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TRICARE Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 7
Contractor Relationships With The Military Health System (MHS) TRICARE Quality Monitoring Contract (TQMC) Contractor
Revision:  
1.0  The TQMC contractor conducts reviews to validate the appropriateness of the contractor’s quality of care and utilization review decisions.
2.0  The Managed Care Support Contractors (MCSCs), Designated Providers (DPs), and the TRICARE Medicare Eligible Program (TMEP) contractor shall transmit paper or electronic copies of the medical record and all case documentation to the TQMC contractor for each case or category of case requested by the TQMC contractor.
2.1  The estimated number of medical records (including inpatient and outpatient care) to be selected will vary depending upon the contractor’s geographic area of responsibility involved and the TQMC’s selection criteria.
2.2  The estimated quantities per geographic area of responsibility could range from up to 5,400 to 11,340 records per year for the MCSCs, up to 120 to 360 records per year for the DPs, and up to 1,200 to 2,400 records per year for TMEP. Records will be requested periodically throughout the year.
3.0  The MCSC, DP, and TMEP contractor shall transmit 95% of the requested records to the TQMC contractor within 45 calendar days and 98% within 60 calendar days from the date the MCSC, DP, and TMEP contractor receive the request for records from the TQMC contractor.
3.1  The MCSC, DP, and TMEP contractor’s records shall include the complete medical record, the MCSC’s, DP’s, and TMEP’s utilization review decision, rationale for that decision, and quality of care determinations.
3.2  The MCSC, DP, and TMEP contractor shall submit a monthly Contractor Records Accountability Report. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
3.2.1  The MCSC, DP, and TMEP shall follow Chapter 2, Section 6, Records Management for all transition and transfer of records.
3.2.2  Records may be transmitted through secure electronic means and stored with the TQMC contractor for review in adherence with the requirements specified in Chapter 9, Records Management.
3.2.3  Adherence to these procedures is essential for compliance with the Privacy Act of 1974 (5 United States Code (USC) 552a), the Department of Defense (DoD) Privacy Program (DoD 5400.11-R), the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules (45 Code of Federal Regulations (CFR) Parts 160 and 164), the DoD Health Information Privacy Regulation (DoD 6025.18-R), the DoD Health Information Security Regulation (DoD 8580.02-R), and other federal laws protecting the privacy and security of Personally Identifiable Information (PII), including health information.
3.2.4  The TQMC contractor shall acknowledge receipt of electronic records from the MCSC, DP, and TMEP contractor by return email.
3.2.5  The MCSC, DP, or TMEP contractor shall follow-up with the TQMC contractor if the acknowledgment email is not received within one business day after the electronic records were transmitted, or if it is determined that the records were not transmitted with the required security safeguards to determine the status and whether a possible breach may have occurred.
3.2.6  The MCSC, DP, or TMEP contractor shall notify, within 24 hours, the Defense Health Agency (DHA) Privacy Office and carry out the other breach response requirements of Chapter 1, Section 5.
3.3  The contractor shall adhere to procedures specified in paragraphs 3.2.1 through 3.9.3 to transfer paper records.
3.3.1  The records shall be packaged in boxes containing a single month of records and a Box Inventory Document (see Figure 7.7-1) stating the number of patient records contained therein and identifying each record by patient name and DHA Internal Control Number (ICN), which should be clearly shown on each patient’s record.
3.3.2  The Box Inventory Document (in both paper and electronic versions) contains PII, and shall be protected from unauthorized use and disclosure in the same manner as the patient records themselves.
3.3.3  The MCSCs, DPs, or TMEP contractor shall notify the designated Point Of Contact (POC) at the TQMC contractor, via email, each day that a box or boxes have shipped, stating the number of boxes (with tracking numbers) in that day’s shipment (see Figure 7.7-2).
3.3.4  The MCSCs, DPs, or TMEP contractor shall track the shipment, including delivery, using the shipping vendor’s tracking method and retain documentation of such.
3.4  The TQMC contractor, using the MCSC, DP, or TMEP Box Inventory Document(s), shall match the number of boxes received with the corresponding email shipment notification within one business day of receipt of a shipment from a contractor.
3.4.1  The contractor and the TQMC contractor, if any boxes are missing, shall investigate and no later than 24 hours after finding that a box is missing, initiate breach response in accordance with Chapter 1, Section 5.
3.4.2  The TQMC contractor shall, if no boxes are missing and for all boxes received, confirm the number of records in each box and a match between each patient record and ICN for the patient names listed on the Box Inventory Document no later than five business days after receipt of the shipment.
3.4.3  The TQMC contractor shall send an email back to the MCSC, DP or TMEP contractor confirming the number of boxes, number of records in each box and match of all ICNs.
3.4.4  Upon receipt of the TQMC contractor’s confirmation email, no further action is required by the MCSC, DP, or TMEP contractor.
3.5  The TQMC contractor, using the Box Inventory Document, shall identify the following:
•  A count discrepancy in either the number of boxes or number of charts in each box;
•  Absence of a record; or
•  A mismatch of the record with the ICN.
