1.0 General
1.1 TOP Prime
is available to Service members (including Reserve Component (RC)
members activated for more than 30 calendar days) who are on permanent
assignment overseas in a location serviced by a Military Medical
Treatment Facility (MTF), Command-Sponsored Active Duty Family Members
(ADFMs), accompanying the sponsor or on service orders, and certain
transitional survivors and Transitional Assistance Management Program (TAMP)-eligible
beneficiaries according to the eligibility and enrollment provisions
of
Section 5. TOP Prime offers enrollees access
to a Primary Care Manager (PCM), clinical preventative services,
and specialty services.
1.2 TOP Prime has no enrollment
fees, and deductibles. Cost-shares are waived except for TOP Prime
ADFMs who receive care under the Point of Service (POS) option,
or who obtain pharmacy services in the 50 United States (US), the
District of Columbia, or US territories where the TRICARE Pharmacy
(TPharm) contractor has established a retail pharmacy network. Waiver
of copayment and deductibles under TOP Prime is subject to review/updating based
on enrollment status.
1.3 Under TOP Prime, annual catastrophic
caps are calculated on calendar years. The enrollment year shall coincide
with the calendar year. Since deductibles and cost-shares are waived
for TOP Prime enrollees, this policy will apply only to TOP Prime
enrollees who incur out-of-pocket expenses.
2.0 CONTRACTOR RESPONSIBILITIES
2.1 TOP Prime enrollees shall select
or have assigned to them PCMs according to guidelines established
by the MTF
Commander Director,
TRICARE Area Office (TAO) Director, or designee. TOP Prime enrollment
to a private sector care PCM may only occur when all available capacity
in the MTF has been reached. The TOP PCM:
2.1.1 May be
an individual professional provider in an overseas MTF, other military
treatment site, or other health care delivery arrangement that is
part of the MTF. MTF PCMs may be organized into teams for the purpose
of ensuring patient continuity and accountability in the event that
the individual’s assigned PCM is absent or unavailable.
2.1.2 May be
a private sector care primary care provider (internist, family practitioner,
pediatrician, General Practitioner (GP), Obstetrician/Gynecologist
(OB/GYN), Physician Assistant (PA), Nurse Practitioner (NP), or
Certified Nurse Midwife (CNM) when determined by the TOP contractor
to meet governing country rules and licensure requirements. See
Section 2831 for
additional provider certification requirements in the Philippines.
2.1.3 May also
act as a Health Care Finder (HCF), when dual responsibility is necessary,
as determined by the MTF Commander Director or
TAO Director.
2.2 A TOP Prime enrollee must seek
all his or her primary health care from the TOP PCM with the exception
of care listed in
Section 8. If the TOP PCM is unable to provide
the care, the TOP PCM is responsible for referring the enrollee
to another primary care provider.
2.3 TOP Prime
enrollees must obtain appropriate referral/authorization for any
non-emergency care rendered by anyone other than the beneficiary’s
PCM or another MTF provider. This provision applies regardless of where
the care is rendered. MTFs may submit requests for retroactive authorizations
up to three business days after the care was rendered. After three
business days, the TAO Directors and/or Chief, TOP Office (TOPO)
may direct retroactive authorizations on a case-by-case basis. Routine
care is generally not authorized while a TOP Prime enrollee is traveling
out of their enrollment region; however, exceptions may be made
for unusual circumstances on a case-by-case basis with PCM referral
and appropriate written justification from the referring MTF. Emergent/urgent
care does not require prior authorization; however, the beneficiary
should contact their PCM and the TOP contractor as soon as possible
to arrange any necessary follow-up care.
2.4 Failure
to obtain a TOP PCM referral/authorization when one is required
for care may result in the service being paid under TOP Point of
Service (POS) procedures for an ADFM with a deductible and cost-shares
for outpatient services and cost-shares for inpatient services.
2.5 The TOP
PCM is responsible for notifying the TOP HCF that a referral is
being made/requested. The TOP HCF will assist the TOP Prime enrollee
and other beneficiaries in locating an MTF or private sector care
TOP network or non-network provider to provide the care, and to
assist in scheduling an appointment upon request. The HCF will conduct
a benefit determination review and provide authorization for service
for which the referral was made. If the contractor has no record
of referral/authorization, prior to denial/payment, the contractor
shall follow the TOP POS rules, assuming the service is a covered
benefit.
2.6 TOP MTF PCMs may be delegated
authority by the TOP MTF Commander Director to
authorize referrals within the MTF. All referrals/authorizations
to civilian private sector care providers and all referrals/authorization made
by a TOP designated private sector care PCM must be made through
the TOP HCF and must receive an authorization.
