1.0 GENERAL
1.1 The TOP
program provides health care administration and claims processing
for individuals with dual eligibility under both Medicare and TRICARE
who receive care in locations where Medicare is not available. This
includes those beneficiaries eligible for TFL under the Medicare
wraparound coverage option of the TRICARE program made under 10
United States Code (USC) 1086(d).
1.2 The provisions
of
Chapter 20 regarding
TFL are applicable to beneficiaries residing in locations where
Medicare is available. These areas include the 50 United States
(U.S.), the District of Columbia, and the U.S. territories of Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana
Islands.
2.0 Jurisdiction
2.1 Dual eligible
beneficiaries are covered under TOP, based on their TRICARE plan
if they receive care in a location where Medicare is not available.
2.2 Dual eligible beneficiaries residing
in Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and
the Northern Mariana Islands are not covered under TOP TFL. These
beneficiaries receive TRICARE coverage under the TRICARE
Medicare Eligible
Program (
TMEP)
according to the provisions of
Chapter
20.
2.3 Claims for services rendered
on board a commercial ship are the responsibility of the TMEP contractor
if the care was rendered in the territorial waters adjoining the
land areas of the U.S. Claims for services rendered on board ship
while outside U.S. territorial waters are the responsibility of
the TOP contractor.
3.0 CONTRACTOR RESPONSIBILITIES
3.1 The TOP contractor shall provide
administration and claims processing services for the TOP TFL program.
3.2 TOP TFL has the same cost-shares
and deductibles as any other TFL claim. TFL beneficiaries who are
not enrolled in Prime are covered under TRICARE Standard benefits,
cost-shares, and deductibles as if TRICARE Standard was still being
implemented. See the TRICARE Reimbursement Manual (TRM),
Chapter 2, Sections 1 and
3.
3.3 All TOP
TFL has the same requirements for referrals or prior authorizations
as TOP Select. TOP requirements regarding provider certification
apply.
3.4 The TOP contractor shall not
develop purchased care sector provider networks to support the TOP
TFL beneficiary population.
3.5 The TOP
contractor shall not provide health care on a cashless, claimless
basis for TOP TFL beneficiaries.
3.6 The TOP
contractor shall not make appointments with purchased care sector
providers for TOP TFL beneficiaries. However, upon beneficiary request,
the contractor shall provide the beneficiary with the name, telephone
number, and address of purchased care sector network or non-network
providers of the appropriate clinical specialty located within the
beneficiary’s geographic region.