TRICARE Manuals - Display Chap 17 Sect 3 (Change 17, Sep 27, 2024)

Supplemental Health Care Program (SHCP)

Chapter 17

Section 3

Contractor Responsibilities

Revision: C-17, September 27, 2024

1.0 CONTRACTOR RECEIPT AND CONTROL OF SHCP CLAIMS

1.1 Claims Processing

1.1.1 Claims Processing And Reporting

1.1.1.1 The contractor shall process SHCP claims using the same standards and requirements in Chapter 1, unless otherwise stated in this chapter, regardless of who submits the claim.

1.1.1.2 The contractor for the geographic area of responsibility in which the patient is enrolled shall process the claim to completion.

1.1.1.3 The contractor for the geographic area of responsibility in which the eligible Service member resides shall process the claim if the Service member is not enrolled.

1.1.1.4 The contractor shall process claims for inpatient and outpatient medical services to completion without application of a cost-share, copayment, or deductible. The contractor shall not apply the claims filing deadline requirements outlined in Chapter 8, Section 3, to any eligible Service member SHCP claim or for Active Duty Family Member (ADFM) SHCP claims for authorized In Vitro Fertilization (IVF) treatment based on the sponsor’s eligibility as a wounded warrior.

1.1.2 Civilian Services Rendered To Market/Military Medical Treatment Facility (MTF) Inpatients

1.1.2.1 The contractor shall process claims for Market/MTF inpatients referred to a civilian facility for medical care (test, procedure, or consult) without application of a cost-share, copayment, or deductible.

1.1.2.2 The contractor shall reimburse costs for transportation of current Market/MTF inpatients by ambulance to or from a civilian provider will be considered medical costs as well as costs for inpatient care in civilian facilities.

1.1.2.3 The contractor shall pay claims for inpatients who are not TRICARE eligible (e.g., Service Secretary designee, parents), based on Market/MTF authorization despite the lack of any Defense Enrollment Eligibility Reporting System (DEERS) indication of eligibility, these are SHCP claims. The contractor shall not use SHCP for TRICARE For Life (TFL) beneficiaries referred from a Market/MTF as an inpatient. The contractor shall process such civilian claims through Medicare first without consideration of SHCP.

1.1.3 Outpatient Care

1.1.3.1 The contractor shall process outpatient civilian care claims according to the patient’s enrollment or eligibility status (see paragraph 3.0). If the patient is shown as eligible in DEERS, the contractor shall follow normal claims processing requirements.

1.1.3.2 The contractor shall, for service determined eligible patients other than active duty, (e.g., Reserve Officer Training Corps (ROTC), former members on the Temporary Disability Retirement List (TDRL), Reserve Component (RC), National Guard, foreign military members), pay claims based on a Market/MTF or Specified Authorization Staff (SAS) authorization despite the lack of any DEERS indication of eligibility.

1.1.4 Department of Defense (DoD)/Department of Veterans Affairs/Veterans Health Administration (DVA/VHA) Memorandum of Agreement (MOA)

The contractor shall process claims for care provided under the national DoD/DVA/VHA MOA for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), and Blind Rehabilitation in accordance with Section 2.

1.1.5 Emergency Civilian Hospitalization

1.1.5.1 The contractor shall report to the referring Market/MTF or the enrolled Market/MTF if not already referred if an emergency civilian hospitalization becomes necessary during the test or procedure referred by the Market/MTF. The contractor shall report all hospitalizations of eligible Service members when it comes to the attention of the contractor, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

1.1.5.2 The Market/MTF will have primary case management responsibility, including authorization of care and patient movement for all civilian hospitalizations. The contractor shall still apply all requirements for authorization of care (such as periodic reviews of inpatient care).

1.1.6 TDRL

1.1.6.1 The contractor shall process claims for periodic physical exams for participants on the TDRL based on the Market/MTF authorization. These claims are SHCP claims, but the contractor shall maintain and track these separately from other SHCP claims.

1.1.6.2 It is the responsibility of the Market/MTF to identify TDRL referrals to the contractor at the time of authorization.

1.1.6.3 The contractor shall not use SHCP funds to pay claims for treating conditions which caused the eligible Service member to be placed on the TDRL or for conditions discovered during the physical examination.

1.1.6.4 The contractor shall use Enrollment/Health Plan Code SR and the Special Processing Code (SPC) DE for each TDRL physical exam.

1.1.7 Comprehensive Clinical Evaluation Program (CCEP)

1.1.7.1 The contractor shall process claims for participants in the CCEP based on the Market/MTF authorization.

1.1.7.2 The contractor shall maintain and track these claims separately from other SHCP claims.

1.1.7.3 It is the responsibility of the Market/MTF to identify CCEP referrals to the contractor at the time of authorization.

1.1.8 Foreign Military Member and Family Member Claims Processing

1.1.8.1 Foreign military members and their family members in the United States (US) may be eligible for health care under an approved agreement (e.g., reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), or Partnership for Peace (PfP) SOFA).

1.1.8.2 DEERS will show foreign military members and their family members on assignment in the US with a Health Care Coverage Member Category Code of T. Foreign military members who are in the US on official business may be eligible for care, but may not be reflected on DEERS.

1.1.8.3 The contractor shall pay claims for foreign military member’s outpatient care provided in the US based on a Market/MTF or Specified Authorization Staff (SAS) authorization despite the lack of any DEERS indication of eligibility.

1.1.8.4 The contractor shall process claims received for foreign military members and their family members as follows:

1.1.8.4.1 Foreign Military Member

1.1.8.4.1.1 The contractor shall accept and follow the referral requirements in Chapter 7, Section 5 for foreign military member care. Foreign military members are eligible for civilian outpatient care, but are not eligible for civilian inpatient care (refer to the TRICARE Policy Manual (TPM), Chapter 1, Section 1.1).

1.1.8.4.1.2 Markets/MTFs or SAS must refer authorized foreign military member for civilian outpatient care. For Market/MTF referral requests, if the foreign military member works and resides in a TRICARE Prime Remote (TPR) area, then the SAS will issue referrals for outpatient care.

1.1.8.4.1.3 The contractor shall follow the same referral processes in place for eligible Service members (which includes pending a claim without a referral and forwarding to either a Market/MTF or SAS for review) for foreign military member care.

1.1.8.4.1.4 The contractor shall defer claims without authorization to the Market/MTF if the foreign military member resides in catchment of a Market/MTF and to SAS if the foreign military member resides in a remote area outside a Market/MTF catchment area.

1.1.8.4.1.5 The contractor shall not charge a copayment or cost-share for authorized civilian outpatient care claims for foreign military members. If the member has double coverage (not including national health plan coverage from his or her home country), the contractor shall apply the double coverage requirements in the TRICARE Reimbursement Manual (TRM), Chapter 4.

1.1.8.4.1.6 Foreign military members are not required nor are they eligible to enroll in any TRICARE plan for their civilian outpatient claims to be paid by TRICARE.

1.1.8.4.2 Family Members of Foreign Military Members

1.1.8.4.2.1 The contractor shall process claims for eligible family members of foreign military members. Family members of foreign military members may be eligible for outpatient civilian care, but are not eligible for inpatient care (refer to TPM, Chapter 1, Section 1.1).

1.1.8.4.2.2 The contractor shall, if the family member is registered and shown as eligible in DEERS (Health Care Coverage Member Category Code of T), process the claim with TRICARE Select Group B ADFM cost-shares, as appropriate (refer to TRM, Chapter 2, Section 2).

1.1.8.4.2.3 If the family member has double coverage (not including national health plan coverage from his or her home country), the contractor shall apply the double coverage requirements in the TRM.

1.1.9 Claims Received With Both Market/MTF-Referred And Non-Referred Lines

1.1.9.1 The contractor shall determine whether a claim falls under an Episode of Care (EOC) when claims are received with lines of care containing both referred and non-referred (directs evaluation or treatment of a condition) lines.

1.1.9.1.1 The contractor shall consider laboratory tests, radiology tests, echocardiogram, Holter monitors, pulmonary function tests, and routine treadmills logically associated with the referred EOC as part of the originally requested services and shall not require additional Market/MTF approval.

1.1.9.1.2 The contractor shall forward claims received which contain services outside the originally referred EOC on an eligible Service member to the Market/MTF for approval.

1.1.9.2 The contractor shall perform medical necessity reviews.

1.2 Eligibility Verification

1.2.1 Market/MTF Referred Care

1.2.1.1 The contractor shall process the claim in accordance with the requirements in paragraph 1.2.2.2 if a Market/MTF referral is on file and the service is either ordinarily covered by the TRICARE Program or covered under paragraph 2.8.5.

1.2.1.2 While DHA requires referrals for Active Duty Service Member (ADSM) care, for administrative reasons, the contractor shall process and pay such claims without a referral for TRICARE covered services or services, supplies and equipment waived under paragraph 2.8.5 as if there were a referral on file. This process makes no changes to contractor requirements under Chapter 16, Section 2.

1.2.1.3 The contractor shall reimburse ADSMs for claims paid out of pocket for a service that is covered by the TRICARE Program or waived under paragraph 2.8.5 that were previously denied by the Market/MTF or denied due to the lack of a Market/MTF referral. The contractor shall issue a reimbursement only upon ADSM request.

1.2.1.4 The contractor shall verify that care provided was authorized by the Market/MTF. If an authorization is not on file, then:

1.2.1.4.1 If the service is either not covered by the TRICARE Program or not covered under paragraph 2.8.5, the contractor shall deny the claim (except for care provided by the DVA/VHA under the current national MOA for SCI, TBI, and Blind Rehabilitation, see Section 2, paragraph 3.1) and notify the ADSM’s Market/MTF.

1.2.1.4.2 The contractor shall notify the Market/MTF of all claims processed and paid with no authorization and all denied claims for non-covered services within one business day and following best business practices. The TOP contractor shall provide the MTF with a report (in accordance with DD Form 1423, Contract Data Requirements Lists (CDRL), located in Section J of the applicable contract), for all claims processed and paid with no authorization and all claims denied for non-covered services.

1.2.1.4.3 For non-ADSM claims, the Market/MTF has 10 business days to retroactively authorize the care. If the Market/MTF determines that the care was not authorized or does not respond within 10 business days, the contractor shall initiate an Explanation of Benefits (EOB) to deny the claim. For ADSM claims, see paragraph 1.2.1.2. The TOP contractor shall follow claims processing guidelines outlined in Chapter 24, Section 9 for Line of Duty (LOD) and RC Service Members on orders less than 30 calendar days.

1.2.1.4.4 If the claim is for a breast pump, the contractor shall require a prescription that indicates whether it is for a manual, standard electric, or heavy-duty hospital grade breast pump. If the claim is for a manual or standard electric pump, the contractor shall not require Market/MTF authorization.

1.2.1.4.5 If the claim is for a heavy-duty hospital grade pump, the contractor shall require a prescription and a referral.

1.2.1.5 The contractor shall contact the Market/MTF for authorization as described below if no referral is on file. The contractor shall not require a prescription or Market/MTF referral/authorization for breast pump claims.

1.2.1.6 The contractor shall contact the Market/MTF within one business day.

1.2.1.7 The contractor shall enter the authorization and notify the claims processor to process the claim for payment if the Market/MTF retroactively authorizes the care.

