1.0 General
All TRICARE requirements regarding Financial
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unless specifically changed, waived, or superseded by this section;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 3 for
additional instructions.
2.0 Payment
POLICY
2.1 Reimbursement of TOP beneficiary claims for
overseas health care shall be based upon the lesser of billed charges,
the negotiated reimbursement rate, or the Government-established
fee schedule. (See
Section 9 and the TRICARE Reimbursement Manual
(TRM),
Chapter 1, Sections 34 and
35 for additional guidelines). Except for
medical evacuations, claims for care in the U.S. commonwealths and
territories shall be reimbursed following stateside reimbursement
guidelines. Philippines and Panama claims shall be reimbursed following
Government-established fee schedules, unless the TOP contractor
has negotiated a lesser rate with a purchase care sector provider.
2.2 Payment
of Skilled Nursing Facility (SNF) claims from Puerto Rico and the
U.S. territories (Guam, the U.S. Virgin Islands, American Samoa,
and the Northern Mariana Islands) shall be processed as routine
foreign claims and shall be subject to the Prospective Payment System
(PPS), as required under Medicare in accordance with the Social
Security Act. These SNFs will be subject to the same rules as applied
to SNFs in the U.S. (see the TRM,
Chapter 8).
SNF care is not available in other TOP locations.
2.2.1 TRICARE contractors, at their
discretion, may conduct concurrent or retrospective review for Standard (through
December 31, 2017) and TRICARE Select (starting January 1, 2018) and
TRICARE for Life (TFL) patients when TRICARE is the primary payer.
The review required for the lower 18 Resource Utilization Groups
(RUGs) for services prior to October 1, 2010, and the lower 14 RUGs
for services on/after October 1, 2010, are a requirement for all
TRICARE patients when TRICARE is primary (see TRM,
Chapter 8, Section 1, paragraph 4.2.17). There
will be no review for Standard (through December 31, 2017) and TRICARE
Select (starting January 1, 2018) or TFL patients where TRICARE
is the secondary payer. The existing referral and authorization
procedures for Prime beneficiaries will remain unaffected.
2.2.2 Beneficiaries
in the lower 18 or 14 RUGs depending on date of service do not automatically qualify
for SNF coverage. These beneficiaries will be individually reviewed
to determine whether they meet the criteria for skilled services
and the need for skilled services (see the TRM,
Chapter 8, Section 1). If these beneficiaries
do not meet these criteria, the SNF PPS claim shall be denied.
2.2.3 The TOP
contractor, at their own discretion, may collect Minimum Data Set
(MDS) assessment data per the TRM,
Chapter 8, Section 1.
2.3 The TOP
contractor shall be responsible for entering into participation
agreements with SNFs in Puerto Rico, Guam, the U.S. Virgin Islands,
American Samoa, and the Northern Mariana Islands.
2.3.1 The TOP contractor, at their
own discretion, may conduct any data analysis to identify aberrant
SNF PPS providers or those providers who might inappropriately place
TRICARE beneficiaries in a high RUG. The contractor shall also assist
the TRICARE Area Office (TAO) Directors in obtaining/providing SNF
data, for conducting any SNF PPS data analysis they deem necessary.
2.4 Balance
billing provisions do not apply to TOP beneficiary claims for care
rendered in a foreign country and paid as billed, since there is
no unpaid balance on these claims. Purchased care sector network
providers, participating providers, and providers in U.S. commonwealths
and territories are prohibited from balance billing.
2.5 For health care rendered in Puerto Rico and
in the U.S., reimbursement for all TOP beneficiary care shall follow
the TRICARE payment policies except as outlined below.
2.5.1 TOP Service
members who have been required by the provider to make “up front”
payment at the time services are rendered may submit a claim for
reimbursement directly to the contractor. Normal TRICARE claims
processing requirements apply (including any authorization requirements
and the use of TRICARE-approved claims forms). If the claim is payable,
the contractor shall allow the billed amount and reimburse the Service
member for charges on the claim.
2.5.2 In no case shall a Service
member be subjected to “balance billing” or ongoing collection action
by a civilian provider for emergency or authorized care. If the
contractor becomes aware of such situations that they cannot resolve,
they shall pend the file and forward the issue to the appropriate TAO
Director. The appropriate TAO Director will issue an authorization
to the contractor for payments in excess of CMAC or other applicable
TRICARE payment ceilings, provided the TAO Director has requested
and has been granted a waiver from the COO, Defense Health Agency
(DHA), or designee.
2.5.5 Payment
may be made for ambulance services provided by commercial transport
(see
Section 7 for additional processing instructions
for these claims).
2.5.6 The provisions of
Chapter 3, Section 2, paragraph 2.1 are not
applicable to the TOP except for the optional provisions of Electronic
Funds Transfer (EFT) payments to TOP beneficiaries. The TOP contractor
is required to make EFT payments to all TOP beneficiaries (upon
beneficiary request) when the beneficiary requests payment to a
U.S. bank account or the other U.S. financial institution.
2.5.7 The provisions
of
Chapter 3, Section 2, paragraph 2.2 are not
applicable to the TOP. The TOP contractor shall not require purchased
care sector providers who submit claims electronically to accept an
electronic remittance advice and to receive payment by EFT. These
electronic processes are optional for purchased care sector providers
since they may create a financial burden for the provider.
