2.0 UM
2.1 The
contractor shall establish a MM/UM Plan for care received by TRICARE
beneficiaries.
2.1.1 The contractor’s MM/UM Plan
shall recognize that the Military Medical 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 (CM) 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 MM 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 specialty care for
beneficiaries enrolled to a stateside contractor who are traveling
outside of the 50 US and the District of Columbia.
2.2 The
MM/UM Plan shall recognize that private sector care network providers
are the responsibility of the TOP contractor and the contractor
shall ensure that any adverse finding related to private sector
care 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 CM services as outlined in the contract
with DHA. Specific CM 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 private sector care country or US 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 private sector care 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 private sector care
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 private
sector care 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 calendar
days (i.e., date of service must be within 180 calendar 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 US 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 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.