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 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).
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).
2.1.3 The contractor
shall review and authorize urgent 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 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 to the Government for
review prior to contractor implementation.
2.4 The MM/UM
Plan shall integrate efforts to identify potential fraud/abuse.
The TOP contractor shall forward all cases identified as possible
fraud/abuse 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
TOP contractor
shall conduct covered benefit reviews to determine whether the referred
care is a covered TRICARE benefit. The
TOP contractor
shall comply with the requirements in
Chapter 7, Section 5 for notifying
beneficiaries about medical or psychological necessity. The
TOP 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
TOP contractor
shall assist with scheduling an appointment for the beneficiary.
The
TOP 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 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 are required to contact their
PCM within three business days so that a retroactive referral may
be submitted.
The contractor shall process claims for
ADSMs in accordance with Section 26. The
TOP contractor shall not accept retroactive authorization requests
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
with the claim or the TOP contractor shall make the preauthorization/authorization
available via an internal contractor system that interfaces with
the claims processing system.
5.7 The TOP
contractor shall maintain a preauthorization/authorization file.
5.8 When necessary,
the TOP contractor shall clarify discrepancies between authorization
data and data on the claims 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. The TOP contractor shall only cover services that are
applicable to the care 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. 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
TOP 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
TOP 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
concludes in either authorization or denial of care. The TOP contractor shall
submit review results via HIPAA compliant electronic means to the
beneficiary/provider within 24 hours of the request. The TOP contractor
shall follow the review and denial processes, as applicable, 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 TOP contractor
shall contact the appropriate overseas TAO Medical Director to discuss
the case. The TAO Director 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.
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 to
accommodate the delivery of health care overseas.
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).