1.0 general
1.1 All TRICARE
requirements regarding the SHCP shall apply to the TRICARE Overseas
Program (TOP) unless specifically changed, waived, or superseded
by this section, 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 17 for additional
instructions.
1.2 Uniformed Service members in an active duty
status of greater than 30 days (also known as Service members) who
are on permanent or official duty assignment in a location outside
the 50 U.S. and the District of Columbia must enroll in TRICARE
Overseas Program (TOP) Prime or TOP Prime Remote. Service members
in a temporary duty status and enrolled elsewhere should not transfer
their enrollment to TOP Prime or TOP Prime Remote unless it is medically
appropriate and will not cause enrollment eligibility disruption
to family members’ enrollment status. Service members are not CHAMPUS-eligible
and do not have the option to use
TOP
Select
or the Point of Service (POS)
option under TOP Prime or TOP Prime Remote. Uniformed Service members
who would normally receive care from a purchased care sector provider
may be directed to transfer their care to a Military Treatment Facility
(MTF). This applies to Service members and Uniformed Service members
not in active duty status (Reserve Component (RC) members under
Line of Duty (LOD) care). These controls ensure the maintenance
of required fitness-for-duty oversight for TOP Uniformed Service
members. Refer to
Section 9 for claims processing instructions.
2.0 Contractor
Responsibilities
2.1 Service members who are enrolled in TOP Prime
shall follow the procedures outlined in
Chapter 17 for
MTF-enrolled Service members, except that any references to the
Defense Health Agency-Great Lakes (DHA-GL) should be replaced by
a reference to the appropriate regional TRICARE Area Office (TAO)
in all overseas locations except the U.S. Virgin Islands concerning
Line of Duty Determinations and except for care delivered under
the National Department of Defense (DoD)/Department of Veterans Affairs
(VA) Memorandum of Agreement (MOA) authorization requirements. See
paragraph 2.4.3 for
National DoD/VA MOA authorization requirements. Service members
who are enrolled in TOP Prime Remote must seek authorization from
the TOP contractor for all non-emergent specialty and inpatient
care. Service members not enrolled in TOP who are on Temporary Additional Duty/Temporary
Duty (TAD/TDY), deployed, deployed on liberty, or in an authorized
leave status outside the 50 U.S. and the District of Columbia shall
follow referral/authorization guidelines for TOP Prime Remote enrollees.
2.2 If a Service
member seeks purchased care sector care without appropriate authorization,
they put themselves at financial risk for claims payment. They are
also at risk for potential compromise of medical readiness posture,
flight status, or disability benefits, and they may be subject to
disciplinary action for disregarding service-specific policy. Lost
work time may be charged as ordinary leave.
2.3 The TOP
contractor shall ensure a benefit review is done on each SHCP referral
and authorization. The TOP contractor shall return deferred-to-network
referrals for non-covered services with an explanation of why it
was denied. The TOP contractor shall not issue an authorization
unless they obtain a copy of an approved waiver. The contractor
shall deny all claims for TRICARE non-covered health care services.
(Reference Health Affairs (HA) Policy 12-002 “Use of Supplemental
Health Care Program Funds for Non-Covered TRICARE Health Care Services
and the Waiver Process for Active Duty Service Members”).
2.3.1 If the
contractor determines that the requested service, supply, or equipment
is not covered by TRICARE policy and no Defense Health Agency (DHA)-approved
waiver is provided, the contractor shall decline to file an authorization
and shall deny any received claims accordingly. If the request was
received as an MTF referral, the contractor shall notify the MTF
(and enrolled MTF if different from the submitting MTF) of the declined
authorization with explanation of the reason. If the request was
received as a referral from a civilian provider (for a remote Service
member/non-enrolled Service member), the contractor shall notify
the civilian provider and the remote Service member/non-enrolled
Service member of the declined authorization with explanation of
the reason. The notification to a civilian provider and the remote
Service member/non-enrolled Service member shall explain the waiver
process and provide contact information for the applicable Uniformed
Services Headquarters Point of Contact (POC)/Service Project Officers
as listed in
Chapter 17, Addendum A, paragraph 2.0. No notification
to the Specified Authorization Staff (SAS) is required.
2.3.2 TRICARE
benefits may not be extended for complications resulting from non-covered surgeries
and treatments performed outside the MTF for a Service member without
an approved waiver. If the treatment is a non-covered TRICARE benefit,
any follow-on care, including care for complications, will not be
covered by TRICARE once the Service member separates from active
duty or retires (
32 CFR 199.4(e)(9); TPM,
Chapter 4, Sections 1.1 and
1.2). The Services will provide appropriate counseling
that such follow-on care is the member’s personal financial responsibility
upon separation or retirement.
2.4 The provisions of
Chapter 17 are changed for the TOP as follows:
2.4.1 The provisions
of
Chapter 17, Section 2, paragraph 2.0 (Uniformed
Services Family Health Plan (USFHP)) are not applicable to the TOP
contract. USFHP services are not available outside the 50 U.S. and
the District of Columbia.
