Medical Management

Peer Review Organization Agreement

In the TRICARE West Region, TriWest has peer review authority over health care services provided in network and non-network civilian facilities. Facilities must establish a Peer Review Organization (PRO) Agreement with TriWest in accordance with 32 Code of Federal Regulations and TRICARE Operations Manual (TOM) to participate in our network. The PRO agreement is separate from a network contract. Both network and non-network facilities are required to sign a PRO, acknowledging that TriWest is the PRO for the TRICARE West Region.

If a corporation has multiple facilities, one signed agreement may cover all the facilities.

By signing the agreement providers confirm that they will cooperate with TriWest and our subcontractors by:

• Providing copies of medical records timely
• Providing accurate information on beneficiaries’ conditions
• Informing beneficiaries of their rights and responsibilities
• Providing other assistance that may be required for TriWest to conduct comprehensive utilization and quality management programs for care of MHS beneficiaries who are facility patients

Emergency Admission

TRICARE providers must notify TriWest of an emergency room inpatient admission and discharge date within 24 hours or by the next business day following admission and discharge. Facilities can submit the admission notification by visiting the Emergency Inpatient Notification profile in Availity online.

Facilities must note the following items on the hospital admission request:

• Beneficiary demographic information including sponsor’s Social Security number (SSN) or DOD Benefits Number
• Health plan information
• Admitting physician’s name
• Admitting diagnosis and date

TriWest reviews admission information and authorizes continued care, if necessary.

Inpatient Notification Process

TriWest requires notification of all inpatient facility admissions and discharge dates by the next business day following the admission and discharge. We also conduct continued stay reviews for many services.

TriWest will send the medical facility an authorization number after we receive clinical information and the discharge date and we will request clinical records, as necessary. Clinical records should be submitted online before the beneficiary is discharged. This ensures that MTFs have insight into care being delivered.

Concurrent Review

Concurrent review ensures appropriate, efficient, and effective utilization of medical resources by evaluating continued inpatient stays. TriWest performs concurrent reviews to determine medical necessity, quality of care and appropriateness of the level of care being provided as well as the setting in which the treatment is being rendered or proposed. It applies to all levels of inpatient care and partial hospitalization programs. If an admission or an extended stay does not meet the required clinical criteria, TriWest will send a request to the medical director or peer review panel for further review.

When approving inpatient medical/surgical admissions, the number of days is assigned and the last covered date is set. If a beneficiary requires additional time in the facility and the facility does not request an extension by submitting necessary clinical information, a provider penalty is applied to the additional days.

When prospective review (pre-authorization) is initiated, TriWest will secure the necessary medical information to support the medical, surgical, or behavioral health care services. Utilization Management staff will perform a medical necessity and appropriateness of setting and treatment review with each concurrent review, utilizing InterQual^® Level of Care Criteria or specific policy key criteria that incorporates specific TRICARE requirements. A TriWest medical management representative may contact the hospital at the time of admission notification to obtain initial clinical information and to discuss discharge planning needs. TriWest may make subsequent contacts to discuss goals for length of stay and/or confirm discharge.

Before or during discharge, facilities must arrange an aftercare appointment to occur within 7-10 days if the beneficiary is not being discharged to another facility. The facility must include this information with the final discharge information transmitted to TriWest.

Discharge Planning

TriWest initiates discharge planning for all admissions during the case’s first review. Discharge planning begins upon admission review and continues throughout the beneficiary’s stay. The intensity of services change when a beneficiary’s illness decreases in severity and/or begins to stabilize. If care can be delivered in a less emergency-oriented setting, TriWest’s medical management staff coordinates efforts with the physician directing the care (and the beneficiary and family members) to facilitate timely and appropriate discharge. These activities include:

• Arranging for services such as home health and DME needed after discharge
• Coordinating transfers to lower levels of care to minimize inappropriate use of hospital resources

Care Coordination

TriWest’s Care Coordination Program is part of whole person clinical care support structure with its primary role to assist with:

• Discharge planning, including assessment of the need for in-home case management visits, and coordinating the visits with network community case management resources
• Coordinating facility transfers
• Coordination of intraregional and interregional transition of care
• Assisting beneficiaries in their understanding on how to utilize, access, and navigate their TRICARE benefits
• Overseeing hospice benefit and requests
• Assisting with provider communication and collaboration when multiple providers are engaged in the care

Program participation for Care Coordination should be less than 60 days. TriWest will transfer the case to a Case Manager for longer term support if the complexity or the need is identified.

