1.0 GENERAL
1.1 All TRICARE
requirements regarding C&CS shall apply to the TRICARE Overseas
Program (TOP) unless specifically changed, waived, or superseded
by the provisions of 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 11 for additional instructions.
1.2 Per Department
of Defense Instruction (DoDI 6010.21 (“TRICARE Marketing Policy”)
dated December 18, 2001, TRICARE marketing materials developed by
contractors must be coordinated with each TRICARE Regional Office
(TRO) and approved by Defense Health Agency (DHA). For the TOP contract,
this coordination includes the TRICARE Area Office (TAO) Directors
and the TOP Office (TOPO). Coordination of local administrative
changes is at the local discretion of Military Treatment Facilities (MTFs).
2.0 TRICARE
Service Centers (TSC
s)
2.1 Location, Operations, And
Staffing
2.1.1 TSCs are jointly staffed by MTF personnel and
TOP contractor personnel. TSCs in the MTFs shall be staffed at a
minimum, Monday - Friday (except holidays recognized by the installation)
during the administrative hours of the MTF.
2.1.2 The TOP
contractor shall provide Beneficiary Service Representatives (BSRs)
on a full-time basis at each location as designated in the contract.
BSRs shall be qualified to perform enrollments/disenrollments/Primary
Care Manager (PCM) changes; perform registrations in Composite Health
Care System (CHCS) (as required to support TRICARE enrollments)
and update patient information in CHCS and Defense Enrollment Eligibility
Reporting System (DEERS); resolve PCM Information Transfer (PIT) discrepancies;
assist beneficiaries with TRICARE benefit/coverage or claims questions;
assist beneficiaries with debt collection issues; and provide TRICARE
briefings as requested by the MTF. The TOP contractor shall provide
sufficient BSR staffing to accomplish all work in a timely manner;
however, at least one full-time BSR will be assigned to each location
regardless of actual workload unless the Government has specifically
authorized part-time coverage. The TOP contractor shall advise the Government
of any locations where the workload does not justify full-time BSR
coverage. The TOP contractor shall implement appropriate business
processes to provide full-time TSC coverage if the assigned Customer
Service Representative(s) (CSR(s)) are unavailable due to planned
or unplanned absences (e.g., illness, leave, personal emergencies,
etc.) for more than two consecutive business days. Local processes
for managing short-term CSR absences (up to two consecutive business
days) shall be addressed in the Statement of Responsibilities (SOR)
between the affected MTF Commander(s) and the TOP contractor.
2.2 TSC Functions
2.2.1 The contractor shall provide
overseas TSCs with BSR support to provide all Military Health System
(MHS) beneficiaries with information and services as specified below.
The contractor shall confirm eligibility for care and enrollment
status of beneficiaries before making any arrangements for medical
services. (Eligibility for the non-active duty patients is determined
by the MTF per
Section 26, paragraph 2.4.4.) TSCs shall have
an interface with the automated claims processing and enrollment systems
to support the functions of the TSC no later than 30 calendar days
prior to the start of health care delivery (SHCD).
2.2.2 The contractor
shall provide all MHS beneficiaries with information regarding:
• TOP
Prime, TOP Prime Remote, and TOP Select enrollment information;
• Access to and referral
for care;
• Information
on the Point of Service (POS) option;
• Information on claims
(including on-line access to the claims processing system for information
about the status of a claim);
• Assistance regarding
claim problems when the TOP contractor is responsible for processing
the claim; and
• Continuity-of-care
services to all MHS beneficiaries including, but not limited to,
active duty personnel, dependents of active duty personnel, retirees
and their dependents, survivors, Medicare-eligible beneficiaries
and all other categories of individuals eligible to receive MHS
services.
