1.0 GENERAL
1.1 The contractor
shall provide a plan for establishing a provider network throughout
the region to support TRICARE Prime and TRICARE Select and to complement
Market/MTF capabilities. This section does not apply to the Uniformed
Services Family Health Plan (USFHP), TRICARE Dual Eligible Fiscal
Intermediary Contract (TDEFIC), or pharmacy contracts.
1.2 The National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2016, Section
717, required the development of a system by which any non-Department
mental health care provider that meets eligibility criteria established
by the Secretary of Defense relating to knowledge of: (1) military
culture; and, (2) evidence-based treatments that have been approved
by the Department for the treatment of mental health issues among members
of the Armed Forces, receives a mental health provider readiness
designation. It further required the Department to establish and
update as necessary a publicly available registry of all non-Department
mental health care providers with the “provider readiness designation”
related to knowledge of military culture and evidence-based treatments.
1.3 The contractor
shall use a “provider readiness designation” to identify, in its
provider directory, all non-Department mental health providers including
psychiatrists and other mental health physicians (i.e., clinical psychologists,
certified psychiatric nurse specialists (CPNSs), certified clinical
social workers (CCSWs), marriage and family therapists, TRICARE
certified mental health counselors (CMHCs), and certified pastoral
counselors under a physician’s supervision) who have knowledge of
military culture and evidence based treatments. The mental health provider
readiness designation does not apply to the TRICARE Overseas Program
(TOP).
1.3.1 The contractor shall designate
or identify those providers who furnish proof (i.e., certificates)
that they have completed:
• The “Military Culture: Core
Competencies for Healthcare Professionals” course developed by the
Department of Defense (DoD) and the Department of Veterans Affairs/Veterans
Health Administration (DVA/VHA) under the auspices of Integrated
Mental Health Strategy (IMHS); and
• The following courses: “Cognitive
Processing Therapy for Post-Traumatic Stress Disorder (PTSD) in
Veterans and Military Personnel,” “Prolonged Exposure (PE) Therapy
for PTSD in Veterans and Military Personnel,” and “Depression in
Service Members and Veterans in evidence-based treatments,” offered
by the Center for Deployment Psychology (CDP) of the Uniformed Services
University of the Health Sciences.
1.3.2 The contractor
shall actively promote attainment of the provider readiness designation
in its education materials to applicable providers.
2.0 GEOGRAPHIC
AVAILABILITY
2.1 The contractor shall establish
and maintain a preferred provider network of individual and institutional providers,
capable of meeting minimum access standards for 100% of TRICARE
Prime beneficiaries and at least 85% of TRICARE Select beneficiaries
in the contractor’s geographic area of responsibility throughout
all health care delivery periods of the contract. (See
Chapter
16 for TRICARE Prime Remote (TPR) network requirements).
2.2 The contractor
shall establish and maintain a network and services to TRICARE Prime
and TRICARE Select enrolled beneficiaries that ensures access to
care (ATC) and the opportunity to choose, enroll, add additional
family members, or remain enrolled in the TRICARE plans.
2.3 The contractor
shall establish minimum health care provider-to-beneficiary ratios.
The provider to beneficiary ratios shall be for the purposes of
network sizing only. Regardless of the provider to beneficiary ratio, the
contractor’s network shall meet or exceed minimum access standards
as the first priority.
2.4 The contractor shall consider
the health characteristics of the beneficiaries in a given market,
including an analysis of disease prevalence and overall health and
well-being of such beneficiaries, and shall use predictive analytics
in the development of its network implementation plan.
2.5 The contractor
shall establish and maintain a network of individual and institutional
providers that ensures that at least 85% of TRICARE Select enrolled
beneficiaries residing in the geographic area of responsibility have
access to a network that meets minimum access time standards in
each of the contractor’s geographic areas of responsibility, each
United States and District of Columbia (East only).
2.6 In developing
and maintaining its network in each state/territory, the contractor
shall consider the entire beneficiary population of the state including
any overlap with TRICARE Prime Service Areas (PSAs).
2.7 In overseas
regions, the contractor shall establish a network as authorized
by the Director to support a special Prime program; this network
may be accessed by Select enrollees based on available resources.
