Attachment_1_of_the_PWS_-_Referral_Management_Center_Guide.pdf

MILITARY TREATMENT FACILITY

REFERRAL MANAGEMENT CENTER GUIDE

Version 9.0

HQ AFMSA/SGSA

Medical Support Division

1 May 2014

INDEX

Chapter

PAGE

1. Introduction and Air Force Medical Service Goals 3

2. Referral Management and Utilization Management Relationship 5

3. Referral Management Center Roles and Responsibilities 6

4. Referral Management Center Staffing Model 7

5. Patient-Centered Medical Home and Referral Management 8

Appendix

1. Air Force Medical Service Referral Management Business Rules 10

2. TRICARE Operations Manual 25

3. Inspection and Accreditation References 33

4. Referral Management Policies, Guidance, and References 40

5. Referral Management Information Systems 43

6. Abbreviations and Acronyms 44

7. 2014 AFMS Referral Management Work Group Members 47

The Referral Management Center (RMC) Guide is the product of the AFMS Referral Management (RM) Working Group and AFMSA (see Appendix 7). The guide is consistent with AFI 44-176, Access to Care Continuum and AFI 41-210, Patient Administration.

The draft AFMS Referral Management business rules (BRs) in Appendix I have been included in the revised AFI 44-176, which was in coordination at the time of this guide’s publication. This guide will be updated with the final version of the BRs when AFI 44-176 is published.

Additional resources to improve MTF RM processes are available on the AFMS Knowledge Exchange: https://kx2.afms.mil/kj/kx8/AccesstoCare/Pages/referral_management.aspx. We welcome any feedback you may have about this guide and offer our assistance to you and your leadership. You can reach us at AFMSA/SG3SA, Health Benefits Division, 703-681-7866, DSN 761, or 210-395-9181, DSN 969.

Introduction

Referral Management (RM) is the process of managing and tracking patient referrals/consults.

The MTF’s Referral Management Center’s (RMC) exists to educated the patient about the referral process, book the patient’s MTF specialty care appointment before leaving the MTF, provide the referring provider/PCM with the initial and follow-up referral results, alleviate the provider and clinical team of the administrative burden of referral tracking and facilitate recapture of MTF direct care capabilities in support of readiness, currency, and decreasing purchased care costs.

AFMS Goals—“Staying on Target”

The AFMS Vision of Trusted Care, Anywhere!

Readiness – We must ensure all Airmen are ready to meet contingency requirements. Our most valuable asset is our people—they deserve and must be in the best physical, psychological and emotional health to meet the challenges both at home station and in the AOR. As medics, it is our core competency to be current and trained, to provide full-spectrum care no matter what the military operation. Our core mission to the DoD and the AF is razor-sharp focus on readiness.

Better Care – The AFMS must continue to strive to provide our patients with a positive experiences and outcomes. To do this we must be consistent and reliable in ensuring our staff focuses on patient safety first, and use evidence-based practices in the provision of quality care.

Our Medics are empowered to be innovative and forward-thinking in providing better care.

Better Health – It is a challenging time for medical providers nation-wide with increasing rates of obesity and chronic illnesses. The AFMS must motivate our patients to be proactive and involved in their health by providing a culture that promotes both resiliency against physical and emotional challenges, as well as optimal human performance. The AFMS core responsibilities are to ensure that every Airman, including ourselves, is ready to meet the call of our nation while being innovative in providing better care and motivating better health. It is our duty to ensure we achieve the best value while meeting enterprise goals. If we are successfully execute our mission we will attain our vision—”Trusted Care, Anywhere.”

Best Value: Focuses on the appropriate utilization of people and resources applied through effective management of the AFMS Enterprise to achieve our goals and targeted goals and vision of “Trusted Care, Anywhere.”

Back to Index

Referral and Utilization Management Relationship

Referral management is a subcomponent of utilization management (UM). Although usually in different chains of command, the UM nurse and the RMC staff should work together to meet the AFMS UM and RM goals. Below is an excerpt defining some of the roles/responsibilities of the UM, Case Managers, and Disease Manager nurses. Further information can be obtained from:

• DODI 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) and

Remote Areas, 9 April 2013 http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf

• DoD DHA Medical Management Guide, Version 3.0, 2009 http://www.tricare.mil/tma/ocmo/Publications.aspx

• AFMOA Medical Management Division (SGHL):

https://kx2.afms.mil/kj/kx4/AFMOAMedMgmt/Pages/home.aspx

Distinctions between UM, CM, and DM Utilization Management Case Management Disease Management Characteristics of Target Population

• Cost-based approach • Individual approach

• Population-based approach

• Most expensive patients, providers, and procedures

• At high-risk for costly, adverse medical events and poor health outcomes

• Diagnosed with specific disease or condition

• Patients who may not be at the appropriate level of care

• Medically, socially, and/or financially vulnerable

• Patients not medically authorized for hospital admission and specific procedures

• Patients who underutilize or over utilize services Methods for Identifying Patients Analysis of Encounter or Claims Data

• Tracks over/underutilization of services and costs

• Searches for patients with patterns of repeated hospitalizations or ED visits

• Searches for patients with selected ICD-10 diagnosis codes

Referrals

• Aggregate data in terms of practice patterns for referrals

• Providers who identify patients as “high risk” or “vulnerable”

• Providers who identify patients with a particular diagnosis or condition

• Prospective review of referrals • Self/family referrals

• Referrals meet Severity of Illness and Intensity of Service criteria (InterQual®)

• Specific beneficiary screening criteria

Back to Index http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf http://www.tricare.mil/tma/ocmo/Publications.aspx https://kx2.afms.mil/kj/kx4/AFMOAMedMgmt/Pages/home.aspx

Referral Management Center Roles and Responsibilities

The RMC is a “One-Stop Shop” for the patient and clinical staff regarding referrals (Figure 1).

