3_Section_C_05-19-15.docx

SECTION C, DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

TRICARE Quality Monitoring Contract (TQMC) Performance Work Statement

1.0 GENERAL:

1.1 The Defense Health Agency (DHA) supports the delivery of integrated, affordable, and high quality health services in excess of 9 million beneficiaries of the Military Health System (MHS) and is responsible for shared services, functions, and activities of the MHS and other common clinical and business processes in support of the Military Services. The DHA oversees the TRICARE health plan, medical resources, and the National Capital Region (NCR), one of the six Enhanced Multi-Service Markets (eMSM).

1.1.1 The MHS is a complex integrated healthcare system that consists of healthcare delivery, medical education, public health, private sector partnerships and innovative medical research and development. The MHS has two major care delivery systems. The direct care system provides care through military treatment facilities (MTFs). The purchased care system provides care through private sector contractors including the three Managed Care Support Contracts (MCSCs); the six Designated Providers (DP) under the Uniformed Services Family Health Plan (USFHP); the TRICARE Overseas Program (TOP) contractor; the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC); TRICARE Dental Program (TDP); TRICARE Retiree Dental Program (TDP) and the TRICARE Pharmacy Program (Pharm) contractor.

1.1.1.1 All purchased-care contracts stated in paragraph 1.1.1 are applicable to this contract.

1.1.2 This contract meets the regulatory requirements of TRICARE’s Quality and Utilization Peer Review Organization Program, 32 Code of Federal Regulations (CFR), Section 199.15; and DOD Instruction and Manual 6025.13, Medical Quality Assurance and Clinical Quality Management in the Military Health System.

1.1.3 The purpose of this contract is to assist the Clinical Support Division (CSD) in assessing and improving the quality of care delivered under the TRICARE benefit across the direct and purchased care systems. This contract will assist DHA in decreasing unwarranted variation in the quality of medical care, implementing proven clinical and business practices, and creating an environment for learning and continuous improvement across the MHS. This contract will also support DHA with the management of clinical quality performance measurement to validate the quality of care.

1.1.3.1 TRICARE quality monitoring is accomplished through a variety of tasks supporting the direct care and purchased care systems. These tasks include external, third party data collection, analysis and reporting of clinical quality measures, and comparison with national healthcare benchmarks; reviewing, evaluating, and reporting on published clinical care studies, evolving practices, and other data to identify superior quality healthcare services and recommend means to transfer successes; and conducting comprehensive, timely medical peer reviews to ensure medically-appropriate healthcare is provided per 32 CFR 199.

1.2 Direct Care: Direct care is provided at military hospitals and military medical clinics worldwide. Oversight of these facilities is provided by each Military Service headquarters command. The scope of work for direct care includes the following:

1.2.1 Conducting clinical quality studies within the direct care system, which DHA identifies as having significant importance to the MHS mission and beneficiaries.

1.2.1.2 Collecting, submitting and presenting the National Hospital Quality Measures (NHQM) data for comparative analysis with healthcare organizations nationwide and to support the accreditation of Department of Defense (DOD) hospitals.

1.2.1.3 Collecting, analyzing and displaying MHS clinical quality measures data with nationally comparable benchmarks in support of the MHS Strategic Plan.

1.2.1.4 Conducting external reviews of MTF Standard of Care (SOC) cases.

1.3 Purchased Care: Purchased care is provided worldwide. The scope of work for purchased care includes the following:

1.3.1 Conducting clinical quality studies within the purchased care system, which DHA identifies as having significant importance to the MHS mission and beneficiaries.

1.3.2 Conducting reviews of medical, surgical and mental health cases to determine the medical necessity and appropriateness of care provided.

1.3.3 Assessing evolving practices, devices, medicines, treatments and procedures.

1.3.4 Certifying behavioral health facilities.

1.4 MHS Care: The scope of work applies to the entire MHS (both direct and purchased care systems) and includes the following:

1.4.1 Conducting clinical quality studies, which cross both systems of care which DHA, identifies as having significant importance to the MHS mission and beneficiaries.

1.4.2 Accessing, analyzing, and reporting health plan quality data for both systems of care for comparative analysis with national benchmarks.

1.4.3 Conducting monthly, interactive, web-based seminars focused on clinical quality topics that promote knowledge transfer and the sharing of best practices in healthcare quality and safety.

1.5 Objectives: The objectives of this contract are two fold: To support the MHS mission of greater integration of the direct and purchased care delivery systems, and to support the MHS’s Quadruple Aim of Readiness, Population Health, Experience of Care, and Control per Capita Cost.

1.5.1 The objectives below represent the expected performance outcomes for this contract and are supported by the technical requirements. The acceptable performance standards are explained further in the contract. Where specific performance standards are not stated, the contractor shall use healthcare industry best practices and standards.

1.5.2 The contract performance objectives are:

1.5.2.1 Provide timely and accurate independent and impartial evaluation of the healthcare provided to MHS beneficiaries to ensure quality of care, medical utilization and patient safety.

1.5.2.2 Provide timely, comprehensive reviews that are consistent with the TRICARE requirements to ensure that appropriate levels of healthcare are provided for all beneficiaries.