In addition to support for the TOP Prime Program, a network for
TOP Select enrollees shall be established only in geographical areas
determined by the Director, Defense Health Agency (DHA) to be economically
in the best interest of the DoD.
2.8 TRICARE
Prime Service Areas (PSAs)
2.8.1 The contractor shall offer
TRICARE Prime in areas where the Director, Defense Health Agency
(DHA) determines that it is appropriate to support the effective
operation of one or more Markets/Military Medical Treatment Facilities
(MTFs). The locations where TRICARE Prime will be offered will be
determined by the Director, DHA and announced prior to the annual
open enrollment period.
2.8.2 Government Designated Authorities
(GDAs) And Market/MTF Interface In Provider Networks
2.8.2.1 The contractor shall ensure
that, in PSAs with Direct Care (DC) markets or MTFs, its network complements
the existing military capabilities and optimizes the market in support
of military readiness. The contractor shall adjust provider networks
and services to compensate for changes in Market/MTF capabilities
and capacities including those resulting from facility/service expansion,
provider deployment, or MTF access downsizing.
2.8.2.2 The contractor shall meet,
at a minimum annually, with the GDA and each Market Director/MTF Director
to discuss Market/MTF optimization efforts. The purpose of these
meetings is to ensure the Market/MTF optimizes care in accordance
with their business plan/optimization initiatives.
2.8.2.3 The contractor shall meet with
the GDA and all Market Directors and MTF Directors within 30 calendar
days of the award to obtain their network size and specialty makeup
input.
2.8.2.4 The contractor shall provide
Market Directors/MTF Directors and the GDA the opportunity to provide input
into the development of the network in the geographic area of responsibility
prior to finalizing the civilian network.
2.8.3 MTF/Market
Collaboration Events
2.8.3.1 The contractor shall, when
requested by the Market/MTF, assist in planning and conducting provider collaboration
events in the local markets.
2.8.3.2 The contractor shall, when
a date and agenda is confirmed by the Market/MTF, assist in administrative
processes that include procuring the venue, coordinating event logistics,
creating and delivering invitations to civilian providers, and catering
refreshments as permitted by Service-specific and other regulations.
3.0 ENROLLMENT
3.1 In each
area where enrollment is offered, the contractor shall permit enrollment
by beneficiaries under the terms and conditions of
Chapters
6 and
11.
3.2 The contractor
shall assign TRICARE Prime beneficiaries only to Market/MTF Primary
Care Managers (PCMs) or to PCMs in the PSA network.
3.3 The contractor
shall follow Market Director/MTF Director directions regarding the
priorities for the assignment of enrollees to PCMs.
4.0 NETWORK
REQUIREMENTS AND STANDARDS
4.1 The contractor shall obtain
health network accreditation of its provider network from a nationally recognized
accrediting organization no later than 18 months after the start
of health care delivery (SHCD).
4.2 The contractor
shall actively seek institutional and individual providers (medical
and mental health) for their network who:
4.2.1 Produce
the best quality clinical outcomes;
4.2.2 Use “evidence-based
medicine, including appropriate national standards of care;”
4.2.3 Report
outcome data, preventive measures date, and laboratory data; and
4.2.4 Are willing
to refer/transfer TRICARE beneficiaries for care at Markets/MTFs
when appropriate.
4.3 The contractor
shall profile and monitor individual and institutional provider
performance in an ongoing manner using profiling/monitoring parameters
that address, but are not limited to, cost-of-care, clinical quality
of care to include population health/prevention practices as appropriate,
patient satisfaction and access.
4.4 The contractor
shall ensure profiles and parameters are based on current and evolving
sources of outcomes and performance data (i.e., Hospital Compare),
kept current (updated biannually at a minimum) and available for
review by the Government at all times.
4.5 The contractor
shall not refer beneficiaries to providers with poor outcomes.
4.6 Where
available, National Committee for Quality Assurance (NCQA) accredited
(or other nationally accepted accrediting organizations) primary
care medical homes shall be recruited to the network to provide
care for beneficiaries with two or more chronic illnesses.
5.0 Provider
Directory
5.1 The contractor shall develop
and maintain a timely and accurate network provider directory for
use by beneficiaries and the Government to assist with health care,
referral management, and claims. Additionally, the contractor shall
develop and maintain an on-line authorized non-network provider
list.
