2.0 JURISDICTION
2.1 In
the early stages of TOP claims review, the TOP contractor shall
determine whether claims received are within its contractual jurisdiction
using the criteria below.
2.2 Services
rendered onboard a commercial ship while outside U.S. territorial
waters are the responsibility of the TOP contractor. Claims for
services provided on a commercial ship that is outside the territorial
waters of the U.S. shall be processed as foreign claims regardless
of the provider’s home address. If the provider is certified within
the U.S., reimbursement for the claim is to be based on the provider’s
home address. If the provider is not certified within the U.S.,
reimbursement will follow the procedures for foreign claims. This
does not include health care for enrolled Service members on a ship at
sea or on a military ship at home port.
2.3 The provisions of
Chapter 8, Section 2, paragraphs 1.0 and
2.0 are superseded as described in
paragraphs 2.3.1 through
2.3.9.
2.3.1 When
a beneficiary is enrolled in TOP Prime or TOP Prime Remote, the
TOP contractor shall process all health care claims for the enrollee,
regardless of where the enrollee receives services. Referral/authorization
rules apply.
2.3.2 Claims for Active Duty Family Members
(ADFMs) (including Reserve Component (RC) ADFMs whose sponsors have
been activated for more than 30 days), retirees, and retiree family members
whose care is normally provided under one of the regional contracts
(i.e., beneficiaries enrolled or residing in the 50 U.S. and the
District of Columbia) who receive Civilian Health Care (CHC) while
traveling or visiting overseas shall be processed by the TOP contractor,
regardless of where the beneficiary resides or is enrolled. Referral/authorization
and Point Of Service (POS) rules apply for TRICARE Prime/TRICARE
Prime Remote (TPR) enrollees.
Note: This provision
does not apply to beneficiaries who are enrolled in the Uniformed
Services Family Health Plan (USFHP) or the Continued Health Care
Benefit Program (CHCBP). Claims for these beneficiaries are processed
by their respective contractor regardless of where the care is rendered.
2.3.3 Claims
for Service members residing in the 50 U.S. and the District of
Columbia (including RC Service members activated for more than 30
days) who are on Temporary Additional Duty/Temporary Duty (TAD/TDY),
deployed, deployed on liberty, or in an authorized leave status
in an overseas location shall be processed by the TOP contractor,
regardless of where the Service members resides or is enrolled.
Referral/authorization rules apply.
2.3.4 Claims for TOP-enrolled Service
members (including RC Service members activated for more than 30
days) on a military ship or with an overseas home port shall not
be processed by the member’s military unit. These claims shall be
processed by the TOP contractor.
2.3.5 Initial and follow-on Line Of Duty
(LOD) claims for RC Service members on orders for 30 consecutive
days or less, who are injured while traveling to or from annual
training or while performing their annual training who receive civilian
medical care overseas, shall have their claims processed by the
TOP contractor upon verification of LOD status. Defense Health Agency-Great
Lakes (DHA-GL) will validate LOD status for RC Service members in
the U.S. Virgin Islands.
2.3.6 The TOP contractor shall process
claims for Durable Equipment (DE) and Durable Medical Equipment
(DME) (otherwise coverable by TRICARE) that is purchased/ordered
by TOP-eligible beneficiaries in an overseas area from a stateside
provider (i.e., Internet, etc.).
2.3.7 For inpatient claims that are paid
under the Diagnosis Related Group (DRG)-based payment system, the
TOP contractor, on the date of admission, shall process and pay
the entire DRG claim, including cost outliers. For inpatient claims
paid on a per diem basis, to include DRG transfers and short stay
outlier cases, and for professional claims that are date-driven,
the contractor shall process and pay the claims.
2.3.8 When
a beneficiary’s enrollment changes from one TRICARE region to another
during a hospital stay that will be paid under the DRG-based payment
system, the contractor with jurisdiction on the date of admission
shall process and pay the entire DRG claim, including cost outliers.
2.3.9 For
information on portability claims for relocating TOP Prime/TOP Prime
Remote enrollees, refer to
Chapter 6, Section 2.
2.7 Refer to the
TRICARE Reimbursement Manual (TRM),
Chapter 4, Section 4, paragraph 5.0 for jurisdictional
guidance regarding health care claims for work-related illness or
injury which is covered under a Worker’s Compensation Program.
