1.0 General
All TRICARE requirements regarding
Financial Administration 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(TOP) unless specifically changed, waived, or superseded by this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 3 for
additional instructions.
2.0 Payment POLICY
2.1 Reimbursement
of TOP beneficiary claims for overseas health care shall be based
upon the lesser of billed charges, the negotiated reimbursement
rate, or the Government-established fee schedule. (See
Section 9 and the TRICARE Reimbursement Manual
(TRM),
Chapter 1, Sections 34 and
35 for additional guidelines). Except for
medical evacuations, claims for care in the U.S. commonwealths and
territories shall be reimbursed following stateside reimbursement
guidelines. Philippines and Panama claims shall be reimbursed following
Government-established fee schedules, unless the TOP contractor
has negotiated a lesser rate with a purchase care sector provider.
2.2 Payment of Skilled Nursing
Facility (SNF) claims from Puerto Rico and the U.S. territories
(Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands) shall be processed as routine foreign claims and
shall be subject to the Prospective Payment System (PPS), as required
under Medicare in accordance with the Social Security Act. These
SNFs will be subject to the same rules as applied to SNFs in the
U.S. (see the TRM,
Chapter 8).
SNF care is not available in other TOP locations.
2.2.1 The
TOP contractor at its discretion,
may conduct concurrent or retrospective review for TRICARE
Select and TRICARE for Life (TFL) patients
when TRICARE is the primary payer. If Medicare requires reviews
to be performed on low Patient Driven Payment Model (PDPM) categories,
per the Medicare Policy Manual Chapter 8, the contractor will be
responsible for all reviews for TRICARE Prime patients.
There will be no review for TRICARE
Select or TFL patients where TRICARE
is the secondary payer. The existing referral and authorization
procedures for Prime beneficiaries will remain unaffected.
2.2.2 Beneficiaries in a low PDPM
category depending on date of service may not automatically qualify
for SNF coverage. These beneficiaries will be individually reviewed
to determine whether they meet the criteria for skilled services
and the need for skilled services (see the TRM,
Chapter 8, Section 1). If these beneficiaries
do not meet these criteria, the SNF PPS claim shall be denied.
2.2.3 The TOP contractor, at their
own discretion, may collect Minimum Data Set (MDS) assessment data
per the TRM,
Chapter 8, Section 1.
2.3 The TOP contractor shall be
responsible for entering into participation agreements with SNFs
in Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and
the Northern Mariana Islands.
2.3.1 The
TOP contractor, at their own discretion, may conduct any data analysis
to identify aberrant SNF PPS providers or those providers who might
inappropriately place TRICARE beneficiaries in a high PDPM category.
The contractor shall also assist the TRICARE Area Office (TAO) Directors
in obtaining/providing SNF data, for conducting any SNF PPS data
analysis they deem necessary.
2.4 Balance
billing provisions do not apply to TOP beneficiary claims for care
rendered in a foreign country and paid as billed, since there is
no unpaid balance on these claims. Purchased care sector network
providers, participating providers, and providers in U.S. commonwealths
and territories are prohibited from balance billing.
2.5 For
health care rendered in Puerto Rico and in the U.S., reimbursement
for all TOP beneficiary care shall follow the TRICARE payment policies
except as outlined below.
2.5.1 TOP
Service members who have been required by the provider to make “up
front” payment at the time services are rendered may submit a claim
for reimbursement directly to the contractor. Normal TRICARE claims
processing requirements apply (including any authorization requirements
and the use of TRICARE-approved claims forms). If the claim is payable,
the contractor shall allow the billed amount and reimburse the Service
member for charges on the claim.
2.5.2 In
no case shall a Service member be subjected to “balance billing”
or ongoing collection action by a civilian provider for emergency
or authorized care. If the contractor becomes aware of such situations
that they cannot resolve, they shall pend the file and forward the
issue to the appropriate TAO Director. The appropriate TAO Director
will issue an authorization to the contractor for payments in excess
of CMAC or other applicable TRICARE payment ceilings, provided the
TAO Director has requested and has been granted a waiver from the Program
Manager, Defense Health Agency (DHA), or designee.
2.5.5 Payment may be made for ambulance
services provided by commercial transport (see
Section 7 for
additional processing instructions for these claims)
.
3.0 Financial Administration
3.1 The TOP contractor shall follow
the Financial Administration non-financially underwritten funds
requirements in
Chapter 3 with the following exceptions:
3.1.1 Foreign overseas drafts (local
currency) and checks (U.S. currency) shall also reflect “TRICARE
Overseas Program”.
3.1.2 Foreign
overseas drafts shall also reflect information that indicates the
draft is valid for 190 days and if reissue is required/necessary,
the draft must be returned to the TOP contractor with a request
for reissuance. The contractor shall issue drafts/checks for Germany
claims which look like local German drafts/checks.
3.2 The TRICARE Encounter Data
(TED) for the overseas claims shall be reported on vouchers/batches
according to the TRICARE Systems Manual (TSM),
Chapter 2.
• Overseas health care claims
for stateside beneficiaries whose health care is normally provided
under one of the regional contracts (i.e., beneficiaries enrolled
or residing in the 50 U.S. or the District of Columbia, who receive
care while traveling or visiting abroad) shall be processed by the
TOP contractor. Claims for these beneficiaries shall be paid from
the current non-financially underwritten bank account. This provision
does not apply to beneficiaries who are enrolled to the Uniformed
Services Family Health Plan (USFHP) or the Continued Health Care
Benefit Program (CHCBP). Claims for these beneficiaries are processed
by their respective contractor regardless of where the care is rendered.
3.3 The
TOP contractor shall:
3.3.1 Provide TRICARE Overseas Currency
reports identifying the gain or loss for the month reported to arrive
by the 10th calendar day following the month reported. Reporting
requirements for net gains/losses are identified by DD Form 1423,
Contract Data Requirements List (CDRL), located in Section J of
the applicable contract.
3.3.2 Calculate
currency gains and losses resulting from payments made to purchased
care sector providers and/or beneficiaries in foreign countries.
The gains and losses shall be computed based on the exchange rate
in effect on the ending date of care. The difference between the
cost of the foreign currency on the ending date of care and the
contractor payment date shall be the gain or loss on the transaction.
Payment shall be as follows for:
3.3.2.1 Net
Gain. For months that result in a net gain, the TOP contractor shall
forward the report along with their check payable to the Department
of Defense (DoD), DHA, for the gain from currency conversion.
3.3.2.2 Net Loss. DHA will reimburse
the TOP contractor for any losses incurred from currency conversion.
The TRICARE Overseas Currency report shall be accompanied by a letter
(invoice) requesting reimbursement for the loss incurred. This payment
will not be subject to the Prompt Payment Act (FAR 32.9) as amended,
therefore, payment by DHA will usually be made within five working
days of receipt of the invoice and the TRICARE Overseas Currency
report.