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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Medicare Eligible Program (TMEP)
Chapter 20
Section 7
Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Revision:  C-108, May 18, 2022
The TMEP contractor shall comply with all TRICARE requirements noted in Chapter 7 regarding MM, UUM, and QM unless specifically changed, waived, or superseded by this section (as indicated below), the TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), TRICARE Systems Manual (TSM), or TMEP contract.
1.0  Medical Management/Utilization Management (MM/UM)
1.1  The TMEP contractor shall comply with the requirements in Chapter 7, Section 1 when TRICARE is primary payer, except for paragraphs 1.0 through 1.2.3, 4.0, 7.7, 8.0 through 8.2, and 11.0 through 11.4.
1.2  Regions specific UM provisions do not apply to the TMEP contractor.
2.0  Preauthorization
2.1  The TMEP contractor shall comply with the requirements in Chapter 7, Section 2. The special authorization/preauthorization services outlined in this section and in the TRICARE Policy Manual (TPM), Chapter 1, Section 6.1 require preauthorization, and if necessary, review of waivers of the day limits when TRICARE is primary payer. As secondary payer, TRICARE will rely on and not replicate Medicare’s determination of medical necessity and appropriateness in all circumstances where Medicare is primary payer.
2.2  In the event that TRICARE is primary payer for these services and preauthorization was not obtained, the contractor shall obtain the necessary information and perform a retrospective review.
3.0  Contractor Relationships with the TRICARE Quality Monitoring Contract (TQMC)
The TMEP contractor shall comply with the requirements in Chapter 7, Section 3 in instances where records are requested. The Government does not anticipate routine record requests from TMEP.
4.0  Clinical Quality Management Program (CQMP)
The requirements in Chapter 7, Section 4 are not applicable to TMEP.
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