1.5.2.3 Measure, evaluate and compare clinical quality performance to national benchmarks to develop recommendations that transfer successes and identify superior quality healthcare services.

1.5.2.4 Support MHS initiatives for data transparency.

1.5.2.5 Use an effective management approach to provide the necessary services, incorporating healthcare best practices and standards when practicable.

2.0 DOCUMENTS: The following documents are hereby incorporated by reference and/or attached as part of the contract:

· DOD Instruction 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS), as revised

· DOD Manual 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS), as revised

· National Institute of Standards and Technology (NIST) Special Publication (SP) 800-53 (current revision) 800-53A (current revision)

· Presidential Executive Order 13410, August 28, 2006 (Section J, Attachment J-23)

· Health Affairs Policy Memorandum for MHS Care Quality Assurance Data Transparency, dated October 20, 2010 (Section J, Attachment J-24)

3.0 TRICARE MANUALS: The TRICARE Manuals apply to this contract as referenced in Section C, Section J Attachments, and in the DD Forms 1423-1, Contract Data Requirements List (CDRL). The contractor shall utilize the most up-to-date versions located at http://manuals.tricare.osd.mil.

3.1 ACRONYMS & ABBREVIATIONS, AND DEFINITIONS: Each TRICARE Manual (TOM, TPM, TRM and TSM) has an Appendix A, Acronyms and Abbreviations. Definitions are in the TOM, Appendix B.

4.0 GOVERNMENT FURNISHED INFORMATION (GFI): The contractor will obtain either paper or electronic copies of medical records or electronic access to medical records and data to meet specific requirements under this contract. The contractor shall use government provided laptop computers to access MTF electronic medical records either remotely or onsite for data abstraction. The process to access purchase care medical records is detailed in TOM Chapter 7, Section 3.

4.1 The contractor will obtain and complete all documentation required to obtain access to healthcare quality data contained in the MHS Population Health Portal (PHP). The MHS PHP is a secure, web-based tool managed by the Government, which contains administrative and clinical data for both the direct-care (MTFs) and purchased-care systems.

4.1.1 The COR will assist the contractor with obtaining all required documentation and access to the healthcare quality data contained in the MHS PHP.

4.1.2 TQMC staff who require access to data housed in the MHS Data Repository (MDR) or MHS Mart (M2) shall send an e-mail request for access to dhssaccess@tma.osd.mil.

5.0 CONTRACTOR FURNISHED ITEMS: Except as provided in paragraph 4.0 above, the contractor shall furnish all necessary labor, facilities, systems, equipment, and supplies, and other items as required for the satisfactory performance of this contract.

6.0 TECHNICAL REQUIREMENTS: These technical requirements represent specific tasks, outcomes, and/or standards to which the contractor shall perform in support of the above objectives.

6.1 Program Management:

6.1.1 The contractor shall designate a single point of contact (POC) to oversee the tasks of this contract, supervise staff assigned to the tasks, and ensure that the tasks of the contract are performed efficiently, accurately, on time, and in compliance with the requirements of this document. The POC shall provide the COR with ongoing status updates of the tasks and any issues relating to the contract.

6.1.2 The contractor shall ensure all personnel, to include subcontractors, are qualified to perform their assigned responsibilities in terms of credentials, education, training and experience, consistent with healthcare best practices and standards.

6.1.3 The contractor shall utilize a nationally recognized process for credentialing, and maintain current and accurate records for all healthcare reviewers under this contract consistent with healthcare best practices and standards and the TOM, Chapter 4.

6.1.3.1 The contractor shall conduct the credentials verification process when the reviewer is first considered for employment or contract, and at least every 3 years after the individual has assumed reviewer responsibilities. The contractor shall ensure that all credentialed personnel maintain the required qualifications and certifications while performing under this contract. Credentialing files shall be available for inspections and audit by the COR upon request.

6.1.4 The contractor shall obtain the services of actively practicing, board-certified, licensed doctors of medicine and osteopathy and doctors of dental medicine as necessary to perform the services of the contract. These professionals shall review services provided by the various MHS medical and dental specialties and subspecialties, as identified by the American Board of Medical Specialties, the Bureau of Osteopathic Specialists and the National Certifying Boards for Dental Specialties. “Actively practicing” means practicing a minimum of 20 hours per week.

6.1.5 Section J, Attachment J-18, TQMC Specialty Reviewer Types, provides historical information regarding specialty types utilized for reviews under this contract. The list is not all inclusive, and the Government may require other types of reviews. If a review requires a specialty not previously identified, the contractor may request a 30-day extension for the review to secure those specialty provider services.

6.1.6 The contractor shall provide actively practicing non-physician reviewers for all the provider types set forth in 32 CFR 199.6, TRICARE Authorized Providers.

6.1.7 The contractor shall have procedures and policies in place that shall ensure independent and objective reviews consistent with healthcare best practices and standards.

6.1.8 Program Management Plan: The contractor shall develop a Program Management Plan (PMP) (CDRL AP030). The PMP shall consist of control policies and procedures for project administration, execution and tracking consistent with program management best practices and standards.

