TRICARE Regional Offices (TROs)/Market/Military Medical Treatment Facility (MTF) and Contractor Interfaces (eMSM) and Contractor Interfaces
Chapter 15
Section 1
Director,
TRICARE Regional Offices (TROs), Market/Military Medical Treatment
Facility (MTF) Director, and Contractor Interface
Revision: C-127, August 21, 2023
The contractor shall assist the
Director, TROs and
Market/MTF
Directors in
coordinating health care delivery in their Prime Service Areas (PSAs)/markets
and in ensuring the optimal use of
Market/MTF
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
days following
the execution of the MOU by the contractor and the
Market/MTF
Director.
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
Market/MTF
support
processes which are standard throughout the region and a supplemental attachment
that documents operational information that is unique to each
Market/MTF
(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
Market/MTF
Directors 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 Market/MTF Director to
discuss Market/MTF optimization
and to enter into written agreements to ensure the Market/MTF receives
the workload that supports their business plan and optimization
initiatives. These agreements shall be utilized to optimize Market/MTF 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 Market/MTF 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 Market/MTF Director 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 Market/MTF Director,
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 Market/MTF Director.
The contractor shall provide appropriate staff to meet with the
TRO and/or Market/MTF Director within
two work days of receiving either a verbal or written request.
2.0 TRO AND
Market/MTF
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 Market/MTF Director for
PCM assignment (by category of beneficiary) or choice for enrollees
who reside in the Market/MTFs’ PSAs. Market/MTF Directors will
designate whether these enrollees shall have Market/MTF or
network PCMs and may be subject to change as impacted by changing Market/MTF capacities. The
contractor shall assign enrollees to PCMs in accordance with the Market/MTF Director’s directions.
3.0
Market/MTF
INTERFACE
FOR SPECIALTY SERVICES
The contractor
shall obtain direction from the Market/MTF Director regarding
which specific specialty services shall be referred to the Market/MTF in
accordance with Military Health System (MHS)/Market optimization
goals. Non-Prime beneficiaries shall be encouraged to use available Market/MTF specialty services
in lieu of civilian providers.
4.0 ADMINISTRATIVE COORDINATION WITH
THE TRO AND
Market/MTF
The contractor shall meet with
each Market/MTF Director 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 Markets/MTFs and
civilian networks. The frequency of these meetings may be altered
at the discretion of the Market/MTF Director and/or
the Director, TROs.
5.0 TRO AND
Market/MTF
Director LIAISON
The contractor shall ensure that
the TRO and the Market/MTF Directors have
access to contractor personnel to facilitate Market/MTF interface
activities and shall ensure that Market/MTF
Directors are kept informed of contractor program or policy changes
which affect the Markets/MTFs.