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Business Rules

The document titled TRICARE Management Activity Appointment Type Standardization represents the methodology for standardization of the clinical appointment data field names for use throughout the Military Health System. This product evolved from the Department of Defense-wide standardization effort of the CHCS data value names for appointment types, clinic names, and other data values as necessary to support standardized business practices in the clinical appointment process. Refer to this document on the Web site for more details. A summary of its recommendations and philosophy is provided below.

The booking philosophy is the right patient appointed to the right provider, at the right time and the right location. The criteria to match the patient to the provider include enrollment status, age, sex, time, location, and clinical need. The appointing system will be demand-focused, not supply-focused, and will strive to match supply to demand. An additional goal of the appointing process is to maximize the utilization of MTF capacity. However, the appointment system will not be developed as a tool for workload or workforce accounting.

Manual Processes

Sites must implement the following processes to improve access to care:

Building Schedules and Privileges
  • Differentiate visit type
  • Assign the authority to arrange visits
  • Differentiate time expectations
  • Differentiate visit duration
  • Booking Appointments
  • Identify procedures
  • Match patient to provider skill
  • Match patient needs to resources
Access to Care Measurement
  • Allow for performance measurement
  • Demonstrate effectiveness, efficiency, and customer satisfaction through surveys and other means
MHS Enterprise Appointment and Referral Business Rules

The order of precedence for the search (non-Specialized Treatment Service (STS)) for an appointment location is:

For Prime patients seeking primary care: 1. PCM-physician based in any place of care where the
    PCM practices
2. PCM-any PCM group member providing service in the
    enrollee's place of care
3. Operational Forces: any provider in any place of care in
    any MCP provider group to which the patient's assigned
    PCM is a member.


For non-prime patients seeking primary care: 1. PCM-civilian or MTF | Next available MTF | Network physician |
    Non-network physician.



For Prime patients seeking specialty care: 1. MTF-based physician or clinic requested by PCM
2. Next available MTF (based physician within access standards
3. Network physician within access standards
4. Non-network physician within access standards


For Non-Prime patients seeking specialty care: 1. Closest MTF
2. Next available MTF
3. Network physician
4. Non-network physician



Specialty Care and Referral Process
  • All Prime patients seeking specialty care will have a referral from their PCM, except in the case of a medical emergency.
  • Limited self-referral will be permitted for certain known and predictable conditions.
  • All referral requests will be electronic via CHCS (or other approved system).
Patient Rights
  • The patient may elect to use the Point of Service Option.
  • Beneficiaries may waive the distance access standard for specialty care.
  • The patient may waive the time access standard and request appointments outside of access standards for convenience reasons or by preference see their own PCM even though appointment with other providers are available within access standard.
  • The patient may waive the time access standard or request appoinments outside of access standards for convenience reasons even though appointments are available within access standards. These refusals will be documented in CHCS (or other approved system).
Booking
  • Clinic appointment templates, other than acute, will be open for booking at least 30 days ahead at all times.
  • Basic CHCS patient demographic information (e.g., name, address, and telephone number) will be updated each time an appointment is booked.
  • Delinquent appointments will be resolved daily with CHCS end-of-day processing.
  • If details fields or optional slot comments are not specified, the clerk is able to book the patient or schedule the provider for any condition in that speciality.
  • Appointment booking will be reserved by type of beneficiary in order to manage access:
    • Active duty
    • Prime
    • Graduate Medical Education (GME)
    • Non-active duty
    • Non-Prime
    • Non-active duty and non-Prime
    For your reference, the operational definitions of these access types are found under Policies and Documents on this web page.
Associated Appointment Process Business Rules
  • Managed Care Support Contractor and MTF (government) appointment clerks will be able to view all available appointments in CHCS or other approved system.

  • One telephone number will function as the beneficiaries' point of access for all appointing and referral needs. The beneficiary's call will be appropriately routed to the right telephone extension if the first Point of Contact is unable to serve the beneficiary's health care information or appointment needs. The routing will occur without requiring the patient to make an additional telephone call.

  • The appointing process will work under the assumption of "PCM by Name" enrollment where applicable in accordance with Assistant Secretary of Defense/Health Affairs Policy Memorandum - Individual Assignments to Primary Care Managers by Name (3 December 1999).