2.0 JURISDICTION
2.1 In
the early stages of TOP claims review, the TOP contractor shall
determine whether claims received are within its contractual jurisdiction
using the criteria below.
2.2 Services
rendered onboard a commercial ship while outside U.S. territorial
waters are the responsibility of the TOP contractor. Claims for
services provided on a commercial ship that is outside the territorial
waters of the U.S. shall be processed as foreign claims regardless
of the provider’s home address. If the provider is certified within
the U.S., reimbursement for the claim is to be based on the provider’s
home address. If the provider is not certified within the U.S.,
reimbursement will follow the procedures for foreign claims. This
does not include health care for enrolled Service members on a ship at
sea or on a military ship at home port.
2.3 The
provisions of
Chapter 8, Section 2, paragraphs 1.0 and
2.0 are superseded as described in
paragraphs 2.3.1 through
2.3.9.
2.3.1 When
a beneficiary is enrolled in TOP Prime or TOP Prime Remote, the
TOP contractor shall process all health care claims for the enrollee,
regardless of where the enrollee receives services. Referral/authorization
rules apply.
2.3.2 Claims
for Active Duty Family Members (ADFMs) (including Reserve Component
(RC) ADFMs whose sponsors have been activated for more than 30 days),
retirees, and retiree family members whose care is normally provided
under one of the regional contracts (i.e., beneficiaries enrolled
or residing in the 50 U.S. and the District of Columbia) who receive
Civilian Health Care (CHC) while traveling or visiting overseas
shall be processed by the TOP contractor, regardless of where the beneficiary
resides or is enrolled. Referral/authorization and Point Of Service
(POS) rules apply for TRICARE Prime/TRICARE Prime Remote (TPR) enrollees.
Note: This provision does not apply
to beneficiaries who are enrolled in 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.
2.3.3 Claims for Service members
residing in the 50 U.S. and the District of Columbia (including RC
Service members activated for more than 30 days) who are on Temporary
Additional Duty/Temporary Duty (TAD/TDY), deployed, deployed on
liberty, or in an authorized leave status in an overseas location
shall be processed by the TOP contractor, regardless of where the
Service members resides or is enrolled.
Claims for
Active Duty Service Members (ADSMs) shall be processed in accordance
with Section 26.
2.3.4 Claims for TOP-enrolled Service
members (including RC Service members activated for more than 30
days) on a military ship or with an overseas home port shall not
be processed by the member’s military unit. These claims shall be
processed by the TOP contractor.
2.3.5 Initial
and follow-on Line Of Duty (LOD) claims for RC Service members on
orders for 30 consecutive days or less, who are injured while traveling
to or from annual training or while performing their annual training
who receive civilian medical care overseas, shall have their claims
processed by the TOP contractor upon verification of LOD status.
Defense Health Agency-Great Lakes (DHA-GL) will validate LOD status
for RC Service members in the U.S. Virgin Islands.
2.3.6 The TOP contractor shall process
claims for Durable Equipment (DE) and Durable Medical Equipment
(DME) (otherwise coverable by TRICARE) that is purchased/ordered
by TOP-eligible beneficiaries in an overseas area from a stateside
provider (i.e., Internet, etc.).
2.3.7 For
inpatient claims that are paid under the Diagnosis Related Group
(DRG)-based payment system, the TOP contractor, on the date of admission,
shall process and pay the entire DRG claim, including cost outliers.
For inpatient claims paid on a per diem basis, to include DRG transfers
and short stay outlier cases, and for professional claims that are
date-driven, the contractor shall process and pay the claims.
2.3.8 When a beneficiary’s enrollment
changes from one TRICARE region to another during a hospital stay
that will be paid under the DRG-based payment system, the contractor
with jurisdiction on the date of admission shall process and pay
the entire DRG claim, including cost outliers.
2.3.9 For
information on portability claims for relocating TOP Prime/TOP Prime
Remote enrollees, refer to
Chapter 6, Section 2.
2.7 Refer to the TRICARE Reimbursement
Manual (TRM),
Chapter 4, Section 4, paragraph 5.0 for jurisdictional
guidance regarding health care claims for work-related illness or
injury which is covered under a Worker’s Compensation Program.
2.8 The provisions of
Chapter 8, Section 2, paragraph 5.0 are applicable
to the TOP in those locations where the TRICARE Pharmacy (TPharm)
contractor has established services (the U.S. territories of Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands). The TOP contractor cannot process pharmacy claims
from these locations except for pharmacy that is part of an emergency
room visit or inpatient treatment. Any prescriptions from this care
that are
not provided at time of treatment for inpatient/emergency
care, shall be required to be submitted through the TPharm contractor.
