2.1 Service members who are enrolled
in TOP Prime shall follow the procedures outlined in
Chapter
17 for MTF-enrolled Service members, except that any references
to the Defense Health Agency-Great Lakes (DHA-GL) should be replaced
by a reference to the appropriate regional TRICARE Area Office (TAO)
in all overseas locations except the U.S. Virgin Islands concerning
Line of Duty Determinations and except for care delivered under
the National Department of Defense (DoD)/Department of Veterans
Affairs (VA) Memorandum of Agreement (MOA) authorization requirements. See
paragraph 2.3.3 for
National DoD/VA MOA authorization requirements. Service members
who are enrolled in TOP Prime Remote must seek authorization from
the TOP contractor for all non-emergent specialty and inpatient
care. Service members not enrolled in TOP who are on Temporary Additional Duty/Temporary
Duty (TAD/TDY), deployed, deployed on liberty, or in an authorized
leave status outside the 50 U.S. and the District of Columbia shall
follow referral/authorization guidelines for TOP Prime Remote enrollees.
2.2 The TOP contractor shall ensure
a benefit review is done on each SHCP referral and authorization.
The TOP contractor shall return deferred-to-network referrals for
non-covered services with an explanation of why it was denied. The
TOP contractor shall not issue an authorization unless they obtain
a copy of an approved waiver. The contractor shall deny all claims
for TRICARE non-covered health care services. (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”).
2.2.1 If the contractor determines
that the requested service, supply, or equipment is not covered
by TRICARE policy and no Defense Health Agency (DHA)-approved waiver
is provided, the contractor shall decline to file an authorization
and shall deny any received claims accordingly. If the request was
received as an MTF referral, the contractor shall notify the MTF
(and enrolled MTF if different from the submitting MTF) of the declined
authorization with explanation of the reason. If the request was
received as a referral from a civilian provider (for a remote Service
member/non-enrolled Service member), the contractor shall notify
the civilian provider and the remote Service member/non-enrolled
Service member of the declined authorization with explanation of
the reason. The notification to a civilian provider and the remote
Service member/non-enrolled Service member shall explain the waiver
process and provide contact information for the applicable Uniformed
Services Headquarters Point of Contact (POC)/Service Project Officers
as listed in
Chapter 17, Addendum A, paragraph 2.0. No notification
to the Specified Authorization Staff (SAS) is required.
2.2.2 TRICARE benefits may not be
extended for complications resulting from non-covered surgeries
and treatments performed outside the MTF for a Service member without
an approved waiver. If the treatment is a non-covered TRICARE benefit,
any follow-on care, including care for complications, will not be
covered by TRICARE once the Service member separates from active
duty or retires (
32 CFR 199.4(e)(9); TPM,
Chapter 4, Sections 1.1 and
1.2). The Services will provide appropriate counseling
that such follow-on care is the member’s personal financial responsibility
upon separation or retirement.
2.3 The provisions of
Chapter
17 are changed for the TOP as follows:
2.3.1 The provisions of
Chapter 17, Section 2, paragraph 2.0 (Uniformed
Services Family Health Plan (USFHP)) are not applicable to the TOP
contract. USFHP services are not available outside the 50 U.S. and
the District of Columbia.
2.3.2 Except for the claims for Service
member care provided under the National DoD/VA MOA, the provisions
of
Chapter 17, Section 3, paragraph 1.2.1 are
applicable for TOP. Service member claims for covered benefits submitted
to the TOP contractor for which an authorization is not on file
are to be processed and paid as if an authorization is on file.
Claims for non-covered services shall be denied. The TOP contractor
shall provide the MTF with a report (in accordance with the CDRL),
for all claims processed and paid with no authorization and all
denied claims for non-covered services.