Figure 1. RMC Process

The Draft AFMS RM Business Rules (BRs) (Appendix 1) describe in detail the duties and responsibilities of the RMC staff. Business rules provide a common language and standard to minimize RM process variations from MTF to MTF.

Patient-Centered Medical Home and Referral Management

How is referral management relevant to Patient-Centered Medical Home (PCMH)?

Referral management is a cornerstone principle of the PCMH model which requires that care is coordinated/integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services)0F

1. The PCMH is an established model of primary care that improves continuity of care and enhances access through patient-centered care and effective patient-provider communication. PCMH is associated with better outcomes, reduced mortality, fewer hospital admissions for patients with chronic diseases, lower utilization, and improved patient compliance with recommended care and reduced medical spending. One of the core principles of the PCMH is that patients have a consistent relationship with their health care provider/team who delivers first contact, continuous, and comprehensive care. PCMs provide the majority of the beneficiaries’ health care needs and refer them to specialized care if needed. PCMs provide follow-up care for patients after they have received care from consultant specialists, and provide ongoing continuity and care coordination.1F

Referral management is an essential component in all five domains of the National Quality Forum’s definition of care coordination. The domains include2F

3 (italics added for emphasis):

1. Healthcare “home”---the healthcare home serves as a clearinghouse for all information about a patient’s health status, including all related activities, services, and results. The healthcare home is responsible for synthesizing, reconciling, and interpreting the most current information from many sources to inform and educate the patient, identify needs, and establish goals.

2. Proactive Plan of Care and Follow-up—referrals to specialists or services should be based on transparent and easily understood evidence that the selected specialist or service provides high-quality care and is appropriately matched to meet the patient’s needs effectively and efficiently. A critically important part of care coordination is a systematic process of follow-up to tests, referrals, treatments, or other services that includes interpretation of the information for the patient and appropriate, timely response to the results. The responsibility for follow-up is shared by the provider ordering the test and the provider of the service.

3. Communication—All team members are aware of tests and services coordinated within the plan of care, and results are readily available at all times to all team members to avoid unnecessary duplication of services. Availability of patient information, such as consultation reports, progress notes, test results, and current medications to all team members caring for a patient reduces the chance of error.

4. Information systems—Important characteristics of an integrated electronic information system include interoperability, efficient and effective integration of patient information, laboratory, imaging, referrals, medications, social and community services.

1 NCQA Physician Practice Connections-Patient-Centered Medical Home, http://www.ncqua.org/tabid/631/Default.aspx 2 Health Affairs Policy Memorandum Implementation of the “Patient-Centered Medical Home” Model of Primary in MTFs, Sept 18, 2009 3 National Quality forum, May 2006-NQF-endoresed definition and framework for measuring care coordination

5. Transitions or “hand-offs”—transitions between settings of care are a special case because they are fraught with numerous mishaps that can make care uncoordinated, disconnected, and unsafe. Some processes that deserve particular attention: medication reconciliation, follow-up tests and services, changes in the plan of care, communication between settings of care, and transfer of current and past health information from old to new home (e.g., Active Duty Service Members (ADSM)s and family members with pending referrals during their move from one base to another).

APPENDIX I

DRAFT AFMS REFERRAL MANAGEMENT

BUSINESS RULES

AFMS Referral Management BRs have been included in the revised AFI 44-176, which was in coordination at the time of this publication. This guide will be updated with the final version of the BRs when AFI 44-176 is published.

No Step/ Decision Point

Referral Management Center (RMC) Business Rules (BRs). The terms referrals and consults are used interchangeably in document. Green Bold identifies an Efficiency Opportunity or Best Practice

1.

RMC Staff Training

At minimum, the RMC staff will:

• Read the AFMS RMC Guide, AFI 44-176, and the Composite Health Care

System (CHCS) Referral Management and Appointing Guide (https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/CHCS%20Referral%20Mana gement%20and%20Appointing%20Guide%2012Apr2013.docx)

• Complete CarePoint Referral Management Suite (RMS) and AHLTA training.

Other job aids: Managed Care Support Contractor (MCSC) website/tools training; TRICARE Operations Manual (TOM) chapters related to referrals;

TRICARE Policy Manual (TPM) on the TRICARE benefit; other MTF training.

2.

Locate RMC w/Patient In Mind

The RMC should be located within the MTF (exception: Multi-Service Markets (MSM) and in close proximity to the primary care clinics to promote patient convenience and staff communication. The RMC location will be configured to accommodate queues and patient privacy. At a minimum, RMC equipment should include telephones, voice mail capability, dual monitor computers with internet, high speed scanners, fax machines with fax forward capability, and phone headsets. The RMC staff will have access to CHCS, AHLTA, RMS, Healthcare Artifact and Image Management Solution (HAIMS) and Secure Messaging (SM). The use of RMS is mandatory.

3.

