARE” (
Addendum A),
“Hospital Issued Notice of Noncoverage” (
Addendum B).
• Institutional providers
will inform the contractor within three working days if they issue
a notice that the beneficiary no longer requires inpatient care.
• Institutional providers
will assure that each case subject to preadmission/pre-procedure review
has been reviewed and approved by the contractor.
• Institutional providers
will agree, when they fail to obtain certification as required,
that they will accept full financial liability for any admission
subject to preadmission review that was not reviewed and is subsequently
found to be medically unnecessary or provided at an inappropriate
level (
32 CFR 199.15(g)).
• The contractor shall
reimburse the provider for the costs of providing documents using
the same reimbursement as Medicare.
• The contractor shall
provide detailed information on the review process and criteria
used, including financial liability incurred by failing to obtain
preauthorization.
5.0 Benefit
Policy Decisions
TRICARE versus local policy.
TRICARE policies have precedence over any local or internal policy of
the contractor or the medical community of the region. However,
the contractor shall notify DHA promptly of any conflicts between
TRICARE policy and local policy. Variations from policy, which expand,
reduce, or adjust benefit coverage shall be referred to DHA for
approval before being implemented.
6.0 Concurrent
Review Requirements
The contractor shall
conduct concurrent review for continuation of inpatient mental health services
within 72 hours of notification of emergency admissions, and authorize,
as appropriate, additional days.
7.0 Retrospective
Reviews Related To DRG Validation
7.1 The contractor shall conduct
quarterly focused reviews of a 1% sample of medical records to assure
that reimbursed services are supported by documentation in the patient’s
medical record. This review must determine if the diagnostic and
procedural information and discharge status of the patient as reported
by the hospital matches the attending physician’s description of
care and services documented in the patient’s record. In order to
accomplish this, the contractor shall conduct the following review
activities:
7.2 Review of claim adjustments submitted by hospitals
which result in the assignment of a higher weighted DRG (see
Addendum C).
7.3 Review
for physician certification as to the major diagnosis and procedures
and the physician’s acknowledgment of a penalty statement on file.
7.4 When the
claim is submitted, the hospital must have on file a signed and
dated acknowledgment from the attending physician that the physician
has received the following notice:
“Notice
to Physicians: TRICARE payment to hospitals is based in part on
each patient’s principal and secondary diagnoses and the major procedures
performed on the patient, as attested to by the patient’s attending
physician by virtue of his or her signature in the medical record.
Anyone who misrepresents, falsifies, or conceals essential information
required for payment of Federal funds may be subject to fine, imprisonment,
or civil penalty under applicable Federal laws.”
7.5 The acknowledgment
must be completed by the physician either before or at the time
that the physician is granted admitting privileges at the hospital,
or before, or at the time the physician admits his or her first
patient. Existing acknowledgments signed by physicians already on
staff remain in effect as long as the physician has admitting privileges
at the hospital.
7.6 Outlier
Review
Claims that qualify for additional
payment as a cost-outlier shall be subject to review to ensure that
the costs were medically necessary and appropriate and met all other
requirements for payment. In addition, claims that qualify as short-stay
outliers shall be reviewed to ensure that the admission was medically
necessary and appropriate and that the discharge was not premature.
7.7 Procedures
Regarding Certain Services Not Covered By The DRG-Based Payment
System
In implementing the quality and utilization
review for services not covered by the DRG-based payment system,
the requirements of this section shall pertain, with the exception
that the ICD-10-CM and ICD-10-PCS codes will be used to provide
basis of correct information for dates of discharge beginning on
or after the mandated date, as directed by Health and Human Services
(HHS), for ICD-10 implementation.
8.0 Retrospective
Review Requirements For Other Than DRG Validation
The
contractor shall conduct and report quarterly focused reviews of
a statistically valid sample or 30 records, whichever is greater,
of medical records to determine the medical necessity and quality of
care provided, validate the review determinations made by review
staff, and determine if the diagnostic and procedural information
and/or discharge status of the patient as reported on the hospital
and/or professional provider’s claim matches the attending physician’s
description of care and services documented in the medical record.
The specific types of records to be sampled shall be determined
separately by the Director, TROs who will provide the contractor
with the sampling criteria (DRG, diagnosis, procedure, Length-Of-Stay
(LOS), provider, incident or occurrence as reported on claim forms)
and the time frame from which the sample is to be drawn 60 calendar
days prior to each quarter. For all cases selected for retrospective
review, the following review activities shall occur:
8.1 Admission
Review
The medical record must indicate that
inpatient hospital care was medically or psychologically necessary
and provided at the appropriate level of care.
