J-3b Program Ops OCONUS v2.docx

ATTACHMENT J-3b Program Operations for OCONUS

1.0 OCONUS RELATIONS. The contractor shall develop a TRICARE Area Office (TAO) Relations Program to facilitate the interface between the OCONUS providers and the OCONUS Dental Service Point of Contact (DSPOC) and also the ODTFs. The TAO Relations Program shall be developed and maintained in coordination with the Active Duty Dental Program (ADDP) Contracting Officer’s Representative (COR) and the OCONUS DSPOC.

2.0. ELIGIBLE ADSMs. The following ADSMs are eligible for OCONUS care:

· ADSMs enrolled in TRICARE Prime Remote

· ADSMs stationed in Bahrain or Souda Bay areas

· ADSMs that require urgent or emergency dental care while on Temporary Duty/Temporary Additional Duty (TDY/TAD), deployed, deployed on liberty, or in an authorized leave status in a remote overseas location (greater than 50 miles from the nearest MTF capable of providing dental care services)

Note: The availability of dental care within an ODTF is subject to change, which may require ODTFs to refer out some ADSMs for their dental care. DHA will coordinate any changes to ODTF dental care with the contractor.

3.0 GOVERNMENT ROLES

3.1. The DHA Dental Program Section’s responsibilities include, but are not limited to the following:

3.1.1. The DHA Dental Program Manager will review the contractor’s submitted recommendations for additions/deletions to the TOPD List, determine which additions and/or deletions will be made to the TOPD list, and forward those selected to the COR. The COR will update the Government’s internal TOPD list. The COR will forward the selected TOPDs (additions and/or deletions) to the contractor who is responsible for updating and maintaining the TOPD List on the contractor’s website. DHA will provide the initial TOPD list to the contractor as stated in the transition requirements at Section J, Attachment J-13, Transition-In.

3.1.2. The DHA Dental Program Manager or the COR will serve as facilitator to the contractor when necessary on specific ADSM/TOPD issues.

3.2. OCONUS DSPOC. The OCONUS DSPOC’s responsibilities include, but are not limited to the following:

3.2.1. Treatment Plans. Authorizes all dental readiness care for which the ADSM cannot self-refer (see paragraph 7.0). Reviews, treatment plans, authorizations and denials will be processed and maintained through the ADDP contractor’s referral and authorization tracking system (see Section J, Attachment J-3c, Program Operations for Data Systems).

3.2.2. The OCONUS DSPOC will coordinate directly with the TOPDs on treatment plans, and diagnostic requirements when necessary. All coordination efforts will be documented in the ADDP contractor’s referral and authorization tracking system. The OCONUS DSPOC may request language translation assistance from the contractor.

3.2.3. As events occur, the OCONUS DSPOC will advise the DHA Dental Program Manager and the contractor on issues concerning OCONUS standards of dental care, specific quality of care and program integrity issues and dental business practices.

4.0 CONTRACTOR RESPONSIBILITIES FOR THE TRICARE OCONUS PREFERRED DENTIST (TOPD)

4.1. The contractor shall meet the standard in Section C.4.1.5 for developing agreements with the TOPDs. TOPDs are not network providers. The contractor shall have a dental consultant (dentist) and staff to oversee the OCONUS program.

4.2. For providers who elect to join the program as TOPDs, the contractor shall establish and operate a credentialing/re-credentialing program to ensure that all TOPDs who provide dental services to TRICARE beneficiaries are qualified to provide high quality care that is commensurate with locality requirements. This program shall track and monitor the credentials of all TOPDs working under this contract. This shall include, at a minimum, verification of dental education and licensure, and verification that the minimum medical malpractice insurance standards (if applicable) have been met for their locality. The contractor’s dental consultant shall review and approve these verifications. The provider must also comply with the requirements of Section H.4, Payment of Taxes and Section H.5, Liability and Indemnification. In addition, the contractor shall ensure that TOPDs comply with the hold harmless provision, and appeals and grievance requirements in Section J, Attachment J-3a, Program Operations.

4.3. As part of the credentialing process, the contractor’s dental consultant shall visit the office/offices for the potential TOPD provider to verify that the office/offices promote appropriate levels of dental care, provide a safe environment to include appropriate patient safety, radiation safety and infection control practices, and billing practices that are commensurate with the ADDP contract and local requirements. The contractor shall re-credential TOPD providers at least once every three years, utilizing the same process used for initial credentialing.