Educate MTF Providers & Clinical Staff

The MTF will train providers/clinical staff during orientation/in-processing and on a recurring basis as needed on the following: roles and responsibilities for ordering referrals/consults, correct order entry via CHCS/AHLTA, specialty capability within the MTF/multi-service market (MSM), non-covered benefits to avoid writing referrals that will be denied, use of network specialists, and avoidance of directed referrals and use of non-network specialists unless clinically justified. Per the TRICARE Third Generation (T3) Contracts, “The contractor shall provide customer service support equal to 40 person-hours per month to be used at the discretion of and for the purpose specified by the MTF Commander.” Therefore, MTFs can request from the MCSC to train MTF providers on non-covered benefits, use of network and non-network providers, and appropriate use of directed referrals. Best Practice (Travis AFB): An RMC staff member regularly attends clinic huddles, clinic staff meetings, medical management meetings, and ProStaff in case providers and clinical staff have referral questions as well as briefs them on referral processes, issues, and trends as needed. UM should also train providers on medical necessity, providing copies of Milliman Care Guidelines (MCG) requirements as needed.

https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/CHCS%20Referral%20Management%20and%20Appointing%20Guide%2012Apr2013.docx https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/CHCS%20Referral%20Management%20and%20Appointing%20Guide%2012Apr2013.docx

4.

Consult and Referral Definitions and Priority Types

Definition of a consult: a request for an opinion on the best course of treatment for a patient; the referring provider continues care for patient based on the advice of the consulted provider. Definition of a referral: a request to evaluate and treat and assume care for the patient for the condition. The terms referrals and consults are used interchangeably in this document. Referrals generated for tracking purposes (labs, radiology, disease management, HEDIS, ancillary orders, etc.) do not meet the definition of a specialty care referral/consult and will not be processed or tracked by the RMC.

4.1 Routine Referrals

The DoD access to care (ATC) standard for routine referrals is 28 days from date the referral was written. See BR 11, “Appoint Referral to MTF Specialty Clinic”, for waiving ATC standards.

4.2

Emergent and Urgent Referrals

For referrals with a priority other than “Routine,” the provider/clinical team will contact the specialist directly and arrange an appointment. The RMC/MCSC can assist the PCM/team with locating a network provider. The accepting provider’s name, appointment date, phone number (if available) and location/facility will be annotated within the referral.

4.3 Urgent Primary Care Referrals

The MTF will manage and track consults for urgent primary care. Per the TOM, Chapter 8, Section 5, the patient is required to contact the MTF during duty hours and his/her PCM after duty hours prior to seeking urgent primary care in the purchased care. Urgent primary care consults requested during or after duty hours will be entered into CHCS/AHLTA NLT the next duty day. With documented training and written algorithms, other staff members (e.g., appointing agents, etc.) may enter consults for urgent primary care into CHCS.

The consult must be signed by a credentialed provider. The RMC will transmit the consult to the MCSC and obtain the urgent primary care consult results. Best Practice: Travis AFB Fast Track Urgent Primary Care Referrals https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/RM%20Best%20Practice%20Folder

5.

Request Referral/ Consult

Credentialed providers will order consults in CHCS/AHLTA before the end of the patient encounter so the patient can go to the RMC for guidance/counseling.

At a minimum, providers should include on the referral: a provisional diagnosis;

reason for referral to include treatments attempted and outcome(s); care or service requested; and whether the specialist is to evaluate or evaluate and treat the patient. The RMC staff will not enter new or renewal referrals/consults.

6.

Route Referrals to

RMC

All specialty care referrals will be routed through CHCS/AHLTA to the RMC or MSM RMC for administrative review, appointing to the MTF, and processing.

Specialty care clinics that perform their own reviews will be approved by the Executive Staff or designee in writing. MTF specialty clinics exempted by the Executive Staff will be responsible for referral review, booking, and tracking of those referrals. See Kx for instructions on correct CHCS file/table, ancillary procedure, and clinic set up.

https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/CHCS%20Referral%20Manageme nt%20and%20Appointing%20Guide%2012Apr2013.docx

6.1

MTFs will configure the RMC as a “Clinic” location type in the CHCS Hospital Location file, use ELAA MEPRs code and populate the “Clinic Specialty” field with all clinic specialties available in the MTF and purchased care.

6.2

The MTF’s CHCS ancillary procedures will have the name of the specialty in the “Clinic Specialty” field and the RMC in the “Consulting Clinic” field. Applies only for specialty care referrals as defined in BR 4.

7.

Send Patients to the RMC

Referring provider/team should instruct patients with referrals to go to the RMC prior to leaving the MTF. (Exception: MSM RMCs located at a distance from the referring MTF). Patients who are unable to go to the RMC should be given an RMC brochure by the provider/clinic staff which explains the RM process, https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/RM%20Best%20Practice%20Folder https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/CHCS%20Referral%20Management%20and%20Appointing%20Guide%2012Apr2013.docx https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/CHCS%20Referral%20Management%20and%20Appointing%20Guide%2012Apr2013.docx contact information of MCSC for authorization questions, and RMC’s contact information for questions. The RMC can save providers/clinical staff 5-10 minutes per patient by educating and answering patient questions on the referral process. Best Practice (Tinker): Providers/clinical staff use verbiage such as “stop by the RMC to activate your referral.” RMC brochures are available in all examination rooms and clinic areas.

