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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Prime Remote (TPR) Program
Chapter 16
Section 6
TRICARE Prime Remote For Active Duty Family Member (TPRADFM) Program
Revision:  C-44, March 7, 2019
1.0  Introduction
TPRADFM provides TRICARE Prime like benefits to certain Active Duty Family Members (ADFMs) who reside with the TRICARE Prime Remote (TPR) enrolled sponsor in remote locations in the United States (U.S.) and the District of Columbia (DC). It also provides continued TPRADFM eligibility for family members residing at remote locations after the departure of the sponsor for an unaccompanied assignment, and eligibility for family members of Reserve Component (RC) members (referred to as sponsors for the remainder of this Section) called or ordered to active duty for more than 30 days. TPRADFM benefits are comparable to TRICARE Prime, including access standards, benefit coverage, and cost-shares. TPRADFM does not apply to ADFM enrollees in areas outside the 50 U.S. Such care and claims shall be processed in accordance with the TRICARE Overseas Program (TOP), Chapter 24 and TRICARE Policy Manual (TPM), Chapter 12. The Specified Authorization Staff (SAS) is not involved in any part of TPRADFM.
2.0  Enrollment Qualifications
Family members qualify to enroll into TPRADFM, if they meet the requirements specified in one of the following paragraphs.
2.1  The sponsor is enrolled in TPR and the ADFM resides with the sponsor in a TPR residence (i.e., TPR zip code).
2.2  The sponsor is enrolled to a small Government clinic, troop medical clinic, Coast Guard clinic or other Military Treatment Facilities/Enhanced Multi-Service Markets (MTFs/eMSMs) designated by the Services to allow Active Duty Service Member (ADSM) enrollment only and offer zero capacity to enroll non-ADSM beneficiaries. DHA will provide a list of Defense Medical Information System Identification Codes (DMIS-IDs) MTFs/eMSMs that only enroll ADSM. The DMIS-ID list will be an attachment in the Managed Care Support Contract (MCSC). The ADFM must reside with the sponsor who is enrolled in an MTF/eMSM that only enrolls ADSMs.
Note:  ADFMs who reside within a Prime Service Area (PSA) are eligible for TRICARE Prime and thus are not eligible for enrollment in TPRADFM even if the Service member is enrolled in TPR. The ADFMs shall be enrolled within the PSA of residence except as specified in paragraph 2.2.
2.3  If an ADSM receives a subsequent unaccompanied assignment after the TPR assignment and the family members are not authorized to accompany the member to the next duty assignment, and they continue to reside in the same TPR address, the family members may remain in TPRADFM for the duration of the subsequent assignment.
2.4  If an RC member sponsor becomes eligible for TRICARE because of a call or order to active duty for a period of more than 30 days, their eligible family members become eligible to enroll into TPRADFM upon becoming TRICARE-eligible (i.e., beginning the date early eligibility TRICARE starts or date of activation, whichever is first) if they meet all of the following eligibility requirements:
2.4.1  The family members reside with the member in a TPR residence (i.e., in a TPR zip code) at the time of activation the RC sponsor and their family members become eligible for TRICARE.
2.4.2  The RC member sponsor does not have to be TPR eligible or enrolled.
2.4.3  Once enrolled in TPRADFM, the family members may remain in TPRADFM for the period of TRICARE eligibility, regardless of the subsequent assignment, enrollment location, or residence of the sponsoring RC member as long as the family member continues to reside at the same TPR residence address.
2.4.4  Family members who meet the TPRADFM eligibility criteria may enroll up to 90 days after the sponsor has deployed/left the TPR address for assigned duty.
2.5  ADFMs currently enrolled in TPRADFM, who transition to Transitional Survivor status, may remain enrolled in TPRADFM. See TPM, Chapter 10, Section 7.1 for further information.
