1.0 UM
1.1 The contractor
shall ensure that all utilization and quality review requirements
are applied to all beneficiaries living within the region, to all
beneficiaries receiving care in the geographic area of responsibility regardless
of their place of residence, and to all providers delivering care
within the geographic area of responsibility.
1.2 The contractor shall be considered
a multi-function Peer Review Organization (PRO) under this contract.
1.3 The contractor shall ensure
that all providers are subject to the same review standards and
criteria in accordance with a multi-function PRO and
32
CFR 199.15.
1.4 The contractor,
using its authority as a PRO, shall apply its own UM practices to
inpatient care received by Market/Military Medical Treatment Facility
(MTF) enrollees in a civilian setting consistent with Market/MTF
referral instructions.
2.0 NOTIFICATION OF UTILIZATION
REVIEW REQUIREMENTS
2.1 The contractor shall provide
education and training to providers and beneficiaries on the requirements and
benefits of UM standards.
2.2 The contractor
shall provide a process and method of notification for all providers,
both network and non-network, of all review requirements such as:
• Prospective review (preadmission/preauthorization)
• Concurrent review/continued
stay review
• Retrospective review
3.0 REVIEWER QUALIFICATIONS AND
PARTICIPATION
3.1 Peer Review By Physicians
3.1.1 Except as provided in
paragraph 3.1.2,
each person who makes an initial or reconsideration denial determination
or standard of care determination about services furnished or proposed
to be furnished by a licensed doctor of medicine (MD) or osteopathy
(DO) or by a doctor of dentistry must be another licensed doctor
of medicine in a like specialty, or osteopathy in a like specialty,
or dentistry with an active clinical practice in the PRO area, if
the initial, reconsideration, or standard of care determination
is based on lack of medical necessity or other reason relative to
reasonableness, necessity, or appropriateness. The Government Designated
Authority (GDA) reserves the right to approve an appropriate alternate
peer reviewer on a case-by-case basis.
3.1.2 If a PRO determines that peers
are not available, then a nationally accredited external independent review
organization shall be used to make the determinations.
3.2 Peer Review By Health Care
Practitioners Other Than Physicians
Health care practitioners other
than physicians may review services and/or make standard of care
determinations for services furnished by other practitioners in
the same professional field and specialty.
3.3 Diagnosis Related Group (DRG)
Validation Review
3.3.1 Decisions about procedural
and diagnostic information must be made by physicians.
3.3.2 Technical coding issues must
be reviewed by individuals with training and experience in International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding
(for outpatient services with dates of service or inpatient services
with dates of discharge provided before the mandated date, as directed
by Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation) and in ICD-10-CM
coding (for outpatient services with dates of service or inpatient
services with dates of discharge provided on or after the mandated
date, as directed by HHS, for ICD-10 implementation, or International Classification
of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
for inpatient services with dates of discharge provided on or after
the mandated date, as directed by HHS, for ICD-10 implementation).
3.4 Persons Excluded From Review
3.4.1 A person may not review health
care services or make initial denial determinations or changes as
a result of DRG validations if he or she, or a member of his or
her family:
• Participated in developing
or executing the beneficiary’s treatment plan.
• Is a member of the beneficiary’s
family.
• Is a governing body member,
officer, partner, 5% or more owner, or managing employee in the
health care facility where the services were or are to be furnished.
3.4.2 A member of a reviewer’s family
is a spouse (other than a spouse who is legally separated under
a decree of divorce or separate maintenance), child (including a
legally adopted child), grandchild, parent, or grandparent.
3.5 Administrative Requirements
Each review shall be dated
and include the signature, legibly printed name, clinical specialty,
and credentials of the reviewer. Each reviewer shall include rationale
for his or her decision (i.e., a complete statement of the evidence
and the reasons for the decision).
