1.0 INTRODUCTION
The TPR program provides health
care to Active Duty Service Members (ADSMs), including Reserve Component (RC)
members activated for more than 30 calendar days who meet the eligibility
criteria specified in
32 CFR 199.16(e)(2) and are enrolled in the
program. This chapter applies to operations of the TPR program in
remote locations of the United States (US) and the District of Columbia
while
Chapter 24, Section 18 applies to operations of
the TPR program outside of the US.
2.0 ELIGIBILITY
2.1 The contractor
has no responsibility for determining eligibility or for deciding
in which geographic area of responsibility an ADSM will enroll.
2.2 The Government
Designated Authority (GDA) will furnish contractors with enrollment
information (refer to
paragraph 3.0).
Note: ADSM Astronauts assigned to
the Johnson Space Center in Houston, Texas shall be enrolled in
TPR.
3.0 TPR PROGRAM UNITS
3.1 The GDA
will supply the contractor with an electronic directory, updated
as needed, that lists, by geographical area of responsibility, the
designated TPR ZIP codes for the contractor’s geographical area
of responsibility.
3.2 The GDA will provide unit listings
to the contractor so the contractor can mail or email educational materials
to the units. In some instances, individual member listings (as
opposed to units) may be provided.
4.0 BENEFITS
4.1 ADSMs
enrolled in the TPR Program shall receive the benefits of TRICARE
Prime, even in areas without contractor networks. Some covered benefits
(see
Section 2, paragraph 5.3) require review by
Specified Authorization Staff (SAS) (identified in
Addendum A, paragraph 1.0) so they may identify
fitness-for-duty issues.
4.2 The contractor shall decline
to file an authorization and deny any received claims if the contractor determines
that a requested or claimed service, supply, or equipment is not
covered by TRICARE (including
Chapter 17, Section 3)
and no Defense Health Agency (DHA)-approved waiver is provided.
4.2.1 The contractor
shall notify the civilian provider and the ADSM or non-enrolled
ADSM of the declined authorization with explanation of the reason.
4.2.2 The contractor’s
notification to a civilian provider and the remote ADSM or non-enrolled
ADSM shall explain the waiver process and provide contact information
for the applicable Uniformed Services Headquarters Service Project
Officers as listed in
Chapter 17, Addendum A, paragraph 2.0. No
notification to the SAS is required.
4.4 SAS do
not have the authority to overturn DHA or Department of Health and
Human Services (DHHS) provider exclusions. See
Section 2 for
referral and authorization requirements.
4.5 The contractor
may, for services that would not have ordinarily been covered under
TRICARE policy (including limitations and exclusions), authorize
services for ADSMs only in accordance with the terms of a waiver approved
by the GDA, at the request of an authorized official of the Uniformed
Service concerned. (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”).
4.6 The contractor
shall process claims for care provided to a ADSM who is not enrolled
in TPR or who is not enrolled in TRICARE Prime at a Market/Military
Medical Treatment Facility (MTF) according to the applicable guidelines
of the Supplemental Health Care Program (SHCP) (
Chapter
17).
4.7 The contractor shall implement
appropriate measures to recognize SAS authorization in order to expedite
claims processing.
4.8 SAS authorization shall be
deemed to constitute referral, authorization, and direction to bypass
edits as appropriate to ensure payment of SAS-approved claims.
5.0 SAS
5.1 Certain
Uniformed Service controls and rules apply to ADSMs due to unique
military readiness requirements. SAS (identified in
Addendum A, paragraph 1.0) serves as liaison
among the ADSM, the ADSM’s Uniformed Service, and the contractor
for managing the ADSM’s health care services.
5.2 The contractor
shall communicate, coordinate and collaborate with the SAS and the
primary care manager (PCM), if assigned, for the ADSM’s required
examinations.
5.3 The SAS reviews referrals for
proposed care as well as information about care already received
in order to determine impact on an individual’s fitness-for-duty
(see
Section 2 and TRICARE Systems Manual (TSM),
Chapter 1, Section 1.1, paragraph 11.0 for
referral, review and authorization procedures).
5.4 The SAS
will provide the protocol, procedures, and required documentation
through the contractor to the provider for these examinations.
5.5 For required
care that may not be obtainable in the civilian community, the SAS
will refer the ADSM to a Market/MTF. Refer to
Addendum A for
the addresses and telephone numbers of the SAS.
6.0 APPEAL
PROCESS
6.1 The contractor shall furnish
the enrollee with clear guidance for requesting a reconsideration
or filing an appeal with the SAS (see
paragraph 6.4) on the Explanation
of Benefits (EOB) or other appropriate document, if, at the direction
of the SAS, the contractor denies authorization of care, or authorization
for reimbursement for a TPR enrollee’s health care services.
6.2 The SAS
will handle only those issues that involve SAS denials of authorization
or authorization for reimbursement.
6.3 The contractor
shall process allowable charge issues, grievances, and other complaints
from beneficiaries.
6.4 If the
TPR enrollee disagrees with a denial rendered by the SAS, the first
level of appeal will be through the SAS who will coordinate the
appeal as appropriate.
6.5 The enrollee may initiate the
appeal by contacting his or her SAS. If the SAS upholds the denial,
the SAS will notify the enrollee of further appeal rights in accordance
with applicable regulations.
6.6 If the
denial is overturned at any level, the SAS will notify the contractor
and the ADSM.
6.7 The contractor shall forward
all written inquiries and correspondence related to SAS denials
of authorization, or authorization for reimbursement to the appropriate
SAS within three business days of receipt.
6.8 The contractor
shall refer telephonic inquiries related to SAS denials to the appropriate
SAS upon receipt of the inquiry.
7.0 ACTIVE
DUTY FAMILY MEMBERS (ADFM
s) AND OTHERS
7.1 TRICARE-eligible
family members accompanying ADSMs who are either eligible for or
enrolled in the TPR program may enroll in the TRICARE Prime Remote
ADFM (TPRADFM) program in accordance with
Section 6.
7.2 Enrollment
jurisdiction for the ADFMs may be based on the enrollment jurisdiction
of the TPR enrolled ADSM per
paragraph 8.7. This includes cross-geographic
area of responsibility enrollment (see
Chapter 6, Section 1).
8.0 TPR
PROGRAM DIFFERENCES
In addition
to the SHCP differences specified in
Chapter 17, Section 1,
the following differences apply to the TPR program:
8.1 The contractor
shall enroll a TPR-designated ADSM without a PCM assigned where
the contractor has not established a network of PCMs in a remote
area.
8.2 The ADSM without an assigned
PCM will be able to use a local TRICARE-authorized provider for
primary health care services without review.
8.3 The contractor
shall process claims for TPR-enrolled ADSMs regardless if they have
received a referral or authorization, provided the claim or care
meets all other TRICARE requirements (e.g., the care is medically necessary,
a covered benefit of TRICARE an approved waiver is provided).
8.4 Annual
ADSM member re-enrollment is not required.
8.5 If the
Uniformed Services determine that an ADSM is eligible for the TPR
program, enrollment of the member is mandatory, unless there are
Service-specific issues that merit assignment to a military PCM,
or if the ADSM elects to waive access standards and enrolls to a
Market/MTF (subject to Director approval).
8.6 If Third
Party Liability (TPL) is involved in a claim, ADSM claim payment
will not be delayed during the development of TPL information from
the ADSM.
8.7 Enrollment
jurisdiction may be based on the location of the military work unit
instead of the ADSM’s residence. This is determined by the Services.