1.0 GENERAL
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changed, waived, or superseded by this section; the TRICARE Policy Manual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.
2.0 CONTRACT
ADMINISTRATION AND INSTRUCTIONS TO CONTRACTOR
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Chapter 1, Section 2, paragraph 4.0 are superseded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.
3.0 TRICARE
PROCESSING STANDARDS
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.
8.0 TRANSITIONS
-- START-UP REQUIREMENTS
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.
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.