J-4 Procedures for Remote ADSM Categories v2.docx

Attachment J-4 Procedures For Remote ADSM Categories

1.0. Early Activation Member Procedures.

1.1. Eligibility.

Reserve Component (RC) members who are issued delayed-effective-date active duty orders for more than 30 days in support of a contingency operation or a preplanned mission become eligible for Active Duty Service Member (ADSM) dental services as defined in the TRICARE Policy Manual (TPM), Chapter 10, Section 9.1, Early Eligibility Benefits for the Reserve Components (RCs).

1.2. Defense Enrollment Eligibility Reporting System (DEERS) Eligibility.

Defense Manpower Data Center (DMDC) will automatically enroll Early Eligible RC members upon notification of their eligibility into Health Care Dental Plan Code 234. Thus, DEERS dental eligibility will indicate remote status for the member.

1.3. Remote Status.

All RC members identified as Early Eligible members will have remote ADSM status (see Attachment J-5a, Instructions for Remote ADSM Dental Care).

1.4. Dental Services.

Dental services for Early Eligible RC members shall be provided in accordance with Section J, Attachment J-3a Program Operations.

2.0. Foreign Forces Members Procedures.

2.1. Eligibility.

Foreign Forces Members (FFMs) may be eligible for dental care under an approved agreement (e.g., reciprocal health care agreement, North Atlantic Treaty Organization (NATO) Status of Forces Agreement (SOFA), Partnership for Peace (PFP) SOFA).

2.2. Eligibility Determination.

FFMs on assignment in the United States will be shown on DEERS with a Health Care Coverage Code of “T”. FFMs that are in the United States on official business may be eligible for care, but may not be reflected in DEERS. When the FFM is not in DEERS, the FFM or referring Dental Treatment Facility (DTF) shall provide a copy of the FFM’s invitational travel orders to the contractor. The contractor shall electronically send the orders to the Dental Service Point of Contact (DSPOC) for determination of eligibility. The contractor will inform the FFM and/or referring DTF of the eligibility determination.

2.3. Referrals and Authorization.

FFMs may be eligible for treatment within a DTF and/or referred civilian dental care, depending on their health care agreement. Prior to making an appointment, the DTF or contractor shall verify using invitational travel orders or DEERS. If no eligibility can be determined then FFM should be redirected to contact the respective embassy for verification of eligibility.

2.4. Claims.

Any FFM’s claim, with the exception of emergency services, that is received without a referral shall be denied and must be resubmitted as an appeal for DSPOC authorization approval.

3.0. Line of Duty Procedures.

3.1. A Line of Duty (LOD) investigation is for RC Service Members (SM) who incur or aggravate an injury, illness or disease while serving on active duty for 30 days or less as defined in Department of Defense Instruction (DoDI) 1241.2 Reserve Component Incapacitation System Management.

3.2. US Code, Title 10, Section A, Part II, Chapter 55, 1074a. defines that each member of a uniformed service who incurs or aggravates an injury, illness, or disease in the line of duty while performing one of the following: (a) active duty for a period of 30 days or less, (b) inactive duty training or (c) service on funeral honors duty under section 12503 of this title or section 115 of title 32 are entitled to medical and dental care appropriate for the treatment of the injury, illness, or disease of that person until the resulting disability cannot be materially improved.

3.3. For the ADDP there will be two separate processes for LODs, depending on the SM’s dental condition:

· Urgent Care Conditions

· Non-Urgent Care Conditions

3.3.1. The first LOD process will be for urgent care for these SMs training in locations without a military dental treatment facility. Urgent Care is defined as services required to prevent serious deterioration of health and oral health following the onset of an unforeseen condition (i.e., severe oral pain, bleeding, infection, unexplained swelling in the oral cavity or supporting structures, fever associated with a potential oral abscess, broken filling/restoration that will not allow the SM to perform the mission, a crown is not considered an emergency service). Treatment for the urgent care condition must be completed while the SM is on active duty status.

3.3.1.1. Urgent care conditions covered by the ADDP are limited to the minimum treatment required to alleviate the immediate urgent dental condition and return the SM to duty. Examples of care authorized under this process include extraction of a single tooth; placement of a restoration; incision and drainage; or pulpectomy. However, this process is not authorized to provide payment for routine dental care.

3.3.1.2. Urgent care claims can be paid with expedited LOD documentation as long as the urgent care is provided while the SM is in an active duty status and information documenting the SM’s active duty status is provided from the military unit. Full LOD documentation is required to allow authorization for payment of claims when the SM is no longer in an active duty status or additional follow-up care is required.

3.3.2. The second LOD process is for Non-Urgent Care conditions. This process is followed for those dental conditions in which the course of treatment is not limited, returning the SM to a ‘whole’ condition, is expected to be lengthy, and the treatment may be completed while the SM is no longer on active duty status.

