TRICARE Overseas Program Provider Manual

R 

TRICARE Overseas Program 

Provider Manual

An Important Note About TRICARE Program Information: 

At the time of printing, the information in this TRICARE Overseas Program (TOP) Provider Manual is current. 

It is important to remember that TRICARE policies and benefits are governed by United States public law and federal regulations. 

Changes to TRICARE programs are continually made as public law and/or federal regulations are amended. 

For the most recent information, contact International SOS or visit www.tricare.mil. 

More information regarding TRICARE, including the Health Insurance Portability 

and Accountability Act (HIPAA) Notice of Privacy Practices, can be 

found online at www.tricare.mil. 

2

TRICARE overseas Program 

Provider Manual 

Table of Contents 

SECTIoN 1: About International SoS and TRICARE overseas Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 

Introduction Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 

About International SOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 

About Defense Health Agency and the Military Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 

What is the TRICARE Overseas Program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 

TRICARE Overseas Program Provider Manual Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 

International SOS TRICARE Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 

Reporting Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 

SECTIoN 2: TRICARE overseas Program Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Identifying TRICARE Patients and Validating Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Sample TOP Prime and TOP Prime Remote Enrollment Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

TOP Prime and TOP Prime Remote Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 

— TOP Prime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 

— TOP Prime Remote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 

Other Covered Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

— Beneficiaries on Active Duty for More Than 30 Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

— Beneficiaries on Active Duty for 30 Days or Less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

— Beneficiaries Enrolled in the Continental U.S. (CONUS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

Other Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

TRICARE Pharmacy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 

TRICARE Dental Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

TOP Prime and TOP Prime Remote Beneficiary Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

TOP Prime and TOP Prime Remote Beneficiary Coverage Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 

TOP Prime and TOP Prime Remote Beneficiary Coverage Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 

SECTIoN 3: International SoS Network Providers and Provider Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 

What is a Network Provider? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 

Becoming an International SOS Network Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 

How to Become an International SOS Network Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 

Network Provider Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 

Keeping Your Provider File Current . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 

Network Provider Quality Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 

TOP Provider Support Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 

Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 

Provider Credentialing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 

Beneficiary Access to TOP Network Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 

SECTIoN 4: Authorizations and Seeing TRICARE Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 

How Are Patients Referred to You? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 

— TOP Prime and TOP Prime Remote Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 

— TOP Standard Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 

Determining Patient Eligibility for Authorized Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 

Authorization Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 

— Authorization for Cases of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 

— Emergency Assistance Treatment and Authorizations and Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 

— Clear and Legible Reporting: Issuing a Medical Report Following Patient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 

Patient Records and Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 

Cultural Differences and Host Nation Patient Liaisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 

3



Table of Contents (continued) 

SECTIoN 5: Provider Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 

Process for Submitting Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 

Web-based Claims Submission Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 

— Secure Message Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 

— Online Claim Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 

Claims for Services Rendered Before September 1, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 

Claim Tracking and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 

Timely Filing of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 

Claim Reimbursement and Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 

Required Criteria for Ensuring Payment of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 

Explanation of Benefits and Applicable Exchange Rate Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 

Transaction Fees Associated with Claim Reimbursement and Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 

What if Both Non-Institutional & Institutional Providers Are Used for the Same ‘Episode of Care’ and Billed Independently? . . . . . . . . . .56 

What if a Beneficiary Does Not Show for an Appointment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 

Step-By-Step Instructions for Accurately Completing Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 

— The Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 

SECTIoN 6: The Provider Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 

Registering to the Provider Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 

Using the Provider Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 

— The Provider Dashboard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 

— Claim Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 

— Patient Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 

— Manage Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 

— My Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97 

TRICARE Covered Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98 

SECTIoN 7: TRICARE overseas Program Provider Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 

Sample: CMS 1500 Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 

Sample: UB-04 Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102 

Sample: International SOS Authorization Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104 

Sample: EDI Agreement Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 

Sample: EFT Form for Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 

Sample: EFT Form for Providers Who Use a Billing Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107 

SECTIoN 8: List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108 

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 

TOP: Explanation of Benefits Denial Codes and Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 

4



SECTIoN 1 

About International SoS and 

the TRICARE overseas Program 

SECTIoN 1: 

About International SoS and the TRICARE overseas Program 

April 2011 

Dear TRICARE Provider, 

International SOS Assistance, Inc. (International SOS) is proud to serve as the Department of Defense TRICARE Overseas Program (TOP) 

contractor, effective September 1, 2010. We are fully committed to delivering high-quality, readily available, and comprehensive health 

care services for the nearly half a million TRICARE beneficiaries, including deployed personnel, travelers, and retirees outside the 50 

United States and the District of Columbia. 

International SOS remains focused on processing all claims and inquiries in a timely and accurate manner. Working together with you, our 

network of health care Providers who will be supporting us, we have created an efficient and timely cashless, claimless process for 

beneficiaries. International SOS has been serving a large population of this customer base since 1998. 

This manual describes the TRICARE program and requirements. It also provides important TOP Regional Call Center numbers and 

website information. International SOS is always here for you in case you need further assistance. We encourage you to visit 

www.tricare-overseas.com for various Provider services, including covered services, how to submit claims for timely reimbursement, 

referrals and authorizations, credentialing and the benefits of becoming part of the TRICARE Provider Network. 

International SOS understands the value of services you provide to our Department of Defense military members and their families. 

We look forward to our continued successful relationships bringing the very best care to beneficiaries worldwide. Thank you for the very 

important role you play in helping us to achieve this goal. 

Kind regards, 

Kelley Harar 

Chief Operating Officer, TRICARE Overseas Program 

International SOS 

5



Since 1998, 

International SOS has 

supported TRICARE in 

ensuring that Active Duty 

Service Members and their 

families receive the highest 

quality care, no matter 

where their work or 

travels take them. 

About International SoS 

International SOS (http://www.internationalsos.com) is 

the world's leading medical and travel security risk services 

company. We care for clients across the globe, from more 

than 700 locations in 89 countries. Our expertise is unique: 

approximately 11,000 employees are led by 1,200 doctors 

and 200 security specialists. Teams work night and day to 

protect our members. 

Since 1998, International SOS has supported TRICARE in 

ensuring that Active Duty Service Members (ADSM) and their 

families receive the highest quality care, no matter where 

their work or travels take them. 

About Defense Health Agency and 

the Military Health System 

Defense Health Agency (DHA), the Defense Department activity 

that administers the health care plan for the uniformed services, 

retirees and their families, serves more than 9.5 million eligible 

beneficiaries worldwide in the Military Health System (MHS). The 

mission of the MHS is to enhance Department of Defense and 

national security by providing health support for the full range of 

military operations. The MHS provides quality medical care 

through a network of Providers, Military Treatment Facilities 

(MTF), medical clinics and dental clinics worldwide. 

What is the TRICARE overseas 

Program? 

TRICARE is a comprehensive health care program provided to 

active and retired members of the United States uniformed 

services, their spouses and children, survivors and certain other 

beneficiaries. 

On October 21, 2009, International SOS was selected by DHA as 

the contractor for the TRICARE Overseas Program (TOP) in 

locations outside the 50 United States and the District of 

Columbia. International SOS began delivering health care 

services on September 1, 2010. 

TOP is designed to enhance existing operations, improve 

Provider satisfaction and deliver high-quality, patient-centered 

care for nearly half a million beneficiaries overseas. 

For TRICARE beneficiaries living overseas, TOP will offer options 

including TOP Prime, TOP Prime Remote and TOP Standard as 

6



SECTIoN 1 

About International SoS and 

the TRICARE overseas Program 

well as TRICARE for Life, TRICARE Reserve Select, TRICARE 

Retired Reserve, and TRICARE Young Adult. 

International SOS is developing a network of Providers primarily 

to support TOP Prime and TOP Prime Remote beneficiaries. We 

recognize that TOP Standard beneficiaries may also choose to 

seek care from some Network Providers. 

The TOP Prime program delivers the prime benefit to ADSM and 

their families in the three overseas areas: Eurasia-Africa, the 

Pacific, and Latin America and Canada. The TOP Prime Remote 

program delivers the prime benefit to ADSM and their families 

stationed in designated remote locations overseas. 

International SoS TRICARE 

Contact Information 

If you have any questions about claims, payments, how to 

become a Network Provider or credentialing and certification 

requirements, please contact your TOP Regional Call Center. 

Customer Service Phone Numbers 

Europe, Middle East & Africa +44-20-8762-8384 


Provider Manual overview 

Latin America and Canada +1-215-942-8393 

Puerto Rico +1-877-867-1091 

This TOP Provider Manual has been developed to provide you 

and your staff with basic, important information about the 

TRICARE Overseas Program (TOP). The manual will assist you in 

coordinating care for TOP beneficiaries. It contains detailed 

information about TOP programs, policies and procedures. 

Additional TOP program information can be found online by 

visiting www.tricare-overseas.com. Providers can also visit the 

TRICARE website at www.tricare.mil. TRICARE program 

manuals are available in their entirety at the DHA Manuals 

website. 

Thank you for your commitment to the Department of Defense 

overseas military community. 

Asia-Pacific +65-6339-2676 

Australasia +61-2-9273-2710 

If a patient attends an appointment and you require assistance 

with determining eligibility, covered benefits, or receiving prior 

authorization for care, please contact the Medical Assistance 

lines below: 

Medical Assistance Phone Numbers 

Europe, Middle East & Africa +44-20-8762-8133 

Latin America and Canada +1-215-942-8320 

Puerto Rico +1-215-942-8320 

Asia-Pacific +65-6338-9277 

Australasia +61-2-9273-2760 

Visit www.tricare-overseas.com for a full listing of toll free phone 

numbers by country. This website will be updated regularly, as 

additional information becomes available. 