4.4. A synopsis of the status of the credentialing program will be provided quarterly for the COR to review in CDRL Q010, Quality Control Program Report. On-site audits of the credentialing program may be conducted by the COR or his/her representative at any time.

4.5. The contractor may submit recommendations for providers to be added to or deleted from the TOPD List to the DHA Dental Program Manager. In coordination with the contractor, the local ODTF commander and OCONUS DSPOC may help identify providers for possible inclusion on the TOPD List.

4.6. The contractor shall inform the DHA Dental Program Manager within 10 calendar days of being made aware of locations where access to care is limited in terms of qualified provider availability, travel time and appointment wait time. The contractor shall make recommendations as to appropriate actions (if any) to improve access in these areas. Section C.4.1.3 network access standards do not apply to TOPDs or OCONUS.

4.7. The contractor shall identify new TOPDs by provider’s name, specialty, implant training, gender, work address, and work telephone number to the COR, via email, within 15 days of completing a TOPD agreement. Upon notification from the COR of the TOPD additions and/or deletions, the contractor shall update the TOPD list within 5 business days of receipt of the updated information. The contractor shall maintain the TOPD list on the contractor’s website and provide access/link to the TOPD list from TRICARE websites. The list will consist of general dentists and appropriate specialty care providers, such as oral surgeons, endodontists, orthodontists, periodontists and implant specialists who are available to provide care to OCONUS ADSMs within the three TAO areas: TRICARE Eurasia/Africa, TRICARE Latin America/Canada, and TRICARE Pacific.

4.8. The contractor shall provide all ADSMs, providers, and Government representatives, access to the TOPD list in a manner that maximizes access and allows for electronic sorting of the providers. Means of access shall include, but are not limited to electronic, paper, telephone or combination of these approaches that accurately conveys the name, specialty, implant training, gender, work address, and work telephone number of each TOPD to the party seeking TOPD list information.

4.9. The contractor is responsible for investigating any potential quality of care issues involving an ADDP ADSM. Once the contractor becomes aware of a potential quality of care issue, the contractor shall investigate to determine if there is a confirmed quality of care issue. For all confirmed quality of care issues, the contractor shall determine the root cause, implement corrective action plans as required, and continue to track the issue until fully resolved through its clinical quality management structure. The contractor shall ensure that the DHA Dental Program Manager, COR and OCONUS DSPOC are informed of any issues concerning OCONUS standards of dental care, specific quality of care and program integrity issues, and dental business practices, within 7 calendar days of becoming aware of the situation. The contractor shall coordinate with the DHA Dental Program Manager, COR and OCONUS DSPOC prior to taking any action against the TOPD. TOPDs may be subject to removal from the TOPD list in cases of fraud and abuse, or repeated quality of care incidents. In addition to being removed from the TOPD list, the provider may also be subject to the U.S. Military Authorities making the provider off limits to military members.

4.10. Translation Services.

4.10.1. The contractor shall provide real-time toll-free telephonic translation support services at the time of service upon ADSM request.

4.10.2. In accordance with Section J, Attachment J-3a, Program Operations, the contractor’s customer service center shall be able to communicate with non-English speaking customers. The contractor shall assist OCONUS providers with translation in order to file their claims.

4.10.3. When required, the contractor shall provide complete and accurate rendering of dental documentation (source material) for beneficiaries and Government customers into grammatically and colloquially correct products in the written English language. The contractor shall establish and maintain a secure, HIPAA-compliant Extranet portal and/or other business process to facilitate the secure transfer of source material for translation between Government customers and the contractor. Unless otherwise specified by the Contracting Officer, only source material, such as provider treatment notes from an office visit, that directly relates to the delivery of dental care is eligible for translation. The contractor shall provide accurate written translation of source material into written English to the requestor within 10 business days of receipt of the request. Time of receipt is defined as the time that documents are posted to a HIPAA-compliant system. The timeliness standard shall apply to translation requests for the following languages: German, Dutch, Flemish, French, Italian, Spanish, Portuguese, Arabic, Hebrew, Turkish, Greek, Polish, Hungarian, Bulgarian, Czech, Romanian, Russian, Chinese, Japanese, Korean, and Tagalog. Translation requests for languages other than those listed shall be accomplished on a best-effort basis.

