2.0 CONTRACTOR RESPONSIBILITIES
2.1 The TOP contractor shall arrange
for medically necessary ambulance/aeromedical evacuation services
for TOP Prime/TOP Prime Remote enrollees, Service members who are
deployed, in a temporary duty status, or in an authorized leave
status in an overseas location, and all Active Duty Family Members
(ADFMs) that are enrolled to TRICARE Prime, TRICARE Prime Remote
(TPR), TRICARE Select, or TRICARE Young Adult (TYA) who require ambulance/aeromedical
evacuation services while traveling/living outside of the 50 US
and the District of Columbia.
Note: Claims jurisdiction for ambulance/aeromedical
evacuation is based on the patient’s location, regardless of the
patient’s enrollment status or the origination or destination location
of the ambulance/aeromedical evacuation service provider.
2.1.1 When arranging
for ambulance/aeromedical evacuation for the beneficiaries identified
in
paragraph 2.1, the contractor shall determine
beneficiary eligibility and enrollment status, prepare quote(s)
for commercial movement options, and obtain signature authority
and direction on evacuation destination from the appropriate Patient
Movement Requirement Center (PMRC). Upon PMRC approval, the contractor
shall authorize the services, arrange for medical records to accompany
the patient, and coordinate the transfer with the receiving institution
or provider. The appropriate TRICARE Area Office (TAO) shall be
notified of all patient movements.
2.1.2 For Service
member emergency medical evacuations (including Service members
who are on temporary duty, in an authorized leave status, or deployed/deployed
on liberty), the TOP contractor shall ensure that the Service member’s
unit is aware of the medical evacuation. The TAO shall be contacted
for assistance if the member’s unit information cannot be determined
by the contractor.
2.1.3 Except for normal TRICARE cost-shares,
these beneficiaries shall not be responsible for any up-front payments
for emergency ambulance service (to include aeromedical evacuation,
when medically necessary and appropriate). The contractor shall
establish business processes (e.g.,Guarantee of Payment to private
sector care ambulance provider) to ensure that these beneficiaries
are not subjected to up-front payments in excess of normal TRICARE
cost-shares.
2.2 Upon request,
the TOP contractor shall facilitate medically necessary ambulance/aeromedical
evacuation services for all TRICARE-eligible beneficiaries not identified
in
paragraph 2.1 (regardless of enrollment location
or residence) according to the processes identified in the TOP contract.
When facilitating ambulance/aeromedical evacuation for these beneficiaries,
the contractor shall identify ambulance/aeromedical evacuation resources
that service the patient’s location; however, the contractor shall
not schedule the evacuation, coordinate with the receiving institution
or provider, obtain medical records, or establish business processes
(e.g., Guarantee of Payment) to limit up-front payments for these
beneficiaries.
2.3 Since medical evacuations may
involve transfers between TRICARE regions, the TOP contractor shall establish
processes for coordinating medical evacuations with the stateside
contractors.
2.4 The TOP contractor shall ensure
that ambulance/aeromedical evacuation services can be accomplished in
an expeditious manner that is appropriate and responsive to the
beneficiary’s medical condition. The contractor shall establish
a dedicated unit for responding to such requests, or may augment
existing service units. Contractor staff shall be available for
ambulance/aeromedical evacuation assistance 24 hours per day, seven
days per week, 365 days per year. Ambulance/aeromedical evacuation
telephone assistance shall be available without toll charges to
the beneficiary, regardless of their location.
2.5 The TOP
contractor shall maximize the use of military medical transport
services before considering other options. If military medical transport
services are not available (or if services cannot be provided in
a timely manner that is appropriate for the patient’s medical condition)
and the appropriate PMRC has approved commercial movement, the contractor
shall attempt to arrange services through the most economical commercial
resource that is capable of providing appropriate services within
the required time frame. Private, chartered evacuation services
will only be used as a last resort when all other options have been
exhausted. The contractor shall document their rationale and selection
process for any commercial and/or private, chartered evacuation
services. If multiple resources are identified that are capable
of providing the needed services, the contractor shall select the resource
that represents the best value to the Government. Upon request,
the contractor shall provide Defense Health Agency (DHA) with documentation
supporting their rationale and selection process.
2.6 Upon transfer
to a facility for stabilization and care, the TOP contractor shall
coordinate with the appropriate Military Medical Treatment Facility
(MTF) (for TOP Prime enrollees) or TAO (for TOP Prime Remote enrollees)
to provide information on the patient’s transfer and to provide
further assistance as appropriate.
2.7 The TOP
contractor shall comply with the provisions of TPM,
Chapter 8, Section 1.1, except that the TOP contractor
shall utilize the coding requirements identified for ambulance charges
and shall develop claims for diagnosis and transfer information
for ambulance services received overseas. The TOP contractor shall
utilize the diagnosis if provided, or may use available in-house
methods such as claims history when processing the claim. A diagnosis
shall be included with the claim.
2.8 All related
documentation (including, but not limited to, original invoices,
supporting documents, and Explanation of Benefits (EOB)) related
to the evacuation shall be submitted with the claim.
2.9 The Ambulance
Fee Schedule (AFS) reimbursement methodology (TRICARE Reimbursement
Manual (TRM),
Chapter 1, Section 14) applies only to ground
ambulance services in Puerto Rico. Air ambulance transport (aeromedical
evacuations) covered under the TOP, including Puerto Rico shall
be reimbursed utilizing reasonable and customary charges.