7



The following email addresses are also available, for contacting 

your TOP Provider Support Services staff: 

Europe, Middle East & Africa 

providerseurasiaafrica@internationalsos.com 

Latin America and Canada 

providerslatinamerica@internationalsos.com 

Puerto Rico 

provider.inquiries.PR@internationalsos.com 

Asia-Pacific 

providersasiapacific@internationalsos.com 

Additionally, Providers can inquire about specific claims issues 

by sending their questions to the International SOS TOP Claims 

Processing Department via the Web-based Secure Message 

Transmission function on the Provider Portal. Please see Section 

6: The Provider Portal for additional information about accessing 

the Secure Message Inbox. 

Reporting Fraud and Abuse 

International SOS as part of the TRICARE Overseas Program is 

committed to detecting, correcting, and preventing health care 

fraud and abuse. 

Fraud happens when a person or organization takes action to 

deliberately deceive others to gain an unauthorized benefit. 

Health care abuse occurs when Providers supply services or 

products that are medically unnecessary or that do not meet 

professional standards. 

Write to the customer service department for TOP to report 

suspected fraud and abuse: 

ATTN: TRICARE Program Integrity 

1717 W. Broadway 

PO Box 7635 

Madison, Wisconsin 53707 

USA 

You can also send an email to reportit@wpsic.com 

or submit an electronic form posted on 

http://www.tricare-overseas.com/fraud.htm. 

Be sure to provide as much information as possible. 

Fraud or abuse issues can also be reported directly to 

TRICARE by emailing fraudline@dha.osd.mil. 

If you would like to obtain additional information about 

International SOS’ Program Integrity mission, please email 

ToPProgramIntegrity@internationalsos.com. 

Program Integrity information is also available online at 

www.tricare-overseas.com/fraud.htm. 

8



SECTIoN 2: 

TRICARE overseas Program Benefits 

Identifying TRICARE Patients and 

Validating Coverage 

Sample ToP Prime and ToP Prime 

Remote Enrollment Cards 

SECTIoN 2 


Benefits 

TRICARE is available to a range of members serving under the 

U.S. Department of Defense. 

It is important to remember that not all U.S. patients are TRICARE 

patients. 

Sample ToP Prime Enrollment Card 

■ Front of Card 

Because there are so many types of U.S. military patients who 

may seek care from you, it is critical to properly identify both the 

patient and their TRICARE status. 

TRICARE patients who seek care from you will have some 

way to prove that they are TRICARE eligible – this can be a U.S. 

Military Identification Card, a written confirmation from the 

Military Treatment Facility (MTF), or an Authorization Form from 

International SOS. 

■ Generally, children under 10 will not have their own Military 

Identification Card. The parent’s valid identification card is 

considered sufficient. 

■ TRICARE Prime Enrollment Cards are only valid when 

presented with a valid Military ID Card or Common Access 

Card (CAC). Please ensure that the names on both cards 

match, that the expiration date on the Military ID Card or CAC 

has not lapsed, and that the photo on this card accurately 

represents the patient. 

■ Back of Card 

■ If you have a concern about an individual patient, you may 

contact your TOP Regional Call Center for assistance 24/7. 

■ Providers are authorized and encouraged to photocopy both 

sides of a patient’s Military ID Card or TRICARE Enrollment 

Card. 

■ Once the Provider is registered to the online Provider Portal 

available at www.tricare-overseas.com they will also be able 

to check a patient’s eligibility through the portal. 

Sample TOP Prime and TOP Prime Remote Enrollment Cards are 

included here for your reference. 

9



Sample ToP Prime Remote Enrollment Card 

■ Front of Card 

ToP Prime and ToP Prime Remote 

Eligibility 

This section introduces several terms you may come across while 

treating TRICARE beneficiaries. 

TRICARE provides payment for covered services as long as the 

beneficiary is eligible and the care is properly authorized. 

Once a Provider agrees to participate, and they have agreed to 

provide cashless, claimless services to TOP Prime and TOP 

Prime Remote beneficiaries, they will submit the appropriate 

Standard U.S. Claim Forms on behalf of the beneficiaries and will 

provide medical services in line with TRICARE policy. 

■ Back of Card 

With the exception of emergency care and the first eight 

outpatient visits for behavioral health care, and one annual 

optometry screening (3 years and older), TOP Prime and TOP 

Prime Remote beneficiaries are eligible to receive cashless, 

claimless service from a Host Nation Provider. 1 

It is important to remember that in most cases International SOS 

will provide you with an Authorization Form for TOP Prime and 

TOP Prime Remote beneficiaries. 

All other beneficiaries who are not TOP Prime or TOP Prime 

Remote are required to pay for service upfront and then file a 

TRICARE claim directly. As an International SOS Network 

Provider, you may choose to file claims on behalf of beneficiaries 

who are not TOP Prime or TOP Prime Remote, but are not 

required to do so. 

Active Duty Service Members (ADSM) are required to enroll in 

TOP Prime. Depending on where they are stationed overseas, 

they must enroll in one of the following two TOP Prime options: 

TOP Prime and TOP Prime Remote Active Duty Service Members 

(ADSM) will receive an enrollment card similar to the sample card 

graphic above. When presented with the beneficiary’s Military ID 

Card or CAC, this is one method Providers can use to validate 

TRICARE eligibility. 

Note: Only TOP Prime and TOP Prime Remote beneficiaries will 

receive an enrollment card. Other TRICARE beneficiaries, such 

as TOP Standard, will not be issued an enrollment card. However, 

they will be given a Military ID Card or CAC. Therefore, the 

enrollment card is key for identifying those beneficiaries who are 

eligible for TOP Prime or TOP Prime Remote care. 

■ TOP Prime 

■ TOP Prime Remote 

Note: If you have any questions about how to determine 

beneficiary eligibility or the TOP option under which the 

beneficiary is covered, please contact your TOP Regional 

Call Center and select option #5 to speak with a member of 

your TOP Provider Support Services staff. 

10 

1 The TRICARE Overseas Program also operates in Puerto Rico, Guam, 

American Samoa, U.S. Virgin Islands and Northern Marianas.



ToP Prime 

TOP Prime beneficiaries live within a 40-mile radius of a U.S. MTF. 

These beneficiaries are required to seek care through their local 

MTF. 

If an MTF does not have the capability to provide treatment to the 

beneficiary, the assigned Primary Care Manager (or treating 

practitioner within the MTF) may refer the beneficiary to 

International SOS to find a Network Provider. International SOS 

will issue an Authorization Form to the Network Provider before 

care can be delivered. 

The medical oversight of the beneficiary’s care still resides with 

the MTF Primary Care Manager or assigned host nation Primary 

Care Manager. All medical notes and consult findings should be 

sent back to the MTF or assigned host nation Primary Care 

Manager within 10 working days for routine consultation reports 

and within 24 hours for urgent consultation reports. 

ToP Prime Remote 

TOP Prime Remote beneficiaries live more than 40 miles away 

from an overseas U.S. MTF. TOP Prime Remote beneficiaries will 

receive their primary care from a Host Nation Provider who will 

serve as their Primary Care Physician. 

International SOS acts as the Primary Care Manager for all TOP 

Prime Remote Beneficiaries. 

International SOS manages all referrals and medical oversight of 

TOP Prime Remote beneficiaries living overseas. All medical 

notes and consult findings, including authorizations for referrals 

to secondary care or inpatient admissions should be discussed 

with International SOS. 

11 

The following table shows the various TOP options available by 

beneficiary type: 

Beneficiary Type 

Active Duty Service 

Members (ADSM) 

Active Duty Family 

Members 2 

(ADFM) and transitional 

survivors 

Retired service members 4 

and family members, 

survivors, Medal of Honor 

recipients, certain unremarried 

former spouse, 

and others who are 

registered in the Defense 

Enrollment Eligibility 

Reporting System (DEERS). 6 

ToP Program options 

■ TOP Prime 


■ TRICARE Active Duty 

Dental Program (ADDP) 1 

■ TOP Prime 


■ TOP Standard 3 

■ TRICARE For Life (TFL) 

(if you have both Medicare 

Part A and Part B) 4 

■ TRICARE Dental Program 

■ TRICARE Young Adult 

Program (TYA) 7 

■ TOP Standard 

■ TFL (if you have both 

Medicare Part A and Part B) 4 

■ TRICARE Retired Reserve 5 

■ TYA 7 

■ TRICARE Reserve Select 

■ Enhanced-Oversease 

TRICARE Retiree Dental 

Program 

■ TRICARE PLUS (depending 

on military hospital or 

clinical availability) 

SECTIoN 2 


Benefits 

1 The ADDP is only available in the United States and in U.S. territories (American Samoa, Guam, 

the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). See page 13 for 

additional details about the TRICARE Dental Program. 

2 Active Duty Family Members (ADFM) include the sponsor’s TRICARE-eligible spouse and 

children. Unmarried children may remain TRICARE-eligible until age 21 (or age 23 if enrolled 

in a full-time course of study at an approved institution of higher learning, and if the sponsor 

provides 50 percent or more of the financial support, (but have not yet reached age 26). A 

disabled child may remain TRICARE-eligible beyond normal age limits. 

3 ADFM who are not eligible for, or choose not to enroll in TOP Prime options may use TOP 

Standard. 

4 Most beneficiaries who are entitled to Medicare Part A must have Medicare Part B to remain 

TRICARE-eligible. ADFMs who have Medicare Part A are not required to have Medicare Part B 

to remain eligible for TRICARE. However, once the sponsor reaches age 65, Medicare Part B 

must be in effect no later than the sponsor’s retirement date to avoid a break in TRICARE 

coverage. 

5 Retired service members and their family members are not eligible to enroll in TOP Prime 

options. They may be eligible to use TOP Standard or TRICARE for Life. Certain retired National 

Guard and Reserve members and their families may qualify to purchase TRICARE Retired 

Reserve coverage. 

