Military Health System

1.1  Non-active duty TRICARE Prime and TRICARE Prime Remote (TPR) enrollees referred for non-emergent medically necessary specialty care over 100 miles (one way) from their Primary Care Manager’s (PCM’s) office to the nearest specialist’s office may be eligible to receive reimbursement for reasonable travel expenses. Entitlement is limited to those specialty referrals when no other specialist (i.e., Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM), network or non-network specialists) is available within 100 miles (one way) of the PCM’s office. Depending on enrollment, the TRICARE Prime Travel Benefit (PTB) Office or the MTF/eMSM will determine if the specialty care is more than 100 miles (one way) from the provider’s office. PTB does not apply to a dependent Outside of the continental United States (OCONUS) or to an Active Duty Service Member (ADSM) who is authorized medical travel.

1.2  PTB Program Attestations - The contractor shall provide a daily spreadsheet with any information needed to assist in validating beneficiary eligibility requirements for Prime travel reimbursement. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. Each beneficiary entry shall be called an “attestation” and shall include information related to network-enrolled beneficiaries or any Coast Guard enrolled beneficiaries (network or direct care) who received approved authorizations for specialty care over 100 miles from the PCM’s Office. The contractor shall respond to all beneficiary inquiries regarding authorization questions. The contractor shall resolve access to care issues with assigned Specialty Care Provider (SCP), SCP capability issues, discuss beneficiaries need for additional letters of medical necessity, etc. The Government will perform all operational functions to include distance validation and final program eligibility determination.

1.3  A retiree with a combat-related disability (as determined by the member’s Branch of Service), not enrolled in TRICARE Prime, and referred by a Primary Care Provider (PCP) for follow-on specialty care related to that specific disability as listed in Combat-Related Special Compensation (CRSC) letter, more than 100 miles (one way) from where the PCP provides services to the retiree, may be eligible to receive reimbursement for reasonable travel expenses. The TRICARE PTB Office for the region in which the retiree resides will determine if the specialty care is more than 100 miles (one way) from the provider’s office. The contractor shall refer inquiries about travel reimbursement for retirees with combat-related disabilities to the regional TRICARE PTB Office travel representative or Beneficiary Counseling and Assistance Coordinator (BCAC) for further information and assistance.

1.4  The Coast Guard Authorization Act of 2010, signed into law on October 15, 2010, authorizes reimbursement for travel to specialty care less than 100 miles (one way) for a non-active duty Coast Guard beneficiary (active duty dependents only) who resides on an island within CONUS, with no public access roads to the mainland, and for one medically necessary attendant. Entitlement is limited to those specialty referrals when no other specialist (i.e., MTF/eMSM, network or non-network specialists) is available on the island. The beneficiary must be enrolled in TRICARE Prime and referred to a specialty care provider by their PCM. The contractor shall refer inquiries about travel reimbursement for Coast Guard beneficiaries to the appropriate PTB travel representative.

1.5  For patients eligible for travel reimbursement under paragraphs 1.1 through 1.4, if the PCM/PCP or servicing provider deems it medically necessary, travel orders and reimbursement may be authorized for one Non-Medical Attendant (NMA) to accompany a non-active duty patient referred for applicable specialty care. The NMA must be a parent, legal guardian, spouse, or other adult member of the patient’s family, or other adult companion who has been delegated a medical Power of Attorney (POA) by the patient or legally responsible party. In most cases, the NMA’s must be at least 21 years old. The Medical POA may be waived at Approving Official (AO) discretion.

1.6  Except for Coast Guard beneficiaries, MTFs/eMSMs will validate the travel expense entitlement and issue travel orders for specialty referrals issued by military PCMs, and the TRICARE PTB Office will validate the travel entitlement and issue travel orders for specialty referrals from civilian PCMs. Travel reimbursements allowed under paragraphs 1.1 through 1.4 will be reimbursed in accordance with the Joint Travel Regulations (JTR). Travel reimbursement claims must be filed no later than one year after the qualifying travel date (exceptions may be made for patients eligible for travel reimbursement under paragraph 1.3). Travel expenses will not be authorized for elective procedures or non-covered benefits. Except for Coast Guard beneficiaries (see paragraph 1.7), the contractor shall refer travel requests for MTF/eMSM-enrolled Prime beneficiaries to the MTFs/eMSMs and civilian-enrolled Prime beneficiary requests to the TRICARE PTB Office for authorization, orders and claim processing if it appears the beneficiary may be entitled to travel benefits. Non-Coast Guard beneficiaries with questions about these travel benefits and the NMA entitlement should contact their local MTF/eMSM or the TRICARE PTB Office or BCAC for assistance. Telephone numbers and addresses for BCAC are available on the TRICARE web site at http://www.tricare.mil/bcacdcao.

1.7  The contractor shall refer inquiries about travel reimbursement for Coast Guard beneficiaries to the appropriate PTB travel representative. This applies to MTFs/eMSMs and civilian-enrolled Prime and Prime Remote beneficiaries.

2.1  October 30, 2000, for TRICARE Prime enrollees.

2.2  January 1, 2008, for retirees with a combat-related disability.

2.3  October 15, 2010, for TRICARE Prime Coast Guard island dwellers.