1.0 General
1.1 AllThe
TOP contractor shall apply all TRICARE requirements
regarding the SHCP
shall apply to the TOP unless
specifically changed, waived, or superseded by this section, TRICARE
Policy Manual (TPM),
Chapter 12,
or the TRICARE contract for health care support services outside
the 50 United States (US) and the District of Columbia (hereinafter
referred to as the “TOP Contract”). See
Chapter
17 for additional instructions.
1.2 Uniformed
Service members in an active duty status of greater than 30 calendar
days (also known as
Active Duty Service
members Members
(ADSMs)) who are on permanent or official duty assignment
in a location outside the 50 US and the District of Columbia must
enroll in TOP Prime or TOP Prime Remote.
Service members ADSMs in
a temporary duty status and enrolled elsewhere should not transfer
their enrollment to TOP Prime or TOP Prime Remote unless it is medically
appropriate and will not cause enrollment eligibility disruption
to family members’ enrollment status.
Service members ADSMs are
not CHAMPUS-eligible and do not have the option to use TOP Select
or the Point of Service (POS) option under TOP Prime or TOP Prime
Remote.
Uniformed Service members ADSMs who
would normally receive care from a private sector care provider
may be directed to transfer their care to a Military Medical Treatment
Facility (MTF). This applies to
Service members ADSMs and Uniformed Service
members not in active duty status (Reserve Component (RC) members
under Line of Duty (LOD) care). These controls ensure the maintenance
of required fitness-for-duty oversight for TOP Uniformed Service
members. Refer to
Section 9 for claims processing instructions.
2.0 Contractor Responsibilities
2.1 Service membersADSMs who
are enrolled in TOP Prime shall follow the procedures outlined in
Chapter 17 for MTF-enrolled
Service members ADSMs,
except
that any the TOP
contractor shall replace references to the Defense Health
Agency-Great Lakes (DHA-GL)
should be replaced by
a with reference
s to
the appropriate regional TRICARE Area Office (TAO) in all overseas
locations except the US Virgin Islands concerning Line of Duty Determinations
and except for care delivered under the National Department of Defense
(DoD)/Department of Veteran Affairs/Veterans Health Administration
(DVA/VHA) Memorandum of Agreement (MOA) authorization requirements.
See
paragraph 2.4.3 paragraph 2.3.3 for
National DoD/DVA/VHA MOA authorization requirements.
Service
members ADSMs who are enrolled
in TOP Prime Remote must seek authorization from the TOP contractor for
all non-emergent specialty and inpatient care.
Service
members ADSMs not enrolled
in TOP
and who are on Temporary Additional
Duty/Temporary Duty (TAD/TDY), deployed, deployed on liberty, or
in an authorized leave status outside the 50 US and the District
of Columbia
shall will follow
referral/authorization guidelines for TOP Prime Remote enrollees.
2.2 If a Service
member seeks private sector care without appropriate authorization,
they put themselves at financial risk for claims payment. They are
also at risk for potential compromise of medical readiness posture,
flight status, or disability benefits, and they may be subject to
disciplinary action for disregarding service-specific policy. Lost
work time may be charged as ordinary leave.
2.2 The TOP contractor shall ensure
a benefit review is done on each SHCP referral and authorization.
The TOP contractor shall return deferred-to-network referrals for
non-covered services with an explanation of why it was denied. The
TOP contractor shall not issue an authorization unless they obtain
a copy of an approved waiver. The
TOP contractor
shall deny all claims for TRICARE non-covered health care services.
(Reference Health Affairs (HA) Policy 12-002 “Use of Supplemental
Health Care Program Funds for Non-Covered TRICARE Health Care Services
and the Waiver Process for Active Duty Service Members”).
