Medical Management
Peer Review Organization Agreement
In the TRICARE West Region, TriWest has peer review authority over health care services provided in civilian facilities. Facilities must establish a Peer Review Organization (PRO) Agreement with TriWest in accordance with 32 Code of Federal Regulations and TRICARE Operations Manual (TOM) to participate in our network. The PRO agreement is separate from a network contract. Both network and non-network facilities are required to sign a PRO, acknowledging that TriWest is the PRO for the TRICARE West Region.
If a corporation has multiple facilities, one signed agreement may cover all the facilities.
By signing the agreement providers confirm that they will cooperate with TriWest and our subcontractors by:
- Providing copies of medical records
- Providing accurate information on beneficiaries’ conditions
- Informing beneficiaries of their rights and responsibilities
Providing other assistance that may be required for TriWest to conduct comprehensive utilization and quality management programs for care of MHS beneficiaries who are patients of the facility
Emergency Admission
TRICARE providers must notify TriWest of an emergency room inpatient admission and discharge date within 24 hours or by the next business day following admission and discharge. Facilities can submit the admission notification utilizing one of the following:
- Visit the Emergency Inpatient Notification profile in CareAffiliate online (specific link to be updated prior to start of health care delivery)
- Fax the beneficiary’s hospital admission record face sheet to TriWest (specific fax number to be updated prior to start of health care delivery)
Facilities must note the following on the hospital admission request:
- Beneficiary demographic information including sponsor’s Social Security number (SSN) or Department of Defense (DOD) Benefits Number
- Health plan information
- Name of the admitting physician
- Admitting diagnosis and date
TriWest reviews admission information and authorizes continued care, if necessary.
Inpatient Notification Process
TriWest requires notification of all inpatient facility admissions and discharge dates by the next business day following the admission and discharge. We also conduct continued stay reviews for many services.
TriWest will send the medical facility an authorization number after we receive clinical information and the discharge date and we will request clinical records, as necessary. Clinical records should be submitted online before the beneficiary is discharged (specific link to be updated prior to start of health care delivery). This ensures that military treatment facilities (MTF) have insight into care being delivered.
Concurrent Review
Concurrent review ensures appropriate, efficient, and effective utilization of medical resources by evaluating continued inpatient stays. TriWest performs concurrent reviews to determine medical necessity, quality of care and appropriateness of the level of care being provided as well as the setting in which the treatment is being rendered or proposed. It applies to all levels of inpatient care and partial hospitalization programs. If an admission or an extended stay does not meet the required clinical criteria, TriWest will send a request to the medical director or peer review panel for further review.
When approving inpatient medical/surgical admissions, the number of days are assigned, and the last covered date is set. If a beneficiary requires additional time in the facility and the facility does not request an extension by submitting necessary clinical information, a provider penalty is applied to the additional days.
When prospective review (pre-authorization) is initiated, TriWest will secure the necessary medical information to support the medical, surgical, or behavioral health care services. Utilization Management staff will perform a medical necessity and appropriateness of setting and treatment review with each concurrent review, utilizing InterQual® Level of Care Criteria or specific policy key criteria that incorporates specific TRICARE requirements. A TriWest medical management representative may contact the hospital at the time of admission notification to obtain initial clinical information and to discuss discharge planning needs. We may make subsequent contacts to discuss goals for length of stay and/or confirm discharge.
Before or during discharge, facilities must arrange an aftercare appointment to occur within 7-10 days if the beneficiary is not being discharged to another facility. The facility must include this information with the final discharge information transmitted to TriWest.
