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TRICARE Operations Manual 6010.59-M, April 1, 2015
Prescription Monitoring Program (PMP)
Chapter 28
Section 3
Provider Prescription Monitoring Program (PMP)
Revision:  C-66, July 2, 2020
For the purpose of this section, the term “contractor” applies to the Managed Care Support (MCS) contractor and Uniformed Services Family Health Plan (USFHP) Designated Providers (DPs).
1.0  Scope
1.1  The provider PMP is a quarterly review of all providers who prescribed controlled substances prescriptions, such as opioids, for beneficiaries using TRICARE benefits. The goals of the program are to:
1.1.1  Maintain compliance with the guidelines described within 32 CFR 199.4;
1.1.2  Monitor provider prescribing practices of controlled substances, such as, but not limited to, opioids;
1.1.3  Ensure providers are practicing within the appropriate clinical practice guidelines according to specialty and disease/condition.
1.1.4  Provide education and resources to providers when needed; and
1.1.5  Improve communication with providers and increase safety and effectiveness of treatment.
1.2  The contractors shall designate a “reviewer”. The reviewer shall be a contractor’s Chief Medical Officer (CMO) or a person approved by the CMO. The reviewer shall have the appropriate credentials to review standard of care determinations (see Chapter 7, Section 1, paragraph 3.1.1). The reviewer shall review providers on the quarterly report (see paragraph 2.1) and make determinations based upon prescribing practices seen over the duration of the report. The reviewer shall conduct a medical review of the provider’s prescribing history to validate the practices with the medical diagnosis and patient overdose history, appropriateness of care, and to ensure the prescription(s) were written and dispensed in support of a legitimate medical purpose. The level of review necessary is the breadth and depth needed to make an accurate determination. It may include claims review, record review, cross referencing with other applicable program, such as the PMP, or any other relevant information as necessary to make an accurate determination. Any inconsistencies with prescribing and medical diagnosis and/or over-prescribing concerns for the medical diagnosis noted by the reviewer shall necessitate the contractors to develop an intervention plan. An intervention plan shall be an alert to the provider and lead to education, training, and appropriate referrals to the contractors’ Quality and/or Program Integrity departments. At a minimum, the intervention plan shall be an alert to the provider to participate in education consistent with industry best practice and standard of care clinical practice guidelines, such as, the Center for Disease Control and Prevention (CDC) and Veterans Health Administration (VHA)/Department of Defense (DoD) related guidelines, provide contractually available resources to complement or manage the provider’s patient population, and present knowledge and training opportunities to support the provider’s prescribing practices. Providers shall be educated on the Substance Abuse and Mental Health Services Administration (SAMHSA) training, such as buprenorphine training, to practice Medication Assisted Treatment (MAT) when appropriate as outlined in paragraph 3.0.
1.3  Contractor shall develop a process to include timelines in which targeted providers acknowledge the alert, education, and intervention plan consistent with nationally recognized clinical practice guidelines and recommendations (U.S. Department of Health and Human Services (HHS), CDC, etc.). Results of the providers’ responses are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
1.4  Contractor’s medical review and intervention decisions are subject to review by the Government.
1.5  The Government has the right to request the contractor to conduct a clinical quality review, case investigation, and report their findings to the Government. The Government may request the contractor to take necessary steps to safeguard the safety of TRICARE beneficiaries.
2.0  Initial Review and Intervention SERVICES
2.1  Each quarter, the Defense Health Agency (DHA) Pharmacy Operations Division will generate a report for each of the contractors, a list outlining the controlled substances prescribing practices of all providers. The bounds of generally accepted prescribing practices will be based upon the industry’s best practices and clinical practice guidelines for identifying and preventing unnecessary prescribing or over-prescribing of controlled substances, such as opioids. These parameters may evolve and are not made publicly available. Providers that fall outside of what are considered to be normal prescribing patterns for controlled substances shall be subject to a more in-depth review. The data provided to the contractor will be divided into subsets based upon region location (e.g., business address of the provider). The report will be sent to the contractors for medical review. The report will flag providers as new or existing on prior reports.
