2.0 Purchased
Care Sector Provider Certification And Credentialing
2.1 The TOP contractor shall be
responsible for provider certification oversight, and monitoring
of provider/institution quality. The contractor shall use
Chapter 4,
32 CFR 199.6,
and TPM,
Chapter 11 to the maximum extent possible
for the certification of purchased care sector providers. The contractor
is
not required to follow TRICARE requirements
for U.S. credentialing standards, except when TRICARE requires the
facility/agency to be Medicare certified (e.g., home health, hospice,
Skilled Nursing Facility (SNF) care). Also, Psychiatric Residential
Treatment Centers (RTCs), Substance Use Disorder Rehabilitation
Facilities (SUDRFs), and Psychiatric Partial Hospitalization Programs
(PHPs) that are located in Puerto Rico require approval by the TOP contractor.
Except for these services and facilities, the TOP contractor shall
establish purchased care sector provider certification processes
based on the accepted licensure and credentialing requirements for
the purchased care sector.
Note: Medicare certification
for organ transplant centers is only required for transplants performed
in the U.S., the District of Columbia, and U.S. territories where
Medicare is available. See TPM,
Chapter 12, Section 1.2.
2.2 Refer to
paragraph 4.7 for
additional certification requirements that have been established
for purchased care sector providers in the Philippines.
3.0 Network
Development
3.1 The TOP contractor shall be responsible for
developing and maintaining a complement of network and non-network
purchased care sector providers to augment the existing capacity
of the Direct Care (DC) system for Service members and Active Duty
Family Members (ADFMs) who are enrolled in TOP Prime, and to provide
or arrange for primary and specialty care services for Service members
and ADFMs who are enrolled in TOP Prime Remote.
Note: In remote overseas locations, the TOP contractor
shall also establish dental provider networks for Service members
in accordance with
Section 10.
3.2 The TOP contractor shall establish
signed provider agreements between network purchased care sector
providers and the contractor.
3.2.1 Network provider agreements
shall include language indicating that the provider agrees to participate
on claims for authorized services for TOP enrollees on a cashless,
claimless basis.
3.2.2 Network provider agreements
must specify rates for Service member medical records photocopying
and postage, if applicable.
Note: “Cashless, claimless”
is defined as a health care encounter that requires no up-front payment
at the time of service, and the provider files the claim for the
beneficiary.
3.3 Networks shall be sized to
meet TOP-enrolled populations only. The TOP contractor may assist other
beneficiaries (non-command sponsored ADFMs, retirees, retiree family
members, etc.) upon request by identifying these purchased care
sector providers as they will be credentialed and familiar with
TRICARE, but networks will not be developed
to accommodate non-TOP enrollees.
3.4 In TOP Prime locations, MTF
Commanders will identify the specialties needed in the network and
will communicate this information on an ongoing basis to the TOP
contractor per the process identified in the Statements of Responsibilities
(SORs) (see
Section 16).
3.5 MTF capabilities and capacities
may change frequently over the life of the contract without prior
notice. The TOP contractor shall ensure that purchased care sector
provider services can be adjusted as necessary to compensate for
changes in MTF capabilities and capacities, when and where they
occur over the life of the contract, including short notice of unanticipated
facility expansion, provider deployment, downsizing, and/or closures.
3.6 Network
providers shall be able to communicate in English, both orally and
in writing, or provide translation services at the time of service.
3.7 The TOP
contractor shall be responsible to enter into participation agreements
with SNFs in Puerto Rico, Guam, the U.S. Virgin Islands, American
Samoa, and the Northern Mariana Islands per the provisions of
Section 3.
4.0 Contractor
Requirements - Purchased Care Sector Providers
4.1 Reimbursement rates for purchased
care sector providers may be negotiated by the contractor. In locations
where the Government has designated specific reimbursement rates
or methodologies, the contractor may not negotiate rates which exceed
the Government directed rate. Refer to the TRICARE Reimbursement
Manual (TRM),
Chapter 1, Section 34 for additional instructions.
4.2 The contractor
shall provide ongoing purchased care sector provider education and
support in accordance with
Section 11.
4.3 The contractor
shall have a Quality Oversight Plan for reviewing
access and quality of care provided by the purchased care sector, as identified in DD
Form 1423, Contract Data Requirements List (CDRL),
located in Section J of the applicable contract.
4.4 The TOP
contractor shall assign provider numbers to purchased care sector
providers, identify providers as network or non-network, and create
and submit TRICARE Encounter Provider (TEPRV) records. Each provider
shall be identified by a single provider number, with a sub-identifier
for multiple service locations. Upon the Government’s request, the
contractor shall provide copies of licensure/certification information
for purchased care sector providers.
4.5 The TOP contractor shall deny
claims from non-certified purchased care sector providers when Defense
Health Agency (DHA) has directed that the country’s purchased care
sector providers must be specially certified in order to receive
TRICARE payments. See
paragraph 4.7 for additional certification requirements.
4.7 The
TOP contractor shall perform on-site verification and provider certification
in the Philippines. At a minimum, this one-site verification shall
confirm the physical existence of a facility/provider office, verify
the credentials/licensure of the facility/provider, verify the adequacy
of the facility/provider office, and verify the capability of the
facility/provider office for providing the expected level and type
of care. This requirement may be expanded to other locations upon
Contracting Officer (CO) Direction.
4.7.1 The TOP contractor shall provide
beneficiaries with easy access to the approved provider listing
and the certified provider listing via a user-friendly searchable
World Wide Web (WWW) site and any other means established at the
contractor’s discretion. Information on the WWW site and any other electronic
lists shall be current within the last 30 calendar days. At a minimum,
the database shall be searchable by provider location, provider
name, and provider specialty (if available).
4.7.2 If a claim
is received for care rendered by a non-certified provider in the
Philippines, the TOP contractor shall pend the claim and initiate
on-site verification/provider certification action. Claims pended
for this reason are excluded from normal claims processing cycle
time standards. If the on-site verification/certification action
is not completed within 90 calendar days, the TOP contractor shall
deny claims based on lack of provider certification.
4.7.3 The TOP
contractor shall use the following guidelines for prioritizing certification
of Philippine providers as follows:
• Reviewing new providers.
• Reviewing the TOP
contractor’s current certified provider files.
• Reviewing non-certified
providers on claims which have been denied by the TOP contractor
and the beneficiary/provider has followed-up on why the claim was
denied.
• Reviewing
non-certified providers on claims which have been denied by the
TOP contractor and the beneficiary/provider has NOT followed-up
on why the claim was denied.
4.7.4 Recertification
of the Philippine providers shall be performed by the TOP contractor
every three years and shall follow the above process. DHA shall,
as necessary, require the contractor to add additional overseas
countries for purchased care sector provider certification. Upon
direction by the Government, the contractor shall follow the process
above outlined for the Philippines, to include prioritization of
certification of new country providers.
4.7.5 The TOP contractor shall deny
claims submitted from non-certified or non-confirmed purchased care
sector providers from the Philippines, advising the provider to
contact the contractor for procedures on becoming certified.
4.8 For the
Philippines, prescription drug may be cost-shared when dispensed
by a certified retail pharmacy or hospital based pharmacy. The TOP
contractor shall deny claims for prescription drugs obtained from
a physician’s office.