M050_Monthly_Workload_Report_5-9-13.pdf

DD FORM 1423-1, FEB 2001

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages cgriffin Highlight cgriffin Highlight

1.0. INSTRUCTIONS FOR TRICARE CONTRACTOR MONTHLY WORKLOAD

REPORT - NETWORK/NON-NETWORK/MEDICARE BRAC, TMA FORM 742

1.1. Information Requirement

The contractor shall electronically submit to the TMA, Claims Operations Office and Regional Director, a TRICARE Contractor Monthly Workload Report as one report containing separate data sheets for each of the following workload reports:

• Claims Workload Report

• SHCP Workload Report

• TPR Workload Report

• TPRADFM Workload Report

1.2. Instructions For Preparation

1.2.1. Section A: Claims

For purposes of this chapter, a claim is defined as any request for payment for services rendered related to care and treatment of a disease or injury which is received from a claimant by a TMA contractor on any TMA-approved claim form or approved electronic media. Reports of services rendered, which do not result in the submission of claims, as defined above, are not to be included in the reports required by this chapter.

1.2.1.1. A.1.a. - Pending End Of Prior Month

Enter the number reported in line A.4. on the preceding month’s report.

1.2.1.2. A.1.a.(1) - Correction to Prior Month’s Report

Enter the net number of claims which were actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section requires an explanation in Section C, “Remarks.”

1.2.1.3. A.1.b. - Adjusted Opening Pending

Enter the result of A.1.a., plus or minus A.1.a.(1).

1.2.1.4. A.2. - Receipts

Enter the number of claims accepted in the custody of the contractor. Estimate the number of non-keyed network versus non-network receipts by applying the percentage of keyed claims received during the reporting period.

EXAMPLE:

Total monthly receipts = 10,000 Total Keyed Receipts = 8,000 (5,000 network = 62.5%)

(3,000 non-network = 37.5%) Total Non-Keyed Receipts = 2,000 (2,000 X 62.5% = 1,250 network)

(2,000 X 37.5% = 750 non-network)

1.2.1.5. A.2.a. - Network Claims Receipts

Enter the number of network claims accepted in the custody of the contractor.

Estimate the number of non-keyed network receipts by applying the percentage of keyed claims received during the reporting period.

1.2.1.5.1. A.2.a.(1) - EMC Network Claims Receipts

Enter the number of processed EMC network claims included in the receipts reported in A.2.a.

1.2.1.6. A.2.b. - Non-Network Claims Receipts

Enter the number of non-network claims accepted in the custody of the contractor. Estimate the number of non-keyed network receipts by applying the percentage of keyed claims received during the reporting period.

1.2.1.6.1. A.2.b.(1) - EMC Non-Network Claims Receipts

Enter the number of processed EMC non-network claims included in the receipts reported in A.2.b.

1.2.1.7. A.2.c. - Transfers

Claims received in A.2. above which are forwarded to another TRICARE contractor having jurisdiction of processing.

1.2.1.8. A.2.d. - Returns

Enter the number of claims returned to the claimant.

1.2.1.9. A.2.e. - Net Receipts

Enter the result of A.2., minus A.2.c. and A.2.d.

1.2.1.10. A.3. - Processed to Completion

Enter the total number of claims paid, applied toward the deductible, or denied.

1.2.1.11. A.4. - Pending End of Month

Enter the difference between A.1.b. plus A.2.c. minus A.3.

Add estimates for non-keyed receipts to keyed receipts:

Total Receipts Network = 5,000 + 1,250 = 6,250 Total Receipts Non-Network = 3,000 + 750 = 3,750

1.2.1.12. A.5. - Point of Service (POS) - Processed to Completion

Enter the total number of the claims paid under POS. The POS numbers shall be included in the total number of claims processed to completion in line A.3. (This is not applicable to the TRICARE Dual Eligible FI Contract.)

1.2.2. Section B: Adjustment Claims

An adjustment is a correction of the payment or the payment record information on a claim previously processed to completion. (Refer to Chapter 11, Section 1, paragraph 5.0.)

1.2.2.1. B.1.a. - Pending End of Prior Month

Enter the number reported in line B.4. of the preceding month’s report.

