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TRICARE Operations Manual 6010.56-M, February 1, 2008 TRICARE Overseas Program (TOP) Chapter 24 Section 1
Administration
1.0 GENERAL
All TRICARE requirements regarding administration shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 1 for additional instructions regarding administration. Specific health care support services required for the performance of this contract are identified in this chapter, in the TPM, Chapter 12, and the TOP contract.
2.0 CONTRACT ADMINISTRATION AND INSTRUCTIONS TO CONTRACTOR
2.1 The provisions of Chapter 1, Section 2 are applicable to the TOP. Additionally, the TOP contractor shall coordinate with the TRICARE Management Activity (TMA) Contracting Officer (CO), the appropriate TMA Contracting Officer Representative (COR), and the appropriate TRICARE Area Office (TAO) Director on any TOP policy or contractual issue that requires additional government clarification or assistance to resolve.
2.2 The provisions of Chapter 1, Section 2, paragraph 4.0 are superseded as described in paragraphs 2.2.1 through 2.2.5.
2.2.1 A 14 calendar day notice will be provided by the TMA Procurement Contracting Officer (PCO) for all meetings hosted by TMA.
2.2.2 The TOP contractor shall provide up to four contractor representatives at the Performance Readiness Validation briefing at TMA.
2.2.3 The TOP contractor shall provide at least two contractor representatives for transition briefings/meetings with each overseas Military Treatment Facility (MTF) and TAO. All briefings/ meetings must be completed no later than 60 calendar days prior to the start of health care delivery.
2.2.4 The TOP contractor shall provide annual representation at two contractor conferences (senior management level) and one Host Nation Provider Representative meeting at TMA. The contractor shall also provide up to four contractor representatives at up to four additional meetings at the direction of the CO per contract year.
2.2.5 The TOP contractor shall provide representation at quarterly semiannual TOP roundtable operational meetings to be held at TMA-Falls Church Aurora with TAO and service representation.
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Chapter 24, Section 1
Administration
2.2.6 The TOP contractor shall provide two contractor representatives at up to 18 additional meetings/site visits at the direction of the Contracting Officer per option period.
3.0 TRICARE PROCESSING STANDARDS
See Chapter 1, Section 3 for instructions regarding TRICARE processing standards.
Note: The standards for telephone inquiries apply to all toll-free lines supporting TOP contract customer service activities.
4.0 MANAGEMENT
The provisions of Chapter 1, Section 4 are applicable to the TOP, except that the provisions of Chapter 1, Section 4, paragraph 2.3 regarding zip code files are only applicable to Puerto Rico.
5.0 COMPLIANCE WITH FEDERAL STATUTES
See Chapter 1, Section 5 for instructions regarding compliance with Federal statutes.
6.0 LEGAL MATTERS
See Chapter 1, Section 6 for instructions regarding legal matters.
7.0 TRANSITIONS -- CONTRACT PHASE-IN
7.1 Start-Up Transition-In (Phase-In) Plan
The provisions of Chapter 1, Section 7, paragraph 1.1 are applicable to the TOP, except that the contractor’s comprehensive start-up plan shall be submitted with their contract proposal (instead of 10 calendar days following contract award). A revised start-up plan shall be submitted within 15 calendar days following the interface meetings. In addition to the start-up (transition-in/ phase-in) plan, the contractor shall provide weekly status reports through the first 180 calendar days of the contract or as directed by the Government.
7.2 Transition Specifications Meeting
See Chapter 1, Section 7, paragraph 1.2 for instructions regarding transition specification meeting(s). Separate meetings may be scheduled with each outgoing TOP contractor.
7.3 Interface Meetings
The provisions of Chapter 1, Section 7, paragraph 1.3 are applicable to the TOP., except that the requirement for interface meeting(s) with the outgoing Managed Care Support Contractor (MCSC) is replaced with a requirement for interface meetings with all outgoing overseas contractors. This includes the outgoing South Region MCSC (and its subcontractor for overseas claims processing), the outgoing TRICARE Global Remote Overseas (TGRO) contractor, the outgoing TRICARE Puerto Rico contractor, and all outgoing TAO regional enrollment/marketing contractors.
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Administration
7.4 MTF/TAO Transition Briefings/Meetings
The contractor shall provide on-site transition briefings/meetings with all MTFs and TAOs per paragraph 2.2.3. These briefings/meetings shall be targeted towards command suite/key leaders and their staff and shall encompass all key contract areas where collaboration between the contractor and the MTF/TAO will occur.
8.0 TRANSITIONS -- START-UP REQUIREMENTS
8.1 See Chapter 1, Section 7, paragraphs 2.1, 2.2, and 2.3 for instructions regarding start-up requirements. For purposes of TOP implementation, all references to TRICARE Prime in paragraph
2.2 shall apply to TOP Prime and TOP Prime Remote.
8.2 Within 30 calendar days following contract award, all Military Treatment Facilities (MTFs) shall provide the TOP contractor with the names and addresses of host nation providers/facilities in the MTF’s Preferred Provider Network (PPN). The TOP contractor is not required to duplicate existing networks.
8.2 See Chapter 1, Section 7, paragraphs 2.4.1 and 2.4.2 Section 16 for instructions regarding Memorandums of Understanding (MOUs) Statements of Responsibilities (SORs). In addition to the MOU SOR requirements in these referenced paragraphs, the TOP contractor shall also execute an MOU SOR with each TAO Director No Later Than (NLT) 60 calendar days prior to the start of health care delivery, with copies to the PCO and the COR within 10 calendar days following MOU SOR execution.
8.3 See Chapter 1, Section 7, paragraphs 2.5 and 2.6 for instructions regarding phase-in of TRICARE enrollment and transfer of enrollment files. For purposes of TOP implementation, all references to TRICARE Prime in these paragraphs shall apply to TOP Prime and TOP Prime Remote.
8.4 The provisions of Chapter 1, Section 7, paragraph 2.7 are not applicable to the TOP, since there are no enrollment fees associated with TOP Prime or TOP Prime Remote.
