1.0 MM PROGRAM
1.1 The TRICARE
Health Plan (THP) defines MM as an integrated managed care model
that includes Utilization Management (UM), Referral Management (RM),
Case Management (CM), Behavioral Health (BH), and Population Health
(PH) programs to manage patient care and the clinical and social
needs of eligible beneficiaries.
1.2 The
contractor shall integrate evidence-based and outcome-oriented processes
in the MM programs to provide the highest quality care to eligible
beneficiaries.
1.3 The
contractor shall use nationally recognized criteria and standard
of care guidelines in identifying, managing, monitoring, processing,
reviewing, and authorizing all medical, virtual medicine, and behavioral
health care services.
1.4 The
contractor’s MM programs shall support and manage the healthcare
utilization of individuals with high-cost claims, complex medical
conditions, inpatient admissions and discharges, pharmacy (specialty
drugs, multiple medications or pharmacies), and beneficiaries receiving
low quality care.
1.5 The
contractor shall submit a written MM plan. For plan submission requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
2.0 ELECTRONIC MM SYSTEM
2.1 The contractor shall manage
and maintain a single, consolidated, easy to use and understand,
fully-electronic, web-based MM data system platform that is available
24 hours a day/seven days a week (24/7), except for scheduled downtime
for system maintenance.
2.2 The
information shall be at the beneficiary and Military Medical Treatment
Facility (MTF) level, that can be viewed, downloaded and printed,
with concurrent and refreshed data no less than once every 24 hours.
2.3 The Government may use the
contractor’s portal to submit referrals in situations when the RM
system is unavailable.
2.4 The
electronic data system platform shall offer Defense Medical Information
System (DMIS) specific access, reporting and consolidated, detailed
information to MTF, Market, THP, and Defense Health Agency (DHA) authorized
personnel.
2.5 The
contractor’s MM data system platform shall include, but not limited
to, access or links to:
• Referrals
• Submission
portal
• Reconciliation capability
• Authorizations
• Authorization
approval letters for beneficiary
• Authorization
approval letters for provider
• Authorization
denial letters for beneficiary
• Authorization
denial letters for provider
• List of
codes that require and do not require a referral and authorization
by beneficiary category
• UM review decisions
• Concurrent
and preadmission/preauthorization
• THP Clinical
Operations only--initial and second reconsideration, appeals
• Appeal
(factual and medical necessity) educational information/process
• Appeal
(factual and medical necessity) submission portal for beneficiaries
• Clinical Documents
• Treatment
plans (TPs)
• History of care
• Plans
of care (POCs)
• Inpatient admissions/Discharges
by DMIS
• CM
• Referral
capability
• MTF and network enrollees assigned
to the contractor’s CM program
• The contact
information for the specific care coordinator(s) assigned to the
enrollee
• Date of opening and closure
of case
• Case notes
• CM beneficiary
education/self-help information
• PH
• Referral
capability
• MTF and network enrollees assigned
to contractor PH care
• The contact
information for the specific care coordinator(s) assigned to the
enrollee
• Date of opening and closure
of case
• Case notes
• Disease
Management (DM)/PH beneficiary education/self-help information
• Data reports
• Provider Directory
• Enrollment
• Claims
• Pharmacy Information and Medication
list
• Potential Quality Issue (PQI)
Market/MTF reporting mechanism
• Updated
(Pending, Open, Closed)
2.6 The contractor shall provide
the UM decisions on the electronic MM data system platform for Market/MTF and
civilian network TRICARE Prime enrollees the day the decision is
made. All denied authorizations or reconsiderations must be mailed
to the beneficiary and the provider.
2.7 The
contractor shall provide access to the Market/MTF and civilian network
Primary Care Managers (PCMs) to inpatient admissions and discharges
for all TRICARE Prime enrollees within 24 hours of the contractor becoming
aware of the admission via the electronic data system platform.
For reporting requirements, see DD Form 1423, CDRL, located in Section
J of the applicable contract.
2.8 The
contractor shall schedule system maintenance windows during weekends
or non-peak hours to minimize disruption of services to Government
workers to the maximum extent possible.
2.9 The
contractor shall provide access to the MM electronic data system
platform for up to 7,500 Government users per region.
2.10 The contractor shall provide
training on the MM data system, prior to start of health care delivery
(SHCD), and at a minimum quarterly thereafter to Market/MTF and
Government users.
3.0 MM PROGRAM REPORTING
The contractor shall report
the effects of MM programs on Market/MTF optimization by MM program
component. For reporting requirements, see DD Form 1423, CDRL, located
in Section J of the applicable contract.
4.0 PROVIDER ACCESS TO DEPARMENT
OF DEFENSE (D
oD) PHARMACY INFORMATION
4.1 The contractor shall provide
access to DoD Pharmacy information which allows MTF
clinic designee and civilian providers or clinic designee to view
and print their patients’ medication lists according to the MOU between the
Managed Care Support Contractor (MCSC) and TRICARE Pharmacy (TPharm)
contractor (see DD Form 1423, CDRL, located in Section J of the
applicable contract). The medications lists will
include medications, to include controlled substances such as opioids,
dispensed by Markets/MTFs, the TRICARE Mail Order Pharmacy (TMOP),
and retail pharmacies.
4.2 The
contractor shall make this information available via the contractor’s
website for PCMs, specialists, and BH providers or clinic designee
who register for this capability.
4.3 The
contractor shall ensure registered providers or clinic designee
will have access to medication lists for all of their assigned TRICARE
patients; specialist access will be limited to those patients for
whom they have a referral or authorization.
5.0 PREDICTIVE ANALYTICS
5.1 The contractor shall use predictive
analytics in the operation of their MM programs to include, but
not limited to medical, telehealth, BH, UM, CM, and PH (to include
chronic care (CC)/DM).
5.2 The
contractor’s predictive analytics tools shall offer an automated
means to forecast future health outcomes for individuals or populations
based on algorithms derived from historical patient data.
5.3 The contractor shall implement
beneficiary-centric data analytic tools/systems to integrate data
from multiple sources (including, but not limited to, Government-provided
Market/MTF real-time data and real-time pharmacy data) to allow
a consolidated view of all data related to each beneficiary.
5.4 The contractor’s system shall
process this information against industry-respected sources of evidence-based
medicine to identify gaps in care, medical errors, identify high-risk
addictive behaviors, such as, opioid use or abuse and quality issues.
5.5 The contractor shall utilize
its analytic tools to treat and to provide a report on annually
identified chronic diseases (including opioid use), identify gaps
in care of Leading Health Indicators (LHIs), identified chronic
diseases identified by DoD, as well as promote prevention and wellness
for at-risk individuals. For reporting requirements, see DD Form
1423, CDRL, located in Section J of the applicable contract.
6.0 PRIVATE SECTOR CARE AND DIRECT
CARE (DC) INTEGRATION
The
contractor shall identify and propose opportunities to coordinate,
collaborate, and implement Market/MTF integrated care and processes
with the Government.
7.0 MM TRAINING
The contractor shall provide
ongoing MM training and presentations at the THP hosted monthly
MM Teleconference for the Government (Markets/MTFs and DHA) in regards
to its electronic MM system and programs.