1.0 GENERAL
1.1 The
contractor shall provide a plan for establishing a provider network
throughout the region to support TRICARE Prime and TRICARE Select
and to complement Market/MTF capabilities. This section does not
apply to the Uniformed Services Family Health Plan (USFHP), TRICARE
Dual Eligible Fiscal Intermediary Contract (TDEFIC), or pharmacy
contracts.
1.2 The National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 2016, Section 717, required the development
of a system by which any non-Department mental health care provider
that meets eligibility criteria established by the Secretary of
Defense relating to knowledge of: (1) military culture; and, (2)
evidence-based treatments that have been approved by the Department
for the treatment of mental health issues among members of the Armed
Forces, receives a mental health provider readiness designation.
It further required the Department to establish and update as necessary
a publicly available registry of all non-Department mental health care
providers with the “provider readiness designation” related to knowledge
of military culture and evidence-based treatments.
1.3 The
contractor shall use a “provider readiness designation” to identify,
in its provider directory, all non-Department mental health providers
including psychiatrists and other mental health physicians (i.e.,
clinical psychologists, certified psychiatric nurse specialists
(CPNSs), certified clinical social workers (CCSWs), marriage and family
therapists, TRICARE certified mental health counselors (CMHCs),
and certified pastoral counselors under a physician’s supervision)
who have knowledge of military culture and evidence based treatments.
The mental health provider readiness designation does not apply
to the TRICARE Overseas Program (TOP).
1.3.1 The
contractor shall designate or identify those providers who furnish
proof (i.e., certificates) that they have completed:
• The “Military Culture: Core
Competencies for Healthcare Professionals” course developed by the
Department of Defense (DoD) and the Department of Veterans Affairs/Veterans
Health Administration (DVA/VHA) under the auspices of Integrated
Mental Health Strategy (IMHS); and
• The following courses: “Cognitive
Processing Therapy for Post-Traumatic Stress Disorder (PTSD) in
Veterans and Military Personnel,” “Prolonged Exposure (PE) Therapy
for PTSD in Veterans and Military Personnel,” and “Depression in
Service Members and Veterans in evidence-based treatments,” offered
by the Center for Deployment Psychology (CDP) of the Uniformed Services
University of the Health Sciences.
1.3.2 The
contractor shall actively promote attainment of the provider readiness
designation in its education materials to applicable providers.
2.0 GEOGRAPHIC
AVAILABILITY
2.1 The contractor shall establish
and maintain a preferred provider network of individual and institutional providers,
capable of meeting minimum access standards for 100% of TRICARE
Prime beneficiaries and at least 85% of TRICARE Select beneficiaries
in the contractor’s geographic area of responsibility throughout
all health care delivery periods of the contract. (See
Chapter
16 for TRICARE Prime Remote (TPR) network requirements).
2.2 The
contractor shall establish and maintain a network and services to
TRICARE Prime and TRICARE Select enrolled beneficiaries that ensures
access to care (ATC) and the opportunity to choose, enroll, add
additional family members, or remain enrolled in the TRICARE plans.
2.3 The
contractor shall establish minimum health care provider-to-beneficiary
ratios. The provider to beneficiary ratios shall be for the purposes
of network sizing only. Regardless of the provider to beneficiary
ratio, the contractor’s network shall meet or exceed minimum access
standards as the first priority.
2.4 The
contractor shall consider the health characteristics of the beneficiaries
in a given market, including an analysis of disease prevalence and
overall health and well-being of such beneficiaries, and shall use
predictive analytics in the development of its network implementation
plan.
2.5 The contractor shall establish
and maintain a network of individual and institutional providers
that ensures that at least 85% of TRICARE Select enrolled beneficiaries
residing in the geographic area of responsibility have access to
a network that meets minimum access time standards in each of the
contractor’s geographic areas of responsibility, each United States
and District of Columbia (East only).
2.6 In
developing and maintaining its network in each state/territory,
the contractor shall consider the entire beneficiary population
of the state including any overlap with TRICARE Prime Service Areas
(PSAs).
2.7 In
overseas regions, the contractor shall establish a network as authorized
by the Director to support a special Prime program; this network
may be accessed by Select enrollees based on available resources.