8.5 See Chapter 1, Section 7, paragraph 2.8 for instructions regarding Health Care Finder (HCF) phase-in.
8.6 See Chapter 1, Section 7, paragraph 2.9 for instructions regarding TRICARE Service Center (TSC) phase-in.
Note: Overseas TSCs are managed by the MTFs and are jointly staffed by MTF and TOP contractor personnel. The TOP contractor is responsible for providing on-site Beneficiary Service Representative (BSR) support in all TSC locations.
8.7 All claims that fall within the scope of the TOP contract received on or after the start of health care delivery on the TOP contract shall be processed by the TOP contractor.
Note: Normal claims filing deadlines apply. See Chapter 8, Section 3 and Section 9, paragraph 3.0.
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8.8 The provisions of Chapter 1, Section 7, paragraph 2.10 are applicable to the TOP, except that the provisions of Chapter 1, Section 7, paragraph 2.10.4 are superseded by a requirement for the incoming contractor to cover non-obstetrical care for 90 days after the start of health care delivery under the incoming contract, in accordance with the outgoing contractor’s existing practices and protocols, within the scope of the TRICARE program and applicable regulations or statutes. This transition period for prior authorizations and referrals is extended to one year for obstetrical care or any other condition for which a one-year authorization has been issued.
8.9 See Chapter 1, Section 7, paragraph 2.11 for instructions regarding contractor weekly status reporting.
8.10 The provisions of Chapter 1, Section 7, paragraph 2.12 are not applicable to the TOP. Instead, the TOP contractor shall prepare a mailing to the Resident Commissioners of Puerto Rico and the Northern Mariana Islands, and the Congressional representatives for American Samoa, Guam, and the U.S. Virgin Islands by the 45th calendar day prior to the start of health care delivery according to the specifications of the official transition schedule. This requirement supersedes the requirements outlined in Chapter 1, Section 7, paragraph 2.12. The proposed mailing shall be submitted to the TMA CO, TMA COR, TAO Directors, and the TMA Program Integration Office for approval NLT 90 calendar days prior to the start of health care delivery. The mailing shall discuss any unique processing requirements of the contractor and any other needed information dictated by the official transition schedule.
8.11 See Chapter 1, Section 7, paragraphs 2.13 and 2.14 for instructions regarding web-based services and applications and TRICARE Handbook mailings.
9.0 TRANSITIONS -- CONTRACT PHASE-OUT
The provisions of Chapter 1, Section 7, paragraph 4.0 are applicable to the TOP, except that the requirement in paragraph 4.4 for the outgoing contractor to process claims and adjustment for 120 days following cessation of health care delivery is waived for the TOP. The outgoing contractor is only required to process claims and adjustments received during it’s period of service delivery.
Processing of all claims shall be completed within 180 calendar days following the start of the incoming contractor’s services delivery.
- END -
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| TO08_top 2014 REVISED Sep 5th.pdf |
| DTP PUBLICATION CHANGE FORM - TOM |
| 02/04/14 |
| 02/06/14 |
| TP08 |
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| - END - |
| c24s30.pdf |
| Chapter 24 |
| Section 30 |
| Figures |
| Figure 24.30-1 Overseas Pharmacy Provider Notice Letter (Sample) |
| Figure 24.30-2 TOP Contractor Provider Certification Request Letter |
| OVERSEAS |
| (Sample Philippine Contractor Provider Certification Request Letter) |
| (Contractor’s Name and Address) |
| Figure 24.30-3 Attestation |
| c24s30.pdf |
| Chapter 24 |
| Section 30 |
| Figures |
| Figure 24.30-1 Overseas Pharmacy Provider Notice Letter (Sample) |
| Figure 24.30-2 TOP Contractor Provider Certification Request Letter |
| OVERSEAS |
| (Sample Philippine Contractor Provider Certification Request Letter) |
| (Contractor’s Name and Address) |
| Figure 24.30-3 Attestation |
| c24s26.pdf |
| Chapter 24 |
| Section 26 |
| TRICARE Overseas Program (TOP) Supplemental Health Care Program (SHCP) |
| 1.0 general |
| 1.1 All TRICARE requirements regarding the Supplemental Health Care Program (SHCP) shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by this section, TRICARE Policy Manual (TPM), Chapter 12, or the T... |
| 1.2 Uniformed service members in an active duty status of greater than 30 days (also known as Active Duty Service Members (ADSMs)) who are on permanent or official duty assignment in a location outside the 50 United States and the District of Columbi... |
| 2.0 Contractor Responsibilities |
| 2.1 ADSMs who are enrolled in TOP Prime shall follow the procedures outlined in Chapter 17 for MTF-enrolled ADSMs, except that any references to the Military Medical Support Office (MMSO) should be replaced by a reference to the appropriate regional ... |
| 2.2 If an ADSM seeks host nation care without appropriate authorization, they put themselves at financial risk for claims payment. They are also at risk for potential compromise of medical readiness posture, flight status, or disability benefits, and... |
| 2.3 The TOP contractor shall ensure a benefit review is done on each SHCP referral and authorization. The TOP contractor shall return deferred-to-network referrals for non-covered services with an explanation of why it was denied. The TOP contractor ... |
| 2.3.1 If the contractor determines that the requested service, supply, or equipment is not covered by TRICARE policy and no TMA approved waiver is provided, the contractor shall decline to file an authorization and shall deny any received claims acco... |
| 2.3.2 TRICARE benefits may not be extended for complications resulting from non-covered surgeries and treatments performed outside the MTF for a Service member without an approved waiver. If the treatment is a non-covered TRICARE benefit, any follow-... |
| 2.4 The provisions of Chapter 17 are changed for the TOP as follows: |
