Purpose of the NQMC Contract

The purpose of this contract is to assist Health Affairs, TRICARE Management Activity (TMA), the Market Managers, and the new TRICARE Regional Offices by providing the Government with an independent, impartial evaluation of care provided to the Military Health System (MHS) beneficiaries.

 

NQMC Primary Responsibilities

• Retrospective Chart Review for Quality of Care
• External Reviews for TMA Appeals, Hearings and Claims Collections Division
• Medical Necessity (Reconsideration) Appeals
• Military Treatment Facility Standard of Care Peer Reviews
• Mental Health Facility Certifications
• Focused Studies
• Technology Assessments

 

 

For retrospective chart reviews the following issues are reviewed, as applicable for each case.

• Was the service provided a TRICARE covered benefit?
• Were there any coding irregularities?
• Were there any appearances of Fraud or Abuse?
• If preauthorization or prepayment review was necessary, was it done?
• Was the hospitalization preventable?
• Did a Patient Safety Event occur?
• Was the care medically necessary and provided at the appropriate level of care, including length of stay?
• Were there are any quality issues including specific clinical indicators for acute myocardial infarction, community acquired pneumonia, heart failure, surgical care, and patient harms?"