2.0 JURISDICTION
2.1 In
the early stages of TOP claims review, the TOP contractor shall
determine whether claims received are within its contractual jurisdiction
using the criteria below.
2.2 Services
rendered onboard a commercial ship while outside U.S. territorial
waters are the responsibility of the TOP contractor. Claims for
services provided on a commercial ship that is outside the territorial
waters of the U.S. shall be processed as foreign claims regardless
of the provider’s home address. If the provider is certified within
the U.S., reimbursement for the claim is to be based on the provider’s
home address. If the provider is not certified within the U.S.,
reimbursement will follow the procedures for foreign claims. This
does not include health care for enrolled Service members on a ship at
sea or on a military ship at home port.
2.3 The provisions of
Chapter 8, Section 2, paragraphs 1.0 and
2.0 are superseded as described in
paragraphs 2.3.1 through
2.3.9.
2.3.1 When
a beneficiary is enrolled in TOP Prime or TOP Prime Remote, the
TOP contractor shall process all health care claims for the enrollee,
regardless of where the enrollee receives services. Referral/authorization
rules apply.
2.3.2 Claims for Active Duty Family Members (ADFMs)
(including Reserve Component (RC) ADFMs whose sponsors have been
activated for more than 30 days), retirees, and retiree family members
whose care is normally provided under one of the regional contracts
(i.e., beneficiaries enrolled or residing in the 50 U.S. and the
District of Columbia) who receive Civilian Health Care (CHC) while
traveling or visiting overseas shall be processed by the TOP contractor,
regardless of where the beneficiary resides or is enrolled. Referral/authorization
and Point Of Service (POS) rules apply for TRICARE Prime/TRICARE
Prime Remote (TPR) enrollees.
Note: This provision
does not apply to beneficiaries who are enrolled in the Uniformed
Services Family Health Plan (USFHP) or the Continued Health Care
Benefit Program (CHCBP). Claims for these beneficiaries are processed
by their respective contractor regardless of where the care is rendered.
2.3.3 Claims
for Service members residing in the 50 U.S. and the District of
Columbia (including RC Service members activated for more than 30
days) who are on Temporary Additional Duty/Temporary Duty (TAD/TDY),
deployed, deployed on liberty, or in an authorized leave status
in an overseas location shall be processed by the TOP contractor,
regardless of where the Service members resides or is enrolled.
Referral/authorization rules apply.
2.3.4 Claims for TOP-enrolled Service
members (including RC Service members activated for more than 30
days) on a military ship or with an overseas home port shall not
be processed by the member’s military unit. These claims shall be
processed by the TOP contractor.
2.3.5 Initial and follow-on Line
Of Duty (LOD) claims for RC Service members on orders for 30 consecutive
days or less, who are injured while traveling to or from annual
training or while performing their annual training who receive civilian
medical care overseas, shall have their claims processed by the
TOP contractor upon verification of LOD status. Defense Health Agency-Great
Lakes (DHA-GL) will validate LOD status for RC Service members in
the U.S. Virgin Islands.
2.3.6 The TOP contractor shall process
claims for Durable Equipment (DE) and Durable Medical Equipment
(DME) (otherwise coverable by TRICARE) that is purchased/ordered
by TOP-eligible beneficiaries in an overseas area from a stateside
provider (i.e., Internet, etc.).
2.3.7 For inpatient claims that
are paid under the Diagnosis Related Group (DRG)-based payment system,
the TOP contractor, on the date of admission, shall process and
pay the entire DRG claim, including cost outliers. For inpatient
claims paid on a per diem basis, to include DRG transfers and short stay
outlier cases, and for professional claims that are date-driven,
the contractor shall process and pay the claims.
2.3.8 When a
beneficiary’s enrollment changes from one TRICARE region to another
during a hospital stay that will be paid under the DRG-based payment
system, the contractor with jurisdiction on the date of admission
shall process and pay the entire DRG claim, including cost outliers.
2.3.9 For
information on portability claims for relocating TOP Prime/TOP Prime
Remote enrollees, refer to
Chapter 6, Section 2.
2.7 Refer to
the TRICARE Reimbursement Manual (TRM),
Chapter 4, Section 4, paragraph 5.0 for jurisdictional
guidance regarding health care claims for work-related illness or
injury which is covered under a Worker’s Compensation Program.