6 Individual eligibility is determined by DEERS. Beneficiaries are responsible for ensuring their 

information is current in this system. TRICARE claims for patients who are not listed as eligible in 

DEERS cannot be paid by International SOS. 

7 The premium-based TRICARE Young Adult (TYA) program extends TRICARE coverage to 

certain qualified dependents until reaching age 26, and may be an option for adult children who 

‘age out’ of other TRICARE benefits. For more information, please visit www.tricare.mil/tya.



other Covered Beneficiaries 

Beneficiaries on Active Duty for More Than 30 Days 

If a beneficiary is activated for more than 30 consecutive days, 

they receive TRICARE benefits as an ADSM. 

The TRICARE-eligible family members who reside overseas with 

the ADSM sponsor receive coverage as Active Duty Family 

Members (ADFM) while the sponsor is activated. These ADFM 

are eligible to enroll in TOP Prime options if they are Command 

Sponsored (authorized by the U.S. Government to accompany 

their sponsor to the overseas location). If ADFM do not enroll in 

TOP Prime or TOP Prime Remote, they may choose to use TOP 

Standard, which does not require enrollment. 

Beneficiaries on Active Duty for 30 Days or Less 

National Guard and Reserve members serving overseas on 

orders for 30 days or less are not eligible for TRICARE active duty 

benefits. However, if the beneficiary is injured or becomes ill while 

traveling to or from annual training while on active duty, he/she is 

eligible for line-of-duty care. Beneficiaries may also seek 

emergency and urgent care while serving on their orders. 

Beneficiaries Enrolled in the Continental U.S. (CoNUS) 

For beneficiaries who are enrolled in a Continental U.S. (CONUS) 

TRICARE program and are traveling overseas, authorizations are 

needed for urgent care. Emergency care services can be 

delivered on a cashless, claimless basis without authorization. 

However, Providers are encouraged to call International SOS to 

coordinate care upfront. 

other Health Insurance 

As required by law, TRICARE can only pay after all other active 

insurance policies have paid their share. This includes National 

Health Insurance. As outlined below, proof of submitting the claim 

to the other health insurer (including any payment information) must 

be submitted with the Claim Form. 

If the patient has Other Health Insurance (OHI), you must claim 

payment from the OHI first. 

Once the OHI has processed and paid the claim, you can then 

seek reimbursement for any outstanding payments from TRICARE 

directly. If the OHI covers all costs associated with treating the 

beneficiary, then you will not need to submit a claim to TRICARE. 

Once the OHI has issued your payment, you must enter the amount 

paid in the relevant field on the corresponding Claim Form (field 29 

on the CMS 1500 or field 54 on the UB-04 Claim Form). You may 

also submit a copy of the Explanation of Benefits (EOB) from the 

OHI, when submitting your Claim Form and Itemized Invoice. 

If the OHI has not made any payment, you must submit the EOB 

from the OHI to International SOS when submitting the claim. 

TRICARE Pharmacy Program 

TRICARE offers comprehensive prescription drug coverage and 

several options for filling prescriptions. The beneficiary is 

responsible for paying and claiming for their medications, unless 

the Pharmacy agrees to file claims on behalf of the beneficiary. 

Some Pharmacies may decide to offer cashless medical services to 

TRICARE beneficiaries. This means that the Provider will be 

responsible for submitting a completed Claim Form and Itemized 

Invoice to International SOS for reimbursement. Pharmacists will not 

require an Authorization Form to deliver this service. A TOP 

Pharmacy Pack is available for Pharmacies who decide to provide 

cashless medical services to TRICARE beneficiaries. The TOP 

Pharmacy Pack includes step-by-step instructions for the 

Pharmacist on how to complete the correct Claim Form as well as 

an information guide about formulary drug coverage. To request 

a TOP Pharmacy Pack, please contact your TOP Regional Call 

Center and press option #5 to speak with a member of your 

TOP Provider Support Services staff. 

To fill a prescription, TRICARE beneficiaries will need a written 

prescription and a TRICARE Prime Enrollment Card as well as a 

valid Military ID Card or CAC. 

When Providers write a prescription they are asked to include all of 

the information shown on Figure 2.1: 

12



Figure 2.1 

Name of the clinic 

Patient’s name and 

date of birth 

Clinic 

Name 

Name of Provider 

Provider Street 

Provider Town 

Provider Telephone 

Date of Prescription 

Provider’s name 

Provider’s full 

address/phone number 

Date prescription is issued 

SECTIoN 2 


Benefits 

Generic (chemical) 

name of the medication 

being prescribed. NOTE: 

Do not use the brand name 

Please include dosage 

instructions (e.g. “Take 

2 tablets 2x a day”) 

Attending physician’s 

signature and name 

Name of Patient 

Patient DOB 

Generic (chemical) name of drug xxmg 

capsules, 30 

Dosage instructions 

Refill: not to exceed 12 months 

Dr. Provider 

Dr. Provider 

Strength of the medication 

(e.g. 50mg tablets) 

Number of tablets required 

Please include the number of 

refills the patient may receive. 

This cannot cover more than 

a year. 

Provider’s stamp 

Additional information about the TRICARE Pharmacy Program 

can be found online at www.tricare.mil/pharmacy or 

www.express-scripts.com/TRICARE. 

TRICARE Dental Program 

Active Duty Family Members 

ADFM enrolled in TOP Prime and TOP Prime Remote may receive 

their dental care under the TRICARE Dental Program. This is an 

optional program that requires enrollment. International SOS does 

not manage this care and cannot authorize these treatments. 

For additional information about the TRICARE Dental Program, 

please visit http://www.tricare.mil/Dental/TDP.aspx. 

Active Duty Service Members 

International SOS coordinates dental care for ADSM enrolled in 

TOP Prime Remote only. Care will be referred to an International 

SOS Network Provider Dentist. 

13 

Note: The Network Provider Dentist will need to receive an 

Authorization Form from International SOS first, and will then need 

to file a claim for reimbursement, accordingly. 

TOP Prime ASDM dental care is covered by United Concordia 

(UCCI). TOP Prime ADSM will receive their dental care at the 

Dental Treatment Facility at the MTF. For more information, please 

visit http://www/tricare.mil. 


Beneficiary Covered Services 

TRICARE covers most care that is medically necessary and 

considered proven. Some types of care are not covered at all, 

and there are special rules and limits for certain types of care. 

This section is not intended to be all-inclusive. 

TRICARE policies are very specific about which services are covered 

and which are not. It is in your best interest to take an active role in 

verifying coverage. If you have any questions about whether or not 

services are covered for the TOP Prime or TOP Prime Remote 

beneficiary you are seeing, please contact International SOS. 

Note: The following lists of services are subject to change. 

Please visit www.tricare.mil for a full list of covered services, 

limitations and exclusions.



outpatient Services: Coverage Details 

Figure 2.2 

Service 

Ambulance Services 

Description 

The following ambulance services are covered: 

■ Emergency transfers from a beneficiary’s home, accident scene, or other location to a hospital 

■ Transfers between hospitals 

■ Ambulance transfers from a hospital-based emergency room to a hospital more capable of providing 

the required care 

■ Transfers between a hospital or skilled nursing facility 1 and another hospital-based or freestanding 

outpatient therapeutic or diagnostic department/facility 

The following are excluded: 

■ Use of an ambulance service instead of taxi service when the patient’s condition would have permitted 

use of regular private transportation 

■ Transport or transfer of a patient primarily for the purpose of having the patient nearer to home, family, 

friends, or personal physician 

■ Medicabs or ambicabs that function primarily as public–passenger conveyances transporting patients to 

and from their medical appointments 

Note: Air or boat ambulance is only covered when the pickup point is inaccessible by a land 

vehicle, or when great distance or other obstacles are involved in transporting the beneficiary to 

the nearest hospital with appropriate facilities, and the patient’s medical condition warrants 

speedy admission or is such that transfer by other means is not advisable. 

Durable Medical Equipment, 

Prosthetics, orthotics, and 

Supplies (DMEPoS) 

Emergency Services 

Generally covered if prescribed by a physician and if directly related to a medical condition. Covered 

DMEPOS generally includes: 

■ DMEPOS that are medically necessary and appropriate and prescribed by a physician for a beneficiary’s 

specific use 

■ Duplicate DMEPOS items that are necessary to provide a fail-safe, in-home life-support system (In this 

case, “duplicate” means an item that meets the definition of DMEPOS and serves the same purpose but may 

not be an exact duplicate of the original DMEPOS item. For example, a portable oxygen concentrator may be 

covered as a backup for a stationary oxygen generator.) 

Note: Prosthetic devices must be U.S. Food and Drug Administration–approved. 

TRICARE defines an emergency as a serious medical condition that the average person would consider to 

be a threat to life, limb, sight, or safety. However, most dental emergencies, such as going to the emergency 

room for a severe toothache, are not a covered medical benefit under TRICARE. 

Home Health Care 1 

Covers part-time or intermittent skilled nursing services and home health care services for those confined to 

the home. (All care must be provided by a participating home health care agency and be authorized in advance 

by the regional contractor.) 

Individual Provider Services 

Covers office visits; outpatient, office-based medical and surgical care; consultation, diagnosis, and treatment 

by a specialist; allergy tests and treatment; osteopathic manipulation; rehabilitation services (e.g., physical 

and occupational therapy and speech pathology services); and medical supplies used within the office. 

1 

Skilled nursing facility care and home health care services are only available in the United States and U.S. territories (American Samoa, Guam, the Northern Mariana 

Islands, Puerto Rico, and the U.S. Virgin Islands). 

14



outpatient Services: Coverage Details (continued) 

Service 

Laboratory and X-ray Services 

Active Duty Service Member 

(ADSM) Respite Care 

Generally covered if prescribed by a physician. 

