1.0 GENERAL
TRICARE Overseas Program (TOP)
health care services are provided by Military Treatment Facilities
(MTFs) and purchased care sector network and non-network providers
and institutions. All TRICARE requirements regarding Provider Certification/Credentialing
and Network Development shall apply to the 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changed, waived, or superseded by this section; the TRICARE Policy Manual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
Chapters 4 and
5 for additional
instructions.
2.0 Purchased Care Sector Provider
Certification And Credentialing
2.1 The
TOP contractor shall be responsible for provider certification oversight,
and monitoring of provider/institution quality. The contractor shall
use
Chapter 4,
32 CFR 199.6,
and TPM,
Chapter 11 to the maximum extent possible
for the certification of purchased care sector providers. The contractor
is
not required to follow TRICARE requirements
for U.S. credentialing standards, except when TRICARE requires the
facility/agency to be Medicare certified (e.g., home health, hospice,
Skilled Nursing Facility (SNF) care). Also, Psychiatric Residential
Treatment Centers (RTCs), Substance Use Disorder Rehabilitation
Facilities (SUDRFs), and Psychiatric Partial Hospitalization Programs
(PHPs) that are located in Puerto Rico require approval by the TOP
contractor. Except for these services and facilities, the TOP contractor
shall establish purchased care sector provider certification processes
based on the accepted licensure and credentialing requirements for
the purchased care sector.
Note: Medicare certification for
organ transplant centers is only required for transplants performed
in the U.S., the District of Columbia, and U.S. territories where
Medicare is available. See TPM,
Chapter 12, Section 1.2.
2.2 Refer to
Section 29 for
additional certification requirements that have been established
for purchased care sector providers in the Philippines. The Defense
Health Agency (DHA) may expand these additional certification requirements
to other locations in the future.
3.0 Network Development
3.1 The TOP contractor shall be
responsible for developing and maintaining a complement of network
and non-network purchased care sector providers to augment the existing
capacity of the Direct Care (DC) system for Service members and
Active Duty Family Members (ADFMs) who are enrolled in TOP Prime,
and to provide or arrange for primary and specialty care services
for Service members and ADFMs who are enrolled in TOP Prime Remote.
3.2 The TOP contractor shall establish
signed provider agreements between network purchased care sector
providers and the contractor.
3.2.1 Network
provider agreements shall include language indicating that the provider
agrees to participate on claims for authorized services for TOP
enrollees on a cashless, claimless basis.
3.2.2 Network
provider agreements must specify rates for Service member medical
records photocopying and postage, if applicable.
Note: “Cashless, claimless” is defined
as a health care encounter that requires no up-front payment at
the time of service, and the provider files the claim for the beneficiary.
3.3 In TOP Prime and TOP Prime
Remote locations, networks shall be sized to meet TOP
Prime/TOP Prime Remote-enrolled populations only.
The TOP contractor may assist other beneficiaries (non-command sponsored
ADFMs, retirees, retiree family members, etc.) upon request by identifying
these private sector care providers
which are credentialed and familiar with TRICARE, but networks will not be
developed to accommodate non-TOP Prime/Prime Remote enrollees.
3.4 In TOP Prime locations, MTF
Commanders will identify the specialties needed in the network and
will communicate this information on an ongoing basis to the TOP
contractor per the process identified in the Statements of Responsibilities
(SORs) (see
Section 16).
3.5 MTF
capabilities and capacities may change frequently over the life
of the contract without prior notice. The TOP contractor shall ensure
that purchased care sector provider services can be adjusted as
necessary to compensate for changes in MTF capabilities and capacities,
when and where they occur over the life of the contract, including
short notice of unanticipated facility expansion, provider deployment,
downsizing, and/or closures.
3.6 Network
providers shall be able to communicate in English, both orally and
in writing, or provide translation services at the time of service.
3.7 The TOP contractor shall be
responsible to enter into participation agreements with SNFs in Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands per the provisions of
Section 3.
4.0 Contractor Requirements - Purchased
Care Sector Providers
4.1 The Government requires the
contractor to negotiate rates in specific countries designated in the
contract. Reimbursement rates for purchased care sector providers
in other locations may be negotiated by the contractor. In locations
where the Government has designated specific reimbursement rates
or methodologies. The contractor may not negotiate rates which exceed
the Government directed rate. Refer to the TRICARE Reimbursement
Manual (TRM),
Chapter 1, Section 34 for additional instructions.
4.2 The contractor shall provide
ongoing purchased care sector provider education and support in accordance
with
Section 11.
4.3 The
contractor shall have a Clinical Quality Management Program/Clinical
Quality Oversight Plan for reviewing access and quality of care
provided by the purchased care sector, as identified in DD Form
1423, Contract Data Requirements List (CDRL), located in Section
J of the applicable contract.
4.4 The
TOP contractor shall assign provider numbers to purchased care sector
providers, identify providers as network or non-network, and create
and submit TRICARE Encounter Provider (TEPRV) records. Each provider
shall be identified by a single provider number, with a sub-identifier
for multiple service locations. Upon the Government’s request, the
contractor shall provide copies of licensure/certification information
for purchased care sector providers.
4.5 The
TOP contractor shall deny claims from non-certified purchased care
sector providers when DHA has directed that the country’s purchased
care sector providers must be specially certified in order to receive
TRICARE payments. See
Section 29 for additional certification requirements.