Instructions:

When accessing this Guide from the CD-ROM:

1. Links to outside websites and CD-ROM Resources will open in 

the same browser window as this Guide. When accessing these 

links, use your browser’s “Back” button to return to this Guide. 

2. The CD-ROM Resources are saved as browser-viewable Adobe 

Acrobat PDF files and other native file formats from programs such 

as Microsoft Word, Excel, PowerPoint, etc. These programs must be 

installed on your computer for access.

A note about hyperlinks to outside websites: Links to outside websites found printed 

here are provided only as a convenience to assist you in locating information that may be 

helpful. You should note that changes may occur since the printing of this Guide which may 

affect the accuracy or availability of the referenced link. 

All contents © 2009 DoD/Office of the Chief Medical Officer (OCMO)/TRICARE Management 

Activity (TMA) and the various other organizations whose work is reproduced here.
Medical Management Guide Version 3.0 Executive Summary Page iii

Executive Summary

Secretary of Defense, along with Army, Navy, and 

Air Force Assistant Secretaries for Manpower and 

Reserve Affairs. MM-related measures (i.e., metrics) 

highlighted in the FY 2009 DHP Plan ( CD-ROM 

Resource ES-2) include:

• Beneficiary satisfaction with the health plan. 

• Inpatient production target (relative weighted 

products [RWP]).

• Outpatient production target (relative value 

units [RVUs]).

• Primary care productivity (RVUs per primary care 

provider per day).

• Medical cost per member per year.

LEGISLATIVE GUIDANCE

Under legislative mandates, the ASD (HA) 

submits an annual report to Congress 

regard­ing healthcare delivery for 9.4 million 

Military Health System (MHS) beneficiaries. The 

2009 report documents the MHS goal of providing 

high-quality care, improving perform­ance through 

clinical and process outcomes, and increasing 

patients’ confidence in the care they receive. 

Version 3.0 of the Guide draws more specifically 

from the Report to Congress on the Comprehensive 

Policy Improvements to the Care, Management and 

INTRODUCTION

T

he Department of Defense (DoD) TRICARE 

Management Activity (TMA) values all staff 

involved in the delivery of high-quality health 

care to DoD beneficiaries — Service members and 

their families. TMA is constantly working to provide 

the most current information to its partners in this 

effort.

The Medical Management Guide is issued by the 

Office of the Assistant Secretary of Defense for 

Health Affairs (ASD [HA]) and TMA, Office of the 

Chief Medical Officer (OCMO), Population Health 

and Medical Management Division (PHMMD). 

The Guide covers the components of a Medical 

Management (MM) program, including applicable 

principles, implementation concepts, processes, and 

tools/databases for Utilization Management (UM), 

Case Management (CM), and Disease Management 

(DM). It complements the 2001 DoD Population 

Health Improvement Plan and Guide published by 

TMA and the Government Printing Office (http://

www.tricare.mil/ocmo/download/mhs_phi_guide.

pdf, and CD-ROM Resource ES-1).

The ASD (HA) annually signs a five-year performance 

plan for the Defense Health Program (DHP) with the 
Page iv Executive Summary Version 3.0 Medical Management Guide

Transition of Recovering Service Members, released 

by the DoD and the Department of Veterans Affairs 

(VA) on Sept. 16, 2008 ( CD-ROM Resource ES3). That policy, developed in response to Title XVI, 

Sections 1611 and 1615 of the National Defense 

Authorization Act (NDAA) of 2008 ( CD-ROM 

Resource ES-4), focuses on improving healthcare 

delivery within Medical Treatment Facilities (MTFs) 

by addressing MM-related issues (Sec. 1611) and 

facilitating the transition of Service members from 

Active Duty status to civilian life (Sec. 1615).

The DoD/VA policy was based on the following 

findings and recommendations: 

• An Achievable Vision: Report of the Department 

of Defense Task Force on Mental Health (2007) 

( CD-ROM Resource ES-5)

• Rebuilding the Trust: The Independent Review 

Group on Rehabilitative Care and Administrative 

Processes at Walter Reed Army Medical Center 

and National Naval Medical Center (2007) 

( CD-ROM Resource ES-6)

• The Secretary of Veterans Affairs Task Force on 

Returning Global War on Terror Heroes (2007) 

( CD-ROM Resource ES-7)

• Serve, Support, Simplify: The President’s 

Commission on Care for America’s Returning 

Wounded Warriors (2007) ( CD-ROM 

Resource ES-8)

• Honoring the Call to Duty: Veterans’ Disability 

Benefits in the 21st Century (Veteran’s Disability 

Benefits Commission, 2007) ( CD-ROM 

Resource ES-9)

• The President’s Task Force to Improve Health 

Care Delivery for Our Nation's Veterans (2003) 

( CD-ROM Resource ES-10)

• The Report of the Congressional Commission 

on Service Members and Veterans Transition 

Assistance (1999) ( CD-ROM Resource ES-11)

• The President’s Commission on Veterans’ 

Pensions (1956) ( CD-ROM Resource ES-12)

More specifically, the DoD/VA policy reflects the 

overarching theme of the report Rebuilding the 

Trust: The Independent Review Group (IRG) on 

Rehabilitative Care and Administrative Processes 

at Walter Reed Army Medical Center and National 

Naval Medical Center, which recommends 

permanent changes in MM administration as the 

most effective way to promote treatment for 

wounded, ill, and injured Service members returning 

from the Afghanistan and Iraq theaters — Operation 

Enduring Freedom (OEF) and Operation Iraqi 

Freedom (OIF), respectively. (See also Appendix C, 

Definitions, Global War on Terrorism [GWOT] and 

Overseas Contingency Operations [OCO].)

DESCRIPTION OF GUIDE CONTENTS 

T

he Guide is organized as follows:

Section I, Medical Management 

Essentials, describes crucial components of 

MM within the MHS, including the link between MM 

and Population Health and the dynamics between 

UM, CM, and DM in helping reduce unnecessary or 

inappropriate services and/or duplication of services. 

This section also looks at universally applicable MM 

considerations, such as the utilization of information 

technology and how to protect the privacy of 

personal health information (PHI).
Medical Management Guide Version 3.0 Executive Summary Page v

Section II, Utilization Management, discusses 

the application of UM within the Direct Care System 

(DCS). It provides information on the structure 

and processes needed to develop and implement 

an effective UM program, including a seven­-step 

process for quality improvement (QI). It also contains 

subsections on Utilization Review (UR), decision support tools, and Referral Management (RM). Further, 

it provides guidance on implementing the MTF 

review and appeals process and includes a variety 

of useful tools, such as sample job descriptions and 

a completed MTF UM plan. As in the CM and DM 

sections, it includes a subsection describing how 

patient outcomes are measured, with examples of 

potential measures. 

Section III, Case Management, discusses the 

MTF approach to CM. In the mili­tary setting, CM 

targets Active Duty Service members (ADSMs) and 

beneficiaries with complex, multi-system healthcare 

needs and family members with special needs 

who require care coor­dination or CM services. 

This section focuses on the most current legislative 

priorities for CM in the MHS, including a more 

integrated approach to physical and psychological 

rehabilitation, and recovery coordination and 

transition activities. Further, it provides information 

on the structure and processes needed to develop 

and implement an effective CM program, including 

key process steps, dis­charge planning and care 

coordination, and guidance on establishing local 

CM programs. As in the UM and DM sections, 

it includes a subsection describing how patient 

outcomes are measured, with examples of potential 

measures. 

Section IV, Disease Management, discusses 

DM within the DCS. DM employs evidencebased medicine to guide health care for patient 

populations with common chronic diseases 

or conditions (e.g., dia­betes, asthma). When 

implemented effectively, DM can improve patient 

satisfaction and quality of life, and reduce med­ical 

costs. This section includes information on clinical 

practice guidelines (CPGs) as an impor­tant DM 

tool and provides guidance on establishing a DM 

program. As in the UM and CM sections, it includes 

a subsection describing how patient outcomes are 

measured, with examples of appropriate measures.

Section V, Medical Management Tools, describes 

current information systems, data marts, tools, and 

applications used within the MHS that can help MM 

staff evaluate the effectiveness of their programs. 

Appendices

• Appendix A lists specific and general references 

by section, as applicable.

• Appendix B provides a list of common acronyms 

related to MM in the MHS.

• Appendix C provides a list of common 

definitions related to MM in the MHS.

• Appendix D lists MM-related resources (e.g., 

organizational websites, journals). 

The Guide is available in hard copy, on CD-ROM, 

or as a download from the PHMM Division Support 

Center website: http://www.tricare.mil/ocmo/

OCMO_PHMM.cfm.

All contents © 2009 DoD/Office of the Chief 

Medical Officer (OCMO)/TRICARE Management 

Activity (TMA) and the various other organizations 

whose work is reproduced here.
Page vi Executive Summary Version 3.0 Medical Management Guide

CONTACT INFORMATION

Assistant Secretary of Defense, Health Affairs/

TRICARE Management Activity

Office of the Chief Medical Officer

Population Health and Medical Management 

Division

5111 Leesburg Pike

Suite 810

Falls Church, VA 22041 

COMM: (703) 681-0064

DSN 761-0064

FAX: (703) 681-1242

CD-ROM RESOURCES

ES-1 DoD TMA Population Health Improvement 

Plan and Guide (2001)

ES-2 DoD Defense Health Plan (DHP) 2009 

Highlights

ES-3 Report to Congress on the Comprehensive 

Policy Improvements to the Care, 

Management and Transition of Recovering 

Service Members (Sept. 16, 2008)

ES-4 National Defense Authorization Act (NDAA) 

of 2008, Title XVI, Sections 1611 and 1615

ES-5 An Achievable Vision: Report of the 

Department of Defense Task Force on 

Mental Health (2007) 

ES-6 Rebuilding the Trust: The Independent 

Review Group (IRG) on Rehabilitative Care 

and Administrative Processes at Walter Reed 

Army Medical Center and National Naval 

Medical Center (2007)

ES-7 The Secretary of Veterans Affairs Task Force 

on Returning Global War on Terror Heroes

(2007)

ES-8 Serve, Support, Simplify: The President’s 

Commission on Care for America’s 

Returning Wounded Warriors (2007)

ES-9 Veteran’s Disability Benefits Commission, 

Honoring the Call to Duty: Veterans’ 

Disability Benefits in the 21st Century (2007)

ES-10 The President’s Task Force to Improve Health 

Care Delivery for Our Nation's Veterans

(2003)

ES-11 The Report of the Congressional 

Commission on Service Members and 

Veterans Transition Assistance (1999)

ES-12 The President’s Commission on Veterans’ 

Pensions (1956)

‘
Medical Management Guide Version 3.0 Acknowledgements Page vii

Version 3.0 of the Medical Management Guide was 

prepared by the Population Health and Medical 

Management Division (PHMMD) in collaboration 

with the Tri-Service Medical Management Working 

Group. Service subject matter experts (SMEs) in 

Utilization Management (UM), Case Management 

(CM), and Disease Management (DM), as well as 

healthcare administrators, contributed valuable input 

toward ensuring a complete and current product. 

A special thanks to the many healthcare 

professionals across the Military Health System 

(MHS) who provided critical feedback on the final 

draft. Technology, Automation and Management 

(TeAM), Inc. provided professional technical, 

editorial, training, and graphics expertise in revising 

the Guide, developing accompanying Web-based 

learning modules, and designing appropriate 

graphical elements.

TRICARE Management Activity Population 

Health and Medical Management Division 

Patricia Dorn, CAPT, NC, USN

Teresa M. Long, DHSc, MPA, BSN, CCM

Army 

Catherine A. Mozden, COL, AN

Carla M. Dickinson, MAJ, AN

Pamela S. Birgenheier, MN, RN, CCP

Marjory K. Waterman, MN, RN

Betty I. Thomas, MS, RN

Patricia W. McGregor, RN, CPHQ

Judy C. Terry, MN, RN

Navy 

Annette M. Von Thun, CDR, MC

Mary B. Greenberg, CDR, NC

Laurie S. MacGillivray, CDR, NC

Moise Willis, CDR, NC

Vanessa D. Richards, LCDR, NC

Anne M. Cobb, RNC, MSN, CMAC

Susan R. Blankenship, MS, BSN, RN, CCM

Lisa J. Cockran, RN, CCP, NHC

Joan I. McLeod, RN, MGA

Leanne M. Repko, MPP

Acknowledgements
Page viii Acknowledgements Version 3.0 Medical Management Guide

Air Force 

Carol Andrews, Lt Col, NC

Deona J. Eickhoff, Lt Col, NC

Sabrina M. Preston-Leacock, Lt Col, NC

Melanie A. Prince, Lt Col, NC

Brij B. Sandill, Lt Col, NC

Tammy R. Tenace, Lt Col, NC

Iwona E. Blackledge, Maj, NC

Shawn Dunne, Maj, NC

Karyn L. Revelle, Maj, NC

Paula M. Winters, Maj, NC

Sherry A. Herrera, MSN, NE-BC, CPUM, CMAC

Beverly K. Luce, MHSA, BSN, RN, CCM

U. S. Department of Veterans Affairs

Karen M. Ott, RN, MSN

Industry

Terry Kelley, BSN, RN, CCM — Case Management 

Society of America

Contractor Support 

Technology, Automation and Management 

(TeAM), Inc.

• Charles G. Davis, CEO, Program Manager

• Anne F. Cook, Technical Writer/Editor

• Keira R. Thrasher, Senior Curriculum Developer

• Syreeta M. Collier, Logistics Coordinator

• Valerie Thompson, Graphic Designer

Military Patient Centered Medical 

Home Model

This model was used with permission from and 

was created by the National Naval Medical Center 

Patient Centered Medical Home and by CDR Kevin 

Dorrance, USN, MC.

Cover Photo

Source: http://www.defenseimagery.mil/

Photographer: MSgt Steve Cline

‘
Medical Management Guide Version 3.0 Page ix

 Executive Summary.....................................................................................................................................

Introduction ...........................................................................................................................................................

Legislative Guidance ...............................................................................................................................................

Description of Guide Contents................................................................................................................................

Contact Information ...............................................................................................................................................

CD-ROM Resources................................................................................................................................................

 Acknowledgements ...........................................................................................................................................

 Section I – Medical Management Essentials..........................................................................................

Introduction ...........................................................................................................................................................

Definition of Medical Management..................................................................................................................

Primary Care Management Team Approach .....................................................................................................

Policy Requirements for Medical Management within the Direct Care System...................................................

Medical Management Goals and Approach......................................................................................................

The Link between Medical Management and Population Health .............................................................................

Population Health Elements in Action...............................................................................................................

TRICARE and Other Benefit Programs.....................................................................................................................

Working with Managed Care Support Contractors...........................................................................................

The Link between Clinical and Business Operations.................................................................................................

Integrating Utilization, Case, and Disease Management Functions...........................................................................

Staffing for Combined Functions......................................................................................................................

Essential Considerations for Medical Management Staff .........................................................................................

Benefitting from Information Technology .........................................................................................................

Privacy and Confidentiality of Patient Information.............................................................................................

Program Sustainment .............................................................................................................................................

Summary................................................................................................................................................................

CD-ROM Resources................................................................................................................................................

Table Of Contents

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 Section II – Utilization Management......................................................................................................

Introduction ...........................................................................................................................................................

Definition, Goals, and Purpose .........................................................................................................................

Utilization Management Components ..................................................................................................................

The Seven-Step Quality Improvement Process...................................................................................................

Identify the Purpose ..................................................................................................................................

Determine What to Measure......................................................................................................................

Determine the Gaps ..................................................................................................................................

Attempt to Fix the Problem(s) ....................................................................................................................

Determine the Effectiveness of the Corrective Action.................................................................................

Make Additional Attempts to Fix the Problem(s).........................................................................................

Learn from the Quality Improvement Process.............................................................................................

Utilization Review ............................................................................................................................................

Types of Review.........................................................................................................................................

Outcome Measurement and Management.......................................................................................................

McKesson® InterQual® ...............................................................................................................................

Milliman Care Guidelines®.........................................................................................................................

Provider Profiling..............................................................................................................................................

Referral Management ......................................................................................................................................

Referral Management Center.....................................................................................................................

Active Duty Service Member Referrals........................................................................................................

Authorization ............................................................................................................................................

Episode of Care .........................................................................................................................................

The Electronic Referral Process...................................................................................................................

Utilizing Military Treatment Facility Capability and Right of First Refusal Reports.........................................

Additional Information...............................................................................................................................

The Grievance and Appeal Process...................................................................................................................

Overview...................................................................................................................................................

Grievances.................................................................................................................................................

Appeals.....................................................................................................................................................

Risk Management............................................................................................................................................

Utilization Management Program Accreditation......................................................................................................

The Utilization Management Professional................................................................................................................

Qualifications...................................................................................................................................................

Staffing to Support Utilization Management ....................................................................................................

Summary................................................................................................................................................................

 CD-ROM Resources ..........................................................................................................................................

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 Section III – Case Management ...........................................................................................................

Introduction ........................................................................................................................................................

Definition, Goals, and Purpose .........................................................................................................................

Philosophy ......................................................................................................................................................

The Military Case Manager ..............................................................................................................................

Case Management Components ...........................................................................................................................

Beneficiary Identification/Case Finding .............................................................................................................

Triggers for Potential Referral.....................................................................................................................

Case Screening ................................................................................................................................................

Case Selection .................................................................................................................................................

The Six-Step Case Management Process...........................................................................................................

Assessment ...............................................................................................................................................

Planning....................................................................................................................................................

Implementation.........................................................................................................................................

Coordination .............................................................................................................................................

Monitoring................................................................................................................................................

Evaluation .................................................................................................................................................

Case Closure....................................................................................................................................................

Documentation................................................................................................................................................

Outcome Measurement and Management.......................................................................................................

Patient Outcome Evaluation.......................................................................................................................

Program Outcome Evaluation ....................................................................................................................

Establishing a Case Management Program ..........................................................................................................

Organizational Framework ...............................................................................................................................

Goals...............................................................................................................................................................

Implementation ...............................................................................................................................................

Quality ......................................................................................................................................................

Caseload ...................................................................................................................................................

Discharge Planning ....................................................................................................................................

Care Coordination.....................................................................................................................................

Accreditation ...................................................................................................................................................

Promoting Your Program..................................................................................................................................

Legislative Guidance Specific to Integrating Physical and Psychological Rehabilitation...........................................

Disability Evaluation System..............................................................................................................................

Medical Evaluation Board ..........................................................................................................................

Physical Evaluation Board...........................................................................................................................

Other Types of Evaluation .......................................................................................................................................

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Recovery Coordination Initiatives ............................................................................................................................

Federal Recovery Coordination Program...........................................................................................................

Recovery Care Coordinators.......................................................................................................................

Transition/Coordination of Care ..............................................................................................................................

Transition of Care.............................................................................................................................................

Service-Specific Care Transition Programs...................................................................................................

Inter/Intra-Regional Transfer.......................................................................................................................

Aeromedical Evacuation ............................................................................................................................

Coordination of Care .......................................................................................................................................

Coordination from the Military Health System to the Department of Veterans Affairs.................................

Coordination for Active Duty Service Members in the TRICARE Prime Remote Program .............................

Coordination for Exceptional Family Member Program and Special Needs Families .....................................

Transition/Coordination Challenges..................................................................................................................

Other Types of Transition/Coordination ............................................................................................................

Outside the Continental United States and TRICARE Global Remote Overseas Program..............................

The Case Management Professional .......................................................................................................................

Qualifications...................................................................................................................................................

Education and Experience Requirements....................................................................................................

Certification ..............................................................................................................................................

Ethical Practice Standards ..........................................................................................................................

Resources for Orienting and Training the New Case Manager...........................................................................

Summary................................................................................................................................................................

CD-ROM Resources................................................................................................................................................

 Section IV – Disease Management .........................................................................................................

Introduction ...........................................................................................................................................................

Definition, Goals, and Purpose .........................................................................................................................

The Current State of Disease Management.......................................................................................................

Managing Chronic Disease in the Military Health System ...........................................................................

Employer-Funded Health Plans...................................................................................................................

Cost Savings for Disease Management.......................................................................................................

 Disease Management Components .......................................................................................................................

Population Identification Processes...................................................................................................................

Evidence-Based Clinical Practice Guidelines ......................................................................................................

Fundamentals............................................................................................................................................

Department of Defense/Department of Veterans Affairs Clinical Practice Guidelines...................................

National Guideline ClearinghouseTM...........................................................................................................

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U.S. Preventive Services Task Force.............................................................................................................

Collaborative Practice Models...........................................................................................................................

Patient Self-Management Education.................................................................................................................

Process and Outcome Measurement, Evaluation, and Management..................................................................

Clinical Quality Measures...........................................................................................................................

Feedback and Reporting ..................................................................................................................................

Stakeholder Reporting...............................................................................................................................

Establishing a Disease Management Program ......................................................................................................

Implementing a Disease Management Plan ......................................................................................................

Assess the Target Population .....................................................................................................................

Assemble a Team ......................................................................................................................................

Adopt Guidelines and Protocols.................................................................................................................

Establish Goals and Target Outcomes ........................................................................................................

Create a Prioritized Plan and Implement the Plan .......................................................................................

Collect and Analyze Outcomes Data ..........................................................................................................

Evaluate and Refine the Program ...............................................................................................................

Accreditation.............................................................................................................................................

The Disease Management Professional ................................................................................................................

Qualifications...................................................................................................................................................

Certification.....................................................................................................................................................

Summary.............................................................................................................................................................

CD-ROM Resources.............................................................................................................................................

 Section V – Medical Management Tools ...........................................................................................

Introduction ........................................................................................................................................................

Using Information Systems and Data Marts .........................................................................................................

Accessing the Data...........................................................................................................................................

Understanding the Methodology and Limitations.............................................................................................

Data Quality Concerns .....................................................................................................................................

Information Systems And Data Marts ................................................................................................................

 Military Health System-Level Decision Support Tools and Executive Information Systems...............................

Armed Forces Health Longitudinal Technology Application...............................................................................

Executive Information and Decision Support.....................................................................................................

Tools for Utilization, Case, and Disease Management Collaboration .....................................................................

TRICARE Management Activity Reporting Tools .............................................................................................

Health Assessment Review Tool .......................................................................................................................

MHS Insight.....................................................................................................................................................

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Prospective Payment System ............................................................................................................................

Protected Health Information Management Tool ..............................................................................................

Service-Level Information Systems ..........................................................................................................................

Army ...............................................................................................................................................................

Navy ................................................................................................................................................................

Air Force ..........................................................................................................................................................

Business Planning Tools ..........................................................................................................................................

Tri-Service Business Plans..................................................................................................................................

CD-ROM Resources................................................................................................................................................

 Appendix A – References..........................................................................................................................

Appendix B – Acronyms ............................................................................................................................

 Appendix C – Definitions ..........................................................................................................................

 Appendix D – Resources............................................................................................................................

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Medical Management Guide Version 3.0 Page xv

Table Of Figures

 Section I – Medical Management Essentials

Fig. 1 – Military Medical Home Model.................................................................................................................

Fig. 2 – MHS Medical Management Model..........................................................................................................

Fig. 3 – MHS Population Health Model (2006).....................................................................................................

Fig. 4 – Integrated Medical Management Model (IM3) ........................................................................................

Fig. 5 – Distinctions between UM, CM, and DM..................................................................................................

Fig. 6 – Questions to Consider when Creating an Integrated MM Program ..........................................................

 Section II – Utilization Management

Fig. 7 – Utilization Management within the MHS Integrated MM Model (IM3).....................................................

Fig. 8 – Seven-Step Quality Improvement Process ................................................................................................

Fig. 9 – Sample UM Data Elements or Measures..................................................................................................

Fig. 9 (cont.) – Sample UM Data Elements or Measures ......................................................................................

Fig. 10 – TRICARE Referrals/Preauthorizations/Authorizations..............................................................................

Fig. 11 – MTF Review and Appeal Process: Internal Review ..................................................................................

Fig. 11 (cont.) – MTF Review and Appeal Process: Internal Review/Appeal............................................................

Fig. 11 (cont.) – MTF Review and Appeal Process: External Appeal.......................................................................

 Section III – Case Management

Fig. 12 – Case Management within the Integrated MM Model (IM3) ...................................................................

Fig. 13 – Chronic Care Management Model ........................................................................................................

Fig. 14 – Military-Specific Designations, Programs, and Offices............................................................................

Fig. 15 – Potential Sources for Case Finding.........................................................................................................

Fig. 16 – The Six-Step CM Process .......................................................................................................................

Fig. 17 – Categories of Assessment .....................................................................................................................

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Fig. 18 – Sample Patient and Program Evaluation Outcomes...............................................................................

Fig. 19 – Example of Outcomes Classification: Patient-Related ............................................................................

Fig. 20 – Example of Outcomes Classification: Healthcare Organization-Related .................................................

Fig. 21 – Examples of CM Measures...................................................................................................................

Fig. 22 – CM Hard and Soft Savings...................................................................................................................

Fig. 23 – Disability Evaluation System (DES) ........................................................................................................

Fig. 24 – Recovery Coordination Program...........................................................................................................

Fig. 25 – New Roles for CM in the NDAA...........................................................................................................

Fig. 26 – Aeromedical Evacuation (AE)................................................................................................................

 Section IV – Disease Management

Fig. 27 – Disease Management within the Integrated Medical Management Model............................................

Fig. 28 – VA/DoD Clinical Practice Guidelines .....................................................................................................

Fig. 29 – HEDIS® Domains of Care......................................................................................................................

Fig. 30 – HEDIS® Effectiveness of Care Measure Topics.......................................................................................

Fig. 31 – Healthy People 2010 (HP 2010) Leading Health Indicators.....................................................................

Fig. 32 – MHS CQM Fact Sheets.........................................................................................................................

Fig. 33 – The PDCA Cycle...................................................................................................................................

Fig. 34 – Questions to Ask During Development of a DM Program .....................................................................

Fig. 35 – The Phases of Implementing a Disease Management Plan ....................................................................

Fig. 36 – Example of an Interdisciplinary Healthcare Team ..................................................................................

 Section V — Medical Management Tools

Fig. 37 – Summary of Data Systems for Use in MM ............................................................................................

Fig. 38 – MHS Data Repository...........................................................................................................................

Fig. 39 – Sample MTF Enrollment Template ........................................................................................................

Fig. 40 – Sample MTF Inpatient Demand and Workload Template ......................................................................

Fig. 41 – Sample MTF Outpatient Demand and Workload Template....................................................................

Fig. 42 – Sample MTF Manpower Template ..............................................................................................................

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Medical Management Guide Version 3.0 Medical Management Essentials Page 

Medical Management Essentials

I

SECTION

INTRODUCTION

Definition of Medical Management

I

n the healthcare industry, organizations have 

established programs or systems to improve 

clinical outcomes and manage rising healthcare 

costs. This is broadly referred to as the field of 

“Medical Management” (MM). 

The 2006 Department of Defense Instruction (DoDI) 

6025.20, Medical Management (MM) Programs in 

the Direct Care System (DCS) and Remote Areas 

( CD-ROM Resource MME-1, and http://www.

dtic.mil/whs/directives/corres/pdf/602520p.pdf) 

defines MM as an “integrated managed care model 

that promotes Utilization Management (UM), Case 

Management (CM), and Disease Management (DM) 

programs as a hybrid approach to managing patient 

care.” MM includes a shift to evidence-based, 

outcome-oriented programs that place “a greater 

emphasis on integrating clinical practice guidelines 

into the MM process, thereby holding the system 

accountable for patient outcomes” (DoDI 6025.20). 

This guide provides specific, how-to guidance on 

establishing MM programs within Military Treatment 

Facilities (MTFs) in accordance with the DoD 

instruction.

The three components of MM are commonly 

defined as follows:

• Utilization Management: An organization-wide, 

interdisciplinary approach to balancing cost, 

quality, and risk concerns in the provision of 

patient care. UM is an expansion of traditional 

Utilization Review (UR) activities to encompass 

the management of all available healthcare 

resources, including Referral Management (RM).

• Case Management: A collaborative process 

under the Population Health continuum that 

assesses, plans, implements, coordinates, 

monitors, and evaluates options and services 

to meet an individual’s health needs through 

communication and available resources to 

promote quality, cost-effective outcomes.

• Disease Management: An organized effort to 

achieve desired health outcomes in populations 

with prevalent, often chronic diseases for 

which care practices may be subject to 

considerable variation. DM programs use 

evidence-based interventions to direct patient 

care. DM programs also equip the patient with 

information and a self-care plan to manage 

his/her own health and prevent complications 

that may result from poor control of the disease 

process. The term “condition management” 

includes non-disease states (e.g., pregnancy). 

See also Appendix C, Definitions.
Page 2 Medical Management Essentials Version 3.0 Medical Management Guide

Both patients and MTF leadership have been driving 

forces for more efficient, effective, and integrated 

MM programs in the following ways:

• In today’s healthcare arena, patients are more 

informed and empowered consumers. As 

a result, they demand more choice in their 

healthcare benefits than ever before.

• MTF leadership strives to control rising 

healthcare costs, demonstrate return on 

investment (ROI), and ensure that patients are 

provided with safe, quality care. MTF leadership 

is key to providing the organizational structure, 

appropriate resources, and necessary expertise 

to ensure the success of any MM program.

Primary Care Management Team Approach

Primary care in the MHS revolves around the role of 

the Primary Care Manager (PCM) — this PCM model 

is built on the documented value of patients, with 

consistent access to comprehensive primary care, 

achieving better health outcomes, improved patient 

experience, and more efficient use of resources. In 

this model, each patient has an ongoing relationship 

with a personal primary care provider trained to 

provide continuous and comprehensive care. 

While the MHS primary care system is ultimately 

supervised and led by a PCM, the concept of a team 

of healthcare professionals, under the leadership 

of the credentialed provider team leader, is widely 

accepted and highly valued as a key component of 

the MHS culture. The PCM model in the MHS has 

been expanded to include the concept of a PatientCentered Medical Home (PCMH), as illustrated in 

Fig. 1. In the PCMH, patients have a continuous 

relationship with a medical home that offers stability 

and continuity of care as well as serving as the point 

of first contact when problems or questions arise. 

MM is an integral part of the PCM model and PCMH 

team approach to patient care. Case managers assist 

the PCM team in coordinating, communicating, 

and integrating care. Disease managers assist the 

team in consistently implementing evidenced-based, 

clinical-based guidelines. Utilization managers assist 

the team in the optimal allocation of scarce medical 

resources within the medical home.

The successful appli­cation of MM activities within 

MTFs is geared toward achieving the primary target 

goals of improving access and quality, managing 

cost, and optimizing readiness. 

In addition to applying to the civilian-based 

Purchased Care System (PCS), MM traverses the 

Direct Care System (DCS), which encompasses Army, 

Air Force, and Navy facilities in the North, South, 

and West regions of the United States; and overseas 

in the designated region Outside of the Continental 

United States (OCONUS). MTF staff work closely 

with their Contracting Officer’s Representative/

Contracting Officer’s Technical Representative (COR/

COTR) to help ensure that MTF activities are closely 

coordinated to meet patient needs. Fig. 2 depicts the 

MHS MM model. 
Medical Management Guide Version 3.0 Medical Management Essentials Page 

PERSONAL PHYSICIANS

CONTINUOUS RELATIONSHIP

Military Health Services

 Medical Management Model

Fig. 1 – Military Patient Centered Medical Home Model

WHOLE

PERSO

N

O

RIEN

TAT

OI N

Team-Based

Healthcare Delivery

• Creation of Clinical Micropractices

• Appropriate utilization of medical 

 personnel

• Improve communication among team

 members Access to Care

• Improve phone and electronic appt

 scheduling

• Open access for acute care

• Emphasis on coordination of care

• Proactive appointing for chronic and

 preventive care

Advanced IT Systems

• Secure mode of e-communication

• Creation of educational portal

• Reminders for preventive care

• Easy, efficient tracking of population 

 data

Population

Health

• Emphasis on preventive care

• Form basis of productivity measures

• Evidence-based medicine at the point

 of care

Patient-Centered Care

• Empower active patient participation

• Seamless communications

• Encourage patient participation in 

 process improvement

Refocused Medical

Training

• Emphasize health team leadership

• Incorporate patient-centered care

• Focus on quality indicators Patient & Physician • Evidence-based practice

Feedback

• Real-time data

• Performance reporting

• Patient feedback

• Partnership between patients and care 

 teams to improve care delivery

Decision Support Tools

• Evidence-Based Training

• Integrated Clinical Guidelines

• Decision Support Tools at the point of

 care

Military

Medical

Home

PATIEN

T-CEN

TER

E

D

CARE

Fig. 2 – MHS Medical Management Model
Page  Medical Management Essentials Version 3.0 Medical Management Guide

Policy Requirements for Medical Management 

within the Direct Care System

DoDI 6025.20 defines terms for MM, implements 

policies, assigns responsibilities, and specifies 

content for component activities within the MTF. 

It also codifies support for an interdependent MM 

system between the DCS and Purchased Care 

System (PCS). The instruction outlines the following 

minimal requirements:

Medical Management (General) 

• Designate one individual to be responsible for 

the facility’s MM program. 

• Establish an integrated MM plan and program 

using the quality improvement approach.

Utilization Management 

• Use systematic, data-driven processes to a) 

proac­tively define referral patterns for focused 

inter­ventions and b) identify and improve clinical 

and business outcomes. 

• Incorporate UR activities using the same generally accepted standards and criteria for medical 

necessity, appropriateness, and reasonableness 

when reviewing the quality, completeness, and 

adequacy of health care provided within the 

MTF. 

• Adhere to the established MTF review and 

appeal process. 

• Establish a referral and authorization management process for internal and external referrals 

in accordance with MHS policies. 

• Establish a solid relationship with the Managed 

Care Support Contractor (MCSC) — see 

TRICARE and Other Benefit Programs, 

Working with Managed Care Support 

Contractors, later in this section.

• Establish processes to monitor, man­age, and 

optimize access to care within the MTF (e.g., 

to meet demand and access standards by 

maximizing use of template management tools). 

• Encourage collaboration and communication 

among all MM staff, including clinical and business personnel, to promote efficient, effective, 

and high-quality care and services. 

Case Management 

• Use CM to manage the health care of patients 

with multiple, complex, chronic, and/or

cat­astrophic illnesses or known conditions that 

meet CM criteria.

• Provide the appropriate level of care (e.g., care 

coordination, discharge planning) for individuals 

requiring special assistance (e.g., wounded 

warriors). 

• Coordinate the transfer of information with 

MCSC CMs when patients require CM outside 

the DCS. 

• Encourage case managers to communicate with 

all members of the healthcare team, especially 

with other MM personnel.

• Use CM to promote a seamless transition from 

one duty station to the next for families enrolled 

in the Exceptional Family Member Program 

(EFMP) and Special Needs Identification and 

Assignment Coordination (SNIAC) programs, 

and who are also enrolled in a CM program.

Disease Management 

• Assess the population to determine the 

need for specific DM programs by evaluating 

MTF Population Health data through various 

information systems. 
Medical Management Guide Version 3.0 Medical Management Essentials Page 5

• Use evidence-based tools such as clinical practice 

guidelines (CPGs) as part of the DM program, 

after designated local MTF authorities have 

reviewed and approved them.

o CPGs are systematically developed, nationally 

recognized statements that help practitioners 

and beneficiaries make appropriate decisions 

about healthcare services, depending on 

clinical circumstances. 

o It is important to note that while CPGs are 

most frequently discussed as a tool for DM, 

they are also an integral resource for all MM 

pro­grams. 

• Monitor CPG outcomes and compliance to 

identify practice pattern variances and trends. 

• Collaborate with other MTF and MCSC MM 

staff to promote consistent program goals and 

continuity of care. 

Medical Management Goals and Approach

MM emphasizes the integration of evidence-based 

practices, including CPGs, and focuses on holding 

healthcare systems accountable for optimizing 

patient outcomes. Specifically, the universal goals of 

MM include the following:

• Improve patient outcomes through coordinated/

integrated practices. 

• Incorporate the goals of UM, CM, and DM.

• Provide more efficient approaches to healthcare 

delivery.

• Shift the focus from cost containment to 

continuous quality improvement.

• Recognize the dynamic of MM components 

within the Population Health continuum (see 

Fig. 4, Integrated Medical Management Model 

[IM3]).

In the MHS, the MM “umbrella” comprises UM, CM, 

and DM as a three-pronged strategy to accomplish 

these goals. Based on data analysis, MTFs may 

implement programs for specific care situations 

or chronic conditions. For example, when applied 

appropriately:

• UM may reduce overutilization of either the 

Emer­gency Department (ED) or inpatient setting 

by iden­tifying patients with chronic diseases 

(e.g., asthma) that have a significant impact on 

healthcare out­comes and costs.

• CM can be used to assist patients with multiple 

co-morbid diseases or special healthcare needs 

(e.g., exceptional family members, complex 

patients, wounded warriors) and develop 

interdisciplinary plans to meet those needs.

• DM may minimize complications in those with 

a particular chronic disease and help mitigate 

the long-term consumption of healthcare 

resources for a specific population. Along with 

case managers, disease managers can provide 

important health education and advocacy by 

helping patients adhere to their treatment plans 

and gain control over and responsibility for their 

own health care.
Page  Medical Management Essentials Version 3.0 Medical Management Guide

The MM approach in the health industry has 

evolved rapidly in recent years. This evolution can be 

attributed to several factors, including:

• The desire to increase the effectiveness of 

patient-provider relationships and improve 

clinical outcomes. 

• Greater demand to contain costs and improve 

return on investment (ROI) (i.e., to demonstrate 

value).

• The need to improve technology and 

communication to facilitate data collection, 

analysis, and information sharing (Utilization 

Review Accreditation Commission [URAC], 

2005).

• The need to fulfill regulatory and legislative 

mandates per the Code of Federal Regulations 

(CFR).

MM policy and programs built from high-quality 

data collection, proper analysis, interpretation, 

dissemination, and outcome measurement ensure 

better clinical outcomes and improved quality of 

care for MHS beneficiaries. Cohen and Cesta (2001) 

cite three major types of outcome that are measured 

in healthcare systems: 

• High-quality care – Measured by complications, 

readmission rates, morbidity and mortality, and 

patient satisfaction. These quality measures 

(i.e., metrics) reflect greater accountability on 

the part of healthcare providers to patients and 

other stakeholders. 

• Decreased or appropriate costs – Include 

measures such as length of hospital admission, 

avoidable admission days, decrease in ED 

visits, and decrease in excessive utilization 

of outpatient appointments. In military CM, 

appropriate costs are also measured by retaining 

care in the DCS (i.e., MTFs) if the capability and 

capacity exist. This outcome relates directly to a 

MTF’s business plan.

• Improved health status — Often measured 

through surveys that examine how a patient 

perceives the impact of health on quality of life. 

Other measures may include functional health 

status, reduction or elimination of symptoms, 

resumption of employment, or improved coping 

mechanisms.

It should be noted that many of the same resources 

used to calculate corporate outcome measures are 

available to MM teams at the MTF level. Further, 

healthcare teams should be apprised of and aligned 

with other quality and outcome measure sets that 

fall under the rubric of Quality Management (QM). 

One particular example is quality measures for 

perinatal care. MTF performance for obstetrical 

surgery, complications, post-partum readmissions, 

and neonatal mortality rates is tracked using the 

National Perinatal Information Center (NPIC) dataset 

for comparison across both the MHS and civilian 

facilities. Other sources for quality measures include 

the National Surgical Quality Improvement Program 

(NSQIP) and the Anesthesia Report and Monitoring 

Panel (ARMP). Local QM representatives should be 

able to provide greater detail on which measures 

and data sources are tracked at a specific MTF. 

(Section II, Utilization Management; Section 

III, Case Management; and Section IV, Disease 

Management each offer detailed discussions of 

outcome measurement.)
Medical Management Guide Version 3.0 Medical Management Essentials Page 

THE LINK BETWEEN MEDICAL 

MANAGEMENT AND POPULATION HEALTH

T

he link between MM and Population Health 

is an important one, with the trend in recent 

years for organizations to incorporate total 

Popula­tion Health tech­niques as part of their MM 

programs. Four Population Health concepts specific 

to military medical care are:

• Maintain a fit and healthy Active Duty 

population (which affects readiness).

• Improve the health status of the enrolled 

population.

• Improve the efficiency and effectiveness of the 

MTF healthcare delivery system.

• Improve the military community population 

health status. 

In order to incorporate Population Health 

techniques, MM and Population Health staff need 

to evaluate the current health practices of MTF 

enrollees and identify opportunities to improve 

the health of that beneficiary population. The key 

Population Health process elements listed below 

relate directly to MM: 

1. Population Identification and Assessment

2. Demand Forecasting

3. Demand Management

4. Capacity Management

5. Evidence-based Care and Prevention

6. Program Evaluation and Feedback

Fig. 3 illustrates the relationship between Population 

Health elements and environmental influences 

within the military community.

Fig. 3 – MHS Population Health Model (2001)
Page 8 Medical Management Essentials Version 3.0 Medical Management Guide

Because many of the process steps are similar, 

Population Health and MM staff often collaborate 

on developing, reviewing, and meeting pro­gram 

goals. 

For example:

• UM activities focus on the four Population 

Health principles of defining the population, 

applying epidemiological methods to describe 

the population and its risks, identifying and 

employing evidence-based interventions, and 

managing information — all in the interest of 

supporting ongoing assessment, planning, and 

performance monitoring/improvement. 

• Population-based CM coordinates care and 

services for groups with similar characteristics. 

Case managers are responsible for “managing 

health, illness, prevention, and coordination 

of care and services, including during acute 

episodes or hospitalization.” The case 

manager’s role is to “develop and manage a 

comprehensive plan of care throughout the 

continuum in a way that takes advantage of all 

the resources an integrated system has to offer” 

(Qudah, Brannon, 1998).

• Population Health looks at the broader 

population in a larger context, while DM focuses 

on a particular segment of the population with 

a specific set of co-morbidities. DM activities 

are directly linked to population identification, 

evidence-based care and prevention, and 

program evaluation and feedback. 

Population Health Elements in Action

Population identification and assessment involves 

studying and understanding the population, which 

may consist entirely of beneficiaries within the MTF 

or represent a subset of that group. Regardless of 

the actual size of the population, you should be able 

to identify sub-populations that may benefit from 

specific programs. Knowing your population allows 

you to extract information on age, gender, and 

disease burden in the interest of planning healthcare 

services that best meet beneficiary needs. 

Demand forecasting involves making an estimate 

of the volume of care required by a population or 

population subset. This requires not only accurate 

demographic and disease information, but also 

population-specific knowledge of healthcare needs, 

established clinical practice standards (chronic 

and preventive), and system- or Service-specific 

demands (e.g., pre-deployment exams). Population 

identification and assessment activities allow MM 

staff to anticipate, or “forecast,” the healthcare 

needs of the relevant population or sub-population.

Demand is typically measured by aspects such 

as workload units by provider type, number of 

specific treatments, and pharmacy demand. By 

understanding the demand forecast for an MTF, 

the healthcare team can determine staffing and 

budgetary requirements and prioritize programs to 

support health promotion, prevention, and chronic 

care services.

Demand management involves proactive 

intervention to reduce the rate of unnecessary 

healthcare resource utilization while encouraging 
Medical Management Guide Version 3.0 Medical Management Essentials Page 9

patients to use healthcare resources appropriately. 

Related activities include:

• Evaluating primary care manager (PCM) 

assignments to address the right patient mix for 

the provider role and to generate even patient 

distribution among providers.

• Optimizing the activities of all healthcare team 

members during patient visits.

• Utilizing functions such as nurse triage, group 

appointments, etc.

• Promoting the enrollment of beneficiaries to 

providers at the MTF when sufficient MTF 

resources are available.

• Educating beneficiaries about primary care 

triage systems and self-care programs (e.g., 

advice lines, Web-based materials). 

Capacity management involves matching the needs 

of the population served (as identified during 

demand forecasting) with the quantity and quality 

of services available at the MTF. Related activities 

include:

• Implementing proactive strategies to meet 

forecasted demand.

• Managing clinical processes.

• Clarifying staff roles and responsibilities.

• Controlling leakage to the network. 

To accomplish these endeavors, it is important to 

optimize the supply of healthcare resources to align 

with beneficiary needs or demand. This may include:

• Identifying actions that will reduce excess 

healthcare demand.

• Improving processes to increase system 

“throughput” (amount of work completed 

within a given period of time).

• Using evidence-based practices to perform the 

right actions at the right time.

In terms of patient demand, the Capacity 

Management element is affected by both 

actual healthcare needs and military readiness 

requirements. From the healthcare team perspective, 

it is affected by factors such as provider, support 

staff, and ancillary staff availability; physical space; 

equipment needs; and appointment processes.

Evidence-based care and prevention involves using a 

systematically developed, research-based approach 

to health care. This approach increases the quality 

of care delivered, reduces variation, and decreases 

cost. When evidence-based care is practiced, 

patients will typically experience an enhanced 

quality of life as a result of higher functional status, 

greater ability to self-manage, and less frequent 

hospitalizations. Evidence-based care is informed 

by research rather than provider consensus. It relies 

on an interdisciplinary team to manage care and 

provide referral to health promotion and education 

resources.

Program evaluation and feedback rests on the 

assumption that Population Health programs 

and their respective outcomes (as with any other 

aspect of health care) should be evaluated to 

determine performance and progress. This element

incorporates a range of tools and programs to a) 

identify and address barriers to achieving desired 

outcomes, and b) make changes, as needed, to 

improve healthcare delivery processes. 
Page 10 Medical Management Essentials Version 3.0 Medical Management Guide

understanding of other programs beneficiaries may 

be enrolled in, such as:

• Medicare, Medicaid: http://www.cms.hhs.gov/

• Supplemental Security Income (SSI): 

http://www.ssa.gov/ssi/

• Social Security Disability Insurance (SSDI): 

http://www.ssa.gov/disability/

• U.S. Family Health Plan: http://www.usfhp.com/

• U.S. Department of Veterans Affairs (VA): 

http://www.va.gov/

See Appendix C, Definitions; and Appendix D, 

Resources for more information.

Working with Managed Care Support 

Contractors

The United States are divided into three TRICARE 

regions. Each of the regions has a regional 

contractor that helps administer the TRICARE 

benefit plan. This role is defined as the Managed 

Care Support Contractor (MCSC). MCSCs provide a 

variety of functions, including: 

• Establishing TRICARE provider networks.

• Operating TRICARE service centers. 

• Operating customer service call centers. 

• Providing administrative support, such as 

enrollment, care authorization, and claims 

processing. 

• Communicating and distributing educational 

information to beneficiaries and providers. 

MCSCs work with their TRO to manage the benefit 

at the local level, and receive overall guidance from 

TMA headquarters (TRICARE Fact Sheets, TRICARE 

Regional Contractors for the United States, 2006). 

(See also Appendix C, Definitions.)

TRICARE AND OTHER BENEFIT PROGRAMS

MTF Commanders are responsible for all health 

care provided or purchased within their catchment/

market area. As such, they have direct control over 

appointment and referral services as well as over 

MM programs for their TRICARE Prime enrollees. 

The TRICARE healthcare program (http://tricare.

mil) serves Active Duty Service members (ADSMs), 

National Guard and Reserve members, retirees, 

their families, survivors, and certain former spouses 

worldwide. TRICARE contracts augment MTF 

services. Each MTF, Multi-Service Market Office 

(MSMO), and TRICARE Regional Office (TRO) must 

work with its regional contractor (see Working 

with Managed Care Support Contractors, later 

in this section) to develop individual memoranda of 

understanding (MOUs) that establish programs and 

activities specific to that particular facility. Contract 

implementation may vary based on how each facility 

interprets an MOU. For additional information on 

TRICARE, contact your local TRICARE Service Center 

(TSC) and/or Benefits Counseling and Assistance 

Coordinator (BCAC). 

TRICARE offers special programs, including the 

Extended Care Health Option (ECHO), Continued 

Health Care Benefits Program (CHCBP), and 

Computer/Electronic Accommodation Program 

(CAP). For more information, go to http://tricare.mil/

mybenefit/home/overview/SpecialPrograms. 

Most beneficiaries will have TRICARE as their 

primary provider or payor. But MM staff, specifically 

UM and CM personnel, also need to have a basic 
Medical Management Guide Version 3.0 Medical Management Essentials Page 11

The MHS necessitates close collaboration between

MM staff located in the DCS, embodied by the MTF

— an Active Duty setting; and the PCS, embodied

by the MCSC — in a civilian setting. Patients 

benefit when their healthcare services are smoothly 

coordinated between the DCS and PCS. This “handoff,” or patient transition, is the act of transferring 

MM functions from one responsible entity to 

another. Patients may frequent­ly transition between 

the MTF and the network, or between individual 

MTFs. 

By contract, the MCSC runs programs that manage 

the health care of individuals with high-cost 

conditions or with specific diseases addressed 

by proven clinical management programs; this 

responsibility extends to providing MM services 

for beneficiaries enrolled in ECHO. The MCSC also 

assumes responsibility for enrolled beneficiaries with 

catastrophic, high-risk, high-cost situations whose 

care occurs (or is projected to occur), in whole or 

in part, in the civilian sector. Program specifica­tions 

vary by region and are governed by specific MTF 

MOUs with the MCSC. 

THE LINK BETWEEN CLINICAL AND 

BUSINESS OPERATIONS

T

he fundamental concepts in determining 

appropriate MM measures within the MTF 

are a) integration with the Command’s 

measures and b) alignment with the local MTF’s 

strategic vision and business plan. 

Business planning “encompasses all strategic goals 

and activities needed to ensure an organization’s 

survival and growth,” with the outcome of the 

business planning cycle being “a consolidated MHS 

business plan that serves as a primary input to the 

Prospective Payment System (PPS).” In this regard, 

Tri-Service business plans provide “a common 

framework across the MHS for improving and 

measuring performance” in the DCS (FY 2010-2012 

Navy Bureau of Medicine and Surgery [BUMED] 

Business Planning Supplemental Guidance,

CD-ROM Resource MME-2).

According to the DoD’s Defense Health Program 

(DHP) FY 2009 budget estimates, the DoD’s total 

health costs more than doubled between 2001 and 

2006, from $19 billion to $38 billion — an increase 

representing 8 percent of the DoD budget. This 

increase was attributed to a combination of benefit 

enhancements, increased beneficiary use, stable 

cost shares, and high healthcare inflation. Those 

costs were projected through trend analysis to reach 

$64 billion, or 11.3 percent of the DoD budget, by 

FY 2015 (refer to CD-ROM Resource ES-2, DoD 

Defense Health Plan (DHP) 2009 Highlights).

The business plan is the MTF’s roadmap for financial 

success, but clinical operations, in collaboration 

with Resource Management staff, are crucial in 

determining that road map. It is therefore essential 

for clinical staff to actively engage in the business 

planning process. Their knowledge gives them the 

ability to validate baseline historical data such as 

enrollment, outpatient/inpatient workload, and outpatient/inpatient utilization.

The staff primarily involved in producing workload, 

docu­mentation, and coding should be consulted 

when the MTF is determining a particular 

department’s pro­ductivity targets or goals (e.g., 
Page 12 Medical Management Essentials Version 3.0 Medical Management Guide

number of relative value units [RVUs]). Clinical 

professionals will also be involved in implementing 

some of the critical initia­tives identified within the 

business plan, such as RM and evidence-based 

health care (i.e., DM). (See also Integrating 

Utilization, Case, and Disease Management 

Functions; Staffing for Combined Functions, 

later in this section.)

Eight critical initiatives frame business planning in 

the MTF:

1. Improve Access to Care

2. Improve Provider Productivity

3. Manage Referrals

4. Labor Reporting (performed through the 

Medical Expense & Performance Reporting 

System, or MEPRS: http://www.meprs.info/

— see also Section V, Medical Management 

Tools)

5. Improve Documented Value of Care (Coding)

6. Evidence-based Health Care

7. Manage Pharmacy Expenses

8. Expeditionary Planning (Readiness)

To help MTF Commanders execute their local 

business plans, the MHS has established MM as part 

of both its clinical and business operations. Business 

planning offers the opportunity for annual strategic 

management by creating a defined relationship 

between current performance and the critical 

requirements needed to reach market goals. As 

a new resource allocation methodology, business 

planning forecasts healthcare needs within the DCS 

and PCS with budgets focused on outputs rather 

than inputs. MM measures are calculated at various 

levels within the MHS, with a number of sources 

that centrally calculate and display measures from 

Service-level aggregate to provider-level detail. 

(See Section V, Medical Management Tools, 

for information and resources related to Tri-Service 

business planning.)

INTEGRATING UTILIZATION, CASE, AND 

DISEASE MANAGEMENT FUNCTIONS 

I

ntegrating MM components not only improves 

clini­cal outcomes; it improves organizational 

efficiency and effectiveness. For example, while 

more CM and DM personnel are used to implement 

comprehensive and integrated MM programs, 

staffing needs shift as fewer direct UM-related 

authorizations are needed. 

Integrating UM, CM, and DM functions in the MTF 

facilitates transitions of care and stewardship of 

resources. The National Transitions of Care Coalition 

(http://www.ntocc.org/) advocates for and has 

developed tools to support transitioning patients.

Historically, MTFs placed UM within their Business 

Operations or Resource Management department, 

while CM and DM were placed within the Nursing 

department. This produced significant fragmentation 

of services, higher staffing requirements, and 

increased costs. It also generated the view, 

particularly among providers, that the priority of UM 

staff was to save money for the institution rather 

than to provide safe and quality health care to 

patients. 

