1.0 Introduction
TPRADFM provides TRICARE Prime
like benefits to certain Active Duty Family Members (ADFMs) who
reside with the TRICARE Prime Remote (TPR) enrolled sponsor in remote
locations in the United States (U.S.) and the District of Columbia
(DC).
It also provides continued TPRADFM eligibility for family members
residing at remote locations after the departure of the sponsor
for an unaccompanied assignment, and eligibility for family members
of Reserve Component (RC) members
(referred to as sponsors
for the remainder of this Section) called or ordered
to active duty
for more than 30 days
. TPRADFM
benefits are comparable to TRICARE Prime, including access standards,
benefit coverage, and cost-shares. TPRADFM does not apply to ADFM
enrollees in areas outside the 50 U.S. Such care and claims shall
be processed in accordance with the TRICARE Overseas Program (TOP),
Chapter 24 and TRICARE Policy Manual (TPM),
Chapter 12. The Specified Authorization Staff
(SAS) is not involved in any part of TPRADFM.
2.0
Enrollment
QualificationsFamily
members qualify to enroll into TPRADFM, if they meet
the requirements specified
in one of the following paragraphs.
2.1 The sponsor
is enrolled in TPR and the ADFM resides
with the sponsor in a TPR residence
(i.e., TPR zip code).
2.2 The sponsor is
enrolled to a small Government clinic, troop medical clinic, Coast
Guard clinic or other Military Treatment Facilities/Enhanced Multi-Service
Markets (MTFs/eMSMs) designated by the Services to allow Active
Duty Service Member (ADSM) enrollment only and offer zero capacity
to enroll non-ADSM beneficiaries. DHA will provide a list of Defense
Medical Information System Identification Codes (DMIS-IDs) MTFs/eMSMs
that only enroll ADSM. The DMIS-ID list will be an attachment in
the Managed Care Support Contract (MCSC). The ADFM must reside with
the sponsor who is enrolled in an MTF/eMSM that only enrolls ADSMs.Note: ADFMs who reside
within a Prime Service Area (PSA) are eligible for TRICARE Prime
and thus are not eligible for enrollment in TPRADFM even if the
Service member is enrolled in TPR. The ADFMs shall be enrolled within
the PSA of residence except as specified in paragraph 2.2.
2.3 If an ADSM receives
a subsequent unaccompanied assignment after the TPR assignment and the
family members are not authorized to accompany the member to the
next duty assignment, and they continue to reside in the same TPR address,
the family members may remain in TPRADFM for the duration of the
subsequent assignment.
2.4 If an RC member
sponsor becomes eligible for TRICARE because of a call or order
to active duty for a period of more than 30 days, their eligible
family members become eligible to enroll into TPRADFM upon becoming
TRICARE-eligible (i.e., beginning the date early eligibility TRICARE
starts or date of activation, whichever is first) if they meet all
of the following eligibility requirements:
2.4.1 The family members “reside
with” the member in a
TPR residence (i.e., in a TPR zip code) at the time
of activation the RC
sponsor and their family members become
eligible for TRICARE.
2.4.2 The RC member
sponsor does not have to be TPR eligible or enrolled.
2.4.3 Once enrolled in TPRADFM, the
family members may remain in TPRADFM
for the period of TRICARE eligibility,
regardless of the subsequent assignment, enrollment location, or
residence of the sponsoring RC member as
long as the family member continues to reside at the same TPR residence address.
2.4.4 Family members who
meet the TPRADFM eligibility criteria may enroll up
to 90 days after the sponsor has deployed/left the
TPR address for assigned duty.
2.5 ADFMs
currently enrolled in TPRADFM, who transition to Transitional Survivor
status, may remain enrolled in TPRADFM. See TPM, Chapter 10, Section 7.1 for further information.2.5.1 All
Transitional Survivors may enroll in TPRADFM. At the request of
the Transitional Survivor the contractor shall accept and process
a new and continued enrollment request (enrollment form, the Government
furnished web-based self-service enrollment system/application transaction,
or telephonic request documented in the contractor’s call center
notes) submitted by any Transitional Survivor living in, or moving
to a TPR area. Enrollment in TPRADFM may continue for Transitional Survivors
for the entire Transitional Survivor period. After the Transitional
Survivor period, TPRADFM is not available to Survivors. A Survivor
(versus a Transitional Survivor) is eligible for retiree family member
benefits and cost-sharing.
