1.0 General
1.1 AllThe
TOP contractor shall apply all TRICARE requirements
regarding claims processing
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specifically changed, waived, or superseded by this section; the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 (US) and the District of Columbia (hereinafter
referred to as the “TOP Contract”). See
Chapter
8 for additional instructions.
1.5 The provisions of
Chapter 8, Section 1, paragraph 2.3 are applicable
the TOP; however,
Defense Health Agency (DHA) may establish region
or country-specific requirements regarding third party payments
or payment addresses
may be established by Defense
Health Agency (DHA) at any time to prevent or reduce
fraud.
Note: BenefitThe
TOP contactor shall mail benefit payment checks and
Explanation Of Benefits (EOB) to Philippine providers (and other
nation’s providers as determined by the Government) shall
be mailed to the place of service identified on the
claim. This policy applies even if the provider uses a Third Party
Administrator (TPA). No The
TOP contractor shall not send provider payments shall
be sent to any other address. The Government may discontinue
TPA payments to other countries or specific agencies if it is determined
that significant fraud is occurring on a regular basis.
1.6 Acceptable claim forms are
identified in
Chapter 8, Section 1, paragraph 3.1 Chapter 8, Section 1, paragraphs 3.1 and 3.2, this may be any current or
obsolete claim form (whether submitted by a beneficiary or a provider).
Additionally
, the TOP contractor shall accept
any other claim form or alternative documentation as long as these
methods provide sufficient data to facilitate claims processing
and TRICARE Encounter Data (TED) submission.
1.8 The contractor’s TOP
contractor shall ensure it’s claims processing procedures shall integrate
efforts to prevent and identify fraud/abuse.
2.0 JURISDICTION
2.1 In the early
stages of TOP claims review, the TOP contractor shall determine whether jurisdiction
for claims received are within its contractual
jurisdiction using the criteria below.
2.2 ServicesThe
TOP contractor shall process claims for services rendered
on-board a commercial ship while outside US territorial waters are
the responsibility of the TOP contractor. Claims The
TOP contractor shall process claims for services provided
on a commercial ship that is outside the territorial waters of the
US shall be processed as foreign claims
regardless of the provider’s home address. If the provider is certified
within the US, the TOP contractor shall base reimbursement
for the claim is to be based on the
provider’s home address. If the provider is not certified within
the US, the TOP contractor shall reimbursement
will following the procedures
for foreign claims. This does not include health care for enrolled Active
Duty Service members Members
(ADSMs) on a military ship at
sea or on a military ship at home port.
2.3 The provisions
of
Chapter 8, Section 2, paragraphs 1.0 and
2.0 are superseded as described in
paragraphs 2.3.1 through
2.3.9.
2.3.1 When a beneficiary is enrolled
in TOP Prime or TOP Prime Remote, the TOP contractor shall process
all health care claims for the enrollee, regardless of where the
enrollee receives services. Referral The
TOP contractor shall apply referral/authorization rules apply.
2.3.2 ClaimsThe
TOP contractor shall process claims for Active Duty
Family Members (ADFMs) (including Reserve Component (RC) ADFMs whose
sponsors have been activated for more than 30 calendar days), retirees, and
retiree family members whose care is normally provided under one
of the regional contracts (i.e., beneficiaries enrolled or residing
in the 50 US and the District of Columbia) who receive Civilian
Health Care (CHC) while traveling or visiting overseas shall
be processed by the TOP contractor, regardless of
where the beneficiary resides or is enrolled. Referral The
TOP contractor shall apply referral/authorization and
Point Of Service (POS) rules apply for
TRICARE Prime/TRICARE Prime Remote (TPR) enrollees.
Note: This provision
does not apply toThe TOP contractor shall
not process claims for beneficiaries who
are enrolled in the Uniformed Services Family Health
Plan (USFHP) or the Continued Health Care Benefit Program (CHCBP). Claims The
USFHP and CHCBP contractors process claims for these
beneficiaries are processed by their respective contractor regardless
of where the care is rendered.
2.3.3 ClaimsThe
TOP contractor shall process claims for
Service
members ADSMs residing in
the 50 US and the District of Columbia (including RC Service members
activated for more than 30 calendar days) who are on Temporary Additional
Duty/Temporary Duty (TAD/TDY), deployed, deployed on liberty, or
in an authorized leave status in an overseas location
shall
be processed by the TOP contractor, regardless of
where the
Service members ADSM resides
or is enrolled.
Referral/authorization rules apply. The
TOP contractor shall process claims for ADSMs in accordance with Section 26.
2.3.4 ClaimsThe
TOP contractor shall process claims for TOP-enrolled
Service members (including RC Service members activated for more
than 30 calendar days) on a military ship or with an overseas home
port. shall not be processed
by the The member’s military
unit. These will not process
these claims shall be processed by the
TOP contractor.
2.3.5 InitialThe
TOP contractor shall process initial and follow-on Line
Of Duty (LOD) claims for RC Service members on orders for 30 consecutive
calendar days or less, who are injured while traveling to or from
annual training or while performing their annual training who receive
civilian medical care overseas, shall have their claims processed
by the TOP contractor upon verification of LOD status.
Defense Health Agency-Great Lakes (DHA-GL) will validate LOD status
for RC Service members in the US Virgin Islands.
2.3.6 The TOP
contractor shall process claims for Durable Equipment (DE) and Durable
Medical Equipment (DME) (otherwise coverable by TRICARE) that is
purchased/ordered by TOP-eligible beneficiaries in an overseas area from
a stateside provider (i.e., Internet, etc.).
2.3.7 For inpatient
claims that are paid under the Diagnosis Related Group (DRG)-based
payment system, the TOP contractor, on the date of admission, shall
process and pay the entire DRG claim, including cost outliers. For inpatient
claims paid on a per diem basis, to include DRG transfers and short
stay outlier cases, and for professional claims that are date-driven,
the contractor shall process and pay the claims.
