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
Executive 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 Executive 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
Executive 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 Medical 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 Executive Director
may require a TOP Prime Remote beneficiary to transfer to a TOP
network facility or the MTF. The TOP TAO Executive 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 Executive 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.