| 2.4.1 The provisions of Chapter 17, Section 2, paragraph 2.0 (Uniformed Services Family Health Plan (USFHP)) are not applicable to the TOP contract. USFHP services are not available outside the 50 United States and the District of Columbia. |
| 2.4.2 Except for the claims for ADSM care provided under the National DoD/DVA MOA, the provisions of Chapter 17, Section 3, paragraph 1.2.1 regarding the timeline for review of SHCP claims by overseas MTFs is extended to 10 calendar days. ADSM claims... |
| 2.4.3 The provisions of Chapter 17, Section 2, paragraph 3.1 regarding claims for care provided under the National DoD/DVA MOA for Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation, and Polytrauma are applicable to the TOP ... |
| 2.4.4 The provisions of Section 6, paragraph 5.0 and Chapter 8, Section 5 apply to TOP SHCP referrals. Additionally, when MTFs submit a referral request for purchased care services for a non- AD sub-population beneficiary eligible for SHCP, the MTF s... |
| 2.5 When an ADSM leaves a remote TOP assignment as a result of Permanent Change of Station (PCS) or other service-related change of duty status, the following applies in support of medical record accumulation: |
| 2.5.1 For ADSMs leaving remote TOP assignment in Puerto Rico, the PCM shall provide a complete copy of medical records, to include copies of specialty and ancillary care documentation, to ADSMs within 30 calendar days of the ADSM’s request for the ... |
| 2.5.2 For ADSMs leaving remote TOP assignments from all overseas areas other than Puerto Rico, ADSMs in those locations should request medical records from the host nation provider(s) who provided health care services during the ADSM’s tour of duty... |
| 2.5.3 Records provided by host nation providers in languages other than English may be submitted to the TOP contractor for translation into English according to the terms of the contract. |
| 2.5.4 Network host nation providers shall be reimbursed for medical records photocopying and postage costs incurred at the rates established in their network provider participation agreements. Non-network host nation providers shall be reimbursed for... |
| 2.6 Provision of Respite Care For The Benefit of Seriously Ill or Injured Active Duty Members |
| 2.6.1 The provisions of Chapter 17, Section 3 and the TRICARE Systems Manual (TSM), Chapter 2, Sections 2.8 and 6.4 regarding respite care for seriously ill or injured ADSMs are applicable in locations outside the 50 United States and the District of... |
| 2.6.2 The respite care benefit is applicable to ADSMs enrolled to TOP Prime, TOP Prime Remote, and to any ADSM referred by an overseas MTF or TAO. |
| 2.6.3 All normal ADSM authorization and case management requirements for the TOP apply to the ADSM respite care benefit. |
- END -
| c24s25.pdf |
| Chapter 24 |
| Section 25 |
| Continued Health Care Benefit Program (CHCBP) |
| 1.0 GENERAL |
| 2.0 ELIGIBILITY AND ENROLLMENT |
| 2.1 CHCBP enrollees in overseas locations are not eligible for enrollment in TOP Prime or TOP Prime Remote. |
| 2.2 CHCBP enrollees in overseas locations cannot use the TRICARE Extra program, regardless of whether they receive care from a network host nation purchased care sector provider. TRICARE Extra is not available in any overseas location. CHCBP claims i... |
| 3.0 CONTRACTOR RESPONSIBILITIES |
| 3.1 The TOP contractor is not required to develop host nation purchased care sector provider networks to support the CHCBP beneficiary population. |
| 3.2 The TOP contractor is not required to provide Guarantee of Payment or implement other business processes to provide to host nation providers or institutions for CHCBP enrollees with cashless, claimless care. |
| 3.3 The TOP contractor is not required to make appointments with host nation purchased care sector providers for CHCBP enrollees. However, upon beneficiary request, the contractor shall provide CHCBP enrollees with the name, telephone number, and add... |
| 3.4 The TOP contractor shall provide general CHCBP program information and enrollment forms upon request. |
- END -
| c24s22.pdf |
| Chapter 24 |
| Section 22 |
| TRICARE Plus |
| 1.0 GENERAL |
| 1.1 TRICARE Plus is a service-directed primary care enrollment program that is available at selected Military Treatment Facilities (MTFs). Local MTF commanders determine whether TRICARE Plus shall be offered based on their facility’s capacities, ca... |
| 1.2 All TRICARE requirements regarding TRICARE Plus shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE co... |
| 2.0 ELIGIBILITY |
| 3.0 ENROLLMENT |
| 3.1 All beneficiary inquiries regarding TRICARE Plus enrollment/disenrollment shall be directed to the TOP contractor’s toll-free number or, based on the Memorandum of Understanding (MOU) with each MTF Commander, to the designated MTF Point of Cont... |
| 3.2 MTFs are responsible for approving or disapproving requests for TRICARE Plus enrollment and for managing Primary Care Clinic capacity for TRICARE Plus enrollment. The MTF is responsible for ensuring that TRICARE Plus enrollment forms are complete... |
| 3.3 The TOP contractor is responsible for ensuring that all TRICARE Plus enrollments are entered through the Defense Online Enrollment System (DOES). The contractor shall return incomplete forms or any application for which enrollment/disenrollment c... |
| 3.4 TOP Prime and TOP Prime Remote cannot be used in conjunction with TRICARE Plus. Enrollment in TRICARE Plus will necessitate disenrollment from TOP Prime or TOP Prime Remote. |
| 3.5 TRICARE Plus enrollment to an overseas MTF is effective on the date the enrollment application is approved by the MTF. |
| 4.0 DISENROLLMENT |
| 4.1 All beneficiary inquiries regarding TRICARE Plus disenrollment shall be directed to the appropriate location in accordance with paragraph 3.1. Beneficiaries may disenroll from TRICARE Plus at any time. TRICARE Plus disenrollment is effective on t... |
| 5.0 HOST NATION PROVIDER SERVICES |