2.8 The provisions
of
Chapter 8, Section 2, paragraph 5.0 are applicable
to the TOP in those locations where the TRICARE Pharmacy (TPharm)
contractor has established services (the U.S. territories of Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands). The TOP contractor cannot process pharmacy claims
from these locations except for pharmacy that is part of an emergency
room visit or inpatient treatment. Any prescriptions from this care
that are
not provided at time of treatment for inpatient/emergency
care, shall be required to be submitted through the TPharm contractor.
Copays will apply.
2.9 The TOP contractor shall forward
all retail pharmacy claims to the TPharm contractor within 72 hours
of identifying them as being out-of-jurisdiction. In all other overseas
locations, the contractor shall process claims from purchased care
sector retail pharmacies and providers.
2.10 ADFMs with
TRICARE
Select
and retirees or their family
members residing overseas obtaining prescription from an overseas
purchased care sector pharmacy shall submit their claims to the
TOP contractor. For cost-share/deductible provisions, see TRM,
Chapter 2 regarding the mandatory collection
of pharmacy copayment amounts at the time of service are waived
for foreign providers.
5.0 REFERRALS/PREAUTHORIZATIONS/AUTHORIZATIONS
The
provisions of
Chapter 8, Section 5 are altered for the TOP
by the requirements listed below.
5.1 Referral/Preauthorization/Authorization
Requirements for TOP Prime and TOP Prime Remote Enrollees
5.1.1 Unless
otherwise directed by the Government, referrals/preauthorizations/authorizations are
not required for emergency care, clinical preventive services, ancillary
services, radiological diagnostics (excluding Magnetic Resonance
Imaging (MRI) and Positron Emission Tomography (PET) scans), drugs,
and services provided by a TOP Partnership Provider. Additionally,
TOP Prime/TOP Prime Remote ADFMs will require a referral for all
mental health and Substance Use Disorder (SUD) services except outpatient
office-based visits. TOP Prime/TOP Prime Remote ADFMs will also
require preauthorization for treatment of SUDs as outlined in the
TPM,
Chapter 7, Section 3.5, paragraph 4.0 and
for the treatment of mental disorders as outlined in the TPM,
Chapter 7, Section 3.8, paragraph 6.0. All
other care that is provided to a TOP Prime/TOP Prime Remote-enrolled
Service member or ADFM by anyone other than their Primary Care Manager
(PCM) requires authorization, regardless of where the care is rendered.
5.1.2 Claims
for Service member care not authorized by the TOP contractor shall
be pended for a review to make a determination regarding authorization.
If the care is retroactively authorized by the Government (including
submission of an approved waiver for a non-covered service), then
the contractor shall enter the authorization and process the claim
for payment. If the contractor determines that the care was not
authorized, the contractor shall deny the claim. Refer to
Section 26 for additional information
.
5.1.3 Claims for self-referred, non-emergency,
and non-urgent care for TOP Prime and TPR enrolled
ADFMs shall process with POS deductibles and cost-shares unless
the appropriate TRICARE Area Office (TAO) or TRICARE Overseas Program
Office (TOPO) has approved a retroactive authorization.
5.1.4 TRICARE-eligible beneficiaries
residing in an overseas location who are not enrolled in TOP Prime/TOP
Prime Remote typically do not need to obtain preauthorization/authorization
for care. However, preauthorization reviews shall be performed for
all care and procedures listed in Chapter 7, Section 2. The TOP
contractor may propose additional authorization reviews for non-enrolled
TOP beneficiaries to the government.
5.1.5 TRICARE beneficiaries
whose health care is normally provided under one of the two regional
Managed Care Support Contractors (MCSCs) who require care while
traveling in an overseas location shall request any necessary preauthorizations/authorizations
through the TOP contractor, regardless of where the beneficiary
resides or is enrolled. Denial of requested services should be visible to
the claims processing contractor to ensure claims are denied or
processed as POS as appropriate.
Note: This
process does not apply to beneficiaries enrolled to the USFHP or
the CHCBP.
5.2
Point
of Service (POS) Provisions
5.2.1 Unless specifically excluded by
this section, all self-referred, non-emergency care provided to
TOP Prime/TOP Prime Remote-enrolled ADFMs which is not either provided/referred
by the beneficiary’s PCM or specifically authorized shall be reimbursed
under the POS option. This provision applies regardless of where
the care is rendered. POS provisions also apply to the following
stateside beneficiaries when traveling overseas: ADFMs, retirees,
and retiree family members who are enrolled in TRICARE Prime, and
ADFMs enrolled in TPR for ADFMs.
5.2.2 POS cost-sharing only applies to
TRICARE-covered services. Claims for services that are not a covered
TRICARE benefit shall be denied.
