TOP 2028 DRAFT TOM Chapter 24.docx

Chapter 24 Section 1

Administration

Revision:

1.0 GENERAL

All TRICARE administrative 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regarding administration shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by this section, the TRICARE Policy Manual (TPM), Chapter 12, or the TRICARE contract for healthcare support services outside the 50 United States (US) and the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 administrative instructions. Specific healthcare support service requirements are identified in this chapter, TPM, Chapter 12, and the TOP contract.

2.0 CONTRACT ADMINISTRATION AND INSTRUCTIONS TO CONTRACTOR

2.1 Chapter 1, Section 2 applies to the TOP. Additionally, the TOP Contractor shall coordinate with the Defense Health Agency (DHA) Contracting Officer (CO), the DHA Contracting Officer Representative (COR), and the TRICARE Overseas Program Office (TOPO) on TOP policy or contractual issues needing Government clarification or assistance to resolve.

2.2 Chapter 1, Section 2, paragraph 4.0 is superseded as follows:

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

2.2.2 The TOP Contractor shall provide up to four representatives at up to four additional meetings at the CO’s direction per contract year.

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

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

3.0 TRICARE PROCESSING STANDARDS

TOM Chapter 1, Section 3 is replaced by the following:

3.1 Enrollment:

3.1.1 The Contractor shall process all enrollment actions received from all sources within six calendar days of receiving the request. (This includes but is not limited to: enrollments, re-enrollments, disenrollments, and enrollment transfers; resolve enrollment discrepancies; and assign or change PCMs in accordance with the provisions of the contract.)

3.1.2 The Military Medical Treatment Facilities (MTFs) may request PCM reassignment, including panel reassignments using telephone, email or other electronic submissions. The preferred method for panel reassignments is the batch staging application within PCM Panel Reassignment tool (PCMRA). Regardless of the submission method, the MTF will provide sufficient information identifying both the PCMs and beneficiaries involved in a move to allow the Contractor to reasonably accomplish the move.

3.1.3 The Contractor shall process 100% of Direct Care (DC) PCM reassignments, including both individual and panel reassignment, within three business days of receiving all required information from the MTF.

3.2 Customer Service

3.2.1 Telephone inquiries:

The following required levels of service shall be available at all times (e.g., daily, weekly, and monthly).

· Blockage rates shall not exceed 5%.

· The call abandonment rate shall be less than 5%.

· The average speed of answer by a live agent, including internal transfers and Automated Response Unit (ARU), shall not exceed 45 seconds.

· Total “on hold” time for 95% of all calls shall not exceed 2 minutes during the entire telephone call.

· Eighty-five percent (85%) of all telephone caller inquiries shall achieve resolution in one call. (Includes calls transferred to an individual.)

· All inquiries not fully and completely resolved on the initial call shall be fully and completely resolved to the customer’s satisfaction within 10 business days.

· Response accuracy 100%. (Responses provided by call center staff shall be accurate and complete according to the terms of the contract in all applicable TRICARE programs and policies.)

3.3 Written Inquiries

3.1 For all processing standards, the actual date of receipt shall be counted as the first day and stamped with the actual date of receipt within one business day. The date the reply is mailed shall be counted as the processed to completion date.

3.2 The Contractor shall provide final responses to routine written inquiries as follows:

• Eighty-five percent (85%) within 15 calendar days of receipt;

• Ninety-seven percent (97%) within 30 calendar days of receipt; and

• One hundred percent (100%) within 45 calendar days of receipt.

3.3.1 Priority Written Inquiries (Congressional, Assistant Secretary of Defense (Health Affairs) (ASD(HA)), and DHA) The Contractor shall provide final responses to priority written inquiries as follows:

• Eighty-five percent (85%) within 10 calendar days of receipt.

• One hundred percent (100%) within 30 calendar days of receipt.

3.3.2 The TOP Contractor shall exclude correspondence pending due to stop payment orders, check tracers on foreign banks, and conversion on currency from the 45- calendar day (routine) correspondence standard and the 10-calendar day (priority) correspondence standard.

3.3.3 Grievances

The Contractor shall provide an interim written response by the 30th calendar day after receipt for all grievances not processed to completion by that date. The interim response shall include an explanation for the delay and an estimated date of completion. Ninety-five percent (95%) of all grievances shall be processed to completion within 60 calendar days from the date of receipt.

3.4 Walk-In Inquiries (TRICARE Overseas Contract Only)

• Ninety-five percent (95%) of walk-in inquiries shall be acknowledged and be assisted by a service representative within 15 minutes of entering the reception area.

