1.0 INTRODUCTION
1.1 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 (US) and the District
of Columbia. 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 calendar days.
1.2 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 US and District of Columbia.
1.3 The contractor
shall process care and claims 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
QUALIFICATIONS
2.1 Family members qualify to enroll
into TPRADFM if they meet the requirements specified in one of the following
paragraphs.
2.1.1 The sponsor is enrolled in
TPR and the ADFM resides with the sponsor in a TPR residence (i.e.,
TPR ZIP code).
2.1.2 The sponsor is enrolled to
a small Government clinic, troop medical clinic, Coast Guard clinic
or other Markets/Military Medical Treatment Facilities (MTFs) designated
by the Services to allow Active Duty Service Member (ADSM) enrollment
only and offer zero capacity to enroll non-ADSM beneficiaries.
2.2 The Defense Health Agency (DHA)
will provide a list of Defense Medical Information System Identification Codes
(DMIS-IDs) Markets/MTFs 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 a Market/MTF
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 ADSM 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 calendar days,
his or her 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 sponsors 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 calendar days after
the sponsor has deployed or 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.
2.5.2 The contractor
shall, at the request of the Transitional Survivor, 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.
2.5.3 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.
2.6 Transitional
Survivor or 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 (e.g., reaching age limits,
marriage, remarriage) also results in loss of Transitional Survivor
or Survivor status.
3.0 BENEFITS
TPRADFM enrollees are eligible
for the TRICARE Prime Benefit, including in areas without contractor
networks.
4.0 NETWORK DEVELOPMENT AND PCM
ASSIGNMENT
4.1 The contractor shall enroll
TPRADFMs to a Primary Care Manager (PCM) in the provider network
where one is available. ADFMs enrolled in TPRADFM shall be assigned
a network PCM of their choosing, or a TRICARE authorized PCM if
no network PCM is available.
4.2 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. TPRADFM offered outside
of a PSA does not have network development requirements, except
where contractually required.
4.3 The contractor
shall assist TPRADFM enrollees in finding a network or non-network
TRICARE authorized provider for specialty care. TPRADFMs enrollees
are required to use TRICARE network providers where available within
contractual access standards.
4.3.1 If a network provider cannot
be identified within the access standards, the enrolled family member must
use a TRICARE authorized provider. TPRADFM enrollees may be eligible
for the Prime Travel Benefit (PTB) when referred more than 100 miles
for specialty care inside the 50 US and the District of Columbia.
4.3.2 The contractor
shall enroll a TPRADFM enrollee without a PCM assigned if the contractor
has not established a network of PCMs in a remote area. A generic
PCM code shall be used for TPRADFM enrollees without assigned PCMs.
4.3.3 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.
4.3.4 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 Markets/MTFs
or the TRICARE purchased care system.
6.0 REFERRALS
6.1 The contractor
shall process specialty care referrals from TPRADFM enrollees.
6.1.1 If the
TPRADFM enrollee is assigned to a PCM, the PCM shall follow the
contractor’s referral and authorization procedures.
6.1.2 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.
6.1.3 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 The contractor
shall process TPRADFM specialty care claims lacking authorization
with Point-of-Service (POS) deductible and cost-share unless an
appropriate out-of-network referral is obtained as required under TRICARE
Prime.
6.3 Enrollees are required to obtain
a referral and use TRICARE network providers for specialty care
where available within TRICARE access standards.
7.0 PROVIDER
EDUCATION
7.1 The contractor shall familiarize
network providers and, when appropriate, other providers with TPRADFM.
7.2 The contractor
shall propose an educational plan to the Government Designated Authority
(GDA) outlining how providers will become familiar with TPRADFM.
7.3 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).
This includes 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.
8.1.1 The contractor
shall ensure its customer services include multiple, contemporary
avenues of access (e.g., email, World Wide Web (WWW), telephone,
texting, and smart phone applications, and other social media) for the
MHS beneficiary.
8.1.2 The contractor shall, if it
chooses to distribute the supplied educational materials, cover
all costs (postage, envelopes, and mailing) by US mail.
8.2 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.
8.3 The contractor shall design
and conduct, with GDA approval, TPRADFM briefings. Ongoing briefings
will be on an ‘as needed’ basis and will be coordinated with the
GDA. Briefings may include a mix of in-person or virtual via telephonic
or online platforms as coordinated with the GDA.
8.4 The contractor
shall include TPRADFM information and updates as part of all TRICARE
briefings.
8.5 The contractor shall limit
educational activities for TPRADFM enrollees to distributing the
materials provided or approved by the Government as enrollment in
TPRADFM is optional for ADFMs who qualify for the program.
9.0 ENROLLMENT
9.1 The contractor
shall ensure the sponsor and TPRADFM are qualified based on the
requirements in
paragraph 2.0 upon receipt of 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).