6.1.8.1 The contractor shall notify the COR verbally and in writing of all key milestones and issues directly related to the scope of the contract should any significant performance issues arise. At a minimum, the contractor shall address the following in its PMP:

· All technical activities (including documentation development)

· An estimate of the timing, duration and level of effort (by labor category) for all performance elements

· A matrix of all personnel assigned to the program and total aggregate level of effort for each performance elements

· Project plan with a detailed schedule that identifies all tasks and key milestones

· Quality assurance processes and monitoring methods

· Risk management

· The contractor’s process for tracking the status of the deliverables

· The contractor’s Data Use Agreements, and personnel clearances to access DOD data systems (CDRL A020, NIST Certification of Compliance Report)

6.1.9 Monthly Progress Report (MPR): The contractor shall submit a MPR outlining the progress, status, any problems or issues encountered, and specific information on workload during the preceding month to substantiate the monthly invoice and services rendered in the previous month (CDRL M060, Monthly Progress Report).

6.1.10 Quality Management: The contractor shall establish and continuously operate an Internal Quality Management Program (IQMP) consistent with healthcare best practices and standards, which covers every aspect of the contractor’s operation to ensure control, accuracy, and timeliness, effective at the start of Option Year 1 and continuing through the life of the contract.

6.1.10.1 The contractor shall assess its compliance with its qualitative and quantitative standards, identify problems, and identify corrective actions planned or to be initiated. The IQMP plan (CDRL AP020, Internal Quality Management Program Plan) will detail all aspects of the contractor's quality program including the major components of the program, quality control activities, quality assurance functions, risk management, organizational responsibilities for quality management, and how identified quality problems will be monitored and resolved. The contractor shall submit a quarterly report detailing its compliance with these quality program elements as described in its IQMP Plan (CDRL Q080, Internal Quality Management Report).

6.1.11 Continuity of Operations Plan (COOP): The contractor shall prepare and submit a COOP to the Government (CDRL AP010, Continuity of Operations Plan). The COOP shall document contractor plans and procedures to maintain performance should an actual disaster be declared affecting normal operations.

6.1.11.1 The COOP shall be activated immediately after determining that a disaster has occurred, shall be operational within 12 hours of activation, and shall be sustainable until the disaster situation is resolved and normal conditions are restored or the contract is terminated, whichever comes first. When any disruption of normal, daily operations occur, the contractor and the Government shall promptly open an effective means of communication and verify:

· Key points of contact (Government and contractor)

· Temporary work locations (alternate office spaces, telework, virtual offices, etc.)

· Means of communication available under the circumstances (e.g. email, webmail, telephone, FAX, courier, etc.)

· Essential work products expected to continue performance by priority

6.1.11.2 The COR and contractor must make use of the resources and tools available to continue contracted functions to the maximum extent possible under disaster circumstances. Contractors shall obtain approval from the COR and CO prior to incurring costs exceeding those allowed under the terms of this contract.

6.1.12 Meeting Attendance: The CO may require the contractor to participate in other MHS meetings, such as contractor roundtables, annual conferences, or summits. The contractor may participate in these meetings by telephone conference call, video telephone conference (VTC), or if authorized, in person. If required, the CO may authorize the contractor to travel to attend a specific meeting in person.

6.1.13 To minimize travel costs, the contractor shall establish remote access to both inpatient and outpatient direct care medical records to the fullest extent practicable. Remote access is currently available for all outpatient records. The contractor shall make good faith efforts to obtain remote access to all MTFs. In instances where the contractor is unable to use remote access for an MTF’s medical records, the contractor shall travel to obtain access onsite. The majority of medical record access required is related to the Global Trigger Tool (GTT), the Joint Commission ORYX® Core Measures data collection, and the performance of quality improvement studies. At the majority of sites, the initiation of remote access will not involve travel. However, full implementation of remote inpatient medical record access may initially require the monthly on-site visits at a number projected to be fewer than seven sites. The GTT requires monthly data collection, while ORYX® data collection may require monthly or quarterly data collection, depending upon the volume of files required for abstraction. Despite remote access capabilities, quality improvement studies may require on-site visits for records abstraction if the required documents are not available in an electronic format.

6.2 Transition:

6.2.1 Transition-In: The contractor will have time critical tasks to perform during the transition-in prior to the first day of Option Year 1. The contractor may accomplish some of these tasks concurrently with others. However, there are certain tasks, which the contractor must accomplish and receive government approval before the contractor can proceed.

6.2.1.1 Transition-In Plan: The TQMC contractor shall submit a comprehensive Transition-In Plan to the COR following contract award (CDRL OT010, Transition-In Plan). The plan shall address all events and milestones that need to occur for each functional area described in this contract to enable the start of services under this contract. The plan will be used to manage, track and evaluate the contractor’s performance during transition. This plan shall clearly describe the contractor’s control policies and procedures for project administration, execution and tracking to ensure a seamless transition consistent with project management best practices and standards.

6.2.1.2 The contractor shall keep the COR informed on its progress during transition-in via a weekly report including key transition milestones and issues submitted in an electronic format and by a method (e.g., email, fax) agreed to by the COR (CDRL W010, Transition-In Weekly Report).

