1.0 General
1.1 TOP Prime
Remote is available to Service members (including Reserve Component
(RC) members activated for more than 30 calendar days) on permanent
assignment to a remote overseas location, Command-Sponsored Active
Duty Family Members (ADFMs) accompanying their sponsor in the remote
location or on Service orders, and certain transitional survivors
according to the eligibility and enrollment provisions of
Section 5. TOP Prime Remote offers enrollees
access to a Primary Care Manager (PCM), clinical preventative services,
and specialty services. The TOP contractor, working in concert with
private sector care providers and the TRICARE Area Offices (TAOs),
has primary responsibility for ensuring that TOP Prime Remote enrollees
receive appropriate services and support to facilitate access to
the TOP benefit in remote overseas locations.
1.2 TOP Prime Remote has no enrollment
fees, and deductibles and cost-shares are waived except for TOP Prime
Remote ADFMs who receive care under the Point of Service (POS) option,
or who obtain pharmacy services in the 50 United States (US), the
District of Columbia, and US territories where the TRICARE Pharmacy
(TPharm) has established a retail pharmacy network. Waiver of copayment
and deductibles under TOP Prime Remote is subject to review/updating
based on enrollment status.
1.3 Under
TOP Prime Remote, annual catastrophic caps are calculated on calendar
years. The enrollment year shall coincide with the calendar year.
Since deductibles and cost-shares are waived for TOP Prime Remote
enrollees, this policy will apply only to TOP Prime Remote enrollees
who incur out-of-pocket expenses.
2.0 CONTRACTOR RESPONSIBILITIES
2.1 TOP Prime Remote enrollees
shall select or have assigned to them Primary Care Managers (PCMs) according
to guidelines established by the TAO Director, or designee.
2.1.1 TOP PCMs
may be an individual professional provider an overseas treatment
site, or other health care delivery arrangement. For the purposes
of referral management and authorization for TOP Prime Remote episodes of
care, the TOP contractor’s call center(s) are considered PCMs.
2.1.2 TOP PCMs
may be an internist, family practitioner, pediatrician, General
Practitioner (GP), Obstetrician/Gynecologist (OB/GYN), Physician
Assistant (PA), Nurse Practitioner (NP), or Certified Nurse Midwives
(CNMs) when determined by the TOP contractor to meet governing country
rules and licensure.
2.1.3 May also act as a Health Care
Finder (HCF), when dual responsibility is necessary, as determined
by the TAO Director.
2.2 A TOP
Prime Remote enrollee must seek all his or her primary health care
from the TOP PCM with the exception of care listed in
Section 8. If the TOP PCM is unable to provide
the care, the TOP PCM shall refer the enrollee to another primary
care provider.
2.3 TOP Prime Remote enrollees
must obtain appropriate referral/authorization for any non-emergency,
non-urgent care rendered by anyone other than the beneficiary’s
PCM. This provision applies regardless of where the care is rendered.
TAO Directors may direct retroactive authorizations on a case-by-case
basis.
2.3.1 Routine care is generally not
authorized while a TOP Prime Remote enrollee is traveling out of
their enrollment region. The TOP contractor shall fully document
the justification for authorizing routine out-of-area care. Emergency
care does not require prior authorization; however, the beneficiary
should contact their PCM and the contractor as soon as possible
to obtain authorization for any necessary follow-up care.
2.3.2 ADFMs
enrolled in TOP Prime Remote may obtain urgent care from any authorized
provider without a PCM (if assigned) referral or overseas contractor
authorization. In order to ensure the urgent care visit will be cashless/claimless,
the ADFMs enrolled to TOP Prime Remote should contact the TOP contractor
to obtain an authorization. Without this authorization, overseas
providers may request payment upfront (overseas providers may bill
above the TRICARE allowable amount without any limits) and the beneficiary
will then have to submit a claim for reimbursement.
2.4 Failure
to obtain a TOP PCM referral/authorization when one is required
for care may result in the service being paid under TOP POS procedures
for an Active Duty Family Member (ADFM) with a deductible and cost-shares for
outpatient services and cost-shares for inpatient services.