Providers can make referrals for Care Coordination through online referral management system on Availity. Availity allows providers to see their referral status as well as the completed care plan once the beneficiary has agreed to participate. Care Coordination staff will reach out to providers for support as clinically indicated to ensure optimal outcomes and continuation of care for the beneficiary. Contact is multi-modal and will be made by phone, email, fax, etc., depending on the need.

Case Management

TriWest’s Case Management program coordinates all aspects of medical and behavioral health treatment for at-risk beneficiaries who require extensive, complex, and/or costly services. TriWest case managers manage treatment by coordinating MTFs and TRICARE regional resources to provide high quality, cost-effective services targeted to address the beneficiaries’ unique physical and behavioral health needs. TriWest case managers are nurses, licensed clinical social workers, or other health professionals that acts as a patient advocate, coordinating the beneficiary’s health care between the MTF, PCM, specialists, and other health care providers.

Providers can refer beneficiaries who may benefit from case management for an evaluation to TriWest using the online referral management system on Availity. Availity allows providers to see their referral status as well as the completed care plan once the beneficiary has agreed to participate. Case Management staff will reach out to providers for support as clinically indicated to ensure optimal outcomes and continuation of care for the beneficiary. Contact is multi-modal and will be made by phone, email, fax, etc., depending on the need.

Our case managers offer TRICARE beneficiaries and their families support in a personalized way throughout their health care experience. They also are equipped to identify relevant local, county, state and federal level resources to meet the beneficiary’s needs in a quality and cost-effective manner. Case managers may consult with the beneficiary’s providers regarding treatment plans.

Case Management staff have access to both clinical and non-clinical subject matter experts within our Disease Management team, supporting a multidisciplinary approach to address the unique needs of each beneficiary. This support includes:

• Access to findhelp.org for social determinant of health (SDoH) support.
• Health coaches with expertise in respiratory therapy.
• Dieticians, pharmacy, and counselor support.

Case Management staff can consult with these staff and/or coordinate interactions for the beneficiaries where indicated. Case Management staff also coordinate with community providers and MTF staff to facilitate a whole-person approach to care management.

In-Home Case Management Coordination

TriWest will provide in-home case management coordination for identified high-risk beneficiaries. During discharge planning, TriWest will partner with the hospital discharge planning team so that beneficiaries may be screened and assessed for the need for an in-home case management visit. TriWest uses a scoring tool to assess needs that drive a variety of interactions for the beneficiary and their family. TriWest will manage all notifications and act as a liaison to identify urgency and proper utilization of services needed to ensure successful transitions of care and help avoid readmissions. In-home visits will be scheduled within 48-72 hours of discharge.

Population Health Management

TriWest’s Population Health management approach is to prevent, manage, and incorporate wellness measures for health optimization and disease management. To do this, TriWest provides support to beneficiaries through an integration of secure portals, online tools, and interactive programs developed to create greater autonomy for beneficiaries as they become more fluent in managing their own care needs and more confident in their treatment-seeking behaviors. TriWest offers several digital and interactive programs to support health and wellness, including:

• Wellness and Healthy Lifestyle Education
  • TriWest mobile app
  • Portal education and resources
• Targeted messaging
  • Wellness care for children and adults
  • HEDIS gaps in care
  • Cancer Screenings
  • Chronic disease support
  • Behavioral health challenges
• Disease management programs
  • Anxiety, Asthma, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Coronary Artery Disease/Post-Myocardial Infarction, COVID Long Haulers Depression, Diabetes, Post-Traumatic Stress Disorder (PTSD)
  • Smoking and vaping cessation

Wellness and Healthy Lifestyle Education

TriWest provides a variety of health and wellness information to support our beneficiary’s health journey as well as a mobile app option.

