1.0 GENERAL
1.1 TOP Prime
Remote is available to Service members (including Reserve Component
(RC) members activated for more than 30 days) on permanent assignment
to a remote overseas location, Command-Sponsored Active Duty Family
Members (ADFMs) accompanying their sponsor in the remote location
or on Service orders, and certain transitional survivors according
to the eligibility and enrollment provisions of
Section 5. TOP
Prime Remote offers enrollees access to a Primary Care Manager (PCM),
clinical preventative services, and specialty services. The TOP
contractor, working in concert with purchased care sector providers
and the TRICARE Area Offices (TAOs), has primary responsibility
for ensuring that TOP Prime Remote enrollees receive appropriate
services and support to facilitate access to the TOP benefit in
remote overseas locations.
1.2 TOP Prime Remote has no enrollment
fees, and deductibles and cost-shares are waived except for TOP
Prime Remote ADFMs who receive care under the Point of Service (POS)
option, or who obtain pharmacy services in the 50 United States
(U.S.), the District of Columbia, and U.S. territories where the TRICARE
Pharmacy (TPharm) has established a retail pharmacy network. Waiver
of copayment and deductibles under TOP Prime Remote is subject to
review/updating based on enrollment status.
1.3 Under TOP Prime Remote, annual
catastrophic caps are calculated on calendar years. The enrollment
year shall coincide with the calendar year. Since deductibles and
cost-shares are waived for TOP Prime Remote enrollees, this policy
will apply only to TOP Prime Remote enrollees who incur out-of-pocket
expenses as described above.
2.0 Contractor Responsibilities
2.1 TOP Prime Remote enrollees
shall select or have assigned to them Primary Care Managers (PCMs)
according to guidelines established by the TAO Director, or designee.
2.1.1 TOP PCMs may be an individual
professional provider, an overseas treatment site, or other health
care delivery arrangement. For the purposes of referral management
and authorization for TOP Prime Remote episodes of care, the TOP
contractor’s call center(s) are considered PCMs.
2.1.2 TOP PCMs may be an internist,
family practitioner, pediatrician, General Practitioner (GP), Obstetrician/Gynecologist
(OB/GYN), Physician Assistant (PA), Nurse Practitioner (NP), or
Certified Nurse Midwives (CNMs) when determined by the TOP contractor
to meet governing country rules and licensure.
2.1.3 May also act as a Health Care
Finder (HCF), when dual responsibility is necessary, as determined
by the TAO Director.
2.2 A TOP
Prime Remote enrollee must seek all his or her primary health care
from the TOP PCM with the exception of care listed in
Section 8. If the TOP PCM is unable to provide
the care, the TOP PCM shall refer the enrollee to another primary
care provider.
2.3 TOP Prime Remote enrollees
must obtain appropriate referral/authorization for any non-emergency,
non-urgent care rendered by anyone other than the beneficiary’s
PCM. This provision applies regardless of where the care is rendered.
TAO Directors may direct retroactive authorizations on a case-by-case
basis.
2.3.1 Routine
care is generally not authorized while a TOP Prime Remote enrollee
is traveling out of their enrollment region. The TOP contractor
shall fully document the justification for authorizing routine out-of-area
care. Emergency care does not require prior authorization; however,
the beneficiary should contact their PCM and the contractor as soon
as possible to obtain authorization for any necessary follow-up
care.
2.3.2 ADFMs
enrolled in TOP Prime Remote may obtain urgent care from any authorized
provider without a PCM (if assigned) referral or overseas contractor
authorization. In order to ensure the urgent care visit will be
cashless/claimless, the ADFMs enrolled to TOP Prime Remote should
contact the TOP contractor to obtain an authorization. Without this
authorization, overseas providers may request payment upfront (overseas
providers may bill above the TRICARE allowable amount without any
limits) and the beneficiary will then have to submit a claim for
reimbursement.
2.4 Failure
to obtain a TOP PCM referral/authorization when one is required
for care may result in the service being paid under TOP POS procedures
for an Active Duty Family Member (ADFM) with a deductible and cost-shares
for outpatient services and cost-shares for inpatient services.
Claims for ADSMs shall be processed in accordance with
Section 25 and
Chapter 17, Section 3.
