LCDR Jack T. Gulbranson, USN Navy & Marine Corps Service Point of Contact 888-647-6676

1. MMSO Overview LCDR Jack T. Gulbranson, USN Navy & Marine Corps Service Point of Contact 888-647-6676 jtgulbranson@mmso.med.navy.mil http://mmso.med.navy.mil/ mmsospoc@mmso.med.navy.mil

2. Core Mission To directly support the provision of health care for Active Duty Service Members enrolled in the TRICARE Prime Remote (TPR) Program and Management of the Supplemental Health Care Program: Medical and fitness for duty oversight and coordination Customer Service Support 1-888-MHS-MMSO or http://mmso.med.navy.mil/ Navy and Marine Corps Mortuary Affairs

3. Core Mission Con’t VA National MOU for SCI/TBI/Blind Rehab Navy/MC and Army Only TRI-Service Remote Dental Program (RDP) Includes LOD dental care for RC DTF Referred Dental Program Adjudicated by MMSO, not by TRICARE Dental care pre-authorizations and claim processing VA Medical and Dental Claims MMSO version of EOB sent Paid with service funds, via DFAS, not by TRICARE

4. Regional Office Headquarters Washington DC Regional Office Headquarters San Diego, CA Regional Office Headquarters San Antonio, TX AREAS REGIONS North 1, 2 & 5 South 3,4 & 6 West 7-12, AK

5. Active Duty (CONUS/Hawaii/Alaska only) TPR enrolled Non-enrolled Active Duty not being managed by a MTF Appellate leave Students, recruits, members in travel status not yet enrolled Reserve Component(RC) Not eligible in DEERS or orders less than 31 days Line of Duty (LOD) injuries Weekend (IDT), Annual Training (AT), or ADSW Demobilized members with LOD for service injuries Population Served

6. Service Point of Contact (SPOC) • Service rep to oversee TPR and SHCP • Consultant to TMA/TRO and Service HQ on Tri-service program policy • Review deferred claims from MCSCs for payment determination: • Electronic claims interface with the regional subcontractors • Humana, Health Net (PGBA), Tri-West (WPS) • Active Duty Service Member direct support • Claims • Access to care • Appeals • Benefit education • Reference: CH 17-19 TRICARE Ops Manual

7. Provide clinical oversight & pre-authorization Authorize care through electronic interface with regional contractors for active duty Work directly with unit medical reps and authorize care requests for the RC with internal MMSO authorization number for LOD injuries MMSO may direct care for remote members back to a MTF for FFD evaluation or certain care specialties Assign Medical Cog tracking to Closet MTF for AD civilian admissions when not already managed by a MTF Case Management

8. SPOC Claim Workload Total 5 year increase of 56%

9. $61M paid by TRICARE Savings to the government • Top reasons for a claim denial: • Not eligible for care • Not a covered medical benefit • No prior authorization for specialty care

10. TRICARE Prime Remote (TPR) • “50 Mile Rule” for Active Duty: 10 U.S.C 1074 (c) • If you live AND work > 50 miles from MTF • TRICARE Regional Offices (TROS) may provide exceptions for zip codes based on driving time • May have a civilian assigned PCM or PCM unassigned • Obtain care from assigned PCM, PCM will obtain authorizations for specialty referrals • PCM Unassigned, requesting provider must obtain prior authorization for specialty/IP care utilizing regional HCF • Specialty and inpatient care requests deferred for approval

11. AD TRICARE Enrollment • TRICARE enrollment is mandatory with a permanent duty assignment • Ref: HA 05-014/HA 04-13/HA 96-038 & Policy memo 16 Oct 2000 • Non enrollment may result in claim payment or medical management problems • Op Forces should be assigned to an Operational DMIS associated with an MTF • Clear jurisdiction of care • Enrollment agency is responsible for care management • Claims are routed to enrollment region for final authorization • MHS system is built on TRICARE enrollment • Family member enrollment is optional

12. Active Duty Care • AD claims are either paid or denied • Standard and Extra options do not apply • AD non urgent self referred care, member may be financially responsible for the claim • Non network provider cannot balance bill the Service Member (TMAC or TMAC plus 15%) • TRICARE will not pay the cost share portion for active duty claims if private insurance is used (RC LOD) • Regional contractor is not as risk for AD care • MTF or MMSO can authorize non covered benefits if required for treatment to maintain fitness • Direct Care maximization

