1.0 GENERAL
1.1 All TRICARE
requirements regarding C&CS shall apply to the TRICARE Overseas
Program (TOP) unless specifically changed, waived, or superseded
by the provisions of 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 11 for additional instructions.
2.0 TRICARE Service
Centers (TSC
s) support
2.1 Location, Operations, And Staffing
2.1.1 TSCs are jointly
staffed by Military Treatment Facility (MTF) personnel and TOP contractor personnel.
TSCs in the MTFs are operational, Monday - Friday (except holidays
recognized by the installation) during the administrative hours
of the MTF.
2.1.2 The TOP contractor shall provide
Beneficiary Service Representatives (BSRs) on a full-time basis
at each location as designated in the contract. BSRs shall be qualified
to perform the duties described in
paragraph 2.2.
2.1.3 The TOP contractor shall provide
sufficient BSR staffing to accomplish all work in a timely manner;
however, at least one full-time BSR will be assigned to each location
regardless of actual workload unless the Government has specifically
authorized part-time coverage. The TOP contractor shall advise the
Government of any locations where the workload does not justify
full-time BSR coverage. The TOP contractor shall implement appropriate
business processes to provide full-time TSC coverage if the assigned
Customer Service Representative(s) (CSR(s)) are unavailable due
to planned or unplanned absences (e.g., illness, leave, personal
emergencies, etc.) for more than two consecutive business days.
Local processes for managing short-term CSR absences (up to two
consecutive business days) shall be addressed in the Statement of
Responsibilities (SOR).
2.1.4 BSRs shall have a fully operational,
on-line interface with the automated claims processing and enrollment
systems which support the functions of the TSC no later than 30
calendar days prior to the start of health care delivery (SHCD)
and shall maintain that interface through the life of the contract.
2.2 BSR Functions at TSC
s2.2.1 The contractor
shall provide overseas TSCs with BSR support to provide all Military
Health System (MHS) beneficiaries with the information and services
as specified below.
• Provide TOP
Prime, TOP Prime Remote, and TOP Select enrollment information and perform
enrollments/disenrollments to include assisting MTFs/beneficiaries
with transferring enrollment to another region.
• Perform Health Care Finder (HCF) functions
upon beneficiary/MTF request.
• Provide information on the Point of Service
(POS) option;
• Provide information
on claims (including on-line access to the claims processing system
for information about the status of a claim);
• Provide assistance regarding claim problems
when the TOP contractor is responsible for processing the claim;
and
• Provide continuity-of-care
services to all MHS beneficiaries including, but not limited to,
active duty personnel, dependents of active duty personnel, retirees
and their dependents, survivors, Medicare-eligible beneficiaries
and all other categories of individuals eligible to receive MHS
services.
• Perform Primary Care Manager (PCM) changes
and resolve PCM Information Transfer (PIT) discrepancies.
• Perform registrations
in the Composite Health Care System (CHCS) (as required to support
TRICARE enrollments) and update patient information in CHCS and
Defense Enrollment Eligibility Reporting System (DEERS).
• Assist
beneficiaries with TRICARE benefit/coverage or claims questions
(BSRs shall have sufficient claims knowledge to handle routine questions
regarding claims and the ability to access and navigate the claims
system).
• Assist beneficiaries with debt collection
issues.
• Provide TRICARE briefings as requested
by the MTF.
• Distribute TRICARE marketing materials.
• Assist beneficiaries
with utilizing Government messaging systems.
• Assist beneficiaries
in navigating procurement of Durable Medical Equipment (DME).
Note: The contractor
shall confirm eligibility for care and enrollment status of beneficiaries
before making any arrangements for medical services.
2.2.2 TRICARE Program
Information
The TOP contractor shall provide
personal assistance to all MHS beneficiaries seeking information
about TRICARE Prime, TRICARE Select, TRICARE For Life (TFL), Civilian
Health and Medical Program of the Department of Veteran Affairs
(CHAMPVA), TRICARE Mail Order Pharmacy (TMOP), Global Nurse Advice
Line (NAL), and the TRICARE dental contracts. The TOP contractor
shall ensure that the TSCs are supplied with educational materials to
include enrollment and claims submission information. Through the
BSRs and call centers, the TOP contractor shall establish mechanisms
to advise beneficiaries of care options, including the POS option,
and services offered.
2.2.3 BSR Interface
With MTFs
BSRs shall act as the focal point
for providing information, referral, and assistance to beneficiaries
seeking access to TRICARE services. BSRs shall maintain day-to-day
liaison with MTF staff to promote MTF optimization and ensure effective
performance of the access, referral, information, and continuity
of care functions.
