Military Health System

2.1  The TOP contractor shall arrange for medically necessary ambulance/aeromedical evacuation services for TRICARE Overseas Program (TOP) Prime/TOP Prime Remote enrollees, Service members who are deployed, in a temporary duty status, or in an authorized leave status in an overseas location, and all Active Duty Family Members (ADFMs) who require ambulance/aeromedical evacuation services while traveling outside of the 50 U.S. and the District of Columbia.

2.2  Upon request, the TOP contractor shall facilitate medically necessary ambulance/aeromedical evacuation services for all TRICARE-eligible beneficiaries not identified in paragraph 2.1 (regardless of enrollment location or residence) according to the processes identified in the TOP contract. When facilitating ambulance/aeromedical evacuation for these beneficiaries, the contractor shall identify ambulance/aeromedical evacuation resources that service the patient’s location; however, the contractor shall not schedule the evacuation, coordinate with the receiving institution or provider, obtain medical records, or establish business processes (e.g., Guarantee of Payment) to limit up-front payments for these beneficiaries.

2.3  Since medical evacuations may involve transfers between TRICARE regions, the TOP contractor shall establish processes for coordinating medical evacuations with the stateside contractors. The TOP contractor shall also work cooperatively with the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) contractor to provide customer service support, and to facilitate the medically necessary evacuation of TRICARE dual-eligible beneficiaries back to the U.S.

2.4  The TOP contractor shall ensure that ambulance/aeromedical evacuation services can be accomplished in an expeditious manner that is appropriate and responsive to the beneficiary’s medical condition. The contractor may establish a dedicated unit for responding to such requests, or may augment existing service units. Contractor staff shall be available for ambulance/aeromedical evacuation assistance 24 hours per day, seven days per week, 365 days per year. Ambulance/aeromedical evacuation telephone assistance shall be available without toll charges to the beneficiary, regardless of their location.

2.5  The TOP contractor shall maximize the use of military medical transport services before considering other options. If military medical transport services are not available (or if services cannot be provided in a timely manner that is appropriate for the patient’s medical condition) and the appropriate PMRC has approved commercial movement, the contractor shall attempt to arrange services through the most economical commercial resource that is capable of providing appropriate services within the required time frame. Private, chartered evacuation services will only be used as a last resort when all other options have been exhausted. The contractor shall document their rationale and selection process for any commercial and/or private, chartered evacuation services. If multiple resources are identified that are capable of providing the needed services, the contractor shall select the resource that represents the best value to the Government. Upon request, the contractor shall provide Defense Health Agency (DHA) with documentation supporting their rationale and selection process.

2.6  Upon transfer to a facility for stabilization and care, the TOP contractor shall coordinate with the appropriate Military Treatment Facility (MTF) (for TOP Prime enrollees) or TAO (for TOP Prime Remote enrollees) to advise of the patient’s transfer and to provide further assistance as appropriate.

2.7  The TOP contractor shall comply with the provisions of TPM, Chapter 8, Section 1.1, except that the TOP contractor shall utilize the coding requirements identified for ambulance charges but shall not develop claims for diagnosis or transfer information for ambulance services received overseas. The TOP contractor shall utilize the diagnosis if provided, or may use available in-house methods such as claims history when processing the claim. If a diagnosis is not provided and there are no claim attachments or other claims for the Episode of Care (EOC) from which a diagnosis can be determined, the claim shall be processed using an unlisted diagnosis.

2.8  Medical evacuation charges that are determined to be a TRICARE benefit may be bundled on one claim and coded appropriately as a medical evacuation charge. If this simplified billing approach is adopted, all related documentation (including, but not limited to original invoices, supporting documents, and Explanation of Benefits (EOB)) related to the evacuation must be made available to the Government upon request for further review.

2.9  The Ambulance Fee Schedule (AFS) reimbursement methodology (TRICARE Reimbursement Manual (TRM), Chapter 1, Section 14) applies only to ground ambulance services in Puerto Rico. The AFS does not apply to air ambulance transport (aeromedical evacuations) covered under the TOP for Puerto Rico. Air ambulance transport (aeromedical evacuations) covered under the TOP, including Puerto Rico shall be reimbursed as billed charges.