Military Health System

1.1  The Supplemental Health Care Program (SHCP), with specific exceptions discussed in this chapter, allows for payment of claims for civilian services rendered pursuant to a referral by a provider in a Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM), as well as for Civilian Health Care (CHC) received by eligible Uniformed Service members. The SHCP exists under authority of 10 USC 1074(c) and 32 CFR 199.16(a)(3). The use of the SHCP for pay for care referred by MTF/eMSM providers is governed by Assistant Secretary of Defense (Health Affairs) (ASD(HA)) Policy Memorandum 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,” February 21, 2012.

1.2  SHCP-eligible Service members may include members in travel status (leave, TDY/TAD, permanent change of station), Navy/Marine Corps Service members enrolled to deployable units and referred by the unit Primary Care Manager (PCM) (not an MTF/eMSM), eligible Reserve Component (RC) personnel, Reserved Officer Training Corps (ROTC) students, cadets/midshipmen, and eligible foreign military.

1.3  The fact that civilian services have been rendered to an individual who is enrolled to an MTF/eMSM PCM does not mean that those services were MTF/eMSM referred care. If a claim is received for a Service member MTF/eMSM enrollee and no authorization is on file, the MTF/eMSM must be contacted to determine if the care was MTF/eMSM referred.

2.1  For care that is in a TRICARE Prime Remote (TPR) designated area not referred by an MTF/eMSM and is not in an area served by the TRICARE Overseas Program (TOP) contractor, the SAS will identify, and coordinate the CHC furnished to Service members including preauthorization of care when required and notify the nearest same service MTF/eMSM for civilian routine and emergency hospital admissions so they can assume patient oversight responsibilities. The entities performing the SAS functions are identified in Addendum A.

2.2  The contractor will also receive claims for MTF/eMSM patients who may require medical care that is not available at the MTF/eMSM (e.g., MRI) and the MTF/eMSM refers a patient for civilian medical care (this includes all civilian care provided to a Service member MTF/eMSM enrollee). In these cases, the contractor shall contact the referring MTF/eMSM for any necessary medical oversight or authorization of care.

3.1  The contractor shall provide payment for inpatient and outpatient services, for MTF/eMSM-referred civilian care ordered by an MTF/eMSM provider for an MTF/eMSM patient for whom the MTF/eMSM provider maintains responsibility. This includes claims for members on the Temporary Disability Retirement List (TDRL) obtaining required periodic physical exams. After payment of the claim, the contractor shall furnish the Services with information regarding payment of the claim as specified in the contract.

3.2  The contractor shall provide payment for inpatient and outpatient medical services for CHC received by eligible Uniformed Service members in accordance with the provisions of this chapter. After payment of the claim, the contractor shall furnish reports as specified in the contract.

4.1  Service members have no cost-shares, copayments, Point of Service (POS) charges, or deductibles. If they have been required by the provider to make “up front” payment they may upon approval be reimbursed in full for amounts in excess of what would ordinarily be reimbursable under TRICARE. Application of Other Health Insurance (OHI) is generally not considered (see Section 3, paragraph 1.2.3).

4.2  There will be no application by the contractor of OHI processing procedures for Service member claims under SHCP.

4.3  If Third Party Liability (TPL) is involved in a claim, claim payment will not be delayed while the TPL information is developed (see Section 3, paragraph 1.3).

4.4  The contractor shall provide MTF/eMSM-referred patients the full range of services offered to TRICARE Prime enrollees.

4.5  If a Service member intends, while in a terminal leave status, to reside outside of the Prime Service Area (PSA) of the MTF/eMSM where the Service member is enrolled, the MTF/eMSM shall issue to the TRICARE contractor a single preauthorization for the Service member to obtain from the Department of Veterans Affairs (DVA)/Defense Health Administration (VHA) any routine or urgent outpatient primary medical care that should be required anytime during the terminal leave period, except the preauthorization shall not apply to services provided under the terms of the Department of Defense (DoD)/DVA Memorandum Of Agreement (MOA) for “Medical Treatment Provided to Active Duty Service Members with Polytrauma Injury, Spinal Cord Injury, Traumatic Brain Injury or Blindness.” Claims from the DVA/VHA for services provided under terms of the MOA shall be processed as specified in Section 2, paragraph 3.0. The contractor shall process a claim received from the DVA/VHA for services provided within the scope of the preauthorization using the standards in Chapter 1 unless otherwise stated in this chapter. The claims tracking and retrieval requirements of Chapter 1, Section 3, paragraph 2.1 apply equally to such SHCP claims. The contractor for the region in which the patient is enrolled shall process the claim to completion.

4.6  Services that would not have ordinarily been covered under TRICARE policy (including limitations and exclusions) may be authorized for Service members 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 (paragraph 2.0).

4.7  Payment may be made for services furnished by providers who are not TRICARE-authorized or certified (paragraphs 2.1 and 2.2).