2.2.4 Enrollment
BSRs and contractor call center
staff shall provide personal assistance to eligible beneficiaries,
electing to enroll or disenroll, and permanently assigned active
duty personnel enrolling in TRICARE Prime. The TOP contractor shall
provide assistance to all MHS beneficiaries, including active duty,
Medicare eligibles, and others, in understanding program requirements,
by answering questions, adhering to MTF Commanders’ and TAO Director’s
determinations for PCM assignment, and following grievance and inquiry
procedures in accordance with this manual.
2.2.5 Claims
BSRs in the TSCs shall assist all
TRICARE beneficiaries with all claims issues when the TOP contractor
is responsible for processing the claim. When the TOP contractor
is not responsible for processing the claim, the BSR in the TSC
shall assist the beneficiary in identifying and contacting the organization
that is responsible for processing the claim. The BSR will provide
information (including on-line access to the claims processing system
for information about the status of a claim), assist beneficiaries
with claim problems when the TOP contractor is responsible for processing
the claim and provide continuity-of-care services to all MHS beneficiaries
including, but not limited to, active duty personnel, dependents
of active duty personnel, retirees and their dependents, survivors,
Medicare-eligible beneficiaries and all other categories of individuals
eligible to receive MHS services.
2.2.6 TRICARE Dental
Plans
BSRs in the TSCs shall provide general
information on eligibility for the TRICARE Dental Plans. The beneficiaries
shall be referred to the appropriate dental contractor for additional information.
3.0 HEALTH CARE
FINDER (HCF) SERVICES
3.1 TOP HCF functions are performed
by BSRs located in the TSCs or in contractor-operated call center(s).
The TOP contractor shall offer call center operations to support
HCF services via toll-free lines 24 hours per day, seven days per
week, 365 days per year
.3.1.1 HCFs
are responsible for facilitating access to purchased care sector
provider care (including, but not limited to, primary care, specialty
care, mental health care, ancillary services, DME, and pharmacy
services), and for authorizing certain health care services. Additionally,
HCFs shall inform beneficiaries of access mechanisms, referral procedures,
and rules regarding use of network/non-network providers. They shall
also improve patient continuity of care by establishing mechanisms
to facilitate necessary consultations, follow-up appointments and
the sharing of medical records. TOP HCFs will serve all MHS beneficiaries
in the region, regardless of their enrollment status. This includes dual-eligible
beneficiaries and beneficiaries residing or enrolled in the 50 U.S.
and the District of Columbia who may require assistance when accessing
care in an overseas location.
3.1.2 For MTF enrollees, the specialty
care referral process includes a covered benefit review; entering
appropriate authorizations into the contractor’s system; locating
a qualified network or non-network purchased care sector provider
to provide the care on a cashless, claimless basis; providing the beneficiary
with a written care authorization and the purchased care sector
provider’s information; and assisting the beneficiary with establishing
an appointment with the purchased care sector provider (upon beneficiary
request).The contractor shall also provide information to MTF personnel
regarding the status of specialty care referrals and shall work
cooperatively with the MTF to assist in obtaining consult results
from purchased care sector providers; however, the contractor is
not responsible for tracking receipt of consult results.
3.1.3 For TOP Prime
Remote enrollees, the specialty care referral process includes a
medical necessity review; a covered benefit review; entering appropriate
authorizations into the contractor’s system; locating a qualified
network or non-network purchased care sector provider to provide
the care on a cashless, claimless basis; providing the beneficiary
with a written care authorization and the purchased care sector
provider’s information; and assisting the beneficiary with establishing
an appointment with the purchased care sector provider (upon beneficiary
request). This process is also applicable to Service members who
are on Temporary Additional Duty/Temporary Duty (TAD/TDY), in an
authorized leave status, or deployed/deployed on liberty in a remote
overseas location, and to TRICARE Prime/TRICARE Prime Remote (TPR)
enrollees who require urgent specialty care while traveling outside
the 50 U.S. and the District of Columbia.
Note: This
process applies to all TOP Prime Remote enrollees, regardless of
the status/location of the referring provider or health unit.
3.1.4 Beneficiaries
enrolled to the Uniformed Services Family Health Plan (USFHP) and
the Continued Health Care Benefit Program (CHCBP) must follow the
requirements of those programs when obtaining overseas care.
