Common use of Utilization Management Clause in Contracts

Utilization Management. 2.1 The contractor shall establish a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries. 2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical oversight for TOP Prime enrollees. As such, the enrolling MTF will determine medical and psychological necessity and issue all referrals for TOP Prime enrollees, and provide UM and all case management services for the MTF-enrolled population. The contractor shall ensure that MTF-issued referrals and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location.‌ Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTF. 2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit review, and issue authorizations for specialty care for TOP Prime Remote enrollees and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location. The contractor shall provide notification of cases to the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty care, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor. 2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia. 2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased care sector provider care is forwarded within five calendar days of identification to the appropriate TAO. 2.3 The MM/UM Plan shall include a process for identifying high utilization/high cost patients and locations. 2.3.1 At a minimum, this process shall include the identification of patients exceeding the frequency and/or cost thresholds established in the TOP contract. These thresholds apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018), and TOP TRICARE For Life (TFL). 2.3.2 The TOP contractor shall review these claims for appropriateness of care, and shall propose interventions to reduce overutilization or contain costs whenever possible. Proposed interventions to cost and/or overutilization shall be forwarded to the Government for review prior to contractor implementation. 2.4 The MM/UM Plan shall integrate efforts to identify potential fraud/abuse. Any cases identified as possible fraud/abuse shall be referred directly and exclusively to the Defense Health Agency (DHA) Program Integrity (PI) Office in accordance with Section 14.‌ 2.5 The TOP contractor shall provide case management services as outlined in the contract with DHA. Specific case management processes shall be addressed in the Statements Of Responsibilities (SORs) between the contractor, MTF Commanders, and the TAO Directors. 2.6 The TOP contractor shall closely monitor requests for inpatient care or medical evacuation services to ensure that services are medically or psychologically necessary and appropriate for the patient’s condition. Beneficiaries will not be assigned to a particular facility or medically evacuated to a particular geographic location based solely on personal preference, but will be transported to the closest medical facility capable of providing appropriate stabilization and/or treatment. 2.7 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a purchased care sector country or U.S. commonwealth/territory shall be identified and reviewed for medical or psychological necessity. Unless a different standard has been identified by the government, the contractor shall use best business practices to determine the standard LOS for a particular overseas location. Upon Government request, the TOP contractor shall provide supporting documentation related to LOS determinations.

Utilization Management. 2.1 The contractor shall establish a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries. 2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical oversight for TOP Prime enrollees. As such, the enrolling MTF will determine medical and psychological necessity necessity, and issue all referrals for TOP Prime enrollees, and provide UM and all case management services for the MTF-enrolled population. The contractor shall ensure that MTF-issued referrals and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0the TOP contract. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location.‌ location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTF. 2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit review, and issue authorizations for specialty care for TOP Prime Remote enrollees and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location. The contractor shall provide notification of cases to the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty care, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime Remote (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor.contractor.‌ 2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia. 2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased care sector provider care is forwarded within five calendar days of identification to the appropriate TAO. 2.3 The MM/UM Plan shall include a process for identifying high utilization/high cost patients and locations. 2.3.1 At a minimum, this process shall include the identification of patients exceeding the frequency and/or cost thresholds established in the TOP contract. These thresholds apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018)Select, and TOP TRICARE For Life (TFL). 2.3.2 The TOP contractor shall review these claims for appropriateness of care, and shall propose interventions to reduce overutilization or contain costs whenever possible. Proposed interventions to cost and/or overutilization shall be forwarded to the Government for review prior to contractor implementation. 2.4 The MM/UM Plan shall integrate efforts to identify potential fraud/abuse. Any cases identified as possible fraud/abuse shall be referred directly and exclusively to the Defense Health Agency (DHA) Program Integrity (PI) Office in accordance with Section 14.‌ 2.5 The TOP contractor shall provide case management services as outlined in the contract with DHA. Specific case management processes shall be addressed in the Statements Of Responsibilities (SORs) between the contractor, MTF Commanders, and the TAO Directors. 2.6 The TOP contractor shall closely monitor requests for inpatient care or medical evacuation services to ensure that services are medically or psychologically necessary and appropriate for the patient’s condition. Beneficiaries will not be assigned to a particular facility or medically evacuated to a particular geographic location based solely on personal preference, but will be transported to the closest medical facility capable of providing appropriate stabilization and/or treatment. 2.7 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a purchased care sector country or U.S. commonwealth/territory shall be identified and reviewed for medical or psychological necessity. Unless a different standard has been identified by the government, the contractor shall use best business practices to determine the standard LOS for a particular overseas location. Upon Government request, the TOP contractor shall provide supporting documentation related to LOS determinations.

