1.0 General
All TRICARE requirements regarding
Financial Administration shall apply to the TRICARE Overseas Program
(TOP) unless specifically changed, waived, or superseded by this
section; the TRICARE Policy Manual (TPM),
Chapter 12;
or the TRICARE contract for health care support services outside
the 50 United States (U.S.) and the District of Columbia (hereinafter
referred to as the “TOP contract”). See
Chapter 3 for
additional instructions.
2.0 Payment POLICY
2.1 Reimbursement
of TOP beneficiary claims for overseas health care shall be based
upon the lesser of billed charges, the negotiated reimbursement
rate, or the Government-established fee schedule. (See
Section 9 and the TRICARE Reimbursement Manual
(TRM),
Chapter 1, Sections 34 and
35 for additional guidelines). Except for
medical evacuations, claims for care in the U.S. commonwealths and
territories shall be reimbursed following stateside reimbursement
guidelines. Philippines and Panama claims shall be reimbursed following
Government-established fee schedules, unless the TOP contractor
has negotiated a lesser rate with a purchase care sector provider.
2.2 Payment
of Skilled Nursing Facility (SNF) claims from Puerto Rico and the
U.S. territories (Guam, the U.S. Virgin Islands, American Samoa,
and the Northern Mariana Islands) shall be processed as routine
foreign claims and shall be subject to the Prospective Payment System
(PPS), as required under Medicare in accordance with the Social
Security Act. These SNFs will be subject to the same rules as applied
to SNFs in the U.S. (see the TRM,
Chapter 8).
SNF care is not available in other TOP locations.
2.2.1 The TOP contractor at its discretion,
may conduct concurrent or retrospective review for TRICARE
Select and TRICARE for Life (TFL) patients
when TRICARE is the primary payer. If Medicare requires reviews
to be performed on low Patient Driven Payment Model (PDPM) categories,
per the Medicare Policy Manual Chapter 8, the contractor will be
responsible for all reviews for TRICARE Prime patients.
There will be no review for TRICARE
Select or TFL patients where TRICARE
is the secondary payer. The existing referral and authorization
procedures for Prime beneficiaries will remain unaffected.
2.2.2 Beneficiaries
in a low PDPM category depending on date of service may not automatically qualify
for SNF coverage. These beneficiaries will be individually reviewed
to determine whether they meet the criteria for skilled services
and the need for skilled services (see the TRM,
Chapter 8, Section 1). If these beneficiaries
do not meet these criteria, the SNF PPS claim shall be denied.
2.2.3 The TOP contractor,
at their own discretion, may collect Minimum Data Set (MDS) assessment
data per the TRM,
Chapter 8, Section 1.
2.3 The TOP
contractor shall be responsible for entering into participation
agreements with SNFs in Puerto Rico, Guam, the U.S. Virgin Islands,
American Samoa, and the Northern Mariana Islands.
2.3.1 The TOP contractor, at their own
discretion, may conduct any data analysis to identify aberrant SNF
PPS providers or those providers who might inappropriately place
TRICARE beneficiaries in a high PDPM category. The contractor shall
also assist the TRICARE Area Office (TAO) Directors in obtaining/providing
SNF data, for conducting any SNF PPS data analysis they deem necessary.
2.4 Balance billing
provisions do not apply to TOP beneficiary claims for care rendered
in a foreign country and paid as billed, since there is no unpaid
balance on these claims. Purchased care sector network providers,
participating providers, and providers in U.S. commonwealths and
territories are prohibited from balance billing.
2.5 For health care rendered in Puerto
Rico and in the U.S., reimbursement for all TOP beneficiary care
shall follow the TRICARE payment policies except as outlined below.
2.5.1 TOP Service
members who have been required by the provider to make “up front”
payment at the time services are rendered may submit a claim for
reimbursement directly to the contractor. Normal TRICARE claims
processing requirements apply (including any authorization requirements
and the use of TRICARE-approved claims forms). If the claim is payable,
the contractor shall allow the billed amount and reimburse the Service
member for charges on the claim.
2.5.2 In no case shall a Service member
be subjected to “balance billing” or ongoing collection action by
a civilian provider for emergency or authorized care. If the contractor
becomes aware of such situations that they cannot resolve, they
shall pend the file and forward the issue to the appropriate TAO
Director. The appropriate TAO Director will issue an authorization
to the contractor for payments in excess of CMAC or other applicable
TRICARE payment ceilings, provided the TAO Director has requested
and has been granted a waiver from the Program Manager,
Defense Health Agency (DHA), or designee.
2.5.5 Payment may
be made for ambulance services provided by commercial transport
(see
Section 7 for additional processing instructions
for these claims)
.
3.0 Financial
Administration
3.1 The TOP contractor shall follow
the Financial Administration non-financially underwritten funds
requirements in
Chapter 3 with the following exceptions:
3.1.1 Foreign
overseas drafts (local currency) and checks (U.S. currency) shall
also reflect “TRICARE Overseas Program”.
3.1.2 Foreign overseas drafts shall also
reflect information that indicates the draft is valid for 190 days
and if reissue is required/necessary, the draft must be returned
to the TOP contractor with a request for reissuance. The contractor
shall issue drafts/checks for Germany claims which look like local German
drafts/checks.
3.2 The TRICARE Encounter Data (TED)
for the overseas claims shall be reported on vouchers/batches according
to the TRICARE Systems Manual (TSM),
Chapter 2.
•
• Overseas
health care claims for stateside beneficiaries whose health care
is normally provided under one of the regional contracts (i.e.,
beneficiaries enrolled or residing in the 50 U.S. or the District
of Columbia, who receive care while traveling or visiting abroad)
shall be processed by the TOP contractor. Claims for these beneficiaries
shall be paid from the current non-financially underwritten bank
account. This provision does not apply to beneficiaries who are
enrolled to 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.
3.3 The TOP contractor shall:
3.3.1 Provide
TRICARE Overseas Currency reports identifying the gain or loss for
the month reported to arrive by the 10th calendar day following
the month reported. Reporting requirements for net gains/losses
are identified by DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract.
3.3.2 Calculate
currency gains and losses resulting from payments made to purchased
care sector providers and/or beneficiaries in foreign countries.
The gains and losses shall be computed based on the exchange rate
in effect on the ending date of care. The difference between the
cost of the foreign currency on the ending date of care and the
contractor payment date shall be the gain or loss on the transaction.
Payment shall be as follows for:
3.3.2.1 Net Gain. For months that result
in a net gain, the TOP contractor shall forward the report along
with their check payable to the Department of Defense (DoD), DHA,
for the gain from currency conversion.
3.3.2.2 Net Loss. DHA will reimburse the
TOP contractor for any losses incurred from currency conversion.
The TRICARE Overseas Currency report shall be accompanied by a letter
(invoice) requesting reimbursement for the loss incurred. This payment
will not be subject to the Prompt Payment Act (FAR 32.9) as amended,
therefore, payment by DHA will usually be made within five working
days of receipt of the invoice and the TRICARE Overseas Currency
report.