8. Assist Patients

RMC staff will confirm patient’s TRICARE eligibility and contact information (ensure preferred phone number is entered in the CHCS “home phone number” field); appoint the patient’s MTF specialty appointment prior to leaving the MTF or explain how they will be notified of their appointment and explain the purchased care referral process. Refer the patient to the MCSC or Beneficiary Counseling and Assistance Coordinator for TRICARE health plan coverage information as needed. Best Practice: Encourage all patients to utilize SM for referral questions and provide the RMC their purchased care referral results or appointment information. SM minimizes phone tag with patients.

9.

Perform Referral Review

All specialty care referrals (except self-referrals and “referrals” for administrative tracking) will be initially reviewed and booked (MTF specialty clinics only) by the RMC staff based on the specialty care clinics’ appointing guidelines. RMC staff should consult with MTF’s subspecialty clinics or send the referral to the specialist for review as needed. The review process ends when the referral is dispositioned with an Appoint to MTF or Defer to Network status.

Each referral reviewer (e.g., RMC, specialty clinic, SGH, UM nurse, MSM RMC, etc.) will have one business day from the date the referral was received to make a determination on the referral to prevent delays in care.

9.1

Mandatory Referral Information

The RMC will review referrals for administrative completeness to minimize delays in referral processing and appointing. All RMC staff are expected to be able to perform CHCS referral reviews and RMS processing/tracking. The RMC may complete missing information or over-ride incorrect fields if permitted;

otherwise, the RMC will return the referral to the originating provider for completion. The MTF should ensure that all referrals include sufficient clinical, administrative information to allow the consulted provider to appropriately evaluate the patient and contact the referring provider/MTF as needed. Referring providers should have approved and standardized references (for example, MCG, MCSC medical necessity guidelines, mental health, ASAM for chemical dependency, etc.) to assist them in writing complete referral requests which will mitigate rejection by the MCSC or specialty clinic for “more information needed” reasons. Best Practice: The RMC and MM staffs provide referring providers written examples/specific information from approved references on what information would make the referral complete. This can be done via AHLTA Tasking, email, or paper routing.

10.

Requests for Referrals or Referral Renewals

Patient requests for a referral or referral renewals will be directed to the PCM/team. The RMC will not enter requests for referrals or referral renewals (excludes ROFRs). For requests by network specialists for additional visits, per TOM Chapter 8, Section 5, 6.1.7,”For services beyond the initial authorization, the MCSC shall use its best practices in determining the extent of additional service to authorize. The MCSC shall not request a referral from the MTF…” This applies for non-ADSM patients. ADSM patients require MTF approval/referral renewal.

11.

Appoint Referral to MTF Specialty Clinic

The initial MTF specialty appointment will be booked in CHCS using the Appointment Order Processing (AOP) function in order to link the appointment with the referral and ensure correct tracking through CHCS/RMS. The initial specialty appointment will be booked IAW DoD ATC standards. If the MTF cannot meet the ATC standard, the appointing staff should ask patients if they would waive their ATC standard and opt for a later appointment. MTFs cannot mandate patients to waive their ATC standard. If the patient does not waive their ATC standard, then the patient will be deferred to the purchased care. Best Practice: patient leaves the MTF with initial appointment with the MTF specialty clinic (patient-focused service and prevents rework of phone-tag with the patient by RMC/clinic staff).

11.1

MTF Specialty Clinic Appointing Guidelines

Specialty clinics will provide the RMC and MSM RMC with current appointing guidelines. The appointing guidelines should be as unrestrictive as possible to retain/recapture the maximum number of specialty care referrals within the MTF.

11.2

Appoint or Forward Referral to Another MTF

If the referring MTF (e.g., Bolling AFB) is on the same CHCS host as the consulting MTF (e.g., Andrews AFB), the referring MTF (Bolling) will select the consulting clinic (e.g., Andrews RMC) and enter a review status of “Refer to Subspecialty” (code 14).

If the referring MTF (e.g., Laughlin AFB) is not on the same CHCS host as the consulting MTF (e.g., SAMMC Consult & Appointing Office (CAMO)), the referring MTF (Laughlin) will enter a review status of “Defer to Network” (code #10) and in the first line of the “Review Comment” field will type “To MTF/” plus the DMIS of the consulting MTF, e.g. TO MTF/0066. Complete the Clinic specialty field, indicating the specialty requested. Transmit the referral to the consulting MTF.

The consulting MTF’s RMC (e.g., CAMO) will enter the referral in CHCS/AHLTA as a consult and in the first line of the Review Comment field will type “FROM MTF/” plus the DMIS of the referring MTF, e.g., FROM

MTF/0114.

12.

Perform Right of First Refusal

(ROFR)

A ROFR is a referral from a beneficiary enrolled to a network civilian PCM sent to the MTF by the MCSC for appointing consideration. Beneficiaries enrolled to a civilian PCM have the following CHCS DMIS locations and numbers: USAFE (6913), PACAF (6914), Latin America (6915), (No location assigned to 6916), North (6917), South (6918), and West (6919). RMS recognizes a ROFR entered into CHCS if the clinic from which you are entering the referral displays in its CHCS clinic profile as “Hospital Location: Non-MTF”. MTFs should ensure the fullest extent of ROFR acceptance to sustain clinical currency.

12.1

Timelines to Accept or Decline ROFRs

The MTF will accept/decline urgent priority ROFRs received within 30 minutes of receipt or as updated in TOM 8.5. The MTF will accept/decline routine priority ROFRs received within one business day of receipt or as updated in TOM 8.5. Failure to respond to ROFR requests within the prescribed times is an implied MTF declination and the MCSC will send the patient to the network.