2.8 The provisions
of
Chapter 8, Section 2, paragraph 5.0 are applicable
to the TOP in those locations where the TRICARE Pharmacy (TPharm)
contractor has established services (the U.S. territories of Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands). The TOP contractor cannot process pharmacy claims
from these locations except for pharmacy that is part of an emergency
room visit or inpatient treatment. Any prescriptions from this care
that are
not provided at time of treatment for inpatient/emergency
care, shall be required to be submitted through the TPharm contractor.
Copays will apply.
2.9 The TOP contractor shall forward
all retail pharmacy claims to the TPharm contractor within 72 hours
of identifying them as being out-of-jurisdiction. In all other overseas
locations, the contractor shall process claims from purchased care
sector retail pharmacies and providers.
2.10 ADFMs with
TRICARE
Select
and retirees or their family
members residing overseas obtaining prescription from an overseas
purchased care sector pharmacy shall submit their claims to the
TOP contractor. For cost-share/deductible provisions, see TRM,
Chapter 2 regarding the mandatory collection
of pharmacy copayment amounts at the time of service are waived
for foreign providers.
5.0 REFERRALS/PREAUTHORIZATIONS/AUTHORIZATIONS
The provisions of
Chapter 8, Section 5 are
altered for the TOP by the requirements listed below.
5.1 Referral/Preauthorization/Authorization
Requirements for TOP Prime and TOP Prime Remote Enrollees
5.1.1 Unless
otherwise directed by the Government, referrals/preauthorizations/authorizations are
not required for emergency care, clinical preventive services, ancillary
services, radiological diagnostics (excluding Magnetic Resonance
Imaging (MRI) and Positron Emission Tomography (PET) scans), drugs,
and services provided by a TOP Partnership Provider. Additionally,
TOP Prime/TOP Prime Remote ADFMs will require a referral for all
mental health and Substance Use Disorder (SUD) services except outpatient
office-based visits. TOP Prime/TOP Prime Remote ADFMs will also
require preauthorization for treatment of SUDs as outlined in the
TPM,
Chapter 7, Section 3.5, paragraph 4.0 and
for the treatment of mental disorders as outlined in the TPM,
Chapter 7, Section 3.8, paragraph 6.0. All
other care that is provided to a TOP Prime/TOP Prime Remote-enrolled
Service member or ADFM by anyone other than their Primary Care Manager
(PCM) requires authorization, regardless of where the care is rendered.
5.1.2 Claims
for Service member care not authorized by the TOP contractor shall
be pended for a review to make a determination regarding authorization.
If the care is retroactively authorized by the Government (including
submission of an approved waiver for a non-covered service), then
the contractor shall enter the authorization and process the claim
for payment. If the contractor determines that the care was not
authorized, the contractor shall deny the claim. Refer to
Section 26 for additional information
.
5.1.3 Claims for self-referred, non-emergency,
and non-urgent care for TOP Prime and TPR enrolled
ADFMs shall process with POS deductibles and cost-shares unless
the appropriate TRICARE Area Office (TAO) or TRICARE Overseas Program
Office (TOPO) has approved a retroactive authorization.
5.1.4 TRICARE-eligible beneficiaries
residing in an overseas location who are not enrolled in TOP Prime/TOP
Prime Remote typically do not need to obtain preauthorization/authorization
for care. However, preauthorization reviews shall be performed for
all care and procedures listed in Chapter 7, Section 2. The TOP
contractor may propose additional authorization reviews for non-enrolled
TOP beneficiaries to the government.
5.1.5 TRICARE beneficiaries whose health
care is normally provided under one of the two regional Managed
Care Support Contractors (MCSCs) who require care while traveling
in an overseas location shall request any necessary preauthorizations/authorizations
through the TOP contractor, regardless of where the beneficiary
resides or is enrolled. Denial of requested services should be visible to
the claims processing contractor to ensure claims are denied or
processed as POS as appropriate.
Note: This
process does not apply to beneficiaries enrolled to the USFHP or
the CHCBP.
5.2
Point
of Service (POS) Provisions
5.2.1 Unless specifically excluded
by this section, all self-referred, non-emergency care provided to
TOP Prime/TOP Prime Remote-enrolled ADFMs which is not either provided/referred
by the beneficiary’s PCM or specifically authorized shall be reimbursed
under the POS option. This provision applies regardless of where
the care is rendered. POS provisions also apply to the following
stateside beneficiaries when traveling overseas: ADFMs, retirees,
and retiree family members who are enrolled in TRICARE Prime, and
ADFMs enrolled in TPR for ADFMs.
5.2.2 POS cost-sharing only applies
to TRICARE-covered services. Claims for services that are not a
covered TRICARE benefit shall be denied.