6.2.1.3 The contractor shall coordinate with the incumbent contractor to transfer website content and all active files including, but not limited to National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®), the JC ORYX®, behavioral health facility certification files.

6.2.2 Transition-Out:

6.2.2.1 Upon receipt of the contracting officer’s written notification, the contractor shall submit a Transition-Out Plan (CDRL OT020) for the COR’s review. The contractor and COR shall use the Transition-Out Plan to manage, track and evaluate the contractor’s transition-out performance consistent with the contract requirements.

6.2.2.2 The contractor shall complete all work assigned and all reconsideration appeal requests received during the option year to include all associated reports.

6.2.2.3 The contractor shall notify the COR of its progress during the transition-out phase via a weekly report (CDRL W020, Transition-Out Weekly Report).

6.2.2.4 For all active files the contractor shall organize the files and prepare a transmittal document detailing their status. The contractor shall package all data and documents to transfer any files that have not been completed as directed by the COR in accordance with Section H, paragraph 2.4, Records Management. The preferred method for transmission of all documents, files, and data is electronic, via CD/DVD or other secure means. Throughout the transition-out the contractor shall promptly and thoroughly answer in writing any questions from a successor or the COR within 5 business days after receipt.

6.2.2.5 The contractor shall participate in any transition-out meetings between the Government and the successor if any.

6.2.2.6 The contractor shall transition all remaining contract data back to the Government as directed by the COR.

6.3 Performance Measurement and Reporting:

6.3.1 Health Plan Clinical Quality Measures (Direct and Purchased Care):

6.3.1.1 The MHS Population Health Portal (MHS PHP) contains MHS clinical quality data for outpatient performance measurement. Each month the contractor shall download MHS PHP data and then analyze and report health plan clinical quality measure data for all MTFs and purchased care network providers (CDRL Q010, Health Plan Data Reporting). The Government currently uses selected NCQA HEDIS® measures. The DHA reserves the right to change its clinical quality measures as necessary to meet the MHS’s mission. The contractor shall identify the appropriate national comparable performance/benchmark for each measure, observed trends and opportunities for improvement.

6.3.1.2 The contractor shall post Health Plan Clinical Quality Measures data on the Government-designated secure website. The contractor shall grant access to this website as directed by the COR

6.3.1.3 In order to support MHS transparency initiatives, the contractor shall develop and maintain the functionality for posting MHS PHP data analysis and displays (i.e. statistical process control charts, bar graphs, line charts) by MTF, Military Service, Region, eMSM, DP and MHS level, onto the MHS Clinical Quality Management (CQM) website (see paragraph 6.8.3).

6.3.1.4 The contractor shall be, or retain the services of, an NCQA-certified vendor to perform an annual HEDIS® Compliance Audit of the MHS Population Health Portal of DHA selected HEDIS® measures (CDRL A010, Annual HEDIS® Compliance Audit).

6.3.2 NHQM (Direct and Purchased Care):

6.3.2.1 Centers for Medicare and Medicaid Services (CMS) Hospital Compare Measures:

6.3.2.1.1 Each quarter the contractor shall download NHQM data for all participating civilian facilities from the CMS Hospital Compare website, https://data.medicare.gov/data/hospital-compare.

6.3.2.1.2 Quarterly, the DHA will provide the contractor with a list of network facilities in each TRICARE region. The contractor will then identify whether each facility is a participating purchased care provider in order to analyze and compare facilities by any given region. (CDRL Q050, National Hospital Quality Measures Raw Data File).

6.3.2.1.3 Each quarter, the contractor shall download inpatient MTF NHQM data from the DHA-designated database to compare with purchased care and direct care hospital quality performance and national quality benchmarks.

6.3.2.1.4 There are additional NHQM data that are not currently in the DHA-designated database for inpatient MTFs. Therefore, the contractor shall conduct chart abstraction of inpatient MTF medical records to obtain data for any remaining Hospital Compare ‘Timely and Effective Care’ measures in order to compare with civilian network Hospital Compare quality performance and national quality benchmarks. The contractor may use the most cost effective means available to access each inpatient MTF’s medical data.

6.3.2.1.5 The contractor shall develop a quarterly report and briefing for presentation which includes a comparative analysis between DOD and CMS national performance rates for each quality measure complete with displays by MHS, direct care and by purchased care (CDRL Q060, National Hospital Quality Measure Reports).

6.3.2.1.6 The contractor shall provide all analyses to the COR and other authorized recipients via a secure website. The contractor shall also include graphical displays (i.e. statistical process control charts, bar graphs, line charts) stratified by MHS, direct care (inpatient MTFs, Military Service, eMSM, and purchased care (TRO, and DP)) (CDRL M010, Secure Web Portal).

6.3.2.1.7 The contractor shall submit inpatient MTF “Timely and Effective Care” measures data to CMS for inclusion in the Hospital Compare database.

6.3.3 Joint Commission ORYX® Hospital Quality Measures (Direct Care):

6.3.3.1 Each quarter the contractor shall abstract medical records to obtain, analyze, display and report the data for all approved Joint Commission ORYX® core measures (14 sets currently available) for all inpatient MTFs (CDRL Q020, ORYX® Data Reporting). The contractor shall use the most cost effective means available to access each inpatient MTF’s medical data.