Copays will apply.
2.9 The
TOP contractor shall forward all retail pharmacy claims to the TPharm
contractor within 72 hours of identifying them as being out-of-jurisdiction.
In all other overseas locations, the contractor shall process claims
from purchased care sector retail pharmacies and providers.
2.10 ADFMs with TRICARE Select and
retirees or their family members residing overseas obtaining prescription
from an overseas purchased care sector pharmacy shall submit their
claims to the TOP contractor. For cost-share/deductible provisions,
see TRM,
Chapter 2 regarding the mandatory collection
of pharmacy copayment amounts at the time of service are waived
for foreign providers.
5.0 REFERRALS/PREAUTHORIZATIONS/AUTHORIZATIONS
The provisions of
Chapter 8, Section 5 are altered for the TOP
by the requirements listed below.
5.1 Referral/Preauthorization/Authorization
Requirements for TOP Prime and TOP Prime Remote Enrollees
5.1.1 Unless otherwise directed by
the Government, referrals/preauthorizations/authorizations are not
required for emergency care, clinical preventive services, ancillary
services, radiological diagnostics (excluding Magnetic Resonance
Imaging (MRI) and Positron Emission Tomography (PET) scans), drugs,
and services provided by a TOP Partnership Provider. Additionally,
TOP Prime/TOP Prime Remote ADFMs will require a referral for all
mental health and Substance Use Disorder (SUD) services except outpatient
office-based visits. TOP Prime/TOP Prime Remote ADFMs will also
require preauthorization for treatment of SUDs as outlined in the
TPM,
Chapter 7, Section 3.5, paragraph 4.0 and
for the treatment of mental disorders as outlined in the TPM,
Chapter 7, Section 3.8, paragraph 6.0. All
other care that is provided to a TOP Prime/TOP Prime Remote-enrolled
Service member or ADFM by anyone other than their Primary Care Manager
(PCM) requires authorization, regardless of where the care is rendered.
5.1.2 Claims for
ADSMs
shall be processed in accordance with Section 26.
While
authorizations are required for ADSM care, for administrative reasons,
the contractor shall process and pay such claims without an authorization
for TRICARE covered services (to include services, supplies and
equipment waived under a Supplemental Health Care Program (SHCP)),
as if there were a authorization on file. If the
care is retroactively authorized by the Government (including submission
of an approved
SHCP waiver for a non-covered
service), then the contractor shall enter the authorization and
process the claim for payment. If the contractor determines that
the care was not authorized, the contractor shall deny the claim.
Refer to
Section 26 for additional information.
5.1.3 Claims
for self-referred, non-emergency, and non-urgent care for TOP Prime
and TPR enrolled ADFMs shall process with POS deductibles and cost-shares
unless the appropriate TRICARE Area Office (TAO) or TRICARE Overseas
Program Office (TOPO) has approved a retroactive authorization.
5.1.4 TRICARE-eligible
beneficiaries residing in an overseas location who are not enrolled
in TOP Prime/TOP Prime Remote typically do not need to obtain preauthorization/authorization
for care. However, preauthorization reviews shall be performed for
all care and procedures listed in
Chapter 7, Section 2.
The TOP contractor may propose additional authorization reviews
for non-enrolled TOP beneficiaries to the government.
5.1.5 TRICARE
beneficiaries whose health care is normally provided under one of
the two regional Managed Care Support Contractors (MCSCs) who require
care while traveling in an overseas location shall request any necessary
preauthorizations/authorizations through the TOP contractor, regardless
of where the beneficiary resides or is enrolled. Denial of requested
services should be visible to the claims processing contractor to
ensure claims are denied or processed as POS as appropriate.
Note: This process does not apply
to beneficiaries enrolled to the USFHP or the CHCBP.
5.2
Point
of Service (POS) Provisions
5.2.1 Unless
specifically excluded by this section, all self-referred, non-emergency
care provided to TOP Prime/TOP Prime Remote-enrolled ADFMs which
is not either provided/referred by the beneficiary’s PCM or specifically
authorized shall be reimbursed under the POS option. This provision applies
regardless of where the care is rendered. POS provisions also apply
to the following stateside beneficiaries when traveling overseas:
ADFMs, retirees, and retiree family members who are enrolled in TRICARE
Prime, and ADFMs enrolled in TPR for ADFMs.
5.2.2 POS cost-sharing only applies
to TRICARE-covered services. Claims for services that are not a
covered TRICARE benefit shall be denied.
