2.0 Contractor
Responsibilities
2.1 The
TOP contractor shall arrange for medically necessary ambulance/aeromedical
evacuation services for
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)
that are
enrolled to TRICARE Prime, TRICARE Prime Remote (TPR), TRICARE Select,
or TRCARE Young Adult (TYA) who require ambulance/aeromedical
evacuation services while traveling
/living outside
of the 50 U.S. and the District of Columbia.
Note: Claims jurisdiction for ambulance/aeromedical
evacuation is based on the patient’s location, regardless of the
patient’s enrollment status or the origination or destination location
of the ambulance/aeromedical evacuation service provider.
2.1.1 When arranging
for ambulance/aeromedical evacuation for the beneficiaries identified
in
paragraph 2.1,
the contractor shall determine beneficiary eligibility and enrollment
status, prepare quote(s) for commercial movement options, and obtain
signature authority and direction on evacuation destination from
the appropriate Patient Movement Requirement Center (PMRC). Upon PMRC
approval, the contractor shall authorize the services, arrange for
medical records to accompany the patient, and coordinate the transfer
with the receiving institution or provider. The appropriate TRICARE
Area Office (TAO) shall be notified of all patient movements.
2.1.2 For Service
member emergency medical evacuations (including Service members
who are on temporary duty, in an authorized leave status, or deployed/deployed
on liberty), the TOP contractor shall ensure that the Service member’s
unit is aware of the medical evacuation. The TAO shall be contacted
for assistance if the member’s unit information cannot be determined
by the contractor.
2.1.3 Except for normal TRICARE
cost-shares, these beneficiaries shall not be responsible for any up-front
payments for emergency ambulance service (to include aeromedical
evacuation, when medically necessary and appropriate). The contractor
shall establish business processes (e.g., Guarantee of Payment to
purchased care sector ambulance provider) to ensure that these beneficiaries are
not subjected to up-front payments in excess of normal TRICARE cost-shares.
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.
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 provide information on 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
and shall
develop
claims for diagnosis
and 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.
A
diagnosis shall be included with the claim.
2.8 All
related documentation (including, but not limited to original invoices,
supporting documents, and Explanation of Benefits (EOB)) related
to the evacuation shall be submitted
with the claim.
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.
Air ambulance
transport (aeromedical evacuations) covered under the TOP, including
Puerto Rico shall be reimbursed
utilizing reasonable
and customary charges.