TSCs shall
have a fully operational, on-line interface with the automated claims
processing and enrollment systems to support the functions of the
TSC no later than 30 calendar days prior to the SHCD and shall maintain
that interface through the life of the contract. The activities
of the TSC shall include:
2.2.2.1 MHS Beneficiary Information
The TOP contractor shall provide personal assistance
to all MHS beneficiaries seeking information about TRICARE Prime,
TRICARE Standard (through December 31, 2017) or TRICARE Select (starting
January 1, 2018), and TRICARE For Life (TFL). The TOP contractor
shall ensure that the TSCs are supplied with enrollment and educational
information for TRICARE Prime and TRICARE Standard (through December
31, 2017) or TRICARE Select (starting January 1, 2018), dual-eligible
program and claims submission information, Civilian Health and Medical
Program of the Department of Veterans Affairs
(CHAMPVA), TRICARE dental programs and all other relevant materials.
Through the BSRs and call centers, the TOP contractor shall establish
mechanisms to advise beneficiaries of care options, including the
POS option, and services offered.
2.2.2.2 BSR Interface With MTFs
BSRs shall act as the focal point for providing
information, referral, and assistance to beneficiaries seeking access
to TRICARE services. BSRs shall maintain day-to-day liaison with
MTF staff to promote MTF optimization and ensure effective performance
of the access, referral, information, and continuity of care functions.
2.2.2.3 Enrollment
BSRs and contractor call center staff shall
provide personal assistance to eligible beneficiaries, electing
to enroll or disenroll, and permanently assigned active duty personnel
enrolling in TRICARE Prime. The TOP contractor shall provide assistance
to all MHS beneficiaries, including active duty, Medicare eligibles,
and others, in understanding program requirements, by answering
questions, adhering to MTF Commanders’ and TAO Director’s determinations
for Primary Care Manager (PCM) assignment, and following grievance
and inquiry procedures in accordance with this manual.
2.2.2.4 Providers
The TOP contractor shall maintain an up-to-date
on-line provider search tool for all providers and facilities in
the contractor’s network in accordance with
Chapter 11, Section 4.
A copy of the most current list will be maintained by each BSR for
TSC use. MTF Commanders, TAO and TOPO staff, and MHS beneficiaries
shall be granted access to these lists on an as-needed basis. Contractor
staff in the TSCs shall provide lists of Direct Care (DC) PCMs to
MHS beneficiaries when required for PCM selection, if these lists
are provided to the contractor by the MTF.
2.2.2.5 Claims
Contractor staff in the TSCs shall assist all
TRICARE beneficiaries with all claims issues when the TOP contractor
is responsible for processing the claim. When the TOP contractor
is not responsible for processing the claim, the contractor staff
in the TSC shall assist the beneficiary in identifying and contacting
the organization that is responsible for processing the claim.
2.2.2.6 TRICARE Dental
Plans
Contractor staff in the TSCs shall
provide general information on eligibility for the TRICARE Dental
Plans (Active Duty Dental Program (ADDP), TRICARE Dental Program
(TDP), and TRICARE Retired Dental Program (TRDP)) and how to obtain
dental plan information from the appropriate dental contractor.
The beneficiaries shall be referred to the appropriate dental contractor
for additional information.
2.3 Creating
And Updating Department of Defense (DoD) Self-Service Logon (DS
Logon) Accounts
DoD affiliates and Department
of Veterans Affairs (DVA)
/Veterans Health Administration
(VHA) affiliates qualify for a DS Logon account.
A DS Logon is a secure, self-service logon ID that allows DoD/DVA
/VHA affiliates
to access certain web sites using a single username and password.
DoD/DVA affiliates are DoD sponsors, spouses (regardless of age),
and dependents (18 and older), and retirees and veterans who have
an active affiliation in the Defense Enrollment Eligibility Reporting
System (DEERS), which includes Reserve Component (RC) sponsors (including
all subcomponents such as the Selected Reserve, Retired Reserve,
Individual Ready Reserve (IRR), and Standby Reserve) along with their
spouses, and dependents (18 and older). The DoD Self-Service Access
Station (DS Access Station) is an on-line web application developed
by the Defense Manpower Data Center (DMDC) for the purpose of creating
DS Logon account requests on behalf of DoD/DVA
/VHA affiliates.