Current trends focus on co-locating UM and CM 

resources to maximize and balance both clinical 

and business outcomes. Fully integrating UM and 

CM staff has helped improve the overall quality of 
Medical Management Guide Version 3.0 Medical Management Essentials Page 13

care through a highly synergistic effect, with the 

following results:

• Significant decrease in the duplication of effort 

and redundancy.

• Decrease in negative outcomes from improper 

or poor handoffs.

• Improvement of overall workload management.

• Improvement in the appropriate patient use of 

benefits. 

UM, CM, and DM have many sim­ilarities in terms 

of goals, concepts, and tasks. The key to success 

is establishing links of communica­tion between 

programs or departments. In this regard, it is helpful 

to consider these three MM components within the 

context of a healthcare continuum as described in 

the 2001 DoD Population Health Improvement Plan 

and Guide (next iteration due to be published in 

2011). The Guide is available at http://www.tricare.

mil/ocmo/download/mhs_phi_guide.pdf (see also 

Executive Summary, CD-ROM Resource 

ES-1).

Continuum is defined as an uninterrupted period, 

referring to the various stages of health and 

appli­cations of the CM process. It may be seen 

as running parallel to a "preventive model" that 

measures cause and effect in MM interventions. 

This model comprises three phases, as described 

in part by Wilson, Carneal, and Newman (2008) 

(see CD-ROM Resource MME-12 for full 

article):

• Primary prevention is about preventing the 

onset, or incidence, of disease (e.g., through 

vaccinations).

• Secondary prevention is about detection of 

disease.

• Tertiary prevention is about the prevention of 

further suffering among end-stage prevalent 

cases (e.g., through ameliorating pain and 

providing psychosocial comfort).

Based on this model, success (achievement of 

outcomes) can be understood in one of two ways:

• Slowing, halting, or reversing advancement 

within the same phase.

• Slowing, halting, or reversing transition to the 

next phase.

Fig. 4 illustrates how UM, CM, and DM functions 

interact within the MHS in the context of the 

Population Health continuum and in keeping with 

the three levels of prevention.

While the end goal is to integrate the components of MM, MTFs may first need to develop 

their individual UM, CM, and DM programs. Fig. 5 

compares and contrasts each component. 

Some challenges may prevent successful 

integration. For example, each Service — from the 

headquarters to the local MTF level — organizes 

its medical services and departments differently, 

using a variety of titles, terms, and personnel 

resources. Additionally, there continues to be a 

lack of process standardization within the Services 

themselves. Identification of poor clinical outcomes 

or other red flags (e.g., an inability to meet access 

standards, longer lengths of stay, or outliers of 

any performance measure) may indicate system or 

organizational issues rather than a clinical problem. 
Page 14 Medical Management Essentials Version 3.0 Medical Management Guide

The Integrated Medical Management (MM) Model (IM3) is a pictorial representation of the clinical approach to 

patient management (i.e., MM) along the healthcare continuum. The components of the model are as follows:

• The curved arc depicts how MM falls within the spectrum of Population Health. The clinical activities of 

Utilization Management (UM), Case Management (CM), and Disease Management (DM) are geared toward 

achieving healthy populations.

• The vertical arrows indicate the integration of Population Health and MM functions.

• The large horizontal arrow depicts the healthcare continuum, illustrating the correlation between health, risk, 

disease, and impairment states and their alignment with primary, secondary, and tertiary prevention efforts. A 

patient may move anywhere along the healthcare continuum. 

• The red bar represents UM activities and functions along the entire healthcare continuum. UM functions 

include collecting and analyzing data that assist CM and DM in identifying populations or individuals who may 

benefit from services. 

• The green triangle highlights DM activities and functions. DM typically intervenes on the left side of the 

healthcare continuum with populations who benefit from DM, using primary and secondary prevention 

activities. 

• The blue triangle highlights CM activities and functions. CM typically intervenes on the right side of the 

healthcare continuum with individuals who benefit from CM, using secondary and tertiary prevention activities. 

• The middle triangle is the area where clinical interventions may fall in both DM and CM. These are patients 

who need assistance with care coordination but do not require either extensive DM or long-term CM services.

• The purple bar indicates the MM requirement to link UM, CM, and DM activities to outcomes of readiness, 

quality, cost, and access. Outcomes are the foundation of MM activities in the Military Healthcare System 

(MHS).

Integrated Medical Management Model (IM3)

Source: 2001 DoD Population Health Improvement Plan and Guide (see Executive Summary, CD-ROM Resource ES-1)

Fig. 4 – Integrated Medical Management Model (IM3)
Medical Management Guide Version 3.0 Medical Management Essentials Page 15

Distinctions between UM, CM, and DM

Utilization Management Case Management Disease Management

Characteristics of Target Population

• Cost-based approach

• Most expensive patients, providers, and 

procedures

• Patients who may not be at the appropriate 

level of care

• Patients not medically authorized for hospital 

admission and specific procedures

• Patients who underutilize or overutilize 

services

• Individual approach

• At high-risk for costly, adverse medical 

events and poor health outcomes

• Medically, socially, and/or financially 

vulnerable

• Population-based approach

• Diagnosed with specific disease or 

condition

Methods for Identifying Patients

Analysis of Encounter or Claims Data

• Tracks over/underutilization of services and 

costs

• Searches for patients with patterns of 

repeated hospitalizations or ED visits

• Searches for patients with selected 

ICD-9 diagnosis codes

Analysis of Pharmacy Data

• Reviews provider prescription patterns for 

high-cost brand versus low-cost generic 

medications

• Evaluates compliance with CPG requirements 

or Drug Utilization Evaluations (DUEs) within 

the MTF

• Reviews medication profiles for various 

individuals or populations (medication 

misuse, elder non-adherence)

• Searches for prescriptions 

commonly used for specific 

diseases (i.e., Albuterol for 

asthmatics)

Referrals

• Aggregate data in terms of practice patterns 

for referrals

• Prospective review of referrals

• Referrals meet Severity of Illness and Intensity 

of Service criteria (InterQual®)

• Providers who identify patients as “high 

risk” or “vulnerable”

• Self/family referrals

• Specific beneficiary screening criteria

• Providers who identify patients 

with a particular diagnosis or 

condition

Preadmission/Concurrent Review

• Identifies patients in need of more intensive 

interventions whose length of stay might be 

long and resource utilization high

• Provides opportunity to coordinate with case 

management

• Tracks appropriateness of care

• Identifies expensive, complex cases (red 

flags) prior to/during admission

• Identifies organizational processes that 

need to be streamlined to better address 

patient needs and increase efficiency

• Identifies patients with specific 

diseases/conditions who could 

benefit from an outpatient 

disease management program for 

monitoring and reinforcement of 

patient/family education

Patient Education

• Generally no formal education; however, 

patients should be informed of the different 

levels of care and the appeal process

• Providers are educated on recurring initiatives 

and roles in process improvement

• Generally no classes developed by the 

program itself, although may refer to 

external classes

• Generally no standardized curriculum

• Generally no standardized educational 

materials; individual-specific

• Program may have developed its 

own classes

• Standard curriculum

• Standardized educational materials

• Tailored to individual situation

Relative Reliance on National, Evidence-based, Disease-specific Guidelines

• Not applicable (uses InterQual® and Milliman 

Ambulatory Care GuidelinesTM criteria, which 

are based on best practices during utilization 

reviews)

• Moderate • Extremely high

Relative Reliance on Protocols and Standardization

• Moving toward better use of information in 

clinical practices, identification of needs and 

referrals to targeted support services; and 

greater use and more consistent delivery of 

evidence-based practices

• Moving toward better use of information 

in clinical practices (i.e., critical pathways), 

identification of needs and referrals to 

targeted support services; and greater use 

and more consistent delivery of evidencebased practices

• High

Source: Chen, A., et al., (2001, March). Best Practices in Coordinated Care. Mathematica Policy Research Institute, Inc.

Fig. 5 – Distinctions between UM, CM, and DM
Page 16 Medical Management Essentials Version 3.0 Medical Management Guide

MTF-specific circumstances will dictate whether 

distinct, standalone programs or integrated MM 

processes are required. Large MTFs may choose to 

have indi­vidualized UM, CM, and DM programs. 

In such cases, effective communication can be 

accomplished through regular face-to-­face meetings 

(e.g., patient care conferences, indi­vidual meetings, 

e-mail, MM team meetings, Population Health 

Working Group, teleconferencing). In smaller MTFs, 

there may be staffing limitations that mean one or 

two staff members are responsible for several MM 

compo­nents. 

When developing an integrated MM program, 

network with your peers at other similar-sized 

facilities to partner and share information. This 

consultation process should be expanded to include 

sister Services and civilian organizations (e.g., URAC, 

CMSA, hospitals). 

Staffing for Combined Functions

Although the composition, organi­zation, mission, 

etc. of each MTF varies greatly, general staffing 

guidelines should be followed. According to 

a 2003 Air Force study, Access to Care (First 

Consulting Group), healthcare organizations should 

establish the right staffing mix based on specific 

criteria to address the quantity and complexity of 

beneficiaries’ needs. The study made the following 

recommendations:

• A written staffing plan should be developed 

with clearly defined roles and responsibilities. 

• Leadership should analyze actual staffing patterns, program requirements, and findings 

from quality improvement and benchmarking 

activities and apply that analysis to staffing 

decisions. 

• Performance indicators must be set in 

consideration of the complexity of patient care 

needs. 

• Performance monitoring should be an ongoing 

process between clinical and administrative 

personnel. 

• The staffing plan should be updated periodically 

based on changing patient care needs. 

An organization’s position descriptions, mission 

and vision, and business plan can help in the 

development of objectives for utilization managers, 

case managers, and disease managers. Those 

objectives provide a basis for constructing core 

competency and performance assessments for each 

position. Objectives and competencies should evolve 

as roles evolve. New employees should complete 

a competency self-assessment at the beginning of 

their orientation programs. The director can then 

individualize orientation and training to their specific 

needs.

When integrating a UM, CM, or DM role into an 

MM program, MTF leadership should review the 

overall program and assess the effectiveness of 

each aspect of the program. Occasionally, trouble 

areas may arise that hinder the ability of staff to 

focus on their primary responsibilities. Such areas 

include job overload, roles with a limited sphere of 

influence, responsibility for multiple roles or extra 

duties, and unclear priorities. Ensure that staff have 

role clarification in addition to the skills, equipment, 

mentoring, and support to be successful in their 

positions.

MTFs located OCONUS face additional challenges 

in staffing MM. Typically, overseas regions offer far 

fewer candidates with the requisite expertise to be 
Medical Management Guide Version 3.0 Medical Management Essentials Page 17

successful in MM activities than are available in the 

United States. This may force MTFs to make the 

critical decision of leaving positions empty; or of 

hiring inexperienced staff and training them, with 

the knowledge that these staff are likely to remain 

in the position for two to three years at most. 

(See Section III, Case Management, for more 

information on OCONUS considerations.)

MTFs need to promote close collaboration among 

all MM staff and encourage them to communicate 

with other MTF departments or personnel, such as: 

• What are our objectives?

• What are our short- and long-term goals?

• What are the health needs of our population?

• What are our current UM, CM, and DM resources? Who are our experts in those areas?

• How should we integrate MM roles?

• How do we facilitate inter-organizational integration? What are the advantages to our MTF? Which stakeholders 

should be involved in this effort?

• Which roles are responsible for making which specific decisions to move a patient efficiently and cost-effectively 

through the system?

• How do we promote standardization of UM, CM, and DM processes among team members?

• How do we maintain or restructure individual titles and scopes of work?

• How do we currently handle referrals?

• How do our nurse reviewers alert CM staff that a patient needs evaluation for CM?

• What are the DRG procedures for our patient population?

• Which ICD-9, DRG, and current procedural terminology (CPT) codes do we use most frequently for inpatient and 

outpatient visits?

• Which processes can we automate to expedite tasks and reduce administrative costs?

• Which continuum of care, patient safety, discharge planning, or other regulations apply? Which roles are responsible 

for ensuring that specific regulations are followed?

• Which types of information from external systems would be useful for our MM functions? Who has access to that 

information?

• Which mode of information sharing will increase our effectiveness? How can we facilitate it?

• Which tools do we currently have in place to standardize processes, measure outcomes, maintain reports, and 

document variances?

• Where do we report MM data?

• Which staff members have the authority to make changes regarding reported MM data?

Questions to Consider When Creating an Integrated MM Program

Fig. 6 – Questions to Consider when Creating an Integrated MM Program

• The local TRICARE Service Center Coding and 

coding auditing departments. 

• Information Management (IM)/Information 

Technology (IT). 

• Patient Administration. 

• Population Health Resource Management. 

• Quality/Risk Management — MM program 

measures may align with those obtained 

as part of an MTF’s quality program — for 

example, benchmarking against Healthcare 

Effectiveness Data and Information Set (HEDIS®) 

measures. HEDIS® is a tool used by more than 
Page 18 Medical Management Essentials Version 3.0 Medical Management Guide

90 percent of America's health plans to measure 

performance on important dimensions of 

care and service. To view the current HEDIS®

measures, go to http://www.ncqa.org/. (See also 

Section IV, Disease Management.)

• Relevant MSMO. 

• Relevant TRO. 

• MCSCs — Contractually, MCSCs are responsible 

for different aspects of MM within their region. 

Depending on the local memorandum of 

understanding (MOU) between an MCSC and 

MTF, the MCSC may have additional processes 

or activities in place to support patient care 

activities. 

• Medical staff (e.g., Medical Director). 

• Nursing staff (inpatient and ambulatory).

• Decision support (e.g., data analysis) staff. 

Successfully integrating UM, CM, and DM functions 

requires careful strategic planning and effective 

resource allocation. Even if integration plans 

are included during development of the over­all 

MM plan, MM staff need to consider some key 

questions, as shown in Fig. 6. 

ESSENTIAL CONSIDERATIONS FOR 

MEDICAL MANAGEMENT STAFF

Benefitting from Information Technology

I

nformation technology (IT) is the approach of 

processing and disseminating data through the 

use of computers or other electronic devices and 

“virtual” communication tools (e.g., the Internet). 

Some healthcare facilities still rely largely on a 

paper-based system to collect, store, retrieve, and 

disseminate data. However, IT is the preferred 

method in today’s healthcare arena, where quick 

access to usable, reliable information is critical for 

effective decision-making.

The MHS Population Health Portal (MHS Portal,

or MHSPHP) is an excellent resource for tools and 

templates related to MM activities within the MTF. 

The Portal demonstrates the benefit of applying 

advanced tech­nology across the enterprise, 

allowing for information-sharing by multiple users 

within Army, Air Force, and Navy MTFs. For more 

information, see Section V, Medical Management 

Tools. 

“With healthcare costs once again rising significantly 

faster than inflation, though for different reasons 

than existed two decades ago, pressure is being 

placed once again on the entire healthcare industry, 

including health plans, to identify ways to be more 

proactive in managing the health of individuals. 

Medical management and predictive modeling are 

key components of this effort” (Kongstvedt, 2007). 

Predictive modeling is “a set of tools used to stratify 

a population according to its risk of nearly any 

outcome ... ideally, patients are risk-stratified to 

identify opportunities for intervention before the 

occurrence of adverse outcomes that results in 

increased medical costs” (Cousins, et. al., 2002). For 

a broader perspective on predictive modeling, refer 

to CD-ROM Resources MME-2 and MME-3.

Effective utilization of IT resources and systems 

enhances the ability of MM staff to meet the goals 

of the patient, the MM department, and the MTF. 

“The information system is a purposefully designed 

system that brings people, data, information, and 
Medical Management Guide Version 3.0 Medical Management Essentials Page 19

procedures together for the purpose of managing 

information to support operations, management, 

and decision functions important to an individual, 

team, or organization” (Powell and Tahan, 2008).

IT can be used in innumerable ways within the MM 

arena, as demonstrated in the examples below.

UM staff can use IT systems to:

• Identify variations in provider practice patterns.

• Identify clinics within the DCS with access-tocare issues.

• Review and track referrals for network care.

• Analyze patient patterns of use within the MTF.

CM and DM staff can use IT systems to:

• Identify patients who may benefit from their 

services.

• Manage voluminous information about their 

patients.

• Document care and services.

• Analyze, track, and provide outcome reports.

As Powell and Tahan discuss in their book, the Case 

Management Society of America’s Core Curriculum 

for Case Management, a well-designed IT system 

should:

a. Enable data to be viewed in several places by 

several people at the same time in a format that 

is understandable. 

b. Ensure appropriate information security is 

maintained at all times.

c. Communicate with other systems in real time or 

near-real time.

d. Provide users with the ability to filter out 

unnecessary information.

e. Act as a central repository for patient and 

population levels of data.

f. Generate user-specific reports enabling users to 

evaluate outcomes.

g. Standardize terminology, documentation 

practices, and reporting functions.

Despite significant benefits associated with IT 

implementation, MM staff should be aware of its 

limitations, including:

• Lack of interconnectivity across several different 

systems, which can result in fragmentation of 

care and services.

• Information security practices that can hinder 

timely and consistent access to information. 

• Non-standard IT terminology, which can 

frustrate communications between healthcare 

team members managing patient information. 

• The absence of an intuitive ability to make 

patient care decisions when something “just 

doesn’t feel right.”

Privacy and Confidentiality of Patient 

Information

Records, documents, and data generated in the 

course of MM may contain information subject 

to the Privacy Act, Medical Quality Assurance 

protection, and/or regulations under the Health 

Insurance Portability and Accountability Act (HIPAA), 

Title 45, CFR Parts 160 and 164 (see Appendix C, 

Definitions). HIPAA addresses the use, disclosure, 

and security of protected health information (PHI). 

MM staff should complete HIPAA training, become 

familiar with HIPAA rules, and contact their local 

Privacy Officer for further guidance. (See also 

Section V, Medical Management Tools; Tools 

for Utilization, Case, and Disease Management 

Collaboration; Protected Health Information 

Management Tool.)
Page 20 Medical Management Essentials Version 3.0 Medical Management Guide

PROGRAM SUSTAINMENT 

P

rogram sustainment is a frequently 

overlooked step that should begin upon 

initiation of new pro­grams. It is important for 

the MM plan to match the needs of the organization 

and its primary stakeholders. In the MTF, providers 

transfer and deploy. This means new providers 

are always entering the system, along with new 

beneficiaries. It is therefore crucial to continuously 

promote your services to healthcare team members, 

patients, and families; and to educate them on how 

to refer. 

Leadership and organizational culture are key factors 

in effective program sustainment. With this in mind, 

the MM plan should: 

• Develop a leadership strategy to gain and maintain support at all levels of the organization. 

• Clearly describe the benefits of the program and 

regularly report on its progress to stakeholders. 

• Include feedback from patients, providers, and 

other healthcare team members. 

• Build a seamless organizational culture by 

integrating MM with other MTF programs. 

• Make sure MM program data are communicated 

as feedback to clinical and executive staff.

o Providers must be actively engaged as key 

members of the MM team.

o Practice patterns must change to meet 

the goal of clini­cal and financial outcomes 

improvement. 

An important sustainment strategy is to promote the 

MM program through marketing. Marketing involves 

planning and executing the conception, promotion, 

and distribution of services that satisfy individual 

and organizational objectives. 

To develop a successful marketing strategy, you must 

first define the services your department has to offer. 

Ask questions such as the following: Do we currently 

have MM services? If working in an inpatient facility, 

does that facility require discharge planning?

The next step is to determine the target audience. 

Do you market only to your healthcare providers or 

do you allow patients and their families to self-refer?

Understanding your organization’s mission will help 

you develop your plan. Where does the organization 

need you to focus your services? On patients with 

high utilization? On wounded, ill, and injured Service 

members? On patients with complex needs? On 

ADSMs, family members, or retirees? Who is using 

most of the organization’s resources?

After developing the plan, it is time to promote 

your services. Suggestion: Develop brochures for 

providers and for patients, for the different services 

you offer, or for all services ( CD-ROM Resource 

MME-4 provides a sample MM marketing 

brochure; see also Section III, Case Management, 

CD-ROM Resource CM-23). It may be useful to 

develop a simple reference pocket card for providers 

featuring trigger diagnoses for referral, screening 

criteria, how to refer, and a phone number to call 

with questions. 

Other methods for promoting your services include: 

• Speaking at professional staff meetings.

• Communicating with your organization’s 

leadership.

• Advertising in the clinic or hospital newsletter.
Medical Management Guide Version 3.0 Medical Management Essentials Page 21

Explain the benefits of using your services to the 

provider, patient, and family. The initial challenge is 

to gain exposure.

SUMMARY 

T

o successfully implement MM in the MTF, 

MM staff should incorporate Population 

Health principles and integrate evidencebased, business, and Resource Management 

practices. More specifically, MM program design 

should reflect the integration of UM, CM, and DM 

functions to optimize patient outcomes. Leadership 

support, active provider engagement, appropriate 

resource allocation, and inter/intradepartmental 

communication all play a role in sustaining an 

effective MM program.

CD-ROM RESOURCES

MME-1 Department of Defense Instruction 

 (DoDI) 6025.20, Medical Management 

 Programs in the Direct Care System (DCS) 

 and Remote Areas (2006)

MME-2 Article: Meek, Julie A., DNS.: 

 Predictive Modeling and Proactive Care 

 Management, Part I – Lippincott’s Case 

 Management (July/August 2003)

MME-3 Article: Meek, Julie A., DNS.: Increasing 

 Return on Investment Potential in Care 

 Management, Predictive Modeling and 

 Proactive Care Management, Part II – 

 Lippincott’s Case Management

 (September/October 2003)

MME-4 Sample Medical Management Marketing 

 Brochure – Air Force

MME-5* HA Policy Memo on Implementation for 

 Prospective Payment Systems (2004)

MME-6* HA Policy on Right of First Refusal (2005)

MME-7* HA Policy for Active Duty Service 

 Member Enrollment to TRICARE Prime 

 (2005)

MME-8* HA Policy on Short-term Solutions 

 for the Enterprise-wide Referral and 

 Authorization System (2005)

MME-9* HA Interim Policy for Medical 

 Management

MME-10* Article: Despite Barriers, MCOs Integrate 

 Case, Disease, Utilization Management 

 Functions – Managed Care Week (March 

 14, 2005)

MME-11* Article: Mullahy, C. M. The Effective 

 Integration of Utilization and Case 

 Management –The Case Manager (TCM)

 (March/April 2000)

MME-12 Article: Wilson, Carneal, and Newman,

 Documenting Case Management 

 Outcomes: Advancing The Science While 

 Preserving The Art –Case In Point (CIP) 

 (February/March, 2008)

*Not referenced in text

‘



Medical Management Guide Version 3.0 Utilization Management Page 25

II

SECTION Utilization Management

INTRODUCTION

E

ffective Utilization Management (UM) is a 

key process within Medical Management 

(MM) for improving the quality of health care 

and ensuring the cost effectiveness of healthcare 

services. UM relates to all com­ponents of a 

healthcare delivery system, including care within the 

primary, specialty, and inpatient set­tings.

This section discusses the concept of UM and how 

to develop an effective UM program within the 

Direct Care System (DCS). It describes a seven-step 

process for quality improvement and includes 

information on Utilization Review (UR), deci­sion 

support tools, Referral Management (RM), and the 

grievance and appeal process. This section also covers 

the role and necessary qualifications of today’s UM 

professional.

Fig. 7 illustrates the focus of UM activities throughout 

the various stages of the healthcare continuum. 

Specifically, as the focus of healthcare delivery moves 

along the Population Health continuum from pri­mary 

through tertiary prevention, UM helps guide the 

quality and cost effectiveness of healthcare services. 

Fig. 7 – Utilization Management within the MHS Integrated MM Model (IM3)

*See also Section I, Medical Management Essentials: Fig. 4, Integrated Medical Management Model (IM3) with Key info, page 14.
Page 26 Utilization Management Version 3.0 Medical Management Guide

• Promoting the least costly, most effective 

treatment benefit.

• Determining the presence of medical necessity 

(see Appendix C, Definitions). 

The purpose of UM within the Military Treatment 

Facility (MTF) is to identify, monitor, evaluate, and 

resolve issues that may result in inefficient healthcare 

delivery or that may have an impact on resources 

and services.

UTILIZATION MANAGEMENT COMPONENTS

As with CM and Disease Management 

(DM), the role of UM in the MTF is part 

of a progressively integrated approach 

that emphasizes the importance of facilitating 

environments, treatments, and procedures that 

generate opportunities for improved clinical 

outcomes and/or cost avoidance. 

In the practice of UM, such facilitation is 

accomplished through the regular application of 

UM monitoring — a form of data analysis. The UM 

monitoring process provides MTFs with a “warning 

system” that can help identify at-risk patients at the 

earliest opportunity for intervention, such as during 

the preadmission and concurrent review processes. 

For example, patients with specific diseases/

conditions scheduled for admission to the hospital 

can be identified and referred as potential candidates 

for CM or DM services. These patients may require 

proactive discharge planning to help address their 

post-hospitalization needs. 

Appropriate data analysis and reporting provides 

UM personnel with a foundation for improving 

As discussed in Section I, Medical Management 

Essentials, the recent trend in MM has been to 

replace traditional approaches with more care 

coordination activities based on an integrat­ed MM 

model. 

Definition, Goals, and Purpose 

UM is a methodology that addresses the issue 

of managing the use of resources in the delivery 

of health care, while also measuring the quality 

associated with the delivery of that care (McKesson, 

2009).

UM is an organization-wide, interdisciplinary 

approach to balancing quality, risk, and cost 

concerns in the provision of patient care. It is 

the process of evaluat­ing the medical necessity, 

appropriateness, and effi­ciency of healthcare 

services. “Utilization review takes a retrospective 

view of cases, while UM describes proactive 

procedures and processes” (Freedman, 2006). UR is 

the process of determining whether all aspects of a 

patient’s care, at every level, are medically necessary 

and appropriately delivered (McKesson, 2009). 

In addition, UR in the private sector includes 

many of the following activities: pre-certification 

review, admission review, continued stay review, 

retrospective review, discharge plan­ning, bill review, 

and individual medical Case Management (CM). 

The ultimate goal of UM is to maintain the quality 

and efficiency of healthcare delivery by:

• Providing patients with the appropriate level of 

care.

• Coordi­nating healthcare benefits.
Medical Management Guide Version 3.0 Utilization Management Page 27

performance and developing a sound program 

through an action plan. Effective data analysis 

can reveal obstacles to implementing the action 

plan. This helps decision-makers refine that plan 

and establish new priorities for the next cycle of 

performance improvement.

The Seven-Step Quality Improvement Process

A key element of any UM program is to follow a 

quality improvement (QI) process. A seven-step 

process is used here (see Fig. 8), based on QI 

activities recommended by the 2008 Accreditation 

Association for Ambulatory Health Care Handbook

(for more information, go to http://www.aaahc.org/).

As shown in Fig. 8, in the “ideal” process (numbers 

1 through 7) the seven steps progress in a linear 

manner. However, in practice the process allows for 

flexibility and may not always begin at Step 1. For 

example — as shown in letters a, b, and c in the 

figure — after attempting to fix a problem, you may 

need to adjust what you are measuring then redetermine the gaps before continuing forward. 

This seven-step QI process is just one of many 

different models that can be used to develop a 

UM program. MTFs can choose any model (such 

as FOCUS PDCA or Lean Six Sigma), as long as 

the approach offers a systematic, step-by-step 

technique. Using a template based on a sevenstep QI process, a UM plan would consist of three 

columns or sections for UM, CM, and DM. ( CDROM Resource UM-1 provides a UM plan template 

based on a seven-step QI process, which can be 

customized for MTF use. CD-ROM Resource 

UM-2 provides a completed example.)

The seven steps for establishing a UM action plan 

are listed below in sequential order based on 

standard expectations as data becomes available. 

Fig. 8 – Seven-Step Quality Improvement Process

Learn from the Quality

Improvement Process 7

6

5

4

3

2

1

Make Additional Attempts

to Fix the Problem(s) 

Determine the Effectiveness

of the Corrective Action

Attempt to Fix the Problem(s)

Determine the

Gaps

Determine What

to Measure

Identify the Purpose

c

b

a
Page 28 Utilization Management Version 3.0 Medical Management Guide

1. Identify the Purpose 

Step 1 is to identify priori­ties for focus and 

examination. Priorities evolve from utilization data, 

suspected problem areas, MTF strategic goals, 

Command initiatives, and directives from an MTF’s 

Service Branch and/or other high­er authority. When 

defining priorities, UM staff should solicit input from 

all departments/services within their MTF. 

2. Determine What to Measure

Step 2 is to select measures (i.e., metrics) and collect 

data relevant to the MTF — this despite the fact that 

there is no higher-level mandate to obtain a specific 

set of measures.

Utilization managers should select measures and 

collect data based on priorities. Typically, these 

measures relate to:

• High-cost, high-volume, or “problem-prone” 

diagnoses, procedures, and services.

• Patients who have demonstrated high utiliza­tion 

rates.

The definition of what constitutes a problem-prone 

situation varies by setting. For example:

• Inpatient services — Refers to diagnoses 

including those related to high mortality, high 

morbid­ity, prolonged length of stay (LOS), high 

readmission rates, and preventable admissions.

• Ambulatory servic­es — Includes multiple 

visits for the same condition across various 

settings (e.g., primary care clinic, Emergency 

Department [ED], specialty care) or with multiple 

providers. Also includes polypharmacy (e.g., 

when the patient has been prescribed seven 

or eight concurrent medications), unexpected 

admissions, or death following ambulatory 

surgery.

Utilization measures facilitate the MTF’s ability to:

• Identify Service Branch-specific areas for focused 

UR.

• Develop reports that display the applicable data 

elements for study.

• “Drill down” for patterns of care.

A data query can either focus on a particular, 

identified problem or issue (e.g., number of ED visits 

in the MTF and network during the past year for 

all Active Duty Service members [ADSMs]); or be 

expanded to include a broad range of data elements 

(e.g., all inpatient and outpatient visits for the past 

year for all patient categories) that might help 

identify potential trends or patterns of care that give 

cause for concern. (See also Section V, Medical 

Management Tools.)

If the data include a general range of elements, it is 

best to sort those data into categories to distinguish 

where problems may lie. For example, one table or 

report may list high-cost, high-volume, or problemprone diagnoses and procedures for patients with 

demonstrated high-cost, high-volume, or highly 

complex utilization patterns (i.e., “high utilizers”). 

Your data must make sense to the people who are 

receiving the information and be considered valid 

(Hospital Peer Review, 2008).

Categories are used to present data clearly. They 

do not imply that ambulatory care facilities should 

study only outpatient data; an ambulatory care 
Medical Management Guide Version 3.0 Utilization Management Page 29

facility might evaluate inpatient admissions to the 

Purchased Care System (PCS) to identify opportunities for cost savings or coordination of care. 

UM staff should remember that they are not always 

expected to perform the role of data miner. Rather, 

they need to identify who has access to data (e.g., 

M2 users, data analysts, decision support staff) and 

partner with them by asking what is really going to 

affect patient care, who needs to be involved, and 

how to make the process a priority for decisionmakers (Hospital Peer Review, 2008).

3. Determine the Gaps 

Step 3 is to determine the gaps, if any, between 

actual and desired conditions. Identify:

• Any red flags or undesirable trends and 

variations from internal/external benchmarks 

and comparative data.

• Other potential areas for process improve­ment.

When comparing MTF performance to national 

benchmarks, you must take into account differences 

between the MHS and the civilian health system 

(notably the unique MHS benefit, funding structure, 

military mission, diverse healthcare environments, 

and population distribution). You must also consider 

risk adjustment and severity of illness (i.e., through 

a case mix index) when comparing an MTF to a 

civilian facility or comparing one MTF to another. 

By drilling down further, MTF staff can identify 

high-vol­ume diagnoses, procedures, and services; 

and individual patients with high utilization rates. 

They can then define significant trends and 

determine where to focus primary, secondary, 

and tertiary pre­ventive interventions (see 

Section I, Medical Management Essentials

and Appendix C, Definitions). This can help 

UM staff iden­tify and refer patients who might 

benefit from specific management strategies, 

such as CM or DM. When evaluating data related 

to a particular occurrence, priorities will vary 

from facility to facility. Staff in a smaller MTF 

may elect to focus on their five most frequently 

performed procedures, while staff in a larger MTF 

might study their 10 or even 15 most frequently 

performed procedures. Alternatively, MTF staff 

might focus on the most problematic or prevalent 

diag­noses rather than the most frequent. 

4. Attempt to Fix the Problem(s)

Step 4 is to attempt to fix the problem(s) by 

prioritizing opportunities for improvement based on 

the MTF’s strategic goals, population needs, quality 

initiatives, and patient safety considerations. Here 

it is important to focus on areas with the greatest 

cost-to-benefit ratio and the highest probability 

for success. When evaluating which processes to 

improve, be sure to consider whether or not the 

applicable measures are reliable and valid. When 

reviewing those measures, consider where you can 

realize improvements within the data systems or 

data collection and reporting processes to ensure 

data accuracy and reliability, which, in turn, affects 

decision-making. 

Formulate an action plan and attempt to fix the 

problem, which involves selecting appropriate 

strategies to address each priority stated in the UM 

program. This plan should include milestones and 

delineate individuals or depart­ments responsible for 

meeting those milestones.
Page 30 Utilization Management Version 3.0 Medical Management Guide

UM strategies may include a wide range of 

interventions to:

• Target gaps in healthcare delivery.

• Enhance performance and quality of care.

• Assist in managing resources and improving the 

health of patients. 

• Refer patients who might benefit from other 

programs, such as CM and DM.

How you determine the most appropriate type 

of intervention will depend on the needs of the 

population; the MTF’s capabilities, resources, and 

goals; and available metric data. Consider incorporating various UM strategies as well as other 

MTF programs (e.g., Population Health, Information 

Management, or Resource Management) into the 

action plan.

Implement the action plan by performing the 

interventions identified. Staff members responsible 

for implementing parts of the plan must:

• Document their actions and any issues, 

obstacles, lessons learned, etc. This 

documentation will serve as formal feedback for 

future reference and help establish continuity in 

process improvement.

• Report that information to the appropriate 

supervisor.

5. Determine the Effectiveness of the 

Corrective Action

Step 5 is the crucial step of determining how 

effective you have been in implementing a corrective 

action. This step includes refreshing data elements 

at consis­tent and regular intervals. It is essential to 

evaluate the impact of the actions taken so you can 

determine whether the UM program was successful. 

Compare the action(s) taken to the outcome goals 

and measures. Were there other unknown or new 

factors that allowed for successful implementation? 

If the desired result or outcome was not achieved, 

then refine, adjust, or re-implement the strategies 

and re-measure after an appropriate interval. Repeat 

this step until the desired outcome is achieved 

without undesirable or unin­tended consequences. 

6. Make Additional Attempts to Fix the 

Problem(s)

Step 6 is to continue to address any outstanding 

issues by periodically monitoring the measures. 

This will help you sustain any change or process 

improvement through successive generations of 

staff and/or organizational structure, once you have 

achieved desired outcomes. 

7. Learn from the Quality Improvement Process

Step 7 is to ensure you have learned from the QI 

activity by evaluating outcomes. This step helps you 

deter­mine whether you have achieved your goals 

and makes it easier to update the UM program, if 

needed. If goals have not been achieved, identify 

impediments (e.g., limit­ed resources, poor training, 

ineffective communica­tion). Discuss and validate 

findings, formulate with the process owners a 

plan to address those findings, and communicate 

the results of that eval­uation to the involved 

departments and MTF leadership through the 

appropriate channels.

When updating the UM plan, make sure it continues 

to reflect current goals and mission needs. If 
Medical Management Guide Version 3.0 Utilization Management Page 31

Review criteria may be employed as a screening tool 

during the first level of UR when:

a) The purpose is to manage resource utilization.

b) There is a potential to deny payment for services 

that are not medically necessary or that do not 

represent the most appropriate level of care. 

Care is never denied for failure to meet criteria. 

Failure to meet criteria is only an alert that the case 

requires further examination by a physician or other 

qualified second-level reviewer. 

UM staff perform UR to ensure patients receive the 

right care, at the right time, in the right place, with 

the right provider, and at the right cost. Without 

proper UR, the cost of health care, particularly 

specialty care referred inappropriately to the PCS, 

will spiral out of control. There is an absolute 

correlation between specialty care referrals (e.g., 

RM) and business planning processes. (See also 

Section I, Medical Management Essentials, 

and Section V, Medical Management Tools, 

for more information on business planning and 

business plans.)

All healthcare services for which payment is sought 

should undergo review for appropriateness of 

utilization. UM staff should work with business or 

patient administrative personnel to set up a process 

in which third-party (insurance) payors are given 

priority consideration. For example, third-party 

payors may require completed prospective reviews 

from the MTF for surgery (e.g., hysterecto­my, gastric 

bypass) before they will provide authorization and 

reim­bursement for a surgical procedure performed 

with­in the MTF. 

applicable, redefine UM priorities and begin a 

new performance improvement cycle. Consider 

incorporating the strategy that resulted in successful 

outcomes into a written MTF policy that formally 

incorpo­rates prolonged sustainment of those 

improvements as “routine business.” 

This QI process format is not mandatory. MTF staff 

may use whichever format best meets their needs, 

but they should include all of the steps described in 

the QI process when conducting UM. The range of 

goals and pri­orities will vary by MTF.

As noted in Step 2, while MM staff are not always 

required to act as data miners themselves, they are 

responsible for assisting data analysts by identifying 

issues, asking appropriate ques­tions, and selecting 

the relevant data elements when querying various 

data marts. 

Utilization Review

Utilization Review (UR) as a component of UM is 

integral to the success of both the MTF’s MM and 

business plans. UR is the process of determining 

whether all aspects of a patient’s care, at every 

level, are medically necessary and appropriately 

delivered (McKesson, 2009). It is systematic because 

there is a prescribed sequence in applying the 

criteria and in further reviewing the case if crite­ria 

are not met. It is criteria-based because factors 

based on sound clinical principles and processes are 

applied objectively in the first step of the evaluation 

process. 
Page 32 Utilization Management Version 3.0 Medical Management Guide

UM staff can also apply review criteria to assist the 

MTF in identifying areas for improvement within the 

system. For example:

• If a group of admissions are reviewed 

retrospectively using McKesson® InterQual® 

evidence-based decision support criteria and a 

large number do not meet admission criteria, 

further investigation is warranted to determine 

and resolve the underlying cause. 

• If a group of cases referred for spe­cialty care 

does not meet Milliman Care Guidelines®, a 

training issue may exist indicating the need for 

additional clinical education. 

In both instances cited above, the criteria or 

guidelines have been used to reveal potential areas 

for improvement, but the admissions and referrals 

were not denied. (For more information, see 

Outcome Measurement and Management, later 

in this section.)

The MTF’s plan for UR may include more focused 

reviews in which it iden­tifies a list of healthcare 

services for which preau­thorization and concurrent 

review may be required. It is neither necessary nor 

cost effective to perform a 100 percent review of all 

referrals for medical necessity. Criteria for UR may 

include, but are not limited to, services defined by 

any of the following characteristics: 

• Costly 

• Known to pose potential medical risks for 

mem­bers

• Known to produce variable outcomes

• New or investigational

• Often performed for cosmetic reasons

• Overutilized

• Utilized differently by various providers

Types of Review 

The procedures for UR may be:

• Prospective (before care is provided 

—preadmission)

• Concurrent (while care is in process 

— hospitalization)

• Retrospective (after care has been provided 

— discharge)

Prospective review is designed to evaluate pro­posed 

treatment, determine medical necessity, and assess 

the appropriate level of care prior to the delivery 

of services. When performing reviews, referrals 

to CM or DM target early intervention to improve 

outcomes. Formal prospective review determinations 

require timely attention. Prospective reviews are only 

valid for 30 days. If treatment was authorized but 

not initiated within the window, the review should 

be repeated. 

Concurrent review is designed to evaluate care 

while it is occurring to validate medical neces­sity, 

appropriateness, and quality of care. The reviewer 

also looks for delays in service or complica­tions, 

assesses if tests are appropriate, or evaluates the 

status of discharge planning. 

Inpatient concurrent review consists of two 

components: 

• Admission review is conducted within 24 hours 

of admission or on the next business day to 

verify the appropriateness and medical necessity 

of the hos­pitalization. Documentation in the 

medical record should justify the admission and 

plan of care. Discharge planning must begin at 

the time of admission to resolve potential issues 

that may delay timely discharge or prevent the 

best patient outcome. 
Medical Management Guide Version 3.0 Utilization Management Page 33

• Continued stay review is conducted at regular 

intervals throughout hospitalization to assess 

the need for continued inpatient treatment. 

Review is usually conducted at prescribed time 

frames throughout hospitalization or with a 

change in the level of care or the addition of 

procedures. If the patient is staying longer than 

originally antici­pated, CM should be notified. 

Patient-specific discharge plans should identify 

the need for follow-up (see also Section III, 

Case Management, Discharge Planning).

Retrospective review is conducted after treat­ment 

and/or services are completed. It may identify 

targets for future prospec­tive or concurrent review. 

Third-party payors may require retro­spective review 

to verify that the care being billed was actually 

provided. 

• This process utilizes specific data elements to 

measure outcomes, identify areas of concern 

that may require implementation of a qual­ity 

improvement project, and evaluate the 

effective­ness of health care.

Focused retro­spective review concentrates on one 

aspect of care, such as appropriateness of service.

General retrospective review examines the entire 

spectrum of care including quality, utilization, 

coding, appro­priateness, necessity, and so forth. 

Outcome Measurement and Management

Measuring UM outcomes involves data collection 

and analysis, and appropriate reporting. This process 

is essential for a successful program, but it can be 

challenging to understand and apply the available 

information systems and resources used by the DoD. 

(Refer to Section V, Medical Management Tools, 

for data information systems and analysis that are 

vital to successful MM measurement and integration 

for both clinical and business practices.)

UM outcome measures are commonly divided into 

daily, monthly, and quarterly summaries and tracked 

over specific time frames according to the process 

improvement or business planning needs of the 

facility. Fig. 9 provides examples of UM measures for 

outpatient, ancillary, and inpatient services.

The TRICARE Management Activity (TMA) 

Population Health and Medical Management 

Division (PHMMD) maintains a centralized, external 

contract to license and distribute specific criteria and 

guidelines to MTFs and TRICARE Regional Offices 

(TROs). The selected products are believed to be 

the best choices for the MHS, although they are not 

the only products available in the industry. These 

products include McKesson InterQual evidencebased clinical decision support criteria, which cover 

a broad spectrum of med­ical/surgical and behavioral 

health care; and MillimanCare Guidelines, which 

address the ambulatory care arena. 

McKesson® InterQual® — http://www.mckesson.

com

McKesson InterQual evidence-based clinical 

decision support criteria are sets of measurable, 

objective, clinical indicators reflecting the need for 

hospitalization and for diag­nostic and therapeutic 

services in both the medical/surgical and behavioral 

health arenas. 
Page 34 Utilization Management Version 3.0 Medical Management Guide

Fig. 9 – Sample UM Data Elements or Measures

Sample UM Data Elements or Measures

Outpatient Measures Ancillary Measures Inpatient Measures

Ambulatory procedures (CPT) per 1000 

MTF enrolled per month/per year

• Identify procedures with the highest 

frequency.

• Is the highest frequency of a given 

procedure within the MTF or the 

Purchased Care System (PCS)?

• If higher in the PCS, is that procedure 

available within the MTF? If yes, 

identify causes for referral and 

consider strategies for recapturing 

care.

• Conduct a focused retrospective review 

to determine if the highest frequencies 

meet medical necessity criteria. If high 

numbers do not meet the criteria, 

consider a short-term prospective review 

for high frequency/high cost.

ED encounters per 1000 MTF enrolled 

per month/per year

• Identify high ED utilizers.

• Consider CM, education, DM, and 

marketing of an advice line.

• Is there inappropriate use or overutilization of the ED? Is there an 

access issue?

• Are there implications for community 

outreach (e.g., is there a high volume 

of fractures)?

• Is there a pattern to the cause?

• Which safety factors might be missing 

to prevent fractures?

High volume ICD-9-CM principal 

diagnoses for ED visits for MTF 

enrolled per month/per year

• Identify the highest occurring principal 

diagnoses within the ED.

• Identify patterns by enrollee and by type 

of visit. Consider CM, DM, etc.

• Are there implications for community 

outreach (e.g., is there a high volume 

of fractures)? Is there a pattern for 

the cause?

• Which safety factors might be 

missing?

Radiology procedures per 

MTF enrolled per month/per 

year

• Identify the highest volume 

procedures.

• Are criteria available 

that must be met prior 

to ordering a high-cost 

radiological procedure? Are 

they being used?

• Identify the referral rate to 

the PCS if the procedure is 

available in house.

• If unacceptable and 

inappropriate procedures are 

being ordered, determine 

whether criteria exist to 

address the problem.

• If there are existing criteria, 

ensure all providers are 

educated in their use.

• If not, consider forming a 

team to develop criteria.

MTF average length of stay (ALOS) per diagnosisrelated group (DRG) per month/per year

• Identify the overall MTF ALOS.

• Identify the highest frequency DRGs and compare 

them to the overall MTF ALOS.

• Are one or more DRGs skewing the overall ALOS?

• Compare MTF ALOS to external averages.

• Is the MTF ALOS higher or lower?

• Stratify by department/service (medical, surgical, 

maternity, newborn, behavioral health) and identify 

problem areas for further study.

• Conduct a DRG-specific retrospective focused review 

to determine if discharge planning, CM, clinical 

pathways, or other strategies are indicated for 

aberrant DRGs.

Is concurrent review indicated for a brief period 

to pinpoint barriers to timely discharge?

Admission rate per 1000 MTF enrolled per month/

per year

• Stratify by MTF and PCS and compare admission 

rates.

• Identify the reasons for PCS admissions if your MTF 

has the same inpatient resources.

• Why are MTF beds unavailable?

• Can steps be taken to decrease MTF LOS and 

increase capacity?

• What are the preventable admission rates?

• Are there indications for CM, DM, etc.?

• Stratify data by department/service. Select priority 

and use the UM process to form an action plan.

• Stratify by DRG and/or diagnoses to identify the 

target population for intervention.

Top diagnoses for same-day surgeries with 

unplanned admissions for MTF enrolled per 

month/per year

• Consider reasons for the admissions.

• Were any of these preventable?

• Are there clusters or patterns to the preventable 

admissions?

• Is a quality review indicated?
Medical Management Guide Version 3.0 Utilization Management Page 35

Sample UM Data Elements or Measures (cont.)

Outpatient Measures Ancillary Measures Inpatient Measures

ICD-9-CM principal diagnoses seen within 

the outpatient setting for MTF enrolled per 

month/per year

• Identify the highest occurring diagnoses.

• Stratify by medical, surgical, and behavioral 

health; and by adult/pediatrics.

• Would group visits for select diagnoses be 

appropriate?

• Are CPGs in use? Are they being used 

correctly? Is provider education indicated?

Procedures (CPT): Top high volume for MTF 

enrolled per month/per year

• Identify the highest occurring procedures 

within the outpatient setting.

• Stratify by adult and pediatric categories.

• Conduct a focused review to confirm the 

medical necessity and appropriateness of 

high-volume procedures.

Specialty referrals per MTF enrolled per 

month/per year

• Stratify by referrals within the MTF and 

referrals to the PCS.

• If there is a high volume of referrals sent to 

the PCS, determine contributing factors.

• Reference Milliman Ambulatory Care 

GuidelinesTM or InterQual® criteria.

• Are these guidelines being used to assist 

PCMs?

• Could the care be managed by the PCMs? Is 

PCM education indicated?

Total discharges within 24 hours of an admission for 

MTF enrolled per month/per year

• Distinguish inappropriate admissions (i.e., those that did 

not meet medical necessity or level-of-care criteria).

• Conduct a focused review to identify underlying causes.

• Select appropriate strategies.

• Was the observation level of care more appropriate?

• Is that level of care available within the MTF?

• Can you potentially designate certain beds as 

observation-level?

Top DRGs by RWP for all MTF enrolled per month/

per year (Note: DRG Weight Table lists RWP for each 

DRG)

• Identify the highest frequency DRGs for the date range.

• Identify the ALOS for individual DRGs.

• Utilize the DRG weight table to identify relative weights 

and LOS.

• Stratify by department/service.

• Are there patterns that warrant further investigation?

• Are preventable admissions included in the top 

DRGs?

• Are CM, DM, discharge planning, or other strategies 

indicated?

Total MTF admissions for enrolled population by 

principal diagnosis per month/per year

• Stratify by department/service and key demographics.

• Identify patterns and potential problem areas.

• Compare admission diagnosis to principal diagnosis to 

identify potential patterns (e.g., admission diagnosis 

is rule-out myocardial infarction while the principal 

discharge diagnosis is gastroenteritis).

• Conduct a focused review to confirm the 

appropriateness of targeted admissions.

MTF readmission rate for same or related diagnosis 

within 30 days of discharge for MTF enrollees per 

month/per year

• Identify potential quality-of-care concerns.

• Compare the first and second or subsequent discharges 

for a specific enrollee.

• Were the first discharge or subsequent discharges 

potential premature discharges?

• Was the readmission related to insufficient discharge 

planning, patient education, or follow-up care?

Fig. 9 (cont.) – Sample UM Data Elements or Measures
Page 36 Utilization Management Version 3.0 Medical Management Guide

These criteria are not based on diagnosis but 

rather on the severity of the patient’s illness and 

the intensity of the services required. Thus, they 

serve as criteria for all hospital care, regardless of 

location or facility size. McKesson InterQual products 

are packaged in criteria sets that are continuously 

evolving. The DoD licensing agreement provides 

Web-based access, with online modules available 

for distance learning through the TMA PHMMD 

Support Center at http://www.tricare.mil/ocmo.

Milliman Care Guidelines®— http://www.

careguidelines.com

The Milliman Care Guidelines target conditions 

ordinarily seen by pri­mary care managers (PCMs) in 

the ambulatory care arena. 

These guidelines:

• Provide clinical detail about diagnostic and 

therapeutic approaches, and about referrals 

and procedures. 

• Introduce and integrate pharmaceutical and 

management consid­erations. 

• Define the assessment and treatment modalities 

that should occur at the primary care level prior 

to referral for specialty care.

• Help PCMs provide the fullest spectrum of care 

at the most appropriate level, while helping the 

MTF conserve specialist resources.

The guidelines are not intended to be used without 

the judgment of a qualified healthcare provider 

with the ability to consider each patient’s individual 

circumstances. They are updated every one to two 

years, or as necessary, to reflect industry changes.

The guidelines are published by Milliman in a 

Web-based format and are accessed through its 

CareWeb portal (http://www.careguidelines.com/

login-careweb.htm). Access via CareWeb requires 

a DoD account, which provides a username and 

password. Access is granted only to users employed 

directly by the MTF. For more information and logon instructions, contact your local MTF or designated 

TMA point of contact (POC).

A Milliman Care Guidelines distance learning training 

module is available through the Population Health 

and Medical Management Division (PHMMD) 

Support Center at http://www.tricare.mil/ocmo.

 ( CD-ROM Resource UM-3 shows screenshots 

and provides descriptions of various Milliman 

resources.)

Provider Profiling

Provider profiling can be defined as the 

identification, collection, collation, and analysis of 

data to develop a provider-specific characterization 

of performance. The process represents an 

important application of analytics to improve quality 

and reduce costs. The data analysis that results from 

provider profiling gives providers a more complete 

picture of the quality of care they provide. 

Provider profiling can be tailored to meet specific 

needs based on the healthcare delivery model. 

According to Kongstvedt (2007), profiles should 

share the following characteristics:

• Accurately identify the provider in the profile.

• Accurately identify the specialty of the provider.

• Help improve the process and outcome of care 

in both dollar and quality outcomes.
Medical Management Guide Version 3.0 Utilization Management Page 37

• Have a firm basis in scientific literature and 

professional consensus.

• Meet certain statistical thresholds of validity 

and reliability.

• Compare the provider to the norm.

• Cost the minimum amount possible to produce.

• Respect patient confidentiality.

When profiling a provider, consider the level of 

analysis involved. Profiling at the individual provider 

level is often not possible because the number 

of episodes for each physician is too small. The 

resulting statistical instability introduces too much 

error to generate robust comparative conclusions. 

Instead, profiling should be performed at the 

clinic/group level. This also has the advantage of 

taking into account the fact that care is delivered 

by teams of providers, particularly for complex and 

chronic diseases. 

Referral Management

Referral Management (RM), considered a subcomponent of a UM pro­gram, is the process of 

managing and tracking­ internal/external patient 

referrals within the MTF, to another MTF (i.e., within 

the DCS), or to network specialists (i.e., to the 

PCS). RM provides a mechanism for determining 

patient access to specialty­ clinics, durable medical 

equipment (DME), and network inpatient admissions 

that use evidence-based criteria and predetermined 

clinical/business outcomes. 

RM is an important business and clinical process 

within the MHS. It provides a clear capability to 

minimize costs for care referred to the network. 

RM goals are to promote continuity of care, 

timely intervention, access to care, recap­ture care 

appropriately, and make informed deci­sions about 

the most effective utilization of resources. 

MTFs hold primary responsibility for coordinat­ing 

the tracking and closure of specialty referrals for 

their enrolled population. A referral is the process 

of directing an MHS patient from one healthcare 

provider to another within the DCS, or to a network 

(preferably) or non-network (as necessary) civilian 

provider. A referral request is expected in most 

cases; in some circumstances, a preauthorization 

may be required. A consult report, known as a 

Clearly Legible Report (CLR), is the primary method 

used to close out a referral. 

The RM process involves two types of com­ponent: 

clinical and administrative.

The clinical component includes performing UR 

for medical necessity of specialty referrals and 

determining appropriateness of care. RM staff 

should apply the use of approved clinical practice 

guidelines (CPGs) and proactively identify and refer 

patients for CM or DM.