2.7 The TOP
contractor shall ensure that all authorized services for TOP Prime
enrollees are provided on a cashless, claimless basis. The contractor
shall implement guarantee of payment or other business arrangements
to ensure that TOP Prime enrollees are not required to pay up front
at the time services are rendered by a private sector care provider.
2.8 Cashless,
claimless provisions do not apply to self-referred care that would
normally require authorization.
2.9 In accordance
with the Statement of Responsibilities (SOR), MTFs will determine
if they have the capability and capacity to provide needed specialty
inpatient care. Submission of an MTF referral shall signify that the
referring MTF has determined that the care cannot be provided by
the direct care system within the TRICARE access standards. In Puerto
Rico, the local MTF must have the opportunity to review each referral
from a private sector care PCM to determine if the MTF has the capability
and capacity to provide the care. Specific language regarding this
process shall be incorporated into each SOR with all MTFs with Puerto
Rico.
2.10 For TOP Prime enrollees who
are traveling in the 50 US or the District of Columbia, the TOP
contractor and the TAO Directors will encourage/direct TOP beneficiaries
to utilize stateside MTFs and TRICARE network providers whenever
possible. If MTF care is unavailable, beneficiaries shall be provided
with information regarding the nearest available network provider(s)
who can assist the beneficiary. Non-network providers should only
be used when MTF or network care is not available.
2.11 ADFMs
enrolled in TOP Prime may obtain urgent care from any authorized
provider without a PCM (if assigned) referral or overseas contractor
authorization. In order to ensure the urgent care visit will be
cashless/claimless, the ADFMs enrolled to TOP Prime should contact
the TOP contractor to obtain an authorization. Without this authorization,
overseas providers may request payment upfront (overseas providers
may bill above the TRICARE allowable amount without any limits)
and the beneficiary will then have to submit a claim for reimbursement.
3.0 POS
OPTION
3.1 TOP Prime-enrolled ADFMs are
required to follow established referral/authorization procedures
prior to obtaining specialty care to avoid the application of POS
cost-shares and deductibles. This includes all self-referred, non-emergency
outpatient specialty medical services and all inpatient care (including
inpatient mental health care), except for outpatient mental health
and Substance Use Disorder (SUD) visits, ancillary services, and
drugs. TOP Prime ADFMs who self-refer to a civilian provider other
than their PCM shall have their claims processed as POS.
3.2 POS cost-shares
and deductibles shall not apply to claims for care received by newborns/adoptees during
the deemed enrollment period.
3.3 Self-referred,
non-emergency, non-urgent, specialty, or inpatient care provided
to a TOP Prime enrollee by a network or non-network private sector
care provider, which is not either provided/referred by the beneficiary’s PCM
or specifically authorized may be reimbursed only under the TOP
Prime POS option if it is a TRICARE benefit. Services which are
not a TRICARE benefit shall be denied.
3.4 POS cost-sharing
and deductible amounts do not apply if a TOP Prime enrollee has
Other Health Insurance (OHI) that provides primary coverage. The
OHI must be primary under the provisions of the TRICARE Reimbursement
Manual (TRM),
Chapter 4, Section 1, and documentation that
the other insurance processed the claim and the exact amount paid
must be submitted with the TOP claim.TRICARE OHI provisions apply
for this type of claim.
3.5 The POS option does not apply
to Service member overseas/stateside care.
3.6 The TOP
contractor shall adjust TOP Prime copayments when TOP PCMs or HCFs
do not follow established referral/authorization procedures. For
example, if the contractor processes a claim without evidence of an
authorization and/or a referral under POS provisions, and the contractor
later verifies that the PCM or other appropriate provider referred
the beneficiary for the care, the contractor shall adjust the claim
under TOP Prime provisions. The contractor need not identify past
claims, however, the contractor shall adjust these claims as they are
brought to their attention.
3.7 On a case-by-case
basis, following stabilization of the patient, the MTF Commander Director may
require a TOP Prime beneficiary to transfer to the MTF. The MTF Commander 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 TOP Prime-enrolled ADFM elects to remain in a non-network facility
following notification of an impending transfer to another facility,
TOP POS cost-sharing will begin 24 hours following receipt of the
written notice. The MTF Commander Director may
not require a transfer until such time as the transfer is deemed
medically safe.
3.8 See the TRM,
Chapter 2, Section 5 for the deductible and
cost-share amounts which apply to all TOP Prime POS claims for health
care services.
3.9 POS deductible and cost-sharing
do not apply to the claims for care received by certain newborn
and newly adopted children during the deemed enrollment period.
See
Section 5 for additional guidance regarding deemed
enrollment for newborns/adoptees.