3.2 The TOP
HCF is responsible for the following functions:
3.2.1 Referral Assistance for TOP Beneficiaries
The TOP contractor (working in concert
with the MTF Commander) shall ensure optimal use of MTFs and to
foster coordination of all care delivered in the civilian sector
and care referred to and from the MTF. The TOP HCF is the primary
mechanism for achieving these objectives. The referral services
of the TOP HCF are primarily for ensuring access to care for enrolled
beneficiaries, but the TOP HCF is also available to assist non-enrollees
in finding network/non-network purchased care sector providers.
For TOP Prime/TOP Prime Remote enrollees, the referral is generally
initiated by the beneficiary’s PCM. The PCM or beneficiary contacts
the TOP HCF for assistance in locating an appropriate purchased
care sector provider and to obtain authorization for the care (see
Sections 17 and
18 for additional
information on HCF referral assistance).
3.2.2 Referral
Assistance for Beneficiaries Enrolled or Residing in the 50 U.S.
and the District of Columbia
The TOP
contractor shall provide referral assistance for TRICARE Prime/TPR
enrollees who require urgent or emergent health care while traveling
outside the 50 U.S. and the District of Columbia. These referrals
will generally be initiated by the beneficiary, a purchased care
sector provider, or an overseas MTF provider. Emergency care never
requires preauthorization; however, ADFMs enrolled to TRICARE Prime/TPR
may receive routine, urgent and emergency health care services in
locations outside the 50 U.S. and the District of Columbia (to include
emergency medical evacuation per
Section 7) on
a cashless, claimless basis if the care is coordinated in advance
with the TOP contractor. The TOP contractor shall implement guarantee
of payment or other business processes to ensure that ADFMs enrolled
to TRICARE Prime/TPR receive routine, urgent or emergency medical
services on a cashless, claimless basis upon beneficiary request.
3.2.3 Authorizations
3.2.3.1 The TOP
HCF will authorize care for TPR enrollees; for Service members who
are on TAD/TDY, in an authorized leave status, or deployed, deployed
on liberty in a remote overseas location, and for TRICARE Prime/TPR
enrollees who require urgent or emergent health care while traveling
outside the 50 U.S. and the District of Columbia. The contractor
shall also ensure that MTF-issued authorizations are entered into
all applicable contractor systems. Non-emergent specialty health
care received from a purchased care sector provider must be authorized
if benefits are to be paid as TOP Prime/TPR.
3.2.3.2 Care subject
to a PCM referral/authorization may receive a clinical review and
authorization by the HCF or other designee.
3.2.4 If an
ADFM TOP Prime/TOP Prime Remote enrollee receives care that was
not authorized, the care may be covered under the TOP POS option,
with POS deductibles and cost-shares. POS provisions also apply
to TRICARE Prime/TPR enrollees who receive routine care outside
the 50 U.S. and the District of Columbia without obtaining prior
authorization from the TOP contractor. The care must also be otherwise
coverable under TRICARE or the claim shall be denied.
3.2.5 Service
member care that was not referred and authorized shall be denied
unless it is retroactively authorized by the appropriate service
and Director, DHA. This included obtaining an approved waiver for
any non-covered service. POS does not apply to Service members.
4.0 Customer
Service Responsibilities
TOP customer
support shall be provided to all Military Health System staff to
include, but not limited to, TOPO, TAOs, Beneficiary Counseling
and Assistance Coordinators (BCACs)/Debt Collection Assistance Officers
(DCAOs), stateside TROs, stateside contractors, stateside TRICARE
beneficiaries traveling overseas, and DHA staff. TOP contractor
customer support service shall include the following:
4.1 The TOP
contractor shall secure at a minimum one dedicated post office box
for the receipt of all claims and correspondence from foreign locations
per overseas region.
4.2 The TOP contractor shall identify
a specific individual and an alternate to assist the Director, TROs,
TOPO/TAO Directors, DHA, BCACs and stateside claims processing contractors
with the resolution of TOP issues. Issues which cannot be successfully
resolved shall be referred to the TOP Contracting Officer’s Representative
(COR).
4.3 The TOP contractor shall identify
a specific individual and an alternate to assist DCAOs with the resolution
of TOP beneficiary debt collection issues.
4.4 The TOP contractor shall be responsible
for establishing and operating a dedicated TRICARE overseas claims/correspondence
processing department with a dedicated staff. This department and staff
shall be under the direction of a supervisor, who shall function
as the contractor’s POC for TRICARE overseas claims and related
operational and support services. The contractor’s department for
TRICARE overseas claims shall include at a minimum the following
functions/requirements:
4.4.1 The TOP contractor shall provide
toll-free telephone service for claims assistance to beneficiaries
and providers 24 hours per day, seven
days a week, 365 days a year. Toll-free
services shall be available from any stateside or overseas location.