The use of clinical practice guidelines (CPGs) can 

facili­tate the RM process, since recom­mended 

referrals for specialty care are included within 

the practice guidelines (see Section IV, Disease 

Management, and Appendix C, Definitions, 

for more information on CPGs). The ability to verify 

the appropriateness of a referral for a particular 

dis­ease or procedure is available as a function in 

Milliman Ambulatory Care Guidelines (http://www.

careguidelines.com/brochures/ac/ACebrochure.pdf) 

and McKesson InterQual evidence-based decision 
Page 38 Utilization Management Version 3.0 Medical Management Guide

support criteria. Clearly identifying recommended 

referral points can decrease inappro­priate referrals 

and improve the timeliness of appropri­ate referrals.

The administrative component of RM relates 

primarily to managing the electronic transmission 

of specialty referral requests from the MTF to the 

MCSC, to include ensuring referrals meet access 

and continuity of care standards. 

Administrative staff need to closely monitor and 

track the return of referral results. Tracking of 

referrals encompasses monitoring, timeliness of 

result return, and legibility. The utilization manager 

initiates services by sending a referral to the 

Managed Care Support Contractor (MCSC) (see 

also Section I, Medical Management Essentials, 

TRICARE and Other Benefit Programs, Working 

with Managed Care Support Contractors). 

Contact the MCSC in your region on how to 

appropriately send a referral. 

With contract modifications, the MCSC performs 

benefit and medical necessity reviews for all patients 

except ADSMs. RMC staff must perform benefit 

and medical necessity reviews for ADSMs since 

the MCSC will not deny their care. However, the 

MTF may establish its own internal review process 

to select referrals for appropriateness and medical 

necessity. 

Additionally, red flag situations such as the following 

may require further review:

• Travel

• Out-of-area care

• Non-network provider requests

• Continuity of care

• Care following PCS enrollment

The MTF should have an established process to 

appropriately respond and coordinate high-expense 

requests. However, these items are available to the 

beneficiary but should be closely reviewed for cost 

containment and appropriately addressed by MTF 

staff prior to “defer to network.”

The following are some tips for implementing a 

successful RM program: 

• Perform retrospective reviews to validate 

referral patterns. 

• Evaluate the appropriateness of referrals for 

ADSMs and the strategy for further review. 

• Evaluate multiple referrals for quality and 

continu­ity of care (e.g., referrals for new 

versus estab­lished patients). 

• Maintain current capabilities list to facilitate 

Right of First Refusal (ROFR) opportunities. 

• Monitor access for specialty appoint­ments 

within the MTFs through sound template 

management. 

• Identify opportunities to refer patients for 

CM or DM. 

• Collaborate and coordinate processes and 

prob­lem resolution with the MCSC. 

• Educate patients and staff about the referral 

process. 

• Establish a tracking process to account for 100 

percent referrals.

Referral Management Center (RMC)

The ASD (HA)/TMA have mandated the 

establishment of a Referral Management Center 

(RMC) within each MTF or multi-service market. 

The RMC functions as the primary source for 

processing specialty referrals. With the exception 

of multi-service markets, the RMC should be 
Medical Management Guide Version 3.0 Utilization Management Page 39

the “one-stop shop” for both MTF and MCSC 

personnel and, most importantly, for the patient. 

The RMC is the place where the MTF can maximize 

its MM plan through the recapture of spe­cialty care 

and containment of its TRICARE Prime enrollees 

(access and demand management). The RMC 

operates in accordance with the standardized 

business rules for referrals and authorizations. 

Duties include referral administration, appointments, 

and tracking. Each Service Branch has developed 

its own particular RM processes. RMC staff 

should have a working knowledge of the TRICARE 

benefit program as it applies to referrals (TRICARE 

Operations Manual 6010.51-M). CD-ROM 

Resources UM-4 and UM-5 contain RM policy 

memoranda for the Army and Navy. CD-ROM 

Resource UM-6 is a comprehensive document that 

provides guidelines for establishing an RMC. The 

Army and Navy medical departments defer to the 

Air Force RMC Guide. 

Active Duty Service Member Referrals

Referrals for ADSMs require special attention. 

The MCSC does not perform medical necessity or 

benefit review on ADSM referrals. Once the ADSM 

referral is reviewed and approved by the MTF, the 

MCSC will not deny care to the patient.

The MTF Commander or designee is the approval 

authority for network specialty care for ADSMs. UM 

staff members need to complete a medical necessity 

and benefit review on the referral and make a 

recommendation to the MTF approval authority for 

approval/disapproval of the specialty care requested.

Within the recommendation, consideration for 

approval hinges on medical necessity and on the 

need to meet mission requirements. For example, 

in one scenario an ADSM is suffering from a severe 

case of pseudofolliculitis that requires dermatology 

visits every six weeks. In this case, due to the 

severity of the disease process, the dermatologist 

refers the patient for laser hair removal. However, 

laser hair removal is not currently a covered benefit. 

Yet in this case, laser hair removal is a long-term 

solution that should ultimately decrease the need 

for multiple visits to the dermatologist, which in turn 

will decrease time away from the ADSM’s duty 

section/mission. As a result, UM staff would 

recommend that the procedure be approved.

Elective care without prior approval is prohibited. 

Written approval must be obtained from the 

ADSM’s Squadron or Unit Commander and MTF 

Commander. The ADSM must notify his/her PCM 

prior to the elective care and, finally, the MTF within 

three days of treatment. Elective care requires the 

member to provide the report of care describing 

treatment, medications ordered, etc., to be filed in 

his/her medical record. 

For elective care in the private sector, the ADSM is 

responsible for all expenses related to his/her own 

care, travel, and standard leave for all time away 

from duty. Convalescent leave is not authorized. 

ADSMs are also ineligible under such circumstances 

for any compensation related to elective care. In 

a DCS that offers elective services, members are 

eligible for permissive Temporary Duty (TDY) and 

convalescent leave, with the ADSM responsible for 

all expenses.

It is important to note that approval for a noncovered benefit only applies to ADSMs. There also 

may be Service Branch-specific directives or policies 
Page 40 Utilization Management Version 3.0 Medical Management Guide

that preclude receipt of certain care/procedures. UM 

staff must be aware of Line of Duty (LOD) policies 

of their respective Service Branch in order 

to appropriately process LOD-related referrals.

MTFs should have a protocol in place for the MTF 

Commander designee during initial review of 

referrals, to identify those that could go forward 

to the MCSC and those that need further 

review/approval.

Authorization 

RM staff should be aware of authorization 

policies (TRICARE Operations Manual 6010.51-M, 

Chapter 8, Section 5, Referrals/Preauthorizations/

Authorizations) as they review referrals for 

appropriateness. An authorization (or 

preauthoriza­tion) is defined as a “prior authorization 

for pay­ment of medical/surgical or psychological 

services based on certain criteria that are generally 

accepted by qualified professionals to be reasonable 

for diag­nosis and treatment of an illness, injury, or 

mental disorder” (Code of Federal Regulations [CFR], 

Title 32, National Defense — Chapter 1, Section 

199.2, Definitions). It is essentially a determination 

that a referral for civilian health care represents a 

request for services that are:

• Covered as a TRICARE benefit.

• Medically nec­essary and delivered in an 

appropriate setting.

A consult report is not required because it will be 

provided during the referral process. 

Not all referrals require prior authorization. 

Referrals that require close scrutiny are usually 

high-cost or problem-prone proce­dures or 

services. After analyzing data for the MTF’s 

existing practice patterns, MTF staff should 

decide which service line, if any, would require 

preau­thorization review. 

MCSCs maintain a preauthorization list based on 

best business practices for their region on the 

TRICARE website (http://www.tricare.osd.mil) or 

at the local TRICARE Service Center (TSC). 

Episode of Care

A business principle utilized by MCSCs as part of 

the referral process is the concept of “episode 

of care” (EOC). An EOC is a range of predefined 

procedure codes that can be performed by a single 

provider to ren­der reasonable medical services 

related to a specific condition. It may include an 

initial assessment, fol­low-up interventions, and 

reassessments in accor­dance with best business 

practices. 

Applying an EOC as a business rule in RM can be 

advantageous because an EOC: 

• Is based on claims data. 

• Conforms to norms of civilian clinical 

practice/community standards of care vs. 

overutilization. 

• Enhances accurate and timely claims processing. 

• Incorporates MCSC best practices. 

• Minimizes the frequency of communications 

between the MTF and the MCSC, network 

provider, and patient. 

• Provides clarity on package or bundle of services 

being ordered or requested. 

• Provides positive return on investment (ROI). 
Medical Management Guide Version 3.0 Utilization Management Page 41

The Electronic Referral Process

The RMC will access an electronic copy of the 

referral via CHCS/AHLTA (see Section V, Medical 

Management Tools) or, in very limited cases, a 

paper copy and review it for appropriateness and 

completeness. If the MTF/DCS does not have the 

capability or capacity to process the document, the 

referral will be forwarded manually or via an autofax 

solution to the MCSC for specialty care approval/

authorization. Referrals to the MCSC will include 

the minimum data elements found in the TRICARE 

Operations Manual (see Fig. 10).

Once the MCSC receives the referral via fax, he/she 

enters it into the referral tracking system, assigns 

level-of-service CPT codes, and verifies that all 

needed information is present. If information is 

missing, the referral will be returned to the PCM 

via the RMC. The MCSC will perform a medical 

necessity review (MNR), as needed, and a covered 

benefit review (CBR).

If the referral passes the MNR and CBR, the MCSC 

will notify the patient, the MTF, and the selected 

network provider that network specialty care has 

been authorized. 

If the referral does not pass the MNR and CBR, the 

patient and MTF will be notified of the denial. The 

denial notice will be faxed to the MTF’s RMC and 

mailed to the patient. The patient has the right to 

initiate an appeal with the MCSC.

When the MCSC approves the MTF’s referral for 

treatment, a referral letter is sent to the civilian 

provider. The referral letter authorizes the services 

or EOC, using current procedural terminology (CPT) 

codes that can be rendered to either “evaluate 

only” (provide second opinion) or “evaluate and 

treat” the patient’s condition. 

MTFs should be reassured that the application of 

EOCs is a best business practice that should not 

increase healthcare costs, due to safeguards built 

into the process. That is, the approval of an EOC 

only applies to care for the original diagnosis or 

specialty referral ordered by the MTF PCM. 

The network provider should not refer the patient 

back to his/her PCM for more specialized care. 

When a patient requires admission to the hospital 

or referral to a similar or more specialized provider, 

the original network provider must submit a request 

for another referral to the MCSC (e.g., non-invasive 

cardiologist to a cardiac surgeon, orthopedist to 

a physical therapist or an orthospine surgeon). 

Cardiology cannot refer a patient to an unrelated 

specialty such as urology or endocrinology; such 

requests must come from the PCM.

At this point, the MTF has the opportunity 

to recapture the patient based on the MTF’s 

capabilities and capacity to ren­der the new care 

(e.g., Right of First Refusal [ROFR]). The patient 

must return to the PCM for a new referral if any 

of the following occur:

• There is a break in medical care.

• The period of time between treatments is 

greater than one year.

• The authorization has expired.
Page 42 Utilization Management Version 3.0 Medical Management Guide

Fig. 10 – TRICARE Referrals/Preauthorizations/Authorizations

Source: TRICARE Operations Manual 6010.51-M, Chapter 8, Section 5, (Aug. 1, 2002)

TRICARE OPERATIONS MANUAL 

Referrals/Preauthorizations/Authorizations

Required Data Element Description/Purpose/Use

Request Date/Time DDMMYY/hhmm

Request Priority STAT/24-hour/ASAP/Today/72-hour/Routine

Requester

• Referring Provider NAME

• Referring Provider NPI

• Referring TF

• Referring MT NPI

Name of PCM/MTF individual provider making request

HIPAA National Provider Identifier (NPI) — Type 1 (individual)

Name of Military Treatment Facility (MTF)

HIPAA National Provider Identifier (NPI) — Type 2 (organizational)

Patient Information

Sponsor SSN

Patient ID EDI_PN (from DEERS), if available

Patient Name Full name of patient (if no EDI_PN available)

Patient DOB Date of birth (required if patient not on DEERS)

Patient Gender

Patient Address Full address of beneficiary (including zip code)

Patient Telephone Number Telephone number (including area code), if available

Clinical Information

Patient Primary Provisional Diagnosis Description

Reason for Request Sufficient clinical info to perform MNR

Service

Service1 — Provider Specialty of service provider

Service 1 — Provider Sub-specialty Additional sub-specialist Info, if needed (free text clarifying info entered, 

with reason for request — e.g., Pediatric Nephrologist)

Service 1 — By Name Provider 

Request if Applicable — First and Last Name Optional info regarding preferred specialist provider (free text)

Service 1 — Service Type Inpatient, specialty referral, DM purchase/rental, other health service, etc. 

DME provider to do CMN

Service 1 — Service Quantity (optional) Number of visits, units, etc.

CHCS Generated Order Number

(DMIS-YYMMDD-XXXXX)

Unique Identifier Number (UIN) — The DMIS of the referring facility 

identified in the “Referring MTF” field on this request

(Date in format indicated — consult order number from CHCS)
Medical Management Guide Version 3.0 Utilization Management Page 43

Communication between MTFs and MCSCs 

• There will be a single RM POC at the MTF with 

one phone and fax number. 

• MTF staff will fax referrals to the MCSC (some 

MTFs may be using e-fax to per­form this 

function). 

• MTF staff will not be responsible for coding the 

diagnosis or procedure(s). 

• MTF staff must implement the use of Englishlanguage text. 

Patient Clinical Information 

• Referring providers will include pertinent clinical 

information in the referral. 

• The referring provider and/or the RMC personnel have primary responsibility in coordinating 

the transfer of information to the civilian 

provider(s). 

Medical Necessity and Covered Benefit 

Determinations 

• The MCSC will review all referrals to the network for medical necessity and covered benefit 

determinations, including the associated 

appeals processes within the PCS. However, the 

MTF is responsible for all referrals for ADSMs 

and for the MTF appeal process. 

• No preauthorization is needed for the first eight 

visits of non-ADSM patients who seek mental 

health care with network providers. There is no 

requirement for MTFs to manage the care of 

patients who self-refer. Mental health care for 

ADSMs needs to be preauthorized. 

Utilizing Military Treatment Facility Capability 

and Right of First Refusal Reports 

MTF staff must:

1. Provide the MCSC with accurate, current listings 

of the MTF’s capabilities so ROFR reports can be 

forwarded for MTF care, as appropriate.

o MTF staff will regularly update MCSC 

capability listings.

2. Review all incoming referrals before the close 

of the following business day for routine ROFR 

requests. 

o Urgent ROFRs will include personal 

telephone contact initiated by MCSCs 

and near-immedi­ate (not to exceed 30 

minutes) acceptance or declination by MTF 

representatives. 

MTFs must notify the MCSC of receipt of a routine 

referral within one business day when the referral 

has been accepted. However, if the MTF does not 

respond to an ROFR, either negatively or positively, 

the MCSC will assume an implied decli­nation 

and the patient will be appointed to the network 

(TMA Memorandum, Policy Guidance for Referral 

Management, 2004). It is the MTF’s responsibility 

to provide clinical feedback to the referring civilian 

provider within 10 business days. 

Additional Information

The MCSC does not provide referral services for 

TRICARE Standard, TRICARE Plus (T-Plus) TRICARE 

for Life (TFL), or North Atlantic Treaty Organization 

(NATO) patients, or for those covered by other 

health insurance (OHI). The RMC is responsible for 

assisting with these referral requirements.
Page 44 Utilization Management Version 3.0 Medical Management Guide

Referrals may be required for urgent care deferred to 

the network. Routine primary care in the local area 

without a referral could generate point-of-service 

charges for the beneficiary.

MTFs are required to track and account for all initial 

specialty care referral requests going out of/into the 

MTF on their way to resolution for TRICARE Prime 

and ADSM referrals, including those not tracked 

by the MCSC (e.g., T-PLUS, OHI). For network care 

arranged through the MCSC, network specialty 

care providers will provide CLRs to the MCSC 

within 10 business days of the patient encounter 

for “Evaluation Only” referrals and within 30 days 

of the patient encounter for “Evaluate and Treat” 

referrals, except where exempted by MCSC contract 

modification. The MCSC is contractually required 

to forward CLRs to the RMC, which will annotate 

referral receipt and forward the CLR to the referring 

provider. 

The referring provider/PCM team is responsible 

for acknowledging the results by review/signature 

and for forwarding the results for filing in the 

patient’s medical record. The RMC is responsible 

for reconciling outstanding referral results with the 

MCSC. Prior to the MCSC reconciliation, the RMC 

should first review MCSC Web-based tools and filed 

claims, and conduct in-house retrieval (e.g., from 

clinics or the mail room).

RMCs should also provide to the PCM on a regular, 

recurring basis a list of referrals without results, 

which indicate that no patient appointment was 

made and/or that no report was received. 

The Grievance and Appeal Process

Overview

According to DoDI 6000.14, Patient Bill of Rights and 

Responsibilities in the Military Health System (2007), 

MHS patients have the right to an effi­cient process 

for resolving differences with their healthcare 

providers, MTFs, or MCSCs; this includes being 

able to rely on a system of internal and external 

review. The directive states that the patient be 

given an opportunity to appeal the MTF’s decision 

regarding medical necessity determinations. It also 

requires the MTF appeal process be consistent with 

the reconsideration procedures under CFR Title 

32, National Defense, Chapter 1, Section 199.15 

— Quality and Utilization Review Peer Review 

Organization (PRO) Program; and Section 199.10 

— Appeal and hearing procedures.

The PRO Program is required by Title 10 of the U.S. 

Code (U.S.C.) 1079(o). Medical benefits authorized 

by TRICARE in civilian facilities are required by 

this regulation to be the same as those benefits 

authorized in facilities of the Uniformed Services 

for patients under Title 10 1077(a), except as may 

be specifically limited by other statutory provisions 

under Chapter 55 of Title 10.

The DCS uses CFR Title 32, National Defense, 

Chapter 1, Part 199 — Civilian Health and Medical 

Program of the Uniformed Services to determine 

the scope of the medical benefit in MTFs. The scope 

of the benefit is relevant in determining whether a 

requested healthcare service is medically necessary 

(an appeal issue) or a covered benefit (a grievance 

issue). 
Medical Management Guide Version 3.0 Utilization Management Page 45

The grievance and appeal processes are applicable 

to all TRICARE beneficiaries, subject to the 

limitations described in the sec­tion for uniformed 

patients (see Special Considerations for Active 

Duty Service Members, later in this section). The 

provision of or denial of healthcare services for 

ADSMs based on medical readiness requirements 

or fitness-for-duty determi­nations is not subject to 

the grievance or appeal process. Complaints may be 

made through the appropriate Chain of Command 

or to the Inspector General (IG). Fitness-for-duty 

determinations are addressed through the Medical 

Evaluation Board (MEB) and Physical Evaluation 

Board (PEB) processes (see Section III, Case 

Management, Disability Evaluation System).

The grievance process applies for complaints about 

specific treat­ment or coverage (benefit) decisions 

other than medical necessity. It is therefore essential 

for MTFs to determine whether the patient’s dispute 

involves a grievance or an appeal.

The appeal process applies when healthcare 

services are denied by an MTF based on the 

determination that the services are not medically 

necessary. In such cases, the MTF will neither 

provide nor authorize TRICARE payment for 

services. 

Grievances 

TRICARE defines a grievance as a written complaint 

or concern about a non-appealable issue regarding 

the perceived failure by any member of the 

healthcare delivery team, including TRICAREauthorized providers, military providers, regional 

contractors, or subcontractor personnel, to 

provide appropriate and timely healthcare services, 

access, or quality; or to deliver the proper level of 

care or service. The grievance process allows the 

opportunity to report in writing any concern or 

complaint regarding healthcare quality or service 

to which the patient believes he/she is entitled 

(TRICARE Operations Manual, 6010.51-M, Chapter 

12, Section 9).

Examples of grievances include: 

• Coverage determinations.

• Factors related to quality assurance.

• Length of the waiting period to obtain an 

appointment.

• MTF determinations of space-available 

care (including availability of services, 

pharmaceuticals, equipment, or other items). 

• Undue delays at an office when an appointment 

has been made.

• Refusal of a PCM to provide access to services 

or to refer a patient to a specialist.

Filing a Grievance 

To initiate the grievance process, the patient or 

patient’s representative submits his/her griev­ance in 

writing through the Customer Service department, 

the patient advocate, or a similar mechanism 

developed by the particular MTF for review by the 

MTF Commander. The Commander (or designee) 

appoints an “investi­gator” (most likely the acting 

Chief of Medical Staff) to review the grievance.

Within 60 days of the date of the written grievance 

request, the MTF Commander (or designee) 

forwards a written reply to the patient that includes 

find­ings regarding the grievance. 
Page 46 Utilization Management Version 3.0 Medical Management Guide

The MTF Commander’s (or designee’s) decision 

is final. The reply includes the name of a contact 

person who can address questions regarding the 

review findings. 

Appeals 

An appeal is an administrative review of program 

determinations regarding the medical necessity of 

healthcare services (including behavioral serv­ices) 

made under the legal and regulatory provisions 

(TRICARE Operations Manual 6010.51-M, Chapter 

13, Appeals and Hearings). MTF staff are responsible 

for protecting the rights of appealing parties at 

all levels of the appeal process. That responsibility 

begins with the initial denial determination and ends 

when a final resolution is achieved. Further levels of 

appeal should progress only if the patient wants to 

continue the process (i.e., if the patient disagrees or 

is dissatis­fied with the decision) or if the reviewing 

authority upholds the initial denial. 

The MTF appeal process involves three levels of 

review followed by three levels of appeal. The 

rationale for multiple levels is twofold:

1. The process allows for a check and balance 

within the system.

2. The process provides for objective decisionmaking, progressing from the lowest to the 

highest level in the appeal Chain of Command.

The process also provides for internal and external 

chains of responsibility.

• The internal chain begins with the first level of 

review, at the MTF; and ends with the first level 

of appeal, to the MTF Commander.

• The external chain includes the third and 

fourth levels of appeal to the National Quality 

Monitoring Contractor (NQMC) and TMA, 

respectively.

Fig. 11 summariz­es the MTF review and appeal 

process, including reviewer qualifications and 

guidelines. 

Filing an Appeal 

Appealing Party 

The appealing party is the patient affect­ed by the 

initial denial determination. Participation in an 

appeal is limited to any party associated with the 

initial denial determination, as well as the authorized 

representative(s) of the appealing par­ty. The patient 

may appoint a representative (in writing) to act on 

his/her behalf during the appeal process. 

The MTF provider is not generally an appropriate 

appealing party for a dependent patient. A 

dependent denied services may appoint his/her 

sponsor or any other person as his/her repre­sentative 

subject to the limitation in CFR Title 32, National 

Defense, Chapter 1, Section 199.10 — Appeal and 

hearing procedures. Following the representative’s 

appointment, he/she may file an appeal on behalf of 

the patient.

In cases where the patient is a child under the age 

of 18 (i.e., a minor), the presumption is the sponsor 

is the appointed representative who can appeal on 

behalf of the child without a specific des­ignation or 

appointment, as long as the sponsor is the custodial 

parent. 
MTF Review and Appeal: Internal Review

Level of 

Review/Appeal

Reviewer 

Qualifications

Review Process 

(Reviewer Actions)

Outcome Timelin

First-level Review • Utilizes criteria as a tool 

to review for medical necessity.

• May approve requested 

services based on criteria.

• May not deny services.

• Approves requested 

services;

 OR

• Cannot approve; 

forwards to the secondlevel reviewer for medical standard of care decision.

• Admission: By 

day following a

• Concurrent: W

three (3) businof initial review 

• Prospective: W

30 days of initirequest

• Retrospective

applicable

• Non-physician reviewer• Usually registered nurse or licensed practical 

nurses trained in utilization review

Second-level Review(Initial Denial Determination)

• Contacts PCM or 

attending physician and/or provider for additional documentation or pertinent medical information.

• Approves or denies the 

requested services based on medical standard of care and available information.

• Approves requested 

services;

 OR• Denies requested 

services. Notifies patient, his/her representative, and/or attending physician/PCM, in writing, of:o Upheld denial 

determination

o Reason for denialo Patient’s rightso Steps to appeal denial 

if patient chooses to do so

Notification• Admission: By 

day following radmission

• Concurrent: W

three (3) businof initial review 

• Prospective: W

three (3) businof initial review 

• Retrospective

30 days of initirequest

• Non-physician reviewer• Licensed practitioner with a current, valid, 

unrestricted license in the same or similar specialty as the attending physician or provider. Examples:o Referral Managemento Physician Reviewero Senior Physiciano Chief of the Medical Staff

Third-level Review (MTF Reconsideration)

• Contacts attending 

physician or healthcare provider for additional information.

• Makes decision based 

on medical standards of care and documentation and/or additional information obtained from the attending physician or provider.

• Recommends 

reconsideration determination approving or denying benefits.

• Forwards determination 

to MTF Commander for review and issuance.

• Refer to timelin

requirements fCommander n(under First LevAppeal)

• Medical/Surgical/Specialty• Clinical Peer:

o Licensed doctor of medicine, osteopathy, 

or oral surgery with a current, valid, unrestricted license to practice in the U.S.

o Holds active staff privileges and patient 

care responsibilities in an MTF

o Certified by a board recognized by the 

American Board of Medical Specialties or osteopathic equivalent and practice in the same specialty of the physician provider whose services are under review.

Fig. 11 – MTF Review and Appeal Process: Internal Review
Level of Review/Appeal Reviewer Qualifications Review Process (Reviewer Actions) Outcome Timeline

Third-level Review (MTF Reconsideration) 

• Behavioral Health Clinical Peer

o Physicians must meet the above criteria 

with board certification by the American Board of Psychiatry and Neurology.

o Cannot be the same individual as in the 

previous review.

 Examples:o Internal Reviewer (if available)o External Reviewer (clinician in the same 

market or region)

First-level Appeal (MTF Reconsideration)

• Consults with other 

medical staff (e.g., Chief of the Medical Staff) for guidance, as needed.

• Contacts attending 

physician or healthcare provider for additional information.

• Makes decision based 

on medical standards of care and documentation and/or additional information obtained from the provider and previous levels of review.

• Approves requested 

services and reverses denial determination;

 OR• Upholds initial denial. 

Notifies patient, his/her representative, and/or attending physician/PCM, in writing, of:o Upheld denial 

determination

o Reason for denialo Patient’s rightso Steps to appeal denial 

if patient chooses to do so

• Reversal;

 OR

• Upheld DeniaNotification• Admission: B

day following 

• Concurrent: W

three (3) businof reconsiderareview request

• Prospective: W

three (3) businof reconsiderareview request

• Retrospective

30 days reconsreview request

MTF Commander

Not applicable Request for app

Must be filed wit30 days following date of the initial determination.

MTF Review and Appeal: Internal Review/Appeal

Prior to an appeal leaving the internal MTF Appeals Process, it is recommended that the case be forwarded to an external entity within the Service’s chain of Cintermediate level of review between the internal and external Appeals Process will vary depending on each Service’s specific processes.

Fig. 11 (cont.) – MTF Review and Appeal Process: Internal Review/Appeal
Reviewer Qualifications

• Reversal;  OR• Upheld Denial.Notification• Hearing Officer will hold 

and issue recommended to TMA Director within 6written notice of assignm

• Refer to 32 C.F.R. 199.10 

detailed information regatimeliness of a hearing.

Level of 

Review/Appeal

Review Process 

(Reviewer Actions)

Outcome Timelines 

Second-level Appeal (NQMC: Appeal Requested)

• Contacts attending physician 

or healthcare provider for additional information.

• Decisions are based on 

medical standards of care IAW 32 C.F.R., 199 and documentation and/or additional information obtained from the provider and previous levels of review.

• Reversal; OR• Upheld Denial.NotificationRefer to TOM, Chapter 13, 

Paragraph 2.3.2 and 2.4

• NQMC• Includes 

reviewers who are clinical peers of the healthcare provider under review.

Fourth-level Appeal (TMA Hearing)

• Hearing Officer is assigned to 

the case.

• Facts relevant to the case 

are presented in relation to applicable law, regulation, policies, and guidelines.

• Decision is based on 

medical standards of care and documentation and/or additional information obtained from the provider and previous levels of review and testimony presented at the hearing.

Not applicable

TMA: Hearing Requested • Request shall be mailed w

60 days after date of NQreconsideration determin

• A Hearing Officer is appo

within 60 days following for hearing. 

MTF Review and Appeal: External Appeal

There are no further appeal rights. The TRICARE Director’s decision is final.

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)

Requests for reconsideratiobe postmarked or received deadline.

Third-level Appeal (NQMC Reconsideration)

• Approves requested services and 

reverses denial determination;

 OR• Upholds initial denial. Notifies 

patient, 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 and 

request formal hearing if patient chooses to do so

Sources: 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 Medical Programs for the Uniformed Services (CHAMPUS). 

• Approves requested services and 

reverses denial determination;

 OR• Upholds initial denial. Notifies 

patient, 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 patient 

chooses to do so

Fig. 11 (cont.) – MTF Review and Appeal Process: External Appeal
Page 50 Utilization Management Version 3.0 Medical Management Guide

In such situations, the custodial parent/sponsor or 

legal guardian may file an appeal and will be seen 

as possessing the same authority as the appealing 

party, which also allows him/her to receive 

notification letters. 

Appealable and Non-Appealable Issues 

Only issues that relate directly to medical necessity 

are appealable. Examples of appealable issues 

include the following: 

• Concurrent reviews of inpatient care denials.

• Denial based on inappropriate level of care.

• Denial of a PCM’s request for referral to a 

specialist.

• Denial of inpatient admission.

• Denial of preauthorization for services.

• Denial of request for professional services.

• Denial of supplies and pharmaceuticals.

• Denial of surgical procedures, including invasive 

and non-invasive tests.

• Termination of previously authorized treatments 

or services.

An issue may not be appealed unless it relates to 

medical necessity. Non-appealable issues include the 

following: 

• Care/service that is not a covered benefit.

• Denial of a treatment plan.

• Denial of unproven care.

• Eligibility as a patient.

• Refusal of a PCM to provide access to services 

requested by the patient. (This is distinguish­able 

from an MTF refusing to allow a patient to seek 

care from a PCM or denial of a PCM’s request 

for a specialty referral, both of which are 

medically necessary care in the opinion of the 

PCM and are therefore appealable. PCMs may 

not deny access to emergency services.)

• Whether a provider is TRICARE-authorized.

While these issues are not appealable, they may be 

subject to the grievance process. 

Special Considerations for Active Duty Service 

Members

DoDI 6000.14, Patient Bill of Rights and 

Responsibilities in the Military Health System,

identifies ADSMs as a key beneficiary population in 

the MHS. Yet the DoDI does not expand the scope 

of benefits or create any entitlement inconsistent 

with the medical or dental care authorized under 

Title 10 U.S.C. Chapter 55, Medical and Dental 

Care or Chapter 47, Uniform Code of Military 

Justice; or CFR Title 32, National Defense, Chapter 

1, Section 199.17 — TRICARE program. ADSMs 

have an obligation to comply with Service Branch 

requirements for medical readiness and the special 

rules and pro­cedures under the Title 10 1074(c) and 

CFR Title 32, Section 199.16 — Supplemental Health 

Care Program for active duty members.

An ADSM may not file an appeal for reasons any of 

the following examples: 

• A military readiness requirement to obtain a 

vaccine. 

• A decision to delay or deny medical treatment 

(whether medically necessary or elective) when 

provision of the treatment would affect a 

Service’s military readiness requirement. For 

example:

o An ADSM desires elective surgery, which 

would adversely impact his/her fitness for 

duty and medical readiness status. 

o An ADSM requires medically necessary care, 

which is not available in theater. 
Medical Management Guide Version 3.0 Utilization Management Page 51

The situations described in the examples above 

would affect the ability of the ADSM or of his/her 

unit to deploy in a timely manner. Because providing 

treatment would affect the Service’s military readiness requirement, it would not be appealable. 

Documentation 

If the patient is dissatisfied with a denial decision 

and wishes to pursue the next level of appeal, 

he/she may request an appeal of that decision. 

Every level of the review and appeal process is 

documented in writing, with all commu­nications 

submitted by the appealing party and cre­ated by the 

MTF kept on file. 

The appealing party has the burden of proof to 

affirmatively establish by substantial evidence 

that the healthcare issue in question is a TRICARE 

bene­fit or entitlement that is necessary according 

to medical standards of care. All parties have the 

opportunity to present, obtain, and examine additional documentation or information for consideration during the appeal process. 

MTFs must maintain documentation related to 

appeals for a minimum of one year after the case is 

closed, at which time the case should be transferred 

to the Federal Records Center, according to the TRICARE Operations Manual. All documentation related 

to levels of review and appeal is subject to the 

same prohibitions against disclosure of information 

and the same protections as other documentation, 

according to HIPAA. Initial determinations, 

reconsiderations, and notifications will follow CFR 

Title 32, National Defense, Chapter 1, Part 199 

— Civilian Health and Medical Program of the 

Uniformed Services.

Risk Management 

MTFs should keep in mind that issuing denials 

of care to patients bears a fundamental Risk 

Man­agement liability. Risk Management issues 

include process standardization, standards of care, 

treatment delays, obstacles to communication 

(within the MTF and between the MTF and patients), 

record-keeping, and confidentiality. 

Any additional medical information the attending 

physician provides, insofar as it is pertinent to the 

review and/or submitted during any one of the 

appeal levels, must be subsequently documented 

as an addendum to the medical record. 

The physician/provider reviewer(s) must possess 

the appropriate credentials and be precise when 

deter­mining an appeal decision. The MTF should 

con­duct inter-rater reliability testing of reviewers and 

the facility should be in compliance with applicable 

regulations. The identity of review coordinators, 

physician reviewers, or consultants who assisted 

in the review of the case will not be disclosed, in 

accor­dance with Title 10 U.S.C. 1102, Confidentiality 

of medical quality assurance records: qualified 

immunity for participants.
Page 52 Utilization Management Version 3.0 Medical Management Guide

UTILIZATION MANAGEMENT PROGRAM 

ACCREDITATION

As part of the TRICARE contract requirement, 

network facilities are required to obtain and 

maintain URAC accreditation for their UM 

programs. For more information, go to: 

http://www.urac.org.

. 

THE UTILIZATION MANAGEMENT 

PROFESSIONAL

Qualifications 

T

he job description of the employee working 

in the UM department of an MTF will vary 

depending on the size of the organization 

and its internal resources. Titles include Utilization 

Manager, Nurse Consultant, and Clinical Nurse 

Specialist. The UM professional should possess 

sufficient clinical knowledge and breadth of 

experience in patient care to identify the clinical 

rationale for procedures or tests. He/she should 

be able to gather necessary information and 

determine the medical necessity of services and 

appropriateness of certain levels of care.

Good communication skills are imperative. In their 

goal of providing UM information to clinicians and 

hospital leader­ship, UM professionals may interact 

closely with the following roles and/or personnel:

1. Population Health Nurse Consultant

2. Health Care Integrator (HCI)

3. Group Practice Manager (GPM)

4. Coders

5. Patient Administration staff

6. Medical Records staff

7. MCSC staff

8. Provider teams

9. MTF MM and Managed Care divisions 

10. Resource Management staff

The following are specific education and training 

requirements for the UM position: 

• Licensed Registered Nurse (RN) – i.e., graduate 

of an accredited nursing program, Bachelor of 

Science in Nursing (BSN) preferred; or possessing 

a bachelor’s (or higher) degree in a healthcarerelated field from an accredited educational 

institution (position typically occupied by an RN 

with a BSN). 

• A minimum of three years of progressively 

increasing managed care responsibilities, with a 

focus in UM and/or a minimum of three years of 

broad-based clinical nursing experience (UM/UR 

focus preferred).

• Current Basic Life Support (BLS) certification. 

• Knowledge and experience (or comprehension 

during training) of software and databases 

currently employed at the MTF (e.g., Composite 

Health Care System [CHCS], Armed Forces 

Health Longitudinal Technological Application 

[AHLTA] — see Section V, Medical 

Management Tools).

• Familiarity with customer-focused and process 

improvement principles. 

• Full-time employment for the past twelve 

months in a healthcare-related field. 

• Valid unrestricted clinical license to practice from 

the state where the MTF is located or licensed 

through the Nurse Licensure Compact (NLC) 

if the UM professional is not Active Duty. For 

more information and a list of states, visit the 

joint website of the Nurse Licensure Compact 
Medical Management Guide Version 3.0 Utilization Management Page 53

Administrators (NLCA) and the National Council 

of State Boards of Nursing (NCSBN): http://

www.ncsbn.org.

Desirable qualifications are as follows: 

• Certification by a UM-specific program (most 

desirable) or a professional organization 

recognized by an accrediting body for UM, such 

as: 

o American Nurses Association (ANA): 

http://www.ana.org/ancc

o American Nurses Credentialing 

Center (ANCC): 

http://www.nursingworld.org/ancc/

o National Association of Healthcare Quality 

(NAHQ) Certified Professional in Healthcare 

Quality (CPHQ): http://www.nahq.org

o McKesson: http://www.mckesson.com/

o McKesson Certified Professional in 

Utilization Review (CPUR)TM

o McKesson Certified Professional in 

Utilization Management (CPUM)TM

o McKesson Certified Professional in 

Healthcare Management (CPHM)TM

• Experience with Microsoft Office software. 

• Master’s degree. 

• Six years of broad-based clinical experience. 

Staffing to Support Utilization 

Management 

Personnel functioning separately under the RMC 

need to establish a direct working relationship 

with their UM department. While RMC staff might 

perform many of the tasks related to routine, dayto-day referral processing, there should be a UM 

professional (e.g., a UM nurse) providing oversight 

and a link to higher-level data analysis and UR 

functions. Communication and collaboration 

between UM and the RMC — as well as with the 

other components of CM and DM — needs to be 

seamless. 

SUMMARY

As healthcare organiza­tions have 

implemented MM, a shift has occurred in 

the UM role from its historical focus on 

cost containment to a more proactive approach 

of continuous quality improvement and evidencebased practice. Organizations that use UM solely 

to deter­mine services and cost (i.e., that implement 

benefit management) tend to diminish their primary 

focus on the patient, which can cause interference 

or delays in coordinating patient care. Nonetheless, 

UR and preauthorization remain an important part 

of UM, wherein LOS and appropriateness of care are 

reviewed, so that problems can be identified early 

enough for intervention. 

A successful, cost-efficient, and effective UM 

program depends on skilled, well-trained staff 

informed about current approaches and trends. As 

the field of UM continues to evolve, every UM staff 

member should view him/herself as a stakeholder 

in developing better healthcare delivery models 

throughout the MHS.
Page 54 Utilization Management Version 3.0 Medical Management Guide

CD-ROM RESOURCES

UM-1 UM Plan Based on Seven-Step QI Process 

— Template 

UM-2 UM Plan Based on Seven-Step QI Process 

— Completed Example 

UM-3 Screenshots of Milliman Care Guidelines 

Resources

UM-4 Memorandum: Interim Guidance on Referral 

Management – Army 

UM-5 Memorandum: Interim Guidance on 

Referral Management – Navy 

UM-6 MTF Referral Management Center (RMC) 

User’s Guide (V 6.0, 2008) – Air Force 

‘


Medical Management Guide Version 3.0 Case Management Page 57

Case Management III

SECTION

INTRODUCTION

T

he Military Health System (MHS) incorporates 

Case Management (CM) as a component of 

a comprehensive Medical Management (MM) 

strategy to:

• Support patients through transitions of care.

• Decrease fragmentation of healthcare services.

• Support patient safety, education, and selfdetermination by establishing an active 

partnership with patients, their families, and 

Fig. 12 — Case Management within the Integrated MM Model (IM3)

*See also Section I, Medical Management Essentials: Fig. 4, Integrated Medical Management Model (IM3) with Key info, page 14.

the entire healthcare team to achieve optimal 

healthcare outcomes. 

Fig. 12 highlights the role of CM over the various 

stages of health care (see also Section I, Medical 

Management Essentials). Specifically, as the focus 

of healthcare delivery moves along the Population 

Health continuum from secondary toward tertiary 

preven­tion, a more individualized approach is 

required to manage the unique circumstances of 

patients with a particular disease/illness/injury. 
Page 58 Case Management Version 3.0 Medical Management Guide

Management (DM), which is based on populations 

(see Section IV, Disease Management). One 

significant aspect of CM is care for patients with 

special needs, which may be physical, behavioral, 

emotional, or educational in nature and may require 

intense coordination and collaboration among 

healthcare team members. 

“Complex CM” may be delivered to patients 

with chronic illness resulting from disease or 

complex injuries. The National Committee for 

Quality Assurance (NCQA) defines complex CM 

as follows: The coordination of care and services 

provided to members who have experienced a critical 

event or diagnosis requiring the extensive use of 

resources and who need help navigating the system 

to facilitate appropriate delivery of care and services.

The goal of complex CM is to help members regain 

optimum health or improved functional capability, in 

the right settings, and in a cost-effective manner. It 

involves a comprehensive assessment of the patient’s 

condition; determination of available benefits and 

resources; and development and implementation of 

a CM plan with performance goals, monitoring, and 

follow-up.

Originally, CM almost exclusively targeted inpatients 

with catastrophic illnesses or injuries. However, a 

number of developments have served to change that 

strategy; notably:

• The emergence of the National Committee for 

Quality Assurance (NCQA): http://www.ncqa.org/.

• The development of accreditation standards by 

the Utilization Review Accreditation Commission 

(URAC): http://www.urac.org.

The MHS has established wounded, ill, and injured 

(sometimes referred to as WII) Service member 

requirements, which provide a unique level of 

intensive CM services for Active Duty Service 

members (ADSMs) with complex medical needs 

serving in the Army, Navy, Air Force, Coast Guard, 

and Reserve components.

Definition, Goals, and Purpose 

The TRICARE Management Activity (TMA) utilizes 

the definition of CM employed by the Case 

Management Society of America (CMSA, 2002), 

as follows: A collaborative process of assessment, 

planning, facilitation, and advocacy for options 

and services to meet an individual’s health needs 

through communication and available resources to 

promote quality cost-effective outcomes. (See also 

Appendix C, Definitions.)

Military case managers have adopted the CMSA’s 

definition of CM but broadened its appli­cation by 

placing CM under the Popula­tion Health continuum 

(see Fig. 12, above). CM services, which are focused 

on the individual patient, may overlap with Disease 

Case Management is a 

collaborative process of 

assessment, planning, 

facilitation, and advocacy for 

options and services to meet an 

individual’s health needs through 

communication and available 

resources to promote quality, 

cost-effective outcomes.
Medical Management Guide Version 3.0 Case Management Page 59

Informed,

Activated

Patient

 1. Community Resources and Policies 3. Self Management

 Support

 2. Health System

Health Care Organization

4. Delivery

System

Design

5. Decision

Support

6. Clinical

Information

Systems

Prepared,

Proactive

Practice Team

Productive Interactions

between facilities or between outpatient 

medical and BH services.

• Assist the recovering Service member and his/

her family in understanding the recommended 

treatment (including BH services) and in 

receiving timely access to that treatment.

The goal for patients coping with chronic disease is 

self-management and patient empowerment. While 

disease managers provide the medical care needed 

for the patient’s specific disease, the hand-off to 

case managers supports much-needed, ongoing 

holistic coping and management strategies as 

patients strive to achieve optimal functioning and 

quality of life. Fig. 13 is a useful representation of 

activities involved in Chronic Care Management.

The purpose of CM is to:

• Promote quality, safe, and cost-effective care.

• Promote utilization of available resources to 

achieve clinical and financial outcomes.

• Facilitate appropriate access to care.

• The enrollment of Medicare and Medicaid 

populations in managed care plans.

• New legislation mandating CM services (see 

Sections 1611 and 1615 of the National Defense 

Authorization Act [NDAA] of 2008 and the 

DoD/VA response to those recommendations, 

Executive Summary CD-ROM Resources 

ES-3 and ES-4). 

While CM continues to focus on catastrophic illness 

or injury, CM practices are also intense­ly directed at 

addressing chronic conditions that are more prevalent 

in the general patient population. Case managers 

can affect patient outcomes through proactive 

interventions across multiple healthcare settings. 

Additionally, case managers are expected to engage 

community resources and facilitate ongoing and 

consistent patient education.

The MHS has three primary goals for CM: 

• Improve the care, management, and transition

Fig. 13 – Chronic Care Management Model 

of recovering Service members.

• Broaden the application of CM 

to include benefi­ciaries with 

complex needs and at-risk 

beneficiar­ies before they 

require complex care. 

• Evaluate the impact of CM on 

the quality and efficiency of 

military health care. 

Additional goals applicable to caring 

for wounded warriors are to:

• Assist the recovering Service 

member in receiving quality 

medical and behavioral health 

(BH), which may include lengthy 

inpatient stays and transistions 
Page 60 Case Management Version 3.0 Medical Management Guide

• Collaborate with the patient/family, physician, 

healthcare providers, and others to develop and 

implement a plan that meets the needs and goals 

of the patient.

• Develop individualized patient plans of care.

• Offer objectivity, healthcare choices, and selfmanagement solutions.

Philosophy 

The philosophical key component of CM addresses 

care that is holistic and patient-centered, with mutual 

goals that allow for stewardship of resources for 

both the beneficiary and the healthcare system. By 

working collaboratively with the healthcare team, 

case managers help patients identify care options that 

are acceptable to those patients and their families. 

This approach promotes adherence to the treatment 

plan, increasing the rate of successful outcomes and 

reducing fragmentation of care. Effective CM in the 

MHS directly and positively affects the social, ethical, 

and financial well-being of DoD populations as well as 

the greater communities served by the MHS.

The Military Case Manager

The military case manager’s primary role is as 

advocate for the patient and his/her family within 

the MHS. This is a vital support function for young 

ADSMs coping with complex medical conditions, 

particularly during deployment. Case managers must 

know how to recognize and ease symptoms of stress 

and anx­iety from illness and injury in ADSMs as well 

as the associated effects on family members. One of 

the most important roles a case manager can play in 

the mili­tary environment is to educate the ADSM and 

his/her family about how to become their own best 

advocates. 

The case manager’s experience in patient education, 

support, and advocacy makes him/her an ideal 

integrated health manager — a role that maintains 

communication with all providers and facilitates 

communication between all providers. Further, 

the case manager is involved in all aspects of care 

by continually assessing the patient, providing 

information and education, supporting treatment 

adherence, and evaluating the patient’s response. 

Relationship building is a key factor in reducing 

stress when a patient is faced with life-altering 

events, as well as in helping him/her successfully 

attain treatment goals. A common strategy for 

case managers in managing ADSM care is to keep 

patients informed and help them resolve care-related 

issues. This inspires confidence in the patient and his/

her family that the case manager is the go-to person 

for guidance and assistance. For example, ADSM 

fami­lies may be required to move frequently as duty 

stations change; case managers can be proactive in 

helping them secure access to medical services by 

coordinating the CM assessment and the patient’s 

treatment plan with the receiving case manager prior 

to the move date. 

The military case manager must remain in close 

communication with the Managed Care Support 

Contractor (MCSC) to facilitate a smooth transition 

while avoiding duplication and fragmentation of 

services (see also Section I, Medical Management 

Essentials, TRICARE and Other Benefit 

Programs, Working with Managed Care 

Support Contractors). MTF CMs work closely with 

MCSC CMs to exchange feedback and clinical data 

on the patient’s status and to promote uniform 

documentation of that data.
Medical Management Guide Version 3.0 Case Management Page 61

Given the environment in which the ADSM is 

employed and the various regulations that govern 

a Service member’s employment, military case 

managers need to be knowledgeable about:

• Charac­teristics of the beneficiary population 

compared with the general U.S. population.

• Military regu­lations and policies — 

operational requirements may affect internal 

CM processes, locations for care, or care 

delivery timelines.

• The transient nature of the military pop­ulation 

worldwide and within different Services.

• The presence of multiple MCSCs. 

• Special populations that require CM 

intervention (i.e., wounded warriors).

Further, military-specific designations, programs, 

and offices may influence CM processes (examples 

are listed in Fig. 14). 

Military case managers also must understand the 

TRICARE benefit and how other health benefit 

programs interface with TRICARE (see Section 

I, Medical Management Essentials, TRICARE 

and Other Benefit Programs). Case managers 

can help patients secure the greatest possible 

benefit by demonstrating knowledge of eligibility 

requirements associated with these programs; 

patient/family preferences, financial situation, and 

degree of access to services; and expected level of 

family/caregiver support. 

CD-ROM Resources CM-1 and CM-2 present 

arti­cles related to military CM. See also Recovery 

Coordination Initiatives, later in this section.

• Active Duty Medical Extension (ADME) – Army, 

Reserves

• Active Duty member casualty/Wounded Warrior 

Program – All service branches

• Assignment to Medical Hold 

• Command-directed programs 

• Convalescent leave 

• Special Needs Assignment Identification 

Coordination (SNAIC) – Air Force

• Extended Care Health Option (ECHO)

• Fitness for Duty

• Geographically Separated Units (GSUs)

• Limited Duty - Navy

• Line of Duty (LOD) investigations – All service 

branches

• Mandatory TRICARE enrollment requirements

• Medical Evaluation Board (MEB)

• Physical Evaluation Board (PEB)

• Medical Retention Processing/Reserve 

Component –Army

• Military Medical Support Office (MMSO)

• Non-traditional beneficiaries entitled to military 

medical care (i.e., secretarial designees, refuges, 

NATO members)

• Patient tracking relative to absent sick status 

– Army

• Post-Deployment Health Assessment (PDHA)

• Post-Deployment Health Re-assessment (PDHRA)

• Temporary disability retired list (TDRL)

• Warrior Transition Unit (WTU) – Army

• Warrior Transition Battalion / WTB

*See also Appendix C - Definitions

Military-Specific Programs*

Fig. 14 – Military-Specific Designations, Programs, and 

Offices
Page 62 Case Management Version 3.0 Medical Management Guide

CASE MANAGEMENT COMPONENTS

Case Management begins with the 

identification of individuals with chronic, 

catastrophic, or complex, high risk, and/or 

high-cost health issues who meet applicable CM 

criteria and would likely benefit from CM services. 

This identification process involves the following 

three steps: 

• Beneficiary Identification/Case Finding

• Case Screening

• Case Selection

1. Beneficiary Identification/Case Finding

Beneficiaries may be identified and referred for CM 

services at any point in the healthcare continuum. 

When trying to identify potential candidates for 

CM, military case managers should consider the 

following: 

• Cases complicated by psychosocial or environmental factors that can affect the patient’s 

ability to achieve optimal health or maintain 

functioning. 

• Cases affected by family and/or military circumstances. 

• Catastrophic, extraordinary conditions (e.g., 

transplants and head injuries) that incur high 

costs or require substantial resources. 

• Chronic conditions complicated by traumatic 

events.

• High-risk, multiple, or complex conditions or 

diagnoses. 

• Whether there is a need for closer coordination 

and interaction between the patient and 

healthcare team. 

• Requirements for extensive monitoring. 

The case manager may also identify posthospitalization care requirements candidates for 

CM by participating in preadmission programs or 

discharge planning meetings, or by interfacing with 

ward or clinic staff. 

Sources for case finding include, but are not limited 

to, the items listed in Fig. 15.

Admission and Disposition (A&D) lists

Daily inpatient census review

Composite Health Care System (CHCS) ad 

hoc reports

Daily inpatient ward rounds

Emergency Department (ED)/Urgent Care 

rosters

Exceptional Family Member Program 

(EFMP)/Special Needs Identification and 

Assignment Coordination (SNIAC) Program

Potential Sources for Case Finding

Primary Care Manager (PCM) or

specialty care reports/referrals

Self/family members

Utilization Management (UM)/Disease 

Management (DM)

Referral/Consult Management (RM)

Managed Care Support Contractor (MCSC)

Unit Manning Document (UMD)

Other sources, as necessary, per MTF

Fig. 15 – Potential Sources for Case Finding
Medical Management Guide Version 3.0 Case Management Page 63

The case manager evaluates referrals using criteria 

identified in the CM plan to ascertain whether the 

beneficiary has either CM or care coordination 

needs. One way for providers to refer patients is 

through completion of Standard Form (SF) 513, 

which may be sent electronical­ly through the Armed 

Forces Health Longitudinal Technology Application 

(AHLTA) or other approved electronic sys­tems (see 

Section V, Medical Management Tools).

CD-ROM Resources CM-3 and CM-4 provide 

blank and completed versions of SF 513.

An approach known as “predictive modeling” 

(Meek, 2003) may be used to identify a narrowly 

defined group of patients for CM (see Section I, 

Medical Management Essentials, and

CD-ROM Resources MME-2 and MME-3).

The John Hopkins Adjusted Clinical Groups (ACG) 

Case-Mix System measures morbidity by, among 

other things, forecasting healthcare utilization. The 

ACG system evaluates patient populations based on 

disease patterns, age, and gender.

More specifically, the Johns Hopkins ACG 

methodology is used to: 

• Predict high-risk users for inclusion in CM. 

• Determine government- or employer-budgeted 

payment to health plans. 

• Allocate resources fairly within programs. 

• Set capitation payments for provider groups. 

• Evaluate access to care. 

• Assess the efficiency of provider practices.

• Improve quality. 

• Monitor outcomes. 

For more information, go to: http://www.acg.jhsph.

edu/html/AboutACGs.htm.