When a beneficiary inquiry concerns the DS Logon, the contractor
shall refer the caller to the DoD MyAccessCenter application help
section at
https://myaccess.dmdc.osd.mil/.
2.3.1 DS Access
Station
Upon request by DoD/DVA
/VHA affiliates,
TSC personnel shall use the DS Access Station and perform In-Person
Proofing (IPP) to generate requests for DMDC to create and update
DS Logon accounts following instructions specified in the current
version of the DS Logon - Access Station User Guide. DS Access Station
is currently available at
https://www.dmdc.osd.mil/appj/dsaccessstation/.
The contractor shall request DS Access Station user authorization
for TSC personnel from DMDC through the contractor’s DEERS site
security manager. A copy of the current DS Logon - Access Station
User Guide will be provided upon request.
2.3.2 DS Logon
Account Levels
Two account levels of DS Logon
access are available to DoD/DVA/VHA affiliates,
each with progressing security features and each with a different
user-authentication procedure:
2.3.2.1 Basic Account (Level 1)
This is an entry level user account established
online that only provides limited view access to the user’s personal
information that the user has provided on-line. This level of account
is provided to individuals who have registered online at the eBenefits
web site (
http://www.ebenefits.va.gov) without
being in-person proofed. Many applications will not allow access
with a Basic (Level 1) Account.
2.3.2.2 Premium Account (Level 2)
This account is given to a DoD/DVA/VHA affiliate
who has self-registered using their Common Access Card (CAC) or
Defense Financing and Accounting Service (DFAS)/myPay Login ID or who
has completed an IPP process with designated representatives such
as TSC personnel. To provide enhanced security to the user’s personal
information, access to most applications including TRICARE-related
applications require a Premium (Level 2) Account.
2.3.3 Generating
DS Logon Requests
2.3.3.1 Before generating a request for a Premium Account,
TSC personnel shall determine if the requestor has an existing Basic
Account. If they do, TSC personnel shall follow DS Logon user guide instructions
to generate a request to upgrade the Basic Account to a Premium
Account. Upon successful completion of an upgrade, the Premium Account
is immediately available for use.
2.3.3.2 If a Premium
Account is created outright rather than being upgraded from a Basic
Account, the Premium Account will not be effective and available
for use until the requestor receives a letter in postal mail from
DMDC and follows the instructions in the letter before the specified
deadline to activate the Premium Account. If the requestor does
not have an existing Basic Account, TSC personnel shall inform the
requestor of the advantages of establishing a Basic Account and
provide the requestor with the procedures for obtaining a Basic
Account. If the requestor does not wish to create a Basic Account
first, TSC personnel shall proceed with the procedures for a new
DS Logon request.
2.3.4 DS Access Station Users and
Confidentiality
Only users authorized by
the DMDC may access the DS Access Station and perform IPP. Furthermore,
only authorized DS Access Station users may view any documents presented
for IPP or be informed in any way of information available in the
DS Access Station. Every authorized user must safeguard the confidentiality
of such information at all times to comply with the Privacy Act
of 1974. The contractor shall return all documents presented for
IPP to the requester and shall not retain any documents. The contractor
shall not make photocopies or any other images of documents presented for
IPP.
3.0 HEALTH
CARE FINDER (HCF) SERVICES
3.1 TOP HCF functions are performed
by TOP contractor personnel located in the TSCs or in contractor-operated
call center(s). The TOP contractor shall offer call center operations
to support HCF services via toll-free lines 24 hours per day, seven
days per week, 365 days per year.
Note: The contractor
shall offer claims assistance via toll-free lines seven days per
week, 365 days per year, between the hours of 2:00 AM and 7:00 PM
Central Standard Time (CST). These service hours for claims assistance
apply even if claims assistance is provided via the contractor’s
call center(s).
