TOP 2028 Chapter 24 Draft RFP 06AUG2025 a.pdf

TRICARE Operations Manual 6010.62-M, April 2021 Chapter 24, Section 1

TRICARE Overseas Program (TOP) Administration

Chapter 24 Section 1

Administration

Revision:

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regarding administration shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for healthcare support services outside the 50 United States (US) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 1 for additional instructions regarding administration. Specific healthcare 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 Defense Health Agency (DHA) Contracting Officer (CO), the appropriate DHA Contracting Officer Representative (COR), and the TRICARE Overseas Program Office (TOPO) 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2.2 The provisions of Chapter 1, Section 2, paragraph 4.0 are superseded as described in paragraphs 2.2.1 through 2.2.3.

2.2.1 The TOP contractor shall provide annual representation at two contractor conferences (senior management level) at DHA.

2.2.2 The TOP contractor shall also provide up to four contractor representatives at up to four additional meetings at the direction of the CO per contract year.

2.2.3 The TOP contractor shall provide representation at semiannual TOP operational meetings to be held at DHA-Aurora (DHA-A) with TOPO, TRICARE Area Office (TAO), and other DHA Stakeholders.

2.2.4 The TOP contractor shall provide two contractor representatives at up to 18 additional meetings/site visits at the direction of the CO per option period.

Chapter 24, Section 1

TRICARE Overseas Program (TOP) Administration

3.0 TRICARE PROCESSING STANDARDS

3.1 The provisions of Chapter 1, Section 3 regarding TRICARE processing standards apply.

3.2 Chapter 1, Section 3, paragraph 4.2 does not apply to the TOP contract.

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.

-END-

Chapter 24, Section 2

TRICARE Overseas Program (TOP) Transitions

Chapter 24 Section 2

Transitions

1.0 GENERAL.

All TRICARE requirements regarding transition 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 healthcare support services outside the 50 United States (US) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 2 for additional instructions regarding transition.

1.1 Chapter 2, Section 3, paragraphs 1.4, 1.7, and 3.0 do not apply to the TOP.

2.0 TRICARE Service Center (TSC) Phase-In

2.1 The incoming contractor shall utilize the existing TSCs.

2.2 The outgoing contractor shall allow the incoming contractor reasonable access to the TSC throughout the transition period to become familiar with the communication lines, equipment, and office layout.

2.3 The Government will determine the final schedule for access to, and occupancy of, the TSCs at the Transition Specification (TRANSPEC) Meeting, ensuring both the incoming and outgoing contractor can fulfill its requirements in Chapter 24, Section 9.

2.4 The incoming contractor shall ensure availability and fully train all contractor Customer Service, Education, and Health Care Finder (HCF) Representatives and overseas TSC representatives for all duties no less than 90 calendar days prior to the start of health care delivery (SHCD).

2.5 The incoming contractor shall provide on-site Beneficiary Service Representative (BSR) support in all designated Military Medical Treatment Facility managed TSC locations.

2.6 The incoming contractor shall ensure BSRs have a fully operational, on-line interface with the automated claims processing and enrollment systems which support the functions of the TSC no later than 30 calendar days prior to the SHCD.

-END-

Chapter 24, Section 3

TRICARE Overseas Program (TOP) Financial Administration

Chapter 24 Section 3

Financial Administration

1.1 All TRICARE requirements regarding Financial 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 healthcare support services outside the 50 United States (US) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 3 for additional instructions.

1.2 The annual reviews required in Chapter 3, Section 5 do not apply to the TOP contract.

2.0 PAYMENT POLICY

2.1 The TOP contractor shall reimburse TOP beneficiary claims for overseas healthcare based upon the lesser of billed charges, the negotiated reimbursement rate, or the Government-established fee schedule.

(See Section 9 and the TRICARE Reimbursement Manual (TRM), Chapter 1, Sections 34 and 35 for additional guidelines).

2.1.1 The TOP contractor shall reimburse claims for care in the US commonwealths and territories following stateside reimbursement guidelines. This does not apply to medical evacuation claims.

2.1.2 The TOP contractor shall reimburse claims in the Philippines and Panama following Government-established fee schedules, unless the TOP contractor has negotiated a lesser rate with a private sector care provider.

2.2 The TOP contractor shall process payments of Skilled Nursing Facility (SNF) claims from Puerto Rico and the US territories (Guam, the US Virgin Islands, American Samoa, and the Northern Mariana Islands) as routine foreign claims. These payments shall be subject to the Prospective Payment System (PPS), as required under Medicare in accordance with the Social Security Act. These SNFs will be subject to the same rules as applied to SNFs in the US (see the TRM, Chapter 8).

2.2.1 The TOP contractor shall follow guidance per TPM, Chapter 12, Section 1.2, paragraph 2.6 for TRICARE Overseas Program Sub-Acute Care that is medically necessary and appropriate.

2.2.2 The TOP contractor shall, at its discretion, conduct concurrent or retrospective review for TRICARE Select and TRICARE for Life (TFL) patients when TRICARE is the primary payer.

2.2.2.1 The TOP contractor shall follow the SNF level of care criteria in the Medicare Benefits Manual, Chapter 8, for payment to the lower Patient-Driven Payment Model (PDPM) classification groups.

