Military Health System

1.1  TOP Prime is available to Service members (including Reserve Component (RC) members activated for more than 30 calendar days) who are on permanent assignment overseas in a location serviced by a Military Medical Treatment Facility (MTF), Command-Sponsored Active Duty Family Members (ADFMs), accompanying the sponsor or on service orders, and certain transitional survivors and Transitional Assistance Management Program (TAMP)-eligible beneficiaries according to the eligibility and enrollment provisions of Section 5. TOP Prime offers enrollees access to a Primary Care Manager (PCM), clinical preventative services, and specialty services.

1.2  TOP Prime has no enrollment fees, and deductibles. Cost-shares are waived except for TOP Prime ADFMs who receive care under the Point of Service (POS) option, or who obtain pharmacy services in the 50 United States (US), the District of Columbia, or US territories where the TRICARE Pharmacy (TPharm) contractor has established a retail pharmacy network. Waiver of copayment and deductibles under TOP Prime is subject to review/updating based on enrollment status.

1.3  Under TOP Prime, annual catastrophic caps are calculated on calendar years. The enrollment year shall coincide with the calendar year. Since deductibles and cost-shares are waived for TOP Prime enrollees, this policy will apply only to TOP Prime enrollees who incur out-of-pocket expenses.

2.1  TOP Prime enrollees shall select or have assigned to them PCMs according to guidelines established by the MTF Director, TRICARE Area Office (TAO) Executive Director, or designee. TOP Prime enrollment to a private sector care PCM may only occur when all available capacity in the MTF has been reached. The TOP PCM:

2.2  A TOP Prime enrollee must seek all his or her primary health care from the TOP PCM with the exception of care listed in Section 8. If the TOP PCM is unable to provide the care, the TOP PCM is responsible for referring the enrollee to another primary care provider.

2.3  TOP Prime enrollees must obtain appropriate referral/authorization for any non-emergency care rendered by anyone other than the beneficiary’s PCM or another MTF provider. This provision applies regardless of where the care is rendered. MTFs may submit requests for retroactive authorizations up to three business days after the care was rendered. After three business days, the TAO Executive Directors and/or Chief, TOP Office (TOPO) may direct retroactive authorizations on a case-by-case basis. Routine care is generally not authorized while a TOP Prime enrollee is traveling out of their enrollment region; however, exceptions may be made for unusual circumstances on a case-by-case basis with PCM referral and appropriate written justification from the referring MTF. Emergent/urgent care does not require prior authorization; however, the beneficiary should contact their PCM and the TOP contractor as soon as possible to arrange any necessary follow-up care.

2.4  Failure to obtain a TOP PCM referral/authorization when one is required for care may result in the service being paid under TOP Point of Service (POS) procedures for an ADFM with a deductible and cost-shares for outpatient services and cost-shares for inpatient services.

2.5  The TOP PCM is responsible for notifying the TOP HCF that a referral is being made/requested. The TOP HCF will assist the TOP Prime enrollee and other beneficiaries in locating an MTF or private sector care TOP network or non-network provider to provide the care, and to assist in scheduling an appointment upon request. The HCF will conduct a benefit determination review and provide authorization for service for which the referral was made. If the contractor has no record of referral/authorization, prior to denial/payment, the contractor shall follow the TOP POS rules, assuming the service is a covered benefit.

2.6  TOP MTF PCMs may be delegated authority by the TOP MTF Director to authorize referrals within the MTF. All referrals/authorizations to civilian private sector care providers and all referrals/authorization made by a TOP designated private sector care PCM must be made through the TOP HCF and must receive an authorization.

2.7  The TOP contractor shall ensure that all authorized services for TOP Prime enrollees are provided on a cashless, claimless basis. The contractor shall implement guarantee of payment or other business arrangements to ensure that TOP Prime enrollees are not required to pay up front at the time services are rendered by a private sector care provider.