1.2.1.8 The contractor shall notify the claims processor and initiate Explanation of Benefits (EOB) to deny the claim if the Market/MTF determines that the care was not authorized.

1.2.1.9 The contractor shall, within one business day, enter the contractor’s authorization code into the contractor’s claims processing system if the contractor does not receive a response within four business days from the Market’s/MTF’s response.

1.2.1.9.1 The contractor shall consider claims that are authorized due to a lack of response from the Market/MTF as Referred Care.

1.2.1.9.2 The contractor shall, for services that would not have ordinarily been covered under TRICARE policy, authorize services for eligible Service members only in accordance with the terms of a waiver approved by the Government Designated Authority (GDA), at the request of an authorized official of the Uniformed Service concerned or SAS as appropriate.

1.2.2 Non-Market/MTF Referred Care

1.2.2.1 Check DEERS Status

1.2.2.1.1 The contractor shall, if the Service member is listed in DEERS as TRICARE Prime and No Primary Care Manager (PCM) selected, process the claim in accordance with paragraph 1.4 (Types of Care).

1.2.2.1.2 The contractor shall, if the DEERS check indicates the Service member is enrolled in TPR, process the claim as a TPR claim in accordance with Chapter 16. Otherwise, the contractor shall process the claim in accordance with the requirements of this chapter.

1.2.2.2 Check for SAS Preauthorization

The contractor shall, if a SAS Episode of Care (EOC) preauthorization exists, process the claim to completion in accordance with this Chapter whether or not the eligible Service member is listed in DEERS.

1.2.2.3 Check Claim For Attached Documentation

The contractor shall, if the patient is listed in DEERS as not direct care eligible, but the claim or its attached documentation indicates potential eligibility (e.g., military orders, commander’s letter), pend the case and forward a copy of the claim and attached documentation to the SAS for an eligibility determination.

1.2.2.4 National Guard and Reserve

1.2.2.4.1 The contractor shall process claims for National Guard or Reserve sponsors with treatment dates outside their eligibility dates. The contractor shall not automatically adjudicate these claims.

1.2.2.4.2 The contractor shall check claims for Market/MTF or SAS accept National Guard or Reserve LOD EOC authorization before routing to sent by SAS.

1.2.2.4.2.1 The Government SAS will send authorizations to the contractor using a Government designated, encrypted system.

1.2.2.4.2.2 The contractor shall enter the authorizations into their medical management system.

1.2.2.4.3 The contractor shall suspend claims for ineligible sponsors and routed to SAS for payment approval or denial if no Market/MTF or SAS EOC authorization is on file.

1.2.2.4.4 The contractor shall deny the claim if payment determination is not received within the 85th day of receipt.

1.2.2.5 Criteria Not Met

The contractor shall, if none of the conditions stated above are met, return the claim uncontrolled to the submitting party in accordance with established procedures.

1.2.3 The contractor shall not apply the DEERS Catastrophic Cap and Deductible Data (CCDD) file, Third Party Liability (TPL), or Other Health Insurance (OHI) processing procedures, for supplemental health care claims for outpatient active duty, TDRL, non-TRICARE eligible patients, and for all SHCP inpatients.

1.2.4 The contractor shall apply normal TRICARE rules for all TRICARE eligible outpatients’ claims except those outlined above.

1.2.5 The contractor shall return outpatient claims for non-enrolled Medicare-eligibles to the submitting party for filing with the Medicare claims processor.

1.3 TPL

1.3.1 The contractor shall apply TPL processing requirements (Chapter 10) to all claims covered by this Chapter. However, the contractor shall not delay adjudicating claims to await completion of the requisite questionnaire and document compilation.

1.3.2 The contractor shall process the claim to completion and forward the TPL documentation to the appropriate Uniformed Service claims office when complete.

1.4 Types Of Care

1.4.1 The contractor shall have staff who receive and accept calls directly from eligible Service members requesting authorization for care which has not been Market/MTF referred. The contractor shall publicize the phone number for these staff on the contractor’s TRICARE website.

1.4.2 The contractor shall, if the caller is requesting after hours authorization for care while physically present in the Prime Service Area (PSA) of the Market/MTF to which he or she is enrolled, authorize the care in accordance with the contractor-Market/MTF Memoranda of Understanding (MOU) established between the contractor and the local Market/MTF.

1.4.3 The contractor shall, if the caller is traveling away from his or her duty station, authorize the care if a prudent person would consider the care to be urgent or emergent.

1.4.4 The contractor shall refer callers seeking authorization for routine care back to their Market/MTF for instructions.

1.4.5 The contractor shall send daily notifications to the Market/MTF detailing the after-hours authorizations for Service members according to locally established business rules.

2.0 COVERAGE

Except as authorized by this section, the contractor shall authorize services that would not have ordinarily been covered under TRICARE policy (including limitations and exclusions) for eligible Service members but only in accordance with the terms of a waiver approved by the GDA at the request of an authorized official of the Uniformed Service concerned, or by SAS. (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”). The contractor shall continue to apply TRICARE coverage limits to SHCP services for non-active duty TRICARE-eligible beneficiaries.

Note: The contractor shall not require a waiver (regardless of basic benefit standards) for care provided under the DoD/VA MOA or for emergent care at non-authorized facilities.

2.1 The contractor shall not make claims payments to sanctioned or suspended providers (refer to Chapter 13, Section 5). Markets/MTFs do not have the authority to overturn Defense Health Agency (DHA) or Department of Health and Human Services (DHHS) provider exclusions. The contractor shall not apply TRICARE utilization review and utilization management requirements.

2.2 The contractor may refer or authorize SHCP care or services from a non-TRICARE authorized provider. This is limited to emergent cases, care under the DoD/VA MOA, or with a DHA waiver (refer to the TRM, Chapter 1, Section 29).

2.3 The contractor shall, if a Service member is admitted to a non-TRICARE authorized provider, transfer the service member to an authorized facility when a bed becomes available and it is safe to transfer (as determined by current provider and accepting provider). Continued stay at a non-TRICARE authorized facility beyond the emergent admission requires a waiver under the SHCP. The contractor shall hold the Service member harmless during this process.

2.4 The contractor shall, in determining whether a given service or supply would not have ordinarily been covered under TRICARE policy:

2.4.1 Deny health care services and supplies that are specifically excluded from coverage, as reflected in the TRICARE Manuals and on the No Government Pay List (NGPL),

2.4.2 Ensure application of any published frequency limitations, coverage criteria, and other TRICARE published criteria, and

2.4.3 Allow coverage for care provided under current Demonstration authority.

2.5 In making the determination required by paragraph 2.2, the contractor shall deem a referral from a Market/MTF or an authorization from a SAS as authorization for coverage of the private sector care. Thus the contractor shall not determine medical necessity.

2.6 The contractor shall consider the authorization sufficient to process the claim for payment for Market/MTF referral or SAS authorization for private sector care that is not specifically excluded from coverage, including the off-label use of a Food and Drug Administration (FDA) approved drug, device, or medical procedure for which no published exclusion exists.

2.7 The contractor shall process the authorization or request for a Market/MTF referral or SAS authorization or civilian provider requests for authorization for care that is considered by the contractor to be unproven per the TPM, Chapter 1, unless the request is for a specific published exclusion or all-inclusive limitation.

2.8 The contractor shall perform a coverage review upon receipt of a Market/MTF referral/civilian provider referral (for remote eligible Service members/non-enrolled eligible Service members). The contractor shall deem a referral from a Market/MTF or an authorization from a SAS to constitute Service member eligibility verification, as well as direction to bypass provider authorization/certification (in emergency cases only) rules.

2.8.1 The contractor shall take measures as appropriate to enable them to distinguish between a Market/MTF referral and a SAS authorization.

2.8.2 The contractor shall file an authorization in its system and pay received claims in accordance with the filed authorization if the contractor determines that the service, supply, or equipment requested by a Market/MTF referral is covered under TRICARE policy (including paragraph 2.8.5).

2.8.2.1 The contractor shall forward the appropriate documentation to the SAS for authorization if the contractor determines that the service, supply, or equipment requested by civilian provider referral (for remote eligible Service members/non-enrolled eligible Service members) is covered under TRICARE policy.

2.8.2.2 The contractor shall file an authorization in its system and pay received claims in accordance with the filed authorization upon receipt of the SAS authorization.

2.8.3 The contractor shall file an authorization in its system as specified in the DHA approved waiver and pay received claims in accordance with the filed authorization if the contractor determines that the requested service, supply, or equipment is not covered by TRICARE policy (including paragraph 2.8.5) but an approved waiver is provided.

2.8.4 The contractor shall decline to file an authorization in its system and deny any received claims accordingly if the contractor determines that the requested service, supply, or equipment is not covered by TRICARE policy (including paragraph 2.8.5).

2.8.4.1 The contractor shall notify the Market/MTF (an enrolled Market/MTF if different from the submitting Market/MTF) of the declined authorization with explanation of the reason if the authorization request was received as a Market/MTF referral.

2.8.4.2 The contractor shall notify the civilian provider and the remote eligible Service member/non-enrolled eligible Service member of the declined authorization with explanation of the reason if the request was received as a referral from a civilian provider (for a remote eligible Service member/non-enrolled eligible Service member).

2.8.4.3 The contractor shall ensure that the notification to a civilian provider and the remote eligible Service member/non-enrolled eligible Service member explains the waiver process and provide contact information for the applicable Uniformed Services Headquarters Point of Contact (POC)/Service Project Officers as listed in Addendum A. No notification to the SAS is required.

2.8.5 SHCP Blanket Waivers

Certain services, supplies, and equipment are covered for Service members under the SHCP Blanket Waiver, as specified below, and no waiver is required:

2.8.5.1 Custom-Fitted Orthoses

Custom-fitted orthoses are covered for Service members on active duty. The custom-fitted orthosis must be ordered by the appropriate provider and obtained from a TRICARE-authorized vendor that specializes in this service. Prefabricated or other types of orthoses available in commercial retail entities are excluded. Specifically, this benefit refers to custom fitted orthotics (e.g., foot inserts for plantar fasciitis, flat feet, or similar diagnoses).

2.8.5.2 Hearing Aids

2.8.5.2.1 Hearing device/prosthetics, cochlear and other implant systems and accessories must be procured by the Market/MTF for those eligible Service members who reside in a PSA with audiology services.

2.8.5.2.2 The contractor shall, for eligible Service members residing outside of a PSA, or where Markets/MTFs lack the audiology services necessary for hearing aid procurement, refer to a network provider for hearing aid procurement, fittings, or adjustments through the SHCP without a waiver. Except for TPR enrollees, the contractor shall ensure the referral documents the lack of Market/MTF audiology services before paying the claim. The contractor shall not pay claims for services that are not preauthorized.

2.8.5.3 Continuous Positive Airway Pressure (CPAP) Batteries And Portable Devices

2.8.5.3.1 CPAP batteries for both standard and portable devices and adaptive equipment are covered.

2.8.5.3.1.1 The request shall document that the eligible Active Duty Service Member (ADSM) is on deployment status and is not within one year of retirement or separation.

