1.0 General
TOP health care services are
provided by Military Medical Treatment Facilities (MTFs) and private
sector care network and non-network providers and institutions.
All TRICARE requirements regarding Provider Certification/Credentialing
and Network Development shall apply to the TOP unless specifically
changed, waived, or superseded by this section; the TRICARE Policy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
Chapters
4 and
5 for additional
instructions.
2.0 Private SECTOR Care PROVIDER
CERTIFICATION AND CREDENTIALING
2.1 The TOP
contractor shall be responsible for provider certification oversight,
and monitoring of provider/institution quality. The contractor shall
use
Chapter 4,
32
CFR 199.6, and TPM,
Chapter
11 to the maximum extent possible for the certification
of private sector care providers. The contractor is not required
to follow TRICARE requirements for US credentialing standards, except
when TRICARE requires the facility/agency to be Medicare certified
(e.g., home health, hospice, Skilled Nursing Facility (SNF) care).
Also, Psychiatric Residential Treatment Centers (RTCs), Substance
Use Disorder Rehabilitation Facilities (SUDRFs), and Psychiatric
Partial Hospitalization Programs (PHPs) that are located in Puerto
Rico require approval by the TOP contractor. Except for these services and
facilities, the TOP contractor shall establish private sector care
provider certification processes based on the accepted licensure
and credentialing requirements for the private sector care.
Note: Medicare certification for
organ transplant centers is only required for transplants performed
in the US, the District of Columbia, and US territories where Medicare
is available. See TPM,
Chapter 12, Section 1.2.
2.2 Refer
to
Section 29 additional certification requirements
that have been established for private sector care providers in
the Philippines. The Defense Health Agency (DHA) may expand these
additional certification requirements to other locations in the
future.
3.0 NETWORK
DEVELOPMENT
3.1 The TOP contractor shall be
responsible for developing and maintaining a complement of network
and non-network private sector care providers to augment the existing
capacity of the Direct Care (DC) system for Service members and
Active Duty Family Members (ADFMs) who are enrolled in TOP Prime,
and to provide or arrange for primary and specialty care services
for Service members and ADFMs who are enrolled in TOP Prime Remote.
3.2 The TOP
contractor shall establish signed provider agreements between network
private sector care providers and the contractor.
3.2.1 Network
provider agreements shall include language indicating that the provider
agrees to participate on claims for authorized services for TOP
enrollees on a cashless, claimless basis.
3.2.2 Network
provider agreements must specify rates for Service member medical
records photocopying and postage, if applicable.
Note: “Cashless, claimless” is defined
as a health care encounter that requires no up-front payment at
the time of service, and the provider files the claim for the beneficiary.
3.3 In TOP
Prime and TOP Prime Remote locations, networks shall be sized to
meet TOP Prime/Prime Remote-enrolled populations only. The TOP contractor
shall assist other beneficiaries (non-command sponsored ADFMs, retirees,
retiree family members, etc.) upon request by identifying private
sector care providers which are credentialed and familiar with TRICARE,
but networks will not be developed to accommodate non-TOP Prime/Prime
Remote enrollees.
3.4 In TOP Prime locations, MTF
Commanders will identify the specialties needed in the network and
will communicate this information on an ongoing basis to the TOP
contractor per the process identified in the Statements of Responsibilities
(SORs) (see
Section 16).
3.5 MTF capabilities
and capacities may change frequently over the life of the contract
without prior notice. The TOP contractor shall ensure that private
sector care provider services can be adjusted as necessary to compensate
for changes in MTF capabilities and capacities, when and where they
occur over the life of the contract, including short notice of unanticipated
facility expansion, provider deployment, downsizing, and/or closures.
3.6 Network
providers shall be able to communicate in English, both orally and
in writing, or provide translation services at the time of service.
3.7 The TOP
contractor shall be responsible to enter into participation agreements
with SNFs in Puerto Rico, Guam, the US Virgin Islands, American
Samoa, and the Northern Mariana Islands per the provisions of
Section 3.
4.0 CONTRACTOR
REQUIREMENTS - private sector care PROVIDERS
4.1 The Government
requires the contractor to negotiate rates in specific countries
designated in the contract. Reimbursement rates for private sector
care providers in other locations may be negotiated by the contractor.
In locations where the Government has designated specific reimbursement
rates or methodologies. The contractor may not negotiate rates which
exceed the Government directed rate. Refer to the TRICARE Reimbursement
Manual (TRM),
Chapter 1, Section 34 for additional instructions.
4.2 The contractor
shall provide ongoing private sector care provider education and
support in accordance with
Section 11.
4.3 The contractor
shall have a Clinical Quality Management Program (CQMP)/Clinical
Quality Oversight Plan as outlined in the DD for 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable contract
for reviewing access and quality of care provided by private sector
care providers. This plan shall incorporate customer comments and
feedback regarding care from private sector care providers.
4.4 The TOP
contractor shall deny claims from non-certified private sector care
providers when the DHA has directed that the country’s private sector
care providers must be specially certified in order to receive TRICARE payments.
See
Section 29 for additional certification requirements.