Targeted Messaging

Using data analytics and beneficiary program encounters, our targeted messaging will send personalized messages to our beneficiaries regarding:

• Gaps in care (e.g., HEDIS, cancer screening and absent wellness visits or immunizations) and how to close them
• Upcoming routine health care services that are age and gender appropriate
• Opportunities for engaging in our clinical support programs
• General seasonal or wellness information

The messages will be sent utilizing beneficiary preferences for mail, email, text, and portal options.

Disease Management Programs

TriWest Disease Management programs are designed to improve the health of beneficiaries with newly identified diseases, or those that may be struggling with chronic conditions. TriWest has established programs for the following conditions:

• Anxiety
• Asthma
• Coronary artery disease with new myocardial infarctions
• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure (CHF)
• Long-haul Coronavirus (COVID)
• Depression
• Diabetes

Beneficiaries that engage in our programs are provided education and resources to improve their health outcomes in collaboration with the providers.

Referrals for disease management can be made via the online referral management system on Availity.

Retrospective Review

TriWest clinical staff collaborates with network claims processor PGBA when claims are submitted without a required authorization and require medical necessity review. Clinicians will obtain and utilize appropriate clinical criteria to confirm whether the care met clinical standards. This information is communicated to PGBA so that claims can be processed appropriately.

The clinical staff also support real-time and retrospective review of unlisted codes. Information is reviewed to determine if the unlisted code is appropriate to utilize, pricing meets TRICARE reimbursement requirements, or if another code is more appropriate for submission.

TriWest completes retrospective reviews on a statistical sample of paid claims as required by TRICARE program requirements on a quarterly basis. These reviews are completed to ensure documentation in the beneficiary’s medical record support reimbursed services. Although retrospective reviews may be performed on any service, they are typically focused on:

• Diagnosis-related group (DRG) reimbursement
• Home health services
• Hospice services
• Other specified topics as identified by TRICARE

When reviewing claims as part of a retrospective review, TriWest requests medical records from the billing and/or rendering provider. Medical records are reviewed to:

• Assess the accuracy of information provided during the prospective review process
• Determine the medical or psychological necessity and quality of care provided
• Validate the review determinations made by the utilization review staff
• Determine whether the diagnostic and procedural information and/or discharge status of the beneficiary matches the description of care and services documented in the medical record

TRICARE requires providers to comply with the request for records. Failure to do so could result in the recoupment of payment for the services rendered.

TriWest will initiate the following for all cases that are selected for focused retrospective review:

Additionally, TRICARE policy requires that every beneficiary admitted to a hospital receive and sign a copy of the An Important Message from TRICARE form, detailing the beneficiary’s rights concerning coverage and payment of hospital stays and post-hospital services. The form discusses the Notice of Non-Coverage typically used by hospitals to inform beneficiaries when their health insurance will no longer pay for hospital care. The signed document must be kept in the beneficiary’s file and a new document must be provided for each admission.

Under the rules of the TRICARE Hold Harmless Policy, providers cannot bill TRICARE beneficiaries for non-covered services unless the beneficiary agrees in advance and in writing to pay for such services. Providers must have beneficiaries complete a Request for Non-Covered Services waiver if the beneficiary does not agree to be discharged from the hospital. If the beneficiary signs the form within the stated time frames, they will be responsible for the charges, otherwise, the hospital will be responsible for the beneficiary’s charges.

