1.0 POLICY
1.1 Non-active
duty TRICARE Prime and TRICARE Prime Remote (TPR) 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 (e.g., Market/Military Medical
Treatment Facility (MTF), network or non-network specialists) is
available within 100 miles (one way) of the PCM’s office. Depending
on enrollment, the TRICARE Prime Travel Benefit (PTB) Office or
the Market/MTF will determine if the specialty care is more than
100 miles (one way) from the provider’s office. PTB does not apply
to a dependent Outside of the continental United States (OCONUS)
or to an Active Duty Service Member (ADSM) who is authorized medical
travel. For TRICARE Prime Remote Active
Duty Family Member (TPRADFM) enrollees with unassigned PCM, 100
miles is determined from the referring provider’s office to the
specialty provider.
1.2 Prime
Travel Benefit (PTB
) Program
Attestations -
The contractor shall provide an attestation
that confirms the contractor verified the referred specialist is
100 miles or more from the PCM (or referring provider for TPRADFM
unassigned beneficiaries) 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 daily
spreadsheet and
weekly reports with any information needed to assist
in validating beneficiary
eligibility trip qualification requirements
for TRICARE Prime travel reimbursement. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract. Each
beneficiary entry
shall
be in the report is called
an “attestation
.”
and shall The
daily report, provided to the Defense Health Agency (DHA)/Prime
Travel Section, include
s information
related to network-enrolled beneficiaries or any
non-Active
Duty Service Member (ADSM) United States Coast Guard
(USCG) enrolled
beneficiaries (network or direct care) who received approved authorizations
for specialty care over 100 miles from the PCM’s Office.
The
weekly report, provided to each Market/MTF, includes information
related to the non-ADSM Market/MTF enrolled beneficiaries except
USCG beneficiaries.1.2.1 The contractor
shall respond to all beneficiary inquiries regarding authorization
questions.
1.2.2 TheFor
non-active duty network enrolled and all USCG beneficiaries, the contractor
shall resolve access to care issues, including but not limited to,
assigned Specialty Care Provider (SCP), SCP capability issues, and beneficiaries beneficiary’s need
for additional letters of medical necessity justification.
The Government will perform all operational functions to include
distance validation and final program eligibility determination.
1.2.3 When a manual attestation
is requested, the contractor shall provide the attestation, or a
request for additional information, within three business days 90%
of the time. The Government will request a manual attestation when
an attestation is missing from the PTB Program attestation reports.
1.2.4 For non-active duty
(AD) network and all USCG beneficiaries, when the original attestation
is contested and upon request by the beneficiary, by either direct
inquiry to the contractor or forwarded by the 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.1.2.4.1 For non-AD network and
all USCG beneficiaries, the contractor shall respond to beneficiary
inquiries requesting medical review assessment. The contractor shall
forward the medical review assessment and determination to the DHA
PTB Section within 14 calendar days of receipt of the beneficiary’s
provider justification letter. The contractor shall provide additional
clinical documentation upon request from the DHA PTB Section.
1.2.4.2 If the contractor determines
there are other qualified providers located within 100 miles of
the PCM, the contractor shall provide the beneficiary with that
specialty provider contact information.
1.3 The
contractor shall refer inquires about travel reimbursement for non-TRICARE
Prime enrolled retirees with combat-related disabilities to the
DHA PTB Section. 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 DHA PTB Office Section for
the geographical area in which the retiree resides will determine
if the specialty care is more than 100 miles (one way) from the provider’s
office.
1.4 The
contractor shall refer inquiries about travel reimbursement for
retirees with combat-related disabilities to the TRICARE PTB Office
or Beneficiary Counseling and Assistance Coordinator (BCAC) for
further information and assistance.
1.4 The
contractor shall refer inquiries about travel reimbursement for
USCG beneficiaries to the DHA PTB Section travel representative. 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 USCG 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 (e.g., Market/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.
1.6 For patients
eligible for travel reimbursement under paragraphs
1.1 through 1.5,
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.
1.7 Except for Coast
Guard beneficiaries, Markets/MTFs will validate the travel expense
entitlement and issue travel orders for specialty referrals issued
by military PCMs, and the TRICARE PTB Office will validate the travel entitlement
and issue travel orders for specialty referrals from civilian PCMs.
Travel reimbursements allowed under paragraphs
1.1 through 1.5 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
1.3). Travel expenses will not be authorized
for elective procedures or non-covered benefits.
1.5 The Government determines
if a beneficiary qualifies for the PTB or not. The contractor
shall
(except for Coast Guard beneficiaries-see paragraph
1.9), shall refer
all travel
requests questions
except those regarding authorization issues, to the appropriate
Market/MTF for Market/MTF
non-ADSM-enrolled
TRICARE Prime beneficiaries
, to
the Markets/MTFs and
non-ADSM civilian-enrolled
along
with all USCG TRICARE Prime beneficiary requests to
the
TRICARE DHA PTB
Office 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 Market/MTF or the TRICARE PTB Office
or BCAC for assistance. Telephone numbers and addresses
for
Beneficiary Counseling and Assistance Coordinator
(BCAC
) are available on the TRICARE
website at
http://www.tricare.mil/bcacdcao.
1.9 The
contractor shall refer inquiries about travel reimbursement for
Coast Guard beneficiaries to the appropriate TRICARE PTB Office.
This applies to Markets/MTFs and civilian-enrolled TRICARE Prime
and TPR 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.