1.0 General
1.1 The TOP
program provides health care administration and claims processing
for individuals with dual eligibility under both Medicare and TRICARE
who receive care in locations where Medicare is not available. This includes
those beneficiaries eligible for TFL under the Medicare wraparound
coverage option of the TRICARE program made under 10 United States
Code (USC) 1086(d).
1.2 The provisions
of
Chapter 20 regarding
TFL are applicable to beneficiaries residing in locations where Medicare
is available. These areas include the 50 United States (US), the
District of Columbia, and the US territories of Puerto Rico, Guam,
the US Virgin Islands, American Samoa, and the Northern Mariana
Islands.
2.0 JURISDICTION
2.1 Dual eligible
beneficiaries are covered under TOP, based on their TRICARE plan
if they receive care in a location where Medicare is not available.
2.2 Dual eligible
beneficiaries residing in Puerto Rico, Guam, the US Virgin Islands,
American Samoa, and the Northern Mariana Islands are not covered
under TOP TFL. These beneficiaries receive TRICARE coverage under
the
TRICARE Dual Eligible Fiscal Intermediary Contract
(TDEFIC) TRICARE Medicare Eligible Program
(TMEP) according to the provisions of
Chapter
20.
2.3 ClaimsThe
TMEP contractor shall process claims for services rendered
on board a commercial ship are the responsibility
of the TDEFIC contractor if the care was rendered
in the territorial waters adjoining the land areas of the US.
The TOP contractor shall process claims for services
rendered on board ship while outside US territorial waters are
the responsibility of the TOP contractor.
3.0 CONTRACTOR
RESPONSIBILITIES
3.1 The TOP contractor shall provide
administration and claims processing services for the TOP TFL program.
3.2 TOP TFL
has the same cost-shares and deductibles as any other TFL claim.
TFL beneficiaries who are not enrolled in
TRICARE Prime
are covered under TRICARE Standard benefits, cost-shares, and deductibles
as if TRICARE Standard was still being implemented. See
the
TRICARE Reimbursement Manual (TRM
), Chapter 2, Sections 1 and
3.
3.3 All TOP TFL has the same requirements
for referrals or prior authorizations as TOP Select requirements regarding
provider certification apply.
3.4 The TOP
contractor shall not develop private sector care provider networks
to support the TOP TFL beneficiary population.
3.5 The TOP
contractor shall not provide health care on a cashless, claimless
basis for TOP TFL beneficiaries.
3.6 The TOP
contractor shall not make appointments with private sector care
providers for TOP TFL beneficiaries. However, upon beneficiary request,
the contractor shall provide the beneficiary with the name, telephone
number, and address of private sector care network or non-network
providers of the appropriate clinical specialty located within the
beneficiary’s geographic region.