2.0 UM
2.1 The contractor
shall establish a MM/UM Plan for care received by TRICARE beneficiaries.
2.1.1 The contractor’s
MM/UM Plan shall recognize that the Military Medical 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 (CM) 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 MM 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 specialty care for beneficiaries
enrolled to a stateside contractor who are traveling outside of
the 50 US and the District of Columbia.
2.2 The MM/UM
Plan shall recognize that private sector care network providers
are the responsibility of the TOP contractor and the contractor
shall ensure that any adverse finding related to private sector
care 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 14.
2.5 The TOP
contractor shall provide CM services as outlined in the contract
with DHA. Specific CM 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 private sector care country or US 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
private sector care 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 private sector care 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 private
sector care without obtaining authorization will be required to
contact their PCM within three business days so that a retroactive
referral may be submitted. 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 calendar days (i.e.,
date of service must be within 180 calendar 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 US 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 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 12.
5.11 The required
data elements for MTF referrals prescribed in
Chapter 8, Section 5, paragraph 6.1 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, paragraph 6.1 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 Notification of Case (NOC) to the appropriate
MTF per the medical travel requirements of DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract. The NOC shall identify the nearest private sector care
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).
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 to the appropriate TAO per the medical travel
requirements of DD Form 1423, CDRL, located in Section J of the
applicable contract. The NOC shall identify the nearest private
sector care 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).