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 2.3.3 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 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”).
2.2.1 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.
2.2.2 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.
2.3 The
provisions of
Chapter 17 are changed for the TOP as follows:
2.3.1 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.
2.3.2 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 are
applicable for TOP. Service member claims for covered
benefits submitted to the TOP contractor for which an authorization
is not on file are to be
processed and paid as if
an authorization is on file. Claims for non-covered services shall
be denied. The TOP contractor shall provide the MTF with a report
(in accordance with the CDRL), for all claims processed and paid
with no authorization and all denied claims for non-covered services.
2.3.3 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.
2.3.4 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.
2.4 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:
2.4.1 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.
2.4.2 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.
2.4.3 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.
2.4.4 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.
2.4.5 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.
2.5 Provision of Respite Care For
The Benefit of Seriously Ill or Injured Active Duty Members
2.5.1 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.
2.5.2 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.
2.5.3 All normal Service member authorization
and case management requirements for the TOP apply to the Service
member respite care benefit.