16_Attachment_J-6_OGC_Internal_External_Reviews_Witnesses_5-12-15.docx
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- Attached to
- TRICARE Quality Monitoring Contract (TQMC)
- Solicitation number
- HT9402-15-R-0005
- Issued by
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Defense Health Agency
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Section J Attachment J-6
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Attachment J-6 Appeals & Hearings Internal and External Reviews and Hearing Support
OFFICE OF GENERAL COUNSEL (OGC) APPEALS & HEARINGS INTERNAL AND EXTERNAL REVIEWS
1. SUPPLEMENTAL DEFINITIONS
| a. Adequacy of review: This means the contractor’s documented responses to DHA questions shall: | |
| 1) Specifically relate to the questions raised and supported by medical documents submitted, | |
| 2) Be substantiated by a rationale that draws from contemporary medical knowledge and practices in the United States and specific documents submitted for review; and | |
| 3) Refute contentions raised by a provider of care that are not supported by the medical documents reviewed or contemporary medical knowledge and practices in the United States. | |
| b. Appropriateness of review: This means the contractor’s documented responses shall: | |
| 1) Reflect the current consensus of professional medical practice in the United States, | |
| 2) Be within the scope of the questions raised, | |
| (3) Be consistent and in accord with other responses or information in the record, and | |
| (4) Not be editorial of either TRICARE or Department of Defense policy or current reimbursement practices or benefits by third party payers of health care. | |
| c. Specialty: | |
| 1) For non-physician reviewers or non-dentist reviewers, this refers to the categories of TRICARE providers included in TRICARE Policy Manual (TPM) Chapter 11. | |
| 2) For physician reviewers, this refers to the required American Board of Medical Specialties (ABMS) or Bureau of Osteopathic Specialists (BOS) physician specialty. The term also includes any ABMS or BOS recognized subspecialty. | |
| 3) For dentist reviewers, this refers to the required American Dental Association Recognized Dental Specialty Certifying Boards specialty. |
2. MANAGEMENT AND ADMINISTRATION -ALL REVIEW TASKS
| a. The contractor shall train its reviewers and witnesses on the mission of DHA and TRICARE policy as outlined in 32 CFR 199 and the TPM. | |
| b. The contractor shall retain, as a minimum, 1 copy of all reviews that can be delivered upon request in the most current version of Microsoft Word used at the time of DHA request. The contractor shall also comply with the provisions of the TRICARE Operations Manual, Chapter 2. | |
| c. For the reasons stated below, the DHA may direct the contractor to utilize or not to utilize the services of a particular reviewer(s) in instances of: | |
| 1) Reviewer conflict of interest; | |
| 2) Reviewer lack of requisite qualifications to review cases in general or particular cases; or | |
| 3) Prior deficiencies in reviewer’s review opinions as identified by DHA. | |
| d. The contractor shall have procedures for ensuring availability of physician reviewers, dentist reviewers, and non-physician reviewers of the provider types set forth in TPM Chapter 11, and 32 CFR 199.6. | |
| e. The contractor shall designate a prime point of contact for requests for reviews or witnesses, with procedures for alternate points of contact when the prime point of contact is absent from his or her duties. The contractor shall keep the TQMC contracting officer’s representative (COR) advised of its corporate holidays and changes to its prime and alternate points of contact. Sufficient points of contact shall be available to ensure ready access to a point of contact during the contractor’s normal working hours. |
3. DHA REVIEWS
| a. The contractor shall provide internal (real time question and answer) and external (written question and answer) reviews to ascertain the medical necessity, quality of care, appropriateness of treatment, and appropriate level of care as defined by applicable provisions of the TRICARE regulation. |
| b. The types of care that may be reviewed include, but are not limited to: medical, dental, psychological and mental health, surgical, podiatry, pharmacy, skilled nursing, physical therapy, occupational therapy, speech therapy, optometry, oral surgery, osteopathy, and home health care. With regard to physician review, DHA requires physician reviewers covering the full range of specialties and subspecialties recognized by the ABMS or BOS. While DHA will generally request physician reviewers by ABMS or BOS specialty and subspecialty alone in medical-surgical cases, DHA reserves the right to request a physician reviewer with experience with a particular procedure (when the procedure is within the scope of the particular specialty, but not commonly performed by members of that specialty). Where the care under review is an organ transplant, the contractor shall provide review by a physician with experience in performing the type of transplant under review; DHA may also request review by a physician with experience in pre-operatively evaluating candidates for that type of transplant as part of the review. |