2.2.2.2 The TOP contractor shall be responsible for all reviews for TRICARE Primary-payer patients if Medicare requires reviews to be performed on low PDPM categories. There shall be no review for TOP TRICARE Select or TFL patients where TRICARE is the secondary payer. The existing referral and authorization procedures for Prime beneficiaries will remain unaffected.

2.2.3 The TOP contractor shall, at their own discretion, collect Minimum Data Set (MDS) assessment data per the TRM, Chapter 8, Section 2.

2.3 The TOP contractor shall be responsible for entering into participation agreements with SNFs in Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Mariana Islands.

2.4 The TOP contractor shall, at their own discretion, conduct any data analysis to identify aberrant SNF PPS providers or those providers who might inappropriately place TRICARE beneficiaries in a high PDPM category.

2.4.1 The TOP contractor shall assist the TRICARE Area Office (TAO) Directors in obtaining/providing SNF data, for conducting any SNF PPS data analysis they deem necessary.

2.5 Balance billing provisions do not apply to TOP beneficiary claims for care rendered in a foreign country and paid as billed, since there is no unpaid balance on these claims. Private sector care network providers, participating providers, and providers in US commonwealths and territories are prohibited from balance billing.

2.6 For healthcare rendered in Puerto Rico and in the US:

2.6.1 The TOP contractor shall follow TRICARE payment policies to determine reimbursement for all TOP beneficiary care except as outlined below:

2.6.1.1 TOP Service members required by the provider to make “up front” payment at the time services are rendered may submit a claim for reimbursement directly to the TOP contractor.

2.6.1.1.1 Normal TRICARE claims processing requirements apply (including any authorization requirements and the use of TRICARE-approved claims forms).

2.6.1.1.2 The TOP contractor shall allow the billed amount and reimburse the Service Member for charges on the claim if the claim is payable.

2.6.1.2 In no case shall a Service Member be subjected to “balance billing” or ongoing collection action by a civilian provider for emergency or authorized care. If the TOP contractor becomes aware of such situations that they cannot resolve, they shall pend the file and forward the issue to the appropriate TAO Director for review.

2.6.2 Overseas drug claims shall be paid following the instructions in Section 8 and the TRM, Chapter 1, Section 15.

2.6.3 Overseas ambulance service claims shall be paid following the instructions in TPM, Chapter 8, Section 1.1 and TRM Chapter 1, Section 14. See TRM Chapter 5, Section 3 for CHAMPUS Maximum Allowable Charges.

2.6.4 Payment may be made for ambulance services provided by commercial transport (see Section 8 for additional processing instructions for these claims).

3.0 FINANCIAL ADMINISTRATION

3.1 The TOP contractor shall follow the Financial Administration non-financially underwritten funds requirements in Chapter 3 with the following exceptions:

3.1.1 Foreign overseas drafts (local currency) and checks (US currency) shall also reflect “TRICARE Overseas Program”.

3.1.2 Foreign overseas drafts shall also reflect information that indicates the draft is valid for 190 calendar days and if reissue is required/necessary, the draft must be returned to the TOP contractor with a request for reissuance. The TOP contractor shall issue drafts/checks for Germany claims which look like local German drafts/checks.

3.2 The TOP contractor shall provide TRICARE Overseas Currency reports identifying the gain or loss for the month reported. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

3.3 The TOP contractor shall calculate currency gains and losses resulting from payments made to private sector care providers or beneficiaries in foreign countries in accordance with Section G.

- END -

Chapter 24, Section 4

TRICARE Overseas Program (TOP) Private Sector Care Providers

Chapter 24 Section 4

Private Sector Care Providers

1.1 TRICARE Overseas Program (TOP) healthcare services are provided by Military Medical Treatment Facilities (MTFs) and private sector care network and non-network providers and institutions. All TRICARE requirements regarding Provider Certification/Credentialing and Network Development shall apply to the TOP unless specifically changed, waived, or superseded by this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for healthcare support services outside the 50 United States (US) and the District of Columbia (hereinafter referred to as the “TOP Contract”). See Chapters 4 and 5 for additional instructions.

1.2 Chapter 5, Section 1, paragraphs 2.1, 2.6, 2.8, 3.2, 4.1, 4.6, 6.1, 7, 8.1, 9, 11, 12.3, and 12.4 do not apply to the TOP contract.

2.0 PRIVATE SECTOR CARE PROVIDER CERTIFICATION AND CREDENTIALING

2.1 The TOP contractor shall be responsible for provider certification oversight, and monitoring of provider/institution quality.

2.1.1 The TOP contractor shall use Chapter 4, 32 CFR 199.6, and TPM, Chapter 11 to the maximum extent possible for the certification of private sector care providers.

2.2 The TOP contractor is not required to follow TRICARE requirements for US credentialing standards, except when TRICARE requires the facility/agency to be Medicare certified (e.g., home health, hospice, Skilled Nursing Facility (SNF) care).

2.2.1 The TOP contractor shall ensure Psychiatric Residential Treatment Centers (RTCs), Substance Use Disorder Rehabilitation Facilities (SUDRFs), and Psychiatric Partial Hospitalization Programs (PHPs) located in Puerto Rico receive required approval by the TOP contractor.

