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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Alaska
Chapter 21
Section 1
TRICARE Alaska
Revision:  C-26, May 30, 2018
1.0  General
1.1  All provisions contained in the TRICARE Managed Care Support (MCS) contract, TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Systems Manual (TSM), or TRICARE Reimbursement Manual (TRM) shall apply in the state of Alaska except as specifically modified by this chapter. Chapter references in this section refer to the TOM unless otherwise specified. The word ‘contractor’ is used to reference the MCS contractor throughout this chapter.
1.2  The TRICARE program is not automatically implemented in all areas where it is potentially applicable. Implementation of the program requires an official action by an authorized individual in accordance with 32 CFR 199.17(a)(5). Network implementation will be published in the Federal Register.
2.0  Optimization
While overall responsibility and accountability remains with the Director, TRICARE Regional Offices (TROs), the contractor is responsible for managing network provider development and operations in the state of Alaska.
2.1  Consistent with existing Memorandums of Understanding (MOUs), the contractor shall optimize the Military Treatment Facility (MTF) for all appropriate specialty requests for care received from outside of the MTF within established TRICARE guidelines and access standards. Specialty care that cannot be provided by the MTF or scheduled within TRICARE access standards in the MTF shall be referred to the network as determined by the contractor in coordination with the MTF.
2.2  The contractor shall use every appropriate opportunity for beneficiary and provider education to influence beneficiary and provider behavior in a manner that encourages MTF optimization.
3.0  Beneficiary Satisfaction
The contractor shall achieve the highest level of beneficiary satisfaction possible in the state of Alaska. The contractor’s administrative processes shall be designed and operate to ensure ease in accessing TRICARE information and benefits. These processes shall be designed recognizing the unique nature of health care delivery within the state of Alaska and continuously operated in a manner that achieves the highest level of beneficiary satisfaction. Additionally, beneficiary satisfaction activities shall be coordinated with MTFs/eMSMs and the TRO-West Alaska Branch to achieve a coordinated, uniform approach to Department of Defense (DoD) customer services in Alaska.
4.0  Best Value Health Care
The contractor shall support the best value in the delivery of health care services in the state of Alaska through the efficient operation of all administrative processes. This includes supporting MTF right of first refusal, educating beneficiaries and providers on the benefit of using the MTF based on the collaborative agreement with the MTF Commander, and efficiently and effectively operating all administrative processes.
5.0  Transitions
The contractor shall be fully responsible for all transition activities in the state of Alaska. The contractor shall ensure all required contractor services are fully operational in accordance with Chapter 2 with the exception of the provisions of “Execution of Agreements With Contract Providers”. Those shall not apply. However, the contractor shall load all preferred providers to the contractor’s provider directory no later than 30 calendar days prior to the start of health care delivery (SHCD), or at such other time as mutually agreed between the contractor and the Defense Health Agency (DHA).
6.0  Access To Data
The contractor shall provide ready access to Government personnel for the state of Alaska in the same manner as provided in all other TRICARE West Region locations.
7.0  Administration
The contractor shall comply with all provisions of Chapter 1, with the following exceptions:
7.1  The contractor accomplished preauthorization shall be limited to inpatient mental health care for non-Prime enrollees and those enrolled to civilian Primary Care Managers (PCMs). The MTF will preauthorize/authorize all services for TRICARE Prime enrollees, as required. The contractor shall comply with the preauthorization requirements specified in Chapter 7, Section 2.
7.2  The contractor shall process any grievance related to contractor personnel or contractor actions. Grievances related to MTF providers shall be forwarded to the responsible MTF within five calendar days of receipt (see paragraph 19.0 for appeals) for resolution. The contractor shall process all grievances related to civilian providers consistent with Chapter 11, Section 8.
8.0  Records Management
The contractor shall comply with the provisions of Chapter 9.
9.0  Financial Administration
The contractor shall comply with all of the provisions of the Chapter 3. The contractor shall apply the appropriate financial provisions to the claims for TRICARE enrollees in the state of Alaska based on the Government’s ultimate decision regarding the underwriting of health care performed in Alaska.
10.0  Provider Certification And Credentialing
The contractor shall comply with the provisions of Chapter 4 for providers rendering care in the state of Alaska.
11.0  Support Of TRICARE Providers
11.1  The contractor is required to provide assistance to the Government in servicing participating and non-participating providers. This assistance shall include certifying and credentialing providers according to paragraph 10.0. The contractor shall provide the appropriate level and number of provider representatives to service the participating and non-participating providers throughout the state of Alaska. The provider representative shall be located in contractor furnished facilities in close proximity to the MTF. The provider representative shall assist in establishing provider networks. The contractor’s provider representatives shall also assist providers with TRICARE questions/problems as necessary. In this role, the provider representative shall be supported by all appropriate contractor staff and systems. For example, if a provider wishes to determine the status of a claim, the provider can call the contractor’s claims information toll-free telephone number or check the status via an electronic means. However, if a provider requests the assistance of an individual on- site at the provider’s office to resolve problems, the provider representative shall provide the assistance.
11.2  Alaskan providers shall not be required to submit claims electronically. As such, Alaskan claims shall be removed from both the numerator and the denominator when computing the percentage of claims submitted electronically.
12.0  Enrollment
The contractor is responsible for all enrollment activity in the state of Alaska in accordance with the provisions of Chapter 6.
12.1  TRICARE Prime enrollments within the state of Alaska shall all be to PCMs located within a MTF or in Prime Service Areas (PSAs) around a limited number of MTFs/eMSMs, to PCMs in the TRICARE network.