Description 

Covers respite care for ADSMs who are homebound as a result of a serious injury or illness incurred 

while serving on active duty; available if the ADSM’s plan of care includes frequent interventions by 

the primary caregiver. 1 

SECTIoN 2 


Benefits 

The following respite care limits apply: 

■ Five days per calendar week 

■ Eight hours per calendar day 

Note: Respite care must be provided by a TRICARE-authorized home health care agency and 

requires prior authorization from your regional contractor and the ADSM’s approving authority 

(i.e., referring military hospital or clinic). The ADSM is not required to be enrolled in the TRICARE 

Extended Care Health Option program to receive the respite benefit. 

1 

More than two interventions are required during the eight-hour period per day that the primary caregiver would normally be sleeping. 

Inpatient Services: Coverage Details 

Figure 2.3 

Service 

Hospitalization 

(semi-private room/special care 

units when medically necessary) 

Skilled Nursing Facility Care 1 

(semiprivate room) 

Description 

Covers general nursing; hospital, physician, and surgical services; meals (including special diets); 

drugs and medications; operating and recovery room care; anesthesia; laboratory tests; X-rays and 

other radiology services; medical supplies and appliances; and blood and blood products. 

Note: Surgical procedures designated “inpatient only” may only be covered when performed in an 

inpatient setting. 

Covers skilled nursing services; meals (including special diets); physical, occupational, and speech 

therapy; drugs furnished by the facility; and necessary medical supplies and appliances. (TRICARE 

covers an unlimited number of days as medically necessary.) 

1 

Skilled nursing facility care is only available in the United States and U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin 

Islands). 

15



Clinical Preventive Service: Coverage Details Figure 2.4 

Service 

Comprehensive Health 

Promotion and Disease 

Prevention 

Examinations 

Targeted Health 

Promotion and Disease 

Prevention Services 

Cancer Screenings 

Description 

A comprehensive clinical preventive exam is covered if it includes an immunization, Pap test, mammogram, colon 

cancer screening, or prostate cancer screening. School enrollment physicals for children ages 5–11 are also covered. 

Beneficiaries in each of the following age groups may receive one comprehensive clinical preventive exam without 

receiving an immunization, Pap test, mammogram, colon cancer screening, or prostate cancer screening (one exam 

per age group): 2–4, 5–11, 12–17, 18–39, and 40–64. 

The screening examinations listed below may be covered if provided in conjunction with a comprehensive clinical 

preventive exam. The intent is to maximize preventive care. 

■ Colonoscopy: 

— Average Risk: Individuals at average risk for colon cancer are covered once every 10 years beginning at age 50. 

— Increased Risk: Once every five years for individuals with a first-degree relative diagnosed with a colorectal cancer or an 

adenomatous polyp before age 60, or in two or more first-degree relatives at any age. Optical colonoscopy should be performed 

beginning at age 40 or 10 years younger than the earliest affected relative, whichever is earlier. Once every 10 years, beginning at 

age 40, for individuals with a first-degree relative diagnosed with colorectal cancer or an adenomatous polyp at age 60 or older, or 

colorectal cancer diagnosed in two second-degree relatives. 

— High Risk: Once every one to two years for individuals with a genetic or clinical diagnosis of hereditary non-polyposis colorectal 

cancer (HNPCC) or individuals at increased risk for HNPCC. Optical colonoscopy should be performed beginning at age 20-25 or 

10 years younger than the earliest age of diagnosis, whichever is earlier. For individuals diagnosed with inflammatory bowel disease, 

chronic ulcerative colitis, or Crohn’s disease, cancer risk begins to be significant eight years after the onset of pancolitis or 10-12 

years after the onset of left-sided colitis. For individuals meeting these risk parameters, optical colonoscopy should be performed 

every one to two years with biopsies for dysplasia. 

■ Fecal occult blood testing: Conduct testing annually starting at age 50. 

■ Breast Cancer: 

— Clinical breast examination: For women under age 40, a clinical breast examination may be performed during a 

preventive health visit. For women age 40 and older, a clinical breast examination should be performed annually. 

— Mammograms: Covered annually for all women beginning at age 40. Covered annually beginning at age 30 for women who 

have a 15 percent or greater lifetime risk of breast cancer (according to risk-assessment tools based on family history such 

as the Gail model, the Claus model, and the Tyrer-Cuzick model), or who have any of the following risk factors: 

• History of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia, or atypical 

lobular hyperplasia 

• Extremely dense breasts when viewed by mammogram 

• Known BRCA1 or BRCA2 gene mutation 

• First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves 

• Radiation therapy to the chest between ages 10 and 30 

• History of Li-Fraumeni, Cowden, or hereditary diffuse gastric cancer syndrome, or a first-degree relative with a 

history of one of these syndromes 

• Breast screening magnetic resonance imaging (MRI): Covered annually, in addition to the annual screening mammogram, 

beginning at age 30 for women who have a 20 percent or greater lifetime risk of breast cancer (according to risk assessment 

tools based on family history such as the Gail model, the Claus model, and the Tyrer-Cuzick model), or who have any of the 

following risk factors: 

– Known BRCA1 or BRCA2 gene mutation 

– First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic 

testing themselves 

– Radiation to the chest between ages 10 and 30 

– History of Li-Fraumeni, Cowden, or hereditary diffuse gastric cancer syndrome, or a first-degree relative with a 

history of one of these syndromes 

■ 

Proctosigmoidoscopy or sigmoidoscopy: 

— Average Risk: Once every three to five years beginning at age 50. 

— Increased Risk: Once every five years beginning at age 40 for individuals with a first-degree relative diagnosed with a colorectal 

cancer or an adenomatous polyp at age 60 or older, or two second-degree relatives diagnosed with colorectal cancer. 

— High Risk: Annual flexible sigmoidoscopy, beginning at age 10–12, for individuals with known or suspected familial 

adenomatous polyposis. 

■ Prostate cancer: Perform a digital rectal exam and prostate-specific antigen screening annually for certain high-risk 

men ages 40–49 and all men over age 50. 

16



Clinical Preventive Service: Coverage Details (continued) 

Service 

Cancer Screenings 

(continued) 

Description 

■ Routine Pap tests: Perform a Pap test annually for women starting at age 18 (younger if sexually active) or less often at 

patient and provider discretion (though not less than every three years). Human papillomavirus (HPV) DNA testing is covered 

as a cervical cancer screening only when performed in conjunction with a Pap test, and only for women age 30 and older. 

■ Skin cancer: Exams are covered at any age for a beneficiary who is at high risk due to family history or increased sun 

exposure. 

SECTIoN 2 


Benefits 

Cardiovascular 

Diseases 

■ Cholesterol test (non-fasting): Testing is covered for a lipid panel at least once every five years, 

beginning at age 18. 

■ Blood pressure screening: Screening is covered annually for children (ages 3–6) and a minimum of every 

two years after age 6 (children and adults). 

Eye Examinations ■ Well-child care coverage (infants and children up to age 6): 

— Infants (until reaching age 3): Conduct one eye and vision screening at birth and at 6 months. 

— Children (from age 3 until reaching age 6): Conduct a routine eye exam every two years. Active 

Duty Family Member (ADFM) children are covered for one routine eye exam annually. 

■ Adults and children (over age 6): Conduct a routine eye exam every two years. Active Duty Service 

Members (ADSM) and ADFMs receive one eye exam each year. 

■ Diabetic patients (any age): Eye exams are not limited. One eye exam per year is recommended. 

Note: ADSMs enrolled in TRICARE Prime must receive all vision care at military hospitals or clinics unless 

specifically referred by their primary care managers to civilian network providers, or to non-network providers if a 

network provider is not available. ADSMs enrolled in TRICARE Overseas Program Prime Remote may obtain periodic 

eye examinations from network providers without prior authorizations as needed to maintain fitness-for-duty status. 

Hearing 

Preventive hearing examinations are only allowed under the well-child care benefit. A newborn audiology 

screening should be performed on newborns before hospital discharge or within the first month after birth. 

Evaluative hearing tests may be performed at other ages during routine exams. 

Immunizations 

Infectious Disease 

Screening 

Patient and Parent 

Education 

Counseling 

School Physicals 

Well-Child Care 

(birth until reaching 

age 6) 

Age-appropriate doses of vaccines, including annual influenza vaccines, are covered as recommended by the 

Centers for Disease Control and Prevention (CDC). 

The HPV vaccine is a limited benefit and may be covered when the beneficiary has not been previously 

vaccinated or completed the vaccine series. 

—Females: The HPV vaccine Gardasil (HPV4) or Cervarix (HPV2) is covered for females ages 11–26. The 

series of injections must be completed prior to age 27 for coverage under TRICARE. 

— Males: The HPV vaccine Gardasil (HPV4) is covered for all males ages 11–21 and is covered for males 

ages 22–26 who meet certain criteria. 

A single dose of the shingles vaccine Zostavax ® is covered for beneficiaries age 60 and older. 

Coverage is effective the date the recommendations are published in the CDC’s Morbidity and Mortality Weekly 

Report. Refer to the CDC’s Web site at www.cdc.gov for a current schedule of recommended vaccines. 

Note: Immunizations for ADFMs whose sponsors have permanent change-of-station orders to overseas locations 

are also covered. Immunizations for personal overseas travel are not covered. 

TRICARE covers screening for infectious diseases, including hepatitis B, rubella antibodies and HIV, and 

screening and/or prophylaxis for tetanus, rabies, hepatitis A and B, meningococcal meningitis, and tuberculosis. 

Counseling services expected of good clinical practice that are included with the appropriate office visit are 

covered at no additional charge for dietary assessment and nutrition; physical activity and exercise; cancer 

surveillance; safe sexual practices; tobacco, alcohol, and substance abuse; dental health promotion; accident 

and injury prevention; stress; bereavement; and suicide risk assessment. 