Triggers for Potential Referral 

The MHS supports a population-based approach 

to CM, which coordinates care and services for 

groups with similar characteristics. Coordinating 

care for groups of peo­ple before they are at risk 

is a key preventive measure in Population Health 

improvement. (See Executive Summary,

CD-ROM Resource ES-1, 2001 DoD Population 

Health Improvement Plan and Guide, or go to: 

http://www.tricare.mil/ocmo/download/mhs_

phi_guide.pdf. Publication of the next iteration of 

the Guide is expected in summer 2010. See also 

Section I, Medical Management Essentials, 

The Link between Medical Management and 

Population Health.)

The following are appropriate triggers for referral to 

CM (see also Section II, Utilization Management, 

Referral Management). Sometimes referral is 

based on a diagnosis, condition, or family situation, 

but other factors include:

• Spinal cord injury.

• Head injury – traumatic and non-traumatic.

• Serious trauma. 

• Psychological disorder (including suicide risk). 

• Multiple chronic illnesses. 

• Cancer diagnosis.

• Neonatal Intensive Care Unit (NICU) admission.

• Transplant* or burn.

• Dual diagnosis.

• Blindness.

• Amputation.

• Poly-substance abuse (can be a result of 

polypharmacy — when the patient has 

been prescribed seven or eight concurrent 

medications).
Page 64 Case Management Version 3.0 Medical Management Guide

*May not be based on regional contract. Most 

transplant contracts occur in the civilian system. In 

the MTF, the case manager may coordinate with the 

MCSC on this type of referral.

Additional factors that may trigger a referral to CM 

are:

• Non-adherence to the medical treatment plan.

• A need for care coordination between multiple 

providers/facilities.

• Complicated family dynamics that interfere with 

recovery and maintenance of wellness.

Case managers working in an Air Force MTF should 

contact their Health Care Integrator (HCI) and 

disease manager to coordinate efforts. Army or 

Navy case managers should contact their Population 

Health department.

2. Case Screening 

A beneficiary may qualify for CM if that patient 

requires close collaboration and/or communication 

between healthcare team members, due to the 

complexities of his/her condition/disease and/or 

social situation. If the ben­eficiary does not meet 

screening criteria for CM enrollment, the case 

manager contacts the original referral source to 

communicate the reasons and offer alternative 

assistance, if available. Nonetheless, the case 

manager may provide disposition planning and 

assistance to the patient and act as a reference 

source for immediate, pressing issues. 

(Refer to CD-ROM Resource CM-5 for CM 

screening criteria.)

MTFs should target specific patient populations for 

CM based on the local CM or MM plan and policies 

governing MCSC contracts. Case managers should 

give priority to ADSMs. As noted in the TRICARE 

Policy Manual (available at http://manuals.tricare.

osd.mil/), some of the more common conditions/

diagnoses that require CM in the MHS include 

traumatic brain injury (TBI), burn patients, and 

infants admitted to the NICU. When performing data 

analysis of utilization rates, fre­quent or prolonged 

hospitalizations and treatments (e.g., chemotherapy, 

pain management, use of monitoring equipment 

for uterine conditions or apnea) may be a “red flag” 

indicating patients who could benefit from CM 

services. The utilization manager can obtain and 

analyze relevant data and make referrals to CM (see 

Section II, Utilization Management).

3. Case Selection 

If the beneficiary meets the screening criteria, the 

case manager will meet with the beneficiary and 

offer him/her enrollment into CM. If the beneficiary accepts the offer for CM services, the case 

man­ager will provide his/her contact information 

to the beneficiary. As part of the process of 

developing a treatment plan, the case manager 

should also perform an assessment/risk appraisal 

of the level of severity of the beneficiary’s 

condition and/or the complexity of care required 

(see CD-ROM Resource CM-6).

Case managers should also provide the beneficiary 

and his/her family with an introductory letter, 

enrollment form, and/or marketing brochure 

explaining CM (see Promoting Your Program, 

later in this section, and CD-ROM Resource 
Medical Management Guide Version 3.0 Case Management Page 65

CM-23). The introductory letter should explain the 

circumstances in which information is released to 

other entities, and how and when the beneficiary 

will receive written notification of the plan of 

care (refer to CD-ROM Resource CM-7 for a 

sample introductory letter).

When a beneficiary agrees to be case managed, 

the case manager must obtain written consent 

from either the beneficiary or his/her legal guardian 

prior to acting on the beneficiary’s behalf. Written 

con­sent is a legal requirement that allows the case 

manager to discuss and arrange the beneficiary’s 

treatment plan with other par­ties. (Refer to

CD-ROM Resource CM-8 for a sample 

authorization form for disclosure of medical 

information and CD-ROM Resource CM-9 for 

an original informed consent form.)

If the beneficiary or his/her legal guardian declines 

CM services, or if the beneficiary is not accepted 

into CM, the case manager should document the 

declination or reason for non-acceptance in the 

beneficiary’s outpatient medical record. The primary 

care manager (PCM) and the individual who made 

the initial referral should also be notified of the 

decision. The beneficiary can be re-referred if his/

her status or environment changes. (Refer to

CD-ROM Resource CM-10 for a non-acceptance 

letter and CD-ROM Resource CM-11 for an 

inability to contact form.)

As part of the enrollment process, the case manag­er 

adds the beneficiary to the CM caseload database, 

which allows for efficient beneficiary tracking, 

continu­ity of care, outcome measurement, and 

report­ing.

Fig. 16 — The Six-Step CM Process

Evaluation

Monitoring

Coordination

Implementation

Planning

1. Assessment

2.

3.

4.

5.

6.

The Six-Step Case Management Process

After completing the preparatory steps of 

beneficiary identification/case finding, case 

screening, and case selection, the case manager 

per­forms the six basic steps of CM:

1. Assessment

2. Planning 

3. Implementation

4. Coordination 

5. Monitoring

6. Evaluation

Fig. 16 illustrates the six-step CM process.

These essential steps constitute key activities that 

are systematic, yet dynamic. Your individual Service 

Branch will have established timelines for how long

you have to contact a patient and to complete a 

patient plan of care, and for how often you must 

follow up with your patient and document the 

plan. For more information on the specific policies 

of your Service Branch, contact your supervisor or 

department head. 
Page 66 Case Management Version 3.0 Medical Management Guide

The six steps of CM are described in more detail 

below.

1. Assessment

Assessment is a systematic, ongoing activity that 

involves collecting comprehensive information about 

a patient’s situation, including all relevant sources 

(mili­tary and civilian) to identify individual needs. 

This includes speaking with the patient, caregivers (if 

appropriate), and healthcare providers — especially 

the PCM. Fig. 17 describes categories of assessment.

According to the NCQA (July 2007), case managers 

need to address the following areas pertaining to 

their patients:

• Current health status, including conditionspecific issues and co-morbidities

• Clinical history, including medications

• Activities of daily living (ADLs)

• Caregiver resources

• Available benefits

• Mental health status

• Advanced directives

• Cultural and linguistic needs, preferences, or 

limitations

• Financial considerations

Because the assessment process may require the 

case manager to make multiple contacts, it can 

take several days to complete an assessment. Once 

the assessment is complete and problems have 

been identified, determination is made whether 

CM criteria have been met and whether to open a 

CM case. If the decision is not to open the patient 

to CM, the patient is provided with appropriate 

resources and the referring party is notified of the 

decision. If a CM case is opened for the patient, the 

next step is to develop a plan of care.

2. Planning

Planning involves determining specific objectives, 

goals, and actions designed to meet the patient’s 

needs as identified during assessment. Once the 

patient is accepted into CM, a plan of care is 

developed. The purpose of the plan is to:

• Address problems.

• Set short- and long-term goals.

• Identify barriers to reaching the stated goals.

• Identify actions that can be taken (i.e., 

interventions) to resolve any barriers to achieving 

those goals. 

Problems may include:

• Lack of patient access to appropriate specialists 

or community resources.

• An inadequate patient support system.

• Inappropriate pain management.

Goals may include:

• Short-term goals — e.g., patient access to 

appropriate specialists or community resources.

• Long-term goals — e.g., the patient’s ability to 

effectively self-manage pain.

A time frame is assigned for meeting each goal.

It is important to keep the following considerations 

in mind:

• CMSA standards of practice state that 

measurable goals must be established. Goals 

that promote cost-effective, quality outcomes 

must be included in the plan of care and created 

in collaboration with the patient and family. 
Medical Management Guide Version 3.0 Case Management Page 67

Fig. 17 — Categories of Assessment

Categories of Assessment

Assessment Subject Description

Demographic 

Information

•	 Name, social security number (SSN)

•	 Service branch

•	 Cultural considerations

•	 Financial class (e.g., TRICARE, other health insurance, other benefits)

•	 List of treating physicians, specialties, addresses, telephone numbers

•	 Spiritual needs

Medical History

•	 Advanced directives/living will/power of attorney

•	 Ancillary services

•	 Pharmacology/use of pharmacy services

Vocational Information

•	 Education

•	 Impact of health on work status

•	 Occupation

Health Status/ 

Systems Review

•	 Age-specific considerations

•	 Health status perception

•	 Learning abilities/comprehension

Current/Projected 

Resource Utilization

•	 Community/workplace reintegration

•	 Custodial care needs (activities of daily living)

•	 Durable medical equipment (DME) requirements

•	 Home environment/living arrangements

•	 Medical/functional/disability/rehabilitation status

•	 Beneficiary’s diagnosis/prognosis, short/long-term goals

•	 Rehabilitation potential

•	 Skilled and less-than-skilled nursing needs (hrs/day, days/week, daily visits, intermittent 

visits)

Psychological Status

•	 Beneficiary’s/family’s emotional status

•	 Beneficiary’s mental status

•	 Compliance issues

•	 Substance abuse issues

•	 Understanding/acceptance of current problem

Community/Social 

Support

•	 Age-specific considerations

•	 Assessment of interrelationships between family members

•	 Beneficiary/family propensity for support

•	 Caregiver support system

•	 Cultural considerations, including language barriers

•	 Family members’ perception of their care/support role(s)

•	 Marital status

•	 Need for community resources

•	 Spiritual support

•	 Support system (beneficiary, caregiver, community, faith-based)

Health Risk Assessment •	 Clinical practice guideline (CPG) screening questions

•	 Clinical preventive services

Home/Environment 

Assessment

•	 Fall risk

•	 Beneficiary’s living arrangements

•	 Presence of primary caregiver
Page 68 Case Management Version 3.0 Medical Management Guide

Multiple actions/interventions may be assigned in 

response to each barrier; these may include:

• Providing research on appropriate and available 

specialists within the MTF/network who can 

meet the patient’s medical needs.

• Obtaining a list of all medications the patient 

is taking, including name of prescriber(s) and 

pharmacy(ies) dispensing the medications.

• Requesting referral to a pain clinic.

The plan of care must be agreed to by the patient 

and the PCM, and all parties must sign it. The plan 

should include contacts for medical/behavioral 

health providers; resources to be explored; 

verification of medications to be taken; and an 

assessment of housing needs, transportation, and 

level of caregiver support.

The plan of care is meant to optimize Direct Care 

System (DCS) and Purchased Care System (PCS) 

resources, special health-related programs, and other 

federal/national/state/local agencies and resources.

3. Implementation

Implementation involves executing actions/interventions identified in the plan of care that will 

lead to accomplishing stated goals. This process 

step necessitates communication between 

healthcare team members, including the patient 

and his/her family or caregiver(s). At the outset of 

implementation, the case manager should discuss 

the goals of the plan of care with the patient and 

his/her caregiver(s). This includes advising them they 

will continue to be a resource for the case manager 

until such time that problems have been resolved 

Goals/outcomes must also reflect input from the 

entire healthcare team.

• Goals for the individual patient are defined after 

a thorough patient assessment is completed. 

At that point, the case manager addresses the 

problems that have been identified. Goals/

outcomes are defined based on the resolution 

of those problems.

o For example: Patient A needs specialty 

care that is not readily available in the 

area where he/she lives. The goal is to 

provide access to the needed specialist. 

The case manager's interventions are 

targeted toward linking the patient with 

the specialist in a manner that is accessible, 

affordable, and reliable. When the link 

between specialist and patient is validated, 

the problem is resolved and the goal is 

met. The outcome is appropriate and timely 

specialty care, when needed.

• Individual goals must be re-evaluated when 

psychosocial, medical, or financial changes 

occur. Treatment and plans of care must be 

adjusted accordingly.

Barriers may include:

• Transportation not being available for patient 

visits to a specialist.

• Multiple prescribed medications from various 

providers (i.e., polypharmacy), with the patient 

unable to manage his/her pain.

• The patient being unaware of available 

community resources.

There are usually several barriers associated with 

each problem, which in turn serve to further define 

that problem.
Medical Management Guide Version 3.0 Case Management Page 69

and goals met — at which point, the patient/

caregiver(s) can self-manage. 

The case manager activates the actions/

interventions described in the plan of care, and 

documents the following types of information:

• Date(s) of contact.

• Who was contacted.

• The purpose of the contact(s).

• What was discussed.

• The outcome of the discussion(s).

• The specific plan for next action/intervention, 

including the scheduled date.

During implementation, all elements of CM 

standards of practice must be adhered to along 

with other applicable guidelines, including clinical 

practice guidelines (CPGs). The following resources 

may be useful in this effort:

• VA and DoD CPGs: https://www.qmo.amedd.

army.mil/pguide.htm.

• The Agency for Healthcare Research and 

Quality (AHRQ): http://www.ahrq.gov/. The 

AHRQ has published and dissemi­nated national 

CPGs for more than 19 clinical sub­jects. These 

are accessible through the National Library of 

Medicine’s Medline service: http://www.ncbi.

nlm.nih.gov/entrez/query.fcgi.

Refer to Section IV, Disease Management, for 

more infor­mation on CPGs. 

4. Coordination

Coordination involves organizing, secur­ing, 

integrating, and modifying the necessary resources 

to accomplish the goals set forth in the plan of 

care. This step directs the patient to appropriate 

services to achieve seam­less and timely continuity 

of care. Coordination is achieved by identifying 

patient needs and applying appropriate actions/

interventions (see also Step 2, Planning). 

Coordination of activi­ties helps case managers:

• Avoid duplication of services. 

• Ensure timely and appropriate provision of 

services. 

• Identify barriers to care delivery and explore 

delivery alternatives. 

• Match patient needs with available resources. 

• Optimize healthcare resources in the MTF and 

local community. 

• Organize and manage the activities outlined in 

the plan of care. 

• Ensure all care providers receive necessary 

information in a timely manner.

Depending on the availability of services or agencies 

in the local area, the MTF case manager may need 

to coordinate with the MCSC. Access to community 

resources from all levels — local, state, and national 

— will facilitate coordination of services. 

5. Monitoring

Monitoring involves gathering information from 

relevant sources on an ongoing basis with regard 

to healthcare activities and services, and to patient 

adherence to the treatment plan. Case managers 

conduct monitoring to determine whether planned 

patient goals have been achieved and how effective 

the process is for achieving them.
Page 70 Case Management Version 3.0 Medical Management Guide

During monitoring, the case manager: 

• Ensures timely and appropriate care is provided 

based on the patient’s changing health status 

and/or environment. 

• Ensures timely patient/family and healthcare 

provider contact and follow-up. 

• Establishes and documents progress towards 

meeting plan-of-care goals. 

• Identifies variance(s) from the plan of care and 

revises the plan accordingly. 

• Monitors the result of actions/interventions and 

care delivery. 

• Monitors utilization of healthcare resources. 

The case manager will continually assess and 

moni­tor the patient’s response and adherence to 

treat­ments, and decide whether services should 

con­tinue or new services should be implemented. In 

this respect, monitoring dovetails with assessment. 

Monitoring also includes collecting and tracking 

data. 

6. Evaluation

Evaluation is a continuous step in which the case 

manager measures the patient’s response to the 

healthcare services being delivered. The case 

manager uses critical thinking skills to analyze the 

data obtained during monitoring and revises the 

plan of care to respond to the patient’s ongoing 

needs.

As part of this step, the case manager must make a 

comprehensive routine assessment of the patient’s 

status and progress toward meeting the goals stated 

in the plan of care. If no progress is noted, the case 

manager should determine the reason and revise 

the plan of care to include interventions that will 

promote the identified goals.

Other measures of care may include patient/

caregiver and healthcare team satisfaction, as well as 

cost savings.

Case Closure

Planning for case closure begins at the time the 

patient is accepted into CM. The consistent goal 

and measure of success of a plan of care is that the 

patient/caregiver(s) be able to self-manage — that 

is, to advocate for themselves. Early in a case, it is 

appropriate for a case manager to make referrals, 

contact providers, and research resources. As the 

case progresses, that responsibility needs to be 

transferred to the patient/caregiver(s), as appropriate.

As the case manager works with the patient/

caregiver(s), he/she acknowledges successes in the 

patient’s progress toward greater self-sufficiency. 

As the case manager assesses a patient’s progress 

toward meeting the goals established in the plan of 

care, the case progresses toward closure.

Sometimes not all goals are achieved. A case may 

appropriately be closed based on circumstances such 

as failed adherence to treatment regimes, change 

in eligibility, or even death. In some circumstances, 

it may be useful to conference with another case 

manager in making the decision about whether to 

close.

When the decision to close a case is made, the case 

manager undertakes the following steps:
Medical Management Guide Version 3.0 Case Management Page 71

• Communicates the patient’s status with 

the patient/caregiver(s), provider, and other 

members of the healthcare team; and informs 

them of the reason for the closure decision.

• Documents a summary CM note in the patient’s 

outpatient record and documents the closure 

on the CM tracking log. (Refer to CD-ROM 

Resource CM-12 for a sample case closure 

summary form.)

• Documents the closure on the CM tracking log 

or an electronic form such as the ones available 

through the Air Force’s Access Improvement 

Model (AIM). (Refer to CD-ROM Resources 

CM-13 and CM-14 for sample AIM forms.)

Documentation

As with all other parts of the medical record, documentation is critical in providing a legal record of 

patient care. The case manager should document 

all activities of the plan of care and CM process, 

including interventions with healthcare team 

members, health status updates and progress, new 

problems, and changes in goals. Most importantly, 

all encounters with the patient and family should 

be documented, whether those communications 

are face-to-face, by phone, by e-mail, or through 

another virtual method.

Documentation guidelines vary depending on local 

or Service-specific policies. Complete and correct 

documentation must meet standards established by 

The Joint Commission (TJC) and other professional 

organizations (see Appendix D, Resources). It is 

recommended that the documentation occurs in 

the Armed Forces Health Longitudinal Technology 

Application (AHLTA) and is coded appropriately. 

(See Section V, Medical Management Tools, 

CD-ROM Resource MMT-1 for more information 

on AHLTA, sample screenshots of AHLTA templates, 

and guidance on how to appropriately code patient 

encounters.) 

It is recommended that a satisfaction survey be sent 

to the patient/caregiver(s) and to provider(s) as an 

outcome measure for feedback on CM services. 

Other outcome measures would be performed at 

this time, including on how the CM services affect 

the population health of the MTF ( CD-ROM 

Resources CM-15 and CM-16 provide sample 

surveys). See also Outcome Measurement and 

Management, below.

Outcome Measurement and Management

MM outcomes are measured based on quality, 

cost, access, and readiness (see Section I, Medical 

Management Essentials, including Fig. 2, MHS 

Medical Management Model). In CM, patient and 

program outcome evaluation should be performed.

Patient outcome evaluation is an integral part of the 

CM process and measures patient outcomes using 

clinical, functional, and/or satisfaction indicators.

Program outcome evaluation focuses on how CM 

affects healthcare delivery.

Patient-level evaluation usually involves outcome-based 

measurements, while program-level evaluation usually 

involves process-based measurements. Fig. 18 describes 

sample patient and program evaluation outcomes.
Page 72 Case Management Version 3.0 Medical Management Guide

Fig. 18 – Sample Patient and Program Evaluation Outcomes

Sample Patient and Program Evaluation Outcomes (Local Level)

Patient Outcomes Program Outcomes

• Clinical

Medication compliance (refills, blood pressure, lab 

values)

Reduced LOS

Reduce readmissions

Use of more appropriate levels of care

Cost avoidance

• Psychosocial

• Functional

• Quality

Pain and comfort

Condition state — functional, cognitive, quality of 

life, physiologic indicators

• Fiscal

Cost per visit

Specific cost reductions

• Lab tests

• Medical supplies

• Pharmaceuticals

• Service

Nurse staff satisfaction

Interdisciplinary staff satisfaction

Patient satisfaction

• Follow-up call

• Increased access

• Increased trust and confidence in the MHS

• Reduced patient complaints

• Reduced wait times

• Difference between the number of acute care 

admissions before and after CM is initiated

• Difference between the number of clinic 

appointments before and after CM is initiated

• Difference between the number of ED visits before 

and after CM is initiated

• Efficiency

• Fiscal impact

• High utilizers

• Quality

• Workload

Number of patients initiated into CM per month

Number of CM cases closed per month

Number of referrals to DM per month

Number of referrals (accepted/denied) to MCSC per 

month

• Prevention Initiatives

Number of women/men who have received 

prevention screening (e.g., Paps, prostate screenings)

Number of children with current immunizations
Medical Management Guide Version 3.0 Case Management Page 73

Patient Outcome Evaluation

Successful patient outcomes are based on what is 

expected to happen as a result of the course of the 

disease and the effect of CM interventions. When 

the case manager focuses on patient needs and 

uses a carefully constructed collaborative plan of 

care, individual goals will be met and the outcome 

will be cost-effective, high-quality care. 

As discussed in Section I, Medical Management 

Essentials, there is a preventive model to measure 

cause and effect in MM interventions that includes 

three phases: primary prevention, secondary 

prevention, and tertiary prevention. Based on this 

model, success (achievement of outcomes) can be 

understood as slowing, halting, or reversing either a) 

advancement within the same phase or b) transition 

to the next phase.

Regardless of which CM model is implemented, it 

is essential to have a measurement system in place. 

In addition to measuring outcomes, this system 

must also identify the process of data collection, 

aggregation, analysis, and reporting (Cesta, Tahan, 

Fink, 2002). Because of their responsibilities, case 

managers should make sure to track outcome data 

for the patients in their caseload to determine 

the effectiveness, efficiency, and efficacy of CM 

services.

The success of a CM system depends to a great 

degree on how well case managers employ 

outcome data to manage, plan, facilitate, expedite, 

advocate, coordinate, and evaluate the delivery of 

patient care. To enable case managers to execute 

this role, it is important for the MTF to establish an 

outcome classification system. This system aims at 

evaluating the CM model used. That model must be 

standardized across the MTF and used by all case 

managers (Cesta, et. al.).

There is no best system for measuring outcome 

indicators. Organizations should identify the one 

that works best for their providers and customers. 

Indicators must be measurable — i.e., based 

on cost per case type or episode of care/illness. 

Organizations also must delineate the frequency 

of data collection, the sample, the formulas to be 

applied in the analysis, and the reporting format. 

Some organizations may classify the patient’s 

functional ability as independent from clinical 

indicators, while others may combine the two 

aspects in conducting their analysis. It is important 

to define whether the indicator is a patient/family or 

healthcare organization-related indicator. 

Fig. 19 presents examples of patient-related 

outcome classification.

Program Outcome Evaluation

CM program outcomes should be measured based 

on CM program goals and the MTF’s strategic plan. 

Once specific outcomes have been determined, 

the data must be reported through the Chain of 

Command in order to gain value. (Refer to 

CD-Resource CM-17 for sample CM 

measurement reporting tools, including preventable 

admissions, two quantitative cost avoidance/savings 

reports, and qualitative savings — see different 

tabs in file.) Fig. 20 presents examples of healthcare 

organization-related outcome classification.
Page 74 Case Management Version 3.0 Medical Management Guide

Classification Patient/Family-Related Outcomes

Clinical

• Improved patient care outcomes, such as reduced/controlled pain, morbidity, and mortality 

rates.

• Reduction in signs and symptoms of disease and degree of progression of the disease.

• Prevention of adverse effects of treatments and complications of illness.

• Reduction in practice variation.

Financial

• Optimal and appropriate use of resources and services.

• Provision of care in appropriate setting(s) level of care.

• Maximal coordination of care among providers.

• Streamlining of diagnostic and therapeutic tests and procedures.

Quality of Life

• Improved/maximized physical abilities and level of independence.

• Improved psychological, physiological, and social functioning.

• Improved state of well being.

• Improved perception of health status.

• Enhanced self-care abilities/skills.

• Enhanced knowledge of healthcare needs.

Satisfaction

• Increased patient/family satisfaction with care.

• Improved continuity of care.

• Improved patient-nurse and family-nurse relationships.

Source: T Cesta, H Tahan (2003): Case Manager’s Survival Guide Winning Strategies for Clinical Practice, 2nd Edition, p. 100-103 

(Seminar Nurse Manager), Mosby.

Fig. 19 – Example of Outcomes Classification: Patient-Related

Other program measures may include preventable admissions rates, a measure that can be stratified by 

diagnosis. For example, a potential enterprise measurement for DM is the preventable admission rate for 

CM patients with a primary diagnosis of asthma, diabetes, or congestive heart failure (CHF) compared to the 

preventable admission rate for non-CM patients with the same diagnoses.

CM outcome measures should be patient-centered and within the context of the organization’s overall business 

plan. If care decisions are challenged by constraints within the facility’s business plan, the case manager should 

collaborate with UM to resolve the dilemma in the most cost-effective manner without compromising quality. 

These circumstances may warrant a CM team meeting or case conference with other MM professionals and 

members of the healthcare team. In such cases, it is important to document any variances in the patient’s plan 

of care that will have a direct impact on the outcome measure. 
Medical Management Guide Version 3.0 Case Management Page 75

Fig. 20 – Example of Outcomes Classification: Healthcare Organization-Related

Classification Healthcare Organization-Related Outcomes

Clinical

• Standardization of care processes (establishing standards of care/case management plans).

• Streamlined care processes and delineation of responsibilities.

• Improved turnaround time of tests, treatments, and procedures.

• Increased compliance with standards of regulatory and accreditation agencies.

Financial

• Appropriate changes in staff mix/skill mix.

• Reduced cost (e.g., reduction in length of stay, reduction in or elimination of fragmentation 

and duplicate services).

• Improved reimbursement and revenue.

• Reduction in denials of claims.

• Improved communication among providers and healthcare staff.

Quality of Life

• Prevention of inappropriate hospitalizations.

• Reduction in inappropriate utilization of Emergency Department services.

• Provision of a safe environment of care.

• Provision of programs that meet patient and family needs.

• Improved accessibility to care/services.

Satisfaction

• Improved staff satisfaction.

• Reduced rates of burnout, turnover, attrition, and absenteeism.

• Enhanced states of communication, collaboration, and teamwork among providers and 

disciplines (interpersonal, interdisciplinary, and interdepartmental).

Source: T Cesta, H Tahan (2003): Case Manager’s Survival Guide Winning Strategies for Clinical Practice, 2nd Edition, p. 100-103 

(Seminar Nurse Manager), Mosby.

Fig. 21 lists examples of CM outcome measures.

Measuring program outcomes allows CM to support and objectively track improvements in healthcare 

processes or any decline in patient progress. Outcome measurement enhances compliance with regulatory 

and accreditation requirements and standards of practice; and reduces risk by demonstrating compliance with 

healthcare quality guidelines. 

Cost-Benefit Analysis 

CM activities can have a significant impact on an organization’s business plan. When case managers develop 

effective outcome measures, they demonstrate value to their MM department and the organization as a whole. 
Page 76 Case Management Version 3.0 Medical Management Guide

Outcome measures validate:

• What is effective. 

• What is not effective. 

• The cost of an intervention.

• Return on investment (ROI).

A cost-benefit analysis is performed to help 

determine a) whether to make a change or b) how 

well a planned action (e.g., implementation of a 

program) may turn out.

A cost-benefit analysis relies on adding up positive 

factors and subtracting negative ones to determine 

a net result. The technique is to simply add up the 

benefits of an action/intervention and subtract 

the costs associated with that action/intervention. 

The cost-benefit analysis is closely linked to the 

“evaluation” aspect of the CM process. As the 

case manager coordinates services and makes 

recommendations for care options, he/she should 

conduct an ongoing cost-benefit analysis regarding 

those choices.

Another method of demonstrating value is to 

track and calculate costs that were avoided. 

Using a log to collect data of your caseload is a 

straightforward method for expressing quantity and 

cost effectiveness. (Refer to CD-ROM Resources 

CM-18, CM-19, and CM-20 for examples of CM 

caseload logs.)

According to Kongstvedt (2001), a cost-benefit 

analysis report for CM should include the following 

elements:

• Overview of CM intervention (a brief narrative).

• Summary of intervention.

• Actual charges.

• CM fees.

• Savings (e.g., avoided or potential charges; 

discounted and negotiated reductions; 

reductions in services, products, and/or 

equipment).

• Gross savings (potential charges minus actual 

charges).

• Net savings (gross savings minus CM fees).

• Status of the case (opened or closed).

Examples of CM Measures

• Timeliness of service

• Cost avoidance to the Direct Care System 

(DCS)

• Relative Weighted Product (RWP)/Relative 

Value Unit (RVU) impact of a CM intervention

• Recaptured care as a result of CM 

coordination

• Access to specialty care services as a result of 

CM coordination

• Beneficiary satisfaction

• Reduced hospital admissions

• Patient knowledge of the healthcare 

treatment plan and benefits

• Improved provider/patient interaction

• Measures of clinical improvement

• Appropriate utilization after CM intervention

• Hospital readmissions rate before and after 

CM intervention

Fig. 21 – Examples of CM Measures
Medical Management Guide Version 3.0 Case Management Page 77

Fig. 22 – CM Hard and Soft Savings

Cost-benefit analysis takes into account both hard 

and soft costs incurred as a result of a selected 

option for care or a choice in service delivery.

Hard costs (or hard savings), also known as “avoided 

costs,” are measured in actual dollars when costs 

are measurably saved or avoided (Powell and 

Ignatavicius, 2001). Examples of hard costs may 

include such items as hospital bills, physician fees, 

and medical supplies in which the case manager 

facilitated a change in the level of care, the patient’s 

length of stay (LOS), or negotiated the frequency 

or duration of services. Hard costs can show clear 

savings as a result of eliminating duplication of 

services, reducing Emergency Department (ED) 

visits, transferring to lower levels of care, reducing 

hours of care, preventing unnecessary bed days, 

or reducing the unnecessary use of supplies and 

equipment.

Soft costs (or soft savings), also referred to as 

“potential savings,” are factors that may not have 

an exact dollar measurement but that incur a social 

or personal cost to the patient. Examples of soft 

costs are lost duty time, avoided ED visits, reduced 

productivity, and improved quality of life. 

Fig. 22 describes CM hard and soft savings.

CM Hard and Soft Savings

Hard Savings or Avoided Costs* Soft Savings or Potential Savings**

• Change in the level of care facilitated by CM

• Change in the patient’s length of stay (LOS)

• Change to a contracted PPO provider

• Finding unauthorized charges that are not

warranted

• Negotiation of duration of services

• Negotiation of frequency of services

• Negotiation of price of services, supplies, equipment, 

or per diem rates

• Prevention of unnecessary bed days, supplies, 

equipment, services, or charges

*Measurably saved or avoided costs when facilitated 

by the case manager.

• Avoidance of potential acute care days

• Avoidance of potential costs, equipment, and 

supplies

• Avoidance of potential ED visits

• Avoidance of potential home health visits

• Avoidance of potential hospital admissions

• Avoidance of potential legal exposure

• Avoidance of potential medical complications

• Improved patient/family satisfaction with CM

• Improved patient compliance

• Improved quality of care or quality of life

**Less tangibly measurable than hard savings. 

If no case manager was assigned to the patient, 

the potential costs incurred could have been 

much more than with CM; they represent costs 

that were avoided most likely because of CM 

intervention.

Source: Powell and Ignatavicius, 2001
Page 78 Case Management Version 3.0 Medical Management Guide

ESTABLISHING A CASE MANAGEMENT 

PROGRAM

Organizational Framework 

T

here are multiple types of organizational 

structure for CM program assignment 

in inpatient or ambulatory care facilities. 

Integrating all case managers within one designated 

department or cost center before assigning them 

to individual duty through­out the inpatient and 

outpatient areas is just one model that may add value 

to the CM program. Hospital or facility size, available 

services, resources, and staff qualifications often 

determine the program’s structure. 

The organizational structure of a CM program should 

above all serve to support the practice of quality care. 

This includes ensuring there are a sufficient number 

of:

• Qualified case managers to service the population 

(see The Case Management Professional, later 

in this section).

• Data management systems to meet 

documentation and data mining requirements.

• Support staff to assist the case managers in their 

clinical manage­ment of patients.

The program should also support national CM 

standards of practice and encourage CM certification. 

Access to physician consultation, benefits advisors, 

decision support criteria (e.g., McKesson® InterQual®

evidence-based clinical support criteria, Milliman 

Care Guidelines® — see Section II, Utilization 

Management), decision support staff, and 

educa­tional resources are essential.

Goals

MHS CM program goals include:

• Establishing processes to proactively identify 

wounded, ill, or injured Service members who 

meet the criteria for assignment to clinical CM 

as determined by Directive-Type Memorandum 

(DTM) 08-033, Interim Guidance for Clinical 

Case Management for the Wounded, Ill, and 

Injured Service Members in the Military Health 

System (Draft) —http://www.dtic.mil/whs/

directives/corres/dir3.html. (See also CD-ROM 

Resource CM-21.)

• Creating and implementing comprehensive 

performance measures to facilitate appropriate 

and successful execution of clinical CM, as 

outlined in DTM 08-033.

• Establishing processes that will be used to 

improve care as patients and their families 

transition along the continuum of care, ensuring 

seamless hand-off during transitions of care 

(TOCs) — see Transition/Coordination of 

Care, Transition of Care, later in this section.

• Establishing processes to proactively identify 

other patients who meet the criteria for CM.

• Ensuring services are rendered in a timely and 

cost-effective manner without compromising 

quality of care.

• Assisting patients in maintaining the maximum 

amount of autonomy and human dignity while 

helping minimize the impact of long-term 

changes in living and occupational status, as well 

as disability level.

To successfully administer CM services, the MTF 

must establish processes critical to the pro­gram. A 

CM program must target the right population for 
Medical Management Guide Version 3.0 Case Management Page 79

CM services. The “80/20 rule,” that 20 percent 

of the population is responsible for 80 percent 

of healthcare costs, should be a key concept 

in directing CM interventions. MTFs should 

systematically identify and analyze their population 

to find high-risk and high-volume patients before 

they become high-cost patients.

Implementation

When preparing a plan for CM program 

implementation, you should address the following 

questions: 

• What is the process for case finding, screening 

criteria, and selection; and for deciding to enroll 

eligible beneficiaries into CM? 

• Which tools (i.e., clinical pathways, guidelines) 

will be used to track patient progress? 

• Which forms, computer software, or paperwork 

will be required for documentation or charting? 

As discussed throughout this section, it is 

particularly important to consider:

• Care coordination procedures.

• Case manager qualifications, roles, responsibilities, and job descriptions.

• Discharge planning procedures.

• Intra/interregional transfer policies.

• Outcomes reporting.

• Plans for process improvement.

• Processes for local and regional networking.

• Staff and beneficiary educational programs.

• Standardized beneficiary screening criteria.

• Problem resolution methods.

• Unique ADSM requirements.

It is also important to be aware of challenges related 

to:

• Patient safety during transition.

• The degree to which collateral programs that 

directly affect CM are integrated within the 

MTF.

• The ability to secure reliable connectivity 

through technology.

• The degree to which practices are standardized 

among case managers.

The MTF’s program will be dynamic and evolving 

as it matures from its initial stages. To assist in 

launching a new program, the Web-based MHS 

Learn CM modules course library provides a variety 

of useful forms and tools for the case manager. For 

more information, go to: https://mhslearn.csd.disa.

mil.

Quality

Each CM department and program supports the 

quality program of the MTF Command. CM quality 

programs are geared toward process improvement, 

with CM departments offering Command-specific 

training and professional development programs for 

case managers. Certification is one mechanism for 

enhancing quality by standardizing the individual/

professional knowledge base for CM practice (see 

The Case Management Professional, later in this 

section). 

Quality-based outcomes may include performance 

indicators such as improved functional or health 

status, enhanced quality of life, patient/family/

provider satisfaction, adherence to the treatment 

plan, improved patient safety, appropriate use of 
Page 80 Case Management Version 3.0 Medical Management Guide

healthcare services, cost savings/avoidance, and 

patient/caregiver self-management.

Quality measures can be applied internally or 

externally. For example, an internal quality 

measure might involve supervisor review of case 

documentation to encourage standardization. 

External quality control measures can be established 

by Service-specific governing bodies. For example, 

Navy CM at the Bureau of Medicine and Surgery 

provides documentation reviews for quality and 

compliance, which helps standardize documentation 

practices among Navy MTFs and medical clinics.

Performing a quality review supports the concept of 

“best practice.” The OCMO Healthcare Innovations 

Program is an excellent source for benchmark and 

process improvements: www.tricare.mil/ocmo/

innovations.cfm. 

Caseload 

The various responsibilities involved in MM-related 

activities can affect the case manager's ability to 

provide comprehensive services. A major factor is 

the number of case managers required in an organization, which depends on the composition (case 

mix/acuity) of the membership. A case manager’s 

caseload is dependent on many concurrent factors, 

including:

• Charac­teristics of the patients served.

• Complexity of the plan of care.

• Geographical area covered.

• Amount of administrative support.

• Availability of community-based services.

• Experience and competency of the case 

manager.

• Control over funds used in the delivery of care.

Caseload assignment may also be influenced by: 

• The clinical needs of the patient.

• The psychosocial needs of the patient/family.

• Cognitive challenges to the patient.

• Treatment adherence issues.

• The demographics of the population served.

• Geographic factors.

The 2008 Case Management Caseload Concept 

Paper, a joint publication of the CMSA and the 

National Association of Social Workers (NASW), 

asserts that the clinical practice setting affects the 

patient-to-case-manager ratio (refer to CD-ROM 

Resource CM-22). For example, an experienced case 

manager providing telephonic CM in an outpatient 

setting can manage a higher caseload than an onsite 

case manager in an acute inpatient setting. Page 22 

of the CMSA’s concept paper features a caseload 

matrix.

Specifics in determining caseload assignments 

include:

• Intensity of involvement by the case manager.

• Frequency of interventions by the case manager.

• Case acuity.

• Skill training, roles, competencies, and 

experience of case managers.

• Breadth of the case manager’s responsibility.

• The 2007 Dignified Treatment of Wounded 

Warriors Act (H.R. 1538), which determines 

caseload assignments for the Medical Care Case 

Manager (MCCM).

o No more than 17 wounded warriors in 

an outpatient setting are assigned to the 

MCCM.
Medical Management Guide Version 3.0 Case Management Page 81

Assigning caseloads is a labor-intensive process 

that includes creating and implementing the plan 

of care, as well as maintaining documentation of 

progress toward target goals. Managing the balance 

of tasks is a critical factor in helping case managers 

experience job satisfaction in their day-to-day 

responsibilities. More specifically, assigning a generic 

ratio of patients to a case manager (a “one ratio 

fits all” approach) does not support case managers’ 

ability to consistently reach optimal outcomes for 

their patients. When determining what constitutes 

a manageable caseload, applying the CMSA’s 

research and lessons learned from implementing 

a CM program can generate an environment that 

supports the most desirable patient outcomes. 

Discharge Planning

Discharge planning helps sustain or enhance 

the gains achieved from hospitalization for the 

continued health and welfare of patients and 

their families following discharge. Mullahy (1998) 

describes discharge planning as “assessing the 

patient’s need for treatment after hospitalization 

in order to help arrange for the necessary services 

and resources to affect an appropriate and timely 

discharge.” Discharge planning can be provided 

in multiple settings, whether transitioning the 

patient from an inpatient hospitalization to another 

inpatient facility or residential treatment facility; or 

from an inpatient to skilled nursing facility, home 

health care, or high-intensity outpatient services. 

Discharge planning is critical, as shorter hospital 

LOS are typical. Ideally, discharge planning begins at 

preadmission. In planning the appropriate discharge, 

the case manager must spend time speaking with 

patients/caregiver(s) to determine what they need 

and are willing to do at the next level of care, and 

which resources are available at home. Support 

can range from video teleconferencing with a 

Department of Veterans Affairs (VA) polytrauma 

center to holding conference calls with the family or 

facilitating site visits.

The staff nurse may perform discharge planning 

activities when caring for the patient on the 

inpatient unit. However, the case manager is 

responsible for overseeing discharge planning 

activities and for executing the plan as designed.

The discharge planning process includes the 

following steps. 

1. Assessment. The discharge planner is 

responsible for assessing every patient on 

admission for discharge planning needs — at 

a minimum every 72 hours until discharge, per 

McKesson InterQual guidelines (see Section 

II, Utilization Management). The discharge 

plan must align with the TRICARE benefit and 

policies. Therefore, it is also important for 

the discharge planner to obtain information 

regarding the patient’s enrollment status, as this 

affects the authorization of plan of care upon 

discharge. 

2. Referral. Consideration must be made if referrals 

need to be sent to a social work case manager 

to address patient/family social issues or to make 

arrangements such as nursing home placement. 

Referral can also mean obtaining TRICARE 

referrals and authorizations to execute the 

discharge treatment plan. For example, a patient 

may require assistance with home IV infusion 

therapy. In this case, referrals and authorizations 
Page 82 Case Management Version 3.0 Medical Management Guide

would need to be obtained for infusion therapy 

services. Communication among home health 

companies, the coordinating case manager, and 

the ordering provider further serves to reconcile 

the treatment plan with the service order.

3. Formulation. Discharge planning can be very 

simple or highly complex. It is best accomplished 

using an interdisciplinary approach to determine 

the best plan for each patient. In Active Duty 

cases, the patient’s Command may have input 

on the discharge plan.

4. Implementation. The case manager will review 

each patient’s discharge plan with the patient/

caregiver prior to discharge and enter the 

appropriate documentation in the patient’s 

medical record.

5. Monitoring. Monitoring the quality and 

effectiveness of the discharge planning process 

is a cumulative effort. The importance of timely 

feedback from providers, patients/caregivers, 

case managers, and discharge planners cannot 

be overstated. 

Prior to discharge, the case manager may 

recommend a home assessment to anticipate all 

environmental needs in conducting a safe discharge. 

This is an important intervention, especially when 

the patient is coping with a severe disability that 

may involve complex mechanical assistance. If 

the discharge is likely to be complicated, the case 

manager may convene a pre-discharge planning 

meeting to verify that both family members and 

home care providers understand their roles, and that 

everyone shares similar expectations and goals. 

The discharge plan should be family-centered and 

should take into consideration:

• Patient/family preferences.

• Consideration of existing DoD/VA memoranda 

of understanding (MOUs). 

• TRICARE benefit parameters.

• Qualifications for entitlement programs (e.g., 

ECHO).

• Previous experience with existing providers and 

facilities.

• Most appropriate provider/facility for the 

patient.

• Location of facility and providers, and their 

ability to meet patient/family needs.

• Understanding of patient-specific goals.

• The parent Command and Patient 

Administration departments (if the patient is an 

ADSM).

• Impact on medical readiness and the Disability 

Evaluation System (DES) process.

Barriers to effective and timely discharge planning 

include delays in completing discharge details, 

duplication of services, lack of patient focus, and 

involvement of available patient transport resources. 

Some root problems in discharge planning include 

lack of patient involvement/understanding of the 

discharge plan, poor coordination/communication 

with the patient/family and/or caregiver(s), and 

poor communication within medical providers. 

The patient must agree with the discharge plan to 

support maximum adherence.
Medical Management Guide Version 3.0 Case Management Page 83

Care Coordination 

Care coordination is a function of CM that involves 

assisting individuals with complex circumstances (i.e., 

circumstances that place them at risk for diminished 

independence) in gaining access to needed medical, 

social, educational, financial, and other services 

across various organizations and providers. The 

process coordinates the continuum of care for 

beneficiaries whose needs exceed routine discharge 

planning but do not meet the requirements for longterm CM. 

Examples of patients who might benefit from care 

coordination include those who:

• Are at risk for a failed inpatient discharge plan.

• Have special needs (e.g., children, the elderly, 

newly diagnosed diabetics, individuals with 

catastrophic injuries).

• Require extensive short-term coordination and 

management.

• Have greater-than-average needs identified 

during pre-discharge planning that do not meet 

the criteria for formal CM.

• Have needs that require medium-intensity 

interaction with the case manager.

• Have acute, immediate needs that are not 

expected to require continuous treatment in 

the long term (e.g., patients receiving a hip 

replacement).

Accreditation

While MCSC CM programs may be accredited 

by URAC, the contract is not contingent on 

accreditation. For more information on URAC’s most 

current CM program accreditation guidelines, go to 

http://www.urac.org/. 

The CMSA provides program accreditation 

information at http://www.cmsa.org/.

Promoting Your Program

Whether a CM program is being established or is 

already in place, the key to sustaining the program 

is to optimize the department through marketing. 

Once your marketing strategy is established, you will 

want to build a caseload (see Caseload, earlier in 

this section). Here, the key decision is to expand the 

services offered to other areas or sustain existing 

services. CD-ROM Resource CM-23 provides a 

sample CM marketing brochure. You may also want 

to take advantage of promotional opportunities 

in Nurses Week, Social Workers Week, and Case 

Managers Week to market your CM services.

See Section I, Medical Management Essentials,

Program Sustainment, for more details on 

promoting MM programs.

LEGISLATIVE GUIDANCE SPECIFIC 

TO INTEGRATING PHYSICAL AND 

PSYCHOLOGICAL REHABILITATION

T

itle XVI of the National Defense Authorization 

Act (NDAA) of 2008, Wounded Warrior 

Matters, Section 1611, addresses the 

challenges associated with caring for wounded, 

ill, and injured ADSMs and their families (see

Executive Summary, CD-ROM Resource ES-4). 

In this section of the law, the NDAA outlines specific 

screening, referral, and management requirements 

for identifying the signs of post-traumatic stress 

disorder (PTSD), TBI, and BH conditions such as 

substance abuse and suicide risk. The law places 

particular emphasis on identifying and reacting 

to these conditions in response to the increase of 
Page 84 Case Management Version 3.0 Medical Management Guide

the increase of incidences of severe physical and 

psychological trauma among Service members 

serving in Global War on Terror (GWOT) missions, 

specifically, Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF) (see also Appendix 

C, Definitions).

The ongoing deployments related to the GWOT 

have taken a disproportionate toll on ADSMs 

and their families. The incidence of PTSD has 

increased, especially in ADSMs experiencing 

multiple deployments. TBI has been described 

as the “signature injury” of OEF and OIF. Often 

invisible, particularly in those with mild to moderate 

injury, many of these cases were missed in the 

early days of the conflict. Today, identification and 

treatment of this condition is much improved. Now 

all returning ADSMs are screened for blast exposure 

and TBI. It is not uncommon for an ADSM to be 

diagnosed with both PTSD and TBI, each of which 

requires treatment and intervention. These ADSMs 

need and benefit from CM during their recovery, 

but early recognition and intervention are key to 

successful rehabilitation.

The intent of the NDAA is to ensure that all 

wounded, ill, and injured ADSMs have the benefit 

of both clinical and non-clinical CM, and that case 

managers working with wounded, ill, and injured 

ADSMs receive appropriate training, including 

training on PTSD and screening for TBI. Because 

patients’ psychological health often affects their 

physical recovery, case managers must be trained 

to recognize behaviors that may indicate substance 

abuse, depression, or other psychological crisis. In 

this respect, case managers should become familiar 

with normal coping mechanisms and the stages of 

loss and grief.

In many managed care models, physical and 

behavioral services and care are segregated. This 

also means that physical illnesses are assessed and 

managed independently of psychosocial conditions. 

Yet for those suffering from chronic or complex 

conditions, a common profile for wounded, ill, 

and injured Service members, segregated care 

results in poor outcomes, higher utilization of 

healthcare services, and increased impairment and 

disability. 

A patient with chronic disease is more likely to have 

behavioral or psychosocial co-morbidities. Further, 

medical and behavioral complexities affect overall 

health outcome, use of healthcare services, quality 

of life, and treatment adherence (Steifel, 2006). 

PTSD and TBI can place great stress on the ADSM’s 

family as well. The case manager plays a critical role 

in identifying additional resources and programs that 

enhance the ability of family members to cope with 

and manage the challenges associated with a PTSD 

or TBI diagnosis.

Additionally, the case manager’s body of 

knowledge should include an understanding of the 

following factors that can affect ADSM patients: 

• Cultural issues, including those faced by patients 

living in foreign countries. 

• Family dynamics and the impact of the military 

lifestyle on families. 

• Health expectations and behaviors, including 

demands placed on fit warrior expectations. 

• Psychological and neuropsychological 

assessments, especially post-deployment and 

depression screening. 

• The psychological impact of chronic illness and 

dis­ability. 
Medical Management Guide Version 3.0 Case Management Page 85

• Substance use/abuse/addiction, including the 

use of dietary supplements. 

Disability Evaluation System

When an ADSM suffers from an injury or a chronic 

illness, the MTF’s primary responsibility is to provide 

medical treatment, with the ultimate goal of 

returning the ADSM quickly to duty. However, some 

of these patients may be unable to perform their 

duties and will be required to enter the Disability 

Evaluation System (DES). The DES has two distinct 

stages: the Medical Evaluation Board (MEB) and the 

Physical Evaluation Board (PEB). 

Medical Evaluation Board

The MEB is typically made up of two or three 

physicians who evaluate the ADSM’s injury or 

illness and plan of care to make a determination 

on whether the ADSM can adequately perform the 

assigned duties of his/her position. The ADSM is 

typically referred to the MEB by the primary care 

provider or the unit Commander; or the referral may 

be based on a higher-Command recommendation.

If the ADSM is found fit for duty, the MEB will clear 

the ADSM and return him/her to duty. If the MEB 

finds that the ADSM may return to Active Duty and 

perform his/her duties within a reasonable period of 

time (typically between eight and 16 months with 

treatment), the Board may recommend Temporary 

Duty (TDY) for the ADSM. If the MEB determines 

that the ADSM is unfit for continued duty, the Board 

refers the patient to the PEB.

Physical Evaluation Board

There are two types of PEB: informal and formal.

The informal PEB (IPEB) is the first step in the PEB 

process and is defined by the following aspects:

• It includes three voting members — one must 

be a physician and one must be a nonmedical 

officer.

• The ADSM may not be physically present.

• The ADSM may agree with the recommendation 

of the IPEB or request reconsideration at a 

formal PEB.

The formal PEB is defined by the following aspects:

• It includes three voting members — one must 

be a physician and one must be a nonmedical 

officer.

• It allows the ADSM to appear before the board, 

present evidence and testimony, call witnesses, 

review all documents used by the board, and 

provide any additional documents he/she deems 

important to his/her case.

• The ADSM is generally represented by an 

attorney.

A final determination from the formal PEB will be 

one of the following:

• Separation without Benefits

• Separation with Severance Pay

• Permanent Disability Retirement (PDR)

• Temporary Disability Retirement List (TDRL)

• Return to Duty

The ADSM has a right to appeal the formal PEB 

determination through his/her Service’s appellate 

review agency. Certain ADSMs who are determined 

to be unfit for duty may be able to remain on Active 
Page 86 Case Management Version 3.0 Medical Management Guide

Duty through the Continuation of Active Duty 

(COAD) program. The ADSM must complete the 

COAD application process with his/her PEB Liaison 

Officer (PEBLO).

Fig. 23 illustrates the DES.

For more information on the MEB/PEB process and 

specifics for each Service Branch, refer to Methods 

and Actions for Improving Performance of the 

Department of Defense Disability Evaluation System

(Marcum, Emmerichs, Sloan, Thie, 2002). See also 

Appendix C, Definitions.

Other Types of Evaluation

The case manager should be aware of the processes 

regarding military physical examinations for Service 

members on Release from Active Duty (REFRAD) 

status or who are leaving the Service due to 

retirement or sepa­ration. Members released from 

Active Duty, National Guard, or Reserve service have 

the option of requesting a REFRAD physical when 

changing from Active to Reserve status. The military 

unit coordinates the REFRAD physical exam, which 

should be performed at the MTF. 

As the basis for DoD/VA rating their disability 

compensation, Active Duty, Guard, or Reserve 

Service members who are separating or retiring 

from service should undergo one physical exam. 

Combining the DoD’s separation physical exam with 

the VA’s Compensation and Pension (C&P) exam 

helps streamline the process and minimize costs. 

Service member 

identified with injury or 

 chronic disease.

Medical

Evaluation

Board

Physical

Evaluation/

Disability

Board

Legal

Review

Disposition

(Outcomes)

Case Management

Intervention

Care Coordination

and Counseling

Care Coordination

and Transition of Care

Retirement

Temporary Disability

Retirement List

Separation

Return to

Duty

Fig. 23– Disability Evaluation System (DES)
Medical Management Guide Version 3.0 Case Management Page 87

RECOVERY COORDINATION INITIATIVES

I

n September 2008, the DoD and VA responded 

to the NDAA requirements on wounded warrior 

matters in their Report to Congress on the 

Comprehensive Policy Improvements to the Care, 

Management, and Transition of Recovering Service 

Members (NDAA Section 1611 and 1615) (see 

Executive Summary, CD-ROM Resource ES-3). 

The DoD/VA report outlines provisions implemented 

by the two departments that affect MTF case 

managers.

Federal Recovery Coordination Program

NDAA 2008 requires the Services (Army, Navy, Air 

Force, Marines) to establish a recovery coordination 

program for wounded, ill, and injured Service 

members who have significant illness or injury such 

that they may be medically retired or separated from 

the military. 

