1.0 General
In order to control costs,
reduce aberrant billing activity, and eliminate balance billing
issues for TRICARE Select beneficiaries, the Defense Health Agency
(DHA) implemented an approved provider network in the Philippines.
With establishment of the TRICARE Select option by the National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, it has
been determined economically in the best interest of the DoD to
transition the approved provider network in the Philippines to a
TRICARE Select PPN effective January 1, 2018. A PPN provider will
be available to, and be a participating provider on claims for,
all TRICARE eligible beneficiaries, whether they are TRICARE Prime,
TRICARE Select, or TRICARE for Life. In addition to PPN providers,
TRICARE authorized providers in the Philippines include certified
providers as defined in
paragraph 2.2. TRICARE beneficiaries who travel
to the Philippines and seek urgent/emergent care will be able to
get care from any PPN provider or certified provider, but may be
subject to higher cost-shares and copays for care rendered by non-PPN
providers. Locations for PPN providers will be developed and maintained
by the TRICARE Overseas Program (TOP) contractor; the government
will work with the TOP contractor to identify other locations in
the Philippines where the PPN may be expanded. Locations may be
added or deleted on an annual basis, as warranted. PPN providers
will abide by a set foreign fee schedule, accept payment from the
TOP contractor, and not balance bill the TRICARE beneficiaries.
This will be accomplished by the establishment of a dedicated list
of providers who agree to comply with these requirements and business
processes as outlined below.
2.0 DEFINITIONS
2.1 PPN Philippines Provider
A provider who agrees to accept
TRICARE reimbursement at the lesser of billed charges, a negotiated reimbursement
rate, or the government-directed foreign fee schedule as payment
in full; agrees to submit claims to the TOP contractor on behalf
of TRICARE beneficiaries, and agrees to collect only applicable
cost-shares and copays from beneficiaries for all TRICARE-covered
services. In addition, all PPN providers must comply with the on-site
verification and provider certification process described in this
section and the certification and credentialing requirements outlined
in
Section 4;
32
CFR 199.6; and the TRICARE Policy Manual (TPM),
Chapter
11. PPN providers will include individual professional providers
of care, institutional providers, and providers of ancillary services.
2.2
Certified
Philippines Provider
A provider
who meets the on-site verification and provider certification requirements,
but who has not agreed to the additional conditions required for
participation as a PPN provider. For example, a certified provider
in the Philippines may require a TRICARE beneficiary to provide
payment at time of service and file their own claim for reimbursement.
TRICARE Select beneficiaries will also be subject to the higher
cost-share and co-pay related to utilization of a non-network provider.
Retired beneficiaries who are enrolled to TRICARE Prime within the
United States and who travel to the Philippines may also be subject
to higher cost-shares and deductibles for care received from a non-PPN
provider in the Philippines.
2.3 Non-Approved
Philippines Provider
TRICARE
authorized providers in the Philippines include PPN providers and
TOP contractor certified providers. Any provider in the Philippines
who is not a PPN or certified provider is a non-approved TRICARE
provider except for emergency care.
3.0 TOP CONTRACTOR RESPONSIBILITIES
3.1 Recruit
and retain a sufficient number and mix of PPN providers to ensure
access to the full range of covered TRICARE benefits. PPN providers
must agree to comply with the participation requirements in
paragraph 2.0.
Establish and maintain a list of all PPN providers, including each provider’s
specialty, sub-specialty, gender, work address, work fax number,
and work telephone number, and whether or not they are accepting
new TRICARE patients.
3.1.1 The TOP
contractor shall provide beneficiaries with easy access to both
the PPN provider listing and the certified provider listing via
a user-friendly searchable World Wide Web (WWW) site and any other
means established at the contractor’s discretion. Information on
the WWW site and any other electronic lists shall be current within
the last 30 calendar days. At a minimum, the list shall meet the provider
directory requirements identified in Section C of the contract.
3.1.2 The TOP Contractor shall provide
certification oversight and monitor quality of care for provided
by providers and institutional facilities as prescribed in
Section 4;
32
CFR 199.6; and TPM,
Chapter
12.
3.1.3 The TOP
contractor shall educate PPN providers on aspects of the TRICARE
program, including, but not limited to, TRICARE eligibility requirements,
TRICARE benefits, claims submission requirements, and the requirements
in
32 CFR 199.9 and
Chapters 13 and
24 as they
relate to anti-fraud activities.
3.2 The TOP contractor shall perform
on-site verification and provider certification in the Philippines.
