2.0 JURISDICTION
2.1 In
the early stages of TOP claims review, the TOP contractor shall
determine whether claims received are within its contractual jurisdiction
using the criteria below.
2.2 Services
rendered onboard a commercial ship while outside U.S. territorial
waters are the responsibility of the TOP contractor. Claims for
services provided on a commercial ship that is outside the territorial
waters of the U.S. shall be processed as foreign claims regardless
of the provider’s home address. If the provider is certified within
the U.S., reimbursement for the claim is to be based on the provider’s
home address. If the provider is not certified within the U.S.,
reimbursement will follow the procedures for foreign claims. This
does not include health care for enrolled Service members on a 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Chapter 8, Section 2, paragraphs 1.0 and 2.0 are Chapter 8, Section 2, paragraph 1.0 is superseded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/authorization
rules apply.
2.3.2 Claims for Active Duty Family
Members (ADFMs) (including Reserve Component (RC) ADFMs whose sponsors
have been activated for more than 30 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 U.S. 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/authorization and Point Of Service (POS)
rules apply for TRICARE Prime/TRICARE Prime Remote (TPR) enrollees.
Note: This provision does not apply
to beneficiaries who are enrolled in the Uniformed Services Family
Health Plan (USFHP) or the Continued Health Care Benefit Program
(CHCBP). Claims for these beneficiaries are processed by their respective
contractor regardless of where the care is rendered.
2.3.3 Claims for Service members
residing in the 50 U.S. and the District of Columbia (including RC
Service members activated for more than 30 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 resides or is enrolled. Claims for Active Duty Service
Members (ADSMs) shall be processed in accordance with
Section 25.
2.3.4 Claims
for TOP-enrolled Service members (including RC Service members activated
for more than 30 days) on a military ship or with an overseas home
port shall not be processed by the member’s military unit. These
claims shall be processed by the TOP contractor.
2.3.5 Initial and follow-on Line
Of Duty (LOD) claims for RC Service members on orders for 30 consecutive
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 U.S. 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.
2.7 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.
2.8 The provisions of
Chapter 8, Section 2, paragraph 4.0 are applicable
to the TOP in those locations where the TRICARE Pharmacy (TPharm)
contractor has established services (the U.S. territories of Puerto
Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern
Mariana Islands). The TOP contractor cannot 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.
2.9 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 contractor shall process claims
from purchased care sector retail pharmacies and providers.
2.10 ADFMs with TRICARE Select and
retirees or their family members residing overseas obtaining prescription
from an overseas purchased care sector pharmacy shall submit their
claims to the TOP contractor. For cost-share/deductible provisions,
see TRM,
Chapter 2 regarding
the mandatory collection of pharmacy copayment amounts at the time
of service are waived for foreign providers.
5.0 REFERRALS/PREAUTHORIZATIONS/AUTHORIZATIONS
The provisions of
Chapter 8, Section 5 are altered for the TOP
by the requirements listed below.
5.1 Referral/Preauthorization/Authorization
Requirements for TOP Prime and TOP Prime Remote Enrollees
5.1.1 Unless otherwise directed by
the Government, 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,
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. TOP Prime/TOP Prime Remote ADFMs will also
require preauthorization for treatment of SUDs as outlined in the
TPM,
Chapter 7, Section 3.5 and for the treatment
of mental disorders as outlined in the TPM,
Chapter 7, Section 3.8. 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 Claims for ADSMs shall be processed
in accordance with
Section 25. While authorizations are required
for ADSM care, for administrative reasons, the 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
a 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 25 for additional information.
5.1.3 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 Remote typically do not need to obtain preauthorization/authorization
for care. However, preauthorization reviews shall be performed for
all care and procedures listed in
Chapter 7, Section 2.
The TOP contractor may propose additional authorization reviews
for non-enrolled TOP beneficiaries to the 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 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, 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. POS provisions also apply
to the following stateside beneficiaries when traveling overseas:
ADFMs, retirees, and retiree family members who are enrolled in TRICARE
Prime, and ADFMs enrolled in TPR for ADFMs.
5.2.2 POS cost-sharing only applies
to TRICARE-covered services. 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 contractor processes a claim under
the POS option because there was no evidence of a referral and/or an
authorization, and the contractor later verifies that the PCM or
other appropriate provider referred the beneficiary for the care,
the contractor shall adjust the claim and reverse the POS charges.