6.3.3.1.1 To minimize travel costs, the contractor shall establish remote access to direct care medical records, both inpatient and outpatient, to the greatest extent practicable.

6.3.3.2 The contractor shall use the ORYX® methodology to identify the applicable patient population for each core measure and determine the appropriate data collection process. In addition, the contractor shall continue each quarter’s data collection for a subsequent quarter and submit any additional cases meeting the ORYX® methodology to the Joint Commission.

6.3.3.2.1 The contractor shall make the data available in the JC vendor website so users can drill down to the patient level. The contractor shall also provide data analysis with display (i.e. statistical process control charts, bar graphs, line charts) for each participating MTF, the Military Services/NCR, and MHS level. The contractor shall also provide data for national comparative benchmarks. The contractor shall note and share best practices across the MHS. For measures in which any MTF is significantly below national performance rates as identified in quarterly reports, the contractor will review the healthcare quality or other relevant literature to identify best practices and provide the information to CSD, Military Service representatives, and the inpatient MTFs.

6.3.3.3 Not later than 90 days after the JC’s release of new National Hospital Measure Sets, the contractor shall review and inform to the COR of the applicability to inpatient MTFs, the volume of patient records for the past year that would meet the specifications for the new measures, and the proposed data collection processes.

6.3.3.4 The contractor shall ensure the MTF-specific patient level data created from measure data collection and analysis are available to authorized users as determined by CSD and each Military Service’s quality leaders. There will be approximately 300 users authorized to access this ORYX® data.

6.3.3.5 The contractor shall prepare a quarterly report complete with presentation briefing which includes a comparative analysis between the Joint Commission national performance rates and benchmarks for each clinical performance measure. (CDRL Q020, ORYX® Data Reporting)

6.3.3.6 The contractor shall submit the MTFs’ ORYX® Core measure data according to Joint Commission criteria (CDRL Q030, ORYX® Data Submission) to support MTF JC accreditation. The contractor shall be, or retain the services of, a JC-certified vendor to submit the inpatient ORYX® data. If the contractor fails to submit ORYX® data on time, the Government shall assess the performance guarantee identified in Section H, paragraph 1.

6.3.3.7 Annually, the contractor shall coordinate with the inpatient MTFs and each Military Service’s quality leaders to select the JC ORYX® core measures for submission to the Joint Commission to ensure a successful transition to any new core measure sets.

6.3.4 Institute for Healthcare Improvement (IHI) GTT (Direct Care):

6.3.4.1 Using the IHI GTT and methodology to identify any triggers and resultant harms, to include the level of harm associated with the trigger analysis, the contractor shall randomly select and review 10 inpatient charts every 2 weeks from each inpatient MTF. Pursuant to contract and MTF requirements, the contractor may use its discretion to determine the most cost effective means available to access each inpatient MTF’s medical data.

6.3.4.2 If the COR determines access is limited to an MTF’s medical records, the contractor may alternatively review 20 charts once each month for that MTF. Information on the IHI GTT can be found at http://www.ihi.org/resources/Pages/IHIWhitePapers/IHIGlobalTriggerToolWhitePaper.aspx

6.3.4.3 The contractor shall utilize fully trained and experienced clinical personnel as defined in Section J, Attachment J-19, IHI Global Trigger Tool White Paper, to quickly and efficiently perform the chart reviews.

6.3.4.4 The contractor shall develop and provide each inpatient MTF with a monthly report of identified triggers and identified harms by trigger and category. In addition, the contractor shall submit a consolidated control chart of progress over time to include Adverse Events per 1,000 Patient Days; Adverse Events per 100 Admissions; and Percent of Admissions with an Adverse Event (CDRL M020, Global Trigger Tool-MTF Report).

6.3.4.5 The contractor shall provide a monthly report of GTT data for each Military Service and NCR Medical Directorate (MD) as well as for the direct-care system (Military Services and NCR-MD). The contractor will list individual data for each site and aggregate data by trigger and category. In addition, the contractor shall include a control charts listing of Adverse Events per 1,000 Patient Days; Adverse Events per 100 Admissions; and Percent of Admissions with an Adverse Event (CDRL M030, Global Trigger Tool – Service, DHA and System Level Reporting).

6.3.4.6 Beginning Option Year 1, the contractor shall conduct a monthly teleconference with each inpatient MTF (approximately 54 per month) to review its data, and offer the MTF the opportunity to ask questions about their data and receive education regarding the GTT and what their data shows. For Option Year 2, the contractor shall conduct quarterly teleconferences (approximately 54 per quarter) with the inpatient MTFs. For Option Year 3 and beyond, the contractor shall conduct teleconferences on an as-needed basis in coordination with each inpatient MTF. The contractor shall develop a monthly “Frequently asked Questions (FAQ)” report based upon the outcomes of these teleconferences (CDRL M040, Global Trigger Tool-FAQ Report).