Discharge Planning
TriWest initiates discharge planning for all admissions during the first review of the case. Discharge planning begins upon admission review and continues throughout the beneficiary’s stay. The intensity of services change when a beneficiary’s illness decreases in severity and/or begins to stabilize. If care can be delivered in a less emergency-oriented setting, TriWest’s medical management staff coordinates efforts with the physician directing the care (and the beneficiary and family members) to facilitate timely and appropriate discharge. These activities include:
- Arranging for services such as home health and durable medical equipment needed after discharge
- Coordinating transfers to lower levels of care to minimize inappropriate use of hospital resources
Care Coordination
TriWest’s Care Coordination Program is part of whole person clinical care support structure with its primary role to assist with:
- Discharge planning
- Coordinating transfers
- Overseeing hospice benefit and requests
- Assisting with provider communication and collaboration when multiple providers are engaged in the care
Program participation for Care Coordination should be less than 60 days. TriWest will transfer the case to a Case Manager for longer term support if the complexity or the need is identified.
Providers can make referrals for Care Coordination through CareAffiliate online (specific link to be updated prior to start of health care delivery).
Case Management
TriWest’s Case Management program coordinates all aspects of medical and behavioral health treatment for at-risk beneficiaries who require extensive, complex, and/or costly services. TriWest case managers manage treatment by coordinating MTFs and TRICARE regional resources to provide high quality, cost-effective services targeted to address the beneficiaries’ unique physical and behavioral health needs. TriWest case managers are nurses, licensed clinical social workers, or other health professionals that acts as a patient advocate, coordinating the beneficiary’s health care between the MTF, Primary Care Manager (PCM), specialists, and other health care providers.
Providers can refer beneficiaries who may benefit from case management for an evaluation to TriWest using CareAffiliate online (specific link to be updated prior to start of healthcare delivery). Our case managers offer TRICARE beneficiaries and their families support in a personalized way throughout their health care experience. They also are equipped to identify relevant local, county, state and federal level resources to meet the beneficiary’s needs in a quality and cost-effective manner. Case managers may consult with the beneficiary’s providers regarding treatment plans.
In-Home Case Management Coordination
TriWest will provide in-home case management coordination for identified high-risk beneficiaries. During discharge planning, TriWest will partner with the hospital discharge planning team so that beneficiaries may be screened and assessed for the need for an in-home case management visit. TriWest uses a scoring tool to assess needs that drive a variety of interactions for the beneficiary and their family. TriWest will manage all notifications and act as a liaison to identify urgency and proper utilization of services needed to ensure successful transitions of care and help avoid readmissions. In-home visits will be scheduled within 48-72 hours of discharge.
Population Health Management
Our Population Health management approach is to provide support to beneficiaries through an integration of secure portals, online tools, and interactive programs developed to create greater autonomy for beneficiaries as they become more fluent in managing their own care needs and more confident in their treatment-seeking behaviors. TriWest offers several digital and interactive programs to support health and wellness, including:
- Wellness and Healthy Lifestyle Education
- TriWest mobile app
- Portal education and resources
- Targeted messaging
- Disease management programs
- Smoking and vaping cessation
Wellness and Healthy Lifestyle Education
TriWest provides a variety of health and wellness information to support our beneficiary’s health journey. We also offer a mobile app option.
Targeted Messaging
Using data analytics and beneficiary program encounters, our targeted messaging will send personalized messages to our beneficiaries regarding:
- Gaps in care and how to close them
- Upcoming routine health care services that are age and sex appropriate
- Opportunities for engaging in our clinical support programs
- General seasonal or wellness information
The messages will be sent utilizing beneficiary preferences for mail, email, text, and portal options.
Disease Management Programs
TriWest Disease Management programs are designed to improve the health of beneficiaries with newly identified diseases, or those that may be struggling with chronic conditions. We have established programs for the following conditions: anxiety, asthma, coronary artery disease with new myocardial infarctions, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), long-haul Coronavirus (COVID), depression, and diabetes.
Beneficiaries that engage in our programs are provided education and resources to improve their health outcomes in collaboration with the providers.
Referrals for disease management can be made within CareAffiliate online (specific link to be updated prior to start of health care delivery).
