1.0 General
1.1 All provisions
contained in the TRICARE Managed Care Support (MCS) contract, TRICARE Operations
Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Systems Manual
(TSM), or TRICARE Reimbursement Manual (TRM) shall apply in the
state of Alaska except as specifically modified by this chapter.
Chapter references in this section refer to the TOM unless otherwise
specified. The word ‘contractor’ is used to reference the MCS contractor
throughout this chapter.
1.2 The TRICARE program is not automatically
implemented in all areas where it is potentially applicable. Implementation
of the program requires an official action by an authorized individual
in accordance with
32 CFR 199.17(a)(5). Network implementation
will be published in the Federal Register.
2.0 Optimization
While
overall responsibility and accountability remains with the Director,
TRICARE Regional Offices (TROs), the contractor is responsible for
managing network provider development and operations in the state
of Alaska.
2.1 Consistent with existing Memorandums
of Understanding (MOUs), the contractor shall optimize the Military
Treatment Facility (MTF) for all appropriate specialty requests
for care received from outside of the MTF within established TRICARE
guidelines and access standards. Specialty care that cannot be provided
by the MTF or scheduled within TRICARE access standards in the MTF
shall be referred to the network as determined by the contractor
in coordination with the MTF.
2.2 The contractor shall use every appropriate
opportunity for beneficiary and provider education to influence
beneficiary and provider behavior in a manner that encourages MTF
optimization.
3.0 Beneficiary
Satisfaction
The contractor shall achieve the
highest level of beneficiary satisfaction possible in the state
of Alaska. The contractor’s administrative processes shall be designed
and operate to ensure ease in accessing TRICARE information and
benefits. These processes shall be designed recognizing the unique nature
of health care delivery within the state of Alaska and continuously
operated in a manner that achieves the highest level of beneficiary
satisfaction. Additionally, beneficiary satisfaction activities shall
be coordinated with MTFs/eMSMs and the TRO-West Alaska Branch to
achieve a coordinated, uniform approach to Department of Defense
(DoD) customer services in Alaska.
4.0 Best Value
Health Care
The contractor shall support the
best value in the delivery of health care services in the state
of Alaska through the efficient operation of all administrative
processes. This includes supporting MTF right of first refusal,
educating beneficiaries and providers on the benefit of using the
MTF based on the collaborative agreement with the MTF Commander,
and efficiently and effectively operating all administrative processes.
5.0 Transitions
The contractor shall be fully responsible
for all transition activities in the state of Alaska. The contractor
shall ensure all required contractor services are fully operational
in accordance with
Chapter 2 with the exception of the provisions
of “Execution of Agreements With Contract Providers”. Those shall
not apply. However, the contractor shall load all preferred providers
to the contractor’s provider directory no later than 30 calendar
days prior to the start of health care delivery (SHCD), or at such other
time as mutually agreed between the contractor and the Defense Health
Agency (DHA).
6.0 Access To
Data
The contractor shall provide ready
access to Government personnel for the state of Alaska in the same
manner as provided in all other TRICARE West Region locations.
7.0 Administration
The contractor shall comply with
all provisions of
Chapter 1, with the following exceptions:
7.1 The contractor
accomplished preauthorization shall be limited to inpatient mental
health care for non-Prime enrollees and those enrolled to civilian
Primary Care Managers (PCMs). The MTF will preauthorize/authorize
all services for TRICARE Prime enrollees, as required. The contractor
shall comply with the preauthorization requirements specified in
Chapter 7, Section 2.
7.2 The
contractor shall process any grievance related to contractor personnel
or contractor actions. Grievances related to MTF providers shall
be forwarded to the responsible MTF within five calendar days of
receipt (see
paragraph 19.0 for appeals) for resolution.
The contractor shall process all grievances related to civilian
providers consistent with
Chapter 11, Section 8.
8.0 Records Management
The contractor shall comply with
the provisions of
Chapter 9.
9.0 Financial
Administration
The contractor shall comply with
all of the provisions of the
Chapter 3. The
contractor shall apply the appropriate financial provisions to the
claims for TRICARE enrollees in the state of Alaska based on the
Government’s ultimate decision regarding the underwriting of health
care performed in Alaska.
10.0
Provider
Certification And Credentialing
The contractor
shall comply with the provisions of
Chapter 4 for
providers rendering care in the state of Alaska.
11.0 Support Of
TRICARE Providers
11.1 The contractor is required to provide
assistance to the Government in servicing participating and non-participating
providers. This assistance shall include certifying and credentialing
providers according to
paragraph 10.0. The contractor shall provide
the appropriate level and number of provider representatives to
service the participating and non-participating providers throughout
the state of Alaska. The provider representative shall be located
in contractor furnished facilities in close proximity to the MTF.
The provider representative shall assist in establishing provider
networks. The contractor’s provider representatives shall also assist
providers with TRICARE questions/problems as necessary. In this
role, the provider representative shall be supported by all appropriate
contractor staff and systems. For example, if a provider wishes
to determine the status of a claim, the provider can call the contractor’s
claims information toll-free telephone number or check the status
via an electronic means. However, if a provider requests the assistance
of an individual on- site at the provider’s office to resolve problems,
the provider representative shall provide the assistance.
11.2 Alaskan
providers shall not be required to submit claims electronically.
As such, Alaskan claims shall be removed from both the numerator
and the denominator when computing the percentage of claims submitted
electronically.
12.0 Enrollment
The
contractor is responsible for all enrollment activity in the state
of Alaska in accordance with the provisions of
Chapter 6.
12.1 TRICARE Prime enrollments within
the state of Alaska shall all be to PCMs located within a MTF or
in Prime Service Areas (PSAs) around a limited number of MTFs/eMSMs,
to PCMs in the TRICARE network.