5.2.3 The TOP contractor shall adjust
POS deductibles and cost-shares when TOP PCMs or Health Care Finders
(HCFs) do not follow established referral/authorization procedures.
For example, if the contractor processes a claim under the POS option
because there was no evidence of a referral and/or an authorization,
and the contractor later verifies that the PCM or other appropriate
provider referred the beneficiary for the care, the contractor shall
adjust the claim and reverse the POS charges. The contractor need
not identify past claims that may be eligible for POS adjustment;
however, the contractor shall adjust these claims as they are brought
to their attention.
5.2.4 On a case-by-case basis, following
stabilization of the patient, the TAO Director or MTF Commander
may require an enrolled beneficiary to transfer to a TOP network
facility or an MTF. The TAO Director or MTF Commander shall provide
written notice to the beneficiary (or responsible party) advising
them of the impending transfer to a TOP network facility/MTF. If
a beneficiary who is subject to TOP POS provisions elects to remain
in the non-network facility after such notification, POS cost-sharing
provisions will apply beginning 24 hours following the receipt of
the written notice. Neither the TOP Director nor the MTF Commander
will require a transfer until such time as the transfer is deemed medically
safe.
5.2.5 The
following deductible and cost-sharing amounts apply to all TOP POS
claims for health care support services:
• Enrollment year deductible for outpatient
claims: $300 per individual; $600 per family. No deductible applies
to inpatient services.
• Beneficiary cost-share for inpatient and
outpatient claims: 50% of the allowable charge after the deductible
has been met (deductible only applies to outpatient claims).
• POS deductible and cost-share amounts are
not creditable to the enrollment/Fiscal Year (FY) catastrophic cap
and they are not limited by the cap.
• POS deductible and cost-share amounts do
not apply to claims for care received by newborns and newly adopted
children who are deemed enrolled in TOP Prime or TOP Prime Remote.
5.2.6 POS deductible
and cost-share amounts do not apply if a TOP enrollee has Other
Health Insurance (OHI) that provides primary coverage (i.e., the
OHI must be primary under the provisions of the TRM,
Chapter 4, Section 1). Evidence of OHI claims
processing (including the exact amount paid on the claim) must be
submitted with the TOP claim.
5.2.7 EOB shall clearly indicate that
a claim has been processed under the POS Option.
5.2.8 POS is not applicable
to Service members or to TRICARE Select.
5.3 Extended Care
Health Option (ECHO) benefits in overseas locations must be authorized
by the TOP contractor. Refer to
Section 23 and
the TPM,
Chapter 9 for additional guidance.
5.4 Refer to
Section 10 for referral/preauthorization/authorization
requirements for Service member dental care in remote overseas locations.
6.0 CLAIM DEVELOPMENT
6.1 Development
of missing information shall be kept to a minimum. The TOP contractor
shall use available in-house methods, contractor files, telephone,
Defense Enrollment Eligibility Reporting System (DEERS), etc., to
obtain incomplete or discrepant information. If this is unsuccessful,
the contractor may return the claims to sender with a letter which
indicates that the claims are being returned, the reason for return
and requesting the required missing documentation. The contractor’s system
shall identify the claim as returned, not denied. The Government
reserves the right to audit returned claims as required, therefore
the contractor shall retain sufficient information on returned claims
to permit such audits. The contractor shall review all claims to
ensure TOP required information is provided prior to payment. For
the Philippines, claims requiring development of missing or discrepant
information, or those being developed for medical documentation,
shall be pended for 90 days and are excluded from the claims processing
standard.
6.2 Claims
may be filed by eligible TRICARE beneficiaries, purchased care sector
providers, TOP POCs, and TRICARE authorized providers in the 50
U.S. and the District of Columbia as allowed under TRICARE (see
Chapter 8, Section 1)
.
6.3 Confidentiality
requirements for TOP are identical to TRICARE requirements outlined
in
Chapter 8.
6.5 The following minimal information
is required on each overseas claim prior to payment:
6.5.1 Signatures
Beneficiary
and purchased care sector provider signatures (signature on file
is acceptable unless specifically prohibited by the Government).
6.5.2 Name and
Address
6.5.2.1 Complete
beneficiary and purchased care sector provider name and address.
6.5.2.2 If an
address is not available on the claim, obtain the address either
from previously submitted claims, directly from the beneficiary/purchased
care sector provider via phone, fax, or e-mail, DEERS per
paragraph 6.1.Note: The
TOP contractor shall accept APO/FPO for the beneficiary address.
