TRICARE Operations Manual 6010.59-M, April 1, 2015
Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
Chapter 7
Section 3
ContractorRelationships With The Military Health System (MHS) TRICARE QualityMonitoring Contract (TQMC) Contractor
Revision:C-120, June 12, 2023
1.0The TQMC contractor conductsreviews to validate the appropriateness of the contractor’s qualityof care and utilization review decisions. The Managed Care SupportContractors (MCSCs), Designated Providers (DPs), the TRICARE Medicare Eligible Program (TMEP)and TRICARE Overseas Program (TOP) contractor shall transmit paperor electronic copies of the medical record and all case documentationto the TQMC contractor for each case or category of case requestedby the TQMC contractor. The estimated number of medical records(including inpatient and outpatient care) to be selected will varydepending upon the health care region involved and the TQMC’s selectioncriteria. The estimated quantities per region could range from upto 3600 to 7560 records per year for the MCSCs, up to 120 to 360records per year for the DPs, and up to 1200 to 2400 records peryear for the TMEP. Records will berequested periodically throughout the year.
2.0The MCSCs, DPs, and TMEP contractorshall transmit 95% of the requested records to the TQMC contractorwithin 45 calendar days and 98% within 60 calendar days from thedate the MCSCs, DPs, and TMEP contractorreceive the request for records from the TQMC contractor. Recordsto be transmitted shall include the complete medical record, theMCSC’s, DP’s, and TMEP’s utilizationreview decision, rationale for that decision, and quality of caredeterminations. The MCSC’s, DPs, and TMEP contractor shallforward a monthly Contractors Records Accountability Report. Detailsfor reporting are identified by DD Form 1423, Contract Data RequirementsList (CDRL), located in Section J of the applicable contract. Bothpaper and electronic record transfer and storage are acceptableto Defense Health Agency (DHA). Records may be transmitted throughsecure electronic means and stored with the TQMC contractor forreview in adherence with the requirements specified in Chapter9, Records Management. Adherence to these procedures isessential for compliance with the Privacy Act of 1974 (5 USC 552a),the Department of Defense (DoD) Privacy Program (DoD 5400.11-R),the Health Insurance Portability and Accountability Act (HIPAA)Privacy and Security Rules (45 CFR Parts 160 and 164), the DoD HealthInformation Privacy Regulation (DoD 6025.18-R), the DoD Health InformationSecurity Regulation (DoD 8580.02-R), and other federal laws protectingthe privacy and security of Personally Identifiable Information(PII), including health information. Receipt of electronic recordsshall be acknowledged by return e-mail from the TQMC contractor.If the acknowledgment e-mail is not received within one businessday after the electronic records were transmitted, or if it is determined thatthe records were not transmitted with the required security safeguards,then the contractor (MCSC, DP, TMEP)shall immediately follow-up to determine the status and whethera possible breach may have occurred. Unless it is determined thatno possible breach occurred, then, within 24 hours, the contractorshall notify the DHA Privacy Office and carry out the other breachresponse requirements of Chapter 1, Section 5.
2.1Transfer of paper records shalladhere to procedures specified in paragraphs 2.1.1 through 2.5.
2.1.1Therecords shall be packaged in boxes containing a single month ofrecords and a Box Inventory Document (see Figure 7.3-1) stating the numberof patient records contained therein and identifying each recordby patient name and DHA Internal Control Number (ICN), which shouldbe clearly shown on each patient’s record. Because the Box InventoryDocument contains PII, that document (in both its paper and electronicversions) shall be protected from unauthorized use and disclosurein the same manner as the patient records themselves.
2.1.2The MCSCs, DPs, or TMEP shallnotify the designated Point Of Contact (POC) at the TQMC contractor,via e-mail, each day that a box or boxes have shipped, stating thenumber of boxes (with tracking numbers) in that day’s shipment (see Figure 7.3-2).The MCSCs, DPs, or TMEP shall trackthe shipment, including delivery, using the shipping vendor’s trackingmethod and retain documentation of such.
2.2Within one business day ofreceipt of a shipment from a contractor (MCSC, DP, or TMEP),the TQMC contractor, using the MCSC, DP, or TMEP BoxInventory Document(s), the TQMC shall match the number of boxesreceived with the corresponding e-mail shipment notification. Ifany boxes are missing, the contractor and the TQMC shall immediatelyinvestigate and, no later than 24 hours after finding that a boxis missing, initiate breach response in accordance with Chapter 1, Section 5. If no boxes are missingand for all boxes received, then the TQMC contractor shall confirmthe number of records in each box, and a match between each patientrecord and ICN for the patient names listed on the Box InventoryDocument no later than the Close of Business (COB) on the fifthbusiness day after receipt of the shipment. By that date, the TQMCcontractor shall send an e-mail back to the MCSC/DP/TMEP confirmingthe number of boxes, number of records in each box and match ofall ICNs. Upon receipt of the TQMC contractor’s confirmation e-mail,no further action is required by the MCSC, DP, or TMEP.
