2.0 PAYMENT POLICY
2.1 Reimbursement
of TOP beneficiary claims for overseas health care shall be based
upon the lesser of billed charges, the negotiated reimbursement
rate, or the Government-established fee schedule. (See
Section 9 and the TRICARE Reimbursement Manual
(TRM),
Chapter 1, Sections 34 and
35 for additional guidelines).
Except for medical evacuations, claims for care in the US commonwealths
and territories shall be reimbursed following stateside reimbursement
guidelines. Philippines and Panama claims shall be reimbursed following
Government-established fee schedules, unless the TOP contractor
has negotiated a lesser rate with a purchase care sector provider.
2.2 Payment
of Skilled Nursing Facility (SNF) claims from Puerto Rico and the
US territories (Guam, the US Virgin Islands, American Samoa, and
the Northern Mariana Islands) shall be processed as routine foreign
claims and shall be subject to the Prospective Payment System (PPS),
as required under Medicare in accordance with the Social Security
Act
(SSA). These SNFs will be subject to
the same rules as applied to SNFs in the US (see the TRM,
Chapter 8).
SNF care is not available in other TOP locations.
2.2.1 The TOP
contractor, at its discretion, may conduct concurrent or retrospective
review for TRICARE Select and TRICARE for Life (TFL) patients when
TRICARE is the primary payer. The review required for the lower
18 Resource Utilization Groups (RUGs) for services prior to October
1, 2010, and the lower 14 RUGs for services on or after October
1, 2010, are a requirement for all TRICARE patients when TRICARE
is primary (see the TRM, Chapter 8, Section 1, paragraph
4.2.17). There will be no review for TOP TRICARE Select
or TFL patients where TRICARE is the secondary payer. The existing
referral and authorization procedures for Prime beneficiaries will
remain unaffected.
2.2.2 Beneficiaries in the lower
18 or 14 RUGs depending on date of service do not automatically
qualify for SNF coverage. These beneficiaries will be individually
reviewed to determine whether they meet the criteria for skilled
services and the need for skilled services (see the TRM,
Chapter 8, Section 1). If these beneficiaries
do not meet these criteria, the SNF PPS claim shall be denied.
2.2.3 The TOP
contractor, at their own discretion, may collect Minimum Data Set
(MDS) assessment data per the TRM,
Chapter 8, Section 1.
2.3 The TOP
contractor shall be responsible for entering into participation
agreements with SNFs in Puerto Rico, Guam, the US Virgin Islands,
American Samoa, and the Northern Mariana Islands.
2.4 The TOP
contractor, at their own discretion, may conduct any data analysis
to identify aberrant SNF PPS providers or those providers who might
inappropriately place TRICARE beneficiaries in a high RUG. The contractor shall
also assist the TRICARE Area Office (TAO) Executive Directors
in obtaining/providing SNF data, for conducting any SNF PPS data
analysis they deem necessary.
2.5 Balance
billing provisions do not apply to TOP beneficiary claims for care
rendered in a foreign country and paid as billed, since there is
no unpaid balance on these claims. Private sector care network providers, participating
providers, and providers in US commonwealths and territories are
prohibited from balance billing.
2.6 For health
care rendered in Puerto Rico and in the US, reimbursement for all
TOP beneficiary care shall follow the TRICARE payment policies except
as outlined below.
2.6.1 TOP Service members who have
been required by the provider to make “up front” payment at the
time services are rendered may submit a claim for reimbursement
directly to the contractor. Normal TRICARE claims processing requirements
apply (including any authorization requirements and the use of TRICARE-approved
claims forms). If the claim is payable, the contractor shall allow
the billed amount and reimburse the Service member for charges on
the claim.
2.6.2 In no case shall a Service
member be subjected to “balance billing” or ongoing collection action
by a civilian provider for emergency or authorized care. If the
contractor becomes aware of such situations that they cannot resolve,
they shall pend the file and forward the issue to the appropriate
TAO Executive Director. The appropriate TAO Executive Director
will issue an authorization to the contractor for payments in excess
of CHAMPUS Maximum Allowable Charge (CMAC) or other applicable TRICARE
payment ceilings, provided the TAO Executive Director
has requested and has been granted a waiver from the Program Manager,
Defense Health Agency (DHA), or designee.
2.6.5 Payment
may be made for ambulance services provided by commercial transport
(see
Section 7 for additional processing instructions
for these claims).
3.0 FINANCIAL
ADMINISTRATION
3.1 The TOP contractor shall follow
the Financial Administration non-financially underwritten funds requirements
in
Chapter 3 with
the following exceptions:
3.1.1 Foreign overseas drafts (local
currency) and checks (US currency) shall also reflect “TRICARE Overseas Program”.
3.1.2 Foreign
overseas drafts shall also reflect information that indicates the
draft is valid for 190 calendar days and if reissue is required/necessary,
the draft must be returned to the TOP contractor with a request
for reissuance. The contractor shall issue drafts/checks for Germany
claims which look like local German drafts/checks.
3.2 The TRICARE
Encounter Data (TED) for the overseas claims shall be reported on
vouchers/batches according to the TRICARE Systems Manual (TSM),
Chapter
2.
3.3 Overseas health care claims
for stateside beneficiaries whose health care is normally provided
under one of the regional contracts (i.e., beneficiaries enrolled
or residing in the 50 US or the District of Columbia, who receive care
while traveling or visiting abroad) shall be processed by the TOP
contractor. Claims for these beneficiaries shall be paid from the
current non-financially underwritten bank account. This provision
does not apply to beneficiaries who are enrolled to the Uniformed
Services Family Health Plan (USFHP) or the Continued Health Care
Benefit Program (CHCBP). Claims for these beneficiaries are processed
by their respective contractor regardless of where the care is rendered.
3.4 The TOP
contractor shall:
3.4.1 Provide TRICARE Overseas Currency
reports identifying the gain or loss for the month reported to arrive by
the 10th calendar day following the month reported.
3.4.2 The TOP
contractor shall calculate currency gains and losses resulting from
payments made to private sector care providers and/or beneficiaries
in foreign countries. The gains and losses shall be computed based
on the exchange rate in effect on the ending date of care. The difference
between the cost of the foreign currency on the ending date of care
and the contractor payment date shall be the gain or loss on the
transaction. Payment shall be as follows for:
3.4.2.1 Net Gain. For months that result
in a net gain, the TOP contractor shall forward the report along
with their check payable to the Department of Defense (DoD), DHA,
for the gain from currency conversion.
3.4.2.2 Net Loss. DHA will reimburse
the TOP contractor for any losses incurred from currency conversion. The
TRICARE Overseas Currency report shall be accompanied by a letter
(invoice) requesting reimbursement for the loss incurred. This payment
will not be subject to the Prompt Payment Act (FAR 32.9) as amended,
therefore, payment by DHA will usually be made within five business
days of receipt of the invoice and the TRICARE Overseas Currency
report.