In January 2009, the Under Secretary of Defense 

issued Directive-Type Memorandum (DTM) 08-049, 

Recovery Coordination Program: Improvements to 

the Care, Management, and Transition of

Recovering Service Members (RSMs): http://www.

dtic.mil/whs/directives/corres/pdf/DTM-08-049.pdf. 

See also CD-ROM Resource CM-24.

DTM 08-049 states the purpose of the DoD 

Recovery Coordination Program (RCP), as follows:

• Provide for improvements to the care, 

management, and transition of RSMs and their 

families.

• Develop and implement standardized policies, 

processes, personnel programs, and tools to 

accomplish comprehensive care coordination.

• Adjust policies and operational procedures, as 

necessary, based on data collected during the 

first six months after the signature date of the 

DTM.

The Services have since established the Federal 

Recovery Coordination Program (FRCP), which is 

operated by the VA. Service members participating 

in this program are expected to have lifelong care 

needs. ( CD-ROM Resources CM-25 through 

CM-32 provide more detailed information on the 

FRCP, including program descriptions, forms, and a 

national resource directory.)

Recovery Care Coordinators

Referral for the FRCP is through a screening process 

performed by the Services that considers acuity 

in both medical and nonmedical (e.g., financial, 

housing, family support) areas. The VA program 

provides senior-level clinical nurses and social 

workers, designated as federal Recovery Care 

Coordinators (RCCs), to provide oversight of the 

recovery plan for catastrophically injured ADSMs.

If the ADSM meets the criteria, he/she is referred to 

an RCC who:

• Develops a Federal Individual Recovery Plan 

(FIRP) with the ADSM along with his/her family 

and recovery team.

• Provides oversight of the FIRP to help meet the 

ADSM’s and his/her family’s needs.
Page 88 Case Management Version 3.0 Medical Management Guide

New Roles for CM in the NDAA

Recovery Care Coordinators

–	 Responsible for assistance to Service member (i.e., access)

–	 Employed by Military Branch

Medical Care Case Managers (MCCMs)

–	 Licensed, healthcare professional

–	 Understand Rx and receive appropriate care

Non-Medical Care Managers (NMCMs)

–	 Finance, personnel, admin, transitional, family support

Federal Recovery Coordinators

–	 Primary responsibility/oversight for R3

–	 Employed by Veterans Administration: LCSW or RNs

Source: National Defense Authorization Act

TRANSITION/COORDINATION OF CARE

Transition of Care

I

n the military, unique transitions of care (TOCs) 

occur when patients move:

• From the DCS to the PCS.

• From MHS care to VA care.

• Among multiple Service-level settings 

— for example: An injured Marine receives 

emergency care in an Air Force ED, is 

transferred to a Navy medical center for limbsaving surgery, is rehabilitated in an Army 

setting, and is moved jointly between his/her 

home base primary care and the VA for PEB 

purposes.

• From one TRICARE regional case manager to 

another.

The FIRP plan should track with the plan of care 

developed by the recovery team as a whole. 

The RCC continues to work with the ADSM and his/

her family throughout the recovery, rehabilitation, 

and transition process to meet their needs. For best 

outcomes, the RCC is treated as a member of the 

overall outpatient recovery team that includes clinical 

and non-clinical staff. The RCC participates in team 

discussions and plan-of-care development. 

Additional resources specific to wounded warrior 

care are found in the June 2008 provision of the 

NDAA (H.R. 5658 — see Appendix D, Resources). 

Figs. 24 and 25 describe aspects of wounded 

warrior care coordination under the NDAA.

Fig. 25 – New Roles for CM in the NDAA

Recovery, Rehabilitation, Reintegration (R3)

Recovery Coordination Program

Recovery

Plan

Recovery

Coordinator

Recovery 

Team

National Resource 

Directory

Fig. 24 – Recovery Coordination Program

FOUR CORNERSTONES
Medical Management Guide Version 3.0 Case Management Page 89

heart, and spirit and on transition back to duty 

status or civilian life. Each Service has its own 

integrated care transition program, as follows:

1. Warrior in Transition Program (WT) and Army 

Wounded Warrior Program (AW2): https://

www.aw2.army.mil/index.html, http://mhs.osd.

mil/WoundedWarrior.aspx

2. Navy Safe Harbor: http://www.npc.navy.mil/

CommandSupport/SafeHarbor/

3. Air Force Wounded Warrior Program (AFW2): 

http://www.woundedwarrior.af.mil/

4. Wounded Warrior Regiment (WWR): http://

www.woundedwarriorregiment.org/WWR.aspx

Appendix D, Resources, provides more detail 

on Service-level wounded warrior recovery 

coordination programs and related CM roles, such 

as the Warrior Transition Unit (WTU) Nurse Case 

Manager.

Inter/Intra-Regional Transfer 

When a beneficiary enrolled in CM within the MTF 

relocates to another region, the MTF case manager 

in the originating MTF (“transferring” case manager) 

is responsible for ensuring continuity of care and a 

smooth transition for the patient and family to the 

case manager at the relocation site (“receiving” case 

manager). 

The process for transfers includes the following: 

• Once it is determined that a beneficiary in CM 

is mov­ing to a new location, the transferring 

case manager requests/documents written 

permission to communicate with the receiving 

case manager in the new location, from either 

the beneficiary or his/her legal representative.

• Between Commands.

• Between facilities (e.g., rehabilitation hospitals, 

psychiatric hospitals, skilled nursing facilities).

• From one hospital unit to another.

• From one level of care to another (e.g., acute 

care to outpatient care or to home health care).

• From overseas to stateside.

Case managers need to maintain awareness 

that care transitions and care coordinations 

require continuous monitoring, and to develop or 

refine processes that support patient TOCs. An 

organization’s CM program should empower staff 

to create tools and tracking mechanisms that allow 

for enhanced communication, monitoring, and 

follow-up. Performance measures of success are 

not only essential to documenting outcomes; they 

provide secondary value in “forcing” patient CM 

follow-up.

Effective and safe transitions depend on effective 

communication between the transferring facility 

(where the transition originates) and the receiving 

facility (where the patient is sent). In addition 

to the healthcare team, the patient/caregivers 

need to actively participate in the TOC process. 

( CD-ROM Resource CM-33 provides a TOC 

implementation plan.)

For more information on TOCs, visit the National 

Transitions of Care Coalition (NTOCC) website: 

http://www.ntocc.org. 

Service-Specific Care Transition Programs

CM services for Warriors in Transition (WTs) are 

centered on holistic healing of the body, mind, 
Page 90 Case Management Version 3.0 Medical Management Guide

• The transferring case manager contacts the 

receiving case manager as soon as possible to 

initiate and coordinate the transfer. 

• The transferring and receiving case managers 

collaborate on a transi­tion plan to verify that 

services are available and in place at the new 

location. 

• If the beneficiary’s relocation is imminent and 

a receiving case manager cannot be identified, 

the transferring case manager contacts the CM 

point of contact (POC) at the TRICARE Regional 

Office (TRO) before the Service member 

departs. 

• The case manager uses the Inter/intra Regional 

Transfer Form to document information. The 

form will include identification of any special 

needs or programs that address special 

needs, such as EFMP or ECHO. ( CD-ROM 

Resources CM-34 and CM-35 provide inter/

intra-regional transfer documents for ADSM and 

MHS-eligible, non-ADSM beneficiaries.)

• When a transfer involves an organ transplant, en 

route aeromedical evacuation (AE) services (see 

Aeromedical Evacuation, below), complex 

transportation arrangements, or a high visibility 

case, the transferring case manager coordinates 

with the TRO case manager. 

• The transferring case manager provides 

instructions for expediting the medical 

record transfer and iden­tifying caregiver(s), 

special needs issues, transporta­tion, or other 

assistance, as required. A cost/benefit analysis is 

recommended, particularly if the transfer is from 

the DCS to the PCS. 

• Prior to the transfer, the transferring case 

manager documents the beneficiary’s health 

status, case manager contact information, and 

actions (includ­ing the rationale). 

• The receiving case manager also documents the 

communication (including transfer instructions 

or requests) in the appropriate hard copy or electronic medical record. 

• The transferring case manager continues to 

provide CM services until the beneficiary has 

transferred enrollment to the receiving case 

manager at the new location. 

Additional responsibilities for the transferring case 

manager may involve: 

• Arranging medically appropriate patient 

transport.

• Coordinating care with the provider at the 

transferring/receiving sites and with the patient’s 

family. 

• Ensuring availability of supplies/equipment 

during transport and at the receiving location. 

• Confirming an initial appointment with the 

receiving MTF for EFMP families.

• Identifying and ensuring availability of resources 

to accomplish the transfer.

Aeromedical Evacuation

Aeromedical evacuation (AE) is the transportation of 

patients under medical supervision to and between 

medical treatment facilities by air transportation. 

This includes timely evacuation of patients from a 

combat zone. 

The Health Service Support (HSS) patient movement 

mission in joint operations is designed to minimize 

the effects of wounds, injuries, and disease by 

rapidly evacuating affected personnel from the 

location of wounding, injury, or illness in a combat 

theater to a hospital in the continental United States 

(CONUS). The patient movement system operates 
Medical Management Guide Version 3.0 Case Management Page 91

worldwide to regulate all Service component patient 

movements and is supported by the following:

• Global Patient Movement Requirements Center

• U.S. Transportation Command (USTRANSCOM)

• Aeromedical Evacuation Coordination Center

• Defense Medical Regulating Information System

• Theater patient movement requirements centers

• Joint patient movement teams

• In-transit visibility

• Service component evacuation assets

Determine requirement for patient evacuation.

AE liaison/MRO Requests patient evacuation.

Prepare patient for movement.

Ensure adequate supplies.

Transport to on-load airfield.

Determine Eligibility.

Validate medically and administratively.

Identify destination options.

Assign to Service Component.

Identify resources.

Collaborate with PMRC.

Decide appropriate aircraft.

Send ATO for lift, crew, etc.

Follow mission execution.

Receive ATO

Task aircrew(s)

Stage patient for evacuation. Launch aircraft to on-load airfield

Provide supportive patient care.

Brief AE medical crew on patient load.

Load patient on aircraft.

Inform AELT, AMD/AECT of aircraft departure.

Coordinate patient movement requirements with User.

Validate patient preparation.

IAW applicable instructions.

Fig. 26 – Aeromedical Evacuation (AE)

Aeromedical Evacuation Model

The transferring MTF is responsible for transporting 

patients between the MTF and the aerial port of 

embarkation. The movement of patients from one 

level of treatment to another for more definitive 

treatment, or between and within levels of 

treatment, requires in-depth planning, adequate 

resourcing, and skillful execution (Joint Publication 

4-02.2 — Joint Tactics, Techniques, and Procedures 

for Patient Movement in Joint Operations).

Fig. 26 illustrates how AE services are coordinated.
Page 92 Case Management Version 3.0 Medical Management Guide

Patient movement has advanced to support critical 

care capabilities via the AE system. Patients returning 

to CONUS MTFs with complex and catastrophic 

injuries and/or complicated medical sequelae 

(abnormal condition resulting from a previous 

disease) will likely require CM services and may 

benefit from enrollment into one of the Services’ 

warrior care programs. Case managers need a basic 

understanding of patient movement through the AE 

system, as it offers perspective on patients’ medical 

and psychosocial health needs from onset of injury 

or illness to definitive treatment in stateside MTFs. 

For more information, contact your MTF Patient 

Administration office.

Coordination of Care

Coordination from the MHS to the Department 

of Veterans Affairs

Depending on eligibility (i.e., Service-connected 

condition or disability), Active Duty, retired, or 

separated Service members may receive health care 

from the VA’s Veterans Health Administration (VHA). 

In 1996, Congress established Public Law 104-262, 

the Veterans Health Care Eligibility Reform Act, in 

which enrolled veterans are entitled to a medical 

benefits package that emphasizes preventive and 

primary care. For more information on eligibility 

and enrollment, refer to the VA website: http://

www.va.gov/healtheligibility/coveredservices/

StandardBenefits.asp.

The DoD and VA (VHA and Veterans Benefits 

Administration [VBA]) continue to partner to 

improve the dialogue and collaboration between the 

two departments at all levels, focusing on the ability 

to identify and serve all ADSMs who have sustained 

injuries or illnesses in combat operations. 

When the transition of healthcare services is 

required between an MTF and a VA medical 

center (VAMC), the MTF case manager (or patient 

administrative staff, as appropriate) is responsible 

for coordinating the tran­sfer with the VHA Liaison 

located at the MTF and/or the OEF/OIF Care 

Management Team located at the VAMC. To locate 

the appropriate VHA Liaison for referral, refer to the 

con­tact list table on CD-ROM Resource CM-36

(this list is continuously updated). 

When the MTF case manager identifies the requirement to transfer care to the VA, he/she com­pletes 

a referral packet to include the DoD/VA Liaison 

Referral Form ( CD-ROM Resource CM-37) with 

a discharge plan and medical record documenta­tion. 

Once the VHA Liaison receives the referral form and 

medical record documentation, he/she initi­ates the 

referral with the accepting VAMC. Depending on 

the urgency and request for healthcare services, the 

transition time may occur as quickly as a few days. 

Coordination for Active Duty Service Members 

in the TRICARE Prime Remote Program

The Military Medical Support Office (MMSO) is a 

Tri-Service agency providing CM services for the following populations:

• ADSMs enrolled in the TRICARE Prime Remote 

(TPR) program.

• Reserve and National Guard members injured in 

the line of duty (LOD).

• New accessions awaiting the start of training.
Medical Management Guide Version 3.0 Case Management Page 93

• Any ADSM en route to a first school, training, or 

permanent duty station who is not yet enrolled 

in the TPR or in an MTF.

While the organization and scope of responsibility 

for the MMSO may change over time, its main 

mission will continue to directly support the 

healthcare needs of ADSMs in TPR. For more 

information, visit the MMSO website at http://www.

tricare.mil/tma/MMSO/.

Through clinical review, oversight, preauthorization, 

and coordination for all specialty care referrals, 

the MMSO verifies that remote and non-enrolled 

ADSMs are receiving needed medical care within 

TRI­CARE standards. MMSO staff identify fit­nessfor-duty issues and make recommendations to 

Commands for referral to MTFs or the MEB. Staffed 

by a team of regis­tered nurses (RNs), the CM division 

identifies cases and plans of care that include noncovered benefits or experimental procedures, and 

consults with spe­cialty advisers to obtain clinical 

opinions and recom­mendations. Based on the 

recommendations of those advisers and the patient’s 

condition, the nurses will either continue the care in 

the remote area or make a referral to the nearest, 

same-Service MTF. 

The MMSO’s primary CM responsibilities relate to:

• Chronic and complicated cases.

• Long-term care for remotely located Service 

members and those who have sustained a TBI 

or spinal cord injury (SCI), or have been blinded.

When an ADSM sustains a TBI, SCI, or has been 

blinded, and it has been decided to refer the patient 

to the VA program under the national MOU, the 

MTF case manager should contact the MMSO case 

manager as soon as possible to facilite authorization 

for admission to a VAMC. The MMSO case manager 

can also answer questions regarding processes for 

care once the patient is released from the VA. 

As a conduit between the beneficiary and TRO, the 

MMSO can act as an information resource to assist 

MTF case managers with problems or complicated 

issues. Although case information can be faxed to 

the MMSO, it is recom­mended that the CM division 

be contacted directly by telephone for assistance. 

Coordination for Exceptional Family Member 

Program and Special Needs Families 

Enrollment in the Exceptional Family Member 

Program (EFMP), also referred to as Special Needs 

Identification and Assignment Coordination 

(SNIAC), is used dur­ing the assignment process to 

identify ADSMs whose family members have special 

needs. Special needs range from medical, dental, 

and mental health concerns to educational or 

developmental requirements. 

The purpose of early identification is to verify that 

necessary services are available upon change of 

duty stations. The EFMP proactively considers a family member’s special requirements while assisting 

families in finding and using appropriate services 

and pro­grams with the dual goal of increasing family 

self-suffi­ciency and improving self-advocacy skills. 

(Note: Not all EFMP families require CM; however, all 

CM fami­lies with qualifying special needs should be 

enrolled in the EFMP.) 
Page 94 Case Management Version 3.0 Medical Management Guide

Each Service administers the program differently 

(e.g., point of contact [POC] titles may vary; 

program responsibilities may be located in different 

departments). The sponsor of the family member 

with special needs must also enroll in the program. 

Families usually self-identify, but medical person­nel 

may also identify eligible members during routine 

healthcare visits.

EFMP eligibility should be re-evalu­ated on a regular 

basis, since a family member’s sta­tus may change. 

Case managers or special needs coordinators 

should assist the EFMP member; espe­cially during 

the coordination of overseas screening, processing, 

and enrollment. Since there is minimal medical 

oversight in the EFMP, case managers may provide 

the necessary structure to promote standardi­zation, 

uniformity, connectivity, and transferability of 

benefits from one TRICARE region to another. 

When an ADSM is notified of potential duty 

relocation or must complete a move expeditiously 

and a dependent family member has special needs, 

the following steps should occur:

• The transferring case manager obtains 

authorization from the sponsor or legal 

guardian for release of information from the 

adult beneficiary with the special need(s) prior 

to discussing healthcare arrangements with the 

ADSM. 

• The transferring case manager consults the 

receiving case manager to determine available 

medical care and special needs resources in the 

location of possible assignment.

• The transferring case manager pro­vides the 

necessary clinical data so the receiving region 

can make a determination on the avail­ability of 

resources. This may include, but is not limited to: 

o Additional programs the family is currently 

engaged or enrolled (e.g., ECHO). 

o Case history and current treatment 

plan, includ­ing stability of condition and 

rehabilitation, if indicated. 

o Discovery date and summary of medical 

condition. 

o Support system at home. 

If the family member’s needs can­not be met in the 

receiving region/location and the ADSM proceeds 

with assignment to that region/location, the case 

manager must discuss with the ADSM the potential 

or actual impact on the family member’s care and 

the need for coordi­nation with regions/locations on 

the availability of medical care. In such cases, the 

following process applies:

• The transferring case manager will document 

the following in the CM transition plan: 

o Current needs, services, and medical 

condition(s) of the affected family 

member(s).

o Communication with the TRO informing the 

receiving case manager of the potential/actual 

shortfalls in healthcare resources required by 

the beneficiary. 

o Discussion with the receiving case manager 

regarding the identification of potential gaps 

or shortfalls in local healthcare resources. 

o The Service member’s decisions on the plan 

of care and fol­low-up plan. 

• The receiving case manager will: 

o Assist family members in coordinating the 

care needed upon arrival to the new duty 

station.

o Coordinate with schools to transfer 

Individual Education Plans (IEPs).

o Document interventions and decisions made. 
Medical Management Guide Version 3.0 Case Management Page 95

Transition/Coordination Challenges

The World Health Organization (WHO) in 

collaboration with TJC and TJC International agreed 

in April 2007 on a list of nine National Patient Safety 

Goals (NPSGs). Based on the list of current NPSGs, 

the most important challenges to seamless TOC 

identified by the Commission include:

• Communication. It is critical to share current, 

comprehensive information within and among 

care providers and delivery systems. The 

acronym SBAR, for Situation-BackgroundAssessment-Recommendation, is an easy-toremember mechanism for communicating 

on issues that require a clinician’s immediate 

attention and action. SBAR is recommended 

as a tool in one of the NPSGs used in hospital 

settings when patients are transferred from one 

unit to another (http://www.ccforpatientsafety.

org/common/pdfs/fpdf/presskit/PS-Solution3.

pdf).

• Medication accuracy/reconciliation. Transitions 

are the most common situation in which 

medication errors occur. Medication accuracy/

reconciliation is a process designed to prevent 

medication errors at patient transition points 

(http://www.ccforpatientsafety.org/common/

pdfs/fpdf/presskit/PS-Solution6.pdf).

• Accountability and responsibility. Healthcare 

professionals involved in a patient’s care, both 

clinically and administratively, are responsible for 

breaking down barriers that impede TOCs. Case 

managers may face legal accountability when 

patients are not transitioned appropriately or in 

a timely manner.

• Role clarification. It can be difficult to assign 

accountability if there is confusion about the 

roles of various healthcare team members in the 

transition of care for a patient in CM. Ongoing 

communication via all available systems (e.g., 

telephone, secure e-mail, paper documents) and 

care conferences can minimize confusion when 

specific roles are identified.

• Follow-up. This is one of the most effective 

actions a case manager can take in promoting 

safe and complete TOC. Case managers should 

use caution when relying on the patient or 

family/caregiver(s) to be entirely responsible for 

follow-up. The patient’s condition may be a 

limiting factor, impeding his/her ability to secure 

care as part of the medical plan. Conversely, the 

family/caregiver(s) may be subject to stressors 

unrelated to healthcare issues that are impeding 

effective follow-up or maintenance of the care 

plan.

For more information, go to http://www.who.int/. 

Other Types of Transition/Coordination 

Title XVI of the National Defense Authorization Act 

(NDAA) of 2008, Wounded Warrior Matters, Section 

1615 (refer to CD-ROM Resource ES-4), focuses 

on facilitating the transition of Service members from 

Active Duty status to civilian life. In the MTF, the case 

manager arranges for housing modifications, assistive devices, or adaptive equipment. As previously 

discussed, this may involve collaboration with the VA 

to identify the best options for an ADSM’s physical 

and behavioral rehabilitative care.

Case managers strive to help patients return to 

activities that are productive, meaningful, and 

rewarding to them, which is extremely important 

for their recovery and quality of life. 
Page 96 Case Management Version 3.0 Medical Management Guide

Aspects of this process include: 

• Disability compensation (e.g., worker’s 

compensation and auto insurance). 

• Ergonomics. 

• Job analysis, job modification, job accommodation, and job hardening. 

• Job development and placement.

• Life care planning. 

• Military boards and medical retirement 

procedures. 

• Other military programs.

Outside the Continental United States 

(OCONUS) and TRICARE Global Remote 

Overseas (TRGO) Program

CM plays an important role in supporting Service 

members Outside the Continental United States 

(OCONUS). Specifically, case managers working 

at specialty treatment centers or MTFs may be 

called on to assist in the acceptance and transfer of 

complex patients from other MTFs for specialized 

treatment.

ADSMs serving overseas must be enrolled in the 

TRICARE Global Remote Overseas (TRGO) program, 

where available. For more information, go to: http://

www.military.com/benefits/tricare/tricare-overseas/

tricare-global-remote-overseas.

North Atlantic Treaty Organization (NATO)

Members of the North Atlantic Treaty Organization 

(NATO) Armed Forces occasionally call upon MTFs or 

their host Service Branch medical clinics to provide 

care to their overseas Service members and/or 

families. In such cases, the case manager needs to 

be familiar with individual countries’ arrangements 

with the United States before arranging care.

Depending on the scope of any signed agreements, 

ADSMs or their family members may only be eligible, 

for example, for outpatient direct care medical 

treatment. To understand enrollment and eligibility 

requirements in individual countries, the case 

manager should access the following websites: 

• http://www.tricare.osd.mil/recip

• http://www.nato.int/structur/countries.htm

CM also comprises an important UM role when it 

comes to understanding and working within the 

boundaries of agreements between the United 

States and other NATO countries. Depending on the 

healthcare utilization patterns and practices (medical 

and/or dental) of an individual NATO member 

country, case requirements can quickly escalate. 

The case manager needs to manage the access and 

utilization of care while liaisoning with the ADSM’s 

embassy staff for authorization. 

In non-NATO cases, only ADSMs are eligible for care; 

their family members are not covered. However, 

because ADSMs often move between various 

theaters of operation and because international 

agreements continually change, it is recommended 

that case managers consult with their Patient 

Administration departments on a case-by-case basis.
Medical Management Guide Version 3.0 Case Management Page 97

THE CASE MANAGEMENT PROFESSIONAL

Qualifications 

T

he job description of the employee working 

in the CM department of an MTF will vary 

depending on the size of the organization 

and its internal resources. Titles include Case 

Manager, Health Care Integrator (HCI), Nurse 

Clinical Case Manager, Medical Care Case Manager 

(MCCM), and Licensed Clinical Social Worker 

(LCSW).

The following resources can aid in understanding 

the essential skill sets required for successful case 

managers:

• Nursing Case Management from Essentials to 

Advance Practice Applications, 4th Edition.

• The Case Manager’s Survival Guide, Winning 

Strategies for Clinical Practice, 2nd Edition.

• CMSA Core Curriculum for Case Management, 

2nd Edition. 

See Appendix A, References, for publication 

information.

Knowledge of key CM skill sets and assistance 

from the Human Resources and/or Personnel 

departments can help case managers prepare 

appropriate interview questions to determine 

whether your candidates possess these skill sets.

The CM professional:

• Should have sufficient clinical knowledge and 

breadth of patient care experience to identify 

the clinical rationale for procedures or tests. 

• Should be able to gather necessary information 

and determine the medical necessity of services 

and the appropriateness of care. 

• Must have knowledge in the area of CM and 

expertise applying his/her professional skills to 

the full range of bio-psychosocial health-related 

problems in the provision of CM services. 

• Must have a patient- and family-centered 

approach to performing assessments and plans 

of care.

The case manager will have knowledge of human 

behavior/dynamics and motivation, healthcare 

service delivery, healthcare financial systems and 

funding sources, professional ethics, and clinical 

standards and outcomes. He/she should also 

possess knowledge of accreditation standards 

from organizations such as TJC and privacy and 

confidentially requirements as detailed in the Health 

Insurance Portability and Accountability Act (HIPAA). 

CD-ROM Resource CM-38 is a Privacy Act 

Statement for Health Care Records form. (See also 

Section I, Medical Management Essentials; and

Appendix C, Definitions.)

Education and Experience Requirements

CM professionals must possess the following specific 

education and experience credentials: 

• Licensed Registered Nurse (RN) – i.e., graduate 

of an accredited nursing program, Bachelor of 

Science in Nursing (BSN) preferred; or bachelor’s 

(or higher) degree in a healthcare-related field 

from an accredited educational institution 

(position typically occupied by an RN with a 

BSN).
Page 98 Case Management Version 3.0 Medical Management Guide

• Valid unrestricted clinical license to practice.

• Social worker case managers — current license 

from a U.S. jurisdiction and must be Licensed 

Master’s Social Worker (LMSW).

• A minimum of two years of recent experience 

(within the last four years) in professional 

nursing, social work, or CM for adults, children, 

families, seniors, or groups.

• Employed for the past 12 months in a 

healthcare-related field. 

• Current basic life support (BLS) certification. 

• Knowledge and experience, or comprehension 

during training, in the performance of core CM 

activities (i.e., patient advocacy, assessment, 

planning, implementation, coordination, 

monitoring, evaluation). 

• Demonstrated expertise in resolving complicated 

healthcare, social, interpersonal, and financial 

patient situations.

• Experience in program planning and conducting 

individual, family, group, and community 

assessments.

Certification

Valid desirable qualifications are certification by a 

CM-specific program upon hire or within 24 months 

of employment. Refer to the following resources:

• Commission for Case Manager Certification 

(CCMC): http://www.ccmcertification.org/.

• American Nurse Credentialing 

Center (ANCC): http://www.

nursecredentialing.org/.

• CMSA: http://www.cmsa.org.

Ethical Practice Standards

Ethics address the judgment of right and wrong 

and good or bad. Per the CMSA’s 1996 statement 

on ethical CM practice, case managers adhere to 

the code of ethics for their profession of licensure. 

CM is guided by the ethical principles of autonomy, 

beneficence, non-maleficence (not harming others), 

justice, and veracity (Beauchamp and Childress, 

1994/2008). 

The patient is always the primary consideration 

when making CM decisions. This means the 

patient must be involved in all aspects of decisionmaking, including being informed of options and 

consequences prior to making decisions. The case 

manager works closely with the patient during 

this process in order to help him/her achieve selfmanagement.

The case manager is obliged to promote for the 

good of the patient (beneficence) and refrain 

from doing harm to the patient (maleficence). 

The case manager is intimately involved with the 

dissemination of services and resources on an 

individual basis (justice). Truth-telling (veracity) is 

imperative for development of trust with a patient, 

and must be built among patients, case managers, 

and healthcare providers.

The case manager must follow the regulations 

set forth in his/her state licensing body, as well as 

those practice guidelines published by nationally 

recognized organizations in the industry of managed 

care, particularly the CMSA and URAC. In 2002, the 

CMSA published standards of practice delin­eating 

guidelines for the CM profession. 
Medical Management Guide Version 3.0 Case Management Page 99

Each Service and MTF may offer its own required 

or optional training opportunities. For more 

information, contact your Education and Training 

manager.

A “continuity binder” — also called a standard 

operating procedure (SOP), orientation, or resource 

manual — specific to individualized CM role(s) can 

be a useful tool. The binder may be in paper or 

electronic form, and can help personnel covering 

another staff member’s position in his/her absence 

understand the responsibilities of that staff 

member’s position(s). The binder provides:

• Descriptions of daily, weekly, and monthly 

responsibilities and related tasks.

• A list of personnel in the organization and their 

counterparts within the TMA region.

• A hard copy of any forms or logs used, in case of 

computer system failures. 

• A list of scheduled meetings.

• Other relevant information. 

The continuity binder should be updated on a 

regular basis. 

In addition to possessing the basic educational 

background for the position, it is also crucial for CM 

personnel to maintain practice competency. 

( CD-ROM Resource CM-39 provides a Sample 

Case Manager Core Competencies Form.) 

The standards require that the case manager 

provide services within the scope of practice defined 

by their community, licensure, and published 

practice standards. Case managers are potentially 

liable if they do not follow these CM standards of 

practice. DoD and Service Branch-specific policies 

and directives concerning the provision of health 

care also apply.

Resources for Orienting and Training 

the New Case Manager 

Web-based learning modules to assist in orienting 

and training newly hired staff are available at MHS 

Learn: https://mhslearn.csd.disa.mil. MHS-required 

CM training includes the following topic areas:

1. Case Management

2. TRICARE Fundamentals

3. Military Medical Support Office

4. Traumatic Brain Injury

5. Post-Traumatic Stress Disorder

6. Suicide Awareness

7. Homicide Awareness

8. Substance Abuse

9. Clinical Decision Support Tools

10. Introduction to the Veterans Administration

11. Disability Evaluation System

12. Federal Recovery Coordination Program

13. Recovery Care Coordinators

As part of the CM orientation process, case 

managers are required to complete and pass all 

relevant MHS Learn modules prior to providing 

patient care. It is also vital for personnel to have 

a basic knowledge of each position within their 

department, as MM roles are often interdependent. 
Page 100 Case Management Version 3.0 Medical Management Guide

SUMMARY

Clinical CM moves beyond the historical practice 

of coordinating systems and brokering for cost 

reduction. It is a personal involvement in the 

medical, behavioral, psychosocial, and functional 

aspects of a patient’s health care. The case 

manager’s span of influence encompasses the 

continuum from health to impairment, requiring 

an integrated approach that involves collaboration 

with utilization managers and disease managers for 

effective coordination across healthcare settings.

Military CM practice requires licensed healthcare 

professionals who are experienced in Population 

Health, the MHS and related benefits, payor 

mechanisms, community resource models, and 

disease states. With appropriate education and 

training, nursing or social work professionals are 

well equipped to support patients and their family 

members in the pursuit of optimal wellness.

Case managers seek to promote self-management 

education and an optimal quality of life while 

implementing cost-effective resourcing and the 

timely resolution of clinical and system issues. 

Specifically, case managers serve as catalysts, 

facilitators, and communicators when advocating 

for patients who are unable to meet or unsuccessful 

in meeting their own healthcare needs. Case 

managers serve not only as “connectors” of 

fragmented systems; they also function as the 

“hub” in a wheel of coordinated, multiple-care 

delivery systems, acting as a central POC for 

patients.

Case managers facilitate and ensure that “one hand 

knows what the other hand is doing.” This visibility 

fosters timely and appropriate interventions from a 

myriad of providers who may be delivering care to 

complex and chronic care patients. 

CM plays a crucial role in supporting the MHS 

despite a financially challenging environment and 

the high operational tempo of military missions. As 

such, it is an excellent resource for patients, families, 

providers, and military Commands when advanced 

MM interventions are required to meet healthcare 

and mission goals.

CD-ROM RESOURCES

CM-1 Article: Reineck, C. A., Farris, P.: Case 

Management: Conserving the Fighting 

Strength in the U.S. Military — Care 

Management (August 2003)

CM-2 Article: Lewis-Fleming, G., Laing, D., 

Whiting, D. (CDR), Dawe-Gillis, C. (CAPT): 

Case Management and the Active Duty 

Service Member — Care Management

(February 2001)

CM-3 Standard Form (SF) 513 – Blank

CM-4 Standard Form (SF) 513 – Completed 

CM-5 Case Management Screening Criteria

CM-6 Severity/Complexity Index – Army

CM-7 Sample Introductory Letter

CM-8 Sample Authorization Form for Disclosure 

of Medical Information – Army

CM-9 Original Informed Consent

CM-10 Non-Acceptance Letter

CM-11 Inability to Contact

CM-12 Sample Case Closure Summary Letter

CM-13 AIM Screenshot, CM Plan of Care – Air 

Force
Medical Management Guide Version 3.0 Case Management Page 101

CM-14 AIM Screenshot, Initial Assessment – Air 

Force

CM-15 Patient/Family Satisfaction Survey 

– Sample

CM-16 Provider Satisfaction Survey – Sample

CM-17 CM Measurement Reporting Tool 

– Sample

CM-18 CM Caseload Log Sample #1

CM 19 CM Caseload Log Sample #2

CM-20 CM Caseload Log Sample #3

CM-21 Directive-Type Memorandum (DTM) 08-

033, Interim Guidance for Clinical Case 

Management for the Wounded, Ill, and 

Injured Service Members in the Military 

Health System – DRAFT

CM-22 CMSA CM Caseload Concept Paper

CM-23 Sample CM Marketing Brochure – Patient/

Provider

CM-24 Directive-Type Memorandum (DTM) 08-

049 – Recovery Coordination Program: 

Improvements to the Care, Management, 

and Transition of Recovering Service 

Members (RSMs)

CM-25 Federal Recovery Coordination Program 

– Overview 

CM-26 Federal Recovery Coordination Program 

– Care Coordination Office (Mission)

CM-27 Federal Recovery Coordination Program 

– Description

CM-28 Federal Recovery Coordination Program 

– Care Coordination Office (National 

Resources Directory)

CM-29 Federal Recovery Coordination Program 

– Enrollment Form

CM-30 Federal Recovery Coordination Program 

– Comprehensive Needs Assessment

CM-31 Federal Recovery Coordination Program 

– Comprehensive Recovery Plan

CM-32 Federal Recovery Coordination Program 

– Category Assignment Tool

CM-33 Transitions of Care Implementation Plan

CM-34 Inter/Intra-Regional Transfer Form 

– ADSMs

CM-35 Inter/Intra-Regional Transfer Form – nonADSMs

CM-36 VHA Liaison Contact List

CM-37 VHA Liaison Referral Form 

CM-38 Privacy Act Statement for Health Care 

Records Form

CM-39 Sample Case Manager Core Competencies 

Form

CM-40* Wounded Warrior Regiment Brief for New 

Personnel (February 2008) 

CM-41* Department of the Army Warrior 

Transition Unit (WTU) Consolidated 

Guidance (July 18, 2008)

CM-42* Frequently Asked Questions (FAQs) and 

answers pertaining to the Army Medical 

Action Plan (AMAP) and United States 

Army Europe (USAEUR) WTUs

*Not referenced in text

‘



Medical Management Guide Version 3.0 Disease Management Page 105

Disease Management IV

SECTION

INTRODUCTION

Disease Management (DM) is focused on 

optimizing health in specific populations. 

It should be noted that all components 

of MM — Utilization Management (UM), Case 

Management (CM), and Disease Management 

(DM) — blend together when they are 

operationalized. The lines of distinction between 

UM, CM, and DM programs may become less 

defined as UM, CM, and DM personnel collaborate 

with Military Treatment Facility (MTF) providers and 

Fig. 27 – Disease Management within the Integrated Medical Management Model

*See also Section I, Medical Management Essentials: Fig. 4, Integrated Medical Management Model (IM3) with Key info, page 14.

staff to achieve the best healthcare benefit possible 

for the patient and the organization. 

Fig. 27 highlights the role of DM over the various 

stages of health care (see also Section I, Medical 

Management Essentials). Specifically, as the focus 

of healthcare delivery moves along the Population 

Health continuum, when the focus of health care is 

pri­mary prevention, interventions are most effective 

for groups of people with similar characteristics. The 

same is true when providing healthcare services at 

the level of secondary prevention for people who 
Page 106 Disease Management Version 3.0 Medical Management Guide

system of coordinated healthcare interventions and 

communications for populations with conditions in 

which patient self-care efforts are significant.”

The DMAA has broadened its focus from strictly 

DM to a Population Health model, of which DM 

is a component. This model promotes a proactive, 

accountable, patient-centric approach featuring a 

“physician-guided” healthcare delivery approach 

designed to “develop and engage informed and 

activated patients over time to address both illness 

and long term health” (DMAA, 2009). The MHS 

Population Health model (see Section I, Medical 

Management Essentials, Fig. 3) is based on a 

healthcare delivery approach that incorporates six 

key components illustrating this paradigm from a 

provider-guided approach.

DM program goals are to improve clinical outcomes, 

increase patient and provider satisfaction, and 

promote appropriate utilization of resources 

throughout the MHS. The purpose of DM is 

to improve the quality of life for individuals by 

preventing or minimizing the impact of a disease or 

chronic condition. This purpose is accomplished by 

activities such as implementing more standardized 

care and improving patients’ ability to care for 

themselves.

Per the DMAA (2009), a DM program: 

• Emphasizes prevention of exacerbations and 

com­plications by using evidence-based practice 

guide­lines and patient empowerment strategies. 

• Supports the healthcare provider/patient relationship and plan of care. 

• Evaluates clinical, humanistic, and economic 

outcomes on an ongoing basis with the goal of 

improving overall health.

are at risk for exacerbating or complicating their 

disease.

In the Department of Defense (DoD), MTFs have 

success­fully implemented DM programs for a 

number of conditions and disease states. In 

accordance with the National Defense Authorization 

Act (NDAA) of 2007, the Military Health System 

(MHS) was tasked with developing DM programs 

for a variety of diseases and chronic conditions 

including asthma, chronic obstructive pulmonary 

disease, diabetes, depression and anxiety disorders, 

cancer, and heart disease. Thus, MTFs and Managed 

Care Support Contractors (MCSCs) have begun to 

systematically incorporate these disease states into 

their DM programs.

Definition, Goals, and Purpose

DM is an organized effort aimed at achieving 

desired health outcomes in populations with 

prevalent, often chronic, diseases for which 

healthcare delivery may be subject to considerable 

variation (Kongstvedt, 2007) (see also Appendix C, 

Definitions). In con­trast to CM’s focus on individual 

patients, DM is aimed at sub-populations of patients 

with a specific condition, disease, or set of comorbidities (e.g., the metabolic syndrome associated 

with diabetes, hypertension, and hyperlipidemia). 

The principles of DM are applicable to all venues 

of healthcare delivery, including the inpatient and 

outpatient settings in both the primary and specialty 

care arenas.

According to the Disease Management Association 

of America (DMAA, 2009): The Care Continuum 

Alliance (hereafter referred to as DMAA), DM is “a 
Medical Management Guide Version 3.0 Disease Management Page 107

The Current State of Disease 

Management

Providers have long strived to return patients to 

optimum health. It has only been since the mid1990s that DM became the program of choice for 

managing patient populations (Sprague, 2003). 

Several driving forces (e.g., congressional mandates, 

TMA policy, increasing costs) have influenced the 

MHS’ move to adopt more robust DM practices. 

There is strong evidence for efficacy of health promotion, disease prevention, and condition management programs in both the MHS and the civilian 

healthcare arena.

Effective DM is a cost-effective approach 

to enhancing quality of life, postponing the 

development of complications, and consistently 

improving health outcomes for all beneficiary 

populations in the MHS. DM should no longer be 

viewed as a burden to healthcare teams but rather 

as an effective means for improving the future 

health of defined populations.

Managing Chronic Disease in the Military 

Health System

In the MHS, the incidence of chronic disease in 

Active Duty Service members (ADSMs) is approximately 21 percent (Armed Forces Health Surveillance 

Center, 2009). However, the vast majority of chronic 

illnesses in the MHS are present in the retiree and 

family member population. Approximately 30 

percent of military members remain in the Serv­ice 

until retirement and become lifetime beneficiaries 

(Force Readiness and Manpower Information 

System, 2003). Therefore, the long-term care 

coordination and resulting program benefits for this 

population can be maximally realized in the MHS by 

leveraging MM resources.

In 2005, 133 million people — almost half of 

all Americans — lived with at least one chronic 

condition (e.g., heart disease, cancer, diabetes). 

These diseases cause major limitations in daily 

living for almost 1 in 10 Americans (Agency for 

Healthcare Research and Quality [AHRQ], 2009). In 

fact, chronic diseases account for 70 percent of all 

deaths in the U.S., or about 1.7 million each year 

(National Center for Chronic Disease Prevention and 

Health Promotion [NCCDPHP], 2008). These diseases 

have a severe impact on quality of life, resulting in 

significant increases in individual healthcare costs 

and the development of conditions that lead to a 

high rate of morbidity. 

Supporting the link between clinical and business 

operations and evidence-based health care (e.g., 

asth­ma, diabetes, and cancer screening) is included 

as one of eight critical initiatives in Tri-Service 

business planning (described in Section I, Medical 

Management Essentials). In accordance with the 

NDAA of 2007, the MHS placed a greater emphasis 

on integrating DM programs for a variety of diseases 

and chronic conditions with enterprise activities. 

Consequently, the incorporation of evidence-based 

medicine practices and programs has assumed 

a higher priority in the administration of cur­rent 

TRICARE contracts. (For more on the link between 

clinical and business operations, see Section I, 

Medical Management Essentials. For more 

information on Tri-Service business planning, see

Section V, Medical Management Tools.)

To support the objectives of their business plans, 
Page 108 Disease Management Version 3.0 Medical Management Guide

MTFs have implemented the clinical practice 

guidelines (CPGs) established by the Department 

of Veterans Affairs (VA) and the DoD for numerous 

high-cost and high-volume conditions, including 

diabetes and asthma. However, significant gaps in 

quality still exist for conditions covered by these 

CPGs, requiring further emphasis and continued 

evaluation. 

Employer-Funded Health Plans 

Employer funding of healthcare plans has been a 

driving force in civilian DM efforts, as employers 

seek to control healthcare program costs.

According to a study in the American Journal of 

Managed Care (Welch et. al., 2002), DM programs 

were most likely to focus on three main diseases: 

diabetes, asthma, and congestive heart failure. The 

study found that medical directors perceived their 

DM programs to be highly effective not only in 

reducing mortality and morbidity and improving the 

functional status of patients, but also in lowering 

costs. This highlighted the need for DM programs 

to undergo critical evaluation for quality and cost 

effectiveness. In a survey by the Kaiser Family 

Foundation (KFF) and the Health Research and 

Educational Trust, 55 percent of large employers 

(those with 200 or more employees) offering health 

benefits included one or more DM programs. The 

same survey found that 62 percent of large firms 

had one or more wellness programs, including injury 

prevention, fitness, smoking cessation, and weight 

loss (KFF, 2006). 

A report by America’s Health Insurance Plans (AHIP) 

examined a variety of civilian health programs aimed 

at improving the quality of life for members with 

chronic disease (AHIP, 2007). Important trends in 

chronic care included: 

• Providing health coaching for behavior change: 

Healthcare professionals, usually nurses or health 

promotion staff, coach high-risk members on 

lifestyle changes.

• Harnessing advancements in information 

technology (IT): Technology, such as electronic 

medical records and electronic registries, is used 

to improve effective care.

• Caring for the whole person: Rather than 

targeting individual diseases (such as one 

program for asthma, one for diabetes, and one 

for depression), the needs of the whole person 

are addressed.

• Offering a continuum of care: Health outcomes 

are improved by the provision of a variety of 

services, ranging from wellness and prevention 

to acute, chronic, and end-of-life care.

Cost Savings for Disease Management

As previously discussed, cost control is an important 

focus for DM. Medical expenditures in 2006 for 

individuals with one or more chronic diseases totaled 

about $1.58 trillion, or 75 percent of total U.S. health 

spending (Partnership to Fight Chronic Disease, 

2008). 

An analysis on the economic burden of chronic 

disease in 2003 demonstrated: 

• The highest treatment expenditures for chronic 

diseases were $64 billion for heart disease, 

$45.8 billion for mental disorders, and $45.2 

billion for pulmonary conditions. 
Medical Management Guide Version 3.0 Disease Management Page 109

• Direct costs per person were $3,381 for heart 

disease, $1,977 for diabetes, $1,509 for mental 

disorders, and $919 for pulmonary conditions 

(DeVol, Bedroussian, 2007).

As recently as 2003, costs for seven common 

chronic diseases, cancer, diabetes, heart disease, 

hypertension, stroke, mental disorders, and 

pulmonary conditions, were $277 billion with 

lost productivity totaling $1.1 trillion (DeVol, 

Bedroussian, 2007). This lost productivity included 

absenteeism, missed work days, and presenteeism. 

Presenteeism, defined as being at work but not 

performing optimally, was identified as causing the 

largest share of lost economic output (Partnership to 

Fight Chronic Disease, 2008). 

According to the Centers for Disease Control and 

Prevention (CDC), the approach of focusing on 

various risk factors not only helps prevent chronic 

disease; it is cost effective. Reducing cholesterol 

levels for U.S. adults by 10 percent can reduce the 

number of heart attacks and stroke overall by 30 

percent. U.S. adults lowered blood pressure and 

high cholesterol during the 1980s, which reduced 

costs associated with coronary heart disease by 

about 9 percent — from about $240 billion in 1981 

to about $220 billion in 1990 (CDC, 2009).

For Americans with diabetes, foot care examinations 

and improved self-care as a result of patient 

education could prevent up to 85 percent of 

diabetes-related amputations. Blood pressure 

control among people with diabetes reduces the 

risk of heart disease and stroke by up to 50 percent 

and the risk of eye, kidney, and nerve diseases by 

approximately 33 percent. Blood pressure control 

alone for this population can result in a concomitant 

cost savings of $1,200 over a lifetime for a person 

with Type 2 diabetes. In addition, self-management 

training for diabetics prevents hospitalizations: every 

$1 invested in training reduces healthcare costs by 

up to $8.76 (Capital District Physicians’ Health Plan 

[CDPHP], 2008).

DISEASE MANAGEMENT COMPONENTS

T

here are six essential components to effective 

DM:

1. Population identification processes. 

2. Evidence-based clinical practice guidelines 

(CPGs) to reduce practice variation and improve 

care.

3. Collaborative practice models, including 

providers and interdisciplinary healthcare team 

members.

4. Patient self-management education. 

5. Process and outcome measurement, evaluation, 

and management. 

6. Feedback and reporting to stakeholders, 

including patients, the healthcare team, and 

Command leadership. 

Full-service DM pro­grams must include all of the 

aforementioned ele­ments. Programs not inclusive 

of all six components are considered “DM support 

services” (DMAA, 2009).

1. Population Identification Processes

DM begins with a thorough assessment and analysis 

of the population served by the healthcare system. 

This assessment includes, at a minimum, knowledge 
Page 110 Disease Management Version 3.0 Medical Management Guide

of population age distribution, gender, beneficiary 

category, risk factors, and disease burden. Disease 

managers will also be interested in any known 

healthcare utilization patterns (e.g., high utilizers, 

inpatient admissions, Emergency Department [ED] 

visits).

Tools to identify population demographic 

characteristics include:

• Defense Eligibility Enrollment Reporting System 

(DEERS)

• MHS Management Analysis and Reporting Tool 

(M2)

• MHS Population Health Portal (MHSPHP)

• Armed Forces Health Longitudinal Technology 

Application (AHLTA) 

For more information, refer to Section V, Medical

Management Tools.

Armed with a thorough knowledge of their 

population, disease managers can risk-stratify that 

population and its healthcare needs in order to 

determine the priority of interventions. This risk 

stratification includes identifying chronic disease 

conditions and required treatment along with 

defining unhealthy behaviors within specific subpopulations or cohorts.

 

2. Evidence-Based Clinical Practice Guidelines

Fundamentals

Evidence-based practice forms the foundation of 

DM. DM programs use CPGs to guide patient care. 

The MHSPHP is a centralized, secure, Web-based Population Health management system 

used by Army, Navy, and Air Force healthcare teams. The MHSPHP transforms Department of 

Defense (DoD) and Network healthcare administrative data into actionable information. 

Military Treatment Facility (MTF) TRICARE Prime enrollees in need of potential clinical 

preventive services, Disease Management, or Case Management are identified on healthcare 

action lists. MHSPHP documentation defines specific data sources and methodologies 

that are based on HEDIS® parameters. Using the MHSPHP, all MTF healthcare teams can 

proactively manage the health status of their patients over the Web.

What is the Military Health System Population Health Portal (MHSPHP)?
Medical Management Guide Version 3.0 Disease Management Page 111

(CM and UM may also use CPGs as part of their 

work flow and patient care processes.)

CPGs are systematically developed, evidencebased, nationally recognized statements to assist 

practitioners and patients in making decisions 

about appropriate healthcare services for specific 

clinical circumstances (Field & Lohr, 1990). Using 

CPGs as a tool is an important strategy in any 

healthcare organization, particularly where there is 

an opportunity to improve the quality of care and 

individual patient quality of life, reduce variation 

in clinical practice, and decrease costs. CPGs 

help standardize DM process­es and may be used 

as a framework for evaluating interven­tions by 

specifying treatment goals and outcome measures 

(i.e., metrics). When successfully implemented, 

CPGs offer the opportunity for improving both 

patient clinical outcomes (by decreasing the rate of 

complications) and financial outcomes (by reducing 

inappropriate utilization of healthcare services). 

In contrast to practices reflecting expert consensus 

or the anecdotal experiences of individual providers, 

evidence-based CPGs are explicitly linked to the 

strength of evidence established after extensive and 

systematic review of all relevant litera­ture. CPGs 

must be: 

• Clinically applicable and flexible.

• Developed through an interdisciplinary process.

• Reviewed on a scheduled basis.

• Based on valid, reliable, and reproducible 

evidence.

• Well documented.

CPGs are frequently displayed as an algorithm — a 

flowchart format providing step-by-step decision 

support and care guidance for a specific disease 

or condition. CPGs are seen by many as a potential 

solution to inefficiency and inappropriate variations 

in the quality of care. However, it is acknowledged 

that the use of guidelines must always be applied 

in conjunction with a provider’s clinical judgment 

for the care of a par­ticular patient. For that reason, 

CPGs may be viewed as an educational tool 

analogous to text­books and journals but presented 

in a more user-friendly for­mat.

The MHS rationale for adopting CPGs is that they 

provide practitioners with a clinical decision-support 

tool for determining appropriate evidence-based 

health care for specific clinical conditions. A welldesigned guideline offers a broad approach to 

sup­porting interdisciplinary, coordinated care for 

patients with a variety of conditions. However, 

providers should be able to deviate from a guideline 

without incur­ring sanctions or jeopardizing coverage 

for services when, in their judgment, the healthcare 

needs or desires of the individual patient indicate 

such a deviation. 

The Joint Commission (TJC, 2009) acknowledges 

that CPGs can “improve the quality, utilization, and 

value of healthcare resources.” The Commission has 

incorporated their use into its standards for 2009, 

which state that leaders in hospitals (LD.4.240 

through LD.4.270) and ambulatory care facilities 

(LD.4.280) will use CPGs to design or improve 

processes that evaluate and treat specific diagnoses, 

conditions, and/or symptoms. 

The 2006 Department of Defense Instruction (DoDI) 

6025.20, Medical Management Programs in the 

Direct Care System (DCS) and Remote Areas (see 

Section I, Medical Management Essentials, 
Page 112 Disease Management Version 3.0 Medical Management Guide

CD-ROM Resource MME-1) describes the 

require­ment for MTFs to identify and select at least 

one clinical process each year for improvement 

through the application of a CPG. Further­more, one 

of the critical initiatives informing Tri-Service business 

planning (see Section I, Medical Management 

Essentials and Section V, Medical Management 

Tools) calls for increasing the use of evidence-based 

health care (EBHC), including the incorporation 

of CPGs, to address clinical quality and outcomes 

for specific diseases and conditions. ( CD-ROM 

Resources DM-1 and DM-2 provide Service-specific 

policy guidance on incorporating CPGs.)

Department of Defense/Department of 

Veterans Affairs Clinical Practice Guidelines

MTFs are encouraged not to create CPGs 

themselves, but rather to adopt or adapt an existing 

CPG, ideally with a rigorous, evidence-review 

foundation. Creating a CPG is a labor- and timeintensive process. CPGs created at the national level 

are developed by well-supported teams of subject 

matter experts (SMEs) who are experienced in the 

evidence review process.

The VA and DoD have partnered since 1998 to 

develop evidence-based CPGs that are pertinent 

to the DoD population’s needs while also free 

from pharmaceutical and industry bias. In effect, 

these CPGs serve to standardize care for specific 

conditions across federal healthcare systems. The 

VA/DoD Evidence-Based Practice Working Group 

develops CPGs for select high-volume, high-cost 

conditions specific to VA and DoD populations. The 

Working Group reports to the Assistant Secretary of 

Defense for Health Affairs (ASD [HA]) and the Under 

Secretary for Health, Veterans Health Administration 

(VHA). The Army Medical Department (AMEDD) has 

assumed the responsibilities as Executive Agent for 

the DoD.