4.0 PREADMISSION AND PREAUTHORIZATION
4.1 The contractor shall perform
benefit and medical necessity reviews for all TRICARE-eligible beneficiaries for
preadmission, preauthorization, and other services requiring special
authorization in accordance with
Chapter 1, Section 3;
Chapter 7, Section 5; TRICARE Policy Manual
(TPM),
Chapter 1, Section 6.1;
32
CFR 199.4;
32 CFR 199.5; and
the other TRICARE Manuals when care occurs in the private sector.
4.1.1 The contractor shall perform
benefit and medical necessity reviews for Active Duty Service Members (ADSMs)
within the Episode of Care (EOC) for preadmission, preauthorization,
and other services requiring special authorization in accordance
with
Chapter 1, Section 3,
Chapter 7, Section 5,
Chapter 17, Section 3,
32
CFR 199.4,
32 CFR 199.5,
and the other TRICARE Manuals once care is occurring in the private
sector.
4.1.2 The contractor shall perform
preadmission and preauthorization reviews listed in the table in
paragraph 4.2.
These admissions and procedures are subject to change over time
based upon the Government’s assessment of the efficacy of the review.
The changes will include adding or removing admissions or procedures.
4.2 The contractor shall propose
additional authorization reviews and coordinate the list to the
appropriate GDA. In those instances where a contractor requires
authorization of services in addition to those listed below, such authorization
must be available to and appealable by all beneficiaries, who reside
within its jurisdiction.
|
PREAUTHORIZED INPATIENT ADMISSIONS
INCLUDE:
|
|
Any inpatient hospitalization
unless emergency.
|
|
Non-emergency inpatient Mental
Health (MH) and Substance Use Disorder (SUD) services.
|
|
Skilled Nursing Facility (SNF)
care.
Note: SNF care
received in the United States (US) and US territories must be preauthorized
for all TRICARE beneficiaries to include dual eligible beneficiaries.
The TRICARE Medicare Eligible Program (TMEP) contractor shall preauthorize
SNF care beginning on day 101, when TRICARE becomes primary payer.
|
|
Organ and stem cell transplants.
|
|
Inpatient care at a rehabilitation
facility.
|
|
Inpatient care at a Residential
Treatment Facility (RTF).
|
|
The Following Services shall
Be Preauthorized:
|
|
Adjunctive Dental
|
|
Applied Behavior Analysis (ABA)
Services
|
|
Extended Care Health Option
(ECHO) Services
|
|
Home Health Care (HHC)
|
|
Hospice
|
Provisional Coverage for Emerging
Services and Supplies, if required (see TPM, Chapter 13, Section 1.1.) |
Low Protein Modified Foods
(LPMF) for the treatment of Inborn Errors of Metabolism (IEM) (see
TPM, Chapter 8, Section 7.2) |
|
Dental Anesthesia and Institutional
Benefits
|
Electroconvulsive Therapy (ECT)
(see TPM, Chapter 13, Section 1.1). |
Transcranial Magnetic Stimulation
(TMS) (see TPM, Chapter 13, Section 1.1) |
Psychoanalysis (see TPM, Chapter 13, Section 1.1) |
Spravato™ (esketamine) nasal
spray shall be preauthorized under the medical benefit (see TPM, Chapter 7, Section 3.8) |
4.3 The contractor
shall advise beneficiaries, sponsors, providers, and other responsible
persons of those benefits requiring preadmission or preauthorization.
4.4 The contractor shall provide
criteria to eligible beneficiaries and providers for cases where preauthorization
is not required, to enable beneficiaries to confirm a TRICARE benefit.
4.5 When the beneficiary has other
insurance that provides primary coverage, exception to the preauthorization
requirements shall apply as provided in the TPM,
Chapter 1, Section 6.1.
4.6 The contractor shall perform
retrospective reviews for medical necessity when the contractor
is acting as the secondary payer.
4.7 The contractor
shall issue notification of preadmission and preauthorization approval
to the beneficiary, parent or guardian of a minor or incompetent
adult, the provider, and to its claims processing staff.
4.7.1 Notification may be made in
writing by letter, or on a form developed by the contractor.
