Military Health System

2.1  The TOP contractor shall arrange and provide access to dental care on a cashless, claimless basis to TOP Prime Remote enrolled Service members, except for Service members located in U.S. territories (including Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands). This includes routine, urgent, and emergent dental care services, including dental transportation/evacuation when medically necessary and appropriate. The contractor shall also arrange and provide access to urgent and emergent dental care services (including dental transportation/evacuation when medically necessary and appropriate) to non-enrolled Service members who require urgent or emergent dental care services while on Temporary Additional Duty /Temporary Duty (TAD/TDY), deployed, deployed on liberty, or in an authorized leave status in a remote overseas location.

2.2  The TOP contractor shall establish a network of purchased care sector dental providers who have been evaluated and determined to meet international hygiene and clinical practice standards. Upon beneficiary request, the contractor will also provide information to any TRICARE beneficiary regarding dental network providers; however, the contractor is not required to establish dental networks to support Active Duty Family Members (ADFMs), retirees, or retiree family members in any overseas location.

2.3  The TOP contractor’s Call Center(s) shall provide assistance regarding Service member dental care 24 hours per day, seven days per week, 365 days per year.

2.4  Service members in remote overseas locations shall contact the TOP contractor’s Call Center to schedule routine care under $750. Treatment plans that exceed $750 per episode or $1,500 per calendar year require prior authorization and approval from the Defense Health Agency (DHA) Dental Program Office even if the dental visits are considered “routine care”. The contractor shall assist Service members in submitting treatment plans for TAO review.

2.5  The TOP contractor shall ensure that the following documentation is provided to the TAO for all pre-authorization reviews: radiographs and diagnosis, treatment plan, estimated time required for care, probable cost, and projected length of tour of duty at the patient’s present duty station.

2.6  All Service member orthodontic service requests shall be forwarded to the DHA Dental Program Office for review and authorization, regardless of treatment cost.

2.7  Service members who seek dental service without coordinating their care through the TOP contractor may be required to pay up-front at the time services are rendered. The Service member shall be responsible for submitting claims for reimbursement. Dental care claims that lack proper authorization (where required) shall be denied. The DHA Dental Program Office may provide a retroactive authorization for dental care services when appropriate.

2.8  Prior authorizations are not required for emergency dental care services. However, Service members shall be encouraged to contact the contractor’s Call Center for assistance with obtaining emergency dental care whenever possible. This shall ensure that services can be provided on a cashless, claimless basis for covered services from a qualified dental provider.

2.9  Dental claims may be submitted by TOP Points of Contact (POCs) on behalf of remote Service members in accordance with Section 12.

2.10  Reserve component members who are on orders for less than 30 days may not appear eligible in Defense Enrollment Eligibility Reporting System (DEERS). Claims submitted for these beneficiaries must be accompanied by proof of eligibility in order to adjudicate the claim.

2.11  Claims will be accepted without Current Dental Terminology (CDT) procedure codes and will be manually coded by the TOP contractor based on narratives provided.

2.12  Purchased care sector dental providers shall not be required to indicate dental readiness classification on the claim form.

2.13  Payment for remote overseas active duty dental care shall be at billed charges, unless a different process has been identified by the Government.

2.14  Normal TRICARE foreign currency rules apply.

2.15  Upon beneficiary request, the TOP contractor shall assist the Service member in locating an appropriate dental provider and making dental appointments.

2.16  The Government will provide the TOP contractor with a Dental Overseas Benefit Brochure/Handout explaining local requirements. This material shall be incorporated into all applicable beneficiary education briefings and mailings.

2.17  At the discretion of the TOP contractor, dental emergencies that cannot be adequately addressed through the contractor’s dental network may be treated as medical cases and shall interface with the medical management program (e.g., if a Service member resides in a remote area where there are no dental providers, they may be referred to a purchased care sector medical provider for pain management pending travel to an area with a qualified dentist).

2.18  The TOP contractor shall prepare and submit a quarterly report for TOP Service member dental care per Section 15.