1.0 INTRODUCTION
1.1 The SHCP, with specific exceptions
discussed in this chapter, allows for payment of claims for civilian services
rendered pursuant to a referral by a provider in a Market/Military
Medical Treatment Facility (MTF) as well as for Civilian Health
Care (CHC) received by eligible Uniformed Service members. The SHCP
exists under authority of 10 United States Code (USC) 1074(c) and
32 CFR 199.16(a)(3). The use of the SHCP to
pay for care referred by Market/MTF providers is governed by Assistant
Secretary of Defense (Health Affairs) (ASD(HA)) Policy Memorandum
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,” February 21, 2012 or a successor document.
1.2 SHCP-eligible Service Members
are primarily Active Duty Service Members (ADSMs). As utilized in
this chapter, ‘Service Members’ may also include ADSMs in travel
status (leave, Temporary Duty/Temporary Additional Duty (TDY/TAD),
permanent change of station), Navy/Marine Corps Service members
enrolled to deployable units and referred by the unit Primary Care
Manager (PCM) (not at a Market/MTF), eligible Reserve Component
(RC) personnel, Reserved Officer Training Corps (ROTC) students,
cadets/midshipmen, and eligible foreign military. In all cases where
a non-ADSM is authorized care under this chapter, an appropriate
referral/authorization from the Market/MTF Manager or Specified
Authorization Staff (SAS) must be present to authorize care or pay
claims.
1.3 The fact that civilian services
have been rendered to an individual who is enrolled to a Market/MTF
PCM does not mean that those services were Market/MTF referred care.
If a claim is received for an eligible Service Members Market/MTF
enrollee and no authorization is on file, the Market/MTF must be
contacted to determine if the care was Market/MTF-referred.
2.0 SAS
OR MILITARY SERVICE PARTICIPATION
2.1 For care
that is in a TRICARE Prime Remote (TPR) designated area not referred
by a Market/MTF and is not in an area served by the TRICARE Overseas
Program (TOP) contractor, the SAS will identify and coordinate the
CHC furnished to eligible Service Members including preauthorization
of care when required and notify the nearest same service intermediate
commands or Market/MTF for civilian routine and emergency hospital
admissions so they can assume patient oversight responsibilities,
assist with patient movement and coordinate case management as needed.
The entities performing the SAS functions are identified in
Addendum A.
2.2 The contractor
shall contact the referring Market/MTF for any necessary medical
oversight or authorization of care for the TPR patients who may
require medical care that is not available at the Market/MTF (e.g.,
Magnetic Resonance Imaging (MRI)). The contractor will continue
to provide medical necessity reviews as appropriate for care.
2.3 The contractor
shall perform a benefit review on the requests.
3.0 CONTRACTOR
RESPONSIBILITIES
3.1 The contractor shall provide
payment for inpatient and outpatient services, for Market/MTF-referred civilian
care ordered by a Market/MTF provider for a Market/MTF patient for
whom the Market/MTF provider maintains responsibility. This includes
claims for members on the Temporary Disability Retirement List (TDRL) obtaining
required periodic physical exams.
3.2 The contractor
shall furnish the Services with information regarding payment of
the claim as specified in the contract.
3.3 The contractor
shall provide payment for inpatient and outpatient medical services
for CHC received by eligible Uniformed Service members in accordance
with the provisions of this chapter.
3.4 The contractor
shall furnish reports as specified in the contract.
4.0 SHCP
DIFFERENCES
4.1 Eligible Service members have
no cost-shares, copayments, Point-of-Service (POS) charges, or deductibles.
If Service Members have been required by the provider to make “up
front” payment they may upon approval be reimbursed in full for
amounts in excess of what would ordinarily be reimbursable under
TRICARE. Application of Other Health Insurance (OHI) is generally
not considered (refer to
Section 3).
4.2 The contractor
shall not perform OHI processing procedures for eligible Service
member claims under SHCP.
4.3 If Third Party Liability (TPL)
is involved in a claim, claim payment will not be delayed while
the TPL information is developed (refer to
Section 3).
4.4 The contractor
shall provide Market/MTF-referred patients the full range of services
offered to TRICARE Prime enrollees.
4.5 If an
eligible Service member intends, while in a terminal leave status,
to reside outside of the Prime Service Area (PSA) of the Market/MTF
where the Service member is enrolled, the Market/MTF will issue
to the TRICARE contractor a single preauthorization for the Service
member to obtain from the Department of Veterans Affairs/Veterans
Health Administration (DVA/VHA) any routine or urgent outpatient
primary medical care that should be required anytime during the
terminal leave period.
4.5.1 The preauthorization will not
apply to services provided under the terms of the Department of
Defense (DoD)/DVA/VHA Memorandum Of Agreement (MOA) for “Medical
Treatment Provided to Active Duty Service Members with Polytrauma
Injury, Spinal Cord Injury, Traumatic Brain Injury or Blindness.”
4.5.2 The contractor
shall process claims from the DVA/VHA for services provided under
terms of the MOA as specified in
Section 2.
4.6 The contractor
shall process a claim received from the DVA/VHA for services provided
within the scope of the preauthorization using the standards in
Chapter
1 unless otherwise stated in this chapter. The claims
tracking and retrieval requirements of
Chapter 1, Section 3 apply
equally to such SHCP claims.
4.7 The contractor
(for the geographic area of responsibility in which the patient
is enrolled) shall process the claim to completion.
4.8 The contractor
shall require Defense Health Agency (DHA) authority to process services
that would not have ordinarily been covered under TRICARE policy
(including limitations and exclusions or services furnished by a non-TRICARE
authorized provider). Such services may be authorized for eligible
Service members in accordance with the terms of a waiver approved
by the Government Designated Authority (GDA) at the request of an authorized
official of the uniformed service concerned (refer to
paragraph 2.0).
5.0 SERVICE
PROJECT OFFICERS
5.1 Each Service will designate
a Service Project Officer to be the Service’s official Point of
Contact (POC) with DHA and the contractor to resolve any overall
service-related matters regarding the program.
5.2 The Service
Project Officers will be the POC for SHCP waivers. (Refer to
Addendum A for the list of Service Project
Officers).
5.3 Communication with Service
Project Officers shall be coordinated with the GDA or their designee
for SHCP-related issues.