12.2  Where TRICARE Prime enrollment to private sector PCMs is permitted, the contractor shall coordinate with the MTF Commander to ensure the combined total of MTF and private sector enrollees does not exceed the number for which compliance with TRICARE Prime access to care standards can be assured, considering MTF and preferred provider network resources together. Enrollment will be to the MTF first and then to the private sector at the discretion of the MTF Commander in coordination with the contractor.
13.0  Utilization And Quality Management
The contractor shall comply with the provisions of Chapter 7, regarding utilization and quality management. The MTF is responsible for issuing all authorizations for its Prime enrollees. The contractor shall ensure that MTF issued authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service, and claims adjudication.
13.1  Cases for care rendered in the state of Alaska shall be included in the selection of cases for review by the TRICARE Quality Management Contract (TQMC) contractor per Chapter 7, Section 3. If the TQMC identifies an aberrant provider from the state of Alaska, and the provider is a network provider, the contractor shall advise the TRO-W Alaska Branch of the findings.
13.2  The contractor shall comply with and include care rendered in the state of Alaska in its Clinical Quality Management Program (CQMP) per Chapter 7, Section 4. The CQMP shall include a separate section specifically addressing Alaska.
13.3  All potential quality issues and unusual provider findings by the TQMC during their case reviews shall be processed and investigated by the contractor per existing Clinical Quality Management (CQM) policies.
14.0  claims Processing
The contractor shall process claims in accordance with Chapter 8.
15.0  Duplicate Claims
The contractor shall comply with the TSM, Chapter 4, as appropriate, for the identification, correction and resolution of duplicate and potentially duplicate claims.
16.0  Claims Adjustments And Recoupments
The contractor shall comply with the provisions of Chapter 10, regarding claims adjustments and recoupments.
17.0  Beneficiary And Provider Services
17.1  The contractor shall comply with the provisions of Chapter 11, Section 1 relating to the provision of marketing and education materials in the state of Alaska.
17.2  The contractor shall comply with the provisions of Chapter 11, Section 2 and the contract regarding briefings within the state of Alaska.
18.0  Customer Service Operations
The contractor shall provide customer service support to include benefit and enrollment assistance to all beneficiaries in the state of Alaska. The functions of the contractor’s call center shall be as specified in Chapter 11. In providing assistance with referrals, the contractor shall first direct all beneficiaries to the MTF (beneficiaries referred out of the MTF for specialty services shall not be referred back to the MTF) and then to the network providers. The contractor shall maintain an up-to-date on-line list of network providers.
18.1  The contractor shall comply with the provisions of Chapter 11, Section 3 in accomplishing Beneficiary, Congressional, and Beneficiary Counseling and Assistance Coordinator (BCAC) relations within the state of Alaska.
18.2  The contractor shall comply with the provisions of Chapter 11, Section 4 in responding to inquiries regarding TRICARE within the state of Alaska.
18.3  The contractor shall comply with the provisions of Chapter 11, Section 5.
18.4  The contractor shall provide toll-free telephone service to Alaskan beneficiaries in accordance with the provisions of Chapter 11, Section 6.
18.5  The contractor shall provide allowable charge reviews in accordance with the provisions of Chapter 11, Section 7.
18.6  The contractor shall operate a grievance process in accordance with paragraph 7.2 and Chapter 11, Section 8.
18.7  The contractor shall administer collection actions against beneficiaries in accordance with Chapter 11, Section 9.
19.0  Appeals And Hearings
The contractor shall implement and operate an appeals system for services requested or rendered in the state of Alaska in accordance with Chapter 12.
20.0  Program Integrity
The state of Alaska shall be included in the contractor’s Regional Program Integrity Program per Chapter 13.
21.0  Audits, Inspections, And Reports
21.1  The contractor shall comply with the provisions of Chapter 14, regarding audits, inspections, and reports. The contractor shall provide a Monthly Preferred Provider Adequacy Report to the Contracting Office and the Director, TRO-W. Details for reporting are identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
21.2  The TRICARE network shall be developed so that 75% of enrollee referrals are to an MTF or civilian network provider.
22.0  Director And MTF/Contractor Interfaces
The contractor shall comply with the requirements of Chapter 15 when developing and operating MTF and Director, TROs interfaces. The contractor shall also enter into an agreement with the TRO-W Alaska Branch, as required by the contract, regarding contractor activities in the State of Alaska.
23.0  TRICARE Prime Remote (TPR) Program
The contractor shall operate the TPR program in the state of Alaska in accordance with Chapter 16.
24.0  Civilian Care Referred By MHS Facilities
The contractor shall comply with the provisions of Chapter 17 in the State of Alaska.
25.0  Civilian Health Care (CHC) of Uniformed Service Members
The contractor shall comply with the provisions of Chapter 17 for services in the state of Alaska provided through the Supplemental Health Care Program (SHCP).
26.0  Demonstrations
The contractor shall comply with the provisions of Chapter 18 for eligible beneficiaries in the state of Alaska.
27.0  Health Insurance Portability And Accountability Act of 1996 (HIPAA)
The contractor shall comply with the provisions of Chapter 19 when administering the TRICARE program in the state of Alaska.
28.0  TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
The contractor shall not be responsible for services that are the responsibility of the TDEFIC contractor in the state of Alaska. This does not relieve the contractor from their customer service responsibilities to dual eligible beneficiaries.
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