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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Prime Remote (TPR) Program
Chapter 16
Section 4
Contractor Responsibilities And Reimbursement
Revision:  C-17, September 27, 2024
1.0  CONTRACTOR RECEIPT AND CONTROL OF CLAIMS
1.1  The contractor shall establish a dedicated Post Office (PO) Box to receive claims related to the TPR Program. This dedicated PO Box may also be the one used for handling Supplemental Health Care Program (SHCP) claims.
1.2  The contractor shall follow appropriate SHCP requirements for claims received for medical care furnished to Active Duty Service Members (ADSMs) not enrolled in the TPR Program.
2.0  CLAIMS PROCESSING
2.1  Jurisdiction
2.1.1  The contractor shall process inpatient and outpatient medical claims for health care services provided to the contractor’s TPR enrollees, except in the case of care provided overseas (i.e., outside of the 50 United States (US) and the District of Columbia).
2.1.2  The TRICARE Overseas Program (TOP) contractor shall process civilian health care claims for beneficiaries traveling or visiting overseas, regardless of where the beneficiary is enrolled.
2.1.3  The contractor shall process claims for non-covered benefits in accordance with Section 2.
2.1.4  The contractor shall forward claims for ADSMs enrolled in TPR in other geographical area of responsibility to the contractors for the geographical area of responsibility in which the members are enrolled according to provisions in Chapter 8, Section 2.
2.1.5  The contractor shall process claims received for ADSMs who receive care in its geographic area of responsibility, but who are not enrolled in TPR, according to the instructions applicable to the SHCP.
2.1.6  The contractor shall forward ADSM non-adjunctive dental claims and inquiries to the Active Duty dental program contractor.
2.2  Claims for Care Provided Under the National Department of Defense/Department of Veterans Affairs/Veterans Health Administration (DoD/DVA/VHA) Memorandum of Agreement (MOA) for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), and Blind Rehabilitation
2.2.1  The contractor shall process claims for ADSM care provided by the DVA/VHA for SCI, TBI, and Blind Rehabilitation. Claims shall be processed in accordance with this chapter and the following criteria:
2.2.1.1  The contractor shall process claims received from a DVA/VHA health care facility for ADSM care with any of the following diagnosis codes (principal or secondary) as an MOA claim: V57.4; 049.9; 139.0; 310.2; 323.x; 324.0; 326; 344.0x; 344.1; 348.1; 367.9; 368.9; 369.01; 369.02; 369.05; 369.11; 369.15; 369.4; 430; 431; 432.x; 800.xx; 801.xx; 803.xx; 804.xx; 806.xx; 851.xx; 852.xx; 853.xx; 854.xx; 905.0; 907.0; 907.2; and 952.xx.
2.2.1.2  The contractor shall verify whether the MOA DVA/VHA-provided care has been was authorized by the Defense Health Agency-Great Lakes (DHA-GL) Specified Authorization Staff (SAS). SAS will send authorizations to the contractor by fax using a Government designated, encrypted system. The contractor shall enter these SAS MOA authorizations into their medical management system.
2.2.1.3  The contractor shall not deny claims for lack of authorization, but rather place the claim in a pending status and will forward appropriate documentation to SAS for determination if a required authorization is not on file.
2.2.2  The contractor shall reimburse MOA claims as follows:
2.2.2.1  The contractor shall pay claims for inpatient care using DVA/VHA interagency rates. The interagency rate is a daily per diem to cover an inpatient stay and includes room and board, nursing, physician, and ancillary care.
2.2.2.1.1  These rates will be provided to the contractor by DHA (including periodic updates as needed).
2.2.2.1.2  There are three different interagency rates to be paid for rehabilitation care under the MOA. The Rehabilitation Medicine rate will apply to TBI care. Blind rehabilitation and SCI care each have their own separate interagency rate. Additionally, it is possible that two or more separate rates may apply to one inpatient stay.
2.2.2.1.3  The contractor shall, if the DVA/VHA-submitted claim identifies more than one rate (with the appropriate number of days identified for each separate rate), process the claim using the separate rates. (For example, a stay for SCI may include days paid with the SCI rate and days paid at a surgery rate.)
2.2.2.2  The contractor shall pay claims for outpatient services at the appropriate TRICARE allowable rate (e.g., CHAMPUS Maximum Allowable Charge (CMAC)) with a 10% discount applied.
