1.0 MEDICAL MANAGEMENT (MM)
1.1 The incoming contractor shall
develop and implement a MM Program that addresses all aspects of
MM as described in
Chapter 7, to include:
Referral Management (RM), Case Management (CM), Behavioral Health
(BH), Utilization Management (UM) and Population Health (PH).
1.2 The incoming contractor shall
ensure that all aspects of their MM Program are fully operational
no later than 30 calendar days prior to the start of health care
delivery (SHCD).
1.3 The incoming
contractor shall report the development and integration progress
on an on-going basis at the transition meetings.
1.4 The incoming contractor shall
develop and implement a single, consolidated, user friendly, fully electronic,
web-based MM data system platform that is available 24 hours a day/seven
days a week (24/7), in accordance with
Chapter 7, Section 1,
and ready for end user training 120 calendar days prior to the SHCD.
2.0 PHASE-IN REQUIREMENTS RELATED
TO MM AREAS
2.1 The incoming contractor shall
begin the MM validation process by demonstrating its planned web-based application
which will provide access, reporting and detailed information to
the Government on, all above listed MM areas and pharmacy application
120 calendar days after contract award.
2.2 The outgoing
contractor shall transfer to the incoming contractor, in an electronic
format, all beneficiary history (both medical and mental health),
in accordance with
Chapter 9, Section 2.
2.3 The outgoing contractor shall
provide information to beneficiaries and providers on how they may obtain
assistance and coordinate care during the transition.
2.4 The outgoing contractor shall
communicate, collaborate, and coordinate with the incoming contractor
all cases involving beneficiary change of provider from network
to non-network as a result of transition 30 calendar days prior
to the SHCD.
2.5 The outgoing contractor shall
communicate, collaborate, and coordinate with the incoming contractor on
the authorization episode of care timeframes for inpatient, institutional,
Residential Treatment Center (RTC), respite, Home Health Care (HHC),
discharge planning and next level of care, outpatient authorized
care 30 calendar days prior to the SHCD.
2.6 The outgoing contractor shall
communicate and collaborate with the Government Designated Authority (GDA)
and incoming contractor in meetings (at least weekly) beginning
60 calendar days prior to the start of service delivery. Meeting
topics shall include: CM and Disease Management (DM) high cost,
high profile, high visibility, and sensitive medical and mental
health cases to ensure seamless continuity of services to those
beneficiaries.
2.7 The incoming contractor shall
provide MM training twice weekly to the Government (Defense Health Agency
(DHA) and Markets/Military Medical Treatment Facilities (MTFs))
in their geographic area of responsibility on the contractor’s electronic
MM data system and usage beginning no later than 120 calendar days
prior to the SHCD.
6.0 UM
6.1 The incoming
contractor shall ensure health care services are provided in accordance
with the contractor’s MM Plan (see
Chapter
7).
6.2 The incoming contractor shall
fulfill valid authorizations and referrals issued by the outgoing
contractor, covering care through 180 calendar days after the start
of service delivery under the incoming contract.
6.3 The incoming contractor shall
receive complete open and closed case files for appeals and reconsideration
documentation regarding all beneficiaries under active UM programs
(to include BH) as required above.
6.4 The incoming
contractor shall ensure that the Peer Review Organization (PRO)
requirements are in place, to include written agreements guidelines
in
Chapter 2, Section 3.
6.5 The outgoing contractor shall
provide the incoming contractor with authorization-related clinical information
to preclude requiring a provider or beneficiary to duplicate the
paperwork and other efforts related to established authorizations
in accordance with
Chapter 9, Section 2.
6.6 The outgoing contractor shall
issue authorizations as late as midnight on the day prior to the
end of its health care delivery (HCD) for inpatient stays that will
continue as transitional cases.
6.7 The outgoing
and incoming contractors shall interface on the clinical issues
of a case where both contractors will, or can reasonably expect
to, have periods of liability for the same episode of care.
7.0 CLINICAL
QUALITY MANAGEMENT (CQM)
7.1 The outgoing contractor shall
communicate, collaborate, and coordinate with the incoming contractor for
all Potential Quality Issue (PQI) cases and make every attempt to
close prior to the end of the contract.
7.2 The outgoing
contractor shall provide the incoming contractor with all new and
open PQI cases the outgoing contractor is unable to close, starting
30 calendar days prior to the SHCD and will continue to send cases on
a weekly (or routine) basis for all new cases that come in until
midnight on the last day of the outgoing contractor’s HCD.
7.3 The outgoing
contractor shall collaborate and be available to discuss any open
or new cases until close of business on the first business day of
the incoming contractor’s SHCD.
8.0 MM
PERFORMANCE READINESS VALIDATION (PRV)/PERFORMANCE READINESS ASSESSMENT
AND VERIFICATION (PRAV)
The incoming
contractor’s performance readiness status regarding MM shall be
subject to PRV/PRAV reviews during transition as described below.
8.1 MM
PRV
8.1.1 The incoming contractor shall
validate that its MM electronic data system is fully operational
for training in test mode 120 calendar days prior to the SHCD.
8.1.2 The incoming
contractor shall validate that its web-based MM electronic data
system can connect to the DHA Pharmacy Operations
Center TRICARE Pharmacy contractor no
later than 120 calendar days prior to the SHCD.
8.1.3 The incoming
contractor shall validate, no later than 90 calendar days prior
to the SHCD, that it’s web-based MM electronic data system is accessible
by TRICARE authorized providers and GDA to view and print patient medication
lists.
8.1.4 The incoming contractor shall
validate that systems for tracking and trending of quality assurance
and clinical quality issues and UM processes for peer review are
in place 60 calendar days prior to SCHD.
8.2 MM
PRAV
The incoming contractor’s performance
readiness status regarding MM shall be subject to PRAV reviews during transition,
as described above.
8.2.1 The incoming contractor shall
comply with the Government’s approach for assessment and verification of
the contractor’s performance readiness regarding MM as described
below.
8.2.2 The incoming contractor shall
submit a detailed mitigation plan no later than 10 business days following
the Government’s findings, if, after review, the Government finds
the contractor’s performance readiness for MM to be deficient.
8.2.3 The Government
will identify thresholds for specific PRAV activities, assessment
techniques, and performance readiness during the Transition Specification
(TRANSPEC) Meeting.