1.0 GENERAL
1.1 All
TRICARE requirements regarding C&CS shall apply to the TRICARE
Overseas Program (TOP) unless specifically changed, waived, or superseded
by the provisions of 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
Chapter 11 for additional instructions.
2.0 TRICARE Service Centers (TSC
s)
support
2.1 Location, Operations, And Staffing
2.1.1 TSCs are jointly staffed by
Military Treatment Facility (MTF) personnel and TOP contractor personnel.
TSCs in the MTFs are operational, Monday - Friday (except holidays
recognized by the installation) during the administrative hours
of the MTF.
2.1.2 The
TOP contractor shall provide Beneficiary Service Representatives
(BSRs) on a full-time basis at each location as designated in the
contract. BSRs shall be qualified to perform the duties described
in
paragraph 2.2.
2.1.3 The
TOP contractor shall provide sufficient BSR staffing to accomplish
all work in a timely manner; however, at least one full-time BSR
will be assigned to each location regardless of actual workload
unless the Government has specifically authorized part-time coverage.
The TOP contractor shall advise the Government of any locations
where the workload does not justify full-time BSR coverage. The
TOP contractor shall implement appropriate business processes to
provide full-time TSC coverage if the assigned Customer Service
Representative(s) (CSR(s)) are unavailable due to planned or unplanned
absences (e.g., illness, leave, personal emergencies, etc.) for
more than two consecutive business days. Local processes for managing
short-term CSR absences (up to two consecutive business days) shall
be addressed in the Statement of Responsibilities (SOR).
2.1.4 BSRs
shall have a fully operational, on-line interface with the automated
claims processing and enrollment systems which support the functions
of the TSC no later than 30 calendar days prior to the start of
health care delivery (SHCD) and shall maintain that interface through
the life of the contract.
2.2 BSR Functions at TSC
s2.2.1 The contractor shall provide
overseas TSCs with BSR support to provide all Military Health System
(MHS) beneficiaries with the information and services as specified
below.
• Provide
TOP Prime, TOP Prime Remote, and TOP Select enrollment information
and perform enrollments/disenrollments to include assisting MTFs/beneficiaries
with transferring enrollment to another region.
• Perform
Health Care Finder (HCF) functions upon beneficiary/MTF request.
• Provide
information on the Point of Service (POS) option;
• Provide
information on claims (including on-line access to the claims processing system
for information about the status of a claim);
• Provide
assistance regarding claim problems when the TOP contractor is responsible for
processing the claim; and
• Provide
continuity-of-care services to all MHS beneficiaries including,
but not limited to, active duty personnel, dependents of active
duty personnel, retirees and their dependents, survivors, Medicare-eligible
beneficiaries and all other categories of individuals eligible to
receive MHS services.
• Perform
Primary Care Manager (PCM) changes and resolve PCM Information Transfer (PIT)
discrepancies.
• Perform
registrations in the Composite Health Care System (CHCS) (as required
to support TRICARE enrollments) and update patient information in
CHCS and Defense Enrollment Eligibility Reporting System (DEERS).
• Assist beneficiaries with TRICARE
benefit/coverage or claims questions (BSRs shall have sufficient
claims knowledge to handle routine questions regarding claims and
the ability to access and navigate the claims system).
• Assist beneficiaries with debt
collection issues.
• Provide
TRICARE briefings as requested by the MTF.
• Distribute TRICARE marketing
materials.
• Assist
beneficiaries with utilizing Government messaging systems.
• Assist beneficiaries in navigating
procurement of Durable Medical Equipment (DME).
Note: The contractor shall confirm
eligibility for care and enrollment status of beneficiaries before making
any arrangements for medical services.
2.2.2 TRICARE Program Information
The
TOP contractor shall provide personal assistance to all MHS beneficiaries
seeking information about TRICARE Prime, TRICARE Select, TRICARE
For Life (TFL), Civilian Health and Medical Program of the Department
of Veteran Affairs (CHAMPVA), TRICARE Mail Order Pharmacy (TMOP), Global
Nurse Advice Line (NAL), and the TRICARE dental contracts. The TOP
contractor shall ensure that the TSCs are supplied with educational
materials to include enrollment and claims submission information.
Through the BSRs and call centers, the TOP contractor shall establish
mechanisms to advise beneficiaries of care options, including the
POS option, and services offered.
2.2.3 BSR Interface With MTFs
BSRs
shall act as the focal point for providing information, referral,
and assistance to beneficiaries seeking access to TRICARE services.