If the ROFR is accepted, the RMC will enter the ROFR into CHCS/AHLTA as a consult. If the ROFR is entered in Referral Booking, convert the referral to a consult in CHCS in order to track results. In both cases, use the CHCS downtown provider or generic downtown provider as the referring provider.

Include ROFR or Right of First Refusal on the first line of the Reason for Referral or Review Comment fields. The RMC or specialty clinic will notify the patient of their ROFR appointment. The RMC will forward the specialty care report via a HIPAA compliant method to the referring civilian PCM within 10-business days of the patient’s kept appointment.

13.

Recapture Referrals

Definition of recaptured referral: When a MTF enrolled patient receives a secondary referral from the purchased care specialist and the MTF has the specialty capability requested in the secondary referral, the secondary referral becomes a recaptured referral. Documenting recaptured referrals shows the value of the RMC and the purchased care cost avoidance (savings) accomplished by the MTF. Examples: The purchased care orthopedic specialist refers the patient to radiology to get an MRI and to physical therapy. The MTF has a MRI and PT. The MCSC sends the referrals to the MTF which accepts them. The MTF has recaptured two referrals. Another example is when the RM staff redirects a referral for the purchased care back into the MTF. This occurs when the referring provider does not know that the specialty care requested is available within the MTF. The difference between a ROFR and Recapture referral is the patient’s place of enrollment (civilian vs. MTF PCM).

13.1

Measuring Recaptured and Redirected Referrals

Measuring the number of referrals that the RMC/MTF recaptured or redirected back to the MTF provides data on the MTFs efforts to maximize MTF capabilities and decrease purchased care costs. Enter the following codes in the CHCS Review comment field in hard brackets, [xx]. Reports available in RMS.

[RECAP]

MTF enrollee received secondary referral and MTF was able to recapture the specialty/service requested.

[REDIRECT] Referral redirected back to the MTF. Shows return on investment for RMC

13.2 ROFR vs.

Recapture

Although the Services define ROFRs and recapture as above, the MCSC does not differentiate between the two. The MCSC sends recapture opportunities as ROFRs. Therefore, the MCSC ROFR metrics will include recapture opportunities. Use of RMS deferred reason codes assists MTFs with identifying ROFR versus recapture referrals.

14.

Defer Referral to Network Provider

When there is no specialty care available in the MTF, the RMC or MSM Referral Center will defer the referral to the network and transmit the referral to the MCSC. The RMC will assist patients with specialty care referrals not requiring MCSC authorization and advise them of their options based on their TRICARE health plan and eligibility (e.g., give provider options, book appointment). Best Practice: Book the appointment for the Non-Prime patient (e.g., TFL, Medicare, T-Plus) with the specialist of their choice while at the RMC. Service is patient-focused and helps the RMC when chasing results.

15.

Defer Referral to Non- Network Providers

The referring provider will provide the clinical justification for sending a patient to a non-network provider in the referral. The RMC should educate MTF providers to allow the MCSC to determine where to send the patient versus requesting by-name non-network providers. Non-network providers may not be TRICARE certified providers. Best Practice: non-network and out of area specialty care referrals require second level review/approval from the SGH to ensure all direct care and local specialty care options have been exhausted.

Patient requests for specific non-network providers may exercise their Point of Service (POS) option which incurs additional out of pocket costs. Non-Active Duty patients may also enroll in TRICARE Standard instead of TRICARE Prime. The POS option allows patients to receive non-emergency TRICARE-covered services from any TRICARE-authorized provider without requesting a referral from a PCM. The POS option does not apply to:

• Active duty service members

• Newborns and adopted children until they are enrolled in TRICARE

Prime.

• Beneficiaries with OHI,

• Services that don't normally require a referral: Emergency care, preventative Care (from network provider)

• First 8 outpatient mental health visits per fiscal year

Source: http://www.tricare.mil/Costs/HealthPlanCosts/PrimeOptions/POS.aspx http://www.tricare.mil/Costs/HealthPlanCosts/PrimeOptions/POS.aspx

16.

Document Reasons for Deferring a Referral to the Purchased Care

All Defer to Network referrals will have at least one of the below codes typed in the referral Review Comment field. Best Practice: Utilize the RMS “Deferred Reason Error Report to analyze reasons referrals are sent to the purchased care instead of kept in the MTF. Type the codes below in the CHCS Review Comment field of the referral encased in hard brackets [xx]. Use of at least one code is mandatory. Multiple codes may be used; however, each code must be in its own brackets. Reports available in RMS.

[2nd] Second opinion requested. Patient or provider requested a second opinion

[CB] Capability. MTF did not have specialty or services requested

[CC] Continuity of Care

[CMD]

Command Directed. Referrals requiring approval from Chief of the Medical Staff or designee

[CP]

Capacity. MTF did not have appointments available within the access to care standards

[DS] Distance. Exceeds TRICARE distance/travel requirements

[NAR] No Pre-authorization required

[OHI] Other Health Insurance. Patient has OHI or is Medicare eligible

[POS] Point of Service or Self-Referred care

17.

