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TRICARE Operations Manual 6010.59-M, April 1, 2015
Chapter 2
Section 7
Critical Processes (CPs) - Referral Management
1.1  The contractor shall implement an electronic referral management system, which integrates with the Government’s electronic Referral Management Suite (RMS). The contractor shall ensure referral management processes are consistent with Section C of the contract and Chapter 8, Section 5.
1.2  The contractor’s referral management system shall interface with the Government RMS at each Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM). Interfaces shall be accomplished at the following minimum thresholds:
•  Fifty percent (50%) of MTF/eMSM interfaces are established 90 days prior to the start of health care delivery (SHCD).
•  Seventy-five percent (75%) of MTF/eMSM interfaces are established 75 days prior to the SHCD.
•  Ninety-five percent (95%) of MTF/eMSM interfaces are established 60 days prior to the SHCD.
1.3  The contractor’s referral management system shall also interface with the Coast Guard’s referral management process/system, which is separate from the Government RMS.
1.4  The contractor’s referral management process will include the Right Of First Refusal (ROFR) management and other business processes as necessary to ensure that inbound/outbound referrals are processed accurately and timely.
2.0  Performance Readiness Validation (PRV)/performance Readiness Assessment And Verification (PRAV)
During transition, the incoming contractor’s performance readiness status regarding referral management will be subject to PRV/PRAV reviews as described below.
2.1  Referral Management PRV
2.1.1  The contractor shall validate establishing referral management system interfaces with MTF/eMSM referral management systems. Establishing an MTF/eMSM interface must meet two criteria: 1) MTF/eMSM can send and receive referrals with no technical problems, and (2) contractor sends ROFRs in accordance with the MTF/eMSM capability table with 95% accuracy. Milestones for validating MTF/eMSM interfaces are:
•  Fifty percent (50%) of MTF/eMSM interfaces are established 90 days prior to SHCD.
•  Seventy-five percent (75%) of MTF/eMSM interfaces are established 75 days prior to SHCD.
•  Ninety-five percent (95%) of MTF/eMSM interfaces are established 60 days prior to SHCD.
2.1.2  Sixty days prior to SHCD, the contractor shall validate its systems can effectively interface with the Government’s RMS, Defense Enrollment Eligibility Reporting System (DEERS), TRICARE Regional Offices (TROs), MTFs/eMSMs, claims, Network Provider Directory, and Network Providers and the contractor’s portal/web site. The contractor shall inspect, test, and produce connectivity test results on all interfaces.
2.1.3  Fifty days prior to SHCD, the contractor shall validate all aspects of its referral, authorization, ROFR and command approval process by utilizing test scenarios which include referrals to MTF/eMSM and Network providers. The validation must encompass all necessary beneficiary categories to include processing referrals for beneficiaries with Medicare Part A (but under age 65) and still enrolled in TRICARE Prime and referrals from United States Coast Guard (USCG) facilities. The validation must incorporate a review of the contractor’s ability to utilize open authorizations that were transferred from the outgoing contractor.  The contractor shall validate that their system can timely and accurately communicate referral, authorization and ROFR determinations with beneficiaries, network providers, MTFs/eMSMs, Government systems and claims systems without technical problems. The contractor shall demonstrate beneficiary and provider ability to view/print authorization from the contractor’s web site/portal. The contractor shall demonstrate accurate letter generation.  The contractor’s validation shall demonstrate their referral management system’s ability to accurately process 90% of referrals within two working days and 100% within three working days. The contractor shall validate its Referral Management beneficiary communications system--approval/denial letters, etc. is accessible by MTFs/eMSM, TROs, and beneficiaries.  The contractor shall validate that referrals and ROFRs processed meet Program requirements with a 95% accuracy rate. To be considered accurate, processed referrals/ROFRs shall include:
•  Correct Beneficiary.
•  Correct Beneficiary Demographics.
•  To include sponsor’s last four Social Security Number (SSN) or Department of Defense (DoD) ID Number.
•  Date of Birth (DOB).
•  Unique Identifier Number (UIN) is present if MTF/eMSM 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  Referral Management PRAV
2.2.1  The contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding referral management as described above. If, after review, the Government finds the contractor’s performance readiness for referral management to be deficient, the contractor must submit a detailed mitigation plan no later than 10 business days following the Government’s findings.
2.2.2  Specific PRAV activities, assessment techniques, and performance readiness thresholds will be identified by the Government during the Transition Specification Meeting.
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