1.0 Introduction
TPRADFM provides TRICARE Prime like
benefits to certain Active Duty Family Members (ADFMs) who reside
with the TRICARE Prime Remote (TPR) enrolled sponsor in remote locations
in the United States (U.S.) and the District of Columbia
(DC).
It also provides continued TPRADFM eligibility for family members
residing at remote locations after the departure of the sponsor
for an unaccompanied assignment, and eligibility for family members
of Reserve Component (RC) members
(referred to as sponsors
for the remainder of this Section) called or ordered
to active duty
for more than 30 days
. TPRADFM
benefits are comparable to TRICARE Prime, including access standards,
benefit coverage, and cost-shares. TPRADFM does not apply to ADFM
enrollees in areas outside the 50 U.S. Such care and claims shall
be processed in accordance with the TRICARE Overseas Program (TOP),
Chapter 24 and TRICARE Policy Manual (TPM),
Chapter 12. The Specified Authorization Staff
(SAS) is not involved in any part of TPRADFM.
2.0
Enrollment QualificationsFamily
members qualify to enroll into TPRADFM, if they meet
the requirements specified
in one of the following paragraphs.
2.1 The sponsor
is enrolled in TPR and the ADFM resides
with the sponsor in a TPR residence
(i.e., TPR zip code).
2.2 The
sponsor is enrolled to a small Government clinic, troop medical
clinic, Coast Guard clinic or other Military Treatment Facilities/Enhanced
Multi-Service Markets (MTFs/eMSMs) designated by the Services to
allow Active Duty Service Member (ADSM) enrollment only and offer
zero capacity to enroll non-ADSM beneficiaries. DHA will provide
a list of Defense Medical Information System Identification Codes
(DMIS-IDs) MTFs/eMSMs that only enroll ADSM. The DMIS-ID list will
be an attachment in the Managed Care Support Contract (MCSC). The
ADFM must reside with the sponsor who is enrolled in an MTF/eMSM
that only enrolls ADSMs.Note: ADFMs
who reside within a Prime Service Area (PSA) are eligible for TRICARE
Prime and thus are not eligible for enrollment in TPRADFM even if
the Service member is enrolled in TPR. The ADFMs shall be enrolled
within the PSA of residence except as specified in paragraph 2.2.
2.3 If
an ADSM receives a subsequent unaccompanied
assignment after the TPR assignment and the family members are not
authorized to accompany the member to the next duty assignment,
and they continue to reside in the same TPR address,
the family members may remain in TPRADFM for the duration of the
subsequent assignment.
2.4 If
an RC member sponsor becomes eligible for TRICARE because of a call
or order to active duty for a period of more than 30 days, their
eligible family members become eligible to enroll into TPRADFM upon
becoming TRICARE-eligible (i.e., beginning the date early eligibility
TRICARE starts or date of activation, whichever is first) if they
meet all of the following eligibility requirements:
2.4.1 The
family members “reside with” the
member in a TPR residence (i.e., in a TPR zip code) at the
time of activation the
RC sponsor and their family members
become eligible for TRICARE.
2.4.2 The
RC member sponsor does not have to be TPR eligible or enrolled.
2.4.3 Once
enrolled in TPRADFM, the family members may
remain in TPRADFM for the period of TRICARE eligibility,
regardless of the subsequent assignment, enrollment location, or
residence of the sponsoring RC member as
long as the family member continues to reside at the same TPR residence address.
2.4.4 Family
members who meet the TPRADFM eligibility criteria may
enroll up to 90 days after the sponsor
has deployed/left the TPR address for assigned
duty.
2.5 ADFMs currently enrolled
in TPRADFM, who transition to Transitional Survivor status, may remain
enrolled in TPRADFM. See TPM, Chapter 10, Section 7.1 for further information.2.5.1 All Transitional Survivors
may enroll in TPRADFM. At the request of the Transitional Survivor the
contractor shall accept and process a new and continued enrollment
request (enrollment form, the Government furnished web-based self-service
enrollment system/application transaction, or telephonic request
documented in the contractor’s call center notes) submitted by any
Transitional Survivor living in, or moving to a TPR area. Enrollment
in TPRADFM may continue for Transitional Survivors for the entire
Transitional Survivor period. After the Transitional Survivor period,
TPRADFM is not available to Survivors. A Survivor (versus a Transitional
Survivor) is eligible for retiree family member benefits and cost-sharing.