| 5.1 TRICARE Plus is an MTF primary care access program, not a health plan. TRICARE Plus has no impact on care received from civilian providers. Claims for care rendered to TRICARE-eligible TRICARE Plus enrollees by civilian providers will be processe... |
| 5.2 The TOP contractor is not required to develop host nation provider networks to support the TRICARE Plus beneficiary population. |
| 5.3 The TOP contractor is not required to provide Guarantee of Payment to host nation providers or institutions for TRICARE Plus enrollees. |
| 5.4 The TOP contractor is not required to make appointments with host nation providers for TRICARE Plus enrollees. However, upon beneficiary request, the contractor shall provide the beneficiary with the name, telephone number, and address of host na... |
- END -
| c24s21.pdf |
| Chapter 24 |
| Section 21 |
| TRICARE Reserve Select (TRS) |
| 1.0 General |
| 2.0 ELIGIBILITY |
| 2.1 The TOP contractor shall provide TRS information and enrollment/disenrollment assistance to Reserve Component (RC) members residing in overseas locations outside the 50 United States and the District of Columbia. |
| 3.0 ENROLLMENT |
| 3.1 The TOP contractor shall process TRS enrollment applications and collect premium payments for TRS enrollment. |
| 3.2 TRS enrollees will receive a TRS member card reflecting their overseas region of enrollment (TRICARE Eurasia-Africa, TRICARE Pacific, or TRICARE Latin America/Canada (TLAC)). |
| 3.3 The TOP contractor shall process claims for TRS members enrolled overseas (regardless of where the care was rendered), and for TRS members enrolled in the 50 United States and the District of Columbia who receive health care services in an overse... |
| 3.4 The TOP contractor is not required to develop host nation purchased care sector provider networks to support the TRS beneficiary population. |
| 3.5 The TOP contractor is not required to provide Guarantee of Payment or implement other business processes to provide to host nation providers or institutions for TRS enrollees with cashless, claimless service. |
| 3.6 The TOP contractor is not required to make appointments with host nation purchased care sector providers for TRS enrollees. However, upon beneficiary request, the contractor shall provide the TRS enrollee with the name, telephone number, and addr... |
- END -
| c24s20.pdf |
| Chapter 24 |
| Section 20 |
| TRICARE Overseas Program (TOP) TRICARE For Life (TFL) |
| 1.0 GENERAL |
| 1.1 The TRICARE Overseas Program (TOP) TRICARE For Life (TFL) program provides health care administration and claims processing for individuals with dual eligibility under both Medicare and TRICARE who receive care in locations where Medicare is not ... |
| 1.2 The provisions of Chapter 20 regarding TFL are applicable to beneficiaries residing in locations where Medicare is available. These areas include the 50 United States, the District of Columbia, and the U.S. territories of Puerto Rico, Guam, the U... |
| 2.0 Jurisdiction |
| 2.1 Dual eligible beneficiaries are covered under TOP TFL if they receive care in a location where Medicare is not available. TOP TFL benefits, cost-shares, and deductibles are identical to TOP Standard. |
| 2.2 Dual eligible beneficiaries residing in Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands are not covered under TOP TFL. These beneficiaries receive TRICARE coverage under the TRICARE Dual Eligible Fisca... |
| 2.3 Claims for services rendered on board a commercial ship are the responsibility of the TDEFIC contractor if the care was rendered in the territorial waters adjoining the land areas of the United States. Claims for services rendered on board ship w... |
| 3.0 CONTRACTOR RESPONSIBILITIES |
| 3.1 The TOP contractor shall provide administration and claims processing services for the TOP TFL program. |
| 3.2 TOP TFL has the same cost-shares and deductibles as TOP Standard. |
| 3.3 TOP TFL has the same requirements for referrals or prior authorizations as TOP Standard. All TOP requirements regarding provider certification apply. |
| 3.4 The TOP contractor is not required to develop host nation purchased care sector provider networks to support the TOP TFL beneficiary population. |
| 3.5 The TOP contractor is not required to provide health care on a cashless, claimless basis for TOP TFL beneficiaries. |
| 3.6 The TOP contractor is not required to make appointments with host nation purchased care sector providers for TOP TFL beneficiaries. However, upon beneficiary request, the contractor shall provide the beneficiary with the name, telephone number, a... |
- END -
| c24s19.pdf |
| Chapter 24 |
| Section 19 |
| TRICARE Overseas Program (TOP) Standard |
| 1.0 General |
| 1.1 All TRICARE requirements regarding TRICARE Standard shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICAR... |
| 1.2 TOP Standard is identical to TRICARE Standard in the United States with benefits, deductibles, and cost-shares unchanged. Beneficiaries residing overseas may be required to pay up front and file a claim for reimbursement. |
| 1.3 TRICARE requirements regarding TRICARE Extra are not applicable to the TOP contract. TRICARE Extra is not available overseas. |
| 2.0 ELIGIBILITY |
| 3.0 Contractor Responsibilities |
| 3.1 The TOP contractor shall process claims and provide claims assistance for TRICARE Standard beneficiaries who reside in an overseas location (regardless of where the care was rendered), and for TRICARE Standard beneficiaries residing in the United... |
| 3.2 The TOP contractor is not required to develop host nation purchased care sector provider networks to support the TOP Standard beneficiary population. |
| 3.3 The TOP contractor is not required to provide health care services on a cashless, claimless basis for TOP Standard beneficiaries, or for TRICARE Standard beneficiaries residing in the United States and the District of Columbia who receive health ... |
| 3.4 The TOP contractor is not required to make appointments with host nation purchased care sector providers for TOP Standard beneficiaries, or for TRICARE Standard beneficiaries residing in the United States and the District of Columbia who receive ... |
