1.0 General
All TRICARE requirements regarding
Utilization Management (UM) and Quality Management (QM) shall apply
to the TRICARE Overseas Program (TOP) unless specifically changed,
waived, or superseded by the provisions of this section; the TRICARE
Policy Manual (TPM),
Chapter 12;
or the TRICARE contract for health care support services outside
the 50 United States (U.S.) and the District of Columbia (hereinafter
referred to as the “TOP contract”). See
Chapter
7 for additional instructions. Language in
Chapter
7 that has no direct application to the TOP contract does
not apply (e.g., Diagnosis Related Group (DRG) validation reviews
which are not applicable in any overseas location except Puerto
Rico).
2.0 Utilization Management
2.1 The contractor shall establish
a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries.
2.1.1 The contractor’s MM/UM Plan
shall recognize that the Military Treatment Facility (MTF) Primary
Care Manager (PCM) retains clinical oversight for TOP Prime enrollees.
As such, the enrolling MTF will determine medical and psychological
necessity, and issue all referrals for TOP Prime enrollees, and
provide UM and all case management services for the MTF-enrolled
population. The contractor shall ensure that MTF-issued referrals
and appropriate authorizations are entered into all applicable contractor
systems to ensure accurate, timely customer service and claims adjudication.
The contractor shall perform certain UM activities to assist the
MTF with the medical management of TOP Prime inpatients as described
in the TOP contract. The contractor shall provide notification to
the MTF Commander or designee whenever an MTF enrollee is admitted
to an inpatient facility (including mental health admissions), regardless
of location.
Note: Newborns/adoptees
who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment)
shall receive clinical oversight from the MTF.
2.1.2 The contractor shall determine
medical and psychological necessity, conduct covered benefit review,
and issue authorizations for specialty care for TOP Prime Remote
enrollees and all Service members who are on Temporary Duty/Temporary
Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed
on liberty in a remote overseas location. The contractor shall provide
notification of cases to the appropriate TRICARE Area Office (TAO)
for reviews involving remote Service member requests for specialty
care, and whenever hospital admissions have occurred for any beneficiary
not enrolled to a TOP MTF (including mental health admissions),
regardless of location.
Note: Newborns/adoptees who are deemed
enrolled in TOP Prime Remote (based on the sponsor’s TOP Prime Remote
enrollment) shall receive clinical oversight from the TOP contractor.
2.1.3 The contractor shall review
and authorize urgent care for beneficiaries enrolled to a stateside
contractor who are traveling outside of the 50 U.S. and the District
of Columbia.
2.2 The
MM/UM Plan shall recognize that purchased care sector network providers
are the responsibility of the TOP contractor and the contractor
shall ensure that any adverse finding related to purchased care
sector provider care is forwarded within five calendar days of identification
to the appropriate TAO.
2.3 The
MM/UM Plan shall include a process for identifying high utilization/high
cost patients and locations.
2.3.1 At
a minimum, this process shall include the identification of patients
exceeding the frequency and/or cost thresholds established in the
TOP contract. These thresholds apply to all TOP beneficiaries, including
TOP Prime, TOP Prime Remote, TRICARE Select, and TOP TRICARE For
Life (TFL).
2.3.2 The
TOP contractor shall review these claims for appropriateness of
care, and shall propose interventions to reduce overutilization
or contain costs whenever possible. Proposed interventions to cost
and/or overutilization shall be forwarded to the Government for
review prior to contractor implementation.
2.4 The MM/UM Plan shall integrate
efforts to identify potential fraud/abuse. Any cases identified as
possible fraud/abuse shall be referred directly and exclusively
to the Defense Health Agency (DHA) Program Integrity (PI) Office
in accordance with
Section 13.
2.5 The TOP contractor shall provide
case management services as outlined in the contract with DHA. Specific
case management processes shall be addressed in the Statements Of
Responsibilities (SORs) between the contractor, MTF Commanders,
and the TAO Directors.
2.6 The
TOP contractor shall closely monitor requests for inpatient care
or medical evacuation services to ensure that services are medically
or psychologically necessary and appropriate for the patient’s condition.
Beneficiaries will not be assigned to a particular facility or medically
evacuated to a particular geographic location based solely on personal
preference, but will be transported to the closest medical facility
capable of providing appropriate stabilization and/or treatment.