2.2.2.3  The contractor shall pay claims for the following care at the interagency rate if one exists and, if not, then at billed charges: transportation; prosthetics; orthotics; Durable Medical Equipment (DME); adjunctive dental care; home care; personal care attendants; and extended care (e.g., nursing home care).
2.2.2.4  Since this is care for ADSMs, normal TRICARE coverage limitations do not apply to services rendered for MOA care. As long as a service has been authorized by SAS, it will be covered regardless of whether it would have ordinarily not been covered under TRICARE policy.
2.2.2.5  All TRICARE Encounter Data (TED) records for this care must include Special Processing Code (SPC) 17 - DVA/VHA medical provider claim.
2.3  Time Limitations On Filing Service Member Claims
The claims filing deadline outlined in Chapter 8, Section 3, does not apply to any ADSM claims.
3.0  CLAIM REIMBURSEMENT
3.1  The contractor shall pay TPR medical claims at the CHAMPUS allowable charge or at a lower negotiated rate for network providers, if applicable.
3.2  The contractor shall not apply deductibles, cost-sharing, or copayment amounts to ADSM claims.
3.3  The contractor shall process claims submitted by a TPR enrollee who sought health care services from a non-participating provider who required an ‘up front’ payment.
3.3.1  In order for the enrollee to be reimbursed, the enrollee must submit a claim to the contractor with proof of payment and an explanation of the circumstances.
3.3.2  The contractor shall process the claim according to the provisions in this chapter.
3.3.3  The contractor shall allow the billed amount and reimburse the enrollee for the charges on the claim if the claim is payable without SAS review.
3.3.4  The contractor shall pend the claim to the SAS for determination if the claim requires SAS review.
3.3.5  The contractor shall allow the billed amount and reimburse the enrollee for charges on the claim if the SAS authorizes the care.
3.4  The contractor shall follow contract procedures for notifying the provider that balance billing is prohibited should they become aware that a civilian provider is trying to collect balance billing amounts from a TPR enrollee or has initiated collection action for emergency or authorized care.
3.4.1  The contractor shall pend the file and forward the issue to the SAS for determination if unable to resolve the situation.
3.4.2  The SAS will issue an authorization to the contractor for payments in excess of the applicable TRICARE payment ceilings provided the SAS has requested and has been granted a waiver from the Government Designated Authority (GDA).
3.5  The contractor shall arrange for care with a non-participating provider subject to the normal reimbursement rules if required services are not available from a network or participating provider within the medically appropriate time frame.
3.5.1  The contractor shall determine the lowest acceptable rate that the provider will accept using the following order of precedence:
3.5.1.1  Obtain the provider’s agreement to accept, as payment in full, a rate within the 100% of CMAC limitation.
3.5.1.2  Obtain the provider’s agreement to accept, as payment in full, a rate between 100% and 115% of CMAC.
3.5.1.3  Request a waiver of CMAC limitation from the GDA before a patient referral is made to ensure the patient does not bear any out-of-pocket expense. The waiver request shall include the patient name, TPR location, services requested (Current Procedural Terminology, 4th Edition [CPT-4] codes), CMAC rate, billed charge, and anticipated negotiated rate. Obtain approval from the GDA before the negotiation can be concluded.
3.5.2  The contractor shall ensure that the approved payment is annotated in the authorization and claims processing system, and that payment is issued directly to the provider, unless there is information presented that the ADSM has personally paid the provider.
4.0  ADVANCED REHABILITATION CENTERS
See Chapter 7, Section 5.
5.0  THIRD PARTY LIABILITY (TPL)
5.1  TPL processing requirements in Chapter 10 apply to all claims covered by this chapter.
5.2  The contractor shall not delay adjudication action on a claim while awaiting completion of the TPL questionnaire and compilation of documentation but process the claim(s) to completion.
5.3  The contractor shall forward the documentation as directed in Chapter 10 upon receipt of a completed TPL questionnaire or other related documentation.
6.0  END OF PROCESSING
The contractor shall issue Explanations of Benefits (EOBs) and provider summary vouchers for TPR claims according to TRICARE Prime claims processing procedures.
7.0  TED VOUCHER SUBMITTAL
The contractor shall report the TPR Program claims on vouchers according to TRICARE Systems Manual (TSM), Chapter 2, Section 2.3. The TED for each claim must reflect the appropriate data element values.
8.0  STANDARDS
All TRICARE Program claims processing standards apply to TPR claims (see Chapter 1, Section 3).
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