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TRICARE Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 1
Medical Management (MM)
1.1  The TRICARE Health Plan (THP) defines MM as an integrated managed care model that includes Utilization Management (UM), Referral Management (RM), Case Management (CM), Behavioral Health (BH), and Population Health (PH) programs to manage patient care and the clinical and social needs of eligible beneficiaries.
1.2  The contractor shall integrate evidence-based and outcome-oriented processes in the MM programs to provide the highest quality care to eligible beneficiaries.
1.3  The contractor shall use nationally recognized criteria and standard of care guidelines in identifying, managing, monitoring, processing, reviewing, and authorizing all medical, virtual medicine, and behavioral health care services.
1.4  The contractor’s MM programs shall support and manage the healthcare utilization of individuals with high-cost claims, complex medical conditions, inpatient admissions and discharges, pharmacy (specialty drugs, multiple medications or pharmacies), and beneficiaries receiving low quality care.
1.5  The contractor shall submit a written MM plan. For plan submission requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
2.1  The contractor shall manage and maintain a single, consolidated, easy to use and understand, fully-electronic, web-based MM data system platform that is available 24 hours a day/seven days a week (24/7), except for scheduled downtime for system maintenance.
2.2  The information shall be at the beneficiary and Military Medical Treatment Facility (MTF) level, that can be viewed, downloaded and printed, with concurrent and refreshed data no less than once every 24 hours.
2.3  The Government may use the contractor’s portal to submit referrals in situations when the RM system is unavailable.
2.4  The electronic data system platform shall offer Defense Medical Information System (DMIS) specific access, reporting and consolidated, detailed information to MTF, Market, THP, and Defense Health Agency (DHA) authorized personnel.
2.5  The contractor’s MM data system platform shall include, but not limited to, access or links to:
•  Referrals
•  Submission portal
•  Reconciliation capability
•  Authorizations
•  Authorization approval letters for beneficiary
•  Authorization approval letters for provider
•  Authorization denial letters for beneficiary
•  Authorization denial letters for provider
•  List of codes that require and do not require a referral and authorization by beneficiary category
•  UM review decisions
•  Concurrent and preadmission/preauthorization
•  THP Clinical Operations only--initial and second reconsideration, appeals
•  Appeal (factual and medical necessity) educational information/process
•  Appeal (factual and medical necessity) submission portal for beneficiaries
•  Clinical Documents
•  Treatment plans (TPs)
•  History of care
•  Plans of care (POCs)
•  Inpatient admissions/Discharges by DMIS
•  CM
•  Referral capability
•  MTF and network enrollees assigned to the contractor’s CM program
•  The contact information for the specific care coordinator(s) assigned to the enrollee
•  Date of opening and closure of case
•  Case notes
•  CM beneficiary education/self-help information
•  PH
•  Referral capability
•  MTF and network enrollees assigned to contractor PH care
•  The contact information for the specific care coordinator(s) assigned to the enrollee
•  Date of opening and closure of case
•  Case notes
•  Disease Management (DM)/PH beneficiary education/self-help information
•  Data reports
•  Provider Directory
•  Enrollment
•  Claims
•  Pharmacy Information and Medication list
•  Ability to print list
•  Potential Quality Issue (PQI) Market/MTF reporting mechanism
•  Updated (Pending, Open, Closed)
2.6  The contractor shall provide the UM decisions on the electronic MM data system platform for Market/MTF and civilian network TRICARE Prime enrollees the day the decision is made. All denied authorizations or reconsiderations must be mailed to the beneficiary and the provider.
2.7  The contractor shall provide access to the Market/MTF and civilian network Primary Care Managers (PCMs) to inpatient admissions and discharges for all TRICARE Prime enrollees within 24 hours of the contractor becoming aware of the admission via the electronic data system platform. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
2.8  The contractor shall schedule system maintenance windows during weekends or non-peak hours to minimize disruption of services to Government workers to the maximum extent possible.
2.9  The contractor shall provide access to the MM electronic data system platform for up to 7,500 Government users per region.
2.10  The contractor shall provide training on the MM data system, prior to start of health care delivery (SHCD), and at a minimum quarterly thereafter to Market/MTF and Government users.
The contractor shall report the effects of MM programs on Market/MTF optimization by MM program component. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.1  The contractor shall provide access to DoD Pharmacy information which allows MTF clinic designee and civilian providers or clinic designee to view and print their patients’ medication lists according to the MOU between the Managed Care Support Contractor (MCSC) and TRICARE Pharmacy (TPharm) contractor (see DD Form 1423, CDRL, located in Section J of the applicable contract). The medications lists will include medications, to include controlled substances such as opioids, dispensed by Markets/MTFs, the TRICARE Mail Order Pharmacy (TMOP), and retail pharmacies.
4.2  The contractor shall make this information available via the contractor’s website for PCMs, specialists, and BH providers or clinic designee who register for this capability.
4.3  The contractor shall ensure registered providers or clinic designee will have access to medication lists for all of their assigned TRICARE patients; specialist access will be limited to those patients for whom they have a referral or authorization.
5.1  The contractor shall use predictive analytics in the operation of their MM programs to include, but not limited to medical, telehealth, BH, UM, CM, and PH (to include chronic care (CC)/DM).
5.2  The contractor’s predictive analytics tools shall offer an automated means to forecast future health outcomes for individuals or populations based on algorithms derived from historical patient data.
5.3  The contractor shall implement beneficiary-centric data analytic tools/systems to integrate data from multiple sources (including, but not limited to, Government-provided Market/MTF real-time data and real-time pharmacy data) to allow a consolidated view of all data related to each beneficiary.
5.4  The contractor’s system shall process this information against industry-respected sources of evidence-based medicine to identify gaps in care, medical errors, identify high-risk addictive behaviors, such as, opioid use or abuse and quality issues.
5.5  The contractor shall utilize its analytic tools to treat and to provide a report on annually identified chronic diseases (including opioid use), identify gaps in care of Leading Health Indicators (LHIs), identified chronic diseases identified by DoD, as well as promote prevention and wellness for at-risk individuals. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
The contractor shall identify and propose opportunities to coordinate, collaborate, and implement Market/MTF integrated care and processes with the Government.
The contractor shall provide ongoing MM training and presentations at the THP hosted monthly MM Teleconference for the Government (Markets/MTFs and DHA) in regards to its electronic MM system and programs.
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