1.0 Introduction
TPRADFM provides TRICARE Prime like benefits
to certain Active Duty Family Members (ADFMs) who reside with the
TRICARE Prime Remote (TPR) enrolled sponsor in remote locations
in the United States (U.S.) and the District of Columbia. It also
provides continued TPRADFM eligibility for family members residing
at remote locations after the departure of the sponsor for an unaccompanied assignment,
and eligibility for family members of Reserve Component (RC) members
ordered to active duty. It covers family members of Service members
(on active duty for more than 30 days) of all seven Uniformed Services
in the U.S. and the District of Columbia. TPRADFM benefits are comparable
to TRICARE Prime, including access standards, benefit coverage,
and cost-shares. TPRADFM does not apply to ADFM enrollees in areas
outside the 50 U.S. Such care and claims shall be processed in accordance
with the TRICARE Overseas Program (TOP),
Chapter 24 and
TRICARE Policy Manual (TPM),
Chapter 12.
The Specified Authorization Staff (SAS) is not involved in any part
of TPRADFM.
2.0 Eligibility
To be eligible for enrollment under TPRADFM,
family members of Service members must meet the following eligibility
requirements:
2.1 The Service member sponsor is eligible for,
and enrolled in TPR and the ADFM resides with the Service member
in a TPR area; or
2.2 The Service member is enrolled
to a small Government clinic, troop medical clinic, or other facility
not capable of primary care management functions. These clinics
have been designated by the Services and are located in certain
TPR zip codes. These clinics allow active duty enrollment only,
and are identified by Defense Medical Information System Identification
Codes (DMIS-IDs). A list of applicable DMIS-IDs for the region will
be provided to the contractor by the Director, TRICARE Regional Offices
(TROs). The ADFM must reside with the Service member who is enrolled
in a DMIS-ID Clinic in a TPR area.
2.3 ADFMs who reside within a
Prime Service Area (PSA) are not eligible for enrollment in TPRADFM even
if the Service member is enrolled in TPR. The ADFMs shall be enrolled
within the PSA of residence.
2.4 National Guard/Reserve members
who are ordered to active duty for a period of more than 30 days
are not required to be eligible for, or enrolled, in TPR for their
family members to be eligible for TPRADFM. Their family members
are eligible for TPRADFM if they meet the criteria of
paragraph 2.7.
2.5 If a Service
member receives a subsequent unaccompanied assignment after the
TPR assignment and the family members are not authorized to accompany
the member to the next duty assignment, and they continue to reside
in the same TPR location, the family members may remain in TPRADFM
for the duration of the subsequent assignment.
2.5.1 ADFMs currently enrolled in
TPRADFM, who transition to Transitional Survivor status, may remain
enrolled in TPRADFM. See TPM,
Chapter 10, Section 7.1 for further information.
2.5.2 All Transitional
Survivors may enroll in TPRADFM. At the request of the Transitional
Survivor the contractor shall accept and process a new and continued
enrollment request (enrollment form, the Government furnished web-based
self-service enrollment system/application transaction, or telephonic
request documented in the contractor’s call center notes) submitted
by any Transitional Survivor living in, or moving to a TPR area.
Enrollment in TPRADFM may continue for Transitional Survivors for
the entire Transitional Survivor period. After the Transitional
Survivor period, TPRADFM is not available to Survivors. A Survivor
(verses a Transitional Survivor) is eligible for retiree family
member benefits and cost-sharing. For example, after three years
the surviving spouse is considered a Survivor (verses a Transitional
Survivor) and retiree payment rates and rules are applied, while
still eligible for TRICARE, eligibility is at retiree payment rates
and rules. Consequently, they are ineligible for TPRADFM which is
an active duty program.
2.5.3 Transitional Survivor/Survivor
status does not impact TRICARE eligibility rules. Loss of eligibility
as a result of any condition which routinely results in loss of
TRICARE eligibility such as reaching age limits, marriage, remarriage,
etc. also results in loss of Transitional Survivor/Survivor status.
2.6 “Resides
with” is defined as the TPR residence address at which the family
resides/resided with the sponsor while the sponsor was enrolled
in TPR. Transitional Survivors only have to have a residence address
in a TPR area to be eligible to enroll in TPRADFM.
2.7 To
be eligible for enrollment under TPRADFM, family members of federalized
National Guard/Reserve members ordered to active duty for a period
of more than 30 days must meet the following eligibility requirements:
• The
family members reside with the member at the time of activation;
and
• The
residence address is located in a TPR zip code;
• “Resides with” is
defined as the TPR residence address at which the family resides
with the activated reservist upon activation.
• The federalized National
Guard/Reserve member does not have to be TPR eligible or enrolled.
However, for their family members to be eligible for TPRADFM the
member must be ordered to active duty for a period of more than
30 days.
