2.0
Eligibility
Contractors
have no responsibility for determining eligibility or for deciding
in which region a Service member shall enroll. Director, TRICARE
Regional Offices (TROs) will furnish contractors with enrollment
information (
see paragraph 3.0).
Note: Service member astronauts assigned
to the Johnson Space Center in Houston, Texas must and shall be
enrolled in TPR.
3.0
TPR Program
Units
The
Director, TROs will supply the contractor with an electronic directory,
updated as needed, that lists, by region, the designated TPR zip
codes for the contractor’s region(s). The Director, TROs will also
provide unit listings to the contractor so the contractor can mail
or e-mail educational materials to the units. In some instances,
individual member listings (as opposed to units) may be provided.
4.0
Benefits
4.1 Remote
Service members enrolled in the TPR program shall receive the benefits
of TRICARE Prime, even in areas without contractor networks. Some
covered benefits (see
Section 2) require
review by Specified Authorization Staff (SAS) (identified in
Addendum A, paragraph 1.0) so they may identify fitness-for-duty
issues.
4.2 If
the contractor determines that a requested or claimed service, supply,
or equipment is not covered by TRICARE (including
Chapter 17, Section 3) and
no Defense Health Agency (DHA)-approved waiver is provided, the
contractor shall decline to file an authorization and shall deny
any received claims accordingly. The contractor shall notify the
civilian provider and the remote Service member/non-enrolled Service
member of the declined authorization with explanation of the reason.
The notification to a civilian provider and the remote Service member/non-enrolled
Service member shall explain the waiver process and provide contact
information for the applicable Uniformed Services Headquarters Service
Project Officers as listed in
Chapter 17, Addendum A, paragraph 2.0. No notification
to the SAS is required.
4.3 The
contractor shall not make claims payments to sanctioned or suspended
providers (see
Chapter 13, Section 5).
The claim shall be denied if a sanctioned or suspended provider
bills for services. SAS do not have the authority to overturn DHA
or Department of Health and Human Services (DHHS) provider exclusions.
See
Section 2 for referral and authorization requirements.
4.4 Services that would not have
ordinarily been covered under TRICARE policy (including limitations
and exclusions) may be authorized for Service members only in accordance
with the terms of a waiver approved by the Director, DHA, at the
request of an authorized official of the Uniformed Service concerned.
(Reference HA Policy 12-002 “Use of Supplemental Health Care Program
Funds for Non-Covered TRICARE Health Care Services and the Waiver
Process for Active Duty Service Members”).
4.5 If
a contractor receives a claim for care provided to a Service member
who is not enrolled in TPR or who is not enrolled in TRICARE Prime
at a Military Treatment Facility (MTF)/Enhanced Multi-Service Market
(eMSM), the contractor shall process the claim according to the
applicable guidelines of the Supplemental Health Care Program (SHCP)
(
Chapter 17).
4.6 A SAS authorization shall be
deemed to constitute referral, authorization, and direction to bypass
edits as appropriate to ensure payment of SAS-approved claims. Contractors
shall implement appropriate measures to recognize SAS authorization
in order to expedite claims processing.
5.0 SAS
Certain Uniformed Service controls
and rules apply to Service members due to unique military readiness
requirements. SAS (identified in
Addendum A, paragraph 1.0) serves as liaison
among the Service member, the Service member’s Uniformed Service,
and the contractor for managing the Service member’s health care
services.
5.1 The
SAS reviews referrals for proposed care as well as information about
care already received in order to determine impact on an individual’s
fitness for duty (see
Section 2, paragraph 5.3 and
Addendum B for
referral and review/authorization procedures). The SAS, the PCM
(if assigned) and the contractor shall work together in making arrangements
for the Service member’s required examinations.
5.2 The SAS will provide the protocol,
procedures, and required documentation through the contractor to
the provider for these examinations. For required care that may
not be obtainable in the civilian community, the SAS will refer
the Service member to an MTF/eMSM. Refer to
Addendum A for the
addresses and telephone numbers of the SASs.
6.0 Appeal Process
6.1 If
the contractor, at the direction of the SAS, denies authorization
of, or authorization for reimbursement, for a TPR 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 SAS (see
paragraph 6.2). The SAS will handle only those
issues that involve SAS denials of authorization or authorization
for reimbursement. The contractor shall handle allowable charge
issues, grievances, etc.
6.2 If
the TPR enrollee disagrees with a denial rendered by the SAS, the
first level of appeal will be through the SAS who will coordinate
the appeal as appropriate. The enrollee may initiate the appeal
by contacting his/her SAS. If the SAS upholds the denial, the SAS
will notify the enrollee of further appeal rights with the appropriate
Surgeon General’s office.
6.3 If
the denial is overturned at any level, the SAS will notify the contractor
and the Service member.
6.4 The
contractor shall forward all written inquiries and correspondence
related to SAS denials of authorization, or authorization for reimbursement
to the appropriate SAS. The contractor shall refer telephonic inquiries
related to SAS denials to the appropriate SAS.
7.0
Active
Duty Family Members (ADFM
S) And Others
TRICARE-eligible family members
accompanying Service members who are either eligible for or enrolled
in the TPR program may enroll in the TPRADFM Program in accordance
with
Section 6. Enrollment jurisdiction for the
ADFMs may be based on the enrollment jurisdiction of the TPR enrolled Service
member per
paragraph 8.6. This includes cross-region
enrollment (see
Chapter 6, Section 1, paragraph 11.4).
8.0 TPR Program Differences
In addition to the SHCP differences
specified in
Chapter 17, Section 1, paragraph 4.0, the following
differences apply to the TPR program.
8.1 If
the contractor has not established a network of PCMs in a remote
area, a TPR designated Service member will still be enrolled without
a PCM assigned. The Service member without an assigned PCM will
be able to use a local TRICARE-authorized provider for primary health
care services without review.
8.2 Point
of Service (POS) cost-sharing and deductible amounts do not apply
to Service members. If a TPR enrolled Service member receives primary
care without a referral or authorization, the enrolling contractor
shall process the claim and make payment if the care meets all other
TRICARE requirements (i.e., the care is medically necessary, a covered
benefit of TRICARE an approved waiver is provided, etc.).
8.3 Annual Service member re-enrollment
is not required.
8.4 If the
Uniformed Services determine that an active duty member is eligible
for the TPR program, enrollment of the member is mandatory, unless
there are service-specific issues that merit assignment to a military
PCM, or if the Service member elects to waive access standards and
enrolls to an MTF/eMSM (subject to unit commander/supervisor approval).
8.5 If Third Party Liability (TPL)
is involved in a claim, Service member claim payment will not be delayed
during the development of TPL information from the Service member.
8.6 Enrollment
jurisdiction may be based on the location of the military work unit
instead of the Service member’s residence. This is determined by
the Services.