TRICARE Operations Manual 6010.62-M, April 2021
Transitions
Chapter 2
Section 7
CriticalProcesses (CPs) - Referral Management (RM)
Revision:
1.0RM
1.1The incomingcontractor shall establish an automated RM process in accordancewith Section C of the contract and Chapter 7, Section 5 nolater than the 90 calendar days prior to the start of health caredelivery (SHCD).
1.2The incomingcontractor shall implement an electronic RM system that integrateswith the Government’s electronic RM system no later than 60 calendardays prior to the SHCD.
1.3The incomingcontractor’s RM system shall interface with the Uniformed ServicesRM process and/or system(s) at each Military Medical Treatment Facility(MTF), United States Coast Guard (USCG) clinics, and Markets nolater than 60 calendar days prior to the SHCD.
1.4The incoming contractor’s RMsystem shall include the ability to capture referrals and authorizationsfrom civilian providers into the Markets/MTFs and other businessprocesses as necessary to ensure that inbound and outbound referralsare processed accurately and timely in accordance with Chapter 1, Section 3, with a focus on thosereferrals with high value Knowledge, Skills and Abilities (KSAs)as defined by the Government.
1.5The incomingcontractor shall phase in referral processing as follows:
•Day 1 of health care delivery(HCD) - The contractor shall process Active Duty Service Member(ADSM) and TRICARE Prime Remote (TPR) ADSM and Active Duty FamilyMember (ADFM) referrals only.
•Day 31 of HCD - The contractorshall include in its referral processing TRICARE Prime beneficiariesenrolled to MTF Primary Care Managers (PCMs).Day 61 of HCD - Thecontractor shall include in its referral processing TRICARE Primebeneficiaries enrolled to a network PCM.Day 91 of HCD - The contractorshall include any other beneficiary category that requires a referral.
1.5.1A PCMreferral waiver and/or Point of Service (POS) waiver will be implementedwith this phased-in approach of referrals.
1.5.2The contractorshall submit a Daily Authorization Inventory Report and a DailyRolling Referral Inventory Report to the Government. For reportingrequirements, see DD Form 1423, Contract Data Requirements List(CDRL), located in Section J of the applicable contract.
2.0PERFORMANCE READINESS VALIDATION(PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)
During transition, the incomingcontractor’s performance readiness status regarding RM will be subjectto PRV/PRAV reviews as described below.
2.1RMPRV
2.1.1The incoming contractor shallvalidate its RM system can interface with the Government’s RM systems (MHSGenesis and RM Suite (375)).
2.1.2The incomingcontractor shall validate its interface meets two criteria:
2.1.2.1Markets/MTFs can send and receivereferrals with priority to those with a high KSA value with no technicalproblems, and
2.1.2.2The contractor sends referralsand authorizations in accordance with the Market/MTF Capability Tablewith 95% accuracy, as listed in paragraph 2.1.9.2.
2.1.3The incoming contractor shallvalidate its RM systems can effectively interface with the Government’s RMsystem(s), Defense Enrollment Eligibility Reporting System (DEERS),contractor’s claims systems, network provider directory, and thesystem network providers utilize to submit referrals and authorizationno later than 60 calendar days prior to the SHCD.
2.1.4The incoming contractor shalltest, validate, and produce connectivity test results on all interfaces.
2.1.5The incoming contractor shallvalidate all aspects of its referral, authorization and commandapproval (overseas only) processes by utilizing test scenarios whichinclude referrals to Market/MTF and network providers and referralsfrom contractor to Market/MTF no later than 60 calendar days priorto the SHCD.
2.1.6The incoming contractor’s processvalidation shall encompass all beneficiary categories and will use livedata from the Government’s RM system as part of the validation.
2.1.7The incoming contractor shallvalidate that its system can timely and accurately communicate referral, authorizationdeterminations with beneficiaries, network providers, Governmentsystems and claims systems without technical problems.
2.1.8The incoming contractor shallvalidate its ability to communicate with beneficiaries with multiple referralstatus alerts and notification options, including email, text, web-portaland hardcopy letters, to include beneficiary view and print capabilities.
2.1.9The incoming contractor’s validationshall demonstrate their RM system’s ability to accurately process 90%of all requests within one business day and 100% within two businessdays.
2.1.9.1The contractor shall validateits RM system (e.g., approval/denial letters) is accessible by the Government,beneficiaries, and providers.
2.1.9.2The incoming contractor shallvalidate that referrals processed meet contract requirements witha 95% accuracy rate. To be considered accurate, processed referralshall include:
•Correct beneficiary
•Correct beneficiary demographics
•To include sponsor’s last fourdigits of the Social Security Number (SSN) or Department of Defense(DoD) ID Number
•Date of Birth (DOB)
•Unique Identifier Number (UIN)is present if Market/MTF generated request
•Correct Servicing Provider
•Correct Servicing Specialty
•Correct Episode of Care (EOC)
•Evaluate and Treat
•Evaluate only
•Number of visits
•Length of authorization
•Range of Current ProceduralTerminology (CPT) codes
2.2RM PRAV
2.2.1The incomingcontractor shall comply with the Government’s approach for assessmentand verification of the contractor’s performance readiness regardingenrollment activities as described above.
2.2.2The incomingcontractor shall submit a detailed mitigation plan no later than10 business days following the Government’s findings if, after review,the Government finds the contractor’s performance readiness forenrollment processing to be deficient. Specific PRAV activities,assessment techniques, and performance readiness thresholds willbe identified by the Government during the Transition Specifications(TRANSPEC) Meeting.
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