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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Overseas Program (TOP)
Chapter 24
Section 20
TRICARE Overseas Program (TOP) TRICARE For Life (TFL)
Revision:  C-6, October 20, 2017
1.0  GENERAL
1.1  The TOP program provides health care administration and claims processing for individuals with dual eligibility under both Medicare and TRICARE who receive care in locations where Medicare is not available. This includes those beneficiaries eligible for TFL under the Medicare wraparound coverage option of the TRICARE program made under 10 United States Code (USC) 1086(d).
1.2  The provisions of Chapter 20 regarding TFL are applicable to beneficiaries residing in locations where Medicare is available. These areas include the 50 United States (U.S.), the District of Columbia, and the U.S. territories of Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands.
2.0  Jurisdiction
2.1  Dual eligible beneficiaries are covered under TOP, based on their TRICARE plan if they receive care in a location where Medicare is not available.
2.2  Dual eligible beneficiaries residing in Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands are not covered under TOP TFL. These beneficiaries receive TRICARE coverage under the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) according to the provisions of Chapter 20.
2.3  Claims for services rendered on board a commercial ship are the responsibility of the TDEFIC contractor if the care was rendered in the territorial waters adjoining the land areas of the U.S. Claims for services rendered on board ship while outside U.S. territorial waters are the responsibility of the TOP contractor.
3.0  CONTRACTOR RESPONSIBILITIES
3.1  The TOP contractor shall provide administration and claims processing services for the TOP TFL program.
3.2  TOP TFL has the same cost-shares and deductibles as any other TFL claim. Effective January 1, 2018, TFL beneficiaries who are not enrolled in Prime are covered under TRICARE Standard benefits, cost-shares, and deductibles as if TRICARE Standard was still being implemented. See TRM Chapter 2, Sections 1 and 3.
3.3  All TOP TFL has the same requirements for referrals or prior authorizations as TOP Standard (through December 31, 2017) or TOP Select (starting on January 1, 2018). TOP requirements regarding provider certification apply.
3.4   The TOP contractor shall not develop purchased care sector provider networks to support the TOP TFL beneficiary population.
3.5  The TOP contractor shall not provide health care on a cashless, claimless basis for TOP TFL beneficiaries.
3.6  The TOP contractor shall not make appointments with purchased care sector providers for TOP TFL beneficiaries. However, upon beneficiary request, the contractor shall provide the beneficiary with the name, telephone number, and address of purchased care sector network or non-network providers of the appropriate clinical specialty located within the beneficiary’s geographic region.
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