Utilization Management. 2.1 The contractor shall establish a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries. 2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical oversight for TOP Prime enrollees. As such, the enrolling MTF will determine medical and psychological necessity necessity, perform covered benefit reviews, and issue all referrals for TOP Prime enrollees, and provide UM and all case management services for the MTF-MTF- enrolled population. The contractor shall ensure that MTF-issued referrals and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0the TOP contract. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location.‌ location.‌‌ Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTF. 2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit review, and issue authorizations for specialty care for TOP Prime Remote enrollees and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location. The contractor shall provide notification of cases to the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty care, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor. 2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia. 2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased care sector provider care is forwarded within five calendar days of identification to the appropriate TAO. 2.3 The MM/UM Plan shall include a process for identifying high utilization/high cost patients and locations. 2.3.1 At a minimum, this process shall include the identification of patients exceeding the frequency and/or cost thresholds established in the TOP contract. These thresholds apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018)Select, and TOP TRICARE For Life (TFL).TFL).‌ 2.3.2 The TOP contractor shall review these claims for appropriateness of care, and shall propose interventions to reduce overutilization or contain costs whenever possible. Proposed interventions to cost and/or overutilization shall be forwarded to the Government for review prior to contractor implementation. 2.4 The MM/UM Plan shall integrate efforts to identify potential fraud/abuse. Any cases identified as possible fraud/abuse shall be referred directly and exclusively to the Defense Health Agency (DHA) Program Integrity (PI) Office in accordance with Section 14.‌ 2.5 The TOP contractor shall provide case management services as outlined in the contract with DHA. Specific case management processes shall be addressed in the Statements Of Responsibilities (SORs) between the contractor, MTF Commanders, and the TAO Directors. 2.6 The TOP contractor shall closely monitor requests for inpatient care or medical evacuation services to ensure that services are medically or psychologically necessary and appropriate for the patient’s condition. Beneficiaries will not be assigned to a particular facility or medically evacuated to a particular geographic location based solely on personal preference, but will be transported to the closest medical facility capable of providing appropriate stabilization and/or treatment. 2.7 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a purchased care sector country or U.S. commonwealth/territory shall be identified and reviewed for medical or psychological necessity. Unless a different standard has been identified by the government, the contractor shall use best business practices to determine the standard LOS for a particular overseas location. Upon Government request, the TOP contractor shall provide supporting documentation related to LOS determinations.

Utilization Management. 2.1 The contractor Contractor shall establish maintain a Utilization Management plan and procedures consistent with the following: Staffing of all Utilization Management activities shall include, but not be limited to, a Medical Management (MM)/UM Plan Director, or Medical Director’s designee. The Contractor shall also have a Medical Director’s designee for Behavioral Health Utilization Management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two or more years of experience in managed care received or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by TRICARE beneficiaries. 2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical relevant professional licensing or oversight for TOP Prime enrolleesboard or the Medicare and Medicaid programs; and Not have any legal sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS. As suchIn addition to the requirements set forth in Section 2.9.D.1, the enrolling MTF will determine Medical Director’s designee for Behavioral Health Utilization Management shall also: Be board-certified or board-eligible in psychiatry; and Be available 24 hours per day, seven days a week for consultation and decision-making with the Contractor’s clinical staff and Providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the Utilization Management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and psychological necessity technology, Behavioral Health treatments, pharmacy formularies and issue all referrals devices; Target areas of suspected inappropriate service utilization; Detect over- and under-utilization; Routinely generate Provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and Provider utilization with norms for TOP Prime enrolleescomparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area services, and provide UM out-of-network services, as well as Behavioral Health Inpatient and all case management services for Outpatient Services, Diversionary Services, and ESPs; Ensure that treatment and Discharge Planning are addressed at the MTF-enrolled population. The contractor shall ensure that MTF-issued referrals time of authorization and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location.‌ Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTF. 2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit concurrent review, and issue authorizations for specialty care for TOP Prime Remote enrollees that the treatment planning includes coordination with the PCP, other Providers, and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location. The contractor shall provide notification other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty careMedical Necessity, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor. 2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia. 2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased care sector provider care is forwarded within five calendar days of identification to the appropriate TAO. 2.3 The MM/UM Plan shall include a process for identifying high utilization/high cost patients and locations. 