2.2.2 The TOP contractor shall establish private sector care provider certification processes based on the accepted licensure and credentialing requirements for the host nation for services outside of

TRICARE Overseas Program (TOP) Private Sector paragraph 2.2 and 2.2.1.

2.2.1 Refer to Section 20 for additional certification requirements established for private sector care providers in the Philippines. The Defense Health Agency (DHA) may expand these additional certification requirements to other locations in the future.

3.0 NETWORK DEVELOPMENT

3.1 The TOP contractor shall be responsible for developing and maintaining a complement of network and non-network private sector care providers to augment the existing capacity of the Direct Care (DC) system for Active Duty Service Members (ADSMs) and Active Duty Family Members (ADFMs) who are enrolled in TOP Prime, and to provide or arrange for primary and specialty care services for ADSMs and ADFMs who are enrolled in TOP Prime Remote.

3.2 The TOP contractor shall establish signed provider agreements between network private sector care providers and the TOP contractor.

3.2.1 Network provider agreements shall include language indicating the provider agrees to participate on claims for authorized services for TOP enrollees on a cashless, claimless basis. “Cashless, claimless” is defined as a healthcare encounter that requires no up-front payment at the time of service, and the provider files the claim for the beneficiary.

3.2.2 Network provider agreements shall include language stating the private sector care provider shall comply with all TOP contract requirements pertaining to network providers.

3.2.3 Network provider agreements shall specify rates for ADSM medical records photocopying and postage, if applicable.

3.3 The TOP contractor shall size networks in TOP Prime and TOP Prime Remote locations, to meet TOP Prime/Prime Remote-enrolled populations only.

3.3.1 The TOP contractor shall assist other beneficiaries (non-command sponsored ADFMs, retirees, retiree family members, etc.) by identifying private sector care providers which are credentialed and familiar with TRICARE, but networks shall not be developed to accommodate non-TOP Prime/Prime Remote enrollees.

3.4 The Government will have MTF Directors identify in TOP Prime locations the specialties needed in the network and will communicate this information on an ongoing basis to the TOP contractor per the process identified in the Statements of Responsibilities (SORs) (see Section 13).

The TOP contractor shall be responsible to enter into participation agreements with SNFs in Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Mariana Islands per the provisions of Section 3.

4.0 CONTRACTOR REQUIREMENTS - PRIVATE SECTOR CARE PROVIDERS

TRICARE Overseas Program (TOP) Private Sector

4.1 The TOP contractor shall negotiate rates in specific countries designated in the contract.

Reimbursement rates for private sector care providers in other locations may be negotiated by the TOP contractor.

4.1.1 The TOP contractor shall not negotiate rates which exceed the Government directed rate in locations where the Government has designated specific reimbursement rates or methodologies. Refer to the TRICARE Reimbursement Manual (TRM), Chapter 1, Section 34 for additional instructions.

- END-

Chapter 24, Section 5

TRICARE Overseas Program (TOP) Enrollment

Chapter 24 Section 5

TOP Eligibility and Enrollment

1. GENERAL

All TRICARE requirements regarding eligibility, enrollments, re-enrollments, disenrollments, and transfers 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 contract for healthcare support services outside the 50 United States (US) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 6; the TPM, Chapter 10; and the TRICARE Systems Manual (TSM) for additional instructions.

2. ELIGIBILITY

2.1. Eligibility for TRICARE is verified via the Defense Enrollment Eligibility Reporting System (DEERS).

The DEERS record will indicate dates of eligibility.

2.1.1. The TOP contractor shall enroll and provide benefits only to those beneficiaries who are shown as eligible in DEERS.

2.1.2. The TOP contractor shall enroll newborns regardless of reflected DEERS eligibility.

2.2. TOP Active Duty Family Members (ADFMs) shall demonstrate Command Sponsorship to be eligible for TOP Prime and TOP Prime Remote enrollment unless a specific exception exists.

2.3. The TOP contractor shall verify DEERS eligibility (and Command Sponsorship, where required) prior to enrolling beneficiaries into TOP.

2.4. Reserve Component (RC) members who incur or aggravate an injury, illness, or disease while serving on active duty for 30 calendar days or less are eligible for Line of Duty (LOD) care as defined in DoD Directive 1241.1, Reserve Component Medical Care and Incapacitation Pay for Line of Duty Conditions; and DoD Instruction 1241.2, Reserve Component Incapacitation System Management.

2.4.1. DEERS will not identify RC members as ’TRICARE eligible.’ Therefore, additional documentation is required to establish their eligibility for LOD care.

2.4.1.1. Military Medical Treatment Facility (MTF) RC referrals

2.4.1.1.1 The Government will verify LOD eligibility through the MTF prior to issuing the referral.

2.4.1.1.2 The TOP contractor shall establish systems and processes to accept MTF LOD referrals, issue care authorizations, and process claims as if the member were eligible in DEERS.

2.4.1.2 RC members who are not referred by an MTF. The TOP contractor shall establish systems and processes to verify LOD eligibility with the Military Medical Support Office in Great Lakes (DHA-Great Lakes), Illinois, (for care in the US Virgin Islands only) or the applicable military unit or Command for care in all other overseas locations prior to issuing the LOD care authorization.