2.8  Cashless, claimless provisions do not apply to self-referred care that would normally require authorization.

2.9  In accordance with the Statement of Responsibilities (SOR), MTFs will determine if they have the capability and capacity to provide needed specialty inpatient care. Submission of an MTF referral shall signify that the referring MTF has determined that the care cannot be provided by the direct care system within the TRICARE access standards. In Puerto Rico, the local MTF must have the opportunity to review each referral from a private sector care PCM to determine if the MTF has the capability and capacity to provide the care. Specific language regarding this process shall be incorporated into each SOR with all MTFs with Puerto Rico.

2.10  For TOP Prime enrollees who are traveling in the 50 US or the District of Columbia, the TOP contractor and the TAO Executive Directors will encourage/direct TOP beneficiaries to utilize stateside MTFs and TRICARE network providers whenever possible. If MTF care is unavailable, beneficiaries shall be provided with information regarding the nearest available network provider(s) who can assist the beneficiary. Non-network providers should only be used when MTF or network care is not available.

2.11  ADFMs enrolled in TOP Prime may obtain urgent care from any authorized provider without a PCM (if assigned) referral or overseas contractor authorization. In order to ensure the urgent care visit will be cashless/claimless, the ADFMs enrolled to TOP Prime should contact the TOP contractor to obtain an authorization. Without this authorization, overseas providers may request payment upfront (overseas providers may bill above the TRICARE allowable amount without any limits) and the beneficiary will then have to submit a claim for reimbursement.

3.1  TOP Prime-enrolled ADFMs are required to follow established referral/authorization procedures prior to obtaining specialty care to avoid the application of POS cost-shares and deductibles. This includes all self-referred, non-emergency outpatient specialty medical services and all inpatient care (including inpatient mental health care), except for outpatient mental health and Substance Use Disorder (SUD) visits, ancillary services, and drugs. TOP Prime ADFMs who self-refer to a civilian provider other than their PCM shall have their claims processed as POS.

3.2  POS cost-shares and deductibles shall not apply to claims for care received by newborns/adoptees during the deemed enrollment period.

3.3  Self-referred, non-emergency, non-urgent, specialty, or inpatient care provided to a TOP Prime enrollee by a network or non-network private sector care provider, which is not either provided/referred by the beneficiary’s PCM or specifically authorized may be reimbursed only under the TOP Prime POS option if it is a TRICARE benefit. Services which are not a TRICARE benefit shall be denied.

3.4  POS cost-sharing and deductible amounts do not apply if a TOP Prime enrollee has Other Health Insurance (OHI) that provides primary coverage. The OHI must be primary under the provisions of the TRICARE Reimbursement Manual (TRM), Chapter 4, Section 1, and documentation that the other insurance processed the claim and the exact amount paid must be submitted with the TOP claim. TRICARE OHI provisions apply for this type of claim.

3.5  The POS option does not apply to Service member overseas/stateside care.

3.6  The TOP contractor shall adjust TOP Prime copayments when TOP PCMs or HCFs do not follow established referral/authorization procedures. For example, if the contractor processes a claim without evidence of an authorization and/or a referral under POS provisions, and the contractor later verifies that the PCM or other appropriate provider referred the beneficiary for the care, the contractor shall adjust the claim under TOP Prime provisions. The contractor need not identify past claims, however, the contractor shall adjust these claims as they are brought to their attention.

3.7  On a case-by-case basis, following stabilization of the patient, the MTF Director may require a TOP Prime beneficiary to transfer to the MTF. The MTF Director shall provide written notice to the beneficiary (or responsible party) advising them of the impending transfer to a TOP network facility/MTF. If a TOP Prime-enrolled ADFM elects to remain in a non-network facility following notification of an impending transfer to another facility, TOP POS cost-sharing will begin 24 hours following receipt of the written notice. The MTF Director may not require a transfer until such time as the transfer is deemed medically safe.

3.8  See the TRM, Chapter 2, Section 5 for the deductible and cost-share amounts which apply to all TOP Prime POS claims for health care services.

3.9  POS deductible and cost-sharing do not apply to the claims for care received by certain newborn and newly adopted children during the deemed enrollment period. See Section 5 for additional guidance regarding deemed enrollment for newborns/adoptees.