2.5.2 Transitional
Survivor/Survivor status does not impact TRICARE eligibility rules.
Loss of eligibility as a result of any condition which routinely
results in loss of TRICARE eligibility such as reaching age limits,
marriage, remarriage, etc. also results in loss of Transitional
Survivor/Survivor status.
3.0 Benefits
TPRADFM enrollees are
eligible for the TRICARE Prime Benefit,
even in areas without contractor networks.
4.0 Network Development
4.1 TPRADFM offered
outside of a PSA has no network development requirements,
except where contractually required. ADFMs enrolled in TPRADFM shall
be assigned, or be allowed to select, a Primary Care Manager (PCM)
when in the provider network. If a
network provider is not available to serve as a primary care provider,
the TPRADFM enrollee may utilize any local TRICARE participating
or authorized provider for primary care services.
4.2 TPRADFMs enrollees are
required to use TRICARE network providers
where available within contractual access standards. If a network
provider cannot be identified within the access standards, the enrolled
family member shall use a TRICARE authorized provider. Contractors
shall assist TPRADFM enrollees
in finding a network or non-network
TRICARE authorized provider for specialty care. TPRADFM
enrollees may be eligible for the Prime travel benefit
when referred more than 100 miles for specialty care inside
the 50 U.S. and DC. If the contractor has not established
a network of PCMs in a remote area, a TPRADFM enrollee will
be enrolled without a PCM assigned. A generic PCM code shall be used
for TPRADFM enrollees without assigned PCMs. The ADFM without an
assigned PCM will be able to use a local TRICARE authorized
provider (participating or non-participating) for
primary health care services without a PCM’s approval.
If a TPRADFM questions whether a service is covered as primary care,
they may contact the contractor for assistance.
5.0 Uniformed Services Family Health
Plan (USFHP)
If
a USFHP is available to ADFMs in a TPR area, the ADFMs have the
choice of enrolling in the USFHP, enrolling in TPRADFM or
enrolling in TRICARE Select. ADFMs
choosing to enroll in USFHP will be unable to access care through MTFs/eMSMs or
the TRICARE system.
6.0 Referrals
6.1 Specialty
care requires a referral through the contractor. If the TPRADFM enrollee
is assigned to a PCM, the PCM shall follow the contractor’s
referral and authorization procedures. In cases where the TPRADFM enrollee is
not assigned to a PCM, the TPRADFM enrollee,
or the TPRADFM enrollee’s
parent or guardian, is responsible
for directly contacting the contractor to obtain referrals and authorizations
if required. The TPRADFM enrollee should
obtain a referral request from their primary care provider and the TPRADFM enrollee
should forward that request to
the contractor.
6.2 TPRADFM
enrollees are required to obtain a referral and use TRICARE network
providers for specialty care where available within TRICARE access
standards or pay the Point of Service (POS) deductible and cost-share
unless an appropriate out-of-network referral is obtained as required
under TRICARE Prime.
7.0 Provider Education
Contractors
shall familiarize network providers and, when appropriate, other
providers with TPRADFM. The contractor shall propose an educational
plan to the Director, TRICARE Health Plan (THP) outlining
how providers will become familiar with TPRADFM. The contractor
shall provide separate and distinct information to PCMs about the
requirements and the special procedures for handling TPRADFM enrollees’
care (e.g., specialty care referral requirements, balance billing
limitations, etc.). The contractors shall include information on
TPRADFM specialty care procedures, benefits, or requirements in
routine information and educational programs.
8.0 Beneficiary Education
8.1 Beneficiary education will
be a joint effort with the Government providing all beneficiary educational
materials for the TPR program.
8.2 The
contractor shall utilize leading industry best practices in its
outreach and communication with all MHS customers consistent with
that offered to its commercial customers. Customer services shall
include multiple, contemporary avenues of access (for example, e-mail,
World Wide Web (WWW), telephone, texting, and smart phone applications,
and other social media) for the MHS beneficiary. If the contractor
chooses to distribute the supplied
educational materials, the contractor is responsible for postage,
envelopes, and mailing costs.