2.3.8 When a
beneficiary’s enrollment changes from one TRICARE region to another
during a hospital stay that will be paid under the DRG-based payment
system, the contractor with jurisdiction on the date of admission shall
process and pay the entire DRG claim, including cost outliers.
2.3.9 For information on portability
claims for relocating TOP Prime/TOP Prime Remote enrollees, refer
to
Chapter 6, Section 2.
2.4 The provisions
of
Chapter 8, Section 2, paragraphs 6.0, Chapter 8, Section 2, paragraphs 6.1,
6.2,
and 6.3, 6.4, 7.1, 7.2, 7.3, 8.0, and 8.1 are applicable to the TOP.
2.5 The provisions
of
Chapter 19, Section 4 are applicable to the
TOP for US citizens who are practicing outside the US
2.6 The provisions
of Chapter 8, Section 2, paragraphs 6.6, 6.7, 7.1, 7.2, and 8.1 are applicable to the TOP.
2.6 Refer to the TRICARE Reimbursement
Manual (TRM),
Chapter 4, Section 4, paragraph 5.0 for jurisdictional guidance
regarding health care claims for work-related illness or injury
which is covered under a Worker’s Compensation Program.
2.7 The provisions of
Chapter 8, Section 2, paragraph 5.0 are applicable
to the TOP in those locations where the TRICARE Pharmacy (TPharm)
contractor has established services (the US territories of Puerto
Rico, Guam, the US Virgin Islands, American Samoa, and the Northern
Mariana Islands). The TOP contractor
cannot shall
not process pharmacy claims from these locations except
for pharmacy that is part of an emergency room visit or inpatient treatment.
Any prescriptions from this care that are not provided at time of
treatment for inpatient/emergency care, shall be
required
to be submitted through the TPharm contractor.
Copays
will apply. The TOP contractor shall apply
copayments.
2.8 The TOP contractor shall forward
all retail pharmacy claims to the TPharm contractor within 72 hours
of identifying them as being out-of-jurisdiction. In all other overseas
locations, the TOP contractor shall process
claims from purchased care private sector care retail
pharmacies and providers.
2.9 ADFMs with TRICARE Select and
retirees or their family members residing overseas obtaining prescription
from an overseas
purchased care private sector
care pharmacy
shall will submit
their claims to the TOP contractor.
For The
TOP contractor shall waive the cost-share/deductible
provisions
in,
see TRM,
Chapter
2 regarding the mandatory collection of pharmacy copayment
amounts at the time of service
are waived for
foreign providers.
3.0 CLAIMS
FILING DEADLINE
The provisions
of
Chapter 8, Section 3 are applicable to the
TOP except
that the claim
s
filing deadline is no later than three years after the date services
were provided (or three years from the date of discharge for an
inpatient admission) for services provided outside the
50 US or the District of Columbia, the Commonwealth of Puerto Rico, or
the possessions of the US
are considered to be filed
in a timely manner if they are filed no later than three years after
the date the services were provided or three years from the date
of discharge for an inpatient admission.
All Providers
and beneficiaries shall file all other claims
must
be filed within one year according to the requirements listed
in
Chapter 8, Section 3, unless an exception
to the filing deadline has been granted. See
Chapter 1, Section 2, paragraph 5.0 for
the timely filing waiver process.
4.0 SIGNATURE
REQUIREMENTS
4.1 The provisions of
Chapter 8, Section 4 are applicable to the
TOP unless a different process has been directed by the DHA Contracting
Officer (CO).
4.2 The TOP contractor shall, at
its discretion, accept a thumb print in lieu of a signature on a
claim form, unless otherwise directed by the Government. When directed
by the DHA CO, the TOP contractor shall not use signature on file
and may not accept facsimile or thumb print signatures on claims.
5.0 REFERRALS/PREAUTHORIZATIONS/AUTHORIZATIONS
The provisions of
Chapter 7, Section 5 and
Chapter 8, Section 5 are altered for the TOP
by the following requirements.
5.1 Referral/Preauthorization/Authorization
Requirements for TOP Prime and TOP Prime Remote Enrollees
5.1.1 Unless otherwise
directed by the Government,
the contractor shall not
require referrals/preauthorizations/authorizations
are
not required for emergency care, clinical preventive
services, ancillary services, radiological diagnostics (excluding
Magnetic Resonance Imaging (MRI) and Positron Emission Tomography
(PET) scans), drugs, and services provided by a TOP Partnership
Provider.
Additionally, The
TOP contractor shall require a referral for TOP Prime/TOP
Prime Remote ADFMs
will require a referral for
all mental health and Substance Use Disorder (SUD) services except
outpatient office-based visits.
The TOP contractor shall require
preauthorization for TOP Prime/TOP Prime Remote ADFMs
will
also require preauthorization for treatment of SUDs
as outlined in the TPM,
Chapter 7, Section 3.5, paragraph 4.0 and
for the treatment of mental disorders as outlined in the TPM,
Chapter
7, Section 3.8, paragraph 6.0 Chapter 7, Section 3.7, paragraph 6.0.
All The
TOP contractor shall require authorization for all other
care that is provided to a TOP Prime/TOP Prime Remote-enrolled Service
member or ADFM by anyone other than their Primary Care Manager (PCM)
requires
authorization, regardless of where the care is rendered.
5.1.2 ClaimsThe
TOP contractor shall process claims for
Service
member care
not authorized by the TOP contractor
shall be pended for a review to make a determination regarding authorization in
accordance with Section 26.