• Ninety-nine percent (99%) of walk-in inquiries shall be acknowledged and assisted by a service representative within 20 minutes of entering the reception area

3.5 Paragraph 4.1 is revised as follows:

3.5.1 Starting in Option Period 1, the following percentage of total paid claims for TOP Prime and Prime Remote shall be for care rendered by a network provider. This excludes claims for services or supplies not requiring authorization, Emergency Room (ER), urgent care, Point-of-Service (POS), or claims with Other Health Insurance (OHI).

• Eighty percent (80%) Option Period 1.

• Eighty-four percent (84%) Option Period 2.

• Eighty-eight percent (88%) Option Period 3.

• Ninety-two percent (92%) Option Period 4.

• Ninety-six percent (96%) Option Period 5 through 9.

3.6 PREAUTHORIZATIONS/AUTHORIZATIONS AND REFERRALS

3.6.1 Preauthorizations/Authorizations

3.6.1.1 The Contractor shall issue determinations on at least:

• Ninety percent (90%) of all requests for preauthorization/authorization within two business days following receipt of the request and all required information.

• One hundred percent (100%) of such requests within five business days following receipt of the request and all required information.

• One hundred percent (100%) of all urgent authorizations, excluding those requiring peer review or factual determination, shall be processed within one business day. Exclusions shall be processed within two business days.

3.6.2 Referral Processing

3.6.2.1 The Contractor shall issue an authorization or denial following the date of receipt of a request for a referral, on at least:

• Ninety percent (90%) of all requests within two business days.

• One hundred percent (100%) of all requests within three business days.

• One hundred percent (100%) of all urgent referrals, excluding those requiring peer review or factual determination, shall be processed within one business day. Exclusions shall be processed within two business days.

3.6.2.2 The Contractor shall provide a monthly report to the Government of the number of returned referrals and a summary of the most common types of information missing. This feedback shall also be provided with the returned referral. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

3.6.2.3 The Contractor shall report on 100% of all referrals processed to completion in regard to timeliness standards and accuracy. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

3.6.3 For Japan specific referral and authorization requirements, see the applicable requirements in Sections C and J in the contract. Comment by Cox, Christopher D CTR (USA): @Ruther, Dawn R CIV DHA TRICARE HEALTH PLAN (USA) Comment by Ruther, Dawn R CIV DHA TRICARE HEALTH PLAN (USA): we can’t list specific contract references in the Manuals

3.7 CLAIMS

Claims Processing Timeliness: Unless otherwise specified, the standards below apply to all claims.

3.7.1 Retained Claims

3.7.1.2 The Contractor shall process 95% retained and adjustment claims accurately and to completion within 30 calendar days from the date of receipt.

3.7.1.3 The Contractor shall retain all claims that contain sufficient information to allow processing to completion and all claims for which missing information may be developed from in-house sources, including DEERS and Contractor operated or maintained electronic, paper, or film files. A “retained claim” is defined as any claim retained (held in the Contractor’s possession) for any reason.

Note: The above does not prohibit a Contractor from retaining a claim for external development.

3.7.2 Retained and Excluded Claims

3.7.2.1 The Contractor shall process 100% of all claims (both retained and excluded, including adjustments) accurately and to completion within 90 calendar days from the date of receipt.

3.7.3 Duplicate Claims Resolution

3.7.3.1 The Contractor shall utilize the automated TRICARE Duplicate Claims System (DCS) to resolve DHA identified potential duplicate claims payments.

3.7.3.2 The Contractor shall move Open status potential duplicate claim sets to Pending, Validate, or Closed status on a first-in/first-out basis. To this end, Contractor performance will be measured against the percentage of claim sets in Open status at the end of a month with load dates over 30 calendar days old. No more than 10% of the potential duplicate claim sets remaining in Open status at the end of a month shall have load dates over 30 calendar days old. For reporting requirements, see the DD Form 1423, CDRL, located in Section J of the applicable contract.

3.7.3.3 Contractor compliance with this standard shall be determined from the Performance Standard Report generated by the DCS (see the TSM, Chapter 4, Addendum B, Summary/Management Report entitled “Performance Standard,” for a description and example of the Performance Standard Report). The 10% standard becomes effective on the first calendar day of the seventh month following the start of health care delivery (SHCD). For reporting requirements, see the DD Form 1423, CDRL, located in Section J of the applicable contract.

3.7.4 Claim Payment Errors

3.7.4.1 Claim payment errors for the first two option periods, the extrapolated absolute error total shall not exceed 2% of the total paid amount of each universe. In all remaining option periods, the extrapolated absolute error total shall not exceed 1.75% of the total amount paid for each universe.