• Once
enrolled in TPRADFM the family members of the federalized National
Guard/Reserve member, continuing to reside at the TPR residence
address, may remain in TPRADFM for the period of active duty of
the member, regardless of the subsequent assignment, enrollment
location, or residence of the member.
• Family members of
the federalized National Guard/Reserve member, continuing to reside at
the TPR residence address, may enroll even after the sponsor has
deployed/left for a subsequent assignment.
2.8 DEERS will automatically update
start and/or end dates of coverage when a beneficiary’s eligibility
is updated as described in Chapter 6, Section 1.
The contractor will receive a Policy Notification Transaction (PNT)
advising them of all changes.
3.0 Benefits
ADFMs enrolled in TPRADFM are eligible for
the Uniform Health Maintenance Organization (HMO) Benefit, even
in areas without contractor networks.
4.0 Network
Development
4.1 TPRADFM has no network development requirements,
except where contractually required. ADFMs enrolled in TPRADFM shall
be assigned, or be allowed to select, a Primary Care Manager (PCM) when
available through the TRICARE civilian provider network. If a network
provider is not available to serve as a primary care provider, the
TPRADFM enrollee may utilize any local TRICARE participating or authorized
provider for primary care services.
4.2 Enrolled ADFMs are required
to use network providers where available within contractual access
standards. If a network provider cannot be identified within the
access standards, the enrolled family member shall use a TRICARE
authorized provider. Contractors shall assist ADFMs in finding a TRICARE
network or authorized provider for specialty care. The beneficiary
may be eligible for the Prime travel benefit when referred more
than 100 miles for specialty care. If the contractor has not established a
network of PCMs in a remote area, a TPR designated ADFM will be
enrolled without a PCM assigned. A generic PCM code shall be used
for TPRADFM enrollees without assigned PCMs. The ADFM without an assigned
PCM will be able to use a local TRICARE participating or authorized
provider for primary health care services without preauthorization.
If a TPRADFM questions whether a service is covered as primary care,
they may contact the contractor for assistance.
5.0 Uniformed
Services Family Health Plan (USFHP)
If a
USFHP is available to ADFMs in a TPR area, the ADFMs have the choice
of enrolling in the USFHP, enrolling in TPRADFM, or to remaining
in TRICARE Standard (through December 31, 2017) or enrolling
in TRICARE Select (starting January 1, 2018). ADFMs
choosing to enroll in USFHP will be unable to access care through
Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs)
or the TRICARE system.
6.0 Referrals
6.1 Specialty
care requires a referral through the contractor. If the ADFM has
a PCM, the PCM shall follow the contractor’s referral and authorization
procedures. In cases where the ADFM is not enrolled to a PCM, the
ADFM, or the ADFM’s parent or guardian is responsible for directly
contacting the contractor to obtain referrals and authorizations
if required. The ADFM should obtain a referral request from their
primary care provider which the ADFM would forward to the contractor.
6.2 TPRADFM
enrollees are required to obtain a referral and use TRICARE network
providers for specialty care where available within TRICARE access
standards or pay the Point of Service (POS) deductible and cost-share
unless an appropriate out-of-network referral is obtained as required
under TRICARE Prime.
7.0 Provider
Education
Contractors shall familiarize network
providers and, when appropriate, other providers with TPRADFM. The
contractor shall propose an educational plan to the Director, TROs
outlining how providers will become familiar with TPRADFM. The contractor
shall provide separate and distinct information to PCMs about the
requirements and the special procedures for handling TPRADFMs’ care (e.g.,
specialty care referral requirements, balance billing limitations,
etc.). The contractors shall include information on TPRADFM specialty
care procedures, benefits, or requirements in routine information and
educational programs.
8.0 Beneficiary
Education
8.1 Beneficiary education will be a joint effort
with the Government providing all beneficiary educational materials
for the TPR program.
8.2 The contractor shall utilize
leading industry best practices in its outreach and communication with
all MHS customers consistent with that offered to its commercial
customers. Customer services shall include multiple, contemporary
avenues of access (for example, e-mail, World Wide Web (WWW), telephone,
texting, and smart phone applications, and other social media) for
the MHS beneficiary. If the contractor choses to distribute the
supplied educational materials, the contractor is responsible for postage,
envelopes, and mailing costs.
8.3 The contractor shall give
ADFMs the option of participating in health promotion and wellness programs
offered in the direct care system and network locations.
The contractor shall design and conduct, with Director, TROs approval,
TPRADFM briefings. The contractor shall include TPRADFM information
and updates as part of all TRICARE briefings. Ongoing briefings
will be on an “as needed” basis and will be coordinated with the
Director, TROs.
8.4 Enrollment in TPRADFM is optional
for ADFMs who qualify for the program; therefore, a contractor shall
limit educational activities for TPRADFM enrollees to distributing
the materials provided or approved by the Government.