In addition to support for the TOP Prime Program, a network for
TOP Select enrollees shall be established only in geographical areas
determined by the Director, Defense Health Agency (DHA) to be economically
in the best interest of the DoD.
2.8 TRICARE
Prime Service Areas (PSAs)
2.8.1 The
contractor shall offer TRICARE Prime in areas where the Director,
Defense Health Agency (DHA) determines that it is appropriate to
support the effective operation of one or more Markets/Military
Medical Treatment Facilities (MTFs). The locations where TRICARE
Prime will be offered will be determined by the Director, DHA and
announced prior to the annual open enrollment period.
2.8.2 Government
Designated Authorities (GDAs) And Market/MTF Interface In Provider
Networks
2.8.2.1 The contractor shall ensure
that, in PSAs with Direct Care (DC) markets or MTFs, its network complements
the existing military capabilities and optimizes the market in support
of military readiness. The contractor shall adjust provider networks
and services to compensate for changes in Market/MTF capabilities
and capacities including those resulting from facility/service expansion,
provider deployment, or MTF access downsizing.
2.8.2.2 The contractor shall meet,
at a minimum annually, with the GDA and each Market Director/MTF Director
to discuss Market/MTF optimization efforts. The purpose of these
meetings is to ensure the Market/MTF optimizes care in accordance
with their business plan/optimization initiatives.
2.8.2.3 The contractor shall meet with
the GDA and all Market Directors and MTF Directors within 30 calendar
days of the award to obtain their network size and specialty makeup
input.
2.8.2.4 The
contractor shall provide Market Directors/MTF Directors and the
GDA the opportunity to provide input into the development of the
network in the geographic area of responsibility prior to finalizing
the civilian network.
2.8.3 MTF/Market
Collaboration Events
2.8.3.1 The
contractor shall, when requested by the Market/MTF, assist in planning
and conducting provider collaboration events in the local markets.
2.8.3.2 The contractor shall, when
a date and agenda is confirmed by the Market/MTF, assist in administrative
processes that include procuring the venue, coordinating event logistics,
creating and delivering invitations to civilian providers, and catering
refreshments as permitted by Service-specific and other regulations.
3.0 ENROLLMENT
3.1 In
each area where enrollment is offered, the contractor shall permit
enrollment by beneficiaries under the terms and conditions of
Chapters
6 and
11.
3.2 The
contractor shall assign TRICARE Prime beneficiaries only to Market/MTF
Primary Care Managers (PCMs) or to PCMs in the PSA network.
3.3 The
contractor shall follow Market Director/MTF Director directions
regarding the priorities for the assignment of enrollees to PCMs.
4.0 NETWORK
REQUIREMENTS AND STANDARDS
4.1 The
contractor shall obtain health network accreditation of its provider
network from a nationally recognized accrediting organization no
later than 18 months after the start of health care delivery (SHCD).
4.2 The
contractor shall actively seek institutional and individual providers
(medical and mental health) for their network who:
4.2.1 Produce
the best quality clinical outcomes;
4.2.2 Use “evidence-based
medicine, including appropriate national standards of care;”
4.2.3 Report
outcome data, preventive measures date, and laboratory data; and
4.2.4 Are
willing to refer/transfer TRICARE beneficiaries for care at Markets/MTFs
when appropriate.
4.3 The
contractor shall profile and monitor individual and institutional
provider performance in an ongoing manner using profiling/monitoring
parameters that address, but are not limited to, cost-of-care, clinical
quality of care to include population health/prevention practices
as appropriate, patient satisfaction and access.
4.4 The
contractor shall ensure profiles and parameters are based on current
and evolving sources of outcomes and performance data (i.e., Hospital
Compare), kept current (updated biannually at a minimum) and available
for review by the Government at all times.
4.5 The
contractor shall not refer beneficiaries to providers with poor
outcomes.
4.6 Where
available, National Committee for Quality Assurance (NCQA) accredited
(or other nationally accepted accrediting organizations) primary
care medical homes shall be recruited to the network to provide
care for beneficiaries with two or more chronic illnesses.
5.0 Provider
Directory
5.1 The contractor shall develop
and maintain a timely and accurate network provider directory for
use by beneficiaries and the Government to assist with health care,
referral management, and claims. Additionally, the contractor shall
develop and maintain an on-line authorized non-network provider
list.
