4.0 POLICY
4.1 This demonstration
is applicable to all TRICARE Standard/Select beneficiaries who reside
in the Philippines and receive care in designated demonstration
area(s). The demonstration is also applicable to beneficiaries who
are receiving the TRICARE Standard benefit under TOP TRICARE For
Life (TFL) and TRICARE Standard/Select benefit under TRICARE Retired
Reserve (TRR), TRICARE Reserve Select (TRS), or TRICARE Young Adult
(TYA) programs, who reside in the Philippines.
4.2 For
demonstration purposes, beneficiary residence will be determined
by the address listed on the claim. This rule applies regardless
of the residence address listed in Defense Enrollment Eligibility Reporting
System (DEERS).
4.3 Demonstration
area(s) will be determined by Defense Health Agency (DHA) and will
be publicized at least 60 calendar days in advance of the effective
date for each location. In addition, expansion of demonstration
areas may occur on an annual basis during the demonstration project
and will be publicized at least 60 calendar days in advance of the
effective date for the expanded locations. DHA anticipates using
a phased approach to implement the demonstration in multiple locations.
4.4 TRICARE
Standard/Select beneficiaries who reside in the Philippines, in
accordance with
paragraph 4.2, and receive care in designated
demonstration area(s) must receive all care from approved demonstration
providers, unless a specific waiver has been granted (see
paragraphs 4.8 and
4.9).
If these beneficiaries receive care from a non-approved demonstration
provider without a waiver, TRICARE will not cost-share the claim
and the beneficiary will be responsible for 100% of the charges. Normal
TRICARE cost-shares and deductibles apply to care rendered to eligible
beneficiaries by approved providers under the terms of the demonstration.
Additionally, when a beneficiary receives care from an approved
provider in a designated demonstration area, the provider will file
the claim on the beneficiary’s behalf, and the provider will collect
only applicable cost-shares and deductibles after receipt of the
TOP Explanation of Benefits (EOB). The beneficiary will be held
harmless for denied charges rendered by an approved demonstration
provider unless the beneficiary was notified in writing that the
care provided was not a covered benefit prior to receiving the care.
Beneficiary-submitted claims for services provided by an approved
demonstration provider in an approved demonstration area shall be
denied unless it is submitted with proof of payment showing that
the beneficiary has paid for the service(s).
4.5 Service members are not eligible
for TRICARE Standard/Select and therefore are not included in this
demonstration, regardless of their residence address or enrollment
status. Service members not enrolled in TOP who are on Temporary
Additional Duty/Temporary Duty (TAD/TDY), deployed, deployed on
liberty, or in an authorized leave status in the Philippines shall
follow referral/authorization guidelines for TOP Prime Remote enrollees
(see
Chapter 24, Section 25).
4.6 This demonstration is not applicable
to beneficiaries enrolled in TOP Prime, TOP Prime Remote, TRICARE
Prime, TRICARE Prime Remote (TPR), TRICARE Prime Remote for Active
Duty Family Members (TPRADFMs), or TYA (Prime option). Additionally,
this demonstration is not applicable to TRICARE Standard/Select
beneficiaries whose home address (as determined by the claim) indicates
a residence other than the Philippines. The demonstration is also
not applicable to TRICARE Standard/Select beneficiaries who reside
in the Philippines (as determined by the claim) when they receive
care from a provider who renders care in a location that is not
included in the demonstration.
4.7 All TOP
requirements regarding utilization management, case management,
quality management, and preauthorizations are applicable to demonstration
participants. The TOP contractor is not required to enroll participants
into the demonstration or to provide referral/authorization services
to demonstration participants unless the requested service requires
preauthorization (per
Chapter 7, Section 2 and
TPM,
Chapter 1, Section 6.1). 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.
4.8 TRICARE
Standard/Select beneficiaries who reside in the Philippines may
request a waiver if they elect to receive care from non-approved
providers or facilities in a demonstration area. Beneficiary waiver
requests should be submitted in writing to the TOP contractor and
will be considered on a case-by-case basis. Except for emergency
care (which never requires prior approval), beneficiaries are encouraged
to submit waiver requests prior to receiving care. However, the
TOP contractor will also consider waiver requests that are submitted
after care has been rendered. The Director, TRICARE Area Office
(TAO)-Pacific will make the final determination if the beneficiary
disagrees with the TOP contractor’s decision. In such cases, the
TOP contractor shall forward all supporting documentation and rationale
regarding the waiver denial determination to the Director, TAO-Pacific
to assist in the final determination. Some examples of potential
beneficiary waiver situations include (this list is not all-inclusive):
• Beneficiaries who were engaged
in an ongoing episode of care with a non-approved provider when
the demonstration began, and who wish to continue care with their
established provider.
• Beneficiaries who are unable
to obtain an appointment with an approved provider within the appropriate
time frame (based on TRICARE access standards for urgent, routine,
and specialty care).
Note: Waivers for emergency care
rendered by non-approved providers or facilities shall be approved
on a retrospective basis based on TRICARE policy. Emergency care
never requires preauthorization.