3.6  The TQMC contractor shall notify the MCSC, DP, or TMEP contractor by email of the discrepancy including details of the discrepancy no later than five business days from receipt of shipment if the TQMC contractor concludes that records are or may be missing.
3.6.1  The MCSC, DP, or TMEP contractor shall investigate the discrepancy, take appropriate steps and notifications, and be in telephone, fax and email communication to resolve the potential violations of applicable law as soon as possible after notification of the count discrepancy.
3.6.2  The MCSC, DP, or TMEP contractor shall initiate breach response in accordance with Chapter 1, Section 5 if the missing records are not promptly located within 24 hours of receiving the notice from the TQMC contractor.
3.7  The TQMC contractor shall send a “non-receipt” email to the MCSC, DP, or TMEP contractor no later than five business days if no shipment was received from the MCSC, DP, or TMEP contractor following notification that a shipment was sent.
3.7.1  The MCSC, DP, or TMEP contractor shall immediately track the shipment and notify the TQMC contractor by email of the status of the shipment upon receipt of a “non-receipt of a shipment.”
3.7.2  The MCSC, DP, or TMEP contractor shall be in telephone, fax or email communication with the TQMC contractor to determine the appropriate steps and notifications, based upon the investigation to resolve the potential HIPAA violation.
3.8  The MCSC, DP, or TMEP contractor shall notify the DHA Clinical Operations Division (COD), and the DHA Privacy Office within two hours. By close of business (COB) on the same day, all parties are required to receive notice under the breach notification provisions of Chapter 1, Section 5 and applicable law.
3.9  If the MCSC, DP, or TMEP contractor does not receive an email from the TQMC contractor indicating either confirmation of receipt, confirmation of receipt with discrepancy, or a non-receipt of shipment, by the morning of the sixth business day after shipment, the MCSC, DP, or TMEP contractor shall notify the TQMC contractor, the DHA COD, and the DHA Privacy Office.
3.9.1  The notifications shall provide available details about the shipment and the circumstances.
3.9.2  The TQMC contractor shall verify that these notifications are sent, and shall provide the notifications itself if the sender of the records fails to do so.
3.9.3  The MCSC, DP, or TMEP contractor shall comply with breach response requirements of Chapter 1, Section 5 and applicable law.
4.0  The MCSC, DP, and TMEP contractor shall provide the appropriate DHA Government Designated Authority (GDA), DP and TMEP Contracting Officer’s Representative (COR) written responses to all TQMC contractor findings. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
5.0  The TQMC contractor shall attend Government sponsored meetings with the MCSC, DP, and TMEP as approved by the TQMC COR. Approval for attendance will be based on the relevance of the agenda topics to the TQMC requirements.
Figure 7.7-1  Box Inventory Document (Sample)
(Logo or Letterhead of Company)
Inside mailing address identifying Organization and Person Shipping POC
Privacy/HIPAA Warning Notice:
The information in the enclosed documents may be subject to the Privacy Act of 1974, the Health Insurance Portability and Accountability Act (HIPAA) and other Federal Laws protecting the privacy and security of Personally Identifiable Information (PII), including health information. Personal information contained in this inventory and in the enclosed documents may be used and disclosed only by authorized persons in the conduct of official business and only in accordance with the Privacy Act, HIPAA, and other applicable Federal law. Any unauthorized use or disclosure of personal information may result in criminal and/or civil penalties. If you are not the intended recipient of this correspondence, you must notify the sender upon receipt and transfer the documents in accordance with the sender’s instructions. If you inspect, copy or transfer the enclosed documents other than as instructed, a violation of applicable law may occur.
This is Box X of Y mailed on MM/DD/YEAR
Record Request Received by Contractor: Month & Year
Recommended Per Box Inventory Letter Example (to be included in each box)
Name of Contractor:
Date Mailed: M/D/YR
Month of Chart Request: M/YR
Number of records in box =
ICN
Patient Name
Patient Year of Birth
Admission Date
Discharge Date
Figure 7.7-2  Routine Email (Sample)
Information to include:
Universal
Date Shipment to be “picked up”
Number of boxes in shipment
For Each Box in Shipment
Tracking number for box: 1ZV300Y4019919XXX
Audit Month (05/2009)
Number of records in box (XY)
Signatory
References:
1.  OASD/HA Memorandum, Use of Digital Signature on Official TMA Electronic Mail (email), June 13, 2007.
2.  OASD/HA Memorandum, Protection of Sensitive Information in Electronic Mail, August 13, 2007.
3.  OASD/HA Memorandum, Guidelines on Protection of Sensitive Information in Electronic Email, June 25, 2008.
4.  OASD/HA Memorandum, Updated Guidelines on Protection of Sensitive Information in Electronic Mail, September 19, 2008.
5.  DoD Memorandum, “DoD Guidance on Protecting Personally Identifiable Information (PII),” August 18, 2006.
6.  DoD Regulation 6025.18-R, “DoD Health Information Privacy Regulation,” January 24, 2003, and
7.  DoD Regulation 8580.02-R, “DoD Health Information Security Regulation,” July 12, 2007.
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