3.7.5 Claims Reprocessing

3.7.5.1 The Contractor shall not exceed 2% reprocessing rate of the total monthly claims volume processed for the first two option periods. In all remaining option periods, the Contractor shall not exceed 1.75% reprocessing rate of the total monthly claims volume processed. Deferred claims include some claims that are excluded from the total monthly claims volumes. Details for reporting are identified in DD Form 1423, CDRL, located in Section J of the applicable contract. Deferred claims excluded from this requirement are defined as:

• Claims requiring development for possible TPL or OHI;

• Claims requiring intervention by another TRICARE Prime Contractor; and

• Claims requiring Government intervention (i.e., claims held for pricing updates, claims held pending the issuance of a policy change or as a result of change orders, etc.).

3.8 APPEALS

3.8.1 Expedited Preadmission or Preprocedure Reconsiderations

3.8.1.1 The Contractor shall process to completion 100% of requests for expedited preadmission or preprocedure reconsiderations within three business days of the date of receipt by the Contractor of the reconsideration request (unless the reconsideration is rescheduled at the written request of the appealing party). Expedited preadmission or preprocedure requests are those requests filed by the beneficiary within three calendar days after the beneficiary receipt of the initial denial determination.

3.8.2 Non-Expedited Medical Necessity Reconsiderations

3.8.2.1 The Contractor shall meet the following processing standards for non-expedited medical necessity reconsiderations which begins from the date of receipt by the Contractor until processed to completion:

• Ninety-five percent (95%) within 30 calendar days.

• One hundred percent (100%) within 60 calendar days.

3.8.3 Non-Expedited Factual Reconsiderations

3.8.3.1 The Contractor shall meet the following standards for non-expedited factual reconsiderations which begins from the date of receipt by the Contractor until processed to completion:

• Ninety-five percent (95%) within 30 calendar days of receipt.

• One hundred percent (100%) within 60 calendar days from the date of receipt of the reconsideration request. The date of completion is the date the reconsideration determination is mailed to the appropriate parties.

3.8.4 Determinations Reversed by DHA Appeals and Hearings Process

3.8.4.1 The Contractor shall process to completion 100% of Contractor determinations reversed by the appeals process within 21 calendar days of receipt.

4.0 MANAGEMENT

Chapter 1, Section 4 applies, except paragraph 2.3 (ZIP Code files) is only applicable to Puerto Rico.

5.0 COMPLIANCE WITH FEDERAL STATUTES

See Chapter 1, Section 5 for instructions.

6.0 LEGAL MATTERS

See Chapter 1, Section 6 for instructions.

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TRICARE Operations Manual 6010.62-M, April 2021 Chapter 24, Section 12 TRICARE Overseas Program (TOP) Program Integrity

TRICARE Operations Manual 6010.62-M, April 2021 Attachment J-22-- DRAFT Chapter 24, Section 1 TRICARE Overseas Program (TOP) Administration

Chapter 24 Section 2

Transitions

1.1 TOM Chapter 2 does not apply to the TRICARE Overseas Program (TOP), except for TOM Chapter 2 Section 2 - System Development, Section 6 - Records Management, and Section 10 – Other Requirements, Paragraphs 1.0-5.0 & 8.0. For transition requirements see TOM Chapter 24 Section 2.

2.1.2 The TOP Contractor shall deliver a transition-in plan 10 calendar days after contract award. For reporting details, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

2.2 Transition Specifications Meeting

2.2.1 The Contractor shall attend a meeting with the Government within 15 days following contract award. This meeting is for the purpose of developing a schedule for transition-in and transition-out activities. DHA will notify the Contractor as to the exact date of the meeting. Contractor representatives attending this meeting shall have the experience, expertise, and authority to approve processes and establish project commitments on behalf of their organization.

2.3 Interface Meetings

2.3.1 The Contractor shall participate in all interface meetings with the Government, and any external agencies applicable, during the transition period. The purpose of these meetings is to establish all interfaces necessary to meet the requirements of this contract.

2.4 Transition Status Reports and Meetings

2.4.1 The Contractor shall provide weekly status reports throughout transition period or as directed by the Government. For reporting details, see DD Form 1423, CDRL, located in Section J of the applicable contract.

2.4.2 The Contractor shall participate in transition-in meetings to provide the Government a status or progress of all transition activities.

