Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
1.0 mm/UM Program
Plan
The Defense Health Agency (DHA) defines
MM as an integrated managed care model that promotes UM, Case Management
(CM), and chronic care/Disease Management (DM) programs as a hybrid
approach to managing patient care. MM integrates evidence-based
and outcome-oriented programs into the MM processes.
1.1 These
requirements are applicable to utilization and quality review of
all health care services delivered to all beneficiaries living within
the region, to all beneficiaries receiving care in the Region regardless
of their place of residence, and to all providers delivering care
within the region. Additional requirements for enrollees (such as
authorizations for specialty care are found throughout 32 CFR 199 and
the TRICARE Manuals) and network providers (such as qualifications
to be network providers are further identified in
Chapter 5 and
the TRICARE Policy Manual (TPM)). All providers shall be subject
to the same review standards and criteria. The contractor shall
be considered a multi-function Peer Review Organization (PRO) under
this contract.
1.2 The contractor shall fully describe
in a written MM/UM Plan all processes, procedures, criteria, staff
and staff qualifications, and information and data collection activities
and requirements the contractor shall use in conducting MM/UM activities.
Details
for
providing this plan are
identified
by DD Form 1423, Contract Data Requirements List
(CDRL)
, located in Section J of the applicable contract.
1.2.1 The DHA
Program Office (Clinical Operations Division (COD)/TRICARE Overseas
Program Office) will review the plan and make recommendations
for revision if necessary within 45 calendar days or provide written
approval through the Contracting Officer (CO). In the absence of MM/UM staff in
the Uniformed Services Family Health Plan Program
Office (USFHP PO), the DHA Clinical
Support Division (CSD) will review the plans submitted and
provide recommendations for revision or written acceptance within
45 days.
1.2.2 The contractor shall provide a revised
plan addressing the recommendations within 15 business days to the
appropriate reviewing office which, will provide written approval
of the plan through the appropriate CO within 45 calendar days if
there are no recommendations or upon receipt of a revised plan which
addresses the recommendations.
1.2.3 The contractor shall participate
in DHA sponsored medical management training as requested, to include
coordination of training schedules and the development of the agenda
and training schedules and the development of the agenda and training
materials. Each contractor shall participate in two four-day training
sessions per year in their respective region. The location of the training
will be designated by DHA.
2.0 Notification
Of Review Requirements
The contractor is responsible for
education and training to providers and beneficiaries on the requirements
of the MM/UM programs. The contractor shall describe fully the process
for notification, in a timely manner (but not less than 30 calendar
days prior to commencement of review), of all providers, both network
and non-network, of all review requirements such as:
• Preauthorization;
• Concurrent review;
• Retrospective review (including the fiscal
penalties for failing to obtain review authorizations); and
• Review criteria to be used, and requirements
for CM.
3.0
Reviewer
qualifications and participation
3.1 Peer Review By Physicians
3.1.1 Except
as provided in
paragraph 3.1.2, each person who makes an
initial
or reconsideration denial determination
or standard of care determination about services furnished or proposed
to be furnished by a licensed doctor of medicine or osteopathy or
by a doctor of dentistry must be another licensed doctor of medicine
in a like specialty, or osteopathy in a like specialty, or
dentistry
with an active clinical practice in the PRO area, if the initial,
reconsideration, or standard of care determination is based on lack
of medical necessity or other reason relative to reasonableness,
necessity, or appropriateness.
3.1.2 If
a PRO determines that peers are not available, then
a nationally accredited external independent review organization
shall be used to make the determinations.
3.2 Peer Review
By Health Care Practitioners Other Than Physicians
Health
care practitioners other than physicians may review services and/or
make standard of care determinations for services furnished
by other practitioners in the same professional field and specialty.
3.3 Diagnosis
Related Group (DRG) Validation Review
3.3.1 Decisions about procedural and diagnostic
information must be made by physicians.
