1.0 General
1.1 The TOP
contractor shall apply all TRICARE requirements regarding claims
processing unless specifically changed, waived, or superseded by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 at any time to prevent or reduce fraud.
Note: The 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) to
the place of service identified on the claim. This policy applies
even if the provider uses a Third Party Administrator (TPA). The
TOP contractor shall not send provider payments 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 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 TOP contractor shall ensure
it’s claims processing procedures 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
jurisdiction for claims received.
2.2 The TOP
contractor shall process claims for services rendered on-board a
commercial ship while outside US territorial waters. The TOP contractor
shall process claims for services provided on a commercial ship
that is outside the territorial waters of the US 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 on the provider’s home address. If the provider is not certified
within the US, the TOP contractor shall reimburse following the
procedures for foreign claims. This does not include health care
for enrolled Active Duty Service 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. The TOP contractor shall apply referral/authorization
rules.
2.3.2 The 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,
regardless of where the beneficiary resides or is enrolled. The
TOP contractor shall apply referral/authorization and Point Of Service
(POS) rules for TRICARE Prime/TRICARE Prime Remote (TPR) enrollees.
Note: The TOP contractor shall not
process claims for beneficiaries enrolled in the Uniformed Services
Family Health Plan (USFHP) or the Continued Health Care Benefit
Program (CHCBP). The USFHP and CHCBP contractors process claims
for these beneficiaries regardless of where the care is rendered.
2.3.3 The TOP
contractor shall process claims for 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, regardless
of where the ADSM resides or is enrolled. The TOP contractor shall
process claims for ADSMs in accordance with
Section 25.
2.3.4 The 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. These
claims will not be processed by the member’s military
unit will not process these claims.
2.3.5 The 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, 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 6.1,
6.2,
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 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 shall not process pharmacy claims
from these locations except for pharmacy that is part of an emergency
room visit or inpatient treatment.
Any The
TOP contractor shall require prescriptions from this
care that are not provided at time of treatment for inpatient/emergency
care
, shall be submitted
through to the
TPharm contractor. 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 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 private sector care pharmacy
will submit their claims to the TOP contractor. 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 for foreign providers.
3.0 CLAIMS
FILING DEADLINE
The provisions
of
Chapter 8, Section 3 are applicable to the
TOP except the claims 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. Providers and beneficiaries
shall file all other claims 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.
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
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. The TOP contractor shall
require a referral for TOP Prime/TOP Prime Remote ADFMs 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 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 3.7,
paragraph 6.0. 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), regardless of where the care is rendered.
5.1.2 The TOP
contractor shall
process pend claims
for care in accordance with
Section 2526. 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
TOP contractor
shall enter the authorization and process the claim for payment.
If the
TOP contractor determines that the
care was not authorized, the
TOP contractor
shall deny the claim. Refer to
Section 2526 for
additional information.
5.1.3 The TOP contractor shall process
claims for self-referred, non-emergency, and non-urgent care for
TOP Prime and TPR enrolled ADFMs 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/TPR typically do not need to obtain preauthorization/authorization
for care. However, the TOP contractor shall perform preauthorization
reviews 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.
5.1.5 TRICARE beneficiaries whose health
care is normally provided under one regional Managed Care Support
Contractors (MCSCs) who require care while traveling in an overseas
location 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 under the POS option. This provision
applies regardless of where the care is rendered. The TOP contractor
shall apply POS provisions to the following stateside enrollees
when they are traveling overseas: ADFMs, retirees, retiree family
members enrolled in TRICARE Prime, and ADFMs enrolled in TPR for
ADFMs.
5.2.2 The TOP contractor shall apply
POS cost-sharing only to TRICARE-covered services. The TOP contractor shall
deny claims for services that are not a covered TRICARE benefit.
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 Director may require an enrolled beneficiary to transfer
to a TOP network facility or an MTF. The TAO Director or MTF 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 beginning
24 hours following the receipt of the written notice. Neither the
TOP Director nor the MTF 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 to all TOP POS claims for health care support services:
• Enrollment year deductible for
outpatient claims: $300 per individual; $600 per family. The TOP
contractor shall not apply a deductibles 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 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 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
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). The TOP contractor
shall submit evidence of OHI claims processing (including the exact amount
paid on the claim) with the TOP claim.