8.2 Invasive
Procedure Review
The performance of unnecessary
procedures may represent a quality and/or utilization problem. In
addition, the presence of codes of procedures often affects DRG
classification. Therefore, for every case under review, the medical
record must support the medical necessity of the procedure performed.
For this purpose, invasive procedures are defined as all surgical
and any other procedures which affect DRG assignment.
8.3 Discharge
Review
Records shall be reviewed using appropriate
criteria for questionable discharges or other potential quality
problems.
8.4 Mental
Health Review
The contractor shall review
all mental health claims consistent with how it reviews other medical/surgical
claims in accordance with the provisions in
32 CFR 199.4(a)(11).
8.5 Details
for reporting all quarterly focused
review reports are identified by DD
Form 1423, CDRL, located in Section J of the applicable
contract.
9.0 Review
Results
9.1 Actions As
A Result Of Retrospective Review Related To Individual Claims
If it is determined, based upon information
obtained during reviews, that a hospital has misrepresented admission,
discharge, or billing information, or is found to have quality of
care defects, or has taken an action that results in the unnecessary
admission of an individual entitled to benefits, unnecessary multiple
admission of an individual, or other inappropriate medical or other
practices with respect to beneficiaries or billing for services
furnished to beneficiaries, the contractor shall, as appropriate:
• Deny
payment for or recoup (in whole or in part) any amount claimed or
paid for the inpatient hospital and professional services related
to such determination.
• Require the hospital
to take other corrective action necessary to prevent or correct
the inappropriate practice.
• Advise the provider
and beneficiary of appeal rights, as required by
Chapter 12, Section 4, paragraph 2.0.
9.2 Findings
Related To A Pattern Of Inappropriate Practices
The
contractor shall notify DHA of the hospital and practice involved
in all cases where a pattern of inappropriate admissions and/or
billing practices, that have the effect of circumventing the TRICARE
DRG-based payment system, is identified.
9.3 Revision
Of Coding Relating To DRG Validation
The
contractor shall ensure the application of the following provisions
in connection with the DRG validation process.
• If
the diagnostic and procedural information attested to by the attending
physician is found to be inconsistent with the hospital’s coding
or DRG assignment, the hospital’s coding on the TRICARE claim shall
be appropriately changed and payments recalculated on the basis
of the appropriate DRG assignment.
• If the information
attested to by the physician as stipulated in
paragraph 7.3 is found not
to be correct, the contractor shall change the coding and assign
the appropriate DRG on the basis of the changed coding in accordance
with the paragraph above.
9.4 Notice Of Changes As A Result
Of A DRG Validation
The contractor shall
notify the provider of changes to procedural and diagnostic information that
result in a change of DRG assignment within 30 calendar days of
the contractor’s decision. The notice must be understandable, written
in English and shall contain:
• The corrected DRG
assignment;
• The
reason for the change resulting from the DRG validation;
• A statement addressing
who is liable for payment of denied services;
• A statement informing
each party (or his or her representative) of the right to request
a review of a change resulting from DRG validation in accordance
with the provisions in
paragraph 9.5;
• The locations for
filing a request for review and the time period within which a request must
be filed; and
• A
statement concerning the duties and functions of the multi-function
PRO.
9.5
Review
Of DRG Coding Change
9.5.1 A provider dissatisfied with a change to the
diagnostic or procedural coding information made by the contractor
as a result of DRG validation is entitled to a review of that change
if the change caused an assignment of a different DRG and resulted
in a lower payment. A beneficiary may obtain a review of the contractor’s
DRG coding change only if that change results in non-coverage of
a furnished service (see 42 CFR 478.15(a)(2)).
9.5.2 The contractor
shall issue written notification of the results of the DRG validation
review within 60 calendar days of receipt of the request for review.
In the notification, the contractor shall summarize the issue under
review and discuss the additional information relevant to such issue.
The notification shall state the contractor’s decision and fully
state the reasons that were the basis for the decision with clear
and complete rationale. The notification shall include a statement
that the decision is final and no further reviews are available.
10.0 Prepayment
Review
10.1 The contractor shall establish procedures and
conduct prepayment utilization review to address those cases involving
diagnoses requiring prospective review, where such review was not obtained,
to focus on program exclusions and limitations and to assist in
the detection of and/or control of fraud and abuse. The contractor
shall not be excused from claims processing cycle time standards
because of this requirement.
10.2 The contractor shall perform
prepayment review of all cases involving diagnoses requiring preauthorization
where review was not obtained. No otherwise covered care shall be
denied solely on the basis that authorization was not requested
in advance, except for care provided by a network provider.