2.5.1  All Transitional Survivors may enroll in TPRADFM. At the request of the Transitional Survivor the contractor shall accept and process a new and continued enrollment request (enrollment form, the Government furnished web-based self-service enrollment system/application transaction, or telephonic request documented in the contractor’s call center notes) submitted by any Transitional Survivor living in, or moving to a TPR area. Enrollment in TPRADFM may continue for Transitional Survivors for the entire Transitional Survivor period. After the Transitional Survivor period, TPRADFM is not available to Survivors. A Survivor (versus a Transitional Survivor) is eligible for retiree family member benefits and cost-sharing.
2.5.2  Transitional Survivor/Survivor status does not impact TRICARE eligibility rules. Loss of eligibility as a result of any condition which routinely results in loss of TRICARE eligibility such as reaching age limits, marriage, remarriage, etc. also results in loss of Transitional Survivor/Survivor status.
3.0  Benefits
TPRADFM enrollees are eligible for the TRICARE Prime Benefit, even in areas without contractor networks.
4.0  Network Development
4.1  TPRADFM offered outside of a PSA has no network development requirements, except where contractually required. ADFMs enrolled in TPRADFM shall be assigned, or be allowed to select, a Primary Care Manager (PCM) when in the provider network. If a network provider is not available to serve as a primary care provider, the TPRADFM enrollee may utilize any local TRICARE participating or authorized provider for primary care services.
4.2  TPRADFMs enrollees are required to use TRICARE network providers where available within contractual access standards. If a network provider cannot be identified within the access standards, the enrolled family member shall use a TRICARE authorized provider. Contractors shall assist TPRADFM enrollees in finding a network or non-network TRICARE authorized provider for specialty care. TPRADFM enrollees may be eligible for the Prime travel benefit when referred more than 100 miles for specialty care inside the 50 U.S. and DC. If the contractor has not established a network of PCMs in a remote area, a TPRADFM enrollee will be enrolled without a PCM assigned. A generic PCM code shall be used for TPRADFM enrollees without assigned PCMs. The ADFM without an assigned PCM will be able to use a local TRICARE authorized provider (participating or non-participating) for primary health care services without a PCM’s approval. If a TPRADFM questions whether a service is covered as primary care, they may contact the contractor for assistance.
5.0  Uniformed Services Family Health Plan (USFHP)
If a USFHP is available to ADFMs in a TPR area, the ADFMs have the choice of enrolling in the USFHP, enrolling in TPRADFM or enrolling in TRICARE Select. ADFMs choosing to enroll in USFHP will be unable to access care through MTFs/eMSMs or the TRICARE system.
6.0  Referrals
6.1  Specialty care requires a referral through the contractor. If the TPRADFM enrollee is assigned to a PCM, the PCM shall follow the contractor’s referral and authorization procedures. In cases where the TPRADFM enrollee is not assigned to a PCM, the TPRADFM enrollee, or the TPRADFM enrollee’s parent or guardian, is responsible for directly contacting the contractor to obtain referrals and authorizations if required. The TPRADFM enrollee should obtain a referral request from their primary care provider and the TPRADFM enrollee should forward that request to the contractor.
6.2  TPRADFM enrollees are required to obtain a referral and use TRICARE network providers for specialty care where available within TRICARE access standards or pay the Point of Service (POS) deductible and cost-share unless an appropriate out-of-network referral is obtained as required under TRICARE Prime.
7.0  Provider Education
Contractors shall familiarize network providers and, when appropriate, other providers with TPRADFM. The contractor shall propose an educational plan to the Director, TRICARE Health Plan (THP) outlining how providers will become familiar with TPRADFM. The contractor shall provide separate and distinct information to PCMs about the requirements and the special procedures for handling TPRADFM enrollees’ care (e.g., specialty care referral requirements, balance billing limitations, etc.). The contractors shall include information on TPRADFM specialty care procedures, benefits, or requirements in routine information and educational programs.
8.0  Beneficiary Education
8.1  Beneficiary education will be a joint effort with the Government providing all beneficiary educational materials for the TPR program.
