1.0 General
1.1 All TRICARE
requirements regarding claims processing 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unless specifically changed, waived, or superseded by this section;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
Chapter
8 for additional instructions.
1.5 The provisions of
Chapter 8, Section 1, paragraph 2.3 are applicable
the TOP; however, region or country-specific requirements regarding
third party payments or payment addresses may be established by
Defense Health Agency (DHA) at any time to prevent or reduce fraud.
Note: Benefit payment checks and
Explanation Of Benefits (EOB) to Philippine providers (and other
nation’s providers as determined by the Government) shall be mailed
to the place of service identified on the claim. This policy applies
even if the provider uses a Third Party Administrator (TPA). No
provider payments shall be sent to any other address. The Government
may discontinue TPA payments to other countries or specific agencies
if it is determined that significant fraud is occurring on a regular
basis.
1.6 Acceptable claim forms are
identified in
Chapter 8, Section 1, paragraph 3.1, this
may be any current or obsolete claim form (whether submitted by
a beneficiary or a provider). Additionally the TOP contractor shall accept
any other claim form or alternative documentation as long as these
methods provide sufficient data to facilitate claims processing
and TRICARE Encounter Data (TED) submission.
1.8 The contractor’s claims processing
procedures shall integrate efforts to prevent and identify fraud/abuse.
2.0 JURISDICTION
2.1 In the
early stages of TOP claims review, the TOP contractor shall determine
whether claims received are within its contractual jurisdiction
using the criteria below.
2.2 Services rendered on-board
a commercial ship while outside US territorial waters are the responsibility
of the TOP contractor. Claims for services provided on a commercial
ship that is outside the territorial waters of the US shall be processed
as foreign claims regardless of the provider’s home address. If
the provider is certified within the US, reimbursement for the claim
is to be based on the provider’s home address. If the provider is
not certified within the US, reimbursement will follow the procedures
for foreign claims. This does not include health care for enrolled
Service members on a ship at sea or on a military ship at home port.
2.3 The provisions
of
Chapter 8, Section 2, paragraphs 1.0 and
2.0 are superseded as described in
paragraphs 2.3.1 through
2.3.9.
2.3.1 When a beneficiary is enrolled
in TOP Prime or TOP Prime Remote, the TOP contractor shall process
all health care claims for the enrollee, regardless of where the
enrollee receives services. Referral/authorization rules apply.
2.3.2 Claims
for Active Duty Family Members (ADFMs) (including Reserve Component
(RC) ADFMs whose sponsors have been activated for more than 30 calendar
days), retirees, and retiree family members whose care is normally
provided under one of the regional contracts (i.e., beneficiaries
enrolled or residing in the 50 US and the District of Columbia)
who receive Civilian Health Care (CHC) while traveling or visiting
overseas shall be processed by the TOP contractor, regardless of
where the beneficiary resides or is enrolled. Referral/authorization
and Point Of Service (POS) rules apply for TRICARE Prime/TRICARE
Prime Remote (TPR) enrollees.
Note: This provision does not apply
to beneficiaries who are enrolled in the Uniformed Services Family
Health Plan (USFHP) or the Continued Health Care Benefit Program
(CHCBP). Claims for these beneficiaries are processed by their respective
contractor regardless of where the care is rendered.
2.3.3 Claims
for Service members residing in the 50 US and the District of Columbia
(including RC Service members activated for more than 30 calendar
days) who are on Temporary Additional Duty/Temporary Duty (TAD/TDY),
deployed, deployed on liberty, or in an authorized leave status
in an overseas location shall be processed by the TOP contractor,
regardless of where the Service members resides or is enrolled.
Referral/authorization rules apply.
2.3.4 Claims
for TOP-enrolled Service members (including RC Service members activated
for more than 30 calendar days) on a military ship or with an overseas
home port shall not be processed by the member’s military unit.
These claims shall be processed by the TOP contractor.
2.3.5 Initial
and follow-on Line Of Duty (LOD) claims for RC Service members on
orders for 30 consecutive calendar days or less, who are injured
while traveling to or from annual training or while performing their
annual training who receive civilian medical care overseas, shall
have their claims processed by the TOP contractor upon verification
of LOD status. Defense Health Agency-Great Lakes (DHA-GL) will validate
LOD status for RC Service members in the US Virgin Islands.
2.3.6 The TOP
contractor shall process claims for Durable Equipment (DE) and Durable
Medical Equipment (DME) (otherwise coverable by TRICARE) that is
purchased/ordered by TOP-eligible beneficiaries in an overseas area from
a stateside provider (i.e., Internet, etc.).
2.3.7 For inpatient
claims that are paid under the Diagnosis Related Group (DRG)-based
payment system, the TOP contractor, on the date of admission, shall
process and pay the entire DRG claim, including cost outliers. For inpatient
claims paid on a per diem basis, to include DRG transfers and short
stay outlier cases, and for professional claims that are date-driven,
the contractor shall process and pay the claims.
2.3.8 When a
beneficiary’s enrollment changes from one TRICARE region to another
during a hospital stay that will be paid under the DRG-based payment
system, the contractor with jurisdiction on the date of admission shall
process and pay the entire DRG claim, including cost outliers.