BSRs shall maintain day-to-day liaison with MTF staff to promote
MTF optimization and ensure effective performance of the access,
referral, information, and continuity of care functions.
2.2.4 Enrollment
BSRs and contractor call center
staff shall provide personal assistance to eligible beneficiaries,
electing to enroll or disenroll, and permanently assigned active
duty personnel enrolling in TRICARE Prime. The TOP contractor shall
provide assistance to all MHS beneficiaries, including active duty,
Medicare eligibles, and others, in understanding program requirements,
by answering questions, adhering to MTF Commanders’ and TAO Director’s
determinations for PCM assignment, and following grievance and inquiry
procedures in accordance with this manual.
2.2.5 Claims
BSRs in the TSCs shall assist
all TRICARE beneficiaries with all claims issues when the TOP contractor
is responsible for processing the claim. When the TOP contractor
is not responsible for processing the claim, the BSR in the TSC
shall assist the beneficiary in identifying and contacting the organization
that is responsible for processing the claim. The BSR will provide
information (including on-line access to the claims processing system
for information about the status of a claim), assist beneficiaries
with claim problems when the TOP contractor is responsible for processing
the claim and provide continuity-of-care services to all MHS beneficiaries
including, but not limited to, active duty personnel, dependents
of active duty personnel, retirees and their dependents, survivors,
Medicare-eligible beneficiaries and all other categories of individuals
eligible to receive MHS services.
2.2.6 TRICARE Dental Plans
BSRs
in the TSCs shall provide general information on eligibility for
the TRICARE Dental Plans. The beneficiaries shall be referred to
the appropriate dental contractor for additional information.
3.0 HEALTH CARE FINDER (HCF) SERVICES
3.1 TOP HCF functions are performed
by BSRs located in the TSCs or in contractor-operated call center(s).
The TOP contractor shall offer call center operations to support
HCF services via toll-free lines 24 hours per day, seven days per
week, 365 days per year.
3.1.1 HCFs
are responsible for facilitating access to purchased care sector
provider care (including, but not limited to, primary care, specialty
care, mental health care, ancillary services, DME, and pharmacy
services), and for authorizing certain health care services. Additionally,
HCFs shall inform beneficiaries of access mechanisms, referral procedures,
and rules regarding use of network/non-network providers. They shall
also improve patient continuity of care by establishing mechanisms
to facilitate necessary consultations, follow-up appointments and
the sharing of medical records. TOP HCFs will serve all MHS beneficiaries
in the region, regardless of their enrollment status. This includes dual-eligible
beneficiaries and beneficiaries residing or enrolled in the 50 U.S.
and the District of Columbia who may require assistance when accessing
care in an overseas location.
3.1.2 For
MTF enrollees, the specialty care referral process includes a covered
benefit review; entering appropriate authorizations into the contractor’s
system; locating a qualified network or non-network purchased care
sector provider to provide the care on a cashless, claimless basis;
providing the beneficiary with a written care authorization and
the purchased care sector provider’s information; and assisting
the beneficiary with establishing an appointment with the purchased
care sector provider (upon beneficiary request).The contractor shall
also provide information to MTF personnel regarding the status of
specialty care referrals and shall work cooperatively with the MTF
to assist in obtaining consult results from purchased care sector
providers; however, the contractor is not responsible for tracking
receipt of consult results.
3.1.3 For TOP
Prime Remote enrollees, the specialty care referral process includes
a medical necessity review; a covered benefit review; entering appropriate
authorizations into the contractor’s system; locating a qualified
network or non-network purchased care sector provider to provide
the care on a cashless, claimless basis; providing the beneficiary
with a written care authorization and the purchased care sector
provider’s information; and assisting the beneficiary with establishing
an appointment with the purchased care sector provider (upon beneficiary
request). This process is also applicable to Service members who
are on Temporary Additional Duty/Temporary Duty (TAD/TDY), in an
authorized leave status, or deployed/deployed on liberty in a remote
overseas location, and to TRICARE Prime/TRICARE Prime Remote (TPR)
enrollees who require urgent specialty care while traveling outside
the 50 U.S. and the District of Columbia.
Note: This process applies to all
TOP Prime Remote enrollees, regardless of the status/location of the
referring provider or health unit.
3.1.4 Beneficiaries
enrolled to the Uniformed Services Family Health Plan (USFHP) and
the Continued Health Care Benefit Program (CHCBP) must follow the
requirements of those programs when obtaining overseas care.