4.11. TOPD Agreements. A TOPD shall agree to:

· Abide to the licensing requirements for the country in which they practice

· Abide to the standards of care for the country in which they practice

· Not collect payment upfront from an ADSM for authorized and/or covered services care

· Not require ADSMs to submit the claim to the contractor

· Submit claims directly to the contractor for authorized and/or covered services rendered to ADSMs

· Office visitations by the contractor to verify the adequacy of their dental practice

· Communicate in English (written and verbally) with the contractor and the ADSM. At a minimum, providers shall be able to communicate by utilizing staff to assist with language translation.

· Will furnish any information deemed necessary by the contractor and/or the Government Representative to make determinations of coverage and/or resolve questions concerning the services.

· Indicate Dental Readiness Classification (DRC) on the claim form

· Abide by the hold harmless, appeal and grievance requirements stated in Section J, Attachments J-3a, Program Operations.

· Acknowledge that in the event of a determination of fraud or abuse, they are subject to removal from the TOPD list and may also be subject to U.S. Military Authorities placing a ban on ADSMs utilizing their services.

· Notify their OCONUS DSPOC and the contractor if their practice is closed to new patients or is reopening to new patients after having been closed

· TOPDs shall provide copies of the treatment narrative summary (in the English language) and any radiographs of that treatment session within 10 business days of the treatment to the contractor. The provider shall include any duty limiting conditions for the ADSM in the treatment narrative summaries. The TOPD shall provide these copies at no additional charge. The contractor shall deny claims until these documents are received.

· If requested by the ADSM, TOPDs shall provide, within 10 business days of request, copies of the treatment narrative summaries in the English language at no additional charge to the ADSM.

5.0 EDUCATION

5.1. The contractor shall comply with the education requirements stated in Section J, Attachment J-3a, Program Operations. In addition, the contractor’s website will inform ADSMs that OCONUS standards of care are that of the locality in which they are received. The contractor shall assist in educating/assisting TOPDs to understand the rules of a TOPD agreement in accordance with paragraph 4.11, specific coverage, billing, and claim filing requirements of the ADDP. While the law permits OCONUS claims to be filed 3 years after the date of service, the contractor shall encourage TOPDs to file claims within 1 year after the date of service (see 10 U.S.C. 55 Section 1106). The contractor shall ensure all TOPDs are informed that claims not filed by the end of the residual claims processing period will not be accepted for processing, and in the event the claim is time barred the TOPDs are also prohibited from seeking to recover the cost of care from the ADSM. The education materials required to facilitate participation as a TOPD, or to encourage provision of care to ADSMs shall be developed by the contractor in coordination with the DHA Dental Program Section.

5.2. The contractor shall inform the OCONUS ADSMs:

· It is in their best interests to first contact the contractor before seeking any dental care.

· The benefits of seeking care from a TOPD.

· When an ADSM must receive an authorization for dental care.

· The process of how a claim is paid when a non-TOPD’s license cannot be verified (see paragraph 10.4).

6.0 CUSTOMER SERVICE

6.1. The contractor shall comply with the customer service requirements stated in Section C.4.1.10, and Section J, Attachment J-3a, Program Operations.

6.2. The contractor shall provide assistance if the ADSM requests help in finding an OCONUS provider, and/or scheduling an appointment.

7.0 REMOTE ADSM PROCEDURES AND POLICIES

71. The OCONUS DSPOC’s authorization is required for all care for which the remote ADSM cannot self-refer. The contractor shall submit all authorization requests, all supporting documentation, diagnostic quality radiographs, estimated time required for care, estimated cost in U.S. dollars, projected length of tour of duty at the patient’s present duty station, the patient’s enrolled site for medical and dental care, if known, and the patient’s case documents, in an electronic format to the OCONUS DSPOC via the contractor’s referral and authorization tracking system (see Section J, Attachment J-3c, Program Operations for Data Systems). The contractor shall utilize the DSPOC Review Codes listed in Section J, Attachment J-8, Dental Service Points of Contact (DSPOC) Review Codes, in conveying the OCONUS DSPOC’s approval/disapproval of authorization requests to the provider or ADSM.

7.1.1. The exception to the requirement of OCONUS DSPOC authorization is the contractor shall approve or deny authorizations for certain specialty care as specified in Section J, Attachment J-5a, Instructions for Remote ADSM’s Dental Care

7.2. Remote ADSMs can self-refer for all covered routine care except for care over $750 per procedure or appointment, or over a cumulative total of $1,500 for treatment plans completed within a consecutive 12-month period, and certain designated specialty procedures as described in Section J,-Attachment J-5a, Instructions for Remote ADSM’s Dental Care. These dollar thresholds are based on the OCONUS provider’s billed charges. In addition, the OCONUS DSPOC’s authorization is required for all care on appointments where routine care under $750 may be combined with specialty care that is provided on the same date of service, even if a portion of it has been previously approved.

