Military Health System

1.1  TOP Prime Remote is available to Service members (including Reserve Component (RC) members activated for more than 30 calendar days) on permanent assignment to a remote overseas location, Command-Sponsored Active Duty Family Members (ADFMs) accompanying their sponsor in the remote location or on Service orders, and certain transitional survivors according to the eligibility and enrollment provisions of Section 5. TOP Prime Remote offers enrollees access to a Primary Care Manager (PCM), clinical preventative services, and specialty services. The TOP contractor shall, working in concert with private sector care providers and the TRICARE Area Offices (TAOs), have primary responsibility for ensuring that TOP Prime Remote enrollees receive appropriate services and support to facilitate access to the TOP benefit in remote overseas locations.

1.2  TOP Prime Remote has no enrollment fees, and deductibles and cost-shares are waived except for TOP Prime Remote 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, and US territories where the TRICARE Pharmacy (TPharm) has established a retail pharmacy network. Waiver of copayment and deductibles under TOP Prime Remote is subject to review/updating based on enrollment status.

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

2.1  TOP Prime Remote enrollees shall select or the TOP contractor shall assign to them Primary Care Managers (PCMs) according to guidelines established by the TAO Executive Director, or designee.

2.2  A TOP Prime Remote 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 shall refer the enrollee to another primary care provider.

2.3  TOP Prime Remote enrollees must obtain appropriate referral/authorization for any non-emergency, non-urgent care rendered by anyone other than the beneficiary’s PCM. This provision applies regardless of where the care is rendered. TAO Executive Directors may direct retroactive authorizations on a case-by-case basis.

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 POS procedures for an Active Duty Family Member (ADFM) with a deductible and cost-shares for outpatient services and cost-shares for inpatient services.

2.5  The TOP PCM shall assist the TOP Prime Remote enrollee and other beneficiaries in locating a Military Medical Treatment Facility (MTF) or private sector care network or non-network provider to provide the care, and shall assist in scheduling an appointment with a private sector care provider upon request. The HCF shall conduct a benefit determination review and provide authorization for service for which the referral was made. If the TOP contractor has no record of referral/authorization, prior to denial/payment, the TOP contractor shall follow the TOP POS rules, assuming the service is a TRICARE benefit.

2.6   The TOP contractor shall ensure all referrals made by a TOP designated private sector care PCM are made through the TOP HCF and receive an authorization.

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

2.8  The TOP contractor shall not apply cashless/claimless provisions to self-referred care that would normally require an authorization.

2.9  For TOP Prime Remote enrollees who are traveling stateside, the TOP contractor shall direct TOP beneficiaries to use stateside MTFs whenever possible. If MTF care is unavailable, the contractor shall provide beneficiaries with information regarding the nearest available network provider(s) who can assist the beneficiary. The contractor shall only refer to non-network providers when MTF or network care is not possible.

3.1  TOP Prime Remote-enrolled ADFMs shall 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. The TOP contractor shall process claims for TOP Prime Remote ADFMs who self-refer to a civilian provider other than their PCM as POS.

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

3.3  The TOP contractor shall reimburse self-referred, routine, specialty, or inpatient care provided to a TOP Prime Remote ADFM 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 only under the TOP Prime Remote POS option if it is a benefit under TRICARE. The TOP contractor shall deny services which are not a TRICARE benefit.

3.4  The TOP contractor shall not apply POS cost-sharing and deductible amounts if a TOP Prime Remote ADFM 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 the TOP contractor shall submit documentation that the other insurance processed the claim and the exact amount paid with the TOP claim. The TOP contractor shall apply TRICARE OHI provisions for this type of claim.

3.5  The TOP contractor shall not apply the POS option to ADSM overseas/stateside care.

3.6  The TOP contractor shall adjust TOP Prime Remote copayments when TOP PCMs or HCFs do not follow established referral/authorization procedures. For example, if the TOP contractor processes a claim without evidence of an authorization and/or a referral under POS provisions, and the TOP contractor later verifies that the PCM or other appropriate provider referred the beneficiary for the care, the TOP contractor shall adjust the claim under TOP Prime Remote provisions. The TOP contractor need not identify past claims, however, the TOP 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 TAO Executive Director may require a TOP Prime Remote beneficiary to transfer to a TOP network facility or the MTF. The TAO Executive Director will provide written notice to the beneficiary (or responsible party) advising them of the impending transfer to a TOP network facility/MTF. If a TOP Prime Remote-enrolled ADFM elects to remain in a non-network facility after being notified of an impending transfer to another facility, the TOP contractor shall begin POS cost-sharing 24-hours following receipt of the written notice. The TAO Executive Director will not require a transfer until such time as the transfer is deemed medically safe.

3.8  See the TRM, Chapter 2 for deductible and cost-share amounts. The TOP contractor shall not apply POS deductible and cost-sharing 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.