1.0 General
1.1 All provisions
contained in the TRICARE Managed Care Support (MCS) contract, TRICARE Operations
Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Systems Manual
(TSM), or TRICARE Reimbursement Manual (TRM) shall apply in the
state of Alaska except as specifically modified by this chapter.
Chapter references in this section refer to the TOM unless otherwise
specified. The word ‘contractor’ is used to reference the MCS contractor
throughout this chapter.
1.2 The TRICARE
program is not automatically implemented in all areas where it is
potentially applicable. Implementation of the program requires an
official action by an authorized individual in accordance with
32 CFR 199.17(a)(5). Network implementation
will be published in the Federal Register.
2.0 Optimization
While overall responsibility
and accountability remains with the Director, TRICARE Regional Offices (TROs),
the contractor is responsible for managing network provider development
and operations in the state of Alaska.
2.1 Consistent
with existing Memorandums of Understanding (MOUs), the contractor
shall optimize the Military Treatment Facility (MTF) for all appropriate
specialty requests for care received from outside of the MTF within
established TRICARE guidelines and access standards. Specialty care that
cannot be provided by the MTF or scheduled within TRICARE access
standards in the MTF shall be referred to the network as determined
by the contractor in coordination with the MTF.
2.2 The contractor shall use every
appropriate opportunity for beneficiary and provider education to
influence beneficiary and provider behavior in a manner that encourages
MTF optimization.
3.0 Beneficiary Satisfaction
The contractor shall achieve
the highest level of beneficiary satisfaction possible in the state
of Alaska. The contractor’s administrative processes shall be designed
and operate to ensure ease in accessing TRICARE information and
benefits. These processes shall be designed recognizing the unique
nature of health care delivery within the state of Alaska and continuously
operated in a manner that achieves the highest level of beneficiary
satisfaction. Additionally, beneficiary satisfaction activities
shall be coordinated with MTFs/eMSMs and the TRO-West Alaska Branch
to achieve a coordinated, uniform approach to Department of Defense
(DoD) customer services in Alaska.
4.0 Best Value Health Care
The contractor shall support
the best value in the delivery of health care services in the state
of Alaska through the efficient operation of all administrative
processes. This includes supporting MTF right of first refusal,
educating beneficiaries and providers on the benefit of using the
MTF based on the collaborative agreement with the MTF Director,
and efficiently and effectively operating all administrative processes.
5.0 Transitions
The contractor shall be fully
responsible for all transition activities in the state of Alaska.
The contractor shall ensure all required contractor services are
fully operational in accordance with
Chapter
2 with the exception of the provisions of “Execution of
Agreements With Contract Providers”. Those shall not apply. However,
the contractor shall load all preferred providers to the contractor’s
provider directory no later than 30
days
prior to the start of health care delivery (SHCD), or at such other
time as mutually agreed between the contractor and the Defense Health
Agency (DHA).
6.0 Access To Data
The contractor shall provide
ready access to Government personnel for the state of Alaska in
the same manner as provided in all other TRICARE West Region locations.
7.0 Administration
The contractor shall comply
with all provisions of
Chapter 1, with
the following exceptions:
7.1 The contractor
accomplished preauthorization shall be limited to inpatient mental
health care for non-Prime enrollees and those enrolled to civilian
Primary Care Managers (PCMs). The MTF will preauthorize/authorize
all services for TRICARE Prime enrollees, as required. The contractor
shall comply with the preauthorization requirements specified in
Chapter 7, Section 2.
7.2 The
contractor shall process any grievance related to contractor personnel
or contractor actions. Grievances related to MTF providers shall
be forwarded to the responsible MTF within five
days of
receipt (see
paragraph 19.0 for appeals) for resolution.
The contractor shall process all grievances related to civilian
providers consistent with
Chapter 11, Section 8.
8.0 Records Management
The contractor shall comply
with the provisions of
Chapter 9.
9.0 Financial Administration
The contractor shall comply
with all of the provisions of the
Chapter
3. The contractor shall apply the appropriate financial
provisions to the claims for TRICARE enrollees in the state of Alaska
based on the Government’s ultimate decision regarding the underwriting
of health care performed in Alaska.
10.0
Provider
Certification And Credentialing
The contractor shall comply
with the provisions of
Chapter 4 for providers
rendering care in the state of Alaska.
11.0 Support Of TRICARE Providers
11.1 The contractor is required
to provide assistance to the Government in servicing participating and
non-participating providers. This assistance shall include certifying
and credentialing providers according to
paragraph 10.0. The contractor
shall provide the appropriate level and number of provider representatives
to service the participating and non-participating providers throughout
the state of Alaska. The provider representative shall be located
in contractor furnished facilities in close proximity to the MTF.
The provider representative shall assist in establishing provider
networks. The contractor’s provider representatives shall also assist
providers with TRICARE questions/problems as necessary. In this
role, the provider representative shall be supported by all appropriate
contractor staff and systems. For example, if a provider wishes
to determine the status of a claim, the provider can call the contractor’s
claims information toll-free telephone number or check the status
via an electronic means. However, if a provider requests the assistance
of an individual on- site at the provider’s office to resolve problems,
the provider representative shall provide the assistance.
11.2 Alaskan providers shall not
be required to submit claims electronically. As such, Alaskan claims shall
be removed from both the numerator and the denominator when computing
the percentage of claims submitted electronically.
12.0 Enrollment
The contractor is responsible
for all enrollment activity in the state of Alaska in accordance
with the provisions of
Chapter 6.
12.1 TRICARE Prime enrollments within
the state of Alaska shall all be to PCMs located within a MTF or
in Prime Service Areas (PSAs) around a limited number of Markets/MTFs, to
PCMs in the TRICARE network.
