1.0 General
TOP health care services are
provided by Military Medical Treatment Facilities (MTFs) and private
sector care network and non-network providers and institutions.
All TRICARE requirements regarding Provider Certification/Credentialing
and Network Development shall apply to the TOP unless specifically
changed, waived, or superseded by this section; the TRICARE Policy
Manual (TPM),
Chapter 12;
or the TRICARE contract for health care support services outside
the 50 United States (US) and the District of Columbia (hereinafter
referred to as the “TOP Contract”). See
Chapters
4 and
5 for additional
instructions.
2.0 Private SECTOR Care PROVIDER
CERTIFICATION AND CREDENTIALING
2.1 The TOP
contractor shall provide provider certification oversight, and monitor
provider/institution quality. The contractor shall use
Chapter
4,
32 CFR 199.6,
and TPM,
Chapter 11 to
the maximum extent possible for the certification of private sector
care providers. The contractor is not required to follow TRICARE
requirements for US credentialing standards, except when TRICARE
requires the facility/agency to be Medicare certified (e.g., home health
(HH),
hospice, Skilled Nursing Facility (SNF) care). Also, Psychiatric
Residential Treatment Centers (RTCs), Substance Use Disorder Rehabilitation
Facilities (SUDRFs), and Psychiatric Partial Hospitalization Programs
(PHPs) that are located in Puerto Rico require approval by the TOP
contractor. Except for these services and facilities, the TOP contractor
shall establish private sector care provider certification processes
based on the accepted licensure and credentialing requirements for
the private sector care.
Note: Medicare certification for
organ transplant centers is only required for transplants performed
in the US, the District of Columbia, and US territories where Medicare
is available. See TPM,
Chapter 12, Section 1.2.
2.2 Refer
to
Section 28 additional certification requirements
that have been established for private sector care providers in
the Philippines. The Defense Health Agency (DHA) may expand these
additional certification requirements to other locations in the
future.
3.0 NETWORK
DEVELOPMENT
3.1 The TOP contractor shall develop
and maintain a complement of network and non-network private sector
care providers to augment the existing capacity of the Direct Care
(DC) system for Service members and Active Duty Family Members (ADFMs)
who are enrolled in TOP Prime, and provide or arrange for primary
and specialty care services for Service members and ADFMs who are
enrolled in TOP Prime Remote.
3.2 The TOP
contractor shall establish signed provider agreements between network
private sector care providers and the contractor.
3.2.1 Network
provider agreements shall include language indicating that the provider
agrees to participate on claims for authorized services for TOP
enrollees on a cashless, claimless basis.
3.2.2 Network
provider agreements must specify rates for Service member medical
records photocopying and postage, if applicable.
Note: “Cashless, claimless” is defined
as a health care encounter that requires no up-front payment at
the time of service, and the provider files the claim for the beneficiary.
3.3 In TOP Prime
and TOP Prime Remote locations, the contractor shall size networks
to meet TOP Prime/Prime Remote-enrolled populations only. The TOP
contractor shall assist other beneficiaries (non-command sponsored
ADFMs, retirees, retiree family members, etc.) upon request by identifying
private sector care providers which are credentialed and familiar
with TRICARE, but the contractor shall not develop networks to accommodate non-TOP
Prime/Prime Remote enrollees.
3.4 In TOP Prime
locations, MTF Director
s will identify the
specialties needed in the network and will communicate this information
on an ongoing basis to the TOP contractor per the process identified
in the Statements of Responsibilities (SORs) (see
Section 15).
3.5 MTF capabilities
and capacities may change frequently over the life of the contract
without prior notice. The TOP contractor shall ensure that private
sector care provider services can be adjusted as necessary to compensate
for changes in MTF capabilities and capacities, when and where they
occur over the life of the contract, including short notice of unanticipated
facility expansion, provider deployment, downsizing, and/or closures.
3.6 Network
providers shall be able to communicate in English, both orally and
in writing, or provide translation services at the time of service.
3.7 The TOP
contractor
shall enter into participation
agreements with SNFs in Puerto Rico, Guam, the US Virgin Islands,
American Samoa, and the Northern Mariana Islands per the provisions
of
Section 3.
4.0 CONTRACTOR
REQUIREMENTS - private sector care PROVIDERS
4.1 The contractor
shall negotiate rates in specific countries designated in the contract.
Reimbursement rates for private sector care providers in other locations
may be negotiated by the contractor. In locations where the Government
has designated specific reimbursement rates or methodologies, the
contractor may not negotiate rates which exceed the Government directed
rate. Refer to the TRICARE Reimbursement Manual (TRM),
Chapter 1, Section 34 for additional instructions.
4.2 The contractor
shall provide ongoing private sector care provider education and
support in accordance with
Section 10.
4.3 The contractor
shall have a Clinical Quality Management Program (CQMP)/Clinical
Quality Oversight Plan as outlined in the DD for 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable contract
for reviewing access and quality of care provided by private sector
care providers. This plan shall incorporate customer comments and
feedback regarding care from private sector care providers.
4.4 The TOP
contractor shall deny claims from non-certified private sector care
providers when the DHA has directed that the country’s private sector
care providers must be specially certified in order to receive TRICARE payments.
See
Section 28 for additional certification requirements.