While
authorizations are required for ADSM care, for administrative reasons,
the TOP contractor shall process and pay such claims without an
authorization for TRICARE covered services (to include services,
supplies and equipment waived under a Supplemental Health Care Program
(SHCP)), as if there were an authorization on file. If
the care is retroactively authorized by the Government (including
submission of an approved
SHCP waiver for a
non-covered service), then the contractor shall enter the authorization
and process the claim for payment. If the contractor determines
that the care was not authorized, the contractor shall deny the
claim. Refer to
Section 26 for additional information.
5.1.3 ClaimsThe
TOP contractor shall process claims for self-referred,
non-emergency, and non-urgent care for TOP Prime and TPR enrolled
ADFMs shall process with POS deductibles
and cost-shares unless the appropriate TRICARE Area Office (TAO)
or TRICARE Overseas Program Office (TOPO) has approved a retroactive
authorization.
5.1.4 TRICARE-eligible beneficiaries
residing in an overseas location who are not enrolled in TOP Prime/
TOP Prime
RemoteTPR typically do not
need to obtain preauthorization/authorization for care. However,
the
TOP contractor shall perform preauthorization reviews
shall
be performed for all care and procedures listed in
Chapter 7, Section 2. The TOP contractor shall
propose additional authorization reviews for non-enrolled TOP beneficiaries to
the
government Government.
5.1.5 TRICARE
beneficiaries whose health care is normally provided under one of
the two regional Managed Care Support
Contractors (MCSCs) who require
care while traveling in an overseas location shall must request
any necessary preauthorizations/authorizations through the TOP contractor,
regardless of where the beneficiary resides or is enrolled. Denial
of requested services should be visible to the claims processing
contractor to ensure claims are denied or processed as POS as appropriate.
Note: This process does not apply
to beneficiaries enrolled to the USFHP or the CHCBP.
5.2 Point
of Service (POS) Provisions
5.2.1 Unless specifically excluded
by this section, the TOP contractor shall reimburse all
self-referred, non-emergency care provided to TOP Prime/TOP Prime
Remote-enrolled ADFMs which is not either provided/referred by the
beneficiary’s PCM or specifically authorized shall
be reimbursed under the POS option. This provision
applies regardless of where the care is rendered. The
TOP contractor shall apply POS provisions also
apply to the following stateside beneficiaries enrollees when they
are traveling overseas: ADFMs, retirees, and retiree
family members who are enrolled in
TRICARE Prime, and ADFMs enrolled in TPR for ADFMs.
5.2.2 The
TOP contractor shall apply POS cost-sharing only applies to
TRICARE-covered services. Claims The TOP
contractor shall deny claims for services that are not
a covered TRICARE benefit shall be denied.
5.2.3 The TOP
contractor shall adjust POS deductibles and cost-shares when TOP
PCMs or Health Care Finders (HCFs) do not follow established referral/authorization
procedures. For example, if the TOP contractor processes
a claim under the POS option because there was no evidence of a
referral and/or an authorization, and the TOP contractor
later verifies that the PCM or other appropriate provider referred
the beneficiary for the care, the TOP contractor
shall adjust the claim and reverse the POS charges. The TOP contractor
need not identify past claims that may be eligible for POS adjustment;
however, the TOP contractor shall adjust
these claims as they are brought to their attention.
5.2.4 On a case-by-case
basis, following stabilization of the patient, the TAO Director
or MTF Commander Director may
require an enrolled beneficiary to transfer to a TOP network facility
or an MTF. The TAO Director or MTF Commander shall Director
will provide written notice to the beneficiary (or responsible
party) advising them of the impending transfer to a TOP network
facility/MTF. If a beneficiary who is subject to TOP POS provisions
elects to remain in the non-network facility after such notification, the
TOP contractor shall apply POS cost-sharing provisions will
apply beginning 24 hours following the receipt of
the written notice. Neither the TOP Director nor the MTF Commander Director will
require a transfer until such time as the transfer is deemed medically
safe.
5.2.5 The
TOP contractor
shall apply the following deductible and cost-sharing
amounts
apply to all TOP POS claims
for health care support services:
• Enrollment year deductible for
outpatient claims: $300 per individual; $600 per family. No The
TOP contractor shall not apply a deductible applies
to inpatient services.
• Beneficiary cost-share for
inpatient and outpatient claims: 50% of the allowable charge after
the deductible has been met (deductible only applies to outpatient
claims).
• The TOP contractor
shall not credit POS deductible and cost-share amounts are
not creditable to the enrollment/Fiscal Year (FY)
catastrophic cap and they are not limited by the cap.
• The TOP contractor
shall not apply POS deductible and cost-share amounts do
not apply to claims for care received by newborns
and newly adopted children who are deemed enrolled in TOP Prime
or TOP Prime Remote.
5.2.6 The
TOP contractor shall not apply POS deductible and cost-share
amounts
do not apply if a TOP enrollee
has Other Health Insurance (OHI) that provides primary coverage
(i.e., the OHI must be primary under the provisions of the TRM,
Chapter 4, Section 1).
Evidence The
TOP contractor shall submit evidence of OHI claims processing
(including the exact amount paid on the claim)
must
be submitted with the TOP claim.
5.2.7 The
contractor shall ensure the EOB shall clearly
indicates that a claim has been processed
under the POS Option.
5.2.8 The TOP contractor
shall not apply POS is not applicable to Service
members ADSMs or to TRICARE Select enrollees.
5.3 Extended
Care Health Option (ECHO) benefits in overseas locations must be
authorized by the TOP contractor. Refer to
Section 23 and
the TPM,
Chapter 9 for
additional guidance.
5.4 Refer to
Section 10 for
referral/preauthorization/authorization requirements for
Service
member ADSM dental care in
remote overseas locations.