13. MMSO Coordination with TRICARE • Electronic interface with Regional contractors: • Review AD deferred medical claims for: • TPR enrolled • Specialty/Inpatient/ER/Non covered care • Non enrolled active duty and non MTF referred • RC care in absence of an MTF authorization • Contractual payment authority to override DEERS ineligibility • Payment decision must be made within 2 business days or claim auto pays

14. MMSO Coordination with TRICARE Con’t • TMA Policy/TRICARE Operations Manual instruct regional contractors to accept authorizations of care and claim payment from MMSO or the MTF • MTF and MMSO have the same authority, but have different jurisdictions • TOM references • Ch 18 Sec 3, 1.2.3/1.3.1 and 2.2 • Ch 19 Sec 3, 3.1/5.2 and 6.2

15. Civilian care for the Non enrolled AD • MTF managing care = MTF referral and authorization • If non-enrolled SM resides in catchment area, MTF manages care and makes referrals to civilian care (Should enroll member) • If non-enrolled SM resides in remote area, consider member enrolling in TPR (MMSO manages the care) • No budget impact in TRICARE for MTFs referring non-enrolled or non eligible service members for civilian medical care

16. AD Out of region care • ISSUE: Local MTF refers AD for civilian medical care • TRICARE contractor loads the authorization with the regional contractor where the specialty care is rendered • Rather than the regional contractor loading authorization where the service member is enrolled or residential address

17. AD Out of region care (Con’t) • SOLUTIONS: • Referring MTF coordinates with enrolled MTF, requests enrolled TSC contractor to load auth in region where member is enrolled or resides so claims will pay • Unique Identifying number (UIN) from MTF attached to the claim to drive payment, when claim is routed by local contractor to contractor of enrolled region • Deployment of EWRAS, contingent on ability to authorize care across regional contractors • EWRAS must be able to load authorizations for RC • Extreme Challenge, usually MMSO intervenes for resolution

18. Fitness for Duty • MMSO identifies conditions with Pre Authorization for care request or upon reviewing claim for payment • Acute or lingering conditions without improvement, usually one year or more • Notification letter is sent to unit commander • 600 notification letters sent per month • Unit funds TAD to MTF for a FFD evaluation • MMSO may deny future civilian care authorizations if member is not profiled or evaluated by a MTF

19. Fitness for Duty Conditions • Respiratory Conditions • (Sleep Apnea with CPAP, Asthma, debilitating allergies ) • Major Psychiatric conditions • Use of Psychotropic drugs, alcohol or substance abuse • Cancer • Brain Injury • Cardiology with major incident • Transplant candidates • Diabetes with insulin dependence • Chronic Orthopedic conditions • Spinal cord injuries • HIV

20. Non covered Care • Chiropractic care • (HA Policy 03-021) • (MTF care only, NDAA 2001, Sec 702) • Eye glasses, contacts • MTF or NOSTRA Opthalmic labs • http://138.143.250.101/nostra/ • Bariatric Bypass surgery • (usually MTF only), service guidelines vary • Hearing Aids • All Psychological care must be pre-authorized • Interest or late charges

21. High Use of ER by Non-Enrolled Service Members • Highest use among the Non-enrolled Service members • Strategy: • MMSO identify high ER use by active duty for enrollment in Prime/Prime Remote and case management • Notify member’s command of high ER use Purchased Care ER versus Total Visits for service members by Enrollment Status: • 16% Non-MTF SHCP (MMSO) ($4M) • 6% MTF SHCP ($2.3M) • 4% TPR AD ($1.2M)

22. RC and MMSO • RC members on orders for 30 days or less are not registered as eligible in DEERS • MMSO authorizes the majority of the RC LOD • Unit expedites eligibility doc’s to the MMSO • Unit COC/Service HQ determines LOD eligibility • Claims are sent to the regional contractor • Regional contractor defers claims for DEERS non eligible w/o a MTF auth to MMSO for approval • Non ER civilian care must be pre-authorized by either the MTF or the MMSO: Or Claim(s) will be denied for DEERS ineligibility