| c. With regard to dentist review, DHA requires dentist reviewers covering the full range of specialties recognized by the American Dental Association Recognized Dental Specialties Boards. While DHA will generally request dentist reviewers by specialty alone, DHA reserves the right to request a dentist reviewer with experience with a particular procedure (when the procedure is within the scope of the particular specialty, by not commonly performed by members of that specialty). |
| d. Also included in the types of reviews required are those cases or portions of cases involving treatment of mental disorders in outpatient or inpatient care settings by the types of institutional and individual providers listed in TPM Chapter 11 and 32 CFR 199.6. The reviewers requested by DHA shall have experience in treating patients in the same setting or level of care as the setting or level of care that is being reviewed. DHA may also require reviews in cases involving psychoanalysis, for which the reviewer provided shall be an actively practicing psychoanalyst. |
| e. Also included in the types of reviews required are those cases or portions of cases involving skilled nursing care and treatment in skilled nursing facilities, as defined in 32 CFR 199.2(b), with specific criteria outlined at 32 CFR 199.6(b)(4)(vi). The reviewers requested by DHA shall have experience in treating patients in the skilled nursing facility setting. |
| f. Generally, reviewers shall be from the same discipline (in the case of a non-physician, non-dentist), or ABMS or BOS specialty (in the case of a physician), or American Dental Association Recognized Dental Specialties Boards specialty (in the case of a dentist), as the individual provider of care, unless DHA specifically requests otherwise. Additionally, physician mental health reviewers shall generally be from the same diagnostic category specialization (e.g., substance abuse), and have the same setting/level of care experience, and age specialization (e.g., child, adolescent, adult and geriatric), as the individual provider of care, unless DHA specifically requests otherwise. |
| g. All physician, non-physician, and dentist reviewers required by DHA under this contract shall be currently licensed and actively engaged in the practice of clinical medicine (i.e., the reviewer usually practices, on a routine basis, a minimum of 20 hours per week). |
| h. In cases that are appealed from medical necessity reconsideration decisions issued by the contractor, Internal and External Reviews shall not be performed by anyone involved with the contractor’s medical necessity (reconsideration) review of the case under review. |
| i. The primary volume of cases is generated by beneficiary and provider appeals of contractor decisions to deny coverage. |
| j. A review shall be limited to review of a single appeal request for a single beneficiary and will usually involve requesting an opinion from one reviewer. However, if the beneficiary’s care involves multiple providers, more than one reviewer may be requested to address the care being provided by multiple specialties. |
| k. Reviewers shall be sufficiently competent to provide adequate review of assigned cases to ascertain medical necessity of care, appropriateness of the treatment, the level of care required for treatment, quality of care provided, compliance with medical requirements under TRICARE policy, and accuracy of provider billings. |
| l. Because time is of the essence in this task, the contractor shall direct any questions regarding particular cases to the designated Appeals Hearings and Claims Collection Division (OGC-AC) employee for the case. |
| m. The contractor shall return all case documentation provided by DHA and a review opinion, which shall include: |
1) Patient/beneficiary name;
2) Case Number assigned by DHA;
3) DHA employee who referred the case to review;
4) Reviewer(s) Specialty;
5) Reviewer(s) Response to Questions (in chronological order);
| (i) Question: | |
| (ii) Response: | |
| (iii) Rationale: (to be supported with specific citation of the clinical record and other documentation from the case file and medical literature, if applicable, that was relied upon in formulating the answer. General references to “the clinical record” do not meet this requirement.). |