2.5.2 Transitional
Survivor/Survivor status does not impact TRICARE eligibility rules.
Loss of eligibility as a result of any condition which routinely
results in loss of TRICARE eligibility such as reaching age limits,
marriage, remarriage, etc. also results in loss of Transitional
Survivor/Survivor status.
3.0 Benefits
TPRADFM enrollees are
eligible for the TRICARE Prime Benefit,
even in areas without contractor networks.
4.0 Network Development
4.1 TPRADFM offered
outside of a PSA has no network development requirements,
except where contractually required. ADFMs enrolled in TPRADFM shall
be assigned, or be allowed to select, a Primary Care Manager (PCM)
when in the provider network. If a
network provider is not available to serve as a primary care provider,
the TPRADFM enrollee may utilize any local TRICARE participating
or authorized provider for primary care services.
4.2 TPRADFMs enrollees are
required to use TRICARE network providers
where available within contractual access standards. If a network
provider cannot be identified within the access standards, the enrolled
family member shall use a TRICARE authorized provider. Contractors
shall assist TPRADFM enrollees
in finding a network or non-network
TRICARE authorized provider for specialty care. TPRADFM
enrollees may be eligible for the Prime travel benefit
when referred more than 100 miles for specialty care inside
the 50 U.S. and DC. If the contractor has not established
a network of PCMs in a remote area, a TPRADFM enrollee will
be enrolled without a PCM assigned. A generic PCM code shall be used
for TPRADFM enrollees without assigned PCMs. The ADFM without an
assigned PCM will be able to use a local TRICARE authorized
provider (participating or non-participating) for
primary health care services without a PCM’s approval.
If a TPRADFM questions whether a service is covered as primary care,
they may contact the contractor for assistance.
5.0 Uniformed
Services Family Health Plan (USFHP)
If a USFHP
is available to ADFMs in a TPR area, the ADFMs have the choice of
enrolling in the USFHP, enrolling in TPRADFM or
enrolling in TRICARE Select. ADFMs
choosing to enroll in USFHP will be unable to access care through MTFs/eMSMs or
the TRICARE system.
6.0 Referrals
6.1 Specialty
care requires a referral through the contractor. If the TPRADFM enrollee
is assigned to a PCM, the PCM shall follow the contractor’s
referral and authorization procedures. In cases where the TPRADFM enrollee is
not assigned to a PCM, the TPRADFM enrollee,
or the TPRADFM enrollee’s
parent or guardian, is responsible
for directly contacting the contractor to obtain referrals and authorizations
if required. The TPRADFM enrollee should
obtain a referral request from their primary care provider and the TPRADFM enrollee
should forward that request to
the contractor.
6.2 TPRADFM enrollees are required to obtain
a referral and use TRICARE network providers for specialty care
where available within TRICARE access standards or pay the Point
of Service (POS) deductible and cost-share unless an appropriate
out-of-network referral is obtained as required under TRICARE Prime.
7.0 Provider
Education
Contractors shall familiarize network
providers and, when appropriate, other providers with TPRADFM. The
contractor shall propose an educational plan to the Director, TRICARE
Health Plan (THP) outlining how providers will become
familiar with TPRADFM. The contractor shall provide separate and distinct
information to PCMs about the requirements and the special procedures
for handling TPRADFM enrollees’ care
(e.g., specialty care referral requirements, balance billing limitations,
etc.). The contractors shall include information on TPRADFM specialty
care procedures, benefits, or requirements in routine information
and educational programs.
8.0 Beneficiary
Education
8.1 Beneficiary education will be a joint
effort with the Government providing all beneficiary educational
materials for the TPR program.
8.2 The contractor shall utilize leading
industry best practices in its outreach and communication with all
MHS customers consistent with that offered to its commercial customers.
Customer services shall include multiple, contemporary avenues of
access (for example, e-mail, World Wide Web (WWW), telephone, texting,
and smart phone applications, and other social media) for the MHS
beneficiary. If the contractor chooses
to distribute the supplied educational materials, the contractor
is responsible for postage, envelopes, and mailing costs.
