Medical Management Guide, 2009, Version 3.0 - Tricare

Page 46Utilization Management Version 3.0Medical Management GuideThe MTF Commander’s (or designee’s) decisionis final. The reply includes the name of a contactperson who can address questions regarding thereview findings.• The external chain includes the third andfourth levels of appeal to the National QualityMonitoring Contractor (NQMC) and TMA,respectively.AppealsAn appeal is an administrative review of programdeterminations regarding the medical necessity ofhealthcare services (including behavioral services)made under the legal and regulatory provisions(TRICARE Operations Manual 6010.51-M, Chapter13, Appeals and Hearings). MTF staff are responsiblefor protecting the rights of appealing parties atall levels of the appeal process. That responsibilitybegins with the initial denial determination and endswhen a final resolution is achieved. Further levels ofappeal should progress only if the patient wants tocontinue the process (i.e., if the patient disagrees oris dissatisfied with the decision) or if the reviewingauthority upholds the initial denial.The MTF appeal process involves three levels ofreview followed by three levels of appeal. Therationale for multiple levels is twofold:1. The process allows for a check and balancewithin the system.2. The process provides for objective decisionmaking,progressing from the lowest to thehighest level in the appeal Chain of Command.Fig. 11 summarizes the MTF review and appealprocess, including reviewer qualifications andguidelines.Filing an AppealAppealing PartyThe appealing party is the patient affected by theinitial denial determination. Participation in anappeal is limited to any party associated with theinitial denial determination, as well as the authorizedrepresentative(s) of the appealing party. The patientmay appoint a representative (in writing) to act onhis/her behalf during the appeal process.The MTF provider is not generally an appropriateappealing party for a dependent patient. Adependent denied services may appoint his/hersponsor or any other person as his/her representativesubject to the limitation in CFR Title 32, NationalDefense, Chapter 1, Section 199.10 — Appeal andhearing procedures. Following the representative’sappointment, he/she may file an appeal on behalf ofthe patient.The process also provides for internal and externalchains of responsibility.• The internal chain begins with the first level ofreview, at the MTF; and ends with the first levelof appeal, to the MTF Commander.In cases where the patient is a child under the ageof 18 (i.e., a minor), the presumption is the sponsoris the appointed representative who can appeal onbehalf of the child without a specific designation orappointment, as long as the sponsor is the custodialparent.