5.2 The contractor shall ensure
that the information is refreshed with any updated data in the on-line network
provider directory no less than once every 24 hours.
5.3 The contractor
shall provide web access to the directory and list, making it available
for all beneficiaries, providers, and Government representatives.
5.4 The contractor’s
on-line network provider directory shall include a search tool that
allows beneficiaries to locate providers based on a wide range of
avenues, to include but not limited to name, specialty, sub-specialty, group,
body part or condition. Results from the beneficiary search shall
have the capability of sorting on all elements of provider data
including mapping providers by distance to the beneficiary.
5.5 The contractor’s
on-line authorized non-network provider list shall include a search
tool that allows beneficiaries to locate providers with results
based on claims submissions for a rolling 14 month period. The accuracy
standard does not apply to the authorized non-network provider list.
6.0 Standards
for TRICARE Beneficiary Access to Network Providers
6.1 The contractor
shall ensure access standards for appointments for health care that
meet or exceed those of high-performing health care systems in the
US.
6.2 The contractor shall maintain
networks through the life of the contract and adjust the size of
the networks to ensure beneficiaries in the geographic areas meet
or exceed ATC standards.
6.3 The contractor shall establish
mechanisms for monitoring and reporting compliance with access standards.
6.4 Where
MTFs use an Integrated Referral and Medical Appointment Center or
Referral and Appointment Center, data received from the appointing
center about availability of appointments in the contractor’s network shall
be included in compliance monitoring metrics.
6.5 The contractor
shall ensure ATC standards listed in
32 CFR 199.17(p)(5) are met for enrollees.
6.5.1 The contractor
shall ensure travel time does not exceed 30 minutes from home to
primary care delivery site unless a longer time is necessary because
of the absence of providers (including providers not part of the network)
in the area.The contractor shall ensure that travel time for specialty
care does not exceed one hour, unless a longer time is necessary
because of the absence of providers (including providers not part
of the network) in the area.The contractor shall ensure that the
wait time for an appointment for a well-patient visit or a specialty care
referral for enrollees do not exceed four weeks; for a routine visit,
the wait time for an appointment shall not exceed one week; and
for an urgent care visit the wait time for an appointment shall
generally not exceed 24 hours.The contractor shall ensure that emergency
services be available and accessible to handle emergencies (and
urgent care visits if not available from other primary care providers
(PCPs) within the service area 24 hours a day, seven days a week
(24/7) for enrollees.
7.0 Urgent
Care Centers (UCC
s) Network Requirements
and Standards
7.1 The contractor shall establish
network agreements with TRICARE authorized UCCs and publish information,
including on a website, informing TRICARE beneficiaries of the availability
and access to network UCCs.
7.2 The contractor
shall ensure adequate access to UCCs when Markets/MTFs are unavailable
or unable to provide such services. See the website (
https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf)
for the definition of UCC. The NDAA FY 2017, Section 704(a) enacted
10 United States Code (USC) 1077a, in part, to improve access to
urgent care services both in military Markets/MTFs and the TRICARE
Network.
7.3 The contractor shall include
in network agreements with UCCs located in all Market/MTF PSAs within
the 50 United States and District of Columbia the following to better
integrate care between Markets/MTFs and network UCCs:
7.3.1 The contractor
shall instruct UCCs in Market/MTF PSAs for TRICARE Prime beneficiaries
enrolled to a Market/MTF to send a Clear and Legible Report (CLR)
of the UCC encounter within two business days to the Market/MTF
where the beneficiary is enrolled.
7.3.1.1 The CLR shall include the patient’s
encounter specifics (histories and physicals, progress notes, notes on
Episodes Of Care (EOC), and other patient information (such as laboratory
reports, x-ray readings, operative reports), and discharge summaries).
7.3.1.2 The CLR shall include any follow-up
appointments recommended during the urgent care visit.
7.3.2 Advise
TRICARE Prime beneficiaries enrolled to a Market/MTF that non-emergency
follow-on care should be sought at the enrollees’ Market/MTF PCM
whenever possible.
7.3.3 The contractor shall provide
the network UCCs with Market/MTF fax numbers.
7.4 The contractor
shall ensure that TRICARE authorized UCCs practice standard of care
based on the NCQA Health Effectiveness Data and Information Set
(HEDIS) using the guidelines for the following four conditions:
7.4.1 Children
With Pharyngitis (CWP).