5.2.3 The TOP contractor shall adjust
POS deductibles and cost-shares when TOP PCMs or Health Care Finders
(HCFs) do not follow established referral/authorization procedures.
For example, if the contractor processes a claim under the POS option
because there was no evidence of a referral and/or an authorization,
and the contractor later verifies that the PCM or other appropriate
provider referred the beneficiary for the care, the contractor shall
adjust the claim and reverse the POS charges. The contractor need
not identify past claims that may be eligible for POS adjustment;
however, the contractor shall adjust these claims as they are brought
to their attention.
5.2.4 On a case-by-case basis, following
stabilization of the patient, the TAO Director or MTF Commander
may require an enrolled beneficiary to transfer to a TOP network
facility or an MTF. The TAO Director or MTF Commander shall provide
written notice to the beneficiary (or responsible party) advising
them of the impending transfer to a TOP network facility/MTF. If
a beneficiary who is subject to TOP POS provisions elects to remain
in the non-network facility after such notification, POS cost-sharing
provisions will apply beginning 24 hours following the receipt of
the written notice. Neither the TOP Director nor the MTF Commander
will require a transfer until such time as the transfer is deemed medically
safe.
5.2.5 The following deductible and cost-sharing amounts
apply to all TOP POS claims for health care support services:
• Enrollment
year deductible for outpatient claims: $300 per individual; $600
per family. No deductible applies to inpatient services.
• Beneficiary cost-share
for inpatient and outpatient claims: 50% of the allowable charge after
the deductible has been met (deductible only applies to outpatient
claims).
• POS
deductible and cost-share amounts are not creditable to the enrollment/Fiscal Year
(FY) catastrophic cap and they are not limited by the cap.
• POS deductible and
cost-share amounts do not apply to claims for care received by newborns
and newly adopted children who are deemed enrolled in TOP Prime
or TOP Prime Remote.
5.2.6 POS deductible and cost-share
amounts do not apply if a TOP enrollee has Other Health Insurance
(OHI) that provides primary coverage (i.e., the OHI must be primary
under the provisions of the TRM,
Chapter 4, Section 1). Evidence of OHI claims
processing (including the exact amount paid on the claim) must be
submitted with the TOP claim.
5.2.7 EOB shall clearly indicate
that a claim has been processed under the POS Option.
5.2.8 POS is
not applicable to Service members or to TRICARE Select.
5.3 Extended
Care Health Option (ECHO) benefits in overseas locations must be
authorized by the TOP contractor. Refer to
Section 23 and
the TPM,
Chapter 9 for additional guidance.
5.4 Refer to
Section 10 for referral/preauthorization/authorization
requirements for Service member dental care in remote overseas locations.
6.0 CLAIM
DEVELOPMENT
6.1 Development
of missing information shall be kept to a minimum. The TOP contractor
shall use available in-house methods, contractor files, telephone,
Defense Enrollment Eligibility Reporting System (DEERS), etc., to
obtain incomplete or discrepant information. If this is unsuccessful,
the contractor may return the claims to sender with a letter which
indicates that the claims are being returned, the reason for return
and requesting the required missing documentation. The contractor’s system
shall identify the claim as returned, not denied. The Government
reserves the right to audit returned claims as required, therefore
the contractor shall retain sufficient information on returned claims
to permit such audits. The contractor shall review all claims to
ensure TOP required information is provided prior to payment. For
the Philippines, claims requiring development of missing or discrepant
information, or those being developed for medical documentation,
shall be pended for 90 days and are excluded from the claims processing
standard.
6.2 Claims may be filed by eligible TRICARE beneficiaries,
purchased care sector providers, TOP POCs, and TRICARE authorized
providers in the 50 U.S. and the District of Columbia as allowed
under TRICARE (see
Chapter 8, Section 1)
.
6.3 Confidentiality
requirements for TOP are identical to TRICARE requirements outlined
in
Chapter 8.
6.5 The following
minimal information is required on each overseas claim prior to
payment:
6.5.1 Signatures
Beneficiary and purchased care sector provider
signatures (signature on file is acceptable unless specifically
prohibited by the Government).
6.5.2 Name and Address
6.5.2.1 Complete
beneficiary and purchased care sector provider name and address.
6.5.2.2 If an address
is not available on the claim, obtain the address either from previously submitted
claims, directly from the beneficiary/purchased care sector provider
via phone, fax, or e-mail, DEERS per
paragraph 6.1.Note: The TOP contractor shall accept APO/FPO for the
beneficiary address.