3.1.1 HCFs are responsible for facilitating access
to purchased care sector provider care (including, but not limited
to, primary care, specialty care, mental health care, ancillary
services, Durable Medical Equipment (DME), and pharmacy services),
and for authorizing certain health care services. Additionally,
HCFs shall inform beneficiaries of access mechanisms, referral procedures,
and rules regarding use of network/non-network providers. They shall
also improve patient continuity of care by establishing mechanisms
to facilitate necessary consultations, follow-up appointments and
the sharing of medical records. TOP HCFs will serve all MHS beneficiaries
in the region, regardless of their enrollment status. This includes
dual-eligible beneficiaries and beneficiaries residing or enrolled
in the 50 U.S. and the District of Columbia who may require assistance
when accessing care in an overseas location.
3.1.2 For MTF
enrollees, the specialty care referral process includes a covered
benefit review; entering appropriate authorizations into the contractor’s
system; locating a qualified network or non-network purchased care
sector provider to provide the care on a cashless, claimless basis;
providing the beneficiary with a written care authorization and
the purchased care sector provider’s information; and assisting
the beneficiary with establishing an appointment with the purchased
care sector provider (upon beneficiary request).The contractor shall
also provide information to MTF personnel regarding the status of
specialty care referrals and shall work cooperatively with the MTF
to assist in obtaining consult results from purchased care sector
providers; however, the contractor is not responsible for tracking
receipt of consult results.
3.1.3 For TOP Prime Remote enrollees,
the specialty care referral process includes a medical necessity
review; a covered benefit review; entering appropriate authorizations
into the contractor’s system; locating a qualified network or non-network
purchased care sector provider to provide the care on a cashless,
claimless basis; providing the beneficiary with a written care authorization
and the purchased care sector provider’s information; and assisting
the beneficiary with establishing an appointment with the purchased
care sector provider (upon beneficiary request). This process is
also applicable to Service members who are on Temporary Additional
Duty/Temporary Duty (TAD/TDY), in an authorized leave status, or
deployed/deployed on liberty in a remote overseas location, and
to TRICARE Prime/TRICARE Prime Remote (TPR) enrollees who require
urgent specialty care while traveling outside the 50 U.S. and the
District of Columbia.
Note: This process
applies to all TOP Prime Remote enrollees, regardless of the status/location
of the referring provider or health unit.
3.1.4 Beneficiaries
enrolled to the Uniformed Services Family Health Plan (USFHP) and
the Continued Health Care Benefit Program (CHCBP) must follow the
requirements of those programs when obtaining overseas care.
3.2 The TOP
HCF is responsible for the following functions:
3.2.1 Referral Assistance for TOP
Beneficiaries
The TOP contractor (working
in concert with the MTF Commander) shall ensure optimal use of MTFs
and to foster coordination of all care delivered in the civilian
sector and care referred to and from the MTF. The TOP HCF is the
primary mechanism for achieving these objectives. The referral services
of the TOP HCF are primarily to ensure access to care for enrolled
beneficiaries, but the TOP HCF is also available to assist non-enrollees
in finding network/non-network purchased care sector providers.
For TOP Prime/TOP Prime Remote enrollees, the referral is generally
initiated by the beneficiary’s PCM. The PCM or beneficiary contacts
the TOP HCF for assistance in locating an appropriate purchased
care sector provider and to obtain authorization for the care (see
Sections 17 and
18 for additional
information on HCF referral assistance).
3.2.2 Referral
Assistance for Beneficiaries Enrolled or Residing in the 50 U.S.
and the District of Columbia
The TOP contractor
shall provide referral assistance for TRICARE Prime/TPR enrollees
who require urgent or emergent health care while traveling outside
the 50 U.S. and the District of Columbia. These referrals will generally
be initiated by the beneficiary, a purchased care sector provider,
or an overseas MTF provider. Emergency care never requires preauthorization;
however, ADFMs enrolled to TRICARE Prime/TPR may receive urgent
and emergency health care services in locations outside the 50 U.S.
and the District of Columbia (to include emergency medical evacuation
per
Section 7) on a cashless, claimless basis
if the care is coordinated in advance with the TOP contractor. The
TOP contractor shall implement guarantee of payment or other business
processes to ensure that ADFMs enrolled to TRICARE Prime/TPR may
receive urgent or emergency medical services on a cashless, claimless
basis upon beneficiary request.
