2.0 Contractor Responsibilities
2.1 The
TOP contractor shall arrange for medically necessary ambulance/aeromedical
evacuation services for
TOP
Prime/TOP
Prime Remote enrollees, Service members who are deployed, in a temporary
duty status, or in an authorized leave status in an overseas location,
and all Active Duty Family Members (ADFMs)
that are
enrolled to TRICARE Prime, TRICARE Prime Remote (TPR), TRICARE Select,
or TRCARE Young Adult (TYA) who require ambulance/aeromedical
evacuation services while traveling
/living outside
of the 50 U.S. and the District of Columbia.
Note: Claims jurisdiction for ambulance/aeromedical
evacuation is based on the patient’s location, regardless of the
patient’s enrollment status or the origination or destination location
of the ambulance/aeromedical evacuation service provider.
2.1.1 When arranging for ambulance/aeromedical
evacuation for the beneficiaries identified in
paragraph 2.1, the contractor
shall determine beneficiary eligibility and enrollment status, prepare quote(s)
for commercial movement options, and obtain signature authority
and direction on evacuation destination from the appropriate Patient
Movement Requirement Center (PMRC). Upon PMRC approval, the contractor
shall authorize the services, arrange for medical records to accompany the
patient, and coordinate the transfer with the receiving institution
or provider. The appropriate TRICARE Area Office (TAO) shall be
notified of all patient movements.
2.1.2 For Service
member emergency medical evacuations (including Service members
who are on temporary duty, in an authorized leave status, or deployed/deployed
on liberty), the TOP contractor shall ensure that the Service member’s
unit is aware of the medical evacuation. The TAO shall be contacted
for assistance if the member’s unit information cannot be determined
by the contractor.
2.1.3 Except
for normal TRICARE cost-shares, these beneficiaries shall not be
responsible for any up-front payments for emergency ambulance service
(to include aeromedical evacuation, when medically necessary and
appropriate). The contractor shall establish business processes
(e.g., Guarantee of Payment to purchased care sector ambulance provider)
to ensure that these beneficiaries are not subjected to up-front
payments in excess of normal TRICARE cost-shares.
2.2 Upon request, the TOP contractor
shall facilitate medically necessary ambulance/aeromedical evacuation
services for all TRICARE-eligible beneficiaries not identified in
paragraph 2.1 (regardless
of enrollment location or residence) according to the processes
identified in the TOP contract. When facilitating ambulance/aeromedical
evacuation for these beneficiaries, the contractor shall identify ambulance/aeromedical
evacuation resources that service the patient’s location; however,
the contractor shall not schedule the evacuation, coordinate with
the receiving institution or provider, obtain medical records, or
establish business processes (e.g., Guarantee of Payment) to limit
up-front payments for these beneficiaries.
2.3 Since
medical evacuations may involve transfers between TRICARE regions,
the TOP contractor shall establish processes for coordinating medical
evacuations with the stateside contractors.
2.4 The TOP contractor shall ensure
that ambulance/aeromedical evacuation services can be accomplished
in an expeditious manner that is appropriate and responsive to the
beneficiary’s medical condition. The contractor may establish a
dedicated unit for responding to such requests, or may augment existing
service units. Contractor staff shall be available for ambulance/aeromedical evacuation
assistance 24 hours per day, seven days per week, 365 days per year.
Ambulance/aeromedical evacuation telephone assistance shall be available
without toll charges to the beneficiary, regardless of their location.
2.5 The TOP contractor shall maximize
the use of military medical transport services before considering
other options. If military medical transport services are not available
(or if services cannot be provided in a timely manner that is appropriate
for the patient’s medical condition) and the appropriate PMRC has
approved commercial movement, the contractor shall attempt to arrange services
through the most economical commercial resource that is capable
of providing appropriate services within the required time frame.
Private, chartered evacuation services will only be used as a last
resort when all other options have been exhausted. The contractor
shall document their rationale and selection process for any commercial
and/or private, chartered evacuation services. If multiple resources
are identified that are capable of providing the needed services,
the contractor shall select the resource that represents the best
value to the Government. Upon request, the contractor shall provide
Defense Health Agency (DHA) with documentation supporting their
rationale and selection process.
2.6 Upon transfer
to a facility for stabilization and care, the TOP contractor shall
coordinate with the appropriate Military Treatment Facility (MTF)
(for TOP Prime enrollees) or TAO (for TOP Prime Remote enrollees)
to provide information on the patient’s
transfer and to provide further assistance as appropriate.
2.7 The TOP contractor shall comply
with the provisions of TPM,
Chapter 8, Section 1.1, except that the TOP
contractor shall utilize the coding requirements identified for
ambulance charges
and shall
develop
claims for diagnosis
and transfer information
for ambulance services received overseas. The TOP contractor shall
utilize the diagnosis if provided, or may use available in-house
methods such as claims history when processing the claim.
A
diagnosis shall be included with the claim.
2.8 All
related documentation (including, but not limited to original invoices,
supporting documents, and Explanation of Benefits (EOB)) related
to the evacuation shall be submitted
with the claim.
2.9 The Ambulance
Fee Schedule (AFS) reimbursement methodology (TRICARE Reimbursement Manual
(TRM),
Chapter 1, Section 14) applies only to ground
ambulance services in Puerto Rico.
Air ambulance
transport (aeromedical evacuations) covered under the TOP, including
Puerto Rico shall be reimbursed
utilizing reasonable
and customary charges.