6.5.3 Diagnosis(es)
6.5.3.1 Prior to
returning a claim that is missing a diagnosis, the TOP contractor
shall research the patient’s history and determine whether a diagnosis
from a related claim can be applied. The diagnosis should
be reflective of the services rendered.
6.5.3.2 Claims
received for dates of service for outpatient services or dates of
discharge for inpatient services before the mandated date, as directed
by Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation, with ICD-10
codes shall be converted to International Classification of Diseases,
9th Revision, Clinical Modifications (ICD-9-CM) codes by the TOP
contractor. Claims received for dates of service for outpatient
services or dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 or ICD-9-CM codes shall be converted to ICD-10-CM codes
by the TOP contractor. Refer to
Chapter 8, Section 6, paragraphs 4.0 and
5.0 regarding the use of ICD-9-CM
V codes (factors
influencing health status and contact with health services) and
ICD-10-CM
Z codes (factors influencing health status
and contact with health services).
6.5.4 Procedures/Services/Supply/DME
The TOP contractor shall identify the procedure(s)/service(s)/supply/DME
ordered, performed or prescribed, including the date ordered performed
or prescribed. The TOP contractor may use the date the claim form
was signed as the specific date of service, if the service/purchase
date/order date is not on the bill.
6.5.5 Claims received with a narrative
description of services provided shall be coded by the TOP contractor
with as accurate-coding as possible based upon the level of detail
provided in the narrative description or as directed by the
TOPO.
Services
which contain sufficient detail to identify an accurate procedure
code shall be used. All surgical procedures must be coded accurately
based on the level of detailed description. Outpatient professional
services shall be coded accurately. Office visits which include
multiple services shall be coded accurately and not bundled when
the description of services are available. The provisions
of
paragraph 6.1 apply
for narrative claims that cannot be accurately coded due to insufficient
or vague information. Claims received for dates of service for outpatient services
or dates of discharge for inpatient services before the mandated
date, as directed by HHS, for ICD-10 implementation, with ICD-10
codes shall be converted to ICD-9 codes by the TOP contractor. Claims
received for dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 codes shall be converted to ICD-10 codes by the TOP contractor.
Refer to
Chapter 8, Section 6, paragraph 4.0 regarding
the use of
V and
Z codes.
6.5.5.1 Inpatient Institutional Procedures
Inpatient institutional (i.e., hospital) claims
received for dates of discharge for inpatient services before the
mandated date, as directed by HHS, for ICD-10 implementation, shall
have the procedure narratives coded by the TOP contractor using
ICD-9-CM, Volume 3 procedure codes. Inpatient institutional (i.e.,
hospital) claims received for dates of discharge on or after the
mandated date, as directed by HHS, for ICD-10 implementation, shall
have the procedure narratives coded by the TOP contractor using
ICD-10-Procedure Classification System (ICD-10-PCS) procedure codes.
6.5.5.2 Outpatient
Institutional Procedures and Professional Services
Claims received for outpatient institutional
(e.g., ambulance services, laboratory, Ambulatory Surgery Centers
(ASCs), partial hospitalizations, outpatient hospital services)
services and professional services shall be coded using Healthcare
Common Procedure Coding System (HCPCS) or Current Procedural Terminology
(CPT).
6.5.6 Care authorizations (when
required).
6.5.7 Itemization of total charges. (Itemization
of hospital room rates are not required on institutional claims).
6.5.8 Proof of
payment is required for all beneficiary submitted claims if the
claim indicates that the beneficiary made payment to the provider
or facility.
Due to cultural differences,
there may be significant variation in provider processes for issuing
receipts to the beneficiaries. Therefore, the overseas claims processor
shall use best business practices when determining if the documentation provided
is acceptable for the country where the services were rendered.
6.5.8.1 Examples of ACCEPTABLE Beneficiary
Proof of Payment:
• Cancelled
checks (made payable to the provider)
• Credit
or bank card statements or receipts
• Bank
account statements (with documentation of payment to the provider)
• Receipt,
itemized bill, or statement issued by the provider’s office stamped
“PAID” on all pages
• Proof
of Electronic Funds Transfer (EFT) from the beneficiary to the provider
• Invoice
for pharmaceuticals dispensed on an outpatient basis (overseas pharmacies
will not dispense drugs without payment; therefore, an invoice represents
proof of payment)
• Invoice
for health care from providers in Turkey (Turkish providers will
not provide an invoice to the patient until payment has been made;
therefore, an invoice represents proof of payment)
6.5.8.2 Examples of UNACCEPTABLE Beneficiary
Proof of Payment:
• Cancelled
check made payable to “Cash” or to the beneficiary or sponsor
• Bank
account statements showing cash withdrawal (without additional documentation of
payment to the provider)
• Letter
signed by patient saying s/he has paid the bills
• Paid
amount shown only on the claim or itemized bill
• Handwritten
statements (e.g., “Paid in Full,” “Paid by Patient”, “Paid in Cash”)
• Paid
in cash (without additional documentation of payment to the provider)
6.6 Non-prescription
(Over-The-Counter (OTC)) drugs are to be denied. This includes drugs
that are considered OTC by U.S. standards, even when they require
a prescription in a foreign country.