2.8.5.3.1.2 The contractor shall provide a replacement battery if the current battery is no longer functional after normal use or damaged during deployment at no fault of the eligible ADSM. The ADSM will document so in the request.

2.8.5.3.1.3 If the battery is lost or damaged because of the ADSM personal negligence, the contractor shall not use SHCP funds to replace the battery.

2.8.5.3.2 Portable CPAP devices are covered.

2.8.5.3.3 The following criteria shall be met and documented on the referral:

2.8.5.3.3.1 The ADSM has a diagnosis of Obstructive Sleep Apnea (OSA); and

2.8.5.3.3.2 The ADSM travels on official business at least three days per month or is being deployed.

2.8.5.3.3.3 The device shall have humidification and battery capability.

2.8.5.3.3.4 If the ADSM already has a standard CPAP device, the contractor shall authorize a portable device if criteria are met.

2.8.5.3.3.5 Upon initial referral for a CPAP device, the contractor shall authorize a portable device if criteria are met. The contractor shall not authorize a standard CPAP device in addition to a portable device.

2.8.5.3.4 The contractor shall code portable CPAP devices using Healthcare Common Procedure Coding System (HCPCS) code E1399 and shall reimburse based upon the billed charge.

2.8.5.4 Ambulance Fees

2.8.5.4.1 In some localities that do not provide an Advanced Life Support (ALS) ambulance, a Basic Life Support (BLS) ambulance will be dispatched and a separate call is made to an ALS responder to meet the BLS ambulance at the scene. Under current TRICARE policy, there is a contract between the BLS ambulance provider and the ALS responder in order to pay for both claims.

2.8.5.4.2 The contractor shall reimburse the BLS ambulance provider under normal TRICARE reimbursement policy, and shall reimburse the ALS responder claim when a contract between both ambulance service providers does not exist.

2.8.5.4.3 There may be situations where an ambulance responds to an emergency call and provides evaluation or treatment without transport, as the person either refuses transport or it is unnecessary to transport after assessment and treatment. This is sometimes referred to as “response and evaluation or treatment but no transport” or “treat and release.”

2.8.5.4.4 The contractor shall reimburse a claim submitted by an ambulance provider or first responder if there was a response and evaluation/treatment, but no transport for eligible Service members.

2.8.5.4.5 For services provided on or after September 13, 2018, see TRM, Chapter 1, Section 14.

2.8.5.5 Maintenance of Wakefulness Test (MWT) for Obstructive Sleep Apnea (OSA)

Where there is a military need to determine the effectiveness of treatment in regard to sleepiness for an eligible Service member with a diagnosis of OSA, the contractor shall cover an MWT when all of the following criteria are met:

2.8.5.5.1 The MWT referral documents the eligible Service member OSA diagnosis and receipt of at least 30 calendar days of described treatment, for example, CPAP.

2.8.5.5.2 The referral documents that the nearest Market/MTF with a Sleep Disorder Center and Sleep Lab cannot accommodate the request for MWT within access standards.

2.8.5.5.3 For members treated with Positive Airway Pressure (PAP), the referral includes Service specific PAP treatment compliance requirements such as number of hours used on percentage of nights since initiation of treatment.

2.8.5.5.4 The MWT is performed by a network/civilian sleep facility that is American Academy of Sleep Medicine (AASM) certified.

2.8.5.5.5 Prior to conducting the MWT, the sleep lab documents PAP usage and compare to Service specific compliance requirements.

2.8.5.5.6 If compliance requirements are met, the sleep lab proceeds with the MWT.

2.8.5.5.7 If compliance requirements are not met, the contractor shall ensure the sleep lab does not proceed with the MWT and report the results to the referring provider.

2.8.5.5.8 For members treated with surgical therapy, the contractor shall only approve an MWT if the Service member had a post-operative polysomnography confirming an Apnea Hypopnea Index (AHI) less than five per hour documented on the referral.

2.8.5.6 Multiple Prostheses

2.8.5.6.1 Multiple prostheses are covered for ADSMs with major limb amputation(s). This includes amputations at or above the ankle and/or wrist including partial hand or foot amputations. Additional prostheses may be necessary based on the ADSM’s fitness, duties and deployment requirements.

2.8.5.6.2 Every limb with an amputation may require multiple prostheses.

2.8.5.6.3 All ADSMs who have sustained an amputation(s) undergo an initial assessment (in person or telephonically) at one of the following Advanced Rehabilitation Center (ARC) locations: The Center for the Intrepid, San Antonio Military Medical Center, San Antonio, Texas; Walter Reed National Military Medical Center, Bethesda, Maryland; or the Comprehensive Combat and Complex Casualty Care, Naval Medical Center, San Diego, California. See Chapter 7, Section 5.

2.8.5.6.4 The ARC will:

2.8.5.6.4.1 Determine the appropriateness and availability of a transfer or admission to the ARC for additional prostheses.

2.8.5.6.4.2 If ARC is unable to accommodate the referral, the ARC will assist the provider in determining the specific type of prostheses required (e.g., for running, swimming, or navigating uneven terrain) for the referral to a civilian network providers.

2.8.5.6.4.3 Track all ADSMs with major amputations and prosthetic prescriptions.

2.8.5.6.5 The contractor shall cover replacement prostheses when the treating physician determines that an ADSM’s physiological condition changes or that the device is lost, irreparably damaged, or replacement is necessary. An assessment by the ARC is not necessary for replacements.

2.8.5.6.6 The contractor shall provide prostheses covered in accordance with paragraph 2.8.5.6.5 regardless of remaining time on active duty subject to the ADSM’s fitness and duty requirements.

2.8.5.6.7 TRICARE covers one permanent prosthesis at a time unless the beneficiary requires a bilateral prosthesis. See the TPM, Chapter 8, Section 4.1. Upon the ADSM’s retirement, prior to separation, TRICARE’s coverage policy will apply regarding repair and replacement of one prosthetic device. TRICARE coverage will not extend to any additional prostheses. ADSMs who separate or retire may seek replacement and repairs from the ARCs or Veterans Health Administration (VHA), as eligible.

2.8.5.6.8 MOA Between DVA and DoD for Medical Treatment Provided to Service Members With SCI, TBI, Blindness, or Polytraumatic Injuries

Addendum D contains the MOA Between DVA And DoD For Medical Treatment Provided To Service Members With SCI, TBI, Blindness, Or Polytraumatic Injuries. Acquired conditions referred to DVA/VHA medical facilities/programs referenced in the MOA or similar private sector programs are exempt from the SHCP waiver process and the contractor shall reimburse under normal TRICARE reimbursement policy. DHA-Great Lakes (DHA-GL) will not process referrals for programs, DME, or other authorized treatment for acquired conditions, but the contractor shall process referrals in alignment with the conditions of the MOA. Acquired conditions include:

2.8.5.6.8.1 Acquired Brain Injuries (ABIs) (e.g., cardiovascular accident, brain cancer, aneurysm, brain arteriovenous malformation). This includes ABIs due to International Classification of Diseases, 10th Revision (ICD-10) codes including S06 (other than those already covered under the MOA as TBI), A87.9, F01.50, F02.80, F02.81, F03.90, F03.91, F07.81, G00.9, G03.0, G03.1, G03.9, G04.00, G05.3, G05.4, G06.0, G06.1, G06.2, G08, G09, G92, G93.0, G93.1, I60.00, I60.01, I60.02, I60.10, I60.11, I60.12, I60.2, I60.30, I60.31, I60.32, I60.4, I60.50, I60.51, I60.52, I60.6, I60.7, I60.8, I60.9, I61.9, I62.00, I62.1, I63.019, I63.119, I63.139, I63.20, I63.219, I63.22, I63.239, I63.30, I63.40, I63.50, I63.59, I67.89, I69.810, I69.811, I69.812, I69.813, I69.814, I69.815, I69.818, I69.819, I69.898, I69.910, I69.911, I69.912, I69.913, I69.914, I69.915, I69.918, I69.919, I69.928, P10.1, P10.3, P10.8, P10.9, P52.4, P52.5, P52.6, P52.8, P52.9, R09.0, R09.01, R09.02, R41.2, R41.3, R41.82, T75.1, T75.1XXA, T75.1XXD, T75.1XXS.

2.8.5.6.8.2 Acquired blindness (e.g., blindness caused by diabetes, infections, glaucoma or other non-traumatic injury). This includes ICD-10 codes under Blindness and Low Vision (H54).

2.8.5.6.8.3 Non-traumatic spinal cord disorders (e.g., conditions due to infection, loss of blood supply, compression caused by cancer, or degeneration of the spinal vertebrae). This includes ICD-10 codes under deforming dorsopathies (M40-M43), spondylopathies (M45-49) and other dorsopathies (M50-M54).

2.8.5.7 Laser Therapy for Pseudofolliculitis Barbae (PFB) of the Face and Neck

2.8.5.7.1 The contractor shall cover laser therapy in the private sector care to ensure medical readiness of ADSMs with a diagnosis of PFB of the face and neck when all of the following criteria are met and documented on the referral:

2.8.5.7.1.1 There is a safety risk in operational, maintenance and training environments where the wearing of breathing protection may be required.

2.8.5.7.1.2 The ADSM has been diagnosed with PFB of the face and neck and has failed conservative therapy.

2.8.5.7.1.3 The ADSM’s PCM has referred the case to a Market/MTF dermatologist for an in-person, telephone or telehealth consultation.

2.8.5.7.1.4 The Market/MTF dermatologist has recommended laser therapy and the laser therapy is not available at the Market/MTF.

2.8.5.7.2 The Market/MTF dermatologist will assess each case to limit inappropriate referrals, encourage laser therapy in Markets/MTFs, and ensure referred care is consistent with any Service-specific polices on PFB. The Market/MTF dermatologist may establish local policies to streamline this process.

2.8.5.7.3 The contractor shall ensure the laser therapy in the civilian sector is provided by a dermatologist qualified to provide laser therapy.

2.8.6 Coronavirus 2019 (COVID-19) Testing for Asymptomatic (ADSMs)

The contractor shall cover COVID-19 in-vitro diagnostic tests using FDA approved, cleared or authorized Nucleic Acid Amplification (NAA) tests which includes the Reverse Transcription Polymerase Chain Reaction (RT-PCR) test for asymptomatic ADSMs when ordered by a TRICARE authorized provider. The TRICARE Overseas Program (TOP) contractor shall follow the established guidelines/standards of care for COVID-19 testing for the country, host-nation, and/or regional health authority (e.g., World Health Organization (WHO)), where the patient is treated. (See the TPM, Chapter 12, Section 1.2.)

2.8.7 Waiver of Preauthorization Requirement for COVID-19 Vaccinations

2.8.7.1 The preauthorization requirement is waived for ADSMs to receive DoD-authorized COVID-19 vaccinations in the private sector. This includes vaccinations from non-TRICARE authorized providers (e.g., state, county, or city public departments or local Government-sanctioned mass vaccination sites, other TRICARE authorized providers), Urgent Care Center (UCCs), Convenience Clinics (CCs), non-network providers, and in providers offices.

2.8.7.2 The waiver only applies to COVID-19 vaccinations within the US (the 50 US, District of Columbia, Puerto Rico, Guam, US Virgin Islands, American Samoa, and the Northern Mariana Islands).