12.2 Where TRICARE Prime enrollment
to private sector PCMs is permitted, the contractor shall coordinate
with the MTF Director to ensure the
combined total of MTF and private sector enrollees does not exceed
the number for which compliance with TRICARE Prime access to care
standards can be assured, considering MTF and preferred provider
network resources together. Enrollment will be to the MTF first
and then to the private sector at the discretion of the MTF Director in
coordination with the contractor.
13.0 Utilization And Quality Management
The contractor shall comply
with the provisions of
Chapter 7, regarding
utilization and quality management. The MTF is responsible for issuing
all authorizations for its Prime enrollees. The contractor shall
ensure that MTF issued authorizations are entered into all applicable
contractor systems to ensure accurate, timely customer service,
and claims adjudication.
13.1 Cases
for care rendered in the state of Alaska shall be included in the
selection of cases for review by the TRICARE Quality Management
Contract (TQMC) contractor per
Chapter 7, Section 3.
If the TQMC identifies an aberrant provider from the state of Alaska,
and the provider is a network provider, the contractor shall advise
the TRO-W Alaska Branch of the findings.
13.2 The contractor
shall comply with and include care rendered in the state of Alaska
in its Clinical Quality Management Program (CQMP) per
Chapter 7, Section 4. The CQMP shall include
a separate section specifically addressing Alaska.
13.3 All potential quality issues
and unusual provider findings by the TQMC during their case reviews
shall be processed and investigated by the contractor per existing
Clinical Quality Management (CQM) policies.
14.0 claims Processing
The contractor shall process
claims in accordance with
Chapter 8.
15.0 Duplicate Claims
The contractor shall comply
with the TSM,
Chapter 4,
as appropriate, for the identification, correction and resolution
of duplicate and potentially duplicate claims.
16.0 Claims Adjustments And Recoupments
The contractor shall comply
with the provisions of
Chapter 10, regarding
claims adjustments and recoupments.
17.0 Beneficiary And Provider Services
17.1 The contractor shall comply
with the provisions of
Chapter 11, Section 1 relating
to the provision of marketing and education materials in the state
of Alaska.
17.2 The contractor shall comply
with the provisions of
Chapter 11, Section 2 and
the contract regarding briefings within the state of Alaska.
18.0 Customer Service Operations
The contractor shall provide
customer service support to include benefit and enrollment assistance
to all beneficiaries in the state of Alaska. The functions of the
contractor’s call center shall be as specified in
Chapter
11. In providing assistance with referrals, the contractor
shall first direct all beneficiaries to the MTF (beneficiaries referred
out of the MTF for specialty services shall not be referred back
to the MTF) and then to the network providers. The contractor shall
maintain an up-to-date on-line list of network providers.
18.1 The contractor shall comply
with the provisions of
Chapter 11, Section 3 in
accomplishing Beneficiary, Congressional, and Beneficiary Counseling
and Assistance Coordinator (BCAC) relations within the state of
Alaska.
18.2 The contractor shall comply
with the provisions of
Chapter 11, Section 4 in
responding to inquiries regarding TRICARE within the state of Alaska.
18.4 The contractor shall provide
toll-free telephone service to Alaskan beneficiaries in accordance with
the provisions of
Chapter 11, Section 6.
18.5 The contractor shall provide
allowable charge reviews in accordance with the provisions of
Chapter 11, Section 7.
18.7 The contractor shall administer
collection actions against beneficiaries in accordance with
Chapter 11, Section 9.
19.0
Appeals
And Hearings
The contractor
shall implement and operate an appeals system for services requested
or rendered in the state of Alaska in accordance with
Chapter
12.
20.0 Program Integrity
The state of Alaska shall be
included in the contractor’s Regional Program Integrity Program
per
Chapter 13.
21.0 Audits, Inspections, And Reports
21.1 The contractor shall comply
with the provisions of
Chapter 14, regarding
audits, inspections, and reports. The contractor shall provide a
Monthly Preferred Provider Adequacy Report to the Contracting Office
and the Director, TRO-W. Details for reporting are identified by
DD Form 1423, Contract Data Requirements List (CDRL), located in
Section J of the applicable contract.
21.2 The TRICARE
network shall be developed so that 75% of enrollee referrals are
to an MTF or civilian network provider.
22.0 Director And MTF/Contractor
Interfaces
The contractor
shall comply with the requirements of
Chapter
15 when developing and operating MTF and Director, TROs
interfaces. The contractor shall also enter into an agreement with
the TRO-W Alaska Branch, as required by the contract, regarding
contractor activities in the State of Alaska.
23.0 TRICARE Prime Remote (TPR)
Program
The contractor
shall operate the TPR program in the state of Alaska in accordance
with
Chapter 16.
24.0 Civilian Care Referred By MHS
Facilities
The contractor
shall comply with the provisions of
Chapter
17 in the State of Alaska.
25.0 Civilian Health Care (CHC)
of Uniformed Service Members
The contractor shall comply
with the provisions of
Chapter 17 for
services in the state of Alaska provided through the Supplemental
Health Care Program (SHCP).
26.0 Demonstrations
The contractor shall comply
with the provisions of
Chapter 18 for
eligible beneficiaries in the state of Alaska.
27.0 Health Insurance Portability
And Accountability Act of 1996 (HIPAA)
The contractor shall comply
with the provisions of
Chapter 19 when
administering the TRICARE program in the state of Alaska.
28.0 TRICARE Medicare Eligible program (TMEP)
The contractor shall not be responsible
for services that are the responsibility of the TMEP contractor
in the state of Alaska. This does not relieve the contractor from
their customer service responsibilities to dual eligible beneficiaries.