2.0 POC Designation
2.1 Designated
TOP POCs are established by the Uniformed Services, the Defense
Intelligence Agency (DIA), the Defense Security Assistance Agency
(DSAA), or other organizations as established by the Government,
with final approval by the TRICARE Area Office (TAO) Directors.
2.2 Requests
for POC designation shall be submitted in writing by the Commanding
Officer of a military organizational unit or location, Defense Attache
Offices (DAOs), and Security Assistant Organizations (SAOs) to the
appropriate TAO Director. Requests for POC designation shall include
the POC’s name, anticipated date of transfer/reassignment from the
unit or location 24-hour commercial fax number, 24-hour commercial
phone number, e-mail address, and a valid and secure mailing address for
pouch mail. The request shall indicate whether the individual is
being designated as the primary POC or alternate POC (if any), along
with the names of other POCs in the organization. The request should
also indicate whether the POC will be replacing a previously designated
POC who is scheduled for reassignment or transfer. POC designation
is generally limited to one primary POC and one or two alternate
POCs per organization. If more than two alternate POCs are desired,
the organization must submit additional justification with the request.
2.3 Upon receipt of a written request
for POC designation, the TAO Director will review the nomination
for approval. After approval has been granted, the TAO Director
will notify the TOP contractor of the POC designation. This notification
must be in writing and may be sent electronically or faxed to the
contractor, with a copy to the POC’s organization, the Defense Health
Agency (DHA) Contracting Officer Representative (COR), and the DHA
technical expert for overseas claims.
2.4 POC designations
are not Uniformed Service-specific, nor is designation limited to
a specific beneficiary category (e.g., Service member) or a specific
TRICARE benefit category (e.g., medical, pharmacy, maternity, etc.).
2.5 POC organizations shall provide
updated POC information to TAO Directors and the TOP contractor
as needed. Information updates for designated primary/alternate
POCs must be provided in a timely manner to avoid possible delays
in claims processing. Updates to POC’s commercial fax/phone numbers,
e-mail address, and mailing address shall be e-mailed directly to
the appropriate TAO Director as soon as the change occurs.
2.6 Primary and alternate POCs
are responsible for notifying the appropriate TAO Director in writing
of any pending reassignments or transfers. This written notification
should indicate the POC’s projected date of departure, the names
of any remaining POCs in the organization, and whether a new POC
will be designated as a replacement. If a new POC will be designated,
the POC’s organization should request designation as outlined in
paragraph 2.2.
3.0 Government RESPONSIBILITIES
3.1 POCs
shall assist TRICARE beneficiaries (including Service members) with
the timely completion and filing of TOP claim forms. POCs shall
secure and safeguard Protected Health Information (PHI), Personally
Identifiable Information, and Sensitive Information for TRICARE beneficiaries
in accordance with Department of Defense (DoD) 5400.11-R, “Department
of Defense Privacy Program”, May 14, 2007 and DoD Instruction 8500.2,
“Information Assurance Implementation”, February 6, 2003 and DoD
Instruction (DoDI) 6025.18, “Privacy of Individually Identifiable
Health Information in DoD Programs,” December 2, 2009.
3.2 POCs are not authorized to
sign as a claimant for any beneficiary’s claim other than the POC’s personal
claim.
3.3 As needed, the POCs shall assist
Service members and Prime enrolled ADFMs with coordinating their
return travel after a medical evacuation and hospital discharge
with the Service member or ADFM service representative. This shall
include making the necessary phone calls and sending e-mails to assist
with the return travel. The POCs will assist to the extent possible
using the existing personnel. The Services’ commands are still responsible
for arranging and funding the return travel.
3.4 Each TAO office shall develop
and distribute a region-specific POC Program booklet outlining specific
POC duties and responsibilities. Each TAO office shall also develop
and implement region-specific POC training. POC booklets and training
materials shall include instructions regarding the security requirements
identified in
paragraph 3.1 and other relevant security
instructions. POCs shall use the current version of their region’s
POC booklet (and any additional training materials and sessions)
as a guide in the performance of their POC duties.
