TRICARE Regional Offices (TROs)/Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) and Contractor Interfaces
Chapter 15
Section 1
Director, TRICARE Regional
Offices (TROs), Military Treatment Facility (MTF) Commander/Enhanced
Multi-Service Market (eMSM) Manager, and Contractor Interface
Revision: C-26, May 30, 2018
The contractor shall assist the Director,
TROs and MTF Commanders/eMSM Managers in coordinating health care
delivery in their Prime Service Areas (PSAs)/markets and in ensuring
the optimal use of MTF/eMSM capacities. The contractor shall define
this activity through Memoranda of Understanding (MOU). Each MOU
shall describe the processes expected to be executed in good faith
by each party to operate the TRICARE Program in accordance with
the performance based objectives of the Managed Care Support (MCS)
contract(s) and TRICARE Manuals (see
Addendum A).
The MOU shall follow the format in
Addendum A. Copies of local program documentation
may be obtained through the TRO. The contractor shall provide copies
of each MOU executed to the Procuring Contracting Officer (PCO)
through the TRO, within 10 calendar days following the execution
of the MOU by the contractor and the MTF Commander/eMSM Manager.
All MOUs shall be approved by the TROs and with final approval by
the PCO.
As described in
Addendum A,
the MOU consists of two parts: a core document that describes major MTF/eMSM
support processes which are standard throughout the region and a
supplemental attachment that documents operational information that
is unique to each MTF/eMSM (i.e., Right of First Refusal (ROFR)
capabilities table, Point of Contact (POC) information, after hours
care instructions, enrollment guidance, etc.). The core document
is not expected to change often, but any such changes will be vetted
and incorporated at the annual review at the beginning of an option
period. Information in the supplemental attachment may be changed
at any time. Once signed at the beginning of an option period, the
core MOU document stands and does not need to be affirmed if MTF
Commanders/eMSM Managers change.
The MOU will remain in force throughout the
duration of the contract, unless any party provides a written notice
of intention to modify at least
90 days
prior to the new option period. In the event that such notice is
provided, but has not been negotiated as of the end of the current
option period, the MOU will remain in effect until a modification
is agreed upon and approved. If no modification is necessary, the
contractor will prepare and submit an Affirmation of MOU Review
(
Addendum A)
90 days
prior to the end of each option period.
1.0 COORDINATION
PROCEDURES TO ENSURE OPTIMIZATION
The contractor
shall meet with the TRO and each MTF Commander/eMSM Manager to discuss MTF/eMSM
optimization and to enter into written agreements to ensure the
MTF/eMSM receives the workload that supports their business plan
and optimization initiatives. These agreements shall be utilized
to optimize MTF/eMSM capabilities and capacities and provide mechanisms
to reallocate workload, establish priorities for needed network
development, and determine Primary Care Manager (PCM) assignment
locations for enrollees. The agreements may be modified during the
year; however, all agreements/modifications shall be concurred upon
by the Director, TROs and CO prior to implementation. The MTF/eMSM
will provide the contractor with the current status of their capabilities and
available capacity. The contractor shall be responsible for initiating
meetings and/or other actions with the TRO and the MTF Commander/eMSM
Manager to assist in remedying problems which can be resolved within
the scope of the contractor’s responsibility and authority. The
contractor shall follow the direction of the MTF Commander/eMSM
Manager, in consonance with the TRO, regarding the priorities for
the assignment of enrollees to PCMs. Additionally, the contractor
shall respond to requests for meetings regarding capabilities and
optimization initiated by the TRO and MTF Commander/eMSM Manager.
The contractor shall provide appropriate staff to meet with the
TRO and/or MTF Commander/eMSM Manager within two work days of receiving
either a verbal or written request.
2.0 TRO
AND MTF/
eMSM INTERFACE FOR PRIMARY CARE MANAGEMENT
Both civilian and military individual providers
may act as PCMs for TRICARE Prime. During the MOU development process,
the contractor shall obtain guidelines from the TRO and the MTF Commander/eMSM
Manager for PCM assignment (by category of beneficiary) or choice
for enrollees who reside in the MTF/eMSMs’ PSAs. MTF Commanders/eMSM
Managers will designate whether these enrollees shall have MTF/eMSM
or network PCMs and may be subject to change as impacted by changing
MTF/eMSM capacities. The contractor shall assign enrollees to PCMs
in accordance with the MTF Commander’s/eMSM Manager’s directions.
3.0 MTF/
eMSM
INTERFACE FOR SPECIALTY SERVICES
The contractor
shall obtain direction from the MTF Commander/eMSM Manager regarding which
specific specialty services shall be referred to the MTF/eMSM in
accordance with Military Health System (MHS)/eMSM optimization goals.
Non-Prime beneficiaries shall be encouraged to use available MTF/eMSM
specialty services in lieu of civilian providers.
4.0 ADMINISTRATIVE
COORDINATION WITH THE TRO AND MTF/
eMSM
The contractor shall meet with each MTF Commander/eMSM
Manager or designee and TRO representative at least quarterly. These
meetings shall review current contractor activities in enrollment,
quality management, utilization management, marketing, network development,
external resource sharing and other activities, such as briefings
to provider or beneficiary groups or interface with Congressional
or other Governmental officials. The contractor shall also meet
with the Director, TROs or designee at least quarterly to facilitate
activity coordination between the MTFs/eMSMs and civilian networks.
The frequency of these meetings may be altered at the discretion
of the MTF Commander/eMSM Manager and/or the Director, TROs.
5.0 TRO
AND MTF Commander/
eMSM Manager LIAISON
The contractor shall ensure that the TRO and
the MTF Commanders/eMSM Managers have access to contractor personnel
to facilitate MTF/eMSM interface activities and shall ensure that
MTF Commanders/eMSM Managers are kept informed of contractor program
or policy changes which affect the MTFs/eMSMs.