3.1 TOP HCF functions are performed
by BSRs located in the TSCs or in contractor-operated call center(s).
The TOP contractor shall offer call center operations to support
HCF services via toll-free lines 24 hours per day, seven days per
week, 365 days per year.
Note: The contractor shall offer
claims assistance via toll-free lines seven days per week, 365 days
per year, between the hours of 2:00 AM and 7:00 PM Central Standard
Time (CST). These service hours for claims assistance apply even
if claims assistance is provided via the contractor’s call center(s).
3.1.1 HCFs are
responsible for facilitating access to private sector care provider
care (including, but not limited to, primary care, specialty care,
mental health care, ancillary services, Durable Medical Equipment
(DME), and pharmacy services), and for authorizing certain health
care services. Additionally, HCFs shall inform beneficiaries of
access mechanisms, referral procedures, and rules regarding use
of network/non-network providers. They shall also improve patient
continuity of care by establishing mechanisms to facilitate necessary consultations,
follow-up appointments and the sharing of medical records. TOP HCFs
will serve all MHS beneficiaries in the region, regardless of their
enrollment status. This includes dual eligible beneficiaries and beneficiaries
residing or enrolled in the 50 US and the District of Columbia who
may require assistance when accessing care in an overseas location.
3.1.2 For MTF
enrollees, the specialty care referral process includes a covered
benefit review; entering appropriate authorizations into the contractor’s
system; locating a qualified network or non-network private sector care
provider to provide the care on a cashless, claimless basis; providing
the beneficiary with a written care authorization and the private
sector care provider’s information; and assisting the beneficiary
with establishing an appointment with the private sector care provider
(upon beneficiary request).The contractor shall also provide information
to MTF personnel regarding the status of specialty care referrals
and shall work cooperatively with the MTF to assist in obtaining
consult results from private sector care providers; however, the
contractor is not responsible for tracking receipt of consult results.
3.1.3 For TOP
Prime Remote enrollees, the specialty care referral process includes
a medical necessity review; a covered benefit review; entering appropriate
authorizations into the contractor’s system; locating a qualified network
or non-network private sector care provider to provide the care
on a cashless, claimless basis; providing the beneficiary with a
written care authorization and the private sector care provider’s
information; and assisting the beneficiary with establishing an
appointment with the private sector care provider (upon beneficiary
request). This process is also applicable to Service members who
are on Temporary Additional Duty/Temporary Duty (TAD/TDY), in an
authorized leave status, or deployed/deployed on liberty in a remote
overseas location, and to TRICARE Prime/TRICARE Prime Remote (TPR)
enrollees who require urgent specialty care while traveling outside
the 50 US and the District of Columbia.
Note: This process applies to all
TOP Prime Remote enrollees, regardless of the status/location of
the referring provider or health unit.
3.1.4 Beneficiaries
enrolled to the Uniformed Services Family Health Plan (USFHP) and
the Continued Health Care Benefit Program (CHCBP) must follow the
requirements of those programs when obtaining overseas care.
3.2 The TOP
HCF is responsible for the following functions:
3.2.1 Referral
Assistance for TOP Beneficiaries
The TOP contractor (working
in concert with the MTF Commander) shall ensure optimal use of MTFs
and to foster coordination of all care delivered in the civilian
sector and care referred to and from the MTF. The TOP HCF is the primary
mechanism for achieving these objectives. The referral services
of the TOP HCF are primarily for ensuring access to care for enrolled
beneficiaries, but the TOP HCF is also available to assist non-enrollees
in finding network/non-network private sector care providers. For
TOP Prime/TOP Prime Remote enrollees, the referral is generally
initiated by the beneficiary’s PCM. The PCM or beneficiary contacts
the TOP HCF for assistance in locating an appropriate private sector
care provider and to obtain authorization for the care (see Sections
17 and 18 for additional information on HCF referral assistance).
3.2.2 Referral
Assistance for Beneficiaries Enrolled or Residing in the 50 US and
the District of Columbia
The TOP
contractor shall provide referral assistance for TRICARE Prime/TPR
enrollees who require urgent or emergent health care while traveling
outside the 50 US and the District of Columbia. These referrals
will generally be initiated by the beneficiary, a private sector
care provider, or an overseas MTF provider. Emergency care never requires
preauthorization; however, ADFMs enrolled to TRICARE Prime/TPR may
receive routine, urgent and emergency health care services in locations
outside the 50 US and the District of Columbia (to include emergency medical
evacuation per
Chapter 24, Section 7)
on a cashless, claimless basis if the care is coordinated in advance with
the TOP contractor. The TOP contractor shall implement guarantee
of payment or other business processes to ensure that ADFMs enrolled
to TRICARE Prime/TPR receive routine, urgent or emergency medical
services on a cashless, claimless basis upon beneficiary request.
3.2.3 Authorizations
3.2.3.1 The TOP HCF will authorize
care for TPR enrollees; for Service members who are on TAD/TDY,
in an authorized leave status, or deployed, deployed on liberty
in a remote overseas location, and for TRICARE Prime/TPR enrollees
who require urgent or emergent health care while traveling outside
the 50 US and the District of Columbia. The contractor shall also
ensure that MTF-issued authorizations are entered into all applicable
contractor systems. Non-emergent specialty health care received
from a private sector care provider must be authorized if benefits
are to be paid as TOP Prime/TPR.
3.2.3.2 Care subject to a PCM referral/authorization
may receive a clinical review and authorization by the HCF or other
designee.
3.2.4 If an ADFM TOP Prime/TOP Prime
Remote enrollee receives care that was not authorized, the care
may be covered under the TOP POS option, with POS deductibles and
cost-shares. POS provisions also apply to TRICARE Prime/TPR enrollees
who receive routine care outside the 50 US and the District of Columbia
without obtaining prior authorization from the TOP contractor. The
care must also be otherwise coverable under TRICARE or the claim shall
be denied.
3.2.5 Service member care that was
not referred and authorized shall be denied unless it is retroactively authorized
by the appropriate service and Director, DHA. This includes obtaining
an approved waiver for any non-covered service. POS does not apply
to Service members.