2.3.9 For information on portability
claims for relocating TOP Prime/TOP Prime Remote enrollees, refer
to
Chapter 6, Section 2.
2.5 The provisions
of
Chapter 19, Section 4 are applicable to the
TOP for US citizens who are practicing outside the US
2.6 The provisions
of
Chapter 8, Section 2, paragraphs 6.6,
6.7,
7.1,
7.2, and
8.1 are applicable to the TOP.
2.7 Refer
to the TRICARE Reimbursement Manual (TRM),
Chapter 4, Section 4, paragraph 5.0 for jurisdictional guidance
regarding health care claims for work-related illness or injury
which is covered under a Worker’s Compensation Program.
2.8 The provisions
of
Chapter 8, Section 2, paragraph 5.0 are applicable
to the TOP in those locations where the TRICARE Pharmacy (TPharm)
contractor has established services (the US territories of Puerto
Rico, Guam, the US Virgin Islands, American Samoa, and the Northern
Mariana Islands). The TOP contractor cannot process pharmacy claims
from these locations except for pharmacy that is part of an emergency
room visit or inpatient treatment. Any prescriptions from this care
that are not provided at time of treatment for inpatient/emergency
care, shall be required to be submitted through the TPharm contractor.
Copays will apply.
2.9 The TOP contractor shall forward
all retail pharmacy claims to the TPharm contractor within 72 hours
of identifying them as being out-of-jurisdiction. In all other overseas
locations, the contractor shall process claims from purchased care
sector retail pharmacies and providers.
2.10 ADFMs
with TRICARE Select and retirees or their family members residing
overseas obtaining prescription from an overseas purchased care
sector pharmacy shall submit their claims to the TOP contractor.
For cost-share/deductible provisions, see TRM,
Chapter
2 regarding the mandatory collection of pharmacy copayment amounts
at the time of service are waived for foreign providers.
3.0 CLAIMS
FILING DEADLINE
The provisions
of
Chapter 8, Section 3 are applicable to the
TOP except that claims for services provided outside the 50 US or
the District of Columbia, the Commonwealth of Puerto Rico, or the
possessions of the US are considered to be filed in a timely manner
if they are filed no later than three years after the date the services
were provided or three years from the date of discharge for an inpatient
admission. All other claims must be filed within one year according
to the requirements listed in
Chapter 8, Section 3,
unless an exception to the filing deadline has been granted. See
Chapter 1, Section 2, paragraph 5.0 for the
timely filing waiver process.
4.0 SIGNATURE
REQUIREMENTS
4.1 The provisions of
Chapter 8, Section 4 are applicable to the
TOP unless a different process has been directed by the DHA Contracting
Officer (CO).
4.2 The TOP contractor shall, at
its discretion, accept a thumb print in lieu of a signature on a
claim form, unless otherwise directed by the Government. When directed
by the DHA CO, the TOP contractor shall not use signature on file
and may not accept facsimile or thumb print signatures on claims.
5.0 REFERRALS/PREAUTHORIZATIONS/AUTHORIZATIONS
The provisions of
Chapter 7, Section 5 and
Chapter 8, Section 5 are altered for the TOP
by the following requirements.
5.1 Referral/Preauthorization/Authorization
Requirements for TOP Prime and TOP Prime Remote Enrollees
5.1.1 Unless
otherwise directed by the Government, referrals/preauthorizations/authorizations
are not required for emergency care, clinical preventive services,
ancillary services, radiological diagnostics (excluding Magnetic
Resonance Imaging (MRI) and Positron Emission Tomography (PET) scans),
drugs, and services provided by a TOP Partnership Provider. Additionally,
TOP Prime/TOP Prime Remote ADFMs will require a referral for all mental
health and Substance Use Disorder (SUD) services except outpatient
office-based visits. TOP Prime/TOP Prime Remote ADFMs will also
require preauthorization for treatment of SUDs as outlined in the
TPM,
Chapter 7, Section 3.5, paragraph 4.0 and
for the treatment of mental disorders as outlined in the TPM,
Chapter
7, Section 3.8, paragraph 6.0. All other care that is
provided to a TOP Prime/TOP Prime Remote-enrolled Service member
or ADFM by anyone other than their Primary Care Manager (PCM) requires
authorization, regardless of where the care is rendered.
5.1.2 Claims
for Service member care not authorized by the TOP contractor shall
be pended for a review to make a determination regarding authorization.
If the care is retroactively authorized by the Government (including submission
of an approved waiver for a non-covered service), then the contractor
shall enter the authorization and process the claim for payment.
If the contractor determines that the care was not authorized, the
contractor shall deny the claim. Refer to
Section 26 for
additional information.
5.1.3 Claims for self-referred, non-emergency,
and non-urgent care for TOP Prime and TPR enrolled ADFMs shall process
with POS deductibles and cost-shares unless the appropriate TRICARE
Area Office (TAO) or TRICARE Overseas Program Office (TOPO) has
approved a retroactive authorization.
