TRICARE Manuals - Display Chap 7 Sect 1 (Change 5, May 16, 2024) (2024)

1.0MMPROGRAM

1.1The TRICARE Health Plan (THP)defines MM as an integrated managed care model that includes UtilizationManagement (UM), Referral Management (RM), Case Management (CM),Behavioral Health (BH), and Population Health (PH) programs to managepatient care and the clinical and social needs of eligible beneficiaries.

1.2The contractor shall integrateevidence-based and outcome-oriented processes in the MM programsto provide the highest quality care to eligible beneficiaries.

1.3The contractor shall use nationallyrecognized criteria and standard of care guidelines in identifying, managing,monitoring, processing, reviewing, and authorizing all medical,virtual medicine, and behavioral health care services.

1.4The contractor’s MM programsshall support and manage the healthcare utilization of individualswith high-cost claims, complex medical conditions, inpatient admissionsand discharges, pharmacy (specialty drugs, multiple medicationsor pharmacies), and beneficiaries receiving low quality care.

1.5The contractor shall submita written MM plan. For plan submission requirements, see DD Form1423, Contract Data Requirements List (CDRL), located in SectionJ of the applicable contract.

2.0ELECTRONIC MM SYSTEM

2.1The contractor shall manageand maintain a single, consolidated, easy to use and understand,fully-electronic, web-based MM data system platform that is available24 hours a day/seven days a week (24/7), except for scheduled downtimefor system maintenance.

2.2The informationshall be at the beneficiary and Military Medical Treatment Facility(MTF) level, that can be viewed, downloaded and printed, with concurrentand refreshed data no less than once every 24 hours.

2.3The Government may use thecontractor’s portal to submit referrals in situations when the RMsystem is unavailable.

2.4The electronicdata system platform shall offer Defense Medical Information System(DMIS) specific access, reporting and consolidated, detailed informationto MTF, Market, THP, and Defense Health Agency (DHA) authorizedpersonnel.

2.6The contractor shall providethe UM decisions on the electronic MM data system platform for Market/MTF andcivilian network TRICARE Prime enrollees the day the decision ismade. All denied authorizations or reconsiderations must be mailedto the beneficiary and the provider.

2.7The contractorshall provide access to the Market/MTF and civilian network PrimaryCare Managers (PCMs) to inpatient admissions and discharges forall TRICARE Prime enrollees within 24 hours of the contractor becomingaware of the admission via the electronic data system platform.For reporting requirements, see DD Form 1423, CDRL, located in SectionJ of the applicable contract.

2.8The contractorshall schedule system maintenance windows during weekends or non-peakhours to minimize disruption of services to Government workers tothe maximum extent possible.

2.9The contractorshall provide access to the MM electronic data system platform forup to 7,500 Government users per region.

2.10The contractorshall provide training on the MM data system, prior to start ofhealth care delivery (SHCD), and at a minimum quarterly thereafterto Market/MTF and Government users.

3.0MM PROGRAM REPORTING

The contractor shall reportthe effects of MM programs on Market/MTF optimization by MM programcomponent. For reporting requirements, see DD Form 1423, CDRL, locatedin Section J of the applicable contract.

4.0PROVIDERACCESS TO DEPARMENT OF DEFENSE (DoD) PHARMACYINFORMATION

4.1The contractor shall provideaccess to DoD Pharmacy information which allows MTF clinic designeeand civilian providers or clinic designee to view and print theirpatients’ medication lists according to the MOU between the ManagedCare Support Contractor (MCSC) and TRICARE Pharmacy (TPharm) contractor(see DD Form 1423, CDRL, located in Section J of the applicablecontract). The medications lists will include medications, to include controlledsubstances such as opioids, dispensed by Markets/MTFs, the TRICAREMail Order Pharmacy (TMOP), and retail pharmacies.

4.2The contractor shall make thisinformation available via the contractor’s website for PCMs, specialists,and BH providers or clinic designee who register for this capability.

4.3The contractor shall ensureregistered providers or clinic designee will have access to medicationlists for all of their assigned TRICARE patients; specialist accesswill be limited to those patients for whom they have a referralor authorization.

5.0PREDICTIVE ANALYTICS

5.1The contractor shall use predictiveanalytics in the operation of their MM programs to include, butnot limited to medical, telehealth, BH, UM, CM, and PH (to includechronic care (CC)/DM).

5.2The contractor’spredictive analytics tools shall offer an automated means to forecastfuture health outcomes for individuals or populations based on algorithmsderived from historical patient data.

5.3The contractorshall implement beneficiary-centric data analytic tools/systemsto integrate data from multiple sources (including, but not limitedto, Government-provided Market/MTF real-time data and real-time pharmacydata) to allow a consolidated view of all data related to each beneficiary.

5.4The contractor’s system shallprocess this information against industry-respected sources of evidence-basedmedicine to identify gaps in care, medical errors, identify high-riskaddictive behaviors, such as, opioid use or abuse and quality issues.

5.5The contractor shall utilizeits analytic tools to treat and to provide a report on annuallyidentified chronic diseases (including opioid use), identify gapsin care of Leading Health Indicators (LHIs), identified chronicdiseases identified by DoD, as well as promote prevention and wellnessfor at-risk individuals. For reporting requirements, see DD Form1423, CDRL, located in Section J of the applicable contract.

6.0PRIVATE SECTOR CARE AND DIRECTCARE (DC) INTEGRATION

The contractorshall identify and propose opportunities to coordinate, collaborate,and implement Market/MTF integrated care and processes with theGovernment.

7.0MM TRAINING

The contractor shall provideongoing MM training and presentations at the THP hosted monthlyMM Teleconference for the Government (Markets/MTFs and DHA) in regardsto its electronic MM system and programs.