2.0 UM
2.1 The contractor
shall establish a MM/UM Plan for care received by TRICARE beneficiaries.
2.1.1 The contractor’s
MM/UM Plan shall recognize that the Military Medical Treatment Facility
(MTF) Primary Care Manager (PCM) retains clinical oversight for
TOP Prime enrollees. As such, the enrolling MTF will determine medical
and psychological necessity, and issue all referrals for TOP Prime
enrollees, and provide UM and all Case Management (CM) services
for the MTF-enrolled population. The contractor shall ensure that
MTF-issued referrals and appropriate authorizations are entered
into all applicable contractor systems to ensure accurate, timely customer
service and claims adjudication. The contractor shall perform certain
UM activities to assist the MTF with the MM of TOP Prime inpatients
as described in the TOP contract. The contractor shall provide notification
to the MTF Commander Director or
designee whenever an MTF enrollee is admitted to an inpatient facility
(including mental health admissions), regardless of location.
Note: The MTF will exercise
clinical oversight for newborns/adoptees who are deemed
enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall
receive clinical oversight from the MTF.
2.1.2 The contractor
shall determine medical and psychological necessity, conduct covered
benefit review, and issue authorizations for specialty care for
TOP Prime Remote enrollees and all Service members who are on Temporary
Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave
status, or deployed/deployed on liberty in a remote overseas location.
The contractor shall provide notification of cases to the appropriate
TRICARE Area Office (TAO) for reviews involving remote Service member
requests for specialty care, and whenever hospital admissions have
occurred for any beneficiary not enrolled to a TOP MTF (including
mental health admissions), regardless of location.
Note: The TOP contractor
shall exercise clinical oversight for newborns/adoptees
who are deemed enrolled in TOP Prime Remote (based on the sponsor’s
TOP Prime Remote enrollment) shall receive clinical
oversight from the TOP contractor.
2.1.3 The contractor
shall review and authorize urgent specialty care
for beneficiaries enrolled to a stateside contractor who are traveling
outside of the 50 US and the District of Columbia.
2.2 The MM/UM
Plan shall recognize that private sector care network providers
are the responsibility of the TOP contractor’s
responsibility and the contractor shall ensure that
any adverse finding related to private sector care provider care
is forwarded within five calendar days of identification to the
appropriate TAO.
2.3 The MM/UM Plan shall include
a process for identifying high utilization/high cost patients and
locations.
2.3.1 At a minimum, this process
shall include the identification of patients exceeding the frequency
and/or cost thresholds established in the TOP contract. These thresholds
apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote,
TRICARE Select and TOP TRICARE For Life (TFL).
2.3.2 The TOP
contractor shall review these claims for appropriateness of care,
and shall propose interventions to reduce overutilization or contain
costs whenever possible. The TOP contractor shall forward proposed
interventions to cost and/or overutilization shall
be forwarded to the Government for review prior to contractor
implementation.
2.4 The MM/UM Plan shall integrate
efforts to identify potential fraud/abuse.
AnyThe
TOP contractor shall forward all cases identified as
possible fraud/abuse
shall be referred directly
and exclusively to the Defense Health Agency (DHA) Program Integrity
(PI) Office in accordance with
Section 14.
2.5 The TOP
contractor shall provide CM services as outlined in the contract
with DHA. Specific CM processes shall be addressed in the Statements
of Responsibilities (SORs) between the contractor, MTF Commanders,
and the TAO Directors.
2.6 The TOP contractor shall closely
monitor requests for inpatient care or medical evacuation services
to ensure that services are medically or psychologically necessary
and appropriate for the patient’s condition. Beneficiaries will
not be assigned to a particular facility or medically evacuated
to a particular geographic location based solely on personal preference,
but will be transported to the closest medical facility capable
of providing appropriate stabilization and/or treatment.
2.7 Inpatient
stays that exceed the standard Length-Of-Stay (LOS) for a local
area in a private sector care country or US commonwealth/territory
shall be identified and reviewed for medical or psychological necessity. Unless
a different standard has been identified by the Government,
the contractor shall use best business practices to determine the
standard LOS for a particular overseas location. Upon Government
request, the TOP contractor shall provide supporting documentation
related to LOS determinations.
