1.0 POLICY
1.1 Non-active
duty TRICARE Prime and TRICARE Prime Remote
Active
Duty Family Member (TPR
ADFM)
enrollees referred for non-emergent
, medically
necessary specialty care over 100 miles (one way) from their Primary
Care Manager’s (PCM’s) office to the nearest specialist’s office
may be eligible to receive reimbursement for reasonable travel expenses.
Entitlement is limited to those specialty referrals when no other
specialist (i.e., Military
Medical Treatment
Facility (MTF)
, network
, or
non-network specialists) is available within 100 miles (one way)
of the PCM’s office.
For TPRADFM enrollees with unassigned
PCM program qualification is determined from referring provider’s
office. Travel reimbursements allowed under paragraphs 1.1 through 1.4 will
be reimbursed in accordance with the Joint Travel Regulations (JTR).
Travel reimbursement claims must be filed no later than one year
after the qualifying travel date (exceptions may be made for patients
eligible for travel reimbursement under paragraph 1.4). Travel expenses
will not be authorized for non-medically necessary elective procedures or
non-covered benefits. TRICARE Prime Travel Benefit
(PTB)
does not apply to a
beneficiaries
enrolled to TRICARE Overseas Program (TOP) or to
an Active Duty Service Member (ADSM) who is authorized medical travel.
1.2 PTB Program Attestations -
Each
beneficiary entry shall be called an attestation. The attestation confirms
that Managed Care Support Contractors (MCSCs) have verified that
the referred specialist is 100 miles or more from the PCM, and there
are no suitable providers to meet the patient’s needs within 100
miles of the PCM within appointment access to care (ATC) standards. The
contractor shall provide a
report with
any information needed to assist in validating beneficiary
trip
qualification requirements for
TRICARE Prime
travel reimbursement.
The Government (TRICARE PTB
Section or the MTF, depending on member enrollment) will perform
all operational functions to include distance validation and final
program trip qualification. The Government determines beneficiary
PTB qualification based on the attestations.1.2.1 A daily report
will be provided to the TRICARE PTB Section to include information
related to TRICARE Prime network-enrollees, any TPRADFM enrollee
or any Coast Guard enrollee beneficiaries (network or Direct Care
(DC)) who received approved authorizations for specialty care over
100 miles from the PCM’s office. Details for reporting
are identified in DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract.
Each
approved authorization for specialty care over 100 miles from the
PCM will be annotated on the report.1.2.1.1 When a manual
attestation is requested the contractor shall provide the attestation,
or the response for the need of additional information, within three
business days 90% of the time.
1.2.1.2 A manual attestation
is requested by the government when an attestation is missing from either
the daily or weekly PTB Program attestation reports.
1.2.1.3 When the original
attestation is contested and upon request by the beneficiary, by
either direct inquiry to the MCSC or forwarded by the Defense Health
Agency (DHA), the contractor shall perform a medical review of all
available documentation, to include additional provider justification letters,
to determine if there is medical justification to be evaluated and
treated by the selected specialty provider.1.2.1.3.1 The contractor
shall respond to beneficiary inquiries requesting medical review assessment.
The MCSC shall forward the medical review assessment and determination
to the TRICARE PTB Section within 14 calendar days of receipt of
the beneficiary’s provider justification letter. The contractor
will provide additional clinical documentation upon TRICARE PTB
Section request.
1.2.1.3.2 If the contractor
determines there are other qualified providers located within 100 miles
of the PCM they shall provide the beneficiary with that specialty
contact information.
1.2.1.3.3 The contractor
shall track and report beneficiary contested attestations.
1.2.2 A weekly report
will be provided to each MTF to include information
related to each individual MTF’s enrolled
beneficiaries or any (exclude Coast
Guard enrolled beneficiaries) who received
approved authorizations for specialty care over 100 miles from the
PCM’s office. Details
for reporting are identified in DD Form 1423, CDRL, located in Section
J of the applicable contract. Each approved authorization for specialty
care over 100 miles from the MTF will be annotated on the report.