Retrospective Review
TriWest clinical staff collaborates with PGBA when claims are submitted without a required authorization and require medical necessity review. Clinicians will obtain and utilize appropriate clinical criteria to confirm whether the care met clinical standards. This information is communicated to PGBA so that claims can be processed appropriately.
The clinical staff also support real-time and retrospective review of unlisted codes. Information is reviewed to determine if the unlisted code is appropriate to utilize, pricing meets TRICARE reimbursement requirements, or if another code is more appropriate for submission.
TriWest completes retrospective reviews on a statistical sample of paid claims as required by TRICARE program requirements on a quarterly basis. These reviews are completed to ensure documentation in the beneficiary’s medical record support reimbursed services. Although retrospective reviews may be performed on any service, they are typically focused on:
- Diagnosis-related group (DRG) reimbursement
- Home health services
- Hospice services
- Other specified topics as identified by TRICARE
When reviewing claims as part of a retrospective review, TriWest requests medical records from the billing and/or rendering provider. Medical records are reviewed to:
- Assess the accuracy of information provided during the prospective review process
- Determine the medical or psychological necessity and quality of care provided
- Validate the review determinations made by the utilization review staff
- Determine whether the diagnostic and procedural information and/or discharge status of the beneficiary matches the description of care and services documented in the medical record
TRICARE requires providers to comply with the request for records, and failure to do so could result in the recoupment of payment for the services rendered.
TriWest will initiate the following for all cases that are selected for focused retrospective review:
| Review | Description |
|---|---|
| Admission review | Review to ensure medical records indicate that the inpatient hospital care was medically or psychologically necessary and provided at the appropriate level of care |
| Invasive procedure review (surgical or other procedure that affects DRG assignment) | Review medical records for surgical or other procedures that affects DRG assignment. Review ensures the medical records support medical necessity of the procedure performed. The performance of unnecessary procedures may represent a quality and/or utilization problem. |
| Discharge review | Medical records are reviewed using appropriate criteria (i.e., InterQual®) to determine potential problems with questionable discharges, as well as other potential quality problems. |
| Home health prospective payment system review |
A monthly retrospective review of medical records and claims, reviewed in accordance with the TRICARE Reimbursement Manual, Chapter 12. This review evaluates whether services provided were reasonable and necessary, delivered, coded correctly, and appropriately documented. |
| DRG validation | This review determines if the diagnostic and procedural information and discharge status of the beneficiary, as reported by the hospital, matches the attending physician’s description of care and services documented in the beneficiary’s record. During this review, selected records receive focused and intensified reviews to ensure that medical documentation supports the services received. |
| Outlier review | Claims that qualify for additional payment as cost-outliers are reviewed to ensure costs were medically necessary, appropriate, and met all payment requirements. Claims that qualify as short-stay outliers are reviewed to ensure that the admission was medically necessary and appropriate and that the discharge was not premature or questionable. Procedures and services not covered by the DRG-based payment system International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT) codes provide the basis for determining whether diagnostic and procedural information is correct and matches the information contained in the medical record |
Additionally, TRICARE policy requires that every beneficiary admitted to a hospital receive and sign a copy of the An Important Message from TRICARE form (specific link to be updated prior to start of health care delivery), detailing the beneficiary’s rights concerning coverage and payment of hospital stays and post-hospital services. The form discusses the Notice of Non-Coverage typically used by hospitals to inform beneficiaries when their health insurance will no longer pay for hospital care. The signed document must be kept in the beneficiary’s file and a new document must be provided for each admission.
Under the rules of the TRICARE Hold Harmless Policy, providers cannot bill TRICARE beneficiaries for non-covered services unless the beneficiary agrees in advance and in writing to pay for such services. Providers must have beneficiaries complete a Request for Non-Covered Services waiver if the beneficiary does not agree to be discharged from the hospital. If the beneficiary signs the form within the stated time frames, they will be responsible for the charges, otherwise, the hospital will be responsible for the beneficiary’s charges.