2.3.1 At a minimum, this process shall include the identification of patients exceeding the frequency and/or cost thresholds established in the TOP contract. These thresholds apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018), and TOP TRICARE For Life (TFL). 2.3.2 The TOP contractor shall review these claims for appropriateness of care, and the duration and level of care; Refer suspected cases of Provider or Enrollee Fraud or Abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the ICO, EOHHS, Enrollees, and Providers, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor’s Utilization Management activities shall propose interventions include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting Providers to reduce overutilization or contain costs whenever possibleeffectively provide inpatient Discharge Planning; Behavioral Health treatment and Discharge Planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor’s Utilization Management clinical staff and Providers on: The standard application of Medical Necessity criteria and Utilization Management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization Management policies, practices and data reported to the ICO to ensure that it is standardized across all Providers within the ICO’s Provider Network; and The consistent application and implementation of the Contractor’s Clinical Criteria and guidelines including the Behavioral Health Clinical Criteria approved by EOHHS. Proposed interventions Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to cost and/or overutilization support Utilization Management activities; and Care management programs. Ensure that clinicians conducting Utilization Management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be forwarded a clinician with experience and training in mental health services; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with Co-Occurring Disorders shall have experience and training in Co-Occurring Disorders. The Contractor shall have policies and procedures for its approach to the Government for retrospective utilization review prior to contractor implementation. 2.4 The MM/UM Plan of Providers. Such approach shall integrate efforts include a system to identify potential fraud/abuseutilization patterns of all Providers by significant data elements and established outlier criteria for all services. Any cases identified as possible fraud/abuse The Contractor shall be referred directly have policies and exclusively procedures for conducting retrospective and peer reviews of a sample of Providers to ensure that the Defense Health Agency (DHA) Program Integrity (PI) Office services furnished by Providers were provided to Enrollees, were appropriate and Medically Necessary, and were authorized and billed in accordance with Section 14.‌ 2.5 the ICO’s requirements. The TOP contractor Contractor shall provide case management services as outlined in the contract with DHA. Specific case management processes shall be addressed in the Statements Of Responsibilities (SORs) between the contractor, MTF Commanders, have policies and the TAO Directors. 2.6 The TOP contractor shall closely monitor requests procedures for inpatient care or medical evacuation services conducting monthly reviews of a random sample of no fewer than 500 Enrollees to ensure that such Enrollees received the services are medically for which Providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or psychologically necessary and appropriate entities that conduct utilization management activities is not structured so as to provide incentives for the patientindividual or entity to deny, limit, or discontinue Medically Necessary Services to any Enrollee. Submit an annual report of Enrollees who have been enrolled in the Contractor’s conditionPlan for one year or more with no utilization. Beneficiaries will The report shall include an explanation of outreach activities to engage these Enrollees. Effective October 1, 2015, if utilization management review activities are performed for Clinical Support Services for Substance Use Disorders (Level III.5), such activities may be performed no earlier than day 7 of the provision of such services, provided, however, that the Contractor may not be assigned make any utilization review decisions that impose any restriction or deny any future medically necessary clinical stabilization services unless an Enrollee has received at least 14 consecutive days of clinical stabilization services. Any such decisions must follow the requirements set forth in Section 2.12 regarding the transmission of adverse determination notifications to Enrollees and clinicians and processes for internal and external appeals of Contractor’s decisions. Effective October 1, 2015, the Contractor may not impose concurrent review and deny coverage for ATS based on utilization review; however, the Contractor may contact providers of ATS to discuss coordination of care, treatment plans, and after care. Effective October 1, 2015, the Contractor may not establish utilization management strategies that require enrollees to “fail-first” or participate in “step therapy” as a particular facility or medically evacuated to a particular geographic location based solely on personal preference, but will be transported to the closest medical facility capable condition of providing appropriate stabilization and/or treatmentcoverage for injectable naltrexone (Vivitrol™). Contractor must cover Vivitrol™ as a pharmacy and medical benefit. 2.7 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a purchased care sector country or U.S. commonwealth/territory shall be identified and reviewed for medical or psychological necessity. Unless a different standard has been identified by the government, the contractor shall use best business practices to determine the standard LOS for a particular overseas location. Upon Government request, the TOP contractor shall provide supporting documentation related to LOS determinations.”