The scientific rigor of the VA/DoD evidence review 

process has been acknowledged by a multitude 

of civilian healthcare organizations that have 

volunteered to collaborate with the two agencies on 

federal CPG development. The rigorous process for 

selecting and developing a VA/DoD CPG is outlined 

below. 

1. Selection — A condition for CPG development is 

selected by the VA/DoD Work Group based on 

relevant high-volume, high-cost conditions. 

2. Development — Reviewing guidelines already in 

exis­tence, a VA/DoD CPG is developed or revised 

based on a current review of research-based 

literature, with a focus on implementing that 

guideline in primary care settings. 

3. Toolkit — Educational materials specific to 

providers and patients are developed and 

packaged in a toolkit to aid in CPG 

imple­mentation. 

4. Dissemination — The CPG is launched to 

MTFs using a variety of modalities, such as 

direct mail, Web-based programming, and site 

assistance visits. 

5. Implementation — MTF facility champions and 

action teams are identified and empowered to 

implement the CPG. 

6. Maintenance — CPGs and toolkits are updated every two to four years based on current 

evidence and feedback from VA and DoD 

facilities. Patient outcomes are monitored at 

the local, Service, and MHS levels to assess 

the impact of CPG implementa­tion on patient 

health. 
Medical Management Guide Version 3.0 Disease Management Page 113

CPG and toolkit development involves bringing 

together VA and DoD SMEs as well as patients, 

providers, and support staff to develop process tools 

that support patients, providers, and the healthcare 

system as a whole. By developing and deploying the 

toolkits centrally, items are standardized throughout 

the MHS and resources are conserved. Resources 

supporting CPG implementation include:

• Patient self-management tools encompassing a 

variety of resources, such as self-care brochures, 

wallet cards, care cards, posters, videos, and 

CD-ROMs.

• Clinical support tools that streamline 

and standardize clinician assessment, 

documentation, and treatment of patients 

(e.g., algorithms, medical education videos, 

posters, exam room cards, and pocket cards).

• System support tools, including AHLTA 

templates, disease registries such as the MHS 

Population Health Portal (MHSPHP), Servicespecific scorecards, and suggested process 

outcome measures (refer to Section V, Medical 

Management Tools). 

CPGs developed by the VA/DoD collaboration are 

displayed in Fig. 28. These CPGs, available supporting 

materials, and ordering information are available at 

the U.S. Army Medical Command (USA MEDCOM) 

Quality Management Office (QMO): https://www.

qmo.amedd.army.mil/ (see also Appendix D, 

Resources). VA/DoD CPGs are frequently under 

development or under­going routine updates, so it is 

important to check the website regularly for the most 

current version. 

• Amputation*

• Asthma* 

• Chronic Heart Failure*

• Chronic Kidney Disease

• Chronic Obstructive Pulmonary Disease 

• Diabetes Mellitus* 

• Disease Prevention

• Dyslipidemia*

• Dysuria

• Gastroesophageal Reflux Disease 

• Hypertension in Primary Care* 

• Ischemic Heart Disease* 

• Low Back Pain* 

• Management of Pregnancy* (formerly 

Uncomplicated Pregnancy)

• Major Depressive Disorder* (includes 

Substance Use Disorder and Suicide 

Prevention)

• Medically Unexplained Symptoms 

(Chronic Pain and Fatigue)* 

• Mild Traumatic Brain Injury (mTBI)

• Obesity* 

• Opioid Therapy for Chronic Pain 

• Post-Deployment Health Evaluation and 

Management* 

• Post Traumatic Stress Disorder (PTSD)* 

• Post-Operative Pain* 

• Psychoses* 

• Stroke Rehabilitation* 

• Substance Use Disorder* 

• Tobacco Use Cessation* 

VA/DoD Clinical Practice Guidelines (CPGs)

*Supporting toolkit available

Fig. 28 – VA/DoD Clinical Practice Guidelines
Page 114 Disease Management Version 3.0 Medical Management Guide

The AMEDD enlisted the assistance of the RAND 

Corporation in developing the best method for 

imple­menting VA/DoD CPGs (Nichols, 2001). That 

collaboration resulted in an implementation guide 

published in 2001, titled Putting Practice Guidelines 

to Work in the Department of Defense Medical 

System: A Guide for Action ( CD-ROM Resource 

DM-3). This document is also available at the Army 

QMO website: https://www.qmo.amedd.army.mil

(see also Appendix D, Resources). 

From its work with RAND, the AMEDD developed 

the current plan for implementing CPGs within 

primary care. That plan, the VA/DoD Manual for 

Facility Clinical Practice Guideline Champions (refer 

to CD-ROM Resource DM-4) includes the 

following steps: 

1. Know the Guideline (CPG)

2. Assess Current MTF Practice Patterns

3. Compare Practice Patterns with CPG 

Recommendations 

4. Identify "Gaps" in MTF Practice Patterns 

5. Develop an "Action Plan" to Close the Gaps 

6. Implement the Plan 

7. Develop a System to Monitor Practice Change

National Guideline ClearinghouseTM – http://

www.guideline.gov/

The National Guideline Clearinghouse (NGC) is 

a joint effort among the AHRQ, the American 

Medical Association (AMA), and AHIP. The NGC 

is a comprehensive database of evidence-based 

CPGs and related documents. The NGC website 

provides an easily accessible mechanism for 

obtaining objective, detailed information on CPGs 

and furthering their dissemination, implementation, 

and use. A template of attributes is completed for 

each guideline included in the NGC; and the NCG 

verifies the currency of all guidelines represented 

in the database. The NGC website allows users to 

view more than 2,000 guidelines by clinical specialty, 

disease/condition, target population, treatment/

intervention, or issuing organization. The website 

also features comprehensive structured summaries, 

full-text guidelines, guideline syntheses, guideline 

comparisons, and PDA downloads.

U. S. Preventive Services Task Force – http://

odphp.osophs.dhhs.gov/pubs/guidecps/uspstf.

htm 

The U. S. Preventive Services Task Force (USPSTF) 

is an independent panel of primary care and 

prevention experts who systematically review 

current evidence for effectiveness and develop 

recommendations for clinical preventive services. 

USPSTF recommendations, while not technically 

CPGs, are firmly based in evidence and deserve 

mention because of their common use and 

acceptance. USPSTF recommendations and their 

evidence reviews are routinely used by the TMA 

as the basis for determining TRICARE benefits. 

The USPSTF aims to:

• Create age-, gender-, and risk-based 

recommendations regarding services that should 

be a routine part of primary care.

• Evaluate the benefits of individual services.

• Identify a research agenda for clinical preventive 

care. 

 The USPSTF has provided recommendations for 

preventive interventions related to screening, 
Medical Management Guide Version 3.0 Disease Management Page 115

nutritionists, physical therapists; and dental, health 

promotion, health benefits, and laboratory staff. 

Deployment health services, health promotion, and 

medical counterparts in the field should also be 

considered as potential partners. Other military and 

civilian resources include organizations such as family 

support services, local health departments, and local 

fitness centers. To maximize the use of resources 

and increase efficiencies, it may be advantageous to 

collaborate with MCSCs, the Multi-Service Market 

Office (MSMO), and the TRICARE Regional Office 

(TRO) (see Appendix D, Resources). 

counseling, immu­nizations, and chemoprophylactic 

treatments for more than 80 conditions and 

disorders, including in the following areas: 

1. Cancer (oncology)

2. Cardiovascular

3. Infectious disease

4. Injury and violence

5. Mental health and substance abuse

6. Metabolics, nutrition, and endocrinology 

7. Musculoskeletal 

8. Obstetrics and gynecology 

9. Pediatrics

10. Vision and hearing 

Clinical protocols and pathways are tools that 

delineate the optimal sequencing and timing of 

interventions by providers for a particular diagnosis 

or procedure. They are designed to minimize delays 

and resource utilization and maximize the quality 

of care. (Refer also to Appendix C, Definitions.) 

They often have a role in the clinical setting, in 

both the inpatient and outpatient arenas. Although 

they may be evidence-based, these protocols are 

distinguishable from CPGs in that they do not have 

the full complement of support resources. They are 

adjunct tools that may be leveraged by healthcare 

teams to streamline patient care processes.

3. Collaborative Practice Models

The MHS has a wide variety of practice models 

in place. The most effective are those that foster 

collaboration and communication among healthcare 

team members, including providers, support/ancillary 

staff, and Command leadership, as well as patients 

and their families. Examples of ancillary staff who 

may be involved in patient care include pharmacists, 

T

he United States are divided into 

three TRICARE regions. Each of 

the regions has a regional civilian 

care partner, the Managed Care Support 

Contractor (MCSC), who helps administer 

the TRICARE benefit plan. The MCSC works 

with the TRICARE Regional Offices 

(TROs) to manage the benefit at the local 

level and receives overall guidance from 

TRICARE Management Activity (TMA) 

headquarters.

A Multi-Service Market Office (MSMO) is 

a TRICARE area with more than one Service 

with a Military Treatment Facility (MTF). A 

designated MTF Commander is appointed 

to serve as Senior Market Manager for 

each MSMO. This role is responsible for 

developing a single, consolidated, integrated 

business plan for the Direct Care System 

(DCS) and Purchased Care System (PCS) for 

all services located within the MSMO. There 

are currently 12 MSMOs.
Page 116 Disease Management Version 3.0 Medical Management Guide

The most effective processes have been 

demonstrated in teams whose members exercise 

joint accountability. This means that qualified 

staff are expected to be involved in direct care 

activities and patient/family education, and in 

adding patient information to the medical record 

and correcting such information. Commanders 

assist team members by clarifying expectations, 

prioritizing responsibilities, and allocating resources 

to provide care. Providers should strive to know the 

healthcare needs of their entire panel, document 

their interventions accurately in AHLTA, and provide 

leadership in the clinical arena.

In addition to providing patient care and education, 

providers, nurses, and support staff within the clinic 

should critically evaluate their program and take 

action, as necessary, to improve clinical processes. 

These stakeholders should be involved not only in 

direct care activities but also in MTF outreach and 

marketing activities to promote patient education 

and awareness. 

Open and ongoing communication among team 

members enhances the effectiveness of team 

activities and allows all members to be involved 

in patient care to the fullest extent possible. 

Communicating with patients and families clearly 

and consistently serves to strengthen the patienthealthcare team relationship and to maximize patient 

safety. Communication patterns must be clear — not 

only in the clinic, but also during patient transitions 

to other clinics, facilities, healthcare services, or the 

inpatient setting. 

Clinic reengineering to facilitate patient flow and 

patient care activities is integral to the success 

of collaborative practice models. Strategies to 

streamline patient care and improve communication 

among healthcare team members can include 

utilizing group visits, promoting standard order sets, 

and implementing nurse-run clinics.

4. Patient Self-Management Education 

Self-management (also referred to as self-care) is a 

broad term describing interventions targeted toward 

patients with a chronic disease and condition and 

their families. The goal of self-management is to help 

patients with chronic disease(s) learn to incorporate 

the skills to lead an active and satisfying life (Loring, 

1993). DM programs empower patients with 

information and self-management plans to enable 

them to participate directly in decisions related to 

their own health care. Because individual patients 

live within a context that includes their families 

and/or their immediate environment, selfmanagement includes the family as an integral 

participant in the patient’s education and skillbuilding process.

The good physician 

treats the disease; 

the great physician 

treats the patient 

who has the 

disease.

Sir William Osler
Medical Management Guide Version 3.0 Disease Management Page 117

Self-management may include:

• Health promotion activities (e.g., tobacco 

cessation) and clinical preventive services (e.g., 

cancer screenings) as recommended by the 

USPSTF.

• Behavior modification, where indicated, to 

reduce chronic disease complications (e.g., 

dietary monitoring for patients with diabetes 

or obesity). Examples of specific programs 

targeting behavior modification include healthy 

eating and menu planning and exercises for 

managing blood glucose. 

• Compliance monitoring (e.g., review of 

hypertension daily blood pressure logs). 

The benefits of patient self-management are many 

and include reduced hospital admissions, reduced 

demand for clinical services, improved clinician and 

patient satisfaction, improved health outcomes 

and standard of living, and improved medication 

adherence. Clinical outcomes for diseases such as 

depression, asthma, hypertension, and diabetes only 

improve when patients are involved in their own 

care (Weingarten, 2002). 

While patient education may teach diseasespecific information and skills, self-management 

education implies that the patient not only learns 

the information but also acquires the skills to 

better manage his/her health. It includes exposing 

patients to problem-solving skills that will help them 

handle issues that affect their lifestyle, regardless 

of whether or not those issues are directly related 

to their condition or disease. Whereas the goal 

of general patient education is compliance with 

treatment regimes, the goal of self-management 

education is to increase a patient’s confidence 

in the ability to manage his/her own health.

The underlying assumption in patient education is 

that knowledge will create a change in behavior, 

possibly because it is demanded by the educator. 

In contrast, self-management education empowers 

the patient to achieve a change based on a strategy 

that combines knowledge and his/her own self-care 

skills. A patient’s health is more likely to improve 

when the patient is confident of his/her ability to 

adapt to change. 

To support patients in managing their lifestyle 

choices to better adapt to living with a condition or 

disease, the healthcare professional needs to assess 

a patient’s self-management knowledge, behaviors, 

abilities, confidence, and barriers. Armed with 

this assessment, the healthcare professional can 

provide behavior change information and ongoing 

support. This allows the patient to understand the 

effect of personal behavior on his/her own health, 

enabling that patient to develop strategies for health 

improvement to meet his/her lifestyle expectations. 

According to the Institute for Healthcare 

Improvement (2008), typical failures found in 

patient/family self-management education include:

• Assumptions that the patient is the key learner.

• Confusion regarding self-care instructions, 

particularly medication use.

• Non-compliance, resulting in repeat clinic visits 

or hospitalizations. 

When developing, selecting, and providing specific 

patient self-management education, it is critical that 

education efforts target both the patient and his/her 

family. Challenges in working toward patient selfmanagement include low patient education level, 

language barriers, cultural barriers, low 

socio-economic status, and lack of family support. 
Page 118 Disease Management Version 3.0 Medical Management Guide

Each of these should be considered when planning 

care with patients. 

Education materials should reflect an appropriate 

level of understanding for the patient/family and be 

presented in their preferred modality and learning 

style. Education strategies include:

• Individual and group classes on wellness or on 

specific diseases or chronic conditions.

• Patient-friendly written handouts.

• Audio and video libraries.

• Disease-specific telephone information centers.

• Telephone prompts for screening or healthcare 

needs.

CD-ROM Resource DM-5 shows the WISE 

Disease Self-Care Model, which was developed by 

the HealthSciences Institute (HSI) as a framework for 

patient self-management.

5. Process and Outcome Measurement, 

Evaluation, and Management

The critical evaluation of current programs and 

processes is an important element of both MM and 

Population Health. This evaluation can be applied 

to all clinical departments within MTFs as disease 

managers assess the health of the population, the 

impact of clinical practices on care rendered, and 

the quality and cost effectiveness of the delivery 

system. 

Quality of care can be measured by any number of 

means, including:

• Inpatient admission rates.

• Emergency Department (ED) utilization.

• Surgical outcomes.

• Immunization rates.

• Patient satisfaction.

• Compliance with preventive health assessments.

• Provision of recommended clinical preventive 

services.

Process and outcome measures allow the disease 

manager to understand how the DM program 

is performing and to evaluate the impact of 

implemented actions on patient health.

• Process measures evaluate specific aspects of 

the healthcare delivery practice, such as the 

percentage of patients with diabetes with an 

A1c test completed in the past 12 months or the 

percentage of patients with asthma who are on 

long-term controller medication.

• Outcome measures assess the results of 

a specific test or how many patients are 

experiencing a particular outcome (e.g., the 

number of patients with diabetes who had an 

LDL level less than 100 mg/dl). 

Clinical outcome measurements, such as process 

or outcome measures help gauge the progress 

of a DM program by improving specific aspects 

of healthcare quality in the MTF. They are 

especially useful in determining the effectiveness 

of a new program or of a specific aspect of 

that program. Tracking outcomes within an 

organization provides a basis for modifying 

processes to improve future outcomes and offers 

a mechanism for identifying barriers to desired 

outcomes.

Disease managers should use standard, nationally 

recognized measures to enable goal-setting and 

benchmarking — the review of processes, services, 

and clinical practices to compare performance 

and gauge whether and where clinical processes 
Medical Management Guide Version 3.0 Disease Management Page 119

may need to be improved (see also Appendix C, 

Definitions). Benchmarking enables the following 

comparisons:

• Among clinics/MTFs/services throughout an 

organization.

• Between the MHS and its civilian counterparts.

• Against individual DM programs over time.

These comparisons often allow for ready 

identification or adoption of best practices which 

may prompt the re-engineering of clinical processes 

to ultimately improve the health of a population.

Tools to readily collect healthcare information for 

specific diseases or preventive services include 

the MHSPHP, M2, AHLTA, and Clinical Data Mart, 

as well as Service-specific sites (see Section V, 

Medical Management Tools).

Clinical Quality Measures 

A longstanding approach within the MHS has 

been to leverage nationally recognized measures 

to make comparisons to civilian benchmarks and 

organizations. Numerous civilian organizations and 

governmental agencies have developed measures 

of clinical quality and business efficacy. These 

organizations include the CDC, TJC, National 

Committee for Quality Assurance (NCQA), and 

Agency for Healthcare Research and Quality 

(AHRQ). 

The requirements for centralized MM measures 

are developed through the MHS Clinical Measures 

Steering Panel, which includes representatives from 

the Services, MCSCs, and TMA.

Healthcare Effectiveness Data and Information 

Set (HEDIS®) —http://www.ncqa.org/Portals/0/

HEDISQM/HEDIS2009/2009_Measures.pdf

HEDIS® is sponsored by the NCQA. As the most 

widely utilized set of measures of clinical quality 

in health care, HEDIS® is used by more than 90 

percent of managed care organizations throughout 

the United States. Using very explicit methodology 

(including age/gender/enrollment restrictions and 

inclusion/exclusion criteria), this set of standardized 

measures specifies how health plans collect and 

report data on quality of care. HEDIS® measures 

are frequently utilized by organizations to create a 

“report card” on the quality of services and care 

provided by healthcare plans. These measures do 

not necessarily reflect the standard of care; rather, 

they serve to provide objective comparisons across 

organizations. 

The HEDIS® measures assess various dimensions 

of care and services and are organized in eight 

different domains encompassing more than 70 

different measures (refer to Fig. 29). 

The category the MHS leverages most to report on 

the quality of care delivered to DoD beneficiaries is 

the Effectiveness of Care (EOC) dataset. Measures 

of interest to the MHS, including cancer screening, 

comprehensive diabetes care, and asthma 

management, have been incorporated into the 

quality and business plans of all three Services and 

MCSCs. For a list of HEDIS® EOC topics, 

refer to Fig. 30.
Page 120 Disease Management Version 3.0 Medical Management Guide

ORYX — http://www.jointcommission.org/

AccreditationPrograms/Hospitals/ORYX/facts_oryx.

htm

ORYX is a set of objective measures to assess 

the clinical quality provided by inpatient facilities. 

Implementation of ORYX is a requirement for 

hospital accreditation with TJC. Under MHS Clinical 

Quality Management (CQM — https://www.mhscqm.info/), ORYX data are abstracted from medical 

records in all bedded (inpatient) MTFs. MTFs must 

choose a combination of applicable core and noncore measure sets. *The USAF may not exclusively 

use TJC for MTF accreditation, but ORYX data are 

still collected and reported.

Core measure sets generally reflect inpatient 

processes and outcomes, and include the following:

• Acute myocardial infarction

• Heart failure

• Pneumonia

• Pregnancy and related conditions

Fig. 30 – HEDIS® Effectiveness of Care Measure Topics

• ADHD

• Asthma

• Cancer Screening

• Chlamydia Screening

• Cholesterol Management 

• COPD

• Diabetes

• Geriatrics

• Glaucoma Screening 

• Hypertension

• Immunizations

• Lead Screening 

• Low Back Pain 

• Medication Management

• Mental Illness 

• Myocardial Infarction

• Osteoporosis 

• Rheumatoid Arthritis

• Smoking Cessation

• Upper Respiratory Infections

• Urinary Incontinence 

• Weight/Activity Assessments 

List of HEDIS® Effectiveness of 

Care Measure Topics

Source: http://www.ncqa.org/Portals/0/

HEDISQM/HEDIS2009/2009_Measures.pdf

• Effectiveness of Care

• Access/Availability of Care

• Satisfaction with the Experience of Care

• Use of Services

• Cost of Care

• Health Plan Descriptive Information

• Health Plan Stability

• Informed Health Care Choices

Source: http://www.ncqa.org/Portals/0/HEDISQM/

HEDIS2009/2009_Measures.pdf

HEDIS® Domains of Care

Fig. 29 – HEDIS® Domains of Care
Medical Management Guide Version 3.0 Disease Management Page 121

• Hospital-based inpatient psychiatric services 

(DoD does not report this data to TJC)

• Children's asthma care

• Surgical Care Improvement Project (SCIP)

• Hospital outpatient measures

Non-core measures are generally ambulatory 

care measures and include diabetes, asthma, and 

hypertension. For more information, visit the MHS 

CQM website or contact a local QM representative.

The MHS publishes MTF performance data for 

HEDIS® and ORYX measures on publically available 

portals, including the Hospital Compare and MHS 

CQM websites.

Healthy People 2010 (HP 2010) — http://www.

healthypeople.gov/

The Healthy People 2010 measure set was 

developed by the CDC to serve as a road map 

for improving the health of all people in the 

United States. HP 2010 consists of 28 focus areas 

containing 467 objectives with measures to assess 

the health of American communities. A limited 

set of 10 objectives, the Leading Health Indicators 

(Fig. 31), reflects the major health concerns in the 

United States for the beginning of the 21st century. 

Indicators were selected based on their ability to 

motivate action and their importance as public 

health issues, and on the availability of data to 

measure progress. 

HP 2010 provides measure definitions and current 

baseline data with epidemiologic stratifications, 

along with desired targets. The HP 2010 website 

provides additional resources and helpful strategies 

for implementing programs to meet the HP 2010 

goals. Every 10 years, the Department of Health 

and Human Services (HHS) revises this document 

to account for major risks to health and wellness, 

evolving public health priorities, and emerging 

technologies related to our nation's health 

preparedness and prevention. Healthy People 

2020 is anticipated to be published in early 2010. 

Additional information is available at the CDC 

website at http://www.cdc.gov/.

The MHS has recently focused on the 10 Leading 

Health Indicators identified by HP 2010 (Fig. 32), 

with an emphasis on tobacco use, alcohol abuse, 

• Physical Activity 

• Overweight and Obesity 

• Tobacco Use 

• Substance Abuse 

• Responsible Sexual Behavior 

• Mental Health 

• Injury and Violence 

• Environmental Quality 

• Immunization 

• Access to Health Care

Healthy People 2010 Leading

Health Indicators

Fig. 31 – Healthy People 2010 (HP 2010) 

Leading Health Indicators 
Page 122 Disease Management Version 3.0 Medical Management Guide

and overweight/obesity. Some of these indicators 

have been integrated into corporate and strategic 

documents, including the MHS Values Dashboard. 

National Quality Measures Clearinghouse (NQMC)TM 

— http://www.qualitymeasures.ahrq.gov/

The NQMC, which is sponsored by the AHRQ, is a 

public archive for evidence-based quality measures 

and measure sets. It was developed to promote 

widespread access to quality measures by the 

healthcare community (NQMC, 2009). The NQMC 

website allows users to view measures by disease/

condition, treatment/intervention, domain, or issuing 

organization. Users can also explore measures 

endorsed by the National Quality Forum (NQF) or 

those associated with related guidelines, housed on 

the National Guidelines ClearinghouseTM website 

(refer to DM Component 2, Evidence-Based Clinical 

Practice Guidelines). Other features of the NQMC 

website include measure summaries, tutorials, expert 

commentary, measure comparisons, and resources to 

correctly assess and apply quality measures.

Other measure sets are available for diseasespecific conditions. Various consortia have created a 

nationally-recognized set of measures for assessing 

DM programs. These consortia include the National 

Diabetes Quality Improvement Alliance (DQIA) and 

the American College of Cardiology (ACC)/American 

Heart Association (AHA) Task Force on Performance 

Measures, which have addressed various cardiac 

conditions. Since these measure sets are the product 

of collaborative efforts, they are generally endorsed 

and supported by agencies such as the AHRQ, TJC, 

NQF, and other physician-based organizations.

Fig. 32 – MHS CQM Fact Sheets

• Asthma Care 

• Birth Trauma

• Breast Cancer Screening 

• Cervical Cancer Screening 

• Childhood/Adolescent Immunizations

• Chiropractic Health Care Services

• Chlamydia Screening 

• Clinical Practice Guidelines Use

• Depression 

• Depressive Disorder 

• Diabetes Mellitus Care 

• Dyslipidemia 

• Healthcare Acquired Infections

• Heart Failure

• Hypertension (also Pre-hypertension and 

Blood Pressure Measurement)

• Ischemic Heart Disease 

• Obesity 

• Prenatal Access to Care

• Post Deployment Health Care

• Postpartum Depression

• Post-Traumatic Stress Disorder

• Tobacco Use Cessation 

MHS CQM Fact Sheets 

For access to all NQMP Fact Sheets, please go to: https://www.mhs-cqm.info/Open/Education/Factsheets.aspx
Medical Management Guide Version 3.0 Disease Management Page 123

Stakeholder Reporting

Reporting outcome measures serves to inform 

MHS stakeholders of the progress of DM activities 

on improving the health of the population. 

Reporting should be performed on a periodic 

interval determined by the DM and MTF leadership. 

It should include communication with patients, 

healthcare providers, ancillary and interdisciplinary 

support staff, and Command leadership to facilitate 

prioritization of resources and planning for future 

DM efforts. Reporting of individual provider or 

clinic outcomes to the healthcare team encourages 

ownership and refinement of care delivery practices. 

MTF-specific data and performance on HEDIS®

measures for many outpatient diseases and 

preventive screenings are available on the MHSPHP. 

Disease registries, AHLTA, and the Clinical Data Mart 

are other tools that can be leveraged to generate 

clinical data (see Section V, Medical Management 

Tools). 

Every year, MHS CQM performs special studies 

to critically eval­uate clinical outcomes to assess 

the quality of care rendered in the MHS. CQM 

summarizes these special studies in fact sheets 

and provides educational opportunities for MHS 

staff. Fig. 32 provides a list of fact sheet topics 

published since 2001.

MM may use other Service-level, corporate, and 

strategic measures, as well as national benchmark 

measures, but the aforementioned measures 

highlight the MHS’ current priorities (see also 

Section I, Medical Management Essentials, 

Medical Management Goals and Approach).

6. Feedback and Reporting

The complete outcomes management process 

requires not only defining data requirements 

and obtaining outcomes, but analyzing data and 

reporting results. Without obtaining feedback 

on the effectiveness of the current program and 

processes, it is difficult to appreciate the need for 

change. Program assessments and subsequent 

modifications allow for effective process 

improvement using the Plan-Do-Check-Act 

(PDCA) cycle (Fig. 33).

While some MM staff may not possess the skill sets 

or expertise to obtain and analyze appropriate data, 

they should communicate and collaborate with MTF 

personnel experienced in those areas to acquire the 

information they need. 

Fig. 33 – The PDCA Cycle
Page 124 Disease Management Version 3.0 Medical Management Guide

The MHS and Services display Aggregate

performance data on MHS and Service-specific

websites (some are CAC-enabled or

password-protected), including:

• MHS — CQM: https://www.mhs-cqm.info/

• Army — Command Management System (CMS): 

https://cms.mods.army.mil/cms

• Air Force — Surgeon General’s Executive Global 

Look (EGL): https://egl.afms.mil

• Navy — Population Health Navigator Dashboard: 

http://www-nehc.med.navy.mil/Data_Statistics/

Clinical_Epidemiology/pophealthnav.aspx

(restricted access, CAC card required)

See also Section V, Medical Management Tools.

MTF leadership and the DM team should refer to 

their DM plan on an ongoing basis to determine 

whether their goals have been attained and to 

identify opportunities for process improvement.

ESTABLISHING A DISEASE MANAGEMENT 

PROGRAM

I

n the MHS, the DM program directly supports the 

strategic priority of promoting patient choice and 

accountability, building healthy communities, and 

demonstrating the MHS’ commitment to safety and 

quality outcomes. To build an effective DM program 

in the MTF, a disease manager must be cognizant 

of the six components of DM as identified earlier 

in this chapter. Healthcare team members involved 

in planning a DM program must consider certain 

questions to provide direction for their MTFs (see 

Fig. 34). 

Implementing a Disease Management Plan

Once the DM program components are analyzed 

and aligned to meet the needs of the MTF’s 

population and Service-specific mission, the disease 

• What are the MTF’s population demographics?

• Which risk factors are most prevalent in your population? Which subpopulations require clinical 

preventive services?

• What are the disease burdens/chronic conditions of the population served?

• Which MTF resources are currently available?

• Which disease or conditions should the MTF focus on? Could a CPG be adapted/applied as a tool for 

better management?

Questions to Ask During Development of a DM Program

Fig. 34 – Questions to Ask During Development of a DM Program
Medical Management Guide Version 3.0 Disease Management Page 125

manager is ready to focus on implementing a 

specific plan. An eight-phase approach provides 

a systematic construct to help stakeholders 

become comfortable with the processes of plan 

implementation. Fig. 35 summarizes the phases 

involved in setting up a DM plan.

Let’s break each phase down to get a more precise 

appreciation of what the disease manager should 

do at each level:

1. Assess the Target Population

For example, consider a chronic disease such as 

diabetes mellitus: How many patients are enrolled 

and to which providers are they assigned? The 

disease manager may further risk-stratify the 

population to examine glycemic control, overdue 

lab tests, and associated co-morbidities.

2. Assemble a Team

This phase allows the disease manager to present 

the clinical data identified in Phase 1 to the 

healthcare team that will be man­aging the diseases/

conditions. Collaboration and communication are 

crucial in identifying the best way to assist a patient/

group of patients in adhering to the treatment 

plan(s) and in taking more control and responsibility 

for their own health care. Phase 2 teams should be 

interdisciplinary, including providers, nursing staff, 

MM, and ancillary support personnel (see Fig. 36).

Fig. 35 – The Phases of Implementing a Disease Management Plan

ASSEMBLE

Assemble a 

Team

ADOPT

Adopt

Guidelines and

Protocols

ESTABLISH

Establish Goals

and Target

Outcomes

IMPLEMENT

Implement

the Plan

CREATE

Create a 

Prioritized

Plan

ANALYZE

Collect and Analyze

Outcomes

Data

EVALUATE

Evaluate

and Refine

the Program

ASSESS

Assess

the Target

Population
Page 126 Disease Management Version 3.0 Medical Management Guide

communicating the processes to all participants. 

The steps taken in developing and/or choosing an 

appropriate CPG should be documented in Servicespecific executive/leadership functional minutes, 

Population Health committee minutes, or MTF policy. 

4. Establish Goals and Target Outcomes

In establishing goals and targets, it may be helpful 

to look at prior performance, MTF trends, Command 

expectations and available resources. Targets should 

mirror the common project management approach 

SMART — that is, be specific, measureable, 

achievable, realistic, and time-bound. The disease 

manager, in collaboration with the interdisciplinary 

healthcare team, may develop a timeline for 

monitoring the status of the population selected 

by the team. For example, a desirable goal may 

begin with notifying patients overdue for diabetic 

hemoglobin A1C testing and encouraging them to 

complete laboratory tests within 60 days of DM plan 

implementation. 

Based on contractual agree­ments, the MTF may 

also collaborate with the local MCSC in providing 

a seamless program between the DCS and PCS. 

Implementation must be a healthcare team effort 

that incorporates all available resources to avoid 

“reinventing the wheel.”

3. Adopt Guidelines and Protocols

The healthcare team may decide to implement a 

disease-specific guideline and adapt it to facilitate 

local policies, business plan initiatives, or Command 

directives. Prior to implementing a CPG, team 

members will need education and training in the 

application of the algorithm(s) and toolkits. This will 

most likely involve reengi­neering MTF processes to 

mobilize the entire healthcare team. Roles will need 

to be assigned so that all personnel understand their 

role(s) in the process (e.g., appointing a provider 

champion). Other methods — such as the use of 

flow charts, lists, and the PDCA cycle (refer to Fig. 

33) — can help in designing, tracking, and 

Fig. 36 – Example of an Interdisciplinary Healthcare Team

• Providers (physicians, physician assistants, 

nurse practitioners)

• Registered Nurses (RNs)

• Health educators

• Technicians, medics, medical assistants/clerks

• Utilization management (UM) and Case

Management (CM) staff

• Any ancillary and allied healthcare staff 

who participate in managing the targeted 

disease/condition (e.g., pharmacists, 

nutritionists, dental hygienists/dentists)

• Command leadership

• Information management/technology

specialists

Example of an Interdisciplinary Healthcare Team
Medical Management Guide Version 3.0 Disease Management Page 127

steps and follow-on goals. Benchmarking against 

internal and external outcomes (e.g., applying 

HEDIS® measures) is a good method for tracking 

performance and progress. 

Accreditation

Organizations such as URAC, the NCQA, and TJC 

provide accreditation to DM programs. Other 

disease-specific organizations, such as the American 

Diabetes Association (ADA), provide certifications 

that recognize outstanding educational programs 

based on nation­al standards. (Based on the NDAA 

2007, it is the MHS’ policy to promote meeting 

the standards for program accreditation but not 

necessarily for programs to become accredited. 

The topic is included here to increase awareness of 

accreditation possibilities.)

URAC has established accreditation standards for 

DM programs. According to URAC, DM standards 

promote evidence-based practice, collaborative 

relationships with providers, consumer education, 

and shared decision-making with consumers. These 

standards apply to all types of entities providing 

services for individuals with chronic illnesses, 

including health plans and freestanding 

DM or MM organizations.

The URAC accreditation process occurs in four 

phases:

1. Application

2. Desktop Review

3. On-site Review

4. Commit­tee Review 

5. Create a Prioritized Plan 

6. Implement the Plan

In these two phases, the disease manager focuses 

on selected patient groups previously identified by 

the healthcare team and helps the team determine 

the decisions and tasks that need to occur and the 

order in which they should be executed. Individual 

and family education is just one type of intervention 

a disease manager can use to promote patient selfmanagement in an effort to minimize complications 

and avoid unnecessary and inefficient healthcare 

utilization. Other strategies are to send reminder 

postcards or use automated telephone messaging 

systems to notify patients of the need for healthcare 

visits, medication changes, or recommended 

behavior changes. These techniques offer a simple 

yet effective way to collaborate with patients in 

reaching their desired treatment goals. 

7. Collect and Analyze Outcomes Data

This phase should be accomplished at regular 

intervals to track progress. The disease manager 

is encouraged to liaison with other members of 

his/her Command (e.g., business office, quality 

management, IT) to determine whether this data 

collection is already occurring at the MTF, or to 

leverage existing resources or expertise.

8. Evaluate and Refine the Program

During this phase, the disease manager may identify 

barriers that are preventing the MTF from reaching 

its goals and determine the necessity of developing 

a plan to remove those barriers. It is critical that 

the MTF perform annual reviews to determine next 
Page 128 Disease Management Version 3.0 Medical Management Guide

The NCQA offers program accreditation options to 

include various patient- and practitioner-oriented 

programs. The NCQA’s DM standards address key 

areas for which organizations are reviewed. The 

standards are based on patient service, practitioner 

service, program content, clinical systems, 

measurement and quality improvement, and 

program operations.

TJC certifies DM programs as a complemen­tary 

process to MTF accreditation. TJC’s Disease-Specific 

Care (DSC) Certification Program is designed to 

evaluate DM and chronic care services that are 

provided by health plans, DM service companies, 

hospitals, and other care delivery settings. The evaluation and resulting certification decision is based 

on an assessment of the following: 

• An organized approach to performance 

measure­ment and improvement activities.

• Compliance with consensus-based national 

stan­dards.

• Effective use of evidence-based CPGs to 

manage and optimize care.

For organizations, TJC accreditation is available for 

virtually any chronic disease or condition. Advanced 

accreditation is available for chronic kidney disease, 

inpatient diabetes, primary stroke centers, and other 

specialized disease states/procedures.

THE DISEASE MANAGEMENT 

PROFESSIONAL

Qualifications

T

he job description of the DM profes­sional 

will vary depending on the size of the 

MTF and the availability of resources. 

DM professionals should possess sufficient 

clinical knowledge and patient care experience 

to identify appropriate use of and compliance 

with CPGs, as well as conduct and/or arrange 

patient care. The DM professional also needs 

excellent communication skills, as he/she works 

in collaboration with a range of healthcare 

personnel to promote delivery of appropriate, 

cost-effective care to patient populations.

Typically, a candidate for the disease manager role 

can best succeed with the following qualifications 

or commensurate experience: 

• A bachelor’s degree (or higher) in a healthrelated field from an accredited institution. 

• A valid unrestricted healthcare license.

• Current basic life support (BLS) certification. 

• Experience with software and databases 

currently employed at the MTF. 

• Strong communication and organizational skills.

Desirable qualifications include: 

• Certification by the HealthSciences Institute 

(HSI) through its Chronic Care Professional (CCP) 

certification program or another disease-specific, 

patient-education certifying institution (e.g., 

American Diabetes Association [ADA]). (See 

Certification, next page.)
Medical Management Guide Version 3.0 Disease Management Page 129

• Familiarity with evidence-based CPGs and 

USPSTF recommendations.

• Familiarity with clinical quality measures (e.g., 

HEDIS®, ORYX).

• Three years of broad-based clinical healthcare 

experience. 

• Full-time employment in a healthcare role for 

the previous 12 months. 

• Previous DM experience.

The disease burden of the MTF’s enrolled 

population will determine the size and specificity 

of any DM program. CD-ROM Resource Item 

DM-6 provides a list of sample contract tasks for a 

DM nurse, which could be adapted to either a 

state­ment of work or another type of job 

description. CD-ROM Resources DM-7, 

DM-8, and DM-9 provide sample Service-specific 

DM position descriptions.

It should be noted that, depending on the particular 

Service or MTF, DM responsibilities or oversight 

may be included as part of roles such as Clinical 

Staff Nurse, Physician, or Health Care Integrator 

(HCI) — an Air Force-specific position ( CD-ROM 

Resource DM-10 provides a description of the HCI 

role).

Certification

The HSI has offered a CCP certification program 

since 2004. In October 2007, the DMAA partnered 

with the HSI and endorsed the program, which 

encompasses 25 chronic diseases and late-life 

conditions. The program promotes an evidencebased approach to leveraging Population Health 

strategies, DM practices, and health coaching.

CCP certification is valid for three years. Recertification 

through re-examination or documentation of 15 hours 

of continuing DM or chronic care education may be 

obtained. Additionally, organizations that require 

CCP for their professional staff may include the CCP 

seal on their promotional materials, proposals, and 

website documentation to demonstrate to patients 

and customers that their staff have completed 

specialized training and passed a national examination 

(i.e., to show the organization is CCP-accredited).

SUMMARY 

Closely linked to Population Health, DM 

focuses on fostering consistent, evidencebased care for beneficiaries with one or 

more chronic diseases or conditions. While the role 

of DM may have been underappreciated in the past, 

expanded IT capabilities and a renewed appreciation 

for the impact of chronic disease on the individual and 

the healthcare system have served to highlight the 

proactive role DM plays in improving the future health 

of defined populations. 

To promote program goals and reduce duplication 

of efforts, DM must be accomplished in con­cert with 

both UM and CM staff and the entire healthcare 

team. Strategies for implementing DM should 

incorporate other policies and program documents, 

such as the 2006 Department of Defense Instruction 

(DoDI) 6025.20, Medical Management Programs in 

the Direct Care System (DCS) and Remote Areas (see 

Section I, Medical Management Essentials,

CD-ROM Resource MME-1), and the current 

edition of the DoD Population Health Improvement 

Plan and Guide (see Executive Summary, 

CD-ROM Resource ES-1). 
Page 130 Disease Management Version 3.0 Medical Management Guide

DM-8 Navy Disease Management Position 

 Description – Sample

DM-9 Air Force Disease Management Position 

 Description – Sample

DM-10 Healthcare Integrator Job Description – Air 

 Force

DM-11* Disease Management Road Map 

 – Narrative Overview

DM-12* Disease Management Road Map 

 – Assessment Form

DM-13* Disease Management Road Map – Action 

 Plan (Blank)

*Not referenced in text

CD-ROM RESOURCES

DM-1 DM Policy Guidance – Navy

DM-2 DM Policy Guidance – Air Force

DM-3 Putting Practice Guidelines to Work in the 

 Department of Defense Medical System: A 

 Guide for Action – RAND

DM-4 VA/DoD Manual for Facility Clinical Practice 

 Guideline Champions

DM-5 WISE Self-Care Model – HealthSciences 

 Institute

DM-6 Sample Contract Tasks for the Disease 

 Management Nurse

DM-7 Army Disease Management Position 

 Description – Sample

‘


Medical Management Guide Version 3.0 Medical Management Tools Page 133

Medical Management Tools V

SECTION

INTRODUCTION

T

his section focuses on tools and resources 

for successful Medical Management 

(MM) programs. It complements the 2001 

Population Health Improvement Plan and Guide, 

Section IV, p. 67, Analyze Performance and Health 

Status (see Executive Summary, CD-ROM 

Resource ES-1). 

As discussed in Section I, Medical Management 

Essentials and throughout this Guide, the MHS 

emphasizes enhanced collaboration between clinical 

and business practices within Military Treatment 

Facilities (MTFs), since much of the same data are 

used to derive both clinical and business plans. 

Specifically, the priorities and measures (i.e., metrics) 

set for the local MM plan may directly affect the 

assumptions and data for the local business plan, 

and vice versa. 

The tools described in this section are meant to help 

support this collaborative approach to MM. 

USING INFORMATION SYSTEMS AND DATA 

MARTS

Accessing the Data

Many of the tools described here require 

passwords and/or are only accessible 

at “.mil” domains. Health Insurance 

Portability and Accountability Act (HIPAA) standards 

require security training and justification for system 

access. Some tools presented here advise the user 

of “*Restricted access.” In such cases, please follow 

up with your supervisor or department head for 

more information on accessing and utilizing these 

tools. 

Note that some Web links may take you to a page 

warning you of a problem with the website’s 

security certificate. This is a standard message 

prior to accessing sensitive websites that may have 

restricted access. To access the site when this occurs, 

click on the red shield icon with the X and proceed.

Also note that some tools are presented without 

Web hyperlinks, as website addresses are often 

updated or rendered inactive due to domain name 

changes. 
Page 134 Medical Management Tools Version 3.0 Medical Management Guide

Understanding the Methodology and 

Limitations

Each system or data mart has detailed data 

dictionaries, defined methodologies, and business 

rules for its respective applications. It is imperative 

for MM teams to understand the applicability and 

limitations of the system or mart being used. The 

TRICARE Management Activity (TMA) sponsors and 

conducts training to assist MM staff in using these 

tools, including:

• Data Quality Training

• TRICARE Fundamentals

• TRICARE Financial Management Education 

Program (TFMEP)

• TRICARE Uniform Business Office (UBO)/Unified 

Biostatistical Utility (UBU) Conference

• Working Information Systems to Determine 

Optimal Management (WISDOM)

Courses are listed under the training section on the 

TMA conference website at http://www.tricare.mil/

conferences.cfm.

Data Quality Concerns

Several coding validation studies conducted within 

the MHS have corroborated concerns about coding 

accuracy, especially regarding outpatient care. 

However, initiatives to establish training programs, 

involve leadership in more direct oversight, 

employ certified coders, and deploy the 3M 

Coding Compliance Editor (CCE) software should 

significantly improve the quality of MHS data over 

time. Still, it is advisable to scrutinize analyses that 

have been conducted using MHS data, to identify 

and minimize inconsistencies.

INFORMATION SYSTEMS AND DATA 

MARTS

Military Health System-Level Decision Support 

Tools and Executive Information Systems

Armed Forces Health Longitudinal Technology 

Application: http://www.health.mil/ahlta/

T

he MHS’ electronic healthcare record system 

is the Armed Forces Health Longitudinal 

Technology Application (AHLTA), which 

interfaces with the Composite Healthcare System 

(CHCS) for patient record management. CD-ROM 

Resource MMT-1 provides step-by-step instructions 

on accessing AHLTA in a user-friendly visual format.

Clinical Data Mart (CDM) is the clinical reporting 

tool for AHLTA. It allows users to measure, analyze, 

and manage performance of direct patient care, 

wellness, prevention, and DM of the MHS patient 

population. The CDM can be used to create ad 

hoc queries to help measure quality, safety, and 

efficiency. CDM accounts are created by the local 

MTF system administrator. Types of account (based 

on demonstrated need) include MTF Access (nonProtected Health Information [PHI] and PHI levels), 

Enterprise Access (non-PHI and PHI levels), and 

Provider Access (PHI level). Contact your supervisor 

or department head for more information.

Executive Information and Decision Support: 

https://dhss.csd.disa.mil/MX/Common/EIDS/

mxAppHome.cfm?subMenuItem=about

The Executive Information and Decision Support 

(EI/DS) Web portal provides a centralized data store 
Medical Management Guide Version 3.0 Medical Management Tools Page 135

for the MHS. EI/DS tools help provide complete, 

accurate information to MM staff, including 

beneficiary, provider, financial, and healthcare use 

data. These data are evaluated, integrated, and 

made available to MHS users through a variety of 

EI/DS tools and specialized data sets developed 

to meet business requirements. EI/DS actively 

interfaces with more than 260 systems around the 

globe and is comprised of a data warehouse and 

seven operational data marts supporting nearly 

3,000 users, including MHS managers, clinicians, 

and analysts.

EI/DS includes the following tools, many of which 

are discussed in this section: 

1. Military Health System Data Repository (MDR)

2. MHS Management Analysis and Reporting (M2)

3. Prospective Payment System (PPS)

4. ESSENCE Medical Surveillance

5. CDM

6. TRICARE Encounter Data (TED)

7. Patient Encounter Processing and Reporting 

(PEPR) and its reporting applications.

All tools and resources provided by EI/DS require an 

account. The various tools have a limited number of 

licenses; therefore, accounts must be approved by 

a Service representative. To become a user, contact 

EI/DS via email at: eids.access@tma.osd.mil.

TOOLS FOR UTILIZATION, CASE, AND 

DISEASE MANAGEMENT COLLABORATION

F

ig. 37 provides a summary of information 

systems that may be helpful for UM, CM, 

and DM collaboration. (For more information 

on collaboration between MM components, see 

Section I, Medical Management Essentials; 

Integrating Utilization, Case, and Disease 

Management Functions.)

Multiple source systems feed the MHS Data 

Repository (MDR) to create various data marts and 

applications. These source systems include:

• The Composite Health Care System (CHCS) 

— where data are gathered directly from the 

MTFs.

• The Medical Expense & Performance Reporting 

System (MEPRS) Executive Query System 

(MEQS).

• The Defense Eligibility Enrollment Reporting 

System (DEERS).

• Managed Care Support Contractor (MCSC) 

systems.

The data from these systems are reviewed, analyzed, 

and aggregated in the MDR to create the various 

marts and applications listed in Fig. 38. 

Be sure to see the companion CD-ROM for more 

important Medical Management Tools and Resources.
Page 136 Medical Management Tools Version 3.0 Medical Management Guide

TRICARE Management Activity Reporting Tools

TMA Reporting Tools (TMA-RT) comprise the 

following seven applications:

1. Military Health System Management Analysis and 

Reporting Tool: http://www.mhs-helpdesk.com/

Pages/m2.asp

The Military Health System Management Analysis 

and Reporting Tool (M2) is used to obtain summary 

and detailed views of population, clinical, and 

financial data from all MHS regions. Access is 

granted at six levels of report from Level 1 (MTFlevel data) through Level 6 (personally identifiable 

information). 

Fig. 37 – Summary of Data Systems for Use in MM

Summary of Data Systems for Use in Medical Management

Data Source Utilization 

Management Case Management Disease 

Management Population Health

DMSS

M2

MCFAS

CDM

MEWACS

MHS Portal

PDTS

SADR

SIDR

TMA Purchased Care

TMA-RT

TOC

Service Sources:

AFP2R2 

Army PASBA 

MHS Data Repository

Fig. 38 –MHS Data Repository
Medical Management Guide Version 3.0 Medical Management Tools Page 137

M2 includes MTF and commercial network claims 

data integrated with eligibility and enrollment data. 

It allows users to perform trend analyses, conduct 

patient and provider profiling studies, and conduct 

business case analyses to maximize health plan 

efficiency. Many corporate measures are derived 

from M2.

Comprehensive data sets are compiled from various 

sources including, but not limited to:

• MTF data sets.

• Expense Assignment System, Version 4 (EAS IV).

• Standard Ambulatory Data Record (SADR).

• Standard Inpatient Data Record (SIDR).

• World Wide Workload Reports (WWRs).

• External data sets.

• Health Care Service Record (HCSR) — Network 

institutional and professional services claims. 

The name HCSR has been changed to 

“TRICARE Encounter Data” (TED); however, 

any claims submitted prior to contract changes 

remain an HCSR record.

• Pharmacy Detail Transaction Service (PDTS) 

— A centralized data repository that allows the 

DoD to build a common patient medication 

profile for all DoD beneficiaries, regardless 

of the point of service they use (excluding 

Standard TRICARE).

• National Mail Order Pharmacy (NMOP).

• Patient (i.e., beneficiary) demographic data.

• DEERS eligibility data.

• TRICARE enrollment data.

• TRICARE longitudinal enrollment data.

• TRICARE Mail Order Policy (TMOP).

2. Defense Medical Surveillance System: *Restricted 

access

3. Defense Medical Epidemiology Database: 

http://afhsc.army.mil/

The Defense Medical Surveillance System (DMSS) 

and Defense Medical Epidemiology Database 

(DMED) are operated by the Armed Forces Health 

Surveillance System (AFHSC).

As the DoD’s premier epidemiologic resource, DMSS 

provides the MHS with a longitudinal record of upto-date historical data related to:

• Medical events (e.g., hospitalizations, 

ambulatory visits, immunizations, reportable 

medical events, health risk appraisals, 

deployment health assessments).

• Individual/demographic characteristics.

• Military experiences (assignments, deployments, 

casualty information) spanning a Service 

member’s entire career. 

The DMSS is an excellent source for processing TriService epidemiologic queries on disease burdens 

and injury rates, and can be used to demonstrate 

Service trends and potential for disease/condition 

management initiatives. Features include the ability 

to create results in tabular, line graph, or bar graph 

formats. DMSS also has the ability to save, export, 

and print query results. 

The DMED application enables Web-based, userdefinable queries of de-identified DMSS data 

subsets. Its user-friendly interface provides data on 

population statistics, disease summaries, detailed 

queries, and Top 10 diagnoses for Active Duty 

populations. Data can be obtained for inpatient 
Page 138 Medical Management Tools Version 3.0 Medical Management Guide

and ambulatory encounters, reportable events, and 

demographic data elements. 

4. Medical Expense & Performance Reporting 

System Early Warning and Control System: http://

www.meprs.info/mol3

The Medical Expense & Performance Reporting 

System (MEPRS) Early Warning and Control System 

(MEWACS) is a robust, interactive, user-friendly data 

quality surveillance tool developed by the MEPRS 

Management Improvement Group (MMIG) to 

proactively identify, investigate, resolve, or correct 

MEPRS data anomalies in a timely manner using 

systematic, repeatable processes. It is a valuable MM 

tool for monitoring resource consumption and clinic 

productivity. MEWACS provides detailed information 

at the MTF level and does not require a password 

for access. 

MEWACS currently contains up to 24 months of 

Tri-Service MTF activity-level measures, including:

• EAS IV Repository data status and compliance 

with 45-day reporting suspense.

• Interactive MTF MEPRS data profiles by 

third-level functional cost code.

• MTF-specific summary data outliers and variance 

assessments.

• A WWR vs. EAS IV Repository total ambulatory 

visit comparison.

• Ancillary and support expense allocation tests.

MEWACS is updated monthly and is available for 

download at the end of each month.

5. TRICARE Operations Center: http://mytoc.tma.osd.

mil/

This tool is an MHS healthcare information Web 

portal providing decision-makers at all levels of 

the organization with meaningful, easy-to-use, 

Web-based operational tools and reports. The 

Center provides useful MM resources, such as a 

template analysis tool, inpatient daily summaries, 

length-of-stay (LOS) analysis, provider schedules, 

and appointment cancellations by MTFs. General 

access is available through the TRICARE website; 

direct access to the tool requires a username and 

password. 

6. Patient Administration Systems and Biostatistics 

Activity: *Restricted access

The Patient Administration Systems and Biostatistics 

Activity (PASBA) offers a wealth of valuable 

information for preparing MM plans. The Army 

uses PASBA to post utilization reports for the MHS 

that are stratified by Service, fiscal year, current 

procedural terminology (CPT) code, diagnosis-related 

group (DRG), and International Classification of 

Diseases-Ninth Edition-Clinical Module (ICD-9-CM) 

codes. (See also Appendix C, Definitions.)