4.7.2 These forms and letters are
all referred to as TRICARE authorization forms.
4.8 ADSMs who have sustained an
amputation shall be considered for transfer or admission to an appropriate
Department of Defense (DoD) Advanced Rehabilitation Center (ARC),
Center of Excellence (CoE).
5.0 ARC PREAUTHORIZATION
5.1 The contractor shall contact
one of the three DoD ARCs for all ADSMs with referrals for amputations
to ensure an ARC assessment has been completed with a care plan
in place prior to authorizing rehabilitative treatment at a private
sector care provider or facility.
5.2 The DoD
ARCs: (1) Center for the Intrepid (CFI), San Antonio Military Medical
Center (SAMMC), San Antonio, Texas; (2) Military Advanced Training
Center (MATC), Walter Reed National Military Medical Center (WRNMMC),
Bethesda, Maryland; and (3) the Comprehensive Combat and Complex
Casualty Care (C5), Naval Medical Center, San Diego, California.
The assigned MTF (or Defense Health Agency-Great Lakes (DHA-GL)
for TRICARE Prime Remote (TPR) enrollees) and the ARC will determine
appropriateness of the transfer/referral.
5.3 The contractor
shall facilitate the transfer or admission of the ADSM based on
the patient’s condition if care is available within access standards
and appropriate in one of these facilities.
5.4 The contractor shall provide
a report of all referrals for amputations to ensure ARC coordination
has been completed. For reporting requirements, see DD Form 1423,
Contract Data Requirements List (CDRL), located in Section J of
the applicable contract.
6.0 MH AND SUD PREADMISSION AND
PREAUTHORIZATON
6.1 Inpatient MH and SUD
6.1.1 The contractor shall require
preauthorization for all non-emergency inpatient MH services.
• Acute hospitalization psychiatric
care
• Residential Treatment Center
(RTC) care
• SUD inpatient hospitalization
• SUD residential
6.1.2 The contractor shall, in the
event that non-emergency inpatient MH services were not preauthorized, obtain
the necessary information and complete a retrospective review. Penalties
for failing to obtain preauthorization apply (see
32
CFR 199.15).
6.1.3 The contractor
shall not require referral or authorization for emergent inpatient
MH or SUD admissions.
6.1.4 The contractor
shall issue an authorization for acute inpatient MH care for no
more than seven calendar days at a time.
6.1.5 The contractor
shall follow up within two business days of an MH inpatient discharge
to ensure the beneficiary has a follow up appointment secured within
seven calendar days of discharge.
6.1.6 The contractor
shall make at least three outreach attempts on three separate days/times
and note the attempts in their system prior to sending an unable
to reach letter.
6.1.7 The contractor
shall note the follow-up appointment date and time and outreach
to the beneficiary within two business days following the appointment
to ensure the beneficiary was seen, and if not, assist the beneficiary
with securing another appointment.
6.1.8 The contractor
shall make at least three outreach attempts on three separate days/times
and note the attempts in their system prior to sending an unable
to reach letter.
6.2 Outpatient
MH and SUD
6.2.1 The contractor shall require
a Primary Care Manager (PCM) referral for non-office based, outpatient (e.g.,
Partial Hospitalization Program (PHP) or Intensive Outpatient Program
(IOP) and Opioid Treatment Program (OTP)) MH and SUD services. However,
if the non-office based, outpatient MH provider is a network provider,
a request for preauthorization from the network provider to the
contractor may be accepted in lieu of the PCM referral.
6.2.2 The contractor shall not require
referral or preauthorization for office-based outpatient MH treatment, including
Medication Assisted Treatment (MAT) and Office Based Opioid Treatment
Programs (OBOT).
6.3 The contractor
shall comply with the provisions of
Chapters
16 and
17 when processing
requests for active duty personnel. See
Chapter 16, Sections 2 and
6 for
referral requirements under the TPR program. ADSMs require referral
and preauthorization before receiving any MH and SUD services.
