LCDR Jack T. Gulbranson, USN

1
MMSO Overview

• LCDR Jack T. Gulbranson, USN
• Navy Marine Corps Service Point of Contact
• 888-647-6676
• jtgulbranson_at_mmso.med.navy.mil
• http//mmso.med.navy.mil/
• mmsospoc_at_mmso.med.navy.mil

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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

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Core Mission Cont

• 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

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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
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Population Served

• 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

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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

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Case Management

• 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

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

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TRICARE Prime Remote (TPR)

• 50 Mile Rule for Active Duty 10 U.S.C 1074
  (c)
• If you live AND work gt 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

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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

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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

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MMSO Coordination with TRICARE Cont

• 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

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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

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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

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AD Out of region care (Cont)

• 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

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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

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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

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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

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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 members 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)
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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 docs 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

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RC and MMSO Cont

• 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

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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

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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

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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

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RC LOD Overseas Health Care

• -Effective March 2006, tasked by TMA
• Urgent/Emergent care only in remote overseas
  areas not referred by overseas MTFs
• 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

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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

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PDHRA Cont

• 5000 additional LODs 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

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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

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Future Considerations

• LODI code within DEERS for the RC
• Reserve unit administrator enters information
  into DMDC Web Portal application for limited
  eligibility
• Includesinjury 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

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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

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Final Reminders

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