Note: Routine care will not be authorized for traveling
TRICARE Prime/TPR enrollees overseas.
3.2.3 Authorizations
3.2.3.1 The TOP
HCF will authorize care for TPR enrollees; for Service members who
are on TAD/TDY, in an authorized leave status, or deployed, deployed
on liberty in a remote overseas location, and for TRICARE Prime/TPR
enrollees who require urgent or emergent health care while traveling
outside the 50 U.S. and the District of Columbia. The contractor
shall also ensure that MTF-issued authorizations are entered into
all applicable contractor systems. Non-emergent specialty health
care received from a purchased care sector provider must be authorized
if benefits are to be paid as TOP Prime/TPR.
3.2.3.2 Care subject
to a PCM referral/authorization/Non-Availability Statement (NAS)
may receive a clinical review and authorization by the HCF or other
designee.
3.2.4 If an ADFM TOP Prime/TOP Prime
Remote enrollee receives care that was not authorized, the care
may be covered under the TOP POS option, with POS deductibles and
cost-shares. POS provisions also apply to TRICARE Prime/TPR enrollees
who receive non-emergency care outside the 50 U.S. and the District
of Columbia without obtaining prior authorization from the TOP contractor.
The care must also be otherwise coverable under TRICARE or the claim
shall be denied.
3.2.5 Service member care that was
not referred and authorized shall be denied unless it is retroactively
authorized by the appropriate service and Director, DHA. This included
obtaining an approved waiver for any non-covered service. POS does
not apply to Service members.
4.0 Customer
Service Responsibilities
TOP customer support
shall be provided to the Director, TROs, TOPO/TAO staffs, TOP purchased care
sector providers, MHS beneficiaries, designated Services POCs, TOP
MTF staffs including Beneficiary Counseling and Assistance Coordinators
(BCACs)/Debt Collection Assistance Officers (DCAOs), stateside TROs,
stateside contractors, stateside TRICARE beneficiaries traveling
overseas, and DHA. TOP contractor customer support service shall
include the following:
4.1 The TOP contractor shall secure
at a minimum one dedicated post office box for the receipt of all
claims and correspondence from foreign locations per overseas region.
4.2 The TOP
contractor shall identify a specific individual and an alternate
to assist the Director, TROs, TOPO/TAO Directors, DHA, BCACs and
stateside claims processing contractors with the resolution of TOP
issues. Issues which cannot be successfully resolved shall be referred
to the TOP Contracting Officer’s Representative (COR).
4.3 The TOP
contractor shall identify a specific individual and an alternate
to assist DCAOs with the resolution of TOP beneficiary debt collection
issues.
4.4 The TOP contractor shall be responsible for
establishing and operating a dedicated TRICARE overseas claims/correspondence
processing department with a dedicated staff. This department and staff
shall be under the direction of a supervisor, who shall function
as the contractor’s POC for TRICARE overseas claims and related
operational and support services. The contractor’s department for
TRICARE overseas claims shall include at a minimum the following
functions/requirements:
4.4.1 The TOP contractor shall provide
toll-free telephone service for claims assistance to beneficiaries
and providers seven days a week, 365 days a year, between the hours
of 2:00 AM and 7:00 PM CST. Toll-free services shall be available
from any stateside or overseas location.
4.4.2 The TOP contractor shall have
the ability to translate claims submitted in a foreign language
and write in German, Italian, Japanese, Korean, Tagalog (Filipino),
and Spanish, or shall have the ability to obtain such translation
or writing.
4.4.3 The TOP contractor shall provide on-line read
only access to their claims processing system to the Director, TROs,
each TOPO/TAO Director, and the DHA technical representative for
TOP claims.
4.4.4 The TOP contractor shall provide a secure,
user-friendly internet portal for receipt of customer claims status
inquiries and access to claims status information (to include the
ability to view and print Explanation of Benefits (EOBs).
4.4.5 The TOP
contractor shall provide, upon Government request, documentation
of claims for auditing purposes.