6.0 CLAIM
DEVELOPMENT
6.1 DevelopmentThe
TOP contractor shall keep development of missing information shall
be kept to a minimum. The TOP contractor shall use
available in-house methods, contractor files, telephone, Defense Enrollment
Eligibility Reporting System (DEERS), etc., to obtain incomplete
or discrepant information. If this is unsuccessful, the contractor
shall return the claim(s) to
sender with a letter which indicates that the claims are being returned,
the reason for return and requesting requests the
required missing documentation. The contractor’s system shall identify
the claim as returned, not denied. The Government reserves the right
to audit returned claims as required, therefore the contractor shall
retain sufficient information on returned claims to permit such
audits. The contractor shall review all claims to ensure TOP required
information is provided prior to payment. For the Philippines, the
TOP contractor shall pend claims requiring development
of missing or discrepant information, or those being developed for
medical documentation, shall be pended for
90 calendar days and are excluded them from
the claims processing standard.
6.2 Claims
mayThe TOP contractor shall allow claims
to be filed by eligible TRICARE beneficiaries,
purchased care private sector
care providers,
TOP POCs, and TRICARE authorized providers in the 50 US and the
District of Columbia
as allowed under TRICARE (see
Chapter 8, Section 1).
6.3 ConfidentialityThe
TOP contractor shall meet confidentiality requirements
for
TOP are identical to TRICARE requirements outlined
in
Chapter 8.
6.5 The
TOP
contractor shall require the following minimal information
is
required on each overseas claim prior to payment:
6.5.1 Signatures
Beneficiary and purchased
care private sector care provider
signatures (signature on file is acceptable unless specifically
prohibited by the Government).
6.5.2 Name
and Address
6.5.2.1 Complete beneficiary and purchased
care private sector care provider
name and address.
6.5.2.2 If an address is not available
on the claim,
the TOP contractor shall obtain
the address either from previously submitted claims, directly from
the beneficiary/
purchased care private sector
care provider
via phone, fax, or email, DEERS per
paragraph 6.1.
Note: The TOP contractor shall accept
APO/FPO for the beneficiary address.
6.5.3 Diagnosis(es)
6.5.3.1 Prior
to returning a claim that is missing a diagnosis, the TOP contractor
shall research the patient’s history and determine whether a diagnosis
from a related claim can be applied. The diagnosis should be reflective
of the services rendered.
6.5.3.2 Claims
received for dates of service for outpatient services or dates of
discharge for inpatient services before the mandated date, as directed
by Health and Human Services (HHS), for International Classification
of Diseases, 10th Revision (ICD-10) implementation, with ICD-10
codes shall be converted to International Classification of Diseases,
9th Revision, Clinical Modifications (ICD-9-CM) codes by the TOP
contractor. Claims received for dates of service for outpatient
services or dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation,
with ICD-9 or ICD-9-CM codes shall be converted to ICD-10-CM codes
by the TOP contractor. Refer to Chapter 8, Section 6, paragraphs 4.0 and 5.0 regarding
the use of ICD-9-CM V codes
(factors influencing health status and contact with health services)
and ICD-10-CM Z codes (factors
influencing health status and contact with health services).
6.5.4 Procedures/Services/Supply/DME
The TOP contractor shall identify
the procedure(s)/service(s)/supplysupplies/DME
ordered, performed or prescribed, including the date ordered performed
or prescribed. The TOP contractor shall use the date the claim form
was signed as the specific date of service, if the service/purchase
date/order date is not on the bill.
6.5.5 ClaimsThe
TOP contractor shall code claims received with a narrative
description of services provided
shall be coded by
the TOP contractor with as accurate
ly-coding as
possible based upon the level of detail provided in the narrative
description or as directed by the TOPO. Services which contain sufficient
detail to identify an accurate procedure code shall be used. All
surgical procedures must be coded accurately based on the level
of detailed description. Outpatient professional services shall
be coded accurately.
Office The
TOP contractor shall code office visits which include
multiple services
shall be coded accurately
and
the TOP contractor shall not bundle
d when
the description of services are available. The
TOP contractor
shall apply the provisions of
paragraph 6.1 apply for
narrative claims that cannot be accurately coded due to insufficient
or vague information.
Claims received for dates of
service for outpatient services or dates of discharge for inpatient
services before the mandated date, as directed by HHS, for ICD-10
implementation, with ICD-10 codes shall be converted to ICD-9 codes
by the TOP contractor. Claims received for dates of discharge for
inpatient services on or after the mandated date, as directed by
HHS, for ICD-10 implementation, with ICD-9 codes shall be converted
to ICD-10 codes by the TOP contractor. Refer to Chapter 8, Section 6, paragraph 4.0 regarding
the use of V and Z codes.6.5.5.1 Inpatient
Institutional Procedures
InpatientThe
TOP contractor shall code the procedural narratives for inpatient institutional
(i.e., hospital) claims received for dates of discharge for inpatient
services before the mandated date, as directed by HHS, for ICD-10 implementation,
shall have the procedure narratives coded by the TOP contractor
using ICD-9-CM, Volume 3 procedure codes. Inpatient institutional
(i.e., hospital) claims received for dates of discharge on or after
the mandated date, as directed by HHS, for ICD-10 implementation, shall
have the procedure narratives coded by the TOP contractor using
ICD-10-Procedure Classification System (ICD-10-PCS) procedure codes.
6.5.5.2 Outpatient
Institutional Procedures and Professional Services
ClaimsThe
TOP contractor shall code claims received for outpatient
institutional (e.g., ambulance services, laboratory, Ambulatory
Surgery Centers (ASCs), partial hospitalizations, outpatient hospital
services) services and professional services shall
be coded using Healthcare Common Procedure Coding
System (HCPCS) or Current Procedural Terminology (CPT).
6.5.6 Care
authorizations (when required)
6.5.7 Itemization
of total charges. (Itemization of hospital room rates are not required
on institutional claims).
6.5.8 ProofThe
TOP contractor shall require proof of payment
is
required for all beneficiary submitted claims if
the claim indicates that the beneficiary made payment to the provider
or facility. Due to cultural differences, there may be significant
variation in provider processes for issuing receipts to the beneficiaries.