5.1.4 TRICARE-eligible
beneficiaries residing in an overseas location who are not enrolled
in TOP Prime/TOP Prime Remote typically do not need to obtain preauthorization/authorization
for care. However, preauthorization reviews shall be performed for
all care and procedures listed in
Chapter 7, Section 2.
The TOP contractor shall propose additional authorization reviews
for non-enrolled TOP beneficiaries to the government.
5.1.5 TRICARE
beneficiaries whose health care is normally provided under one of
the two regional MCSCs who require care while traveling in an overseas
location shall request any necessary preauthorizations/authorizations
through the TOP contractor, regardless of where the beneficiary
resides or is enrolled. Denial of requested services should be visible
to the claims processing contractor to ensure claims are denied
or processed as POS as appropriate.
Note: This process does not apply
to beneficiaries enrolled to the USFHP or the CHCBP.
5.2 Point
of Service (POS) Provisions
5.2.1 Unless specifically excluded
by this section, all self-referred, non-emergency care provided
to TOP Prime/TOP Prime Remote-enrolled ADFMs which is not either
provided/referred by the beneficiary’s PCM or specifically authorized
shall be reimbursed under the POS option. This provision applies
regardless of where the care is rendered. POS provisions also apply
to the following stateside beneficiaries when traveling overseas:
ADFMs, retirees, and retiree family members who are enrolled in
TRICARE Prime, and ADFMs enrolled in TPR for ADFMs.
5.2.2 POS cost-sharing
only applies to TRICARE-covered services. Claims for services that
are not a covered TRICARE benefit shall be denied.
5.2.3 The TOP
contractor shall adjust POS deductibles and cost-shares when TOP
PCMs or Health Care Finders (HCFs) do not follow established referral/authorization
procedures. For example, if the contractor processes a claim under
the POS option because there was no evidence of a referral and/or
an authorization, and the contractor later verifies that the PCM
or other appropriate provider referred the beneficiary for the care,
the contractor shall adjust the claim and reverse the POS charges.
The contractor need not identify past claims that may be eligible
for POS adjustment; however, the contractor shall adjust these claims
as they are brought to their attention.
5.2.4 On a case-by-case
basis, following stabilization of the patient, the TAO Director
or MTF Commander may require an enrolled beneficiary to transfer
to a TOP network facility or an MTF. The TAO Director or MTF Commander
shall provide written notice to the beneficiary (or responsible
party) advising them of the impending transfer to a TOP network
facility/MTF. If a beneficiary who is subject to TOP POS provisions
elects to remain in the non-network facility after such notification,
POS cost-sharing provisions will apply beginning 24 hours following the
receipt of the written notice. Neither the TOP Director nor the
MTF Commander will require a transfer until such time as the transfer
is deemed medically safe.
5.2.5 The following
deductible and cost-sharing amounts apply to all TOP POS claims
for health care support services:
• Enrollment year deductible
for outpatient claims: $300 per individual; $600 per family. No
deductible applies to inpatient services.
• Beneficiary cost-share for
inpatient and outpatient claims: 50% of the allowable charge after
the deductible has been met (deductible only applies to outpatient
claims).
• POS deductible and cost-share
amounts are not creditable to the enrollment/Fiscal Year (FY) catastrophic
cap and they are not limited by the cap.
• POS deductible and cost-share
amounts do not apply to claims for care received by newborns and
newly adopted children who are deemed enrolled in TOP Prime or TOP
Prime Remote.
5.2.6 POS deductible
and cost-share amounts do not apply if a TOP enrollee has Other
Health Insurance (OHI) that provides primary coverage (i.e., the
OHI must be primary under the provisions of the TRM,
Chapter 4, Section 1). Evidence of OHI claims
processing (including the exact amount paid on the claim) must be
submitted with the TOP claim.
5.2.7 EOB shall
clearly indicate that a claim has been processed under the POS Option.
5.2.8 POS is
not applicable to Service members or to TRICARE Select.
5.3 Extended
Care Health Option (ECHO) benefits in overseas locations must be
authorized by the TOP contractor. Refer to
Section 23 and
the TPM,
Chapter 9 for
additional guidance.
5.4 Refer to
Section 10 for
referral/preauthorization/authorization requirements for Service
member dental care in remote overseas locations.
6.0 CLAIM
DEVELOPMENT
6.1 Development of missing information
shall be kept to a minimum. The TOP contractor shall use available in-house
methods, contractor files, telephone, Defense Enrollment Eligibility
Reporting System (DEERS), etc., to obtain incomplete or discrepant
information. If this is unsuccessful, the contractor shall return
the claims to sender with a letter which indicates that the claims
are being returned, the reason for return and requesting the required missing
documentation. The contractor’s system shall identify the claim
as returned, not denied. The Government reserves the right to audit
returned claims as required, therefore the contractor shall retain
sufficient information on returned claims to permit such audits.
The contractor shall review all claims to ensure TOP required information is
provided prior to payment. For the Philippines, claims requiring
development of missing or discrepant information, or those being
developed for medical documentation, shall be pended for 90 calendar
days and are excluded from the claims processing standard.