- END -
| c24s18.pdf |
| Chapter 24 |
| Section 18 |
| TRICARE Overseas Program (TOP) Prime Remote Program |
| 1.0 GENERAL |
| 1.1 TRICARE Overseas Program (TOP) Prime Remote is available to Active Duty Service Members (ADSMs) (including Reserve Component (RC) members activated for more than 30 days) on permanent assignment to a remote overseas location, Command-Sponsored Ac... |
| 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, the District ... |
| 1.3 Under TOP Prime Remote, annual catastrophic caps are calculated on fiscal years. The enrollment year shall coincide with the fiscal year. Since deductibles and cost-shares are waived for TOP Prime Remote enrollees, this policy will apply only to ... |
| 2.0 Contractor Responsibilities |
| 2.1 TOP Prime Remote enrollees shall select or have assigned to them Primary Care Managers (PCMs) according to guidelines established by the TAO Director, or designee. The TOP PCM: |
| 2.1.1 TOP PCMs may be an individual professional provider (not a Partnership Provider), an overseas treatment site, or other health care delivery arrangement. For the purposes of referral management and authorization for TOP Prime Remote episodes of ... |
| 2.1.2 TOP PCMs may be an internist, family practitioner, pediatrician, general practitioner, obstetrician/gynecologist, physician assistant, nurse practitioner, or certified nurse midwives when determined by the TOP contractor to meet governing count... |
| 2.1.3 May also act as a Health Care Finder (HCF), when dual responsibility is necessary, as determined by the TAO Director. |
| 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 is responsible for referring the enrollee to anoth... |
| 2.3 TOP Prime Remote enrollees must obtain appropriate referral/authorization for any non- emergency care rendered by anyone other than the beneficiary’s PCM. This provision applies regardless of where the care is rendered. TAO Directors (or design... |
| 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 c... |
| 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 Remote enrollee and other beneficiaries in locating an Military Treatment Facility (MTF) or host nation TOP purch... |
| 2.6 All referrals made by a TOP designated host nation purchased care sector 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 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 R... |
| 2.8 Cashless, claimless provisions do not apply to self-referred care that would normally require an authorization. |
| 2.9 For TOP Prime Remote enrollees who are traveling stateside, the TOP contractor and the TAO Directors will encourage direct TOP beneficiaries to utilize stateside MTFs and network providers whenever possible. If MTF care is unavailable, beneficiar... |
| 3.0 Point of service (POS) Option |
| 3.1 TOP Prime Remote-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 out... |
| 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 There are no Non-Availability Statement (NAS) requirements for TOP Prime Remote enrollees. This requirement is replaced by a care authorization from the TOP contractor or other appropriate authority. |
| 3.4 Self-referred, non-emergency, specialty, or inpatient care provided to a TOP Prime Remote ADFM enrollee by a network or non-network host nation purchased care sector provider, which is not either provided/referred by the beneficiary’s PCM or sp... |
| 3.5 POS cost-sharing and deductible amounts do not apply 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), Chap... |
| 3.6 The POS option does not apply to ADSM overseas/stateside care. |
| 3.7 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 contractor processes a claim without evidence of an authorization and/or a referral... |
| 3.8 On a case-by-case basis, following stabilization of the patient, the TAO Director may require a TOP Prime Remote beneficiary to transfer to a TOP network facility or the MTF. The TOP TAO Director shall provide written notice to the beneficiary (o... |
| 3.9 The following deductible and cost-share amounts apply to all TOP Prime Remote POS claims for health care services: |
| 3.9.1 Enrollment year deductible for outpatient claims (no deductible applies to inpatient services): $300 per individual; $600 per family. |
| 3.9.2 Beneficiary cost-share for inpatient and outpatient claims: 50% of the allowable charge after the deductible has been met (deductible only applies to outpatient claims). |
| 3.9.3 POS deductible and cost-share amounts are NOT creditable to the enrollment/fiscal year catastrophic cap and they are not limited by the cap. |
| 3.9.4 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 |
- END -
| c24s17.pdf |
| Chapter 24 |
| Section 17 |
| TRICARE Overseas Program (TOP) Prime Program |
| 1.0 GENERAL |
| 1.1 TRICARE Overseas Program (TOP) Prime is available to Active Duty Service Members (ADSMs) (including Reserve Component (RC) members activated for more than 30 days) who are on permanent assignment overseas in a location serviced by a Military Trea... |
| 1.2 TOP Prime has no enrollment fees, and deductibles and cost-shares are waived except for TOP Prime ADFMs who receive care under the Point of Service (POC) option, or who obtain pharmacy services in the 50 United States, the District of Columbia, o... |
| 1.3 Under TOP Prime, annual catastrophic caps are calculated on fiscal years. The enrollment year shall coincide with the fiscal year. Since deductibles and cost-shares are waived for TOP Prime enrollees, this policy will apply only to TOP Prime enro... |
| 2.0 Contractor Responsibilities |
| 2.1 TOP Prime enrollees shall select or have assigned to them PCMs according to guidelines established by the MTF Commander, TRICARE Area Office (TAO) Director, or designee. TOP Prime enrollment to a host nation purchased care sector PCM may only occ... |
| 2.1.1 May be an individual professional provider (not a Partnership Provider) in an overseas MTF, other military treatment site, or other health care delivery arrangement that is part of the MTF. MTF PCMs may be organized into teams for the purpose o... |