Clinical Quality Management
TriWest’s clinical quality management (CQM) program monitors care and services rendered to TRICARE beneficiaries throughout the health care delivery system. The goal of the CQM program is to create demonstrable quality improvement in the quality and value of health care provided to beneficiaries. To do this, TriWest’s CQM program was developed to determine issues, analyze potential improvements, and implement timely and appropriate corrective action, when needed. The CQM department investigates potential quality issues (PQI) and patient safety issues (PSI) that are referred to TriWest, resolves beneficiary and provider grievances, and performs clinical quality review studies. CQM also conducts studies and quality improvement projects on Healthcare Effectiveness Data and Information Set (HEDIS) measures or Department of Health and Human Services Agency for Healthcare Research and Quality PSI.
As part of their investigation, CQM may implement a corrective action plan (CAP). Our CQM department follows up on CAPS to ensure interventions have been implemented and remain effective. Corrective action includes, but is not limited to:
- Provider notification and education (e.g., through required further training), including provider office staff training
- Provider recertification
- Administrative policies and procedure revision
- Prospective or retrospective trend analysis of practice patterns
- Intensified review of practitioners or facilities, including but not limited to, requirements for second opinions for procedures, retrospective or prospective review of medical records, claims, or requests for pre-authorization
- Modification, suspension, restriction, or termination from the network
TRICARE Quality Monitoring Contractor
The TRICARE Quality Monitoring Contractor (TQMC) assists the Department of Defense (DOD), Defense Health Agency (DHA), military treatment facility (MTF) market managers, and the Health Plan West Region office by providing the government with an independent, impartial evaluation of the care provided to beneficiaries within the Military Health System (MHS). The TQMC is part of TRICARE’s Quality and Utilization PRO program, in accordance with 32 Code of Federal Regulations (CFR) and reviews care provided by TRICARE network providers and subcontractors on a limited basis. To facilitate these reviews, TriWest may request providers’ medical records on a monthly basis to comply with requirements detailed in the TRICARE Operations Manual, Chapter 7. Records must be submitted in their entirety. Failure to do so will result in recoupment of payment for the hospitalization and/or any other services in accordance with 32 CFR 199.4(a) (5).
Medical Records Documentation
TriWest reviews medical records to evaluate patterns of care and compliance with performance standards. We require each provider to maintain adequate medical documentation and medical treatment records, including contemporaneous clinical records that substantiate the clinical rationale for each course of treatment, periodic evaluation of the efficacy of treatment, and the outcome at completion or discontinuation of treatment. Medical records must include information that justifies admission and continued hospitalization, supports the diagnosis, and describes the beneficiary’s progress and response to medications and services.
Providers must maintain clinical and other records related to individuals for whom TRICARE payment was made for services rendered for a period of 60 months from the date of service. Providers must provide copies of medical treatment records to TriWest within 10 business days of our request so we can conduct peer review, quality assurance activities, HEDIS, and utilization review.
TriWest will not pay (and provider agrees to waive) any costs associated with the required submission of medical treatment records, including but not limited to copying or handling fees, unless otherwise specified (e.g., TRICARE requirements, this TriWest TRICARE provider handbook, or the provider’s contract with TriWest). We accept secure electronic medical records in a HIPAA-compliant, encrypted format.
Providers must adhere to Medical Treatment Record guidelines. See the TriWest Medical Treatment Record Quick Reference Guide for details (specific documents to be updated prior to start of health care delivery).
When requested, providers must transmit accurate, complete, and legible clinical records and information to the Government pertaining to the care delivered, pursuant to referrals or orders from MTF providers, in compliance with applicable privacy and confidentiality laws and regulations, and in accordance with the TRICARE Requirements and TriWest TRICARE Provider Handbook.
DRAFT — pending DHA approval. Submitted for review on 2/15/24.