6.4 Behavioral Health Facility Certification (Purchased Care):

6.4.1 The contractor shall determine whether network Residential Treatment Centers (RTC), freestanding Substance Use Disorder Rehabilitation Facilities (SUDRF) and freestanding Psychiatric Partial Hospitalization Programs (PHP) meet TRICARE requirements for authorized provider status in accordance with the provisions of 32 CFR 199.6; TOM Chapter 4, and the TPM Chapter 11. The contractor will review each facility’s initial certification or recertification application and recommend approval or disapproval to DHA. The contractor shall maintain a current listing of available mental health facilities (Section J, Attachment J-11, Behavioral Health Facility List) and provide this list monthly to the COR (CDRL M050, Behavioral Health Facility Certification List).

6.4.1.1 After receiving the facility’s initial application, the contractor shall calculate the facility’s initial reimbursement rates for RTCs, using the methodology in the TRM, Chapter 7. The contractor will note this rate on the facility’s TRICARE participation agreement in accordance with Section J, Attachment J-7, Behavioral Health Facility Certification.

6.4.1.2 The contractor shall conduct reconsiderations of denials for facility initial certifications or re-certifications in accordance with Section J, Attachment J-7, Behavioral Health Facility Certification.

6.4.1.3 The contractor shall provide the technical and professional expertise to perform and report its on-site review of behavioral health facilities (CDRL R030, Assessment Reports of Behavioral Health Facilities). The contractor shall evaluate the qualifications and capabilities of designated facilities to provide specialized behavioral health treatment that complies with 32 CFR 199.6 and TPM, Chapter 11, Addendum H. The COR will determine which facilities the contractor will visit based on the processed applications, utilization and customer complaints or comments regarding facilities. Most reviews will be unannounced. Based upon its findings, the contractor will recommend to DHA whether to certify or decertify the facility. If the results indicate an imminent threat to beneficiary safety, the contractor shall notify the COR as soon as possible, however no later than the next business day.

6.4.1.4 The contractor shall provide an on-site review team composed of the appropriate professional expertise to meet the facility review requirements. The team members shall meet the qualifications for their respective provider type, consistent with 32 CFR 199.6. The Government shall review the composition of the team for each site visit. DHA anticipates each review will require 2 days on-site.

6.5 Medical Reviews: The contractor shall perform the following types of medical reviews:

· Medical Necessity Reconsideration Reviews

· Appeals and Hearings Internal and External Reviews

· Transition Assistance Management Program (TAMP) Benefit Extension Second-Level Reviews

· Standard of Care Reviews

· Quality of Care (QOC) Reviews

If the contractor fails to submit a review on time, the Government shall assess the performance guarantee identified in Section H, paragraph 1.

6.5.1 Quality and Utilization Reviews (Purchased Care): The following applies to all purchased-care inpatient medical record reviews. The contractor shall request medical records from the appropriate purchased-care contractor in accordance with TOM Chapter 7, Section 3. The contractor shall review each purchased-care inpatient medical record in accordance with 32 CFR 199.15 as follows:

6.5.1.1 The contractor shall review medical, surgical, and mental health cases to determine the medical necessity and appropriateness of care. To carry out this review, the contractor shall use generally accepted healthcare standards, norms and criteria for medical necessity appropriateness. The contractor shall identify cases of potential inappropriate medical care and potential preventable care and admissions that are not a TRICARE benefit. The contractor shall complete all case reviews within 30 days of receipt of the medical record from the purchased care contractor.

6.5.1.2 For each case reviewed, the contractor shall determine whether the respective purchased-care contractor performed pre-authorizations and retrospective and prepayment review consistent with TOM, Chapters 7 and 13.

6.5.1.3 The contractor shall report potential cases of fraud and abuse, consistent with 32 CFR 199.9. Potential cases of fraud and abuse shall be referred to the DHA Program Integrity Office, in accordance with TOM, Chapter 13.

6.5.1.4 If the case reviewed is covered by the Diagnostic Related Group (DRG) payment system or the Skilled Nursing Facility (SNF) Prospective Payment System, the contractor shall review the medical record to determine if the diagnostic and procedural information match the discharge status per TRM, Chapter 8, Section 2.

6.5.1.5 The contractor shall apply appropriate quality screens and medical judgment to identify potential quality issues consistent with healthcare best practices and standards. These quality reviews shall utilize both process and outcome measures that focus on deficiencies in the delivery of healthcare that result in an adverse effect on the patient. For example, if reviewing potential adverse drug events, the contractor will use healthcare best practice tools, such as the Institute for Healthcare Improvement (IHI) Adverse Drug Event Trigger Tool, Agency for Healthcare Research and Quality (AHRQ) tools or others as identified in the contractor’s IQMP Plan (CDRL AP020, Internal Quality Management Program (IQMP) Plan). If the contractor changes its quality review process or tools, the COR shall review these changes prior to contractor’s implementation.

6.5.1.6 When the contractor reviews a purchased-care medical record in accordance with Section C, paragraph 6.5.1.1, and the contractor identifies a potential quality issue, the contractor shall perform peer review, which is the assessment of the quality of medical care carried out by a healthcare professional, including any such assessment of professional performance. The contractor shall complete its peer reviews in accordance with healthcare best practices and standards. The contractor shall retain the services of a board-certified licensed physician, who is actively practicing in the clinical area being reviewed, to confirm potential quality issues, utilization concerns, inappropriate medical care or preventable admissions. The contractor shall complete the peer review within 45 days after receiving the purchased-care medical record.