6) Reviewer(s) signature(s);
7) Reviewer(s) typed name and professional degree (signature block);
| n. With each review opinion, the contractor shall provide the reviewer’s curriculum vitae (CV) on DHA Form 780, Professional Qualifications. The form is available in the TRICARE Operations Manual, Chapter 12, Addendum A, Figure 12.A-3, Professional Qualifications. The CV shall be current as of the time of the review. CVs required under this contract shall include the following information: | ||
| 1) Full name and year of birth, business address, business telephone number, and business | fax number, if available. | |
| 2) Undergraduate, graduate, and professional education, including degrees and years awarded; licensure including issuing state(s) and year(s) of issuance; | ||
| 3) Specialty and subspecialty board certifications; professional work experience; current institutional provider of care affiliations, including but not limited to hospital privileges, membership, and, if applicable, Fellow status in professional organizations; professional publications (texts and journals); professional presentations at conventions, conferences, and symposia; and any other information relevant to the reviewer's duties under this contract. | ||
| 4) For reviewers of mental health cases, a statement of the levels of care at which the reviewer has experience in treating patients, i.e., acute inpatient hospital, residential treatment center, substance abuse disorder facility, partial hospitalization, and/or outpatient care. | ||
| o. The contractor is advised that professional qualification statements, i.e., CVs as described above, are released to appealing parties in TRICARE hearings as part of the hearing record, to appealing parties upon request during or following formal reviews, and to requesters under the Freedom of Information Act. The contractor shall advise its reviewers of this. The professional qualification statements, therefore, shall not include the reviewer's social security number, home address, home telephone number, or marital or family information, or similar private information. | ||
| p. Where a peer review opinion includes citation to medical literature not already in the record provided to the peer reviewer, the contractor shall provide a copy of the medical literature article cited. The reviewer shall not make comments contrary to TRICARE policy. |
4. SUPERVISION AND MANAGEMENT OF CASE REVIEWS
| a. All tasks shall be implemented on the start date of the order. The contractor shall be responsible for: | |
| 1) Establishing and implementing the administrative procedures for conducting the review services. | |
| 2) Supervising the reviewers and the adequacy and appropriateness of the reviews. | |
| b. The contractor shall utilize reviewers who meet TRICARE standards for authorized provider status in their respective discipline as outlined in TPM Chapter 11, and 32 CFR 199.6. | |
| c. Upon specific request of TQMC COR, the contractor will provide reviewers and/or witnesses of exemplary credentials and national reputation to conduct review of difficult, unusual, or noteworthy cases. | |
| d. All documents required under this Attachment shall be provided on CD-RW or by electronic transmission protected to prevent unauthorized release of protected health information and/or Privacy Act information. All documents shall be supplied in a format that can be read, copied, and printed with the most current version of Microsoft Word. The contractor shall provide required signed transcription with or in the electronic media. (CDRL R090, External Reviews) |
5. INTERNAL REVIEWS
| a. Cases for internal review shall be reviewed by a reviewer on-site at DHA, in a conference setting; by telephone or video teleconferencing (VTC) in order to obtain real-time responses to questions put to the reviewer. OGC-AC will determine the medical specialty and subspecialty of the reviewer and the minimum number of cases to be reviewed per case conference session. | |
| b. Internal reviews shall be held within 14 days of the date the contractor is informed of the need for an internal review. | |
| c. DHA requires readily available medical experts to provide timely and expedient review, but because requests for internal reviews are expected to be infrequent, DHA cannot establish a regular schedule for internal reviews and cannot precisely predict the types of specialties required for frequency of internal reviews. | |
| d. Processing of Reviews. | |
| 1) The internal case reviewer(s) shall orally communicate answers to questions asked by the designated OGC-AC employee in charge of the case or his/her designee. The reviewer’s oral response shall answer the questions presented, provide underlying rationale for that answer, and cite the specific clinical documentation and other appeal file records that were relied upon to formulate the answer. | |