Therefore, the
overseas claims processor TOP
contractor shall use best business practices when determining
if the documentation provided is acceptable for the country where
the services were rendered.
6.5.8.1 Examples of ACCEPTABLE Beneficiary
Proof of Payment
• Canceled checks (made payable
to the provider)
• Credit or bank card statements
or receipts
• Bank account statements (with
documentation of payment to the provider)
• Receipt, itemized bill, or
statement issued by the provider’s office stamped ‘PAID’ on all
pages
• Proof of electronic funds transfer
(EFT) from the beneficiary to the provider
• Invoice for pharmaceuticals
dispensed on an outpatient basis (overseas pharmacies will not dispense
drugs without payment; therefore, an invoice represents proof of
payment)
• Invoice for health care from
providers in Turkey (Turkish providers will not provide an invoice
to the patient until payment has been made; therefore, an invoice
represents proof of payment).
6.5.8.2 Examples
of UNACCEPTABLE Beneficiary Proof of Payment:
• Canceled check made payable
to ‘Cash’ or to the beneficiary or sponsor;
• Bank account statements showing
cash withdrawal (without additional documentation of payment to
the provider);
• Letter signed by patient beneficiary saying s/he they has
paid the bills;
• Paid amount shown only on the
claim or itemized bill;
• Handwritten statements (e.g.,
‘Paid in Full’, ‘Paid by Patient’, ‘Paid in Cash’);
• Paid in cash (without additional
documentation of payment to the provider).
6.6 NonThe
TOP contractor shall deny claims for non-prescription
(Over-The-Counter (OTC)) drugs are to be denied.
This includes drugs that are considered OTC by US standards, even
when they require a prescription in a foreign country.
6.7 The TOP
contractor shall use a schedule of allowable charges based on the
Average Wholesale Price (AWP) as a reference source for processing
drug related TRICARE overseas claims.
6.8 ClaimsThe
TOP contractor shall cost-share claims for medications
prescribed by a host-nation physician, and commonly used in the
host-nation country, shall be cost-shared unless
they are considered OTC by US standards.
6.9 For the
Philippines, the TOP contractor shall only cost-share prescription
drugs may only be cost-shared when
dispensed by a certified retail pharmacy or hospital-based pharmacy.
The TOP contractor shall deny claims for prescription drugs dispensed
by a physician’s office. Certification requirements outlined in
Section 31 apply.
Note: This does not apply to Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
6.10 ClaimsThe
TOP contractor shall develop claims for DME involving
lease/purchase shall always be developed for
missing information.
6.11 The TOP contractor shall use
ECHO claims processing procedures outlined in TPM,
Chapter 9, Section 18.1, when processing ECHO
overseas claims.
6.12 The TOP contractor shall deny
claims from non-certified or non-confirmed purchased
care private sector care providers
when the DHA CO has directed contractor certification/confirmation
of the purchased care private sector care provider
prior to payment.
6.13 RequestsThe
TOP contractor shall send requests for missing information shall
be sent on the TOP contractor’s TRICARE/TOP letterhead.
When development is necessary, the contractor shall include a special
insert in German, Italian, Spanish, Tagalog, Japanese, and Korean
which indicates what the missing
information is required to process the claim and includes the contractor’s return address for
returning requested information.
6.14 If the
TOP contractor elects to develop for additional/missing information,
and the request for additional information is not received/returned
within 45 calendar days, the contractor shall deny the claim.
6.15 If the
TOP contractor has no record of referral/authorization prior to
denial/payment of the claim, the contractor shall follow the TOP
POS rules, if the service would otherwise be covered under TOP.
6.16 The TOP
contractor shall develop procedures for the identification and tracking
of TOP enrollee claims submitted by either a
purchased
care private sector
care designated
or non-designated overseas
purchased care private sector
care provider
without preauthorization/authorization. Upon receipt of a claim
for a TOP-enrolled ADFM submitted by a
purchased care private sector
care designated
or non-designated overseas
purchased private care
sector provider without preauthorization/authorization, the contractor
shall process the claims following POS payment procedures. For
Service
member ADSM claims submitted
by a
purchased care private sector
care provider without
preauthorization/authorization, the contractor shall
pend
the claim for review prior to denying the claim process
the claim if services are covered by TRICARE.
If
services are non-covered services and no authorization is on file,
the TOP contractor shall deny the claim. Refer to
Section 26 for more information on ADSM pended
claims.
6.17 The TOP contractor shall have
an automated data system for eligibility, deductible and claims
history data and
must shall maintain
on the automated data system all the necessary TOP data elements
to ensure the ability to reproduce both TED and EOBs as outlined
in
Chapter 8, Section 8.,
except for requiring Except, the contractor
shall not require overseas providers to use HCPCS to
bill outpatient rehabilitation services, issue provider’s the Form 1099
and suppression of checks/drafts for $.99 or less. The contractor
shall split claims to accommodate multiple invoice numbers in order
to reference invoice numbers on EOBs when necessary. Refer to
Chapter 8, Section 6 for additional requirements
related to claims splitting.
6.18 The TOP
contractor shall not pay for pharmacy services obtained through
the Internet.
6.19 The TOP contractor shall pay
all TOP
Service member ADSM stateside
claims as outlined in
Section 26.
6.20 AllThe
TOP contractor shall submit all claims
shall
be submitted in a Health Insurance Portability and Accountability
Act (HIPAA) compliant format. Refer to
Section 28 for
more information on HIPAA requirements.
6.21 Electronic The
TOP contractor shall reject electronic claims not accepted
by the TOP contractor’s Electronic Data Information (EDI) system/program shall
be rejected.
