1.0 GENERAL
1.1 All provisions
contained in the TRICARE Managed Care Support (MCS) contract, TRICARE
Operations Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Systems
Manual (TSM), or TRICARE Reimbursement Manual (TRM) shall apply
in the state of Alaska except as specifically modified by this Chapter.
Chapter references in this section refer to the TOM unless otherwise
specified. The word ‘contractor’ is used to reference the MCS contractor throughout
this Chapter.
1.2 The TRICARE program is not
automatically implemented in all areas where it is potentially applicable. Implementation
of the program requires an official action by an authorized individual
in accordance with
32 CFR 199.17(a)(5). Network implementation
will be published in the
Federal Register.
2.0 OPTIMIZATION
2.1 The contractor
shall, while overall responsibility and accountability remains with
the Government Designated Authority (GDA), manage network provider
development and operations in the state of Alaska. Overall responsibility
and accountability remains with the GDA.
2.2 The contractor
shall optimize the Military Medical Treatment Facility (MTF) for
all appropriate specialty requests for care received from outside
of the MTF within established TRICARE guidelines and access standards, consistent
with existing Memorandums of Understanding (MOUs).
2.3 The contractor
shall, in coordination with the MTF, process network referrals for
specialty care that cannot be provided by the MTF or scheduled within
TRICARE access standards in the MTF.
2.4 The contractor
shall use every appropriate opportunity for beneficiary and provider
education to influence beneficiary and provider behavior in a manner
that encourages MTF optimization.
3.0 BEST
VALUE HEALTH CARE
The contractor
shall support the delivery of high-value health care services in
the state of Alaska in the most efficient and cost-effective manner
through the efficient operation of all administrative processes
while ensuring timely access to high quality care and services.
This includes supporting MTF right of first refusal, educating beneficiaries
and providers on the benefit of using the MTF based on the collaborative
agreement with the MTF Commander Director,
and efficiently and effectively operating all administrative processes.
4.0 TRANSITIONS
4.1 The contractor
shall be fully responsible for all transition activities in the
state of Alaska in accordance with
Chapter
2.
4.2 The contractor shall ensure
all required contractor services are fully operational in accordance
with
Chapter 2 with
the exception of the provisions of ‘Execution of Agreements With
Contract Providers’.
4.3 The contractor shall load all
preferred providers to the contractor’s provider directory no later
than 30 calendar days prior to the start of health care delivery
(SHCD), or at such other time as mutually agreed between the contractor
and the Defense Health Agency (DHA).
5.0 ACCESS
TO DATA
The contractor
shall provide ready access to Government personnel for the state
of Alaska in the same manner as provided in all other TRICARE locations.
6.0 ADMINISTRATION
The contractor shall comply
with all provisions of
Chapter 1, with
the following exceptions:
6.1 The contractor shall process
preauthorizations for inpatient mental health care for non-Prime
enrollees and those enrolled to civilian Primary Care Managers (PCMs).
6.2 The MTF
will preauthorize or authorize all services for TRICARE Prime enrollees,
as required.
6.3 The contractor shall comply
with the preauthorization requirements specified in
Chapter 7, Section 4.
6.4 The contractor shall process
any grievance related to contractor personnel or contractor actions.
6.4.1 The contractor
shall forward grievances related to MTF providers to the responsible
MTF within five calendar days of receipt (see
paragraph 19.0 for appeals)
for resolution.
6.4.2 The contractor shall process
all grievances related to civilian providers consistent with
Chapter 11, Section 8.
7.0 RECORDS
MANAGEMENT
The contractor
shall comply with the provisions of
Chapter
9.
8.0 FINANCIAL
ADMINISTRATION
8.1 The contractor shall comply
with all of the provisions of the
Chapter
3.
8.2 The contractor shall apply
the appropriate financial provisions to the claims for TRICARE enrollees
in the state of Alaska based on guidance from the GDA.
9.0 PROVIDER
CERTIFICATION AND CREDENTIALING
The contractor shall comply
with the provisions of
Chapter 4 for providers
rendering care in the state of Alaska.
10.0 SUPPORT OF TRICARE PROVIDERS
10.1 The contractor
shall provide assistance to the Government in servicing participating
and non-participating providers. This assistance shall include certifying
and credentialing providers according to
paragraph 10.0.
10.1.1 The contractor shall provide
the appropriate level and number of provider representatives to
service the participating and non-participating providers throughout
the state of Alaska.
10.1.1.1 The contractor shall ensure
their provider representative is located in contractor furnished
facilities in close proximity to the MTF.
10.1.1.2 The contractor shall ensure
their provider representative assists in establishing provider networks.
10.1.2 The contractor shall provide
provider representatives to assist providers with TRICARE questions
or problems as necessary.
10.1.3 The contractor shall ensure
provider representative is supported by all appropriate contractor
staff and systems. For example, if a provider wishes to determine
the status of a claim, the provider can call the contractor’s claims
information toll-free telephone number or check the status via an
electronic means. However, if a provider requests the assistance
of an individual on-site at the provider’s office to resolve problems,
the provider representative shall provide the assistance.
10.2 The contractor
shall not require that Alaskan providers submit claims electronically
to the greatest extent possible, but may not require it.
10.3 The contractor
shall remove Alaskan claims from both the numerator and the denominator
when computing the percentage of claims submitted electronically.
11.0 ENROLLMENT
The contractor shall perform
all enrollment activity in the state of Alaska in accordance with
the provisions of
Chapter 6.
12.0 UTILIZATION
Management (UM) AND QUALITY MANAGEMENT (QM)
12.1 The contractor
shall comply with the provisions of
Chapter
7, regarding UM and QM.