5.2.3 The
TOP contractor shall adjust POS deductibles and cost-shares when
TOP PCMs or Health Care Finders (HCFs) do not follow established
referral/authorization procedures. For example, if the contractor
processes a claim under the POS option because there was no evidence
of a referral and/or an authorization, and the contractor later
verifies that the PCM or other appropriate provider referred the
beneficiary for the care, the contractor shall adjust the claim
and reverse the POS charges. The contractor need not identify past
claims that may be eligible for POS adjustment; however, the contractor
shall adjust these claims as they are brought to their attention.
5.2.4 On a case-by-case basis, following
stabilization of the patient, the TAO Director or MTF Commander
may require an enrolled beneficiary to transfer to a TOP network
facility or an MTF. The TAO Director or MTF Commander shall provide
written notice to the beneficiary (or responsible party) advising
them of the impending transfer to a TOP network facility/MTF. If
a beneficiary who is subject to TOP POS provisions elects to remain
in the non-network facility after such notification, POS cost-sharing
provisions will apply beginning 24 hours following the receipt of
the written notice. Neither the TOP Director nor the MTF Commander
will require a transfer until such time as the transfer is deemed medically
safe.
5.2.5 The following deductible and
cost-sharing amounts apply to all TOP POS claims for health care
support services:
• Enrollment
year deductible for outpatient claims: $300 per individual; $600
per family. No deductible applies to inpatient services.
• Beneficiary
cost-share for inpatient and outpatient claims: 50% of the allowable
charge after the deductible has been met (deductible only applies
to outpatient claims).
• POS deductible
and cost-share amounts are not creditable to the enrollment/Fiscal Year
(FY) catastrophic cap and they are not limited by the cap.
• POS deductible
and cost-share amounts do not apply to claims for care received
by newborns and newly adopted children who are deemed enrolled in
TOP Prime or TOP Prime Remote.
5.2.6 POS deductible and cost-share
amounts do not apply if a TOP enrollee has Other Health Insurance
(OHI) that provides primary coverage (i.e., the OHI must be primary
under the provisions of the TRM,
Chapter 4, Section 1). Evidence of OHI claims
processing (including the exact amount paid on the claim) must be
submitted with the TOP claim.
5.2.7 EOB
shall clearly indicate that a claim has been processed under the
POS Option.
5.2.8 POS is not applicable to Service
members or to TRICARE Select.
5.3 Extended
Care Health Option (ECHO) benefits in overseas locations must be
authorized by the TOP contractor. Refer to
Section 23 and
the TPM,
Chapter 9 for additional guidance.
5.4 Refer to
Section 10 for
referral/preauthorization/authorization requirements for Service member
dental care in remote overseas locations.
6.0 CLAIM DEVELOPMENT
6.1 Development
of missing information shall be kept to a minimum. The TOP contractor
shall use available in-house methods, contractor files, telephone,
Defense Enrollment Eligibility Reporting System (DEERS), etc., to
obtain incomplete or discrepant information. If this is unsuccessful,
the contractor may return the claims to sender with a letter which
indicates that the claims are being returned, the reason for return
and requesting the required missing documentation. The contractor’s system
shall identify the claim as returned, not denied. The Government
reserves the right to audit returned claims as required, therefore
the contractor shall retain sufficient information on returned claims
to permit such audits. The contractor shall review all claims to
ensure TOP required information is provided prior to payment. For
the Philippines, claims requiring development of missing or discrepant
information, or those being developed for medical documentation,
shall be pended for 90 days and are excluded from the claims processing
standard.
6.2 Claims may be filed by eligible
TRICARE beneficiaries, purchased care sector providers, TOP POCs,
and TRICARE authorized providers in the 50 U.S. and the District
of Columbia as allowed under TRICARE (see
Chapter 8, Section 1).
6.3 Confidentiality requirements
for TOP are identical to TRICARE requirements outlined in
Chapter 8.
6.5 The following minimal information
is required on each overseas claim prior to payment:
6.5.1 Signatures
Beneficiary and purchased care
sector provider signatures (signature on file is acceptable unless
specifically prohibited by the Government).
6.5.2 Name and Address
6.5.2.1 Complete beneficiary and purchased
care sector provider name and address.
6.5.2.2 If an address is not available
on the claim, obtain the address either from previously submitted
claims, directly from the beneficiary/purchased care sector provider
via phone, fax, or e-mail, DEERS per
paragraph 6.1.
Note: The TOP contractor shall accept
APO/FPO for the beneficiary address.