9.0 Enrollment
9.1 When the
contractor receives an enrollment request (enrollment form, the
Government furnished web-based self-service enrollment system/application
transaction, or telephonic request documented in the contractor’s
call center notes) from an ADFM for TPRADFM, the contractor shall ensure
the Service member’s sponsor is eligible for, and enrolled in the
TPR program or a DMIS-ID clinic located in TPR designated zip codes.
If an ADFM enrollment request is received and the Service member
sponsor is either not eligible for TPR, or not enrolled in TPR or
a TPR DMIS-ID clinic, the request shall be returned to the sender
with a notice that the ADFM is not eligible for TPRADFM and the reason(s)
why enrollment was denied. See
paragraph 9.5 when a TPRADFM enrollment request
is received for a family member of a Reserve Component (RC) member
called or ordered to active service for more than 30 days.
9.2 Enrollment
in TPRADFM is optional for ADFMs. However, ADFMs must enroll within
90 days of their move to a TPR location (a QLE) or during the open
enrollment season in TPRADFM to receive the TPRADFM
benefit. ADFMs who elect not to enroll in TPRADFM may use the TRICARE
Standard (through December 31, 2017) benefit,
or enroll in TRICARE Prime or TRICARE Select (starting
January 1, 2018), where available, with access standards
waived.
9.3 An enrollment request (enrollment
form, the Government furnished web-based self-service enrollment
system/application transaction, or telephonic request documented
in the contractor’s call center notes) must be submitted to the
contractor by either the ADFM or the Service member’s sponsor for
each family member enrolling in TPRADFM.
See Chapter 6, Section 1, for effective date rules. An official enrollment request includes those
with:
• An original signature;
• An electronic signature
offered by and collected by the contractor;
• A verbal consent provided by telephone
and documented in the contractor’s call notes; or
• A self-attestation
by the beneficiary when using the Government furnished web-based
self-service enrollment system/application.
9.4 The residence
address zip code of the TPR eligible or enrolled Service members
must match with the ADFMs. If the zip codes match, the contractor
shall deem the ADFM as eligible for TPRADFM and enroll the ADFM
in the program. If the residence address zip codes of the TPR Service
members and their ADFMs do not match, the ADFMs shall be advised
by letter that they are not eligible for enrollment in TPRADFM but
they remain eligible for TRICARE Prime or
TRICARE Select as appropriate.
9.5 When
the contractor receives an enrollment request (enrollment form,
Government furnished web-based self-service enrollment system/application
transaction, or telephonic request documented in the contractor’s
call center notes) for TPRADFM from a family member of an RC member
called or ordered to active service for more than 30 days, the contractor
shall ensure the family members are registered as eligible on DEERS.
9.6 The contractor
shall match the TPR residence addresses from the enrollment request (enrollment
form, Government furnished web-based self-service enrollment system/application transaction,
or telephonic request documented in the contractor’s call center
notes) of the activated federalized National Guard/Reservist member
and the family members. If the residence addresses match, to include
zip code only match, the contractor shall deem the family members
as eligible for TPRADFM and enroll the family member in the program.
9.7 If the
TPR residence addresses from the enrollment request (enrollment
form, Government furnished web-based self-service enrollment system/application
transaction, or telephonic requests documented in the contractor’s
call center notes) of the activated federalized National Guard/Reserve member
and the family members do not match, the family members shall be
advised by letter they are not eligible for enrollment in TPRADFM
and they shall remain eligible for TRICARE Standard, Extra, or Prime (through
December 31, 2017) and TRICARE Prime or Select (starting January
1, 2018) as appropriate. They must
enroll in TRICARE Prime or TRICARE Select within 90 days of the
date of notification or they will be eligible for MTF/eMSM care
only on a space-available basis.
9.8 Enrollments
or disenrollments will occur upon change of duty location out of
the remote area, transfer into an MTF/eMSM/clinic PSA, retirement,
or separation from the Service. The ADFM or Service member is responsible
for notifying the contractor when an enrollment transfer is needed.
The contractor shall follow enrollment portability and transfer
procedures in
Chapter 6, Section 2.
• If
at any point during the enrollment period the contractor determines
or is advised that a family member is no longer eligible for TPRADFM,
the contractor shall notify (letter, telephone call, or e-mail)
the Service member of the discrepant enrollment immediately. If the
discrepant enrollment is not corrected within 30 days of the notification
date, the contractor shall disenroll the family member(s) from TPRADFM
effective the first of the month after 30 days from the initial
notification date and provide information on TRICARE Standard/Extra (through
December 31, 2017) and TRICARE Select (starting January 1, 2018), and
that they have 90 days from the date of the disenrollment to enroll
in a TRICARE plan or they only will be eligible for MTF/eMSM care
on a space-available basis.
