4.0 POLICY
4.1 This demonstration
is applicable to all TRICARE Standard/Select beneficiaries who reside
in the Philippines and receive care in designated demonstration
area(s). The demonstration is also applicable to beneficiaries who
are receiving the TRICARE Standard benefit under TOP TRICARE For
Life (TFL) and TRICARE Standard/Select benefit under TRICARE Retired
Reserve (TRR), TRICARE Reserve Select (TRS), or TRICARE Young Adult
(TYA) programs, who reside in the Philippines.
4.2 For
demonstration purposes, beneficiary residence will be determined
by the address listed on the claim. This rule applies regardless
of the residence address listed in Defense Enrollment Eligibility Reporting
System (DEERS).
4.3 Demonstration area(s) will be determined
by Defense Health Agency (DHA) and will be publicized at least 60
calendar days in advance of the effective date for each location.
In addition, expansion of demonstration areas may occur on an annual
basis during the demonstration project and will be publicized at
least 60 calendar days in advance of the effective date for the
expanded locations. DHA anticipates using a phased approach to implement
the demonstration in multiple locations.
4.4 TRICARE
Standard/Select beneficiaries who reside in the Philippines, in
accordance with
paragraph 4.2, and receive care in designated
demonstration area(s) must receive all care from approved demonstration
providers, unless a specific waiver has been granted (see
paragraphs 4.8 and
4.9).
If these beneficiaries receive care from a non-approved demonstration
provider without a waiver, TRICARE will not cost-share the claim
and the beneficiary will be responsible for 100% of the charges. Normal
TRICARE cost-shares and deductibles apply to care rendered to eligible
beneficiaries by approved providers under the terms of the demonstration.
Additionally, when a beneficiary receives C-1, March 10, 2017care
from an approved provider in a designated demonstration area, the
provider will file the claim on the beneficiary’s behalf, and the
provider will collect only applicable cost-shares and deductibles
after receipt of the TOP Explanation of Benefits (EOB). The beneficiary
will be held harmless for denied charges rendered by an approved
demonstration provider unless the beneficiary was notified in writing
that the care provided was not a covered benefit prior to receiving
the care. Beneficiary-submitted claims for services provided by
an approved demonstration provider in an approved demonstration
area shall be denied unless it is submitted with proof of payment
showing that the beneficiary has paid for the service(s).
4.5 Service
members are not eligible for TRICARE Standard/Select and therefore
are not included in this demonstration, regardless of their residence
address or enrollment status. 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 in the Philippines
shall follow referral/authorization guidelines for TOP Prime Remote
enrollees (see
Chapter 24, Section 26).
4.6 This demonstration
is not applicable to beneficiaries enrolled in TOP Prime, TOP Prime
Remote, TRICARE Prime, TRICARE Prime Remote (TPR), TRICARE Prime
Remote for Active Duty Family Members (TPRADFMs), or TYA (Prime
option). Additionally, this demonstration is not applicable to TRICARE Standard/Select
beneficiaries whose home address (as determined by the claim) indicates
a residence other than the Philippines. The demonstration is also
not applicable to TRICARE Standard/Select beneficiaries who reside
in the Philippines (as determined by the claim) when they receive
care from a provider who renders care in a location that is not
included in the demonstration.
4.7 All TOP requirements regarding utilization
management, case management, quality management, and preauthorizations
are applicable to demonstration participants. The TOP contractor is
not required to enroll participants into the demonstration or to
provide referral/authorization services to demonstration participants
unless the requested service requires preauthorization (per
Chapter 7, Section 2 and TPM,
Chapter 1, Section 6.1). The TOP contractor
shall conduct a covered benefit review upon beneficiary or provider
request; however, an authorization letter will not be generated
except for those services which require preauthorization.
4.8 TRICARE
Standard/Select beneficiaries who reside in the Philippines may
request a waiver if they elect to receive care from non-approved
providers or facilities in a demonstration area. Beneficiary waiver
requests should be submitted in writing to the TOP contractor and
will be considered on a case-by-case basis. Except for emergency
care (which never requires prior approval), beneficiaries are encouraged
to submit waiver requests prior to receiving care. However, the
TOP contractor will also consider waiver requests that are submitted
after care has been rendered. The Director, TRICARE Area Office
(TAO)-Pacific will make the final determination if the beneficiary
disagrees with the TOP contractor’s decision. In such cases, the
TOP contractor shall forward all supporting documentation and rationale
regarding the waiver denial determination to the Director, TAO-Pacific
to assist in the final determination. Some examples of potential
beneficiary waiver situations include (this list is not all-inclusive):
• Beneficiaries who were engaged in an ongoing
episode of care with a non-approved provider when the demonstration
began, and who wish to continue care with their established provider.
• Beneficiaries who are unable to obtain
an appointment with an approved provider within the appropriate
time frame (based on TRICARE access standards for urgent, routine,
and specialty care).
Note: Waivers
for emergency care rendered by non-approved providers or facilities
shall be approved on a retrospective basis based on TRICARE policy.
Emergency care never requires preauthorization.