6.5.3 Diagnosis(es)
6.5.3.1 Prior to returning a claim
that is missing a diagnosis, the TOP contractor shall research the patient’s
history and determine whether a diagnosis from a related claim can
be applied. The diagnosis should be reflective of the services rendered.
6.5.3.2 Claims received for dates of
service for outpatient services or dates of discharge for inpatient
services before the mandated date, as directed by Health and Human
Services (HHS), for International Classification of Diseases, 10th
Revision (ICD-10) implementation, with ICD-10 codes shall be converted
to International Classification of Diseases, 9th Revision, Clinical
Modifications (ICD-9-CM) codes by the TOP contractor. Claims received
for dates of service for outpatient services or dates of discharge
for inpatient services on or after the mandated date, as directed
by HHS, for ICD-10 implementation, with ICD-9 or ICD-9-CM codes
shall be converted to ICD-10-CM codes by the TOP contractor. Refer
to
Chapter 8, Section 6, paragraphs 4.0 and
5.0 regarding the use of ICD-9-CM
V codes (factors
influencing health status and contact with health services) and
ICD-10-CM
Z codes (factors influencing health status
and contact with health services).
6.5.4 Procedures/Services/Supply/DME
The
TOP contractor shall identify the procedure(s)/service(s)/supply/DME
ordered, performed or prescribed, including the date ordered performed
or prescribed. The TOP contractor may use the date the claim form
was signed as the specific date of service, if the service/purchase
date/order date is not on the bill.
6.5.5 Claims
received with a narrative description of services provided shall
be coded by the TOP contractor with as accurate-coding as possible
based upon the level of detail provided in the narrative description
or as directed by the TOPO. Services which contain sufficient detail
to identify an accurate procedure code shall be used. All surgical
procedures must be coded accurately based on the level of detailed
description. Outpatient professional services shall be coded accurately.
Office visits which include multiple services shall be coded accurately
and not bundled when the description of services are available. The
provisions of
paragraph 6.1 apply for narrative claims that
cannot be accurately coded due to insufficient or vague information.
Claims received for dates of service for outpatient services or
dates of discharge for inpatient services before the mandated date,
as directed by HHS, for ICD-10 implementation, with ICD-10 codes
shall be converted to ICD-9 codes by the TOP contractor. Claims
received for dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 codes shall be converted to ICD-10 codes by the TOP contractor.
Refer to
Chapter 8, Section 6, paragraph 4.0 regarding
the use of
V and
Z codes.
6.5.5.1 Inpatient
Institutional Procedures
Inpatient institutional (i.e.,
hospital) claims received for dates of discharge for inpatient services
before the mandated date, as directed by HHS, for ICD-10 implementation,
shall have the procedure narratives coded by the TOP contractor
using ICD-9-CM, Volume 3 procedure codes. Inpatient institutional
(i.e., hospital) claims received for dates of discharge on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
shall have the procedure narratives coded by the TOP contractor
using ICD-10-Procedure Classification System (ICD-10-PCS) procedure
codes.
6.5.5.2 Outpatient Institutional Procedures
and Professional Services
Claims received for outpatient
institutional (e.g., ambulance services, laboratory, Ambulatory
Surgery Centers (ASCs), partial hospitalizations, outpatient hospital
services) services and professional services shall be coded using
Healthcare Common Procedure Coding System (HCPCS) or Current Procedural
Terminology (CPT).
6.5.6 Care authorizations
(when required).
6.5.7 Itemization
of total charges. (Itemization of hospital room rates are not required
on institutional claims).
6.5.8 Proof
of payment is required for all beneficiary submitted claims if the
claim indicates that the beneficiary made payment to the provider
or facility. Due to cultural differences, there may be significant
variation in provider processes for issuing receipts to the beneficiaries.
Therefore, the overseas claims processor shall use best business
practices when determining if the documentation provided is acceptable
for the country where the services were rendered.