2.4.3 The Government will notify the Contractor as to the frequency, location, and provide the agenda of the meeting(s).

2.6.1 During transition, the Government must approve the Contractor’s proposed health informatics data systems, including data governance and management, security and privacy, analytics and interpretation, interoperability and integration of data systems, and continuous improvement strategies.

2.6.2 The Contractor shall ensure initial data repository training is completed no later than 75 days prior to SHCD.

2.7 Provider Networks

2.7.1 The Contractor shall have completed 100% of provider network development (to include completion of provider agreements and credentialing) no later than 60 calendar days prior to the start of health care delivery (SHCD).

2.7.2 The Contractor shall submit a Network Implementation Plan (NIP), as identified in DD Form 1423, CDRL, located in Section J of the applicable contract. Submission of the NIP shall be no later than 240 calendar days prior to the SHCD.

2.7.3 The incoming Contractor shall not rely on the provider database from the outgoing Contractor to create the network of providers.

2.7.4 All network provider agreements shall be executed, and loaded to the Contractor’s system, 80 days prior to the start of health care delivery, or at such other time as is mutually agreed between the Contractor and DHA.

2.7.4.1 The Contractor shall ensure each network provider agreement clearly identifies the provider has the required malpractice insurance.

2.7.5 The Contractor shall distribute initial provider education material to network and participating non-network providers no earlier than 60 days and no later than 30 days prior to the SHCD.

2.7.6 The Contractor shall validate the completeness and accuracy of the online directory of providers no later than 60 days prior to SHCD.

2.8 Enrollment

2.8.1 The Contractor shall begin the enrollment process no later than (NLT) 60 days prior to the scheduled SHCD, with actual enrollment processing to begin 40 days prior to the SHCD, subject to DHA approval of systems under the contract.

2.8.1.3 For all other enrollment actions with an effective date prior to SHCD (e.g., Primary Care Manager (PCM) changes; Defense Medical Information System-Identification Code (DMIS-ID) changes; enrollment begin date changes; etc.), requested by the outgoing Contractor, the incoming Contractor must cancel the future enrollment segment and notify the outgoing Contractor when this action has been completed. When notified by the outgoing Contractor that their change has been effected, the incoming Contractor must reinstate the future enrollment segment.

2.8.1.4 Once health care delivery begins, all enrollment actions will be accomplished by the incoming Contractor. If the outgoing Contractor requires a retroactive change, they must submit their request to the incoming Contractor who will perform the change and notify the outgoing Contractor when it is complete.

2.8.2 Transfer of Enrollment Files

2.8.2.1 The Contractor shall ensure that enrollments and transfers of enrollments during the transition-in period are accomplished in a way that allows for uninterrupted coverage for TRICARE enrollees.

2.8.2.2 The incoming Contractor shall obtain enrollment information from DEERS through an initial enrollment load file. DMDC will provide the incoming Contractor with an incremental enrollment load file for each contract transition.

2.8.2.2.1 The incoming Contractor shall process each enrollment load file within 24 hours or less from receipt of the file.

2.8.2.3 Each contract transition shall require a three-day freeze of enrollment and claim processing. This freeze will occur beginning the first weekend that precedes the 60 day window prior to the SHCD. The actual calendar dates will be determined during the transition meeting.

2.8.2.4 The incoming Contractor shall send enrollment renewal notices for all enrollees whose current enrollment period expires on or after the SHCD.

2.8.2.5 The incoming Contractor shall send billing statements where the enrollment fee payment would be due on or after the SHCD.

2.8.2.6 The incoming Contractor shall start sending billing notices and process renewals 45 days prior to the SHCD.

2.8.2.7 Outstanding enrollment record discrepancies and issues reported to the DEERS Support Office (DSO) by the outgoing Contractor will be transferred to the incoming Contractor for reconciliation. Records will be reconciled in accordance with TSM, Chapter 3.

2.8 Customer Service

2.8.1 The Contractor shall ensure that Call Centers are fully staffed with qualified, trained personnel; and that all Call Center-based toll-free customer services, referral/authorization processing systems, provider network development activities, and claims processing systems are functional no later than 80 calendar days prior to the start of health care delivery.

2.8.2 TRICARE Service Center (TSC) Phase-In

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

2.8.2.2 The Government will provide the incoming Contractor with reasonable TSC access throughout the transition period to become familiar with the communication lines, equipment, and office layout.

2.8.2.3 The Government will determine the TSC access and occupancy schedule ensuring both the incoming and outgoing Contractor meet Chapter 24, Section 9 requirements.

2.9.1 The Contractor shall establish an RM program in accordance with Section C of the contract and Chapter 7, Section 5 no later than the 90 calendar days prior to the start of health care delivery (SHCD).