6.22 For all
overseas claims, the TOP contractor shall create and submit TEDs
following current guidelines in the TSM for TED development and
submission. Claim The TOP
contractor shall access claim information will
be able to be accessed through the TRICARE Patient
Encounter Processing and Reporting (PEPR) Purchased Care Detail Information
System (PCDIS).
6.23 The TOP contractor shall establish
Utilization Management (UM) high dollar/frequency thresholds in accordance
with
Section 6.
6.24 ClaimsThe
TOP contractor shall process claims either denied as
“beneficiary not eligible” or “found to be not eligible on DEERS”
may
be processed as a “good faith payment” when received
from the Defense Health Agency (DHA) Communications Office. The
TAO Director
shall will work
with the TOP contractor on claims issues related to good faith payment
documentation (e.g., a completed claim form and other documentation
as required by
Chapter 10, Section 2 and
3).
6.26 The Claims Auditing Software
requirements outlined in the TRM,
Chapter 1, Section 3 do not apply to TOP claims;
however, the TOP contractor shall implement an internal process
for identifying upcoding, unbundling, etc. on coded claims.
7.0 APPLICATION
OF DEDUCTIBLE AND COST-SHARING
Application ofThe
TOP contractor shall apply TOP deductible and cost-
sharing
procedures shallshare follow
ing the
guidelines
outlined requirements in
Chapter 8, Section 7.
8.0 EOB
VOUCHERS
The TOP
contractor shall follow the EOB voucher requirements in
Chapter 8, Section 8, where applicable, with
the following exceptions and additional requirements:
8.1 The TOP
contractor shall ensure the letterhead on all TOP EOBs shall
also reflects “TRICARE Overseas Program”
and shall be annotated TRICARE Prime or TRICARE
Select.
8.2 TOP EOBs may be issued on regular
stock,. The TOP contractor shall
provide a message indicating the exchange rate used to determine
payment and shall clearly indicate
that indicating ‘This is not
a bill’.
8.3 The TOP contractor
shall ensure TOP EOBs shall include
the toll-free number for beneficiary and provider assistance.
8.4 The
TOP contractor shall ensure TOP EOBs for overseas enrolled Service
member ADSM claims shall
be are annotated ‘ACTIVE DUTY.’
8.5 For Point
of Sale or Vendor pharmacy overseas claims, the TOP contractor
shall ensure TOP EOBs shall have
the name of the provider of service on the claim.
8.6 For beneficiary
submitted pharmacy claims, the TOP contractor shall ensure TOP
EOBs shall contain the name of the
provider of service, if the information is available. If the information
is not available, the TOP contractor shall ensure EOBs shall contain
‘your pharmacy’ as the provider of service.
8.7 The TOP
contractor shall insert the provider’s payment invoice numbers in
the patient’s account field on all provider EOBs, if available.
8.8 The TOP
contractor shall designate an EOB message for overseas claims rendered
by non-network purchased care private sector care providers
who are required to be certified, but have not been certified by
the TOP contractor. Refer to Section 4 for more information regarding
certification of providers in designated locations.
8.9 When a provider’s/beneficiary’s
EOB, EOB and check, or letter is returned as undeliverable, the TOP contractor
shall void the check shall be voided.
8.10 The TOP
contractor shall utilize use secure
electronic EOB delivery to beneficiaries unless mail delivery has
been requested by the beneficiary or the beneficiary has
not signed up for electronic delivery.
8.11 The contractor
shall issue monthly summary EOBs to beneficiaries on claims when
there is no beneficiary liability. The TOP contractor
shall ensure the processing date of the oldest claim
for the summary EOB shall is not be greater
than 31 calendar days.
9.0 DUPLICATE
PAYMENT PREVENTION
9.1 The TOP contractor shall follow
the duplicate payment prevention requirements outlined in
Chapter 8, Section 9.
9.2 The TOP
contractor shall ensure that business processes are established
which require appropriate system and/or supervisory controls to
prevent erroneous manual overrides when reviewing potential duplicate payments.
10.0 DOUBLE
COVERAGE
10.1 The TOP contractor
shall accomplish double coverage review on TOP claims
require
double coverage review as outlined in the TRM,
Chapter
4.
10.2 BeneficiaryThe
TOP contractor shall coordinate beneficiary/provider
disagreements regarding the contractor’s determination shall
be coordinated through the overseas TOP office Office for
resolution with the contractor.
10.3 Overseas
insurance plans such as German Statutory Health Insurance, Japanese
National Insurance (JNI), and Australian Medicare, etc., are considered
OHI. National Health Insurance (NHI) plans do not always provide EOBs
to assist in the adjudication of TRICARE claims. If a beneficiary
has attempted unsuccessfully to obtain an EOB from their NHI plan,
they may submit a beneficiary attestation and an itemized claim
checklist (approved by DHA) with their claim. The TOP contractor
shall waive the requirement for an EOB from the NHI plan when accompanied by
the DHA-approved document. If the TOP contractor has validated and
documented the NHI does not provide coverage for something that
is a TRICARE benefit (e.g. breast pumps), the TOP contractor shall
waive the requirement for an EOB from the NHI plan.
Note: If the Japanese insurance points
are not clearly indicated on the claim/bill, the TOP contractor
shall contact the submitter or the appropriate TOP POC for assistance
in determining the Japanese insurance points prior to processing
the claim.
11.0 THIRD
PARTY LIABILITY (TPL)
The TOP
contractor shall reimburse TOP claims suspected of TPL and then
develop for TPL information. Upon receipt of the information, the
contractor shall refer claims/documentation to the appropriate Judge
Advocate General (JAG) office, as outlined in the
Chapter
10.