3.3.2 Technical
coding issues must be reviewed by individuals with training and
experience in International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM) coding (for outpatient services
with dates of service or inpatient services with dates of discharge
provided before the mandated date, as directed by Health and Human
Services (HHS), for International Classification of Diseases, 10th
Revision (ICD-10) implementation) and in ICD-10-CM coding (for outpatient
services with dates of service or inpatient services with dates
of discharge provided on or after the mandated date, as directed
by HHS, for ICD-10 implementation, or International Classification
of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
for inpatient services with dates of discharge provided on or after
the mandated date, as directed by HHS, for ICD-10 implementation).
3.4 Persons Excluded
From Review
3.4.1 A
person may not review health care services or make initial denial
determinations or changes as a result of DRG validations if he or
she, or a member of his or her family:
• Participated in developing or executing
the beneficiary’s treatment plan;
• Is a member of the beneficiary’s family;
or
• Is a governing
body member, officer, partner, 5% or more owner, or managing employee
in the health care facility where the services were or are to be
furnished.
3.4.2 A member of a reviewer’s family is a spouse
(other than a spouse who is legally separated under a decree of
divorce or separate maintenance), child (including a legally adopted
child), grandchild, parent, or grandparent.
3.5 Administrative
Requirements
Each review shall be dated and include
the signature, legibly printed name, clinical specialty, and credentials
of the reviewer. Each reviewer shall include rationale for his or
her decision (i.e., a complete statement of the evidence and the
reasons for the decision).
4.0
Written
Agreements With Institutional Providers
The contractor
shall establish written agreements with each institutional provider
over which the contractor has review authority. These agreements
shall be maintained throughout health care delivery. Agreements
must specify that:
• Institutional
providers will cooperate with the contractor in the assumption and
conduct of review activities.
• Institutional providers will allocate
adequate space for the conduct of on-site review.
• Institutional providers will deliver
to the contractor a paper or electronic copy of all required information
within 30 calendar days of a request for off-site review.
• Institutional providers will provide
all beneficiaries, in writing, their rights and responsibilities
(e.g., “An Important Message from TRICARE” (
Addendum A),
“Hospital Issued Notice of Noncoverage” (
Addendum B).
• Institutional providers will inform
the contractor within three working days if they issue a notice
that the beneficiary no longer requires inpatient care.
• Institutional providers will assure
that each case subject to preadmission/pre-procedure review has
been reviewed and approved by the contractor.
• Institutional providers will agree,
when they fail to obtain certification as required, that they will
accept full financial liability for any admission subject to preadmission
review that was not reviewed and is subsequently found to be medically
unnecessary or provided at an inappropriate level (
32 CFR 199.15(g)).
• The contractor shall reimburse
the provider for the costs of providing documents using the same
reimbursement as Medicare.
• The contractor shall provide detailed
information on the review process and criteria used, including financial
liability incurred by failing to obtain preauthorization.
5.0 Benefit Policy
Decisions
TRICARE versus local policy. TRICARE
policies have precedence over any local or internal policy of the
contractor or the medical community of the region. However, the
contractor shall notify DHA promptly of any conflicts between TRICARE
policy and local policy. Variations from policy, which expand, reduce,
or adjust benefit coverage shall be referred to DHA for approval
before being implemented.
6.0 Concurrent
Review Requirements
The contractor shall conduct concurrent
review for continuation of inpatient mental health services within
72 hours of notification of emergency admissions, and authorize,
as appropriate, additional days.
7.0 Retrospective
Reviews Related To DRG Validation
7.1 The contractor shall conduct quarterly
focused reviews of a 1% sample of medical records to assure that
reimbursed services are supported by documentation in the patient’s
medical record. This review must determine if the diagnostic and
procedural information and discharge status of the patient as reported
by the hospital matches the attending physician’s description of
care and services documented in the patient’s record. In order to
accomplish this, the contractor shall conduct the following review
activities:
7.2 Review
of claim adjustments submitted by hospitals which result in the
assignment of a higher weighted DRG (see
Addendum C).
