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
, perform covered benefit
reviews, 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
the TOP contract. The contractor shall
provide notification to the MTF Commander
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 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, TRICARE Select,
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.
5.2 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.
5.3 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.
5.4 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, ADSMs enrolled
in TOP Prime or TOP Prime Remote 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.
5.5 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.
5.6 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.
5.7 The TOP contractor shall maintain a preauthorization/authorization
file.
5.8 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.
5.9 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).
5.10 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:
5.10.1 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.
5.10.2 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.
5.10.3 The review determination must conclude in either
authorization or denial of care. Review results must be
submitted
via Health Insurance Portability and Accountability Act (HIPAA)
compliant electronic means 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.
5.10.4 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.
5.10.5 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.
5.10.6 The TOP contractor shall adhere to the appeals
process outlined in
Section 12.
5.11 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).