2.9.2 The Contractor shall implement an electronic RM system that integrates with the Government’s electronic RM system no later than 60 calendar days prior to the SHCD.

2.9.3 Management of Existing Authorizations.

2.9.3.1 The incoming Contractor shall honor current authorizations issued by the outgoing Contractor, covering care through 60 days after the SHCD under the incoming contract, in accordance with the outgoing Contractors existing practices and protocols, within the scope of the TRICARE program and applicable regulations or statutes.

2.9.3.2 In the case of Residential Treatment Care (RTC) care, both the incoming and outgoing Contractors are responsible for authorizing that part of the stay falling within their areas of responsibility; however, the incoming Contractor may utilize the authorization issued by the outgoing Contractor as the basis for continued stay.

2.9 Receipt of Outgoing Contractor’s Weekly Shipment of History Updates and Dual Operations

2.10.1.1 The provisions of this section are applicable to the TRICARE Overseas Program (TOP) except that the requirement for the outgoing Contractor to process residual claims and adjustments for 120 days following cessation for health care delivery is waived for the TOP. The outgoing Contractor is only required to process claims and adjustments received during its period of service delivery. Processing of all claims shall be completed within 280 calendar days following the start of the incoming Contractor’s services delivery.

2.10.1.2 Beginning with the 120th calendar day prior to the SHCD and continuing for 180 calendar days after the SHCD, the incoming Contractor shall convert the weekly shipments of the beneficiary history updates from the outgoing Contractor(s) within two working days following receipt. These files shall be validated by the incoming Contractor before use. Tests for claims and duplicate claims shall be performed within two workdays following conversion. Following the SHCD, these files shall be loaded to history and used for claims processing.

2.10.1.3 During the 180 calendar days after the SHCD when both the incoming and outgoing Contractors are processing claims, both Contractors shall maintain close interface on history update exchanges and provider file information.

2.10.1.4 During the first 60 calendar days of dual operations, the Contractors shall exchange beneficiary history updates with each Contractor’s claims processing cycle run. Thereafter, the exchange shall not be less than twice per week until the end of dual processing.

2.10.1.5 The incoming Contractor shall assume total responsibility for the maintenance of the TRICARE Encounter Provider Record (TEPRV) beginning with the SHCD.

2.10.1.6 The incoming Contractor will coordinate and cooperate with the outgoing Contractor to ensure that the outgoing Contractor can continue to process claims accurately; conversely, the outgoing Contractor has responsibility to notify the incoming Contractor of any changes in provider status that they become aware of through their operations.

2.11 Transition-In Requirements Related To Transitional Cases

2.11.1 In notifying beneficiaries of the transition to another Contractor, both the incoming and outgoing Contractors shall include instructions on how the beneficiary may obtain assistance with transitional care. If the outgoing Contractor succeeds itself, costs related to each contract will be kept separate for purposes of contract accountability.

2.11.2 Non-Network Inpatient Transitional Cases

2.11.2.1 These are beneficiaries who are inpatients (occupying an inpatient bed) at 0001 hours on the first day of any health care contract period in which the incoming Contractor begins health care delivery. In the case of Diagnosis Related Group (DRG) reimbursement, the outgoing Contractor shall pay through the first month of health care delivery or the date of discharge, whichever occurs first. If the facility is reimbursed on a per-diem basis, the outgoing Contractor is responsible for payment of all the institutional charges accrued prior to 0001 hours on the first day of health care delivery, under the incoming Contractor. The incoming Contractor thereafter is responsible for payment.

2.11.3 Non-Network Outpatient/Professional Transitional Cases

2.11.3.1 These are cases, such as obstetric care, that are billed and payable under “Global” billing provisions of Current Procedural Terminology, 4th edition (CPT-4), HCFA Common Procedure Coding System (HCPCS), or local coding in use at the time of contract transition, and where an Episode Of Care (EOC) shall have commenced during the period of health care delivery of the outgoing Contractor and continues, uninterrupted, after the SHCD by the incoming Contractor. Outpatient/professional services related to transitional cases are the responsibility of the outgoing Contractor for services delivered prior to 0001 hours on the first day of health care delivery and of the incoming Contractor thereafter.

8.9.4 Network Inpatient Care During Contract Transition The status of network provider changes (provider’s network agreement with the outgoing Contractor is terminated resulting in the provider’s loss of network status) with the SHCD of the new contract. As a result, claims for inpatient care shall be reimbursed in accordance with paragraph 8.9.2 for non-network transitional cases. Beneficiary copay is based on the date of admission; therefore, Prime beneficiaries who are inpatients as described in paragraph 8.9.2, shall continue to be subject to Prime network copayments and shall not be subject to Point Of Service (POS) copayments.