6.2 Claims
may be filed by eligible TRICARE beneficiaries, purchased care sector
providers, TOP POCs, and TRICARE authorized providers in the 50
US and the District of Columbia as allowed under TRICARE (see
Chapter 8, Section 1).
6.3 Confidentiality
requirements for TOP are identical to TRICARE requirements outlined
in
Chapter 8.
6.5 The following
minimal information is required on each overseas claim prior to
payment:
6.5.1 Signatures
Beneficiary and purchased care
sector provider signatures (signature on file is acceptable unless
specifically prohibited by the Government).
6.5.2 Name
and Address
6.5.2.1 Complete beneficiary and purchased
care sector provider name and address.
6.5.2.2 If an address is not available
on the claim, obtain the address either from previously submitted
claims, directly from the beneficiary/purchased care sector provider
via phone, fax, or email, DEERS per
paragraph 6.1.
Note: The TOP contractor shall accept
APO/FPO for the beneficiary address.
6.5.3 Diagnosis(es)
6.5.3.1 Prior to returning a claim
that is missing a diagnosis, the TOP contractor shall research the
patient’s history and determine whether a diagnosis from a related
claim can be applied. The diagnosis should be reflective of the
services rendered.
6.5.3.2 Claims received for dates of
service for outpatient services or dates of discharge for inpatient
services before the mandated date, as directed by Health and Human
Services (HHS), for International Classification of Diseases, 10th
Revision (ICD-10) implementation, with ICD-10 codes shall be converted
to International Classification of Diseases, 9th Revision, Clinical
Modifications (ICD-9-CM) codes by the TOP contractor. Claims received
for dates of service for outpatient services or dates of discharge
for inpatient services on or after the mandated date, as directed
by HHS, for ICD-10 implementation, with ICD-9 or ICD-9-CM codes
shall be converted to ICD-10-CM codes by the TOP contractor. Refer
to
Chapter 8, Section 6, paragraphs 4.0 and
5.0 regarding the use of ICD-9-CM
V codes
(factors influencing health status and contact with health services)
and ICD-10-CM
Z codes (factors influencing health status
and contact with health services).
6.5.4 Procedures/Services/Supply/DME
The TOP contractor shall identify
the procedure(s)/service(s)/supply/DME ordered, performed or prescribed, including
the date ordered performed or prescribed. The TOP contractor shall
use the date the claim form was signed as the specific date of service,
if the service/purchase date/order date is not on the bill.
6.5.5 Claims
received with a narrative description of services provided shall
be coded by the TOP contractor with as accurate-coding as possible
based upon the level of detail provided in the narrative description
or as directed by the TOPO. Services which contain sufficient detail
to identify an accurate procedure code shall be used. All surgical
procedures must be coded accurately based on the level of detailed
description. Outpatient professional services shall be coded accurately.
Office visits which include multiple services shall be coded accurately
and not bundled when the description of services are available.
The provisions of
paragraph 6.1 apply for narrative claims that
cannot be accurately coded due to insufficient or vague information.
Claims received for dates of service for outpatient services or
dates of discharge for inpatient services before the mandated date,
as directed by HHS, for ICD-10 implementation, with ICD-10 codes
shall be converted to ICD-9 codes by the TOP contractor. Claims
received for dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 codes shall be converted to ICD-10 codes by the TOP contractor. Refer
to
Chapter 8, Section 6, paragraph 4.0 regarding
the use of
V and
Z codes.
6.5.5.1 Inpatient
Institutional Procedures
Inpatient
institutional (i.e., hospital) claims received for dates of discharge
for inpatient services before the mandated date, as directed by
HHS, for ICD-10 implementation, shall have the procedure narratives
coded by the TOP contractor using ICD-9-CM, Volume 3 procedure codes.
Inpatient institutional (i.e., hospital) claims received for dates
of discharge on or after the mandated date, as directed by HHS,
for ICD-10 implementation, shall have the procedure narratives coded
by the TOP contractor using ICD-10-Procedure Classification System
(ICD-10-PCS) procedure codes.
6.5.5.2 Outpatient
Institutional Procedures and Professional Services
Claims received for outpatient
institutional (e.g., ambulance services, laboratory, Ambulatory
Surgery Centers (ASCs), partial hospitalizations, outpatient hospital
services) services and professional services shall be coded using Healthcare
Common Procedure Coding System (HCPCS) or Current Procedural Terminology
(CPT).
6.5.6 Care authorizations (when required)
6.5.7 Itemization
of total charges. (Itemization of hospital room rates are not required
on institutional claims).
6.5.8 Proof
of payment is required for all beneficiary submitted claims if the
claim indicates that the beneficiary made payment to the provider
or facility. Due to cultural differences, there may be significant
variation in provider processes for issuing receipts to the beneficiaries.
Therefore, the overseas claims processor shall use best business
practices when determining if the documentation provided is acceptable
for the country where the services were rendered.