2.2.1 If the
TOP contractor
determines that the requested service, supply, or equipment is not
covered by TRICARE policy and no Defense Health Agency (DHA)-approved
waiver is provided, the
TOP contractor shall
decline to file an authorization and shall deny any received claims
accordingly. If the request was received as an MTF referral, the
TOP contractor
shall notify the MTF (and enrolled MTF if
it is different
from the submitting MTF) of the declined authorization with explanation
of the reason. If the request was received as a referral from a
civilian provider (for a remote
Service member ADSM/non-enrolled
Service
member ADSM), the
TOP contractor
shall notify the civilian provider and the remote
Service
member ADSM/non-enrolled
Service
member ADSM of the declined authorization
with explanation of the reason. The
TOP contractor shall
ensure the notification to
a the civilian provider
and the remote
Service member ADSM/non-enrolled
Service
member shall ADSM explain
s the
waiver process and provide contact information for the applicable
Uniformed Services Headquarters Point of Contact (POC)/Service Project
Officers as listed in
Chapter 17, Addendum A, paragraph
2.0. No notification to the Specified Authorization
Staff (SAS) is required.
2.2.2 The TOP contractor
shall not extend TRICARE benefits
may
not be extended for complications resulting from
non-covered surgeries and treatments performed outside the MTF for
a
Service member an ADSM without
an approved waiver. If the treatment is a non-covered TRICARE benefit,
TRICARE
will not cover any follow-on care, including care for
complications,
will not be covered by TRICARE once
the
Service member ADSM separates
from active duty or retires (
32 CFR 199.4(e)(9); TPM,
Chapter 4, Sections 1.1 and
1.2). The
Uniformed Services
will provide appropriate counseling that such follow-on care is
the member’s personal financial responsibility upon separation or
retirement.
2.3 The provisions of
Chapter
17 are changed for the TOP
contract as
follows:
2.3.1 The provisions of
Chapter 17, Section 2, paragraph 2.0 are not
applicable to the TOP contract. USFHP services are not available
outside the 50 US and the District of Columbia.
2.3.2 Except for the claims for
Service
member ADSM care provided
under the National DoD/DVA/VHA MOA,
the contractor shall
apply the provisions of
Chapter 17, Section 3, paragraph 1.2.1 regarding
the timeline for review of SHCP claims by overseas MTFs is extended
to 10 calendar days.
Service member The
TOP contractor shall process and pay ADSM claims for
covered benefits submitted to the TOP contractor for which an authorization
is not on file
are to be pended for a determination
of whether the care should be authorized as
if an authorization is on file.
The claim
shall be pended and the MTF of enrollment shall be notified that
an authorization determination should be accomplished and returned
to the TOP contractor within 10 calendar days. If the TOP contractor
does not receive the MTF’s response within 10 calendar days, the
contractor shall move the claim back into active processing within one
business day and shall process the claim as if the MTF had authorized
the care. Claims authorized due to a lack of response by the MTF
shall be considered as “Referred Care”, but the contractor shall
be able to distinguish these claims from MTF-authorized claims.
Claims pended under the provisions of this section shall be considered
to be excluded claims for the purposes of calculating and reporting
claims processing cycle time performance. The
TOP contractor shall deny claims for non-covered services. The TOP
contractor shall provide the MTF with a report (details for reporting
are identified in DD Form 1423, Contract Data Requirements List
(CDRL) located in Section J of the applicable contract) for all
claims processed and paid with no authorization and all denied claims
for non-covered services.
2.3.3 The
TOP contractor
shall apply the provisions of
Chapter 17, Section 2, paragraph 3.2 regarding
claims for care provided under the National DoD/DVA/VHA MOA for
Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma
are applicable to the TOP and
shall
be process
ed these
claims in accordance with
Chapter 17, Section 2, paragraph 3.2.3
through 3.2.6.1.
Such care will be
authorized by the DHA-GL
for Service members will
authorize the ADSM care under this MOA.
2.3.4 The
TOP contractor
shall apply the provisions of
Section 6, paragraph 5.0 and
Chapter 8, Section 5 apply Chapter 7, Section 5 to TOP SHCP
referrals. Additionally, when MTFs submit a referral request for
purchased private care
services for a non-AD sub-population beneficiary eligible for SHCP,
the MTF
shall utilize the required data elements identified
in Chapter 8, Section 5, paragraph 6.1 and
shall will annotate the referral
with “SHCP”
in line item 12, “Review Comment”.