5.0 REFERRAL/AUTHORIZATION/HEALTH
CARE FINDER (HCF) REQUIREMENTS
5.1 The TOP contractor shall develop
procedures for processing referrals for TOP Prime and TOP Prime Remote
enrollees in accordance with the TOP contract;
Chapter 7, Section 5; and this
chapter. The TOP contractor shall conduct related authorization
and HCF activities. The MTF will conduct medical and psychological
necessity reviews for TOP MTF enrollees and determine that the requested
care is not available in the MTF prior to forwarding the referral
to the contractor.
5.2 The contractor shall conduct
covered benefit reviews to determine whether the referred care is
a covered TRICARE benefit.
The contractor shall comply
with the requirements in Chapter 7, Section 5 for
notifying beneficiaries about medical or psychological
necessity
notification to beneficiaries regarding
covered benefit findings shall follow the provisions of Chapter 8, Section 5. The contractor
shall locate an appropriate network or non-network private sector
care provider for all authorized care and shall provide the provider
information to the beneficiary. Upon beneficiary request, the contractor
shall assist with scheduling an appointment for the beneficiary.
The contractor shall also implement guarantee of payment or other
business processes to ensure that TOP Prime and TOP Prime Remote
beneficiaries have access to authorized care on a cashless, claimless
basis.
5.3 The TOP contractor shall develop
procedures for the identification and tracking of TOP enrollee claims submitted
by a private sector care provider or a beneficiary without preauthorization/authorization.
5.4 The TOP
contractor shall educate beneficiaries of the preauthorization/authorization
requirements and of the procedures for requesting preauthorization/authorization.
In MTF locations, these beneficiary education efforts may be conducted
in conjunction with MTF staff. In remote locations, the contractor
shall provide all beneficiary education. Although beneficiaries
are required to obtain authorization for care prior to receiving payment
for the care requiring TOP preauthorization/authorization, the
beneficiary may request retroactive authorization may
be requested following the care from the appropriate
authority for issuing authorizations. Specifically, ADSMs enrolled
in TOP Prime or TOP Prime Remote who seek urgent care from a private
sector care without obtaining authorization will be are required
to contact their PCM within three business days so that a retroactive
referral may be submitted. The TOP contractor shall not
accept retroactive authorization requests shall not
be accepted by the TOP contractor after this initial
time frame without higher level approval (TAO or TOP Office). The
contractor shall document preauthorization/authorizations according
to current contract requirements.
5.5 If medical
review is required to determine medical or psychological necessity
of a service rendered, the TOP contractor shall follow the requirements
outlined in
Chapter 7, Section 1 related to medical review
staff qualifications and review processes.
5.6 The TOP contractor
shall ensure the provider submits the preauthorization/authorization must
be submitted with the claim or be the
TOP contractor shall make the preauthorization/authorization available
via an internal contractor systems
designated to that interfaces with
the claims processing system.
5.7 The TOP
contractor shall maintain a preauthorization/authorization file.
5.8 When necessary, clarification
of the TOP contractor shall clarify discrepancies
between authorization data and data on the claims shall
be made by the TOP contractor with the appropriate
authorizing authority.
5.9 Except for obstetrical care or
other long-term/chronic care authorizations, the TOP contractor
shall consider authorizations valid for 180 calendar days (i.e.,
date of service must be within 180 calendar days of issue date).
Authorizations may be granted for 365 days for obstetrical care,
or for any other long-term/chronic conditions for which an extended
care period is medically or psychologically necessary and appropriate. OnlyThe TOP
contractor shall only cover services that are applicable
to the care authorization shall be covered under the authorization (i.e.,
a care authorization for obstetrical care cannot be extended to
cover specialty care that is unrelated to the pregnancy).
5.10 The
TOP contractor shall develop procedures for preauthorizations/authorizations
for TOP beneficiaries for inpatient mental health care rendered
in the 50 US or the District of Columbia
shall be
developed by the TOP contractor. The TOP contractor
shall authorize/review all stateside non-emergency inpatient mental
health care (i.e., acute hospitalization psychiatric care, psychiatric
Residential Treatment Center (RTC), Substance Use Disorder (SUD)
inpatient/residential detoxification and rehabilitation for TOP
Prime/TOP Prime Remote ADFMs, regardless of where the care is rendered.