6.5.3 Diagnosis(es)
6.5.3.1 Prior
to returning a claim that is missing a diagnosis, the TOP contractor
shall research the patient’s history and determine whether a diagnosis
from a related claim can be applied. The diagnosis should
be reflective of the services rendered.
6.5.3.2 Claims
received for dates of service for outpatient services or dates of
discharge for inpatient services before the mandated date, as directed
by Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation, with ICD-10
codes shall be converted to International Classification of Diseases,
9th Revision, Clinical Modifications (ICD-9-CM) codes by the TOP
contractor. Claims received for dates of service for outpatient
services or dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 or ICD-9-CM codes shall be converted to ICD-10-CM codes
by the TOP contractor. Refer to
Chapter 8, Section 6, paragraphs 4.0 and
5.0 regarding the use of ICD-9-CM
V codes (factors
influencing health status and contact with health services) and
ICD-10-CM
Z codes (factors influencing health status
and contact with health services).
6.5.4 Procedures/Services/Supply/DME
The TOP contractor shall identify
the procedure(s)/service(s)/supply/DME ordered, performed or prescribed,
including the date ordered performed or prescribed. The TOP contractor
may use the date the claim form was signed as the specific date
of service, if the service/purchase date/order date is not on the
bill.
6.5.5 Claims received with a narrative
description of services provided shall be coded by the TOP contractor
with as accurate-coding as possible based upon the level of detail
provided in the narrative description or as directed by the
TOPO.
Services
which contain sufficient detail to identify an accurate procedure
code shall be used. All surgical procedures must be coded accurately
based on the level of detailed description. Outpatient professional
services shall be coded accurately. Office visits which include
multiple services shall be coded accurately and not bundled when
the description of services are available. The provisions
of
paragraph 6.1 apply
for narrative claims that cannot be accurately coded due to insufficient
or vague information. Claims received for dates of service for outpatient services
or dates of discharge for inpatient services before the mandated
date, as directed by HHS, for ICD-10 implementation, with ICD-10
codes shall be converted to ICD-9 codes by the TOP contractor. Claims
received for dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 codes shall be converted to ICD-10 codes by the TOP contractor.
Refer to
Chapter 8, Section 6, paragraph 4.0 regarding
the use of
V and
Z codes.
6.5.5.1 Inpatient Institutional Procedures
Inpatient institutional (i.e., hospital)
claims received for dates of discharge for inpatient services before
the mandated date, as directed by HHS, for ICD-10 implementation,
shall have the procedure narratives coded by the TOP contractor
using ICD-9-CM, Volume 3 procedure codes. Inpatient institutional
(i.e., hospital) claims received for dates of discharge on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
shall have the procedure narratives coded by the TOP contractor
using ICD-10-Procedure Classification System (ICD-10-PCS) procedure
codes.
6.5.5.2 Outpatient
Institutional Procedures and Professional Services
Claims received for outpatient institutional
(e.g., ambulance services, laboratory, Ambulatory Surgery Centers
(ASCs), partial hospitalizations, outpatient hospital services)
services and professional services shall be coded using Healthcare
Common Procedure Coding System (HCPCS) or Current Procedural Terminology
(CPT).
6.5.6 Care authorizations (when required).
6.5.7 Itemization
of total charges. (Itemization of hospital room rates are not required
on institutional claims).
6.5.8 Proof of payment is required for
all beneficiary submitted claims if the claim indicates that the
beneficiary made payment to the provider or facility.
Due
to cultural differences, there may be significant variation in provider
processes for issuing receipts to the beneficiaries. Therefore,
the overseas claims processor shall use best business practices
when determining if the documentation provided is acceptable for
the country where the services were rendered.
6.5.8.1 Examples of ACCEPTABLE
Beneficiary Proof of Payment:
• Cancelled
checks (made payable to the provider)
• Credit
or bank card statements or receipts
• Bank
account statements (with documentation of payment to the provider)
• Receipt,
itemized bill, or statement issued by the provider’s office stamped
“PAID” on all pages
• Proof
of Electronic Funds Transfer (EFT) from the beneficiary to the provider
• Invoice
for pharmaceuticals dispensed on an outpatient basis (overseas pharmacies
will not dispense drugs without payment; therefore, an invoice represents
proof of payment)
• Invoice
for health care from providers in Turkey (Turkish providers will
not provide an invoice to the patient until payment has been made;
therefore, an invoice represents proof of payment)
6.5.8.2 Examples
of UNACCEPTABLE Beneficiary Proof of Payment:
• Cancelled
check made payable to “Cash” or to the beneficiary or sponsor
• Bank
account statements showing cash withdrawal (without additional documentation of
payment to the provider)
• Letter
signed by patient saying s/he has paid the bills
• Paid
amount shown only on the claim or itemized bill
• Handwritten
statements (e.g., “Paid in Full,” “Paid by Patient”, “Paid in Cash”)
• Paid
in cash (without additional documentation of payment to the provider)
6.6 Non-prescription
(Over-The-Counter (OTC)) drugs are to be denied. This includes drugs
that are considered OTC by U.S. standards, even when they require
a prescription in a foreign country.