| 2) The internal case reviews shall be recorded to reflect all questions posed by the OGC-AC employee and reviewer’s responses. | |
| 3) The contractor shall transcribe its copy of the recording. The contractor shall submit the transcription to the reviewer for the reviewer’s approval and signature. Because time is of the essence in this task, the contractor shall forward the signed transcription to DHA so that DHA receives the transcription DHA within 7 days after the date the internal review was conducted. The transcription will distinguish between the questions asked by the OGC-AC employee in charge of the case and the reviewer’s responses. | |
| 4) The reviewer shall complete an analysis of the case based upon the records in the case file provided to the reviewer before or at the time of the case conference. In cases where the records are provided to the reviewer in advance, the review may require citation of medical literature researched by the reviewer in preparation for the review session. |
6. EXTERNAL CASE REVIEW
| a. OGC-AC will determine the type of case submitted to the contractor for external case review based on its complexity, volume of case documentation, and difficulty. These cases require review of the record and may require citation of medical literature researched by the reviewer in preparation for the review session. These cases do not require real-time conferences with OGC-AC staff. The reviewer shall not make any comments contrary to TRICARE policy. | |
| b. External case reviews shall be designated by OGC-AC as either urgent, or routine. Most reviews will be routine. | |
| c. Because time is of the essence, the reviewer(s) shall complete, and the contractor shall process, external review cases, as follows: | |
| 1) Urgent cases: Urgent cases shall be completed and a signed transcript delivered to DHA within 7 days following the date DHA sends the case to the contractor for review. | |
| 2) Routine cases: Routine cases shall be completed and a signed transcript delivered to DHA within 14 days following the date DHA sends the case to the contractor for review. |
7. WITNESS HEARING--PRE-HEARING PREPARATIONS, HEARING ATTENDANCE, POST-HEARING–-TRANSCRIPTION AND ATTENDANCE AT DHA CONFERENCES Ordering Process for Witness Appearances:
1. The OGC-AC attorney will submit basic information regarding the specific hearing to the TQMC COR. This information should include the name of the appealing party and other data such as the name of the witness (if a potential witness is requested by name), approximate dates, location, and the size and content of any files that will be sent to the expert witness. The COR will provide the same information to the contracting officer (CO) to prepare a notice of intent and request for the contractor’s estimate of hours required to provide services. If OGC-AC requests a specific expert witness, the hearing attorney shall include adequate justification for the individual in the documentation.
2. The CO’s notice of intent to order services will state the specifics of the anticipated hearing.
3. The contractor shall submit its estimate of hours at a fixed price rate based on the following:
a. Pre-Hearing Preparations: The contractor shall estimate hours based on the estimated number of hours required for telecommunications to identify and accept a hearing witness, to review the files, clarification and resolution of the expert witness’s questions relating to preparation for appearance at hearing.
b. Hearing Appearance: The contractor shall estimate hours based on the number of hours the expert witness will spend traveling to and from the hearing or DHA Conference location (currently hearings are held within the continental United States) and hearing appearance expenses based on an estimated number of hours the expert witness is in attendance at a hearing or attendance at DHA Conference(s).
c. Post hearing: The contractor shall perform tasks associated with the finalization of post hearing documentation and post hearing responses to questions posed by the Hearing Officer.
d. Transcription The services for a transcriptionist as needed and the delivery of a final transcript. The contractor shall provide required signed transcription with or in the electronic media. (CDRL R070, Internal Reviews)
4. The contractor shall also submit an estimate for the travel and lodging expense to and from the location where the hearing or DHA Conference will be held. Travel (Transportation, lodging, and per diem) required to attend a hearing shall be paid for in accordance with Section C, paragraph 9.