1.3 A
retiree with a combat-related disability (as determined by the member’s
Branch of Service), not enrolled in TRICARE Prime, and referred
by a Primary Care Provider (PCP) for follow-on specialty care related
to that specific disability as listed in Combat-Related Special
Compensation (CRSC) letter, more than 100 miles (one way) from where
the PCP provides services to the retiree, may be eligible to receive
reimbursement for reasonable travel expenses. The TRICARE PTB Section for
the region in which the retiree resides will determine if the specialty
care is more than 100 miles (one way) from the provider’s office.
The contractor shall refer inquiries about travel reimbursement
for retirees with combat-related disabilities to the regional TRICARE
PTB Section travel representative or
Beneficiary Counseling and Assistance Coordinator (BCAC) for further
information and assistance.
1.4 The
Coast Guard Authorization Act of 2010, signed into law on October
15, 2010, authorizes reimbursement for travel to specialty care
less than 100 miles (one way) for a non-active duty Coast Guard
beneficiary (active duty dependents only) who resides on an island
within the continental United States (CONUS),
with no public access roads to the mainland, and for one medically
necessary attendant. Entitlement is limited to those specialty referrals
when no other specialist (i.e., MTF, network, or
non-network specialists) is available on the island. The beneficiary
must be enrolled in TRICARE Prime or TPRADFM and
referred to a specialty care provider by their PCM. The contractor
shall refer inquiries about travel reimbursement for Coast Guard
beneficiaries to the appropriate PTB travel representative.
1.5 For patients eligible for travel
reimbursement under
paragraphs 1.1 through
1.4,
if the PCM/PCP or servicing provider deems it medically necessary,
travel orders and reimbursement may be authorized for one Non-Medical
Attendant (NMA) to accompany a non-active duty patient referred
for applicable specialty care. The NMA must be a parent, legal guardian,
spouse, or other adult member of the patient’s family, or other
adult companion who has been delegated a medical Power of Attorney (POA)
by the patient or legally responsible party. In most cases, the
NMA’s must be at least 21 years old. The
medical
POA may be waived at Approving Official (AO) discretion.
1.6 Except for Coast Guard beneficiaries,
MTFs
will validate the travel expense
entitlement and issue travel orders for specialty referrals issued
by military PCMs, and the TRICARE PTB
Section will validate
the travel entitlement and issue travel orders for specialty referrals
from civilian PCMs. Travel reimbursements allowed under
paragraphs 1.1 through
1.4 will
be reimbursed in accordance with the
JTR
. Travel
reimbursement claims must be filed no later than one year after
the qualifying travel date (exceptions may be made for patients
eligible for travel reimbursement under
paragraph 1.3). Travel expenses
will not be authorized for elective procedures or non-covered benefits.
Except for Coast Guard beneficiaries (see
paragraph 1.7), the contractor
shall refer travel requests for MTF
-enrolled
TRICARE Prime
beneficiaries to the MTFs
and civilian-enrolled
TRICARE Prime
beneficiary requests to the TRICARE PTB
Section for
authorization, orders and claim processing if it appears the beneficiary may
be entitled to travel benefits. Non-Coast Guard beneficiaries with
questions about these travel benefits and the NMA entitlement should
contact their local MTF
or the TRICARE
PTB
Section or BCAC for assistance.
Telephone numbers and addresses for BCAC are available on the TRICARE
web site at
http://www.tricare.mil/bcacdcao.
1.7 The
contractor shall refer general PTB Program inquiries
about travel reimbursement for Coast Guard beneficiaries to the
appropriate PTB travel representative. This applies to MTFs, civilian-enrolled TRICARE Prime, and TPRADFM beneficiaries.
2.0 EFFECTIVE DATES
2.1 October
30, 2000, for TRICARE Prime enrollees.
2.2 January
1, 2008, for retirees with a combat-related disability.
2.3 October 15, 2010, for TRICARE
Prime Coast Guard island dwellers.