7.3 Review
for physician certification as to the major diagnosis and procedures
and the physician’s acknowledgment of a penalty statement on file.
7.4 When the claim
is submitted, the hospital must have on file a signed and dated acknowledgment
from the attending physician that the physician has received the
following notice:
“Notice to Physicians:
TRICARE payment to hospitals is based in part on each patient’s principal
and secondary diagnoses and the major procedures performed on the patient,
as attested to by the patient’s attending physician by virtue of
his or her signature in the medical record. Anyone who misrepresents,
falsifies, or conceals essential information required for payment
of Federal funds may be subject to fine, imprisonment, or civil
penalty under applicable Federal laws.”
7.5 The acknowledgment
must be completed by the physician either before or at the time
that the physician is granted admitting privileges at the hospital,
or before, or at the time the physician admits his or her first
patient. Existing acknowledgments signed by physicians already on
staff remain in effect as long as the physician has admitting privileges
at the hospital.
7.6 Outlier Review
Claims that qualify for additional
payment as a cost-outlier shall be subject to review to ensure that
the costs were medically necessary and appropriate and met all other
requirements for payment. In addition, claims that qualify as short-stay
outliers shall be reviewed to ensure that the admission was medically
necessary and appropriate and that the discharge was not premature.
7.7 Procedures
Regarding Certain Services Not Covered By The DRG-Based Payment
System
In implementing the quality and
utilization review for services not covered by the DRG-based payment
system, the requirements of this section shall pertain, with the
exception that the ICD-10-CM and ICD-10-PCS codes will be used to
provide basis of correct information for dates of discharge beginning
on or after the mandated date, as directed by Health and Human Services
(HHS), for ICD-10 implementation.
8.0 Retrospective
Review Requirements For Other Than DRG Validation
The contractor
shall conduct and report quarterly focused reviews of a statistically
valid sample or 30 records, whichever is greater, of medical records
to determine the medical necessity and quality of care provided,
validate the review determinations made by review staff, and determine
if the diagnostic and procedural information and/or discharge status
of the patient as reported on the hospital and/or professional provider’s
claim matches the attending physician’s description of care and services
documented in the medical record. The specific types of records
to be sampled shall be determined separately by the Director, TROs
who will provide the contractor with the sampling criteria (DRG,
diagnosis, procedure, Length-Of-Stay (LOS), provider, incident or
occurrence as reported on claim forms) and the time frame from which
the sample is to be drawn 60 calendar days prior to each quarter. For
all cases selected for retrospective review, the following review
activities shall occur:
8.1 Admission Review
The medical
record must indicate that inpatient hospital care was medically
or psychologically necessary and provided at the appropriate level
of care.
8.2 Invasive
Procedure Review
The performance of unnecessary procedures
may represent a quality and/or utilization problem. In addition,
the presence of codes of procedures often affects DRG classification.
Therefore, for every case under review, the medical record must
support the medical necessity of the procedure performed. For this
purpose, invasive procedures are defined as all surgical and any
other procedures which affect DRG assignment.
8.3 Discharge
Review
Records shall be reviewed using
appropriate criteria for questionable discharges or other potential
quality problems.
8.4 Mental Health Review
The contractor
shall review all mental health claims consistent with how it reviews
other medical/surgical claims in accordance with the provisions
in
32 CFR 199.4(a)(11).
8.5 Details
for reporting all quarterly focused
review reports are identified by DD
Form 1423, CDRL, located in Section J of the applicable
contract.
9.0 Review Results
9.1 Actions As
A Result Of Retrospective Review Related To Individual Claims
If it is determined, based upon
information obtained during reviews, that a hospital has misrepresented
admission, discharge, or billing information, or is found to have
quality of care defects, or has taken an action that results in
the unnecessary admission of an individual entitled to benefits, unnecessary
multiple admission of an individual, or other inappropriate medical
or other practices with respect to beneficiaries or billing for
services furnished to beneficiaries, the contractor shall, as appropriate:
• Deny payment for or recoup (in whole or
in part) any amount claimed or paid for the inpatient hospital and
professional services related to such determination.