8.3 The contractor
shall give TPRADFM enrollees
the option of participating in health promotion and wellness programs
offered in the direct care system and network locations. The contractor
shall design and conduct, with Director, THP approval,
TPRADFM briefings. The contractor shall include TPRADFM information
and updates as part of all TRICARE briefings. Ongoing briefings
will be on an “as needed” basis and will be coordinated with the
Director, THP.
8.4 Enrollment
in TPRADFM is optional for ADFMs who qualify for the program; therefore,
a contractor shall limit educational activities for TPRADFM enrollees
to distributing the materials provided or approved by the Government.
9.0 Enrollment
9.1 When
the contractor receives an enrollment request (enrollment form,
the Government furnished web-based self-service enrollment system/application
transaction, or telephonic request documented in the contractor’s
call center notes) from an ADFM for TPRADFM, the contractor shall ensure
the
sponsor is
qualified
based on the requirements in paragraph 2.0. If a
TPRADFM
enrollment request is received and the
family member
does not qualify for TPRADFM, the request shall be
returned to the sender with a notice that the
family
member is not eligible for TPRADFM and the reason(s)
why
TPRADFM enrollment was denied.
Additionally,
see
paragraph 9.4 when a TPRADFM enrollment request
is received for a family member of a
n RC
sponsor
on active service for more than 30 days.
9.2 Enrollment in
TPRADFM is optional for qualified family members.
However, qualified family members must
enroll within 90 days of their move to a TPR location (a Qualifying
Life Event (QLE)) or during
the open enrollment season in TPRADFM to receive the TPRADFM benefit. Qualified
family members who elect not to enroll in TPRADFM
may enroll in TRICARE Prime (where
available, with access standards waived) or TRICARE
Select.
9.3 An enrollment request (enrollment form,
the Government furnished web-based self-service enrollment system/application
transaction, or telephonic request documented in the contractor’s
call center notes) must be submitted to the contractor by either
the
qualified family members or the Service
member’s sponsor for each family member enrolling in TPRADFM. See
Chapter 6, Section 1, for effective date rules.
An
official enrollment request includes those with:
• An original signature;
• An electronic signature offered by and
collected by the contractor;
• A verbal consent provided by telephone
and documented in the contractor’s call notes; or
• A self-attestation by the beneficiary when
using the Government furnished web-based self-service enrollment
system/application.
Note: A
written signature is not required to make enrollment changes when
using the Enrollment Portability process outlined in
Chapter 6, Section 2.
9.4 When
the contractor receives an enrollment request (enrollment form,
Government furnished web-based self-service enrollment system/application
transaction, or telephonic request documented in the contractor’s
call center notes) for TPRADFM from a family member of an RC sponsor called
or ordered to active service for more than 30 days, the contractor
shall validate the family members’ eligibility
in DEERS.
9.5 The
contractor shall follow enrollment portability and transfer procedures
in
Chapter 6, Section 2.
Additionally,
if at any point
the
contractor determines or is advised that a family member is no longer eligible
for TPRADFM, the contractor shall notify (letter, telephone call,
or e-mail) the
sponsor of the discrepant
enrollment immediately. If the discrepant enrollment is not corrected
within 30 days of the notification date, the contractor shall disenroll
the family member(s) from TPRADFM effective the first of the month
after 30 days from the initial notification date
.
The contractor shall provide information on
TRICARE
Select
, and that they have 90 days
from the date of the disenrollment to enroll in a TRICARE plan or
they only will be eligible for MTF/eMSM care on a space-available
basis.
9.6 The contractor
shall enroll the
TPRADFM
qualified
family member in the Government furnished web-based
system/application and enter the TPRADFM
’s
enrollment status into Government furnished web-based system/application.
The contractor shall use the DMIS-ID code(s) designated by the
Director,
THP for that region to enroll ADFMs into TPRADFM
(see the TRICARE Systems Manual (TSM)).
See paragraph 10.0 for
PCM assignment requirements.
9.7 DEERS will automatically
update start and/or end dates of coverage when a beneficiary’s eligibility
is updated as described in Chapter 6, Section 1.