6.5.8.1 Examples
of ACCEPTABLE Beneficiary Proof of Payment
• Canceled checks (made payable
to the provider)
• Credit or bank card statements
or receipts
• Bank account statements (with
documentation of payment to the provider)
• Receipt, itemized bill, or
statement issued by the provider’s office stamped ‘PAID’ on all
pages
• Proof of electronic funds transfer
(EFT) from the beneficiary to the provider
• Invoice for pharmaceuticals
dispensed on an outpatient basis (overseas pharmacies will not dispense
drugs without payment; therefore, an invoice represents proof of
payment)
• Invoice for health care from
providers in Turkey (Turkish providers will not provide an invoice
to the patient until payment has been made; therefore, an invoice
represents proof of payment).
6.5.8.2 Examples
of UNACCEPTABLE Beneficiary Proof of Payment:
• Canceled check made payable
to ‘Cash’ or to the beneficiary or sponsor;
• Bank account statements showing
cash withdrawal (without additional documentation of payment to
the provider);
• Letter signed by patient saying
s/he has paid the bills;
• Paid amount shown only on the
claim or itemized bill;
• Handwritten statements (e.g.,
‘Paid in Full’, ‘Paid by Patient’, ‘Paid in Cash’);
• Paid in cash (without additional
documentation of payment to the provider).
6.6 Non-prescription
(Over-The-Counter (OTC)) drugs are to be denied. This includes drugs
that are considered OTC by US standards, even when they require
a prescription in a foreign country.
6.7 The TOP
contractor shall use a schedule of allowable charges based on the
Average Wholesale Price (AWP) as a reference source for processing
drug related TRICARE overseas claims.
6.8 Claims
for medications prescribed by a host-nation physician, and commonly
used in the host-nation country, shall be cost-shared unless they
are considered OTC by US standards.
6.9 For the
Philippines, prescription drugs may only be cost-shared when dispensed
by a certified retail pharmacy or hospital-based pharmacy. The TOP
contractor shall deny claims for prescription drugs dispensed by
a physician’s office. Certification requirements outlined in Section
31 apply.
Note: This does not apply to Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
6.10 Claims
for DME involving lease/purchase shall always be developed for missing
information.
6.11 The TOP contractor shall use
ECHO claims processing procedures outlined in TPM,
Chapter 9, Section 18.1, when processing ECHO
overseas claims.
6.12 The TOP contractor shall deny
claims from non-certified or non-confirmed purchased care sector providers
when the DHA CO has directed contractor certification/confirmation
of the purchased care sector provider prior to payment.
6.13 Requests
for missing information shall be sent on the TOP contractor’s TRICARE/TOP
letterhead. When development is necessary, the contractor shall
include a special insert in German, Italian, Spanish, Tagalog, Japanese,
and Korean which indicates what missing information is required
to process the claim and includes the contractor’s address for returning
requested information.
6.14 If the TOP contractor elects
to develop for additional/missing information, and the request for
additional information is not received/returned within 45 calendar
days, the contractor shall deny the claim.
6.15 If the
TOP contractor has no record of referral/authorization prior to
denial/payment of the claim, the contractor shall follow the TOP
POS rules, if the service would otherwise be covered under TOP.
6.16 The TOP
contractor shall develop procedures for the identification and tracking
of TOP enrollee claims submitted by either a purchased care sector
designated or non-designated overseas purchased care sector provider
without preauthorization/authorization. Upon receipt of a claim
for a TOP-enrolled ADFM submitted by a purchased care sector designated
or non-designated overseas purchased care sector provider without preauthorization/authorization,
the contractor shall process the claims following POS payment procedures.
For Service member claims submitted by a purchased care sector provider
without preauthorization/authorization, the contractor shall pend
the claim for review prior to denying the claim. Refer to
Section 26 for more information on ADSM pended
claims.
6.17 The TOP contractor shall have
an automated data system for eligibility, deductible and claims
history data and must maintain on the automated data system all
the necessary TOP data elements to ensure the ability to reproduce
both TED and EOBs as outlined in
Chapter 8, Section 8,
except for requiring overseas providers to use HCPCS to bill outpatient
rehabilitation services, issue provider’s the Form 1099 and suppression
of checks/drafts for $.99 or less. The contractor shall split claims
to accommodate multiple invoice numbers in order to reference invoice
numbers on EOBs when necessary. Refer to Chapter 8, Section 6 for
additional requirements related to claims splitting.
6.18 The TOP
contractor shall not pay for pharmacy services obtained through
the Internet.
6.19 The TOP contractor shall pay
all TOP Service member stateside claims as outlined in
Section 26.
6.20 All claims
shall be submitted in a Health Insurance Portability and Accountability
Act (HIPAA) compliant format. Refer to
Section 28 for
more information on HIPAA requirements.
6.21 Electronic
claims not accepted by the TOP contractor’s Electronic Data Information
(EDI) system/program shall be rejected.
6.22 For all
overseas claims, the TOP contractor shall create and submit TEDs
following current guidelines in the TSM for TED development and
submission. Claim information will be able to be accessed through
the TRICARE Patient Encounter Processing and Reporting (PEPR) Purchased
Care Detail Information System (PCDIS).
6.23 The TOP
contractor shall establish Utilization Management (UM) high dollar/frequency
thresholds in accordance with
Section 6.
6.24 Claims
either denied as “beneficiary not eligible” or “found to be not
eligible on DEERS” may be processed as a “good faith payment” when
received from the Defense Health Agency (DHA) Communications Office.