2.7 Inpatient stays that exceed
the standard Length-Of-Stay (LOS) for a local area in a purchased care
sector country or U.S. commonwealth/territory shall be identified
and reviewed for medical or psychological necessity. Unless a different
standard has been identified by the government, the contractor shall
use best business practices to determine the standard LOS for a
particular overseas location. Upon Government request, the TOP contractor
shall provide supporting documentation related to LOS determinations.
5.0
Referral/Authorization/Health
Care Finder (HCF) Requirements
5.1 The
TOP contractor shall develop procedures for processing referrals
for TOP Prime and TOP Prime Remote enrollees in accordance with
the TOP contract;
Chapter 8, Section 5;
and this chapter. The TOP contractor shall conduct related authorization
and HCF activities. The MTF will conduct medical and psychological
necessity reviews for TOP MTF enrollees and determine that the requested care
is not available in the MTF prior to forwarding the referral to
the contractor.
5.2 The
contractor shall conduct covered benefit reviews to determine whether
the referred care is a covered TRICARE benefit. Medical or psychological
necessity notification to beneficiaries regarding covered benefit
findings shall follow the provisions of
Chapter 8, Section 5.
The contractor shall locate an appropriate network or non-network
purchased care sector provider for all authorized care and shall provide
the provider information to the beneficiary. Upon beneficiary request,
the contractor shall assist with scheduling an appointment for the
beneficiary. The contractor shall also implement guarantee of payment
or other business processes to ensure that TOP Prime and TOP Prime
Remote beneficiaries have access to authorized care on a cashless,
claimless basis.
5.3 The
TOP contractor shall develop procedures for the identification and
tracking of TOP enrollee claims submitted by a purchased care sector
provider or a beneficiary without preauthorization/authorization.
5.4 The
TOP contractor shall educate beneficiaries of the preauthorization/authorization requirements
and of the procedures for requesting preauthorization/authorization.
In MTF locations, these beneficiary education efforts may be conducted
in conjunction with MTF staff. In remote locations, the contractor
shall provide all beneficiary education. Although beneficiaries
are required to obtain authorization for care prior to receiving
payment for the care requiring TOP preauthorization/authorization,
retroactive authorization may be requested following the care from
the appropriate authority for issuing authorizations. Specifically,
ADSMs enrolled in TOP Prime or TOP Prime Remote who seek urgent
care from a purchased care sector without obtaining authorization
will be required to contact their PCM within three business days
so that a retroactive referral may be submitted. Claims for ADSMs
shall be processed in accordance with
Section 25.
Retroactive authorization requests shall not be accepted by the
TOP contractor after this initial time frame without higher level
approval (TAO or TOP Office). The contractor shall document preauthorization/authorizations
according to current contract requirements.
5.5 If
medical review is required to determine medical or psychological
necessity of a service rendered, the TOP contractor shall follow
the requirements outlined in
Chapter 7, Section 1 related
to medical review staff qualifications and review processes.
5.6 The TOP preauthorization/authorization
must be submitted with the claim or be available via internal contractor
systems designated to interface with the claims processing system.
5.7 The
TOP contractor shall maintain a preauthorization/authorization file.
5.8 When
necessary, clarification of discrepancies between authorization
data and data on the claims shall be made by the TOP contractor
with the appropriate authorizing authority.
5.9 Except
for obstetrical care or other long-term/chronic care authorizations,
the TOP contractor shall consider authorizations valid for 180 days
(i.e., date of service must be within 180 days of issue date). Authorizations
may be granted for 365 days for obstetrical care, or for any other
long-term/chronic conditions for which an extended care period is
medically or psychologically necessary and appropriate. Only services
that are applicable to the care authorization shall be covered under
the authorization (i.e., a care authorization for obstetrical care
cannot be extended to cover specialty care that is unrelated to
the pregnancy).
5.10 Procedures
for preauthorizations/authorizations for TOP beneficiaries for inpatient
mental health care rendered in the 50 U.S. or the District of Columbia
shall be developed by the TOP contractor. The TOP contractor shall
authorize/review all stateside non-emergency inpatient mental health
care (i.e., acute hospitalization psychiatric care, psychiatric
Residential Treatment Center (RTC), Substance Use Disorder (SUD)
inpatient/residential detoxification and rehabilitation for TOP
Prime/TOP Prime Remote ADFMs, regardless of where the care is rendered.
