COMPLIANCE WITH TMA. UTILIZATION REVIEW ACTIVITIES Under the terms of this agreement, the PHP shall:
(a) Appoint a single individual within the facility to serve as the point of contact for conducting utilization review activities with TMA or its designee. This individual must have a clinical background and be capable of directly responding to questions from professionally qualified reviewers. The PHP will inform TMA in writing of the designated individual.
(b) Obtain precertification for all care to be rendered to a beneficiary within the PHP.
(c) Promptly provide medical records and other documentation required in support of the utilization review process upon request by TMA or its designee. Confidentiality considerations are not valid reasons for refusal to submit medical records on any beneficiary. Failure to comply with documentation requirements will usually result in denial of certification of care.
(d) Maintain medical records, including progress notes, clinical formulation, and the master treatment plan in compliance with standards and regulations.
COMPLIANCE WITH TMA. UTILIZATION REVIEW ACTIVITIES Under the terms of this agreement, the RTC shall:
(a) Appoint a single individual within the RTC to serve as the point of contact for conducting utilization review activities with TMA or its designee. This individual must have a clinical background and be capable of directly responding to questions from professionally qualified reviewers. The RTC will inform TMA in writing of the designated individual.
(b) Obtain precertification for all care to be rendered within the RTC. Failure to obtain precertification will subject the facility to payment reductions according to 32 CFR 199.15(b)(4)(iii).
(c) Promptly provide medical records and other documentation required in support of the utilization review process upon request by TMA or its designee. Confidentiality considerations are not valid reasons for refusal to submit medical records on any TRICARE beneficiary. Failure to comply with documentation requirements will result in the denial of certification of care and/or termination of provider status.
(d) Maintain medical records, including progress notes, clinical formulation, and the master treatment plan, in compliance with TRICARE standards and regulations.
COMPLIANCE WITH TMA. UTILIZATION REVIEW ACTIVITIES Under the terms of this agreement, the SUDRF shall:
(a) Appoint a single individual within the facility to serve as the point of contact for conducting utilization review activities with TMA or its designee. This individual must have a clinical background and be capable of directly responding to questions from professionally qualified reviewers. The SUDRF will inform TMA in writing of the designated individual.
(b) Obtain precertification for all inpatient or partial hospitalization services to be rendered to TRICARE/CHAMPUS beneficiaries within the facility.
(c) Promptly provide medical records and other documentation required in support of the utilization review process upon request by TMA or its designee. Confidentiality considerations are not valid reasons for refusal to submit medical records on any TRICARE/CHAMPUS beneficiary. Failure to comply with documentation requirements will usually result in the denial of certification of care.
(d) Maintain medical records, including the clinical formulation, progress notes, and master treatment plan, in compliance with TRICARE/CHAMPUS standards and regulations.
