1.0 GENERAL
1.1 TOP Prime
Remote is available to Service members (including Reserve Component
(RC) members activated for more than 30 days) on permanent assignment
to a remote overseas location, Command-Sponsored Active Duty Family
Members (ADFMs) accompanying their sponsor in the remote location
or on Service orders, and certain transitional survivors according
to the eligibility and enrollment provisions of
Section 5. TOP
Prime Remote offers enrollees access to a Primary Care Manager (PCM),
clinical preventative services, and specialty services. The TOP
contractor, working in concert with purchased care sector providers
and the TRICARE Area Offices (TAOs), has primary responsibility
for ensuring that TOP Prime Remote enrollees receive appropriate
services and support to facilitate access to the TOP benefit in
remote overseas locations.
1.2 TOP Prime
Remote has no enrollment fees, and deductibles and cost-shares are
waived except for TOP Prime Remote ADFMs who receive care under
the Point of Service (POS) option, or who obtain pharmacy services
in the 50 United States (U.S.), the District of Columbia, and U.S.
territories where the TRICARE Pharmacy (TPharm) has established
a retail pharmacy network. Waiver of copayment and deductibles under
TOP Prime Remote is subject to review/updating based on enrollment
status.
1.3 Under TOP Prime Remote, annual catastrophic
caps are calculated on calendar years.
The enrollment year shall coincide with the calendar year.
Since deductibles and cost-shares are waived for TOP Prime Remote
enrollees, this policy will apply only to TOP Prime Remote enrollees
who incur out-of-pocket expenses as described above.
2.0 Contractor
Responsibilities
2.1 TOP Prime Remote enrollees shall select or
have assigned to them Primary Care Managers (PCMs) according to
guidelines established by the TAO Director, or designee.
2.1.1 TOP PCMs
may be an individual professional provider, an
overseas treatment site, or other health care delivery arrangement.
For the purposes of referral management and authorization for TOP Prime
Remote episodes of care, the TOP contractor’s call center(s) are
considered PCMs.
2.1.2 TOP PCMs may be an internist,
family practitioner, pediatrician, General Practitioner (GP), Obstetrician/Gynecologist
(OB/GYN), Physician Assistant (PA), Nurse Practitioner (NP), or
Certified Nurse Midwives (CNMs) when determined by the TOP contractor
to meet governing country rules and licensure.
2.1.3 May also
act as a Health Care Finder (HCF), when dual responsibility is necessary,
as determined by the TAO Director.
2.2 A TOP Prime
Remote enrollee must seek all his or her primary health care from
the TOP PCM with the exception of care listed in
Section 8. If
the TOP PCM is unable to provide the care, the TOP PCM shall refer
the enrollee to another primary care provider.
2.3 TOP Prime
Remote enrollees must obtain appropriate referral/authorization
for any non-emergency
, non-urgent care
rendered by anyone other than the beneficiary’s PCM. This provision applies
regardless of where the care is rendered. TAO Directors may direct
retroactive authorizations on a case-by-case basis.
2.3.1 Routine care is generally not authorized while
a TOP Prime Remote enrollee is traveling out of their enrollment
region. The TOP contractor shall fully document the justification
for authorizing routine out-of-area care. Emergency care does not
require prior authorization; however, the beneficiary should contact
their PCM and the contractor as soon as possible to obtain authorization
for any necessary follow-up care.
2.3.2 ADFMs enrolled in TOP Prime Remote
may obtain urgent care from any authorized provider without a PCM
(if assigned) referral or overseas contractor authorization. In
order to ensure the urgent care visit will be cashless/claimless,
the ADFMs enrolled to TOP Prime Remote should contact the TOP contractor
to obtain an authorization. Without this authorization, overseas
providers may request payment upfront (overseas providers may bill
above the TRICARE allowable amount without any limits) and the beneficiary
will then have to submit a claim for reimbursement.
2.4 Failure
to obtain a TOP PCM referral/authorization when one is required
for care may result in the service being paid under TOP POS procedures
for an Active Duty Family Member (ADFM) with a deductible and cost-shares
for outpatient services and cost-shares for inpatient services.