Covered for children ages 5–11 if required in connection with school enrollment. 

Note: Annual sports physicals are not covered. 

Covers routine newborn care; comprehensive health promotion and disease prevention exams; vision and 

hearing screenings; height, weight, and head circumference measurement; routine immunizations; and 

developmental and behavioral appraisal. TRICARE covers well-child care in accordance with American 

Academy of Pediatrics (AAP) and CDC guidelines. Your child can receive preventive care well-child visits as 

frequently as the AAP recommends, but no more than nine visits in two years. Visits for diagnosis or treatment of 

an illness or injury are covered separately under outpatient care. 

17



Behavioral Health Care Services: outpatient Coverage Details Figure 2.5 

Service 

outpatient Psychotherapy* 

(physician referral and supervision 

required when seeing licensed or 

certified mental health counselors 

and pastoral counselors) 

Description 

The following outpatient psychotherapy limits apply: 

■ Psychotherapy: Two sessions per week, in any combination of the following types: 

— Individual (adult or child): 60 minutes per session; may extend to 120 minutes for 

crisis intervention 

— Family or conjoint: 90 minutes per session; may extend to 180 minutes for crisis intervention 

— Group: 90 minutes per session 

■ Collateral visits Up to 60 minutes per visit (Collateral visits are counted as individual 

psychotherapy sessions. Beneficiaries have the option of combining collateral visits with 

other individual or group psychotherapy visits.) 

Psychoanalysis 

Psychological Testing and 

Assessment 

Psychoanalysis differs from psychotherapy and requires prior authorization. After prior authorization 

is obtained, treatment must be given by approved providers who are specifically trained in 

psychoanalysis. 

Testing and assessment is generally covered when medically or psychologically necessary and 

provided in conjunction with otherwise-covered psychotherapy. Psychological tests are considered 

to be diagnostic services and are not counted toward the limit of two psychotherapy visits per week. 

■ Limitations: 

— Testing and assessment is generally limited to six hours per fiscal year (FY 1 ). Any testing 

beyond six hours requires a review for medical necessity. Psychological testing must be 

medically necessary and not for educational purposes. 

■ Exclusions: 

Psychological testing is not covered for the following circumstances: 

• Academic placement 

• Job placement 

• Child-custody disputes 

• General screening in the absence of specific symptoms 

• Teacher or parental referrals 

• Testing to determine whether a beneficiary has a learning disability 

• Diagnosed, specific learning disorders or learning disabilities 

Medication Management 

If you are taking prescription medications for a behavioral health condition, you must be under the 

care of a provider who is authorized to prescribe those medications. Your provider will manage the 

dosage and duration of your prescription to ensure you are receiving the best care possible. 

Medication-management appointments are medical appointments and do not count against the first 

eight outpatient behavioral health care visits per FY. 1 

1 

For ADFM, the first 8 outpatient visits per FY 1 do not require authorization. For ADSM, authorization is required for all behavioral health care. Also, certain clinical 

preventive services do not require authorization when received from a Network Provider. If you are unsure about covered services, please contact International SOS and 

press option #5 to speak with a member of the TOP Provider Support Services staff. 

2 

October 1- September 30. 

18



Behavioral Health Care Services: Inpatient Coverage Details 

Prior authorization is required for all nonemergency inpatient behavioral health care services. Psychiatric emergencies do not require 

prior authorization for inpatient admissions, but authorization is required for continued stay. Admissions resulting from psychiatric 

emergencies should be reported to the TOP contractor within 24 hours of admission or on the next business day, and must be reported 

within 72 hours of an admission. Authorization for continued stay is coordinated between the inpatient unit and the TOP contractor. 

Note: Active duty service members who receive care at military hospitals or clinics do not require prior authorization. 

Note: This figure is not all-inclusive and additional limitations on behavioral health care services may apply overseas. 

Figure 2.6 

SECTIoN 2 


Benefits 

Service 

Acute Inpatient Psychiatric Care 

Description 

May be covered on an emergency or nonemergency basis. Prior authorization from your regional 

contractor is required for all nonemergency inpatient admissions. In emergency situations, 

authorization is required for continued stay. 


— Patients age 19 and older: 30 days per fiscal year (FY 1 ) or in any single admission 

— Patients age 18 and under: 45 days per FY 1 or in any single admission 

— Inpatient admissions for substance use disorder detoxification and rehabilitation 

count toward the 30- or 45-day limit for acute inpatient psychiatric care. 

(Limitations may be waived if determined to be medically or psychologically necessary.) 

Psychiatric Partial 

Hospitalization Program (PHP) 

Psychiatric PHPs are treatment settings capable of providing interdisciplinary therapeutic services at 

least three hours a day, five days a week, in any combination of day, evening, night, and weekend 

treatment programs. The following rules apply: 

— Prior authorization is required. PHP admissions are not considered emergencies. 

— Facilities must be TRICARE-authorized. 

— PHPs must have participation agreements with TRICARE. 


— PHP care is limited to 60 treatment days (whether full- or partial-day treatment) per FY 1 . 

These 60 days are not offset by or counted toward the 30- or 45-day limit for acute inpatient 

psychiatric care. 


Residential Treatment Center 

(RTC) Care 

RTC care provides extended psychiatric care for children and adolescents with psychological 

disorders that require continued treatment in a therapeutic environment. The following rules apply: 

— Facilities must be TRICARE-authorized. 

— Unless therapeutically contraindicated, the family and/or guardian should actively participate 

in the continuing care of the patient through either direct involvement at the facility or 

geographically distant family therapy. 

— Prior authorization is always required. RTC admissions are not considered emergencies. 

— RTC care is considered elective and will not be covered for emergencies. 

— Admission primarily for substance use rehabilitation is not authorized for psychiatric RTC 

care. In an emergency, psychiatric inpatient hospitalization must be sought first. 

— Care must be recommended and directed by a psychiatrist or clinical psychologist. 


— Care is limited to 150 days per FY 1 or for a single admission. (Limitations may be waived if 

determined to be medically or psychologically necessary.) 

— RTC care is only covered for patients until reaching age 21. 

— RTC care does not count toward the 30- or 45-day inpatient limit. 

1 


19



Behavioral Health Care Services: Substance Use Disorder Services 

Figure 2.7 provides coverage details for covered substance use disorder services (up to three benefit periods per beneficiary, per lifetime). 

NoTE: This figure is not all-inclusive and additional limitations on substance use disorder services may apply overseas. 

Figure 2.7 

Service 

Inpatient Detoxification 

Description 

TRICARE covers emergency and inpatient hospital services for the treatment of the acute phases of 

substance use withdrawal (detoxification) when the patient’s condition requires the personnel and 

facilities of a hospital or substance use disorder rehabilitation facility (SUDRF). 


— Diagnosis-related group-exempt facility, services are limited to seven days per episode. 

— Inpatient detoxification in a free-standing SUDRF counts toward the 30- or 45-day inpatient 

psychiatric care limit. 

SUDRF Rehabilitation 

Rehabilitation of a substance use disorder may occur in an inpatient (residential) or partial 

hospitalization setting. TRICARE covers 21 days of rehabilitation per benefit period in a TRICAREauthorized 

facility, whether in an inpatient or partial hospitalization facility or a combination of both. 1 


— 21-day rehabilitation limit per episode 

— Three episodes per lifetime 

— Days for inpatient rehabilitation count toward the 30- or 45-day limit for acute inpatient 

psychiatric care 


SUDRF outpatient Care Outpatient substance use care must be provided by an approved SUDRF. 


— Individual or group therapy: Up to 60 visits per benefit period 1 

— Family therapy: Up to 15 visits per benefit period 1 

— Partial hospitalization program care: 21 treatment days per fiscal year 2 


1 

A benefit period begins with the first day of covered treatments and ends 365 days later. Stay limitations for inpatient services may be waived if determined 

to be medically or psychologically necessary. 

2 



Beneficiary Coverage Limitations 

The following is a list of medical, surgical and behavioral health 

care services that may not be covered unless exceptional 

circumstances exist. This list is not intended to be all-inclusive. 

Please visit www.tricare.mil for a full list of covered services, 

limitations and exclusions. 

20



Services or Procedures with Significant Limitations Figure 2.8 

Service 

Botulinum Toxin Type A 

Injections 

Description 

Botulinum toxin type A injections for cosmetic procedures, myofascial pain, and fibromyalgia are not 

covered. Cost-sharing may apply for injections to treat severe primary axillary hyperhidrosis, 

dystonia-related blepharospasm or strabismus, cervical dystonia, cerebral palsy-related spasticity, 

or for the treatment of sialorrhea associated with Parkinson’s disease. Botulinum toxin type A 

injections may also be cost-shared for prophylaxis of headaches in adult patients with chronic 

migraines, which is defined as 15 days or more per month with headache lasting four hours a day or 

longer. TRICARE may also consider off-label cost-sharing for Botox ® injections used to treat chronic 

anal fissure (if unresponsive to conservative therapeutic measures). 

SECTIoN 2 


Benefits 

Breast Pumps 

Cardiac and Pulmonary 

Rehabilitation 

Cosmetic, Plastic or 

Reconstructive Surgery 

Cranial orthotic Device or 

Molding Helmet 

Dental Care and Dental X-rays 

Education and Training 

Eyeglasses or Contact Lenses 

Facility Charges for Non- 

Adjunctive Dental Services 

Food, Food Substitutes and 

Supplements, or Vitamins 

Heavy-duty, hospital-grade electric breast pumps (including services and supplies related to the use of 

the pump) for mothers of premature infants are covered. An electric breast pump is covered while 

the premature infant remains hospitalized during the immediate postpartum period. Hospital-grade 

electric breast pumps may also be covered after the premature infant is discharged from the 

hospital with a physician-documented medical reason. This documentation is also required for 

premature infants delivered in non-hospital settings. Breast pumps of any type, when used for 

reasons of personal convenience, are excluded even if prescribed by a physician. 

