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changed, waived, or superseded by this section; the TRICARE Policy Manual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.