12.0 REIMBURSEMENT/PAYMENT
OF OVERSEAS CLAIMS
When processing
TOP claims, the TOP contractor shall follow the reimbursement payment
guidelines outlined in the TRM,
Chapter 1, Section 34 and the cost-sharing
and deductible policies outlined in the TRM,
Chapter 2, Section 1, and shall:
12.1 Reimburse
claims for purchased care private sector care services/charges
for care rendered to TOP eligible beneficiaries which is generally
considered purchased care private sector care practice
and incidental to covered services, but which would not typically
be covered under TRICARE. An example of such services may be, charges
from purchased care private sector care ambulance
companies for driving purchased care private sector care physicians
to accidents or private residences, or the manner in which services
are rendered and considered the standard of care in a purchased
care private sector care country,
such as rehabilitation services received in an inpatient setting.
12.2 Reimburse
claims at the lesser of the billed amount, the negotiated reimbursement
rate, the CHAMPUS Maximum Allowable Charge (CMAC), or the Government
established fee schedules (when applicable) (TRM,
Chapter 1, Sections 34 and
35), unless a different reimbursement
rate has been established as described in TPM,
Chapter 12, Section 1.3.
Note: Government established fee
schedules (per TRM,
Chapter 1, Sections 34 and
35 are only applicable to retirees or their
eligible family or TRICARE Select ADFMs.
12.3 Not reimburse
for purchased care private sector care/services
specifically excluded under TRICARE.
12.4 Not reimburse
for
purchased care private sector
care/services
provided in the Philippines unless all of the certification requirements
listed in
Section 14 have been met.
12.5 Not reimburse
for administrative charges billed separately on claims, except for
individual administrative charges as determined by the Government.
The TOP contractor shall reimburse these
charges only in instances when the fee is billed concurrently with
the corresponding health care services. If a bill is received for
these charges without a corresponding health care service, the TOP
contractor shall deny the charges shall
be denied.
12.6 DetermineThe
TOP contractor shall determine exchange rates as follows:
12.6.1 Use the exchange rate in effect
on the ending date that services were received unless evidence of
OHI and then the TOP contractor shall use the exchange rate of the
primary insurer, not the rate based on the last date of service
to determine the TOP payment amount, and/or;
12.6.2 Use the ending dates of the
last service to determine exchange rates for multiple services.
12.6.3 Use the exchange rate in
paragraph 12.6.1 to determine deductible and
copayment amounts, if applicable, and to determine the amount to
be paid in foreign currency.
12.6.4 Overseas drafts/checks and EOBs.
Upon completion of processing, the TOP contractor
shall create checks (payable in US dollars). The TOP contractor
shall do this within 48 hours after approval by DHA Contract Resource
Management (CRM). Drafts The
TOP contractor shall create drafts (payable in foreign
currency units) shall be created by the TOP contractor within
96 hours following CRM approval, unless a different process has
been authorized by DHA. Payments The
TOP contractor shall calculate payments that need to
be converted to a foreign currency shall be calculated based
on the exchange rate in effect on the last date of service listed
on the EOB. Drafts The TOP
contractor shall match drafts/checks shall
be matched with the appropriate EOB, and mailed them to
the beneficiary/sponsor/ purchased care private sector care provider/POC
as applicable.
Note: Drafts for certain foreign
currency units may require purchase from a bank location other than
the one normally used by the TOP contractor (out of state or out
of country). Currency units that must be purchased from an alternate
bank (out of state or out of country) may take up to 10 business
days for the draft to be returned and matched up with the EOB.
12.7 Convert
lump sum payments, instead of line items, to minimize conversion
problems.
12.8 Pay provider claims for all overseas
locations in the country’s local currency as identified on the claim
for the specific country by foreign currency/drafts. Drafts
may not be changed The TOP contractor
shall not change drafts to a US dollar check after the
contractor has issued issuing a
foreign draft.
12.9 Know that foreign overseas drafts
(in local currency) are good for 190 calendar days and may be cashed
at any time, unless a different process has been established by
DHA. US dollar checks are good for 120 calendar days unless a different
process has been established by DHA. The
provisions
of TOP contractor shall meet Chapter 3, Section 4 requirements regarding
stale dated, voided, or returned checks/Electronic Funds Transfers
(EFTs)
are applicable to the TOP.
12.10 Pay TOP
claims submitted by a beneficiary in US dollars, unless there is
a beneficiary request on the claim at the time of submission for
payment in a foreign currency. The TOP contractor shall reissue
the payment in US dollars if a request is subsequently received
from the beneficiary and the foreign draft is included in the request
or the payment has stale dated, or if directed by the appropriate
DHA COR.
12.11 Payment shall be
madeMake payment in local
currency.
12.12 Issue drafts/checks for German
claims which look like German drafts/checks.
Note: In order for TRICARE drafts/checks
to look like German drafts/checks, the TOP contractor
shall use a German address must be used.
The TOP contractor shall use a corporate address in Germany or the
TAO Eurasia-Africa address for this purpose.
12.13 The
contractor shall payPay all
beneficiary-submitted claims for TRICARE covered drugs dispensed
by a US embassy health clinic to the beneficiary. The TOP contractor is shall not to make
payments directly to the embassy health clinic.
12.14 Know that
professional services rendered by a US embassy health clinic are
not covered by TRICARE/TOP. These services are covered under International
Cooperative Administrative Support Services (ICASS) agreements. Embassy
providers (acting as PCMs) may refer TOP enrollees to purchased
care private sector care providers,.
The TOP contractor shall process these claims shall
be processed per TOP policy and procedures.
12.15 Reimburse
claims for drugs or diagnostic/ancillary services purchased overseas
following applicable deductible/cost-share policies.
12.16 InWaive,
in emergency situations, the requirement for Medicare
certification for facilities in US commonwealths and territories
may
be waived. After a review of the facts, the
TOP contractor
shall cost-share otherwise covered services or supplies rendered
in an emergency situation by an unauthorized provider to the beneficiary,
or on behalf of the beneficiary, to the beneficiary’s appointed
payee, guardian, or parent in accordance with TPM,
Chapter 11, Section 4.2 and TRM,
Chapter 1, Section 29.
