1.0 GENERAL
1.1 TOP Prime Remote
is available to Service members (including Reserve Component (RC) members
activated for more than 30 days) on permanent assignment to a remote
overseas location, Command-Sponsored Active Duty Family Members
(ADFMs) accompanying their sponsor in the remote location or on
Service orders, and certain transitional survivors according to
the eligibility and enrollment provisions of
Section 5. TOP
Prime Remote offers enrollees access to a Primary Care Manager (PCM),
clinical preventative services, and specialty services. The TOP
contractor, working in concert with purchased care sector providers
and the TRICARE Area Offices (TAOs), has primary responsibility
for ensuring that TOP Prime Remote enrollees receive appropriate
services and support to facilitate access to the TOP benefit in
remote overseas locations.
1.2 TOP Prime Remote
has no enrollment fees, and deductibles and cost-shares are waived
except for TOP Prime Remote ADFMs who receive care under the Point
of Service (POS) option, or who obtain pharmacy services in the
50 United States (U.S.), the District of Columbia, and U.S. territories
where the TRICARE Pharmacy (TPharm) has established a retail pharmacy
network. Waiver of copayment and deductibles under TOP Prime Remote
is subject to review/updating based on enrollment status.
1.3 Under
TOP Prime Remote, annual catastrophic caps are calculated on calendar years.
The enrollment year shall coincide with the calendar year.
Since deductibles and cost-shares are waived for TOP Prime Remote
enrollees, this policy will apply only to TOP Prime Remote enrollees
who incur out-of-pocket expenses as described above.
2.0 Contractor
Responsibilities
2.1 TOP Prime Remote enrollees shall
select or have assigned to them Primary Care Managers (PCMs) according
to guidelines established by the TAO Director, or designee.
2.1.1 TOP PCMs may
be an individual professional provider, an
overseas treatment site, or other health care delivery arrangement.
For the purposes of referral management and authorization for TOP Prime
Remote episodes of care, the TOP contractor’s call center(s) are
considered PCMs.
2.1.2 TOP PCMs may be an internist, family practitioner,
pediatrician, General Practitioner (GP), Obstetrician/Gynecologist
(OB/GYN), Physician Assistant (PA), Nurse Practitioner (NP), or
Certified Nurse Midwives (CNMs) when determined by the TOP contractor
to meet governing country rules and licensure.
2.1.3 May also act
as a Health Care Finder (HCF), when dual responsibility is necessary,
as determined by the TAO Director.
2.2 A TOP
Prime Remote enrollee must seek all his or her primary health care
from the TOP PCM with the exception of care listed in
Section 8. If the TOP PCM is unable to provide
the care, the TOP PCM shall refer the enrollee to another primary
care provider.
2.3 TOP Prime Remote enrollees must
obtain appropriate referral/authorization for any non-emergency
,
non-urgent care rendered by anyone other than the
beneficiary’s PCM. This provision applies regardless of where the
care is rendered. TAO Directors may direct retroactive authorizations
on a case-by-case basis.
2.3.1 Routine care is generally not authorized
while a TOP Prime Remote enrollee is traveling out of their enrollment
region. The TOP contractor shall fully document the justification
for authorizing routine out-of-area care. Emergency care does not
require prior authorization; however, the beneficiary should contact
their PCM and the contractor as soon as possible to obtain authorization
for any necessary follow-up care.
2.3.2 ADFMs enrolled in TOP
Prime Remote may obtain urgent care from any authorized provider without
a PCM (if assigned) referral or overseas contractor authorization.
In order to ensure the urgent care visit will be cashless/claimless,
the ADFMs enrolled to TOP Prime Remote should contact the TOP contractor
to obtain an authorization. Without this authorization, overseas
providers may request payment upfront (overseas providers may bill
above the TRICARE allowable amount without any limits) and the beneficiary
will then have to submit a claim for reimbursement.
2.4 Failure to obtain
a TOP PCM referral/authorization when one is required for care may
result in the service being paid under TOP POS procedures for an
Active Duty Family Member (ADFM) with a deductible and cost-shares
for outpatient services and cost-shares for inpatient services.