2.8.7.3 COVID-19 vaccine and administration are at no cost to the ADSM or the health plan. If the provider submits a claim to the contractor, the contractor shall adjudicate the claim, but at no cost to the ADSM.

Note: Although there is no separate cost for clinical preventive services, there may be a cost if the vaccine is administered as part of a primary or specialty visit for a reason other than preventive care or for other services received during the office visit, to include a cost for the office visit.

2.8.8 Gender-Affirming Surgery (GAS) Evaluations

GAS pre-surgical evaluations are covered under a blanket SHCP waiver for ADSMs whose DoD Transgender Care Team (TGCT) or trained military health care provider(s), have determined a GAS Evaluation to be medically necessary in the assessment and treatment of Gender Dysphoria (GD)/Gender Incongruence (GI). To proceed with a GAS evaluation referral, ADSMs need documentation of the following required eligibility criteria:

2.8.8.1 Medical Treatment Plan (MTP)

The ADSM must have an MTP, approved by the DoD TGCT, or trained military medical provider, in their electronic medical record indicating the medical necessity of GAS.

2.8.8.2 Surgical Evaluations For GAS Procedures Affecting Fertility (e.g., Orchiectomy, Oophorectomy, Hysterectomy, etc.)

A GAS surgical evaluation referral for procedure(s) affecting fertility requires documented completion of nine months of continuous Real Life Experience (RLE) and nine months of Gender-Affirming Hormone Treatment (GAHT); if GAHT is indicated in the MTP and if there is no medical contraindication to receiving such therapy.

2.8.8.3 Non-Fertility Affecting GAS Surgical Evaluations

A GAS surgical evaluation referral for procedure(s) NOT affecting fertility (e.g., top surgery, such as mastectomy), may be placed when the DoD TGCT concludes (and documents) that the ADSM is ready for GAS based upon their physical and mental health status and as determined jointly by the ADSM and their care team.

2.8.8.4 GAS Hair Removal

Pre-surgical medically necessary hair removal by laser or electrolysis of the requested GAS surgical areas, when indicated in the pre-op surgical evaluation, is covered under a blanket SHCP waiver, as follows:

2.8.8.4.1 Documentation of the necessity of hair removal in preparation of the surgical site(s) as part of an ADSM’s GAS procedure(s) and surgical plan by the treating surgeon in the pre-op evaluation is sufficient to obtain hair removal at the planned surgical site(s) either by laser or electrolysis.

2.8.8.4.2 It is understood that a blanket waiver for hair removal by laser or electrolysis does not represent an assumed approval of the associated requested GAS procedure(s) and subsequent GAS surgical SHCP waiver request. Therefore, should an ADSM proceed with hair removal by laser or electrolysis prior to receiving approval for the requested GAS procedure(s), and their GAS surgical waiver request is denied, any subsequent hair removal by laser or electrolysis sessions, and/or post-laser treatment complications (from treatment obtained after GAS surgical waiver denial), will be the responsibility of the ADSM.

2.9 Non-Waiverable Health Care Services

2.9.1 Bariatric surgery.

2.9.2 Chiropractic services outside of the Market/MTF.

2.10 Specifically Defined Health Care

2.10.1 Ancillary Services

The Regulation governing SHCP requires each service be authorized, with very limited exceptions. For purposes of SHCP claims processing, the contractor shall deem a Market/MTF referral/SAS authorization for care to include authorization of any TRICARE-covered ancillary services directly and clearly related to the specific EOC authorized (e.g., evaluation or treatment of a specific medical condition). The contractor shall seek a Market/MTF referral/SAS authorization if the contractor has questions regarding whether a particular service is related to the EOC already authorized.

2.10.2 Benefit Coverage Comparable To The Extended Care Health Option (ECHO) For Seriously Ill Or Injured Service Members

2.10.2.1 Under 10 USC 1074(c)(4)(A) and (B), seriously ill or injured eligible Service members shall receive services comparable to those provided to family members of eligible Service members under 10 USC 1079(d) and (e), the TRICARE ECHO Program. Statutory authority for these benefits for retirees ended December 31, 2012. Former Service members that used this benefit will continue to be covered by this provision for benefits received before December 31, 2012 (e.g., anti-rejection medication for a limb transplant).

2.10.2.2 The contractor shall meet all TRICARE Encounter Data (TED) requirements outlined in the TRICARE Systems Manual (TSM), Chapter 2 including appropriate use of Special Processing Code PF to identify TED records for care rendered under the ECHO benefit for seriously ill or injured eligible Service members.

2.10.2.3 The contractor shall not apply cost-shares, copayments, or financial caps for any of these ECHO-like benefits when these services are authorized. The contractor shall not require registration in the Exceptional Family Member Program (EFMP). The contractor shall not apply time limits to disability or illness requirements.

2.10.2.4 The contractor shall preauthorize these benefits and document Category II/III designation per Department of Defense Instruction (DoDI) 1300.24. The contractor shall document that the eligible Service member was referred to a Medical Evaluations Board (MEB).

2.10.2.5 The contractor shall authorize the following categories of care listed under 10 USC 1079(e) (see 10 USC 1079(e)(1-7)):

2.10.2.5.1 Diagnosis.

2.10.2.5.2 Inpatient, outpatient, and comprehensive Home Health Care (HHC) supplies and services which may include cost-effective and medically-appropriate services other than part-time or intermittent services, as these terms are currently used under the TRICARE ECHO Program.

2.10.2.5.3 Training, rehabilitation, special education, and assistive technology devices.

2.10.2.5.4 Institutional care in private nonprofit, public, and state institutions and facilities and, if appropriate, transportation to and from such institutions and facilities.

2.10.2.5.5 Home health services, including custodial care in conjunction with authorized home health services.

2.10.2.5.6 Seriously ill or injured eligible Service members are defined as Category II or III per DoDI 1300.24.

2.10.2.6 The eligible Service member’s primary care provider or primary specialty care provider will document and provide the eligible Service member’s category status on a referral as well as documentation of a referral to an MEB. The contractor shall require preauthorization. If the documentation supports the category designation of Category II/III, the eligible Service member is eligible for benefits comparable to ECHO.

2.10.2.6.1 The contractor shall apply the ECHO Health Care Delivery Plan (HCDP) code of 400 to the eligible Service member. The provider’s documentation of Category II/III status is the authorizing document allowing the contractor to apply the ECHO HCDP code to the eligible Service member using the Government-furnished web-based enrollment application.

2.10.2.6.2 The contractor shall meet all TED requirements outlined in the TSM, Chapter 2, including appropriate use of Special Processing Code PF to identify TED records for care rendered under the ECHO benefit for seriously ill or injured eligible Service members.

2.10.2.7 The contractor shall collaborate with all DVA/VHA case managers along with the eligible Service member’s healthcare team to ensure continuity of care and transition to DVA/VHA care and management upon the eligible Service member’s retirement or separation.

2.10.2.8 As much as practical, these benefits shall mirror the ECHO Program and be coordinated between the contractor and the health care team. Benefits for these eligible Service members arise from any physiological disorder or condition or anatomical loss affecting one or more body system, and which precludes the person with the disorder, condition, or anatomical loss from unaided performance of at least one of the following major life activities: breathing, cognition, hearing, seeing, and ability to bathe, dress, eat, groom, speak, stair use, toilet use, transferring, and walking. Benefits include services for rehabilitative, habitative care as well as Durable Equipment (DE) and Durable Medical Equipment (DME).

2.10.2.9 Designation of comparable to ECHO benefits for eligible Service members.

2.10.2.9.1 The eligible Service member’s PCM or specialty provider will send the contractor requests for benefits under the comparable to ECHO and documentation of the category description (II/III) and reason(s) for that category description.

2.10.2.9.2 The eligible Service member’s PCM or specialty provider will provide the contractor documentation of an MEB referral to an MEB.

2.10.2.10 Provision of Respite Care

2.10.2.10.1 The contractor shall not apply eligibility rules and exclusions contained in 32 CFR 199.5(b)(3) to the provision of respite benefits for an eligible Service member. See https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf for definitions, terms, and limitations applicable to the respite care benefit.

2.10.2.10.2 Seriously ill or injured eligible Service members shall qualify for respite care benefits regardless of their enrollment status. Eligible Service members in the 50 US and the District of Columbia qualify if they are enrolled in TRICARE Prime, TPR, or not enrolled and receiving services in accordance with the non-enrolled/non-referred requirements for the use of SHCP funds. eligible Service members outside the 50 US and the District of Columbia qualify if they are enrolled to TOP Prime (with enrollment to an Market/MTF), TOP Prime Remote, or not enrolled and receiving services in accordance with the non-enrolled/non-referred requirements for eligible Service member care overseas (see TPM, Chapter 12, Section 1.1).

Note: Respite care benefits must be performed by a TRICARE-authorized Home Health Agency (HHA), regardless of the eligible Service member’s location (see 32 CFR 199.6(b)(4)(xv) for HHA definition).

2.10.2.10.3 The contractor shall not apply cost-shares or copays for eligible Service member respite benefits when those services are approved by the eligible Service member’s Direct Care System (DCS) case manager or other appropriate DCS authority (i.e., SAS, the enrolled or referring Market/MTF, TRICARE Area Office (TAO), or Community Care Units (CCUs)).

2.10.2.10.4 The contractor shall apply all SHCP requirements and provisions of Chapters 16 and 17 to this benefit unless changed or modified by this paragraph. The contractor shall apply the appropriate chapter for the status of the eligible Service member.

2.10.2.10.5 The contractor shall follow the requirements and provisions of these chapters, to include:

• Market/MTF or SAS referrals and authorizations;

• Receipt and control of claims;

• Authorization, verification, reimbursement and payment mechanisms to providers;

• Reimbursement specifying no cost-share, copay, or deductible to be paid by the eligible Service member or their lawful spouse; and

• Use of CHAMPUS Maximum Allowable Charges (CMACs)/Diagnosis Related Groups (DRGs) when applicable.

2.10.2.10.6 The contractor shall follow the requirements of the TSM, Chapter 2, Sections 2.8 and 6.4 regarding the TED SPC for the eligible Service member respite benefit.

2.10.2.10.6.1 The contractor shall ensure that claims indicate an appropriate procedure code for respite care (CPT code 99600 or HCPCS codes S9122-S9124).

2.10.2.10.6.2 The contractor shall reimburse claims based upon the allowable charge or the negotiated rate.

2.10.2.10.7 Respite care services and requirements.

2.10.2.10.7.1 Respite care is authorized for an eligible Service member of the Uniformed Services on active duty and has a qualifying condition as defined in https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf.

2.10.2.10.7.2 Respite care is available if an eligible Service member’s plan of care includes interventions by the primary caregiver(s).

2.10.2.10.7.3 Eligible Service members receiving respite care are eligible to receive a maximum of 40 respite hours in a calendar week, no more than five days per calendar week and no more than eight hours per calendar day. The contractor shall not apply any additional benefit caps.

2.10.2.10.7.4 The contractor shall ensure respite benefits are provided by a TRICARE-authorized HHA and mirror the benefits under the TRICARE ECHO Home Health Care (EHHC) program described in the TPM, Chapter 9, Section 15.1.