6.7 The TOP contractor shall use
a schedule of allowable charges based on the Average Wholesale Price
(AWP) as a reference source for processing drug related TRICARE
overseas claims.
6.8 Claims for medications prescribed
by a host-nation physician, and commonly used in the host-nation
country, shall be cost-shared unless they are considered OTC by
U.S. standards.
6.9 For the Philippines, prescription
drugs may only be cost-shared when dispensed by a certified retail
pharmacy or hospital-based pharmacy. The TOP contractor shall deny
claims for prescription drugs dispensed by a physician’s office.
Certification requirements outlined in
Section 29 apply.
Note: This does not apply to Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS).
6.10 Claims
for DME involving lease/purchase shall always be developed for missing
information.
6.11 The TOP contractor shall use ECHO claims processing
procedures outlined in TPM,
Chapter 9, Section 18.1, when processing ECHO
overseas claims.
6.12 The TOP contractor shall deny
claims from non-certified or non-confirmed purchased care sector
providers when the DHA CO has directed contractor certification/confirmation
of the purchased care sector provider prior to payment.
6.13 Requests
for missing information shall be sent on the TOP contractor’s TRICARE/TOP
letterhead. When development is necessary,
the contractor shall include a special insert in German, Italian, Spanish,
Tagalog, Japanese, and Korean which indicates what missing information
is required to process the claim and includes the contractor’s address
for returning requested information.
6.14 If the TOP contractor elects
to develop for additional/missing information, and the request for additional
information is not received/returned within 45 days, the contractor
shall deny the claim.
6.15 If the TOP contractor has
no record of referral/authorization prior to denial/payment of the claim,
the contractor shall follow the TOP POS rules, if the service would
otherwise be covered under TOP.
6.16 The TOP contractor shall develop
procedures for the identification and tracking of TOP enrollee claims
submitted by either a purchased care sector designated or non-designated
overseas purchased care sector provider without preauthorization/authorization.
Upon receipt of a claim for a TOP-enrolled ADFM submitted by a purchased
care sector designated or non-designated overseas purchased care sector
provider without preauthorization/authorization, the contractor
shall process the claims following POS payment procedures. For Service
member claims submitted by a purchased care sector provider without
preauthorization/authorization, the contractor shall pend the claim
for review prior to denying the claim.
Refer to Section 26 for more information
on ADSM pended claims.
6.17 The TOP contractor must have
an automated data system for eligibility, deductible and claims history
data and must maintain on the automated data system all the necessary
TOP data elements to ensure the ability to reproduce both TED and
EOBs as outlined in
Chapter 8, Section 8,
except for requiring overseas providers to use HCPCS to bill outpatient
rehabilitation services, issue provider’s the Form 1099 and suppression
of checks/drafts for
$.99 or less.
The contractor may split claims to accommodate multiple invoice
numbers in order to reference invoice numbers on EOBs when necessary.
Refer to
Chapter 8, Section 6 for additional requirements
related to claims splitting.
6.18 The TOP contractor shall not
pay for pharmacy services obtained through the Internet.
6.19 The TOP
contractor shall pay all TOP Service member stateside claims as
outlined in
Section 26.
6.20 All claims shall be submitted
in a Health Insurance Portability and Accountability Act (HIPAA) compliant
format. Refer to
Section 28 for more information on HIPAA requirements.
6.21 Electronic
claims not accepted by the TOP contractor’s Electronic Data Information
(EDI) system/program shall be rejected.
6.22 For all overseas claims, the
TOP contractor shall create and submit TEDs following current guidelines
in the TSM for TED development and submission. Claim information
will be able to be accessed through the TRICARE Patient Encounter
Processing and Reporting (PEPR) Purchased Care Detail Information
System (PCDIS).
6.23 The TOP contractor shall establish
Utilization Management (UM) high dollar/frequency thresholds in
accordance with
Section 6.