9.9 The contractor
shall enroll the ADFM in the Government furnished web-based system/application
and enter the TPRADFMs enrollment status into Government furnished
web-based system/application. The contractor shall use the DMIS-ID
code(s) designated by the TRO for that region to enroll ADFMs into
TPRADFM (see the TRICARE Systems Manual (TSM)). If the contractor
has not established a network of PCMs in a remote area, a TPR designated
ADFM will be enrolled without a PCM assigned. A generic PCM code
shall be used for TPRADFM enrollees without assigned PCMs. The ADFM without
an assigned PCM will be able to use a local TRICARE participating
or authorized provider for primary health care services without
preauthorization.
9.10 The contractor shall provide
TPRADFM enrollment information in the formats indicated in the contract
requirements.
10.0 PCM
Assignment
At the time of enrollment, an
ADFM will select (or will be assigned) a PCM within the access standard.
The contractor shall advise the ADFM of the availability of PCMs.
If a PCM is not available, the ADFM shall be enrolled to TPRADFM
without an identified PCM. An ADFM without an assigned PCM may use
any TRICARE-authorized provider for primary care.
11.0 Support
Services
11.1 Inquiries
The contractor shall designate a point of contact
for Government inquiries related to TPRADFM. The contractor may
establish a dedicated unit for responding to inquiries about TPRADFM,
or may augment existing TPR service units already serving the Service
members enrolled in TPR. The correspondence requirements and standards
in
Chapter 1, Section 3, apply to TPRADFM written inquiries.
11.2 Toll-Free
Telephone Service
The contractor shall provide
toll-free telephone access for TPRADFM beneficiary inquiries.
12.0 Claims
Processing
The regional contractor where
the TPRADFM is enrolled shall process all claims for that enrollee, except
for care provided overseas (i.e., care outside of the 50 U.S. and
the District of Columbia). Civilian health care while traveling
or visiting overseas shall be processed by the TOP contractor, regardless
of where the beneficiary is enrolled. POS claims processing provisions
do apply. The contractor shall provide TPRADFM claims information
in the format for the Monthly Workload Reports and the Monthly Cycle
Time Aging reports.
13.0 Claim
Reimbursement
13.1 The payment provisions applicable under TPR
for Service members which allow for additional payment in excess
of otherwise allowable amounts to providers who are not TRICARE-authorized
or certified do not apply to TPRADFM. Such payments shall not be
made unless such payments are otherwise allowed under the payment
provisions for unauthorized providers contained in the TPM.
13.2 For network
providers, the contractor shall pay TPRADFM claims at the negotiated
rate. For participating providers the contractor shall pay up to
the CHAMPUS Maximum Allowable Charge (CMAC), or billed charges,
whichever is less. Contractors shall follow the requirements in
Chapter 8, Section 5 and the TRICARE Reimbursement
Manual (TRM),
Chapter 5, Section 1, for claims for TPRADFM enrollees
receiving care from non-participating providers.
13.3 If a non-participating
provider requires a TPRADFM enrollee to make an “up front” payment
for health care services, in order for the enrollee to be reimbursed,
the enrollee must submit a claim to the contractor with proof of
payment and an explanation of the circumstances.
13.4 If the
contractor becomes aware that a civilian provider is “balance billing”
a TPRADFM enrollee or has initiated collection action for emergency
or authorized care, the contractor shall notify the provider that
balance billing is prohibited (see TRM,
Chapter 3, Section 1).
13.5 If CMAC
rates have been waived for TPR Service member enrollees under
Section 4, paragraph 3.5, the TPRADFM enrollee
shall not be extended the same waived CMAC rates. If required services
are not available from a network or participating provider within
the medically appropriate time frame, the contractor shall arrange
for care with a non-participating provider subject to the normal reimbursement
rules. The contractor shall make every effort to obtain the provider’s
agreement to accept, as payment in full, a rate within 100% of the
CMAC limitation. If this is not feasible, the contractor shall make
every effort to obtain the provider’s agreement to accept, as payment
in full, a rate between 100% and 115% of CMAC. By law the contractor
shall not negotiate a rate higher than 115% of CMAC for TPRADFM
care rendered by a non-participating provider. The contractor shall
ensure that the approved payment is annotated in the authorization/claims
processing system.
14.0 Appeals
Process
TPRADFM enrollees may appeal denials
of authorization or reimbursement through the contractor in accordance
with
Chapter 12. If the contractor denies authorization
or reimbursement for a TPRADFM enrollee’s health care services,
the contractor shall, on the Explanation of Benefits (EOB) or other
appropriate document, furnish the enrollee with clear guidance for
requesting a reconsideration from, or filing an appeal with, the
contractor.
15.0 TRICARE
Encounter Data (TED) Submittal
The contractor
shall report TPRADFM claims under the financially underwritten provisions
of the contract.