1.0 ENROLLMENT
1.1 The Government
Designated Authority (GDA) will, on an as needed basis, but at least
semi-annually, provide the contractor with an update to the TPR
directory of units whose members are eligible for enrollment in the
program according to
Section 1.
1.2 An enrollment
request must be submitted by either the Active Duty Service Member
(ADSM) or the ADSM’s unit commander for each ADSM enrolling in the
TPR Program.
1.2.1 The effective date for TPR
Program enrollment is the date the ADSM or the ADSM’s unit commander submitted
the enrollment request.
1.2.2 An official enrollment request
includes those with:
• An original signature;
• A validated electronic signature
offered by and collected by the contractor;
• A verbal consent provided vial
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.
1.2.3 An ADSM’
signature is not required to make enrollment changes using the enrollment
portability process outlined in
Chapter 6, Section 2.
1.2.4 A signature
in not required to complete the enrollment.
1.3 The contractor
shall follow enrollment portability and transfer procedures in
Chapter 6, Section 2 for ADSM enrollment in
the TPR Program.
1.4 Enrollment transfers or disenrollments
will occur upon change of duty location out of the geographic area
of responsibility, transfer into a Market/Military Medical Treatment
Facility (MTF) clinic Prime Service Area (PSA), retirement, or separation
from the service.
1.5 The ADSM is responsible for
notifying the contractor when an enrollment transfer is needed.
1.6 The contractor
shall notify (letter, telephone call, or email) the ADSM of the
discrepant enrollment immediately at any point during the enrollment
period in which the contractor determines or is advised that an ADSM
is no longer eligible for TPR.
1.7 The contractor
shall disenroll the ADSM from TPR effective the first of the month
after the 30-day notification period if the discrepant enrollment
is not corrected within 30 calendar days of the notification date
and enroll them in Prime under the following guidelines:
1.7.1 The contractor
shall use the address in Defense Enrollment Eligibility Reporting
System (DEERS) to reassign the ADSM to TRICARE Prime at a Market/MTF
utilizing the Market/MTF enrollment guidelines.
1.7.2 The contractor
shall record the ADSM’s TPR enrollment in the DEERS via Government-furnished
web-based system/application.
The TPR enrollment card is
provided by DMDC.
1.7.3 The contractor
shall use the Primary Care Manager (PCM) (unassigned) procedure
when enrolling ADSM Astronauts into the TPR program.
1.7.3.1 ADSM Astronauts are not be
assigned to a network or other TRICARE authorized PCM.
1.7.3.2 The National Aeronautics and
Space Administration (NASA) providers provide primary care for ADSM Astronauts.
1.8 The contractor
shall coordinate referrals and authorizations from NASA providers
for TPR-enrolled ADSM Astronauts in accordance with
Section 2.
2.0 PCM ASSIGNMENT
2.1 At the
time of enrollment, an ADSM will select (or will be assigned) a
PCM in the local community, if available.
2.2 An ADSM
without an assigned PCM may use a local TRICARE-authorized provider
for primary care.
3.0 BENEFICIARY
EDUCATION
3.1 The contractor shall limit
educational activities for TPR enrollees to distributing the informational materials
provided by the Government.
3.1.1 Enrollment in the TPR Program
is mandatory for ADSMs who qualify for the program (refer to
Section 1); therefore, the GDA will determine
the initial supply (if hard copies are used) of materials required.
3.1.2 The contractor
shall forward materials to the TPR Program Units, including enrollment
request options (enrollment forms, the Government-furnished web-based
self-service enrollment system/application transactions, and telephonic
requests documented in the contractor’s call center notes) for the
TPR Program in the ADSM informational materials.
3.2 Educational
issues include the PCM concept (and what procedures to follow when
a network PCM is not assigned), how to access care in and out of
the area using the contractor, how to access specialty care through
the contractor and Specified Authorization Staff (SAS), and information
on filing medical claims.
3.3 The contractor shall give TPR-enrolled
ADSMs and their family members the option of participating in health
promotion and wellness programs offered by the contractor in Market/MTF
PSAs.
3.4 The Government will provide
all TPR enrollees with information about how to obtain self-care
manuals (hard or electronic versions).
3.5 The contractor
shall distribute Defense Health Agency (DHA)-supplied educational
materials unique to the TPR Program.
3.5.1 The contractor
may use multiple, contemporary avenues of access (e.g., email, World
Wide Web (WWW), telephone, texting, smart phone applications, and
other social media) to distribute these educational materials to
the ADSM and their family members.
3.5.2 The contractor
shall, if the contractor uses traditional mail, pay for postage,
envelopes, and mailing costs for distributing educational material.
3.5.3 The contractor
shall work in joint efforts of the service unit of the ADSM, the
SASs, the Service Medical Departments, and the GDA for educational
activities in the TPR Program areas.
3.6 The contractor
shall include TPR Program information and updates as part of all
TRICARE briefings. The contractor may propose alternative methods
for supplying educational information to ADSMs eligible to enroll
in the TPR Program.
4.0 SUPPORT
SERVICES
4.1 General
The requirements and standards
in
Chapters 1 and
11,
apply to the TPR Program unless otherwise stated in this chapter.
4.2 Inquiries
4.2.1 The contractor
shall designate a point of contact for Government inquiries related
to the TPR Program.
4.2.2 The contractor shall establish
a process for responding to inquiries about the TPR Program and
the Supplemental Health Care Program (SHCP).
4.2.3 The contractor
shall respond to all inquiries (e.g., written, telephone, walk-in
(overseas only)) that are not related to dental care or to SAS reviews
of medical care.
4.2.4 The contractor shall forward
all inquiries that specifically address dental care or SAS review
of medical care to the active duty dental claims contractor or the
TPR enrollee’s SAS for response.
4.3 Toll-Free
Telephone Service
4.3.1 The contractor shall provide
toll-free telephone access for TPR Program beneficiary inquiries.
4.3.2 The contractor’s
toll-free access telephone line may also serve SHCP beneficiaries,
refer to
Chapter 1, Section 3 for telephone standards.
4.3.3 The contractor
shall be able to differentiate between provider inquiries and beneficiary
inquiries through the contractor’s inquiry system, and be able to
provide appropriate data on request of the Government.