Both are covered only for certain indications. Phase III cardiac rehabilitation for lifetime maintenance 

performed at home or in medically unsupervised settings is excluded. 

Surgery is only covered when used to restore function, correct a serious birth defect, restore body 

form after a serious injury, improve appearance of a severe disfigurement after cancer surgery, or 

reconstruct the breast after cancer surgery. 

Cranial orthotic devices are excluded for treatment of nonsynostic positional plagiocephaly. 

Both are covered only for adjunctive dental care (i.e., dental care that is medically necessary in the 

treatment of an otherwise covered medical – not dental – condition). Prior authorization is required for 

adjunctive dental care. 

Education and training are covered under the TRICARE Extended Care Health Option (ECHO) 

and diabetic outpatient self-management training programs. Diabetic outpatient self-management 

training programs must be accredited by the American Diabetes Association ® . The provider’s 

accreditation must accompany the claim for reimbursement. 

Active duty service members may receive eyeglasses at a militray hospital or clinic at no cost. For all 

other beneficiaries, the following are covered: 

— Contact lenses and/or eyeglasses for treatment of infantile glaucoma 

— Corneal or scleral lenses for treatment of keratoconus 

— Scleral lenses to retain moisture when normal tearing is not present or is inadequate 

— Corneal or scleral lenses to reduce corneal irregularities other than astigmatism 

— Intraocular lenses, contact lenses, or eyeglasses for loss of human lens function resulting from 

intraocular surgery, ocular injury, or congenital absence 

Note: Adjustments, cleaning, and repairs for eyeglasses are not covered. 

Hospital and anesthesia charges related to routine dental care for children under age 5, or those 

with disabilities, may be covered in addition to dental care related to some medical conditions. 

Medically necessary nutrition formulas are covered when used as the primary source of nutrition for 

enteral, parenteral, or oral nutritional therapy. Intraperitoneal nutrition therapy is covered for 

malnutrition as a result of end-stage renal disease. Vitamins may be reimbursed when used as a 

specific treatment of a medical condition. Additionally, prenatal vitamins that require a prescription 

may be reimbursed for prenatal care only. 

21



Services or Procedures with Significant Limitations (continued) 

Gastric Bypass 

Genetic Testing 

Hearing Aids 

Service 

Laser/LASIK/Refractive 

Corneal Surgery 

Private Hospital Rooms 

Shoes, Shoe Inserts, Shoe 

Modifications, and Arch 

Supports 

Description 

This procedure is covered for the treatment of morbid obesity under certain limited circumstances. 

Testing is covered when medically proven and appropriate, and when the results of the test will 

influence the medical management of the patient. Routine genetic testing is not covered. 

Hearing aids are covered only for active duty family members who meet specific hearing-loss 

requirements. 

Surgery is covered only to relieve astigmatism following a corneal transplant. 

Private rooms are not covered unless ordered for medical reasons or because a semi-private room is 

not available. Hospitals that are subject to the TRICARE diagnosis-related group (DRG) payment 

system may provide the patient with a private room but will receive only the standard DRG amount. 

The hospital may bill the patient for the extra charges if the patient requests a private room. 

Shoe and shoe inserts are covered only in very limited circumstances. Orthopedic shoes may be 

covered if they are a permanent part of a brace. For beneficiaries with diabetes, extra-depth shoes 

with inserts or custom-molded shoes with inserts may be covered. 


Beneficiary Coverage Exclusions 

In general, TRICARE excludes services and supplies that are not 

medically or psychologically necessary for the diagnosis or 

treatment of a covered illness (including behavorial health 

disorders), injury, or for the diagnosis and treatment of pregnancy 

or well-child care. All services and supplies (including inpatient 

institutional costs) related to a non-covered condition or 

treatment, or provided by an unauthorized Provider, are excluded. 

The following specific services are excluded under all 

circumstances. This list is not intended to be all-inclusive. Please 

visit www.tricare.mil for a full list of covered services, limitations 

and exclusions. 

■ Abortion (except in cases where the life of the mother would 

be endangered if the pregnancy were carried to term or when 

the pregnancy is the result of rape or incest) 

■ Acupuncture (may be offered at some military hospitals or 

clinics and approved for certain active duty service members, 

but is not covered for care received by civilian providers) 

■ Alterations to living spaces 

■ Artificial insemination, including in vitro fertilization, gamete 

intrafallopian transfer, and all other such reproductive 

technologies (except in very limited circumstances for some 

wounded, ill, or injured service members) 

■ Autopsy services or post-mortem examinations 

■ Birth control/contraceptives (non-prescription) 

■ Camps (e.g., for weight loss) 

■ Charges that providers may apply to missed or rescheduled 

appointments 

■ Counseling services that are not medically necessary in the 

treatment of a diagnosed medical condition (e.g., educational, 

vocational, and socioeconomic counseling; stress management; 

or lifestyle modification) 

■ Custodial care 

■ Diagnostic admissions 

■ Domiciliary care 

■ Dyslexia treatment 

■ Electrolysis 

■ Elevators or chair lifts 

■ Exercise equipment, spas, whirlpools, hot tubs, swimming 

pools, health club memberships, or other such charges or 

items 

■ Experimental or unproven procedures (unless authorized 

under specific exceptions in the TRICARE regulations) 

22



■ Foot care (routine), except if required as a result of a 

diagnosed, systemic medical disease affecting the lower limbs, 

such as severe diabetes 

■ General exercise programs, even if recommended by a 

physician and regardless of whether rendered by an authorized 

Provider 

■ Inpatient stays: 

— For rest or rest cures 

— To control or detain a runaway child, whether or not 

admission is to an authorized institution 

— To perform diagnostic tests, examinations, and procedures 

that could have been and are performed routinely on an 

outpatient basis 

— In hospitals or other authorized institutions above the 

appropriate level required to provide necessary medical 

care 

■ Learning disability services 

■ Medications: 

— Drugs prescribed for cosmetic purposes 

— Fluoride preparations 

— Food supplements 

— Homeopathic and herbal preparations 

— Multivitamins 

— Over-the-counter products (except insulin and diabetic 

supplies) 

— Weight reduction products 

■ Megavitamins and orthomolecular psychiatric therapy 

■ Mind expansion and elective psychotherapy 

■ Naturopaths 

■ Non-surgical treatment of obesity or morbid obesity 

■ Personal, comfort, or convenience items, such as beauty and 

barber services, radio, television, and telephone 

■ Postpartum inpatient stay for a mother to stay with a newborn 

infant (usually primarily for the purpose of breast-feeding the 

infant) when the infant (but not the mother) requires the 

extended stay, or continued inpatient stay of a newborn infant 

primarily for purposes of remaining with the mother when the 

mother (but not the newborn infant) requires extended 

postpartum inpatient stay 

■ Preventive care, such as routine, annual, or employmentrequested 

physical examinations; routine screening 

procedures; or immunizations (except as provided under the 

clinical preventive services benefit. See “Clinical Preventive 

Services” earlier in this section.) 

■ Psychiatric treatment for sexual dysfunction 

■ Services and supplies: 

— Provided under a scientific or medical study, grant, or 

research program 

— Furnished or prescribed by an immediate family member 

— For which the beneficiary has no legal obligation to pay or 

for which no charge would be made if the beneficiary or 

sponsor were not TRICARE-eligible 

— Furnished without charge (i.e., cannot file claims for 

services provided free-of-charge) 

— For the treatment of obesity, such as diets, weight-loss 

counseling, weight-loss medications, wiring of the jaw, or 

similar procedures (See “Services or Procedures with 

Significant Limitations” earlier in this section.) 

■ Inpatient stays directed or agreed to by a court or other 

governmental agency (unless medically necessary) 

■ Required as a result of occupational disease or injury for which 

any benefits are payable under a worker’s compensation or 

similar law, whether such benefits have been applied for or paid 

(except if benefits provided under these laws have run out) 

■ That are (or are eligible to be) fully payable under another medical 

insurance or program, either private or governmental, such as 

coverage through employment or Medicare (in such instances, 

TRICARE is the last payer for any remaining charges) 

■ Sex changes or sexual inadequacy treatment (except for the 

treatment of ambiguous genitalia that has been documented 

to be present at birth) 

■ Sterilization reversal surgery 

■ Surgery performed primarily for psychological reasons (such as 

psychogenic surgery) 

■ Therapeutic absences from an inpatient facility (except when 

such absences are specifically included in a treatment plan 

approved by TRICARE) 

■ Transportation (except by ambulance) 

■ X-ray, laboratory, and pathological services and machine 

diagnostic tests not related to a specific illness or injury or a 

definitive set of symptoms (except for cancer-screening 

mammography, cancer screening, Pap tests, and other tests 

allowed under the clinical preventive services benefit) 

SECTIoN 2 


Benefits 

23



SECTIoN 3: 

International SoS Network Providers and Provider Credentialing 

What is a Network Provider? 

Network Providers are Providers who have entered into a formal 

agreement with International SOS, have signed a Mutual 

Cooperation Protocol Agreement and supplied International SOS 

with their full credentials. Network Providers have agreed to 

provide cashless, claimless services to TOP Prime and TOP 

Prime Remote beneficiaries, submit the appropriate Standard 

U.S. Claim Forms on behalf of the TRICARE beneficiaries they 

treat, and provide medical services in line with TRICARE policy. 

Network Providers are added to International SOS’ database of 

Providers and will always be our first choice when referring 

patients to the host nation network. Network Providers will also be 

continually published on www.tricare-overseas.com, which can 

be accessed by all TRICARE beneficiaries. 