8.9.5 Home Health Care (HHC) During Contract Transition HHC, for a 60-day EOC, initiated during the outgoing Contractor’s health care delivery period and extending, uninterrupted, into the health care delivery period of the incoming Contractor are considered to be transitional cases. Reimbursement for both the Request for Anticipated Payment (RAP) and the final claim shall be the responsibility of the outgoing Contractor for the entire 60-day episodes covering the transition period from the outgoing to the incoming Contractor.

3.0 TRANSITION-OUT (PENDING)

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TRICARE Operations Manual 6010.62-M, April 2021 Attachment J-22-- DRAFT Chapter 24, Section 2 TRICARE Overseas Program (TOP) Transitions

Chapter 24 Section 3

Financial Administration

1.1 All TRICARE Financial Administration requirements 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.

2.0 PAYMENT POLICY

2.1 The TOP Contractor shall follow non-financially underwritten funds requirements in Chapter 3, with these exceptions:

2.1.1 The TOP Contractor shall ensure foreign overseas drafts (local currency) and checks (US currency) reflect “TRICARE Overseas Program”.

2.1.2 The TOP Contractor ensure foreign overseas drafts indicate 190 calendar day validity and if reissue is required/necessary, the draft must be returned to the TOP Contractor with a request for reissuance.

2.1.3 The TOP Contractor shall issue drafts/checks for Germany claims which resemble local German drafts/checks.

2.1.4 The TOP Contractor shall issue German drafts/checks using a German corporate address or the TAO Eurasia-Africa address.

2.1.5 The TOP Contractor shall create checks (payable in US dollars) within 48 hours after approval by DHA Contract Resource Management (CRM).

2.1.6 The TOP Contractor shall create drafts (payable in foreign currency units) within 96 hours following CRM approval, unless a different process has been authorized by DHA. Payments that need to be converted to a foreign currency shall be calculated based on the exchange rate in effect on the last date of each service.

2.1.7 The TOP Contractor shall ensure drafts/checks match with the appropriate EOB and are mailed to the beneficiary/sponsor/private sector care provider/POC as applicable.

2.1.8 The TOP Contractor shall pay provider claims for all overseas locations in the country’s local currency as identified on the claim for the specific country by foreign currency/drafts. Drafts may not be changed to a US dollar check after the TOP Contractor has issued a foreign draft. Comment by McCammon, Danielle H CIV DHA (USA): what does this mean?q Comment by Cox, Christopher D CTR (USA): Jurgen will check. Send T17 language to verify.

The TOP Contractor shall comply with the provisions of Chapter 3, Section 4 regarding stale dated, voided, or returned checks/Electronic Funds Transfers (EFTs) and are applicable to the TOP. Foreign overseas drafts are good for 190 calendar days and may be cashed at any time. US dollar checks are good for 120 calendar days.

2.1.9 The TOP Contractor shall mail drafts/checks and EOBs to private sector care providers unless the claim indicates payment should be made to the beneficiary. In conformity with banking requirements, the drafts/checks shall contain the TOP Contractor’s address. Drafts and EOBs shall be mailed using US postage. Additionally, payments/checks may be made to network providers, with an Embassy address. Comment by Cox, Christopher D CTR (USA): @Johnson, Laura L CIV DHA J-10 (USA)

2.1.10 The Contractor shall void checks when the provider/beneficiary’s EOB and check is returned as undeliverable.

2.2 EFT payments

2.2.1 The TOP Contractor shall reimburse providers on a weekly basis through EFT payment. Payment may be issued via check upon request.

2.2.2 The TOP Contractor shall reimburse beneficiaries via EFT payments to US financial institutions only. Payment may be issued via check upon request.

2.2.3 Bank charges incurred for EFT payments shall be the responsibility of the payee.

2.3 Reimbursements

2.1 The TOP Contractor shall reimburse TOP beneficiary claims based upon the lesser of billed charges, negotiated reimbursement rate, or Government-established fee schedules. (See Section 9, TRICARE Reimbursement Manual (TRM), Chapter 1, Sections 34 and 35) unless a different reimbursement rate has been established as described in TPM, Chapter 12, Section 1.3.

2.1.1 The TOP Contractor shall reimburse claims for care (excluding medical evacuation) in US commonwealths and territories following stateside reimbursement guidelines.