The contractor need not identify past claims that may be eligible
for POS adjustment; however, the 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 Executive Director
or Military Medical Treatment Facility (MTF) Director may require
an enrolled beneficiary to transfer to a TOP network facility or
an MTF. The TAO Executive Director or MTF Director shall 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, POS cost-sharing
provisions will apply beginning 24 hours following the receipt of
the written notice. Neither the TAO Executive Director nor the MTF Director will
require a transfer until such time as the transfer is deemed medically
safe.
5.2.5 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 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).
• 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.
• 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 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 of OHI claims
processing (including the exact amount paid on the claim) must be
submitted with the TOP claim.
5.2.7 EOB shall
clearly indicate that a claim has been processed under the POS Option.
5.2.8 POS is not applicable to Service
members or to TRICARE Select.
5.3 Extended
Care Health Option (ECHO) benefits in overseas locations must be
authorized by the TOP contractor. Refer to
Section 22 and
the TPM,
Chapter 9 for
additional guidance.
6.0 CLAIM DEVELOPMENT
6.1 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 may return the claims to sender with a letter which
indicates that the claims are being returned, the reason for return
and requesting 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, claims requiring development of missing or discrepant
information, or those being developed for medical documentation,
shall be pended for 90 days and are excluded from the claims processing
standard.
6.2 Claims may be filed by eligible
TRICARE beneficiaries, purchased care sector providers, TOP POCs,
and TRICARE authorized providers in the 50 U.S. and the District
of Columbia as allowed under TRICARE (see
Chapter 8, Section 1).
6.3 Confidentiality requirements
for TOP are identical to TRICARE requirements outlined in
Chapter 8.
6.5 The following minimal information
is required on each overseas claim prior to payment:
6.5.1 Signatures
Beneficiary and purchased care
sector 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 sector provider name and address.
6.5.2.2 If an address is not available
on the claim, obtain the address either from previously submitted
claims, directly from the beneficiary/purchased care sector provider
via phone, fax, or e-mail, 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)/supply/DME ordered, performed or prescribed,
including the date ordered performed or prescribed. The TOP contractor
may 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 Claims received with a narrative
description of services provided shall be coded by the TOP contractor
with as accurate-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 visits which include
multiple services shall be coded accurately and not bundled when
the description of services are available. 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
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
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 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 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:
• Cancelled 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:
• Cancelled 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 saying
s/he 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 Non-prescription (Over-The-Counter
(OTC)) drugs are to be denied. This includes drugs that are considered
OTC by U.S. 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 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 U.S. standards.
6.9 For the
Philippines, 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 28 apply.
Note: This does not apply to Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
6.10 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 sector providers when the DHA CO has directed contractor
certification/confirmation of the purchased care sector provider
prior to payment.
6.13 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 missing information is required
to process the claim and includes the contractor’s 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 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 sector
designated or non-designated overseas purchased care sector provider
without preauthorization/authorization. Upon receipt of a claim
for a TOP-enrolled ADFM submitted by a purchased care sector designated
or non-designated overseas purchased care sector provider without
preauthorization/authorization, the contractor shall process the
claims following POS payment procedures. For Service member claims
submitted by a purchased care sector provider without preauthorization/authorization,
the contractor shall process the claim if services are covered by
TRICARE. If services are non-covered services and no authorization
is on file, the claim shall be denied. Refer to
Section 25 for
more information on ADSM pended claims.
6.17 The TOP
contractor must have an automated data system for eligibility, deductible
and claims history data and must 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
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 may 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 stateside claims as outlined in
Section 25.
6.20 All claims
shall be submitted in a Health Insurance Portability and Accountability
Act (HIPAA) compliant format. Refer to
Section 27 for
more information on HIPAA requirements.
6.21 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 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 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 Executive Director shall 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, Sections 3 and
4).
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.
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 letterhead on all TOP EOBs
shall also reflect “TRICARE Overseas Program” and shall be annotated
Prime or TRICARE Select.
8.2 TOP EOBs may be issued on regular
stock, shall provide a message indicating the exchange rate used
to determine payment and shall clearly indicate that “This is not
a bill”.
8.3 TOP EOBs
shall include the toll-free number for beneficiary and provider
assistance.
8.4 TOP EOBs
for overseas enrolled Service member claims shall be annotated “ACTIVE
DUTY.”
8.5 For Point
of Sale or Vendor pharmacy overseas claims, TOP EOBs shall have
the name of the provider of service on the claim.