8.2  The contractor shall utilize leading industry best practices in its outreach and communication with all MHS customers consistent with that offered to its commercial customers. Customer services shall include multiple, contemporary avenues of access (for example, e-mail, World Wide Web (WWW), telephone, texting, and smart phone applications, and other social media) for the MHS beneficiary. If the contractor chooses to distribute the supplied educational materials, the contractor is responsible for postage, envelopes, and mailing costs.
8.3  The contractor shall give TPRADFM enrollees the option of participating in health promotion and wellness programs offered in the direct care system and network locations. The contractor shall design and conduct, with Director, THP approval, TPRADFM briefings. The contractor shall include TPRADFM information and updates as part of all TRICARE briefings. Ongoing briefings will be on an “as needed” basis and will be coordinated with the Director, THP.
8.4  Enrollment in TPRADFM is optional for ADFMs who qualify for the program; therefore, a contractor shall limit educational activities for TPRADFM enrollees to distributing the materials provided or approved by the Government.
9.0  Enrollment
9.1  When the contractor receives an enrollment request (enrollment form, the Government furnished web-based self-service enrollment system/application transaction, or telephonic request documented in the contractor’s call center notes) from an ADFM for TPRADFM, the contractor shall ensure the sponsor is qualified based on the requirements in paragraph 2.0. If a TPRADFM enrollment request is received and the family member does not qualify for TPRADFM, the request shall be returned to the sender with a notice that the family member is not eligible for TPRADFM and the reason(s) why TPRADFM enrollment was denied. Additionally, see paragraph 9.4 when a TPRADFM enrollment request is received for a family member of an RC sponsor on active service for more than 30 days.
9.2  Enrollment in TPRADFM is optional for qualified family members. However, qualified family members must enroll within 90 days of their move to a TPR location (a Qualifying Life Event (QLE)) or during the open enrollment season in TPRADFM to receive the TPRADFM benefit. Qualified family members who elect not to enroll in TPRADFM may enroll in TRICARE Prime (where available, with access standards waived) or TRICARE Select.
9.3  An enrollment request (enrollment form, the Government furnished web-based self-service enrollment system/application transaction, or telephonic request documented in the contractor’s call center notes) must be submitted to the contractor by either the qualified family members or the Service member’s sponsor for each family member enrolling in TPRADFM. See Chapter 6, Section 1, for effective date rules. An official enrollment request includes those with:
•  An original signature;
•  An electronic signature offered by and collected by the contractor;
•  A verbal consent provided by telephone and documented in the contractor’s call notes; or
•  A self-attestation by the beneficiary when using the Government furnished web-based self-service enrollment system/application.
Note:  A written signature is not required to make enrollment changes when using the Enrollment Portability process outlined in Chapter 6, Section 2.
9.4  When the contractor receives an enrollment request (enrollment form, Government furnished web-based self-service enrollment system/application transaction, or telephonic request documented in the contractor’s call center notes) for TPRADFM from a family member of an RC sponsor called or ordered to active service for more than 30 days, the contractor shall validate the family members’ eligibility in DEERS.
9.5  The contractor shall follow enrollment portability and transfer procedures in Chapter 6, Section 2. Additionally, if at any point the contractor determines or is advised that a family member is no longer eligible for TPRADFM, the contractor shall notify (letter, telephone call, or e-mail) the sponsor of the discrepant enrollment immediately. If the discrepant enrollment is not corrected within 30 days of the notification date, the contractor shall disenroll the family member(s) from TPRADFM effective the first of the month after 30 days from the initial notification date. The contractor shall provide information on TRICARE Select, and that they have 90 days from the date of the disenrollment to enroll in a TRICARE plan or they only will be eligible for MTF/eMSM care on a space-available basis.
9.6  The contractor shall enroll the TPRADFM qualified family member in the Government furnished web-based system/application and enter the TPRADFMs enrollment status into Government furnished web-based system/application. The contractor shall use the DMIS-ID code(s) designated by the Director, THP for that region to enroll ADFMs into TPRADFM (see the TRICARE Systems Manual (TSM)). See paragraph 10.0 for PCM assignment requirements.