2.5 The TOP
PCM shall assist the TOP Prime Remote enrollee and other beneficiaries
in locating a Military Medical Treatment Facility (MTF) or private
sector care network or non-network provider to provide the care,
and shall assist in scheduling an appointment with a private sector
care provider upon request. The HCF shall conduct a benefit determination
review and provide authorization for service for which the referral
was made. If the contractor has no record of referral/authorization,
prior to denial/payment, the claims processing contractor shall follow
the TOP POS rules, assuming the service is a TRICARE benefit.
2.6 All referrals
made by a TOP designated private sector care PCM shall be made through
the TOP HCF and shall receive an authorization.
2.7 The TOP
contractor shall ensure that all authorized services for TOP Prime
Remote enrollees are provided on a cashless, claimless basis. The
contractor shall implement guarantee of payment or other business arrangements
to ensure that TOP Prime Remote enrollees are not required to pay
up front at the time services are rendered by a private sector care
provider.
2.8 Cashless, claimless provisions
do not apply to self-referred care that would normally require an authorization.
2.9 For TOP
Prime Remote enrollees who are traveling stateside, the TOP contractor
shall direct TOP beneficiaries to utilize stateside MTFs whenever
possible. If MTF care is unavailable, beneficiaries shall be provided with
information regarding the nearest available network provider(s)
who can assist the beneficiary. Non-network providers shall only
be used when MTF or network care is not possible.
3.0 POS
OPTION
3.1 TOP Prime Remote-enrolled ADFMs
shall follow established referral/authorization procedures prior
to obtaining specialty care to avoid the application of POS cost-shares
and deductibles. This includes all self-referred, non-emergency
outpatient specialty medical services and all inpatient care (including
inpatient mental health care), except for outpatient mental health
and Substance Use Disorder (SUD) visits, ancillary services, and
drugs. TOP Prime Remote ADFMs who self-refer to a civilian provider
other than their PCM shall have their claims processed as POS.
3.2 POS cost-shares
and deductibles shall not apply to claims for care received by newborns/adoptees during
the deemed enrollment period.
3.3 Self-referred,
routine, specialty, or inpatient care provided to a TOP Prime Remote
ADFM enrollee by a network or non-network private sector care provider,
which is not either provided/referred by the beneficiary’s PCM or
specifically authorized may be reimbursed only under the TOP Prime
Remote POS option if it is a benefit under TRICARE. Services which
are not a TRICARE benefit shall be denied.
3.4 POS cost-sharing
and deductible amounts do not apply if a TOP Prime Remote ADFM enrollee
has Other Health Insurance (OHI) that provides primary coverage.
The OHI must be primary under the provisions of the TRICARE Reimbursement
Manual (TRM),
Chapter 4, Section 1, and documentation that
the other insurance processed the claim and the exact amount paid
shall be submitted with the TOP claim. TRICARE OHI provisions apply
for this type of claim.
3.5 The POS option does not apply
to Service member overseas/stateside care.
3.6 The TOP
contractor shall adjust TOP Prime Remote copayments when TOP PCMs
or HCFs do not follow established referral/authorization procedures.
For example, if the contractor processes a claim without evidence
of an authorization and/or a referral under POS provisions, and
the contractor later verifies that the PCM or other appropriate
provider referred the beneficiary for the care, TOP contractor shall
adjust the claim under TOP Prime Remote provisions. The contractor
need not identify past claims, however, the contractor shall adjust
these claims as they are brought to their attention.
3.7 On a case-by-case
basis, following stabilization of the patient, the TAO Director
may require a TOP Prime Remote beneficiary to transfer to a TOP
network facility or the MTF. The TOP TAO Director shall provide
written notice to the beneficiary (or responsible party) advising
them of the impending transfer to a TOP network facility/MTF. If
a TOP Prime Remote-enrolled ADFM elects to remain in a non-network
facility after being notified of an impending transfer to another
facility, TOP POS cost-sharing will begin 24-hours following receipt
of the written notice. The TAO Director may not require a transfer
until such time as the transfer is deemed medically safe.
3.8 See the
TRM,
Chapter 2 for
deductible and cost-share amounts. POS deductible and cost-sharing
do not apply to the claims for care received by certain newborn
and newly adopted children during the deemed enrollment period.
See
Section 5 for additional guidance regarding
deemed enrollment for newborns/adoptees.