6.7 The TOP contractor shall use a schedule
of allowable charges based on the Average Wholesale Price (AWP)
as a reference source for processing drug related TRICARE overseas
claims.
6.8 Claims for medications prescribed
by a host-nation physician, and commonly used in the host-nation
country, shall be cost-shared unless they are considered OTC by
U.S. standards.
6.9 For the Philippines, prescription
drugs may only be cost-shared when dispensed by a certified retail
pharmacy or hospital-based pharmacy. The TOP contractor shall deny
claims for prescription drugs dispensed by a physician’s office.
Certification requirements outlined in
Section 29 apply.
Note: This
does not apply to Durable Medical Equipment, Prosthetics, Orthotics,
and Supplies (DMEPOS).
6.10 Claims for DME involving lease/purchase
shall always be developed for missing information.
6.11 The TOP
contractor shall use ECHO claims processing procedures outlined
in TPM,
Chapter 9, Section 18.1, when processing ECHO
overseas claims.
6.12 The TOP contractor shall deny claims
from non-certified or non-confirmed purchased care sector providers
when the DHA CO has directed contractor certification/confirmation
of the purchased care sector provider prior to payment.
6.13 Requests
for missing information shall be sent on the TOP contractor’s TRICARE/TOP
letterhead. When development is necessary,
the contractor shall include a special insert in German, Italian, Spanish,
Tagalog, Japanese, and Korean which indicates what missing information
is required to process the claim and includes the contractor’s address
for returning requested information.
6.14 If the TOP contractor elects to
develop for additional/missing information, and the request for additional
information is not received/returned within 45 days, the contractor
shall deny the claim.
6.15 If the TOP contractor has no record
of referral/authorization prior to denial/payment of the claim,
the contractor shall follow the TOP POS rules, if the service would
otherwise be covered under TOP.
6.16 The TOP contractor shall develop
procedures for the identification and tracking of TOP enrollee claims
submitted by either a purchased care sector designated or non-designated
overseas purchased care sector provider without preauthorization/authorization.
Upon receipt of a claim for a TOP-enrolled ADFM submitted by a purchased
care sector designated or non-designated overseas purchased care sector
provider without preauthorization/authorization, the contractor
shall process the claims following POS payment procedures. For Service
member claims submitted by a purchased care sector provider without
preauthorization/authorization, the contractor shall pend the claim
for review prior to denying the claim.
Refer to Section 26 for more information
on ADSM pended claims.
6.17 The TOP contractor must have an automated
data system for eligibility, deductible and claims history data
and must maintain on the automated data system all the necessary
TOP data elements to ensure the ability to reproduce both TED and
EOBs as outlined in
Chapter 8, Section 8,
except for requiring overseas providers to use HCPCS to bill outpatient
rehabilitation services, issue provider’s the Form 1099 and suppression
of checks/drafts for
$.99 or less.
The contractor may split claims to accommodate multiple invoice
numbers in order to reference invoice numbers on EOBs when necessary.
Refer to
Chapter 8, Section 6 for additional requirements
related to claims splitting.
6.18 The TOP contractor shall not pay
for pharmacy services obtained through the Internet.
6.19 The TOP
contractor shall pay all TOP Service member stateside claims as
outlined in
Section 26.
6.20 All claims shall be submitted in
a Health Insurance Portability and Accountability Act (HIPAA) compliant
format. Refer to
Section 28 for more information on HIPAA requirements.
6.21 Electronic
claims not accepted by the TOP contractor’s Electronic Data Information
(EDI) system/program shall be rejected.
6.22 For all overseas claims, the TOP
contractor shall create and submit TEDs following current guidelines
in the TSM for TED development and submission. Claim information
will be able to be accessed through the TRICARE Patient Encounter
Processing and Reporting (PEPR) Purchased Care Detail Information
System (PCDIS).
6.23 The TOP contractor shall establish
Utilization Management (UM) high dollar/frequency thresholds in
accordance with
Section 6.