2.3.3 The
provisions of
Chapter 17, Section 2, paragraph 3.1 regarding
claims for care provided under the National DoD/VA MOA for Spinal
Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma are applicable to the TOP and shall be processed
in accordance with
Chapter 17, Section 2, paragraph 3.1.3. Such
care will be authorized by the DHA-GL for Service members under
this MOA.
2.3.4 The
provisions of
Section 6, paragraph 5.0 and
Chapter 8, Section 5 apply to TOP SHCP referrals.
Additionally, when MTFs submit a referral request for purchased
care services for a non-AD sub-population beneficiary eligible for
SHCP, the MTF shall utilize the required data elements identified in
Chapter 8, Section 5, paragraph 6.1 and shall
annotate the referral with “SHCP” in line item 12, “Review Comment”.
This will ensure that SHCP claims for eligible non-AD sub-population
beneficiaries are properly adjudicated.
Note: Circumstances where supplemental
funds may be used to reimburse for care rendered by non-Governmental
health care providers to non-active duty patients are limited to
those where a MTF provider orders the needed health care services
from civilian sources for a patient, and the MTF provider maintains
full clinical responsibility for the episode of care. This means
that the patient is not disengaged from the MTF that is providing
the care. See
Chapter 17, Section 1.
2.4 When a Service member leaves
a remote TOP assignment as a result of Permanent Change of Station
(PCS) or other service-related change of duty status, the following
applies in support of medical record accumulation:
2.4.1 For Service members leaving
remote TOP assignment in Puerto Rico, the PCM shall provide a complete
copy of medical records, to include copies of specialty and ancillary
care documentation, to Service members within 30 calendar days of
the Service member’s request for the records. The Service member
may also request copies of medical care documentation (specialty
care visits and discharge summaries) on an ongoing, Episode of Care
(EOC) basis.
2.4.2 For Service
members leaving remote TOP assignments from all overseas areas other
than Puerto Rico, Service members in those locations should request
medical records from the purchased care sector provider(s) who provided
health care services during the Service member’s tour of duty. These
Service members may also request copies of medical care documentation
(specialty care visits and discharge summaries) on an ongoing, EOC
basis.
2.4.3 Records
provided by purchased care sector providers in languages other than
English may be submitted to the TOP contractor for translation into
English according to the terms of the contract.
2.4.4 Network purchased care sector
providers shall be reimbursed for medical records photocopying and
postage costs incurred at the rates established in their network
provider participation agreements. Non-network purchased care sector
providers shall be reimbursed for medical records photocopying and
postage costs on the basis of billed charges unless the Government has
directed a lower reimbursement rate. Service members who have paid
for copied records and applicable postage costs shall be reimbursed
for the full amount paid to ensure they have no out-of-pocket expenses.
All providers and/or Service members must submit a claim form, with
the charges clearly identified, to the contractor for reimbursement.
Note: The purpose of copying medical
records is to assist the Service member in maintaining accurate
and current medical documentation. The contractor shall not make
payment to a purchased care sector provider who photocopies medical
records to support the adjudication of a claim.
2.4.5 The provisions of
Chapter 17, Section 3, paragraph 1.1.8 are
not applicable to the TOP. SHCP funds may not be used to pay for
overseas purchased sector care for foreign military members or their families.
The TOP contractor shall deny any MTF referrals and claims for such
care.
2.5 Provision
of Respite Care For The Benefit of Seriously Ill or Injured Active
Duty Members
2.5.1 The provisions
of
Chapter 17, Section 3 and the TRICARE Systems
Manual (TSM),
Chapter 2, Sections 2.8 and
6.4 regarding respite care for seriously ill
or injured Service members are applicable in locations outside the
50 U.S. and the District of Columbia where TRICARE-authorized Home
Health Agencies (HHAs) have been established.
2.5.2 The respite care benefit is
applicable to Service members enrolled to TOP Prime, TOP Prime Remote,
and to any Service member referred by an overseas MTF or TAO.
2.5.3 All normal Service member authorization
and case management requirements for the TOP apply to the Service
member respite care benefit.