10.3 The contractor
shall perform prepayment review of all DRG claim adjustments submitted
by a provider which result in higher weighted DRGs.
11.0
Case
Management (CM)
11.1 The contractor shall establish Case Management
Liaison positions to facilitate the hand off of CM information between
the MTFs/eMSMs, civilian Primary Care Managers (PCMs), and the contractor. Case
Management Liaisons are not required to be co-located in MTFs/eMSMs;
however, specific contact information for each Case Management Liaison
shall be provided to each MTF/eMSM.
11.2 The contractor shall provide
a Case Management Liaison staff member for each Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM) to facilitate
the hand off to the MTF/eMSM Direct Care (DC) system when beneficiaries
are discharged from network provider care. Contact information for
each Case Management Liaison shall be provided in the MTF/eMSM Memorandum
of Understanding (MOU).
11.3 CM shall not be accomplished
for beneficiaries eligible for Medicare Part A and enrolled in Medicare
Part B unless it is specifically contracted for inside an individual
MTF/eMSM or if the individual is part of the Individual Case Management
Program For Persons with Extraordinary Conditions (ICMP-PEC).
11.4 The contractor
shall provide MTFs/eMSMs with visibility via dashboard-based access
to all CM assignment information. At a minimum, this information
shall provide notification to the MTFs/eMSMs whenever an MTF/eMSM
Prime enrollee is assigned a Managed Care Support Contractor (MCSC)
case manager, to include the contact information for the specific
case manager assigned to the enrollee. Information that is available
via the dashboard shall be current and refreshed no less frequently
than once every 24 hours. The dashboard shall be made accessible
to authorized Government users on a continual (24/7) basis except
for scheduled downtime for system maintenance.
12.0 Confidentiality
Applicable To All MM/UM Activities, Including Recommendations And
Findings
12.1 The contractor shall develop and implement
procedures, processes, and policies that meet the confidentiality
and disclosure requirements set forth in Title 10, United States
Code (USC), Chapter 55, Section 1102; the Social Security Act, Section
1160, and implementing regulations at 42 CFR 476, the Alcohol, Drug
Abuse and Mental Health Administration (ADAMHA) Reorganization Act
(42 USC 290dd-2), the Privacy Act (5 USC 552a),
32 CFR 199.15(j) and
(l). Additionally, the contractor shall display
the following message on all quality assurance documents:
“Quality Assurance document under 10
USC 1102. Copies of this document, enclosures thereto, and information
therefrom will not be further released under penalties of law. Unauthorized
disclosure carries a possible $3,000 fine.”
12.2 Release
of Information - If an inquiry is made by the beneficiary, including
an eligible family member (child) regardless of age, the reply should
be addressed to the beneficiary, not the beneficiary’s parent or
guardian. The only exceptions are when a parent writes on behalf
of a minor child or a guardian writes on behalf of a physically
or mentally incompetent beneficiary. The contractor must not provide
information to parents/guardians of minors or incompetents when
the services are related to the following diagnoses:
• Abortion
• Substance Use Disorder
(SUD)
• Sexually
Transmitted Disease
• Human Immunodeficiency
Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)
12.3 The term
“minor” means any person who has not attained the age of 18 years.
Generally, the parent of a minor beneficiary and the legally appointed
guardian of an incompetent beneficiary shall be presumed to have
been appointed the representative without specific designation by
the beneficiary. Therefore, for beneficiaries who are under the
age of 18 years or who are incompetent, a notice issued to the parent
or guardian, under established TRICARE procedures, constitutes notice
to the beneficiary.
12.4 If a beneficiary has been
legally declared an emancipated minor, they are to be considered
as an adult. If the beneficiary is under 18 years of age and is
(or was) a spouse of a Service member or retiree, they are considered
to be an emancipated minor.
13.0 Documentation
The contractor shall develop and implement
a program for providing beneficiaries and providers with the written
results of all review activities affecting benefit determinations.
All notifications to beneficiaries and providers shall be completed
and mailed within the time limits established for the completion
of reviews in this section. Notifications of denials shall include:
• Patient’s
name;
• Sponsor’s
name;
• Last
four digits of the sponsor’s Social Security Number (SSN);
• The clinical rationale
for denial of payment for specific services (form letters are unacceptable
as the clinical rationale shall provide a complete explanation,
referencing any and all appropriate documentation, for the cause
of the denial);
• All
applicable appeal and grievance procedures; and
• The name and telephone
number of an individual from whom additional information may be
obtained.