5.2.7 The contractor
shall ensure the EOB clearly indicates that a claim has been processed
under the POS Option.
5.2.8 The TOP contractor shall not
apply POS to 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 2223 and
the TPM,
Chapter 9 for
additional guidance.
5.4 Refer
to Section 10 for
referral/preauthorization/authorization requirements for ADSM dental
care in remote overseas locations.
6.0 CLAIM
DEVELOPMENT
6.1 The TOP contractor shall keep
development of missing information 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 TOP contractor
shall return the claim(s) to sender with a letter which indicates
that the claims are being returned, the reason for return and requests
the required missing documentation. The TOP 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 TOP 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, for 90 calendar
days. and These
claims are excluded them from
the claims processing standard.
6.2 The TOP
contractor shall allow claims to be filed by eligible TRICARE beneficiaries,
private sector care providers, TOP POCs, and TRICARE authorized
providers in the 50 US and the District of Columbia (see
Chapter 8, Section 1).
6.3 The TOP
contractor shall meet confidentiality requirements outlined in
Chapter
8.
6.5 The TOP
contractor shall require the following minimal information on each
overseas claim prior to payment:
6.5.1 Signatures
Beneficiary and 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 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/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)
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.
6.5.4 Procedures/Services/Supply/DME
The TOP contractor shall identify
the procedure(s)/service(s)/supplies/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 The TOP
contractor shall code claims received with a narrative description
of services provided as accurately 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 The
TOP contractor shall ensure all surgical procedures
must be coded accurately based on the level of detailed description. Outpatient
professional services
shall be are coded
accurately. The TOP contractor shall code office visits which include
multiple services accurately and the TOP contractor shall not bundle
when the description of services are available. The TOP contractor
shall apply the provisions of
paragraph 6.1 for narrative claims that cannot
be accurately coded due to insufficient or vague information.
6.5.5.1 Inpatient
Institutional Procedures
The 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, using
ICD-10-Procedure Classification System (ICD-10-PCS) procedure codes.
6.5.5.2 Outpatient
Institutional Procedures and Professional Services
The 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
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 The TOP
contractor shall require proof of payment 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 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 beneficiary
saying they has paid the bill;
• 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 The TOP
contractor shall deny claims for non-prescription (Over-The-Counter
(OTC)) drugs. 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 The TOP
contractor shall cost-share claims for medications prescribed by
a host-nation physician, and commonly used in the host-nation country,
unless they are considered OTC by US standards.
6.9 For the
Philippines, the TOP contractor shall only cost-share prescription
drugs 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 2831 apply.
Note: This does not apply to Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
6.10 The TOP
contractor shall develop claims for DME involving lease/purchase
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 private sector care providers when
the DHA CO has directed contractor certification/confirmation of
the private sector care provider prior to payment.
6.13 The TOP
contractor shall send requests for missing information 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 the missing
information is required to process the claim and includes the contractor’s
return address.
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 private sector care
designated or non-designated overseas private sector care provider without
preauthorization/authorization. Upon receipt of a claim for a TOP-enrolled
ADFM submitted by a private sector care designated or non-designated
overseas private care sector provider without preauthorization/authorization,
the contractor shall process the claims following POS payment procedures.
For ADSM claims submitted by a private sector care 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 TOP contractor shall
deny the claim. Refer to
Section 2526 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 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, 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 ADSM stateside claims as outlined in
Section 2526.
6.20 The TOP
contractor shall submit all claims in a Health Insurance Portability
and Accountability Act (HIPAA) compliant format. Refer to
Section 2728 for
more information on HIPAA requirements.
6.21 The TOP
contractor shall reject electronic claims not accepted by the TOP
contractor’s Electronic Data Information (EDI) system/program.
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. The TOP contractor shall access claim information 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 The TOP
contractor shall process claims either denied as “beneficiary not
eligible” or “found to be not eligible on DEERS” as a “good faith
payment” when received from the Defense Health Agency (DHA) Communications
Office. The TAO Director 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
The TOP contractor shall apply
TOP deductible and cost-share following the 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 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 clearly indicating ‘This is not
a bill’.
