All TRICARE requirements regarding
program integrity shall apply to the TRICARE Overseas Program (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unless specifically changed, waived, or superseded by this section;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
Chapter 13 for
additional instructions.
1.1 In
addition to the requirements outlined in
Chapter 13,
the Government may implement additional requirements as necessary
to prevent or detect fraud in overseas locations.
1.1.1 The
contractor shall perform 12 Statistically Valid Random Sample (SVRS)
audits per option period to examine and verify the accuracy of claims.
See
Chapter 13, Section 3 for additional information
regarding case development audits. The contractor shall ensure that
an SVRS is done in accordance with
Chapter 13, Section 3, paragraph 3.2.2. Those
audits meeting the dollar threshold for case referrals shall be
handled in accordance with
Chapter 13 provisions.
1.1.2 For
those audits not meeting the dollar threshold for case referrals,
recoupment action shall be taken on actual damages determined as
a result of errors identified in an SVRS. See
Chapter 13 for further
guidance.
Note: TRICARE guidance regarding
anti-fraud programs at Military Treatment Facilities (MTFs) is contained
in Department of Defense Instruction (DoDI) 5505.12 (October 3,
2013). This instruction is located at:
https://www.hsdl.org/?view&did=744970.