2.5 The TOP
PCM shall assist the TOP Prime Remote enrollee and other beneficiaries
in locating an Military Treatment Facility (MTF) or purchased care
sector network or non-network provider to provide the care, and
shall assist in scheduling an appointment with a purchased care
sector provider upon request. The HCF shall conduct a benefit determination
review and provide authorization for service for which the referral
was made. If the contractor has no record of referral/authorization,
prior to denial/payment, the claims processing contractor shall
follow the TOP POS rules, assuming the service is
a TRICARE benefit.
2.6 All referrals made by a TOP designated
purchased care sector PCM shall be made through the TOP HCF and
shall receive an authorization.
2.7 The TOP contractor shall ensure
that all authorized services for TOP Prime Remote enrollees are provided
on a cashless, claimless basis. The contractor shall implement guarantee
of payment or other business arrangements to ensure that TOP Prime
Remote enrollees are not required to pay up front at the time services
are rendered by a purchased care sector provider.
2.8 Cashless, claimless
provisions do not apply to self-referred care that would normally
require an authorization.
2.9 For TOP Prime Remote enrollees who
are traveling stateside, the TOP contractor shall direct TOP beneficiaries
to utilize stateside MTFs whenever possible. If MTF care is unavailable,
beneficiaries shall be provided with information regarding the nearest
available network provider(s) who can assist the beneficiary. Non-network
providers shall only be used when MTF or network care is not possible.
3.0 Point of
service (POS) Option
3.1 TOP Prime Remote-enrolled ADFMs
shall follow established referral/authorization procedures prior
to obtaining specialty care to avoid the application of POS cost-shares
and deductibles. This includes all self-referred, non-emergency
outpatient specialty medical services and all inpatient care (including
inpatient mental health care), except for outpatient mental health
and Substance Use Disorder (SUD) visits, ancillary services, and drugs. TOP
Prime Remote ADFMs who self-refer to a civilian provider other than
their PCM shall have their claims processed as POS.
3.2 POS cost-shares
and deductibles shall not apply to claims for care received by newborns/adoptees
during the deemed enrollment period.
3.3 Self-referred, routine,
specialty, or inpatient care provided to a TOP Prime Remote ADFM enrollee
by a network or non-network purchased care sector provider, which
is not either provided/referred by the beneficiary’s PCM or specifically
authorized may be reimbursed only under the TOP Prime Remote POS
option if it is a benefit under TRICARE. Services which are not
a TRICARE benefit shall be denied.
3.4 POS cost-sharing and deductible
amounts do not apply if a TOP Prime Remote ADFM enrollee has Other
Health Insurance (OHI) that provides primary coverage. The OHI must
be primary under the provisions of the TRICARE Reimbursement Manual
(TRM),
Chapter 4, Section 1, and documentation that
the other insurance processed the claim and the exact amount paid
shall be submitted with the TOP claim. TRICARE OHI provisions apply
for this type of claim.
3.5 The
POS option does not apply to Service member overseas/stateside care.
3.6 The TOP contractor shall adjust
TOP Prime Remote copayments when TOP PCMs or HCFs do not follow
established referral/authorization procedures. For example, if the
contractor processes a claim without evidence of an authorization
and/or a referral under POS provisions, and the contractor later verifies
that the PCM or other appropriate provider referred the beneficiary
for the care, TOP contractor shall adjust the claim under TOP Prime
Remote provisions. The contractor need not identify past claims, however,
the contractor shall adjust these claims as they are brought to
their attention.
3.7 On a
case-by-case basis, following stabilization of the patient, the
TAO Director may require a TOP Prime Remote beneficiary to transfer
to a TOP network facility or the MTF. The TOP TAO Director shall
provide written notice to the beneficiary (or responsible party)
advising them of the impending transfer to a TOP network facility/MTF.
If a TOP Prime Remote-enrolled ADFM elects to remain in a non-network
facility after being notified of an impending transfer to another
facility, TOP POS cost-sharing will begin 24-hours following receipt
of the written notice. The TAO Director may not require a transfer until
such time as the transfer is deemed medically safe.
3.8 See
the TRM,
Chapter 2 for deductible and cost-share amounts.
POS deductible and cost-sharing do not apply to the claims for care
received by certain newborn and newly adopted children during the
deemed enrollment period. See
Section 5 for
additional guidance regarding deemed enrollment for newborns/adoptees.