TRICARE Regional Offices (TROs)/Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) and Contractor Interfaces
Chapter 15
Section 1
Director,
TRICARE Regional Offices (TROs), Military Treatment Facility (MTF)
Commander/Enhanced Multi-Service Market (eMSM) Manager, and Contractor
Interface
Revision: C-26, May 30, 2018
The contractor shall assist
the Director, TROs and MTF Commanders/eMSM Managers in coordinating health
care delivery in their Prime Service Areas (PSAs)/markets and in
ensuring the optimal use of MTF/eMSM capacities. The contractor
shall define this activity through Memoranda of Understanding (MOU).
Each MOU shall describe the processes expected to be executed in
good faith by each party to operate the TRICARE Program in accordance
with the performance based objectives of the Managed Care Support
(MCS) contract(s) and TRICARE Manuals (see
Addendum A).
The MOU shall follow the format
in
Addendum A. Copies of local program documentation
may be obtained through the TRO. The contractor shall provide copies
of each MOU executed to the Procuring Contracting Officer (PCO)
through the TRO, within 10 calendar days following the execution
of the MOU by the contractor and the MTF Commander/eMSM Manager.
All MOUs shall be approved by the TROs and with final approval by
the PCO.
As described in
Addendum A,
the MOU consists of two parts: a core document that describes major MTF/eMSM
support processes which are standard throughout the region and a
supplemental attachment that documents operational information that
is unique to each MTF/eMSM (i.e., Right of First Refusal (ROFR)
capabilities table, Point of Contact (POC) information, after hours
care instructions, enrollment guidance, etc.). The core document
is not expected to change often, but any such changes will be vetted
and incorporated at the annual review at the beginning of an option
period. Information in the supplemental attachment may be changed
at any time. Once signed at the beginning of an option period, the
core MOU document stands and does not need to be affirmed if MTF
Commanders/eMSM Managers change.
The MOU will remain in force
throughout the duration of the contract, unless any party provides
a written notice of intention to modify at least
90 days
prior to the new option period. In the event that such notice is
provided, but has not been negotiated as of the end of the current
option period, the MOU will remain in effect until a modification
is agreed upon and approved. If no modification is necessary, the
contractor will prepare and submit an Affirmation of MOU Review
(
Addendum A)
90 days
prior to the end of each option period.
1.0 COORDINATION PROCEDURES TO
ENSURE OPTIMIZATION
The contractor
shall meet with the TRO and each MTF Commander/eMSM Manager to discuss
MTF/eMSM optimization and to enter into written agreements to ensure
the MTF/eMSM receives the workload that supports their business
plan and optimization initiatives. These agreements shall be utilized
to optimize MTF/eMSM capabilities and capacities and provide mechanisms
to reallocate workload, establish priorities for needed network
development, and determine Primary Care Manager (PCM) assignment
locations for enrollees. The agreements may be modified during the
year; however, all agreements/modifications shall be concurred upon
by the Director, TROs and CO prior to implementation. The MTF/eMSM
will provide the contractor with the current status of their capabilities and
available capacity. The contractor shall be responsible for initiating
meetings and/or other actions with the TRO and the MTF Commander/eMSM
Manager to assist in remedying problems which can be resolved within
the scope of the contractor’s responsibility and authority. The
contractor shall follow the direction of the MTF Commander/eMSM
Manager, in consonance with the TRO, regarding the priorities for
the assignment of enrollees to PCMs. Additionally, the contractor
shall respond to requests for meetings regarding capabilities and
optimization initiated by the TRO and MTF Commander/eMSM Manager.
The contractor shall provide appropriate staff to meet with the
TRO and/or MTF Commander/eMSM Manager within two work days of receiving
either a verbal or written request.
2.0 TRO AND MTF/
eMSM
INTERFACE FOR PRIMARY CARE MANAGEMENT
Both civilian and military
individual providers may act as PCMs for TRICARE Prime. During the
MOU development process, the contractor shall obtain guidelines
from the TRO and the MTF Commander/eMSM Manager for PCM assignment
(by category of beneficiary) or choice for enrollees who reside
in the MTF/eMSMs’ PSAs. MTF Commanders/eMSM Managers will designate
whether these enrollees shall have MTF/eMSM or network PCMs and
may be subject to change as impacted by changing MTF/eMSM capacities.
The contractor shall assign enrollees to PCMs in accordance with
the MTF Commander’s/eMSM Manager’s directions.
3.0 MTF/
eMSM
INTERFACE FOR SPECIALTY SERVICES
The contractor shall obtain
direction from the MTF Commander/eMSM Manager regarding which specific
specialty services shall be referred to the MTF/eMSM in accordance
with Military Health System (MHS)/eMSM optimization goals. Non-Prime
beneficiaries shall be encouraged to use available MTF/eMSM specialty
services in lieu of civilian providers.
4.0 ADMINISTRATIVE COORDINATION
WITH THE TRO AND MTF/
eMSM
The contractor shall meet with
each MTF Commander/eMSM Manager or designee and TRO representative
at least quarterly. These meetings shall review current contractor
activities in enrollment, quality management, utilization management,
marketing, network development, external resource sharing and other
activities, such as briefings to provider or beneficiary groups
or interface with Congressional or other Governmental officials.
The contractor shall also meet with the Director, TROs or designee
at least quarterly to facilitate activity coordination between the
MTFs/eMSMs and civilian networks. The frequency of these meetings
may be altered at the discretion of the MTF Commander/eMSM Manager
and/or the Director, TROs.
5.0 TRO AND MTF Commander/
eMSM
Manager LIAISON
The contractor
shall ensure that the TRO and the MTF Commanders/eMSM Managers have
access to contractor personnel to facilitate MTF/eMSM interface
activities and shall ensure that MTF Commanders/eMSM Managers are
kept informed of contractor program or policy changes which affect the
MTFs/eMSMs.