1.0 GENERAL
TRICARE Overseas Program (TOP)
health care services are provided by Military Treatment Facilities (MTFs)
and purchased care sector network and non-network providers and
institutions. All TRICARE requirements regarding Provider Certification/Credentialing
and Network Development shall apply to the 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changed, waived, or superseded by this section; the TRICARE Policy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
Chapters
4 and
5 for additional
instructions.
2.0 Purchased Care Sector Provider
Certification And Credentialing
2.1 The TOP
contractor shall be responsible for provider certification oversight,
and monitoring of provider/institution quality. The contractor shall
use
Chapter 4,
32
CFR 199.6, and TPM,
Chapter
11 to the maximum extent possible for the certification
of purchased care sector providers. The contractor is
not required
to follow TRICARE requirements for U.S. credentialing standards,
except when TRICARE requires the facility/agency to be Medicare
certified (e.g., home health, hospice, Skilled Nursing Facility (SNF)
care). Also, Psychiatric Residential Treatment Centers (RTCs), Substance
Use Disorder Rehabilitation Facilities (SUDRFs), and Psychiatric
Partial Hospitalization Programs (PHPs) that are located in Puerto
Rico require approval by the TOP contractor. Except for these services
and facilities, the TOP contractor shall establish purchased care
sector provider certification processes based on the accepted licensure
and credentialing requirements for the purchased care sector.
Note: Medicare certification for
organ transplant centers is only required for transplants performed
in the U.S., the District of Columbia, and U.S. territories where
Medicare is available. See TPM,
Chapter 12, Section 1.2.
2.2 Refer to
Section 28 for
additional certification requirements that have been established
for purchased care sector providers in the Philippines. The Defense
Health Agency (DHA) may expand these additional certification requirements
to other locations in the future.
3.0 Network Development
3.1 The TOP contractor shall be
responsible for developing and maintaining a complement of network
and non-network purchased care sector providers to augment the existing
capacity of the Direct Care (DC) system for Service members and
Active Duty Family Members (ADFMs) who are enrolled in TOP Prime,
and to provide or arrange for primary and specialty care services
for Service members and ADFMs who are enrolled in TOP Prime Remote.
3.2 The TOP contractor shall establish
signed provider agreements between network purchased care sector
providers and the contractor.
3.2.1 Network
provider agreements shall include language indicating that the provider
agrees to participate on claims for authorized services for TOP
enrollees on a cashless, claimless basis.
3.2.2 Network
provider agreements must specify rates for Service member medical
records photocopying and postage, if applicable.
Note: “Cashless, claimless” is defined
as a health care encounter that requires no up-front payment at
the time of service, and the provider files the claim for the beneficiary.
3.3 In TOP Prime and TOP Prime
Remote locations, networks shall be sized to meet TOP Prime/TOP Prime
Remote-enrolled populations only. The TOP contractor may assist
other beneficiaries (non-command sponsored ADFMs, retirees, retiree
family members, etc.) upon request by identifying these private
sector care providers which are credentialed and familiar with TRICARE,
but networks will not be developed to accommodate
non-TOP Prime/Prime Remote enrollees.
3.4 In TOP Prime
locations, MTF
Directors will identify
the specialties needed in the network and will communicate this
information on an ongoing basis to the TOP contractor per the process
identified in the Statements of Responsibilities (SORs) (see
Section 15).
3.5 MTF capabilities
and capacities may change frequently over the life of the contract
without prior notice. The TOP contractor shall ensure that purchased
care sector provider services can be adjusted as necessary to compensate
for changes in MTF capabilities and capacities, when and where they
occur over the life of the contract, including short notice of unanticipated
facility expansion, provider deployment, downsizing, and/or closures.
3.6 Network providers shall be
able to communicate in English, both orally and in writing, or provide
translation services at the time of service.
3.7 The TOP contractor shall be
responsible to enter into participation agreements with SNFs in Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands per the provisions of
Section 3.
4.0 Contractor Requirements - Purchased
Care Sector Providers
4.1 The Government requires the
contractor to negotiate rates in specific countries designated in the
contract. Reimbursement rates for purchased care sector providers
in other locations may be negotiated by the contractor. In locations
where the Government has designated specific reimbursement rates
or methodologies. The contractor may not negotiate rates which exceed
the Government directed rate. Refer to the TRICARE Reimbursement
Manual (TRM),
Chapter 1, Section 34 for additional instructions.
4.2 The contractor shall provide
ongoing purchased care sector provider education and support in accordance
with
Section 10.
4.3 The contractor
shall have a Clinical Quality Management Program/Clinical Quality
Oversight Plan for reviewing access and quality of care provided
by the purchased care sector, as identified in DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract.
4.4 The TOP contractor shall assign
provider numbers to purchased care sector providers, identify providers
as network or non-network, and create and submit TRICARE Encounter
Provider (TEPRV) records. Each provider shall be identified by a
single provider number, with a sub-identifier for multiple service
locations. Upon the Government’s request, the contractor shall provide
copies of licensure/certification information for purchased care
sector providers.
4.5 The TOP
contractor shall deny claims from non-certified purchased care sector
providers when DHA has directed that the country’s purchased care
sector providers must be specially certified in order to receive
TRICARE payments. See
Section 28 for additional certification requirements.