5.2 The contractor shall ensure
that the information is refreshed with any updated data in the on-line network
provider directory no less than once every 24 hours.
5.3 The
contractor shall provide web access to the directory and list, making
it available for all beneficiaries, providers, and Government representatives.
5.4 The
contractor’s on-line network provider directory shall include a
search tool that allows beneficiaries to locate providers based
on a wide range of avenues, to include but not limited to name,
specialty, sub-specialty, group, body part or condition. Results
from the beneficiary search shall have the capability of sorting
on all elements of provider data including mapping providers by
distance to the beneficiary.
5.5 The
contractor’s on-line authorized non-network provider list shall
include a search tool that allows beneficiaries to locate providers
with results based on claims submissions for a rolling 14 month
period. The accuracy standard does not apply to the authorized non-network
provider list.
6.0 Standards
for TRICARE Beneficiary Access to Network Providers
6.1 The
contractor shall ensure access standards for appointments for health
care that meet or exceed those of high-performing health care systems
in the US.
6.2 The
contractor shall maintain networks through the life of the contract
and adjust the size of the networks to ensure beneficiaries in the
geographic areas meet or exceed ATC standards.
6.3 The
contractor shall establish mechanisms for monitoring and reporting
compliance with access standards.
6.4 Where
MTFs use an Integrated Referral and Medical Appointment Center or
Referral and Appointment Center, data received from the appointing
center about availability of appointments in the contractor’s network shall
be included in compliance monitoring metrics.
6.5 The
contractor shall ensure ATC standards listed in
32 CFR 199.17(p)(5) are met for enrollees.
6.5.1 The
contractor shall ensure travel time does not exceed 30 minutes from
home to primary care delivery site unless a longer time is necessary
because of the absence of providers (including providers not part
of the network) in the area.The contractor shall ensure that travel
time for specialty care does not exceed one hour, unless a longer time
is necessary because of the absence of providers (including providers
not part of the network) in the area.The contractor shall ensure
that the wait time for an appointment for a well-patient visit or
a specialty care referral for enrollees do not exceed four weeks;
for a routine visit, the wait time for an appointment shall not exceed
one week; and for an urgent care visit the wait time for an appointment
shall generally not exceed 24 hours.The contractor shall ensure
that emergency services be available and accessible to handle emergencies (and
urgent care visits if not available from other primary care providers
(PCPs) within the service area 24 hours a day, seven days a week
(24/7) for enrollees.
7.0 Urgent
Care Centers (UCC
s) Network Requirements
and Standards
7.1 The contractor shall establish
network agreements with TRICARE authorized UCCs and publish information,
including on a website, informing TRICARE beneficiaries of the availability
and access to network UCCs.
7.2 The
contractor shall ensure adequate access to UCCs when Markets/MTFs
are unavailable or unable to provide such services. See the website
(
https://manuals.health.mil/pages/v3/DownloadManualFile.aspx?Filename=Definitions.pdf)
for the definition of UCC. The NDAA FY 2017, Section 704(a) enacted
10 United States Code (USC) 1077a, in part, to improve access to
urgent care services both in military Markets/MTFs and the TRICARE
Network.
7.3 The
contractor shall include in network agreements with UCCs located
in all Market/MTF PSAs within the 50 United States and District
of Columbia the following to better integrate care between Markets/MTFs
and network UCCs:
7.3.1 The
contractor shall instruct UCCs in Market/MTF PSAs for TRICARE Prime
beneficiaries enrolled to a Market/MTF to send a Clear and Legible
Report (CLR) of the UCC encounter within two business days to the
Market/MTF where the beneficiary is enrolled.
7.3.1.1 The CLR shall include the patient’s
encounter specifics (histories and physicals, progress notes, notes on
Episodes Of Care (EOC), and other patient information (such as laboratory
reports, x-ray readings, operative reports), and discharge summaries).
7.3.1.2 The CLR shall include any follow-up
appointments recommended during the urgent care visit.
7.3.2 Advise
TRICARE Prime beneficiaries enrolled to a Market/MTF that non-emergency
follow-on care should be sought at the enrollees’ Market/MTF PCM
whenever possible.
7.3.3 The
contractor shall provide the network UCCs with Market/MTF fax numbers.
