Medical Management Guide, 2009, Version 3.0 - Tricare

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Page xivVersion 3.0Medical Management GuideProspective Payment System............................................................................................................................. 140Protected Health Information Management Tool............................................................................................... 140Service-Level Information Systems........................................................................................................................... 140Army................................................................................................................................................................ 140Navy................................................................................................................................................................. 141Air Force........................................................................................................................................................... 141Business Planning Tools........................................................................................................................................... 141Tri-Service Business Plans.................................................................................................................................. 141CD-ROM Resources................................................................................................................................................. 144Appendix A – References.......................................................................................................................... 147Appendix B – Acronyms............................................................................................................................. 156Appendix C – Definitions........................................................................................................................... 161Appendix D – Resources............................................................................................................................ 185
Medical Management Guide Version 3.0Page xvTable Of FiguresClick text listing to viewSection I – Medical Management EssentialsFig. 1 – Military Medical Home Model................................................................................................................. 3Fig. 2 – MHS Medical Management Model.......................................................................................................... 3Fig. 3 – MHS Population Health Model (2006)..................................................................................................... 7Fig. 4 – Integrated Medical Management Model (IM3)......................................................................................... 14Fig. 5 – Distinctions between UM, CM, and DM.................................................................................................. 15Fig. 6 – Questions to Consider when Creating an Integrated MM Program........................................................... 17Section II – Utilization ManagementFig. 7 – Utilization Management within the MHS Integrated MM Model (IM3)..................................................... 25Fig. 8 – Seven-Step Quality Improvement Process................................................................................................. 27Fig. 9 – Sample UM Data Elements or Measures.................................................................................................. 34Fig. 9 (cont.) – Sample UM Data Elements or Measures ....................................................................................... 35Fig. 10 – TRICARE Referrals/Preauthorizations/Authorizations............................................................................... 42Fig. 11 – MTF Review and Appeal Process: Internal Review................................................................................... 47Fig. 11 (cont.) – MTF Review and Appeal Process: Internal Review/Appeal............................................................ 48Fig. 11 (cont.) – MTF Review and Appeal Process: External Appeal....................................................................... 49Section III – Case ManagementFig. 12 – Case Management within the Integrated MM Model (IM3).................................................................... 57Fig. 13 – Chronic Care Management Model......................................................................................................... 59Fig. 14 – Military-Specific Designations, Programs, and Offices............................................................................. 61Fig. 15 – Potential Sources for Case Finding......................................................................................................... 62Fig. 16 – The Six-Step CM Process........................................................................................................................ 65Fig. 17 – Categories of Assessment...................................................................................................................... 67
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Medical Management Guide, 2009, Version 3.0 - Tricare

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