Laboratory and Radiology Studies, Durable Medical Equipment (DME) Which Require

MCSC

Authorization

The RMC will track (process and close) laboratory and radiologic study and DME referrals that require MCSC authorizations. DME invoices should be considered as a “result.” The RMC will check claims NLT 120 days from the date of the request to determine if patient obtained the DME and close the referral in CHCS as “Deferred Results Received.” If there is no claim or referral is cancelled by the patient, the RMC will notify the referring provider of the unused referral and close the referral in CHCS with the status of “No Appointment Required” (code #13) and in the very first spaces of the Review Comment field, type “{NU}” for ”Not Utilized (see BR 30). Best Practice (USAFA and the Colorado MSM): When a patient presents to radiology for a procedure and it cannot be done at the MTF, the radiology clerk prints out the CHCS ancillary order. This order with the patient demographic is transmitted to the MCSC. This is care coordination that is done by the team and/or the ancillary service which cannot accommodate the patient requirement.

17.1

Laboratory and, Radiology Studies, DME Which Do Not Require

MCSC

Authorization

Laboratory and radiological orders that do not require MCSC authorization should not be entered as referrals. If the MTF enters referrals for ancillary services not requiring TRICARE authorizations, the “referral” will not be processed or tracked by the RMC staff. Tracking of DME that do not require authorization is optional. The RMC will close these DME referrals with “No Appointment Required.” Best Practice (USAFA, Travis): The UM or CM review and assist patients with obtaining their DME.

17.2

Disease Management, HEDIS

Screening

Preventive care testing does not require TRICARE authorization; therefore, the RMC will not process, manage, or track PCM orders/referrals for screening exams. The RMC will not enter cancer screenings (breast, cervical and colorectal cancer screenings), HgbA1c results, and LDL HEDIS results in the TSWF MHSPHP AIM form. This function is out of the scope of RM functions and central RM contract.

18.

Send Clinical Information to Purchased Care Providers

The referring provider/team will obtain additional medical information (e.g. lab reports, x-rays, previous encounter notes, etc.) to provide to the purchased care specialist as requested/clinically required. The RMC can assist the PCM/team by faxing the documents to the specialist’s office. For STAT/ASAP referrals, the ordering provider/team is responsible for obtaining and sending the requested information to the specialist. Best Practice: Determine if purchased care providers are using the same SM vendor as the AFMS and transmit information via colleague to colleague communication. RMC brochures/education materials should specify how patients can obtain clinical records for the specialist. The MTF’s Release of Information department can provide requested patient records to the specialists’ office.

19.

Active Duty Service Members

(ADSM)

MTFs will have processes to perform medical necessity reviews for ADSM referrals. By contract, the MCSCs does not perform medical necessity on ADSMs. Referrals for non-covered benefits require a waiver from DHA prior to sending referral to MCSC (see BR 20.1)

20.

Non-Covered Benefits

See TOM, Chapter 17, Section 3 for complete policy http://manuals.tricare.osd.mil/ : The MCSC performs a covered benefit review for ADSM referrals. If the referral is a non-covered benefit, the MTF will provide the DHA Waiver approval with the referral. If the waiver approval is not included when the referral is sent, the referral will be denied.

IMPORTANT: TOM.17.2.2.4: TRICARE benefits may not be extended for complications resulting from non-covered surgeries and treatments performed outside the MTF for a Service member without an approved waiver. If the treatment is a non-covered TRICARE benefit, any follow-on care, including care for complications, will not be covered by TRICARE once the Service member separates from active duty or retires (32 CFR 199.4(e)(9); TPM, Chapter 4, Sections 1.1 and 1.2). The Services will provide appropriate counseling that such follow-on care is the member’s personal financial responsibility upon separation or retirement.

20.1

Waiver for Non-Covered Benefit

The requesting provider and the MTF SGH will initiate the waiver process and complete required documents. All waiver packages for approval will be electronically sent to afmoa.sgat@us.af.mil with an email copy to the respective MAJCOM SGH per HIPAA/Privacy Act requirements. For questions, contact the AFMOA/SGAT region POC. Forms, DHA and AFMOA policy can be downloaded at:

https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/Forms/HideFolders.aspx?FilterFiel d1=Classification&FilterValue1=hbreferralmgmtpoliciesdirectives Once the waiver is approved, the RMC will fax the approved waiver with the referral to the MCSC.

21.

ADSM on Medical Hold

Health Affairs policy requires MTFs to ensure specialty care services are available for ADSMs on “medical hold” within two weeks of identifying the need for an appointment. MTFs should collaborate with their MCSCs to ensure that ADSMs receive their referral authorizations and appointments expeditiously.

Referring MTF providers will specify in the body of the referral when the ADSM should be seen (e.g., 72 hours, 7 days, 14 days, etc.) rather than using the default 28-day ATC standard for “Routine” priority referrals.

22.

ADSMs on Terminal Leave: Pre- Authorization

The MTF should assist ADSMs on terminal leave to obtain a pre-authorization for routine and urgent outpatient care at the Department of Veterans Affairs (DVA). If the ADSM intends to reside outside of the Prime Service Area (PSA) of the CONUS MTF while on terminal leave, the ADSM must coordinate with http://manuals.tricare.osd.mil/ https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/Forms/HideFolders.aspx?FilterField1=Classification&FilterValue1=hbreferralmgmtpoliciesdirectives https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/Forms/HideFolders.aspx?FilterField1=Classification&FilterValue1=hbreferralmgmtpoliciesdirectives of Care at Department of Veterans Affairs their PCM/clinical team for the pre-authorization referral. This does not apply to the OCONUS ADSM on terminal leave that will take their terminal leave in CONUS. (Note: There is no requirement for the MTF to determine if the ADSM on terminal leave is going to leave the area. There is no requirement for the MTF to determine if a DVA medical center/facility is in the area where the ADSM will reside while on terminal leave. This information has been included in the Air Force Preparation Guide used for base separations briefings.