5. The contractor shall coordinate with the expert witness to determine the reliability of the estimated hours identified in the estimates. Based on the estimated hours and the estimate of travel, the CO will issue the task order.
6. The CO will issue an individual task order for each hearing case in accordance with the ordering clauses of the contract, Section B, Section C, and this attachment.
7. Once the task order is issued, the OGC-AC hearing attorney will forward the hearing files to the expert witness with a letter of transmittal and instruction with a copy of the letter to the contractor, the COR, and CO. The letter will include a shipping form and instructions for the return of the materials in the original shipping containers at the conclusion of the hearing. In lieu of return shipping, when shredding of file documents is permitted, the expert witness will coordinate with the OGC-AC hearing attorney and the contractor to shred the file documents at a mutually agreed upon location. The contractor shall notify the COR in writing after the file documents are shredded.
6. Whenever the contractor anticipates the incurred costs will exceed 75% of the not-to-exceed amount for a task order, the contractor shall immediately notify the CO in writing. The contractor shall provide an estimated cost to complete with an explanation of the need for additional funding. Under no circumstances shall the contractor continue to work under an order that has insufficient funding. If additional funding is justified, the CO will modify the task order.
7. Travel costs shall be in accordance with Section C, paragraph 9.0. The COR will coordinate with the OGC-AC attorney to verify that work under the order has been completed.
| a. Witness Hearing and Trial Attendance. The CO shall issue a task order for the contractor to perform this task. As required, the contractor shall provide reviewers to serve as witnesses in DHA administrative hearings, civil or criminal litigation, and/or related discovery for the purpose of providing review opinions either in the first instance or for explaining, clarifying, or elaborating upon previously expressed or written review opinions. | |
| 1) DHA will determine which specialty is required. The contractor shall provide a reviewer in the specialty area requested by DHA. The witness may be a reviewer who previously conducted an internal or external case review of the case. DHA, in its discretion, may request a witness who did not previously review the case in place of or in addition to any internal or external case reviewer who previously reviewed the case. The contractor shall provide DHA witness statement transcriptions within 7 days of the date the media are sent by DHA to the contractor (CDRL R070). The post mark will be deemed to be the date the media are sent. | |
| 2) The need for this task is entirely driven by the quantity of the requests for hearings, requests for discovery by TRICARE beneficiaries and providers of care, or TRICARE related litigation. The actual number of witnesses required under this task and the actual specialties required will depend on requests for hearing and for discovery filed with DHA, under 32 CFR 199.10, appeal and hearing procedures, or on the number of cases litigated in Federal Courts. | |
| b. Discovery by Parties Other than the Government. Title 32 CFR 199.10(d)(10)(ii) provides for discovery in TRICARE hearings, which may include discovery with TRICARE reviewers. DHA does not pay for such discovery efforts by appealing parties. | |
| 1)The COR shall provide the contractor with the written discovery order received from the TRICARE hearing officer assigned to the hearing. The contractor shall have procedures for negotiating with the requester for discovery, including provisions for compensation by the requester. The contractor shall not commence performance under discovery prior to the issuance of a written discovery order by the TRICARE Hearing Officer assigned to the Hearing in question. |
For discovery arising out of litigation in Federal Courts that is not to be reimbursed by the Government, the contractor shall be provided instructions for the case in question by the COR.
| c. DHA Conferences. When required, the contractor shall provide its representative or reviewer(s) to serve as speakers at DHA Conferences, such as DHA Hearing Officer Conferences. The contractor shall provide reviewers in the specialty areas requested by DHA. DHA may request one or more reviewers to attend a DHA Conference. The contractor's representative or reviewer(s) are expected to be able to discuss the review process. Conferences are held infrequently, i.e., not more than once a year or not less than once every 5 years. The cost to DHA shall be negotiated for each requirement. The CO will issue a task order for conference attendance. | ||
| TQMC HT9402-15-R-0005, Section J, Attachment J-6 | Page 1 of 4 |
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