2.4.2. Verbal attestation of duty status alone is not sufficient to establish LOD eligibility. There must be written documentation from DHA-Great Lakes or the applicable military unit or Command which confirms the member’s eligibility for LOD care.

2.4.3. The TOP contractor shall ensure that claims associated with the LOD authorization are processed as if the member were eligible in DEERS.

2.4.4. The TOP contractor shall deny claims for care that are not associated with the LOD authorization.

2.5. Family members of the Armed Forces of foreign North Atlantic Treaty Organization (NATO) or Partnership for Peace (PFP) nations are not eligible for the TOP.

3.0 ENROLLMENT PROCESSING

3.1 The TOP contractor shall enroll TOP Prime enrollees to a MTF Primary Care Manager (PCM).

TOP Prime enrollment procedures shall be established in the Statements of Responsibilities (SORs) between the TOP contractor and the MTF Director.

3.2 The TOP contractor shall ensure TOP Prime Remote enrollees are enrolled to a remote Defense Medical Information System (DMIS) code with assignment to the TOP contractor, according to the specific regional enrollment procedures established in the SORs between the TOP contractor and the TRICARE Area Office (TAO) Directors.

3.3 Unless a specific exception exists, enrollment to TOP Prime or TOP Prime Remote (TOP PR) is available only to Active Duty Service Members (ADSMs) who are permanently assigned overseas, and to ADFMs who are Command Sponsored and accompanying their sponsor on his or her overseas tour, or on orders in an overseas location (see paragraph 6.1 for additional information regarding Command Sponsorship). This includes activated RC Service Members who are on orders to an overseas location for more than 30 calendar days, and their Command Sponsored ADFMs who accompany the RC Member on his or her overseas tour or are on orders in an overseas location. See paragraph 5.0 for additional details on family member eligibility.

3.4 Non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for TOP Prime or TOP PR enrollment in any overseas location. ADFMs who are not Command Sponsored or on military orders as described in this section are eligible to enroll in TRICARE Select. Because TRICARE for Life (TFL) beneficiaries are not eligible to enroll in TRICARE Select, they are covered as if TRICARE Standard was still implemented (see the TRICARE Reimbursement Manual (TRM), Chapter 2).

3.5 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 PR. Once enrolled, beneficiaries remain enrolled in these programs until:

3.5.1 They disenroll.

3.5.2 Transfer enrollment to another TRICARE region/program.

3.5.3 Lose eligibility for TRICARE, TOP Prime, or TPR.

3.6. The TOP contractor shall perform all enrollment-related activities for TOP Prime, TOP PR, TRICARE Plus, TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), and TOP Select in overseas locations.

3.6.1 Enrollment activities may include validation of eligibility, enrollment, re-enrollment, disenrollment, transfers, updating information in DEERS, assigning or changing PCMs, collecting Other Health Insurance (OHI) information, and related enrollment functions.

3.6.2 The TOP contractor shall use the approved TRICARE enrollment request options for enrollment activities.

3.7 The TOP contractor shall accomplish enrollment within five business days of receipt of a complete TRICARE enrollment request.

3.8 Overseas insurance plans such as German Statutory Health Insurance, Japanese National Insurance (JNI), Philippines Phil Health, and Australian Medicare, etc., are considered OHI.

3.9 The TOP contactor shall follow the requirements in TPM, Chapter 10, Section 2.1, paragraph

2.5.3 to process the enrollment in accordance with a Qualifying Life Event (QLE) for enrollment requests received outside of the annual open enrollment season.

3.9.1 The effective date of enrollment shall be the date of the QLE unless a retroactive enrollment or enrollment change outside of the QLE is authorized by the TAO Director or designee.

3.9.2 The TOP contractor shall collect the Military Sponsor’s Order Number, to include the date on the orders, and document both in the TOP contractor’s call notes for telephonic enrollments. By providing the Order Number and date on the orders, the Sponsor or ADFM attests to Command

Sponsorship.

3.9.3 For TOP emergency cases that should be placed under immediate case management, TOP MTF Directors and/or the TAO Directors may approve exceptions on a case-by-case basis for retroactive TOP enrollment or enrollment change outside of the QLE.

3.10 Except for administrative errors, the effective date for retroactive enrollments shall not be earlier than the first day of the month that the application is submitted (see the TPM, Chapter 10, Section 2.1).

3.11 An officially signed enrollment request includes those with (1) an original signature, (2) an electronic signature offered by and collected by the TOP contractor, or (3) a verbal consent provided via telephone and documented in the TOP contractor’s call notes. A signature is not required to make enrollment changes by phone if the verbal request is documented. A signature from an ADSM is never required to complete Prime enrollment as enrollment in Prime is mandatory per TPM, Chapter 10, Section 2.1, paragraph 1.1.

3.12 The TOP 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 PR beneficiaries shall be enrolled to the appropriate DMIS code for the beneficiary’s remote overseas location. TOP PR enrollees in Canada will follow guidance applicable to the US and Canada Reciprocal Healthcare Agreement and may be assigned to a Canadian Forces Health Facility for their primary care.

3.13 Newborn/Adoptee Claims. See TPM, Chapter 10, Section 3.1

4.0 ENROLLMENT FEES.

4.1 The provisions of Chapter 6, Section 1 and the TPM, Chapter 10, Section 2.1 regarding TRICARE Prime enrollment fees shall not apply to TOP Prime or TOP PR. There are no enrollment fees associated with TOP Prime or TOP PR.