At a minimum, this one-site verification shall confirm the physical
existence of a facility/provider office, verify the credentials/licensure
of the facility/provider, verify the adequacy of the facility/provider
office, and verify the capability of the facility/provider office
for providing the expected level and type of care. This requirement
may be expanded to other locations upon Contracting Officer (CO)
Direction. The on-site verification shall ensure the provider’s
physical address matches the address identified on the invoice.
However, if there is indication the provider relocated to another
office within the same building, the contractor shall accept documentation
from the provider which confirms a change in office location that
occurred since the date of service identified on the claim.
3.2.1 The TOP contractor shall use
the following guidelines for prioritizing certification of Philippine
providers as follows:
• Reviewing new providers.
• Reviewing the TOP contractor’s
current certified provider files.
• Reviewing non-certified providers
on claims which have been denied by the TOP contractor and the beneficiary/provider
has followed-up on why the claim was denied.
• Reviewing non-certified providers
on claims which have been denied by the TOP contractor and the beneficiary/provider
has NOT followed-up on why the claim was denied.
3.2.2 Recertification of the Philippine
providers shall be performed by the TOP contractor every three years
and shall follow the above process. DHA shall, as necessary, require
the contractor to add additional overseas countries for purchased
care sector provider certification. Upon direction by the Government,
the contractor shall follow the process above outlined for the Philippines,
to include prioritization of certification of new country providers.
3.2.3 A
PPN provider may be removed from the PPN Provider list for administrative
reasons or may be removed for cause by the TOP contractor. The Government
may also direct the TOP contractor to remove PPN providers from
the list for cause. A PPN provider removed from the approved list
may submit a written request to the TOP contractor for reconsideration.
If the TOP contractor upholds the removal, the PPN provider shall
be given the right to appeal to the Executive Director,
TRICARE Area Office (TAO)-Pacific. If the appeal decision is upheld
by the Executive Director, TAO-Pacific,
there is no right to further appeal.
3.2.4 The appeal process does not
apply to certified providers who are not selected by the TOP contractor
to participate as PPN providers. Recruiting and retaining a sufficient
number and mix of PPN providers is the responsibility of the TOP
contractor.
3.2.5 Claims
for a PPN provider removed from the approved list will be processed
in accordance with
Chapter 13, Section 5.
The approved list will be updated on the contractor’s web site on
the first of the month following the provider being removed from
the list.
3.3 All TOP
requirements regarding utilization management, case management,
quality management, and preauthorizations are applicable to TRICARE
beneficiaries. The TOP contractor will enroll beneficiaries to TRICARE
Select according to procedures outlined in
Section 18.
The TOP contractor will not provide referral/authorization services
to beneficiaries unless the requested service requires preauthorization
(per
Chapter 7, Section 2 and TPM,
Chapter 1, Section 7.1). The TOP contractor
shall conduct a covered benefit review upon beneficiary or provider
request; however, an authorization letter will not be generated
except for those services which require preauthorization.
3.4 If TRICARE beneficiaries receive
care from a non-PPN provider who is not currently certified and a
claim is received for the care rendered, the contractor needs to
certify the provider as outlined in
paragraph 3.2 and then process
the claim according to the rules for non-network care as outlined
Section 9. Normal TRICARE cost-shares/co-pays
and deductibles applicable to the specific category of eligible
beneficiary shall apply to care rendered to eligible beneficiaries
by PPN providers. Additionally, when a beneficiary receives care
from a PPN provider, the provider will file the claim on the beneficiary’s
behalf, and the provider will collect only applicable cost-shares
and co-pays after receipt of the TOP Explanation of Benefits (EOB).
The beneficiary will be held harmless for denied charges rendered
by a PPN provider unless the beneficiary was informed in writing
that the specific services were not a covered TRICARE benefit and
the beneficiary agreed in writing, in advance of the services being
provided, to pay for the services. If a beneficiary submits a claim
for services provided by a PPN provider, the TOP contractor shall
deny the claim if the beneficiary does not submit proof of payment showing
that the beneficiary has paid for the service(s).
3.5 If a claim is received for
care rendered by a non-certified provider in the Philippines, the
TOP contractor shall pend the claim and initiate on-site verification/provider
certification action. Claims pended for this reason are excluded
from normal claims processing cycle time standards. If the on-site verification/certification
action is not completed within 90 calendar days, the TOP contractor
shall deny claims based on lack of provider certification.
3.6 The TOP contractor shall deny
claims submitted from non-certified purchased care sector providers
from the Philippines, advising the provider to contact the contractor
for procedures on becoming certified.
3.7 For the Philippines, prescription
drug may be cost-shared when dispensed by a certified retail pharmacy
or hospital based pharmacy. The TOP contractor shall deny claims
for prescription drugs obtained from a physician’s office.