7.4.2 Appropriate treatment for children
with Upper Respiratory Infection (URI).
7.4.3 Avoidance
of Antibiotic for Adults with Bronchitis (AAB).
7.4.4 Use of
imaging studies for Low Back Pain (LBP).
7.5 The contractor
shall ensure that all beneficiaries in its geographic region have
access to a 24/7 telehealth urgent care option available through
a computer and smartphone application.
8.0 Participation
On Claims
8.1 The contractor shall only include
in their network Medicare participating providers (unless they are
not eligible to be a Medicare participating provider) and shall
be sufficient in number, mix, and geographic distribution to provide
the full scope of benefits for which all Prime and Select enrollees
are eligible under this contract, as described in
32
CFR 199.4,
199.5, and
199.17.
8.2 The contractor
shall ensure that all network provider agreements require the provider
to participate on all claims and submit claims on behalf of all
Military Health System (MHS) and Medicare beneficiaries. All network provider
agreements shall include the following provision:
8.2.1 The submission
of a claim by a physician or supplier or their representative certifies
that the services shown on the claim are medically indicated and
necessary for the health of the patient and were personally furnished
by the physician/supplier or furnished incident to his or her professional
service by his or her employee under his or her immediate personal
supervision, except as otherwise permitted by Medicare or TRICARE regulations.
8.2.2 Services,
to be considered as “incident” to a physician’s professional service,
must:
8.2.2.1 Be rendered under the physician’s
immediate personal supervision by his or her employee;
8.2.2.2 Be an integral, although incidental
part of a covered physician’s service;
8.2.2.3 Consist of commonly furnished
in physician’s offices; and
8.2.2.4 Be included on the physician’s
bills for services of non-physicians.
8.2.3 The non-institutional
network provider/supplier further certifies that he or she (or any
employee) who rendered services is not an active duty member of
the Uniformed Services or a civilian employee of the US Government
(refer to 5 USC 5536).
8.2.4 An exception exists for part-time
DVA/VHA employees fulfilling the requirements of
Chapter 4, Section 1.
8.3 Anyone
who misrepresents or falsifies essential information to receive
payment from Federal funds may upon conviction be subject to fine
and imprisonment under applicable Federal law.
9.0 Balance
Billing
9.1 The contractor shall include
the following provision in provider contracts:
9.1.1 Providers
in the contractor’s network will only bill MHS beneficiaries for
applicable deductibles, copayments, and/or cost-sharing amounts.
9.1.2 Providers
will not bill for charges which exceed contractually allowed payment
rates.
9.1.3 Network providers will only
bill Markets/MTFs/contractors for services provided to Service members
at the contractually agreed amount, or less, and will not bill for
charges which exceed the contractually agreed allowed payment amount.
9.2 If a network
provider bills a beneficiary for more than the contractually agreed
upon amount, the contractor shall require the provider to reverse
the charges and refund any overpayment to the beneficiary.
9.3 The contractor
shall ensure that the amount charged MHS beneficiaries without civilian
network PCMs is the same as the amount charged TRICARE Prime enrollees
with civilian network PCMs.If the contractor is using different
reimbursement mechanisms, the contractually agreed amount will be equal
to or less than the TRICARE allowable amount minus the discount
the contractor negotiated with the provider.
9.5 ADSMs and ADFMs without MTF
audiology access continue to be tested, treated, and fitted by their network
audiologists.
10.0 Billing
For Non-Covered Services (Hold Harmless)
10.1 A network
provider may not require payment from the beneficiary for any excluded
or excludable services that the beneficiary received from the network
provider (i.e., the beneficiary will be held harmless) except as
follows:
10.1.1 If the beneficiary did not
inform the provider that he or she was a TRICARE beneficiary, the
provider may bill the beneficiary for services provided.
10.1.2 If the beneficiary was informed
that the services were excluded or excludable and he or she agreed
in advance to pay for the services, the provider may bill the beneficiary.