| 2.1.2 May be a host nation purchased care sector primary care provider (internist, family practitioner, pediatrician, general practitioner, obstetrician/gynecologist, physician assistant, nurse practitioner, or certified nurse midwife) when determine... |
| 2.1.3 May also act as a Health Care Finder (HCF), when dual responsibility is necessary, as determined by the MTF commander or TAO Director. |
| 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 prim... |
| 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. TAO Dire... |
| 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 Active Duty Family Member (ADFM) with a deductible and cost-shares for outpat... |
| 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 host nation TOP network or non-network provider to provide... |
| 2.6 TOP MTF PCMs may be delegated authority by the TOP MTF Commander to authorize referrals within the MTF. All referrals/authorizations to civilian host nation providers and all referrals/authorization made by a TOP designated host nation PCM must b... |
| 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 enrollee... |
| 2.8 Cashless, claimless provisions do not apply to self-referred care that would normally require authorization. |
| 2.9 MTFs have right of first refusal for any specialty care provided to TOP Prime enrollees. First right of refusal is defined as providing the MTF with an opportunity to review each referral from either an MTF or purchased care sector provider to de... |
| 2.10 For TOP Prime enrollees who are traveling in the 50 United States or the District of Columbia, the TOP contractor and the TAO Directors will encourage direct TOP beneficiaries to utilize stateside MTFs and TRICARE network providers whenever poss... |
| 3.0 POS Option |
| 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... |
| 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 There are no NAS requirements for TOP Prime enrollees. This requirement is replaced by a care authorization from the PCM. |
| 3.4 Self-referred, non-emergency, specialty, or inpatient care provided to a TOP Prime enrollee by a network or non-network host nation purchased care sector provider, which is not either provided/referred by the beneficiary’s PCM or specifically a... |
| 3.5 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, Secti... |
| 3.6 The POS option does not apply to ADSM overseas/stateside care. |
| 3.7 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 ... |
| 3.8 On a case-by-case basis, following stabilization of the patient, the MTF Commander may require a TOP Prime beneficiary to transfer to a TOP network facility or the MTF. The MTF Commander shall provide written notice to the beneficiary (or respons... |
| 3.9 The following deductible and cost-share amounts apply to all TOP Prime POS claims for health care services: |
| 3.9.1 Enrollment year deductible for outpatient claims (no deductible applies to inpatient services): $300 per individual; $600 per family. |
| 3.9.2 Beneficiary cost-share for inpatient and outpatient claims: 50% of the allowable charge after the deductible has been met (deductible only applies to outpatient claims). |
| 3.9.3 POS deductible and cost-share amounts are NOT creditable to the enrollment/fiscal year catastrophic cap and they are not limited by the cap. |
| 3.9.4 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 6 for additional guidance regarding deemed enrollment for newborns/adoptees |
- END -
| c24s16.pdf |
| Chapter 24 |
| Section 16 |
| TRICARE Area Office (TAO) Director/Military Treatment Facility (MTF) And Contractor Interfaces |
| 1.0 GENERAL |
| 2.0 Government/Contractor Responsibilities |
| 2.1 The Memorandum of Understanding (MOU) requirements outlined in Chapter 15, Section 1 are applicable to the TOP. The TOP contractor shall enter into a MOU with each TRICARE Area Office (TAO) Director to address region-specific issues and procedure... |
| 2.2 Note: MOUs must be re-executed and approved annually (Chapter 15, Section 1). Beginning with Option Period 2, MOUs may be re-executed by the development of a cover sheet which identifies any changes in processes/staff since the previous MOU was s... |
| 2.3 MOUs shall identify MTF hours/days of operation, to include any holiday or training days, and other unique issues regarding MTF operation (e.g., inclement weather procedures). The MTFs shall ensure that the MOU is updated as changes occur. |
| 2.4 MOUs shall include a process for ongoing, regular communication between TAOs, MTFs, and the contractor regarding anticipated changes that may affect health care delivery for TOP beneficiaries (e.g., deployments, increase/decrease in MTF capacity ... |
| 2.5 The provisions of Chapter 15, Sections 2 and 3 are not applicable to the TOP. |
| 2.6 The TOP contractor shall immediately notify the TAO Directors and TRICARE Management Activity (TMA) of any changes to telephone and/or fax numbers for contractor facilities or key personnel. |
- END -
| c24s15.pdf |
| Chapter 24 |
| Section 15 |
| Audits, Inspections, Reports, And Plans |
| w |
| 1.0 General |
| 2.0 Audits And Inspections |
| 2.1 The TOP contractor shall comply with the provisions of Chapter 14, Section 1 regarding audits and inspections. |
| 2.2 The TRICARE Overseas Currency reports, and the claims supporting them, are subject to audit by TRICARE Management Activity (TMA) or other authorized Government auditors as part of any financial audit. |
| 2.3 The claims auditing software requirements outlined in the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 3 do not apply to TOP claims. |
| 3.0 Reports And Plans |
| 3.1 All TOP reports and plans shall be submitted to TMA in accordance with the process identified in Chapter 14, Section 2, unless a different method of submission is identified in the Contract Data Requirement Lists (CDRLs), DD Forms 1423, incorpora... |
| 3.2 Reports must be sortable by all fields and by TOP Region/TRICARE Area Office (TAO) Director unless a different format is specified by the government. |