• Require the hospital to take other corrective
action necessary to prevent or correct the inappropriate practice.
• Advise the provider and beneficiary of
appeal rights, as required by
Chapter 12, Section 4, paragraph 2.0.
9.2 Findings
Related To A Pattern Of Inappropriate Practices
The contractor
shall notify DHA of the hospital and practice involved in all cases
where a pattern of inappropriate admissions and/or billing practices,
that have the effect of circumventing the TRICARE DRG-based payment
system, is identified.
9.3 Revision Of Coding Relating To DRG Validation
The contractor shall ensure the
application of the following provisions in connection with the DRG
validation process.
• If the diagnostic and procedural
information attested to by the attending physician is found to be
inconsistent with the hospital’s coding or DRG assignment, the hospital’s coding
on the TRICARE claim shall be appropriately changed and payments
recalculated on the basis of the appropriate DRG assignment.
• If the information attested to by
the physician as stipulated in
paragraph 7.3 is found not to be correct,
the contractor shall change the coding and assign the appropriate
DRG on the basis of the changed coding in accordance with the paragraph
above.
9.4 Notice Of Changes As A Result Of A DRG
Validation
The contractor shall notify the
provider of changes to procedural and diagnostic information that
result in a change of DRG assignment within 30 calendar days of
the contractor’s decision. The notice must be understandable, written
in English and shall contain:
• The corrected DRG assignment;
• The reason for the change resulting from
the DRG validation;
• A statement addressing who is liable for
payment of denied services;
• A statement informing each party (or his
or her representative) of the right to request a review of a change
resulting from DRG validation in accordance with the provisions
in
paragraph 9.5;
• The locations for filing a request for
review and the time period within which a request must be filed;
and
• A statement
concerning the duties and functions of the multi-function PRO.
9.5
Review
Of DRG Coding Change
9.5.1 A
provider dissatisfied with a change to the diagnostic or procedural
coding information made by the contractor as a result of DRG validation
is entitled to a review of that change if the change caused an assignment
of a different DRG and resulted in a lower payment. A beneficiary
may obtain a review of the contractor’s DRG coding change only if
that change results in non-coverage of a furnished service (see
42 CFR 478.15(a)(2)).
9.5.2 The contractor shall issue written
notification of the results of the DRG validation review within
60 calendar days of receipt of the request for review. In the notification,
the contractor shall summarize the issue under review and discuss
the additional information relevant to such issue. The notification
shall state the contractor’s decision and fully state the reasons
that were the basis for the decision with clear and complete rationale.
The notification shall include a statement that the decision is
final and no further reviews are available.
10.0 Prepayment
Review
10.1 The contractor shall establish procedures
and conduct prepayment utilization review to address those cases
involving diagnoses requiring prospective review, where such review
was not obtained, to focus on program exclusions and limitations
and to assist in the detection of and/or control of fraud and abuse.
The contractor shall not be excused from claims processing cycle
time standards because of this requirement.
10.2 The contractor
shall perform prepayment review of all cases involving diagnoses
requiring preauthorization where review was not obtained. No otherwise
covered care shall be denied solely on the basis that authorization
was not requested in advance, except for care provided by a network provider.
10.3 The contractor
shall perform prepayment review of all DRG claim adjustments submitted
by a provider which result in higher weighted DRGs.
11.0
Case
Management (CM)
11.1 The contractor shall establish Case
Management Liaison positions to facilitate the hand off of CM information
between the MTFs/eMSMs, civilian Primary Care Managers (PCMs), and
the contractor. Case Management Liaisons are not required to be
co-located in MTFs/eMSMs; however, specific contact information
for each Case Management Liaison shall be provided to each MTF/eMSM.