6.5.8.1 Examples
of ACCEPTABLE Beneficiary Proof of Payment:
• Cancelled checks (made payable
to the provider)
• Credit
or bank card statements or receipts
• Bank account statements (with
documentation of payment to the provider)
• Receipt, itemized bill, or
statement issued by the provider’s office stamped “PAID” on all pages
• Proof of Electronic Funds Transfer
(EFT) from the beneficiary to the provider
• Invoice for pharmaceuticals
dispensed on an outpatient basis (overseas pharmacies will not dispense
drugs without payment; therefore, an invoice represents proof of payment)
• Invoice for health care from
providers in Turkey (Turkish providers will not provide an invoice
to the patient until payment has been made; therefore, an invoice
represents proof of payment)
6.5.8.2 Examples of UNACCEPTABLE Beneficiary
Proof of Payment:
• Cancelled check made payable
to “Cash” or to the beneficiary or sponsor
• Bank account statements showing
cash withdrawal (without additional documentation of payment to
the provider)
• Letter
signed by patient saying s/he has paid the bills
• Paid amount shown only on the
claim or itemized bill
• Handwritten statements (e.g.,
“Paid in Full,” “Paid by Patient”, “Paid in Cash”)
• Paid in cash (without additional
documentation of payment to the provider)
6.6 Non-prescription (Over-The-Counter
(OTC)) drugs are to be denied. This includes drugs that are considered
OTC by U.S. standards, even when they require a prescription in
a foreign country.
6.7 The
TOP contractor shall use a schedule of allowable charges based on
the Average Wholesale Price (AWP) as a reference source for processing
drug related TRICARE overseas claims.
6.8 Claims
for medications prescribed by a host-nation physician, and commonly
used in the host-nation country, shall be cost-shared unless they
are considered OTC by U.S. standards.
6.9 For
the Philippines, prescription drugs may only be cost-shared when
dispensed by a certified retail pharmacy or hospital-based pharmacy.
The TOP contractor shall deny claims for prescription drugs dispensed
by a physician’s office. Certification requirements outlined in
Section 29 apply.
Note: This does not apply to Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
6.10 Claims for DME involving lease/purchase
shall always be developed for missing information.
6.11 The TOP contractor shall use
ECHO claims processing procedures outlined in TPM,
Chapter 9, Section 18.1, when processing ECHO
overseas claims.
6.12 The
TOP contractor shall deny claims from non-certified or non-confirmed
purchased care sector providers when the DHA CO has directed contractor
certification/confirmation of the purchased care sector provider
prior to payment.
6.13 Requests
for missing information shall be sent on the TOP contractor’s TRICARE/TOP
letterhead. When development is necessary, the contractor shall
include a special insert in German, Italian, Spanish, Tagalog, Japanese,
and Korean which indicates what missing information is required
to process the claim and includes the contractor’s address for returning
requested information.
6.14 If
the TOP contractor elects to develop for additional/missing information,
and the request for additional information is not received/returned
within 45 days, the contractor shall deny the claim.
6.15 If the TOP contractor has no
record of referral/authorization prior to denial/payment of the claim,
the contractor shall follow the TOP POS rules, if the service would
otherwise be covered under TOP.
6.16 The
TOP contractor shall develop procedures for the identification and
tracking of TOP enrollee claims submitted by either a purchased
care sector designated or non-designated overseas purchased care
sector provider without preauthorization/authorization. Upon receipt
of a claim for a TOP-enrolled ADFM submitted by a purchased care
sector designated or non-designated overseas purchased care sector
provider without preauthorization/authorization, the contractor
shall process the claims following POS payment procedures. For Service
member claims submitted by a purchased care sector provider without
preauthorization/authorization, the contractor shall
process
the claim if services are covered by TRICARE. If services are non-covered
services and no authorization is on file, the claim shall be denied. Refer
to
Section 26 for more information on ADSM pended
claims.
6.17 The TOP contractor must have
an automated data system for eligibility, deductible and claims history
data and must maintain on the automated data system all the necessary
TOP data elements to ensure the ability to reproduce both TED and
EOBs as outlined in
Chapter 8, Section 8,
except for requiring overseas providers to use HCPCS to bill outpatient
rehabilitation services, issue provider’s the Form 1099 and suppression
of checks/drafts for $.99 or less. The contractor may split claims
to accommodate multiple invoice numbers in order to reference invoice
numbers on EOBs when necessary. Refer to
Chapter 8, Section 6 for
additional requirements related to claims splitting.
6.18 The TOP contractor shall not
pay for pharmacy services obtained through the Internet.
6.19 The TOP contractor shall pay
all TOP Service member stateside claims as outlined in
Section 26.
6.20 All
claims shall be submitted in a Health Insurance Portability and
Accountability Act (HIPAA) compliant format. Refer to
Section 28 for more information on HIPAA requirements.
6.21 Electronic claims not accepted
by the TOP contractor’s Electronic Data Information (EDI) system/program
shall be rejected.
6.22 For
all overseas claims, the TOP contractor shall create and submit
TEDs following current guidelines in the TSM for TED development
and submission. Claim information will be able to be accessed through
the TRICARE Patient Encounter Processing and Reporting (PEPR) Purchased
Care Detail Information System (PCDIS).