5.0 ENROLLMENT POLICY FOR ADSMs

5.1 Except as described in paragraph 5.2, all ADSMs who are permanently assigned to an overseas duty location must be enrolled into the TOP program available in their area. This includes RC Service members who are called to active duty for more than 30 consecutive calendar days with a final assignment to an overseas duty station.

5.2 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 with existing or embedded organic medical treatment and support capabilities for healthcare. Enrollment to a Service or Region-specific operational forces’ DMIS for all Service members should occur prior to deployment.

5.3 The TOP contractor shall accept enrollment spreadsheets (with all applicable information) as a valid process for enrolling ADSMs into TOP Prime or TOP PR. A signature from an ADSM is never required to complete Prime enrollment as enrollment in Prime is mandatory per TPM, Chapter 10, Section 2.1, paragraph 1.1.

6.0 ENROLLMENT POLICY FOR ADFMs

6.1 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 PR enrollment. In order to enroll in these programs, ADFMs must meet the definition of Command Sponsorship in the Joint Federal Travel Regulation (JFTR), Volume I, Appendix A (available at https://secureapp2/hqda.pentagon.mil/perdiem) unless one of the following exceptions exists:

6.1.1. If the ADSM and his or her Command Sponsored ADFM(s) are enrolled in TOP Prime or TOP PR, and the sponsor is reassigned on unaccompanied PCS orders to a location that does not permit Command Sponsored family members, the family member(s) may retain their TOP enrollment for a period based on the length of the sponsor’s unaccompanied orders (but not to exceed two years). To retain TOP enrollment in this situation, the family member(s) must continue to be Command Sponsored and may not relocate elsewhere during the sponsor’s PCS move.

6.1.2. 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 appropriate TOP program consistent with their orders.

6.1.3. 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 activation/mobilization. The ADFM(s) must have had the same overseas residential address as the sponsor at the time of activation/mobilization.

6.1.4. If the ADFM(s) are currently enrolled in TOP Prime, TOP PR, or TRICARE Select and the family has a newborn or adopts a child, then the new family member is eligible to enroll in the same TOP program.

6.1.5. If the ADFMs are eligible for Transitional Survivor benefits. See TPM, Chapter 10, Section 7.1.

6.2. 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 PR. These ADFMs are eligible for TRICARE Select, TRICARE Select with TRICARE Plus (where available), or MTF care on a space-available basis only. ADFMs may not retain TRICARE Prime enrollment to a stateside Managed Care Support Contract (MCSC) while residing overseas.

6.3. Once registered in DEERS, newly eligible ADFMs residing in an overseas area are automatically enrolled into TOP Select and have 90 calendar days after the auto enrollment to change their enrollment to TOP Prime/TOP PR, desired and if command sponsored.

6.4. 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 an overseas location to an overseas location and transfer enrollment except as specified under the exceptions in this section.

6.5. The TOP contractor shall verify that all 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 PR.

6.6. 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 shall accept any current, valid method of identifying Command Sponsorship to meet the TOP enrollment requirements (e.g., Navy ADFMs who are not listed on the sponsor’s orders, but who are in receipt of a letter from the Navy Personnel Services Division (PSD)).

6.7. ADFMs may request enrollment to a MTF that is not located at the sponsor’s assigned installation; however, only requests for enrollment within the same TAO region as the sponsor’s assigned location will be considered. All ADFM enrollments are subject to the MTF’s enrollment/empanelment guidelines.

7. ASSIGNMENT OF PCM

7.1. TOP Prime beneficiaries must enroll to an overseas DMIS with assignment to a MTF PCM.

7.2. The TOP contractor shall assign TOP Prime enrollees to a MTF PCM unless the Government approved enrollment to a private sector care PCM.

7.3. The TOP contractor shall assign TOP enrollees to a PCM at the time of enrollment via the Government furnished web-based enrollment system/application per the SOR, access standards, or other specific Government guidance. The Government furnished web-based enrollment system/application will only display PCMs with available capacity.

7.4. The MTFs will maintain current PCM lists and will make these lists available to the TOP contractor on a regular basis as determined in the SORs. MTF PCM lists will contain sufficient detail to facilitate new enrollments or PCM reassignments until capacity is optimized per MTF guidance.

7.5. The MTF may establish specific MTF enrollment/empanelment guidelines for their facilities.

7.5.1 The TOP contractor shall enroll TOP Prime beneficiaries and assign PCMs according to these MTF guidelines.

7.5.2 The TOP contractor shall attempt to enroll the beneficiary according to the identified preferences (e.g., specific provider, sex, or specialty preference) upon receipt of a completed TRICARE enrollment request.

7.5.3 The TOP contractor shall enroll the beneficiary according to MTF guidelines if the beneficiary’s PCM preferences are incompatible with MTF enrollment/empanelment guidelines.

7.5.4 The TOP contractor shall use the default PCM for the MTF if the preferred PCM is not available (no capacity).

7.5.5 The TOP contractor shall contact the MTF for instructions if there is no PCM capacity in the

MTF.

