1.0 General
All TRICARE requirements regarding Financial
Administration shall apply to the TRICARE Overseas Program (TOP)
unless specifically changed, waived, or superseded by this section;
the 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 3 for
additional instructions.
2.0 Payment
POLICY
2.1 Reimbursement of TOP beneficiary claims for
overseas health care shall be based upon the lesser of billed charges,
the negotiated reimbursement rate, or the Government-established
fee schedule. (See
Section 9 and the TRICARE Reimbursement Manual
(TRM),
Chapter 1, Sections 34 and
35 for additional guidelines). Except for
medical evacuations, claims for care in the U.S. commonwealths and
territories shall be reimbursed following stateside reimbursement
guidelines. Philippines and Panama claims shall be reimbursed following
Government-established fee schedules, unless the TOP contractor
has negotiated a lesser rate with a purchase care sector provider.
2.2 Payment
of Skilled Nursing Facility (SNF) claims from Puerto Rico and the
U.S. territories (Guam, the U.S. Virgin Islands, American Samoa,
and the Northern Mariana Islands) shall be processed as routine
foreign claims and shall be subject to the Prospective Payment System
(PPS), as required under Medicare in accordance with the Social
Security Act. These SNFs will be subject to the same rules as applied
to SNFs in the U.S. (see the TRM,
Chapter 8).
SNF care is not available in other TOP locations.
2.2.1 The TOP contractor at its discretion,
may conduct concurrent or retrospective review for TRICARE
Select and TRICARE for Life (TFL) patients
when TRICARE is the primary payer. If Medicare requires reviews
to be performed on low Patient Driven Payment Model (PDPM) categories,
per the Medicare Policy Manual Chapter 8, the contractor will be
responsible for all reviews for TRICARE Prime patients.
There will be no review for TRICARE
Select or TFL patients where TRICARE
is the secondary payer. The existing referral and authorization
procedures for Prime beneficiaries will remain unaffected.
2.2.2 Beneficiaries
in a low PDPM category depending on date of service may not automatically qualify
for SNF coverage. These beneficiaries will be individually reviewed
to determine whether they meet the criteria for skilled services
and the need for skilled services (see the TRM,
Chapter 8, Section 1). If these beneficiaries
do not meet these criteria, the SNF PPS claim shall be denied.
2.2.3 The TOP
contractor, at their own discretion, may collect Minimum Data Set
(MDS) assessment data per the TRM,
Chapter 8, Section 1.
2.3 The TOP
contractor shall be responsible for entering into participation
agreements with SNFs in Puerto Rico, Guam, the U.S. Virgin Islands,
American Samoa, and the Northern Mariana Islands.
2.3.1 The TOP contractor, at their
own discretion, may conduct any data analysis to identify aberrant
SNF PPS providers or those providers who might inappropriately place
TRICARE beneficiaries in a high PDPM category. The contractor shall
also assist the TRICARE Area Office (TAO) Directors in obtaining/providing
SNF data, for conducting any SNF PPS data analysis they deem necessary.
2.4 Balance
billing provisions do not apply to TOP beneficiary claims for care
rendered in a foreign country and paid as billed, since there is
no unpaid balance on these claims. Purchased care sector network
providers, participating providers, and providers in U.S. commonwealths
and territories are prohibited from balance billing.
2.5 For health care rendered in Puerto Rico and
in the U.S., reimbursement for all TOP beneficiary care shall follow
the TRICARE payment policies except as outlined below.
2.5.1 TOP Service
members who have been required by the provider to make “up front”
payment at the time services are rendered may submit a claim for
reimbursement directly to the contractor. Normal TRICARE claims
processing requirements apply (including any authorization requirements
and the use of TRICARE-approved claims forms). If the claim is payable,
the contractor shall allow the billed amount and reimburse the Service
member for charges on the claim.
2.5.2 In no case shall a Service
member be subjected to “balance billing” or ongoing collection action
by a civilian provider for emergency or authorized care. If the
contractor becomes aware of such situations that they cannot resolve,
they shall pend the file and forward the issue to the appropriate TAO
Director. The appropriate TAO Director will issue an authorization
to the contractor for payments in excess of CMAC or other applicable
TRICARE payment ceilings, provided the TAO Director has requested
and has been granted a waiver from the Program Manager,
Defense Health Agency (DHA), or designee.
2.5.5 Payment
may be made for ambulance services provided by commercial transport
(see
Section 7 for additional processing instructions
for these claims)
.
3.0 Financial
Administration
3.1 The TOP contractor shall follow the Financial
Administration non-financially underwritten funds requirements in
Chapter 3 with the following exceptions:
3.1.1 Foreign
overseas drafts (local currency) and checks (U.S. currency) shall
also reflect “TRICARE Overseas Program”.
3.1.2 Foreign overseas drafts shall
also reflect information that indicates the draft is valid for 190 days
and if reissue is required/necessary, the draft must be returned
to the TOP contractor with a request for reissuance. The contractor
shall issue drafts/checks for Germany claims which look like local German
drafts/checks.
3.2 The TRICARE Encounter Data
(TED) for the overseas claims shall be reported on vouchers/batches
according to the TRICARE Systems Manual (TSM),
Chapter 2.
•
• Overseas health care
claims for stateside beneficiaries whose health care is normally provided
under one of the regional contracts (i.e., beneficiaries enrolled
or residing in the 50 U.S. or the District of Columbia, who receive
care while traveling or visiting abroad) shall be processed by the
TOP contractor. Claims for these beneficiaries shall be paid from
the current non-financially underwritten bank account. This provision
does not apply to beneficiaries who are enrolled to 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.
3.3 The TOP contractor shall:
3.3.1 Provide TRICARE Overseas Currency reports identifying
the gain or loss for the month reported to arrive by the 10th calendar
day following the month reported. Reporting requirements for net
gains/losses are identified by DD Form 1423, Contract Data Requirements
List (CDRL), located in Section J of the applicable contract.
3.3.2 Calculate currency
gains and losses resulting from payments made to purchased care sector
providers and/or beneficiaries in foreign countries. The gains and
losses shall be computed based on the exchange rate in effect on
the ending date of care. The difference between the cost of the foreign
currency on the ending date of care and the contractor payment date
shall be the gain or loss on the transaction. Payment shall be as
follows for:
3.3.2.1 Net Gain.
For months that result in a net gain, the TOP contractor shall forward
the report along with their check payable to the Department of Defense
(DoD), DHA, for the gain from currency conversion.
3.3.2.2 Net Loss.
DHA will reimburse the TOP contractor for any losses incurred from
currency conversion. The TRICARE Overseas Currency report shall
be accompanied by a letter (invoice) requesting reimbursement for
the loss incurred. This payment will not be subject to the Prompt Payment
Act (FAR 32.9) as amended, therefore, payment by DHA will usually
be made within five working days of receipt of the invoice and the
TRICARE Overseas Currency report.