1.0 General
1.1 All TRICARE
requirements regarding the SHCP shall apply to the TOP unless specifically
changed, waived, or superseded by this section, TRICARE Policy Manual
(TPM),
Chapter 12,
or the TRICARE contract for health care support services outside
the 50 United States (US) and the District of Columbia (hereinafter
referred to as the “TOP Contract”). See
Chapter
17 for additional instructions.
1.2 Uniformed
Service members in an active duty status of greater than 30 calendar
days (also known as Service members) who are on permanent or official
duty assignment in a location outside the 50 US and the District of
Columbia must enroll in TOP Prime or TOP Prime Remote. Service members
in a temporary duty status and enrolled elsewhere should not transfer
their enrollment to TOP Prime or TOP Prime Remote unless it is medically appropriate
and will not cause enrollment eligibility disruption to family members’
enrollment status. Service members are not CHAMPUS-eligible and
do not have the option to use TOP Select or the Point of Service
(POS) option under TOP Prime or TOP Prime Remote. Uniformed Service
members who would normally receive care from a private sector care
provider may be directed to transfer their care to a Military Medical
Treatment Facility (MTF). This applies to Service members and Uniformed
Service members not in active duty status (Reserve Component (RC)
members under Line of Duty (LOD) care). These controls ensure the
maintenance of required fitness-for-duty oversight for TOP Uniformed
Service members. Refer to
Section 9 for
claims processing instructions.
2.0 Contractor Responsibilities
2.1 Service members who are enrolled
in TOP Prime shall follow the procedures outlined in Chapter 17
for MTF-enrolled Service members, except that any references to
the Defense Health Agency-Great Lakes (DHA-GL) should be replaced
by a reference to the appropriate regional TRICARE Area Office (TAO)
in all overseas locations except the US Virgin Islands concerning
Line of Duty Determinations and except for care delivered under
the National Department of Defense (DoD)/Department of Veteran Affairs/Veterans
Health Administration (DVA/VHA) Memorandum of Agreement (MOA) authorization
requirements. See
paragraph 2.4.3 for National DoD/DVA/VHA MOA
authorization requirements. Service members who are enrolled in
TOP Prime Remote must seek authorization from the TOP contractor
for all non-emergent specialty and inpatient care. Service members
not enrolled in TOP who are on Temporary Additional Duty/Temporary
Duty (TAD/TDY), deployed, deployed on liberty, or in an authorized
leave status outside the 50 US and the District of Columbia shall
follow referral/authorization guidelines for TOP Prime Remote enrollees.
2.2 If a Service
member seeks private sector care without appropriate authorization,
they put themselves at financial risk for claims payment. They are
also at risk for potential compromise of medical readiness posture,
flight status, or disability benefits, and they may be subject to
disciplinary action for disregarding service-specific policy. Lost
work time may be charged as ordinary leave.
2.3 The TOP
contractor shall ensure a benefit review is done on each SHCP referral
and authorization. The TOP contractor shall return deferred-to-network
referrals for non-covered services with an explanation of why it was
denied. The TOP contractor shall not issue an authorization unless
they obtain a copy of an approved waiver. The contractor shall deny
all claims for TRICARE non-covered health care services. (Reference
Health Affairs (HA) Policy 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”).
2.3.1 If the
contractor determines that the requested service, supply, or equipment
is not covered by TRICARE policy and no Defense Health Agency (DHA)-approved
waiver is provided, the contractor shall decline to file an authorization
and shall deny any received claims accordingly. If the request was
received as an MTF referral, the contractor shall notify the MTF
(and enrolled MTF if different from the submitting MTF) of the declined authorization
with explanation of the reason. If the request was received as a
referral from a civilian provider (for a remote Service member/non-enrolled
Service member), the contractor shall notify the civilian provider
and the remote Service member/non-enrolled Service member of the
declined authorization with explanation of the reason. The notification
to a civilian provider and the remote Service member/non-enrolled
Service member shall explain the waiver process and provide contact
information for the applicable Uniformed Services Headquarters Point
of Contact (POC)/Service Project Officers as listed in
Chapter 17, Addendum A, paragraph 2.0. No
notification to the Specified Authorization Staff (SAS) is required.
2.3.2 TRICARE
benefits may not be extended for complications resulting from non-covered
surgeries and treatments performed outside the MTF for a Service
member without an approved waiver. If the treatment is a non-covered
TRICARE benefit, any follow-on care, including care for complications,
will not be covered by TRICARE once the Service member separates
from active duty or retires (
32 CFR 199.4(e)(9); TPM,
Chapter 4, Sections 1.1 and
1.2). The Services will provide appropriate
counseling that such follow-on care is the member’s personal financial responsibility
upon separation or retirement.
2.4 The provisions
of
Chapter 17 are
changed for the TOP as follows:
2.4.1 The provisions of
Chapter 17, Section 2, paragraph 2.0 are not
applicable to the TOP contract. USFHP services are not available
outside the 50 US and the District of Columbia.