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.

2.1.3 The TOP Contractor shall implement and maintain internal management controls to ensure that payments are reasonable and customary for the service location.

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

2.1.4.1 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.

2.1.5 The TOP Contractor shall pay Value Added Tax (VAT) included on applicable healthcare claims for all beneficiary categories.

2.1.6 The TOP Contractor shall reimburse itemized fees for incidental inpatient supplies (e.g., hospital gowns) only if similar supplies would be covered under U.S. reimbursement methodologies.

2.1.7 The TOP Contractor shall implement and maintain internal management controls to ensure that payments are reasonable and customary for the service location.

2.1.8 The TOP Contractor shall pay TOP claims submitted by a beneficiary in US dollars, unless there is a beneficiary request on the claim at the time of submission for payment in a foreign currency.

2.1.9 The TOP Contractor shall reissue the original foreign currency payment in US dollars if a request is subsequently received from the beneficiary, is stale dated, and the draft is included in the request.

2.1.10 The TOP Contractor shall convert lump sum payments, instead of line items, to minimize conversion problems.

2.1.11 The TOP Contractor shall pay all beneficiary-submitted claims for TRICARE covered drugs dispensed by a US embassy health clinic directly to the beneficiary, not the embassy health clinic.

2.1.12 Professional services rendered by a US embassy health clinic are not reimbursable by TRICARE/TOP. These services are covered under International Cooperative Administrative Support Services (ICASS) agreements. Embassy providers (acting as PCMs) may refer TOP enrollees to private sector care providers, these claims shall be processed per TOP policy and procedures.

2.2 Healthcare in Puerto Rico and the US:

2.4.1 The TOP Contractor shall follow the below exceptions for Healthcare in Puerto Rico and the US:

2.4.1.1 The TOP Contractor shall allow the billed amount and reimburse TOP Service Members for charges required to be paid up front f the claim is payable. Normal TRICARE claims processing requirements apply (including any authorization requirements and use of TRICARE-approved claims forms).

2.6.1.2 The TOP Contractor shall ensure Service Members are not subjected to “balance billing” or ongoing collection action by a civilian provider for emergency or authorized care. If the TOP Contractor is aware of an issue they cannot resolve, they shall pend the file and forward the issue to the appropriate TAO Executive Director for review.

2.6.2 The TOP Contractor shall reimburse Overseas drug claims following the instructions in Section 8 and TRM, Chapter 1, Section 15.

2.6.3 the TOP Contractor shall reimburse Overseas ambulance service claims 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 The TOP Contractor shall follow Section 7 for payments made for ambulance services provided by commercial transport.

3.0 ADMINISTRATION

3.1 The TOP Contractor shall calculate currency gains and losses from payments to private sector care providers or beneficiaries in foreign countries per Section G.

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.

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Attachment J-22-- DRAFT Chapter 24, Section 3 TRICARE Overseas Program (TOP) Financial Administration

Chapter 24 Section 4

Private Sector Care Providers

1.1 TRICARE Overseas Program (TOP) healthcare is provided by Military Medical Treatment Facilities (MTFs) and private sector care network and non-network providers and institutions. All TRICARE Provider Certification/Credentialing and Network Development requirements apply to the TOP unless specifically changed, waived, or superseded by this section, 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 1.3, 2.1, 2.6, 2.8, 3.2, 4.1, 4.6, 5.0, 6.1, 7.0, 8.1, 9.0, 11.0, 12.3, and 12.4 do not apply to TOP.

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 private sector care provider certification.

2.2 The TOP Contractor is not required to follow 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) in Puerto Rico receive required approval.

2.2.2 The TOP Contractor shall establish certification processes based on host nation licensure and credentialing requirements for services outside paragraph 2.2 and 2.2.1.

2.2.3 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 develop and maintain a network, and non-network, of private sector care providers to augment the existing Direct Care (DC) system capacity for Active Duty Service Members (ADSMs) and Active Duty Family Members (ADFMs) enrolled in TOP Prime and provide or arrange for primary and specialty care services for ADSMs and ADFMs enrolled in TOP Prime Remote.

3.2 The TOP Contractor shall establish signed provider agreements with network providers.

3.2.1 Network provider agreements shall include language indicating the provider agrees to participate on a cashless, claimless basis for authorized services for TOP enrollees. “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 compliance 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 the needs of the 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 credentialed private sector care providers familiar with TRICARE, but networks shall not be developed to accommodate non-TOP Prime/Prime Remote enrollees.

3.4 The Government (MTF Directors) will identify network specialty needs in TOP Prime locations 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).

