1.0 GENERAL
1.1 TOP Prime
is available to Service members (including Reserve Component (RC)
members activated for more than 30 days) who are on permanent assignment
overseas in a location serviced by a Military Treatment Facility
(MTF), Command-Sponsored Active Duty Family Members (ADFMs), accompanying
the sponsor or on service orders, and certain transitional survivors
and Transitional Assistance Management Program (TAMP)-eligible beneficiaries
according to the eligibility and enrollment provisions of
Section 5. TOP Prime offers enrollees access
to a Primary Care Manager (PCM), clinical preventative services,
and specialty services.
1.2 TOP Prime has no enrollment
fees, and deductibles. Cost-shares are waived except for TOP Prime
ADFMs who receive care under the Point of Service (POS) option,
or who obtain pharmacy services in the 50 United States (U.S.),
the District of Columbia, or U.S. territories where the TRICARE Pharmacy
(TPharm) contractor has established a retail pharmacy network. Waiver
of copayment and deductibles under TOP Prime is subject to review/updating
based on enrollment status.
1.3 Under
TOP Prime, annual catastrophic caps are calculated on calendar years.
The enrollment year shall coincide with the calendar year. Since
deductibles and cost-shares are waived for TOP Prime enrollees,
this policy will apply only to TOP Prime enrollees who incur out-of-pocket
expenses as described above.
2.0 Contractor Responsibilities
2.1 TOP Prime enrollees shall select
or have assigned to them PCMs according to guidelines established
by the MTF Commander, TRICARE Area Office (TAO) Director, or designee.
TOP Prime enrollment to a purchased care sector PCM may only occur
when all available capacity in the MTF has been reached. The TOP
PCM:
2.1.1 May be an individual professional
provider in an overseas MTF, other military treatment site, or other
health care delivery arrangement that is part of the MTF. MTF PCMs
may be organized into teams for the purpose of ensuring patient
continuity and accountability in the event that the individual’s
assigned PCM is absent or unavailable.
2.1.2 May be
a purchased care sector primary care provider (internist, family
practitioner, pediatrician, General Practitioner (GP), Obstetrician/Gynecologist
(OB/GYN, Physician Assistant (PA), Nurse Practitioner (NP), or Certified
Nurse Midwife (CNW)) when determined by the TOP contractor to meet
governing country rules and licensure requirements. See
Section 28 for additional provider certification
requirements in the Philippines.
2.1.3 May also
act as a Health Care Finder (HCF), when dual responsibility is necessary,
as determined by the MTF Commander or TAO Director.
2.2 A TOP Prime enrollee must seek
all his or her primary health care from the TOP PCM with the exception
of care listed in
Section 8. If the TOP PCM is unable to provide
the care, the TOP PCM is responsible for referring the enrollee
to another primary care provider.
2.3 TOP Prime
enrollees must obtain appropriate referral/authorization for any
non-emergency care rendered by anyone other than the beneficiary’s
PCM or another MTF provider. This provision applies regardless of
where the care is rendered. MTFs may submit requests for retroactive authorizations
up to three business days after the care was rendered. After three
business days, the TAO Directors and/or Chief, TOP Office (TOPO)
may direct retroactive authorizations on a case-by-case basis. Routine
care is generally not authorized while a TOP Prime enrollee is traveling
out of their enrollment region; however, exceptions may be made
for unusual circumstances on a case-by-case basis with PCM referral
and appropriate written justification from the referring MTF. Emergent/urgent care
does not require prior authorization; however, the beneficiary should
contact their PCM and the TOP contractor as soon as possible to
arrange any necessary follow-up care.
2.4 Failure
to obtain a TOP PCM referral/authorization when one is required
for care may result in the service being paid under TOP Point of
Service (POS) procedures for an ADFM with a deductible and cost-shares
for outpatient services and cost-shares for inpatient services.
2.5 The TOP PCM is responsible
for notifying the TOP HCF that a referral is being made/requested. The
TOP HCF will assist the TOP Prime enrollee and other beneficiaries
in locating an MTF or purchased care sector TOP network or non-network
provider to provide the care, and to assist in scheduling an appointment
upon request. The HCF will conduct a benefit determination review
and provide authorization for service for which the referral was
made. If the contractor has no record of referral/authorization,
prior to denial/payment, the contractor will follow the TOP POS
rules, assuming the service is a covered benefit.
2.6 TOP MTF PCMs may be delegated
authority by the TOP MTF Commander to authorize referrals within
the MTF. All referrals/authorizations to civilian purchased care
sector providers and all referrals/authorization made by a TOP designated
purchased care sector PCM must be made through the TOP HCF and must
receive an authorization.
