As the TRICARE Quality Monitoring Contractor (TQMC), KEPRO assists DHA and other
DHA contractors by providing independent, impartial evaluation of the healthcare
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 med-surg care cases retrospectively and reports
- 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. Please refer to the guideline checklists