9.7  DEERS will automatically update start and/or end dates of coverage when a beneficiary’s eligibility is updated as described in Chapter 6, Section 1. The contractor will receive a Policy Notification Transaction (PNT) advising them of all changes.
10.0  PCM Assignment
At the time of enrollment, a TPMADFM qualified family member will select (or will be assigned) a PCM within the access standard. The contractor shall advise the TPMADFM enrollee of the availability of PCMs. If a PCM is not available or the contractor has not established a network of PCMs in a TPR area, the ADFM shall be enrolled to TPRADFM without an identified PCM assigned. See paragraph 4.2.
11.0  Support Services
11.1  Inquiries
The contractor shall designate a point of contact for Government inquiries related to TPRADFM. The contractor may establish a dedicated unit for responding to inquiries about TPRADFM, or may augment existing TPR service units already serving TPR enrollees. The correspondence requirements and standards in Chapter 1, Section 3, apply to TPRADFM written inquiries.
11.2  Toll-Free Telephone Service
The contractor shall provide toll-free telephone access for TPRADFM beneficiary inquiries.
12.0  Claims Processing
The regional contractor where the TPRADFM is enrolled shall process all claims for that enrollee, except for care provided overseas (i.e., care outside of the 50 U.S. and DC). Civilian health care while traveling or visiting overseas shall be processed by the TOP contractor, regardless of where the beneficiary is enrolled. POS claims processing provisions do apply. Details for reporting TPRADFM claims information are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
13.0  Claim Reimbursement
13.1  The payment provisions applicable under TPR for Service members which allow for additional payment in excess of otherwise allowable amounts to providers who are not TRICARE-authorized or certified do not apply to TPRADFM. Such payments shall not be made unless such payments are otherwise allowed under the payment provisions for unauthorized providers contained in the TPM.
13.2  For network providers, the contractor shall pay TPRADFM claims at the negotiated rate. For participating providers the contractor shall pay up to the CHAMPUS Maximum Allowable Charge (CMAC), or billed charges, whichever is less. Contractors shall follow the requirements in Chapter 8, Section 5 and the TRICARE Reimbursement Manual (TRM), Chapter 5, Section 1, for claims for TPRADFM enrollees receiving care from non-participating providers.
13.3  If a non-participating provider requires a TPRADFM enrollee to make an “up front” payment for health care services, in order for the enrollee to be reimbursed, the enrollee must submit a claim to the contractor with proof of payment and an explanation of the circumstances.
13.4  If the contractor becomes aware that a civilian provider is “balance billing” a TPRADFM enrollee or has initiated collection action for emergency or authorized care, the contractor shall notify the provider that balance billing is prohibited (see TRM, Chapter 3, Section 1).
13.5  If CMAC rates have been waived for TPR Service member enrollees under Section 4, paragraph 3.5, the TPRADFM enrollee shall not be extended the same waived CMAC rates. If required services are not available from a network or participating provider within the medically appropriate time frame, the contractor shall arrange for care with a non-participating provider subject to the normal reimbursement rules. The contractor shall make every effort to obtain the provider’s agreement to accept, as payment in full, a rate within 100% of the CMAC limitation. If this is not feasible, the contractor shall make every effort to obtain the provider’s agreement to accept, as payment in full, a rate between 100% and 115% of CMAC. By law the contractor shall not negotiate a rate higher than 115% of CMAC for TPRADFM care rendered by a non-participating provider. The contractor shall ensure that the approved payment is annotated in the authorization/claims processing system.
14.0  Appeals Process
TPRADFM enrollees may appeal denials of authorization or reimbursement through the contractor in accordance with Chapter 12. If the contractor denies authorization or reimbursement for a TPRADFM enrollee’s health care services, the contractor shall, on the Explanation of Benefits (EOB) or other appropriate document, furnish the enrollee with clear guidance for requesting a reconsideration from, or filing an appeal with, the contractor.
15.0  TRICARE Encounter Data (TED) Submittal
The contractor shall report TPRADFM claims under the financially underwritten provisions of the contract.
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