1.0 General
In order to control costs,
reduce aberrant billing activity, and eliminate balance billing
issues for TRICARE Select beneficiaries, the Defense Health Agency
(DHA) implemented an approved provider network in the Philippines. With
establishment of the TRICARE Select option by the National Defense
Authorization Act (NDAA) for Fiscal Year (FY) 2017, it has been
determined economically in the best interest of the DoD to transition
the approved provider network in the Philippines to a TRICARE Select
PPN effective January 1, 2018. A PPN provider will be available
to, and be a participating provider on claims for, all TRICARE eligible
beneficiaries, whether they are TRICARE Prime, TRICARE Select, or
TRICARE for Life (TFL). In addition to PPN providers, TRICARE authorized
providers in the Philippines include certified providers as defined
in
paragraph 2.2. TRICARE beneficiaries who travel
to the Philippines and seek urgent/emergent care will be able to
get care from any PPN provider or certified provider, but may be
subject to higher cost-shares and copays for care rendered by non-PPN
providers. Locations for PPN providers will be developed and maintained
by the TOP contractor; the government will work with the TOP contractor
to identify other locations in the Philippines where the PPN may
be expanded. Locations may be added or deleted on an annual basis,
as warranted. PPN providers will abide by a set foreign fee schedule,
accept payment from the TOP contractor, and not balance bill the
TRICARE beneficiaries. This will be accomplished by the establishment
of a dedicated list of providers who agree to comply with these
requirements and business processes.
3.0 TOP
CONTRACTOR RESPONSIBILITIES
3.1 Recruit and retain a sufficient
number and mix of PPN providers to ensure access to the full range
of covered TRICARE benefits. PPN providers must agree to comply
with the participation requirements in
paragraph 2.0. Establish and
maintain a list of all PPN providers, including each provider’s
specialty, sub-specialty, gender, work address, work fax number,
and work telephone number, and whether or not they are accepting
new TRICARE patients.
3.1.1 The TOP contractor shall provide
beneficiaries with easy access to both the PPN provider listing
and the certified provider listing via a user-friendly searchable
World Wide Web (WWW) site and any other means established at the
contractor’s discretion. Information on the WWW site and any other
electronic lists shall be current within the last 30 calendar days.
At a minimum, the list shall meet the provider directory requirements identified
in Section C of the contract.
3.1.2 The TOP
contractor shall provide certification oversight and monitor quality
of care for provided by providers and institutional facilities as
prescribed in
Section 4;
32
CFR 199.6; and TPM,
Chapter
12.
3.1.3 The TOP contractor shall educate
PPN providers on aspects of the TRICARE program, including, but
not limited to, TRICARE eligibility requirements, TRICARE benefits,
claims submission requirements, and the requirements in
32
CFR 199.9 and
Chapters 13 and
24 as
they relate to anti-fraud activities.
3.2 The TOP contractor shall perform
on-site verification and provider certification in the Philippines.
At a minimum, this one-site verification shall confirm the physical
existence of a facility/provider office, verify the credentials/licensure
of the facility/provider, verify the adequacy of the facility/provider
office, and verify the capability of the facility/provider office
for providing the expected level and type of care. This requirement
may be expanded to other locations upon Contracting Officer (CO)
direction. The on-site verification shall ensure the provider’s
physical address matches the address identified on the invoice.
However, if there is indication the provider relocated to another
office within the same building, the contractor shall accept documentation
from the provider which confirms a change in office location that
occurred since the date of service identified on the claim.
3.2.1 The TOP
contractor shall use the following guidelines for prioritizing certification
of Philippine providers as follows:
• Reviewing new providers.
• Reviewing the TOP contractor’s
current certified provider files.
• Reviewing non-certified providers
on claims which have been denied by the TOP contractor and the beneficiary/provider
has followed-up on why the claim was denied.
• Reviewing non-certified providers
on claims which have been denied by the TOP contractor and the beneficiary/provider
has NOT followed-up on why the claim was denied.
3.2.2 Recertification
of the Philippine providers shall be performed by the TOP contractor
every three years and shall follow the above process. DHA shall,
as necessary, require the contractor to add additional overseas countries
for private sector care provider certification. Upon direction by
the Government, the contractor shall follow the process above outlined
for the Philippines, to include prioritization of certification
of new country providers.
3.2.3 A PPN
provider may be removed from the PPN Provider list for administrative
reasons or may be removed for cause by the TOP contractor. The Government
may also direct the TOP contractor to remove PPN providers from
the list for cause. A PPN provider removed from the approved list
may submit a written request to the TOP contractor for reconsideration.
If the TOP contractor upholds the removal, the PPN provider shall
be given the right to appeal to the Director, TRICARE Area Office
(TAO)-Pacific. If the appeal decision is upheld by the Director,
TAO-Pacific, there is no right to further appeal.
3.2.4 The appeal
process does not apply to certified providers who are not selected
by the TOP contractor to participate as PPN providers. Recruiting
and retaining a sufficient number and mix of PPN providers is the responsibility
of the TOP contractor.
3.2.5 Claims for a PPN provider removed
from the approved list will be processed in accordance with
Chapter 13, Section 5. The approved list will
be updated on the contractor’s website on the first of the month
following the provider being removed from the list.
3.3 All TOP
requirements regarding Utilization Management (UM), Case Management
(CM), Quality Management (QM), and preauthorizations are applicable
to TRICARE beneficiaries.
3.4 The TOP contractor shall enroll
beneficiaries to TRICARE Select according to procedures outlined
in Section 19. The TOP contractor shall not provide referral/authorization
services to beneficiaries unless the requested service requires
preauthorization (per
Chapter 7, Section 5 and
TPM,
Chapter 1, Section 7.1). The TOP contractor
shall conduct a covered benefit review upon beneficiary or provider
request; however, an authorization letter will not be generated
except for those services which require preauthorization.
3.5 If TRICARE
beneficiaries receive care from a non-PPN provider who is not currently
certified and a claim is received for the care rendered, the contractor
needs to certify the provider and then process the claim according
to the rules for non-network care as outlined in
paragraph 3.2 and
Section 9. Normal TRICARE cost-shares/co-pays
and deductibles applicable to the specific category of eligible
beneficiary shall apply to care rendered to eligible beneficiaries
by PPN providers. Additionally, when a beneficiary receives care
from a PPN provider, the provider will file the claim on the beneficiary’s
behalf, and the provider will collect only applicable cost-shares
and co-pays after receipt of the TOP Explanation of Benefits (EOB).
The beneficiary will be held harmless for denied charges rendered by
a PPN provider unless the beneficiary was informed in writing that
the specific services were not a covered TRICARE benefit and the
beneficiary agreed in writing, in advance of the services being
provided, to pay for the services. If a beneficiary submits a claim
for services provided by a PPN provider, the TOP contractor shall
deny the claim if the beneficiary does not submit proof of payment
showing that the beneficiary has paid for the service(s).
3.6 If a claim
is received for care rendered by a non-certified provider in the
Philippines, the TOP contractor shall pend the claim and initiate
on-site verification/provider certification action. Claims pended
for this reason are excluded from normal claims processing cycle
time standards. If the on-site verification/certification action
is not completed within 90 calendar days, the TOP contractor shall
deny claims based on lack of provider certification.
3.7 The TOP
contractor shall deny claims submitted from non-certified private
sector care providers from the Philippines, advising the provider
to contact the contractor for procedures on becoming certified.
3.8 For the
Philippines, prescription drug may be cost-shared when dispensed
by a certified retail pharmacy or hospital based pharmacy. The TOP
contractor shall deny claims for prescription drugs obtained from
a physician’s office.