3.0 Financial
Administration
3.1 The TOP contractor shall follow the Financial
Administration non-financially underwritten funds requirements in
Chapter 3 with the following exceptions:
3.1.1 Foreign
overseas drafts (local currency) and checks (U.S. currency) shall
also reflect “TRICARE Overseas Program”.
3.1.2 Foreign overseas drafts shall
also reflect information that indicates the draft is valid for 190 days
and if reissue is required/necessary, the draft must be returned
to the TOP contractor with a request for reissuance. The contractor
shall issue drafts/checks for Germany claims which look like local German
drafts/checks.
3.2 The TRICARE Encounter Data
(TED) for the overseas claims shall be reported on vouchers/batches
according to the TRICARE Systems Manual (TSM),
Chapter 2 and
as follows for remote sites:
3.2.1 Active Duty Family Member
(ADFM) and Service member remote site claims, excluding health care
claims for emergent/urgent care for Navy and Marine Corps Service
member who are either deployed and or deployed on liberty status
in a remote site shall be submitted on vouchers instead of batches
and shall be paid from the current non-financially underwritten
foreign bank account. They shall be submitted like all other claims
currently processed from that account.
3.2.2 Navy deployed and/or deployed
on liberty emergent or urgent care claims shall be submitted on
a separate voucher. A separate bank account will be established
for these beneficiaries. The Automated Standard Application for
Payment (ASAP) account on the voucher header will identify the voucher
as Navy.
3.2.3 Marine Corps deployed and/or deployed on liberty
emergent or urgent care claims shall be submitted on a separate
voucher. A separate bank account will be established for these beneficiaries. The
ASAP account on the voucher header will identify the voucher as
Marine Corps.
3.2.4 Claims for retirees and their
eligible family members living in a remote site shall be submitted
on vouchers instead of batches and shall be paid from the current
non-financially underwritten bank account. They shall be submitted
on the same voucher as all other claims currently processed from
that account.
3.2.4.1 Claims for care rendered in the U.S. or the
District of Columbia to TOP Service member, ADFM, retirees and their
dependents living in a remote overseas site shall be submitted on
vouchers and shall be paid from the current non-financially underwritten
bank account. They shall be submitted on the same voucher as all
other claims currently processed from that account.
3.3 For other
than remote site claims:
3.3.1 TOP eligible Service member
and ADFM claims shall be submitted on vouchers and shall be paid
from the current non-financially underwritten bank account. They
shall be submitted on the same voucher as all other claims currently
processed from that account.
3.3.2 Claims for retirees and their
eligible family members living overseas shall be submitted on vouchers
and shall be paid from the current non-financially underwritten
or TFL/accrual fund bank accounts. They shall be submitted on the
same voucher as all other claims currently processed from that account.
3.3.3 TOP Prime
(Service member and ADFM) and TOP Standard (through December 31,
2017) and TRICARE Select (starting January 1, 2018) beneficiary
stateside claims for health care shall be submitted on vouchers
and shall be paid from the current non-financially underwritten
bank account. They shall be submitted on the same voucher as all
other claims currently processed from that account.
3.3.4 Overseas
health care claims for stateside beneficiaries whose health care
is normally provided under one of the regional contracts (i.e.,
beneficiaries enrolled or residing in the 50 U.S. or the District
of Columbia, who receive care while traveling or visiting abroad)
shall be processed by the TOP contractor. Claims for these beneficiaries
shall be paid from the current non-financially underwritten bank
account. This provision does not apply to beneficiaries who are
enrolled to the Uniformed Services Family Health Plan (USFHP) or
the Continued Health Care Benefit Program (CHCBP). Claims for these
beneficiaries are processed by their respective contractor regardless
of where the care is rendered.
3.4 The TOP contractor shall:
3.4.1 Provide
TRICARE Overseas Currency Reports identifying
the gain or loss for the month reported to arrive by the 10th calendar
day following the month reported. Reporting requirements for net
gains/losses are identified by DD
Form 1423, Contract Data Requirements List (CDRL),
located in Section J of the applicable contract.
3.4.2 The TOP
contractor shall calculate currency gains and losses resulting from
payments made to purchased care sector providers and/or beneficiaries
in foreign countries. The gains and losses shall be computed based
on the exchange rate in effect on the ending date of care. The difference
between the cost of the foreign currency on the ending date of care
and the contractor payment date shall be the gain or loss on the
transaction. Payment shall be as follows for:
3.4.2.1 Net Gain.
For months that result in a net gain, the TOP contractor shall forward
the report along with their check payable to the Department of Defense
(DoD), DHA, for the gain from currency conversion.
3.4.2.2 Net Loss.
DHA will reimburse the TOP contractor for any losses incurred from
currency conversion. The TRICARE Overseas Currency report shall
be accompanied by a letter (invoice) requesting reimbursement for
the loss incurred. This payment will not be subject to the Prompt Payment
Act (FAR 32.9) as amended, therefore, payment by DHA will usually
be made within five working days of receipt of the invoice and the
TRICARE Overseas Currency report.