3.3.3. Each branch of Service reports LOD incidents differently. The Marines use a database named McMEDS; the Navy uses an official notification letter on letterhead from the Department of Navy personnel center at Millington, Tennessee; the Army uses a database called MODS and also prepares a hard copy DD Form 2173; and the Air Force uses a database called ILOD and AF Form 348 or AFRC Form 348. These Service databases restrict access to their individual Service.

3.4. LOD Process for Urgent Care Conditions. The ADDP will use an expedited process for approval of urgent care LOD conditions.

3.4.1. The SM is entitled to urgent care from a civilian provider during the period of active duty status limited to care to the definitions of urgent care above. The SM may also receive any care that can be provided by an active duty DTF during the time of active duty status.

3.4.2. It is the SM’s responsibility to report the injury, illness or disease to their unit chain of command/ medical authority. The SM’s unit/ medical authority is responsible for initiating the urgent care LOD documentation.

3.4.3. No follow-up dental treatment resulting from an urgent care LOD encounter will be authorized. Eligibility will not likely be reflected in DEERS for the date of LOD injury if the SM was on active duty status for 30 days or less.

3.4.4. The SM’s civilian provider will return the ADDP claim form to the SM’s military unit. The SM’s unit/medical authority will submit the ADDP claim form and a Memorandum detailing the request for urgent care (Sample Memorandum Provided).

3.4.5. Only care directly related to the aforementioned illness /disease as documented in the urgent care LOD documentation/Memorandum will be authorized for payment through the contractor/ADDP/military Dental Service Point of Contact (DSPOC) process.

3.4.6. NOTE – The U.S. Army Selected Reserve Dental Readiness System (ASDRS) provides Class 3 dental care to U.S. Army Reserve Component Soldiers. If the urgent condition results in a Class 3 condition, Army Soldiers should request a DD2813 (or a copy of the ADDP Claim form) that documents the Class 3 condition. The Soldier can then use the ASDRS program to remedy the Class 3 condition.

3.4.7. Army Guard and U.S. Army Reserve Soldiers should contact LHI at 888-901-6609 for their Class 3 care.

3.5. LOD Process for Non-Urgent Care Conditions. Non-Urgent care conditions include injuries/diseases in which the course of treatment is expected to be longer in duration and for dental care provided when the SM is no longer in an active duty status.

3.5.1. It is the SM’s responsibility to report the injury, illness or disease to their unit chain of command/ medical authority. The SM’s unit/ medical authority is responsible for initiating the non-urgent care LOD documentation. The SM's unit/medical authority should submit the completed LOD documentation to the ADDP contractor as soon as possible.

3.5.2. All follow-up dental treatment resulting from an LOD that will be provided via private sector care requires substantiating paperwork from the Service indicating the date, time, and nature of the injury, illness or disease. Eligibility will not likely be reflected in DEERS for the date of LOD injury if the SM was on active duty status for 30 days or less.

3.5.3. Non-Urgent dental treatment, resulting from an LOD, should not be rendered until authorization has been obtained.

3.5.4. The SM's civilian provider will request treatment approval via submission of an Authorization Request Form along with appropriate diagnostic materials to the ADDP contractor.

3.5.5. Requested treatment must be the result of and directly related to an injury incurred or illness or disease aggravated as a result of a period of active duty, per DoDI 1241.2. It is the SM’s responsibility to demonstrate and document that these conditions have been met in each case.

3.5.6. Only care directly related to the aforementioned illness/injury/disease as documented in the LOD/ Notification of Eligibility (NOE) will be authorized for payment through the contractor/ADDP/DSPOC process.

3.5.7. Once all appropriate materials have been received, the contractor will forward the LOD documentation, Authorization Request Form and diagnostic materials, in scanned PDF format, to the DSPOCs for review and approval/denial.

3.5.7.1. Appropriate clinical documentation includes: substantiating clinical documentation, and most recent dental exam within the last 12 months.

3.5.7.2. Appropriate administrative documentation includes: Service Specific form and copy of orders.

3.5.8. The DSPOCs will determine the appropriate and necessary treatment for the specific illness/injury. This determination is made through reviewing submitted documentation and consulting with DTF dentists and treating civilian dentists as needed.

3.5.8.1. The DSPOCs will request that the contractor contact the SM’s military unit regarding submitted cases not meeting those requirements.

3.5.8.2. Appeals of DSPOC denials for payment of dental treatment shall be processed in accordance with Section J, Attachment J-3a, Program Operations, Appeals and Grievances.