6.24 Claims either denied as “beneficiary
not eligible” or “found to be not eligible on DEERS” may be processed
as a “good faith payment” when received from the Defense Health
Agency (DHA) Communications Office. The TAO Director shall work
with the TOP contractor on claims issues related to good faith payment
documentation (e.g., a completed claim form and other documentation
as required by
Chapter 10, Sections 3 and
4).
6.26 The Claims Auditing Software requirements
outlined in the TRM,
Chapter 1, Section 3 do not apply to TOP claims;
however, the TOP contractor shall implement an internal process
for identifying upcoding, unbundling, etc. on coded claims.
8.0 EOB Vouchers
The TOP contractor shall follow
the EOB voucher requirements in
Chapter 8, Section 8,
where applicable, with the following exceptions and additional requirements:
8.1 The letterhead on all TOP EOBs shall
also reflect “TRICARE Overseas Program” and shall be annotated Prime or
TRICARE Select.
8.2 TOP EOBs may be issued on regular
stock, shall provide a message indicating the exchange rate used
to determine payment and shall clearly indicate that “This is not
a bill”.
8.3 TOP EOBs shall include the toll-free
number for beneficiary and provider assistance.
8.4 TOP EOBs for overseas enrolled Service
member claims shall be annotated “ACTIVE DUTY.”
8.5 For Point of Sale or Vendor pharmacy
overseas claims, TOP EOBs shall have the name of the provider of
service on the claim.
8.6 For beneficiary submitted pharmacy
claims, TOP EOBs shall contain the name of the provider of service,
if the information is available. If the information is not available,
the EOBs shall contain “your pharmacy” as the provider of service.
8.7 The TOP contractor shall insert
the provider’s payment invoice numbers in the patient’s account field
on all provider EOBs, if available.
8.8 The
TOP contractor
shall designate an EOB message
for overseas
claims rendered by non-network purchased care sector providers who
are required to be certified, but have not been certified by the
TOP contractor, “Your provider has not submitted documentation required
to validate his/her training and/or licensure for designation as
an authorized TRICARE provider”.
Refer to Section 4 for more information regarding certification
of providers in designated locations.
8.9 When a provider’s/beneficiary’s
EOB, EOB and check, or letter is returned as undeliverable, the check
shall be voided.
8.10 The TOP contractor may utilize secure electronic
EOB delivery to beneficiaries unless mail delivery
has been requested by the beneficiary or has not signed
up for electronic delivery.
8.11 The contractor may
issue monthly summary EOBs to beneficiaries on claims when there
is no beneficiary liability. The processing date of the oldest claim
for the summary EOB shall not be greater than 31 calendar days.
12.0 Reimbursement/Payment
Of Overseas Claims
When processing TOP claims, the
TOP contractor shall follow the reimbursement payment guidelines
outlined in the TRM,
Chapter 1, Section 34 and the cost-sharing
and deductible policies outlined in the TRM,
Chapter 2, Section 1, and shall:
12.1 Reimburse claims
for purchased care sector services/charges for care rendered to
TOP eligible beneficiaries which is generally considered purchased
care sector practice and incidental to covered services, but which
would not typically be covered under TRICARE. An example of such
services may be, charges from purchased care sector ambulance companies
for driving purchased care sector physicians to accidents or private
residences, or the manner in which services are rendered and considered
the standard of care in a purchased care sector country, such as
rehabilitation services received in an inpatient setting.
12.2 Reimburse claims
at the lesser of the billed amount, the negotiated reimbursement
rate, the CHAMPUS Maximum Allowable Charge (CMAC), or the Government
established fee schedules (when applicable) (TRM,
Chapter 1, Sections 34 and
35), unless a different reimbursement rate
has been established as described in TPM,
Chapter 12, Section 1.3.
Note: Government
established fee schedules (per TRM,
Chapter 1, Sections 34 and
35) are only applicable to retirees or their
eligible family members
or TRICARE
Select
ADFMs.
12.3 Not reimburse
for purchased care sector care/services specifically excluded under
TRICARE.
12.4 Not
reimburse for purchased care sector care/services provided in the
Philippines unless all of the certification requirements listed
in
Section 14 have been met.
12.5 Not reimburse
for administrative charges billed separately on claims, except for
individual administrative charges as determined by the Government.
The contractor shall reimburse these charges only in instances when
the fee is billed concurrently with the corresponding health care services.
If a bill is received for these charges without a corresponding
health care service, the charges shall be denied.