Clinical Quality Management

TriWest’s clinical quality management (CQM) program monitors quality of care and services rendered to TRICARE beneficiaries throughout the health care delivery system. The CQM program’s goal is to create demonstrable quality improvement in the quality and value of health care provided to beneficiaries. To do this, TriWest’s CQM program was developed to:

• Support with credentialing and provider quality activities, such as developing and implementing provider global and/or targeted education for suicide risk, mandated Autism Care Demonstration (ACD) program, and audits
• Support quality evaluations utilized in credentialing and clinical operations provider search selection
• Identify high-quality providers for the TriWest provider network
• Communicate expectations to network providers to ensure participation in the clinical quality process including but not limited to submission of requested records and completion of Corrective Action Plans.

To maintain high-quality options for our beneficiaries’ care, TriWest’s CQM utilizes data and analytics to measure provider and facility adherence to evidenced-based guidelines, and identify over- and under-utilization, identify gaps in care to provide an overall quality scoring methodology. These outcomes are provided to the Credentialing Committee and also used in our provider directory as a High Performing Provider (HPP) indicator.

The following committees are instrumental in ensuring high quality provider performance:

• Clinical Quality Management Committee (CQMC)
  • Reviews provider performance data and identifies and pursues collegial opportunities to improve the quality of clinical care provided to TRICARE beneficiaries and reviews timely access to quality care throughout the TRICARE West Region
  • Reviews reports on provider credentialing, grievances, clinical operations, patient safety, TRICARE Quality Monitoring Contractor (TQMC) findings, TQMC recommendations, quality projects, and staff audits
  • Adheres to the National Quality Forum (NQF) goals and monitors compliance with URAC guidelines for managing quality
  • Reviews health plan measures progress against corresponding benchmarks
  • Makes recommendations on reported findings
  • Approves quality studies to become Quality Improvement Projects (QIPs)
  • Receives CQMP Annual Plan and CQMP Annual reports that have been submitted to DHA for approval
• Credentialing Committee
  • Ensures that all TriWest direct contracted practitioners, including corporate and institutional providers, have the appropriate education, training, licensure, experience, and malpractice as required by TRICARE and URAC
  • Has authority to approves or deny any practitioner who does not meet TRICARE or URAC standards
  • Incorporates TriWest CQM’s quality scoring methodology derived from provider performance data, complaints and grievances into decisions to credential or re-credential providers
  • Receives and reviews credentialing audits for delegated contracting processed by TriWest’s network subcontractors
  • Communicates with the peer review committees to identify providers and facilities with quality of care issues, Corrective Action Plans (CAPs), and other findings and incorporate that information in decisions to credential or re-credential providers
• Adverse Action Subcommittee (AASC)
  • Acts as a quick response team to intervene rapidly with providers where beneficiary safety concerns or financial fraud are alleged
  • Triages urgent provider issues such as licensure, clinical and administrative quality concerns, civil and criminal matters and requests for removal from the network
  • Responds to urgent provider related concerns and makes recommendations to the Credentialing Committee regarding provider actions
• TRICARE Peer Review Committees – Behavioral Health (TPRC-BH)
  • Direct TriWest’s multi-functional PRO responsibilities for BH
  • Serve as the PRO that reviews individual provider and facility quality of care issues
  • In conjunction with TRICARE Peer Review Committee – Medical/Surgical (TPRC-MS), serves as the highest level of peer review within TriWest
  • Monitors trends
  • Recommends and reviews Corrective Action Plans (CAPs) and evaluates results of CAPs
  • Reviews provider PRO appeals
  • Recommends sanctions of network and non-network providers when warranted
  • Reviews sentinel events and makes the final determination on the severity level of individual quality of care issues
  • Communicates peer review outcomes (e.g., providers and facilities with quality of care issues, CAPs, and other findings) with the Credentialing Committee so they can incorporate that information in decisions to credential or re-credential providers
  • Collaborates with external peer reviewers when the expertise needed to review the case does not exist internally
• TRICARE Peer Review Committee – Medical/Surgical (TPRC-MS)
  • Direct TriWest’s multi-functional PRO responsibilities for medical care
  • Serve as the PRO that reviews individual provider and facility quality of care issues
  • In conjunction with TPRC-BH, serves as the highest level of peer review within TriWest
  • Monitors trends
  • Recommends and reviews CAPs and evaluates results of CAPs
  • Reviews provider PRO appeals
  • Recommends sanctions of network and non-network providers when warranted
  • Reviews sentinel events and makes the final determination on the severity level of individual quality of care issues
  • Communicates peer review outcomes (e.g., providers and facilities with quality of care issues, CAPs, and other findings) to the Credentialing Committee so they can incorporate that information in decisions to credential or re-credential providers
  • Collaborates with external peer reviewers when the expertise needed to review the case does not exist internally

