Helping the Best Doctors Deliver the Best Care

TriWest is committed to ensuring TRICARE patients receive the highest quality care possible. Utilization management is one way TriWest can verify that guarantee.

Essentially, three types of utilization management review ensure patients receive the right care at the right time, and that no additional treatment opportunities are being missed.

Prospective review is conducted in cases where you or your staff submits beneficiary care information to TriWest (e.g., referrals, authorizations), but before the beneficiary actually receives the treatment. This review evaluates the medical necessity and appropriateness of the treatment and ensures the service is a TRICARE-covered benefit. Both you and the beneficiary will be notified concerning the results of the prospective review.

Concurrent review takes place in cases where a TRICARE beneficiary is in an inpatient setting. In these instances, clinicians specializing in medical-surgical and/or behavioral health care supplement a primary review board. In addition to a review of the general quality and appropriateness of care, utilization management will also establish the need for any post-discharge services. Utilization management will then authorize such services, but cannot schedule them for the beneficiary. You will be notified in writing only if the beneficiary is recommended to enter case management, or in the rare occurrence that the case is denied completely.

Retrospective review is conducted in cases where the care has already been rendered. Nurses review any instances where questions arise about the treatment that was administered. You will be notified in writing concerning the results of the retrospective review.

As long as your office submits all required documents and authorizations in a timely manner, nothing more should be required from you or your staff for utilization management to take place. If any questions or errors with your submissions arise, you will then be contacted for further information. Otherwise, unless your patient is recommended for another program, such as case management, the process should be virtually invisible to you.