2.7 The
TOP contractor shall ensure that all authorized services for TOP
Prime enrollees are provided on a cashless, claimless basis. The
contractor shall implement guarantee of payment or other business
arrangements to ensure that TOP Prime enrollees are not required
to pay up front at the time services are rendered by a purchased
care sector provider.
2.8 Cashless,
claimless provisions do not apply to self-referred care that would
normally require authorization.
2.9 In
accordance with the Statement of Responsibilities (SOR), MTFs will
determine if they have the capability and capacity to provide needed
specialty inpatient care. Submission of an MTF referral shall signify
that the referring MTF has determined that the care cannot be provided
by the direct care system within the TRICARE access standards. In
Puerto Rico, the local MTF must have the opportunity to review
each referral from a purchased care sector PCM to determine if the
MTF has the capability and capacity to provide the care. Specific
language regarding this process shall be incorporated into each SOR
with all MTFs with Puerto Rico.
2.10 For
TOP Prime enrollees who are traveling in the 50 U.S. or the District
of Columbia, the TOP contractor and the TAO Directors will encourage/direct
TOP beneficiaries to utilize stateside MTFs and TRICARE network
providers whenever possible. If MTF care is unavailable, beneficiaries
shall be provided with information regarding the nearest available
network provider(s) who can assist the beneficiary. Non-network
providers should only be used when MTF or network care is not available.
2.11 ADFMs
enrolled in TOP Prime may obtain urgent care from any authorized
provider without a PCM (if assigned) referral or overseas contractor
authorization. In order to ensure the urgent care visit will be
cashless/claimless, the ADFMs enrolled to TOP Prime should contact
the TOP contractor to obtain an authorization. Without this authorization,
overseas providers may request payment upfront (overseas providers
may bill above the TRICARE allowable amount without any limits)
and the beneficiary will then have to submit a claim for reimbursement.
3.0 POS Option
3.1 TOP
Prime-enrolled ADFMs are required to follow established referral/authorization
procedures prior to obtaining specialty care to avoid the application
of POS cost-shares and deductibles. This includes all self-referred,
non-emergency outpatient specialty medical services and all inpatient
care (including inpatient mental health care), except for outpatient
mental health and Substance Use Disorder (SUD) visits, ancillary
services, and drugs. TOP Prime ADFMs who self-refer to a civilian
provider other than their PCM shall have their claims processed
as POS.
3.2 POS
cost-shares and deductibles shall not apply to claims for care received
by newborns/adoptees during the deemed enrollment period.
3.3 Self-referred,
non-emergency, non-urgent, specialty, or inpatient care provided
to a TOP Prime enrollee by a network or non-network purchased care
sector provider, which is not either provided/referred by the beneficiary’s
PCM or specifically authorized may be reimbursed only under the
TOP Prime POS option if it is a TRICARE benefit. Services which
are not a TRICARE benefit shall be denied.
3.4 POS cost-sharing and deductible
amounts do not apply if a TOP Prime enrollee has Other Health Insurance
(OHI) that provides primary coverage. The OHI must be primary under
the provisions of the TRICARE Reimbursement Manual (TRM),
Chapter 4, Section 1, and documentation that
the other insurance processed the claim and the exact amount paid
must be submitted with the TOP claim. TRICARE OHI provisions apply
for this type of claim.
3.5 The POS option does not apply
to Service member overseas/stateside care.
3.6 The
TOP contractor shall adjust TOP Prime copayments when TOP PCMs or
HCFs do not follow established referral/authorization procedures.
For example, if the contractor processes a claim without evidence
of an authorization and/or a referral under POS provisions, and
the contractor later verifies that the PCM or other appropriate
provider referred the beneficiary for the care, the contractor shall adjust
the claim under TOP Prime provisions. The contractor need not identify
past claims, however, the contractor shall adjust these claims as
they are brought to their attention.
3.7 On
a case-by-case basis, following stabilization of the patient, the
MTF Commander may require a TOP Prime beneficiary to transfer to the
MTF. The 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 TOP Prime-enrolled ADFM elects
to remain in a non-network facility following notification of an
impending transfer to another facility, TOP POS cost-sharing will
begin 24 hours following receipt of the written notice. The MTF
Commander may not require a transfer until such time as the transfer
is deemed medically safe.
3.8 See the TRM,
Chapter 2, Section 5 for the deductible and
cost-share amounts which apply to all TOP Prime POS claims for health
care services:
• POS deductible and cost-sharing
do not apply to the claims for care received by certain newborn
and newly adopted children during the deemed enrollment period.
See
Section 5 for additional guidance regarding
deemed enrollment for newborns/adoptees.