1.0 general
1.1 All TRICARE
requirements regarding the SHCP shall apply to the TRICARE Overseas
Program (TOP) unless specifically changed, waived, or superseded
by this section, 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 17 for additional
instructions.
1.2 Uniformed Service members in an active
duty status of greater than 30 days (also known as Service members)
who are on permanent or official duty assignment in a location outside
the 50 U.S. and the District of Columbia must enroll in TRICARE
Overseas Program (TOP) Prime or TOP Prime Remote. Service members
in a temporary duty status and enrolled elsewhere should not transfer
their enrollment to TOP Prime or TOP Prime Remote unless it is medically
appropriate and will not cause enrollment eligibility disruption
to family members’ enrollment status. Service members are not CHAMPUS-eligible
and do not have the option to use
TOP
Select
or the Point of Service (POS)
option under TOP Prime or TOP Prime Remote. Uniformed Service members
who would normally receive care from a purchased care sector provider
may be directed to transfer their care to a Military Treatment Facility
(MTF). This applies to Service members and Uniformed Service members
not in active duty status (Reserve Component (RC) members under
Line of Duty (LOD) care). These controls ensure the maintenance
of required fitness-for-duty oversight for TOP Uniformed Service
members. Refer to
Section 9 for claims processing instructions.
2.0 Contractor
Responsibilities
2.1 Service members who are enrolled
in TOP Prime shall follow the procedures outlined in
Chapter 17 for MTF-enrolled Service members,
except that any references to the Defense Health Agency-Great Lakes
(DHA-GL) should be replaced by a reference to the appropriate regional
TRICARE Area Office (TAO) in all overseas locations except the U.S.
Virgin Islands concerning Line of Duty Determinations and except
for care delivered under the National Department of Defense (DoD)/Department
of Veterans Affairs (VA) Memorandum of Agreement (MOA) authorization
requirements. See
paragraph 2.4.3 for National DoD/VA MOA authorization
requirements. Service members who are enrolled in TOP Prime Remote
must seek authorization from the TOP contractor for all non-emergent specialty
and inpatient care. Service members not enrolled in TOP who are
on Temporary Additional Duty/Temporary Duty (TAD/TDY), deployed,
deployed on liberty, or in an authorized leave status outside the
50 U.S. and the District of Columbia shall follow referral/authorization
guidelines for TOP Prime Remote enrollees.
2.2 If a Service member seeks purchased care
sector care without appropriate authorization, they put themselves
at financial risk for claims payment. They are also at risk for
potential compromise of medical readiness posture, flight status,
or disability benefits, and they may be subject to disciplinary action
for disregarding service-specific policy. Lost work time may be
charged as ordinary leave.
2.3 The TOP contractor shall ensure
a benefit review is done on each SHCP referral and authorization.
The TOP contractor shall return deferred-to-network referrals for
non-covered services with an explanation of why it was denied. The
TOP contractor shall not issue an authorization unless they obtain
a copy of an approved waiver. The contractor shall deny all claims
for TRICARE non-covered health care services. (Reference Health
Affairs (HA) Policy 12-002 “Use of Supplemental Health Care Program
Funds for Non-Covered TRICARE Health Care Services and the Waiver
Process for Active Duty Service Members”).
2.3.1 If the contractor determines that
the requested service, supply, or equipment is not covered by TRICARE
policy and no Defense Health Agency (DHA)-approved waiver is provided,
the contractor shall decline to file an authorization and shall
deny any received claims accordingly. If the request was received
as an MTF referral, the contractor shall notify the MTF (and enrolled
MTF if different from the submitting MTF) of the declined authorization
with explanation of the reason. If the request was received as a
referral from a civilian provider (for a remote Service member/non-enrolled Service
member), the contractor shall notify the civilian provider and the
remote Service member/non-enrolled Service member of the declined
authorization with explanation of the reason. The notification to
a civilian provider and the remote Service member/non-enrolled Service
member shall explain the waiver process and provide contact information
for the applicable Uniformed Services Headquarters Point of Contact
(POC)/Service Project Officers as listed in
Chapter 17, Addendum A, paragraph 2.0. No notification
to the Specified Authorization Staff (SAS) is required.
2.3.2 TRICARE
benefits may not be extended for complications resulting from non-covered surgeries
and treatments performed outside the MTF for a Service member without
an approved waiver. If the treatment is a non-covered TRICARE benefit,
any follow-on care, including care for complications, will not be
covered by TRICARE once the Service member separates from active
duty or retires (
32 CFR 199.4(e)(9); TPM,
Chapter 4, Sections 1.1 and
1.2). The Services will provide appropriate counseling
that such follow-on care is the member’s personal financial responsibility
upon separation or retirement.
2.4 The provisions of
Chapter 17 are
changed for the TOP as follows:
2.4.1 The provisions of
Chapter 17, Section 2, paragraph 2.0 (Uniformed
Services Family Health Plan (USFHP)) are not applicable to the TOP
contract. USFHP services are not available outside the 50 U.S. and
the District of Columbia.