12.6 Determine
exchange rates as follows:
12.6.1 Use
the exchange rate in effect on the ending date that services were
received unless evidence of OHI and then the TOP contractor shall
use the exchange rate of the primary insurer, not the rate based
on the last date of service to determine the TOP payment amount,
and/or;
12.6.2 Use
the ending dates of the last service to determine exchange rates
for multiple services.
12.6.3 Use the exchange
rate in
paragraph 12.6.1 to determine deductible and
copayment amounts, if applicable, and to determine the amount to
be paid in foreign currency.
12.6.4 Overseas
drafts/checks and EOBs. Upon completion of processing, the contractor
shall create checks (payable in U.S. dollars). The TOP contractor
shall do this within 48 hours after approval by DHA Contract Resource
Management (CRM). Drafts (payable in foreign currency units) shall
be created by the TOP contractor within 96 hours following CRM approval,
unless a different process has been authorized by DHA. Payments
that need to be converted to a foreign currency shall be calculated based
on the exchange rate in effect on the last date of service listed
on the EOB. Drafts/checks shall be matched with the appropriate
EOB, and mailed to the beneficiary/sponsor/purchased care sector provider/POC
as applicable.
Note: Drafts for certain foreign currency units
may require purchase from a bank location other than the one normally
used by the TOP contractor (out of state or out of country). Currency
units that must be purchased from an alternate bank (out of state
or out of country) may take up to 10 business days for the draft
to be returned and matched up with the EOB.
12.7 Convert lump
sum payments, instead of line items, to minimize conversion problems.
12.8 Pay provider
claims for all overseas locations in the country’s
local currency as identified on the claim for the specific country by
foreign currency/drafts. Drafts may not be changed to a U.S. dollar check
after the contractor has issued a foreign draft.
12.9 Know that foreign
overseas drafts (in local currency) are good for 190 days and may
be cashed at any time, unless a different process has been established
by DHA. U.S. dollar checks are good for 120 days unless a different
process has been established by DHA. The provisions of
Chapter 3, Section 4 regarding staledated,
voided, or returned checks/Electronic Funds Transfers (EFTs) are
applicable to the TOP.
12.10 Pay
TOP claims submitted by a beneficiary in U.S. dollars, unless there
is a beneficiary request on the claim at the time of submission
for payment in a foreign currency. The TOP contractor may reissue
the payment in U.S. dollars if a request is subsequently received
from the beneficiary and the foreign draft is included in the request
or the payment has staledated, or if directed by the appropriate DHA
COR.
12.11 Payment shall be made
in local currency.
12.12 Issue drafts/checks for German claims which
look like German drafts/checks.
Note: In order for
TRICARE drafts/checks to look like German drafts/checks, a German
address must be used. The TOP contractor may use a corporate address
in Germany or the TAO Eurasia-Africa address for this purpose.
12.13 The contractor shall pay all beneficiary-submitted
claims for TRICARE covered drugs dispensed by a U.S. embassy health
clinic to the beneficiary. The contractor is not to make payments
directly to the embassy health clinic.
12.14 Know that professional services
rendered by a U.S. embassy health clinic are not covered by TRICARE/TOP.
These services are covered under International Cooperative Administrative
Support Services (ICASS) agreements. Embassy providers (acting as
PCMs) may refer TOP enrollees to purchased care sector providers,
these claims shall be processed per TOP policy and procedures.
12.15 Reimburse
claims for drugs or diagnostic/ancillary services purchased overseas
following applicable deductible/cost-share policies.
12.16 In
emergency situations, the requirement for Medicare certification
for facilities in U.S. commonwealths and territories may be waived.
After a review of the facts, the contractor may cost-share otherwise
covered services or supplies rendered in an emergency situation
by an unauthorized provider to the beneficiary, or on behalf of
the beneficiary, to the beneficiary's appointed payee, guardian,
or parent in accordance with TPM,
Chapter 11, Section 4.2 and TRM,
Chapter 1, Section 29.
12.17 The contractor shall mail the drafts/checks
and EOBs to purchased care sector providers unless the claim indicates
payment should be made to the beneficiary. In conformity with banking requirements,
the drafts/checks shall contain the contractor’s address. Drafts
and EOBs shall be mailed using U.S. postage. Additionally, payments/checks
may be made to network providers, with an Embassy address.
12.18 Mail
benefit payment checks and EOBs to Philippine providers, and other
nations’ providers as directed by the DHA CO, to the place of service
identified on the claim. No provider checks or EOBs for Philippine
providers, and other nations’ providers as directed by the DHA CO
may be sent to any other address.