9.1.1 The contractor
shall return any requests to the sender with a notice that the family
member is not eligible for TPRADFM and the reason(s) why TPRADFM
enrollment was denied if a TPRADFM enrollment request is received
and the family member does not qualify for TPRADFM.
9.1.2 See
paragraph 9.5 when
a TPRADFM enrollment request is received for a family member of
a RC sponsor on active service for more than 30 calendar days.
9.2 Enrollment
in TPRADFM is optional for qualified family members. However, qualified
family members must enroll within 90 calendar 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.
9.3 Qualified
family members who elect not to enroll in TPRADFM may enroll in
TRICARE Prime (where available, with access standards waived) or
TRICARE Select.
9.4 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 ADSM’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.
9.5 The contractor shall validate
the family members’ eligibility in Defense Enrollment Eligibility
Reporting System (DEERS) for TPRADFM enrollment request from a family
member of an RC sponsor called or ordered to active service for
more than 30 calendar days.
9.6 The contractor
shall follow enrollment portability and transfer procedures in
Chapter 6, Section 2.
9.7 The contractor
shall notify (letter, telephone call, or email) the sponsor of discrepant
enrollment immediately if at any point the contractor determines
or is advised that a family member is no longer eligible for TPRADFM.
9.8 The contractor
shall disenroll the family member(s) from TPRADFM effective the
first of the month after 30 calendar days from the initial notification
date if the discrepant enrollment is not corrected within 30 calendar days
of the notification date and enroll the family member(s) in TRICARE
Select.
9.9 The contractor shall enroll
the TPRADFM qualified family member in the Government-furnished
web-based system/application using the DMIS-ID code(s) designated
by the GDA for that geographical area of responsibility. (See the
TRICARE Systems Manual (TSM). See
paragraph 4.0 for PCM assignment
requirements).
9.10 DEERS will automatically update
start and end dates of coverage when a beneficiary’s eligibility
is updated as described in
Chapter 6, Section 1.
9.11 The contractor
will receive a Policy Notification Transaction (PNT) advising it
of all changes.
10.0 SUPPORT
SERVICES
10.1 Inquiries
10.1.1 The contractor shall designate
a point of contact for Government inquiries related to TPRADFM.
10.1.2 The contractor may establish
a dedicated unit for responding to inquiries about TPRADFM, or may augment
existing TPR service units already serving TPR enrollees.
10.1.3 The correspondence requirements
and standards in
Chapter 1, Section 3,
apply to TPRADFM written inquiries.
10.2 Toll-Free
Telephone Service
The contractor
shall provide toll-free telephone access for TPRADFM beneficiary
inquiries.
11.0 CLAIMS
PROCESSING
11.1 The 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 US and
the District of Columbia).
11.2 The TOP
contractor shall process claims for civilian health care while traveling
or visiting overseas, regardless of where the beneficiary is enrolled.
POS claims processing provisions do apply. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
12.0 CLAIM REIMBURSEMENT
12.1 The payment
provisions applicable under TPR for ADSMs 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.
12.2 The contractor shall not make
payments unless such payments are otherwise allowed under the payment provisions
for unauthorized providers contained in the TPM.
12.3 The contractor
shall pay TPRADFM claims at the negotiated rate for network providers,
if applicable.
12.3.1 The contractor shall pay up
to the CHAMPUS Maximum Allowable Charge (CMAC), or billed charges, whichever
is less, for participating providers.
12.3.2 The contractor shall follow
the requirements in
Chapter 7, Section 5 and
the TRICARE Reimbursement Manual (TRM),
Chapter 5, Section 1, for claims for TPRADFM
enrollees receiving care from non-participating providers.
12.4 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.
12.5 The contractor
shall notify the provider that balance billing is prohibited (see
TRM,
Chapter 3, Section 1) 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.
12.6 The contractor
shall follow the below precedence if CMAC rates have been waived
for TPR ADSM enrollees under
Section 4.
12.7 The contractor
shall not extend the same waived CMAC rates for TPRADFM enrollees.
12.8 The contractor
shall arrange for care with a non-participating provider subject
to the normal reimbursement rules if required services are not available
from a network or participating provider within the medically appropriate
time frame.
12.9 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.
12.10 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 if that
is not feasible.
12.11 The contractor shall not negotiate,
by law, a rate higher than 115% of CMAC for TPRADFM care rendered by
a non-participating provider.
12.12 The contractor
shall ensure that the approved payment is annotated in the authorization
and claims processing system.
13.0 APPEALS PROCESS
13.1 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.
13.2 If authorization
or reimbursement is denied, TPRADFM enrollees may appeal through
the contractor in accordance with
Chapter
12.
14.0 TRICARE ENCOUNTER DATA (TED)
SUBMITTAL
The contractor
shall report TPRADFM claims under the financially underwritten provisions
of the contract.