8.3 The TOP contractor shall ensure
TOP EOBs include the toll-free number for beneficiary and provider assistance.
8.4 The TOP
contractor shall ensure TOP EOBs for overseas enrolled ADSM claims
are annotated ‘ACTIVE DUTY.’
8.5 For Point
of Sale or Vendor pharmacy overseas claims, the TOP contractor shall
ensure TOP EOBs 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 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
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 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.
8.10 The TOP
contractor shall 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 is not
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 as outlined in the TRM,
Chapter
4.
10.2 The TOP contractor shall coordinate
beneficiary/provider disagreements regarding the contractor’s determination
through the TOP Office for resolution.
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 private sector care services/charges for care rendered
to TOP eligible beneficiaries which is generally considered 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 private sector care ambulance companies
for driving 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 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 private sector care/services specifically excluded under TRICARE.
12.4 Not reimburse
for private sector care/services provided in the Philippines unless
all of the certification requirements listed in
Section 1314 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.
12.6 The 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).
The TOP contractor shall create drafts (payable in foreign currency
units) within 96 hours following CRM approval, unless a different
process has been authorized by DHA. The TOP contractor shall calculate
payments that need to be converted to a foreign currency based on
the exchange rate in effect on the last date of service listed on
the EOB. The TOP contractor shall match drafts/checks with the appropriate
EOB, and mail them to the beneficiary/sponsor/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. The TOP contractor
shall not change drafts to a US dollar check after 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 TOP contractor shall meet
Chapter 3, Section 4 requirements regarding
stale dated, voided, or returned checks/Electronic Funds Transfers
(EFTs).
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 Make
paymentPay 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. The TOP contractor shall use a corporate address
in Germany or the TAO Eurasia-Africa address for this purpose.
12.13 Pay all
beneficiary-submitted claims for TRICARE covered drugs dispensed
by a US embassy health clinic to the beneficiary. The TOP contractor
shall not 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 private sector
care providers. The TOP contractor shall process these claims 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 Waive, in
emergency situations, the requirement for Medicare certification
for facilities in US commonwealths and territories. 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 Mail the
drafts/checks and EOBs to 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
contain the contractor’s address. The TOP contractor shall mail
drafts and EOBs using US postage. Additionally, the TOP contractor
shall make payments/checks 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. The
TOP contractor shall not send provider checks or EOBs for Philippine
providers, and other nations’ providers as directed by the DHA CO
to any other address.
12.19 Process/pay inpatient and outpatient
claims for TRICARE overseas eligible beneficiaries, including ADSM claims,
as indicated below:
12.19.1 The TPharm contractor shall allow
TOP 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. The TOP contractor shall make
payment from applicable bank accounts and shall base payment on
billed charges unless a lower reimbursement rate has been established
by the Government or the contractor.
12.20 Upon private
sector care provider request, 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 are the
provider’s responsibility. Upon beneficiary
request, the TOP contractor shall provide EFT payments to a US bank.
Bank charges associated with beneficiary EFT payments are the beneficiary’s
responsibility.
12.21 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 TOP contractor shall report
the number of excluded claims on the designated DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract. The TOP contractor shall process 100% of all claims (both
retained and excluded, including adjustments) 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 on the
designated DD Form 1423, CDRL, located in Section J of the applicable
contract.
12.23 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 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 TOP contractor shall conduct recoupment actions in
a manner that is considered culturally appropriate for the private
sector care provider’s country. The
TOP 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. If the case is under $600,
the TOP contractor shall keep the case open for an additional four
months and the TOP contractor shall write off at 360 calendar days.
13.3 The 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) to delete references to US law. The TOP contractor
shall provide invoice numbers 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 The TOP
contractor shall write provider recoupment letters sent to Germany,
Italy, Spain, Japan, and Korea, in the respective language.
13.5 If the recoupment
action is the result of an inappropriately processed claim by the
TOP contractor, 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 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.