Utilization Management. 2.1 The contractor Contractor shall establish maintain a Utilization Management plan and procedures consistent with the following: Staffing of all Utilization Management activities shall include, but not be limited to, a Medical Management (MM)/UM Plan Director, or Medical Director’s designee. The Contractor shall also have a Medical Director’s designee for Behavioral Health Utilization Management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two or more years of experience in managed care received or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by TRICARE beneficiaries. 2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical relevant professional licensing or oversight for TOP Prime enrolleesboard or the Medicare and Medicaid programs; and Not have any legal sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS. As suchIn addition to the requirements set forth in Section 2.9.D.1, the enrolling MTF will determine Medical Director’s designee for Behavioral Health Utilization Management shall also: Be board-certified or board-eligible in psychiatry; and Be available 24 hours per day, seven days a week for consultation and decision-making with the Contractor’s clinical staff and Providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the Utilization Management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and psychological necessity technology, Behavioral Health treatments, pharmacy formularies and issue all referrals devices; Target areas of suspected inappropriate service utilization; Detect over- and under-utilization; Routinely generate Provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and Provider utilization with norms for TOP Prime enrolleescomparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area services, and provide UM out-of-network services, as well as Behavioral Health Inpatient and all case management services for Outpatient Services, Diversionary Services, and ESPs; Ensure that treatment and Discharge Planning are addressed at the MTF-enrolled population. The contractor shall ensure that MTF-issued referrals time of authorization and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location.‌ Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTF. 2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit concurrent review, and issue authorizations for specialty care for TOP Prime Remote enrollees that the treatment planning includes coordination with the PCP, other Providers, and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location. The contractor shall provide notification other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty careMedical Necessity, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor. 2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia. 2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased care sector provider care is forwarded within five calendar days of identification to the appropriate TAO. 2.3 The MM/UM Plan shall include a process for identifying high utilization/high cost patients and locations. 2.3.1 At a minimum, this process shall include the identification of patients exceeding the frequency and/or cost thresholds established in the TOP contract. These thresholds apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018), and TOP TRICARE For Life (TFL). 2.3.2 The TOP contractor shall review these claims for appropriateness of care, and the duration and level of care; Refer suspected cases of Provider or Enrollee Fraud or Abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the ICO, EOHHS, Enrollees, and Providers, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor’s Utilization Management activities shall propose interventions include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting Providers to reduce overutilization or contain costs whenever possibleeffectively provide inpatient Discharge Planning; Behavioral Health treatment and Discharge Planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor’s Utilization Management clinical staff and Providers on: The standard application of Medical Necessity criteria and Utilization Management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization Management policies, practices and data reported to the ICO to ensure that it is standardized across all Providers within the ICO’s Provider Network; and The consistent application and implementation of the Contractor’s Clinical Criteria and guidelines including the Behavioral Health Clinical Criteria approved by EOHHS. Proposed interventions Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to cost and/or overutilization support Utilization Management activities; and Care management programs. Ensure that clinicians conducting Utilization Management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be forwarded a clinician with experience and training in mental health services; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with Co-Occurring Disorders shall have experience and training in Co-Occurring Disorders. The Contractor shall have policies and procedures for its approach to the Government for retrospective utilization review prior to contractor implementation. 2.4 The MM/UM Plan of Providers. Such approach shall integrate efforts include a system to identify potential fraud/abuseutilization patterns of all Providers by significant data elements and established outlier criteria for all services. Any cases identified as possible fraud/abuse The Contractor shall be referred directly have policies and exclusively procedures for conducting retrospective and peer reviews of a sample of Providers to ensure that the Defense Health Agency (DHA) Program Integrity (PI) Office services furnished by Providers were provided to Enrollees, were appropriate and Medically Necessary, and were authorized and billed in accordance with Section 14.‌ 2.5 the ICO’s requirements. The TOP contractor Contractor shall provide case management services as outlined in the contract with DHA. Specific case management processes shall be addressed in the Statements Of Responsibilities (SORs) between the contractor, MTF Commanders, have policies and the TAO Directors. 2.6 The TOP contractor shall closely monitor requests procedures for inpatient care or medical evacuation services conducting monthly reviews of a random sample of no fewer than 500 Enrollees to ensure that such Enrollees received the services are medically for which Providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or psychologically necessary and appropriate entities that conduct utilization management activities is not structured so as to provide incentives for the patient’s condition. Beneficiaries will not be assigned individual or entity to a particular facility deny, limit, or medically evacuated discontinue Medically Necessary Services to a particular geographic location based solely on personal preference, but will be transported to the closest medical facility capable of providing appropriate stabilization and/or treatmentany Enrollee. 2.7 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a purchased care sector country or U.S. commonwealth/territory shall be identified and reviewed for medical or psychological necessity. Unless a different standard has been identified by the government, the contractor shall use best business practices to determine the standard LOS for a particular overseas location. Upon Government request, the TOP contractor shall provide supporting documentation related to LOS determinations.