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

4.0 CONTRACTOR REQUIREMENTS - PRIVATE SECTOR CARE PROVIDERS

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

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Attachment J-22-- DRAFT Chapter 24, Section 4 TRICARE Overseas Program (TOP) PSCPs

Chapter 24 Section 5

TOP Eligibility and Enrollment

1. GENERAL

All TRICARE eligibility, enrollments, re-enrollments, disenrollments, and transfers requirements apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), ; 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. 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.

2.0 ELIGIBILITY

2.1 The TOP Contractor shall verify eligibility for TRICARE through the Defense Enrollment Eligibility Reporting System (DEERS). In addition to DEERS eligibility, TOP Active Duty Family Members (ADFMs) require Command Sponsorship to be eligible for TOP Prime and TOP Prime Remote enrollment unless a specific exception exists. Family Members of the Armed Forces of foreign North Atlantic Treaty Organization (NATO) or Partnership for Peace (PFP) nations are not eligible for TOP.

2.1.1 The TOP Contractor shall enroll and provide benefits only to those beneficiaries eligible in DEERS with the exception of newborns, who shall be enrolled regardless of DEERS eligibility.

2.1.2 The TOP Contractor shall verify DEERS eligibility and Command Sponsorship (when required) prior to enrolling beneficiaries into TOP.

2.2 Line of Duty (LOD) eligibility. 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 LOD care per 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. Additional documentation is required for LOD eligibility as DEERS will not identify RC members as ’TRICARE eligible.’

2.2.1 Military Medical Treatment Facility (MTF) RC referrals

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

2.2.1.2 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.

2.2.2 RC members who are not referred by an MTF.

2.2.2.1 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.

2.2.2.2 The TOP Contractor shall only accept written documentation from DHA-Great Lakes or the applicable military unit or Command to confirm the member’s LOD eligibility for care. Verbal attestation of duty status is insufficient to establish LOD eligibility.

2.2.2.3 The TOP Contractor shall process claims associated with the LOD authorization as if the member were eligible in DEERS.

2.2.2.4 The TOP Contractor shall deny claims for care not associated with the LOD authorization.

3.0 ENROLLMENT PROCESSING

3.1 TOP Prime or TOP Prime Remote (TOP PR) enrollment is available only to Active Duty Service Members (ADSMs) who are permanently assigned overseas, and Command Sponsored Active Duty Family Members (ADFMs) accompanying them, 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 6.0 for additional details on family member eligibility.

3.1.1 The TOP Contractor shall establish TOP Prime enrollment procedures in the Statements of Responsibilities (SORs) between the TOP Contractor and the MTF Director.

3.1.2 The TOP Contractor shall enroll TOP Prime enrollees to a MTF Primary Care Manager (PCM). Enrollment to a private sector care PCM is authorized when MTF capacity is reached.

3.1.3 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.

3.1.4 The TOP Contractor shall enroll non-command sponsored ADFMs, retirees, and retiree family members in TRICARE Select.

3.2 Enrollment is effective during the sponsor’s overseas tour and does not require annual re-enrollment. Enrollment remains until:

3.2.1 Disenrollment;

3.2.2 Transfer enrollment to another TRICARE region/program;

3.2.3 Loss of eligibility for TRICARE, TOP Prime, or TPR.

3.3 The TOP Contractor shall execute all enrollment-related activities for TOP Prime, TOP Prime Remote, TOP Select, TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), and TRICARE Plus in overseas locations. Enrollment activities shall encompass eligibility validation, enrollment and re-enrollment processing, disenrollment, transfers, updates to DEERS records, resolution of enrollment discrepancies, PCM assignment or changes, collecting Other Health Insurance (OHI) information, and related functions. Overseas insurance plans such as German Statutory Health Insurance, Japanese National Insurance (JNI), Philippines Phil Health, and Australian Medicare, etc., are considered OHI.

3.3.1 The TOP Contractor shall use approved TRICARE enrollment request options for enrollment activities.

3.3.1.1 The TOP Contractor shall ensure that officially signed enrollment requests include (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.

3.3.1.2 The TOP Contractor shall not require a signature to make enrollment changes by phone if the verbal request is documented.

3.3.1.3 The TOP Contractor shall not require a signature from an ADSM to complete TOP Prime/TOP Prime Remote enrollment as enrollment in Prime is mandatory per TPM, Chapter 10, Section 2.1, paragraph 1.1.

3.3.2 The TOP Contractor shall accomplish enrollment within five business days of a complete request.

3.4 The TOP Contactor shall…