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changed, waived, or superseded by this section; the TRICARE Policy Manual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/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 private sector care 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.