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TRICARE Operations Manual 6010.62-M, April 2021
Transitions
Chapter 2
Section 7
Critical Processes (CPs) - Referral Management (RM)
Revision:  C-5001, June 23, 2021
1.0  RM
1.1  The incoming contractor shall establish an automated RM process in accordance with Section C of the contract and Chapter 7, Section 5 no later than the 90 calendar days prior to the start of health care delivery (SHCD).
1.2  The incoming contractor shall implement an electronic RM system that integrates with the Government’s electronic RM system no later than 60 calendar days prior to the SHCD.
1.3  The incoming contractor’s RM system shall interface with the Uniformed Services RM process and/or system(s) at each Military Medical Treatment Facility (MTF), United States Coast Guard (USCG) clinics, and Markets no later than 60 calendar days prior to the SHCD.
1.4  The incoming contractor’s RM system shall include the ability to capture referrals and authorizations from civilian providers into the Markets/MTFs and other business processes as necessary to ensure that inbound and outbound referrals are processed accurately and timely in accordance with Chapter 1, Section 3, with a focus on those referrals with high value Knowledge, Skills and Abilities (KSAs) as defined by the Government.
1.5  The incoming contractor shall phase in referral processing as follows:
•  Day 1 of health care delivery (HCD) - The contractor shall process Active Duty Service Member (ADSM) and TRICARE Prime Remote (TPR) ADSM and Active Duty Family Member (ADFM) referrals only.
•  Day 31 of HCD - The contractor shall include in its referral processing TRICARE Prime beneficiaries enrolled to MTF Primary Care Managers (PCMs).Day 61 of HCD - The contractor shall include in its referral processing TRICARE Prime beneficiaries enrolled to a network PCM.Day 91 of HCD - The contractor shall include any other beneficiary category that requires a referral.
1.5.1  A PCM referral waiver and/or Point of Service (POS) waiver will be implemented with this phased-in approach of referrals.
1.5.2  The contractor shall submit a Daily Authorization Inventory Report and a Daily Rolling Referral Inventory Report to the Government. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
2.0  PERFORMANCE READINESS VALIDATION (PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)
During transition, the incoming contractor’s performance readiness status regarding RM will be subject to PRV/PRAV reviews as described below.
2.1  RM PRV
2.1.1  The incoming contractor shall validate its RM system can interface with the Government’s RM systems (MHS Genesis and RM Suite (375)).
2.1.2  The incoming contractor shall validate its interface meets two criteria:
2.1.2.1  Markets/MTFs can send and receive referrals with priority to those with a high KSA value with no technical problems, and
2.1.2.2  The contractor sends referrals and authorizations in accordance with the Market/MTF Capability Table with 95% accuracy, as listed in paragraph 2.1.9.2.
2.1.3  The incoming contractor shall validate its RM systems can effectively interface with the Government’s RM system(s), Defense Enrollment Eligibility Reporting System (DEERS), contractor’s claims systems, network provider directory, and the system network providers utilize to submit referrals and authorization no later than 60 calendar days prior to the SHCD.
2.1.4  The incoming contractor shall test, validate, and produce connectivity test results on all interfaces.
2.1.5  The incoming contractor shall validate all aspects of its referral, authorization and command approval (overseas only) processes by utilizing test scenarios which include referrals to Market/MTF and network providers and referrals from contractor to Market/MTF no later than 60 calendar days prior to the SHCD.
2.1.6  The incoming contractor’s process validation shall encompass all beneficiary categories and will use live data from the Government’s RM system as part of the validation.
2.1.7  The incoming contractor shall validate that its system can timely and accurately communicate referral, authorization determinations with beneficiaries, network providers, Government systems and claims systems without technical problems.
2.1.8  The incoming contractor shall validate its ability to communicate with beneficiaries with multiple referral status alerts and notification options, including email, text, web-portal and hardcopy letters, to include beneficiary view and print capabilities.
2.1.9  The incoming contractor’s validation shall demonstrate their RM system’s ability to accurately process 90% of all requests within one business day and 100% within two business days.
2.1.9.1  The contractor shall validate its RM system (e.g., approval/denial letters) is accessible by the Government, beneficiaries, and providers.
2.1.9.2  The incoming contractor shall validate that referrals processed meet contract requirements with a 95% accuracy rate. To be considered accurate, processed referral shall include:
•  Correct beneficiary
•  Correct beneficiary demographics
•  To include sponsor’s last four digits of the Social Security Number (SSN) or Department of Defense (DoD) ID Number
•  Date of Birth (DOB)
•  Unique Identifier Number (UIN) is present if Market/MTF generated request
•  Correct Servicing Provider
•  Correct Servicing Specialty
•  Correct Episode of Care (EOC)
•  Evaluate and Treat
•  Evaluate only
•  Number of visits
•  Length of authorization
•  Range of Current Procedural Terminology (CPT) codes
2.2  RM PRAV
2.2.1  The incoming contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding enrollment activities as described above.
2.2.2  The incoming contractor shall submit a detailed mitigation plan no later than 10 business days following the Government’s findings if, after review, the Government finds the contractor’s performance readiness for enrollment processing to be deficient. Specific PRAV activities, assessment techniques, and performance readiness thresholds will be identified by the Government during the Transition Specifications (TRANSPEC) Meeting.
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