2.5 The TOP
PCM shall assist the TOP Prime Remote enrollee and other beneficiaries
in locating an Military Treatment Facility (MTF) or purchased care
sector network or non-network provider to provide the care, and
shall assist in scheduling an appointment with a purchased care
sector provider upon request. The HCF shall conduct a benefit determination
review and provide authorization for service for which the referral
was made. If the contractor has no record of referral/authorization,
prior to denial/payment, the claims processing contractor shall
follow the TOP POS rules, assuming the service is
a TRICARE benefit.
2.6 All referrals made by a TOP
designated purchased care sector PCM shall be made through the TOP
HCF and shall receive an authorization.
2.7 The TOP contractor shall ensure
that all authorized services for TOP Prime Remote enrollees are provided
on a cashless, claimless basis. The contractor shall implement guarantee
of payment or other business arrangements to ensure that TOP Prime
Remote enrollees are not required to pay up front at the time services
are rendered by a purchased care sector provider.
2.8 Cashless,
claimless provisions do not apply to self-referred care that would
normally require an authorization.
2.9 For TOP Prime Remote enrollees
who are traveling stateside, the TOP contractor shall direct TOP beneficiaries
to utilize stateside MTFs whenever possible. If MTF care is unavailable,
beneficiaries shall be provided with information regarding the nearest
available network provider(s) who can assist the beneficiary. Non-network
providers shall only be used when MTF or network care is not possible.
3.0 Point
of service (POS) Option
3.1 TOP Prime Remote-enrolled ADFMs shall follow
established referral/authorization procedures prior to obtaining
specialty care to avoid the application of POS cost-shares and deductibles.
This includes all self-referred, non-emergency outpatient specialty
medical services and all inpatient care (including inpatient mental
health care), except for outpatient mental health and Substance
Use Disorder (SUD) visits, ancillary services, and drugs. TOP
Prime Remote ADFMs who self-refer to a civilian provider other than
their PCM shall have their claims processed as POS.
3.2 POS cost-shares
and deductibles shall not apply to claims for care received by newborns/adoptees
during the deemed enrollment period.
3.3 Self-referred, routine,
specialty, or inpatient care provided to a TOP Prime Remote ADFM enrollee
by a network or non-network purchased care sector provider, which
is not either provided/referred by the beneficiary’s PCM or specifically
authorized may be reimbursed only under the TOP Prime Remote POS
option if it is a benefit under TRICARE. Services which are not
a TRICARE benefit shall be denied.
3.4 POS cost-sharing and deductible amounts do
not apply if a TOP Prime Remote ADFM enrollee has Other Health Insurance
(OHI) that provides primary coverage. The OHI must be primary under
the provisions of the TRICARE Reimbursement Manual (TRM),
Chapter 4, Section 1, and documentation that
the other insurance processed the claim and the exact amount paid
shall be submitted with the TOP claim. TRICARE OHI provisions apply
for this type of claim.
3.5 The POS option does not apply to Service member
overseas/stateside care.
3.6 The TOP contractor shall adjust TOP Prime Remote
copayments when TOP PCMs or HCFs do not follow established referral/authorization
procedures. For example, if the contractor processes a claim without
evidence of an authorization and/or a referral under POS provisions,
and the contractor later verifies that the PCM or other appropriate
provider referred the beneficiary for the care, TOP contractor shall
adjust the claim under TOP Prime Remote provisions. The contractor
need not identify past claims, however, the contractor shall adjust
these claims as they are brought to their attention.
3.7 On a case-by-case basis, following stabilization
of the patient, the TAO Director may require a TOP Prime Remote
beneficiary to transfer to a TOP network facility or the MTF. The
TOP TAO Director shall provide written notice to the beneficiary
(or responsible party) advising them of the impending transfer to
a TOP network facility/MTF. If a TOP Prime Remote-enrolled ADFM
elects to remain in a non-network facility after being notified
of an impending transfer to another facility, TOP POS cost-sharing will
begin 24-hours following receipt of the written notice. The TAO
Director may not require a transfer until such time as the transfer
is deemed medically safe.
3.8 See the TRM,
Chapter 2 for
deductible and cost-share amounts. POS deductible and cost-sharing
do not apply to the claims for care received by certain newborn
and newly adopted children during the deemed enrollment period.
See
Section 5 for additional guidance regarding
deemed enrollment for newborns/adoptees.