3.2 The TOP HCF is responsible
for the following functions:
3.2.1 Referral
Assistance for TOP Beneficiaries
The TOP contractor (working
in concert with the MTF Commander) shall ensure optimal use of MTFs
and to foster coordination of all care delivered in the civilian
sector and care referred to and from the MTF. The TOP HCF is the
primary mechanism for achieving these objectives. The referral services
of the TOP HCF are primarily for ensuring access to care for enrolled
beneficiaries, but the TOP HCF is also available to assist non-enrollees
in finding network/non-network purchased care sector providers.
For TOP Prime/TOP Prime Remote enrollees, the referral is generally
initiated by the beneficiary’s PCM. The PCM or beneficiary contacts
the TOP HCF for assistance in locating an appropriate purchased
care sector provider and to obtain authorization for the care (see
Sections 16 and
17 for additional information
on HCF referral assistance).
3.2.2 Referral
Assistance for Beneficiaries Enrolled or Residing in the 50 U.S.
and the District of Columbia
The TOP contractor shall provide
referral assistance for TRICARE Prime/TPR enrollees who require
urgent or emergent health care while traveling outside the 50 U.S.
and the District of Columbia. These referrals will generally be
initiated by the beneficiary, a purchased care sector provider,
or an overseas MTF provider. Emergency care never requires preauthorization;
however, ADFMs enrolled to TRICARE Prime/TPR may receive routine,
urgent and emergency health care services in locations outside the
50 U.S. and the District of Columbia (to include emergency medical
evacuation per
Section 7) on a cashless, claimless basis
if the care is coordinated in advance with the TOP contractor. The
TOP contractor shall implement guarantee of payment or other business
processes to ensure that ADFMs enrolled to TRICARE Prime/TPR receive
routine, urgent or emergency medical services on a cashless, claimless
basis upon beneficiary request.
3.2.3 Authorizations
3.2.3.1 The TOP HCF will authorize
care for TPR enrollees; for Service members who are on TAD/TDY,
in an authorized leave status, or deployed, deployed on liberty
in a remote overseas location, and for TRICARE Prime/TPR enrollees
who require urgent or emergent health care while traveling outside the
50 U.S. and the District of Columbia. The contractor shall also
ensure that MTF-issued authorizations are entered into all applicable
contractor systems. Non-emergent specialty health care received
from a purchased care sector provider must be authorized if benefits
are to be paid as TOP Prime/TPR.
3.2.3.2 Care subject to a PCM referral/authorization
may receive a clinical review and authorization by the HCF or other
designee.
3.2.4 If
an ADFM TOP Prime/TOP Prime Remote enrollee receives care that was
not authorized, the care may be covered under the TOP POS option,
with POS deductibles and cost-shares. POS provisions also apply
to TRICARE Prime/TPR enrollees who receive routine care outside
the 50 U.S. and the District of Columbia without obtaining prior
authorization from the TOP contractor. The care must also be otherwise
coverable under TRICARE or the claim shall be denied.
3.2.5 Service member care that was
not referred and authorized shall be denied unless it is retroactively
authorized by the appropriate service and Director, DHA. This included
obtaining an approved waiver for any non-covered service. POS does
not apply to Service members.
4.0 Customer Service Responsibilities
TOP
customer support shall be provided to all Military Health System
staff to include, but not limited to, TOPO, TAOs, Beneficiary Counseling
and Assistance Coordinators (BCACs)/Debt Collection Assistance Officers
(DCAOs), stateside TROs, stateside contractors, stateside TRICARE
beneficiaries traveling overseas, and DHA staff. TOP contractor
customer support service shall include the following:
4.1 The TOP contractor shall secure
at a minimum one dedicated post office box for the receipt of all
claims and correspondence from foreign locations per overseas region.
4.2 The TOP contractor shall identify
a specific individual and an alternate to assist the Director, TROs,
TOPO/TAO Directors, DHA, BCACs and stateside claims processing contractors
with the resolution of TOP issues. Issues which cannot be successfully
resolved shall be referred to the TOP Contracting Officer’s Representative
(COR).
4.3 The
TOP contractor shall identify a specific individual and an alternate
to assist DCAOs with the resolution of TOP beneficiary debt collection
issues.
4.4 The
TOP contractor shall be responsible for establishing and operating
a dedicated TRICARE overseas claims/correspondence processing department
with a dedicated staff. This department and staff shall be under
the direction of a supervisor, who shall function as the contractor’s
POC for TRICARE overseas claims and related operational and support
services. The contractor’s department for TRICARE overseas claims
shall include at a minimum the following functions/requirements:
4.4.1 The TOP contractor shall provide
toll-free telephone service for claims assistance to beneficiaries
and providers 24 hours per day, seven days a week, 365 days a year.