7.0 EFFECTIVE AND EXPIRATION DATES
The contractor shall ensure
preadmissions and preauthorizations have an effective date and an
expiration date.
8.0 BENEFIT POLICY DECISIONS
8.1 TRICARE versus local policy.
TRICARE policies have precedence over any local or internal policy
of the contractor or the medical community of the region.
8.2 The contractor shall notify
DHA within one business day of any conflicts between TRICARE policy
and local policy. Variations from policy, which expand, reduce,
or adjust benefit coverage shall be referred to DHA for approval
before being implemented.
8.3 The contractor
shall provide details on how notification will occur in the Medical
Management (MM) Program plan.
9.0 DOCUMENTATION
9.1 The contractor
shall establish a process for providing beneficiaries and providers
with the written results of all preadmission and preauthorization
activities affecting benefit determinations.
9.2 The contractor shall complete
and mail denial notifications to beneficiaries and providers within
the time limits established in accordance with
Chapter
12.
9.3 The contractor shall issue
notification of preadmission and preauthorization approval or denial
to the beneficiary or parent or guardian of a minor or incompetent
adult, and the provider.
9.4 The contractor’s
response to referrals and authorizations shall identify any requested
provider and services that are excluded from coverage and the reason(s)
therefore, and will either not be paid by TRICARE, or paid under
the Point of Service (POS) option, if applicable.
9.5 A preauthorization based on
a contractor’s medical necessity or UM determination is not required
when a network PCM or network specialty care provider makes a referral
to a network specialty care provider except as required under
Section 2. For additional information on access
standards for enrollees, see
32 CFR 199.17(p)(5).
9.6 The contractor
shall ensure that mailed notifications of denials include:
• Patient’s name.
• Sponsor’s name.
• Last four digits of the sponsor’s
Social Security Number (SSN).
• The clinical rationale for
denial of specific services (form letters are unacceptable as the
clinical rationale shall provide a complete explanation, referencing
any and all appropriate documentation, for the cause of the denial).
• All applicable appeal and grievance
procedures.
• The name and telephone number
of an individual from whom additional information may be obtained.
10.0 CONCURRENT REVIEW REQUIREMENTS
10.1 The contractor shall conduct
a concurrent review for continuation of stay for all inpatient and institutional
services, no less frequently than every 30 calendar days, both medical
and MH, and authorize, as appropriate, additional days.
10.2 The contractor shall ensure
the frequency of the reviews for continuation of stay is based on
the severity or complexity of the patient’s condition or on necessary
treatment and discharge planning activity.
10.3 The contractor
shall ensure the criteria utilized in the context of the concurrent
review places special emphasis on evaluating the progress being
made in the active individualized clinical treatment being provided
and on developing appropriate discharge plans.
10.4 For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
10.5 INPATIENT MH AND SUD CONCURRENT
REVIEW
Medical
and psychological necessity will determine the Length-of-Stay (LOS)
for treatment in an acute inpatient MH care facility.
10.5.1 The contractor shall conduct
concurrent reviews determination for continuation of inpatient MH services
and SUD within one business day of notification of emergency admissions
and authorize, as appropriate, additional days.
10.5.2 The contractor shall conduct
initial concurrent reviews of all other non-emergent acute inpatient
MH, RTC care, and SUD admissions within three business days of admission
or the in the case of an emergency admissions three business days
following the initial concurrent review.
10.5.3 The contractors shall conduct
subsequent concurrent reviews no less frequently than every seven calendar
days.
10.5.4 The contractor shall conduct
concurrent review for continuation of RTC services no less frequently
than every 30 calendar days. The criteria for concurrent review
shall be those set forth in TPM,
Chapter 7, Section 3.2.
10.5.4.1 The contractor shall notify
the RTC regarding the decision of concurrent review within three
business days of the review, and shall be followed with written
confirmation to the provider and the beneficiary.
10.5.4.2 The contractor shall ensure
the RTC concurrent review takes into account the provision of family therapy
pursuant to TPM,
Chapter 7, Section 3.12.