23. RC and MMSO Con’t • RC have the same priority for access to MTF care as the Active Duty for LOD injuries only: • HA Policy (97-041) • May need to utilize MTF PAD for appt. assistance/register in CHCS • MTF should not bill for claim reimbursement • MTF provides direct care or authorizes civilian care referrals for members residing w/i MTF AOR • MTF authorization should drive claim payment and bypass ineligibility in DEERS • (TOM Ch 18, sec 3) • MMSO authorizes civilian care in remote areas

24. RC Demobilization • VA space “A” care for service documented injuries • Extensive injuries- consider remaining on Active Duty status (Medical Extension) • Disability Evaluation System or until found FFD • May need to transfer enrollment and care management if re-assigned to a remote unit • If Army and in remote area, may be enrolled in TPR and managed by the Community Based Health Care Organization (CBHCO) • Service issued LOD • For continued care after discharge from AD

25. RC Dual eligibility • Demobilized and enrolled in? • TRICARE Reserve Select Program (TRS) • Transitional Assistance Management Program (TAMP) • Continued Health Care Benefit Program (CHCBP) • And have service related injuries documented on a NOE/LOD • Must contact the MMSO • MMSO will intervene for payment of line of duty injuries at the active duty rate without cost share

26. New MMSO Programs • Retail Pharmacy Reimbursement for LOD injuries (Nov 15, 2004) • Collaboration with Express Scripts Inc./MMSO/TMA • Detailed information posted on website: • MMSO: www.http://mmso.med.navy.mil/esi • Member pays civilian claim out of pocket • Files DD-2642 and sends eligibility documentation to MMSO • MMSO endorses by matching to LOD condition • MMSO requests ESI to honor reimbursement request

27. RC LOD Overseas Health Care -Effective March 2006, tasked by TMA • Urgent/Emergent care only in remote overseas areas not referred by overseas MTF’s • MMSO manually works with WPS overseas contractor • If claim is paid out of pocket, member sends DD-2642, and faxes orders to MMSO • MMSO faxes final approval to WPS • International SOS under TRICARE Global Remote Overseas Program (TEGRO) is still a valid option (Show copy of orders) • http://www.tricare.osd.mil/TGRO/default.cfm

28. Post Deployment Health Reassessment • Effective 2005 • Questionnaire (DD 2900) filed by demobilized RC member 90-180 days post mob • Screened by Logistic Health Institute (LHI) • Document LOD conditions from contingency ops • Informal LOD produced (Army 2173) • Members told they can obtain care at choice (VA, MTF, Civilian Care) • Should obtain Formal LOD for necessary treatment plans

29. PDHRA Con’t • 5000 additional LOD’s per month • Majority of claims will automatically process as TAMP standard with cost shares and deductibles • MMSO must manually reprocess claim with contractors upon appeal to pay claim at 100% • Affects Regional contractors, they must recoup from one program or pay difference with at risk funds • Difficult population to manage • No Identifying HCDP or DEERS Code • Multiple Dx or complaints, many pre-existing in nature • No thorough medical review

30. Early Activation or Delayed Effective Orders • For RC members who are awaiting mobilization orders • Demonstration as part of Section 703 of NDAA 2004 made a permanent benefit in NDAA 2005 • Provides eligibility for medical benefits to member and their family up to 90 days prior to receipt of mobilization orders (Delayed effective orders) • Must be coded in DEERS by their respective service • If found not fit to deploy, eligibility ends the day the orders are terminated • Family members may enroll in TRICARE

31. Future Considerations • LODI code within DEERS for the RC • Reserve unit administrator enters information into DMDC Web Portal application for limited eligibility • Includes…injury description, unit POC, coverage dates • Unique MTF Unit Identification Code (UIC) to be recognized across regions for claim payment • Line of duty supporting information attached on a HIPAA 271 transaction with the referral request

32. Challenges • Readiness • RC mobilized with pre-existing conditions • AD not physically qualified, prolonged conditions • Active Duty TRICARE enrollment • Contractor relationships, compliance with MTF referrals of the RC, proper claim routing to MMSO • New programs, expansion of benefits • Discharged AD members not being fully cleared in DEERS for medical eligibility • MMSO Organizational Changes • BUMED, NAVMED Support Command Jacksonville, TMA

33. Final Reminders • Keep DEERS information accurate and current: • Update enrollment at each new duty station • Utilize your PCM for all routine care • Obtainpre-authorization for all specialty care • RC civilian bills will not be paid without a MTF or MMSO authorization