The following is a list of available reports:

• Top 100 CPT for Non-Same Day Surgery

• Top 100 CPT for Same Day Surgery Report

• Top 100 DRG by Case Weighted Product

• Top 100 DRG by Frequency

• Top 100 ICD-9-CM for Non-Same Day Surgery

• Top 100 ICD-9-CM for Same Day Surgery

• Top 25 CPT for Non-Same Day Surgery for 

Active Duty
Medical Management Guide Version 3.0 Medical Management Tools Page 139

• Top 25 CPT for Same Day Surgery for Active 

Duty

• Top 25 DRG by Case Weighted Product for 

Active Duty

• Top 25 DRG by Frequency for Active Duty

• Top 25 ICD-9-CM for Non-Same Day Surgery 

for Active Duty

• Top 25 ICD-9-CM for Same Day Surgery for 

Active Duty

These reports are available for all DoD and VA 

regional commands and medical facilities. Data are 

posted once a year, usually in January or February, 

for the previous fiscal year. 

7. Military Health System Population Health Portal: 

*Restricted access

The Military Health System Population Health Portal 

(MHSPHP) allows MM professionals to identify 

and assess their populations, forecast and manage 

demand, and provide evidence-based care to 

individuals needing clinical preventive services and 

DM. Although the tool has a common log-in page, 

each Service has a unique name and home page 

for its application — the Army Population Health 

Information Connection, the Navy Population Health 

Navigator, and the Air Force Population Health 

Portal.

This tool provides patient demographic information 

and identifies patients requiring clinical preventive 

services, including but not limited to:

• Cancer screening

o Breast cancer

o Cervical cancer

o Colon cancer

• Chlamydia screening

• High cardiovascular risk

• Lipid risk

By generating provider-level action lists of patients, 

the Portal enables risk stratification and targeting 

of provision of services to the enrolled population.

The ability of the Portal to identify individuals who 

are considered “high utilizers” directly supports MM 

activities and encourages collaboration between 

UM, CM, and DM. 

The Portal also assists in the evaluation of the MM 

program by providing:

• Aggregate measures (e.g., HEDIS®) to assess the 

performance of a branch clinic or MTF.

• Action lists to enable other critical analyses at 

the patient, provider, clinic, or MTF level.

Health Assessment Review Tool — formerly 

Health Enrollment Assessment Review

The Health Assessment Review Tool (HART), 

formerly known as the Health Enrollment 

Assessment Review (HEAR), is a DoD automated 

health assessment tool. Information from the HART 

can be used to help establish prevalence of health 

risk behaviors and to set MM priorities accordingly. 

CD-ROM Resource MMT-2 describes various 

aspects of the tool, and CD-ROM Resource 

MMT-3 records the change from HEAR to HART per 

the Assistant Secretary of Defense for Health Affairs 

(ASD [HA]) in 2005.
Page 140 Medical Management Tools Version 3.0 Medical Management Guide

MHS Insight

MHS Insight is an exceptionally powerful yet easy-touse MHS performance management tool to support 

the periodic review of performance measures to 

actively manage business, operational, and clinical 

activities from the ASD (HA); the TMA; and the 

Army, Navy, and Air Force medical departments 

(including local MTFs, intermediate Commands, and 

headquarters). This Web-based solution improves 

the ability of the MHS to set, monitor, and achieve 

strategic performance goals; and to quickly and 

accurately communicate performance information 

to all levels of the MHS. Contact your supervisor or 

department head for more information.

Prospective Payment System

The Prospective Payment System (PPS) is a modular, 

performance-based budgeting system that facilitates 

the ability of the MHS to provide incentives and 

financial rewards for efficient management. Each 

module of the application is designed to leverage 

information technology that has already been built 

by the Services as part of their business planning.

Protected Health Information Management 

Tool

The Protected Health Information Management 

Tool (PHIMT) is a Web-based application that assists 

in complying with the HIPAA Privacy Disclosure 

Accounting requirement. It enables the MHS to 

simplify its compliance tasks and reduce associated 

costs through the use of sophisticated HIPAA 

process automation features and centralized data 

management.

Information on the PHIMT is available through the 

TRICARE website at http://www.trow.tma.osd.mil/

TMAPrivacy/hipaa/hipaacompliance/tools-training/

PHIMT.htm.

To obtain access to the tool, contact EIDS@mhshelpdesk.com.

SERVICE-LEVEL INFORMATION SYSTEMS

T

he Army, Navy, and Air Force have developed 

Service-specific websites that provide 

measures supporting the Defense Health 

Program (DHP), as well as other measures of interest 

for MM. The tools described below allow Service-, 

regional-, and MTF-level views of their respective 

measures, to assist MM teams in extracting relevant 

measures to support their MTFs’ MM and business 

plans. 

• Army — The Army’s Office of the Surgeon

General (OTSG) maintains a dashboard

of clinical and business measures on the

Command Management System (CMS), and the

Medical Operational Data System (MODS). 

MODS provides the Army Medical Department 

(AMEDD) with an integrated automation system 

supporting all phases of human resource life 

cycle management during both peacetime and 

mobilization. It provides Commanders, staff, 

and functional managers of AMEDD organizations with a real-time source of information 

on the qualifications, training, special pay, and 

readiness of AMEDD personnel. Measures are 

available from the MEDCOM level to the child 

Defense Medical Information System (DMIS) 
Medical Management Guide Version 3.0 Medical Management Tools Page 141

level and are presented in a red-amber-green 

stoplight with contributing data available for 

download. Access to the site is restricted to 

those with a CAC: https://cms.mods.army.mil/.

•	 Navy — In direct support of Tri-Service business 

planning, and of the Navy’s Performancebased Budget (PBB) and current MM policy, the 

Population Health Navigator (PHN) dashboard 

displays clinical quality performance data 

generated by the MHSPHP. In addition to the 

HEDIS-like performance measures, other clinical 

PBB measures are also displayed. The PHN 

dashboard design allows for benchmarking 

with Navy and external standards as well as for 

comparisons with children’s healthcare clinics, 

Navy Medicine regions, or similar MTF types. 

Access is restricted to those with a CAC: 

http://www-nehc.med.navy.mil/Data_Statistics/

Clinical_Epidemiology/pophealthnav.aspx.

•	 Air Force — The Air Force Medical Service 

(AFMS) offers the Surgeon General Executive 

Global Look (SG/EGL) and the SG/EGL Virtual 

Analyst, which provide performance measures 

for all Air Force MTFs. Each of the SG/EGL 

measures directly supports the objectives 

and initiatives of the Air Force SG and Major 

Command (MAJCOM) Surgeons General (SGs) 

for each MTF in the AFMS. The tool tracks 

measures such as:

o Readiness (dental and individual readiness)

o Quality HEDIS® measurements on cancer 

screenings, diabetic management, and 

childhood immunizations)

o Efficiency (access and coding)

o External customer service (delivery 

assessment)

o Financials (business plan, prime 

containment).

A significant innovation is the "Push Report," 

a feature on the SG/EGL website that allows 

custom reports to be pushed directly to Air Force 

customers’ email inboxes. These reports contain the 

same information as what is available on the EGL 

website, but the data are sent in an attachment so 

users receive updated information when the site is 

refreshed.

SG/EGL and Virtual Analyst have become 

the benchmarks of Web-based performance 

measurement improvement efforts within the AFMS.

Access is granted through a ".mil" domain. A 

username and password are required to enable full 

navigation: https://www.egl.afms.mil and 

https://eglva.afms.mil. 

BUSINESS PLANNING TOOLS

As discussed throughout this Guide, 

developing a clear and coherent business 

plan is a central function of today’s 

MM programs (see also Section I, Medical 

Management Essentials). 

Tri-Service Business Plans

Business plans consist of the following four primary 

sections:

1. Enrollment Forecasts

2. Inpatient Demand and Workload

3. Outpatient Demand

4. Workload and Manpower Requirements
Page 142 Medical Management Tools Version 3.0 Medical Management Guide

In 2005, the MHS introduced an automated format 

for Tri-Service business plans. This format is:

• Focused on MTFs that are able to receive input 

and validation from MSMOs and TROs.

• Automated and standardized with easy, onscreen access guidance.

• Mapped to HA and Service-level measures.

• Comprised of measures that relate to critical 

initiatives approved by all Services (modes of 

execution may vary).

Fig. 39 is a sample MTF enrollment template. The 

template is stratified by patient (i.e., beneficiary) 

categories, gender, and age. The demographics of 

the enrolled population can be an indicator of future 

demand.

Fig. 40 is a sample MTF inpatient demand and 

workload template, which forecasts total relative 

Fig. 39 – Sample MTF Enrollment Template

weighted products (RWPs) by major diagnostic 

categories (MDC) and is stratified by treatment 

locations. Normative demand (third column) 

indicates the expected RWP workload based on 

the MTF’s enrolled population. The data under the 

Enrollee columns show the MTF’s actual workload 

for care provided in house, in other MTFs, and in the 

network.

Fig. 41 is a sample MTF outpatient demand and 

workload template, which forecasts total relative 

value units (RVUs) by Service and product lines, 

stratified by treatment locations.

The final section of the business plan is the 

manpower template (Fig. 42). 

The manpower template displays historical full-time 

equivalents (FTEs) by source (i.e., contract staff, 
Medical Management Guide Version 3.0 Medical Management Tools Page 143

Fig. 40 – Sample MTF Inpatient Demand and Workload Template

Fig. 41 – Sample MTF Outpatient Demand and Workload Template
Page 144 Medical Management Tools Version 3.0 Medical Management Guide

civilian, and military personnel). It also documents 

whether personnel are borrowed or loaned out to 

other facilities. The number of FTEs should correlate 

to productivity measures.

CD-ROM Resource MMT-4 shows a screenshot 

of a Tri-Service business planning tool from the 

Army. CD-ROM Resource MMT-5 offers a 

TRICARE conference presentation on business 

planning.

Tri-Service business plans should also offer MTFs the 

opportunity to validate historical clinical information 

regarding elements such as eligibility, enrollment, 

outpatient/inpatient workload, and outpatient/

inpatient utilization. 

CD-ROM RESOURCES

MMT-1 AHLTA Step-by-Step Instructions

MMT-2 Assistant Secretary of Defense for Health 

 Affairs Memorandum, Policy for TRICARE 

 Health Enrollment Assessment Review 

 (HEAR) Survey (Oct. 11, 1996)

MMT-3 Assistant Secretary of Defense for 

 Health Affairs Memorandum, Policy 

 Memorandum for Name Change of the 

 DoD Automated Health Assessment Tool 

 from HEAR to HART (Oct. 28, 2005)

MMT-4 Tri-Service Business Planning Tool 

 Screenshot (Army)

MMT-5 MHS Business Planning, TRICARE 

 Conference (Jan. 26, 2005)

Fig. 42 – Sample MTF Manpower Template


Medical Management Guide Version 3.0 Appendix A - References Page 147

Appendix A – References

CITED REFERENCES

Executive Summary

An Achievable Vision: Report of the Department of Defense Task Force on Mental Health, 2007. See Executive 

Summary, CD-ROM Resource ES-5.

Department of Defense (DoD)/TRICARE Management Activity (TMA), Population Health Improvement Plan and 

Guide. TMA/Government Printing Office, 2001: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf. 

See Executive Summary, CD-ROM Resource ES-1.

Honoring the Call to Duty: Veterans’ Disability Benefits in the 21st Century. Veteran’s Disability Benefits 

Commission, 2007. See Executive Summary, CD-ROM Resource ES-9.

Rebuilding the Trust: The Independent Review Group on Rehabilitative Care and Administrative Processes at 

Walter Reed Army Medical Center and National Naval Medical Center, 2007. See Executive Summary, CDROM Resource ES-6.

Report to Congress on the Comprehensive Policy Improvements to the Care, Management and Transition of 

Recovering Service Members. DoD/VA, Sept. 16, 2008. See Executive Summary, CD-ROM Resource ES-3.

Serve, Support, Simplify: The President’s Commission on Care for America’s Returning Wounded Warriors, 

2007. See Executive Summary, CD-ROM Resource ES-8.

The President’s Commission on Veterans’ Pensions. Government Printing Office, 2006: http://eisenhower.

archives.gov/Research/Finding_Aids/PDFs/US_Pres_Commission_on_Veterans'_Pensions.pdf. See Executive 

Summary, CD-ROM Resource ES-12.

The President’s Task Force to Improve Health Care Delivery for Our Nation's Veterans, 2003. See Executive 

Summary, CD-ROM Resource ES-10.

The Report of the Congressional Commission on Service Members and Veterans Transition Assistance, 1999. 

See Executive Summary, CD-ROM Resource ES-11.
Page 148 Appendix A - References Version 3.0 Medical Management Guide

The Secretary of Veterans Affairs Task Force on Returning Global War on Terror Heroes, 2007. See Executive 

Summary, CD-ROM Resource ES-7.

Title XVI, Section 1611 of the National Defense Authorization Act (NDAA). U.S. House of Representatives, 2008. 

See Executive Summary, CD-ROM Resource ES-4.

Section I – Medical Management Essentials

Cousins, Michael S., Shickle, Lisa M., Bander, John A. An Introduction to Predictive Modeling for Disease 

Management Risk Stratification. Disease Management, September 2002, 5(3): 157-167.

Crossing the Quality Chasm: a new health system for the 21st Century. Committee on Quality Health Care in 

America, Institute of Medicine. National Academy Press, 2001.

Despite Barriers, MCOs Integrate Case, Disease, Utilization Management Functions. Managed Care Week. 

March 2005.

DoD Instruction 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) and Remote 

Areas: http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.

Favor, G., Ricks, R. Preparing to automate the case management process. Nursing Case Management, 1996, 

1(3), 100-106. 

First Consulting Group. Access to Care Report for the Air Force Office of the Surgeon General. February 2003.

Kelley, M. Model for integrating case manage­ment and utilization management. Inside Case Management, 

2001, 8(8), 8-10.

Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed., 378-379. Jones and Bartlett Publishers, 2007.

Koulopoulos, T., Champy, J. Building digital value chain. Optimize, 2005, 4(9), 24-34. 

McKendry, M. J., Sherwin, K. Utilization review and case management integration: An idea whose time has 

come...Are you ready? Care Management, 2002, 32-35. 

Mullahy, C. M. Effective Integration of Utilization and Case Management. The Case Manager, 53­-55. 2000.

Owen, M. Changes in Case Management. In P. Rossi (Ed.), Case Management in Health Care, 19-32. Saunders, 

2003.

Powell, S.K., Tahan, H.A. CMSA Core Curriculum for Case Management, 2nd ed., 294-300. Lippincott, Williams 

& Wilkins, 2008.
Medical Management Guide Version 3.0 Appendix A - References Page 149

Qudah, F. J., Brannon, M. Population-Based Case Management. In C. M. Mullahy (Ed.), Essential Readings in 

Case Management, 2nd ed., 86, 87. Aspen Publishers, 1998.

Soumerai, S. B., Avron, J. Principles of education outreach (“academic detailing”) to improve clinical decisionmaking. Journal of American Medical Association, January 1990, 263(4), 549-556. 

Trends and Practices in Medical Management: 2005 Industry Profile. URAC: http://www.urac.org/docs/

resources/MMReport2005.pdf.

TRICARE Management Activity (TMA), Population Health Improvement Plan and Guide. TMA/ Government 

Printing Office, 2001: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.

TRICARE Fact Sheets, TRICARE Regional Contractors for the United States, Sept. 18, 2006: http://www.tricare.

mil/factsheets/viewfactsheet.cfm?id=92.

Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. Case 

Management Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.

Section II – Utilization Management

Accreditation Handbook for Ambulatory Health Care. Accreditation Association for Ambulatory Health Care, 

2008: http://www.aaahc.org/. 

Carneal, G., Korsch, D. I. (Eds.). The Utilization Management Guide, 3rd ed. URAC, 2005. The Utilization Management Guide, 3rd ed. URAC, 2005.

Code of Federal Regulation (CFR) Title 32, National Defense, Chapter 1: Office of the Secretary of Defense, 

Section 199, Civilian Health and Medical Program of the Uniformed Services: http://www.gpoaccess.gov/cfr/

index.html.

• Section 199.2 — Definitions

• Section 199.10 — Appeal and hearing procedures

• Section 199.15 — Quality and Utilization Review Peer Review Organization (PRO) 

• Section199.16 — Supplemental Health Care Program for active duty members

• Section 199.17 — TRICARE Program

Freedman, Skip (MD). Understand the nuances of utilization review and utilization management. Managed 

Healthcare Executive, Jan. 1, 2006. 

Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Jones and Bartlett Publishers, 2007.

McKesson Certified Professional in Healthcare Management (CPHM) Study Guide 2, 2009.

TMA Memorandum, Policy Guidance for Referral Management. May 5, 2004; http://www.health.mil/hapolicies.

aspx.
Page 150 Appendix A - References Version 3.0 Medical Management Guide

TRICARE Operations Manual 6010.51-M, 2002: http://manuals.tricare.osd.mil:

• Chapter 8, Section 5 — Referrals/Preauthorizations/Authorizations 

• Chapter 12, Section 9 — Grievance and Grievance Processing

• Chapter 13 — Appeals and Hearings, 2002

DoD Instruction 6000.14, Patient Bill of Rights and Responsibilities in the Military Health System (MHS), 2007; 

http://www.dtic.mil/whs/directives

United States Code (U.S.C.) Title 10: http://www.gpoaccess.gov/cfr/index.html:

• Section 47 — Uniformed Code of Military Justice

• Section 55 — Medical and Dental Care:

• 1074: Medical and dental care for members and certain former members

• 1077: Medical care for dependents: authorized care in facilities of uniformed services

• 1079: Contracts for medical care for spouses and children: plans

• 1102: Confidentiality of medical quality assurance records: qualified immunity for participants 

Section III – Case Management

American Health Consultants. Consider a New CM Model to Help Your Staff Work More Efficiently. Hospital 

Case Management, September 2005.

Beauchamp, Tom L., Childress, James F. Principles of Biomedical Ethics. Oxford University Press, 1994, 2008 (6th 

ed.).

Cesta, Toni G., Hussein, Tahan, A. Case Manager’s Survival Guide Winning Strategies for Clinical Practice, 2nd 

ed., 2003.

Cohen, E. L., Cesta, T. G. Nursing Case Management: From Essentials to Advanced Practice Applications. Mosby, 

2001. 

Dignified Treatment of Wounded Warriors Act, H.R. 1538. U.S. House of Representatives, July 25, 2007: 

http://www.govtrack.us/congress/billtext.xpd?bill=h110-1538.

Hendricks, A. G. How prepared are you? Ethical and legal challenges facing case man­agers today. The Case 

Manager, May/June 2003, 56-62. 

Joint Publication 4-02.2 — Joint Tactics, Techniques, and Procedures for Patient Movement in Joint Operations, 

Dec. 30, 1996: http://www.dtic.mil/doctrine/jel/new_pubs/jp4_02_2.pdf.

Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Aspen, 2007. 
Medical Management Guide Version 3.0 Appendix A - References Page 151

Marcum, Cheryl Y., Emmerichs, Robert M.; Sloan, Jennifer S.; Thie, Harry J. Methods and Actions for Improving 

Performance of the Department of Defense Disability Evaluation System. Rand, 2002.

Meek, J. A. Predictive Modeling and Proactive Care Management: Part 1. Lippincott’s Case Management, July/

August 2003, 8(4), 170-174. 

Mullahy, C. M. The Case Manager’s Handbook, 3rd ed. Aspen, 2004.

Powell, S.K.; Ignatavicius, D. (Eds.) Case Management Society of America’s Core Curriculum for Case 

Management. Lippincott, Williams & Wilkins, 2001.

Powell, S.K., Tahan, H.A. CMSA Core Curriculum for Case Management, 2nd ed., 294-300. Lippincott, Williams 

& Wilkins, 2008.

Public Law 194-262 (H.R. 3118), Veterans’ Health Care Eligibility Reform Act of 1996. U.S. House of 

Representatives, Oct. 9, 1996: http://www.tavausa.org/PL%20104-262.pdf.

Steifel, F.E. Operationalizing integrated care on a clinical level: the INTERMED project, 713-758. The Medical 

Clinics of North America, 2006.

Under Secretary of Defense, Directive-Type Memorandum (DTM) 08-049 – Recovery Coordination Program: 

Improvements to the Care, Management, and Transition of Recovering Service Members (RSMs), Jan. 19, 2009: 

http://www.dtic.mil/whs/directives/corres/pdf/DTM-08-049.pdf.

Section IV – Disease Management

Advancing the Population Health Improvement Model. DMAA: The Care Continuum Alliance, 2009: http://

www.dmaa.org/phi_definition.asp. 

Agency for Healthcare Research and Quality (AHRQ): http://www.ahrq.gov. 

Almanac of Chronic Disease: Statistics and Commentary on Chronic Disease and Prevention, 2008 ed. 34, 39-

44. Partnership to Fight Chronic Disease: http://www.fightchronicdisease.org/pdfs/PFCD_FINAL_PRINT.pdf.

U.S. Army Medical Command (MEDCOM) Quality Management Office (QMO): http://www.qmo.amedd.army.

mil.

DeVol, R., Bedroussian, A. An Unhealthy America: The Economic Burden of Chronic Disease: Charting a New 

Course to Save Lives and Increase Productivity and Economic Growth, 1-2, 39-40, 45-50. Milken Institute, 

October 2007: http://www.milkeninstitute.org/pdf/chronic_disease_report.pdf.

DMAA Definition of Disease Management. DMAA: The Care Continuum Alliance, 2009: http://www.dmaa.

org/dm_definition.asp.
Page 152 Appendix A - References Version 3.0 Medical Management Guide

Employer Health Benefits: 2006 Summary of Findings, 6. Kaiser Family Foundation and Health Research and 

Educational Trust, 2006: http://www.kff.org/insurance/7527/upload/7528.pdf. 

Healthcare Effectiveness Data and Information Set (HEDIS®): http://www.ncqa.org/tabid/59/Default.aspx.

Innovations in Chronic Care: A New Generation of Initiatives to Improve America’s Health, ix-x. America’s Health 

Insurance Plans, March 2007: http://www.ahipresearch.org/PDFs/Innovations_InCC_07.pdf. 

Kongstvedt, P. R. Essentials of Managed Health Care, 5th ed. Aspen, 2007.

MHS Clinical Quality Management: https://www.mhs-cqm.info/Open/Files/2006_Report_to_Congress.pdf.

Most American Adults Have at Least One Chronic Medical Condition. AHRQ News and Numbers, Agency for 

Healthcare Research and Quality. March 28, 2008: http://www.ahrq.gov/news/nn/nn052808.htm.

National Committee for Quality Assurance (NCQA): http://www.ncqa.org.

Military Health System Clinical Quality Management (CQM): https://www.mhs-cqm.info/index.aspx.

Nichols, W., Farley, D. O., Vaiana, M. E., Cretin, S. Putting Practice Guidelines to Work in the Department of 

Defense Medical System: A Guide for Action. Rand, 2001.

Overview: National Center for Chronic Disease Prevention and Health Promotion, 2009: http://www.cdc.gov/

nccdphp/overview.htm.

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health 

Promotion, revised August 2008: 

• Preventing Heart Disease and Stroke. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/

dhdsp.htm.

• Preventing Diabetes and Its Complications: http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/

diabetes.htm.

Sprague, L. Disease management to population-based health: Steps in the right direction. National Health Policy 

Forum, 2003, 791(3). 

The Joint Commission (TJC): http://www.jointcommission.org.

Welch W. P., Bergsten, C., Cutler, C., Bocchino, C., Smith, Richard I. Disease management practices of health 

plans. American Journal of Managed Care, (8) 353-361, 2002.

Section V – Medical Management Tools

Defense Health Program (DHP) Performance Contract, TOPS Feature Fourth Quarter FY 2000: http://www.

tricare.mil/reptcard/tops/topsrept0012.htm.
Medical Management Guide Version 3.0 Appendix A - References Page 153

GENERAL REFERENCES

Executive Summary

Accreditation Handbook for Ambulatory Health Care. Accreditation Association for Ambulatory Health Care, 

2008: http://www.aaahc.org/eweb/StartPage.aspx. 

32 CFR 199.17, TRICARE Program: http://www.access.gpo.gov/nara/cfr/waisidx_05/32cfr199_05.html.

42 CFR, Public Health, Centers for Medicare and Medicaid Services (CMS) — Information updated as of July 16, 

2009: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=/ecfrbrowse/Title42/42tab_02.tpl.

Section I – Medical Management Essentials

DoD Population Health Improvement Plan and Guide, 2001. TMA/Government Printing Office: 

http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.

DoDD 1010.10, Health Promotion and Disease/Injury Prevention, Aug. 22, 2003: 

http://www.dtic.mil/whs/directives.

DoDD 6025.18-R, DoD Health Information Privacy Regulation, January 2003: 

http://www.dtic.mil/whs/directives.

Dranove, D. The Economic Evolution of American Healthcare: From Marcus Welby to Managed Care. Princeton 

University Press, 2002.

Kongstvedt, P. R. Managed Care: What It Is and How It Works, 2nd ed. Jones and Bartlett, 2007. 

Privacy Act of 1974 (as amended): http://www.usdoj.gov/opcl/privstat.htm (U.S. Department of Justice).

Health Insurance Privacy and Accountability Act of 1996 (HIPAA), Aug. 21, 1996: 

http://aspe.hhs.gov/admnsimp/pL104191.htm. See also:

• Centers for Medicare & Medicaid Services (DMS): 

http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/HIPAALaw.pdf.

• Department of Health and Human Services (HHS): http://www.hhs.gov/ocr/privacy/index.html.

Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act of 1992 (S. 1306) 

TRICARE Policy Manual 6010.54-M, TRICARE Overseas Program (TOP), Chap. 12, Sec. 11.1 — Managed Care 

Support Contractor (MCSC) Responsibilities for Claims Processing. Aug. 1, 2002: http://www.tricare.mil/tp02/

C12S11_1.PDF.
Page 154 Appendix A - References Version 3.0 Medical Management Guide

Section II – Utilization Management

DoD Administrative Instruction No. 81, Privacy Program, 2000. DoD Issuances: http://www.dtic.mil/whs/

directives.

DoD Directive 5400.11, DoD Privacy Program, 2007. DoD Issuances: http://www.dtic.mil/whs/directives.

DoD Instruction 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) and Remote 

Areas, 2006: http://www.dtic.mil/whs/directives/.

Public Law 104-191, Health Insurance Portability and Accountability Act of 1996, Sections 261-264. Aug. 21, 

1996: http://aspe.hhs.gov/admnsimp/pL104191.htm.

McKesson® InterQual® evidence-based clinical decision support criteria: http://www.mckesson.com.

Milliman Ambulatory Care Guidelines®. Milliman, USA: www.careguidelines.com.

Section III – Case Management

Disease Management, Version 2.0, Program Guide. URAC: www.urac.org.

DoDD 1010.10, Health Promotion and Disease/Injury Prevention, Aug. 22, 2003: DoD Issuances: http://www.

dtic.mil/whs/directives.

DoDD 6025.18-R, DoD Health Information Privacy Regulation, January 2003: DoD Issuances: http://www.dtic.

mil/whs/directives.

Dorland Healthcare Information, Case Management Resource Guide. Dorland Healthcare Information, 2003: 

http://www.cmrg.com/

Kuhn, A. A necessary discipline: Maximizing case management ROI. Nursing Watch. The Advisory Board 

Company, 2000. 

Meek, Julie A., DNS. Increasing Return on Investment Potential in Care Management — Predictive Modeling 

and Proactive Care Management: Part II. Lippincott’s Case Management, September/October 2003, 8 (5):198-

202.

National Library of Medicine, Medline Plus: http://www.nlm.nih.gov/, http://www.nlm.nih.gov/medlineplus/.

Powell, S. K. Advanced Case Management: Outcomes and Beyond. Lippincott, Williams & Wilkins, 2000. 

Quinn, J., Kellogg, F.R. (Eds.). Case management return on investment: Summary report on the state of the art. 

Care Management Journal, December 2003.
Medical Management Guide Version 3.0 Appendix A - References Page 155

‘

The Joint Commission (TJC) 2009 National Patient Safety Goals (NPSGs): http://www.jointcommission.org/

patientsafety/nationalpatientsafetygoals/.

TRICARE Benefits: http://www.tricare.osd.mil/.

TRICARE Fact Sheets: http://www.tricare.osd.mil/Factsheets/viewfactsheet.cfm?id=127.

TRICARE Handbook: http://tricare.osd.mil/tricarehandbook/results.cfm?tn=30&cn=8. 

TRICARE Policy Manual, 6010.54­, Chapter 9, Section 1.1: http://manuals.tricare.osd.mil/.

Section IV – Disease Management

HEALTHeFORCES: Walter Reed Army Medical Center's health outcomes management program.

Centers for Medicare and Medicaid Services (CMS): http://www.cms.hhs.gov/.

CD-ROM RESOURCES

AppendixA-Ref1 TMA Medical Management Guide References
Page 156 Appendix B - Acronyms Version 3.0 Medical Management Guide

A&D Admissions and Disposition

AAAHC Accreditation Association for 

Ambulatory Health Care

AC Active Component

ADAMHA Alcohol, Drug Abuse, and Mental 

Health Administration

ADFM Active Duty Family Member

ADL Activity of Daily Living

ADM Ambulatory Data Module (formerly 

Ambulatory Data System [ADS])

ADME Active Duty Military Extension

ADSM Active Duty Service Member

AE Aeromedical Evacuation

AFHSC Armed Forces Health Surveillance 

Center

AFI Air Force Instruction

AFPD Air Force Policy Directive

AFPHSD Air Force Population Health 

Support Division

AHLTA Armed Forces Health Longitudinal 

Technology Application (formerly 

CHCS II)

AHRQ Agency for Healthcare Research 

and Quality

AIM Access Improvement Model (Air 

Force)

ALC Assignment Limitation Code

ALOS Average Length of Stay

AMEDD Army Medical Department

ANG Air National Guard

APHIC Army Population Health Information 

Connection

AR Army Regulation

ARMP Anesthesia Report and Monitoring 

Panel

ARNG Army National Guard

ASAM American Society of Addiction 

Medicine

ASD (HA) Assistant Secretary of Defense 

(Health Affairs)

BCAC Beneficiary Counseling and 

Assistance Coordinator

BLS Basic Life Support

BUMED Bureau of Medicine and Surgery 

(Navy)

CBHCO Community-Based Healthcare 

Organization

CCE Coding Compliance Editor

CCM Certified Case Manager

CCP Chronic Care Professional

CCTP Custodial Care Transitional Policy

CDC Centers for Disease Control and 

Prevention

CDIS Care Detail Information System

CDM Clinical Data Mart

CDR Clinical Data Repository

CDW Clinical Data Warehouse

CHCC Cooperative Health Care Clinic

Appendix B – Acronyms
Medical Management Guide Version 3.0 Appendix B - Acronyms Page 157

CHCS Composite Health Care System

CM Case Management

CMAC Champus Maximum Allowable 

Charge

CMG Clinical Management Group

CMI Case Mix Index

CMIS CHAMPUS/TRICARE Medical 

Information System

CMS Centers for Medicare & Medicaid 

Services

CMSA Case Management Society of 

America

COE Center of Excellence

CONUS Continental United States

COR Contracting Officer’s 

Representative

COTR Contracting Officer’s Technical 

Representative

CPG Clinical Practice Guideline

CPT Current Procedural Terminology

CQI Clinical Quality Improvement/

Continuous Quality Improvement

CTP Comprehensive Transition Plan

CURES CHAMPUS/TRICARE Utilization 

Reporting and Evaluation System

DA Department of the Army

DCAO Debt Collector Assistance Officer

DCS Direct Care System

DEERS Defense Enrollment Eligibility 

Reporting System

DES Disability Evaluation System

DHIMS Defense Health Information 

Management System

DHSS Defense Health Services Systems

DIGMAS Drop-in Group Medical 

Appointments

DM Disease Management

DMAA Disease Management Association 

of America: The Care Continuum 

Alliance

DME Durable Medical Equipment

DMED Defense Medical Epidemiology 

Database

DMIS Defense Military Identification 

System

DMSS Defense Medical Surveillance 

System

DoD Department of Defense

DQ Data Quality

DRG Diagnosis Related Group

EASIV Expense Assignment System, 

Version IV

ECHO Extended Care Health Option

ED Emergency Department

EFMP Exceptional Family Member 

Program

EGL Executive Global Look (formerly 

Privilege, Pleasure, Relevant, 

Reasonable [P2R2])

E/M Evaluation and Management

EOC Episode of Care

FHI Family Health Initiative

FIRP Federal Individual Recovery Plan

FRC Federal Recovery Coordinator

FTE Full-time Equivalent

FY Fiscal Year

GPM Group Practice Manager

GWOT Global War on Terrorism (see also 

Overseas Contingency Operations 

– OCO)

HA Health Affairs

HART Health Assessment Reporting 

Tool (formerly Health Enrollment 

Assessment Review [HEAR])
Page 158 Appendix B - Acronyms Version 3.0 Medical Management Guide

HAWC Health and Wellness Center

HBA Health Benefits Advisor

HCI Health Care Integrator

HCIL Healthcare Information Line

HCPCS Healthcare Common Procedure 

Coding System

HCSR Healthcare Service Record

HEDIS® Healthcare Effectiveness Data and 

Information Set

HIPAA Health Insurance Portability and 

Accountability Act (of 1996)

HSI HealthSciences Institute

HSS Health Service Support

HSSC Health Service and Support 

Contractor

ICD-9-CM International Classification of 

Diseases, Ninth Revision, Clinical 

Modification

ICDB Integrated Clinical Database

IOP Improving Organizational 

Performance

JPTA Joint Patient Tracking Application

JTF Joint Task Force

LCSW Licensed Clinical Social Worker

LIMDU Limited Duty

LOD Line of Duty

LOS Length of Stay

M2 MHS Management Analysis and 

Reporting Tool

MAJCOM Major Command (Air Force)

MCFAS Managed Care Forecasting and 

Analysis System

MCSC Managed Care Support Contractor

MDC Major Diagnostic Category

MDR MHS Data Repository

MEB Medical Evaluation Board

MEDCEN Medical Center

MEDCOM Medical Command (Army)

MEDDAC Medical Department Activity (Army)

MEPRS Military Expense and Performance 

Reporting System

MEQS MEPRS Executive Query Summary

MEWACS MEPRS Early Warning and Control 

System

MHO Medical Holdover

MHS Military Health System

MHS CQM Military Health System Clinical 

Quality Management

MHSPHP Military Health System Population 

Health Portal

MM Medical Management

MMIG MEPRS Management Improvement 

Group

MMSO Military Medical Support Office

MRP/MRP2 Medical Retention Processing

MSA Medical Savings Account

MSIP Modeling and Simulation (M&S) 

Investment Plan

MSMO Multi-Service Market Office

MSMP Modeling and Simulation (M&S) 

Master Plan

MSW Master of Social Work

MTF Military Treatment Facility

NAS Non-availability Statement

NATO North Atlantic Treaty Organization

NCM Nurse Case Manager

NCQA National Committee for Quality 

Assurance

NDAA National Defense Authorization Act

NED National Enrollment Database

NMCPHC Navy and Marine Corps Public 

Health Center

NGC National Guideline ClearinghouseTM

NAVMISSA Navy Medical Informatic Systems 

Support Activity
Medical Management Guide Version 3.0 Appendix B - Acronyms Page 159

NMOP	 National Mail Order Pharmacy

NPIC	 National Perinatal Information 

Center

NQF	 National Quality Forum

NQMC	 National Quality Measures 

ClearinghouseTM/National Quality 

Monitoring Contractor

NRD	 National Resource Directory

NSQIP	 National Surgical Quality 

Improvement Program

OCMO	 Office of the Chief Medical Officer

OCO	 Overseas Contingency Operations 

(see also Global War on Terrorism 

– GWOT)

OCONUS	 Outside of the Continental United 

States

ODPHP	 Office of Disease Prevention and 

Health Promotion

OEF	 Operation Enduring Freedom

OHI	 Other Health Insurance

OIF	 Operation Iraqi Freedom

OIG	 Office of the Inspector General

OSHA	 Occupational Safety Health Act

P4P	 Pay for Performance

PASBA	 Patient Administration Systems and 

Biostatistical Activity

PBAM	 Performance-based Adjustment 

Model (Army)

PBB	 Performance-based Budget

PCE	 Primary Care Element

PCM	 Primary Care Manager

PCO	 Primary Care Optimization

PCP	 Primary Care Provider

PCS	 Purchased Care System

PDCA	 Plan, Do, Check, Act

PDES	 Physical Disability Evaluation 

System

PDHRA	 Post Deployment Health Risk 

Assessment

PDTS	 Pharmacy Data Transaction Service

PEB	 Physical Evaluation Board

PEBLO	 Physical Evaluation Board Liaison 

Officer

PEC	 Pharmacoeconomic Center

PHA	 Periodic Health Assessment

PHI	 Protected Health Information

PHMMD	 Population Health and Medical 

Management Division

PHN	 	 Population Health Navigator

PII	 Personal Identifying Information

PKC	 Problem Knowledge Couplers

PPS	 Prospective Payment System

QA	 Quality Assurance

QM	 Quality Management

RAP	 Recruitment Assessment Program

RC	 Reserve Component

RCC	 Recovery Care Coordinator

RCP	 Recovery Coordination Program

REFRAD	 Released from Active Duty 

REFRADT	 Released from Active Duty for 

Training

RITPO	 Resource Information Technology 

Program Office

RM	 Referral Management

RMC	 Referral Management Center

ROFR	 Right of First Refusal

ROI	 Return on Investment

RVU	 Relative Value Unit

RWP	 Relative Weighted Product

SADR	 Standard Ambulatory Data Record

SECNAV	 Secretary of the Navy

SG	 Surgeon General

SIDR	 Standard Inpatient Data Record

SJA	 Staff Judge Advocate
Page 160 Appendix B - Acronyms Version 3.0 Medical Management Guide

SME	 Subject Matter Expert

SNIAC	 Special Needs Identification and 

Assignment Coordination (formerly 

USAF EFMP)

SSDI	 Social Security Disability Index

SSI	 Supplemental Security Income

SWII	 Severely Wounded, Ill, and Injured

TAMP	 Transitional Assistance Medical 

Program

TDY	 Temporary Duty

TJC	 The Joint Commission

TLD	 Temporary Limited Duty

TMA	 TRICARE Management Activity

TMA-RT	 TMA Reporting Tools

TMIP	 Theater Medical Information 

Program

TOA	 Theater of Operations

TOC	 TRICARE Operations Center

TOL	 TRICARE Online

TPC	 Third Party Collection

TPL	 Third Party Liability

TPR	 TRICARE Prime Remote

TSC	 TRICARE Service Center

TRO	 TRICARE Regional Office

UBU	 Unified Biostatistical Utility

UBO	 Uniform Business Office

UFR	 Unfunded Request

UM	 Utilization Management

UR	 Utilization Review

URAC	 Utilization Review Accreditation 

Commission

USA	 United States Army

USACHPPM	 U. S. Army Center for Health 

Promotion and Preventive Medicine

USAF	 United States Air Force

USAFR	 United States Air Force Reserve

USAR	 United States Army Reserve

USCG	 United States Coast Guard

USMC United States Marine Corps

USN	 United States Navy

USNR	 United States Navy Reserve

USPSTF	 United States Preventive Services 

Task Force

VA	 Department of Veterans Affairs

VBA	 Veterans Benefits Administration

VHA	 Veterans Health Administration

WII	 Wounded, Ill, and Injured

WT	 Warrior Transition

WTB	 Warrior Transition Battalion

WTU	 Warrior Transition Unit (Army)

WISDOM	 Working Information Systems to 

Determine Optimal Management

WWR	 Wounded Warrior Regiment

WWWR	 World Wide Workload Reports

CD-ROM RESOURCES

AppendixC-Def2 TRICARE Operations Manual

 6010.51-M, Appendix A, 

 Acronyms and Definitions 

‘
Medical Management Guide Version 3.0 Appendix C - Definitions Page 161

Appendix C - Definitions

Absent Sick

An Active Duty (Army, Navy, Air Force, and Marine Corps) member hospitalized in other than a U.S. Military 

Treatment Facility and for whom administrative responsibility has been assigned to an MTF. Includes “absent 

sick moved to an MTF” and “total absent sick.” 

Resources:

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):

http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.

See CD-ROM Resource AppendixC-Def1

Accreditation

A formal process by which an agency or organization evaluates and recognizes an institution or program of 

study as meeting certain predetermined criteria or standards.

Resources:

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):

http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.

See CD-ROM Resource AppendixC-Def1

Appeals

An administrative review of program determinations made under the provisions of law and regulation. An 

appeal cannot challenge the propriety, equity, or legality of any provision of law or regulation.

Resources:

Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 10 (199.10): Appeal and 

hearing procedures: http://www.tricare.mil/FR05/C10.PDF.

Benchmark/Benchmarking

Benchmark: A TRICARE clerical and automated systems test using claims and other documents created or 

approved by TMA and processed by the contractor. The contractor’s output is compared to predetermined 

results prepared or approved by TMA to determine the accuracy, completeness, and operational characteristics 
Page 162 Appendix C - Definitions Version 3.0 Medical Management Guide

of the contractor’s clerical and automated systems components. The purpose of the benchmark is to identify 

clerical and automated systems deficiencies which must be corrected before claims can be processed in 

accordance with TMA requirements. The comprehensiveness of the benchmark will vary depending on the 

number and type of conditions tested.

Benchmarking:

• The practice of comparing outcomes against local, Service, or national industry standards. Benchmarking 

allows for the identification of areas for improvement and goal-setting as well as recognition of best 

practices.

• The comparison of like provider's performance. It is a standard from which to establish what "quality" 

medical care is and to develop measurements from which to evaluate providers and patient outcomes.

Resources:

TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):

http://www.tricare.mil/to02/APPA.PDF.

See CD-ROM Resource AppendixC-Def2

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):

http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.

See CD-ROM Resource AppendixC-Def1

General definition as provided in Section IV, Disease Management

Care Coordination

A comprehensive method of client assessment by Registered Nurses, designed to identify client vulnerability, 

needs identification, and client goals which results in the development plan of action to produce an outcome 

that is desirous for the client. The goal is to provide client advocacy, a system for coordinating client services, 

and providing a systematic approach for evaluation of the effectiveness of the client’s Life Plan.

Resources:

TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):

http://www.tricare.mil/to02/APPA.PDF.

See CD-ROM Resource AppendixC-Def2

Case Management (CM)

• A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet 

an individual’s health needs through communication and available resources to promote quality, costeffective outcomes. 

• A collaborative process under the population health continuum which assesses, plans, implements, 

coordinates, monitors, and evaluates options and services to meet an individual’s health needs through 

communication and available resources to promote quality, cost-effective outcomes. 
Medical Management Guide Version 3.0 Appendix C - Definitions Page 163

• A method of managing the provision of health care to members with catastrophic or high cost medical 

conditions. The goal is to coordinate the care so as to both improve continuity and quality of care as well as 

lower costs. This generally is a dedicated function in the utilization management department.

Resources:

Case Management Society of America www.cmsa.org

DoDI 6025.20, Medical Management Programs in the Direct Care System (DCS) and Remote Areas: http://

www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.

See CD-ROM Resource MME-1

Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199. Part 2 (199.2):

http://www.tricare.mil/CFR/C2.PDF. See CD-ROM Resource AppendixC-Def3

Case Mix

Categories of patients, classified by disease, procedure, method of payment, or other characteristics, in an 

institution at any given time, usually measured by counting or aggregating groups of patients sharing one or 

more characteristics.

Resources:

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):

http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf

See CD-ROM Resource AppendixC-Def1

Certification

The process by which a governmental or non-governmental Agency or association evaluates and recognizes 

a person who meets predetermined standards; it is sometimes used with reference to materials or services. 

"Certification" is usually applied to individuals and "accreditation" to institutions.

Resources:

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):

http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf See CD-ROM Resource AppendixC-Def1

Clinical Pathways/ Protocols

Tools that delineate the optimal sequencing and timing of interventions by providers for a particular diagnosis 

or procedure designed to minimize delays and resource utilization and maximize quality of care. They often 

have a role in the clinical setting, in both the inpatient and outpatient arenas. Although they may be evidencebased, these protocols are distinguished from clinical practice guidelines (CPGs) in that they do not have the full 

complement of additional resources to support them.

Resources:

Open Clinical: http://www.openclinical.org/clinicalpathways.html
Page 164 Appendix C - Definitions Version 3.0 Medical Management Guide

Clinical Practice Guidelines (CPGs)

Systematically developed statements to assist practitioner and patient decisions about appropriate health care 

for specific clinical circumstances (Institute of Medicine, 1990). CPGs define the role of specific diagnostic and 

treatment modalities in the diagnosis and management of patients. The statements contain recommendations 

based on evidence from a rigorous systematic review and synthesis of the published medical literature.

Resources:

Department of Health & Human Services (HHS), National Heart Lung and Blood Institute (NHLBI):

http://www.nhlbi.nih.gov/guidelines/about.htm.

Department of Veterans Affairs (VA): http://www.healthquality.va.gov/index.asp.

National Guideline Clearinghouse (NGC): http://www.guideline.gov/index.aspx.

U.S. Army Quality Management Office (QMO): https://www.qmo.amedd.army.mil/pguide.htm.

Code of Federal Regulations (CFR)

The codification of the general and permanent rules published in the Federal Register by the executive 

departments and agencies of the federal government. It is divided into 50 titles that represent broad areas 

subject to federal regulation. Each volume of the CFR is updated once each calendar year and is issued on a 

quarterly basis.

Resources: Government Printing Office: http://www.gpoaccess.gov/CFR/.

Convalescent Leave

An authorized leave status, not chargeable to the individual, granted to active duty Uniformed Service 

members while under medical or dental care that is part of the care and treatment prescribed for a member's 

recuperation or convalescence. Convalescent leave days are not counted as occupied bed days but are counted 

as sick days when the convalescent leave occurs before the disposition of the patient. Convalescent leave 

occurring after disposition of the patient while en route to a new command or convalescent leave granted by a 

line commander after patient discharge from the hospital is not counted as occupied bed days or sick days.

Resources: DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):

http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf. See CD-ROM Resource AppendixC-Def 1

Cooperative Health Care Clinic (CHCC)

In cooperative health care clinics (CHCC), health care is provided to older patients in a group setting. The CHCC 

concept, which was developed under a research grant by Kaiser Permanente in Colorado in 1991, showed 

improvement in patient and provider satisfaction, as well as improved quality of care and cost effectiveness.

Resources:

Scott, J., Gade, G., McKenzie, M., Venohr, I. Cooperative health care clinics: a group approach to individual 

care. Geriatrics, May 1998, 53(5):68-70, 76-8, 81. National Center for Biotechnology Information (NCBI): http://

www.ncbi.nlm.nih.gov/pubmed/9597981?dopt=Abstract.
Medical Management Guide Version 3.0 Appendix C - Definitions Page 165

Cost-Benefit Analysis

The process of weighing the total expected costs vs. the total expected benefits of one or more actions in order 

to choose the most profitable option. This often involves monetary calculations of initial expense vs. expected 

return. It is usually done to decide whether to make a change or to determine how well, or how poorly, a 

planned action (e.g., implementation of a program) will turn out. Also known as “running the numbers.”

A cost-benefit analysis finds, quantifies, and adds all the positive factors. These are the benefits. Then it 

identifies, quantifies, and subtracts all the negatives, the costs. The difference between the two indicates 

whether the planned action is advisable. The real trick to doing a cost benefit analysis well is making sure you 

include all the costs and all the benefits and properly quantify them.

Resources:

About Business Management: http://management.about.com/cs/money/a/CostBenefit.htm.

Covered Entity

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), any entity that is:

• A healthcare provider that conducts certain transactions in electronic form (called here a "covered 

healthcare provider"). 

• A healthcare clearinghouse. 

• A health plan.

Resources:

Centers for Medicare & Medicaid Services (CMS): http://www.cms.hhs.gov/HIPAAGenInfo/06_

AreYouaCoveredEntity.asp.

Current Procedural Terminology® (CPT)

A coding system that describes the procedures, services, or supplies provided to patients within the outpatient 

setting.

Current Procedural Terminology® (CPT), 4th Edition, is a listing of descriptive terms and identifying codes for 

reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately 

describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable 

nationwide communication among physicians, and other healthcare providers, patients, and third parties.

Resources:

American Medical Association (AMA): 

http://www.ama-assn.org/ama/no-index/physician-resources/3882.shtml.

Custodial Care

The treatment or services, regardless of who recommends treatment or services or which such treatment or 

services are provided, that a) can be rendered safely and reasonably by a person who is not medically skilled or 

b) is/are designed mainly to help the patient with the activities of daily living.
Page 166 Appendix C - Definitions Version 3.0 Medical Management Guide

Resources:

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999): http://www.dtic.mil/whs/directives/

corres/pdf/601501m.pdf

See CD-ROM Resource AppendixC-Def 1

Custodial Care Transition Policy, TRICARE: http://manuals.tricare.osd.mil/.

Demand Management

A collection of proactive interventions focused on reducing unnecessary healthcare utilization while 

simultaneously encouraging the appropriate use of healthcare resources.

Resources:

DoD Population Health Improvement Plan and Guide, p. 43 (December 2001): http://www.tricare.mil/ocmo/

download/mhs_phi_guide.pdf.

See CD-ROM Resource ES-1

Diagnosis-Related Group (DRG)

A patient classification system that relates demographic, diagnostic, and therapeutic characteristics of patients 

to length of inpatient stay and amount of resources consumed. It provides a framework for specifying hospital 

case mix and identifies classifications of illness and injury for which payment is made under prospective pricing 

programs.

Resources:

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999): http://www.dtic.mil/whs/directives/

corres/pdf/601501m.pdf.

See CD-ROM Resource AppendixC-Def 1

Disability Evaluation System (DES)

The purpose of the DES is to maintain a fit and vital force. According to DoD regulations, the DES should 

include a Medical Evaluation Board (MEB), a Physical Evaluation Board (PEB), an appellate review process, and a 

final disposition. Service members should be assigned a Physical Evaluation Board Liaison Officer (PEBLO) to help 

them navigate the system.

Resources:

Deployment Health Clinical Center: http://www.pdhealth.mil/hss/des.asp.

See Section III, Case Management

Discharge Planning

The development of an individualized discharge plan for the patient prior to leaving an institution for home, 

with the aim of improving patient outcomes, reducing the chance of unplanned readmission to an institution, 

and containing costs.
Medical Management Guide Version 3.0 Appendix C - Definitions Page 167

Resources:

TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002): http://www.

tricare.mil/to02/APPA.PDF.

See AppendixC-Def2

Disease Management (DM)

• A system of coordinated healthcare interventions and communications for populations with conditions in 

which patient self-care efforts are significant.

• An organized effort to achieve desired health outcomes in populations with prevalent, often chronic 

diseases, for which care practices may be subject to considerable variation.

An organized effort to achieve desired health outcomes in populations with prevalent, often chronic diseases, 

for which care practices may be subject to considerable variation. DM programs manage populations and use 

interventions that are evidence-based. The term “condition management” is also used to include non-disease 

states, such as pregnancy.

Resources:

Disease Management Association of America (DMAA): The Care Continuum Alliance: http://www.dmaa.org/

dm_definition.asp.

DoDI 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) and Remote Areas: 

http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.

Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Jones and Bartlett Publishers, 2007.

DoD Population Health Improvement Plan and Guide, p. 43. December 2001: http://www.tricare.mil/ocmo/

download/mhs_phi_guide.pdf.

Exceptional Family Member Program (EFMP)

See also Military OneSource

The Military Services use the term Exceptional Family Member Program (EFMP) to refer to two different 

functions: a personnel function and a family support function. The EFMP family support function is not 

mandatory. DoD policy allows, but does not require, the Services to offer family support services to EFMs 

within their family support systems. 

In the Army and Marine Corps, EFM support staff are called EFMP Managers (Army) or EFMP Coordinators 

(Marine Corps).

In the Navy, the EFMP staff that support the personnel function may also provide family support services, but 

the Navy does not staff their family centers with EFMP Coordinators. In the Air Force, special needs staff are 

located in the Military Treatment Facility (MTF) only. 

Resources:

DoDI 1342.22, Family Centers, Dec. 30, 1992: http://www.dtic.mil/whs/directives/corres/pdf/134222p.pdf.
Page 168 Appendix C - Definitions Version 3.0 Medical Management Guide

Extended Care Health Option (ECHO)

See also Program for Persons with Disabilities (PFPWD)

A supplemental program to the basic TRICARE program. ECHO provides financial assistance for an integrated 

set of services and supplies to eligible active duty family members (including family members of activated 

National Guard or Reserve members). There is no enrollment fee for ECHO; however, family members must:

• Have an ECHO-qualifying condition.

• Enroll in the Exceptional Family Member Program (EFMP) as provided by the sponsor's Service Branch.

• Register in ECHO through ECHO case managers in each TRICARE region.

Resources:

Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 5 (199.5):

www.tricare.mil/cfr/C5.PDF.

See CD-ROM Resource AppendixC-Def5

TRICARE: www.tricare.mil/mybenefit/Download/Forms/ECHO_Flyer_v3_09_L.pdf.

Factual Determinations (nonmedical necessity)

Determinations issued in cases involving coverage issues, provider authorization (status) requests, hospice care, 

foreign claims, denials based on sections other than National Defense Civilian Health and Medical Program 

of the Uniformed Services (CHAMPUS), Title 32, Section 199, Part 4 (199.4), and both medical necessity and 

factual determinations.

Resources:

TRICARE Operations Manual 6010.51-M, Chapter 13, Section 5, Appeal of Factual (Nonmedical Necessity) 

Determinations: http://www.tricare.mil/TO02/C13S5.pdf.

Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 4 (199.4):

www.tricare.mil/cfr/C4.PDF.