| 3.3 All reports and plans shall be titled as listed in the TOP contract CDRLs. |
| 3.4 All reports and plans shall contain the contact information for contractor personnel who were involved in preparation of the report/plan, and who can be contacted if questions arise. |
| 3.5 All reports and plans shall contain a legend for abbreviations or other terms used in the report. |
| 3.6 All TRICARE requirements regarding Health Insurance Portability and Accountability Act of 1996 (HIPAA) and privacy of Individually Identifiable Health Information (IIHI) shall apply to TOP reports and plans. |
- END -
| c24TOC.pdf |
| Chapter 24 |
| TRICARE Overseas Program (TOP) |
| 1 |
| 2 |
| 3 |
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| 5 |
| 6 |
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| 23 |
| 24 |
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| Binder1.pdf |
| c24s1 |
| c24s3 |
| c24s4 |
| c24s5 |
| c24s6 |
| c24s7 |
| c24s9 |
| c24s10 |
| c24s11 |
| c24s12 |
| c24s14 |
| c24s15 |
| c24s16 |
| c24s17 |
| c24s18 |
| c24s19 |
| c24s20 |
| c24s21 |
| c24s22 |
| c24s25 |
| c24s26 |
| c24s30 |
| c24TOC |
| to08IX |
| c24TOC.pdf |
| Chapter 24 |
| TRICARE Overseas Program (TOP) |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 6 |
| 7 |
| 8 |
| 9 |
| 10 |
| 11 |
| 12 |
| 13 |
| 14 |
| 15 |
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| 20 |
| 21 |
| 22 |
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| 29 |
| 30 |
| TO08chgfrm.pdf |
| DTP PUBLICATION CHANGE FORM - TOM |
| 02/04/14 |
| 02/11/14 |
| TP08 |
| C-117, 02/11/14 |
| 1. |
| x |
| 1, 2, 4 - 8 |
| 1, 2, 4 - 10 |
| 6. |
| x |
| 1 - 5, 7 - 12, 14 - 17 |
| 1 - 17 |
| 9. |
| x |
| 1 - 4 |
| 1 - 4 |
| 25. |
| 26. |
| 27. |
| 28. |
| 29. |
| 30. |
| 31. |
| to08IX.pdf |
| Index |
| Appendix A |
| 16 |
| B |
| 24 |
| 10 |
| 19 |
| A |
| 1 |
| A |
| 1 |
| 4 |
| 1 |
| 7 |
| 11 |
| 7 |
| 24 |
| 7 |
| 12 |
| 5 |
| 12 |
| A |
| 12 |
| 1 |
| 24 |
| 13 |
| 12 |
| 4 |
| 8 |
| 7 |
| 18 |
| 15 |
| 20 |
| 6 |
| 14 |
| 1 |
| 14 |
| 2 |
| 14 |
| 3 |
| 24 |
| 15 |
| 24 |
| 15 |
| 18 |
| A |
| 24 |
| 11 |
| 11 |
| 3 |
| 13 |
| 2 |
| 24 |
| 26 |
| 8 |
| 6 |
| 3 |
| 3 |
| 10 |
| A |
| 10 |
| 1 |
| 8 |
| 3 |
| 20 |
| 3 |
| 8 |
| A |
| 8 |
| 1 |
| 24 |
| 9 |
| 24 |
| 8 |
| 7 |
| 4 |
| 15 |
| 3 |
| 11 |
| 9 |
| 1 |
| 5 |
| 26 |
| 1 |
| 24 |
| 25 |
| 1 |
| 2 |
| 7 |
| 3 |
| 17 |
| 3 |
| 16 |
| 4 |
| 11 |
| 5 |
| 18 |
| 7 |
| 24 |
| 11 |
| Appendix B |
| 18 |
| 15 |
| 18 |
| 8 |
| 18 |
| 14 |
| 18 |
| 12 |
| 18 |
| 7 |
| 18 |
| 6 |
| 18 |
| 2 |
| 18 |
| 3 |
| 18 |
| 5 |
| 18 |
| 4 |
| 18 |
| 9 |
| 18 |
| 10 |
| 18 |
| 1 |
| 18 |
| 16 |
| 18 |
| 13 |
| 24 |
| 27 |
| 18 |
| 11 |
| 2 |
| 6 |
| 2 |
| 3 |
| 8 |
| 9 |
| 11 |
| 1 |
| 2 |
| B |
| 2 |
| 4 |
| 18 |
| 8 |
| 18 |
| A |
| 6 |
| 2 |
| 6 |
| 1 |
| 8 |
| 8 |
| 24 |
| 23 |
| 3 |
| 1 |
| 24 |
| 3 |
| 12 |
| 2 |
| 11 |
| 2 |
| 11 |
| 8 |
| 16 |
| 2 |
| 19 |
| 1 |
| 19 |
| B |
| 24 |
| 28 |
| 19 |
| 4 |
| 7 |
| C |
| 7 |
| B |
| 24 |
| 4 |
| 11 |
| 4 |
| 8 |
| 2 |
| 1 |
| 6 |
| 10 |
| B |
| 16 |
| 3 |
| 24 |
| 6 |
| 17 |
| D |
| 17 |
| C |
| 15 |
| A |
| 5 |
| 1 |
| 1 |
| 1 |
| 20 |
| 4 |
| 23 |
| 2 |
| 10 |
| 3 |
| 10 |
| 4 |
| 2 |
| A |
| 7 |
| A |
| 3 |
| 2 |
| 23 |
| 3 |
| 7 |
| 2 |
| 13 |
| 3 |
| 27 |
| 1 |
| 19 |
| 3 |
| 13 |
| 4 |
| 13 |
| A |
| 13 |
| 1 |
| 13 |
| 5 |
| 24 |
| 14 |
| 4 |
| A |
| 4 |
| 1 |
| 13 |
| 6 |
| 13 |
| 7 |
| 17 |
| 2 |
| 24 |
| 4 |
| 12 |
| 3 |
| 2 |
| 2 |
| 2 |
| 1 |
| 24 |
| 2 |
| 8 |
| 5 |
| 15 |
| 1 |
| 15 |
| 2 |
| 17 |
| B |
| 16 |
| C |
| 8 |
| 4 |
| 6 |
| 3 |
| 3 |
| 4 |
| 19 |
| 2 |
| 17 |
| 1 |
| 17 |
| A |
| 11 |
| 6 |
| 10 |
| 5 |
| 13 |
| 8 |
| 2 |
| 5 |
| 24 |
| 24 |
| 21 |
| 1 |
| 24 |
| 16 |
| 20 |
| 6 |
| 20 |
| 3 |
| 20 |
| 1 |
| 20 |
| 2 |
| 20 |
| 4 |
| 20 |
| 5 |
| 9 |
| 4 |
| 9 |
| C |
| 9 |
| E |
| 9 |
| 3 |
| 9 |
| A |
| 9 |
| 7 |
| 9 |
| 6 |
| 9 |
| 1 |
| 9 |
| 2 |
| 9 |
| B |
| 9 |
| D |
| 9 |
| 8 |
| 9 |
| 9 |
| 9 |
| 5 |
| 11 |
| A |
| 12 |
| 6 |
| 24 |
| 1 |
| 24 |
| 25 |
| 24 |
| 5 |
| 24 |
| 30 |
| 24 |
| 29 |
| 24 |
| 12 |
| 24 |
| 17 |
| 24 |
| 18 |
| 24 |
| 19 |
| 24 |
| 26 |
| 24 |
| 20 |
| 24 |
| 22 |
| 24 |
| 21 |
| 23 |
| 3 |
| 23 |
| 1 |
| 23 |
| 4 |
| 23 |
| 2 |
| 23 |
| 5 |
| 6 |
| 4 |
| 16 |
| 1 |
| 16 |
| A |
| 16 |
| 5 |
| 16 |
| 6 |
| 1 |
| 3 |
| 22 |
| 1 |
| 22 |
| A |
| 22 |
| 2 |
| 24 |
| 11 |
| 25 |
| 1 |
| 10 |
| 2 |
| 7 |
| 1 |
| - END - |
| TO08chgfrm.pdf |
| DTP PUBLICATION CHANGE FORM - TOM |
| 02/04/14 |
| 02/11/14 |
| TP08 |
| C-124, 04/07/14 |
| 1. |
| x |
| 1, 2, 4 - 8 |
| 1, 2, 4 - 10 |
| 6. |
| x |
| 1 - 5, 7 - 12, 14 - 17 |
| 1 - 17 |
| 9. |
| x |
| 1 - 4 |
| 1 - 4 |
| 25. |
| 26. |
| 27. |
| 28. |
| 29. |
| 30. |
| 31. |
| c24s5.pdf |
| Chapter 24 |
| Section 5 |
| TRICARE Overseas Program (TOP) Eligibility And Enrollment |
| 1.0 GENERAL |
| 2.0 Eligibility |
| 2.1 Eligibility for TRICARE is verified via the Defense Enrollment Eligibility Reporting System (DEERS). The DEERS record will indicate the dates of eligibility. Except for newborns, only those beneficiaries who are shown as eligible on DEERS will be... |
| 3.0 Enrollment Processing |
| 3.1 TOP Prime and TOP Prime Remote are available to Active Duty Service Members (ADSMs) and certain ADFMs in overseas locations as described below. These programs are similar, but not identical, to TRICARE Prime and TRICARE Prime Remote (TPR)/TRICARE... |
| 3.2 Unless a specific exception exists, enrollment to TOP Prime or TOP Prime Remote is available only to ADSMs who are permanently assigned overseas, and to ADFMs who are Command Sponsored and accompanying their sponsor on his/her overseas tour, or o... |
| 3.3 Non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for TOP Prime or TOP Prime Remote enrollment in any overseas location. This long-standing limitation derives from the limited number and capacity of MTFs and staff... |
| 3.4 Enrollment may occur at any time after TOP eligibility has been established, and normally remains effective during the overseas tour of the sponsor. Annual re-enrollment is not required for TOP Prime or TOP Prime Remote. Once enrolled, beneficiar... |
