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:
3.3.2.1 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;
3.3.2.2 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
3.3.2.3 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.