Medical Management Guide, 2009, Version 3.0 - Tricare

Page Version 3.0Medical Management GuideSection II – Utilization Management...................................................................................................... 25Introduction............................................................................................................................................................ 25Definition, Goals, and Purpose.......................................................................................................................... 26Utilization Management Components .................................................................................................................. 26The Seven-Step Quality Improvement Process................................................................................................... 27Identify the Purpose................................................................................................................................... 28Determine What to Measure...................................................................................................................... 28Determine the Gaps................................................................................................................................... 29Attempt to Fix the Problem(s)..................................................................................................................... 29Determine the Effectiveness of the Corrective Action................................................................................. 30Make Additional Attempts to Fix the Problem(s)......................................................................................... 30Learn from the Quality Improvement Process.............................................................................................. 30Utilization Review............................................................................................................................................. 31Types of Review......................................................................................................................................... 32Outcome Measurement and Management........................................................................................................ 33McKesson ® InterQual ® ............................................................................................................................... 33Milliman Care Guidelines ® .......................................................................................................................... 36Provider Profiling.............................................................................................................................................. 36Referral Management....................................................................................................................................... 37Referral Management Center..................................................................................................................... 38Active Duty Service Member Referrals........................................................................................................ 39Authorization............................................................................................................................................. 40Episode of Care.......................................................................................................................................... 40The Electronic Referral Process................................................................................................................... 41Utilizing Military Treatment Facility Capability and Right of First Refusal Reports......................................... 43Additional Information............................................................................................................................... 43The Grievance and Appeal Process.................................................................................................................... 44Overview................................................................................................................................................... 44Grievances................................................................................................................................................. 45Appeals..................................................................................................................................................... 46Risk Management............................................................................................................................................. 51Utilization Management Program Accreditation....................................................................................................... 52The Utilization Management Professional................................................................................................................ 52Qualifications................................................................................................................................................... 52Staffing to Support Utilization Management..................................................................................................... 53Summary................................................................................................................................................................ 53CD-ROM Resources........................................................................................................................................... 54