Military Health System

4.1  Remote Service members enrolled in the TPR program shall receive the benefits of TRICARE Prime, even in areas without contractor networks. Some covered benefits (see Section 2, paragraph 5.3) require review by Specified Authorization Staff (SAS) (identified in Addendum A, paragraph 1.0) so they may identify fitness-for-duty issues.

4.2  If the contractor determines that a requested or claimed service, supply, or equipment is not covered by TRICARE (including Chapter 17, Section 3, paragraph 2.2.4) 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. 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 Service Project Officers as listed in Chapter 17, Addendum A, paragraph 2.0. No notification to the SAS is required.

4.3  The contractor shall not make claims payments to sanctioned or suspended providers (see Chapter 13, Section 5). The claim shall be denied if a sanctioned or suspended provider bills for services. SAS do not have the authority to overturn DHA or Department of Health and Human Services (DHHS) provider exclusions. See Section 2 for referral and authorization requirements.

4.4  Services that would not have ordinarily been covered under TRICARE policy (including limitations and exclusions) may be authorized for Service members only in accordance with the terms of a waiver approved by the Director, DHA, at the request of an authorized official of the Uniformed Service concerned. (Reference 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”).

4.5  If a contractor receives a claim for care provided to a Service member who is not enrolled in TPR or who is not enrolled in TRICARE Prime at a Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM), the contractor shall process the claim according to the applicable guidelines of the Supplemental Health Care Program (SHCP) (Chapter 17).

4.6  A SAS authorization shall be deemed to constitute referral, authorization, and direction to bypass edits as appropriate to ensure payment of SAS-approved claims. Contractors shall implement appropriate measures to recognize SAS authorization in order to expedite claims processing.

5.1  The SAS reviews referrals for proposed care as well as information about care already received in order to determine impact on an individual’s fitness for duty (see Section 2, paragraph 5.3 and Addendum B for referral and review/authorization procedures). The SAS, the PCM (if assigned) and the contractor shall work together in making arrangements for the Service member’s required examinations.

5.2  The SAS will provide the protocol, procedures, and required documentation through the contractor to the provider for these examinations. For required care that may not be obtainable in the civilian community, the SAS will refer the Service member to an MTF/eMSM. Refer to Addendum A for the addresses and telephone numbers of the SASs.

6.1  If the contractor, at the direction of the SAS, denies authorization of, or authorization for reimbursement, for a TPR enrollee’s health care services, the contractor shall, on the Explanation of Benefits (EOB) or other appropriate document, furnish the enrollee with clear guidance for requesting a reconsideration from or filing an appeal with the SAS (see paragraph 6.2). The SAS will handle only those issues that involve SAS denials of authorization or authorization for reimbursement. The contractor shall handle allowable charge issues, grievances, etc.

6.2  If the TPR enrollee disagrees with a denial rendered by the SAS, the first level of appeal will be through the SAS who will coordinate the appeal as appropriate. The enrollee may initiate the appeal by contacting his/her SAS. If the SAS upholds the denial, the SAS will notify the enrollee of further appeal rights with the appropriate Surgeon General’s office.

6.3  If the denial is overturned at any level, the SAS will notify the contractor and the Service member.

6.4  The contractor shall forward all written inquiries and correspondence related to SAS denials of authorization, or authorization for reimbursement to the appropriate SAS. The contractor shall refer telephonic inquiries related to SAS denials to the appropriate SAS.

8.1  If the contractor has not established a network of PCMs in a remote area, a TPR designated Service member will still be enrolled without a PCM assigned. The Service member without an assigned PCM will be able to use a local TRICARE-authorized provider for primary health care services without review.

8.2  Point of Service (POS) cost-sharing and deductible amounts do not apply to Service members. If a TPR enrolled Service member receives primary care without a referral or authorization, the enrolling contractor shall process the claim and make payment if the care meets all other TRICARE requirements (i.e., the care is medically necessary, a covered benefit of TRICARE an approved waiver is provided, etc.).

8.3  Annual Service member re-enrollment is not required.

8.4  If the Uniformed Services determine that an active duty member is eligible for the TPR program, enrollment of the member is mandatory, unless there are service-specific issues that merit assignment to a military PCM, or if the Service member elects to waive access standards and enrolls to an MTF/eMSM (subject to unit commander/supervisor approval).

8.5  If Third Party Liability (TPL) is involved in a claim, Service member claim payment will not be delayed during the development of TPL information from the Service member.

8.6  Enrollment jurisdiction may be based on the location of the military work unit instead of the Service member’s residence. This is determined by the Services.