10.2 An agreement
to pay must be evidenced by written records. “Written records” include
for example:
10.2.1 Provider notes written prior
to receipt of the services demonstrating that the beneficiary was
informed that the services were excluded or excludable and the beneficiary
agreed to pay for them;
10.2.2 A statement or letter written
by the beneficiary prior to receipt of the services, acknowledging
that the services were excluded or excludable and agreeing to pay
for them;
10.2.3 Statements written by both
the beneficiary and provider following receipt of the services that
the beneficiary, prior to receipt of the services, agreed to pay
for them, knowing that the services were excluded or excludable).
10.3 General
agreements to pay, such as those signed by the beneficiary at the
time of admission, are not evidence that the beneficiary knew specific
services were excluded or excludable.
10.4 Certified
marriage and family therapists (both network and non-network), in
their participation agreements with TRICARE, agree to hold eligible
beneficiaries harmless for non-covered care.
10.5 The beneficiary
shall be entitled to a full refund of any amount paid by the beneficiary
for the excluded services, including any deductible and cost-share
amounts, provided the beneficiary informed the network provider
(or the network or non-network certified marriage and family therapist)
that he or she was a TRICARE beneficiary, and did not agree in advance
to pay for the services after having been informed that the services
were excluded or excludable.
10.6 The beneficiary
shall be refunded any payments made by the beneficiary or by another
party on behalf of the beneficiary (excluding an insurer or provider)
for the excluded services.
10.7 The beneficiary,
or other party making payment on behalf of the beneficiary, must
request a refund in writing from the contractor by the end of the
sixth month following the month in which payment was made to the provider
or by the end of the sixth month following the month in which the
Peer Review Organization (PRO), or the DHA advised the beneficiary
that he or she was not liable for the excludable services.
10.8 The time
limit may be extended where good cause is shown. Good cause is defined
as:
10.8.1 Administrative error, such
as, misrepresentation or mistake, of an officer or employee of DHA
or a PRO, if performing functions under TRICARE and acting within
the scope of the officer’s or employee’s authority.
10.8.2 Mental incompetence of the
beneficiary or, in the case of a minor child, mental incompetence
of his or her guardian, parent, or sponsor.
10.8.3 Adjudication delays by Other
Health Insurance (OHI) (when not attributable to the beneficiary),
if such adjudication is required under
32
CFR 199.8.
11.0 Health
Information Exchanges (HIE
s)
11.1 The contractor
shall include in its network, to the extent possible, and give priority
in its MTF referral steerage model to providers (both individual
and institutional) who are connected to the eHealth Exchange or another
HIE network or framework that connects with the Government’s electronic
health record (EHR) system so that network providers can make available
or exchange necessary clinical information with the MTF providers.
11.2 The contractor
shall designate network providers who utilize a HIE system in the
Government view of the online provider directory.
12.0 Network
Provider Education
12.1 The contractor shall provide
an education program for network providers in accordance with
Chapter
11.
12.2 The contractor shall provide
an outreach and education program on TRICARE requirements for all network
and TRICARE-authorized providers. The program shall include education
on applicable TRICARE program requirements, policies, and procedures
to allow providers to carry out the requirements of this contract
in an efficient and effective manner which promotes beneficiary
satisfaction. The outreach program shall include information on
the Centers for Medicare and Medicaid Services (CMS) Meaningful
Use (MU) Program.
12.3 The contractor outreach shall
include information about DoD/VA clinical practice guidelines, quality/value
improvement efforts, and information about collection and reporting
of outcomes data.
12.4 The contractor shall educate
network providers about the certified HIEs and national health standards
to ensure they comply with Title VI of the 21st Century Cures Act
in relation to HIE (e.g., CMS) and Office of the National Coordinator
(ONC) for Health Information Technology (HIT) interoperability rules
including use of Health Level 7 (HL7) Fast Healthcare Interoperability
Resources (FHIR) and the United States Core Data for Interoperability (USCDI).
12.5 At least
biannually and for all new network providers, the contractor shall
educate providers of the importance of updating their information
in the provider directory (e.g., beneficiary satisfaction, MTF satisfaction, loss
of referrals).
13.0 Durable
Medical Equipment (DME) Providers
The contractor shall establish
preferred provider contracts with national or regional DME vendors
for specific categories of DME supplies which will allow for volume
discounts and specialized service. DME supplies include, but are
not limited to, infant formula, diabetic supplies, home infusion
supplies, and breast pumps.