The TAO Director shall work with the TOP contractor on claims issues
related to good faith payment documentation (e.g., a completed claim
form and other documentation as required by
Chapter 10, Section 2 and
3).
6.26 The Claims Auditing Software
requirements outlined in the TRM,
Chapter 1, Section 3 do not apply to TOP claims;
however, the TOP contractor shall implement an internal process
for identifying upcoding, unbundling, etc. on coded claims.
7.0 APPLICATION
OF DEDUCTIBLE AND COST-SHARING
Application of TOP deductible
and cost-sharing procedures shall follow the guidelines outlined
in
Chapter 8, Section 7.
8.0 EOB
VOUCHERS
The TOP
contractor shall follow the EOB voucher requirements in Chapter
8, Section 8, where applicable, with the following exceptions and
additional requirements:
8.1 The letterhead on all TOP EOBs
shall also reflect “TRICARE Overseas Program” and shall be annotated Prime
or TRICARE Select.
8.2 TOP EOBs may be issued on regular
stock, shall provide a message indicating the exchange rate used
to determine payment and shall clearly indicate that ‘This is not
a bill’.
8.3 TOP EOBs shall include the
toll-free number for beneficiary and provider assistance.
8.4 TOP EOBs
for overseas enrolled Service member claims shall be annotated ‘ACTIVE
DUTY.’
8.5 For Point of Sale or Vendor
pharmacy overseas claims, TOP EOBs shall have the name of the provider
of service on the claim.
8.6 For beneficiary submitted pharmacy
claims, TOP EOBs shall contain the name of the provider of service,
if the information is available. If the information is not available,
the EOBs shall contain ‘your pharmacy’ as the provider of service.
8.7 The TOP
contractor shall insert the provider’s payment invoice numbers in
the patient’s account field on all provider EOBs, if available.
8.8 The TOP
contractor shall designate an EOB message for overseas claims rendered
by non-network purchased care sector providers who are required
to be certified, but have not been certified by the TOP contractor. Refer
to Section 4 for more information regarding certification of providers
in designated locations.
8.9 When a provider’s/beneficiary’s
EOB, EOB and check, or letter is returned as undeliverable, the
check shall be voided.
8.10 The TOP contractor shall utilize
secure electronic EOB delivery to beneficiaries unless mail delivery
has been requested by the beneficiary or has not signed up for electronic
delivery.
8.11 The contractor shall issue
monthly summary EOBs to beneficiaries on claims when there is no
beneficiary liability. The processing date of the oldest claim for
the summary EOB shall not be greater than 31 calendar days.
9.0 DUPLICATE
PAYMENT PREVENTION
9.1 The TOP contractor shall follow
the duplicate payment prevention requirements outlined in
Chapter 8, Section 9.
9.2 The TOP
contractor shall ensure that business processes are established
which require appropriate system and/or supervisory controls to
prevent erroneous manual overrides when reviewing potential duplicate payments.
10.0 DOUBLE
COVERAGE
10.1 TOP claims require double coverage
review as outlined in the TRM,
Chapter
4.
10.2 Beneficiary/provider disagreements
regarding the contractor’s determination shall be coordinated through
the overseas TOP office for resolution with the contractor.
10.3 Overseas
insurance plans such as German Statutory Health Insurance, Japanese
National Insurance (JNI), and Australian Medicare, etc., are considered
OHI. National Health Insurance (NHI) plans do not always provide EOBs
to assist in the adjudication of TRICARE claims. If a beneficiary
has attempted unsuccessfully to obtain an EOB from their NHI plan,
they may submit a beneficiary attestation and an itemized claim
checklist (approved by DHA) with their claim. The TOP contractor
shall waive the requirement for an EOB from the NHI plan when accompanied by
the DHA-approved document. If the TOP contractor has validated and
documented the NHI does not provide coverage for something that
is a TRICARE benefit (e.g. breast pumps), the TOP contractor shall
waive the requirement for an EOB from the NHI plan.
Note: If the Japanese insurance points
are not clearly indicated on the claim/bill, the TOP contractor
shall contact the submitter or the appropriate TOP POC for assistance
in determining the Japanese insurance points prior to processing
the claim.
11.0 THIRD
PARTY LIABILITY (TPL)
The TOP
contractor shall reimburse TOP claims suspected of TPL and then
develop for TPL information. Upon receipt of the information, the
contractor shall refer claims/documentation to the appropriate Judge
Advocate General (JAG) office, as outlined in the
Chapter
10.
12.0 REIMBURSEMENT/PAYMENT
OF OVERSEAS CLAIMS
When processing
TOP claims, the TOP contractor shall follow the reimbursement payment
guidelines outlined in the TRM,
Chapter 1, Section 34 and the cost-sharing
and deductible policies outlined in the TRM,
Chapter 2, Section 1, and shall:
12.1 Reimburse
claims for purchased care sector services/charges for care rendered
to TOP eligible beneficiaries which is generally considered purchased
care sector practice and incidental to covered services, but which
would not typically be covered under TRICARE. An example of such
services may be, charges from purchased care sector ambulance companies
for driving purchased care sector physicians to accidents or private
residences, or the manner in which services are rendered and considered
the standard of care in a purchased care sector country, such as
rehabilitation services received in an inpatient setting.