The CQM department investigates, receives, and actively searches for potential quality issues (PQI) and patient safety issues (PSI), resolves beneficiary and provider grievances, and performs clinical quality review studies. CQM also conducts studies and quality improvement projects on Healthcare Effectiveness Data and Information Set (HEDIS) measures or Department of Health and Human Services Agency for Healthcare Research and Quality PSI.

The CQM determines issues, analyzes potential improvements, and implements timely and appropriate corrective action, when needed. As part of its investigation, CQM may implement a CAP. TriWest’s CQM department follows up on CAPs to ensure interventions have been implemented and remain effective. Corrective action includes, but is not limited to:

• Provider communication and education (e.g., through required further training), including provider office staff training
• Provider credentialing review by querying National Practitioner Data Bank (NPDB)
• Administrative policies and procedure revision
• Prospective or retrospective trend analysis of practice patterns
• Intensified review of practitioners or facilities, including but not limited to, requirements for second opinions for procedures, retrospective or prospective review of medical records, claims, or requests for pre-authorization
• Modification, suspension, restriction, or termination from the network

TRICARE Quality Monitoring Contractor

The TRICARE Quality Monitoring Contractor (TQMC) assists the DOD, DHA, MTF market managers, and the Health Plan West Region office by providing the government with an independent, impartial evaluation of the care provided to beneficiaries within the MHS. TQMC is part of TRICARE’s Quality and Utilization PRO program, in accordance with 32 Code of Federal Regulations (CFR) and reviews care provided by TRICARE network providers and subcontractors on a limited basis. To facilitate these reviews, TriWest may request providers’ medical records on a monthly basis to comply with requirements detailed in the TRICARE Operations Manual, Chapter 7. Records must be submitted in their entirety. Failure to do so will result in recoupment of payment for the hospitalization and/or any other services in accordance with 32 CFR 199.4(a) (5).

Medical Records Documentation

TriWest reviews medical records to evaluate patterns of care and compliance with evidence-based standards of practice, and performance standards. TriWest requires each provider to maintain adequate medical documentation and medical treatment records, including contemporaneous clinical records that substantiate the clinical rationale for each course of treatment, periodic evaluation of the efficacy of treatment, and the outcome at completion or discontinuation of treatment. Medical records must include information that justifies admission and continued hospitalization, supports the diagnosis, and describes the beneficiary’s progress and response to medications and services.

Providers must maintain clinical and other records related to individuals for whom TRICARE payment was made for services rendered for a period of 60 months from the date of service. Providers must provide copies of medical treatment records to TriWest within 10 business days of its request so TriWest can conduct peer review, quality assurance activities, HEDIS, and utilization review.

TriWest will not pay (and provider agrees to waive) any costs associated with the required submission of medical treatment records, including but not limited to copying or handling fees, unless otherwise specified (e.g., TRICARE requirements, the TriWest TRICARE provider handbook, or the provider’s contract with TriWest). We accept secure electronic medical records in a HIPAA-compliant, encrypted format.

Providers must adhere to Medical Treatment Record Guidelines. See the TriWest Medical Treatment Record Quick Reference Guide for details.

When requested, providers must transmit accurate, complete, and legible clinical records and information to the Government pertaining to the care delivered, pursuant to referrals or orders from MTF providers, in compliance with applicable privacy and confidentiality laws and regulations, and in accordance with the TRICARE Requirements and the TriWest TRICARE Provider Handbook.