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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Overseas Program (TOP)
Chapter 24
Section 4
Purchased Care Sector Providers
Revision:  C-72, September 10, 2020
1.0  GENERAL
TRICARE Overseas Program (TOP) health care services are provided by Military Treatment Facilities (MTFs) and purchased care sector network and non-network providers and institutions. All TRICARE requirements regarding Provider Certification/Credentialing and Network Development shall apply to the TOP unless specifically changed, waived, or superseded by this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (U.S.) and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 Chapters 4 and 5 for additional instructions.
2.0  Purchased Care Sector Provider Certification And Credentialing
2.1  The TOP contractor shall be responsible for provider certification oversight, and monitoring of provider/institution quality. The contractor shall use Chapter 4, 32 CFR 199.6, and TPM, Chapter 11 to the maximum extent possible for the certification of purchased care sector providers. The contractor is not required to follow TRICARE requirements for U.S. credentialing standards, except when TRICARE requires the facility/agency to be Medicare certified (e.g., home health, hospice, Skilled Nursing Facility (SNF) care). Also, Psychiatric Residential Treatment Centers (RTCs), Substance Use Disorder Rehabilitation Facilities (SUDRFs), and Psychiatric Partial Hospitalization Programs (PHPs) that are located in Puerto Rico require approval by the TOP contractor. Except for these services and facilities, the TOP contractor shall establish purchased care sector provider certification processes based on the accepted licensure and credentialing requirements for the purchased care sector.
Note:  Medicare certification for organ transplant centers is only required for transplants performed in the U.S., the District of Columbia, and U.S. territories where Medicare is available. See TPM, Chapter 12, Section 1.2.
2.2  Refer to Section 29 for additional certification requirements that have been established for purchased care sector providers in the Philippines. The Defense Health Agency (DHA) may expand these additional certification requirements to other locations in the future.
3.0  Network Development
3.1  The TOP contractor shall be responsible for developing and maintaining a complement of network and non-network purchased care sector providers to augment the existing capacity of the Direct Care (DC) system for Service members and Active Duty Family Members (ADFMs) who are enrolled in TOP Prime, and to provide or arrange for primary and specialty care services for Service members and ADFMs who are enrolled in TOP Prime Remote.
3.2  The TOP contractor shall establish signed provider agreements between network purchased care sector providers and the contractor.
3.2.1  Network provider agreements shall include language indicating that the provider agrees to participate on claims for authorized services for TOP enrollees on a cashless, claimless basis.
3.2.2  Network provider agreements must specify rates for Service member medical records photocopying and postage, if applicable.
Note:  “Cashless, claimless” is defined as a health care encounter that requires no up-front payment at the time of service, and the provider files the claim for the beneficiary.
3.3  In TOP Prime and TOP Prime Remote locations, networks shall be sized to meet TOP Prime Remote-enrolled populations only. The TOP contractor may assist other beneficiaries (non-command sponsored ADFMs, retirees, retiree family members, etc.) upon request by identifying these purchased care sector providers which are credentialed and familiar with TRICARE, but networks will not be developed to accommodate non-TOP Prime/Prime Remote enrollees.
3.4  In TOP Prime locations, MTF Commanders will identify the specialties needed in the network and will communicate this information on an ongoing basis to the TOP contractor per the process identified in the Statements of Responsibilities (SORs) (see Section 16).
3.5  MTF capabilities and capacities may change frequently over the life of the contract without prior notice. The TOP contractor shall ensure that purchased care sector provider services can be adjusted as necessary to compensate for changes in MTF capabilities and capacities, when and where they occur over the life of the contract, including short notice of unanticipated facility expansion, provider deployment, downsizing, and/or closures.
3.6  Network providers shall be able to communicate in English, both orally and in writing, or provide translation services at the time of service.
3.7  The TOP contractor shall be responsible to enter into participation agreements with SNFs in Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands per the provisions of Section 3.
4.0  Contractor Requirements - Purchased Care Sector Providers
4.1  The Government requires the contractor to negotiate rates in specific countries designated in the contract. Reimbursement rates for purchased care sector providers in other locations may be negotiated by the contractor. In locations where the Government has designated specific reimbursement rates or methodologies. The contractor may not negotiate rates which exceed the Government directed rate. Refer to the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 34 for additional instructions.
4.2  The contractor shall provide ongoing purchased care sector provider education and support in accordance with Section 11.
4.3  The contractor shall have a Clinical Quality Management Program/Clinical Quality Oversight Plan for reviewing access and quality of care provided by the purchased care sector, as identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
4.4  The TOP contractor shall assign provider numbers to purchased care sector providers, identify providers as network or non-network, and create and submit TRICARE Encounter Provider (TEPRV) records. Each provider shall be identified by a single provider number, with a sub-identifier for multiple service locations. Upon the Government’s request, the contractor shall provide copies of licensure/certification information for purchased care sector providers.
4.5  The TOP contractor shall deny claims from non-certified purchased care sector providers when DHA has directed that the country’s purchased care sector providers must be specially certified in order to receive TRICARE payments. See Section 29 for additional certification requirements.
4.6  The provisions of Chapter 5, Section 1, paragraph 1.2 regarding Telemental Health (TMH) are not applicable to the TOP contract.
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