6.5.1.7 At least 30 days prior to the start of each option year, the contractor shall obtain the TRICARE DRG Grouper software, developed by Health Information Systems, 3M Health Care and the Resident Assessment Validation and Entry (RAVEN) system, products by the Centers for Medicare and Medicaid Services (CMS).

6.5.1.8 A data dictionary for the DP cases is provided at Section J, Attachment J-4, M2 Data Dictionary. Additionally, the data fields from TRICARE Encounter Data (TEDs) for the MCSC cases are provided at Section J, Attachment J-3, MDR Data Dictionary.

6.5.1.9 Quarterly, the contractor shall provide its analysis of each purchased-care contractor’s quality issues, utilization concerns, coding irregularities, suspected fraud and abuse, inappropriate medical care, preventable admissions, and care that is not a TRICARE benefit to the respective purchase-care contractor. This analysis shall be of sufficient detail that the respective purchased care contractor is able to understand the concerns and respond to the findings. The purchased-care contractor shall have an opportunity to review the issues identified and must respond in writing to issues within 45 calendar days of this report per TOM Chapter 7, Section 3.

6.5.1.10 The contractor shall track and report the purchased-care contractors’ performance regarding the submittal of requested medical records to the reviewer and each purchased- care contractor’s responses to the issues (TOM Chapter 7, Section 3). (CDRL Q070, Purchased-Care Contractor Performance Report).

6.5.2 Medical Necessity Reconsideration Reviews (Second Level Appeals) (Direct and Purchased Care):

6.5.2.1 The contractor shall conduct medical necessity reconsideration reviews and issue decisions per TOM Chapters 12 and 24. These reviews and decisions shall be in accordance with the waiver of liability provisions in TPM Chapter 1, Section 4.1 These reviews shall include medical necessity appeals from the purchased care contractors identified in paragraph 1.1.1, and MTFs (including those from ADSMs). (CDRL R020, Medical Necessity Reconsideration Reviews (Second Level Appeals)).

6.5.2.2 The contractor shall process medical necessity pharmacy appeals in accordance with TOM Chapter 12, Sections 3 and 4.

6.5.2.3 For reviews of care provided at locations outside the continental US (OCONUS), the contractor shall consider the standard of care available in the location when providing medical necessity reconsiderations and second level appeals per TOM Chapter 24. The contractor is not responsible for translation of medical records in support of the appeals process.

6.5.3 Appeals & Hearings Internal and External Reviews and Hearing Support (Direct and Purchased Care): The contractor shall conduct internal and external case reviews to assist the Office of General Counsel (OGC) Appeals and Hearings in accordance with Section J, Attachment J-6, Appeals & Hearings Internal and External Reviews and Hearing Support (CDRLs R070, Internal Reviews and R090, External Reviews). The contractor shall also provide pre- and post-hearing support, including transcription pursuant to paragraph 7.0 in Section J, Attachment J-6; and Section G, paragraph 3.3.2.

6.5.4 Transition Assistance Management Program (TAMP) Reviews: When completing medical reviews for a former service member enrolled in the TRICARE TAMP, the contractor shall provide a board-certified licensed physician in the appropriate medical specialty for the beneficiary’s medical condition. The physician will determine if the medical condition can be fully resolved in an extra 180-day period of coverage under TAMP per TOM Chapter 17, Section 3, paragraph 2.5.

6.5.5 SOC Reviews (CDRL R010, Standard of Care/Quality of Care Reviews): Direct care SOC reviews are external reviews of MTF cases in which the Military Service initially determined an adverse event was not the result of any MTF practitioner’s failure to meet the standard of care in effect when the event occurred. At the request of the Military Services’ Risk Management Offices, the contractor shall conduct external reviews of paid malpractice claim cases in which the Military Service’s preliminary determination is that the malpractice payment was not caused by failure of any practitioner to meet the standard of care. The contractor shall complete SOCs reviews in accordance with DOD Manual, 6025.13, Enclosure 9, Section 2. The contractor shall complete the SOC review within 30 days of receipt of the record from the respective Service. A 15-day extension may be requested if needed documentation is missing or the contractor lacks a particular specialty reviewer not identified previously to the contractor.

6.5.5.1 When the case involves a physician, the contractor shall provide a board-certified licensed physician peer reviewer with an active clinical practice in the same specialty as the physician whose care is being reviewed.

6.5.5.2 If the case involves a non-physician provider, the contractor shall provide a practitioner peer reviewer with an active clinical practice in the same specialty as the provider whose care is being reviewed.

6.5.5.3 Any peer reviewer shall limit his/her determination to his/her specialty or area of qualification. The Government shall not require the contractor’s peer reviewer(s) to testify.

6.5.5.4 When a case involves more than one specialty, the contractor shall prepare a separate report for each specialty. Each specialty report is considered a separate review.

6.5.5.5 Although the Feres Doctrine (Feres v. United States, 340 U.S. 135 (1950)) precludes payments for malpractice allegedly committed on ADSMs, each Military Service reviews unexpected injuries or adverse patient outcomes in ADSMs for SOC determinations, including those cases that result in the payment of a disability claim or death benefit. The contractor shall complete these SOC reviews in the same manner as those involving paid malpractice claims.