7.4 The
contractor shall ensure that TRICARE authorized UCCs practice standard
of care based on the NCQA Health Effectiveness Data and Information
Set (HEDIS) using the guidelines for the following four conditions:
7.4.1 Children
With Pharyngitis (CWP).
7.4.2 Appropriate treatment for children
with Upper Respiratory Infection (URI).
7.4.3 Avoidance
of Antibiotic for Adults with Bronchitis (AAB).
7.4.4 Use of
imaging studies for Low Back Pain (LBP).
7.5 The
contractor shall ensure that all beneficiaries in its geographic
region have access to a 24/7 telehealth urgent care option available
through a computer and smartphone application.
8.0 Participation
On Claims
8.1 The contractor shall only include
in their network Medicare participating providers (unless they are
not eligible to be a Medicare participating provider) and shall
be sufficient in number, mix, and geographic distribution to provide
the full scope of benefits for which all Prime and Select enrollees
are eligible under this contract, as described in
32 CFR 199.4,
199.5,
and
199.17.
8.2 The
contractor shall ensure that all network provider agreements require
the provider to participate on all claims and submit claims on behalf
of all Military Health System (MHS) and Medicare beneficiaries.
All network provider agreements shall include the following provision:
8.2.1 The submission
of a claim by a physician or supplier or their representative certifies
that the services shown on the claim are medically indicated and
necessary for the health of the patient and were personally furnished
by the physician/supplier or furnished incident to his or her professional
service by his or her employee under his or her immediate personal
supervision, except as otherwise permitted by Medicare or TRICARE regulations.
8.2.2 Services,
to be considered as “incident” to a physician’s professional service,
must:
8.2.2.1 Be rendered under the physician’s
immediate personal supervision by his or her employee;
8.2.2.2 Be an integral, although incidental
part of a covered physician’s service;
8.2.2.3 Consist of commonly furnished
in physician’s offices; and
8.2.2.4 Be included on the physician’s
bills for services of non-physicians.
8.2.3 The non-institutional
network provider/supplier further certifies that he or she (or any
employee) who rendered services is not an active duty member of
the Uniformed Services or a civilian employee of the US Government
(refer to 5 USC 5536).
8.2.4 An exception exists for part-time
DVA/VHA employees fulfilling the requirements of
Chapter 4, Section 1.
8.3 Anyone
who misrepresents or falsifies essential information to receive
payment from Federal funds may upon conviction be subject to fine
and imprisonment under applicable Federal law.
9.0 Balance
Billing
9.1 The contractor shall include
the following provision in provider contracts:
9.1.1 Providers
in the contractor’s network will only bill MHS beneficiaries for
applicable deductibles, copayments, and/or cost-sharing amounts.
9.1.2 Providers
will not bill for charges which exceed contractually allowed payment
rates.
9.1.3 Network
providers will only bill Markets/MTFs/contractors for services provided
to Service members at the contractually agreed amount, or less,
and will not bill for charges which exceed the contractually agreed allowed
payment amount.
9.2 If
a network provider bills a beneficiary for more than the contractually
agreed upon amount, the contractor shall require the provider to
reverse the charges and refund any overpayment to the beneficiary.
9.3 The
contractor shall ensure that the amount charged MHS beneficiaries
without civilian network PCMs is the same as the amount charged
TRICARE Prime enrollees with civilian network PCMs.If the contractor
is using different reimbursement mechanisms, the contractually agreed
amount will be equal to or less than the TRICARE allowable amount
minus the discount the contractor negotiated with the provider.
9.5 ADSMs and ADFMs without MTF
audiology access continue to be tested, treated, and fitted by their network
audiologists.
10.0 Billing
For Non-Covered Services (Hold Harmless)
10.1 A
network provider may not require payment from the beneficiary for
any excluded or excludable services that the beneficiary received
from the network provider (i.e., the beneficiary will be held harmless)
except as follows:
10.1.1 If the beneficiary did not
inform the provider that he or she was a TRICARE beneficiary, the
provider may bill the beneficiary for services provided.
10.1.2 If the beneficiary was informed
that the services were excluded or excludable and he or she agreed
in advance to pay for the services, the provider may bill the beneficiary.