| 3.5 The TOP contractor shall perform all enrollment-related activities for TOP Prime, TOP Prime Remote, TRICARE Plus, TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), and TRICARE Retired Reserve (TRR) in overseas locations. These activities i... |
| 3.6 Enrollments for TOP Prime or TOP Prime Remote are effective on the date the enrollment request is received (and appropriate Command Sponsorship orders are received or attested to, when applicable), unless a retroactive enrollment has been authori... |
| 3.7 The contractor shall follow guidance from the TAO Directors and the MTFs regarding PCM assignment when enrolling beneficiaries into TOP Prime. The MTF enrollment area encompasses a 40-mile radius or a one-hour drive time from the MTF. TOP Prime R... |
| 3.8 Newborns/adoptees are deemed to be enrolled for 60 days following birth/adoption when one other family member, to include the sponsor, is enrolled in TOP Prime/TOP Prime Remote. Parents of newborns/adoptees are required to take specific action to... |
| 3.9 The provisions of Chapter 6, Section 1 and the TPM, Chapter 10, Section 2.1 regarding Prime enrollment fees shall not apply to TOP Prime or TOP Prime Remote. There are no enrollment fees associated with TOP Prime or TOP Prime Remote. |
| 4.0 Enrollment Policy For ADsms |
| 4.1 Except as described in paragraph 4.2, all ADSMs who are permanently assigned to an overseas duty location must be enrolled into the TOP program that is available in their area. This includes RC ADSMs who are called to active duty for more than 30... |
| 4.2 ADSMs assigned to operational forces with assigned organic medical assets may be enrolled to an operational forces’ DMIS ID affiliated with its “Parent” DMIS. This includes activated RC members on duty in combatant theaters of operation wit... |
| 5.0 Enrollment Policy For ADFMs |
| 5.1 ADFMs who have Permanent Change of Station (PCS) orders to accompany the sponsor overseas or service-funded orders to relocate overseas without the sponsor are eligible for TOP Prime or TOP Prime Remote enrollment. In order to enroll in these pro... |
| 5.1.1 If the ADSM and his/her Command Sponsored ADFM(s) are enrolled in TOP Prime or TOP Prime Remote, and the sponsor is reassigned on unaccompanied PCS orders to a location that does not permit Command Sponsored family members, the family member(s)... |
| 5.1.2 If the ADFM(s) are authorized to relocate to an overseas location per the sponsor’s PCS orders in accordance with JFTR U5222, or per Noncombatant Evacuation Orders without the sponsor, then the ADFM(s) are eligible for enrollment in the appro... |
| 5.1.3 If the ADFM(s) resided in an overseas location prior to the activation/mobilization of a RC sponsor, then the ADFM(s) are eligible for enrollment in the appropriate TOP program based on the residential mailing address of the sponsor prior to ac... |
| 5.1.4 If the ADFM(s) are currently enrolled in TOP Prime or TOP Prime Remote, and the family has a newborn or adopts a child, then the new family member will be eligible to enroll in the same TOP program. |
| 5.1.5 If the ADFMs are eligible for Transitional Survivor benefits (see Enrollment Policy for Transitional Survivors below). |
| 5.2 ADFMs who choose to reside overseas but are not Command Sponsored as defined in the JFTR, and who do not meet any of the exceptions listed above, are not eligible for enrollment in TOP Prime or TOP Prime Remote. These ADFMs are eligible for TRICA... |
| 5.3 Eligibility for TOP enrollment normally requires the family to be accompanied by the sponsor; therefore, a family member cannot relocate within the overseas region, relocate to another overseas region, or relocate from a overseas location to an o... |
| 5.4 The TOP contractor shall verify that all of the above requirements are met (including DEERS eligibility check and validation of Command Sponsorship/military orders, if required) prior to enrolling an ADFM into TOP Prime or TOP Prime Remote. |
| 5.5 The process for identifying ADFMs who are Command Sponsored may vary by Service. This is a Service personnel decision and as such, these processes may change over the life of the contract. The TOP contractor may accept any current, valid method o... |
| 6.0 Enrollment Policy For Transitional Survivors |
| 6.1 TOP Prime/TOP Prime Remote enrollment policy provisions which require command sponsorship shall not apply to Transitional Survivors whose sponsors died on or after October 7, 2001. |
| 6.2 Transitional Survivors whose sponsors died on or after October 7, 2001 and who choose to remain in an overseas location are eligible for TOP Prime/TOP Prime Remote enrollment during the Transitional Survivor period, regardless of whether they rem... |
| 6.3 Transitional Survivors whose sponsors died on or after October 7, 2001 and who choose to return to the United States from an overseas location are eligible for TRICARE Prime (in TRICARE Prime service areas) or TPRADFMs (in remote locations) durin... |
| 6.4 Transitional Survivors whose sponsors died on or after October 7, 2001 and who choose to move from a stateside location to an overseas location are eligible for TOP Prime or TOP Prime Remote enrollment during the Transitional Survivor benefit period |
| 6.5 Transitional Survivors whose sponsors died on or after October 7, 2001 are eligible for enrollment and claims reprocessing per TPM, Chapter 10, Section 7.1. Transitional Survivors are also eligible for enrollment fee refunds (if applicable) per T... |
| 6.6 If the Transitional Survivors are not enrolled in TOP Prime, the Transitional Survivor’s priority for appointments at overseas MTFs will be the same as that of ADFMs who are not enrolled in TOP Prime. |
| 6.7 At the end of the Transitional Survivor period, survivors lose their eligibility for enrollment in TOP Prime/TOP Prime Remote (in overseas locations) and TRICARE Prime/TPRADFM (in remote locations) in the 50 United States and the District of Colu... |
This is the start of the file's text. The full file is on GovTribe.