Note: The contractor is not required to enroll eligible Service members in the ECHO program (or a comparable program) for this respite benefit.

2.10.2.10.7.5 The contractor shall not authorize respite care for other family members or others who may reside in or be visiting the eligible Service member’s residence.

2.10.2.10.7.6 The contractor shall not authorize services or items provided or prescribed by a member of the patient’s family or a person living in the same household.

2.10.2.10.7.7 The contractor shall follow the reimbursement methodology for the similar respite care benefit found in the TPM, Chapter 9, as modified by eligible Service member SHCP reimbursement methodology contained in Chapters 16 and 17 (for eligible Service members located in the 50 US and the District of Columbia) or TOP reimbursement methodology contained in the TPM, Chapter 12 (for eligible Service members located outside the 50 US and the District of Columbia).

2.10.2.10.7.8 The contractor shall submit a request to the SAS, Market/MTF, or TAO for authorization of payment, should other services or supplies not outlined above, or those otherwise available under the TRICARE program, be considered necessary for the care or treatment of an eligible Service member.

2.10.2.10.7.9 The contractor shall coordinate preauthorization with the respective SAS, Market/MTF, or TAO when preauthorization is possible.

2.10.2.11 Customized Hand-Crank Bikes

2.10.2.11.1 There is a cap of $5,500.

2.10.2.11.2 The bike must be custom fitted for the eligible Service member’s unique injury.

2.10.2.11.3 Must be preauthorized and evidence of a Category II/III illness or injury must accompany the request. No request shall be for more than the $5,500 cap.

2.10.2.12 Custodial Care

2.10.2.12.1 Limited to 30 calendar days if eligible Service member has not been referred to an MEB.

2.10.2.12.2 At the Market/MTF case manager’s request, the appropriate GDA may authorize an additional 30 calendar days if the eligible Service member is due to return to duty at the end of the additional 30 calendar days.

2.10.2.12.3 Any additional extensions must have a waiver from the Director, DHA for those eligible Service members that have not been referred to an MEB.

2.10.2.12.4 For eligible Service members who have been referred to an MEB, authorization is valid until eligible Service member retires, separates, or returns to duty. The contractor shall not require a waiver.

2.10.2.12.5 May be provided in the home or authorized provider or facility. The contractor shall require a waiver to use an unauthorized provider or facility.

2.10.2.12.6 Custodial care services may be provided up to 24/7. The health care team will periodically review the eligible Service member’s care plan to revise amount of custodial care required.

2.10.2.12.7 The eligible Service member’s health care team will determine the requirements of the eligible Service member for Custodial Care, including the number of hours and duration of the service and will adjust these requirements accordingly as the eligible Service member’s requirements change.

2.10.2.12.8 The contractor shall collaborate with DoD and DVA/VHA case managers along with the eligible Service member’s health care team to ensure continuity of care and transition to DVA/VHA care and management upon retirement or separation as required.

2.10.2.12.9 The contractor shall preauthorize care with documentation of Category II/III illness or injury and other inclusion criteria in this section accompanying the request.

2.10.2.13 Cryopreservation And Reproductive Services

2.10.2.13.1 Policy Guidelines For Cryopreservation Of Sperm/Oocytes/Embryos For Eligible Service members With A Diagnosis Of Cancer

2.10.2.13.1.1 The eligible Service member must be either Category II or III as a result of his or her cancer at the time of retrieval. The eligible Service member must be scheduled to undergo a gonadotoxic treatment for their cancer.

2.10.2.13.1.1.1 For females cryopreservation of eggs at age 49 or under at the time of retrieval is covered.

2.10.2.13.1.1.2 For males cryopreservation of sperm at 61 or under at time of retrieval is covered.

2.10.2.13.1.2 The eligible Service member must be on a period of active duty greater than 30 calendar days and are scheduled to remain on active duty for the duration of the retrieval and freezing process.

2.10.2.13.1.3 The eligible Service member must have capacity to provide informed consent (i.e., third party consent is not authorized).

Note: Prior surgical sterilization does not disqualify an eligible Service member from participating.

2.10.2.13.1.4 Mature Oocyte Retrieval

2.10.2.13.1.4.1 The contractor shall require a referral by a PCM (or referral by primary care provider for TPR enrollees) or specialist involved in an eligible Service member’s cancer care for each retrieval cycle. No more than three completed retrieval cycles are covered. Services and supplies covered for mature oocyte retrieval include the following.

2.10.2.13.1.4.1.1 Consultation and subsequent office visits as indicated.

2.10.2.13.1.4.1.2 Laboratory tests and ultrasound imaging as indicated.

2.10.2.13.1.4.1.3 Provider-administered medications as indicated for oocyte retrieval.

2.10.2.13.1.4.1.4 Self-administered medications as indicated for oocyte retrieval are covered under Chapter 23.

2.10.2.13.1.4.1.5 Surgical retrieval and anesthesia.

2.10.2.13.1.4.1.6 Medically necessary services and supplies associated with complications.

2.10.2.13.1.4.2 The benefit is limited to the retrieval of 20 oocytes or three completed cycles, whichever occurs first. There may be a total of four attempts to accomplish three completed cycles.

2.10.2.13.1.4.3 The contractor shall not approve a third cycle if 11 or more oocytes are retrieved in the second cycle.

2.10.2.13.1.4.4 The contractor shall authorize additional retrieval beyond one cycle only if the cumulative number of oocytes retrieved of all previous cycles is less than 20. For instance, if 12 oocytes are retrieved in the first cycle, the contractor may approve a second cycle.

2.10.2.13.1.5 Sperm Collection And Retrieval

2.10.2.13.1.5.1 The contractor shall require a referral by a PCM (or referral by primary care provider for TPR enrollees) or specialist involved in an eligible Service member’s cancer care. If indicated, the referral shall specify the need for invasive procedures for sperm retrieval beyond simple collection of semen (or urine for retrograde ejaculation). Services and supplies covered for sperm collection and retrieval includes the following:

2.10.2.13.1.5.1.1 Consultation and subsequent office visits as indicated.

2.10.2.13.1.5.1.2 Laboratory tests as indicated including semen analysis.

2.10.2.13.1.5.1.3 Provider-administered medications as indicated for sperm retrieval.

2.10.2.13.1.5.1.4 Self-administered medications indicated for sperm retrieval are covered under Chapter 23.

2.10.2.13.1.5.1.5 Invasive procedures for sperm retrieval (e.g., electro-ejaculation, epididymal aspiration) likely to produce viable sperm.

2.10.2.13.1.5.1.6 Medically necessary services and supplies associated with complications.

2.10.2.13.1.5.2 The contractor shall only authorize either two simple specimen collections or one invasive procedure for sperm retrieval.

2.10.2.13.1.6 Cryopreservation

2.10.2.13.1.6.1 Services and supplies associated with cryopreservation of all mature oocytes and sperm retrieved, and embryos.

2.10.2.13.1.6.2 Storage Of Retrieved/Collected Oocyte/Sperm And Embryos

Note: The contractor shall waive the 36 month limitations in paragraphs 2.10.2.13.1.6.2.1 and 2.10.2.13.1.6.2.2 for qualified ADSMs whose coverage ended or will end between the date of the declaration of the COVID-19 national emergency on March 1, 2020, until 90 days following the declared end of the national emergency by the President of the United States. The contractor shall apply all other coverage criteria.

2.10.2.13.1.6.2.1 The contractor shall cover storage for 36 months from date of first retrieval of all mature oocytes and sperm. The cost of storage is incurred on the first day of the initial period of storage and the first day of any subsequent year of storage.

2.10.2.13.1.6.2.2 The eligible Service member is responsible for all costs incurred after 36 months or when the eligible Service member separates or retires (whichever comes first). The eligible Service member is responsible for arranging disposition subject to state regulation on disposal and abandonment of frozen specimens.

2.10.2.13.1.6.2.3 The contractor shall ensure that oocytes, sperm, and embryos are stored at facilities listed and registered in accordance with 21 CFR 1271.

2.10.2.13.1.6.3 Ownership And Disposition

2.10.2.13.1.6.3.1 Issues regarding ownership, future use, donation, or destruction shall be governed by applicable state law and are the responsibility of the eligible Service member and his or her lawful spouse and the facility storing the cryopreserved oocytes/sperm/embryos. DoD’s role is limited to paying for this benefit when requested by the consenting eligible Service member.

2.10.2.13.1.6.3.2 DoD will not have ownership or custody of cryopreserved oocytes/sperm/embryos.

2.10.2.13.1.6.3.3 DoD will not be involved in the ultimate disposition of excess cryopreserved oocytes/sperm/embryos. Ultimate disposition or destruction of excess cryopreserved oocytes/sperm/embryos is not separately reimbursed.

2.10.2.13.2 Policy Guidelines For Assisted Reproductive Technology (ART)

2.10.2.13.2.1 The policy provides for the provision of ART which includes embryo cryopreservation and storage, to assist in the reduction of the disabling effects of the eligible Service member’s qualifying condition. The authority for this policy for care outside of the basic medical benefit is derived from Section 1633 of the 2008 National Defense Authorization Act (NDAA). This section allows the eligible Service member to receive services that are outside the definition of “medical care.”

2.10.2.13.2.2 The contractor shall ensure the provider obtains a preauthorization for every IVF cycle. This benefit is provided through the authorization of the expenditure of SHCP funds and delivery of the needed services in either Markets/MTFs that offer ARTs or in the private sector care that are outside the medical benefit. Although care can be obtained in the private sector care for this benefit depending on the eligible Service member’s circumstances not allowing him or her to travel, the contractor shall encourage the Service member to use the Markets/MTFs. Markets/MTFs give eligible Service members priority for care if there is a waiting list. If the eligible Service member receives care or medications in the private sector care, they will use participating network providers if available.

2.10.2.13.2.3 Assisted reproductive services, including sperm retrieval, oocyte retrieval, IVF, artificial insemination, and blastocyst implantation is offered based on the condition of the seriously or severely ill or injured eligible Service member not the spouse; therefore, the use of the SHCP is authorized.

2.10.2.13.2.4 The benefit is limited to qualified eligible Service members procreating with their lawful spouse, as defined in federal statute and regulation.

2.10.2.13.2.5 Consent must be able to be given by the eligible Service member and their lawful spouse. Third party consent is not authorized under this policy.

2.10.2.13.2.6 The contractor shall not cover third party donations and surrogacy. The benefit is designed to allow the eligible Service members and their spouses to become biological parents through reproductive technologies.

2.10.2.13.3 Cancer

2.10.2.13.3.1 The policy applies to eligible Service members, regardless of gender, who are seriously or severely ill (Category II, III) as a result of their cancer and will or have undergone cancer therapy that may have effected their fertility. Eligible Service members will use their cryopreserved sperm/oocytes or embryos for the ART services such as IVF.

Note: The contractor shall waive the 36 month limitations in paragraphs 2.10.2.11.3.2 and 2.10.2.11.3.3 for qualified ADSMs whose coverage ended or will end between the date of the declaration of the COVID-19 national emergency on March 1, 2020, until 90 days following the declared end of the national emergency by the President of the United States. The contractor shall apply all other coverage criteria.