10.2 An agreement
to pay must be evidenced by written records. “Written records” include
for example:
10.2.1 Provider notes written prior
to receipt of the services demonstrating that the beneficiary was
informed that the services were excluded or excludable and the beneficiary
agreed to pay for them;
10.2.2 A statement or letter written
by the beneficiary prior to receipt of the services, acknowledging
that the services were excluded or excludable and agreeing to pay
for them;
10.2.3 Statements written by both
the beneficiary and provider following receipt of the services that
the beneficiary, prior to receipt of the services, agreed to pay
for them, knowing that the services were excluded or excludable).
10.3 General
agreements to pay, such as those signed by the beneficiary at the
time of admission, are not evidence that the beneficiary knew specific
services were excluded or excludable.
10.4 Certified
marriage and family therapists (both network and non-network), in
their participation agreements with TRICARE, agree to hold eligible
beneficiaries harmless for non-covered care.
10.5 The
beneficiary shall be entitled to a full refund of any amount paid
by the beneficiary for the excluded services, including any deductible
and cost-share amounts, provided the beneficiary informed the network provider
(or the network or non-network certified marriage and family therapist)
that he or she was a TRICARE beneficiary, and did not agree in advance
to pay for the services after having been informed that the services
were excluded or excludable.
10.6 The
beneficiary shall be refunded any payments made by the beneficiary
or by another party on behalf of the beneficiary (excluding an insurer
or provider) for the excluded services.
10.7 The beneficiary,
or other party making payment on behalf of the beneficiary, must
request a refund in writing from the contractor by the end of the
sixth month following the month in which payment was made to the provider
or by the end of the sixth month following the month in which the
Peer Review Organization (PRO), or the DHA advised the beneficiary
that he or she was not liable for the excludable services.
10.8 The time
limit may be extended where good cause is shown. Good cause is defined
as:
10.8.1 Administrative error, such
as, misrepresentation or mistake, of an officer or employee of DHA
or a PRO, if performing functions under TRICARE and acting within
the scope of the officer’s or employee’s authority.
10.8.2 Mental incompetence of the
beneficiary or, in the case of a minor child, mental incompetence
of his or her guardian, parent, or sponsor.
10.8.3 Adjudication delays by Other
Health Insurance (OHI) (when not attributable to the beneficiary),
if such adjudication is required under
32 CFR 199.8.
11.0 Health
Information Exchanges (HIE
s)
11.1 The
contractor shall include in its network, to the extent possible,
and give priority in its MTF referral steerage model to providers
(both individual and institutional) who are connected to the eHealth
Exchange or another HIE network or framework that connects with
the Government’s electronic health record (EHR) system so that network
providers can make available or exchange necessary clinical information
with the MTF providers.
11.2 The
contractor shall designate network providers who utilize a HIE system
in the Government view of the online provider directory.
12.0 Network
Provider Education
12.1 The
contractor shall provide an education program for network providers
in accordance with
Chapter 11.
12.2 The
contractor shall provide an outreach and education program on TRICARE
requirements for all network and TRICARE-authorized providers. The
program shall include education on applicable TRICARE program requirements,
policies, and procedures to allow providers to carry out the requirements
of this contract in an efficient and effective manner which promotes
beneficiary satisfaction. The outreach program shall include information
on the Centers for Medicare and Medicaid Services (CMS) Meaningful
Use (MU) Program.
12.3 The
contractor outreach shall include information about DoD/VA clinical
practice guidelines, quality/value improvement efforts, and information
about collection and reporting of outcomes data.
12.4 The
contractor shall educate network providers about the certified HIEs
and national health standards to ensure they comply with Title VI
of the 21st Century Cures Act in relation to HIE (e.g., CMS) and
Office of the National Coordinator (ONC) for Health Information
Technology (HIT) interoperability rules including use of Health Level
7 (HL7) Fast Healthcare Interoperability Resources (FHIR) and the
United States Core Data for Interoperability (USCDI).
12.5 At
least biannually and for all new network providers, the contractor
shall educate providers of the importance of updating their information
in the provider directory (e.g., beneficiary satisfaction, MTF satisfaction, loss
of referrals).
13.0 Durable
Medical Equipment (DME) Providers
The contractor shall establish
preferred provider contracts with national or regional DME vendors
for specific categories of DME supplies which will allow for volume
discounts and specialized service. DME supplies include, but are
not limited to, infant formula, diabetic supplies, home infusion
supplies, and breast pumps.