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TRICARE Operations Manual 6010.62-M, April 2021
Prescription Monitoring Program (PMP)
Chapter 28
Section 3
Provider Prescription Monitoring Program (PMP)
For the purpose of this section, the term “contractor” applies to the Managed Care Support Contractor (MCSC) and Uniformed Services Family Health Plan (USFHP) Designated Providers (DPs).
1.0  GOALS
1.1  The provider PMP is a quarterly review of all providers who prescribed controlled substances prescriptions, such as opioids, for beneficiaries using TRICARE benefits. The program goals include:
1.1.1  Maintaining compliance with the guidelines described within 32 CFR 199.4;
1.1.2  Monitor provider prescribing practices of controlled substances, such as, but not limited to, opioids;
1.1.3  Ensure providers are practicing within the appropriate clinical practice guidelines according to specialty and disease/condition;
1.1.4  Provide education and resources to providers when needed; and
1.1.5  Improve communication with providers and increase safety and effectiveness of treatment.
1.2  The contractor’s intervention plan shall, at a minimum:
1.2.1  Be an alert to the provider and lead to education, training, and appropriate referrals to the contractors’ Quality and/or Program Integrity departments;
1.2.2  Be an alert to the provider to participate in education consistent with industry best practice and standard of care clinical practice guidelines, such as, the Center for Disease Control and Prevention (CDC) and Veterans Health Administration (VHA)/Department of Defense (DoD) related guidelines;
1.2.3  Provide contractually available resources to complement or manage the provider’s patient population; and
1.2.4  Present knowledge and training opportunities to support the provider’s prescribing practices.
1.3  The contractor shall educate providers on the Substance Abuse and Mental Health Services Administration (SAMHSA) training, such as buprenorphine training, to practice Medication Assisted Treatment (MAT) when appropriate as outlined in paragraph 3.0.
2.1  Provider Identification
2.1.1  Each quarter, the Defense Health Agency (DHA) Pharmacy Operations Division will generate a report for each of the contractors (except for USFHP), a list outlining the controlled substances prescribing practices of all providers.
2.1.2  The bounds of generally accepted prescribing practices will be based upon the industry’s best practices and clinical practice guidelines for identifying and preventing unnecessary prescribing or over-prescribing of controlled substances, such as opioids. These parameters may evolve and are not made publicly available.
2.1.3  Providers that fall outside of what are considered to be normal prescribing patterns for controlled substances shall be subject to a more in-depth review.
2.1.4  The data provided to the contractor will be divided into subsets based upon region location (e.g., business address of the provider).
2.1.5  The report is sent to the contractors (except for USFHP) for medical review. The report will identify providers as new or existing on prior reports.
2.2  Provider Review
2.2.1  The contractor shall designate a reviewer. The contractor’s reviewer shall be a contractor’s Chief Medical Officer (CMO) or a person approved by the CMO. The contractor’s reviewer shall:  Have the appropriate credentials to review standard of care determinations (see Chapter 7, Section 4).  Review providers on the quarterly report (see paragraph 2.1) and make determinations based upon prescribing practices seen over the duration of the report.  Conduct a medical review of the provider’s prescribing history to validate the practices with the medical diagnosis and patient dosing history, appropriateness of care, and to ensure the prescription(s) were written and dispensed in support of a legitimate medical purpose and incorporate:  The level of review necessary is the breadth and depth needed to make an accurate determination.  Other relevant information as necessary to make an accurate determination to include, but not limited to claims review, record review, cross referencing with other applicable program.
2.2.2  The contractor shall provide a medical review to determine potential unnecessary prescribing or over-prescribing, if during the quarter it has concerns about provider prescribing controlled substances, are identified by other entities or reviewers in the course of business.  Give priority to these reviews over the quarterly list; and  The Government may include these individuals towards the contractor’s minimum review per quarter (see paragraph 2.2.1) based on the contractor’s response.
2.3  The contractor shall coordinate efforts with other TRICARE contractors as needed, such as when a provider may see TRICARE beneficiaries from another region, or overseas locations.
