2.1 ADSMs
who are enrolled in TOP Prime shall follow the procedures outlined
in Chapter 17 for MTF-enrolled ADSMs, except the TOP contractor
shall replace references to the Defense Health Agency-Great Lakes (DHA-GL)
with references to the appropriate regional TRICARE Area Office
(TAO) in all overseas locations except the US Virgin Islands concerning
Line of Duty Determinations and except for care delivered under
the National Department of Defense (DoD)/Department of Veteran Affairs/Veterans
Health Administration (DVA/VHA) Memorandum of Agreement (MOA) authorization
requirements. See
paragraph 2.4.3 for National DoD/DVA/VHA MOA
authorization requirements. ADSMs who are enrolled in TOP Prime
Remote must seek authorization from the TOP contractor for all non-emergent
specialty and inpatient care. ADSMs not enrolled in TOP and who
are on Temporary Additional Duty/Temporary Duty (TAD/TDY), deployed,
deployed on liberty, or in an authorized leave status outside the
50 US and the District of Columbia will follow referral/authorization
guidelines for TOP Prime Remote enrollees.
2.2 The TOP contractor shall ensure
a benefit review is done on each SHCP referral and authorization.
The TOP contractor shall return deferred-to-network referrals for
non-covered services with an explanation of why it was denied. The
TOP contractor shall not issue an authorization unless they obtain
a copy of an approved waiver. The TOP contractor shall deny all
claims for TRICARE non-covered health care services. (Reference
Health Affairs (HA) Policy 12-002 “Use of Supplemental Health Care
Program Funds for Non-Covered TRICARE Health Care Services and the
Waiver Process for Active Duty Service Members”).
2.2.1 If the TOP contractor determines
that the requested service, supply, or equipment is not covered
by TRICARE policy and no Defense Health Agency (DHA)-approved waiver
is provided, the TOP contractor shall decline to file an authorization
and shall deny any received claims accordingly. If the request was
received as an MTF referral, the TOP contractor shall notify the
MTF (and enrolled MTF if it is different from the submitting MTF)
of the declined authorization with explanation of the reason. If
the request was received as a referral from a civilian provider
(for a remote ADSM/non-enrolled ADSM), the TOP contractor shall
notify the civilian provider and the remote ADSM/non-enrolled ADSM
of the declined authorization with explanation of the reason. The
TOP contractor shall ensure the notification to the civilian provider
and the remote ADSM/non-enrolled ADSM explains the waiver process
and provide contact information for the applicable Uniformed Services
Headquarters Point of Contact (POC)/Service Project Officers as
listed in
Chapter 17, Addendum A. No notification to
the Specified Authorization Staff (SAS) is required.
2.2.2 The TOP contractor shall not
extend TRICARE benefits for complications resulting from non-covered surgeries
and treatments performed outside the MTF for an ADSM without an
approved waiver. If the treatment is a non-covered TRICARE benefit,
TRICARE will not cover any follow-on care, including care for complications,
once the ADSM separates from active duty or retires (
32 CFR 199.4(e)(9); TPM,
Chapter 4, Sections 1.1 and
1.2). The Uniformed Services will provide
appropriate counseling that such follow-on care is the member’s
personal financial responsibility upon separation or retirement.
2.3 The provisions of
Chapter
17 are changed for the TOP contract as follows:
2.3.1 The provisions of
Chapter 17, Section 2, paragraph 2.0 are not
applicable to the TOP contract. USFHP services are not available
outside the 50 US and the District of Columbia.
2.3.2 Except for the claims for ADSM
care provided under the National DoD/DVA/VHA MOA, the contractor shall
apply the provisions of
Chapter 17, Section 3, paragraph 1.2.1. The
TOP contractor shall process and pay ADSM claims for covered benefits
submitted to the TOP contractor for which an authorization is not
on file as if an authorization is on file. The TOP contractor shall
deny claims for non-covered services. The TOP contractor shall provide
the MTF with a report (details for reporting are identified in DD
Form 1423, Contract Data Requirements List (CDRL) located in Section
J of the applicable contract) for all claims processed and paid
with no authorization and all denied claims for non-covered services.