6.23 The
TOP contractor shall establish Utilization Management (UM) high
dollar/frequency thresholds in accordance with
Section 6.
6.24 Claims either denied as “beneficiary
not eligible” or “found to be not eligible on DEERS” may be processed
as a “good faith payment” when received from the Defense Health
Agency (DHA) Communications Office. The TAO Director shall work
with the TOP contractor on claims issues related to good faith payment
documentation (e.g., a completed claim form and other documentation
as required by
Chapter 10, Sections 3 and
4).
6.26 The
Claims Auditing Software requirements outlined in the TRM,
Chapter 1, Section 3 do not apply to TOP claims;
however, the TOP contractor shall implement an internal process
for identifying upcoding, unbundling, etc. on coded claims.
8.0 EOB Vouchers
The TOP contractor shall follow
the EOB voucher requirements in
Chapter 8, Section 8,
where applicable, with the following exceptions and additional requirements:
8.1 The
letterhead on all TOP EOBs shall also reflect “TRICARE Overseas
Program” and shall be annotated Prime or TRICARE Select.
8.2 TOP
EOBs may be issued on regular stock, shall provide a message indicating
the exchange rate used to determine payment and shall clearly indicate
that “This is not a bill”.
8.3 TOP
EOBs shall include the toll-free number for beneficiary and provider
assistance.
8.4 TOP
EOBs for overseas enrolled Service member claims shall be annotated
“ACTIVE DUTY.”
8.5 For
Point of Sale or Vendor pharmacy overseas claims, TOP EOBs shall
have the name of the provider of service on the claim.
8.6 For
beneficiary submitted pharmacy claims, TOP EOBs shall contain the
name of the provider of service, if the information is available.
If the information is not available, the EOBs shall contain “your pharmacy”
as the provider of service.
8.7 The
TOP contractor shall insert the provider’s payment invoice numbers
in the patient’s account field on all provider EOBs, if available.
8.8 The TOP
contractor shall designate an EOB message for overseas claims rendered
by non-network purchased care sector providers who are required
to be certified, but have not been certified by the TOP contractor,
“Your provider has not submitted documentation required to validate
his/her training and/or licensure for designation as an authorized
TRICARE provider”. Refer to
Section 4 for more
information regarding certification of providers in designated locations.
8.9 When
a provider’s/beneficiary’s EOB, EOB and check, or letter is returned
as undeliverable, the check shall be voided.
8.10 The TOP contractor may utilize
secure electronic EOB delivery to beneficiaries unless mail delivery
has been requested by the beneficiary or has not signed up for electronic
delivery.
8.11 The
contractor may issue monthly summary EOBs to beneficiaries on claims
when there is no beneficiary liability. The processing date of the
oldest claim for the summary EOB shall not be greater than 31 calendar
days.
12.0 Reimbursement/Payment Of Overseas
Claims
When
processing TOP claims, the TOP contractor shall follow the reimbursement
payment guidelines outlined in the TRM,
Chapter 1, Section 34 and the cost-sharing
and deductible policies outlined in the TRM,
Chapter 2, Section 1, and shall:
12.1 Reimburse claims for purchased
care sector services/charges for care rendered to TOP eligible beneficiaries
which is generally considered purchased care sector practice and
incidental to covered services, but which would not typically be
covered under TRICARE. An example of such services may be, charges
from purchased care sector ambulance companies for driving purchased
care sector physicians to accidents or private residences, or the
manner in which services are rendered and considered the standard
of care in a purchased care sector country, such as rehabilitation
services received in an inpatient setting.
12.2 Reimburse
claims at the lesser of the billed amount, the negotiated reimbursement
rate, the CHAMPUS Maximum Allowable Charge (CMAC), or the Government
established fee schedules (when applicable) (TRM,
Chapter 1, Sections 34 and
35), unless a different reimbursement rate
has been established as described in TPM,
Chapter 12, Section 1.3.
Note: Government established fee
schedules (per TRM,
Chapter 1, Sections 34 and
35) are only applicable to retirees or their
eligible family members or TRICARE Select ADFMs.
12.3 Not reimburse for purchased
care sector care/services specifically excluded under TRICARE.
12.4 Not reimburse for purchased
care sector care/services provided in the Philippines unless all
of the certification requirements listed in
Section 14 have
been met.
12.5 Not
reimburse for administrative charges billed separately on claims,
except for individual administrative charges as determined by the
Government. The contractor shall reimburse these charges only in
instances when the fee is billed concurrently with the corresponding
health care services. If a bill is received for these charges without
a corresponding health care service, the charges shall be denied.
