2.0
Eligibility
Contractors have no responsibility
for determining eligibility or for deciding in which region a Service
member shall enroll. Director, TRICARE Regional Offices (TROs) will
furnish contractors with enrollment information (refer to
paragraph 3.0).
Note: Service
member astronauts assigned to the Johnson Space Center in Houston,
Texas must and shall be enrolled in TPR.
3.0
TPR
Program Units
The Director, TROs will supply the
contractor with an electronic directory, updated as needed, that
lists, by region, the designated TPR zip codes for the contractor’s
region(s). The Director, TROs will also provide unit listings to
the contractor so the contractor can mail or e-mail educational
materials to the units. In some instances, individual member listings
(as opposed to units) may be provided.
4.0
Benefits
4.1 Remote
Service members enrolled in the TPR program shall receive the benefits
of TRICARE Prime, even in areas without contractor networks. Some
covered benefits (see
Section 2, paragraph 5.3) require review by
Specified Authorization Staff (SAS) (identified in Addendum A,
paragraph 1.0)
so they may identify fitness-for-duty issues.
4.2 If the
contractor determines that a requested or claimed service, supply,
or equipment is not covered by TRICARE (including
Chapter 17, Section 3, paragraph 2.2.4) 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. 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 Service
Project Officers as listed in
Chapter 17, Addendum A, paragraph 2.0. No notification
to the SAS is required.
4.3 The contractor shall not make claims
payments to sanctioned or suspended providers (see
Chapter 13, Section 5). The claim shall be
denied if a sanctioned or suspended provider bills for services. SAS
do not have the authority to overturn DHA or Department of Health
and Human Services (DHHS) provider exclusions. See
Section 2 for
referral and authorization requirements.
4.4 Services that would not have ordinarily
been covered under TRICARE policy (including limitations and exclusions)
may be authorized for Service members only in accordance with the
terms of a waiver approved by the Director, DHA, at the request
of an authorized official of the Uniformed Service concerned. (Reference
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”).
4.5 If a contractor receives a claim
for care provided to a Service member who is not enrolled in TPR or
who is not enrolled in TRICARE Prime at a Military Treatment Facility
(MTF)/Enhanced Multi-Service Market (eMSM), the contractor shall
process the claim according to the applicable guidelines of the Supplemental
Health Care Program (SHCP) (
Chapter 17).
4.6 A SAS
authorization shall be deemed to constitute referral, authorization,
and direction to bypass edits as appropriate to ensure payment of
SAS-approved claims. Contractors shall implement appropriate measures
to recognize SAS authorization in order to expedite claims processing.
5.0 SAS
Certain
Uniformed Service controls and rules apply to Service members due
to unique military readiness requirements. SAS (identified in Addendum
A,
paragraph 1.0)
serves as liaison among the Service member, the Service member’s
Uniformed Service, and the contractor for managing the Service member’s
health care services.
5.1 The SAS reviews referrals for proposed
care as well as information about care already received in order
to determine impact on an individual’s fitness for duty (see
Section 2, paragraph 5.3 and
Addendum B for
referral and review/authorization procedures). The SAS, the PCM
(if assigned) and the contractor shall work together in making arrangements
for the Service member’s required examinations.
5.2 The SAS
will provide the protocol, procedures, and required documentation
through the contractor to the provider for these examinations. For
required care that may not be obtainable in the civilian community,
the SAS will refer the Service member to an MTF/eMSM. Refer to
Addendum A for the addresses and telephone
numbers of the SASs.
6.0 Appeal Process
6.1 If the
contractor, at the direction of the SAS, denies authorization of,
or authorization for reimbursement, for a TPR enrollee’s health
care services, the contractor shall, on the Explanation of Benefits
(EOB) or other appropriate document, furnish the enrollee with clear
guidance for requesting a reconsideration from or filing an appeal
with the SAS (see
paragraph 6.2). The SAS will handle only those
issues that involve SAS denials of authorization or authorization
for reimbursement. The contractor shall handle allowable charge
issues, grievances, etc.
6.2 If
the TPR enrollee disagrees with a denial rendered by the SAS, the
first level of appeal will be through the SAS who will coordinate
the appeal as appropriate. The enrollee may initiate the appeal
by contacting his/her SAS. If the SAS upholds the denial, the SAS
will notify the enrollee of further appeal rights with the appropriate
Surgeon General’s office.
6.3 If the denial is overturned at any
level, the SAS will notify the contractor and the Service member.
6.4 The contractor
shall forward all written inquiries and correspondence related to
SAS denials of authorization, or authorization for reimbursement
to the appropriate SAS. The contractor shall refer telephonic inquiries
related to SAS denials to the appropriate SAS.
8.0 TPR Program
Differences
In addition to the SHCP differences specified
in
Chapter 17, Section 1, paragraph 4.0, the following
differences apply to the TPR program.
8.1 If the contractor has not established
a network of PCMs in a remote area, a TPR designated Service member
will still be enrolled without a PCM assigned. The Service member
without an assigned PCM will be able to use a local TRICARE-authorized
provider for primary health care services without review.
8.2 Point
of Service (POS) cost-sharing and deductible amounts do not apply
to Service members. If a TPR enrolled Service member receives primary
care without a referral or authorization, the enrolling contractor
shall process the claim and make payment if the care meets all other
TRICARE requirements (i.e., the care is medically necessary, a covered
benefit of TRICARE an approved waiver is provided, etc.).
8.3 Annual Service
member re-enrollment is not required.
8.4 If the Uniformed Services determine that
an active duty member is eligible for the TPR program, enrollment
of the member is mandatory, unless there are service-specific issues
that merit assignment to a military PCM, or if the Service member
elects to waive access standards and enrolls to an MTF/eMSM (subject
to unit commander/supervisor approval).
8.5 If Third Party Liability (TPL) is
involved in a claim, Service member claim payment will not be delayed
during the development of TPL information from the Service member.
8.6 Enrollment
jurisdiction may be based on the location of the military work unit
instead of the Service member’s residence. This is determined by
the Services.