7.6 MTF PCM Rotation. A significant number of MTF PCMs rotate or move each year. The TOP contractor shall move the enrollment panels associated with PCMs who rotate or move.

7.6.1 The TOP contractor shall perform batch PCM reassignments through a Government-provided application based on the parameters established by the MTF. Those parameters include DMIS ID to DMIS ID, PCM ID to PCM ID, Health Care Delivery Plan (HCDP), sex of beneficiary, Unit Identification Code (UIC) (active duty only), age of beneficiary, sponsor Social Security Number (SSN) (for family moves) and name of beneficiary.

7.6.4 The TOP contractor shall perform MTF PCM reassignment moves within three business days of the effective date of the PCM’s reassignment.

7.7 The TOP contractor shall perform PCM reassignment, as necessary, in response to Service member reassignments or turnover in private sector care PCMs.

7.8 The TOP contractor shall enroll TOP PR beneficiaries to the appropriate enrollment DMIS ID based on beneficiary location.

7.8.1 The TOP contractor shall list the name/city/country of the assigned remote location/site or the private sector care PCM, as appropriate.

8. ENROLLMENT PROCEDURES

8.1. The TOP contractor shall not deny a TRICARE-eligible beneficiary enrollment or re-enrollment in, or require them to disenroll from, the TOP Prime/TOP PR program because of a prior or current medical condition.

8.2. The TOP contractor shall be responsible for enrollment processing and for coordinating enrollment processing with the MTF, the appropriate TAO Director, and DEERS. See Chapter 6, Section 1, for enrollment processing requirements.

8.3. See Chapter 6, Section 1, for enrollment periods and effective coverage dates.

8.4. TOP Prime/TOP PR enrollment may be on an individual or family basis. Single enrollment may be changed to family due to marriage or birth of a child at any time during the TOP enrollment period. A new

TOP enrollment period shall be established for the family. See Chapter 6, Section 1, for enrollment timeframes.

8.5. Enrollment fees are not required for TOP Prime or TOP PR. See TRM, Chapter 2, for enrollment fee information.

9. ENROLLMENT OF FAMILY MEMBERS OF E-1 THROUGH E-4

9.1. The provisions of Chapter 6, Section 1 regarding enrollment of family members of E-1 through E-4 shall apply to the TOP, except that TOP Prime/TOP PR shall be effective the date that the enrollment is requested if it coincides with dates of eligibility. See Chapter 6, Section 2, for effective enrollment dates. See TPM, Chapter 10, Section 2.1, for QLE information.

9.2. The provisions of Chapter 6, Section 2 regarding enrollment portability shall apply to the TOP, except that stateside-enrolled retirees and retiree family members may not transfer Prime enrollment to an overseas location.

10. SPLIT ENROLLMENT

The provisions of Chapter 6, Section 3 regarding split enrollment shall apply to TOP Prime and TOP Select.

11. DISENROLLMENT

11.1. The TOP contractor shall disenroll ADFMs from TOP Prime/TOP PR when:

11.1.1. The enrollee requests disenrollment

11.1.2. The enrollee transfers enrollment to a new TRICARE region

11.1.3. The enrollee loses eligibility for TOP Prime or TOP PR

11.1.4. The enrollee loses TRICARE eligibility in DEERS, or

11.1.5. The enrollee has not requested enrollment transfer/disenrollment within 90 calendar days following the end of the overseas tour.

11.2. The TOP contractor shall disenroll ADSMs from TOP Prime/TOP PR when:

11.2.1. The enrollee transfers enrollment to a new TRICARE region

11.2.2. The enrollee loses TRICARE eligibility in DEERS, or

11.2.3. The enrollee has not requested enrollment transfer/disenrollment within 90 calendar days following the end of the overseas tour.

11.3. See Chapter 6, Section 1 for guidance regarding enrollment lockouts. See TPM, Chapter 10, Section 2.1, for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames.

11.4. ADSMs cannot voluntarily disenroll from TOP Prime or TOP PR if they remain on permanent assignment in an overseas location where these programs are offered. ADSM enrollment in TOP Prime or TOP PR continues until they transfer enrollment to another TRICARE region/program or lose eligibility for

TOP/TRICARE.

11.5. TOP Prime/TOP PR enrollees must either transfer enrollment or disenroll within 90 calendar days of the end of the overseas tour when the ADSM departs to a new area of assignment. The TOP contractor shall provide continuing coverage until:

11.5.1. The enrollment has been transferred to the new location

11.5.2. The enrollee disenrolls, or

11.5.3. The TOP contractor shall automatically disenroll the beneficiary on the 91st calendar day following the end date of the overseas tour from TOP Prime/TPR when enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 90th day.

11.6. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at MTF.

12. ENROLLMENT FORMS

12.1. The TOP contractor shall use the current TRICARE Enrollment/Disenrollment Form or other approved forms or processes, including the current Government furnished web-based enrollment system/application to effect enrollment, PCM changes, and disenrollment actions.

12.2. The TOP contractor shall reproduce the forms as necessary to ensure ready availability to all potential enrollees and individuals requesting enrollment, PCM changes, or disenrollment.

13. TRICARE ELIGIBILITY CHANGES

13.1. Refer to the TPM, Chapter 10, Section 3.1 for information on changes in eligibility.

13.2. The TOP contractor shall include full and complete information about the effects of changes in eligibility and sponsor rank in beneficiary materials and briefings.

