2.0 Contractor
Responsibilities
2.1 The
TOP contractor shall arrange for medically necessary ambulance/aeromedical
evacuation services for
TOP
Prime/TOP
Prime Remote enrollees, Service members who are deployed, in a temporary
duty status, or in an authorized leave status in an overseas location,
and all Active Duty Family Members (ADFMs)
that are
enrolled to TRICARE Prime, TRICARE Prime Remote (TPR), TRICARE Select,
or TRCARE Young Adult (TYA) who require ambulance/aeromedical
evacuation services while traveling
/living outside
of the 50 U.S. and the District of Columbia.
Note: Claims
jurisdiction for ambulance/aeromedical evacuation is based on the
patient’s location, regardless of the patient’s enrollment status
or the origination or destination location of the ambulance/aeromedical
evacuation service provider.
2.1.1 When arranging for ambulance/aeromedical
evacuation for the beneficiaries identified in
paragraph 2.1, the contractor
shall determine beneficiary eligibility and enrollment status, prepare quote(s)
for commercial movement options, and obtain signature authority
and direction on evacuation destination from the appropriate Patient
Movement Requirement Center (PMRC). Upon PMRC approval, the contractor
shall authorize the services, arrange for medical records to accompany the
patient, and coordinate the transfer with the receiving institution
or provider. The appropriate TRICARE Area Office (TAO) shall be
notified of all patient movements.
2.1.2 For Service member emergency medical
evacuations (including Service members who are on temporary duty,
in an authorized leave status, or deployed/deployed on liberty),
the TOP contractor shall ensure that the Service member’s unit is
aware of the medical evacuation. The TAO shall be contacted for
assistance if the member’s unit information cannot be determined
by the contractor.
2.1.3 Except for normal TRICARE cost-shares,
these beneficiaries shall not be responsible for any up-front payments
for emergency ambulance service (to include aeromedical evacuation,
when medically necessary and appropriate). The contractor shall
establish business processes (e.g., Guarantee of Payment to purchased
care sector ambulance provider) to ensure that these beneficiaries are
not subjected to up-front payments in excess of normal TRICARE cost-shares.
2.2 Upon
request, the TOP contractor shall facilitate medically necessary
ambulance/aeromedical evacuation services for all TRICARE-eligible
beneficiaries not identified in
paragraph 2.1 (regardless of enrollment location
or residence) according to the processes identified in the TOP contract.
When facilitating ambulance/aeromedical evacuation for these beneficiaries,
the contractor shall identify ambulance/aeromedical evacuation resources
that service the patient’s location; however, the contractor shall
not schedule the evacuation, coordinate with the receiving institution
or provider, obtain medical records, or establish business processes
(e.g., Guarantee of Payment) to limit up-front payments for these
beneficiaries.
2.3 Since medical evacuations may involve
transfers between TRICARE regions, the TOP contractor shall establish
processes for coordinating medical evacuations with the stateside
contractors.
2.4 The TOP contractor shall ensure
that ambulance/aeromedical evacuation services can be accomplished
in an expeditious manner that is appropriate and responsive to the
beneficiary’s medical condition. The contractor may establish a
dedicated unit for responding to such requests, or may augment existing
service units. Contractor staff shall be available for ambulance/aeromedical evacuation
assistance 24 hours per day, seven days per week, 365 days per year.
Ambulance/aeromedical evacuation telephone assistance shall be available
without toll charges to the beneficiary, regardless of their location.
2.5 The TOP
contractor shall maximize the use of military medical transport
services before considering other options. If military medical transport
services are not available (or if services cannot be provided in
a timely manner that is appropriate for the patient’s medical condition)
and the appropriate PMRC has approved commercial movement, the contractor
shall attempt to arrange services through the most economical commercial
resource that is capable of providing appropriate services within
the required time frame. Private, chartered evacuation services
will only be used as a last resort when all other options have been
exhausted. The contractor shall document their rationale and selection
process for any commercial and/or private, chartered evacuation
services. If multiple resources are identified that are capable
of providing the needed services, the contractor shall select the
resource that represents the best value to the Government. Upon
request, the contractor shall provide Defense Health Agency (DHA)
with documentation supporting their rationale and selection process.
2.6 Upon
transfer to a facility for stabilization and care, the TOP contractor
shall coordinate with the appropriate Military Treatment Facility
(MTF) (for TOP Prime enrollees) or TAO (for TOP Prime Remote enrollees)
to provide information on the patient’s
transfer and to provide further assistance as appropriate.
2.7 The TOP
contractor shall comply with the provisions of TPM,
Chapter 8, Section 1.1, except that the TOP
contractor shall utilize the coding requirements identified for
ambulance charges
and shall
develop
claims for diagnosis
and transfer information
for ambulance services received overseas. The TOP contractor shall
utilize the diagnosis if provided, or may use available in-house
methods such as claims history when processing the claim.
A
diagnosis shall be included with the claim.
2.8 All
related documentation (including, but not limited to original invoices,
supporting documents, and Explanation of Benefits (EOB)) related
to the evacuation shall be submitted
with the claim.
2.9 The Ambulance Fee Schedule (AFS)
reimbursement methodology (TRICARE Reimbursement Manual (TRM),
Chapter 1, Section 14) applies only to ground
ambulance services in Puerto Rico.
Air ambulance
transport (aeromedical evacuations) covered under the TOP, including
Puerto Rico shall be reimbursed
utilizing reasonable
and customary charges.