Prospective Review

• Determining medical necessity
• Evaluating proposed treatment
• Assessing level of care required
• Determining appropriate level of care prior to admission
• Identifying potential for discharge planning needs and determining whether the case meets care coordination or case management criteria
• Identifying potential quality-of-care issues 

First-level reviewers may issue denial determinations based on coverage limitations contained in 32 CFR 199, the TRICARE Policy Manual, and other TRICARE guidance (these are considered factual determinations) or refer the case to second-level review. Physicians who did not participate in the first-level review of the care under consideration conduct second-level reviews.

Concurrent Review

Concurrent review is a process of continual reassessment of the beneficiary’s needs during an inpatient stay. Concurrent review activities monitor the patient for appropriate level of care and identify potential care coordination, disease management/demand-management, discharge needs, and case-management candidacy.

The care coordinator responsible for concurrent review evaluates the beneficiary’s level-of-care needs during hospitalization. Based on medical determinations of levels of assistance that may be required, an entire episode of medical care may be adapted to fit the beneficiary’s status and needs. Components may include:

• A continuum of health care based on identified needs and goals
• Design and adaptation of health care initiatives for the beneficiary
• Identification of assistance needs throughout an entire episode of care
• Beneficiary and family education

Case Management

Case management services are provided by Humana Military nurses for TRICARE beneficiaries with complex health needs and should be referred to Humana Military case management for an evaluation. The following conditions warrant mandatory referral to case management:

• Transplant evaluation or procedure (solid organ or bone marrow/peripheral stem cell)
• Ventilator dependence
• Acute inpatient rehabilitation (not skilled facility with therapy only)
• Traumatic brain injury, spinal cord injury, stroke, blindness
• New quadriplegia or paraplegia
• Premature infant: ventilator-dependent more than 24 hours and/or weight less than 1500 grams
• Planned long-term acute care admission
• Catastrophic illness or injury, amputation, multiple trauma
• Pregnancy with significant identified risks
• Hourly nursing care more than four hours per day
• Burn injury requiring a burn unit
• Unplanned admissions to acute hospital three times or more within 90 days with the same diagnosis
• Chronic condition resulting in high resource consumption (e.g. hemophilia, Gaucher’s Disease)
• ECHO requests
• Transfer to an MTF or network facility

This list is not all-inclusive and is subject to change. Any beneficiary with a complex case who may benefit from case management is eligible for an evaluation.

Discharge Planning

The patient care coordinator performs concurrent review and discharge planning. Discharge planning and case management services are automatically considered for all TRICARE beneficiaries in facilities in the South Region where Humana Military provides utilization management services. Discharge planning objectives include measures intended to:

• Minimize inappropriate use of hospital resources
• Evaluate acuity of the cases to project resources necessary to affect positive discharge planning
• Identify and use cost-effective care sites when clinically appropriate
• Prevent unnecessary admissions and/or avoid readmissions caused by incomplete course of treatment
• Locate and use all alternative sources of available funding
• Avoid either underutilization or overutilization of health care services

To help facilitate beneficiary reintegration following inpatient services and prevent hospital readmissions, Humana Military nurses will conduct post-discharge calls to beneficiaries with traumatic injuries, burns, high-risk obstetrics, back surgery, hip and knee replacements, and prolonged hospitalization of more than 20 days.

During these contacts, the nurse will explore (or confirm) family support and assistance at home, durable medical equipment needs, depression screening, understanding of medication, and transportation issues, and will encourage compliance with discharge instructions. Humana Military nurses will also educate the beneficiary on recognizing complications, help manage symptoms, monitor recovery, and ensure follow-up care is received as needed.
           

Retrospective Review

Retrospective review is conducted when a certain procedure or service requires a medical necessity review and authorization was not obtained prospectively. The review is performed under the direction of a registered nurse. Aspects of the retrospective review include the following:

• Inpatient medical necessity and appropriateness of level of care
• Medical necessity of surgical and other procedures that affect diagnosis-related group (DRG) assignment
• Potential quality problems associated with premature discharge identified by first-level review using InterQual® or behavioral health criteria and confirmed by physician review
• Behavioral health claims review, if present in the sample
• Discrepancies between the medical record and the claim in regard to diagnoses, procedures, and discharge status
• Discrepancies between the prospective review information and the medical record

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