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TRICARE Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 2
Case Management (CM)
Revision:  
1.0  CM
The contractor shall provide CM (medical and behavioral health) to TRICARE beneficiaries who are eligible for the contractor’s CM services, including those beneficiaries who are still receiving care under the Custodial Care Transitional Policy (CCTP) and Individual Case Management Program For Persons With Extraordinary Conditions (ICMP-PEC) programs. Medicare/TRICARE dual eligible beneficiaries are not eligible for the contractor’s CM program, except for care under the CCTP and ICMP-PEC programs. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
1.1  The contractor shall provide a dedicated clinical case manager (i.e., Registered Nurse (RN) or social worker) to each beneficiary in the CM program to support each beneficiary in a personalized way throughout their health care experience.
1.2  The contractor shall ensure that case managers are knowledgeable of local, county, state, and federal level resources where the CM enrolled beneficiary is located.
1.3  The contractor shall connect beneficiaries with resources that are targeted to address their unique physical and mental health needs as identified in their CM assessment and care plan.
1.4  The contractor shall also provide CM to Active Duty Service Members (ADSMs) who meet the conditions outlined above, when care occurs or is projected to occur, in whole or in part in, the private sector care.
1.5  The contractor’s case managers shall manage beneficiaries through the continuum of care as it relates to institutional inpatient and outpatient care (TRICARE Policy Manual (TPM), Chapter 11, Section 1.1). The case manager shall prepare individuals and families for hospital admissions and discharges, and collaborate to coordinate care across the continuum.
1.5.1   The contractor’s case manager shall ensure the discharge plan is appropriate and aligns with the services outlined in the TRICARE benefit.
1.5.2  The case manager shall assist with coordinating care prior to and following discharge, if the discharge plan is for a non-covered service.
1.5.3  The contractor shall utilize a multidisciplinary team approach to address the unique needs of each beneficiary. The multidisciplinary team includes both clinical and non-clinical subject matter experts as applicable, i.e., physical therapist, dietician, pharmacist, community health workers, peer support specialists, etc.
1.6  The contractor shall provide Markets/Military Medical Treatment Facilities (MTFs) with visibility via electronic access to all CM assignment information as identified in Chapter 7, Section 1.
2.0  CARE COORDINATION
2.1  The contractor shall ensure care coordination programs and services are available at the start of healthcare delivery and for the duration of the contract for both medical and behavioral health conditions and services.
2.2  The contractor shall utilize a multidisciplinary team approach to address the unique needs of each beneficiary. The multidisciplinary team includes both clinical and non-clinical subject matter experts as applicable, i.e., physical therapist, dietician, pharmacist, community health workers, peer support specialists, etc.
2.3  The contractor shall communicate, collaborate, and coordinate with private sector care providers, Markets/MTFs and Government Designated Authority (GDA) to transfer stabilized patients from one location to another on a 24 hours a day/seven days a week (24/7) basis. Transfers may occur as a result of medical, social, or financial reasons and include moves of non-institutionalized and institutionalized patients to include mental healthcare.
2.4  The contractor shall coordinate care with the Market/MTF clinical staff, as well as the civilian providers, when care occurs outside a Market/MTF.
2.4.1  The contractor shall notify the member’s enrolled Market/MTF within two business days of notification of the care taking place, or notify the Defense Health Agency-Great Lakes (DHA-GL) within two business days of notification for members enrolled to civilian Primary Care Managers (PCMs), when managing the care of an ADSM.
2.4.2  The contractor shall assist the beneficiaries’ understanding on how to utilize, access and navigate the health benefits under the TRICARE program.
2.4.3  The contractor shall provide a dedicated care coordinator to support each beneficiary requiring assistance throughout their coordination and transition of care.
2.5  Coordination of transition of care within the contractor’s geographic area of responsibility (intraregional/interregional transition of care):
2.5.1  The contractor shall communicate, collaborate, and coordinate transition of care/services with the affected Market/MTF(s), the Department of Veterans Affairs/Veterans Health Administration (DVA/VHA), GDA, or private sector care provider(s) upon beneficiary or GDA request.
2.5.2  The contractor shall provide coordination of transition of care services to all eligible beneficiaries except non-active duty TRICARE/Medicare dual eligible beneficiaries.
2.5.3  The contractor shall provide a dedicated care coordinator to each beneficiary requiring assistance to support each beneficiary in a personalized way throughout their transition of care.
2.5.4  The contractor shall commence transition of care/services within three business days of beneficiary or GDA notification.
2.5.5  The contractor shall provide transition of care/services to the following beneficiaries:
•  ADSMs during Permanent Change of Station (PCS) involving TRICARE-eligible family members who are enrolled in the Exceptional Family Member Program (EFMP).
•  ADSMs separating/retiring from active duty service.
•  ADSMs transitioning to the DVA/VHA.
•  TRICARE beneficiaries registered in the Extended Care Health Option (ECHO) program.
•  Seriously ill or injured ADSMs in receipt of benefit coverage comparable to the ECHO program in accordance with Chapter 17, Section 3.
•  TRICARE beneficiaries receiving CM services and moving from one geographical location to another with an active referral, as outlined in Chapter 7, Section 5, paragraph 4.9.
2.5.6  The contractor’s coordination of care shall include all appropriate providers and services needed for transition to a new location or change in level of care setting.
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