12.17 The
contractor shall mailMail the
drafts/checks and EOBs to purchased care private sector care providers unless
the claim indicates payment should be made to the beneficiary. In
conformity with banking requirements, the TOP contractor
shall ensure drafts/checks shall contain
the contractor’s address. Drafts The
TOP contractor shall mail drafts and EOBs shall
be mailed using US postage. Additionally, the
TOP contractor shall make payments/checks may
be made to network providers, with an Embassy address.
12.18 Mail benefit
payment checks and EOBs to Philippine providers, and other nations’
providers as directed by the DHA CO, to the place of service identified
on the claim. No The TOP
contractor shall not send provider checks or EOBs for
Philippine providers, and other nations’ providers as directed by
the DHA CO may be sent to any other address.
12.19 Process/pay
inpatient and outpatient claims for TRICARE overseas eligible beneficiaries,
including
Service member ADSM claims,
as indicated below:
12.19.1 The TPharm contractor shall allow
TOP
Service members ADSMs to
use the TPharm retail pharmacy network under the same contract requirements
as other Military Health System (MHS) eligible beneficiaries (see TPM,
Chapter 8, Section 9.1).
12.19.2 The TPharm contractor shall
allow TOP enrolled ADFM beneficiaries to use their stateside retail pharmacy
network under the same contract requirements as other MHS eligibles
(see TPM,
Chapter 8, Section 9.1).
12.19.3 The TOP contractor shall process
claims for overseas health care received by TRICARE beneficiaries enrolled
to or residing in a stateside contractor’s region following the
guidelines outlined in this chapter. Payment shall
be made The TOP contractor shall make
payment from applicable bank accounts and shall be based payment on
billed charges unless a lower reimbursement rate has been established
by the Government or the contractor.
12.20 EFT
payments. Upon purchased care private sector care provider
request, the TRICARE Overseas health care support
contractor shall provide EFT payment to a US or overseas
bank on a weekly basis. Bank charges incurred by the provider for
EFT payment shall be the responsibility of the provider. Upon beneficiary
request, the TOP contractor shall provide EFT
payments to a US bank may be provided.
Bank charges associated with beneficiary EFT payments shall
be are the beneficiary’s responsibility of
the beneficiary.
12.21 The
TOP contractor shall processProcess 90%
of all retained and adjustment TOP claims to completion within 30
calendar days from the date of receipt. Claims pended per Government
direction are excluded from this standard. However, the TOP
contractor shall report the number of excluded claims shall
be reported on the designated DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract. One hundred percent ( The
TOP contractor shall process 100%) of
all claims (both retained and excluded, including adjustments) shall
be processed to completion within 90 calendar days
from the date of receipt, unless the CO specifically directs the
contractor to continue pending a claim or group of claims.
12.22 Exclude
correspondence pended due to stop payment orders, check tracers
on foreign banks, and conversion on currency from the routine 45
calendar day correspondence standard and the priority 10 calendar day
correspondence standard. However, the TOP contractor
shall report the number of excluded routine and priority
correspondence must be reported on
the designated DD Form 1423, CDRL, located in Section J of the applicable
contract.
12.23 The TOP contractor
shall payPay Value Added Tax
(VAT) included on German health care claims for all beneficiary
categories.
12.24 Reimburse fees for transplant
donor searches in Germany on a global flat fee basis since the German Government
does not permit health care facilities to itemize such charges.
12.25 Reimburse
itemized fees for supplies that are related or incidental to inpatient
treatment (e.g., hospital gowns) if similar supplies would be covered
under reimbursement methodologies used within the US. The
TOP contractor shall implement internal management controls to ensure
that payments are reasonable and customary for the location.
13.0 CLAIMS
ADJUSTMENT AND RECOUPMENT
13.1 The TOP contractor shall follow
the adjustment requirements in
Chapter
10 except for the requirements related to financially
underwritten funds.
13.2 The TOP contractor shall follow
the recoupment requirements in
Chapter
10 for non-financially underwritten funds, except for
providers.
The contractor shall use the following
procedures for purchased care sector provider recoupments. Recoupment The
TOP contractor shall conduct recoupment actions
shall
be conducted in a manner that is considered culturally
appropriate for the
purchased care private sector
care provider’s
country. The contractor shall:
• Send an initial demand letter;
• Send a second demand letter
at 90 calendar days;
• Send a final demand letter
at 120 calendar days; and
• Refer the case to DHA at 240
calendar days, if the case is over $600.,
and if If the case is under
$600, the TOP contractor shall
keep the case shall remain open
for an additional four months and then the
TOP contractor shall be written write off
at 360 calendar days.
13.3 RecoupmentThe
TOP contractor shall modify recoupment letters (i.e.,
the initial letter, the 90 calendar day second request and the 120
calendar day final demand letter) shall be modified to
delete references to US law. Invoice The
TOP contractor shall provide invoice numbers shall
be provided on all recoupment letters. The TOP contractor
shall include language in the recoupment letter requesting that
refunds be returned/provided in the exact amount requested.
13.4 ProviderThe
TOP contractor shall write provider recoupment letters
sent to Germany, Italy, Spain, Japan, and Korea, shall
be written in the respective language.
13.5 If the recoupment
action is the result of an inappropriately processed claim by the
TOP contractor, recoupment is the responsibility of the TOP contractor shall
recoup, not the beneficiary/provider.
13.6 The TOP
contractor shall have a TOP bank account capable of receiving/accepting
wire transfers for purchased care private sector care provider
recoupment/overpayment returns. The TOP contractor shall accept
the amount received as payment against the amount owed. Any fees
associated with the wire transfer are the responsibility of the
payer/provider.