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.