3.5 Questions regarding specific
POC duties and responsibilities shall be addressed to the appropriate
TAO office for resolution.
4.0 TOP Contractor Responsibilities
The TOP contractor shall:
4.1 Maintain a current listing
of POCs, in coordination with the TAO offices.
4.2 Assist DHA staff, TAO staff,
POCs, Uniformed Services, TRICARE beneficiaries, and purchased care
sector providers with information on the completion and filing of
TRICARE claims.
4.3 Provide
a dedicated P.O. Box, fax number, and e-mail address for the receipt
of TOP claims and correspondence from all designated POCs. The fax
number must be able to receive data 24 hours a day, seven days a
week.
4.4 Develop procedures for the
coordination, control, tracking, and processing of health care claims
that are submitted by POCs in accordance with established standards
for the PHI/Personally Identifiable Information (PII). This includes,
but is not limited to, microcopying/imaging of claims upon receipt,
storage/maintenance of the claim and all related correspondence,
verification of beneficiary eligibility for TRICARE benefits, development
of claims for missing information, processing of claims, and issuance
of foreign drafts/U.S. dollar checks/Explanation of Benefits (EOB).
4.5 Contact the appropriate POC
(via phone, fax or e-mail) when additional information is needed to
process a claim submitted by that POC. The TOP contractor shall
pend the claim for 14 calendar days following POC notification.
If the requested information is not received by the contractor by
the Close Of Business (COB) on the 14th calendar day following POC
notification, the contractor shall deny the claim.
4.6 Accept only faxed claims/inquiries/information
faxed by an officially designated primary or alternate POC. Electronic
mail may also be used for TOP inquiries/information, subject to
all applicable privacy rules.
4.7 Report
POC inquiries (including fax, e-mail, and letters) as routine correspondence
as outlined in
Chapter 1, Section 3.
4.8 Pay all beneficiary-submitted
claims for TRICARE covered drugs dispensed by a U.S. embassy health
clinic to the beneficiary. The contractor shall not make payments
directly to an embassy health clinic.
4.9 Use priority
pouch mail to mail foreign drafts/U.S. dollar checks/EOBs for claims
submitted via POCs. Priority pouch mail must be sent to the appropriate
POC’s location, unless a single point of dispersal for all payments
has been established for that country. In those locations where
a single point of dispersal has been established for all payments
for that country, the TOP contractor shall batch payments/EOBs by
country and mail the payments/EOBs in pouches to the designated
point of dispersal at least once every five working days. Payments
and EOBs that are placed in pouch mail shall be placed in sealed
separate envelopes by individual beneficiary/purchased care sector
provider for POC distribution. Pouch mail shall normally be sent
via overnight mail delivery; however, if overnight mail service
is not available or is not timely in a foreign location, the contractor
shall use the most expeditious means available.
4.10 Report unresolved claims problems
or issues between the POC and the contractor to the TAO Director
and the DHA COR.
4.11 Follow
the inquiry process outlined in this section for POC requests for
claims status update and for POC requests for changes to mail, fax
numbers, etc.
4.12 Upon receipt of a POC inquiry
and once the inquiry is completed, fax the response back to the person
identified as the POC. The TOP contractor shall follow the faxed
POC inquiry with a phone call, if necessary.
Note 1: POCs also
assist TRICARE Dental Program (TDP) beneficiaries with the submission
of dental claims. POC responsibilities for TDP claims are described
in the POC Program booklet. The TOP contractor is not responsible
for processing dental claims, except for adjunctive dental services
as identified in the TRICARE Policy Manual (TPM),
Chapter 8, Section 13.1. POC-submitted
TDP claims that are misdirected to the TOP contractor shall be returned
to the appropriate POC.
Note 2: Professional services rendered
by a U.S. embassy health clinic are not covered by TRICARE/TOP.
Those services are covered under International Cooperative Administrative
Support Services (ICASS) agreements. Embassy providers (acting as
Primary Care Managers (PCMs)) may refer TOP enrollees to purchased
care sector providers; these claims shall be processed per TOP policy
and procedures.