Clinical quality

Effective beneficiary care is important for both military readiness and better outcomes over time. The provider clinical quality rating evaluates the quality of care delivered by Primary Care Managers (PCM) and specialists. This rating is a quality measure set to help identify those providers who offer higher quality care. Through a preselected set of measures, providers have numerous opportunities to impact care for both preventive and specialty care. Providers are compared to their peers’ performance in the same geography. Those providers who perform well on their specialty-specific measure set are associated with better quality of care for the TRICARE East population. Ratings are calculated only where Humana Military requirements are met: when there is sufficient data volume, statistical credibility, minimum peer volume, etc. 


Humana Military uses TRICARE East beneficiaries’ claims experiences to evaluate their treatment and quality of care and evaluates claims including medical, pharmacy and lab. The measures are calculated using a software solution widely used across the healthcare industry as a basis to review quality delivered by providers.

The clinical quality rating includes measures from the following governing bodies:

  • Centers for Medicare and Medicaid Services (CMS)
  • National Committee for Quality Assurance (NCQA)
  • National Quality Forum (NQF)
  • Pharmacy Quality Alliance (PQA)

Evaluated specialties 

  • Advanced practice midwife
  • Allergy and immunology
  • Cardiovascular disease
  • Emergency medicine
  • Endocrinology
  • Family medicine
  • General practice
  • Internal medicine
  • Mental health nurse practitioner
  • Midwife
  • Nurse practitioner
  • Obstetrics and gynecology
  • Ophthalmology
  • Pediatrics
  • Physician assistant
  • Psychiatry and neurology
  • Pulmonary disease


Efficient beneficiary care is important for reducing waste and increasing healthcare sustainability. The provider cost-efficiency evaluates the cost of care managed by Primary Care Managers and specialists. Providers have numerous opportunities to impact the beneficiaries they care for and manage costs efficiently. Providers who perform well on their specialty-specific measures are identified and associated with a lower cost of care for the TRICARE East population.

Ratings are calculated only when Humana Military’s requirements are met. These requirements include sufficient data volume, statistical credibility and minimum peer volume.


Humana Military bundles TRICARE East beneficiaries’ experiences in medical, pharmacy and lab claims into episodes of care attributed to a single responsible provider. An episode represents more than a provider’s direct spending, including the total amount for clinical and resource homogenous services for which a provider is the largest contributor. The episodes are calculated through widely-used industry software as a basis to review providers’ costs.

Evaluated specialties

  • Allergy and immunology 
  • Anesthesiology 
  • Counselor 
  • Dermatology 
  • Emergency medicine 
  • Family practice 
  • General practice 
  • Internal medicine 
  • Marriage and family therapist 
  • Neurological surgery 
  • Nurse practitioner 
  • Obstetrics and gynecology 
  • Occupational therapist 
  • Ophthalmology 
  • Optometrist 
  • Orthopedic surgery 
  • Otolaryngology 
  • Pediatrics 
  • Physical medicine and rehabilitation 
  • Physical therapist 
  • Physician assistant 
  • Podiatrist 
  • Psychiatry and neurology 
  • Psychologist 
  • Social worker 
  • Speech-language pathologist 
  • Surgery 
  • Urology

Program methodology

Humana Military rates providers only when there is sufficient data volume, statistical credibility and minimum number of peers available. A weighted average approach is used to create a composite score for individual providers compared to their peer group(s). Humana Military compares performance of the individual provider to performance of their peers at the specialty/state level to determine the rating displayed on the find care tool.

Representatives are available to answer questions about provider clinical quality and cost-efficiency. Providers may contact us via secure message by logging into self-service.

Method Description Measurement level TRICARE providers are captured at the identifier level of Tax Identification Number (TIN) and National Provider Identifier (NPI). Geographic areas Geographic areas include states in the TRICARE East Region of the United States. Peer groups Peer groups include providers of the same specialty and type of care within the same state. Providers working in multiple states will be evaluated per the volume performed in each state (see Minimum volume requirements below). Frequency of evaluation The clinical quality and cost-efficiency ratings are updated on a quarterly basis. Minimum volume requirements Clinical quality The clinical quality rating is measured for all providers who have a minimum of 20 measure results for their attributed beneficiaries and at least five distinct TRICARE members. Peer groups will contain at least five peers for providers to be individually compared against. Cost-efficiency The cost-efficiency rating is measured for all providers in the specialty/episode target list who have a minimum of ten episodes and five beneficiaries. Each peer group will contain at least 100 episodes for providers to be individually compared against. Providers are often in more than one peer group. Each specialty/state must contain at least 10 providers. Provider attribution Clinical quality Providers who contribute the most to a beneficiary’s care are attributed. Attribution is prioritized utilizing a hierarchy per specialty that begins with the highest visit count, most recent visit and highest claim allowed amount. Cost-efficiency Providers who contribute the highest total allowed amount for evaluation and management and/or surgery costs are attributed to an episode of care. The attributed provider is considered the director of care for treating that patient’s condition.

Clinical quality ratings and cost-efficiency ratings are displayed on the provider results page of our find care tool.

The main focus of these ratings is transparency. These ratings should be used only as information when choosing care. TRICARE beneficiaries are encouraged to consider all relevant information and to consult with their treating provider.

Users will not see anything related to ratings if a provider specialty or geography is out of scope. If a specialty and/or geography are in scope, but the data is not statistically credible or there is not enough data to complete a comprehensive evaluation, "Not enough information to measure" will be displayed.

A provider's rating is not affected by TRICARE beneficiary feedback.

Efficiency, also described as cost-efficiency, measures a provider's total cost for treatment that TRICARE beneficiaries received compared to treatment provided by other providers in the same specialty type and geography. Treatment could include services such as doctor's visits, lab test, related medication, surgeries done in hospitals, etc.

Effectiveness, also described as clinical quality, measures a provider's adherence to evidence-based medicine when treating TRICARE beneficiaries as compared to a peer group in the same specialty type and geography.

Provider's ratings will not affect payments, nor will they affect TRICARE beneficiary's premium or benefits.

Other insurance companies may use similar methods, but each payer's program could yield different results since ratings are based on a unique set of claims data for a unique group of beneficiaries.

There are instances where a provider may not receive a rating and "Not enough information to measure" will appear in place of the rating symbols. There could be several reasons a provider does not receive a rating, such as: the specialty may not be among those evaluated, the provider's geographic location may not be in scope, the data may not be statistically credible or not enough data is available to complete a full evaluation.

Providers can access additional information by visiting Effectiveness and efficiency of care - program methodology.

Providers can submit detailed questions or feedback at any time by logging into self-service and sending a secure message. Providers may register for self-service if they don’t have an account.

Administrative claims including labs, pharmacy and medical.

Providers can submit detailed questions or feedback at any time by sending a secure message through provider self-service.

Yes, ratings are updated quarterly.

Humana Military is sharing information about your practice with its members and other providers. Provider ratings will help you and your TRICARE beneficiaries make better-informed healthcare decisions. If you would like to learn more about the program, please visit Effectiveness and efficiency of care - program methodology.

We ask that you review the reports for accuracy of information.

To access the reports, log in or register for provider self-service, then:

  1. In the Group Information section, select View to open the provider roster
  2. Select View PCM/specialty ratings for the comprehensive overview of rating results
  3. In the description for Average Allowed Charges Per Episode of Care or for Provider Effectiveness Scores, select Find Out More
  4. On those efficiency and effectiveness detail pages, select Link here to access your report