TRICARE Regional Offices (TROs)/Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) and Contractor Interfaces
Chapter 15
Section 1
Director,
TRICARE Regional Offices (TROs), Military Treatment Facility (MTF)
Commander/Enhanced Multi-Service Market (eMSM) Manager, and Contractor
Interface
Revision: C-26, May 30, 2018
The
contractor shall assist the Director, TROs and MTF Commanders/eMSM
Managers in coordinating health care delivery in their Prime Service
Areas (PSAs)/markets and in ensuring the optimal use of MTF/eMSM
capacities. The contractor shall define this activity through Memoranda
of Understanding (MOU). Each MOU shall describe the processes expected
to be executed in good faith by each party to operate the TRICARE
Program in accordance with the performance based objectives of the
Managed Care Support (MCS) contract(s) and TRICARE Manuals (see
Addendum A).
The
MOU shall follow the format in
Addendum A.
Copies of local program documentation may be obtained through the
TRO. The contractor shall provide copies of each MOU executed to
the Procuring Contracting Officer (PCO) through the TRO, within
10 calendar days following the execution of the MOU by the contractor
and the MTF Commander/eMSM Manager. All MOUs shall be approved by
the TROs and with final approval by the PCO.
As
described in
Addendum A, the MOU consists of two parts:
a core document that describes major MTF/eMSM support processes
which are standard throughout the region and a supplemental attachment
that documents operational information that is unique to each MTF/eMSM
(i.e., Right of First Refusal (ROFR) capabilities table, Point of
Contact (POC) information, after hours care instructions, enrollment
guidance, etc.). The core document is not expected to change often,
but any such changes will be vetted and incorporated at the annual
review at the beginning of an option period. Information in the
supplemental attachment may be changed at any time. Once signed
at the beginning of an option period, the core MOU document stands
and does not need to be affirmed if MTF Commanders/eMSM Managers
change.
The
MOU will remain in force throughout the duration of the contract,
unless any party provides a written notice of intention to modify
at least
90 days prior to the new option
period. In the event that such notice is provided, but has not been
negotiated as of the end of the current option period, the MOU will
remain in effect until a modification is agreed upon and approved.
If no modification is necessary, the contractor will prepare and
submit an Affirmation of MOU Review (
Addendum A)
90 days
prior to the end of each option period.
1.0 COORDINATION PROCEDURES TO
ENSURE OPTIMIZATION
The
contractor shall meet with the TRO and each MTF Commander/eMSM Manager
to discuss MTF/eMSM optimization and to enter into written agreements
to ensure the MTF/eMSM receives the workload that supports their
business plan and optimization initiatives. These agreements shall
be utilized to optimize MTF/eMSM capabilities and capacities and
provide mechanisms to reallocate workload, establish priorities
for needed network development, and determine Primary Care Manager (PCM)
assignment locations for enrollees. The agreements may be modified
during the year; however, all agreements/modifications shall be
concurred upon by the Director, TROs and CO prior to implementation.
The MTF/eMSM will provide the contractor with the current status
of their capabilities and available capacity. The contractor shall
be responsible for initiating meetings and/or other actions with
the TRO and the MTF Commander/eMSM Manager to assist in remedying
problems which can be resolved within the scope of the contractor’s
responsibility and authority. The contractor shall follow the direction
of the MTF Commander/eMSM Manager, in consonance with the TRO, regarding
the priorities for the assignment of enrollees to PCMs. Additionally,
the contractor shall respond to requests for meetings regarding
capabilities and optimization initiated by the TRO and MTF Commander/eMSM Manager.
The contractor shall provide appropriate staff to meet with the
TRO and/or MTF Commander/eMSM Manager within two work days of receiving
either a verbal or written request.
2.0 TRO AND MTF/
eMSM
INTERFACE FOR PRIMARY CARE MANAGEMENT
Both civilian and military
individual providers may act as PCMs for TRICARE Prime. During the MOU
development process, the contractor shall obtain guidelines from
the TRO and the MTF Commander/eMSM Manager for PCM assignment (by
category of beneficiary) or choice for enrollees who reside in the
MTF/eMSMs’ PSAs. MTF Commanders/eMSM Managers will designate whether
these enrollees shall have MTF/eMSM or network PCMs and may be subject
to change as impacted by changing MTF/eMSM capacities. The contractor
shall assign enrollees to PCMs in accordance with the MTF Commander’s/eMSM
Manager’s directions.
3.0 MTF/
eMSM
INTERFACE FOR SPECIALTY SERVICES
The contractor shall obtain
direction from the MTF Commander/eMSM Manager regarding which specific
specialty services shall be referred to the MTF/eMSM in accordance
with Military Health System (MHS)/eMSM optimization goals. Non-Prime
beneficiaries shall be encouraged to use available MTF/eMSM specialty
services in lieu of civilian providers.
4.0 ADMINISTRATIVE COORDINATION
WITH THE TRO AND MTF/
eMSM
The contractor shall meet with
each MTF Commander/eMSM Manager or designee and TRO representative
at least quarterly. These meetings shall review current contractor
activities in enrollment, quality management, utilization management,
marketing, network development, external resource sharing and other
activities, such as briefings to provider or beneficiary groups
or interface with Congressional or other Governmental officials.
The contractor shall also meet with the Director, TROs or designee
at least quarterly to facilitate activity coordination between the
MTFs/eMSMs and civilian networks. The frequency of these meetings
may be altered at the discretion of the MTF Commander/eMSM Manager
and/or the Director, TROs.
5.0 TRO AND MTF Commander/
eMSM
Manager LIAISON
The
contractor shall ensure that the TRO and the MTF Commanders/eMSM
Managers have access to contractor personnel to facilitate MTF/eMSM
interface activities and shall ensure that MTF Commanders/eMSM Managers
are kept informed of contractor program or policy changes which
affect the MTFs/eMSMs.