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TRICARE Operations Manual 6010.62-M, April 2021
Supplemental Health Care Program (SHCP)
Chapter 17
Section 1
1.1  The 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 Market/Military Medical Treatment Facility (MTF) as well as for Civilian Health Care (CHC) received by eligible Uniformed Service members. The SHCP exists under authority of 10 United States Code (USC) 1074(c) and 32 CFR 199.16(a)(3). The use of the SHCP to pay for care referred by Market/MTF 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 or a successor document.
1.2  SHCP-eligible Service Members are primarily Active Duty Service Members (ADSMs). As utilized in this chapter, ‘Service Members’ may also include ADSMs in travel status (leave, Temporary Duty/Temporary Additional Duty (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 at a Market/MTF), eligible Reserve Component (RC) personnel, Reserved Officer Training Corps (ROTC) students, cadets/midshipmen, and eligible foreign military. In all cases where a non-ADSM is authorized care under this chapter, an appropriate referral/authorization from the Market/MTF Manager or Specified Authorization Staff (SAS) must be present to authorize care or pay claims.
1.3  The fact that civilian services have been rendered to an individual who is enrolled to a Market/MTF PCM does not mean that those services were Market/MTF referred care. If a claim is received for an eligible Service Members Market/MTF enrollee and no authorization is on file, the Market/MTF must be contacted to determine if the care was Market/MTF-referred.
2.1  For care that is in a TRICARE Prime Remote (TPR) designated area not referred by a Market/MTF and is not in an area served by the TRICARE Overseas Program (TOP) contractor, the SAS will identify and coordinate the CHC furnished to eligible Service Members including preauthorization of care when required and notify the nearest same service intermediate commands or Market/MTF for civilian routine and emergency hospital admissions so they can assume patient oversight responsibilities, assist with patient movement and coordinate case management as needed. The entities performing the SAS functions are identified in Addendum A.
2.2  The contractor shall contact the referring Market/MTF for any necessary medical oversight or authorization of care for the TPR patients who may require medical care that is not available at the Market/MTF (e.g., Magnetic Resonance Imaging (MRI)). The contractor will continue to provide medical necessity reviews as appropriate for care.
2.3  The contractor shall perform a benefit review on the requests.
3.1  The contractor shall provide payment for inpatient and outpatient services, for Market/MTF-referred civilian care ordered by a Market/MTF provider for a Market/MTF patient for whom the Market/MTF provider maintains responsibility. This includes claims for members on the Temporary Disability Retirement List (TDRL) obtaining required periodic physical exams.
3.2  The contractor shall furnish the Services with information regarding payment of the claim as specified in the contract.
3.3  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.
3.4  The contractor shall furnish reports as specified in the contract.
4.1  Eligible Service members have no cost-shares, copayments, Point-of-Service (POS) charges, or deductibles. If Service Members 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 (refer to Section 3).
4.2  The contractor shall not perform OHI processing procedures for eligible 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 (refer to Section 3).
4.4  The contractor shall provide Market/MTF-referred patients the full range of services offered to TRICARE Prime enrollees.
4.5  If an eligible Service member intends, while in a terminal leave status, to reside outside of the Prime Service Area (PSA) of the Market/MTF where the Service member is enrolled, the Market/MTF will issue to the TRICARE contractor a single preauthorization for the Service member to obtain from the Department of Veterans Affairs/Veterans Health Administration (DVA/VHA) any routine or urgent outpatient primary medical care that should be required anytime during the terminal leave period.
4.5.1  The preauthorization will not apply to services provided under the terms of the Department of Defense (DoD)/DVA/VHA Memorandum Of Agreement (MOA) for “Medical Treatment Provided to Active Duty Service Members with Polytrauma Injury, Spinal Cord Injury, Traumatic Brain Injury or Blindness.”
4.5.2  The contractor shall process claims from the DVA/VHA for services provided under terms of the MOA as specified in Section 2.
4.6  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 apply equally to such SHCP claims.
4.7  The contractor (for the geographic area of responsibility in which the patient is enrolled) shall process the claim to completion.
4.8  The contractor shall require Defense Health Agency (DHA) authority to process services that would not have ordinarily been covered under TRICARE policy (including limitations and exclusions or services furnished by a non-TRICARE authorized provider). Such services may be authorized for eligible Service members in accordance with the terms of a waiver approved by the Government Designated Authority (GDA) at the request of an authorized official of the uniformed service concerned (refer to paragraph 2.0).
5.1  Each Service will designate a Service Project Officer to be the Service’s official Point of Contact (POC) with DHA and the contractor to resolve any overall service-related matters regarding the program.
5.2  The Service Project Officers will be the POC for SHCP waivers. (Refer to Addendum A for the list of Service Project Officers).
5.3  Communication with Service Project Officers shall be coordinated with the GDA or their designee for SHCP-related issues.
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