3.5.9. Examples of dental conditions typically presented as a Non-Urgent Care LOD include:

3.5.9.1. Repair of tooth fractured as a result of trauma sustained during eligible active training periods.

3.5.9.2. Bridge placement to replace tooth lost due to injury/trauma during the active duty status.

3.5.9.3. Follow-up treatment for acute exacerbations of chronic conditions.

3.5.10. Dental conditions not typically appropriate for LOD treatment include:

3.5.10.1. Pre-existing chronic dental disease

3.5.10.2. Dental treatment needs not completed while on active duty

3.5.10.3. Cleanings

3.5.10.4. Wisdom tooth extraction

Sample Urgent Care Line of Duty (LOD) Memorandum for Active Duty Dental Program

[COMMAND LETTERHEAD]

From: [Command name and mailing address for reply mail]

Signed copy may also be emailed to [Contractor’s E-mail address]

SUBJECT: Active Duty Dental Program – Urgent Dental Care Request for Reserve Component Service Member on Active Duty Status for 30 days or Less

1. Authorization is requested for civilian dental care that qualifies as Line of Duty (LOD) urgent dental care. Urgent care is defined as services required to prevent serious deterioration of health and oral health following the onset of an unforeseen condition (i.e., severe oral pain, bleeding, infection, unexplained swelling in the oral cavity or supporting structures, fever associated with a potential oral abscess, broken filling/restoration that will not allow the service member to perform the mission). Treatment for the urgent care condition must be completed while the service member is on active duty status.

2. (Service Member’s Rank and Full Name) had an urgent dental condition during active duty status of 30 days or less which required dental treatment.

3. Following is (Service Member’s Name) Information:

4. [Service Member’s Rank/Name] and description of dental urgent care condition and treatment provided.

5. My point of contact is: [Name, Rank, and Telephone Number of Command’s Medical Representative]

[Signed by Commander or Designated Representative]

4.0. Wounded Warrior Procedures.

4.1. Wounded Warriors are soldiers or veterans who have a disability that either resulted from injury or disease received in the line of duty as a direct result of armed conflict, or was caused by an instrumentality of war and was incurred in the line of duty during a period of war as defined in section 101(11) of title 38, U. S. C.

4.2. For ADDP there will be two separate processes for the Active Duty Service Member (ADSM) receiving treatment from the Veterans Affairs (VA) Hospital depending on the Service Member’s (SM’s) designation:

· ADSM is receiving inpatient care at the VA Hospital.

· ADSM is identified as a Wounded Warrior.

4.2.1. ADSM Receiving Inpatient Care at VA Hospital. If contact is received regarding the need for dental care for an ADSM that is being treated inpatient at a VA Hospital, the following steps must be taken by the contractor or DHA Dental Care Section (depending on who was contacted):

4.2.1.1. Reference Defense Enrollment Eligibility Reporting System (DEERS) in order to validate that the ADSM is showing in an Active Duty Status.

4.2.1.1.1. If the ADSM is not on Active Duty, then determine if the ADSM should receive care through LOD. If the ADSM is not eligible for LOD then access under the ADDP program will be denied.

4.2.1.1.2. If the ADSM is not showing a remote status, then update the ADSM to a 233 Remote Status.

4.2.1.2. Speak with an administrator of the VA Hospital in order to validate that the ADSM is currently being treated as an inpatient and to collect additional information regarding the dental treatment planned.

4.2.1.2.1. If the ADSM is not inpatient, then advise them to follow the existing ADDP procedures based upon eligibility [Dental Treatment Facility (DTF) Referred or Remote].

4.2.1.3. Create a new Authorization with an automatically 'Approved' status for all planned treatment.

4.2.1.4. Pay all dental claims submitted for the ADSM.

4.2.2. ADSM is Identified as a Wounded Warrior. If contact is received regarding the need for dental care for an ADSM that is identified as a Wounded Warrior, the following steps must be taken by the contractor or DHA Dental Care Section (depending on who was contacted):

4.2.2.1. Reference DEERS in order to validate that the ADSM is showing in an Active Duty Status and is identified as a Wounded Warrior.

4.2.2.1.1. If the ADSM is not on Active Duty, then determine if the ADSM should receive care through LOD. If the ADSM is not eligible for LOD then access under the ADDP program will be denied.

4.2.2.1.2. If the Wounded Warrior is showing a Direct Care status in DEERS then inquire if the ADSM is able and willing to seek treatment at a DTF. If the ADSM is unable to seek care at a DTF, then update DEERS to a 233 Remote Status.

4.2.2.2. If the Wounded Warrior is being treated inpatient at a VA Hospital, follow the specific procedures pertaining to all ADSMs treated inpatient at VA Hospitals.

4.2.2.3. If the Wounded Warrior is being treated outpatient at a VA Hospital, contact the VA Hospital and create an Authorization with an automatically 'Approved' status for all planned treatment.

4.2.2.4. If the Wounded Warrior is being treated by a civilian dental provider, then normal Authorization Requirements and Procedures will apply for all specialty treatment or treatment in excess of the $750/$1500 limits.