Managed Care Support Contractors (MCSCs)/Designated Providers (DPs)
As the TRICARE Quality Monitoring Contractor (TQMC), KEPRO assists DHA and other DHA contractors by providing independent, impartial evaluation of the health care provided to Military Health System (MHS) beneficiaries to validate the quality of that care delivered under the TRICARE benefit.
The TQMC reviews mental health and medical-surgical care cases retrospectively and reports on:
- Care provided that was not a TRICARE benefit
- Inappropriate medical care
- Inappropriate utilization
- Nonconformance with disease-specific key quality performance measures
- Other quality issues
Reports are reviewed and when appropriate follow-up actions are performed. The resources on this page provide information on key quality performance measures, as well as other references, that the TQMC uses to review retrospective cases of care. The key quality performance measures are found in the National Hospital Quality Measures link.
What constitutes a Complete Medical Record?
Adequate medical documentation provides the means for measuring the type, frequency, and duration of active treatment mechanisms employed and progress under the treatment plan. Under TRICARE, it is required that adequate and sufficient clinical records be kept by the provider to substantiate that specific care was actually and appropriately furnished, was medically or psychologically necessary, and to identify the individual(s) who provided the care. Each service provided or billed must be documented in the records.