Medical Management Guide, 2009, Version 3.0 - Tricare

Fig. 11 (cont.) – MTF Review and Appeal Process: External AppealLevel ofReview/AppealSecond-levelAppeal (NQMC:Appeal Requested)Third-levelAppeal (NQMCReconsideration)Fourth-level Appeal(TMA Hearing)ReviewerQualifications• NQMC• Includesreviewers whoare clinical peersof the healthcareprovider underreview.TMA: Hearing RequestedNot applicableMTF Review and Appeal: External AppealReview Process(Reviewer Actions)Request for Appeal to the National Quality Monitoring Contractor (NQMC)(Note: It is the beneficiary’s responsibility to initiate the appeal request directly to the NQMC)• Contacts attending physicianor healthcare provider foradditional information.• Decisions are based onmedical standards of careIAW 32 C.F.R., 199 anddocumentation and/oradditional informationobtained from the providerand previous levels of review.• Hearing Officer is assigned tothe case.• Facts relevant to the caseare presented in relation toapplicable law, regulation,policies, and guidelines.• Decision is based onmedical standards of careand documentation and/oradditional informationobtained from the providerand previous levels of reviewand testimony presented atthe hearing.There are no further appeal rights. The TRICARE Director’s decision is final.Outcome Timelines AppealingParty• Approves requested services andreverses denial determination;OR• Upholds initial denial. Notifiespatient, his/her representative,and/or attending physician/PCM,in writing, of:o Upheld denial determinationo Reason for denialo Patient’s rightso Steps to appeal denial andrequest formal hearing if patientchooses to do so• Approves requested services andreverses denial determination;OR• Upholds initial denial. Notifiespatient, his/her representative,and/or attending physician/PCM,in writing, of:o Upheld denial determinationo Reason for denialo Patient’s rightso Steps to appeal denial if patientchooses to do soRequests for reconsideration shallbe postmarked or received by thedeadline.• Reversal;OR• Upheld Denial.NotificationRefer to TOM, Chapter 13, Section 4,Paragraph 2.3.2 and 2.4.• Request shall be mailed within60 days after date of NQMCreconsideration determination.• A Hearing Officer is appointedwithin 60 days following requestfor hearing.• Reversal;OR• Upheld Denial.Notification• Hearing Officer will hold hearingand issue recommended decisionto TMA Director within 60 days ofwritten notice of assignment.• Refer to 32 C.F.R. 199.10 for moredetailed information regardingtimeliness of a hearing.• Beneficiary• Beneficiary’srepresentativeNotapplicable• Beneficiary• Beneficiary’srepresentativeNotapplicableSources: DoDD 6000.14, Patient Bill of Rights and Responsibilities in the Military Health System. TRICARE Operations Manual 6010.51-M, Chapter 13, Appeals and Hearings. 32 C.F.R. 199, Civilian Health andMedical Programs for the Uniformed Services (CHAMPUS).Medical Management Guide Version 3.0Utilization ManagementPage 49