To perform this requirement, the contractor shall at a minimum provide:
• Three 24-hour telephone lines:
one stateside toll free, one commercial and one fax for overseas
inpatient mental health review requirement;
• Sample forms for use by the
referring physician when requesting preauthorization/authorization
for care; and
• A system for notification of
the contractor when care has been authorized. Additionally, the
TOP contractor shall:
5.10.1 Inform the beneficiary/provider
if a desired facility is not a TRICARE authorized facility and offer
the beneficiary/provider a choice of alternative facilities and
assist with identifying stateside facilities for referring providers.
5.10.2 Upon request, either telephonically
or by fax, from a referring provider, the contractor shall initiate preauthorization
prior to admission for non-emergency inpatient care, including RTC,
Substance Use Disorder Rehabilitation Facility (SUDRF), etc. (Essentially,
all admissions defined by TPM,
Chapter 1, Section 6.1, as requiring preauthorization).
The TOP contractor shall arrange ongoing utilization review, as
indicated, for overseas beneficiaries admitted to any level of inpatient
mental health care.
5.10.3 Ensure the
review determination
must conclude
s in
either authorization or denial of care.
The TOP contractor
shall submit review results
must be submitted via
HIPAA compliant electronic means to the beneficiary/provider within
24 hours of the request. The
TOP contractor shall follow
the review and denial process
es will
follow, as applicable
, the
processes outlined in
Section 7.
5.10.4 The TOP contractor shall provide
an opportunity to discuss the proposed initial denial determination with
the patient’s attending physician AND referring physician (if different
providers). The purpose of this discussion is to allow further explanation
of the nature of the beneficiary’s need for health care support
services, including all factors which preclude treatment of the
patient as an outpatient or in an alternative level of inpatient care.
This is important in those beneficiaries designated to return overseas,
where supporting alternative level of care may be limited, as well
as support for intensive outpatient treatment. If the referring
provider does not agree with the denial determination, then the
contractor shall contact the appropriate overseas TAO Medical Director
to discuss the case. The TAO Director shall will provide
the schedule and contact information for all overseas TAO mental
health advisors. The TOP contractor shall make the final
decision on whether or not to issue a denial will
be made by the TOP contractor.
5.10.5 The TOP contractor shall notify
the referring provider if the patient is returning to ensure coordination of
appropriate after-care arrangements, as well as facilitate discussion
with the attending provider to ensure continuity of care is considered
with the proposed after-care treatment plan.
5.10.6 The TOP contractor shall adhere
to the appeals process outlined in
Section 12.
5.11 With
written DHA Contracting Office permission prior to implementation,
the
TOP contractor may alter the required
data elements for MTF referrals prescribed in
Chapter 7, Section 5, paragraph 4.4 may
be altered to accommodate the delivery of health
care overseas
with the permission of the Government.
Note: Any alteration to the referral data
elements prescribed in Chapter 8, Section 5, paragraph 6.1 must
be approved in writing by the DHA Contracting Officer (CO) prior
to implementation.
6.0 MEDICAL
TRAVEL
6.1 TOP Prime Enrollees and MTF-Referred
Transient Beneficiaries
If the
TOP contractor’s HCF determines that appropriate medical or psychological
care is not available in the beneficiary’s local service area, the
TOP contractor shall provide Notification of Case (NOC) to the appropriate
MTF per the medical travel requirements of DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract. The NOC shall identify the nearest private sector care
provider or facility that can provide adequate specialty care. The
TOP contractor shall issue a care authorization upon the MTF’s
request (as documented in the MTF’s response to the NOC).
6.2 TOP
Prime Remote and Self-Referred Transient Beneficiaries
If the TOP contractor’s HCF
determines that appropriate medical or psychological care is not
available in the beneficiary’s local service area, the TOP contractor
shall provide a NOC to the appropriate TAO per the medical travel
requirements of DD Form 1423, CDRL, located in Section J of the
applicable contract. The NOC shall identify the nearest private
sector care provider or facility that can provide adequate specialty
care. The TOP contractor shall issue a care authorization upon TAO’s
request (as documented in the TAO’s response to the NOC Report).