12.19 Process/pay inpatient and outpatient
claims for TRICARE overseas eligible beneficiaries, including Service
member claims, as indicated below:
12.19.1 The TPharm contractor shall allow
TOP Service members to use the TPharm retail pharmacy network under
the same contract requirements as other Military Health System (MHS)
eligible beneficiaries (see TPM,
Chapter 8, Section 9.1).
12.19.2 The TPharm
contractor shall allow TOP enrolled ADFM beneficiaries to use their
stateside retail pharmacy network under the same contract requirements
as other MHS eligibles (see TPM,
Chapter 8, Section 9.1).
12.19.3 The TOP
contractor shall process claims for overseas health care received
by TRICARE beneficiaries enrolled to or residing in a stateside
contractor’s region following the guidelines outlined in this chapter.
Payment shall be made from applicable bank accounts and shall be
based on billed charges unless a lower reimbursement rate has been
established by the Government or the contractor.
12.20 EFT payments. Upon purchased care
sector provider request, the TRICARE Overseas health care support
contractor shall provide EFT payment to a U.S. or overseas bank
on a weekly basis. Bank charges incurred by the provider for EFT
payment shall be the responsibility of the provider. Upon beneficiary
request, EFT payments to a U.S. bank may be provided. Bank charges
associated with beneficiary EFT payments shall be the responsibility
of the beneficiary.
12.21 The TOP contractor shall process
90% of all retained and adjustment TOP claims to completion within
30 calendar days from the date of receipt. Claims pended per Government
direction are excluded from this standard. However, the number of
excluded claims shall be reported on the designated
DD Form 1423, Contract Data Requirements List (CDRL), located in
Section J of the applicable contract. One hundred
percent (100%) of all claims (both retained and excluded, including adjustments)
shall be processed to completion within 90 calendar days from the
date of receipt, unless the CO specifically directs the contractor
to continue pending a claim or group of claims.
12.22 Exclude
correspondence pended due to stop payment orders, check tracers
on foreign banks, and conversion on currency from the routine 45
calendar day correspondence standard and the priority 10 calendar
day correspondence standard. However, the number of excluded routine
and priority correspondence must be reported on the designated
DD Form 1423, CDRL, located in Section J of the applicable contract.
12.23 The TOP contractor shall pay Value
Added Tax (VAT) included on German health care claims for all beneficiary
categories.
12.24 Reimburse fees
for transplant donor searches in Germany on a global flat fee basis
since the German Government does not permit health care facilities
to itemize such charges.
12.25 Reimburse itemized fees for supplies
that are related or incidental to inpatient treatment (e.g., hospital
gowns) if similar supplies would be covered under reimbursement
methodologies used within the U.S. The TOP contractor shall implement
internal management controls to ensure that payments are reasonable
and customary for the location.
13.0 Claims Adjustment
And Recoupment
13.1 The TOP contractor shall follow
the adjustment requirements in
Chapter 10 except
for the requirements related to financially underwritten funds.
13.2 The TOP
contractor shall follow the recoupment requirements in
Chapter 10 for non-financially underwritten
funds, except for providers. The contractor shall use the following
procedures for purchased care sector provider recoupments. Recoupment
actions shall be conducted in a manner that is considered culturally
appropriate for the purchased care sector provider’s country. The
contractor shall:
• Send an initial
demand letter;
• Send a second
demand letter at 90 days;
• Send a final demand letter at 120 days;
and
• Refer
the case to DHA at 240 days, if the case is over $600, and if under
$600 the case shall remain open for an additional four months and
then shall be written off at 360 days.
13.3 Recoupment
letters (i.e., the initial letter, the 90 day second request and
the 120 day final demand letter) shall be modified to delete references
to U.S. law. Invoice numbers shall be provided on all recoupment
letters. The TOP contractor shall include language in the recoupment
letter requesting that refunds be returned/provided in the exact
amount requested.
13.4 Provider recoupment letters sent
to Germany, Italy, Spain, Japan, and Korea, shall be written in the
respective language.
13.5 If
the recoupment action is the result of an inappropriately processed
claim by the TOP contractor, recoupment is the responsibility of
the contractor, not the beneficiary/provider.
13.6 The TOP contractor shall have a
TOP bank account capable of receiving/accepting wire transfers for
purchased care sector provider recoupment/overpayment returns. The
TOP contractor shall accept the amount received as payment against
the amount owed. Any fees associated with the wire transfer are
the responsibility of the payer/provider.