2.3.3 The TOP
contractor shall apply the provisions of
Chapter 17, Section 2, paragraph 3.2 regarding
claims for care provided under the National DoD/DVA/VHA MOA for
Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,
and Polytrauma and shall process these claims in accordance with
Chapter 17, Section 2, paragraph 3.2. DHA-GL
will authorize the ADSM care under this MOA.
2.3.4 The TOP contractor shall apply
the provisions of
Section 6, paragraph 5.0 and
Chapter
8 Chapter 7, Section 5 to
TOP SHCP referrals.
Additionally, when MTFs submit
a referral request for private care services for a non-AD sub-population
beneficiary eligible for SHCP, the MTF will annotate the referral
with “SHCP”. This will ensure that SHCP
claims for eligible non-AD sub-population beneficiaries are properly
adjudicated.
Note: The TOP contractor shall use
supplemental funds to reimburse for care rendered by non-Governmental health
care providers to non-active duty patients when an MTF provider
orders the needed health care services from civilian sources for
a beneficiary, and the MTF provider maintains full clinical responsibility
for the episode of care. This means that the patient is not disengaged
from the MTF that is providing the care. See
Chapter 17, Section 1, paragraph 1.1.
2.4 When an ADSM leaves a remote
TOP assignment as a result of Permanent Change of Station (PCS)
or other service-related change of duty status, the TOP contractor
shall:
2.4.1 For ADSMs leaving remote TOP
assignment in Puerto Rico, the TOP contractor shall require the
PCM to provide a complete copy of medical records, to include copies
of specialty and ancillary care documentation, to ADSMs within 30
calendar days of the ADSM’s request for the records. The ADSM may
also request copies of medical care documentation (specialty care
visits and discharge summaries) on an ongoing, Episode of Care (EOC) basis.
2.4.2 ADSMs leaving remote TOP assignments
from all overseas areas other than Puerto Rico, should request medical
records from the private sector care provider(s) who provided health
care services during the ADSM’s tour of duty. These ADSMs may also
request copies of medical care documentation (specialty care visits
and discharge summaries) on an ongoing, EOC basis.
2.4.3 Private
sector care providers with records in languages other than English
may submit those to the TOP contractor for translation into English
according to the terms of the contract.
2.4.4 The TOP contractor shall reimburse
network private sector care providers for medical records photocopying
and postage costs incurred at the rates established in their network
provider participation agreements. The TOP contractor shall reimburse
non-network private sector care providers for medical records photocopying
and postage costs on the basis of billed charges unless the Government
has directed a lower reimbursement rate. The TOP contractor shall
reimburse ADSMs, who have paid for copied records and applicable postage
costs, for the full amount paid to ensure they have no out-of-pocket
expenses. The TOP contractor shall require all providers and/or
ADSMs to submit a claim form, with the charges clearly identified,
to the contractor for reimbursement.
Note: The purpose of copying medical
records is to assist the ADSM in maintaining accurate and current medical
documentation. The contractor shall not reimburse a private sector
care provider who photocopies medical records to support the adjudication
of a claim.
2.4.5 The provisions
of
Chapter 17, Section 3, paragraph 1.1.8 are
not applicable to the TOP. The TOP contractor shall not use SHCP
funds to pay for overseas private sector care for foreign military
members or their families. The TOP contractor shall deny any MTF
referrals and claims for such care.
2.5 Provision of Respite Care For
The Benefit of Seriously Ill or Injured Active Duty Members
2.5.1 The TOP contractor shall apply
provisions of
Chapter 17, Section 3 and the TRICARE Systems
Manual (TSM),
Chapter 2, Section 2.8 and
6.4 regarding respite care for seriously ill
or injured ADSMs in locations outside the 50 US and the District
of Columbia where TRICARE-authorized Home Health Agencies (HHAs)
have been established.
2.5.2 The TOP
contractor shall cover respite care for ADSMs enrolled to TOP Prime,
TOP Prime Remote, and to any ADSM referred by an overseas MTF or
TAO.
2.5.3 The TOP
contractor shall apply all normal ADSM authorization and case management
requirements ADSM respite care benefit.