1.0 GENERAL
1.1 The TOP program
provides health care administration and claims processing for individuals with
dual eligibility under both Medicare and TRICARE who receive care
in locations where Medicare is not available. This includes those
beneficiaries eligible for TFL under the Medicare wraparound coverage
option of the TRICARE program made under 10 United States Code (USC)
1086(d).
1.2 The
provisions of
Chapter 20 regarding TFL are applicable to
beneficiaries residing in locations where Medicare is available.
These areas include the 50 United States (U.S.), the District of
Columbia, and the U.S. territories of Puerto Rico, Guam, the U.S.
Virgin Islands, American Samoa, and the Northern Mariana Islands.
2.0 Jurisdiction
2.1 Dual eligible
beneficiaries are covered under TOP, based on their TRICARE plan
if they receive care in a location where Medicare is not available.
2.2 Dual eligible
beneficiaries residing in Puerto Rico, Guam, the U.S. Virgin Islands,
American Samoa, and the Northern Mariana Islands are not covered
under TOP TFL. These beneficiaries receive TRICARE coverage under
the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
according to the provisions of
Chapter 20.
2.3 Claims for services
rendered on board a commercial ship are the responsibility of the
TDEFIC contractor if the care was rendered in the territorial waters
adjoining the land areas of the U.S. Claims for services rendered
on board ship while outside U.S. territorial waters are the responsibility
of the TOP contractor.
3.0 CONTRACTOR
RESPONSIBILITIES
3.1 The TOP contractor shall provide
administration and claims processing services for the TOP TFL program.
3.2 TOP TFL has
the same cost-shares and deductibles as any other TFL claim.
TFL
beneficiaries who are not enrolled in Prime are covered under TRICARE
Standard benefits, cost-shares, and deductibles as if TRICARE Standard
was still being implemented. See TRM
Chapter 2, Sections 1 and
3.
3.3 All TOP TFL has the same requirements for
referrals or prior authorizations as TOP
Select. TOP requirements regarding
provider certification apply.
3.4 The TOP contractor shall not develop
purchased care sector provider networks to support the TOP TFL beneficiary
population.
3.5 The TOP contractor shall not provide
health care on a cashless, claimless basis for TOP TFL beneficiaries.
3.6 The TOP
contractor shall not make appointments with purchased care sector
providers for TOP TFL beneficiaries. However, upon beneficiary request,
the contractor shall provide the beneficiary with the name, telephone
number, and address of purchased care sector network or non-network
providers of the appropriate clinical specialty located within the
beneficiary’s geographic region.