2.10.2.13.3.2 The ART benefit will be available for 36 months from the date of sperm or oocyte retrieval.

2.10.2.13.3.3 If the eligible Service member proceeds with embryo cryopreservation and storage during this 36 month period, the contractor shall only cover these services during the 36 month period.

2.10.2.13.4 The contractor shall cover transportation, shipping and handling costs of oncocryopreserved sperm and oocytes when:

2.10.2.13.4.1 Relocating the specimen from a local cryobank to a local fertility clinic, or

2.10.2.13.4.2 Relocating the specimen from a cryobank to a distant fertility clinic closer to where the eligible Service member currently resides.

2.10.2.13.5 Urogenital Trauma

2.10.2.13.5.1 The policy applies to eligible Service members, regardless of gender, who have sustained a serious or severe illness or injury while on active duty that led to the loss of their natural procreative ability.

2.10.2.13.5.2 It is the intent of this policy to provide ART services, including embryo cryopreservation and storage without limitation while on active duty, only to consenting male eligible Service members whose illness or injury to his urogenital system prevents the successful delivery of his sperm to his spouse’s egg and to a consenting female.

2.10.2.13.5.3 Eligible Service members whose illness or injury to their urogenital system prevents their egg from being successfully fertilized by their spouse’s sperm, but who maintain ovarian function and have a patent uterine cavity. This includes, but is not limited to, those suffering neurological, physiological, or anatomical injuries.

2.10.2.13.5.4 Male eligible Service members must be able to produce sperm but need alternative sperm collection technologies as they can no longer ejaculate in a way that allows for egg fertilization.

2.10.2.13.5.5 Ill or injured female eligible Service members must have ovarian function and a patent uterine cavity that would allow them to successfully carry a fetus even if unable to conceive naturally (e.g., damage to their fallopian tubes).

2.10.2.13.5.6 The contractor shall cover embryo cryopreservation and storage if the eligible Service member remains on active duty.

2.10.2.13.5.7 The eligible Service member is responsible for all storage costs when the eligible ADSM separates or retires. The eligible Service member is responsible for arranging disposition subject to state regulation on disposal and abandonment of frozen specimens.

2.10.2.13.6 Procedures

2.10.2.13.6.1 Prediction of fertility potential (Ovarian Reserve) shall be conducted in accordance with the provider clinic’s practice guidelines. This may include a Clomiphene Citrate Challenge Test (CCCT) and evaluation of the uterine cavity. Beneficiaries with a likelihood of success, based on the specific clinic’s guidelines, shall be provided IVF cycles under this benefit. Infertility testing and treatment, including correction of the physical cause of infertility, are covered in accordance with the TPM, Chapter 4, Section 17.1.

2.10.2.13.6.2 Three completed IVF cycles shall be provided for the seriously or severely ill or injured female eligible Service member or lawful spouse of the seriously or severely ill or injured male eligible Service member. No more than six IVF cycles shall be initiated for the seriously or severely ill/injured female eligible Service member or legal spouse of the seriously or severely ill or injured male eligible Service member. There may be a total of six attempts to accomplish three completed IVF cycles. If the ill or injured eligible Service member has used initiated IVF cycles, subsequently remarries, and desires this benefit with the new spouse, the number of cycles available is dependent on prior cycles used.

2.10.2.13.6.3 Assisted reproductive service centers with capability to provide full services including alternative methods of sperm aspiration will be invited to participate and accept payment at the network discount rate. Reporting outcomes to the Centers for Disease Control and Prevention (CDC) is mandatory. When a network provider is not available, the benefits provided under this policy may be provided by any TRICARE-authorized provider, including those authorized pursuant to 32 CFR 199.6(e).

2.10.2.13.6.4 IVF cycles shall be accomplished in accordance with the protocol for the provider clinic using gonadotropins which are concentrated mixtures of Follicle Stimulating Hormone (FSH) or FSH and Luteinizing Hormone (LH) given as an injection to stimulate the ovary to produce multiple oocytes in preparation for egg retrieval. These medications shall be purchased through the TRICARE Pharmacy (TPharm) contract (to include home delivery, non-network retail pharmacy, and network retail pharmacy options) or Market/MTF.

2.10.2.13.6.5 Anesthesia or conscious sedation shall be provided for the oocyte retrieval and sperm aspiration in accordance with the TPM, Chapter 3, Section 1.1 and 1.2. For males, sperm aspiration through Microsurgical Epididymal Sperm Aspiration (MESA), Percutaneous Epididymal Sperm Aspiration (PESA), or non-surgical fine needle aspiration shall be accomplished in conjunction with egg retrieval. Vibratory stimulation or electro-ejaculation may be used if appropriate for the seriously or severely ill or injured eligible Service member.

2.10.2.13.6.6 Intracytoplasmic sperm injection shall be accomplished for all viable oocytes.

2.10.2.13.6.7 Embryo transfer in accordance with guidelines provided by the ASRM shall be accomplished in accordance with specific clinic practices at either cleavage stage or blastocyst stage of the embryo.

2.10.2.13.6.8 Healthy embryos that progress to an appropriate stage, as assessed by the embryologist, in excess of those used for the fresh embryo transfer may be cryopreserved.

2.10.2.13.6.9 In the event that frozen embryos are available for transfer, TRICARE will authorize frozen embryo transfer cycles to facilitate the utilization of these embryos. Frozen embryo transfers may be accomplished in fresh ovulatory cycles or in medicated transfer cycles in order to provide the optimal uterine environment for embryo implantation.

2.10.2.13.7 Process For Participating In Assisted Reproductive Services Program

2.10.2.13.7.1 For an eligible Service member to be eligible, there must be documentation of Category II or III illness or injury designation as defined in DoDI 1300.24.

2.10.2.13.7.2 The referral to the contractor must contain the following information:

• Eligible Service member’s qualifying diagnosis(es);

• Category (II or III);

• Summary of relevant medical information supporting category designation;

• Name of provider of reproductive services requested to be used;

• Number of initiated IVF cycles; and

• Number of canceled IVF cycles.

2.10.2.13.7.3 The contractor shall follow all applicable TED coding requirements in accordance with TSM, Chapter 2. The contractor shall use Enrollment/Health Plan Code “SR SHCP - Referred Care” regardless of the enrollment status returned by DEERS.

2.10.2.13.7.4 The contractor shall apply all SHCP requirements and provisions of Chapters 16 and 17 to this benefit unless changed or modified by this paragraph. The contractor shall apply the appropriate chapter for the status of the eligible Service member.

2.10.2.13.7.5 The contractor shall follow the requirements and provisions of these chapters, to include Market/MTF or SAS referrals and authorizations, receipt and control of claims, authorization verification, reimbursement and payment mechanisms to providers, reimbursement specifying no cost-share, copay, or deductible to be paid by the eligible Service member or their lawful spouse, and use of CMACs/DRGs when applicable.

2.10.2.13.8 Exclusions

2.10.2.13.8.1 The contractor shall not cost-share third party donations or surrogacy.

2.10.2.13.8.2 Cryopreservation of gametes in anticipation of deployment.

2.10.2.13.8.3 The contractor shall not cost-share services related to gender selection.

2.10.2.14 Incontinence Supplies

The contractor shall cover personal incontinence supplies (e.g., diapers, diaper creams, bed pads) that support skin integrity and prevent deterioration of skin due to incontinence.

2.11 Transitional Care For Service-Related Conditions (TCSRC)

2.11.1 Introduction

The NDAA for FY 2008, Section 1637 provides extended TCSRC for former Service members during the Transitional Assistance Management Program (TAMP) coverage period. This change does not create a new class of beneficiaries but expands or extends the period of TRICARE eligibility for certain former Service members, with certain service-related conditions, beyond the TAMP coverage period.

2.11.2 Prerequisites For TCSRC

In accordance with the NDAA for FY 2008, a Service member, who is eligible for care under the TAMP, and who has a medical (as defined in 32 CFR 199.2) or adjunctive dental condition believed to be related to his or her service on active duty may receive extended transitional care for that condition.

2.11.3 The contractor shall ensure the diagnosis determination includes the following criteria:

2.11.3.1 The condition is service-related; and

2.11.3.2 Discovered or diagnosed by the member’s civilian or TRICARE health care practitioner during the TAMP period and validated by a DoD physician; and

2.11.3.3 The medical condition requires treatment and can be resolved within 180 calendar days, from the date the condition is validated by the DoD physician.

2.11.3.3.1 The period of coverage for TCSRC shall be no more than 180 calendar days from the date the diagnosed condition is validated by a DoD physician. If a medical condition is identified during the TAMP coverage period, but not validated by a DoD physician until a date after the TAMP coverage period, the start date will be the date the condition was validated by a DoD physician.

2.11.3.3.2 The SAS will refer members who are discovered to have a service-related condition, which cannot be resolved within the 180 calendar day transitional care period, to the member’s former Service or to the DVA/VHA for a determination of eligibility for Government provided care.

2.11.3.3.3 Care is authorized for the service-related condition(s) for 180 calendar days from the date the DoD physician validates the service-related condition. For example, a service-related condition validated on day 90 of TAMP will result in the following timelines: Care under TAMP for other than the service-related condition terminates on day 180 after the beginning of TAMP coverage. Care for the service-related condition terminates on day 270 in this example (180 calendar days from the day the service-related condition is validated by a DoD physician).

2.11.4 Eligibility

2.11.4.1 The eligible pool of beneficiaries are former Service members who are within their 180 calendar day TAMP coverage period, regardless of where they currently reside.

2.11.4.2 A DoD physician must determine that the condition meets the criteria in paragraph 2.11.2. Final validation of the condition must be made by a DoD Physician associated with SAS. If the determination is made that the former Service member is eligible for this program, the former Service member shall be entitled to receive medical and adjunctive dental care for that condition only as if they were still on active duty. Enrollment into this program does not affect eligibility requirements for any other TRICARE program for former Service members or their family members.

2.11.4.3 Enrollment in TCSRC includes limited eligibility for Market/MTF Pharmacy, Retail Pharmacy, TRICARE Pharmacy (TPharm) contract, and TRICARE Pharmacy Home Delivery Program benefits.

2.11.5 TCSRC Implementation Steps

The processes and requirements for a former Service member with a possible Section 1637 program condition are detailed in paragraphs 2.11.5.1 through 2.11.5.7. These steps, requirements, and responsibilities are applicable to SAS, the contractor, TRICARE civilian providers, and the Armed Forces.

2.11.5.1 DHA Communications will create materials to support beneficiary education on the Section 1637 benefit.

The contractor shall collaborate with DHA Communications in the development of educational materials for both beneficiaries and providers.

2.11.5.2 The contractor shall refer former Service members on TAMP who believe they have a service-related condition which may qualify them for the TCSRC program, to SAS for instructions on how to apply for the benefit.

2.11.5.3 SAS reviews all TCRSC applications and determines if further clinical evaluation/testing of the former Service member is required. If further clinical evaluation/testing is needed. The SAS will follow existing “defer to network” referral processes.