7.3. All authorizations are valid for 12 months from the authorization date. The contractor shall deny claims for care received more than 12 months after the authorization date. If an appeal of the denial is submitted, the contractor shall follow the appeals process detailed in Section J-Attachment J-3a, Program Operations.

7.4. OCONUS DTF referred care is currently not authorized under this contract. The DHA, Dental Program Office will coordinate with the contractor if the OCONUS DTF is given authority to refer ADSM dental care. Bahrain and Souda Bay have DTFs. However, they cannot always accommodate the ADSMs. All non-DTF care for Bahrain and Souda Bay (except for emergencies) must be authorized by the OCONUS DSPOC prior to the ADSM receiving the care. This includes care under $750.

7.5. The contractor shall deny all OCONUS orthodontic service requests for ADSMs.

7.6. The contractor shall assist the ADSMs in submitting treatment plans for self-referrals to the OCONUS DSPOC for review.

7.7. While a remote ADSM can self-refer to a TOPD or a non-TOPD for all covered routine care under $750, the remote ADSM should be encouraged to contact the contractor’s customer service to schedule the care. Remote ADSMs who seek dental care without coordinating their care through the contractor may be required to pay up-front at the time services are rendered. The remote ADSM will then be responsible for submitting claims for reimbursement. Dental care claims that lack proper authorization when required shall be denied (see Section J, Attachment J-3a, Program Operations, for appeals).

7.8. Prior authorizations are not required for emergency dental care services. However, ADSMs should be encouraged to contact the contractor’s customer service for assistance with obtaining emergency dental care whenever possible. This shall ensure that service can be provided on a cashless, claimless basis for covered services from a qualified dental provider. If a contractor receives a request for payment of services from a TOPD or non-TOPD that qualify as emergency dental care, the contractor shall pay the claim for billed charges.

7.9. Medical Referrals. The contractor shall coordinate with the TRICARE Overseas Program (TOP) medical contractor when no dentist is available for remote ADSM dental emergencies, so that remote ADSMs may be referred to a medical provider for pain management pending travel to an area with a qualified dentist. (see Section J, Attachment J-13, Transition-In, for the Memorandum of Understanding [MOU] with the TOP contractor.)

7.10. Medical Evacuation/Transfer. The contractor shall coordinate with the OCONUS DSPOC, the DHA Dental Program Manager and the TOP medical contractor when an ADSM requires medical evacuation or medical transfer for medically necessary treatment.

7.11. Hold Harmless Provision. When seeking care from a TOPD, ADSMs shall be held harmless as stated in the Hold Harmless Provision requirements of Section J, Attachment J-3a, Program Operations.

7.12. Travel Benefits. TRICARE travel benefits do not apply overseas. Medical travel expenses (not including medical evacuations and medical transfers) are either covered by the Uniformed Services under the guidelines contained in the Joint Federal Travel Regulation (JFTR), or borne by the patient as a personal non-reimbursable cost. The Services are responsible for determining whether medical travel can be funded on official orders, and for issuing the appropriate funding and travel documents.

8. FRAUD AND ABUSE. If the ODTF or the OCONUS DSPOC are made aware of a possible fraudulent or abusive practice by an OCONUS provider or an ADSM in the OCONUS service area, the case should be referred to the contractor for development and possible referral to the DHA Office of Program Integrity. If a case potentially involves contractor fraud or abuse, the ODTF or OCONUS DSPOC should refer the case directly to the DHA Office of Program Integrity through the COR.

9.0 CLAIMS PROCESSING

9.1. The contractor shall comply with the claims requirements stated in Section C.4.1.7. The contractor shall provide a Dental Explanation of Benefits (DEOB) to the provider and ADSM as stated in Section J, Attachment J-3a, Program Operations.

9.2. Payment Assignment. Payment will be made based upon the assignment on the claim form indicated. If the claim is submitted by a TOPD and there is no assignment, the TOPD will be paid. If a provider submits the claim and requests that the payment be made to the ADSM, then the contractor shall forward the payment to the ADSM. Provider claims filed by the ADSM shall be paid to the ADSM in U.S. Dollars, unless the ADSM assigns payment to the provider in which case the payment shall be made in local currency. The currency conversion rate for payment shall be based on the most recent date of service stated on the claim.