If a Provider wishes to participate in TOP, but does not wish to 

sign a Mutual Protocol Agreement with International SOS, they 

may agree to participate without the contract. These Providers 

will still be required to provide cashless, claimless services to 

TOP Prime and TOP Prime Remote beneficiaries, submit the 

appropriate Standard U.S. Claim Forms on behalf of the 

beneficiaries they treat, and provide medical services in line with 

TRICARE policy. They will also be required to provide 

International SOS with their license. These Providers will not be 

published on www.tricare-overseas.com. 

Becoming an International SoS 

Network Provider 

Becoming an International SOS Network Provider benefits both 

Host Nation Providers and TOP beneficiaries. When TOP Prime 

and TOP Prime Remote beneficiaries are referred for host nation 

care, they are referred to one of International SOS’ Network 

Providers. Network Providers are always International SOS’ first 

choice of Providers. 

International SOS’ TOP Provider Support Services staff is 

available 24 hours a day, 365 days a year to assist Network 

Providers. 

In turn, Network Providers offer a number of benefits to TRICARE 

patients: 

■ Patients feel confident that they are receiving quality care, 

because Network Providers’ credentials have been reviewed. 

■ Beneficiaries are more comfortable, because their Provider 

can directly or indirectly communicate with them in English. 

■ TOP Prime and TOP Prime Remote beneficiaries can receive 

cashless, claimless health care. 

How to Become an 

International SoS Network Provider 

We encourage you to contact your International SOS TOP 

Regional Call Center and press option #5 to speak with a TOP 

Provider Support Services staff member on how to become a 

Network Provider. For a full list of phone numbers, see page 7 

of this TOP Provider Manual or visit www.tricare-overseas.com. 

Your Network Coordinator will provide you with all the information 

you need, along with a Mutual Cooperation Protocol Agreement 

between you and International SOS. Once you have reviewed the 

document, provided the required information (including your 

credentials), and both parties have signed the Mutual 

Cooperation Protocol Agreement, you may become an 

International SOS Network Provider. 

Examples of credentials include a copy of professional license, 

proof of malpractice insurance (where applicable), fee schedules 

and other information. 

Network Provider Responsibilities 

A detailed list of Network Provider responsibilities can be found in 

the International SOS Mutual Cooperation Protocol Agreement. 

Network Providers are expected to follow the guidelines below: 

■ Do not discriminate based on sex, race, color, creed or 

religion. 

■ Communicate directly or indirectly with patients in English. 

■ Identify and assist TRICARE patients who seek emergency 

care and properly authorized routine and specialty care. 

24



■ Maintain health records for TRICARE beneficiaries and, 

whenever possible, make English-language summaries of 

these records available for inclusion in the beneficiaries’ U.S. 

military medical records. 

■ Promptly return consultation results to the referring Military 

Treatment Facility (MTF). 

Note: Routine consultation reports should be returned within 10 

working days, emergency consultation reports should be 

returned within 24 hours. 

Keeping Your Provider File Current 

International SOS’ TOP Provider Support Services staff is 

committed to keeping Network Provider files current and 

accurate. Reviewing this information on an annual basis helps 

prevent confusion and avoid problems. 

Listed below are events that will require a yearly update to your 

Network Provider file: 

■ The address from which you provide care changes. 

■ Your billing address or other billing information changes. 

■ Your phone, fax, email or other contact information changes. 

■ Your office hours change. 

■ Your credentials change or are renewed. 

In the case of these events, please contact your TOP Network 

Executive using the email addresses below, or you can refer to 

page 7 of this TOP Provider Manual for your TOP Regional Call 

Center numbers and select option #5. 

Europe, Middle East & Africa 

providerseurasiaafrica@internationalsos.com 

Network Provider Quality Mission 

International SOS is committed to delivering quality medical care 

to all beneficiaries living overseas. By becoming a Network 

Provider, you can be proud to know that you are part of this 

mission. 

International SOS works with you to understand how problems 

can be corrected or improved. We also work with you to develop 

a plan for avoiding quality- or service-related problems in the 

future. 

The Mutual Cooperation Protocol Agreement, together with our 

ongoing development and maintenance of the Network Providers, 

helps International SOS ensure our quality performance. 

From time to time, you may be contacted by International SOS or 

TRICARE directly, to assess and monitor your overall satisfaction 

with TOP, including service, accessibility, Provider education and 

other topics. 

ToP Provider Support Services 

A dedicated team of administrators, nurses and quality staff 

dedicated to the TRICARE Overseas Program are available to 

assist you. The team is responsible for working with Providers in 

their respective countries, building and maintaining relationships 

and answering questions in local languages about TOP covered 

services, authorizations and submitting claims for payment. 

SECTIoN 3 

International SoS Network 

Providers & Provider Credentialing 



Puerto Rico 


Asia-Pacific 


25



Access to Care 

International SOS is committed to ensuring that TOP beneficiaries 

have access to quality care with suitable wait times and other 

standards of service delivery. Below is an overview of these 

standards and guidelines, as established by TRICARE policy. 

Element 

Wait Time for an 

Appointment 

office Waiting 

Times 

ToP Access to Care Standards 

Definition 

When a TRICARE 

beneficiary contacts you 

to make an appointment, 

you are expected to follow 

the guidelines below for 

seeing the patient: 

— Well-patient Visit or 

Specialty Care Referral: 

4 weeks 

— Routine Visit: 1 week 

— Urgent Care: 24 hours 

When a TRICARE 

beneficiary comes in for 

their appointment, the 

office waiting time to see 

their clinician can be no 

more than 30 minutes – 

unless the clinician’s 

schedule is disrupted 

because of a medical 

emergency. 

Service 

Standard 

Well-patient: 

4 weeks 

Routine: 

1 week 

Urgent: 

24 hours 

No more than 

30 minutes 

Provider Credentialing Process 

With 25 years of experience in international health care and 

medical assistance services, and operations in 70+ countries, 

International SOS understands that health care delivery differs 

significantly from country to country. 

Factors such as local country legislation and regulations are 

considered, as well as existing health care infrastructure and any 

unique challenges that may impact the delivery of care in a 

specific region. 

International SOS takes these differences into account, when 

reviewing Provider capabilities and determining eligibility to 

participate in TOP. Country-specific credentialing guidelines are 

used and we work with host nation licensing agencies, to 

maintain accurate and up-to-date information about local 

standards. 

Provider performance is monitored on an ongoing basis so that 

potential problems can be addressed before they impact 

beneficiary satisfaction and quality of care. Provider satisfaction 

surveys are also used to monitor your overall satisfaction with 

International SOS, including how accessible or helpful our call 

center and TOP Provider Support Services staff is in assisting 

with claims processing, Provider education, and other topics. 

The following credentialing items are required to become an 

International SOS Network Provider: 

Availability of 

Emergency 

Services 

Providers of emergency 

care services are 

expected to be available 

24 hours a day, 7 days a 

week. Emergency care 

Providers are selected 

based on their abililty to 

meet this requirment. If 

your availability changes, 

you must notify us 

immediately. 

24 hours a 

day / 

7 days a week 

Note: If you have any questions or concerns about your ability to 

meet these standards and guidelines, please contact 


26



Criteria 

Signed Provider Agreement 

Meet the Standards for 

Authorization 

Standards 

An International SOS Provider Agreement (Mutual Cooperation Protocol) must be signed, in order to 

become a Network Provider. 

All health care services for TOP Prime and TOP Prime Remote beneficiaries are provided on an 

authorized basis. You will be expected to accept International SOS’ authorization for services, and 

agree to submit claims and invoices for payment to International SOS, through our subcontractor 

Wisconsin Physicians Service (WPS). You agree not to balance bill a TOP Prime or TOP Prime 

Remote beneficiary for uncovered services. 

Valid Malpractice Insurance 

(If Applicable) 

Licensure/Registration 

Evidence of Professional 

Qualifications and Experience 

You must have professional liability insurance, if this is required by the laws of your respective host 

nation. If you are a country, state, province, etc., entity Provider, and you are self-insured, then you 

are not required to have malpractice insurance. 

You must meet the requirements for licensure/registration as specified by your local governmental 

authority or licensing board. This includes having a valid license or registration in the host nation 

where you practice. 

You must be a graduate of an accredited program in health care sciences. This includes completing 

a certificate (residency) program, leading to certification in general medicine, family practice, 

gynecology, pediatrics, dentistry or other disciplines/specialties recognized by the applicable 

certifying agency in your country. 

SECTIoN 3 

International SoS Network 

Providers & Provider Credentialing 

English Language Proficiency 

You must be able to proficiently communicate in English (both verbally and in writing), or to provide 

English translation and interpretation services at the time of service. 

Beneficiary Access to ToP 

Network Providers 

All Host Nation Providers with a signed Mutual Cooperation 

Protocol Agreement and approved credentials on file with 

International SOS will be published on www.tricareoverseas.com 

and displayed for beneficiaries. 

The published list of Network Providers is matched with 

International SOS’ internal database, so it is important that you 

keep all of your information up-to-date. 

TRICARE beneficiaries using the www.tricare-overseas.com 

website have the comfort of knowing that listed Providers are 

“quality assured” and recommended for care locally. Detailed 

information about referrals and authorizations is also included on 

this website, making Provider selection easier and more 

convenient for beneficiaries. 

Note: If you would not like your Provider information published, 

please contact your TOP Regional Call Center and select option 

#5 to speak with a member of the TOP Provider Support Services 

staff. 

27



SECTIoN 4: 

Authorizations and Seeing TRICARE Patients 

Effective September 1, 2010, Providers will receive authorization 

from International SOS before providing care to TOP Prime and 


Prior authorization is required for certain procedures and inpatient 

hospital admissions, including patient rehabilitation and skilled 

nursing facilities. Authorizations are based on medical necessity and 

are not a guarantee of payment. 

