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 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 Remote (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 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 180 days
(i.e., date of service must be within 180 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).