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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Overseas Program (TOP)
Chapter 24
Section 26
TRICARE Overseas Program (TOP) Supplemental Health Care Program (SHCP)
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1.1  All TRICARE requirements regarding the SHCP shall apply to the TOP unless specifically changed, waived, or superseded by this section, TRICARE Policy Manual (TPM), Chapter 12, or the TRICARE contract for health care support services outside the 50 United States (US) and the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 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.
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