23.

Prime Patients with Other Health Insurance

(OHI)

OHI is insurance acquired through an employer, entitlement program or other source. The RMC will instruct Prime beneficiaries with OHI to submit referral requests to their primary health insurer and follow the guidance provided by their primary health insurer for referral appointments. Under federal law, TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service or other programs or plans as identified by the Defense Health Agency.

24.

OCONUS Pay Patients

"Pay Patients" are prioritized for care after ADSMs, Prime AD Family Members, Prime Retirees/Family members, AD Family Members not enrolled in TRICARE Prime, and T-Plus enrollees. "Pay Patients" are eligible to be seen within the MTF for primary and specialty care if capacity exists.

25.

TRICARE

Plus, TRICARE For Life (TFL), Medicare Beneficiaries

If MTFs have specialty capability and capacity, MTFs are highly encouraged to accept self-referral specialty care requests from TFL/Medicare beneficiaries with or without a referral/request from their civilian PCMs. Often these requests are written on a provider’s prescription form, requesting specialty care for the patient. These beneficiaries should be afforded the opportunity to be seen in the MTF based on the MTF’s capability and capacity and currency case needs.

Depending on where the patient presents, the specialty clinic or the RMC will enter a consult in CHCS. Be sure to obtain physician information from patient and notate on the referral so MTF results can be sent to the patient’s PCM/referring provider. The RMC will provide the referring provider/PCM the results, and track the referral. Note: specialty access for TFL/T Plus patients cannot be at the expense of access for Prime patients seeking the same specialty care. In other words, Prime patients cannot be deferred to network due to lack of access used by TFL/T-Plus patients. Best Practice: Eglin, Keesler, Travis accepts self-referral patients and do not require the patient to have a referral before booking the specialty appointment.

26. Patient Travel For authorized care outside of the 100 mile MTF-radius, the TOPA travel section will assist patients with travel arrangements.

27.

Integrated Disability Evaluation System (IDES)

The Physical Evaluation Board Liaison Officer shall work with the RMC to process referrals for Compensation and Pension (C&P) examinations at the DVA. The RMC will ensure the administrative documentation required for C&P referrals per TOM, Chapter 8.5 are completed prior to transmitting to the MCSC.

28.

MTF

Capability and

ROFR

/Recapture Reports

The MTF’s Capability and ROFR reports should be as unrestrictive as possible to retain/recapture the maximum number of specialty care referrals to sustain clinical currency and minimize purchased care costs. The MTF will ensure these reports are updated as needed for accuracy. The MTF Executive Staff or designee will approval the MTF’s Capability and ROFR reports. These reports will be provided to the MTF’s RMC, MCSC, and the MSM RMC.

29.

Referral Conditions and Decision Points

The MTF will have processes for the below situations:

1. Patient kept MTF initial specialty appointment—the MTF specialist will document referral report in AHLTA. PCM/referring provider will review the referral report (e.g. AHLTA Consult Log)

2. Received purchased care specialty results—RMC will import results into HAIMs (see BR 33) and will close referral in CHCS with “Deferred Results Received” (Code #23). RMC will notify the PCM/referring provider of purchased care results via T-Con (see BR 33.3).

3. Patient refuses or cancels the referral: RMC will close the referral in CHCS with the status of “No appointment required” (code #13) and will type ‘{NU}” for “Not Utilized” in the “Review Comment” field (see BR 30).

4. Appointment not made after three MTF reminders (automated or other method): RMC will close the referral in CHCS with the status of “No appointment required” (code #13) and will type ‘{NU}” for “Not Utilized” in the “Review Comment” field (see BR 30).

5. Patient “No Shows”: the RMC will follow the MTF’s No Show Policy. If referral is closed, follow 3 or 4 above. Define process when to close the referral (e.g., after 1, 2, or 3 ‘No Shows” and who will close the referral in CHCS: the specialty clinic who documented the “No Show,” the RMC, or the referring provider/clinical team.)

30.

Reasons for Closing a Referral in

CHCS

The below referral Review Comment codes provide a means to track the reason the MTF is closing a referral. The use of the codes is optional except where indicated as mandatory. Use of codes enables leadership to view RMS reports on why the referral was closed. Only one code per referral. See RMS reports

Type the below in the CHCS Review Comment field of the referral encased in "{xx}" soft brackets.

{ACPC} Patient Cancelled via Audio Communicator Referral Reminder

{CRNAR} Closed Referral/No Appointment Required

{CRNRR} Claim Received but No Results Received

{NRR}

Claim in system, but no results received despite efforts to obtain from provider

MANDATORY

{NU} Referral Not Utilized MANDATORY

{PCRMO}

Patient called the RMC/RMO to cancel the referral (not via AudioCommunicator Referral Reminder)

31.

Referral Tracking

The RMC will be the MTF’s single POC to receive all purchased care specialty care referral results. The RMC will track all initial specialty care referral/consult results generated by the MTF from the time the referral is written until the results of the referral are provided to the referring provider/PCM and/or closure of the referral in CHCS. The RMC does not track follow-ups but will provide follow-up results to the referring provider/PCM. Referrals generated for tracking purposes (labs, radiology, disease management, HEDIS, ancillary orders, etc.)

does not meet the definition of a specialty care referral/consult and will not be processed or tracked by the RMC (BR 4).