10.5.4.3 If family therapy is inappropriate
due to the particular circumstances of the case, supporting documentation
and rationale must be provided in the treatment plan. An example
of such circumstances might include not returning to the family
unit following treatment.
10.5.4.4 The contractor shall notify
the DHA within one business day if the contractor finds that a facility’s treatment
planning demonstrates a pattern of failure to provide for family
therapy, as this constitutes a violation of the standards and may
reflect domiciliary care.
10.5.5 The contractor shall conduct
concurrent review for continuation of inpatient and rehabilitation
SUD services no less frequently than every 30 calendar days. The
criteria for concurrent review shall be those set forth in TPM,
Chapter 7, Section 3.3.
10.5.6 The contractor shall notify
the treating provider regarding the decision of concurrent review
within one business day of the review, and shall be followed with
written confirmation to the provider and the beneficiary.
11.0 AMBULATORY CARE FOCUSED REVIEWS
11.1 The contractor shall conduct
quarterly comprehensive ambulatory care focused reviews of a statistically valid
sample or 50 records, whichever is greater, of medical records per
option period focused on ambulatory medical necessity and quality
of care provided in high risk settings such as, but not limited
to, emergency room, Ambulatory Surgical Centers (ASC) and Urgent
Care Centers (UCCs), MH and SUD PHPs, IOPs and OTPs.
11.2 The Government will provide
the contractor with specific review topics, criteria for selection
and time frame from which the sample is to be drawn for the focused
reviews 60 calendar days prior to each option period.
11.3 For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
12.0 RETROSPECTIVE REVIEWS RELATED
TO DRG VALIDATION
12.1 The contractor shall conduct
quarterly focused reviews of a 1% sample of medical records to assure
that reimbursed services are supported by documentation in the patient’s
medical record. This review must determine if the diagnostic and
procedural information and discharge status of the patient as reported
by the hospital matches the attending physician’s description of
care and services documented in the patient’s record. In order to accomplish
this, the contractor shall conduct the following review activities:
12.1.1 Review of claim adjustments
submitted by hospitals which result in the assignment of a higher weighted
DRG (see
Addendum C).
12.1.2 Review for physician certification
as to the major diagnosis and procedures and the physician’s acknowledgment
of a penalty statement on file.
12.1.3 When the claim is submitted,
the hospital must have on file a signed and dated acknowledgment
from the attending physician that the physician has received the
following notice:
“Notice to Physicians: TRICARE
payment to hospitals is based in part on each patient’s principal
and secondary diagnoses and the major procedures performed on the
patient, as attested to by the patient’s attending physician by
virtue of his or her signature in the medical record. Anyone who misrepresents,
falsifies, or conceals essential information required for payment
of Federal funds may be subject to fine, imprisonment, or civil
penalty under applicable Federal laws.”
12.1.4 The acknowledgment must be
completed by the physician either before or at the time that the physician
is granted admitting privileges at the hospital, or before, or at
the time the physician admits his or her first patient. Existing
acknowledgments signed by physicians already on staff remain in
effect as long as the physician has admitting privileges at the
hospital.
12.1.5 Outlier Review
Claims that qualify for additional
payment as a cost-outlier shall be subject to review to ensure that
the costs were medically necessary and appropriate and met all other
requirements for payment. In addition, claims that qualify as short-stay
outliers shall be reviewed to ensure that the admission was medically
necessary and appropriate and that the discharge was not premature.
12.2 Procedures Regarding Certain
Services Not Covered By The DRG-Based Payment System
In implementing the quality
and utilization review for services not covered by the DRG-based
payment system, the requirements of this section shall pertain,
with the exception that the ICD-10-CM and ICD-10-PCS codes will
be used to provide basis of correct information for dates of discharge
beginning on or after the mandated date, as directed by HHS, for
ICD-10 implementation.