12.2 Reimburse
claims at the lesser of the billed amount, the negotiated reimbursement
rate, the CHAMPUS Maximum Allowable Charge (CMAC), or the Government
established fee schedules (when applicable) (TRM,
Chapter 1, Sections 34 and
35), unless a different reimbursement
rate has been established as described in TPM,
Chapter 12, Section 1.3.
Note: Government established fee
schedules (per TRM,
Chapter 1, Sections 34 and
35 are only applicable to retirees or their
eligible family or TRICARE Select ADFMs.
12.3 Not reimburse
for purchased care sector care/services specifically excluded under
TRICARE.
12.4 Not reimburse for purchased
care sector care/services provided in the Philippines unless all
of the certification requirements listed in
Section 14 have
been met.
12.5 Not reimburse for administrative
charges billed separately on claims, except for individual administrative charges
as determined by the Government. The contractor shall reimburse
these charges only in instances when the fee is billed concurrently
with the corresponding health care services. If a bill is received
for these charges without a corresponding health care service, the
charges shall be denied.
12.6 Determine exchange rates as
follows:
12.6.1 Use the exchange rate in effect
on the ending date that services were received unless evidence of
OHI and then the TOP contractor shall use the exchange rate of the
primary insurer, not the rate based on the last date of service
to determine the TOP payment amount, and/or;
12.6.2 Use the ending dates of the
last service to determine exchange rates for multiple services.
12.6.3 Use the exchange rate in
paragraph 12.6.1 to determine deductible and
copayment amounts, if applicable, and to determine the amount to
be paid in foreign currency.
12.6.4 Overseas drafts/checks and
EOBs. Upon completion of processing, the contractor shall create
checks (payable in US dollars). The TOP contractor shall do this
within 48 hours after approval by DHA Contract Resource Management
(CRM). Drafts (payable in foreign currency units) shall be created
by the TOP contractor within 96 hours following CRM approval, unless
a different process has been authorized by DHA. Payments that need
to be converted to a foreign currency shall be calculated based
on the exchange rate in effect on the last date of service listed
on the EOB. Drafts/checks shall be matched with the appropriate
EOB, and mailed to the beneficiary/sponsor/purchased care sector
provider/POC as applicable.
Note: Drafts for certain foreign
currency units may require purchase from a bank location other than
the one normally used by the TOP contractor (out of state or out
of country). Currency units that must be purchased from an alternate
bank (out of state or out of country) may take up to 10 business
days for the draft to be returned and matched up with the EOB.
12.7 Convert
lump sum payments, instead of line items, to minimize conversion
problems.
12.8 Pay provider claims for all
overseas locations in the country’s local currency as identified
on the claim for the specific country by foreign currency/drafts.
Drafts may not be changed to a US dollar check after the contractor has
issued a foreign draft.
12.9 Know that foreign overseas
drafts (in local currency) are good for 190 calendar days and may
be cashed at any time, unless a different process has been established
by DHA. US dollar checks are good for 120 calendar days unless a
different process has been established by DHA. The provisions of
Chapter 3, Section 4 regarding stale dated,
voided, or returned checks/Electronic Funds Transfers (EFTs) are
applicable to the TOP.
12.10 Pay TOP claims submitted by
a beneficiary in US dollars, unless there is a beneficiary request
on the claim at the time of submission for payment in a foreign
currency. The TOP contractor shall reissue the payment in US dollars
if a request is subsequently received from the beneficiary and the
foreign draft is included in the request or the payment has stale
dated, or if directed by the appropriate DHA COR.
12.11 Payment
shall be made in local currency.
12.12 Issue
drafts/checks for German claims which look like German drafts/checks.
Note: In order for TRICARE drafts/checks
to look like German drafts/checks, a German address must be used. The
TOP contractor shall use a corporate address in Germany or the TAO
Eurasia-Africa address for this purpose.
12.13 The contractor
shall pay all beneficiary-submitted claims for TRICARE covered drugs
dispensed by a US embassy health clinic to the beneficiary. The
contractor is not to make payments directly to the embassy health clinic.
12.14 Know that
professional services rendered by a US embassy health clinic are
not covered by TRICARE/TOP. These services are covered under International
Cooperative Administrative Support Services (ICASS) agreements. Embassy
providers (acting as PCMs) may refer TOP enrollees to purchased
care sector providers, these claims shall be processed per TOP policy
and procedures.
12.15 Reimburse claims for drugs
or diagnostic/ancillary services purchased overseas following applicable deductible/cost-share
policies.
12.16 In emergency situations, the
requirement for Medicare certification for facilities in US commonwealths and
territories may be waived. After a review of the facts, the contractor
shall cost-share otherwise covered services or supplies rendered
in an emergency situation by an unauthorized provider to the beneficiary,
or on behalf of the beneficiary, to the beneficiary’s appointed
payee, guardian, or parent in accordance with TPM,
Chapter 11, Section 4.2 and TRM,
Chapter 1, Section 29.