4.4.2 The TOP
contractor shall have the ability to translate claims submitted
in a foreign language and write in German, Italian, Japanese, Korean,
Tagalog (Filipino), and Spanish, or shall have the ability to obtain
such translation or writing.
4.4.3 The TOP contractor shall provide
on-line read only access to their claims processing system to TOPO,
each TAO, and the DHA technical representative for TOP claims.
4.4.4 The TOP
contractor shall provide a secure, user-friendly Internet portal
for receipt of customer claims status inquiries and access to claims
status information (to include the ability to view and print Explanation
of Benefits (EOBs).
4.4.5 The TOP contractor shall provide,
upon Government request, documentation of claims for auditing purposes.
4.5 The TOP
contractor shall assist traveling TOP Prime and Prime Remote enrollees
to ensure beneficiary access/receipt of urgent or emergent care
in the 50 U.S. and the District of Columbia. The contractor shall
also assist beneficiaries residing or enrolled in the U.S. or the
District of Columbia who require urgent or emergent care while traveling
overseas. ADFMs who are enrolled to TRICARE Prime or TPR may receive
emergency medical services in locations outside the 50 U.S. and
the District of Columbia (to include emergency medical evacuation)
on a cashless, claimless basis if the care is coordinated in advance
with the TOP contractor.
5.0 BENEFICIARY
SERVICES
5.1 The TOP contractor shall achieve
the highest level of beneficiary satisfaction possible in the overseas
environment. This shall be accomplished by developing qualified
purchased care sector provider networks (complemented by non-network
purchased care sector providers as necessary), ensuring timely access
to purchased care sector care, providing TOP information/education/training
to beneficiaries and purchased care sector providers, and processing
claims in a timely, accurate manner.
5.2 In
addition to the beneficiary education requirements outlined in
Chapter 11, Sections 1 and
2, the
TOP contractor may be required to conduct beneficiary education/enrollment
activities for arriving/deploying units in accordance with the enrollment
protocols established in the SOR between the TOP contractor and
the MTFs.
5.3 The TOP contractor shall maintain
up-to-date lists of purchased care sector network providers, and
shall make this information available at all TOP TSCs and via web-based
access. Web-based network provider listings shall include information
regarding authorization requirements that are applicable to TOP
Prime and Prime Remote enrollees.
5.4 The TOP contractor’s beneficiary
education activities and materials shall include information for TOP
Prime and Prime Remote enrollees regarding care received in the
50 U.S. and the District of Columbia. This process shall include
information regarding referrals/authorizations while stateside,
TOP POS policy, and the recommended process for accessing care while
stateside. TOP Prime and Prime Remote enrollees traveling stateside
shall be encouraged to utilize MTF care whenever possible. If MTF care
is not available, beneficiaries should be encouraged to seek care
from a network provider before obtaining care from a non-network
provider.
5.5 The
requirement in
Chapter 11, Section 2, paragraph 1.1, is superseded
for the TOP contractor by a requirement for a total of nine three-day
TRICARE training courses per contract option period (two per option
period within the TRICARE Eurasia-Africa area; two within the TRICARE
Pacific area; two within the TRICARE Latin America/Canada (TLAC)
area; and three additional courses that may occur in any stateside
or overseas location at the direction of the Contracting Officer
(CO)).
6.0 PROVIDER
SERVICES
6.1 The TOP contractor shall ensure
that all purchased care sector network providers and their support
staff have sufficient understanding of the applicable TRICARE program
requirements, policies, and procedures to allow them to carry out
the requirements of this contract in an efficient and effective manner
that promotes beneficiary satisfaction.
6.2 The TOP contractor shall have the
responsibility for developing and delivering TRICARE Program information
to purchased care sector providers. The contractor shall determine
the requirements for printed products and will develop and deliver
these products after obtaining approval from the Government. The
information in these products will generally be determined by the contractor
based on their understanding of the needs of their network providers;
however, the Government may mandate the inclusion of certain topics
or information.
6.3 Provider education materials shall
include information regarding claims processing procedures, claims
submission deadlines, and normal claims processing time lines.
6.4 The Government
shall ensure provider satisfaction with contractor-provided information
by conducting random satisfaction surveys of select network providers.