6.24 Claims either denied as “beneficiary
not eligible” or “found to be not eligible on DEERS” may be processed
as a “good faith payment” when received from the Defense Health
Agency (DHA) Communications Office. The TAO Director shall work
with the TOP contractor on claims issues related to good faith payment
documentation (e.g., a completed claim form and other documentation
as required by
Chapter 10, Sections 3 and
4).
6.26 The Claims Auditing Software
requirements outlined in the TRM,
Chapter 1, Section 3 do not apply to TOP claims;
however, the TOP contractor shall implement an internal process
for identifying upcoding, unbundling, etc. on coded claims.
8.0 EOB
Vouchers
The TOP contractor shall follow
the EOB voucher requirements in
Chapter 8, Section 8,
where applicable, with the following exceptions and additional requirements:
8.1 The letterhead on all TOP EOBs shall also reflect
“TRICARE Overseas Program” and shall be annotated Prime or
TRICARE Select.
8.2 TOP EOBs may be issued on regular stock, shall
provide a message indicating the exchange rate used to determine
payment and shall clearly indicate that “This is not a bill”.
8.3 TOP EOBs shall include the toll-free number
for beneficiary and provider assistance.
8.4 TOP EOBs for overseas enrolled Service member
claims shall be annotated “ACTIVE DUTY.”
8.5 For Point of Sale or Vendor pharmacy overseas
claims, TOP EOBs shall have the name of the provider of service
on the claim.
8.6 For beneficiary submitted
pharmacy claims, TOP EOBs shall contain the name of the provider
of service, if the information is available. If the information
is not available, the EOBs shall contain “your pharmacy” as the
provider of service.
8.7 The TOP contractor shall insert the provider’s
payment invoice numbers in the patient’s account field on all provider
EOBs, if available.
8.8 The
TOP contractor shall designate
an EOB message
for overseas
claims rendered by non-network purchased care sector providers who
are required to be certified, but have not been certified by the
TOP contractor, “Your provider has not submitted documentation required
to validate his/her training and/or licensure for designation as
an authorized TRICARE provider”.
Refer to Section 4 for more information regarding certification
of providers in designated locations.
8.9 When a provider’s/beneficiary’s EOB, EOB and
check, or letter is returned as undeliverable, the check shall be
voided.
8.10 The TOP contractor may utilize
secure electronic EOB delivery to beneficiaries unless mail delivery
has been requested by the beneficiary or has not signed
up for electronic delivery.
8.11 The contractor may issue monthly
summary EOBs to beneficiaries on claims when there is no beneficiary
liability. The processing date of the oldest claim for the summary
EOB shall not be greater than 31 calendar days.
12.0 Reimbursement/Payment
Of Overseas Claims
When processing TOP claims,
the TOP contractor shall follow the reimbursement payment guidelines
outlined in the TRM,
Chapter 1, Section 34 and the cost-sharing
and deductible policies outlined in the TRM,
Chapter 2, Section 1, and shall:
12.1 Reimburse
claims for purchased care sector services/charges for care rendered
to TOP eligible beneficiaries which is generally considered purchased
care sector practice and incidental to covered services, but which
would not typically be covered under TRICARE. An example of such
services may be, charges from purchased care sector ambulance companies
for driving purchased care sector physicians to accidents or private
residences, or the manner in which services are rendered and considered
the standard of care in a purchased care sector country, such as
rehabilitation services received in an inpatient setting.
12.2 Reimburse
claims at the lesser of the billed amount, the negotiated reimbursement
rate, the CHAMPUS Maximum Allowable Charge (CMAC), or the Government
established fee schedules (when applicable) (TRM,
Chapter 1, Sections 34 and
35), unless a different reimbursement rate
has been established as described in TPM,
Chapter 12, Section 1.3.
Note: Government established fee schedules (per TRM,
Chapter 1, Sections 34 and
35) are only applicable to retirees or their
eligible family members
or TRICARE
Select
ADFMs.
12.3 Not reimburse
for purchased care sector care/services specifically excluded under
TRICARE.
12.4 Not reimburse for purchased care sector care/services
provided in the Philippines unless all of the certification requirements
listed in
Section 14 have been met.
12.5 Not reimburse
for administrative charges billed separately on claims, except for
individual administrative charges as determined by the Government.
The contractor shall reimburse these charges only in instances when
the fee is billed concurrently with the corresponding health care services.
If a bill is received for these charges without a corresponding
health care service, the charges shall be denied.