8.6 For beneficiary submitted pharmacy
claims, TOP EOBs shall contain the name of the provider of service,
if the information is available. If the information is not available,
the 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 sector providers who are required to be certified, but have
not been certified by the TOP contractor, “Your provider has not
submitted documentation required to validate his/her training and/or
licensure for designation as an authorized TRICARE provider”. 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 check
shall be voided.
8.10 The TOP
contractor may utilize secure electronic EOB delivery to beneficiaries
unless mail delivery has been requested by the beneficiary or has
not signed up for electronic delivery.
8.11 The contractor may issue monthly
summary EOBs to beneficiaries on claims when there is no beneficiary
liability. The processing date of the oldest claim for the summary
EOB shall not be greater than 31 calendar days.
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 sector services/charges for care rendered to TOP eligible beneficiaries
which is generally considered purchased care sector 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 sector ambulance companies for driving purchased
care sector physicians to accidents or private residences, or the
manner in which services are rendered and considered the standard
of care in a purchased care sector 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 members or TRICARE Select ADFMs.
12.3 Not reimburse for purchased
care sector care/services specifically excluded under TRICARE.
12.4 Not reimburse for purchased
care sector care/services provided in the Philippines unless all
of the certification requirements listed in
Section 13 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 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
charges shall be denied.
12.6 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 contractor shall create
checks (payable in U.S. dollars). The TOP contractor shall do this
within 48 hours after approval by DHA Contract Resource Management
(CRM). 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 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/checks shall be matched with the appropriate
EOB, and mailed to the beneficiary/sponsor/purchased care sector 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 to a U.S. dollar check after the contractor
has issued a foreign draft.
12.9 Know that
foreign overseas drafts (in local currency) are good for 190 days
and may be cashed at any time, unless a different process has been
established by DHA. U.S. dollar checks are good for 120 days unless
a different process has been established by DHA. The provisions
of
Chapter 3, Section 4 regarding staledated,
voided, or returned checks/Electronic Funds Transfers (EFTs) are
applicable to the TOP.
12.10 Pay
TOP claims submitted by a beneficiary in U.S. dollars, unless there
is a beneficiary request on the claim at the time of submission
for payment in a foreign currency. The TOP contractor may reissue
the payment in U.S. dollars if a request is subsequently received
from the beneficiary and the foreign draft is included in the request
or the payment has staledated, or if directed by the appropriate DHA
COR.
12.11 Payment shall be made 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, a German address must be used.
The TOP contractor may use a corporate address in Germany or the
TAO Eurasia-Africa address for this purpose.
12.13 The contractor shall pay all
beneficiary-submitted claims for TRICARE covered drugs dispensed by
a U.S. embassy health clinic to the beneficiary. The contractor
is not to make payments directly to the embassy health clinic.
12.14 Know that professional services
rendered by a U.S. 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 sector providers,
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 In emergency situations, the
requirement for Medicare certification for facilities in U.S. commonwealths
and territories may be waived. After a review of the facts, the
contractor may 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 mail the
drafts/checks and EOBs to purchased care sector providers unless the
claim indicates payment should be made to the beneficiary. In conformity
with banking requirements, the drafts/checks shall contain the contractor’s
address. Drafts and EOBs shall be mailed using U.S. postage. Additionally,
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 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 claims, as indicated below:
12.19.1 The TPharm contractor shall
allow TOP Service members 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 from
applicable bank accounts and shall be based on billed charges unless
a lower reimbursement rate has been established by the Government
or the contractor.
12.20 EFT payments. Upon purchased
care sector provider request, the TRICARE Overseas health care support
contractor shall provide EFT payment to a U.S. 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, EFT payments to a U.S. bank may be provided. Bank charges
associated with beneficiary EFT payments shall be the responsibility
of the beneficiary.
12.21 The TOP contractor shall process
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 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 (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 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 pay
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 U.S. 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 actions shall be conducted
in a manner that is considered culturally appropriate for the purchased
care sector provider’s country. The contractor shall:
• Send an initial demand letter;
• Send a second demand letter
at 90 days;
• Send a final demand letter
at 120 days; and
• Refer the case to DHA at 240
days, if the case is over $600, and if under $600 the case shall
remain open for an additional four months and then shall be written
off at 360 days.
13.3 Recoupment
letters (i.e., the initial letter, the 90 day second request and
the 120 day final demand letter) shall be modified to delete references
to U.S. law. 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 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 contractor, not the beneficiary/provider.
13.6 The TOP contractor shall have
a TOP bank account capable of receiving/accepting wire transfers
for purchased care sector 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.