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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Prime Remote (TPR) Program
Chapter 16
Section 1
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.
2.1  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.
3.1  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.
4.1  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.
4.3  The contractor shall deny claims from sanctioned or suspended providers (see Chapter 13, Section 5).
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.
6.1  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.
7.1  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).
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.
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