4.9 Since
provider participation in this demonstration is voluntary, there
may be situations where the TOP contractor is unable to recruit
a sufficient number and mix of approved providers in all specialties
in designated demonstration areas. In these situations, the TOP
contractor may request a specialty waiver so that beneficiaries
can receive care from non-approved (certified) providers in accordance
with normal TRICARE Standard/Select reimbursement policy. The TOP
contractor is responsible for identifying any anticipated or actual
gaps in coverage by approved providers in demonstration area(s),
and submitting a specialty waiver request in writing to the Director,
TAO-Pacific. The waiver request shall include a description of the
contractor’s efforts to recruit approved providers in that particular
specialty, as well as any perceived or known barriers to participation
in the demonstration. If the Government approves the specialty waiver,
the contractor shall implement processes to ensure that claims for
that specialty (in the designated demonstration area) are processed under
normal TRICARE Standard/Select rules. This specialty waiver process
will ensure that TRICARE Standard/Select beneficiaries will not
be liable for 100% of the charges (as described in
paragraph 4.4) if
the TOP contractor is unable to recruit approved providers in a
particular specialty.
4.10 A
provider may be removed from the list for administrative reasons
or may be removed for cause by the TOP contractor. The Government
may also direct the TOP contractor to remove providers from the
list for cause. A 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 provider shall be given
the right to appeal to the Director, TAO-Pacific. If the appeal
decision is upheld by the Director, TAO-Pacific, there is no right
to further appeal.
Note: The appeal process does not
apply to certified providers who are not selected by the TOP contractor
to participate in the demonstration as approved providers. Recruiting
and retaining a sufficient number and mix of approved providers
in demonstration area(s) is the responsibility of the TOP contractor.
The TOP contractor is not required to offer approved provider status
to every current certified provider in demonstration area(s).
4.11 Claims for a provider removed
from the list will be processed in accordance with
Chapter 13, Section 4. The list will be updated
on the contractor’s web site on the first of the month following
the provider being removed from the list.
5.0 DHA And TOP Contractor Responsibilities
5.1 The DHA Director (or designee)
will:
5.1.1 Determine the geographical
area(s) for the demonstration and the phased implementation approach
and timeline (if applicable) and communicate this information in
writing to the TOP contractor no later than 240 calendar days prior
to the start of health care delivery under the demonstration.
5.1.2 Identify areas that will expand
the demonstration areas and communicate those changes in writing
to the TOP contractor at least 60 calendar days before the effective
date.
5.1.3 Establish a process to allow
a provider to appeal his/her removal from the approved list (see
paragraph 4.10).
5.1.4 Issue final determinations
regarding waiver requests from beneficiaries who elect to receive
care from non-approved demonstration providers (see
paragraph 4.8).
5.1.5 Conduct periodic review and
evaluation of the demonstration.
5.2 The TOP
contractor shall:
5.2.1 Be able to provide upon request
by the Government, the following information:
• Number of claims submitted
under the demonstration and the cost of those claims.
• Number of specialty waivers
issued and the reason for the waiver.
5.2.2 At the request of the Government,
the contractor shall assist in the evaluation and analysis of the
demonstration.
5.2.3 Recruit
and retain a sufficient number and mix of approved providers in
demonstration area(s) to ensure access to the full range of covered
TRICARE benefits, unless a specialty waiver has been requested.
Approved providers must agree to comply with the demonstration participation requirements
in
paragraph 3.1.
5.2.4 Establish and maintain a list
of all approved demonstration providers, including each provider’s
specialty, sub-specialty, gender, work address, work fax number,
and work telephone number for each demonstration location, and whether
or not they are accepting new TRICARE patients. The approved list
of providers must be submitted to DHA no later than 120 calendar
days prior to the start of health care delivery under the demonstration.
The TOP contractor shall provide beneficiaries with easy access
to both the approved 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 no
later than 60 calendar days prior to the start of health care delivery
in each demonstration area. Information on the WWW site and any
other electronic lists shall be current within the last 30 calendar
days. At a minimum, the data base shall be searchable by provider
location, provider name, and provider specialty (if available).
5.2.6 Establish
a waiver process for beneficiaries who reside in the Philippines
and who request or receive care from non-approved providers or facilities
in a demonstration area (see
paragraph 4.8).
5.2.7 Develop
and publish materials to educate beneficiaries and providers on
all aspects of the Philippines Demonstration Project. In addition
to providing specific information regarding the demonstration, the
TOP contractor shall educate approved 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.
5.3 DHA and
the TOP contractor shall:
5.3.1 Develop
and implement a communication plan to ensure that beneficiaries
and providers are informed regarding the area(s) that are participating
and not participating in this demonstration. The communication plan
shall also include the process(es) for educating beneficiaries and
providers regarding the demonstration rules and business processes,
to include the processes for requesting waivers.
5.3.2 Establish timelines and processes
to facilitate prompt processing of waiver requests and provider
appeals in accordance with demonstration policy (see
paragraphs 4.8,
4.9,
and
4.10).