Chapter 24, Section 6

TRICARE Overseas Program (TOP) Clinical Operations

Chapter 24 Section 6

Clinical Operations

Revision: C-1, April 5, 2024

1.1 The TOP contractor shall implement a Clinical Operations program which includes Medical Management (MM), Case Management (CM) Population Health (PH), Utilization Management (UM), Referral Management (RM) and Clinical Quality Management (CQM).

1.2 The TOP contractor shall apply all TRICARE requirements regarding Clinical Operations, unless those requirements are specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (US) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 7 for additional instructions. Language in Chapter 7 that has no direct application to the TOP contract does not apply (e.g., Diagnosis Related Group (DRG) validation reviews which are not applicable in any overseas location except Puerto Rico, Pharmacy Information and Medication List, Ability to print medication list, Section 1, paragraphs 4.0 and 7.0, Section 4, paragraphs 5.0, 9.5 and 12).

2.0 MEDICAL MANAGEMENT

2.1 The TOP contractor shall establish a MM Program.

2.1.1 The TOP contractor’s MM Program shall recognize that the Military Medical Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical oversight for TOP Prime enrollees. As such, the enrolling MTF will determine medical and psychological necessity, and issue all referrals for TOP Prime enrollees, and provide UM and CM services for the MTF-enrolled population.

2.1.2 The MTF will exercise clinical oversight for newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment).

2.1.3 The TOP contractor shall collaborate with the MTF CM to provide CM services as necessary for enrolled beneficiaries during any inpatient stay.

2.1.4 The TOP contractor shall submit an annual MM plan. For plan submission requirements, see DD Form 1423, Contract Data List Requirements (CDRL), located in Section J of the applicable contract.

2.2 The MM Program shall recognize that private sector care network providers are the TOP contractor’s responsibility.

2.2.1 The TOP contractor shall ensure that any adverse finding related to private sector care provider care is forwarded within five calendar days of identification to the appropriate TAO.

2.3 The MM Program shall integrate efforts to identify potential fraud/abuse.

2.4 The TOP contractor shall forward all cases identified as possible fraud/abuse directly and exclusively to the Defense Health Agency (DHA) Program Integrity (PI) Office in accordance with Section 12.

3.0 POPULATION HEALTH

Chapter 7, Section 3, paragraph 2.0. only applies to the TOP Prime Remote population not associated with an Embassy Health Unit.

4.0 UTILIZATION MANAGEMENT

4.1 The TOP contractor shall closely monitor requests for inpatient care or medical evacuation services to ensure that services are medically or psychologically necessary and appropriate for the patient’s condition.

4.2 Inpatient stays that exceed the standard Length-Of-Stay (LOS) for a local area in a private sector care country or US commonwealth/territory shall be identified and reviewed for medical or psychological necessity.

4.2.1 The TOP contractor shall use a combination of data analytics, proactive discharge planning and a multidisciplinary approach to determine the standard LOS for a particular overseas location, unless a different standard has been identified by the Government.

4.2.2 The TOP contractor shall provide supporting documentation related to LOS determinations upon Government request.

5.0 REFERRAL/AUTHORIZATION/HEALTH CARE FINDER (HCF) REQUIREMENTS

5.1 The TOP contractor shall develop systems and procedures for processing referrals for TOP Prime and TOP Prime Remote enrollees in accordance with the TOP contract; Chapter 7, Section 5; and this chapter.

5.2 The TOP contractor shall conduct related authorization and HCF activities. The MTF will conduct medical and psychological necessity reviews for TOP MTF enrollees and determine that the requested care is not available in the MTF prior to forwarding the referral to the TOP contractor.

5.3 With written DHA Contracting Officer permission prior to implementation, the TOP contractor may alter the required data elements for MTF referrals prescribed in Chapter 7, Section 5, paragraph 4.4 to accommodate the delivery of healthcare overseas.

5.4 The TOP contractor shall ensure that MTF-issued referrals and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication.

5.5 The TOP contractor shall develop procedures for the identification and tracking of TOP enrollee claims submitted by a private sector care provider or a beneficiary without preauthorization/authorization.

5.5.1 The TOP contractor shall educate beneficiaries of the preauthorization/authorization requirements and of the procedures for requesting preauthorization/authorization. In MTF locations, these beneficiary education efforts may be conducted in conjunction with MTF staff.

5.5.1.1 The TOP contractor shall provide all beneficiary education in remote locations.

5.5.2 Although beneficiaries are required to obtain authorization for care prior to receiving payment for the care requiring TOP preauthorization/authorization, the beneficiary may request retroactive authorization from the appropriate authority for issuing authorizations within three business days of receiving care.

5.5.2.1 The TOP contractor shall not accept retroactive authorization requests after this initial time frame without higher level approval (TAO or TOP Office).

5.5.2.2 The TOP contractor shall document preauthorization/authorizations according to current contract requirements.

5.6 The TOP contractor shall ensure the provider submits the preauthorization/authorization with the claim or the TOP contractor shall make the preauthorization/authorization available via an internal contractor system that interface with the claims processing system.