Utilization Management. 2.1 The contractor shall establish a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries. 2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical oversight for TOP Prime enrollees. As such, the enrolling MTF will determine medical and psychological necessity and issue all referrals for TOP Prime enrollees, and provide UM and all case management services for the MTF-enrolled population. The contractor shall ensure that MTF-issued referrals and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location.‌ Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTFlocation. 2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit review, and issue authorizations for specialty care for TOP Prime Remote enrollees and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed/ deployed on liberty in a remote overseas location. The contractor shall provide notification of cases to the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty care, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor. 2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia. 2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased care sector provider care is forwarded within five calendar days of identification to the appropriate TAO. 2.3 The MM/UM Plan shall include a process for identifying high utilization/high cost patients and locations. 2.3.1 At a minimum, this process shall include the identification of patients exceeding the frequency and/or cost thresholds established in the TOP contract. These thresholds apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018)Standard, and TOP TRICARE For Life (TFL). 2.3.2 The TOP contractor shall review these claims for appropriateness of care, and shall propose interventions to reduce overutilization or contain costs whenever possible. Proposed interventions to cost and/or overutilization shall be forwarded to the Government for review prior to contractor implementation. 2.4 The MM/UM Plan shall integrate efforts to identify potential fraud/abuse. Any cases identified as possible fraud/abuse shall be referred directly and exclusively to the Defense Health Agency (DHA) Program Integrity (PI) Office in accordance with Section 14.‌14. 2.5 The TOP contractor shall provide case management services as outlined in the contract with DHA. Specific case management processes shall be addressed in the Statements Of Responsibilities (SORs) between the contractor, MTF Commanders, and the TAO Directors. 2.6 The TOP contractor shall closely monitor requests for inpatient care or medical evacuation services to ensure that services are medically or psychologically necessary and appropriate for the patient’s condition. Beneficiaries will not be assigned to a particular facility or medically evacuated to a particular geographic location based solely on personal preference, but will be transported to the closest medical facility capable of providing appropriate stabilization and/or treatment. 2.7 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a purchased care sector country or U.S. commonwealth/territory shall be identified and reviewed for medical or psychological necessity. Unless a different standard has been identified by the governmentGovernment, the contractor shall use best business practices to determine the standard LOS for a particular overseas location. Upon Government request, the TOP contractor shall provide supporting documentation related to LOS determinations.

Utilization Management. 2.1 The contractor shall establish a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries. 2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical oversight for TOP Prime enrollees. As such, the enrolling MTF will determine medical and psychological necessity necessity, and issue all referrals for TOP Prime enrollees, and provide UM and all case management services for the MTF-enrolled population. The contractor shall ensure that MTF-issued referrals and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0the TOP contract. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location.‌ location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTF. 2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit review, and issue authorizations for specialty care for TOP Prime Remote enrollees and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location. The contractor shall provide notification of cases to the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty care, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime Remote (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor. 2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia. 2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased care sector provider care is forwarded within five calendar days of identification to the appropriate TAO. 2.3 The MM/UM Plan shall include a process for identifying high utilization/high cost patients and locations. 2.3.1 At a minimum, this process shall include the identification of patients exceeding the frequency and/or cost thresholds established in the TOP contract. These thresholds apply to all TOP beneficiaries, including TOP Prime, TOP Prime Remote, TOP Standard (through December 31, 2017) or TRICARE Select (starting January 1, 2018)Select, and TOP TRICARE For Life (TFL). 2.3.2 The TOP contractor shall review these claims for appropriateness of care, and shall propose interventions to reduce overutilization or contain costs whenever possible. Proposed interventions to cost and/or overutilization shall be forwarded to the Government for review prior to contractor implementation. 2.4 The MM/UM Plan shall integrate efforts to identify potential fraud/abuse. Any cases identified as possible fraud/abuse shall be referred directly and exclusively to the Defense Health Agency (DHA) Program Integrity (PI) Office in accordance with Section 14.‌ 2.5 The TOP contractor shall provide case management services as outlined in the contract with DHA. Specific case management processes shall be addressed in the Statements Of Responsibilities (SORs) between the contractor, MTF Commanders, and the TAO Directors. 2.6 The TOP contractor shall closely monitor requests for inpatient care or medical evacuation services to ensure that services are medically or psychologically necessary and appropriate for the patient’s condition. Beneficiaries will not be assigned to a particular facility or medically evacuated to a particular geographic location based solely on personal preference, but will be transported to the closest medical facility capable of providing appropriate stabilization and/or treatment. 2.7 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a purchased care sector country or U.S. commonwealth/territory shall be identified and reviewed for medical or psychological necessity. Unless a different standard has been identified by the government, the contractor shall use best business practices to determine the standard LOS for a particular overseas location. Upon Government request, the TOP contractor shall provide supporting documentation related to LOS determinations.