12.6 Determine exchange rates as
follows:
12.6.1 Use
the exchange rate in effect on the ending date that services were
received unless evidence of OHI and then the TOP contractor shall
use the exchange rate of the primary insurer, not the rate based
on the last date of service to determine the TOP payment amount,
and/or;
12.6.2 Use the ending dates of the
last service to determine exchange rates for multiple services.
12.6.3 Use the exchange rate in
paragraph 12.6.1 to
determine deductible and copayment amounts, if applicable, and to
determine the amount to be paid in foreign currency.
12.6.4 Overseas drafts/checks and
EOBs. Upon completion of processing, the contractor shall create
checks (payable in U.S. dollars). The TOP contractor shall do this
within 48 hours after approval by DHA Contract Resource Management
(CRM). Drafts (payable in foreign currency units) shall be created
by the TOP contractor within 96 hours following CRM approval, unless
a different process has been authorized by DHA. Payments that need
to be converted to a foreign currency shall be calculated based
on the exchange rate in effect on the last date of service listed
on the EOB. Drafts/checks shall be matched with the appropriate
EOB, and mailed to the beneficiary/sponsor/purchased care sector provider/POC
as applicable.
Note: Drafts
for certain foreign currency units may require purchase from a bank
location other than the one normally used by the TOP contractor
(out of state or out of country). Currency units that must be purchased
from an alternate bank (out of state or out of country) may take
up to 10 business days for the draft to be returned and matched
up with the EOB.
12.7 Convert
lump sum payments, instead of line items, to minimize conversion
problems.
12.8 Pay provider claims for all
overseas locations in the country’s local currency as identified
on the claim for the specific country by foreign currency/drafts.
Drafts may not be changed to a U.S. dollar check after the contractor
has issued a foreign draft.
12.9 Know that
foreign overseas drafts (in local currency) are good for 190 days
and may be cashed at any time, unless a different process has been
established by DHA. U.S. dollar checks are good for 120 days unless
a different process has been established by DHA. The provisions
of
Chapter 3, Section 4 regarding staledated,
voided, or returned checks/Electronic Funds Transfers (EFTs) are
applicable to the TOP.
12.10 Pay
TOP claims submitted by a beneficiary in U.S. dollars, unless there
is a beneficiary request on the claim at the time of submission
for payment in a foreign currency. The TOP contractor may reissue
the payment in U.S. dollars if a request is subsequently received
from the beneficiary and the foreign draft is included in the request
or the payment has staledated, or if directed by the appropriate DHA
COR.
12.11 Payment
shall be made in local currency.
12.12 Issue
drafts/checks for German claims which look like German drafts/checks.
Note: In order for TRICARE drafts/checks
to look like German drafts/checks, a German address must be used.
The TOP contractor may use a corporate address in Germany or the
TAO Eurasia-Africa address for this purpose.
12.13 The
contractor shall pay all beneficiary-submitted claims for TRICARE
covered drugs dispensed by a U.S. embassy health clinic to the beneficiary.
The contractor is not to make payments directly to the embassy health
clinic.
12.14 Know
that professional services rendered by a U.S. embassy health clinic
are not covered by TRICARE/TOP. These services are covered under
International Cooperative Administrative Support Services (ICASS)
agreements. Embassy providers (acting as PCMs) may refer TOP enrollees
to purchased care sector providers, these claims shall be processed
per TOP policy and procedures.
12.15 Reimburse claims for drugs
or diagnostic/ancillary services purchased overseas following applicable
deductible/cost-share policies.
12.16 In emergency situations, the
requirement for Medicare certification for facilities in U.S. commonwealths
and territories may be waived. After a review of the facts, the
contractor may cost-share otherwise covered services or supplies
rendered in an emergency situation by an unauthorized provider to
the beneficiary, or on behalf of the beneficiary, to the beneficiary's
appointed payee, guardian, or parent in accordance with TPM,
Chapter 11, Section 4.2 and TRM,
Chapter 1, Section 29.
12.17 The
contractor shall mail the drafts/checks and EOBs to purchased care
sector providers unless the claim indicates payment should be made
to the beneficiary. In conformity with banking requirements, the
drafts/checks shall contain the contractor’s address. Drafts and
EOBs shall be mailed using U.S. postage. Additionally, payments/checks
may be made to network providers, with an Embassy address.
12.18 Mail benefit payment checks
and EOBs to Philippine providers, and other nations’ providers as directed
by the DHA CO, to the place of service identified on the claim.