2.2  During the quarter, if concerns about provider prescribing controlled substances are identified by other entities or reviewers in the course of business, the contractors shall provide a medical review to determine potential unnecessary prescribing or over-prescribing. These shall be given priority over the quarterly list and may be counted towards the minimum review per quarter.
2.3  The contractors shall coordinate efforts with other TRICARE contractors as needed, such as when a provider may see TRICARE beneficiaries from another region, or overseas locations.
2.4  The contractors shall prioritize and review a minimum of 0.5% of the top and/or outlying prescribing practices or an amount designated by DHA not to exceed 100 cases per quarter from the quarterly list. Providers associated with beneficiaries identified in the Beneficiary PMP shall be prioritized for review. Contractor shall select varying medical conditions and physician specialty types unless directed by DHA. See paragraph 2.5 for responses, and paragraph 2.6 for responses that count towards the minimum review.
2.5  At a minimum, each contractor shall review the data generated on the quarterly report and provide a response in the following manner:
•  No Action (provider’s prescribing deemed appropriate)
•  Intervention plan with education only
•  Intervention plan with escalation
•  Further monitoring needed
•  Not Reviewed
2.6  Each provider shall be documented as no action, intervention plan with education only or escalation count towards cases reviewed. Previously reported providers will be identified and flagged in the generation of a new report for the next quarter for trending across quarters, and when further monitoring is needed.
3.0  Interventions
3.1  Interventions shall be initiated no later than the following quarter after the initial quarterly review.
3.2  Intervention Plan With Education Only
3.2.1  Based upon the outcome of the review, the contractor shall target the individual TRICARE provider with interventions. In cases where interventions are deemed appropriate the contractors shall use industry best practices to intervene and educate providers. At a minimum, the intervention plan shall include:
•  An alert to the individual provider to include Clinical Practice Guideline education, such as the CDC, VHA DoD, and nationally recognized professional organizations’ recommended guidelines;
•  Contractually available resources or other covered TRICARE benefits to complement their patient population (such as covered Substance Use Disorder (SUD) and mental health treatment, covered alternative pain-related medication and treatments, and applicable supportive clinical programs); and
•  Knowledge and training opportunities to support the provider, such as national and state Prescription Drug Monitoring Programs (PDMP) and SAMHSA training, such as buprenorphine training, to provide MAT when appropriate.
3.2.2  The contractor shall direct targeted providers to their website for educational materials dedicated to support providers that prescribe controlled substances, such as opioids. Contractors shall use existing provider information modalities (i.e., newsletters, email blasts, etc.) to disseminate information to educate providers.
3.2.3  Contractor intervention plan with education materials shall be made available to the Government and subject to review by the Government.
3.3  Intervention Plan With Escalation
The contractor shall initiate an intervention plan with escalation when there are concerns of a clinical variance warranting further review and investigation for determination of the presence of an actual Quality Issue (QI) or potential fraud; and shall initiate suspension, denial, and recoupment of claims when a possible drug abuse situation is identified and/or warranted.
4.0  Potential Quality Issue (PQI)
4.1  Based upon the outcome of the review, the contractor shall refer any PQIs as stated in Chapter 7, Section 4.
4.2  Potential Fraud or Abuse
Based upon the outcome of the review, the contractor shall refer any potential fraud, abuse, or patient harm as stated in Chapter 13, Section 3.
5.1  The contractor (excluding Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs)) shall provide to the Government a quarterly summary status report of all reviewed and targeted providers to include provider name, summary of the clinical review, number of interventions, type of interventions, and number not provided intervention (e.g., dosing and prescriptions were deemed appropriate) and provide rationale (e.g., cancer clinic). See paragraph 1.2. Details for reporting are identified in DD Form 1423, CDRL, located in Section J of the applicable contract.
5.2  Contractors with physician portals shall maintain a searchable database of patients currently on a PMP restriction in their secured website and make available to their network providers. These physician portals shall be compliant with Health Insurance Portability and Accountability Act (HIPAA) Privacy standards, HIPAA Electronic Transaction standards, and any other applicable Federal regulations.
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