12.6 Determine
exchange rates as follows:
12.6.1 Use
the exchange rate in effect on the ending date that services were
received unless evidence of OHI and then the TOP contractor shall
use the exchange rate of the primary insurer, not the rate based
on the last date of service to determine the TOP payment amount,
and/or;
12.6.2 Use the ending dates of the last service to
determine exchange rates for multiple services.
12.6.3 Use the
exchange rate in
paragraph 12.6.1 to determine deductible and
copayment amounts, if applicable, and to determine the amount to
be paid in foreign currency.
12.6.4 Overseas
drafts/checks and EOBs. Upon completion of processing, the contractor
shall create checks (payable in U.S. dollars). The TOP contractor
shall do this within 48 hours after approval by DHA Contract Resource
Management (CRM). Drafts (payable in foreign currency units) shall
be created by the TOP contractor within 96 hours following CRM approval,
unless a different process has been authorized by DHA. Payments
that need to be converted to a foreign currency shall be calculated based
on the exchange rate in effect on the last date of service listed
on the EOB. Drafts/checks shall be matched with the appropriate
EOB, and mailed to the beneficiary/sponsor/purchased care sector provider/POC
as applicable.
Note: Drafts for certain foreign currency
units may require purchase from a bank location other than the one
normally used by the TOP contractor (out of state or out of country).
Currency units that must be purchased from an alternate bank (out
of state or out of country) may take up to 10 business days for
the draft to be returned and matched up with the EOB.
12.7 Convert
lump sum payments, instead of line items, to minimize conversion
problems.
12.8 Pay provider claims for all overseas locations in
the country’s local currency as identified on the claim for the
specific country by foreign currency/drafts. Drafts
may not be changed to a U.S. dollar check after the contractor has
issued a foreign draft.
12.9 Know that
foreign overseas drafts (in local currency) are good for 190 days
and may be cashed at any time, unless a different process has been
established by DHA. U.S. dollar checks are good for 120 days unless
a different process has been established by DHA. The provisions
of
Chapter 3, Section 4 regarding staledated,
voided, or returned checks/Electronic Funds Transfers (EFTs) are
applicable to the TOP.
12.10 Pay
TOP claims submitted by a beneficiary in U.S. dollars, unless there
is a beneficiary request on the claim at the time of submission
for payment in a foreign currency. The TOP contractor may reissue
the payment in U.S. dollars if a request is subsequently received
from the beneficiary and the foreign draft is included in the request
or the payment has staledated, or if directed by the appropriate DHA
COR.
12.11 Payment shall be made in local
currency.
12.12 Issue drafts/checks for German
claims which look like German drafts/checks.
Note: In order for TRICARE drafts/checks to look like
German drafts/checks, a German address must be used. The TOP contractor
may use a corporate address in Germany or the TAO Eurasia-Africa address
for this purpose.
12.13 The contractor shall pay all beneficiary-submitted
claims for TRICARE covered drugs dispensed by a U.S. embassy health
clinic to the beneficiary. The contractor is not to make payments
directly to the embassy health clinic.
12.14 Know that professional services rendered by
a U.S. embassy health clinic are not covered by TRICARE/TOP. These
services are covered under International Cooperative Administrative
Support Services (ICASS) agreements. Embassy providers (acting as
PCMs) may refer TOP enrollees to purchased care sector providers,
these claims shall be processed per TOP policy and procedures.
12.15 Reimburse claims for drugs or diagnostic/ancillary
services purchased overseas following applicable deductible/cost-share
policies.
12.16 In emergency
situations, the requirement for Medicare certification for facilities
in U.S. commonwealths and territories may be waived. After a review
of the facts, the contractor may cost-share otherwise covered services
or supplies rendered in an emergency situation by an unauthorized provider
to the beneficiary, or on behalf of the beneficiary, to the beneficiary's
appointed payee, guardian, or parent in accordance with TPM,
Chapter 11, Section 4.2 and TRM,
Chapter 1, Section 29.
12.17 The contractor shall mail the drafts/checks
and EOBs to purchased care sector providers unless the claim indicates
payment should be made to the beneficiary. In conformity with banking requirements,
the drafts/checks shall contain the contractor’s address. Drafts
and EOBs shall be mailed using U.S. postage. Additionally, payments/checks
may be made to network providers, with an Embassy address.
12.18 Mail benefit payment checks and EOBs to Philippine
providers, and other nations’ providers as directed by the DHA CO,
to the place of service identified on the claim. No provider checks
or EOBs for Philippine providers, and other nations’ providers as
directed by the DHA CO may be sent to any other address.