2.4  The contractor shall prioritize and review a minimum of 0.5% of the top and/or outlying prescribing practices or an amount designated by DHA not to exceed 100 cases per quarter from the quarterly list. Providers associated with beneficiaries identified in the Beneficiary PMP shall be prioritized for review.
2.5  The contractor shall select varying medical conditions and physician specialty types unless directed by DHA. See paragraph 2.6 for responses, and paragraph 2.7 for responses that count towards the minimum review.
2.6  The contractor shall, at a minimum, review the data generated on the quarterly report and provide a response in the following manner:
•  No Action (provider’s prescribing deemed appropriate)
•  Intervention plan with education only
•  Intervention plan with escalation
•  Further monitoring needed
•  Not Reviewed
2.7  The contractor shall document each provider as either no action, intervention plan with education only or escalation count towards cases reviewed. See paragraph 4.0 for report information.
2.8  The Government will identify and flag previously reported providers in the generation of a new report for the next quarter for trending across quarters, and when further monitoring is needed.
3.1  The contractor shall develop an intervention plan if any inconsistencies with prescribing and medical diagnosis and/or over-prescribing concerns for the medical diagnosis are noted by the reviewer.
3.2  The contractor shall initiate interventions no later than the following quarter after the initial quarterly review.
3.3  Intervention Plan With Education Only
3.3.1  The contractor shall, based upon the outcome of the review, target the individual TRICARE provider with interventions.
3.3.2  The contractor shall, in cases where interventions are deemed appropriate, use industry best practices to intervene and educate providers. At a minimum, the intervention plan shall include:  An alert to the individual provider to include Clinical Practice Guideline education, such as the CDC, VHA DoD, and nationally recognized professional organizations’ recommended guidelines;  Contractually available resources or other covered TRICARE benefits to complement their patient population (such as covered Substance Use Disorder (SUD) and mental health treatment, covered alternative pain-related medication and treatments, and applicable supportive clinical programs); and  Knowledge and training opportunities to support the provider, such as state Prescription Drug Monitoring Programs (PDMP) and SAMHSA training, such as buprenorphine training, to provide MAT when appropriate.
3.3.3  The contractor shall direct targeted providers to their website for educational materials dedicated to support providers that prescribe controlled substances, such as opioids.
3.3.4  The contractor shall use existing provider information modalities (i.e., newsletters, email blasts, etc.) to disseminate information to educate providers.
3.3.5  The contractor shall develop a process to include timelines in which targeted providers acknowledge the alert, education, and intervention plan consistent with nationally recognized clinical practice guidelines and recommendations (US Department of Health and Human Services (HHS), CDC, etc.).
3.3.6  The contractor shall submit the results of the provider’s response to the Government. For reporting requirements refer to DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
3.3.7  The contractor’s intervention plan with education materials shall be made available to the Government and subject to review by the Government.
3.3.8  The contractor’s medical review and intervention decisions are subject to review by the Government.
3.3.9  The Government has the right to request the contractor to conduct a clinical quality review, case investigation, and report their findings to the Government.
3.3.10  The Government may request the contractor to take necessary steps to safeguard the safety of TRICARE beneficiaries.
3.4  Intervention Plan With Escalation
3.4.1  The contractor shall initiate an intervention plan with escalation when there are concerns of a clinical variance warranting further review and investigation for determination of the presence of an actual Quality Issue (QI) or potential fraud.
3.4.2  The contractor shall initiate warrants suspension, denial, and recoupment of claims when a possible drug abuse situation is identified.
The contractor (excluding Markets/Military Medical Treatment Facilities (MTFs)) shall provide to the Government a quarterly summary status report of all reviewed and targeted providers to include provider name, summary of the clinical review, number of interventions, type of interventions, and number not provided intervention (e.g., dosing and prescriptions were deemed appropriate) and provide rationale (e.g., cancer clinic). See paragraph 1.2. Details for reporting are identified in DD Form 1423, CDRL, located in Section J of the applicable contract.
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