2.4.2 Except for the claims for
Service member care provided under the National DoD/VA MOA, the
provisions of
Chapter 17, Section 3, paragraph 1.2.1 regarding
the timeline for review of SHCP claims by overseas MTFs is extended
to 10 calendar days. Service member claims for covered benefits submitted
to the TOP contractor for which an authorization is not on file
are to be pended for a determination of whether the care should
be authorized. The claim shall be pended and the MTF of enrollment
shall be notified that an authorization determination should be
accomplished and returned to the TOP contractor within 10 calendar
days. If the TOP contractor does not receive the MTF’s response
within 10 calendar days, the contractor shall move the claim back
into active processing within one business day and shall process
the claim as if the MTF had authorized the care. Claims authorized
due to a lack of response by the MTF shall be considered as “Referred
Care”, but the contractor must be able to distinguish these claims
from MTF-authorized claims. Claims pended under the provisions of
this section shall be considered to be excluded claims for the purposes
of calculating and reporting claims processing cycle time performance.
2.4.3 The
provisions of
Chapter 17, Section 2, paragraph 3.1 regarding
claims for care provided under the National DoD/VA MOA for Spinal
Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma are applicable to the TOP and shall be processed
in accordance with
Chapter 17, Section 2, paragraph 3.1.3. Such
care will be authorized by the DHA-GL for Service members under
this MOA.
2.4.4 The
provisions of
Section 6, paragraph 5.0 and
Chapter 8, Section 5 apply to TOP SHCP referrals.
Additionally, when MTFs submit a referral request for purchased
care services for a non-AD sub-population beneficiary eligible for
SHCP, the MTF shall utilize the required data elements identified in
Chapter 8, Section 5, paragraph 6.1 and shall
annotate the referral with “SHCP” in line item 12, “Review Comment”.
This will ensure that SHCP claims for eligible non-AD sub-population
beneficiaries are properly adjudicated.
Note: Circumstances where supplemental funds may be
used to reimburse for care rendered by non-Governmental health care
providers to non-active duty patients are limited to those where
a MTF provider orders the needed health care services from civilian
sources for a patient, and the MTF provider maintains full clinical
responsibility for the episode of care. This means that the patient
is not disengaged from the MTF that is providing the care. See
Chapter 17, Section 1, paragraph 1.1.
2.5 When a
Service member leaves a remote TOP assignment as a result of Permanent
Change of Station (PCS) or other service-related change of duty
status, the following applies in support of medical record accumulation:
2.5.1 For Service
members leaving remote TOP assignment in Puerto Rico, the PCM shall
provide a complete copy of medical records, to include copies of
specialty and ancillary care documentation, to Service members within
30 calendar days of the Service member’s request for the records.
The Service member may also request copies of medical care documentation
(specialty care visits and discharge summaries) on an ongoing, Episode
of Care (EOC) basis.
2.5.2 For Service members leaving
remote TOP assignments from all overseas areas other than Puerto
Rico, Service members in those locations should request medical
records from the purchased care sector provider(s) who provided
health care services during the Service member’s tour of duty. These
Service members may also request copies of medical care documentation
(specialty care visits and discharge summaries) on an ongoing, EOC
basis.
2.5.3 Records provided by purchased care sector providers
in languages other than English may be submitted to the TOP contractor
for translation into English according to the terms of the contract.
2.5.4 Network
purchased care sector providers shall be reimbursed for medical
records photocopying and postage costs incurred at the rates established
in their network provider participation agreements. Non-network
purchased care sector providers shall be reimbursed for medical
records photocopying and postage costs on the basis of billed charges
unless the Government has directed a lower reimbursement rate. Service
members who have paid for copied records and applicable postage
costs shall be reimbursed for the full amount paid to ensure they
have no out-of-pocket expenses. All providers and/or Service members
must submit a claim form, with the charges clearly identified, to
the contractor for reimbursement.
Note: The purpose of copying medical records
is to assist the Service member in maintaining accurate and current
medical documentation. The contractor shall not make payment to
a purchased care sector provider who photocopies medical records
to support the adjudication of a claim.
2.5.5 The provisions
of
Chapter 17, Section 3, paragraph 1.1.8 are
not applicable to the TOP. SHCP funds may not be used to pay for
overseas purchased sector care for foreign military members or their families.
The TOP contractor shall deny any MTF referrals and claims for such
care.
2.6 Provision
of Respite Care For The Benefit of Seriously Ill or Injured Active
Duty Members
2.6.1 The provisions of
Chapter 17, Section 3 and
the TRICARE Systems Manual (TSM),
Chapter 2, Sections 2.8 and
6.4 regarding respite care for seriously ill
or injured Service members are applicable in locations outside the
50 U.S. and the District of Columbia where TRICARE-authorized Home
Health Agencies (HHAs) have been established.
2.6.2 The respite
care benefit is applicable to Service members enrolled to TOP Prime,
TOP Prime Remote, and to any Service member referred by an overseas
MTF or TAO.
2.6.3 All normal Service member authorization and
case management requirements for the TOP apply to the Service member
respite care benefit.