Military Health System

1.1  TOP Prime Remote is available to Service members (including Reserve Component (RC) members activated for more than 30 days) on permanent assignment to a remote overseas location, Command-Sponsored Active Duty Family Members (ADFMs) accompanying their sponsor in the remote location or on Service orders, and certain transitional survivors according to the eligibility and enrollment provisions of Section 5. TOP Prime Remote offers enrollees access to a Primary Care Manager (PCM), clinical preventative services, and specialty services. The TOP contractor, working in concert with purchased care sector providers and the TRICARE Area Offices (TAOs), has primary responsibility for ensuring that TOP Prime Remote enrollees receive appropriate services and support to facilitate access to the TOP benefit in remote overseas locations.

1.2  TOP Prime Remote has no enrollment fees, and deductibles and cost-shares are waived except for TOP Prime Remote ADFMs who receive care under the Point of Service (POS) option, or who obtain pharmacy services in the 50 United States (U.S.), the District of Columbia, and U.S. territories where the TRICARE Pharmacy (TPharm) has established a retail pharmacy network. Waiver of copayment and deductibles under TOP Prime Remote is subject to review/updating based on enrollment status.

1.3  Under TOP Prime Remote, annual catastrophic caps are calculated on fiscal years. The enrollment year shall coincide with the fiscal year. Since deductibles and cost-shares are waived for TOP Prime Remote enrollees, this policy will apply only to TOP Prime Remote enrollees who incur out-of-pocket expenses as described above.

2.1  TOP Prime Remote enrollees shall select or have assigned to them Primary Care Managers (PCMs) according to guidelines established by the TAO Director, or designee.

2.2  A TOP Prime Remote enrollee must seek all his or her primary health care from the TOP PCM with the exception of care listed in Section 8. If the TOP PCM is unable to provide the care, the TOP PCM shall refer the enrollee to another primary care provider.

2.3  TOP Prime Remote enrollees must obtain appropriate referral/authorization for any non-emergency care rendered by anyone other than the beneficiary’s PCM. This provision applies regardless of where the care is rendered. TAO Directors may direct retroactive authorizations on a case-by-case basis. TOP Prime Remote or TAO enrollees who need urgent care while traveling stateside should contact the TOP contractor’s call center(s) for appropriate authorization. Routine care is generally not authorized while a TOP Prime Remote enrollee is traveling out of their enrollment region. The TOP contractor shall fully document the justification for authorizing routine out-of-area care. Emergency care does not require prior authorization; however, the beneficiary should contact their PCM and the contractor as soon as possible to obtain authorization for any necessary follow-up care.

2.4  Failure to obtain a TOP PCM referral/authorization when one is required for care may result in the service being paid under TOP POS procedures for an Active Duty Family Member (ADFM) with a deductible and cost-shares for outpatient services and cost-shares for inpatient services.

2.5  The TOP PCM shall assist the TOP Prime Remote enrollee and other beneficiaries in locating an Military Treatment Facility (MTF) or purchased care sector network or non-network provider to provide the care, and shall assist in scheduling an appointment with a purchased care sector provider upon request. The HCF shall conduct a benefit determination review and provide authorization for service for which the referral was made. If the contractor has no record of referral/authorization, prior to denial/payment, the claims processing contractor shall follow the TOP POS rules, assuming the service would otherwise be covered under the provisions of TRICARE Standard.

2.6  All referrals made by a TOP designated purchased care sector PCM shall be made through the TOP HCF and shall receive an authorization.

2.7  The TOP contractor shall ensure that all authorized services for TOP Prime Remote enrollees are provided on a cashless, claimless basis. The contractor shall implement guarantee of payment or other business arrangements to ensure that TOP Prime Remote enrollees are not required to pay up front at the time services are rendered by a purchased care sector provider.

2.8  Cashless, claimless provisions do not apply to self-referred care that would normally require an authorization.

2.9  For TOP Prime Remote enrollees who are traveling stateside, the TOP contractor shall direct TOP beneficiaries to utilize stateside MTFs whenever possible. If MTF care is unavailable, beneficiaries shall be provided with information regarding the nearest available network provider(s) who can assist the beneficiary. Non-network providers shall only be used when MTF or network care is not possible.

3.1  TOP Prime Remote-enrolled ADFMs shall follow established referral/authorization procedures prior to obtaining specialty care to avoid the application of POS cost-shares and deductibles. This includes all self-referred, non-emergency outpatient specialty medical services and all inpatient care (including inpatient mental health care), except for outpatient mental health and Substance Use Disorder (SUD) visits, ancillary services, drugs, and services provided by a TOP Partnership Provider. TOP Prime Remote ADFMs who self-refer to a civilian provider other than their PCM shall have their claims processed as POS.

3.2  POS cost-shares and deductibles shall not apply to claims for care received by newborns/adoptees during the deemed enrollment period.

3.3  There are no Non-Availability Statement (NAS) requirements for TOP Prime Remote enrollees. This requirement is replaced by a care authorization from the TOP contractor or other appropriate authority.

3.4  Self-referred, non-emergency, specialty, or inpatient care provided to a TOP Prime Remote ADFM enrollee by a network or non-network purchased care sector provider, which is not either provided/referred by the beneficiary’s PCM or specifically authorized may be reimbursed only under the TOP Prime Remote POS option if it is a benefit under TRICARE. Services which are not a TRICARE benefit shall be denied.

3.5  POS cost-sharing and deductible amounts do not apply if a TOP Prime Remote ADFM enrollee has Other Health Insurance (OHI) that provides primary coverage. The OHI must be primary under the provisions of the TRICARE Reimbursement Manual (TRM), Chapter 4, Section 1, and documentation that the other insurance processed the claim and the exact amount paid shall be submitted with the TOP claim. TRICARE OHI provisions apply for this type of claim.

3.6  The POS option does not apply to Service member overseas/stateside care.

3.7  The TOP contractor shall adjust TOP Prime Remote copayments when TOP PCMs or HCFs do not follow established referral/authorization procedures. For example, if the contractor processes a claim without evidence of an authorization and/or a referral under POS provisions, and the contractor later verifies that the PCM or other appropriate provider referred the beneficiary for the care, TOP contractor shall adjust the claim under TOP Prime Remote provisions. The contractor need not identify past claims, however, the contractor shall adjust these claims as they are brought to their attention.

3.8  On a case-by-case basis, following stabilization of the patient, the TAO Director may require a TOP Prime Remote beneficiary to transfer to a TOP network facility or the MTF. The TOP TAO Director shall provide written notice to the beneficiary (or responsible party) advising them of the impending transfer to a TOP network facility/MTF. If a TOP Prime Remote-enrolled ADFM elects to remain in a non-network facility after being notified of an impending transfer to another facility, TOP POS cost-sharing will begin 24-hours following receipt of the written notice. The TAO Director may not require a transfer until such time as the transfer is deemed medically safe.

3.9  See the TRM, Chapter 2 for deductible and cost-share amounts. POS deductible and cost-sharing do not apply to the claims for care received by certain newborn and newly adopted children during the deemed enrollment period. See Section 5 for additional guidance regarding deemed enrollment for newborns/adoptees.