12.2 Where TRICARE Prime enrollment to
private sector PCMs is permitted, the contractor shall coordinate
with the MTF Commander to ensure the combined total of MTF and private
sector enrollees does not exceed the number for which compliance
with TRICARE Prime access to care standards can be assured, considering
MTF and preferred provider network resources together. Enrollment
will be to the MTF first and then to the private sector at the discretion
of the MTF Commander in coordination with the contractor.
13.0 Utilization
And Quality Management
The contractor shall comply with
the provisions of
Chapter 7, regarding utilization and quality management.
The MTF is responsible for issuing all authorizations for its Prime
enrollees. The contractor shall ensure that MTF issued authorizations
are entered into all applicable contractor systems to ensure accurate,
timely customer service, and claims adjudication.
13.1 Cases
for care rendered in the state of Alaska shall be included in the
selection of cases for review by the TRICARE Quality Management
Contract (TQMC) contractor per
Chapter 7, Section 3.
If the TQMC identifies an aberrant provider from the state of Alaska,
and the provider is a network provider, the contractor shall advise
the TRO-W Alaska Branch of the findings.
13.2 The contractor shall comply with
and include care rendered in the state of Alaska in its Clinical Quality
Management Program (CQMP) per
Chapter 7, Section 4.
The CQMP shall include a separate section specifically addressing
Alaska.
13.3 All potential quality issues and
unusual provider findings by the TQMC during their case reviews
shall be processed and investigated by the contractor per existing
Clinical Quality Management (CQM) policies.
14.0 claims Processing
The contractor shall process claims
in accordance with
Chapter 8.
15.0 Duplicate
Claims
The contractor shall comply with
the TSM,
Chapter 4, as appropriate, for the identification, correction
and resolution of duplicate and potentially duplicate claims.
16.0 Claims Adjustments
And Recoupments
The contractor shall comply with
the provisions of
Chapter 10, regarding claims adjustments and
recoupments.
17.0 Beneficiary
And Provider Services
17.1 The contractor shall comply with
the provisions of
Chapter 11, Section 1 relating
to the provision of marketing and education materials in the state
of Alaska.
17.2 The contractor shall comply with
the provisions of
Chapter 11, Section 2 and
the contract regarding briefings within the state of Alaska.
18.0 Customer
Service Operations
The contractor shall provide customer
service support to include benefit and enrollment assistance to
all beneficiaries in the state of Alaska. The functions of the contractor’s
call center shall be as specified in
Chapter 11.
In providing assistance with referrals, the contractor shall first
direct all beneficiaries to the MTF (beneficiaries referred out
of the MTF for specialty services shall not be referred back to
the MTF) and then to the network providers. The contractor shall
maintain an up-to-date on-line list of network providers.
18.1 The contractor
shall comply with the provisions of
Chapter 11, Section 3 in
accomplishing Beneficiary, Congressional, and Beneficiary Counseling
and Assistance Coordinator (BCAC) relations within the state of
Alaska.
18.2 The contractor shall comply with
the provisions of
Chapter 11, Section 4 in
responding to inquiries regarding TRICARE within the state of Alaska.
18.4 The contractor
shall provide toll-free telephone service to Alaskan beneficiaries
in accordance with the provisions of
Chapter 11, Section 6.
18.5 The contractor
shall provide allowable charge reviews in accordance with the provisions
of
Chapter 11, Section 7.
18.7 The contractor
shall administer collection actions against beneficiaries in accordance
with
Chapter 11, Section 9.
19.0
Appeals
And Hearings
The contractor shall implement and
operate an appeals system for services requested or rendered in
the state of Alaska in accordance with
Chapter 12.
20.0 Program Integrity
The state of Alaska shall be included
in the contractor’s
Regional Program
Integrity Program per
Chapter 13.
21.0 Audits, Inspections,
And Reports
21.1 The contractor shall comply with
the provisions of
Chapter 14, regarding audits, inspections, and
reports. The contractor shall provide a
Monthly
Preferred
Provider
Adequacy
Report
to the
Contracting
Office and the Director, TRO-W. Details for reporting are identified
by DD Form 1423, Contract Data Requirements List
(CDRL)
, located in Section J of the applicable contract.
21.2 The TRICARE
network shall be developed so that
75% of enrollee referrals are to an MTF or civilian network provider.
22.0 Director
And MTF/Contractor Interfaces
The contractor
shall comply with the requirements of
Chapter 15 when
developing and operating MTF and Director, TROs interfaces. The
contractor shall also enter into an agreement with the TRO-W Alaska
Branch, as required by the contract, regarding contractor activities
in the State of Alaska.
23.0 TRICARE Prime
Remote (TPR) Program
The contractor shall operate the
TPR program in the state of Alaska in accordance with
Chapter 16.
24.0 Civilian
Care Referred By MHS Facilities
The contractor
shall comply with the provisions of
Chapter 17 in
the
State of Alaska.
25.0 Civilian
Health Care (CHC) of Uniformed Service Members
The contractor
shall comply with the provisions of
Chapter 17 for
services in the state of Alaska provided through the Supplemental
Health Care Program (SHCP).
26.0 Demonstrations
The contractor shall comply with
the provisions of
Chapter 18 for eligible beneficiaries in the state
of Alaska.
27.0 Health Insurance
Portability And Accountability Act of 1996 (HIPAA)
The contractor shall comply with
the provisions of
Chapter 19 when administering the TRICARE program
in the state of Alaska.
28.0 TRICARE Dual
Eligible Fiscal Intermediary Contract (TDEFIC)
The contractor
shall not be responsible for services that are the responsibility
of the TDEFIC contractor in the state of Alaska. This does not relieve
the contractor from their customer service responsibilities to dual
eligible beneficiaries.