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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Prime Remote (TPR) Program
Chapter 16
Section 2
Health Care Providers And Review Requirements
The TPR program does not have network development requirements.
2.1  The contractor shall process claims according to the requirements in this chapter for any services not included in the USFHP Designated Provider (DP) agreement.
2.2  The contractor may also receive TPR Program claims from certain USFHP DPs. The provisions of TPR will not apply to services furnished by a USFHP DP if the services are included as covered services under the current negotiated agreement between the USFHP DP and Office of the Assistant Secretary of Defense, Health Affairs (OASD (HA)).
2.3  The USFHP, administered by the DPs listed below, currently have negotiated agreements that provide the TRICARE Prime benefit (inpatient and outpatient care).
•  CHRISTUS Health, Houston, TX (which includes):
•  St. Mary’s Hospital, Port Arthur, TX
•  St. John Hospital, Nassau Bay, TX
•  St. Joseph Hospital, Houston, TX
•  Martin’s Point Health Care, Portland, ME
•  Johns Hopkins Health Care Corporation, Baltimore, MD
•  Brighton Marine Health Center, Boston, MA
•  St. Vincent’s Catholic Medical Centers of New York, New York City, NY
•  Pacific Medical Clinics, Seattle, WA
2.4  The contractor shall process DP inpatient claims according to applicable TRICARE and TPR reimbursement rules.
3.1  The contractor shall reimburse for services under the current national Department of Defense/Department of Veterans Affairs (DoD/VA) Memorandum of Agreement (MOA) for “Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services” (Refer to Section 4).
3.2  The contractor shall not reimburse for services provided to TPR enrollees under any local Memoranda of Understanding (MOU) between the DoD (including the Army, Air Force and Navy/Marine Corps facilities) and DVA/VHA.
3.3  Claims for these services will continue to be processed by the Military Services.
3.4  The contractor shall process claims according to the requirements in this chapter for any services not included in the local MOU.
The contractor shall process claims for services not included in the MOU between the DoD (including the Army, Air Force and Navy/Marine Corps facilities) and the DHHS (Indian Health Service and US Public Health Service (PHS)) in accordance with the requirements in this chapter.
5.1  Provision Of Documents
The contractor shall send requested copies of supporting documentation related to care reviews, appeals, and claims to the SAS within four business days of receiving the request.
5.2  Primary Care
5.2.1  Active Duty Service Members (ADSMs) enrolled in the TPR program can receive primary care services under TRICARE Prime without a referral, an authorization, or a fitness-for-duty review by the SAS (see Addendum A).
5.2.2  ADSMs with assigned Primary Care Managers (PCMs) will receive primary care services from their PCMs.
5.2.3  ADSMs without assigned PCMs will receive primary care services from TRICARE-authorized civilian providers, where available, or from other civilian providers where TRICARE-authorized civilian providers are not available.
5.3  Care Requiring SAS Review
5.3.1  The following care requires SAS review: all inpatient hospitalization, mental health care, invasive medical and surgical procedures (with the exception of laboratory and diagnostic services), and substance abuse.