1.2.2.2. B.1.a.(1) - Correction to Prior Month’s Report

Enter the net number of adjustments to processed claims which were actually overstated or understated in the previous month’s report will be entered using a plus (+) or minus (-). Any entry in this section requires a narrative explanation in Section C, “Remarks.”

1.2.2.3. B.1.b. - Adjusted Opening Pending

Enter the results of B.1.a., plus or minus B.1.a.(1).

1.2.2.4. B.2. - Receipts

Enter the number of adjustment claims identified during the month. (Refer to Chapter 11, Section 1, paragraph 5.0.)

1.2.2.5. B.3. - Processed To Completion

Enter the number of adjustment claims which were processed to completion.

1.2.2.6. B.4. - Pending End Of Month

Enter the number of adjustment claims identified which have not been processed to completion. Line B.4. is the difference between B.1.b., plus B.2., minus B.3.

1.2.3. Section C: Remarks

1.2.4. Section D: Inquiries

1.2.4.1. D.1. - Telephone Inquiries Received

Enter the total number of incoming telephone inquiries received in all locations, including service center(s). This data must be substantiated by a log or other documentation.

Do not include routine operating calls (calls received from individuals or organizational components within the contractor’s operations involving the conduct of normal business) or personal calls.

1.2.4.2. D.2. - Walk-In’s

Report total walk-ins in all locations, including the service center(s).

1.2.4.3. D.3. - Routine Correspondence

Report in this section the data related to all routine correspondence received into custody. Routine correspondence regarding a returned claim that requires a response shall be reported here. Grievances, collection action cases or requests for appeal should not be reported here. Letters from beneficiaries or providers resubmitting the claim or claim documentation shall not be reported. Questions concerning charges allowed should be included as “routine correspondence.” Requests for “Reconsiderations” on issues considered not appealable and untimely requests for reconsiderations shall be counted as routine correspondence.

1.2.4.4. D.3.a.(1) - Pending End Of Prior Month

Enter the number reported in line D.3.d. of the prior month’s reports.

1.2.4.5. D.3.a.(1)(a) - Correction To Prior Month’s Report

Enter the net number of pieces of routine correspondence which were actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section requires a narrative explanation in Section E, “Remarks,” below.

1.2.4.6. D.3.a.(2) - Adjusted Opening Pending

Enter the result of D.3.a.(1), plus or minus D.3.a.(1)(a).

1.2.4.7. D.3.b. - Receipts

Enter the number of pieces of routine correspondence accepted into custody.

1.2.4.8. D.3.c. - Processed To Completion

Enter the number of pieces of routine correspondence completed, regardless of the manner in which it was completed; i.e., written, telephone, or other.

1.2.4.9. D.3.d. - Pending End Of Month

Enter on line D.3.d. the difference between D.3.a.(2), plus D.3.b., minus D.3.c.

1.2.4.10. D.4. - Priority Correspondence

Enter appropriate data in this section regarding correspondence received from the Office of the Assistant Secretary of Defense (Health Affairs), TMA, members of Congress, and others designated as priority by the contractor.

1.2.4.11. D.4.a.(1) - Pending End Of Prior Month

Enter the number reported in line D.4.d. of the prior month’s report.

1.2.4.12. D.4.a.(1)(a) - Correction To Prior Monthly Report

Enter the net number of pieces of priority correspondence which were actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section (plus or minus) requires a narrative explanation in Section E, “Remarks,” below.

1.2.4.13. D.4.a.(2) - Adjusted Opening Pending

Enter the result of D.4.a.(1), plus or minus D.4.a.(1)(a).

1.2.4.14. D.4.b. - Receipts

Enter the number of pieces of priority correspondence accepted into custody.

1.2.4.15. D.4.c. - Processed To Completion

Enter the number of pieces of priority correspondence completed.

1.2.4.16. D.4.d. - Pending End Of Month

Enter on line D.4.d., the difference between D.4.a.(2), plus D.4.b., minus D.4.c.

1.2.4.17. D.5. - Collection Action Cases

Enter data in this section regarding collection action cases received directly by the contractor. (Cases referred by the DCAOs shall be reported as priority correspondence.)

1.2.4.18. D.5.a.(1) - Pending End Of Prior Month

Enter the number reported in line D.5.d. of the prior month’s report.