The contractor will receive a Policy Notification Transaction (PNT)
advising them of all changes.
10.0 PCM Assignment
At the
time of enrollment, a
TPMADFM
qualified
family member will select (or will be assigned) a
PCM within the access standard. The contractor shall advise the
TPMADFM
enrollee of
the availability of PCMs. If a PCM is not available
or
the contractor has not established a network of PCMs in a TPR area, the
ADFM shall be enrolled to TPRADFM without an identified PCM
assigned.
See paragraph 4.2.
11.0 Support Services
11.1 Inquiries
The contractor shall designate a
point of contact for Government inquiries related to TPRADFM. The
contractor may establish a dedicated unit for responding to inquiries
about TPRADFM, or may augment existing TPR service units already
serving
TPR
enrollees.
The correspondence requirements and standards in
Chapter 1, Section 3, apply to TPRADFM written
inquiries.
11.2 Toll-Free Telephone Service
The contractor shall provide toll-free
telephone access for TPRADFM beneficiary inquiries.
12.0 Claims Processing
The regional contractor where the
TPRADFM is enrolled shall process all claims for that enrollee, except
for care provided overseas (i.e., care outside of the 50 U.S. and DC).
Civilian health care while traveling or visiting overseas shall
be processed by the TOP contractor, regardless of where the beneficiary
is enrolled. POS claims processing provisions do apply. Details
for reporting TPRADFM claims information are identified in DD Form
1423, Contract Data Requirements List (CDRL), located in Section
J of the applicable contract.
13.0 Claim Reimbursement
13.1 The payment
provisions applicable under TPR for Service members which allow
for additional payment in excess of otherwise allowable amounts
to providers who are not TRICARE-authorized or certified do not
apply to TPRADFM. Such payments shall not be made unless such payments
are otherwise allowed under the payment provisions for unauthorized
providers contained in the TPM.
13.2 For network providers, the contractor
shall pay TPRADFM claims at the negotiated rate. For participating
providers the contractor shall pay up to the CHAMPUS Maximum Allowable
Charge (CMAC), or billed charges, whichever is less. Contractors
shall follow the requirements in
Chapter 8, Section 5 and
the TRICARE Reimbursement Manual (TRM),
Chapter 5, Section 1, for claims for TPRADFM enrollees
receiving care from non-participating providers.
13.3 If a non-participating
provider requires a TPRADFM enrollee to make an “up front” payment
for health care services, in order for the enrollee to be reimbursed,
the enrollee must submit a claim to the contractor with proof of
payment and an explanation of the circumstances.
13.4 If the
contractor becomes aware that a civilian provider is “balance billing”
a TPRADFM enrollee or has initiated collection action for emergency
or authorized care, the contractor shall notify the provider that
balance billing is prohibited (see TRM,
Chapter 3, Section 1).
13.5 If CMAC
rates have been waived for TPR Service member enrollees under
Section 4, paragraph 3.5, the TPRADFM enrollee
shall not be extended the same waived CMAC rates. If required services
are not available from a network or participating provider within
the medically appropriate time frame, the contractor shall arrange
for care with a non-participating provider subject to the normal reimbursement
rules. The contractor shall make every effort to obtain the provider’s
agreement to accept, as payment in full, a rate within 100% of the
CMAC limitation. If this is not feasible, the contractor shall make
every effort to obtain the provider’s agreement to accept, as payment
in full, a rate between 100% and 115% of CMAC. By law the contractor
shall not negotiate a rate higher than 115% of CMAC for TPRADFM
care rendered by a non-participating provider. The contractor shall
ensure that the approved payment is annotated in the authorization/claims
processing system.
14.0 Appeals Process
TPRADFM enrollees may appeal denials
of authorization or reimbursement through the contractor in accordance
with
Chapter 12. If the contractor denies authorization
or reimbursement for a TPRADFM enrollee’s health care services,
the contractor shall, on the Explanation of Benefits (EOB) or other
appropriate document, furnish the enrollee with clear guidance for
requesting a reconsideration from, or filing an appeal with, the
contractor.
15.0 TRICARE Encounter
Data (TED) Submittal
The contractor shall report TPRADFM
claims under the financially underwritten provisions of the contract.