This
will ensure that SHCP claims for eligible non-AD sub-population
beneficiaries are properly adjudicated.
Note: Circumstances whereThe
TOP contractor shall use supplemental funds
may
be used to reimburse for care rendered by non-Governmental
health care providers to non-active duty patients
are
limited to those where a when an MTF
provider orders the needed health care services from civilian sources
for a
patient beneficiary,
and the MTF provider maintains full clinical responsibility for
the episode of care. This means that the patient is not disengaged
from the MTF that is providing the care. See
Chapter 17, Section 1, paragraph 1.1.
2.4 When
a Service
member an ADSM leaves a remote
TOP assignment as a result of Permanent Change of Station (PCS)
or other service-related change of duty status, the
following
applies in support of medical record accumulation TOP
contractor shall:
2.4.1 For Service members ADSMs leaving
remote TOP assignment in Puerto Rico, the TOP contractor
shall require the PCM shall to provide
a complete copy of medical records, to include copies of specialty
and ancillary care documentation, to Service members ADSMs within
30 calendar days of the Service member’s ADSM’s request for
the records. The Service member ADSM may
also request copies of medical care documentation (specialty care visits
and discharge summaries) on an ongoing, Episode of Care (EOC) basis.
2.4.2 For Service members ADSMs leaving
remote TOP assignments from all overseas areas other than Puerto
Rico, Service members in those locations should
request medical records from the private sector care provider(s)
who provided health care services during the Service
member’s ADSM’s tour of duty.
These Service members ADSMs may
also request copies of medical care documentation (specialty care
visits and discharge summaries) on an ongoing, EOC basis.
2.4.3 Records provided
by privatePrivate sector care
providers with records in languages other
than English may be submitted those to
the TOP contractor for translation into English according to the
terms of the contract.
2.4.4 NetworkThe
TOP contractor shall reimburse network private sector
care providers shall be reimbursed for
medical records photocopying and postage costs incurred at the rates
established in their network provider participation agreements. Non The
TOP contractor shall reimburse non-network private sector
care providers shall be reimbursed for
medical records photocopying and postage costs on the basis of billed
charges unless the Government has directed a lower reimbursement
rate. Service members The
TOP contractor shall reimburse ADSMs, who have paid
for copied records and applicable postage costs, shall
be reimbursed for the full amount paid to ensure
they have no out-of-pocket expenses. All The
TOP contractor shall require all providers and/or Service
members must ADSMs to submit
a claim form, with the charges clearly identified, to the contractor
for reimbursement.
Note: The purpose of copying medical
records is to assist the Service member ADSM in
maintaining accurate and current medical documentation. The contractor
shall not make payment to reimburse a
private sector care provider who photocopies medical records to
support the adjudication of a claim.
2.4.5 The provisions of
Chapter 17, Section 3, paragraph 1.1.8 are
not applicable to the TOP.
The TOP contractor shall not
use SHCP funds
may not be used to
pay for overseas
purchased private sector
care for foreign military members or their families. The TOP contractor
shall deny any MTF referrals and claims for such care.
2.5 Provision of Respite Care For
The Benefit of Seriously Ill or Injured Active Duty Members
2.5.1 The
TOP contractor
shall apply provisions of
Chapter 17, Section 3 and
the TRICARE Systems Manual (TSM),
Chapter 2, Section 2.8 and
6.4 regarding respite care for seriously ill
or injured
Service members are applicable ADSMs in
locations outside the 50 US and the District of Columbia where TRICARE-authorized
Home Health Agencies (HHAs) have been established.
2.5.2 The TOP contractor
shall cover respite care benefit is applicable
to Service members for ADSMs enrolled to
TOP Prime, TOP Prime Remote, and to any Service member ADSM referred
by an overseas MTF or TAO.
2.5.3 AllThe
TOP contractor shall apply all normal Service
member ADSM authorization
and case management requirements for the TOP apply
to the Service member ADSM respite
care benefit.