12.19 Process/pay inpatient and outpatient claims
for TRICARE overseas eligible beneficiaries, including Service member
claims, as indicated below:
12.19.1 The TPharm contractor shall allow TOP Service
members to use the TPharm retail pharmacy network under the same
contract requirements as other Military Health System (MHS) eligible beneficiaries
(see TPM,
Chapter 8, Section 9.1).
12.19.2 The TPharm
contractor shall allow TOP enrolled ADFM beneficiaries to use their
stateside retail pharmacy network under the same contract requirements
as other MHS eligibles (see TPM,
Chapter 8, Section 9.1).
12.19.3 The TOP
contractor shall process claims for overseas health care received
by TRICARE beneficiaries enrolled to or residing in a stateside
contractor’s region following the guidelines outlined in this chapter.
Payment shall be made from applicable bank accounts and shall be
based on billed charges unless a lower reimbursement rate has been
established by the Government or the contractor.
12.20 EFT payments. Upon purchased care sector provider
request, the TRICARE Overseas health care support contractor shall
provide EFT payment to a U.S. or overseas bank on a weekly basis.
Bank charges incurred by the provider for EFT payment shall be the
responsibility of the provider. Upon beneficiary request, EFT payments
to a U.S. bank may be provided. Bank charges associated with beneficiary
EFT payments shall be the responsibility of the beneficiary.
12.21 The TOP contractor shall process 90% of all
retained and adjustment TOP claims to completion within 30 calendar
days from the date of receipt. Claims pended per Government direction
are excluded from this standard. However, the number of excluded
claims shall be reported on the designated DD Form
1423, Contract Data Requirements List (CDRL), located in Section
J of the applicable contract. One hundred percent
(100%) of all claims (both retained and excluded, including adjustments)
shall be processed to completion within 90 calendar days from the
date of receipt, unless the CO specifically directs the contractor
to continue pending a claim or group of claims.
12.22 Exclude correspondence pended due to stop payment
orders, check tracers on foreign banks, and conversion on currency
from the routine 45 calendar day correspondence standard and the priority
10 calendar day correspondence standard. However, the number of
excluded routine and priority correspondence must be reported on
the designated DD Form 1423, CDRL, located in Section
J of the applicable contract.
12.23 The TOP contractor shall pay Value Added Tax
(VAT) included on German health care claims for all beneficiary
categories.
12.24 Reimburse
fees for transplant donor searches in Germany on a global flat fee
basis since the German Government does not permit health care facilities
to itemize such charges.
12.25 Reimburse itemized fees for supplies that are
related or incidental to inpatient treatment (e.g., hospital gowns)
if similar supplies would be covered under reimbursement methodologies
used within the U.S. The TOP contractor shall implement internal
management controls to ensure that payments are reasonable and customary
for the location.
13.0 Claims
Adjustment And Recoupment
13.1 The TOP contractor shall follow
the adjustment requirements in
Chapter 10 except
for the requirements related to financially underwritten funds.
13.2 The TOP
contractor shall follow the recoupment requirements in
Chapter 10 for non-financially underwritten
funds, except for providers. The contractor shall use the following
procedures for purchased care sector provider recoupments. Recoupment
actions shall be conducted in a manner that is considered culturally
appropriate for the purchased care sector provider’s country. The
contractor shall:
• Send an initial demand
letter;
• Send
a second demand letter at 90 days;
• Send a final demand
letter at 120 days; and
• Refer the case to
DHA at 240 days, if the case is over $600, and if under $600 the
case shall remain open for an additional four months and then shall
be written off at 360 days.
13.3 Recoupment
letters (i.e., the initial letter, the 90 day second request and
the 120 day final demand letter) shall be modified to delete references
to U.S. law. Invoice numbers shall be provided on all recoupment
letters. The TOP contractor shall include language in the recoupment
letter requesting that refunds be returned/provided in the exact
amount requested.
13.4 Provider recoupment letters
sent to Germany, Italy, Spain, Japan, and Korea, shall be written
in the respective language.
13.5 If the recoupment action is the result of an
inappropriately processed claim by the TOP contractor, recoupment
is the responsibility of the contractor, not the beneficiary/provider.
13.6 The TOP contractor shall have a TOP bank account
capable of receiving/accepting wire transfers for purchased care
sector provider recoupment/overpayment returns. The TOP contractor shall
accept the amount received as payment against the amount owed. Any
fees associated with the wire transfer are the responsibility of
the payer/provider.