12.17 The contractor
shall mail the drafts/checks and EOBs to purchased care sector providers
unless the claim indicates payment should be made to the beneficiary.
In conformity with banking requirements, the drafts/checks shall
contain the contractor’s address. Drafts and EOBs shall be mailed
using US postage. Additionally, payments/checks may be made to network
providers, with an Embassy address.
12.18 Mail benefit
payment checks and EOBs to Philippine providers, and other nations’
providers as directed by the DHA CO, to the place of service identified
on the claim. No provider checks or EOBs for Philippine providers, and
other nations’ providers as directed by the DHA CO may be sent to
any other address.
12.19 Process/pay inpatient and outpatient
claims for TRICARE overseas eligible beneficiaries, including Service member
claims, as indicated below:
12.19.1 The TPharm contractor shall
allow TOP Service members to use the TPharm retail pharmacy network under
the same contract requirements as other Military Health System (MHS)
eligible beneficiaries (see TPM,
Chapter 8, Section 9.1).
12.19.2 The TPharm contractor shall
allow TOP enrolled ADFM beneficiaries to use their stateside retail pharmacy
network under the same contract requirements as other MHS eligibles
(see TPM,
Chapter 8, Section 9.1).
12.19.3 The TOP contractor shall process
claims for overseas health care received by TRICARE beneficiaries enrolled
to or residing in a stateside contractor’s region following the
guidelines outlined in this chapter. Payment shall be made from
applicable bank accounts and shall be based on billed charges unless
a lower reimbursement rate has been established by the Government
or the contractor.
12.20 EFT payments.
Upon purchased care sector provider request, the TRICARE Overseas
health care support contractor shall provide EFT payment to a US
or overseas bank on a weekly basis. Bank charges incurred by the provider
for EFT payment shall be the responsibility of the provider. Upon
beneficiary request, EFT payments to a US bank may be provided.
Bank charges associated with beneficiary EFT payments shall be the
responsibility of the beneficiary.
12.21 The TOP
contractor shall process 90% of all retained and adjustment TOP
claims to completion within 30 calendar days from the date of receipt.
Claims pended per Government direction are excluded from this standard. However,
the number of excluded claims shall be reported on the designated
DD Form 1423, Contract Data Requirements List (CDRL), located in
Section J of the applicable contract. One hundred percent (100%)
of all claims (both retained and excluded, including adjustments)
shall be processed to completion within 90 calendar days from the
date of receipt, unless the CO specifically directs the contractor
to continue pending a claim or group of claims.
12.22 Exclude
correspondence pended due to stop payment orders, check tracers
on foreign banks, and conversion on currency from the routine 45
calendar day correspondence standard and the priority 10 calendar day
correspondence standard. However, the number of excluded routine
and priority correspondence must be reported on the designated DD
Form 1423, CDRL, located in Section J of the applicable contract.
12.23 The TOP
contractor shall pay Value Added Tax (VAT) included on German health
care claims for all beneficiary categories.
12.24 Reimburse
fees for transplant donor searches in Germany on a global flat fee
basis since the German Government does not permit health care facilities
to itemize such charges.
12.25 Reimburse itemized fees for
supplies that are related or incidental to inpatient treatment (e.g.,
hospital gowns) if similar supplies would be covered under reimbursement
methodologies used within the US The TOP contractor shall implement
internal management controls to ensure that payments are reasonable
and customary for the location.
13.0 CLAIMS
ADJUSTMENT AND RECOUPMENT
13.1 The TOP contractor shall follow
the adjustment requirements in
Chapter
10 except for the requirements related to financially
underwritten funds.
13.2 The TOP contractor shall follow
the recoupment requirements in
Chapter
10 for non-financially underwritten funds, except for
providers. The contractor shall use the following procedures for
purchased care sector provider recoupments. Recoupment actions shall
be conducted in a manner that is considered culturally appropriate
for the purchased care sector provider’s country. The contractor
shall:
• Send an initial demand letter;
• Send a second demand letter
at 90 calendar days;
• Send a final demand letter
at 120 calendar days; and
• Refer the case to DHA at 240
calendar days, if the case is over $600, and if under $600 the case
shall remain open for an additional four months and then shall be
written off at 360 calendar days.
13.3 Recoupment
letters (i.e., the initial letter, the 90 calendar day second request
and the 120 calendar day final demand letter) shall be modified
to delete references to US law. Invoice numbers shall be provided
on all recoupment letters. The TOP contractor shall include language
in the recoupment letter requesting that refunds be returned/provided
in the exact amount requested.
13.4 Provider
recoupment letters sent to Germany, Italy, Spain, Japan, and Korea,
shall be written in the respective language.
13.5 If the
recoupment action is the result of an inappropriately processed
claim by the TOP contractor, recoupment is the responsibility of
the contractor, not the beneficiary/provider.
13.6 The TOP
contractor shall have a TOP bank account capable of receiving/accepting
wire transfers for purchased care sector provider recoupment/overpayment
returns. The TOP contractor shall accept the amount received as
payment against the amount owed. Any fees associated with the wire
transfer are the responsibility of the payer/provider.