5.3.2  Referred Care  The contractor shall perform a covered benefits review for requested services from a provider. The requesting provider shall follow the contractor’s referral procedures and contact the contractor for an authorization.  The contractor shall enter any required referral data in Addendum B as required by the SAS for a fitness-for-duty review (paragraph 5.3).  The SAS will respond to the contractor within two business days.  The contractor shall determine the services encompassed within the Episode Of Care (EOC), indicated by the referral when a SAS referral directs evaluation or treatment of a condition, as opposed to directing a specific service(s).  A SAS authorization for health care includes authorization for any TRICARE covered ancillary or diagnostic services related to the health care authorized (i.e., associated with the EOC).  The contractor shall not communicate to the provider or patient that the care has been authorized until the SAS review process has been completed.  The contractor shall use the processes as used for other TRICARE Prime enrollees in determining EOC when claims are received with lines of care that contain both referred and non-referred lines.  Laboratory tests, radiology tests, echocardiogram, Holter monitors, pulmonary function tests, and routine treadmill tests logically associated with the original EOC may be considered part of the originally requested services and do not need to come back to the PCM (if assigned) or Primary Care Provider (PCP) for approval.  If the SAS determines that the ADSM may receive the care from a civilian source, the SAS will enter the appropriate code into the authorization or referral system.  The contractor shall notify the ADSM of approved referrals.  The ADSM may receive the specialty care from a Market/MTF, a network provider, or a non-network provider according to TRICARE access standards, where possible.  The contractor shall ensure in areas where providers are not available within TRICARE access standards, community norms apply. (An ADSM may always choose to receive care at a Market/MTF even when the SAS has authorized a civilian source of care and even if the care at the Market/MTF cannot be arranged within the Prime access standards subject to the ADSM’s unit commander [or supervisor] approval.)  The contractor shall instruct the provider on payment requirements for ADSMs (e.g., no deductible or cost-share) and on other issues affecting claim payment (e.g., the balance billing prohibition) if the appointment is with a non-network provider.  The contractor shall follow Chapter 7, Section 5 when there are additional requests by a Market/MTF for Civilian Health Care (CHC) needs.  The contractor shall adjudicate claims for additional Market/MTF requested civilian care in accordance with Chapter 7, Section 5 and Chapter 8, Section 2.  The contractor shall, within one business day after the end of the two business day waiting period, enter the contractor’s authorization code into the contractor’s claims processing system if the contractor does not receive the SAS’s response or request for an extension within two business days.  The contractor shall document each attempt to obtain a review decision from the SAS.  The contractor shall refer civilian care to a network provider as the first option if a network provider is not available within Prime access standards.  The contractor shall assist the ADSM in locating a TRICARE-authorized provider.  If the SAS directs the care to a military source, the SAS will manage the EOC.  If the ADSM disagrees that the care must be provided by a military source, the ADSM may appeal through the SAS who will coordinate the appeal as appropriate.  The contractor shall refer all appeals and inquiries concerning the SAS’s military source determination to the SAS.  If the ADSM’s PCM determines that a specialty referral or test is required on an urgent basis (less than 48 hours from the time of the PCM office visit) the PCM should submit a referral to the contractor.  The contractor shall send all requested information to the SAS for a fitness for duty review.  The ADSM can receive the care as needed without waiting for the SAS determination.  The contractor shall adjudicate the claim according to TRICARE Prime provisions.  If further specialty care is warranted, the PCM should request a referral to specialty care.  The contractor shall contact the SAS with a request for an additional SAS review for the specialty care.
5.3.3  Care Received With No Authorization or Referral  The contractor shall pend claims for care which require referral, authorization, and SAS review, but which have not been authorized or reviewed.  The contractor shall pend the claim and supply the required information (TRICARE Systems Manual (TSM), Chapter 1, Section 1.1, paragraph 11.0) to the SAS for review, if the claim involves care covered under TRICARE policy.  The contractor shall authorize the care, release the claim for payment, and apply any overrides necessary to ensure that the claim is paid with no fees assessed to the ADSM, if the SAS does not notify the contractor of the review determination or ask for an extension for further review within two business days after submitting the request for coverage determination.  The contractor shall not make claims payments to sanctioned or suspended providers (see Chapter 13, Section 5).
Note:  Claims for care provided under the National DoD/DVA/VHA MOA for Payment for Processing Disability Compensation and Pension Examinations (DCPE) in the Integrated Disability Evaluation System (IDES) shall follow the routing requirements specified in Chapter 17, Section 2.  The contractor shall decline to file an authorization and deny any received claims if the contractor determines that the requested service, supply, or equipment is not covered by TRICARE policy (including Chapter 17, Section 3) and no Defense Health Agency (DHA) approved waiver is provided.  The contractor shall notify the civilian provider and the remote ADSM or non-enrolled ADSM of the declined authorization with explanation of the reason.  The contractor’s notification to a civilian provider and the ADSM or non-enrolled ADSM shall explain the waiver process and provide contact information for the applicable Uniformed Services Headquarters Point of Contact (POC) or Service Project Officers as listed in Addendum A. No notification to the SAS is required.
