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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Medicare Eligible Program (TMEP)
Chapter 20
Section 7
Medical Management (MM), Utilization Management (UM), and Quality Management (QM)
All TRICARE requirements noted in Chapter 7 regarding MM, UM, and QM shall apply to the TMEP unless specifically changed, waived, or superseded by this section (as indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.
1.0  Medical Management/Utilization Management (MM/UM)
1.1  The provisions of Chapter 7, Section 1 are applicable to TMEP when TRICARE is primary payer, except for Chapter 7, Section 1, paragraphs 1.0 through 1.2.3, 4.0, 7.7, 8.0 through 8.2, and 11.0 through 11.4.
1.2  Regions-specific UM provisions do not apply to TMEP.
2.0  Preauthorization
2.1  The provisions of Chapter 7, Section 4 are applicable to TMEP. The special authorization/preauthorization services outlined in this section and in the TPM, Chapter 1, Section 6.1 require preauthorization, and if necessary, review of waivers of the day limits when TRICARE is primary payer. As secondary payer, TRICARE will rely on and not replicate Medicare’s determination of medical necessity and appropriateness in all circumstances where Medicare is primary payer.
2.2  In the event that TRICARE is primary payer for these services and preauthorization was not obtained, the contractor shall obtain the necessary information and perform a retrospective review.
3.0  Contractor Relationships with the TRICARE Quality Monitoring Contract (TQMC)
The provisions of Chapter 7, Section 7 are applicable to TMEP in instances where records are requested. Routine record requests are not anticipated from TMEP.
4.0  Clinical Quality Management Program (CQMP)
The provisions of Chapter 7, Section 6 are not applicable to TMEP.
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