1.2.4.19. D.5.a.(1)(a) - Correction To Prior Monthly Report

Enter the net number of collection action cases which were actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section (plus or minus) requires a narrative explanation in Section E, “Remarks,” below.

1.2.4.20. D.5.a.(2) - Adjusted Opening Pending

Enter the result of D.5.a.(1), plus or minus D.5.a.(1)(a).

1.2.4.21. D.5.b. - Receipts

Enter the number of collection action cases accepted into custody.

1.2.4.22. D.5.c. - Processed To Completion

Enter the number of collection action cases completed.

1.2.4.23. D.5.d. - Pending End Of Month

Enter on line D.5.d., the difference between D.5.a.(2), plus D.5.b., minus D.5.c.

1.2.5. Section E: Remarks

1.2.6. Section F: Expedited Preadmission/Preprocedure Reconsiderations (Expedited Appeal Cases)

Report in this section the data related to all expedited appeal cases received into custody. The contractor shall count as a receipt any case received in which the appealing party is raising objection to the contractor’s preadmission/preauthorization medical necessity determination. Correspondence concerning non-appealable issues is to be reported in Section D, “Inquiries.” Correspondence qualifying as a grievance is to be reported in Section I, “Grievances.”

1.2.6.1. F.1.a. - Pending End Of Prior Month

Enter in the “Total” column the number reported in line F.4. of the preceding month’s report.

1.2.6.2. F.1.a.(1) - Correction To Prior Month’s Report

Enter in the “Total” column the net number of expedited appeal cases actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section will require a narrative explanation in Section E, “Remarks,” above.

1.2.6.3. F.1.b. - Adjusted Opening Pending

Enter in the “Total” column the result of F.1.a., plus or minus F.1.a.(1).

1.2.6.4. F.2. - Receipts

Enter in the “Total” column the number of expedited appeal cases accepted in the custody of the contractor.

1.2.6.5. F.3.a. - Initial Decision Upheld

Enter the number of expedited appeal cases receiving final replies when the contractor affirmed the initial decision as being correct in its entirety.

1.2.6.6. F.3.b. - Initial Decision Partially Upheld

Enter the number of expedited appeal cases receiving final replies when the contractor affirmed only a portion of the initial decision as being correct.

1.2.6.7. F.3.c. - Initial Decision Reversed

Enter the number of expedited appeal cases receiving final replies when the contractor reversed the initial decision in its entirety.

1.2.6.8. F.3.d. - Total Processed To Completion

Enter the sum of F.3.a., plus F.3.b., plus F.3.c.

1.2.6.9. F.4. - Pending End Of Month

Enter the sum of F.1.b., plus F.2., minus F.3.d.

1.2.7. Section G: Nonexpedited Medical Necessity Reconsiderations

Report in this section the data related to all nonexpedited medical necessity appeal cases received into custody. The contractor shall count as a receipt any case received in which the appealing party is raising objection to the contractor’s determination of coverage. Correspondence concerning nonappealable issues is to be reported in Section D, “Inquiries.” Correspondence qualifying as a grievance is to be reported in Section I, “Grievances.”

1.2.7.1. G.1.a. - Pending End Of Prior Month

Enter in the “Total” column the number reported in line G.4. of the preceding month’s report.

1.2.7.2. G.1.a.(1) - Correction To Prior Month’s Report

Enter in the “Total” column the net number of nonexpedited medical necessity appeal cases actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section will require a narrative explanation in Section E, “Remarks,” above.

1.2.7.3. G.1.b. - Adjusted Opening Pending

Enter in the “Total” column the result of G.1.a., plus or minus G.1.a.(1).

1.2.7.4. G.2. - Receipts

Enter in the “Total” column the number of nonexpedited medical necessity appeal cases accepted in the custody of the contractor.

1.2.7.5. G.3.a. - Initial Decision Upheld

Enter the number of nonexpedited medical necessity appeal cases receiving final replies when the contractor affirmed the initial decision as being correct in its entirety.

1.2.7.6. G.3.b. - Initial Decision Partially Upheld

Enter the number of nonexpedited medical necessity appeal cases receiving final replies when the contractor affirmed only a portion of the initial decision as being correct.

1.2.7.7. G.3.c. - Initial Decision Reversed

Enter the number of nonexpedited medical necessity appeal cases receiving final replies when the contractor reversed the initial decision in its entirety.