Note:  The contractor shall initiate recoupment actions according to Chapter 10, Section 4 if the SAS retroactively determines that the payment should not have been made.
6.1  Comprehensive Health Promotion and Disease Prevention Examinations
The contractor shall reimburse charges for comprehensive health promotion and disease prevention examinations covered under TRICARE Prime (see the TRICARE Policy Manual (TPM), Chapter 7, Section 2.2) without SAS review.
6.2  Vision And Hearing Examinations
The contractor shall refer ADSMs to SAS for information on how to obtain eyeglasses, hearing aids, and contact lenses as well as examinations for these, as well as provide assistance in arranging for vision and hearing examinations.
6.3  No PCM Assigned
6.3.1  The contractor shall arrange for routine primary care and urgent specialty or inpatient care with a TRICARE-authorized provider in cases where ADSMs work and reside in areas outside of PCM availability.
6.3.2  The contractor shall contact the SAS as required for reviews and other assistance as needed.
6.4  Emergency Care
For emergency care, refer to the TPM for guidelines.
6.5  Dental Care
6.5.1  The contractor shall process claims for adjunctive dental care except for overseas care, which is processed by the TRICARE Overseas Program (TOP) contractor.
6.5.2  Claims for ADSM dental services will be processed and reimbursed by a single separate active duty dental program contractor.
6.6  Immunizations
The contractor shall reimburse immunizations as primary care under the guidelines in the TRICARE Reimbursement Manual (TRM).
6.7  Ancillary Services
A SAS authorization for health care includes authorization for any ancillary services related to the health care authorized.
7.1  The contractor shall follow contract requirements for maintaining medical records for TPR-enrolled ADSMs with assigned PCMs.
7.2  The contractor shall be responsible for all administrative and copying costs of providing medical records as a result of a Permanent Change of Station (PCS) or other service-related change of duty status utilizing the following guidelines:
7.2.1  The contractor shall reimburse network providers for medical records photocopying and postage costs incurred at the rates established in their network provider participation agreements.
7.2.2  The contractor shall reimburse participating and non-participating providers for medical records photocopying and postage costs on the basis of billed charges.
7.2.3  The contractor shall reimburse ADSMs who have paid for copied records and applicable postage costs the full amount paid to ensure they have no out of pocket expenses.
7.2.4  All providers or ADSMs must submit a claim form with the charges clearly identified to the contractor for reimbursement.
7.2.5  ADSM’s claim forms should be accompanied by a receipt showing the amount paid.
7.3  ADSMs will be instructed by their commands to sign annual medical release forms with their PCMs to allow information to be forwarded as necessary to civilian and military providers.
7.3.1  The contractor may use the current “signature on file” procedures to fulfill this requirement (Chapter 8, Section 4).
7.3.2  The contractor shall ensure that the PCM provide a complete copy of medical records, to include copies of specialty and ancillary care documentation, to the ADSM within 30 calendar days of the ADSM’s request for the records.
7.3.3  The ADSM may also request copies of medical care documentation on an ongoing, EOC basis.
Note:  The purpose of the copying of medical records is to assist the ADSM in maintaining accurate and current medical documentation.
7.3.4  Photocopies of medical records by a provider to support the adjudication of a claim are not reimbursable.
7.3.5  ADSMs without assigned PCMs are responsible for maintaining their medical records when receiving care from civilian providers.
8.1  The contractor shall educate network providers and, when appropriate, other providers about the TPR Program, special requirements for ADSM health care and billing procedures (e.g., no cost-share or deductible amounts, balance billing prohibition).
8.2  The contractor shall provide information on ADSM specialty care procedures and billing instructions in routine information and educational programs according to contractual requirements.
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