2.3Using the Box Inventory Document,if the TQMC contractor identifies:
•A count discrepancy in eitherthe number of boxes or number of charts in each box;
•Absence of a record; or
•A mismatch of the record withthe ICN; and
•If the TQMC contractor concludesthat records are or may be missing, the TQMC contractor shall notifyby e-mail the MCSC, DP, or TMEP ofthe discrepancy including details of the discrepancy by COB of thefifth business day from receipt of shipment. Upon notification ofthe count discrepancy, the MCSC, DP, or TMEP shallinvestigate the discrepancy, take appropriate steps and notifications, andbe in telephone, fax and e-mail communication to resolve the potentialviolations of applicable law as soon as possible. If the missingrecords are not promptly located, then, within 24 hours of receivingthe notice from the TQMC, the contractor shall initiate breach responsein accordance with Chapter 1, Section 5.
2.4The TQMC contractor shall senda “non-receipt” e-mail to the MCSC, Uniformed Services Family HealthPlan (USFHP) Designated Providers (DP) and Program Office (PO),or TMEP POC by COB of the fifth businessday if no shipment was received from the MCSC, USFHP DP and PO,or TMEP following notification thata shipment was sent. Upon receipt of a “non-receipt of a shipment”e-mail from the TQMC contractor POC, the MCSC, USFHP PO, or TMEP shallimmediately track the shipment and notify the TQMC contractor POC,by e-mail, of the status of the shipment. The MCSC, USFHP DP andPO, or TMEP shall be in telephone,fax or e-mail communication with the TQMC contractor POC to determine theappropriate steps and notifications, based upon the investigationto resolve the potential HIPAA violation.
2.5Ifthe MCSC, USFHP DP and PO, or TMEP donot receive an e-mail from the TQMC contractor indicating eitherconfirmation of receipt, confirmation of receipt with discrepancy,or a non-receipt of shipment, by the morning of the sixth businessday after shipment, the MCSC, USFHP DP and PO, or TMEP shallnotify, by COB on the same day, all parties required to receivenotice under the breach notification provisions of Chapter 1, Section 5 and applicable law. Theseparties include the DHA Clinical Operations Division (COD), USFHPPO, and the DHA Privacy Office. The notifications shall provideavailable details about the shipment and the circ*mstances. TheTQMC contractor shall verify that these notifications are sent,and shall provide the notifications itself if the sender of therecords fails to do so. Thereafter, the MCSC, USFHP DP, or TMEP shallcomply with breach response requirements of Chapter 1, Section 5 andapplicable law.
3.0The MCSCs, USFHP, and TMEP shallprovide the appropriate COD/USFHP and TMEP Contracting Officer’sRepresentative (COR) written responses to all TQMC contractor findings.The MCSC’s, USFHP’s, and TMEP contractor’sresponses shall state agreement, partial agreement, or nonconcurrencewith each discrepancy found by the TQMC contractor, and includesupporting rationale, and proposed follow-up actions to addressthe issues (see Section J of the contract). Details for reportingthe TQMC Quarterly Findings are identified by DD Form 1423, CDRLlocated in Section J of the applicable contract.
4.0At the direction of the DHAClinical Support Division (CSD), the MCSCs, USFHP, TMEP, andTOP contractors shall attend two face-to-face meetings annually,of one to two days duration, at a location chosen by CSD. Additionally,contractors shall participate in two teleconference meetings notto exceed one day per meeting.
| (Logo or Letterhead of Company) |
| Inside mailing address identifyingOrganization and Person Shipping POC |
| Privacy/HIPAA Warning Notice: |
| The information in the encloseddocuments may be subject to the Privacy Act of 1974, the Health InsurancePortability and Accountability Act (HIPAA) and other Federal Lawsprotecting the privacy and security of Personally Identifiable Information(PII), including health information. Personal information containedin this inventory and in the enclosed documents may be used anddisclosed only by authorized persons in the conduct of officialbusiness and only in accordance with the Privacy Act, HIPAA andother applicable Federal law. Any unauthorized use or disclosureof personal information may result in criminal and/or civil penalties.If you are not the intended recipient of this correspondence, youmust notify the sender upon receipt and transfer the documents inaccordance with the sender’s instructions. If you inspect, copyor transfer the enclosed documents other than as instructed, a violationof applicable law may occur. |
| This is Box X of Y mailed onMM/DD/YEAR |
| Record Request Received byContractor: Month & Year |
| Recommended Per Box InventoryLetter Example (to be included in each box) |
| Name of Contractor: | Date Mailed: M/D/YR | Month of Chart Request: M/YR | Number of records in box = | |
| ICN | Patient Name | Patient Year of Birth | Admission Date | Discharge Date |
| Information to include: |
| Universal Date Shipment to be “pickedup” Numberof boxes in shipment |
| For Each Box in Shipment Tracking number for box: 1ZV300Y4019919XXX Audit Month (05/2009) Number of records in box (XY) |
| Signatory |
| References: |
| 1.OASD/HAMemorandum, Use of Digital Signature on Official TMA ElectronicMail (e-mail), June 13, 2007. |
| 2.OASD/HAMemorandum, Protection of Sensitive Information in Electronic Mail,August 13, 2007. |
| 3.OASD/HAMemorandum, Guidelines on Protection of Sensitive Information inElectronic E-mail, June 25, 2008. |
| 4.OASD/HAMemorandum, Updated Guidelines on Protection of Sensitive Informationin Electronic Mail, September 19, 2008. |
| 5.DoD Memorandum,“DoD Guidance on Protecting Personally Identifiable Information(PII),” August 18, 2006. |
| 6.DoD Regulation6025.18-R, “DoD Health Information Privacy Regulation,” January24, 2003, and |
| 7.DoD Regulation8580.02-R, “DoD Health Information Security Regulation,” July 12,2007. |
- END -