To perform this requirement, the contractor shall at a minimum provide:
• Three
24-hour telephone lines: one stateside toll free, one commercial
and one fax for overseas inpatient mental health review requirement;
• Sample
forms for use by the referring physician when requesting preauthorization/authorization
for care; and
• A system for notification of
the contractor when care has been authorized. Additionally, the TOP
contractor shall:
5.10.1 Inform the beneficiary/provider
if a desired facility is not a TRICARE authorized facility and offer
the beneficiary/provider a choice of alternative facilities and
assist with identifying stateside facilities for referring providers.
5.10.2 Upon
request, either telephonically or by fax, from a referring provider,
the contractor shall initiate preauthorization prior to admission
for non-emergency inpatient care, including RTC, Substance Use Disorder
Rehabilitation Facility (SUDRF), etc. (Essentially, all admissions
defined by TPM,
Chapter 1, Section 6.1, as requiring preauthorization).
The TOP contractor shall arrange ongoing utilization review, as
indicated, for overseas beneficiaries admitted to any level of inpatient
mental health care.
5.10.3 The
review determination must conclude in either authorization or denial
of care. Review results must be submitted via Health Insurance Portability
and Accountability Act (HIPAA) compliant electronic means to the
beneficiary/provider within 24 hours of the request. The review
and denial process will follow, as applicable the processes outlined
in
Section 7.
5.10.4 The
TOP contractor shall provide an opportunity to discuss the proposed
initial denial determination with the patient’s attending physician
AND referring physician (if different providers). The purpose of
this discussion is to allow further explanation of the nature of
the beneficiary’s need for health care support services, including
all factors which preclude treatment of the patient as an outpatient
or in an alternative level of inpatient care. This is important
in those beneficiaries designated to return overseas, where supporting
alternative level of care may be limited, as well as support for intensive
outpatient treatment. If the referring provider does not agree with
the denial determination, then the contractor shall contact the
appropriate overseas TAO Medical Director to discuss the case. The
TAO Director shall provide the schedule and contact information
for all overseas TAO mental health advisors. The final decision
on whether or not to issue a denial will be made by the TOP contractor.
5.10.5 The
TOP contractor shall notify the referring provider if the patient
is returning to ensure coordination of appropriate after-care arrangements,
as well as facilitate discussion with the attending provider to
ensure continuity of care is considered with the proposed after-care
treatment plan.
5.10.6 The TOP contractor shall adhere
to the appeals process outlined in
Section 11.
5.11 The required data elements
for MTF referrals prescribed in
Chapter 8, Section 5 may
be altered to accommodate the delivery of health care overseas with
the permission of the Government.
Note: Any alteration to the referral
data elements prescribed in
Chapter 8, Section 5 must
be approved in writing by the DHA Contracting Officer (CO) prior
to implementation.
6.0 MEDICAL TRAVEL
6.1 TOP
Prime Enrollees and MTF-Referred Transient Beneficiaries
If
the TOP contractor’s HCF determines that appropriate medical or
psychological care is not available in the beneficiary’s local service
area, the TOP contractor shall provide a Notification of Case (NOC)
Report to the appropriate TAO per the medical travel requirements.
Details for reporting are identified in DD Form 1423, Contract Data
Requirements List (CDRL), located in Section J of the applicable
contract. The NOC Report shall identify the nearest purchased care
sector provider or facility that can provide adequate specialty
care. The TOP contractor shall issue a care authorization upon MTF’s
request (as documented in the MTF’s response to the NOC Report).
6.2 TOP Prime Remote and Self-Referred
Transient Beneficiaries
If the TOP contractor’s HCF
determines that appropriate medical or psychological care is not available
in the beneficiary’s local service area, the TOP contractor shall
provide a NOC Report to the appropriate TAO per the medical travel
requirements. Details for reporting are identified in DD Form 1423,
CDRL, located in Section J of the applicable contract. The NOC Report
shall identify the nearest purchased care sector provider or facility
that can provide adequate specialty care. The TOP contractor shall
issue a care authorization upon TAO’s request (as documented in
the TAO’s response to the NOC Report).