9.3. The contractor shall accept claims from non-TOPDs. When a remote ADSM receives authorized care from a non-TOPD provider who demands payment prior to receiving care, the remote ADSM shall contact the contractor who shall arrange reimbursement to the provider. When a remote ADSM has paid a non-TOPD provider (e.g., an emergency situation) and seeks reimbursement, the contractor shall reimburse the ADSM.

9.4. Non-TOPD Licensure Verification. Claims for services rendered by providers who do not meet applicable licensure requirements shall be processed as follows: The contractor shall request the provider to submit verification of their licensure. When a non-TOPD does not respond within 30 days to the contractor’s request to provide verification of their licensure, the contractor shall pay the first claim for each ADSM. (The OCONUS claims processing standards stated at Section C.4.1.7.a.(2) will not apply to any non-TOPD claims held for licensure verification.) The claim may be for multiple visits, but will be counted as one claim submission. Each ADSM is allowed only three claim submissions from the same non-TOPD over the life of the contract when the non-TOPD’s license cannot be verified. Thereafter, the contractor shall deny any future claims for that ADSM for services from that provider until that provider provides verification of their licensure. The contractor shall notify the ADSM after processing each claim, by a means that verifies receipt of the notification, that the provider’s license cannot be verified and recommend that the ADSM switches to a licensed provider. The notification shall also inform the ADSM that after the third claim for services from this provider, no further claims from this provider will be paid until the provider’s licensure is verified by the contractor. The contractor shall include in the notification a minimum of one available licensed provider (TOPD or non-TOPD) in the local area from which the ADSM may receive care.

9.5. Questionable Services or Practices. For claims where the contractor believes the OCONUS provider’s services or practices are questionable, the contractor shall contact the respective OCONUS DSPOC and the DHA Dental Program Manager in advance of the contractor’s intended action to coordinate the proper approach and response (see paragraph 4.9 for quality of care issues).

9.6. No Procedure Codes. If the claim does not have Current Dental Terminology (CDT) procedure codes then the contractor shall manually code the claim based on narratives provided. The contractor shall coordinate with the provider as necessary in order to process the claim.

9.7. OCONUS Procedure Bundling. If the service that is considered integral is on the same claim with the corresponding definitive procedure, then the fee for the integral service will be added into the fee for the definitive service and only the definitive service is processed on the claim for payment.

9.8. Authorized Care. TOPD providers shall submit claims to the contractor for all authorized and/or covered dental care provided to eligible ADSMs. ADSMs shall not be billed for any authorized/covered care, nor be liable for any co-payments or cost-shares. The Government will reimburse the contractor for TOPD and non-TOPD authorized/covered dental care based on Exhibit A, CDT Pricing Table.

9.9. Emergency Claims. The Government will reimburse the contractor for TOPD and non-TOPD emergency dental care based on billed charges.

9.10. The contractor shall deny claims for care received more than 12 months after the authorization date.

9.11. Unauthorized Care. The contractor shall deny unauthorized care (see Section J, Attachment J-2, Benefits, Exclusions and Limitations). If the ADSM or provider appeals the initial denial, the contractor may approve the claim for payment one time, if it is for routine care. If the contractor approves the initial denial, the contractor shall process the claim for billed charges and the Government will pay the billed charges. The contractor shall inform the ADSM of the implications of seeking unauthorized care in that they may be held responsible for all costs. If the ADSM continues to seek unauthorized care, the contractor shall contact the OCONUS DSPOC for a coverage determination. The OCONUS DSPOC will direct the contractor to either pay for the service in full; or direct the ADSM to pay all charges. Payment will be made for billed charges.

9.12. Non-covered Benefit. If the contractor receives a request for payment of services for care that are not covered under Section J, Attachment J-2, Benefits, Exclusions and Limitations, the contractor shall contact the OCONUS DSPOC for a coverage determination. The OCONUS DSPOC will direct the contractor to either pay for the service in full; or direct the ADSM to pay all charges. Payment will be made for billed charges.

9.13. If the ADSM’s duty station is CONUS, but the ADSM requires emergency dental care while on OCONUS Temporary Duty/Temporary Additional Duty (TDY/TAD), deployed, deployed on liberty, or in an authorized leave status in a remote overseas location that is greater than 50 miles from the nearest MTF capable of providing dental care services, the contractor shall process the claim for billed charges.

9.14. If the ADSM’s duty station is OCONUS but is requesting to receive dental care in the United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, or the Northern Mariana Islands, the contractor shall follow the requirements stated in Section J-3a, Program Operations, for ADSMs stationed OCONUS.