8.3 The
contractor shall give TPRADFM enrollees
the option of participating in health promotion and wellness programs
offered in the direct care system and network locations. The contractor
shall design and conduct, with Director, THP approval,
TPRADFM briefings. The contractor shall include TPRADFM information
and updates as part of all TRICARE briefings. Ongoing briefings
will be on an “as needed” basis and will be coordinated with the
Director, THP.
8.4 Enrollment in TPRADFM is optional
for ADFMs who qualify for the program; therefore, a contractor shall
limit educational activities for TPRADFM enrollees to distributing
the materials provided or approved by the Government.
9.0 Enrollment
9.1 When
the contractor receives an enrollment request (enrollment form,
the Government furnished web-based self-service enrollment system/application
transaction, or telephonic request documented in the contractor’s
call center notes) from an ADFM for TPRADFM, the contractor shall ensure
the
sponsor is
qualified
based on the requirements in paragraph 2.0. If a
TPRADFM
enrollment request is received and the
family member
does not qualify for TPRADFM, the request shall be
returned to the sender with a notice that the
family
member is not eligible for TPRADFM and the reason(s)
why
TPRADFM enrollment was denied.
Additionally,
see
paragraph 9.4 when a TPRADFM enrollment request
is received for a family member of a
n RC
sponsor
on active service for more than 30 days.
9.2 Enrollment in TPRADFM is optional
for qualified family members. However, qualified
family members must enroll within 90 days of their
move to a TPR location (a Qualifying Life Event (QLE)) or during
the open enrollment season in TPRADFM to receive the TPRADFM benefit. Qualified
family members who elect not to enroll in TPRADFM
may enroll in TRICARE Prime (where
available, with access standards waived) or TRICARE
Select.
9.3 An enrollment
request (enrollment form, the Government furnished web-based self-service enrollment
system/application transaction, or telephonic request documented
in the contractor’s call center notes) must be submitted to the
contractor by either the
qualified family members or
the Service member’s sponsor for each family member enrolling in
TPRADFM. See
Chapter 6, Section 1, for effective date rules.
An
official enrollment request includes those with:
• An original
signature;
• An electronic signature offered
by and collected by the contractor;
• A verbal
consent provided by telephone and documented in the contractor’s
call notes; or
• A self-attestation by the beneficiary
when using the Government furnished web-based self-service enrollment
system/application.
Note: A written signature is not
required to make enrollment changes when using the Enrollment Portability
process outlined in
Chapter 6, Section 2.
9.4 When
the contractor receives an enrollment request (enrollment form,
Government furnished web-based self-service enrollment system/application
transaction, or telephonic request documented in the contractor’s
call center notes) for TPRADFM from a family member of an RC sponsor called
or ordered to active service for more than 30 days, the contractor
shall validate the family members’ eligibility
in DEERS.
9.5 The
contractor shall follow enrollment portability and transfer procedures
in
Chapter 6, Section 2.
Additionally,
if at any point
the
contractor determines or is advised that a family member is no longer eligible
for TPRADFM, the contractor shall notify (letter, telephone call,
or e-mail) the
sponsor of the discrepant
enrollment immediately. If the discrepant enrollment is not corrected
within 30 days of the notification date, the contractor shall disenroll
the family member(s) from TPRADFM effective the first of the month
after 30 days from the initial notification date
.
The contractor shall provide information on
TRICARE
Select
, and that they have 90 days
from the date of the disenrollment to enroll in a TRICARE plan or
they only will be eligible for MTF/eMSM care on a space-available
basis.
9.6 The contractor shall enroll
the
TPRADFM
qualified
family member in the Government furnished web-based
system/application and enter the TPRADFM
’s
enrollment status into Government furnished web-based system/application.
The contractor shall use the DMIS-ID code(s) designated by the
Director,
THP for that region to enroll ADFMs into TPRADFM
(see the TRICARE Systems Manual (TSM)).
See paragraph 10.0 for
PCM assignment requirements.