See CD-ROM Resource AppendixC-Def4

Federal Recovery Coordinator (FRC)

The DoD/VA federal Recovery Coordination Program (RCP) provides senior-level clinical nurses and social 

workers through the VA designated as Federal Recovery Coordinators (FRCs). These staff provide oversight of 

the recovery plan for catastrophically injured Service members. The FRC works with the Service member, his/her 

family, and the recovery team to develop a Federal Individual Recovery Plan (FIRP). The FRC continues to work 

with the Service member and his/her family throughout the recovery, rehabilitation, and transition process to 

meet their needs. The FRC remains available to the Service member and his/her family for life as long as they 

need.

Resources:

Department of Veterans Affairs (VA): http://www.oefoif.va.gov/.
Medical Management Guide Version 3.0 Appendix C - Definitions Page 169

Federal Individual Recovery Plan (FIRP)

See Federal Recovery Coordinator (FRC)

Resources:

Department of Veterans Affairs (VA): http://www.oefoif.va.gov/.

Global War on Terrorism (GWOT)/Overseas Contingency Operations (OCO)

Following the terrorists attacks of Sept. 11, 2001, the U.S. began military operations to combat terrorism both 

in the United States and overseas. Military operations to defend the United States against further attacks are 

known as Operation Noble Eagle. Ongoing military operations in Afghanistan and Iraq are known as Operation 

Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively. Together, these three military 

operations are identified as the Global War on Terrorism (GWOT).

In a memorandum from the Office of Management and Budget (OMB) in March 2009, which was forwarded 

to Pentagon staff members from the Defense Department's Office of Security Review, the Obama 

administration noted that it “prefers to avoid using the term 'Long War' or 'Global War on Terror' [GWOT].” It 

asked that the term “Overseas Contingency Operation” be used instead.

Resources:

Government Accountability Office (GAO) publication GAO-05-822, Global War on Terrorism — DoD Needs to 

Improve the Reliability of Cost Data and Provide Additional Guidance to Control Costs, p. 1: http://www.gao.

gov/new.items/d05882.pdf.

U.S. Department of Defense, Officer of the Inspector General: http://www.dodig.mil/gwot_iraq/index.htm.

Wilson, S., Kamen, A. “Global War On Terror” Is Given New Name — Bush's Phrase Is Out, Pentagon Says. 

The Washington Post, March 25, 2009: http://www.washingtonpost.com/wp-dyn/content/article/2009/03/24/

AR2009032402818.html.

Grievance

In the DCS, filing a grievance is the proper method for addressing beneficiary concerns (i.e., complaint) when 

there is a perceived inequity of the benefit, rather than a question of medical necessity. 

Resources:

DoDD 6000.14, Patient Bill of Rights and Responsibilities in the Military Health System (July 30, 1998): http://

www.dtic.mil/whs/directives/corres/pdf/600014p.pdf.

See also Section II, Utilization Management

Group Visit

A relatively new model in healthcare delivery where a number of patients meet on a prescribed basis in an 

expanded office visit that includes care delivery, education, socialization, and one-to-one physician-patient 

time, as needed. Group visits offer staff a new and more satisfying way to interact with patients that makes 

efficient use of resources, improves access, and uses group process to help motivate behavior change and 
Page 170 Appendix C - Definitions Version 3.0 Medical Management Guide

improve outcomes. The Group Visit Starter Kit describes the Cooperative Health Care Clinic (CHCC) model 

developed by the Kaiser Colorado staff. Group visits were pioneered with frail elderly patients who were high 

utilizers of primary care.

In this model, the healthcare team facilitates an interactive process of care delivery in a periodic group visit 

program. The team empowers the patient, who is supported by information and encouraged to make informed 

healthcare decisions. The group visit can be conceptualized as an extended doctor's office visit where not 

only physical and medical needs are met, but education, social, and psychological concerns can be dealt with 

effectively.

Resources:

Institute for Healthcare Improvement: http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/Tools/

GroupVisitStartKit.htm.

Improving Chronic Care:

• http://www.improvingchroniccare.org/downloads/groupvisitmodelcomparison.pdf

• http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_copy1.doc

Health Promotion

Any combination of health information, education, diagnostic screening, and healthcare interventions designed 

to facilitate behavioral alterations that will improve or protect health. It includes those activities intended to 

influence and support individual lifestyle modification and self-care.

MHS population health initiatives often follow guidance from Healthy People (e.g., Healthy People 2010).

Resources:

DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999): http://www.dtic.mil/whs/directives/

corres/pdf/601501m.pdf.

See CD-ROM Resource AppendixC-Def 1

DoDD 1010.10, Health Promotion and Disease Injury Prevention (Aug. 22, 2003): http://www.dtic.mil/whs/

directives/corres/pdf/101010p.pdf.

Healthy People 2010: http://www.healthypeople.gov/.

Health Insurance Portability and Accountability Act (of 1996) (HIPAA)

A law that includes provisions for health insurance portability, fraud and abuse control, tax-related provisions, 

group health plan requirements, revenue offset provisions, and administrative simplification requirements. 

It addresses the use, disclosure, and security of private health information. It affects health care in terms of 

patient privacy and confidentiality. The HIPAA Privacy Rule establishes national standards to protect individuals’ 

medical records and other personal health information and applies to health plans, healthcare clearinghouses, 

and those healthcare providers that conduct certain healthcare transactions electronically. The Rule requires 

appropriate safeguards to protect the privacy of personal health information (PHI) and sets limits and conditions 

on the uses and disclosures that may be made of such information without patient authorization. The Rule also 
Medical Management Guide Version 3.0 Appendix C - Definitions Page 171

gives patients rights over their PHI, including the right to examine and obtain a copy of their health records and 

request corrections.

Resources:

TRICARE:

• http://www.tricare.osd.mil/hipaa/faq_ans.htm

• http://www.tricare.osd.mil/tmaprivacy/hipaa/hipaacompliance/images/pdf/Documentation_Jan03.pdf

Department of Health and Human Services (HHS):

• http://www.hhs.gov/ocr/hipaa/

• http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html

International Classification of Diseases – 9th Revision – Clinical Modification (ICD-9-CM)

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the 

World Health Organization's Ninth Revision, International Classification of Diseases (ICD-9). ICD-9-CM is the 

official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United 

States. The ICD-9 is used to code and classify mortality data from death certificates. The ICD-9-CM consists of:

• A tabular list containing a numerical list of the disease code numbers in tabular form.

• An alphabetical index to the disease entries.

• A classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular 

list).

Resources:

Centers for Disease Control and Prevention (CDC) — Classifications of Diseases and Functioning and 

Disabilities: http://www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm.

Inter/Intraregional Care

Care received in a region other than the region in which the beneficiary is enrolled, which includes both 

continental U.S. and overseas locations.

Intraregional care is care received within a region where a beneficiary is enrolled but outside their MTF’s 

catchment area. Care may be received from any branch of Service.

Resources: N/A

Light Duty

Time spent performing “light duty” work does not count against an employee’s FMLA leave entitlement. The 

employee’s right to restoration is held in abeyance during the period of time the employee performs light duty 

(or until the end of the applicable 12-month FMLA leave year). An employee who is voluntarily performing a 

light duty assignment is not on FMLA leave. 

Presumes frequent provider/patient interaction to determine whether return to full duty status or more 

intensive therapeutic intervention is appropriate in any given case; therefore, light duty will be ordered in 
Page 172 Appendix C - Definitions Version 3.0 Medical Management Guide

periods not to exceed 30 days to ensure appropriate patient clinical oversight. Consecutive light duty for 

any “new condition” up to 90 days may be ordered by the provider (in maximum 30-day periods), but in 

no case will light duty exceed 90 consecutive days, inclusive of any convalescent leave periods. The Federal 

Employees' Compensation Program (FECA) for the Army requires that light duty assignments be provided to 

employees faced with job-related injuries or occupational illnesses or diseases. When medical care is authorized 

under the Federal Employees' Compensation Act (FECA), the supervisor, in coordination with the Civilian 

Personnel Assistance Center (CPAC), offers the employee light duty work in his/her assigned position, or in 

another position, compatible with medically imposed restrictions/limitations. Any position offers made must 

be evaluated by the employee's attending physician to ensure the modified work assignment can safely be 

performed by the employee based upon the limitations of his/her medical condition. 

Resources:

Department of Labor, Wage and Hour Division, Final Rule under the Family and Medical Leave Act (FMLA) 

(effective Jan. 16, 2009):

• http://www.dol.gov/esa/whd/fmla/

• http://www.dol.gov/esa/whd/fmla/finalrule.htm

Army Civilian Personnel Online

http://www.cpol.army.mil/library/permiss/2904e.html

http://www.cpol.army.mil/library/permiss/2904.html

Limited Duty (LIMDU)

See also Temporary Limited Duty (TLD)/Permanent Limited Duty (IPLD)

Limited Duty status allows a Marine to remain on Active Duty when they are not currently fit for full duty, but 

there is high likelihood that, with appropriate treatment, they can be restored to ongoing full and productive 

duty in a reasonable amount of time (defined as 6-14 months). This status will usually prevent them from being 

deployable and has some other administrative ramifications.

Resources:

U.S. Marine Corps (USMC): http://www.usmc-mccs.org/LEADERSGUIDE/keyterm_display.

cfm?anchor=LimitedDuty.

Line of Duty (LOD)

An inquiry into the circumstances surrounding the injury or disease of an Active Duty Service member (ADSM). 

LOD is used to determine the status of an ADSM for indemnity and compensation purposes. LOD investigations 

answer three primary questions:

1. Did the member’s injury or disease occur while performing military duty in a duty status?

2. If not, was it aggravated by military duty?

3. Was the occurrence or aggravation due to the ADSM’s intentional injury or willful negligence?
Medical Management Guide Version 3.0 Appendix C - Definitions Page 173

Resources:

Army: AR 635-40, Physical Evaluation for Retention, Retirement, and Separation:

http://www.army.mil/usapa/epubs/pdf/r635_40.pdf.

Air Force: AFI 36-2910, Line of Duty (Misconduct) Determinations: http://www.e-publishing.af.mil/.

Air Force: AFI 48-123, Medical Examinations and Standards: http://www.e-publishing.af.mil/.

Managed Care Support Contractor (MCSC)

The 50 United States are divided into three TRICARE regions. Each of the regions has a regional contractor 

that helps administer the TRICARE benefit plan. These roles are defined as Managed Care Support Contractors 

(MCSCs). The regional contractors provide a variety of functions, including: 

• Establishing TRICARE provider networks.

• Operating TRICARE service centers. 

• Providing customer service call centers. 

• Providing administrative support, such as enrollment, care authorization, and claims processing. 

• Communicating and distributing educational information to beneficiaries and providers. 

MCSCs work with their TRICARE Regional Offices to manage the benefit at the local level, and receive overall 

guidance from TMA headquarters.

Resources:

TRICARE:

• http://www.tricare.mil/factsheets/viewfactsheet.cfm?id=92

• http://www.tricare.mil/tp02/C12S11_1.PDF

See Section I, Medical Management Essentials.

McKesson® InterQual® Evidence-based Clinical Decision Support Criteria 

Criteria that assist in determining the appropriate level of clinical care for adult and pediatric patients in 

the acute, long-term, rehabilitation, subacute, home care, and skilled nursing facility settings. They provide 

evidence-based clinically appropriate decision-making support to promote care management and facilitation, 

quality improvement, and beneficiary satisfaction.

The criteria are designed to screen for cases that warrant medical review. Used as a UM tool for managing care, 

it is not intended to deny care, but can function as a decision support tool. TMA purchases an enterprise-wide 

license annually for a variety of McKesson InterQual criteria sets for use within MTFs.

Resources:

McKesson: http://www.mckesson.com/.
Page 174 Appendix C - Definitions Version 3.0 Medical Management Guide

Medicaid

A healthcare coverage program for certain low-income individuals and families who meet state and federal 

eligibility requirements. Medicaid does not pay money to patients directly; instead, it sends payments directly 

to healthcare providers. Depending on a state's rules, patients may also be asked to pay a small part of the cost 

(co-payment) for some medical services. Medicaid is a state administered program, with each state setting its 

own guidelines regarding eligibility and services. Many groups of people are covered by Medicaid, but certain 

requirements must be met related to age; whether an individual is pregnant, disabled, blind, or aged; income 

and resources; and a U.S. citizenship or an immigration status. The rules for counting income and resources vary 

from state to state and from group to group. There are special rules for those who live in nursing homes and for 

disabled children living at home.

Resources:

Centers for Medicare & Medicaid Services (CMS): http://www.cms.hhs.gov/home/medicaid.asp.

Medical Department Activity (MEDDAC)

The Army’s medical department.

Resources:

Go Army – Army Health Care: http://www.goarmy.com/amedd/.

Medical Evaluation Board (MEB)

The MEB is a board to identify members whose physical or mental qualification for full duty is in doubt or 

whose physical or mental limitation precludes return to full duty within a reasonable period of time; speaks to 

the degree to which a member can perform his or her duties.

Resources:

Army: AR 40-400, Patient Administration: http://www.army.mil/usapa/epubs/pdf/r40_400.pdf.

Army: AR 40-501, Standards of Medical Fitness: http://www.army.mil/usapa/epubs/pdf/r40_501.pdf.

AFI 36-3209, Separation and Retirement Procedures for Air Force National Guard and Air Force Reserve 

Members: www.af.mil/shared/media/epubs/AFI36-3209.pdf.

Navy: SECNAVINST 1850.4E — Disability and Evaluation Manual:

• http://doni.daps.dla.mil/default.aspx Search for: 1850.4E

• http://www-nmcphc.med.navy.mil/LGuide/Medical/Medical_Boards.htm

Medical Hold

• Mobilized RC soldiers who were unable to deploy with their units due to a medical condition, and were 

not REFRAD within 30 days of mobilization. These soldiers remain on Active Duty awaiting medical/

administrative disposition. 

• Redeployed/Demobilizing RC soldiers who sustained injury, disease, or aggravated pre-existing conditions 

that require medical/administrative resolution before REFRAD/ demobilization. 
Medical Management Guide Version 3.0 Appendix C - Definitions Page 175

Medical Retention Processing (MRP) - Medical holdover soldiers mobilized under Title 10 USC 12302 ISO 

GWOT. All RC soldiers with medical conditions that require more than 60 days for resolution will be asked to 

volunteer to transition to a Medical Retention Processing Unit (MRPU). Soldiers who do not volunteer will be 

released from active duty and briefed on follow-on medical entitlements such as VA hospitals. 

Resources:

Fort Carson the Mountain Post: http://www.carson.army.mil/Moblas/Medical%20Hold.htm.

Medical Management (MM)

An integrated managed care model that promotes Utilization Management (UM), Case Management (CM), 

and Disease Management (DM) programs as a hybrid approach to managing patient care. It includes a shift to 

evidence-based, outcome-oriented UM, and a greater emphasis on integrating clinical practice guidelines into 

the MM process, thereby holding the system accountable for patient outcomes.

Resources: DoD Instruction 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) 

and Remote Areas (Jan. 5, 2006): http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.

Medical Necessity

Accepted healthcare services and supplies provided by healthcare entities, appropriate to the evaluation and 

treatment of a disease, condition, illness, or injury and consistent with the applicable standard of care. Whether 

services or supplies are deemed “medically or psychologically necessary,” depends on the frequency, extent, 

and types of medical services or supplies which represent appropriate medical care and that are generally 

accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness, 

injury, pregnancy, and mental disorders or that are reasonable and adequate for well-baby care.

Resources:

American College of Medical Quality (ACMQ), Policy 8: Definition and Application of Medical Necessity: http://

www.acmq.org/policies/policy8.pdf.

Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 2 (199.2):

http://www.tricare.mil/CFR/C2.PDF. See CD-ROM Resource AppendixC-Def3

Medicare

A health insurance program for people age 65 or older, people under age 65 with certain disabilities, and 

people of all ages with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). 

Medicare has Part A (Hospital Insurance), Part B (Medical Insurance), and Prescription Drug Coverage.

Resources:

Centers for Medicare & Medicaid Services (CMS): 

• http://www.cms.hhs.gov/MedicareGenInfo/

• http://www.cms.hhs.gov/home/medicare.asp

Medicare: http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_alp.php.
Page 176 Appendix C - Definitions Version 3.0 Medical Management Guide

Military Medicine

Every Service’s delivery of health care within their departments, under the leadership of the Surgeon General, 

varies in its administration (i.e., different programs and services). Refer to each command/headquarters’ 

references for more specific information. Military medicine within the DoD collaborates closely with the VA.

Resources:

Army Medicine—Army Medical Command (AMEDD): http://www.armymedicine.army.mil/index.html.

Air Force Medicine—Air Force Medical Service (AFMS): http://www.airforcemedicine.afms.mil/.

Navy Medicine—Bureau of Medicine and Surgery (BUMED): https://navymedicine.med.navy.mil/.

Department of Veteran’s Affairs (VA): http://www.va.gov/.

Milliman Care Guidelines® 

Published by Milliman USA, these guidelines are a set of standardized criteria used in Medical Management 

programs, such as UM. The Guidelines are valuable management tools for treatment that span the continuum 

of patient care, describing best practices for treating common conditions in a variety of care settings. Used in 

conjunction with the healthcare professional’s clinical judgment, they define the assessment and treatment 

modalities that should occur at the primary care level prior to referral for specialty care.

TMA maintains an enterprise-wide license annually for use by MTF personnel within the DCS and is user/

password protected.

Milliman Care Guidelines produces annually updated, evidence-based clinical guidelines that span the 

continuum of care, including chronic care management. The Milliman Care Guidelines® provide much more than 

just authorization criteria, driving high-quality care through such tools as care pathway tables, flagged quality 

measures, and integrated medical evidence.

The current best evidence is optimal only when it allows healthcare professionals to make decisions about the 

care of individual patients in an efficient and timely manner. To that end, the Care Guidelines are incorporated 

into easy-to-use software. From Web-based applications, to interactive software producing real-time 

management reports, to handheld versions, Care Guidelines software makes the current best evidence readily 

available for use where it matters: at the point of care.

Resources:

MillimanTM USA: http://www.milliman.com/.

Milliman Care Guidelines: http://www.careguidelines.com/.

CareWeb (Client Access): http://www.careguidelines.com/login-careweb.htm.

National Defense Authorization Act (NDAA) 2008/NDAA 2007

The National Defense Authorization Act (NDAA) 2008, Title XVI — Wounded Warrior Matters, acknowledges 

challenges associated with caring for wounded, ill, and injured (WII) ADSMs and their families. Under Title XVI, 

the law outlines specific screening, referral, and management requirements for PTSD, TBI, and behavioral health 

conditions. 
Medical Management Guide Version 3.0 Appendix C - Definitions Page 177

In September 2008, the DoD and VA released their response to requirements in the Report to Congress on the 

Comprehensive Policy Improvements to the Care, Management, and Transition of Recovering Service Members

(NDAA Section 1611 and 1615). The DoD/VA report outlines provisions implemented by the two Departments 

that affect medical case managers in the MTF.

Resources:

Government Printing Office (GPO): http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_

public_laws&docid=f:publ181.110.

See Executive Summary, CD-ROM Resource ES-3.

Overseas Contingency Operations (OCO)

See Global War on Terrorism (GWOT)

Permanent Disability Retirement List (PDRL)

See also Temporary Disability Retirement List (TDRL)

If a Service member has been found to be unfit by reason of disability that is found to be of a permanent 

nature and has been rated at 30 percent or greater, or if rated at less than 30 percent but the Service member 

has 20 or more years of service, that Service member will be placed on the PDRL under authority of Title 10 

of the U.S. Code, Section 1201 or 1204. This is a permanent status. A member of the Temporary Disability 

Retirement List (TDRL) whose disability is now considered to be of a permanent nature will be transferred to 

the PDRL.

Resources:

Defense Finance and Accounting Service (DFAS): http://www.dfas.mil/retiredpay/disabilityretirements.html.

Permanent Limited Duty (PLD)

See Limited Duty (LIMDU)

(DoD) Pharmacoeconomic Center (PEC)

A DoD customer-oriented center of expertise (COE) implementing recognized state of the art 

pharmacoeconomic analysis for the purpose of improving readiness by increasing value, quality, and access to 

medical care and pharmacotherapy within the MHS’ available resources.

Resources:

http://www.pec.ha.osd.mil/

Physical Evaluation Board (PEB)

A fact-finding body (informal and formal board) that investigates the nature, origin, degree of impairment, 

and probable permanence of the physical or mental defect or condition of an ADSM; speaks to the member’s 

fitness for continued service based on limitations identified in the MEB.
Page 178 Appendix C - Definitions Version 3.0 Medical Management Guide

Resources:

Army: AR 635-40, Physical Evaluation for Retention, Retirement, and Separation (Feb. 8, 2006):

http://www.army.mil/usapa/epubs/pdf/r635_40.pdf.

Army: AR 600-60, Physical Performance Evaluation System (Feb. 28, 2008):

http://www.army.mil/usapa/epubs/pdf/r600_60.pdf.

Air Force: AFI 36-3212, Physical Evaluation for Retention, Retirement, and Separation (Feb. 2, 2006): http://

www.af.mil/shared/media/epubs/AFI36-3212.pdf.

DoDD 1332.18, Separation or Retirement for Physical Disability (Jan. 5, 2006): http://www.dtic.mil/whs/

directives/corres/pdf/133218p.pdf.

Population Health 

Population-based health care improves the health status of all our beneficiaries by delivering proactive, efficient, 

and effective evidence-based interventions in partnership with our patients.

Resources:

2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_

guide.pdf.

See CD-ROM Resource ES-1

Predictive Modeling

A set of tools used to stratify a population according to its risk of nearly any outcome. Ideally, patients are riskstratified to identify opportunities for intervention before the occurrence of adverse outcomes that result in 

increased medical costs.

A technological tool that functions as an electronic claims canvasser searching for predefined variables of 

interest. This tool is used to identify high-cost diagnoses that, in turn, provide a risk score indicative of the 

likelihood to utilize more healthcare resources and dollars than persons of the same age and gender. 

Resources:

Cousins, Michael S., Shickle, Lisa M., Bander, John A. An Introduction to Predictive Modeling for Disease 

Management Risk Stratification. Disease Management, September 2002 — 5(3): 157-167.

Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed., 378-379. Jones and Bartlett Publishers, 2007.

See CD-ROM Resources MME-1 and MME-2

Carlson, B. Predictive Modeling, Sharp Lens on Near Future. Managed Care, July 2003. MediMedia USA: 

http://www.managedcaremag.com/archives/0307/0307.predictive.html.

Hodgman, S.B., BS, MSc, RN, CPUM. Predictive Modeling & Outcomes. Professional Case Management, 13:1, 

19–23, January/February 2008: http://www.nursingcenter.com/prodev/ce_article.asp?tid=765747.
Medical Management Guide Version 3.0 Appendix C - Definitions Page 179

Primary Prevention

(see also Secondary Prevention, Tertiary Prevention)

A stage of Medical Management that occurs when the goal is to avert or slow the onset or incidence of 

disease.

Resources:

2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_

guide.pdf.

See Executive Summary, CD-ROM Resource ES-1

Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. Case 

Management Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.

Profiling 

The collection and analysis of clinical utilization data to produce specific information on resource consumption 

and outcomes of care.

Resources:

Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Jones and Bartlett Publishers, 2007.

Kongstvedt, P. R. The Managed Health Care Handbook. Aspen, 2007. 

Program for Persons with Disabilities (PFPWD) 

See Extended Care Health Option (ECHO)

Recovery Care Coordinator (RCC)

See also Federal Recovery Coordinator, Recovery Care Plan, Recovery Coordination Program

The ultimate resource for wounded, ill, and injured Service members and veterans, and their families. This role 

oversees the development and delivery of services/resources through the comprehensive recovery care plan in 

conjunction with multi-disciplinary teams (MDTs), to ensure quality care and accountability.

Resources:

National Resource Directory: http://www.nationalresourcedirectory.gov/.

Department of Veterans Affairs (VA): http://www.va.gov/JOBS/Fed_Recover_Coord.asp.

See CD-ROM Resources CM-25, CM-26, CM-27, CM-28, CM-29, CM-30, CM-31, CM-32

Recovery Care Plan

See also Recovery Care Coordinator, Recovery Coordination Program

An individualized, integrated, longitudinal, medical/nonmedical service plan across the continuum of care to 

meet personal and professional goals of wounded, ill, and injured Service members and veterans, and their 

families.

Resources: See Recovery Coordination Program
Page 180 Appendix C - Definitions Version 3.0 Medical Management Guide

Recovery Coordination Program (RCP)

See also Recovery Care Coordinator, Recovery Care Plan

NDAA 2008 requires the Services (Army, Navy, AF, Marines) to establish a federal Recovery Care Program (RCP) 

for wounded, ill, and injured Service members who may be medically retired or separated from the military. 

Referral for the program is through a screening process performed by the Service that considers acuity in both 

medical and nonmedical (e.g., financial, housing, family support) areas. 

Resources:

National Resource Directory: http://www.nationalresourcedirectory.gov/.

Department of Veterans Affairs: http://www.va.gov/JOBS/Fed_Recover_Coord.asp.

See CD-ROM Resources CM-25 through CM-32.

Referral Management (RM)

The process by which primary care managers (PCMs) determine if they need to refer a member either to a 

specialist or for services to be performed outside of the PCM’s office (e.g., diagnostic tests, outpatient surgery, 

home health care). If a referral is necessary, the PCM also needs to decide to whom the referral is made, for 

how long, and for which services.

Resources:

Milliman Care Guidelines®: http://www.careguidelines.com/login-careweb.htm.

TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002): 

http://www.tricare.mil/to02/APPA.PDF.

See CD-ROM Resource AppendixC-Def2

Respite Care

Short-term care for a patient in order to provide rest and change for those who have been caring for the patient 

at home, usually the patient’s family. Respite care is an essential part of the overall support that families may 

need to keep their child with a disability or chronic illness at home.

Resources:

TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002): 

http://www.tricare.mil/to02/APPA.PDF.

See CD-ROM Resource AppendixC-Def2

Autism and PPD Support Network: http://www.autism-pdd.net/respite.html.

Secondary Prevention

(see also Primary Prevention, Tertiary Prevention)

A stage of Medical Management that occurs when the goal is to detect disease.
Medical Management Guide Version 3.0 Appendix C - Definitions Page 181

Resources:

2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_

guide.pdf.

See Executive Summary, CD-ROM Resource ES-1

Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. Case 

Management Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.

Self-Management/Self-Care Programs

The provision of information and services to members of a healthcare plan to assist them to maintain personal 

health and make appropriate decisions concerning medical care.

Resources:

HealthWise Handbook: http://www.healthwise.org/p_selfcare.aspx. 

Vickery, D.; Fries, J. Take Care of Yourself, 8th ed. Da-Capo Press, 2004.

Self-Management Education

When patients are involved in their own care, have increased knowledge of their condition, and confidence in 

their ability to adapt to change; and their ability to reach treatment goals is realized. Self-care may include:

• Health promotion activities.

• Clinical preventive services.

• Behavior modification.

• Compliance monitoring. 

Resources:

Institute for Healthcare Improvement (IHI): http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/

Changes/Self-Management.htm.

Healthnet Federal Services: https://www.hnfs.net/bene/healthyliving/self-care.htm.

California HealthCare Foundation: http://www.chcf.org/topics/chronicdisease/index.cfm?subtopic=CL613.

Social Security Disability Income (SSDI)

SSDI is paid to individuals who have worked in the recent years, usually 5 out of the last 10 years. For 

individuals under 31 years old, the requirements are a little different since they may have not been in the work 

force as long.

Resources:

Social Security Administration (SSA): http://www.ssa.gov/disability/.

Social Security Disability Claims: http://www.social-security-disability-claims.org/.
Page 182 Appendix C - Definitions Version 3.0 Medical Management Guide

Supplemental Security Income (SSI)

SSI is a federal income supplement program funded by general tax revenues (not Social Security taxes). It is 

designed to help aged, blind, and disabled people who have little or no income. It provides cash to meet basic 

needs for food, clothing, and shelter.

Resources:

Social Security Administration (SSA): http://www.socialsecurity.gov/ssi/.

Temporary Disability Retirement List (TDRL)

See also Permanent Disability Retirement List (PDRL)

If, as the result of a Physical Evaluation Board finding, a Service member is found unfit to perform his/her duties 

by reason of a disability which may not be of a permanent nature, that Service member may be placed on the 

Temporary Disability Retired List under the authority of Title 10 of the U.S. Code, Section 1202 or 1205.

Resources:

Defense Finance and Accounting Service (DFAS): http://www.dfas.mil/retiredpay/disabilityretirements.html.

Temporary Limited Duty (TLD)

See Limited Duty (LIMDU)

Tertiary Prevention

(see also Primary Prevention, Secondary Prevention)

A stage of Medical Management that occurs when the goal is to prevent further suffering at end the stage of 

the disease.

Resources:

2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_

guide.pdf.

See Executive Summary, CD-ROM Resource ES-1.

Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. Case 

Management Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.

Transitional Assistance Management Program (TAMP)

TAMP offers transitional TRICARE coverage to certain separating ADSMs and their eligible family members. 

Care is available for a limited time. Under the National Defense Authorization Act for Fiscal Year 2005, effective 

Oct. 28, 2004, TRICARE eligibility under the TAMP has been permanently extended from 60 or 120 days to 180 

days.

The four categories for TAMP are:

• Members involuntarily separated from active duty and their eligible family members.

• National Guard and Reserve members, collectively known as the Reserve Component (RC), separated from 
Medical Management Guide Version 3.0 Appendix C - Definitions Page 183

Active Duty after being called up or ordered in support of a contingency operation for an Active Duty 

period of more than 30 days, and their family members.

• Members separated from Active Duty after being involuntarily retained in support of a contingency 

operation, and their family members.

• Members separated from Active Duty following a voluntary agreement to stay on Active Duty for less than 

one year in support of a contingency mission, and their family members.

Resources:

TRICARE: http://www.tricare.mil/factsheets/viewfactsheet.cfm?id=317.

Traumatic Injury Protection under Service members' Group Life Insurance (TSGLI) 

A traumatic injury protection rider under Service members’ Group Life Insurance (SGLI) that provides for 

payment to any member of the Uniformed Services covered by SGLI who sustains a traumatic injury resulting in 

certain severe losses. Effective Dec. 1, 2005, every member who has SGLI also has TSGLI. This coverage applies 

to ADSMs, Reservists, National Guard members, funeral honors duty, and one-day muster duty. This benefit is 

also provided retroactively for members who incur severe losses as a result of traumatic injury between Oct. 7, 

2001 and Dec. 1, 2005 if the loss was the direct result of injuries incurred in Operation Enduring Freedom (OEF) 

or Operation Iraqi Freedom (OIF).

Resources:

Department of Veterans Affairs (VA): http://www.insurance.va.gov/SGLISITE/legislation/TSGLIFacts.htm.

Utilization Management (UM)

A methodology that addresses the issue of managing use of resources in the delivery of health care, while also 

measuring the quality associated with the delivery of that care.

Resources:

McKesson Certified Professional in Healthcare Management (CPHM) Study Guide 2, 148. September 2009.

Utilization Review (UR)

The process of determining whether all aspects of a patient’s care, at every level, are medically necessary and 

appropriate.

Resources:

McKesson Certified Professional in Healthcare Management (CPHM) Study Guide 2, 148. September 2009.
Page 184 Appendix C - Definitions Version 3.0 Medical Management Guide

Variance Analysis

Variance analysis is the variation or differences in quality and cost (underuse or overuse of services) in care that 

identifies opportunities for cost reduction and quality improvement. Variations can be negative or positive and 

may occur in six sources:

1. Patient/family

2. Clinical status

3. Practitioner

4. Community

5. Service delays

6. System delays

There are two types of variance data: patient care activity is not performed as ordered and expected outcomes 

are not achieved. Variance analyses may include both cost and statistical variances.

Resources:

Rossi, P. A. Case Management in Healthcare: A Practical Guide. (2nd ed.). W.B. Saunders, 2003: 

http://www.ramex.com/title.asp?id=9606.

StatGraphics: http://www.statgraphics.com/analysis_of_variance.htm.

CD-ROM RESOURCES

AppendixC-Def1 DoD Manual 6015.1-M, Glossary of Healthcare Terminology

AppendixC-Def2 TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions 

AppendixC-Def3 Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 2 

(199.2)

AppendixC-Def4 Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 4 

(199.4)

AppendixC-Def5 Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 5 

(199.5)

‘
Medical Management Guide Version 3.0 Appendix D - Resources Page 185

Appendix D – Resources

Agency for Health Care Research and Quality (AHRQ) 

A federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for 

all Americans. Information from AHRQ research helps people make more informed decisions and improve the 

quality of healthcare services. The website supports evidence-based practice, clinical practice guidelines (CPGs), 

the National Guideline Clearinghouse, healthcare outcomes and efficacy, quality, and patient safety.

Resources: http://www.ahrq.gov/

Air Force Wounded Warrior (AFW2)

The Air Force facilitates enhanced assistance for airmen/women and their families through AFW2. An AF 

wounded warrior is any airman/woman with a combat or hostile-related injury or illness requiring long-term 

care that will require a Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB) to determine fitness 

for duty. A combat or hostile-related injury results from hazardous service or performance of duty under 

conditions simulating war or through an instrumentality of war.

Resources: http://www.woundedwarrior.af.mil/ VA: http://www.veteransforamerica.org/woundedwarrior/ 

DoD/MHS: http://mhs.osd.mil/WoundedWarrior.aspx

Armed Forces Health Surveillance Center (AFHSC) 

A center designated by Health Affairs and the Secretary of Defense as the central epidemiological resource for 

medical surveillance of military and military-associated populations. Via the DMSS and DMED databases, the 

AFHSC provides regularly scheduled and customer-requested analyses and reports to policymakers, medical 

planners, and researchers.

Resources: http://afhsc.army.mil/

Army Wounded Warrior Program (AW2) — U.S. Army Human Resources Command

See also Warrior in Transition (WT) Program

The Army facilitates enhanced assistance for soldiers and their families through AW2. An Army wounded 

warrior is any soldier with a combat or hostile-related injury or illness requiring long-term care that will require 

a Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB) to determine fitness for duty. A combat or 

hostile-related injury results from hazardous service or performance of duty under conditions simulating war or 

through an instrumentality of war.
Page 186 Appendix D - Resources Version 3.0 Medical Management Guide

Resources: https://www.aw2.army.mil/index.html

VA: http://www.veteransforamerica.org/woundedwarrior/

DoD/MHS: http://mhs.osd.mil/WoundedWarrior.aspx

BNET Business Library

Resources: http://jobfunctions.bnet.com/Industries/Healthcare+and+Medical/

Case Management Society of America (CMSA)

An international, non-profit organization dedicated to the support and development of the profession of Case 

Management through educational forums, networking opportunities, and legislative involvement. CMSA offers 

membership discounts for military personnel, as well as a military forum during its annual national conference.

Resources: http://cmsa.org/

Center for Case Management

Resources: http://www.cfcm.com/

Centers for Medicare & Medicaid Services (CMS)

A federal agency within the Department of Health and Human Services (HHS). CMS programs/initiatives 

include Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and Clinical Laboratory 

Improvement Amendments (CLIA).

Resources: http://www.cms.hhs.gov/

Community Based Warrior Transition Unit (CBWTU) Program

A program initiated in 2004 that allows Reserve Component (RC) soldiers placed in Medical Retention 

Processing (MRP) status to return home and complete their medical care in their local communities, rather than 

being required to remain on an installation that may be thousands of miles from their homes and families. It 

is the policy of the U.S. Army Medical Command (MEDCOM) that all RC WT soldiers be assessed for referral 

to the CBWTU. When referred by the WTU nurse case manager (NCM) and accepted by the CBWTU, the WT 

soldier is transferred and attached to the CBWTU that covers the region where that soldier lives. There are 

nine CBWTU regional headquarters, located in the states of Alabama, Arkansas, California, Florida, Illinois, 

Massachusetts, Utah, and Virginia; and in Puerto Rico. WT soldiers at the CBWTU normally receive their 

medical care from civilian network providers and are managed by their assigned CBWTU NCM. WT soldiers 

who live within the TRICARE catchment area of an MTF are enrolled Prime to that location but continue to be 

managed by the CBWTU NCM.

Resources:

U.S. Army Medical Department (AMEDD), North Atlantic Regional Medical Command: http://www.narmc.

amedd.army.mil/Pages/default.aspx
Medical Management Guide Version 3.0 Appendix D - Resources Page 187

Defense Health Services Systems (DHSS)

The office that provides decision support information and tools used by managers, clinicians, and analysts to 

manage the business of health care within the MHS. DHSS is comprised of a data warehouse and operational 

data marts to support clinical practice, medical logistics, and the business of military medicine. Among the 

deployed applications supported by DHSS are the MCFAS, M2, Clinical Data Mart (CDM), EAS-IV, TRICARE 

Online (TOL), and the TMA reporting tools (CDIS, CMIS, and CURES) — see Section V, Medical Management 

Tools.

Resources: http://www.health.mil/DHSS/

Department of Veterans Affairs (VA)

Established March 15, 1989 as the federal agency succeeding the Veterans Administration. It is responsible for 

providing federal benefits to veterans and their families. Headed by the Secretary of Veterans Affairs, the VA is 

the second-largest of the 15 Cabinet departments and operates nationwide programs for health care, financial 

assistance, and burial benefits.

Resources: http://www.va.gov/

Journals

A list of current journals and other general website publication resources.

Resources: 

Medical Management

American Journal of Managed Care (AJMC): http://www.ajmc.com/

Frontiers of Health Services Management — American College of Healthcare Executives (ACHP), Health 

Administration Press: http://www.ache.org/

Group Practice Journal — American Medical Group Association: http://www.amga.org/

Health Care Management Review — Wolters Kluwer Health/Lippincott, Williams & Wilkins: http://journals.lww.

com/

Health Care Management Science — Springer: http://www.springer.com/

Health Care Risk Report: http://www.healthcareriskreport.com/

Health Economics: http://www.healtheconomics.com/journals.cfm

Healthcare Executive — American College of Healthcare Executives (ACHP), Health Administration Press: http://

www.ache.org/

HealthLeaders Media: http://www.healthleadersmedia.com/

International Journal of Healthcare Quality Assurance: 

http://info.emeraldinsight.com/products/journals/

Journal for Healthcare Quality — National Association for Healthcare Quality: http://www.nahq.org/journal/

Journal of Health Care Finance — Wolters Kluwer/Aspen Publishers: http://www.aspenpublishers.com/

Journal of Healthcare Information Management — Healthcare Information and Management Systems Society 

(HIMSS): http://www.himss.org/
Page 188 Appendix D - Resources Version 3.0 Medical Management Guide

Journal of Healthcare Management — American College of Healthcare Executives (ACHP), Health 

Administration Press: http://www.ache.org/

Managed Care Magazine: http://www.managedcaremag.com/

Managed Care Interface — Medicom International/Managed Care Online: http://www.mcol.com/

Managed Healthcare Executive: http://managedhealthcareexecutive.modernmedicine.com/

Case Management

American Journal of Medical Quality — SAGE JOURNALS Online: http://ajm.sagepub.com/

Care Management Journals (Journal of Case Management/Journal of Long Term Home Health Care) — Springer 

Publishing Company: http://www.springerpub.com/

International Journal for Human Caring (IJHC): http://www.humancaring.org/journal/

Case Management Advisor — AHC Media, LLC: http://www.ahcpub.com/

Collaborative Case Management — American Case Management Association: http://www.acmaweb.org/

The Health Care Manager — Wolters Kluwer/Lippincott, Williams & Wilkins: http://journals.lww.com/

Home Healthcare Nurse — Home Healthcare Nurses Association: http://www.homehealthcarenurseonline.com/

Medical Disability Advisor

Professional Case Management — Wolters Kluwer/Lippincott, Williams & Wilkins: http://journals.lww.com/. 

Official journal of:

•	 Case Management Society of America: http://www.cmsa.org/

•	 National Case Management Network of Canada: http://www.ncmn.ca/

Social Work in Healthcare — Routledge, Taylor and Francis Group: http://www.routledge.com/

The Case Manager: http://www.thecsmgr.com/

Disease Management

Disease Management — Mary Ann Liebert, Inc. Publishers: http://www.liebertpub.com/ — Official journal of 

the Disease Management Association of America: The Care Continuum Alliance (DMAA): http://www.dmaa.

org/

Disease Management and Clinical Outcomes — Elsevier Science: http://www.elsevier.com/

Disease Management and Health Outcomes — ADIS Data Information/Wolters Kluwer: http://pharma.

wkhealth.com/

International Journal of Evidence-Based Healthcare — Joanna Briggs Institute: http://www.joannabriggs.edu.

au/about/home.php — Wiley: http://www.wiley.com/

Evidence-Based Medicine: http://ebm.bmj.com/

MHS Clinical Quality Management (CQM)

The MHS portal offering information and educational resources for MHS staff in the areas of clinical quality, 

patient safety, and quality assurance.

Resources: https://www.mhs-cqm.info/
Medical Management Guide Version 3.0 Appendix D - Resources Page 189

Military OneSource

Military OneSource is a Tri-Service, 24/7 information and referral program for participating Service families. It 

offers resources to help families address a wide range of everyday issues, including parenting and child care, 

older adults, education, and financial and legal matters. Assistance may be obtained via phone or online. Each 

Service has its own home page and log-on tool.

Resources: http://www.militaryonesource.com

Army: http://www.armyonesource.com/

Air Force: http://www.airforceonesource.com/

Navy: http://www.navyonesource.com/

Military Medical Support Office (MMSO)

A TRICARE office that provides a variety of functions, as follows:

•	 Acts as a liaison between MCSCs, Services, Commanders, and MTFs for ADSMs not enrolled to MTFs on 

military-unique issues.

•	 Provides customer service for Commanders, HBA, MTF and TPR ADSMs.

•	 Identifies ADSMs with serious medical conditions for the Services.

•	 Assists MCSC/MTF on care management coordination, as needed.

•	 Authorizes care for National Guard/Reserve members not eligible in DEERS (i.e., line-of-duty injuries/

illnesses).

•	 Provides claims payment determinations for MCSCs unable to pay.

•	 Coordinates appeals for denied claims and debt collection cases.

Resources: http://www.tricare.mil/tma/MMSO/index.aspx

Multi-Service Market Office (MSMO)

A TRICARE office that serves areas with more than one Service with an MTF and in which the markets overlap. 

A Senior Market Manager — a designated MTF Commander — is appointed to each MSMO. This role is 

responsible for developing a single, consolidated, integrated business plan for the DCS and PCS for other 

Services located in the MSMO. There are 12 MSMOs, located in the following geographic areas: National 

Capital Area (NCA), Tidewater, Ft. Bragg/Pope, Charleston, Ft. Jackson/Shaw, Gulf Coast, San Antonio, 

Colorado Springs, San Diego, Puget Sound, Hawaii, and Alaska. All other MTFs are considered single market 

managers.

Resources: http://www.tricare.osd.mil/

National Committee on Quality Assurance (NCQA)

A private, non-profit organization that is dedicated to improving healthcare quality. NCQA also provides 

accreditation for organizational health plans that report performance on quality of care, access, service, and 

member satisfaction.

Resources: http://www.ncqa.org/
Page 190 Appendix D - Resources Version 3.0 Medical Management Guide

National Guideline ClearinghouseTM (NGC)

A public resource for evidence-based clinical practice guidelines. NGCTM is sponsored by the AHRQ and 

provides an easily accessible mechanism for obtaining objective, detailed information on CPGs and furthering 

their dissemination, implementation, and use.

Resources: http://www.guideline.gov/

National Quality Forum (NQF)

Promotes change through development and implementation of a national strategy for healthcare quality 

measurement and reporting.

Resources: http://www.qualityforum.org/

National Quality Measures ClearinghouseTM (NQMC) 

A public archive for evidence-based quality measures and measure sets sponsored by the AHRQ. It was 

developed to promote widespread access to quality measures by the healthcare community.

Resources: http://www.qualitymeasures.ahrq.gov/

National Transition of Care Coalition (NTOCC)

A coalition formed in 2006 that brings together thought leaders, patient advocates, and healthcare providers 

from various care settings who are dedicated to improving the quality of care coordination and communication 

when patients are transferred from one level of care to another.

Resources: http://www.ntocc.org

Navy Safe Harbor

The Navy facilitates enhanced assistance for seamen/women and their families through Navy Safe Harbor. A 

Navy wounded warrior is any seaman/woman with a combat or hostile-related injury or illness requiring longterm care that will require a Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB) to determine 

fitness for duty. A combat or hostile-related injury results from hazardous service or performance of duty under 

conditions simulating war or through an instrumentality of war.

Resources: http://www.npc.navy.mil/CommandSupport/SafeHarbor/

VA: http://www.veteransforamerica.org/woundedwarrior/ DoD/MHS: http://mhs.osd.mil/WoundedWarrior.aspx

Population Health and Medical Management Division (PHMMD)

(formerly MHS Optimization and Population Health Support Center [OPHSC])

The PHMMD is the division within the TRICARE Office of the Chief Medical Officer (OCMO) that provides a 

single point of access for reference materials, tools, Service links, MHS innovations, discussion forums, and 

accredited Web-based learning modules that support and promote essential transformation, cultural change, 

and knowledge transfer.

Resources: http://www.tricare.mil/ocmo/OCMO_PHMM.cfm
Medical Management Guide Version 3.0 Appendix D - Resources Page 191

Social Security Administration (SSA)/Social Security Online

A federal program to assist with the economic security of U.S. citizens. Social Security assists with retirement 

benefits for the primary worker, as well as survivor benefits and benefits for the retiree’s spouse and children. 

Social security also provides for disability benefits through Medicare (see Centers for Medicare & Medicaid 

Services).

Resources: http://www.ssa.gov/

The Joint Commission (TJC)

An independent, non-profit organization that is the predominant standard-setting and accrediting body in 

U.S. health care. TJC develops state-of-the-art, professionally based standards and evaluates the compliance of 

healthcare organizations against these criteria. TJC’s mission is to continuously improve the safety and quality of 

care provided to the public through the provision of healthcare accreditation and related services that support 

performance improvement in healthcare organizations.

Resources: http://www.jointcommission.org/

TRICARE

The DoD’s worldwide healthcare program for Active Duty and retired Uniformed Services members and their 

families. Consists of:

•	 TRICARE Prime (managed care option)

•	 TRICARE Extra (preferred provider option)

•	 TRICARE Standard (fee-for-service option)

•	 TRICARE For Life (for Medicare-eligible beneficiaries age 65 and over effective 1 Oct 01)

Eligible MHS beneficiaries receive certain benefits based on their chosen health plan.

Resources: http://www.tricare.osd.mil/ e-mail: questions@tma.osd.mil

TRICARE Area Office (TAO) — see TRICARE Regional Office (TRO)

In overseas locations, TRICARE Regional Offices (TROs, see below) are called “area offices.” The TAOs consist of 

Europe, Pacific, Alaska, and Latin America/Canada.

Resources: See TRICARE Regional Office (TRO)

TRICARE Online (TOL)

An enterprise-wide, secure Internet portal for use by DoD beneficiaries, providers, and managers worldwide. 

TOL provides access to health and contact information for hospitals, clinics, and providers. It provides links to 

information on TRICARE services and benefits, as well as helpful resources, such as DM tools, a drug interaction 

checker, and a Personal Health Journal. TOL enables TRICARE Prime and Plus members to make appointments 

with a PCM online. TOL is maintained by the Clinical Information Technology Program Office (CITPO) at the 

Defense Health Services Systems (DHSS).

Resources: http://www.tricareonline.com/
Page 192 Appendix D - Resources Version 3.0 Medical Management Guide

TRICARE Regional Office (TRO)

TRICARE has three regional offices: North, South, and West. 

Resources: http://www.tricare.osd.mil/

Uniformed Biostatistical Utility (UBU) Working Group

The group responsible for the detailed analysis required to standardize biostatistical data elements, definitions, 

data collection processes, procedure codes, diagnoses, and algorithms across the MHS. The UBU Working 

Group consists of multi-disciplinary functional experts from each Service. The UBU also consists of a subworkgroup of Service coders who develop and publish DoD Coding Guidelines when coding patient care in the 

MHS.

Resources: http://www.tricare.mil/ocfo/bea/ubu/index.cfm

Uniformed Business Office (UBO)

An office within the TRICARE Office of the Chief Financial Officer (OCFO) Management Control & Financial 

Studies (MCFS) Division. It supports TRICARE managed care programs by providing tools and policies to 

enhance and improve the effectiveness of the financial and collection operations. This includes providing 

support for managing and expediting collections from patients and third-party insurers; consistent and uniform 

reporting of expense, manpower, and workload data; and enhancing third-party reimbursements. These efforts 

are coordinated by the charted UBO Advisory Working Group, which includes members from each Service.

Resources: http://www.tricare.mil/ocfo/mcfs/ubo/index.cfm

U.S. Army Medical Command (MEDCOM) Quality Management Office (QMO)

Resources: https://www.qmo.amedd.army.mil/

U.S. Preventive Services Task Force (USPSTF)

An independent panel of experts in primary care and prevention that systematically reviews the evidence of 

effectiveness and develops recommendations for clinical preventive services.

Resources: http://www.ahrq.gov/clinic/uspstfix.htm

Utilization Review Accreditation Commission (URAC) (formerly American Accreditation Healthcare 

Commission [AAHC])

A not-for-profit organization founded to promote the accountability of healthcare organizations with 

the establishment of utilization review accreditation standards. Individual states often require utilization 

management organizations to be URAC-accredited before they can operate. 

Resources: www.urac.org
Medical Management Guide Version 3.0 Appendix D - Resources Page 193

Warrior in Transition Program (WT) — see also Army Wounded Warrior Program (AW2)

As a result of Global War on Terrorism (GWOT) missions, including Operation Iraqi Freedom (OIF) and Operation 

Enduring Freedom (OEF), the highest rate of transition resource need has occurred in the Army. A unique 

responsibility for case managers working in the MHS involves caring for Army Service members in Warrior 

Transition (WT) status.

A WT member is defined as a Service member from any component (Active Compo [1], Army National Guard 

[2], or USAR [3]) who has been assigned to a WT unit.

•	 Active Compo soldiers who require at least six months of significant care and rehabilitation and intensive 

CM are assigned to a WTU. 

•	 Reserve Component (RC) WT soldiers are assigned to a WTU when they:

o	 Have experienced injury or illness during training prior to mobilization (e.g., during training).

o	 Have sustained injuries during deployment and were Medevaced.

o	 Upon redeployment, were identified with an injury or illness that was caused by mobilization or 

aggravated during mobilization.

RC soldiers are placed on Medical Retention Processing (MRP), MRP2, or Active Duty Medical Extension (ADME) 

orders when they are assigned to the WTU.

WTU Nurse Case Manager (NCM)

The WTU nurse case manager (NCM) in the WTU is involved not only with the medical care and execution 

of the treatment plan, but also with the WT soldier’s transition back to duty; or to civilian life, if separated 

from the Service. As part of the Triad of care (the primary case manager [PCM], NCM, and squad leader), the 

NCM plays a key role in the development of the Comprehensive Transition Plan (CTP). He/she is responsible 

for documenting the clinical aspects of the CTP, coordinating with the VA for post-WTU care and follow-on 

services, and ensuring the family is aware and engaged to the extent possible in the WT soldier’s care and 

transition. The NCM also works closely with other members of the recovery team, including AW2 advocates, 

FRCs, and RCCs.

While in WT status, a soldier is on a Temporary or Permanent profile and receives the appropriate medical care 

until he/she is determined to fall under one of the following statuses:

•	 Found fit for duty and returned to his/her unit.

•	 Released from Active Duty (REFRAD) Reserve Component (RC) soldier. 

•	 Has achieved optimal medical benefit according to the PCM (and therefore does not meet retention 

standards), has been referred to and completed a Medical Evaluation Board (MEB), and has completed the 

Physical Disability Evaluation System (PDES) process. 

The Army has instituted the following enhanced access standards to improve the medical treatment process:

•	 Seventy-two hours for initial specialty referrals.

•	 One week for magnetic resonance imaging and other diagnostic studies.

•	 Two weeks for surgery (from decision time to day of surgery).

In addition, the ratio of WT soldiers to NCMs is 1:20, to facilitate close monitoring and assistance for the WT 
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and his/her family. These standards exceed TRICARE standards and are only applicable to care within MTFs. 

The MEDCOM standard for completing the MEB is 90 days. It is critical that the NCM work closely with the 

assigned Physical Evaluation Board Liaison Officer (PEBLO) to make the process as expeditious as possible. 

Resources: https://www.aw2.army.mil/index.html

Wounded Warrior Regiment (WWR) – Marines

Established in April 2007 as a result of Planning Guidance created in 2006 by the 34th Commandant of the 

Marine Corps, the WWR grew out of a combination of the 2005 Marine for Life Ill/ Injured Support Section 

and the 2004 wounded warrior barracks in Camp Lejeune, North Carolina. Its mission is to provide and 

facilitate assistance to wounded, ill, and injured Marines and sailors attached to or in support of Marine units 

throughout the phases of recovery; as well as assisting their family members. The WWR is headquartered in 

Quantico, Virginia, with Wounded Warrior Battalions on both the East and West Coasts. 

Resources: http://www.woundedwarriorregiment.org/WWR.aspx

CD-ROM RESOURCES

AppendixD_Res1 Army G-1 WTU Consolidated Guidance

Hyperlinks to outside websites: Links to outside websites found printed here are provided only as a convenience to assist you in 

locating information that may be helpful. You should note that changes may occur since the printing of this Guide which may affect 

the accuracy or availability of the referenced hyperlink. Please see the CD-ROM for perma-saved resource information.

All contents © 2009 DoD/Office of the Chief Medical Officer (OCMO)/TRICARE Management Activity (TMA) and the various other 

organizations whose work is reproduced here.

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