4.5 The TOP contractor shall assist
traveling TOP Prime and Prime Remote enrollees to ensure beneficiary
access/receipt of urgent or emergent care in the 50 U.S. and the
District of Columbia. The contractor shall also assist beneficiaries
residing or enrolled in the U.S. or the District of Columbia who require
urgent or emergent care while traveling overseas. ADFMs who are
enrolled to TRICARE Prime or TPR may receive emergency medical services
in locations outside the 50 U.S. and the District of Columbia (to
include emergency medical evacuation) on a cashless, claimless basis
if the care is coordinated in advance with the TOP contractor.
5.0 BENEFICIARY
SERVICES
5.1 The TOP contractor shall achieve the highest
level of beneficiary satisfaction possible in the overseas environment.
This shall be accomplished by developing qualified purchased care
sector provider networks (complemented by non-network purchased
care sector providers as necessary), ensuring timely access to purchased
care sector care, providing TOP information/education/training to beneficiaries
and purchased care sector providers, and processing claims in a
timely, accurate manner.
5.2 In
addition to the beneficiary education requirements outlined in
Chapter 11, Sections 1 and
2, the
TOP contractor may be required to conduct beneficiary education/enrollment
activities for arriving/deploying units in accordance with the enrollment
protocols established in the MOU between the TOP contractor and
the MTFs.
5.3 The TOP contractor shall maintain up-to-date
lists of purchased care sector network providers, and shall make
this information available at all TOP TSCs and via web-based access.
Web-based network provider listings shall include information regarding
authorization requirements that are applicable to TOP Prime and
Prime Remote enrollees.
5.4 The TOP contractor’s beneficiary
education activities and materials shall include information for TOP
Prime and Prime Remote enrollees regarding care received in the
50 U.S. and the District of Columbia. This process shall include
information regarding referrals/authorizations while stateside,
TOP POS policy, and the recommended process for accessing care while
stateside. TOP Prime and Prime Remote enrollees traveling stateside
shall be encouraged to utilize MTF care whenever possible. If MTF care
is not available, beneficiaries should be encouraged to seek care
from a network provider before obtaining care from a non-network
provider.
5.5 The requirement in
Chapter 11, Section 2, paragraph 1.1, is superseded
for the TOP contractor by a requirement for a total of nine three-day
TRICARE training courses per contract option period (two per option
period within the TRICARE Eurasia-Africa area; two within the TRICARE
Pacific area; two within the TRICARE Latin America/Canada (TLAC)
area; and three additional courses that may occur in any stateside
or overseas location at the direction of the Contracting Officer
(CO)).
5.6 The requirement for mailing
TRICARE handbooks, in
Chapter 11, Section 1, paragraph 4.1, is superseded
for the TOP contractor by a requirement for “on-demand” processes
for distributing TRICARE handbooks upon beneficiary request (including,
at a minimum, web-based requests, telephone requests, and on-site
requests at a TSC).
6.0 PROVIDER
SERVICES
6.1 The TOP contractor shall ensure that all purchased
care sector network providers and their support staff have sufficient
understanding of the applicable TRICARE program requirements, policies, and
procedures to allow them to carry out the requirements of this contract
in an efficient and effective manner that promotes beneficiary satisfaction.
6.2 The TOP
contractor shall have the responsibility for developing and delivering
TRICARE Program information to purchased care sector providers.
The contractor shall determine the requirements for printed products
and will develop and deliver these products after obtaining approval
from the Government. The information in these products will generally
be determined by the contractor based on their understanding of
the needs of their network providers; however, the Government may
mandate the inclusion of certain topics or information.
6.3 Provider
education materials shall include information regarding claims processing
procedures, claims submission deadlines, and normal claims processing
time lines.
6.4 The Government shall ensure provider satisfaction
with contractor-provided information by conducting random satisfaction
surveys of select network providers.
7.0 Grievances
And Grievance Processing
The TOP contractor
shall process all grievances related to contractor personnel or
contractor actions. The contractor shall also process all grievances
related to network or non-network purchased care sector providers
or institutions, with a copy provided to the DHA COR and the appropriate
TAO.