Toll-free services shall be available from any stateside or overseas
location.
4.4.2 The
TOP contractor shall have the ability to translate claims submitted
in a foreign language and write in German, Italian, Japanese, Korean,
Tagalog (Filipino), and Spanish, or shall have the ability to obtain
such translation or writing.
4.4.3 The
TOP contractor shall provide on-line read only access to their claims
processing system to TOPO, each TAO, and the DHA technical representative
for TOP claims.
4.4.4 The
TOP contractor shall provide a secure, user-friendly Internet portal
for receipt of customer claims status inquiries and access to claims
status information (to include the ability to view and print Explanation
of Benefits (EOBs).
4.4.5 The
TOP contractor shall provide, upon Government request, documentation
of claims for auditing purposes.
4.5 The
TOP contractor shall assist traveling TOP Prime and Prime Remote
enrollees to ensure beneficiary access/receipt of urgent or emergent
care in the 50 U.S. and the District of Columbia. The contractor
shall also assist beneficiaries residing or enrolled in the U.S.
or the District of Columbia who require urgent or emergent care
while traveling overseas. ADFMs who are enrolled to TRICARE Prime
or TPR may receive emergency medical services in locations outside
the 50 U.S. and the District of Columbia (to include emergency medical
evacuation) on a cashless, claimless basis if the care is coordinated
in advance with the TOP contractor.
5.0 BENEFICIARY SERVICES
5.1 The TOP contractor shall achieve
the highest level of beneficiary satisfaction possible in the overseas
environment. This shall be accomplished by developing qualified
purchased care sector provider networks (complemented by non-network
purchased care sector providers as necessary), ensuring timely access
to purchased care sector care, providing TOP information/education/training
to beneficiaries and purchased care sector providers, and processing
claims in a timely, accurate manner.
5.2 In
addition to the beneficiary education requirements outlined in
Chapter 11, Sections 1 and
2, the
TOP contractor may be required to conduct beneficiary education/enrollment
activities for arriving/deploying units in accordance with the enrollment
protocols established in the SOR between the TOP contractor and
the MTFs.
5.3 The
TOP contractor shall maintain up-to-date lists of purchased care
sector network providers, and shall make this information available
at all TOP TSCs and via web-based access. Web-based network provider
listings shall include information regarding authorization requirements
that are applicable to TOP Prime and Prime Remote enrollees.
5.4 The TOP contractor’s beneficiary
education activities and materials shall include information for TOP
Prime and Prime Remote enrollees regarding care received in the
50 U.S. and the District of Columbia. This process shall include
information regarding referrals/authorizations while stateside,
TOP POS policy, and the recommended process for accessing care while
stateside. TOP Prime and Prime Remote enrollees traveling stateside
shall be encouraged to utilize MTF care whenever possible. If MTF care
is not available, beneficiaries should be encouraged to seek care
from a network provider before obtaining care from a non-network
provider.
5.5 The requirement in
Chapter 11, Section 2, paragraph 1.1, is superseded
for the TOP contractor by a requirement for a total of nine three-day
TRICARE training courses per contract option period (two per option
period within the TRICARE Eurasia-Africa area; two within the TRICARE
Pacific area; two within the TRICARE Latin America/Canada (TLAC)
area; and three additional courses that may occur in any stateside
or overseas location at the direction of the Contracting Officer
(CO)).
6.0 PROVIDER SERVICES
6.1 The TOP contractor shall ensure
that all purchased care sector network providers and their support
staff have sufficient understanding of the applicable TRICARE program
requirements, policies, and procedures to allow them to carry out
the requirements of this contract in an efficient and effective manner
that promotes beneficiary satisfaction.
6.2 The
TOP contractor shall have the responsibility for developing and
delivering TRICARE Program information to purchased care sector
providers. The contractor shall determine the requirements for printed
products and will develop and deliver these products after obtaining approval
from the Government. The information in these products will generally
be determined by the contractor based on their understanding of
the needs of their network providers; however, the Government may
mandate the inclusion of certain topics or information.
6.3 Provider education materials
shall include information regarding claims processing procedures, claims
submission deadlines, and normal claims processing time lines.
6.4 The Government shall ensure
provider satisfaction with contractor-provided information by conducting
random satisfaction surveys of select network providers.