12.2 The contractor
shall ensure that MTF issued authorizations are entered into all
applicable contractor systems to ensure accurate, timely customer
service, and claims adjudication.
12.3 The contractor
shall advise the GDA overseeing the Alaska Branch of any findings
where the TRICARE Quality Management Contractor (TQMC) identifies
provider with aberrant patterns in medical care, drug utilization, claims
or other from the state of Alaska, and the provider is a network
provider.
12.4 Cases for care rendered in
the state of Alaska shall be included in the selection of cases
for review by the TQMC per
Chapter 7, Section 7.
12.5 The contractor
shall comply with and include care rendered in the state of Alaska
in its Clinical Quality Management Program (CQMP) per
Chapter 7, Section 6.
12.6 The contractor’s
CQMP plan will include a separate section specifically addressing
Alaska.
12.7 The contractor shall process
and investigate all potential quality issues and unusual provider
findings by the TQMC during its case reviews per existing Clinical
Quality Management (CQM) policies.
13.0 CLAIMS
PROCESSING
The contractor
shall process claims in accordance with
Chapter
8.
14.0 DUPLICATE
CLAIMS
The contractor
shall comply with the TSM,
Chapter 4,
as appropriate, for the identification, correction and resolution
of duplicate and potentially duplicate claims.
15.0 CLAIMS
ADJUSTMENTS AND RECOUPMENTS
The contractor shall comply
with the provisions of
Chapter 10, regarding
claims adjustments and recoupments.
16.0 BENEFICIARY
AND PROVIDER SERVICES
16.1 The contractor shall comply
with the provisions of
Chapter 11, Sections 1 and
Section 6 relating to the provision of marketing
and education materials in the state of Alaska.
16.2 The contractor
shall comply with the provisions of
Chapter 11, Section 2 and
the contract regarding briefings within the state of Alaska.
17.0 CUSTOMER
SERVICE OPERATIONS
17.1 The contractor shall provide
customer service support to include benefit and enrollment assistance
to all beneficiaries in the state of Alaska. The functions of the
contractor’s call center shall be as specified in
Chapter
11.
17.2 The contractor shall first
direct all beneficiaries to the MTF (beneficiaries referred out
of the MTF for specialty services shall not be referred back to
the MTF) and then to the network providers when providing assistance
with referrals.
17.3 The contractor shall maintain
an up-to-date on-line list of network providers.
17.4 The contractor
shall comply with the provisions of
Chapter 11, Section 3 in
accomplishing Beneficiary, Congressional, and Beneficiary Counseling
and Assistance Coordinator (BCAC) relations within the state of
Alaska.
17.5 The contractor shall comply
with the provisions of
Chapter 11, Section 4 in
responding to inquiries regarding TRICARE within the state of Alaska.
17.6 The contractor
shall comply with the provisions of
Chapter 11, Section 5 regarding
correspondence, quality control and related reporting requirements.
17.7 The contractor
shall provide toll-free telephone service to Alaskan beneficiaries
in accordance with the provisions of
Chapter 11, Section 7.
17.9 The contractor
shall administer collection actions against beneficiaries in accordance
with
Chapter 11, Section 9.
18.0 APPEALS
AND HEARINGS
The contractor shall implement
and operate an appeals system for services requested or rendered
in the state of Alaska in accordance with
Chapter
12.
19.0 PROGRAM INTEGRITY (PI)
The contractor shall include
the state of Alaska in its PI Program per
Chapter
13.
20.0 AUDITS,
INSPECTIONS, AND REPORTS
20.1 The contractor shall comply
with the provisions of
Chapter 14 regarding
audits, inspections, and reports.
20.2 The contractor
shall provide a Monthly Preferred Provider Adequacy Report. For
reporting requirements, see DD Form 1423, Contract Data Requirements
List (CDRL), located in Section J of the applicable contract.
20.3 The contractor
shall develop the TRICARE network so that 75% of enrollee referrals
are to an MTF or civilian network provider.
21.0 GOVERNMENT
DESIGNATED AUTHORITY, MTF, AND CONTRACTOR INTERFACES
21.1 The contractor
shall comply with the requirements of
Chapter
15 when developing and operating MTF and GDA interfaces.
21.2 The contractor
shall also enter into an agreement with the appropriate GDA overseeing
the Alaska Branch, as required by the contract, regarding contractor
activities in the State of Alaska.
22.0 TRICARE
PRIME REMOTE (TPR) PROGRAM
The contractor shall operate
the TPR program in the state of Alaska in accordance with
Chapter
16.
23.0 CIVILIAN
CARE REFERRED BY MILITARY HEALTH SYSTEM (MHS) FACILITIES
The contractor shall comply
with the provisions of
Chapter 17 in
the State of Alaska.
24.0 CIVILIAN
HEALTH CARE (CHC) OF UNIFORMED SERVICE MEMBERS
The contractor shall comply
with the provisions of
Chapter 17 for
services in the state of Alaska provided through the Supplemental
Health Care Program (SHCP).
25.0 DEMONSTRATIONS
The contractor shall comply
with the provisions of
Chapter 18 for
eligible beneficiaries in the state of Alaska.
26.0 HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
The contractor shall comply
with the provisions of
Chapter 19 when
administering the TRICARE program in the state of Alaska.
27.0 TRICARE
MEDICARE ELIGIBLE Program (TMEP) CONTRACT
The contractor shall not be
responsible for services that are the responsibility of the TMEP
contractor in the State of Alaska. This does not relieve the contractor
from its customer service responsibilities to dual eligible beneficiaries.