1.0 General
All TRICARE requirements regarding
Financial Administration shall apply to the TRICARE Overseas Program
(TOP) unless specifically changed, waived, or superseded by this
section; the TRICARE Policy Manual (TPM),
Chapter
12; or the TRICARE contract for health care support services
outside the 50 United States (U.S.) and the District of Columbia
(hereinafter referred to as the “TOP contract”). See
Chapter
3 for additional instructions.
2.0 Payment POLICY
2.1 Reimbursement
of TOP beneficiary claims for overseas health care shall be based
upon the lesser of billed charges, the negotiated reimbursement
rate, or the Government-established fee schedule. (See
Section 9 and the TRICARE Reimbursement Manual
(TRM),
Chapter 1, Sections 34 and
35 for additional guidelines). Except for
medical evacuations, claims for care in the U.S. commonwealths and
territories shall be reimbursed following stateside reimbursement
guidelines. Philippines and Panama claims shall be reimbursed following
Government-established fee schedules, unless the TOP contractor
has negotiated a lesser rate with a purchase care sector provider.
2.2 Payment of Skilled Nursing
Facility (SNF) claims from Puerto Rico and the U.S. territories
(Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands) shall be processed as routine foreign claims and
shall be subject to the Prospective Payment System (PPS), as required
under Medicare in accordance with the Social Security Act. These
SNFs will be subject to the same rules as applied to SNFs in the
U.S. (see the TRM,
Chapter 8).
SNF care is not available in other TOP locations.
2.2.1 The TOP contractor at its discretion,
may conduct concurrent or retrospective review for TRICARE Select and
TRICARE for Life (TFL) patients when TRICARE is the primary payer.
If Medicare requires reviews to be performed on low Patient Driven
Payment Model (PDPM) categories, per the Medicare Policy Manual
Chapter 8, the contractor will be responsible for all reviews for
TRICARE Prime patients. There will be no review for TRICARE Select or
TFL patients where TRICARE is the secondary payer. The existing
referral and authorization procedures for Prime beneficiaries will
remain unaffected.
2.2.2 Beneficiaries
in a low PDPM category depending on date of service may not automatically qualify
for SNF coverage. These beneficiaries will be individually reviewed
to determine whether they meet the criteria for skilled services
and the need for skilled services (see the TRM,
Chapter 8, Section 1). If these beneficiaries
do not meet these criteria, the SNF PPS claim shall be denied.
2.2.3 The TOP contractor, at their
own discretion, may collect Minimum Data Set (MDS) assessment data
per the TRM,
Chapter 8, Section 1.
2.3 The TOP contractor shall be
responsible for entering into participation agreements with SNFs
in Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and
the Northern Mariana Islands.
2.3.1 The TOP
contractor, at their own discretion, may conduct any data analysis
to identify aberrant SNF PPS providers or those providers who might
inappropriately place TRICARE beneficiaries in a high PDPM category.
The contractor shall also assist the TRICARE Area Office (TAO) Executive Directors
in obtaining/providing SNF data, for conducting any SNF PPS data
analysis they deem necessary.
2.4 Balance
billing provisions do not apply to TOP beneficiary claims for care
rendered in a foreign country and paid as billed, since there is
no unpaid balance on these claims. Purchased care sector network
providers, participating providers, and providers in U.S. commonwealths
and territories are prohibited from balance billing.
2.5 For health care rendered in
Puerto Rico and in the U.S., reimbursement for all TOP beneficiary care
shall follow the TRICARE payment policies except as outlined below.
2.5.1 TOP Service members who have
been required by the provider to make “up front” payment at the
time services are rendered may submit a claim for reimbursement
directly to the contractor. Normal TRICARE claims processing requirements
apply (including any authorization requirements and the use of TRICARE-approved
claims forms). If the claim is payable, the contractor shall allow
the billed amount and reimburse the Service member for charges on
the claim.
2.5.2 In no case shall a Service member
be subjected to “balance billing” or ongoing collection action by
a civilian provider for emergency or authorized care. If the contractor
becomes aware of such situations that they cannot resolve, they
shall pend the file and forward the issue to the appropriate TAO Executive Director.
The appropriate TAO Executive Director
will issue an authorization to the contractor for payments in excess
of CMAC or other applicable TRICARE payment ceilings, provided the TAO Executive Director
has requested and has been granted a waiver from the Program Manager, Defense
Health Agency (DHA), or designee.
2.5.5 Payment may be made for ambulance
services provided by commercial transport (see
Section 7 for
additional processing instructions for these claims).
3.0 Financial Administration
3.1 The TOP contractor shall follow
the Financial Administration non-financially underwritten funds
requirements in
Chapter 3 with
the following exceptions:
3.1.1 Foreign
overseas drafts (local currency) and checks (U.S. currency) shall
also reflect “TRICARE Overseas Program”.
3.1.2 Foreign
overseas drafts shall also reflect information that indicates the
draft is valid for 190 days and if reissue is required/necessary,
the draft must be returned to the TOP contractor with a request
for reissuance. The contractor shall issue drafts/checks for Germany
claims which look like local German drafts/checks.
3.2 The TRICARE Encounter Data
(TED) for the overseas claims shall be reported on vouchers/batches
according to the TRICARE Systems Manual (TSM),
Chapter
2.
• Overseas health care claims
for stateside beneficiaries whose health care is normally provided under
one of the regional contracts (i.e., beneficiaries enrolled or residing
in the 50 U.S. or the District of Columbia, who receive care while
traveling or visiting abroad) shall be processed by the TOP contractor.
Claims for these beneficiaries shall be paid from the current non-financially underwritten
bank account. This provision does not apply to beneficiaries who
are enrolled to the Uniformed Services Family Health Plan (USFHP)
or the Continued Health Care Benefit Program (CHCBP). Claims for
these beneficiaries are processed by their respective contractor
regardless of where the care is rendered.
3.3 The TOP contractor shall:
3.3.1 Provide TRICARE Overseas Currency
reports identifying the gain or loss for the month reported to arrive
by the 10th calendar day following the month reported. Reporting
requirements for net gains/losses are identified by DD Form 1423,
Contract Data Requirements List (CDRL), located in Section J of
the applicable contract.
3.3.2 Calculate currency gains and
losses resulting from payments made to purchased care sector providers
and/or beneficiaries in foreign countries. The gains and losses
shall be computed based on the exchange rate in effect on the ending
date of care. The difference between the cost of the foreign currency
on the ending date of care and the contractor payment date shall
be the gain or loss on the transaction. Payment shall be as follows
for:
3.3.2.1 Net Gain. For months that result
in a net gain, the TOP contractor shall forward the report along
with their check payable to the Department of Defense (DoD), DHA,
for the gain from currency conversion.
3.3.2.2 Net Loss. DHA will reimburse
the TOP contractor for any losses incurred from currency conversion.
The TRICARE Overseas Currency report shall be accompanied by a letter
(invoice) requesting reimbursement for the loss incurred. This payment
will not be subject to the Prompt Payment Act (FAR 32.9) as amended,
therefore, payment by DHA will usually be made within five working
days of receipt of the invoice and the TRICARE Overseas Currency
report.