11.2 The contractor
shall provide a Case Management Liaison staff member for each Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM) to facilitate
the hand off to the MTF/eMSM Direct Care (DC) system when beneficiaries
are discharged from network provider care. Contact information for
each Case Management Liaison shall be provided in the MTF/eMSM Memorandum
of Understanding (MOU).
11.3 CM shall not be accomplished for
beneficiaries eligible for Medicare Part A and enrolled in Medicare
Part B unless it is specifically contracted for inside an individual
MTF/eMSM or if the individual is part of the Individual Case Management
Program For Persons with Extraordinary Conditions (ICMP-PEC).
11.4 The contractor
shall provide MTFs/eMSMs with visibility via dashboard-based access
to all CM assignment information. At a minimum, this information
shall provide notification to the MTFs/eMSMs whenever an MTF/eMSM
Prime enrollee is assigned a Managed Care Support Contractor (MCSC)
case manager, to include the contact information for the specific
case manager assigned to the enrollee. Information that is available
via the dashboard shall be current and refreshed no less frequently
than once every 24 hours. The dashboard shall be made accessible
to authorized Government users on a continual (24/7) basis except
for scheduled downtime for system maintenance.
12.0 Confidentiality
Applicable To All MM/UM Activities, Including Recommendations And
Findings
12.1 The contractor shall develop and
implement procedures, processes, and policies that meet the confidentiality
and disclosure requirements set forth in Title 10, United States
Code (USC), Chapter 55, Section 1102; the Social Security Act, Section
1160, and implementing regulations at 42 CFR 476, the Alcohol, Drug
Abuse and Mental Health Administration (ADAMHA) Reorganization Act
(42 USC 290dd-2), the Privacy Act (5 USC 552a),
32 CFR 199.15(j) and
(l). Additionally, the contractor shall display
the following message on all quality assurance documents:
“Quality Assurance document under
10 USC 1102. Copies of this document, enclosures thereto, and information
therefrom will not be further released under penalties of law. Unauthorized
disclosure carries a possible $3,000 fine.”
12.2 Release of Information
- If an inquiry is made by the beneficiary, including an eligible
family member (child) regardless of age, the reply should be addressed
to the beneficiary, not the beneficiary’s parent or guardian. The
only exceptions are when a parent writes on behalf of a minor child
or a guardian writes on behalf of a physically or mentally incompetent
beneficiary. The contractor must not provide information to parents/guardians
of minors or incompetents when the services are related to the following
diagnoses:
• Abortion
• Substance Use
Disorder (SUD)
• Sexually Transmitted
Disease
• Human Immunodeficiency
Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)
12.3 The term
“minor” means any person who has not attained the age of 18 years.
Generally, the parent of a minor beneficiary and the legally appointed
guardian of an incompetent beneficiary shall be presumed to have
been appointed the representative without specific designation by
the beneficiary. Therefore, for beneficiaries who are under the
age of 18 years or who are incompetent, a notice issued to the parent
or guardian, under established TRICARE procedures, constitutes notice
to the beneficiary.
12.4 If a beneficiary has been legally declared
an emancipated minor, they are to be considered as an adult. If
the beneficiary is under 18 years of age and is (or was) a spouse
of a Service member or retiree, they are considered to be an emancipated
minor.
13.0 Documentation
The contractor shall develop and
implement a program for providing beneficiaries and providers with
the written results of all review activities affecting benefit determinations.
All notifications to beneficiaries and providers shall be completed
and mailed within the time limits established for the completion
of reviews in this section. Notifications of denials shall include:
• Patient’s name;
• Sponsor’s name;
• Last four digits of the sponsor’s Social
Security Number (SSN);
• The clinical rationale for denial
of payment for specific services (form letters are unacceptable
as the clinical rationale shall provide a complete explanation,
referencing any and all appropriate documentation, for the cause
of the denial);
• All applicable
appeal and grievance procedures; and
• The name and telephone number of an individual
from whom additional information may be obtained.