6.5.6 QOC Reviews (CDRL R010 Standard of Care/Quality of Care Reviews) (Direct and Purchased Care): A quality of care review is done when DHA identifies a quality concern regarding care provided within the MHS. The contractor shall conduct these reviews in the same manner as SOC reviews when directed by the COR.

6.5.6.1 The contractor shall treat all information involved in the standard of care and quality of care review process as quality assurance information which is confidential, non-releasable, and protected in accordance with TOM Chapter 7, Section 1, Paragraph 12.0; and DOD M 6025.13, Enclosure 2.

6.6 Quality Improvement Studies:

6.6.1 Clinical Quality Improvement Studies (Direct and Purchased Care):

A quality improvement study is an assessment of a patient care problem for the purpose of improving patient care through peer analysis, intervention, resolution of the problem, and follow-up. The focus of the studies is to improve MHS performance and not the development of generalizable knowledge. Studies may be specific to direct care, purchased care or the entire MHS. Clinical Quality Studies may be performed using data obtained via administrative means utilizing DHA databases and/or medical record abstraction (See Section J, Attachment J-5, Clinical Quality Improvement Study Examples).

6.6.1.1 The contractor shall propose at least twelve quality improvement study topics per option year for DHA’s consideration based on a thorough review and analysis of information gathered from the Government and purchased care contractors. The contractor may also recommend study topics based on current trends in the healthcare industry, findings from previous MHS quality improvement studies, or the results of outcome measures from MHS data. The contractor shall also recommend study topics for the purpose of evaluating the quality of care provided across the entire MHS as an integrated healthcare system.

6.6.1.2 Any purchased care inpatient medical record reviewed during the course of performing a clinical quality improvement study shall follow the requirements of 32 CFR 199.15, as stated in Section C, paragraph 6.5.1.

6.6.1.3 The COR will notify the contractor of the approved study topics for the contractor to perform each clinical quality improvement study. The contractor will collect, measure, synthesize, analyze, report findings and formulate recommendations based on prevailing healthcare standards and evidence-based practices. Pursuant to contract and MTF requirements, regarding access to medical records, the contractor may use its discretion to determine the most cost effective means available to access each inpatient MTF’s medical data. The contractor shall produce a study report comparable to the quality of performance improvement studies presented in professional medical healthcare literature (CDRL R050, Quality Improvement Studies).

6.6.1.4 For all purchased care medical records reviewed in the performance of a quality improvement study, the contractor shall apply appropriate quality screens and medical judgment to identify potential quality issues. These quality reviews shall utilize both process and outcome measures that focus on deficiencies in the delivery of healthcare that result in adverse effects on the patient. For example, the contractor shall review medical records for potential adverse drug events using industry best practice tools, such as the Institute for Healthcare Improvement (IHI) Adverse Drug Event Trigger Tool, and Agency for Healthcare Research and Quality (AHRQ) tools.

6.6.1.5 The contractor’s clinical quality improvement studies shall collect, measure, synthesize, analyze, report findings and formulate recommendations based on prevailing healthcare standards and evidence based practices, with the goal to improve healthcare and reduce variation in the MHS. The contractor shall conduct and present these studies in a manner which is comparable in rigor to those presented in professional medical or quality improvement journals. The contractor will select studies for consideration based on a thorough review and analysis of information gathered from the Government, current trends in the healthcare industry with reference to their application to the MHS, and the findings of past MHS studies/ outcome measures.

6.6.1.6 The contractor shall develop the methodology for the quality improvement studies which requires the application of bio-statistical and epidemiological processes to determine sample size, accurate data collection techniques, scientifically sound analytical processes, appropriate sample stratification procedures, association of patient risk factors (risk adjustment when required), and identifying where processes of care impact significantly on variations in outcomes. Methods used by the contractor for comparing data elements and calculating metrics shall be aligned with national benchmark performance measures and current MHS established measures. Prior to presenting the study methodology to the Government, a review by a physician with expertise in clinical performance review and study methodology development and implementation shall be conducted. The study methodology design and documentation must be of the same caliber as for those published in the professional healthcare and clinical quality literature.

6.6.1.7 Data collection based on the best-approved methodology will include administrative (electronic) file, survey, and manual medical record abstraction (paper or automated files). The contractor shall implement appropriate processes to obtain access to DOD healthcare information. The contractor shall consider medical record availability to abstract data for performance review when estimating the number of records that must be pulled for performance measure samples. The contractor shall maximize the use of remote data abstraction capabilities. If remote access is not possible, the contractor shall abstract MTF medical records for studies on-site and shall not request MTF staff to abstract, copy, or forward medical records on its behalf. Per Section C, paragraph 6.5.1, the contractor shall review all purchased-care inpatient medical records abstracted in the course of completing a clinical quality study for the quality, completeness and adequacy of care provided, as well as its necessity, appropriateness and reasonableness.

6.6.1.8 The contractor shall develop effective methods for the translation of study knowledge into practice. At a minimum, the contractor shall prepare a fact sheet and an electronic educational presentation.