Q A_Updates_6.5.15.pdf

129 Will DHA provide the annual number of referrals from MTF/eMSMs to Purchased Care by specialty, by region, for the past 3 years?

C.2.2.1 The referral data the Government is providing is the consolidated referral data for CY 2014 at Attachment J-99, "Regionals Referrals and Auths.xlsx." Claims data, previously provided, is the best measure of the volume of authorized and provided health care. It must be noted that in general, referrals are required for Prime enrollees when a PCM needs to refer a member to a specialist for services or for services to be performed outside the PCM’s office (this includes Prime enrollees whose PCM is at an MTF and requires care in the civilian network). However, not all health care requires a referral, not all referrals result in health care delivery, and multiple claims may result from a single referral. We believe an estimate is better obtained by offerors using the detail-level claims data which includes treatment/care data and beneficiary enrollment status. Offerors should use their best judgment/experience, and an in depth understanding of statutes, regulations and policies to estimate workload in this regard."

130 Will DHA provide the total number of referrals processed by Region for each of the past 3 years?

C.2.2.1 See Response for #129.

131 Will DHA provide the total number of referrals submitted by an MTF subtotaled by method of submission: phone, fax, RMS, for the past 3 years?

C.2.2.1 See Response for #129.

132 Will DHA provide Referral administrative workload volumes related for the last three years including the following? Total number of Referrals processed (by specialty and type of service if available)Number of Referrals from MTFs to contractor provider network (by specialty and MTF if available)Number of ROFR Referrals to MTFs (by specialty and MTF if available)Percentage of ROFR Referrals accepted by MTF (by specialty and MTF if available)

C.2.2.2 / Attach L-9

See Response for #129.

171 Will DHA please provide, for each of the regions, the total number of authorizations issued for MTF-enrolled beneficiaries and for ADSM, to the purchased care system?

L. 6.2.3.1 The Government is not providing any historical authorization data/numbers. In general, authorizations are a determination that requested treatment is medically necessary, delivered in an appropriate setting and is a TRICARE benefit. The minimum care requiring authorization is outlined in both the TRICARE Operations Manual (TOM, Chapter 7, Section 2) and the TRICARE Policy Manual (TPM, Chapter 1, Section 6.1). In addition to the procedures that DHA mandates must be authorized, each contractor has the option of requiring additional procedures that require authorization. These ‘optional’ contractor-added authorizations vary by contractor/region and can significantly impact the number of authorizations issued. Offerors can estimate the number of authorizations using the detailed claims data provided and by identifying those procedures DHA requires authorization for in addition to identifying those procedures the offeror will mandate authorization for.

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