2.5 The TOP PCM shall assist the
TOP Prime Remote enrollee and other beneficiaries in locating an Military
Treatment Facility (MTF) or purchased care sector network or non-network
provider to provide the care, and shall assist in scheduling an
appointment with a purchased care sector provider upon request.
The HCF shall conduct a benefit determination review and provide
authorization for service for which the referral was made. If the
contractor has no record of referral/authorization, prior to denial/payment,
the claims processing contractor shall follow the TOP POS rules,
assuming the service is a TRICARE benefit.
2.6 All referrals
made by a TOP designated purchased care sector PCM shall be made
through the TOP HCF and shall receive an authorization.
2.7 The TOP contractor shall ensure
that all authorized services for TOP Prime Remote enrollees are provided
on a cashless, claimless basis. The contractor shall implement guarantee
of payment or other business arrangements to ensure that TOP Prime
Remote enrollees are not required to pay up front at the time services
are rendered by a purchased care sector provider.
2.8 Cashless, claimless provisions
do not apply to self-referred care that would normally require an authorization.
2.9 For TOP Prime Remote enrollees
who are traveling stateside, the TOP contractor shall direct TOP beneficiaries
to utilize stateside MTFs whenever possible. If MTF care is unavailable,
beneficiaries shall be provided with information regarding the nearest
available network provider(s) who can assist the beneficiary. Non-network
providers shall only be used when MTF or network care is not possible.
3.0 Point of service (POS) Option
3.1 TOP Prime Remote-enrolled ADFMs
shall follow established referral/authorization procedures prior
to obtaining specialty care to avoid the application of POS cost-shares
and deductibles. This includes all self-referred, non-emergency
outpatient specialty medical services and all inpatient care (including
inpatient mental health care), except for outpatient mental health
and Substance Use Disorder (SUD) visits, ancillary services, and
drugs. TOP Prime Remote ADFMs who self-refer to a civilian provider
other than their PCM shall have their claims processed as POS.
3.2 POS cost-shares and deductibles
shall not apply to claims for care received by newborns/adoptees
during the deemed enrollment period.
3.3 Self-referred, routine, specialty,
or inpatient care provided to a TOP Prime Remote ADFM enrollee by
a network or non-network purchased care sector provider, which is
not either provided/referred by the beneficiary’s PCM or specifically
authorized may be reimbursed only under the TOP Prime Remote POS
option if it is a benefit under TRICARE. Services which are not
a TRICARE benefit shall be denied.
3.4 POS cost-sharing and deductible
amounts do not apply if a TOP Prime Remote ADFM enrollee has Other
Health Insurance (OHI) that provides primary coverage. The OHI must
be primary under the provisions of the TRICARE Reimbursement Manual
(TRM),
Chapter 4, Section 1, and documentation that
the other insurance processed the claim and the exact amount paid
shall be submitted with the TOP claim. TRICARE OHI provisions apply
for this type of claim.
3.5 The POS option does not apply
to Service member overseas/stateside care.
3.6 The TOP contractor shall adjust
TOP Prime Remote copayments when TOP PCMs or HCFs do not follow
established referral/authorization procedures. For example, if the
contractor processes a claim without evidence of an authorization
and/or a referral under POS provisions, and the contractor later verifies
that the PCM or other appropriate provider referred the beneficiary
for the care, TOP contractor shall adjust the claim under TOP Prime
Remote provisions. The contractor need not identify past claims, however,
the contractor shall adjust these claims as they are brought to
their attention.
3.7 On a case-by-case
basis, following stabilization of the patient, the TAO Director
may require a TOP Prime Remote beneficiary to transfer to a TOP
network facility or the MTF. The TOP TAO Director shall provide
written notice to the beneficiary (or responsible party) advising
them of the impending transfer to a TOP network facility/MTF. If
a TOP Prime Remote-enrolled ADFM elects to remain in a non-network
facility after being notified of an impending transfer to another
facility, TOP POS cost-sharing will begin 24-hours following receipt
of the written notice. The TAO Director may not require a transfer until
such time as the transfer is deemed medically safe.
3.8 See the TRM,
Chapter
2 for deductible and cost-share amounts. POS deductible
and cost-sharing do not apply to the claims for care received by
certain newborn and newly adopted children during the deemed enrollment
period. See
Section 5 for additional guidance regarding
deemed enrollment for newborns/adoptees.