2.4.2 Except
for the claims for Service member care provided under the National
DoD/DVA/VHA MOA, the provisions of
Chapter 17, Section 3, paragraph 1.2.1 regarding
the timeline for review of SHCP claims by overseas MTFs is extended
to 10 calendar days. Service member claims for covered benefits
submitted to the TOP contractor for which an authorization is not
on file are to be pended for a determination of whether the care
should be authorized. The claim shall be pended and the MTF of enrollment
shall be notified that an authorization determination should be
accomplished and returned to the TOP contractor within 10 calendar
days. If the TOP contractor does not receive the MTF’s response
within 10 calendar days, the contractor shall move the claim back into
active processing within one business day and shall process the
claim as if the MTF had authorized the care. Claims authorized due
to a lack of response by the MTF shall be considered as “Referred
Care”, but the contractor shall be able to distinguish these claims
from MTF-authorized claims. Claims pended under the provisions of
this section shall be considered to be excluded claims for the purposes
of calculating and reporting claims processing cycle time performance.
2.4.3 The provisions of
Chapter 17, Section 2, paragraph 3.2 regarding
claims for care provided under the National DoD/DVA/VHA MOA for
Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma are applicable to the TOP and shall be processed
in accordance with
Chapter 17, Section 2, paragraph 3.2.3 through
3.2.6.1.
Such care will be authorized by the DHA-GL for Service members under
this MOA.
2.4.4 The provisions of
Section 6, paragraph 5.0 and
Chapter 8, Section 5 apply to TOP SHCP referrals. Additionally,
when MTFs submit a referral request for purchased care services
for a non-AD sub-population beneficiary eligible for SHCP, the MTF
shall utilize the required data elements identified in
Chapter 8, Section 5, paragraph 6.1 and shall
annotate the referral with “SHCP” in line item 12, “Review Comment”.
This will ensure that SHCP claims for eligible non-AD sub-population
beneficiaries are properly adjudicated.
Note: Circumstances where supplemental
funds may be used to reimburse for care rendered by non-Governmental
health care providers to non-active duty patients are limited to
those where a MTF provider orders the needed health care services
from civilian sources for a patient, and the MTF provider maintains
full clinical responsibility for the episode of care. This means
that the patient is not disengaged from the MTF that is providing the
care. See
Chapter 17, Section 1, paragraph 1.1.
2.5 When a
Service member leaves a remote TOP assignment as a result of Permanent
Change of Station (PCS) or other service-related change of duty
status, the following applies in support of medical record accumulation:
2.5.1 For Service
members leaving remote TOP assignment in Puerto Rico, the PCM shall
provide a complete copy of medical records, to include copies of
specialty and ancillary care documentation, to Service members within
30 calendar days of the Service member’s request for the records.
The Service member may also request copies of medical care documentation
(specialty care visits and discharge summaries) on an ongoing, Episode
of Care (EOC) basis.
2.5.2 For Service members leaving
remote TOP assignments from all overseas areas other than Puerto
Rico, Service members in those locations should request medical
records from the private sector care provider(s) who provided health
care services during the Service member’s tour of duty. These Service
members may also request copies of medical care documentation (specialty
care visits and discharge summaries) on an ongoing, EOC basis.
2.5.3 Records
provided by private sector care providers in languages other than
English may be submitted to the TOP contractor for translation into
English according to the terms of the contract.
2.5.4 Network
private sector care providers shall be reimbursed for medical records
photocopying and postage costs incurred at the rates established
in their network provider participation agreements. Non-network private
sector care providers shall be reimbursed for medical records photocopying
and postage costs on the basis of billed charges unless the Government
has directed a lower reimbursement rate. Service members who have
paid for copied records and applicable postage costs shall be reimbursed
for the full amount paid to ensure they have no out-of-pocket expenses.
All providers and/or Service members must submit a claim form, with
the charges clearly identified, to the contractor for reimbursement.
Note: The purpose of copying medical
records is to assist the Service member in maintaining accurate
and current medical documentation. The contractor shall not make
payment to a private sector care provider who photocopies medical
records to support the adjudication of a claim.
2.5.5 The provisions
of
Chapter 17, Section 3, paragraph 1.1.8 are
not applicable to the TOP. SHCP funds may not be used to pay for
overseas purchased sector care for foreign military members or their
families. The TOP contractor shall deny any MTF referrals and claims
for such care.
2.6 Provision of Respite Care For
The Benefit of Seriously Ill or Injured Active Duty Members
2.6.1 The provisions
of
Chapter 17, Section 3 and the TRICARE Systems
Manual (TSM),
Chapter 2, Section 2.8 and
6.4 regarding respite care for seriously ill
or injured Service members are applicable in locations outside the
50 US and the District of Columbia where TRICARE-authorized Home
Health Agencies (HHAs) have been established.
2.6.2 The respite
care benefit is applicable to Service members enrolled to TOP Prime,
TOP Prime Remote, and to any Service member referred by an overseas
MTF or TAO.
2.6.3 All normal Service member authorization
and case management requirements for the TOP apply to the Service
member respite care benefit.