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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Overseas Program (TOP)
Chapter 24
Section 1
Revision:  C-1, March 10, 2017
All TRICARE requirements regarding administration shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (U.S.) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 1 for additional instructions regarding administration. Specific health care support services required for the performance of this contract are identified in this chapter, in the TPM, Chapter 12, and the TOP contract.
2.1  The provisions of Chapter 1, Section 2 are applicable to the TOP. Additionally, the TOP contractor shall coordinate with the Defense Health Agency (DHA) Contracting Officer (CO), the appropriate DHA Contracting Officer Representative (COR), and the appropriate TRICARE Area Office (TAO) Director on any TOP policy or contractual issue that requires additional Government clarification or assistance to resolve.
2.2  The provisions of Chapter 1, Section 2, paragraph 4.0 are superseded as described in paragraphs 2.2.1 through 2.2.6.
2.2.1  A 14 calendar day notice will be provided by the DHA Procurement Contracting Officer (PCO) for all meetings hosted by DHA.
2.2.2  The TOP contractor shall provide up to four contractor representatives at the Performance Readiness Validation briefing at DHA.
2.2.3  The TOP contractor shall provide at least two contractor representatives for transition briefings/meetings with each overseas Military Treatment Facility (MTF) and TAO. All briefings/meetings must be completed no later than 60 calendar days prior to the start of health care delivery (SHCD).
2.2.4  The TOP contractor shall provide annual representation at two contractor conferences (senior management level) at DHA. The contractor shall also provide up to four contractor representatives at up to four additional meetings at the direction of the CO per contract year.
2.2.5  The TOP contractor shall provide representation at semiannual TOP operational meetings to be held at DHA Aurora with TAO and service representation.
2.2.6  The TOP contractor shall provide two contractor representatives at up to 18 additional meetings/site visits at the direction of the CO per option period.
See Chapter 1, Section 3 for instructions regarding TRICARE processing standards.
Note:  The standards for telephone inquiries apply to all toll-free lines supporting TOP contract customer service activities.
The provisions of Chapter 1, Section 4 are applicable to the TOP, except that the provisions of Chapter 1, Section 4, paragraph 2.3 regarding zip code files are only applicable to Puerto Rico.
See Chapter 1, Section 5 for instructions regarding compliance with Federal statutes.
See Chapter 1, Section 6 for instructions regarding legal matters.
7.0  TRANSITIONS -- contract phase-in
7.1  Transition-In (Phase-In) Plan
The provisions of Chapter 2 are applicable to the TOP. In addition to the start-up (transition-in/phase-in) plan, the contractor shall provide weekly status reports through the first 180 calendar days of the contract or as directed by the Government.
7.2  Transition Specifications Meeting
See Chapter 2 for instructions regarding transition specification meeting(s).
7.3  Interface Meetings
The provisions of Chapter 2, Section 1, paragraph 1.2 are applicable to the TOP.
7.4  MTF/TAO Transition Briefings/Meetings
The contractor shall provide on-site transition briefings/meetings with all MTFs and TAOs per paragraph 2.2.3. These briefings/meetings shall be targeted towards command suite/key leaders and their staff and shall encompass all key contract areas where collaboration between the contractor and the MTF/TAO will occur.
8.1  See Chapter 2, for instructions regarding start-up requirements.
8.2  See Section 16, for instructions regarding Statements of Responsibilities (SORs). In addition to the SOR requirements in these referenced paragraphs, the TOP contractor shall also execute a SOR with each TAO Director no later than 60 calendar days prior to the SHCD, with copies to the PCO and the COR within 10 calendar days following SOR execution.
8.3  See Chapter 2, for instructions regarding phase-in of TRICARE enrollment and transfer of enrollment files. For purposes of TOP implementation, all references to TRICARE Prime in these paragraphs shall apply to TOP Prime and TOP Prime Remote.
8.4  The provisions of Chapter 2 are not applicable to the TOP, since there are no enrollment fees associated with TOP Prime or TOP Prime Remote.
8.5  See Chapter 2, for instructions regarding Health Care Finder (HCF) phase-in.
8.6  See Chapter 2, for instructions regarding TRICARE Service Center (TSC) phase-in.
8.6.1  The incoming contractor shall utilize the existing TSCs. The outgoing contractor shall allow reasonable access to the incoming contractor throughout the transition period to become familiar with the communication lines, equipment and office layout.
8.6.2  The final schedule for access to and occupancy of the TSCs will be determined at the Transition Specifications Meeting. The approved schedule must allow the outgoing contractor to fulfill all contract requirements through the last day of health care delivery, and must provide the incoming contractor sufficient access to the TSC to prepare for delivery of all required functions on the first day of their contract.
8.6.3  Acquisition of Resources.
8.6.4  All Contractor Customer Service, Education and HCF Field Representatives and overseas TSC representatives shall be fully trained and available for all duties no less than 40 calendar days prior to initiation of health care services.
Note:  Overseas TSCs are managed by the MTFs and are jointly staffed by MTF and TOP contractor personnel. The TOP contractor is responsible for providing on-site Beneficiary Service Representative (BSR) support in all TSC locations.
8.7  All claims that fall within the scope of the TOP contract received on or after the SHCD on the TOP contract shall be processed by the TOP contractor.
Note:  Normal claims filing deadlines apply. See Chapter 8, Section 3 and Section 9, paragraph 3.0.
8.8  The provisions of Chapter 2 is applicable to the TOP, except that the provisions of Chapter 2 are superseded by a requirement for the incoming contractor to cover non-obstetrical care for 90 days after the SHCD under the incoming contract, in accordance with the outgoing contractor’s existing practices and protocols, within the scope of the TRICARE program and applicable regulations or statutes. This transition period for prior authorizations and referrals is extended to one year for obstetrical care or any other condition for which a one-year authorization has been issued.
8.9  See Chapter 2 for instructions regarding contractor weekly status reporting.
8.10  The provisions of Chapter 2 are not applicable to the TOP. Instead, the TOP contractor shall prepare a mailing to the Resident Commissioners of Puerto Rico and the Northern Mariana Islands, and the Congressional representatives for American Samoa, Guam, and the U.S. Virgin Islands by the 45th calendar day prior to the SHCD according to the specifications of the official transition schedule. This requirement supersedes the requirements outlined in Chapter 2. The proposed mailing shall be submitted to the DHA CO, DHA COR, and TAO Directors, for approval no later than 90 calendar days prior to the SHCD. The mailing shall discuss any unique processing requirements of the contractor and any other needed information dictated by the official transition schedule.
8.11  See Chapter 2, for instructions regarding web-based services.
8.12  The provisions in Chapter 2 regarding Performance Readiness Validation (PRV) and Performance Readiness Assessment Verification (PRAV) are not applicable to the TOP. The TOP contractor shall follow the PRV/PRAV instructions contained in Section H of the TOP contract.
The provisions of Chapter 2, Section 8 are applicable to the TOP, except that the requirement for the outgoing contractor to process residual claims and adjustments for 120 days following cessation of health care delivery is waived for the TOP. The outgoing contractor is only required to process claims and adjustments received during its period of service delivery. Processing of all claims shall be completed within 180 calendar days following the start of the incoming contractor’s services delivery.
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