2.4.2 Except for the claims for Service
member care provided under the National DoD/VA MOA, the provisions
of
Chapter 17, Section 3, paragraph 1.2.1 regarding
the timeline for review of SHCP claims by overseas MTFs is extended
to 10 calendar days. Service member claims for covered benefits submitted
to the TOP contractor for which an authorization is not on file
are to be pended for a determination of whether the care should
be authorized. The claim shall be pended and the MTF of enrollment
shall be notified that an authorization determination should be
accomplished and returned to the TOP contractor within 10 calendar
days. If the TOP contractor does not receive the MTF’s response
within 10 calendar days, the contractor shall move the claim back
into active processing within one business day and shall process
the claim as if the MTF had authorized the care. Claims authorized
due to a lack of response by the MTF shall be considered as “Referred
Care”, but the contractor must be able to distinguish these claims
from MTF-authorized claims. Claims pended under the provisions of
this section shall be considered to be excluded claims for the purposes
of calculating and reporting claims processing cycle time performance.
2.4.3 The
provisions of
Chapter 17, Section 2, paragraph 3.1 regarding
claims for care provided under the National DoD/VA MOA for Spinal
Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma are applicable to the TOP and shall be processed
in accordance with
Chapter 17, Section 2, paragraph 3.1.3. Such
care will be authorized by the DHA-GL for Service members under
this MOA.
2.4.4 The
provisions of
Section 6, paragraph 5.0 and
Chapter 8, Section 5 apply to TOP SHCP referrals.
Additionally, when MTFs submit a referral request for purchased
care services for a non-AD sub-population beneficiary eligible for
SHCP, the MTF shall utilize the required data elements identified in
Chapter 8, Section 5, paragraph 6.1 and shall
annotate the referral with “SHCP” in line item 12, “Review Comment”.
This will ensure that SHCP claims for eligible non-AD sub-population
beneficiaries are properly adjudicated.
Note: Circumstances
where supplemental funds may be used to reimburse for care rendered
by non-Governmental health care providers to non-active duty patients
are limited to those where a MTF provider orders the needed health
care services from civilian sources for a patient, and the MTF provider
maintains full clinical responsibility for the episode of care.
This means that the patient is not disengaged from the MTF that
is providing the care. See
Chapter 17, Section 1, paragraph 1.1.
2.5 When
a Service member leaves a remote TOP assignment as a result of Permanent
Change of Station (PCS) or other service-related change of duty
status, the following applies in support of medical record accumulation:
2.5.1 For Service
members leaving remote TOP assignment in Puerto Rico, the PCM shall
provide a complete copy of medical records, to include copies of
specialty and ancillary care documentation, to Service members within
30 calendar days of the Service member’s request for the records.
The Service member may also request copies of medical care documentation
(specialty care visits and discharge summaries) on an ongoing, Episode
of Care (EOC) basis.
2.5.2 For Service members leaving remote TOP
assignments from all overseas areas other than Puerto Rico, Service
members in those locations should request medical records from the
purchased care sector provider(s) who provided health care services
during the Service member’s tour of duty. These Service members
may also request copies of medical care documentation (specialty
care visits and discharge summaries) on an ongoing, EOC basis.
2.5.3 Records provided
by purchased care sector providers in languages other than English
may be submitted to the TOP contractor for translation into English
according to the terms of the contract.
2.5.4 Network purchased care sector providers
shall be reimbursed for medical records photocopying and postage
costs incurred at the rates established in their network provider participation
agreements. Non-network purchased care sector providers shall be
reimbursed for medical records photocopying and postage costs on
the basis of billed charges unless the Government has directed a
lower reimbursement rate. Service members who have paid for copied
records and applicable postage costs shall be reimbursed for the
full amount paid to ensure they have no out-of-pocket expenses.
All providers and/or Service members must submit a claim form, with
the charges clearly identified, to the contractor for reimbursement.
Note: The
purpose of copying medical records is to assist the Service member
in maintaining accurate and current medical documentation. The contractor
shall not make payment to a purchased care sector provider who photocopies
medical records to support the adjudication of a claim.
2.5.5 The provisions
of
Chapter 17, Section 3, paragraph 1.1.8 are
not applicable to the TOP. SHCP funds may not be used to pay for
overseas purchased sector care for foreign military members or their families.
The TOP contractor shall deny any MTF referrals and claims for such
care.
2.6 Provision
of Respite Care For The Benefit of Seriously Ill or Injured Active
Duty Members
2.6.1 The
provisions of
Chapter 17, Section 3 and the TRICARE Systems
Manual (TSM),
Chapter 2, Sections 2.8 and
6.4 regarding respite care for seriously ill
or injured Service members are applicable in locations outside the
50 U.S. and the District of Columbia where TRICARE-authorized Home
Health Agencies (HHAs) have been established.
2.6.2 The respite
care benefit is applicable to Service members enrolled to TOP Prime,
TOP Prime Remote, and to any Service member referred by an overseas
MTF or TAO.
2.6.3 All
normal Service member authorization and case management requirements
for the TOP apply to the Service member respite care benefit.