31.1

Automatic CHCS Closure of Referrals

MTFs will disable the automatic closure function in CHCS for referrals/consults.

Exceptions to policy should be addressed to AFMSA/SG3SA.

31.2

Direct Care Referral Results

Referring providers will review the MTF specialty results available in AHLTA (e.g., AHLTA Consult Log).

31.3

ROFR and Recapture Results

The RMC will return completed ROFR/recapture specialty care referral results to the referring purchased care provider within 10 business days of the kept specialty encounter.

31.4

STAT / Urgent Referral Results

If immediate results for STAT and urgent priority specialty care referrals are clinically required, then the PCM/clinical team will request them from the purchased care specialist. The clinic will provide the purchased care provider the RMC fax number. If the PCM/clinical team needs referral results today or for a future scheduled patient appointment regarding the CLR results, and the CLR results are not in AHLTA, HAIMs or the medical records, then the PCM/clinical team should provide the RMC as much prior notice as possible for the RMC to obtain the needed CLR. Once received, the RMC will make the result(s) available to the requesting PCM/team.

32.

When to Start “Chasing” Purchased Care Clear and Legible Reports (CLRs)

The RMC will track the initial result of all specialty care referrals written by the MTF to closure (sent to the referring provider/PCM for review). If follow-up visit results are received from the specialist, the RMC will upload results in HAIMs and notify the referring provider/PCM for review.

The RMC will request CLRs for specialty care referrals NLT 120 calendar days after the order entry date, unless otherwise requested by the referring provider or when scheduling appointments is known to require more than 120 calendar days from order entry date.

32.1

If a CLR has not been received in 120 calendar days after the order entry date, RMC personnel will:

1. Check the MCSC claims database to see if a claim has been paid.

a. If claim was paid, the RMC will obtain purchased care provider’s name and contact information from the claim or the MCSC database and request the CLR from the provider.

1) If there is no response from the provider in 10 calendar days, repeat.

2) If the provider still does not provide the CLR, the RMC will close the referral in CHCS using the status of “Deferred results received” and type “{NRR}” for “No results received” in the “Review Comment” field. .

b. Provide the MCSC Contract Liaison a list of purchased care providers that have refused to provide results. The liaison will submit list to the TROs.

2. If there is no claim, and the MTF has reminded the patient three times to use their referral, the RMC will close the referral in CHCS with the status of “No appointment required” (code #13) and type “{NU}” for “Not Utilize” in the “Review Comment” field (see BR 30)..

33.

Import CLRs into HAIMs

The RMC will import the initial and follow up specialty care results, urgent primary care results, and laboratory results and radiology reports that require an authorization into HAIMs within three working days from receipt of results.

The RMC will notify the referring provider/PCM of the results via T-Con.

(Note: Use of HAIMs for CLRs is mandatory per DoDI. If the MTF does not have HAIMs, follow AHLTA Scanning policy. If HAIMs is down, revert to AHLTA Scanning policy (see BR 40). Best Practice: SGH defines the priority of scanning results by general category. All referrals will be entered into the EHR, but it would help the RMC prioritize workload. The RMC contract staff will not import results for hospital discharge summaries, emergency room visits, labs/rads/exams for preventative health/HEDIS measures, and all loose documents not directly related to a referral.

See HAIMS RM Workflow Training slides_Nov 2013_Colorado MSMO found at below link.

https://kx2.afms.mil/kj/kx8/AccesstoCare/_layouts/listform.aspx?PageType=4&ListId={

6C562712-0EEB-4E55-AE37-DA9BC8CBACC9}&ID=984

Other HAIMs resources can be found at:

https://kx2.afms.mil/kj/kx8/AccesstoCare/Documents/Forms/HideFolders.aspx?FilterFiel d1=Classification&FilterValue1=referralmanagementahltascanning

33.1 General Information

1. A T-Con and HAIMs entry will be created for each CLR/result.

a. The T-Con will be associated with the HAIMs entry so that the reviewing provider clearly understands which T-Con is for which HAIMs entry.

b. For both parts, the following mandatory standard naming convention will be used: Network Results – Specialty MM/DD/YY where the MM/DD/YY is the date the patient was seen. For example, Network Results – Cardiology 2/10/14.

2. Any existing shared folders used for the purpose of storing temporary results or other Protected Health Information may be maintained for 30 calendar days following the date of the original image upload. Thereafter, the electronic folder and documents must be deleted.

3. Both the original foreign language and the English translated result/report will be uploaded into HAIMs. The untranslated result/report does not have to be signed by the referring provider if the translated result/report was already signed.

4. Once loaded into HAIMs, the reviewing provider is not required to handwrite or “wet” sign the hard copy result/report. The paper copy of the result/report is not required to be filed into the paper outpatient medical record. However wet signatures and filing of paper copy may be required for special programs (e.g. PRP) or payment issues. Before destroying the original hard copy or electronic result/report, ensure that the scanned document is legible by the provider. Ensure you have a quality check process in place to ensure right patient, right CLR and right record.

5. Correcting errors: The MTF will have a quality check process to minimize PHI/PII errors.

6. Contingency plan: When HAIMs is down for several hours, results may be entered into AHLTA Clinical Notes per the instructions in BR 40. If both AHLTA and HAIMs are down indefinitely, paper copy result/reports may be reviewed and signed by the provider. The signed reports will be sent back to the department scanning the reports/results to enter into HAIMs per the above instructions.