9.7 DEERS
will automatically update start and/or end dates of coverage when
a beneficiary’s eligibility is updated as described in Chapter 6, Section 1. The contractor will
receive a Policy Notification Transaction (PNT) advising them of
all changes.
10.0 PCM
Assignment
At
the time of enrollment, a
TPMADFM
qualified
family member will select (or will be assigned) a
PCM within the access standard. The contractor shall advise the
TPMADFM
enrollee of
the availability of PCMs. If a PCM is not available
or
the contractor has not established a network of PCMs in a TPR area, the
ADFM shall be enrolled to TPRADFM without an identified PCM
assigned.
See paragraph 4.2.
11.0 Support Services
11.1 Inquiries
The
contractor shall designate a point of contact for Government inquiries
related to TPRADFM. The contractor may establish a dedicated unit
for responding to inquiries about TPRADFM, or may augment existing
TPR service units already serving
TPR
enrollees.
The correspondence requirements and standards in
Chapter 1, Section 3, apply to TPRADFM written
inquiries.
11.2 Toll-Free
Telephone Service
The
contractor shall provide toll-free telephone access for TPRADFM
beneficiary inquiries.
12.0 Claims Processing
The
regional contractor where the TPRADFM is enrolled shall process
all claims for that enrollee, except for care provided overseas
(i.e., care outside of the 50 U.S. and DC).
Civilian health care while traveling or visiting overseas shall
be processed by the TOP contractor, regardless of where the beneficiary
is enrolled. POS claims processing provisions do apply. Details
for reporting TPRADFM claims information are identified in DD Form
1423, Contract Data Requirements List (CDRL), located in Section
J of the applicable contract.
13.0 Claim
Reimbursement
13.1 The
payment provisions applicable under TPR for Service members which
allow for additional payment in excess of otherwise allowable amounts
to providers who are not TRICARE-authorized or certified do not
apply to TPRADFM. Such payments shall not be made unless such payments
are otherwise allowed under the payment provisions for unauthorized
providers contained in the TPM.
13.2 For network providers, the
contractor shall pay TPRADFM claims at the negotiated rate. For participating
providers the contractor shall pay up to the CHAMPUS Maximum Allowable
Charge (CMAC), or billed charges, whichever is less. Contractors
shall follow the requirements in
Chapter 8, Section 5 and
the TRICARE Reimbursement Manual (TRM),
Chapter 5, Section 1, for claims for TPRADFM enrollees
receiving care from non-participating providers.
13.3 If a non-participating provider
requires a TPRADFM enrollee to make an “up front” payment for health
care services, in order for the enrollee to be reimbursed, the enrollee
must submit a claim to the contractor with proof of payment and
an explanation of the circumstances.
13.4 If
the contractor becomes aware that a civilian provider is “balance
billing” a TPRADFM enrollee or has initiated collection action for
emergency or authorized care, the contractor shall notify the provider
that balance billing is prohibited (see TRM,
Chapter 3, Section 1).
13.5 If CMAC rates have been waived
for TPR Service member enrollees under
Section 4, paragraph 3.5, the TPRADFM enrollee
shall not be extended the same waived CMAC rates. If required services
are not available from a network or participating provider within
the medically appropriate time frame, the contractor shall arrange
for care with a non-participating provider subject to the normal reimbursement
rules. The contractor shall make every effort to obtain the provider’s
agreement to accept, as payment in full, a rate within 100% of the
CMAC limitation. If this is not feasible, the contractor shall make
every effort to obtain the provider’s agreement to accept, as payment
in full, a rate between 100% and 115% of CMAC. By law the contractor
shall not negotiate a rate higher than 115% of CMAC for TPRADFM
care rendered by a non-participating provider. The contractor shall
ensure that the approved payment is annotated in the authorization/claims
processing system.
14.0 Appeals
Process
TPRADFM
enrollees may appeal denials of authorization or reimbursement through
the contractor in accordance with
Chapter 12.
If the contractor denies authorization or reimbursement for a TPRADFM
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 contractor.
15.0 TRICARE
Encounter Data (TED) Submittal
The contractor shall report
TPRADFM claims under the financially underwritten provisions of the
contract.