TRICARE

TRICARE is a component of the Military Health System that was created in the early 1990s as a managed care program to better provide health care services for active duty service members, military retirees, and their families. TRICARE Management Activity (TMA) is the government entity under the Department of Defense (DoD) responsible for the management of TRICARE. TMA contracts with three managed care support contractors, one TRICARE dual-eligible fiscal intermediary contractor, and six designated providers who are enrolled in the US Family Health Plan. These contractors develop networks of health care providers to perform services outside of the military treatment facilities. MAXIMUS, the National Quality Monitoring Contractor (NQMC), provides the DoD with an independent, impartial evaluation of the care provided to the Military Health System TRICARE beneficiaries.

In 2004, HSAG subcontracted with MAXIMUS to assess, through chart review, the care provided to TRICARE beneficiaries at ambulatory surgery centers, hospitals, mental health and/or substance abuse facilities, and residential care facilities, and to determine whether this care complies with evidence-based standards. Additionally, benefit determination, medical necessity, and the quality of care received are addressed through the HSAG chart review process. When these evaluations determine that a quality-of-care concern exists, contracted providers are notified and given an opportunity to respond. Through this process, the NQMC provides contractors educational opportunities that improve the quality of care available to TRICARE beneficiaries.