2.11.5.3.1 The contractor shall execute the referral and authorization to support health care delivery in the area in where the former Service member resides as follows:

2.11.5.3.1.1 If a DoD Market/MTF is within the one-hour drive time Access To Care (ATC) standards and has the capabilities, the Market/MTF have first right of refusal.

2.11.5.3.1.2 The contractor shall ascertain if a DVA/VHA medical facility (as a network provider) is within ATC standards and the facility has the necessary capabilities and capacity if a Market/MTF does not exist or the Market/MTF does not have the capacity. The contractor shall process these claims in the same manner as other active duty claims.

2.11.5.3.1.3 The contractor shall locate a civilian provider that has both the capability and capacity to accept this referral request within the prescribed ATC standards if neither a Market/MTF or DVA/VHA facility is available.

2.11.5.3.1.4 The contractor shall execute an active provider locator process (Health Care Finder (HCF)) to support the former Service member’s need for this referral request. The contractor shall act on SAS’s “defer to network” request under the normal “urgent/72 hour” requirement.

2.11.5.3.1.5 The contractor shall provide the provider location and contact information to the former Service member so the former Service member can schedule an appointment.

2.11.5.3.2 The contractor shall pay these claims in the same manner as other active duty claims.

2.11.5.3.3 The contractor shall instruct the accepting provider to return the results of the encounter to SAS within 48 hours of the encounter.

2.11.5.3.4 Once the additional information is received, the DoD physician associated with SAS makes the determination of eligibility for the Section 1637 program. SAS will make an eligibility determination for coverage under the Section 1637 within 30 calendar days of receiving the former Service member’s request, inclusive of the time required to obtain additional information.

2.11.5.3.5 If the coverage is denied, the former Service member may appeal the decision in writing to SAS within 30 calendar days of receipt of the denial. SAS will issue a final determination within 30 calendar days of receipt of the appeal. If SAS determines the condition shall be covered under the Section 1637 program, coverage will begin on the date SAS renders the final determination.

2.11.5.4 If SAS determines the individual is eligible for the Section 1637 program, they will provide the enrollment information (Enrollment Start date and condition authorized for treatment) to the former Service member and the contractor responsible for enrollments in the geographical area of responsibility where the former Service member resides.

2.11.5.4.1 The contractor shall enroll the former Service member into the Section 1637 program on DEERS using Government-furnished web-based system/application within four business days of receiving the notification from SAS. The notice will clearly identify it is for the Section 1637 program. The contractor shall ensure this entry includes the Start Date (date condition validated by the DoD physician); an EOC Code; and an EOC Description.

2.11.5.4.2 The contractor shall enter the validated condition covered by the Section 1637 program (received from SAS) into the contractor’s referral and authorization system within eight business days of receipt of the notification from SAS.

2.11.5.4.3 The contractor shall actively assist the former Service member using the HCF program to determine the location of final restorative health care for the identified Section 1637 condition. The contractor shall ensure the service location meets ATC standards.

2.11.5.4.4 The contractor shall instruct the accepting provider on the terms of this final “eval and treat” referral from SAS along with when and where to send clinical results/findings necessary to close out SAS’s files. DEERS will store the secondary HCDP code, the date the condition was validated by the DoD physician, the EOC Code, and the EOC Description. DEERS will return the HCDP code, the start and end dates for the coverage plan, the EOC Code, and the EOC Description with every eligibility query. This program is portable across all contractors.

2.11.5.5 The contractor shall process civilian and VA claims for the specific condition as if the Service member were still on active duty, and shall not require copayments. If the “eval” or “eval and treat” referrals sent to the contractor from SAS are presented to a Market/MTF for execution, and the Market/MTF accepts, any subsequent Market/MTF generated “defer to network” requests will be accepted, recorded, and claim adjudicated; and this process may be outside the contractor’s EOC coding/criteria.

2.11.5.6 The contractor may request clarifications from the Market/MTF on a subsequent “defer to network” request if the referral is for healthcare delivery that is not apparently related to the Section 1637 determined condition.

2.11.5.7 The Section 1637 benefit shall be terminated 180 calendar days after the validated diagnosis is made by the DoD physician, no matter the status of the service-related condition. Following the termination of the Transitional Care period, further care for this service-related condition may be provided by the DVA/VHA.

2.11.5.8 Personnel on active duty for longer than 30 calendar days will have their Section 1637 coverage terminated by DEERS. Personnel scheduled to report for active duty (Early Alert Status), may have both the Section 1637 HCDP and HCDP 001 (for Active Duty). Once the active duty period actually begins, Section 1637 coverage will be terminated. If active duty orders are canceled prior to entry on active duty, Section 1637 coverage will continue until the original end date. Reinstatement of the terminated Section 1637 coverage does not apply.

2.11.6 Claims Processing And Payment

2.11.6.1 The contractor shall first determine if the claim being processed is for the Section 1637 condition or not; the Section 1637 HCDP code may be present with any other HCDP code. If the claim is for the specific service-related condition, the contractor shall process and pay the claim as if the former ADSM were on active duty.

2.11.6.2 The contractor shall determine if the claim is for a Market/MTF directed “defer to network” request for the Section 1637 condition which may not relate to the EOC codes determined by the contractor. If the claim is not for the covered condition, the contractor shall process the claim following the standard TRICARE procedures.

2.11.6.3 The contractor shall assess the claim’s status and take one of the following actions if the claim includes services for the Section 1637 covered condition, and additional services:

2.11.6.3.1 Contractor Splits Claim

The contractor shall split the claim into separate claims if a contractor receives a claim for a Service member eligible for Section 1637 coverage and the claim includes services not covered by the Section 1637 diagnosis, and the contractor can determine which services are covered under the Section 1637 condition.

2.11.6.3.2 Contractor Returns Claim to Provider

2.11.6.3.2.1 The contractor shall return the claim to the submitter with an explanation that indicates the claim must be split in order to be paid if the claim does not meet the conditions described above.

2.11.6.3.2.2 The contractor shall process any claim(s) received for such clinical evaluation(s)/tests and shall pay any such claim as if the Service member were an ADSM where a beneficiary has had clinical evaluation(s)/tests performed in order to determine eligibility for Section 1637 program coverage and has paid for those clinical evaluation(s)/tests out-of-pocket.

2.11.6.3.2.3 Service members with multiple service-related conditions will have multiple Section 1637 enrollments. Each condition may have the same or different begin and end dates.

2.11.6.3.2.4 Jurisdiction rules for Section 1637 program coverage shall be in accordance with Chapter 8, Section 2.

2.11.6.3.3 The contractor shall pay all claims submitted for the specific service-related condition in the same manner as other active duty claims. The contractor shall not apply catastrophic cap, deductibles, cost-shares, copayments or coordination of benefits for these claims. The contractor shall pay claims for the specific service-related condition from non-financially underwritten funds.

2.11.6.3.4 The contractor shall pay claims paid for medical care under the 180 calendar day TAMP program, for other than the service-related condition, continue to be paid as an ADFM beneficiary under TRICARE with application of appropriate cost-shares and deductibles for these claims. The Section 1637 benefit does not extend the duration of the TAMP period beyond 180 calendar days.

2.11.6.3.5 The contractor shall, if it is unable to determine if the care received is covered by the Section 1637 diagnosis, pend the claim while the contractor obtains further clarification from SAS.

2.11.6.3.6 Pharmacy transactions at retail network pharmacies are processed on-line using the HIPAA data transaction standard of the National Council for Prescription Drug Programs (NCPDP). Under this standard, the pharmacy contractor shall adjudicate claims real time for eligibility along with clinical and administrative edits at the point of sale which includes cost-share determinations based on the ADSM’s primary HCDP code.

2.11.6.3.6.1 Enrolled Service members determined to be eligible for pharmacy services based on their primary HCDP code will pay appropriate cost-shares as determined by their primary HCDP code and will submit a paper claim to the pharmacy contractor to seek reimbursement of these costs shares. Enrollment documentation that includes the specific condition for Section 1637 enrollment will be submitted with their claim.

2.11.6.3.6.2 The pharmacy contractor shall verify eligibility in DEERS and determine coverage of the prescription based on the specific condition detailed in the supporting documentation.

2.11.6.3.7 Enrolled Service members determined to not be eligible for pharmacy services based on their primary HCDP code will pay out-of-pocket for the total cost of the prescription and then submit a paper claim to the pharmacy contractor for reimbursement.

2.11.6.3.7.1 The pharmacy contractor shall verify eligibility in DEERS and determine coverage of the prescription based on the specific condition detailed in the supporting documentation.

2.11.6.3.7.2 In situations where the supporting document submitted by the former Service member to the pharmacy contractor does not provide sufficient detail of his or her covered condition, the pharmacy contractor shall contact SAS to obtain appropriate documentation to make a coverage determination and process the claim.

2.12 Advanced Rehabilitation Centers

See Chapter 7, Section 5.

3.0 ENROLLMENT STATUS EFFECT ON CLAIMS PROCESSING

3.1 The contractor shall process active duty claims without application of a cost-share, copayment, or deductible. These are SHCP claims.

3.2 The contractor shall process claims for TRICARE Prime enrollees who are in Market/MTF inpatient status without applying a cost-share, copayment, or deductible. These are SHCP claims.

3.3 The contractor shall process and adjudicate claims for services provided under the current MOU between the DoD (including Army, Air Force, and Navy/Marine Corps facilities) and the DHHS (e.g., Indian Health Service, Public Health Service) under the claims processing requirements applicable to those specific agreements. These are not SHCP claims.

3.4 The contractor shall process and adjudicate claims for services provided under any local MOU between the DoD (including the Army, Air Force, and Navy/Marine Corps facilities) and the DVA/VHA under the claims processing requirements applicable to those specific agreements. (Claims for services provided under the current national MOA for SCI, TBI, and Blind Rehabilitation are covered, see Section 2). These are not SHCP claims.

3.5 The contractor shall process claims for participants in the CCEP for payment solely on the basis of Market/MTF authorization. There will not be a cost-share, copayment, or deductible applied to these claims. These are SHCP claims.

3.6 The contractor shall process claims for non-TRICARE eligibles for payment solely on the basis of Market/MTF or SAS authorization. The contractor shall process these claims without applying a cost-share, copayment, or deductible. These are SHCP claims.

3.7 The contractor shall return outpatient claims for non-TRICARE Medicare eligibles to the submitting party for filing with the Medicare claims processor. These are not SHCP or TRICARE claims.

3.8 The contractor shall process claims for TDRL participants for payment in accordance with DoD/HA Policy Letter dated March 30, 2009, Subject: Policy Guidance for Use of Supplemental Health Care Program Funds to Pay for Required Physical Examinations for Members on the Temporary Disability Retirement List. The contractor shall process these claims without applying a cost-share, copayment, or deductible. These are SHCP claims. The contractor shall only use SHCP funds for the exam. The contractor shall not use SHCP funds to treat the condition which caused the eligible ADSM to be placed on the TDRL or for conditions discovered during the exam.

3.9 The contractor shall process claims from Service members enrolled in the Federal Recovery Coordination Program (FRCP) without applying a cost-share, copayment, or deductible. These are SHCP claims.

4.0 MEDICAL RECORDS

4.1 The current contract requirements for medical records shall also apply to eligible Service members in this program, with the additional requirement that eligible Service members shall also be given copies directly.

