KEPRO is the TRICARE Quality Monitoring Contractor (TQMC) and assists DoD Health Affairs, Defense Health Agency (DHA), military hospitals or clinic market managers and the Health Plan East Region office by providing the government with an independent, impartial evaluation of the care provided to beneficiaries within the Military Health System (MHS). The TQMC reviews care provided by TRICARE network providers and subcontractors on a limited basis. The TQMC is part of TRICARE’s Quality and Utilization Peer Review Organization (PRO) program, in accordance with 32 Code of Federal Regulations (CFR) 199.15.
To facilitate TQMC reviews, providers’ medical records may be requested by Humana Military on a monthly basis to comply with requirements detailed in the TRICARE Operations Manual, Chapter 7, Section 3. Providers may be required to submit records to Humana Military to comply with requests for medical records submitted by KEPRO to Humana Military.
Providers who receive requests for medical records are required to submit the requested medical record in its entirety to Humana Military. Failure to do so will result in recoupment of payment for the hospitalization and/or any other services in accordance with 32 CFR 199.4(a) (5).