13.0 RETROSPECTIVE REVIEW REQUIREMENTS
FOR OTHER THAN DRG
s VALIDATION
13.1 The contractor shall conduct
and report semi-annual focused reviews of a statistically valid
sample or 50 records, whichever is greater, of medical records to
determine the medical necessity and quality of care provided, validate
the review determinations made by review staff, and determine if
the diagnostic and procedural information and discharge status of
the patient as reported on the hospital or professional provider’s
claim matches the attending physician’s description of care and
services documented in the medical record.
13.2 The Government
will provide to the contractor specific review topics, criteria
for selection and time frame from which the sample is to be drawn
for these focused reviews 60 calendar days prior to each option
period.
13.3 This information shall be included
in the annual Clinical Quality Report. For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
13.4 For all cases selected for
retrospective review, the following review activities shall occur:
13.4.1 Admission Review
The medical record must indicate
that inpatient hospital care was medically or psychologically necessary
and provided at the appropriate level of care.
13.4.2 Invasive Procedure Review
The performance of unnecessary
procedures may represent a quality or utilization problem. In addition,
the presence of codes of procedures often affects DRG classification.
Therefore, for every case under review, the medical record must
support the medical necessity of the procedure performed. For this
purpose, invasive procedures are defined as all surgical and any
other procedures which affect DRG assignment.
13.4.3 Discharge Review
The contractor shall use nationally
recognized clinical decision support tools when reviewing discharge,
discharge planning, follow up care, questionable discharges or other
potential quality problems for questionable discharges or other
potential quality problems.
13.4.4 For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
14.0 WRITTEN AGREEMENTS WITH INSTITUTIONAL
PROVIDERS
The contractor
shall establish written agreements with each institutional provider
as noted in
Chapter 2, Section 3.
15.0 CONFIDENTIALITY APPLICABLE
TO ALL CLINICAL ACTIVITIES, INCLUDING RECOMMENDATIONS AND FINDINGS
The contractor shall develop
and implement procedures, processes, and policies that meet the
confidentiality and disclosure requirements set forth in Title 10,
United States Code (USC), Chapter 55, Section 1102; the Social Security Act,
Section 1160, and implementing regulations at 42 CFR 476, the Alcohol,
Drug Abuse and Mental Health Administration (ADAMHA) Reorganization
Act (42 USC 290dd-2), the Privacy Act (5 USC 552a),
32 CFR 199.15(j) and
(l). Additionally, the contractor shall display
the following message on all Quality Assurance (QA) documents:
15.1 QA Document under 10 USC 1102
Copies of this document, enclosures
and information will not be further released under penalties of
law. Unauthorized disclosure carries a possible $3,000 fine.
15.2 Release of Information
15.2.1 The contractor shall provide
a detailed description that includes identification process information
that will be communicated. If an inquiry is made by the beneficiary,
including an eligible family member (child) regardless of age, the
reply should be addressed to the beneficiary, not the beneficiary’s
parent or guardian. The only exceptions are when a parent writes
on behalf of a minor child or a guardian writes on behalf of a physically
or mentally incompetent (as declared by a competent legal authority)
beneficiary.
15.2.2 The contractor shall not provide
information to parents or guardians of minors or incompetents when the
services are related to the following diagnoses:
• Abortion/reproductive services,
including contraception
• SUD
• Sexually Transmitted Disease
(STD)
• Gender Dysphoria
• Human Immunodeficiency Virus
(HIV)/Acquired Immune Deficiency Syndrome (AIDS)
15.2.3 The term “minor” means any
person who has not attained the age of 18 years. Generally, the
parent of a minor beneficiary and the legally appointed guardian
of an incompetent beneficiary shall be presumed to have been appointed
the representative without specific designation by the beneficiary.
Therefore, for beneficiaries who are under the age of 18 years or
who are incompetent, a notice issued to the parent or guardian,
under established TRICARE procedures, constitutes notice to the
beneficiary.
15.2.4 If a beneficiary has been legally
declared an emancipated minor, they are to be considered as an adult. If
the beneficiary is under 18 years of age and is (or was) a spouse
of an ADSM or retiree, they are considered to be an emancipated
minor.