5.7 The TOP contractor shall maintain a preauthorization/authorization file.

5.8 The TOP contractor shall clarify discrepancies between authorization data and data on the claims with the appropriate authorizing authority, when necessary.

5.9 The TOP contractor shall consider authorizations valid for 180 calendar days (i.e., date of service must be within 180 calendar days of issue date).

5.9.1 Authorizations may be granted for 365 days for obstetrical care, or for any other long-term/chronic conditions for which an extended care period is medically or psychologically necessary and appropriate.

5.9.2 The TOP contractor shall only cover services that are applicable to the care authorization (i.e., a care authorization for obstetrical care cannot be extended to cover specialty care that is unrelated to the pregnancy).

5.10 The TOP contractor shall develop procedures for preauthorizations/authorizations for TOP beneficiaries for inpatient mental healthcare rendered in the 50 US or the District of Columbia.

5.10.1 The TOP contractor shall authorize/review all stateside non-emergency inpatient mental healthcare (e.g., acute hospitalization psychiatric care, psychiatric Residential Treatment Center (RTC), Substance Use Disorder (SUD) inpatient/residential detoxification and rehabilitation for TOP Prime/TOP Prime Remote ADFMs, regardless of where the care is rendered.

5.10.2. The TOP contractor shall at a minimum provide:

5.10.2.1 Three 24-hour telephone lines: one stateside toll free, one commercial, and one fax for overseas inpatient mental health review.

5.10.2.2 Sample forms for use by the referring physician when requesting preauthorization/authorization for care; and

5.10.2.3 A system for notification of the TOP contractor when care has been authorized.

5.10.3 The TOP contractor shall inform the beneficiary/provider if a desired facility is not a TRICARE authorized facility and offer the beneficiary/provider a choice of alternative facilities and assist with identifying stateside facilities for referring providers.

5.10.4 The TOP contractor shall initiate preauthorization prior to admission for non-emergency inpatient care, including RTC, Substance Use Disorder Rehabilitation Facility (SUDRF), etc. (Essentially, all admissions defined by TPM, Chapter 1, Section 6.1, as requiring preauthorization), upon request, either telephonically or by fax, from a referring provider.

5.10.5 The TOP contractor shall arrange ongoing utilization review, as indicated, for overseas beneficiaries admitted to any level of inpatient mental healthcare.

5.10.5.1 The TOP contractor shall ensure the review determination concludes in either authorization or denial of care.

5.10.5.2 The TOP contractor shall submit review results via HIPAA compliant electronic means to the beneficiary/ provider within 24 hours of the request.

5.10.6 The TOP contractor shall follow the review and denial processes as applicable, outlined in Section 7.

5.10.6.1 The TOP contractor shall provide an opportunity to discuss the proposed initial denial determination with the patient’s attending physician AND referring physician (if different providers). The purpose of this discussion is to allow further explanation of the nature of the beneficiary’s need for healthcare support services, including all factors which preclude treatment of the patient as an outpatient or in an alternative level of inpatient care. This is important for those beneficiaries designated to return overseas, where supporting alternative level of care may be limited, as well as support for intensive outpatient treatment.

5.10.6.2 The TOP contractor shall contact the appropriate overseas TAO Medical Director to discuss the case if the referring provider does not agree with the denial determination. The TAO Medical Director will provide the schedule and contact information for all overseas TAO mental health advisors.

5.10.6.3 The TOP contractor shall make the final decision on whether to issue a denial.

5.11 The TOP contractor shall notify the referring provider if the patient is returning to ensure coordination of appropriate after-care arrangements, as well as facilitate discussion with the attending provider to ensure continuity of care is considered with the proposed after-care treatment plan.

5.12 The TOP contractor shall adhere to the appeals process outlined in Section 12.

6.0 CONTRACTOR RELATIONSHIP WITH THE MILITARY HEALTH SYSTEM (MHS) TRICARE

QUALITY MANAGEMENT CONTRACT (TQMC) CONTRACTOR

The provisions of Chapter 7, Section 7 do not apply to the TOP.

7.0 MEDICAL TRAVEL

7.1 TOP Prime Enrollees and MTF-Referred Transient Beneficiaries

7.1.1 If the TOP contractor’s HCF determines that appropriate medical or psychological care is not available in the beneficiary’s local service area, the TOP contractor shall provide Notification of Case (NOC) to the appropriate MTF. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. The NOC shall identify the nearest private sector care provider or facility that can provide adequate specialty care.

7.1.1.1 The TOP contractor shall issue a care authorization upon the MTF’s request (as documented in the MTF’s response to the NOC).

7.2 TOP Prime Remote and Self-Referred Transient Beneficiaries

7.2.1 If the TOP contractor’s HCF determines that appropriate medical or psychological care is not available in the beneficiary’s local service area, the TOP contractor shall provide a NOC to the appropriate TAO per the medical travel requirements of DD Form 1423, CDRL, located in Section J of the applicable contract. The NOC shall identify the nearest private sector care provider or facility that can provide adequate specialty care.

7.2.1.1 The TOP contractor shall issue a care authorization upon TAO’s request (as documented in the TAO’s response to the NOC Report).

Chapter 24, Section 7

TRICARE Overseas Program (TOP) Medical Evacuation Services

Chapter 24 Section 7

Ambulance/Aeromedical Evacuation…