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TRICARE Operations Manual 6010.59-M, April 1, 2015
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.
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.
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.
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.
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.
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