No provider checks or EOBs for Philippine providers, and other nations’
providers as directed by the DHA CO may be sent to any other address.
12.19 Process/pay
inpatient and outpatient claims for TRICARE overseas eligible beneficiaries, including
Service member claims, as indicated below:
12.19.1 The
TPharm contractor shall allow TOP Service members to use the TPharm
retail pharmacy network under the same contract requirements as
other Military Health System (MHS) eligible beneficiaries (see TPM,
Chapter 8, Section 9.1).
12.19.2 The
TPharm contractor shall allow TOP enrolled ADFM beneficiaries to
use their stateside retail pharmacy network under the same contract
requirements as other MHS eligibles (see TPM,
Chapter 8, Section 9.1).
12.19.3 The
TOP contractor shall process claims for overseas health care received
by TRICARE beneficiaries enrolled to or residing in a stateside
contractor’s region following the guidelines outlined in this chapter.
Payment shall be made from applicable bank accounts and shall be
based on billed charges unless a lower reimbursement rate has been
established by the Government or the contractor.
12.20 EFT
payments. Upon purchased care sector provider request, the TRICARE
Overseas health care support contractor shall provide EFT payment
to a U.S. or overseas bank on a weekly basis. Bank charges incurred
by the provider for EFT payment shall be the responsibility of the
provider. Upon beneficiary request, EFT payments to a U.S. bank
may be provided. Bank charges associated with beneficiary EFT payments
shall be the responsibility of the beneficiary.
12.21 The
TOP contractor shall process 90% of all retained and adjustment
TOP claims to completion within 30 calendar days from the date of
receipt. Claims pended per Government direction are excluded from
this standard. However, the number of excluded claims shall be reported
on the designated DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract. One hundred
percent (100%) of all claims (both retained and excluded, including adjustments)
shall be processed to completion within 90 calendar days from the
date of receipt, unless the CO specifically directs the contractor
to continue pending a claim or group of claims.
12.22 Exclude correspondence pended
due to stop payment orders, check tracers on foreign banks, and
conversion on currency from the routine 45 calendar day correspondence
standard and the priority 10 calendar day correspondence standard.
However, the number of excluded routine and priority correspondence
must be reported on the designated DD Form 1423, CDRL, located in
Section J of the applicable contract.
12.23 The
TOP contractor shall pay Value Added Tax (VAT) included on German
health care claims for all beneficiary categories.
12.24 Reimburse fees for transplant
donor searches in Germany on a global flat fee basis since the German
Government does not permit health care facilities to itemize such
charges.
12.25 Reimburse
itemized fees for supplies that are related or incidental to inpatient
treatment (e.g., hospital gowns) if similar supplies would be covered
under reimbursement methodologies used within the U.S. The TOP contractor
shall implement internal management controls to ensure that payments are
reasonable and customary for the location.
13.0 Claims Adjustment And Recoupment
13.1 The TOP contractor shall follow
the adjustment requirements in
Chapter 10 except
for the requirements related to financially underwritten funds.
13.2 The TOP contractor shall follow
the recoupment requirements in
Chapter 10 for
non-financially underwritten funds, except for providers. The contractor
shall use the following procedures for purchased care sector provider
recoupments. Recoupment actions shall be conducted in a manner that is
considered culturally appropriate for the purchased care sector
provider’s country. The contractor shall:
• Send an
initial demand letter;
• Send a
second demand letter at 90 days;
• Send a
final demand letter at 120 days; and
• Refer
the case to DHA at 240 days, if the case is over $600, and if under
$600 the case shall remain open for an additional four months and
then shall be written off at 360 days.
13.3 Recoupment letters (i.e., the
initial letter, the 90 day second request and the 120 day final demand
letter) shall be modified to delete references to U.S. law. Invoice
numbers shall be provided on all recoupment letters. The TOP contractor
shall include language in the recoupment letter requesting that
refunds be returned/provided in the exact amount requested.
13.4 Provider recoupment letters
sent to Germany, Italy, Spain, Japan, and Korea, shall be written
in the respective language.
13.5 If the recoupment action is
the result of an inappropriately processed claim by the TOP contractor,
recoupment is the responsibility of the contractor, not the beneficiary/provider.
13.6 The
TOP contractor shall have a TOP bank account capable of receiving/accepting
wire transfers for purchased care sector provider recoupment/overpayment
returns. The TOP contractor shall accept the amount received as
payment against the amount owed. Any fees associated with the wire
transfer are the responsibility of the payer/provider.