4.9 Since
provider participation in this demonstration is voluntary, there
may be situations where the TOP contractor is unable to recruit
a sufficient number and mix of approved providers in all specialties
in designated demonstration areas. In these situations, the TOP
contractor may request a specialty waiver so that beneficiaries
can receive care from non-approved (certified) providers in accordance
with normal TRICARE Standard/Select reimbursement policy. The TOP
contractor is responsible for identifying any anticipated or actual
gaps in coverage by approved providers in demonstration area(s),
and submitting a specialty waiver request in writing to the Director,
TAO-Pacific. The waiver request shall include a description of the
contractor’s efforts to recruit approved providers in that particular
specialty, as well as any perceived or known barriers to participation
in the demonstration. If the Government approves the specialty waiver,
the contractor shall implement processes to ensure that claims for
that specialty (in the designated demonstration area) are processed under
normal TRICARE Standard/Select rules. This specialty waiver process
will ensure that TRICARE Standard/Select beneficiaries will not
be liable for 100% of the charges (as described in
paragraph 4.4) if
the TOP contractor is unable to recruit approved providers in a
particular specialty.
4.10 A
provider may be removed from the list for administrative reasons
or may be removed for cause by the TOP contractor. The Government
may also direct the TOP contractor to remove providers from the
list for cause. A provider removed from the approved list may submit
a written request to the TOP contractor for reconsideration. If
the TOP contractor upholds the removal, the provider shall be given
the right to appeal to the Director, TAO-Pacific. If the appeal
decision is upheld by the Director, TAO-Pacific, there is no right
to further appeal.
Note: The appeal process
does not apply to certified providers who are not selected by the
TOP contractor to participate in the demonstration as approved providers.
Recruiting and retaining a sufficient number and mix of approved
providers in demonstration area(s) is the responsibility of the TOP
contractor. The TOP contractor is not required to offer approved
provider status to every current certified provider in demonstration
area(s).
4.11 Claims for a provider removed from
the list will be processed in accordance with
Chapter 13, Section 4. The list will be updated
on the contractor’s web site on the first of the month following
the provider being removed from the list.
5.0 DHA And TOP
Contractor Responsibilities
5.1 The DHA Director (or designee) will:
5.1.1 Determine the
geographical area(s) for the demonstration and the phased implementation approach
and timeline (if applicable) and communicate this information in
writing to the TOP contractor no later than 240 calendar days prior
to the start of health care delivery under the demonstration.
5.1.2 Identify
areas that will expand the demonstration areas and communicate those
changes in writing to the TOP contractor at least 60 calendar days
before the effective date.
5.1.3 Establish a process to allow a provider
to appeal his/her removal from the approved list (see
paragraph 4.10).
5.1.4 Issue final
determinations regarding waiver requests from beneficiaries who
elect to receive care from non-approved demonstration providers
(see
paragraph 4.8).
5.1.5 Conduct periodic review and evaluation
of the demonstration.
5.2 The TOP contractor shall:
5.2.1 Be able to provide
upon request by the Government, the following information:
• Number of claims submitted under the demonstration
and the cost of those claims.
• Number of specialty
waivers issued and the reason for the waiver.
5.2.2 At the
request of the Government, the contractor shall assist in the evaluation
and analysis of the demonstration.
5.2.3 Recruit and retain a sufficient number
and mix of approved providers in demonstration area(s) to ensure
access to the full range of covered TRICARE benefits, unless a specialty
waiver has been requested. Approved providers must agree to comply
with the demonstration participation requirements in
paragraph 3.1.
5.2.4 Establish
and maintain a list of all approved demonstration providers, including
each provider’s specialty, sub-specialty, gender, work address,
work fax number, and work telephone number for each demonstration
location, and whether or not they are accepting new TRICARE patients. The
approved list of providers must be submitted to DHA no later than
120 calendar days prior to the start of health care delivery under
the demonstration. The TOP contractor shall provide beneficiaries with
easy access to both the approved provider listing and the certified
provider listing via a user-friendly searchable World Wide Web (WWW)
site and any other means established at the contractor’s discretion
no later than 60 calendar days prior to the start of health care
delivery in each demonstration area. Information on the WWW site
and any other electronic lists shall be current within the last
30 calendar days. At a minimum, the data base shall be searchable
by provider location, provider name, and provider specialty (if
available).
5.2.6 Establish a
waiver process for beneficiaries who reside in the Philippines and
who request or receive care from non-approved providers or facilities
in a demonstration area (see
paragraph 4.8).
5.2.7 Develop and publish materials to
educate beneficiaries and providers on all aspects of the Philippines
Demonstration Project. In addition to providing specific information
regarding the demonstration, the TOP contractor shall educate approved
providers on aspects of the TRICARE program, including (but not
limited to) TRICARE eligibility requirements, TRICARE benefits,
claims submission requirements, and the requirements in
32 CFR 199.9 and
Chapters 13 and
24 as they relate to anti-fraud activities.
5.3 DHA and
the TOP contractor shall:
5.3.1 Develop and implement a communication
plan to ensure that beneficiaries and providers are informed regarding
the area(s) that are participating and not participating in this
demonstration. The communication plan shall also include the process(es)
for educating beneficiaries and providers regarding the demonstration
rules and business processes, to include the processes for requesting waivers.
5.3.2 Establish timelines
and processes to facilitate prompt processing of waiver requests
and provider appeals in accordance with demonstration policy (see
paragraphs 4.8,
4.9,
and
4.10).