4.2 Narrative summaries and other documentation of care rendered (including laboratory reports and x-rays) shall be given to the eligible Service member for delivery to their PCM and inclusion in their military health record.

4.3 The contractor shall pay for all administrative/copying costs. Under no circumstances will the eligible Service member be charged for this documentation.

4.4 The contractor shall reimburse network providers for medical records photocopying and postage costs incurred at the rates established in their network provider participation agreements. The contractor shall reimburse participating and non-participating providers for medical records photocopying and postage costs on the basis of billed charges. The contractor shall reimburse eligible Service members who have paid for copied records and applicable postage costs for the full amount paid to ensure they have no out-of-pocket expenses. All providers or patients must submit a claim form, with the charges clearly identified, to the contractor for reimbursement. Eligible Service member’s claim forms shall be accompanied by a receipt showing the amount paid.

5.0 REIMBURSEMENT

5.1 The contractor shall determine allowable amounts based upon the TRICARE payment reimbursement methodology applicable to the services reflected on the claim (e.g., DRGs, mental health per diem, CMAC, Outpatient Prospective Payment System (OPPS), or TRICARE network provider discount). The contractor shall reimburse for services not ordinarily covered by TRICARE or rendered by a provider who cannot be a TRICARE-authorized provider at billed amounts unless a CMAC or DRG exists. The contractor shall not apply cost-sharing and deductibles to SHCP claims.

5.2 The contractor shall deny claims with codes on the TRICARE inpatient only list performed in an outpatient setting, except in those situations where the beneficiary dies in an emergency room prior to admission. Reference the TRM, Chapter 13, Section 2. Professional providers may submit with modifier CA. No bypass authority is authorized for inpatient only procedure editing.

5.3 The contractor shall, pending development and implementation of recently enacted legislative authority to waive CMACs under TRICARE, use the following interim procedures when necessary to assure adequate availability of health care to eligible Service members under SHCP in the following order of precedence:

5.3.1 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.

5.3.2 The contractor shall, initially, make every effort to obtain the provider’s agreement to accept, as payment in full, a rate within the 100% of CMAC limitation.

5.3.3 The contractor shall make every effort to obtain the provider’s agreement to accept, as payment in full, a rate between 100% and 115% of CMAC.

5.3.4 The contractor shall determine the lowest acceptable rate that the provider will accept and communicate the same to the referring Market/MTF. The Market/MTF will obtain a CMAC limitation waiver from the GDA before patient referral is made to ensure that the patient does not bear any out-of-pocket expense.

5.3.5 The contractor shall, upon receipt of notification from the Market/MTF of an approved CMAC waiver by the GDA, conclude rate negotiations. The contractor shall notify the Market/MTF when they reach an agreement with the provider.

5.3.6 The contractor shall ensure that the approved payment is annotated in the authorization/claims processing system, and that payment is issued directly to the provider, unless there is information presented that the eligible Service member has personally paid the provider.

5.3.7 The contractor shall submit the waiver request to the GDA in the case of non-Market/MTF referred care.

5.4 Eligible uniformed Service members or referred patients who have been required by the provider to make ‘up front’ payment at the time services are rendered must submit a claim to the contractor with an explanation and proof of such payment.

5.4.1 The contractor shall allow the billed amount and reimburse the eligible Service member for charges on the claim if the claim is payable without SAS review.

5.4.2 The contractor shall pend the claim to the SAS for determination if the claim requires SAS review.

5.4.3 The contractor shall allow the billed amount and reimburse the eligible Service member for charges on the claim if the SAS authorizes the care.

5.4.4 The contractor shall promptly reimburse supplemental health care claims for Uniformed Service members and all Market/MTF inpatients receiving referred civilian care while remaining in a Market/MTF inpatient status and shall not require the patient to bear any out-of-pocket expense.

5.4.5 The contractor shall allow the billed amount and reimburse the patient for charges on the claim if such payment exceeds normally allowable amounts. As a goal, no such claim shall remain unpaid after 30 calendar days.

5.5 The contractor shall pend the file and forward the issue to the referring Market/MTF or SAS, as appropriate, for determination if the contractor becomes aware of ‘balance billing’ or ongoing collection action by a civilian provider for referred, emergency or authorized care that they cannot resolve. In no case shall a Uniformed Service member be subjected to ‘balance billing’ or ongoing collection action by a civilian provider for referred, emergency or authorized care.

5.6 The referring Market/MTF or SAS will issue an authorization to the contractor for payments in excess of CMAC or other applicable TRICARE payment ceilings, provided the referring Market/MTF or SAS has requested and has been granted a waiver from the COO, DHA, or designee.

6.0 END OF PROCESSING

6.1 EOB

6.1.1 The contractor shall prepare an EOB for each supplemental health care claim processed, and send copies to the provider and the patient in accordance with normal claims processing procedures.

6.1.2 The contractor shall, for all SHCP claims, include on the EOB the statement that this is a supplemental health care claim, not a TRICARE claim.

6.1.3 The contractor shall indicate on the EOB that questions concerning the processing of the claim must be addressed to the contractor or SAS, as appropriate. The contractor shall also use any standard TRICARE EOB messages which are applicable to the claim, e.g., “No authorization on file.”

6.2 Appeal Rights

6.2.1 For supplemental health care claims, the contractor shall apply the appeals process in Chapter 12, as limited herein. If the care is still denied after completion of a review to verify that no miscoding or other clerical error took place and the Market/MTF/SAS will not authorize the care in question, then the contractor shall include in the denial notification the following statement: “If you disagree with this decision, please contact (insert Market/MTF name/SAS here).” TRICARE appeal rights shall pertain to outpatient claims for treatment of TRICARE eligible patients. The SAS will handle only those issues that involve SAS denials of authorization or authorization for reimbursement.

6.2.2 The contractor shall process allowable charge issues, grievances, etc.

6.2.3 If the eligible Service member disagrees with a denial of authorization, rendered by SAS, the first level of appeal will be through the SAS who will coordinate the appeal as appropriate. The eligible Service member may initiate the appeal by contacting his or her SAS. If the SAS upholds the denial, the SAS will notify the eligible Service member of further appeal rights with the appropriate Surgeon General’s office. If the denial is overturned at any level, the SAS will notify the contractor and the eligible Service member.

6.2.4 The contractor shall forward all written inquiries and correspondence related to the SAS or Market/MTF denials of authorization or authorization for reimbursement to the appropriate SAS or Market/MTF.

6.2.5 The contractor shall refer telephonic inquiries related to SAS denials to the appropriate SAS or Market/MTF.

7.0 TED SUBMITTAL

The contractor shall ensure the TED for each claim reflects the appropriate data element values. The contractor shall use the appropriate TSM codes for SHCP claims.

8.0 CONTRACTOR’S RESPONSIBILITY TO RESPOND TO INQUIRIES

8.1 Telephonic Inquiries

8.1.1 Inquiries relating to the SHCP need not be tracked nor reported separately from other inquiries received by the contractor. Most SHCP inquiries to the contractor shall come from the Markets/MTFs claims offices, the Service Project Officers, DHA, or the SAS. In some instances, inquiries may also come from Congressional offices, patients, or providers.

8.1.2 The contractor shall provide Markets/MTFs/claims offices, the Service Project Officers, DHA, and the SAS a specific telephone number, different from the public toll-free number, for inquiries related to the SHCP Claims Program.

8.1.2.1 The contractor shall ensure the line is operational and continuously staffed according to the hours and schedule specified in the contract for toll-free and other service phone lines. It may be the same line as required in support of TPR under Chapter 16.

8.1.2.2 The contractor shall ensure it meets the telephone response standards of Chapter 1, Section 3, for SHCP telephonic inquiries.

8.1.3 Congressional Telephonic Inquiries

8.1.3.1 The contractor shall refer any Congressional telephonic inquiries to the referring Market/MTF or the SAS, as appropriate, if the inquiry is related to the authorization or non-authorization of a specific claim or episode of treatment.

8.1.3.2 The contractor shall respond or refer the caller as appropriate if it is a general Congressional inquiry regarding the SHCP claims program.

8.1.4 Provider And Other Telephonic Inquiries

8.1.4.1 The contractor shall refer any other telephonic inquiries it receives, including calls from the provider, eligible Service member or the Market/MTF patient, to the referring Market/MTF or the SAS, as appropriate, if the inquiry pertains to the authorization or non-authorization of a specific claim.

8.1.4.2 The contractor shall respond as appropriate to general inquiries regarding the SHCP.

8.2 Written Inquiries

8.2.1 Congressional Written Inquiries

8.2.1.1 The contractor shall refer written Congressional inquiries to the Service Project Officer of the referring Market’s/MTF’s branch of service if the inquiry is related to the authorization or non-authorization of a specific claim for Market/MTF-referred care. For non-Market/MTF referred care, the inquiry shall be referred to the SAS.

8.2.1.2 The contractor shall attach a copy of all supporting documentation related to the inquiry.

8.2.1.3 The contractor shall refer the inquiry to the GDA if it is a general Congressional inquiry regarding the SHCP.

8.2.1.4 The contractor shall refer all Congressional written inquiries within 72 hours of identifying the inquiry as relating to the SHCP.

8.2.1.5 The contractor shall send a letter to the Congressional office informing them of the action taken and providing them with the name, address, and telephone number of the individual or entity to which the Congressional correspondence was transferred.

8.2.2 Provider And Service Member (Or Market/MTF Patient) Written Inquiries

8.2.2.1 The contractor shall refer provider and eligible Service member or Market/MTF patient written inquiries to the referring Market/MTF or the SAS, as appropriate, if the inquiry pertains to the authorization or non-authorization of a specific claim.

8.2.2.2 The contractor shall respond as appropriate to general written inquiries regarding the SHCP.

8.2.3 Market/MTF Written Inquiries

8.2.3.1 The contractor shall provide a final written response to all written inquiries from the Market/MTF within 10 business days of the receipt of the inquiry, or if appropriate, refer the inquiry to the SAS upon receipt of the inquiry.

8.2.3.2 The Government intends to take action on all referrals to the SAS as quickly as possible. To support this objective, the contractor shall keep SAS apprised of those claims by telephone, email or fax on which the contractor cannot take further action until the SAS has completed its reviews and approvals.

9.0 EFFECTIVE DATES

9.1 April 21, 2017, for oncofertility and cryopreservation for seriously ill eligible Service members diagnosed with cancer.

9.2 September 28, 2018, for removal of 36 month limitation on the cryopreservation and storage of embryos for seriously ill or injured eligible Service members with a diagnosis of urogenital trauma. Public Law 115-245, Section 8129.

9.3 January 24, 2019, for portable CPAP devices for eligible Service members with OSA who meet the established criteria.

9.4 February 22, 2019, for coverage of shipping and handling costs of cryopreserved sperm and oocytes for seriously ill eligible Service members with a cancer diagnosis.

9.5 May 20, 2020, for coding and reimbursement of portable CPAP devices.

9.6 November 1, 2019, for FDA approved COVID-19 in vitro diagnostic tests, using RT-PCR for asymptomatic ADSMs. Authority valid until 90 days following the declared end of the national emergency by the President of the United States.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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