1.2.7.8. G.3.d. - Total Processed To Completion

Enter the sum of G.3.a., plus G.3.b., plus G.3.c.

1.2.7.9. G.4. - Pending End Of Month

Enter the sum of G.1.b., plus G.2., minus G.3.d.

1.2.8. Section H: Nonexpedited Factual Determinations

Report in this section the data related to all non-expedited factual determination appeal cases received into custody. The contractor shall count as a receipt any case received in which the appealing party is raising objection to the contractor’s determination of coverage. Correspondence concerning nonappealable issues is to be reported in Section D, “Inquiries.” Correspondence qualifying as a grievance is to be reported in Section I, “Grievances.”

1.2.8.1. H.1.a. - Pending End Of Prior Month

Enter in the “Total” column the number reported in line G.4. of the preceding month’s report.

1.2.8.2. H.1.a.(1) - Correction To Prior Month’s Report

Enter in the “Total” column the net number of nonexpedited factual determination appeal cases actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section will require a narrative explanation in Section E, “Remarks” above.

1.2.8.3. H.1.b. - Adjustment Opening Pending

Enter in the “Total” column the result of H.1.a., plus or minus H.1.a.(1).

1.2.8.4. H.2. - Receipts

Enter in the “Total” column the number of nonexpedited factual determination appeal cases accepted in the custody of the contractor.

1.2.8.5. H.3.a. - Initial Decision Upheld

Enter the number of nonexpedited factual determination appeal cases receiving final replies when the contractor affirmed the initial decision as being correct in its entirety.

1.2.8.6. H.3.b. - Initial Decision Partially Upheld

Enter the number of nonexpedited factual determination appeal cases receiving final replies when the contractor affirmed only a portion of the initial decision as being correct.

1.2.8.7. H.3.c. - Initial Decision Reversed

Enter the number of nonexpedited factual determination appeal cases receiving final replies when the contractor reversed the initial decision in its entirety.

1.2.8.8. H.3.d. - Total Processed To Completion

Enter the sum of H.3.a., plus H.3.b., plus H.3.c.

1.2.8.9. H.4. - Pending End of Month

Enter the sum of H.1.b., plus G.2., minus G.3.d.

1.2.9. Section I: Grievances

In this section report the data related to all grievances received into custody.

1.2.9.1. I.1.a. - Pending End Of Prior Month

Enter in the “Total” column the number reported in I.4. of the preceding month’s report.

1.2.9.2. I.1.a.(1) - Correction To Prior Month’s Report

Enter in the “Total” column the net number of grievances actually overstated or understated in the previous month’s report using a plus (+) or minus (-). Any entry in this section will require a narrative explanation in Section E, “Remarks,” above.

1.2.9.3. I.1.b. - Adjusted Opening Pending

Enter in the “Total” column the result of I.1.a., plus or minus I.1.a.(1).

1.2.9.4. I.2. - Receipts

Enter in the “Total” column the number of grievances accepted in the custody of the contractor. The contractor should count as a receipt any case received which meets the definition of a grievance.

1.2.9.5. I.3. - Total Processed To Completion

Enter the number of grievances completed.

1.2.9.6. I.4. - Pending End Of Month

Enter the sum of I.1.b., plus I.2., minus I.3.

TRICARE Contractor Monthly Workload Report - Network/Non-Network/Medicare BRAC, TMA Form 742

TRICARE CONTRACTOR MONTHLY WORKLOAD REPORT

Network/Non-Network/Medicare BRAC State: Contractor Name: Contract No.: Report Period

(MM/YY)

Section A. CLAIMS Total Working Days (during month):

1. OPENING PENDING

a. Pending End of Prior Month

(1) Corrections to Prior Month’s Report (+ or -)

b. Adjusted Opening Pending

2. RECEIPTS

a. Network Claims Receipts

(1) EMC Network Claims Receipts

b. Non-Network Claims Receipts

(1) EMC Non-Netork Claims Receipts

c. Transfers

d. Returns

e. Net Receipts

3. PROCESSED TO COMPLETION

4. PENDING END OF MONTH

5. POINT OF SERVICE (POS) PROCESSED TO COMPLETION

SECTION B. ADJUSTMENT CLAIMS TOTAL

1. OPENING PENDING

a. Pending End of Month

(1) Correction to Prior Month’s Report (+ or -)

b. Adjusted Opening Pending

2. RECEIPTS

3. PROCESSED TO COMPLETION

4. PENDING END OF MONTH

SECTION C. Remarks:

Report Prepared By: Telephone No. Date Prepared:

Report Approved By (Authorized Officer’s Signature) Date Submitted to

TMA:

TRICARE CONTRACTOR MONTHLY WORKLOAD REPORT

Network/Non-Network/Medicare BRAC State: Contractor Name: Contract No.: Report Period

(MM/YY)

Section D. INQUIRIES TOTAL

1. Telephone Inquiries Received

2. Walk-Ins

3. Routine Correspondence

a. Opening Pending

(1) Pending End of Prior Month

(a) Corrections to Prior Month’s Report (+ or -)

(2) Adjusted Opening Pending

b. Receipts

c. Processed to Completion

d. Pending End of Month

4. Priority Correspondence

a. Opening Pending

(1) Pending End of Prior Month

(a) Corrections to Prior Month’s Report (+ or -)

(2) Adjusted Opening Pending

b. Receipts

c. Processed to Completion

d. Pending End of Month

5. Collection Action of Correspondence

a. Opening Pending

(1) Pending End of Prior Month

(a) Corrections to Prior Month’s Report (+ or -)

(2) Adjusted Opening Pending

b. Receipts

c. Processed to Completion

d. Pending End of Month

SECTION E. Remarks:

TRICARE Contractor Monthly Workload Report - Network/Non-Network/Medicare BRAC, TMA Form 742 (Continued)

Network/Non-Network/Medicare BRAC State: Contractor Name: Contract No.: Report Period

(MM/YY)

SECTION F. EXPEDITED APPEALS TOTAL

1. Opening Pending

a. Pending End of Prior Month

(1) Corrections to Prior Month’s Report (+ or -)

b. Adjusted Opening Pending

2. Receipts

3. Processed to Completion

a. Initial Decision Upheld

b. Initial Decision Partially Upheld

c. Initial Decision Reversed

d. Total Processed to Completion

4. Pending End of Month Section G. NON EXPEDITED MEDICAL NECESSITY APPEALS TOTAL

1. Opening Pending

a. Pending End of Prior Month

(1) Corrections to Prior Month’s Report (+ or -)

b. Adjusted Opening Pending

2. Receipts

3. Processed to Completion

a. Initial Decision Upheld

b. Initial Decision Partially Upheld

c. Initial Decision Reversed

d. Total Processed to Completion

4. Pending End of Month Section H. NON EXPEDITED FACTUAL DETERMINATION APPEALS TOTAL

1. Opening Pending

a. Pending End of Prior Month

(1) Corrections to Prior Month’s Report (+ or -)

b. Adjusted Opening Pending

2. Receipts

3. Processed to Completion

a. Initial Decision Upheld

b. Initial Decision Partially Upheld

c. Initial Decision Reversed

d. Total Processed to Completion

4. Pending End of Month

TRICARE Contractor Monthly Workload Report - Network/Non-Network/Medicare

Network/Non-Network/Medicare BRAC State: Contractor Name: Contract No.: Report Period

(MM/YY)

Section I. GRIEVANCES TOTAL

1. Opening Pending

a. Pending End of Prior Month

(1) Corrections to Prior Month’s Report (+ or -)

b. Adjusted Opening Pending

2. Receipts

3. Processed to Completion

4. Pending End of Month Remarks

TRICARE Contractor Monthly Workload Report - Network/Non-Network/Medicare

TRICARE Contractor Monthly Workload Report - Network/Non-Network/Medicare BRAC, TMA Form 742

TRICARE Contractor Monthly Workload Report - Network/Non-Network/Medicare BRAC, TMA Form 742

Block 13 - 15th calendar day of each month (or the first workday following the 15th calendar day if the 15th is not a business day) following the report period

See the attached document for content and completion instructions.

NOTE: Collection Action Cases (paragraphs 1.2.4.17-1.2.4.23 in the attached document) and Grievances (paragraphs 1.2.9-1.2.9.6 in the attached document) do not apply to the TDEFIC. There are no reporting requirements for these two categories.