This section explains the authorization process and what you can 

expect when seeing TRICARE patients. 

How Are Patients Referred to You? 


Beneficiaries 

TOP Prime and TOP Prime Remote beneficiaries should first visit 

their Primary Care Manager when seeking medical care. 

ToP Prime Beneficiaries: 

For TOP Prime beneficiaries, the Primary Care Manager is 

typically based at a Military Treatment Facility (MTF). If the MTF 

does not have the capability to provide the necessary care, they 

will refer the beneficiary to a Host Nation Provider. 

ToP Prime Remote Beneficiaries: 

International SOS acts as the Primary Care Manager for TOP 

Prime Remote beneficiaries and can authorize and refer these 

beneficiaries to Host Nation Providers for primary and secondary 

care. Host Nation Providers receive authorization directly from 

International SOS, to ensure that the services are covered. The 

authorization will be sent to the Network Provider via fax or secure 

email. The beneficiary will also be informed when the 

authorization has been sent. 

TOP Prime and TOP Prime Remote beneficiaries may only receive 

care from a Network Provider. After the authorization has been 

issued, the beneficiary may contact the Network Provider directly 

to schedule an appointment. 

ToP Standard Beneficiaries 

TOP Standard beneficiaries may seek care from any Provider 

they prefer. They are required to pay and claim for any medical 

care they receive from a Host Nation Provider. 

Standard beneficiaries often prefer to seek care from a TOP 

Network Provider, because of the guaranteed quality of care they 

will receive. Host Nation Providers may offer to file a claim on 

behalf of the TOP Standard beneficiary and bill them for the 

balance owed. However, you are not required/obligated to do 

this. 

Additional information about submitting claims can be found in 

Section 5 of this TOP Provider Manual as well as online at 

www.tricare-overseas.com. 

Note: TOP Prime and TOP Prime Remote beneficiaries may 

come to your office without an Authorization Form. If a TRICARE 

beneficiary requests non-emergent health care at your facility 

without prior TRICARE authorization, the claims submitted for 

these services may be denied. 

Determining Patient Eligibility for 

Authorized Care 

You will receive an Authorization Form for TOP Prime and TOP 

Prime Remote beneficiaries that are eligible for cashless, 

claimless care under TOP. The authorization will state ‘TRICARE 

Authorization Form’ in the title and specify whether the 

authorization is for a TOP Prime or TOP Prime Remote 

beneficiary. It will also specify what type of care is being 

authorized. 

Before an Authorization Form is issued, International SOS will 

verify the patient’s eligibility to receive care from your facility. 

The Authorization Form will have a unique identification number 

(Authorization Number), which will be located on the top right 

section of the form. 

The Authorization Form will indicate the name and address of 

your facility, and will also contain the first name, surname and 

date of birth of the patient eligible for care. 

28



To confirm a TRICARE beneficiary’s eligibility, Providers should 

ask to see both of the following: 

■ TOP Prime Enrollment Card and 

■ U.S. Military ID or CAC 

It is important to verify that the name on both cards matches 

exactly, and that the photo on the U.S. Military ID Card or CAC 

accurately represents the patient. 

Providers should also check: 

■ The expiration date on the U.S. Military ID Card or CAC 

(to ensure that coverage is still valid) 

■ The sponsor’s Social Security Number (this will always be 

in the same format: XXX-XX-XXXX) or the Department of 

Defense (DOD) Benefits Number (this can be found above the 

bar code on the back of the beneficiary’s ID card and will be 

in the following format: XXXXXXXXX-XX). Only the first 9 digits 

of the DOD Benefits Number will be needed for the Provider to 

verify eligibility. 

You can also call your International SOS TOP Regional Call 

Center for assistance, if you are unsure. 

Note: International SOS will only issue a TRICARE Authorization 

Form for TOP Standard beneficiaries for the following types of 

medical care, which do require prior authorization: 

■ Adjunctive Dental Services 

■ Home Health Services 

■ Hospice Care 

■ Non-emergency Inpatient Admissions for Substance Use 

Disorders or Behavioral Health Care 

■ Outpatient Behavioral Health Care Visits Beyond 8th Visit per 

Fiscal Year (10/1-9/30) 

■ Transplants (all solid organ and stem cell) 

The TRICARE Standard Authorization Form will be issued to the 

MTF and the TOP Standard beneficiary. The TOP Standard 

beneficiary may give this to the Provider when they seek medical 

care. 

TOP Standard coverage is available to the family members of 

Active Duty Service Members (ADSM) living and working 

overseas. TOP Standard enrolled beneficiaries manage their own 

health care and also have the freedom to choose any Host Nation 

Provider they wish to see. 

TOP Standard beneficiaries receive reimbursable health care, 

after meeting their annual deductible payment and cost-sharing 

obligations. This means that the beneficiary will pay the first 

portion of costs toward health care services received each year 

(the annual deductible). After this portion is paid, the beneficiary 

is responsible to pay a certain percentage of each medical bill 

they receive – TOP Standard beneficiaries who are Active Duty 

Family Members (ADFM) pay 20% of the total cost and Retirees 

29 

pay 25% of the total cost. Once the beneficiary has contributed 

over a determined limit (i.e., they reach their catastrophic cap), 

TRICARE will pay all medical costs for the remainder of the 

financial year. 

TOP Standard beneficiaries will not be issued a TRICARE 

Enrollment Card. They will only have a Military ID Card. As a Host 

Nation Provider under TOP, your commitment is to provide 

cashless, claimless services to TOP Prime and TOP Prime 

Remote beneficiaries only. You are not obligated to provide 

similar services to TOP Standard beneficiaries. 

Depending on your location, you may experience a large number 

of TOP Standard beneficiaries living and working in your region. 

If you decide to provide services to these beneficiaries, you may 

do so in one of the following two ways: 

■ Request TOP Standard beneficiaries to pay the cost of 

treatment upfront. This means the TOP Standard beneficiary 

will be personally responsible for claiming reimbursement from 

TRICARE. 

■ File the claim on behalf of the TOP Standard beneficiary (using 

the CMS 1500 for Non-Institutional Providers or UB-04 Claim 

Form for Institutional Providers) and bill the patient directly for 

the patient responsibility amount. 

Note: Providers should be prepared to collect required 

beneficiary cost shares at the time of service delivery. The 

most up-to-date beneficiary cost-share information can be 

found online at www.tricare.mil. Providers registered to the 

Provider Portal can also check patient eligibility on 

www.tricare-overseas.com by entering the sponsor’s Social 

Security Number or DOD Benefits Number, and date of 

service. Additional information on understanding the Provider 

Portal can be found in Section 6 of this TOP Provider Manual. 

Based on your location, you may see TOP Prime, TOP Prime 

Remote and TOP Standard beneficiaries. TOP Standard 

beneficiaries are required to pay upfront and submit their 

claims for reimbursement. As a TRICARE Overseas Provider, 

you are not required to file claims on behalf of TOP Standard 

beneficiaries. If you would like to offer this service, you are 

responsible for ensuring that any cost shares or deductibles 

are collected from the TOP Standard beneficiary by your 

facility. 

Note: When submitting claims on behalf of TOP Standard 

beneficiaries, Providers must invoice for the full amount 

charged. If the Provider submits an invoice for only the 

balance (after the TOP Standard beneficiary has paid their 

deductible and cost share), International SOS will apply the 

deductible and cost share to the balance, as required by 

TRICARE policy. Therefore, International SOS will need the 

Itemized Invoice to reflect the full cost of medical care 

(i.e., the total invoiced amount). 

Please visit www.tricare-overseas.com for additional information 

about how to handle TOP Standard claims for reimbursement. 

SECTIoN 4 

Authorizations and Seeing 

TRICARE Patients



Authorization Forms 

International SOS will send an Authorization Form to you and the 

referring MTF along with a pre-populated Claim Form (see 

Section 5). 

The Authorization Form will include your contact information (as 

the Network Provider), the patient’s name, date of birth, and 

instructions regarding the scope and validity of the authorization. 

The Authorization Form will also include the name of the MTF 

referring the care. 

A sample TRICARE Authorization Form is included on the 

following page, as well as in Section 7 of this TOP Provider 

Manual. 

A specific Authorization Form will be issued depending on 

whether a beneficiary is a TOP Prime or TOP Prime Remote 

patient. Authorization Forms will also vary depending on whether 

the beneficiary is receiving inpatient or outpatient care. 

A separate Authorization Form will be needed for TOP Prime 

Remote ADSM before receiving dental care. 

Below is a brief description about the fields you will find on an 

International SOS Authorization Form. You will need this 

information before delivering health care services. 

■ Priority Care — this will either state ‘Urgent’ or ‘Routine’ 

— Urgent: An appointment must be provided within 24 hours 

of the beneficiary’s request for care. 

Note: For urgent care, medical results and any consult notes 

must be sent to the referring party, either the MTF or 

International SOS, within 24 hours. 

The referring party’s contact details are indicated on the 

Authorization Form. 

— Routine: An appointment must be provided within 1 week 

of the beneficiary’s request for routine care and within 

4 weeks of the beneficiary’s request for specialty care. 

Note: For routine care, medical results and any consult 

notes must be sent to the referring party, either the MTF, 

the assigned Primary Care Manager (in Puerto Rico) or 

International SOS, within 10 days. 

■ Specialty required 

■ Preliminary diagnosis from referring physician 

■ Scope of care – this will either state ‘Evaluate’ or 

‘Evaluate and Treat’ 

— Evaluate: You are authorized to evaluate only, using 

diagnostic tools such as laboratory tests, consultation, 

X-rays (to determine appropriate treatment). 

— Evaluate and Treat: You are authorized to both evaluate 

and treat the patient. A separate Authorization Form will be 

provided for surgical procedures and inpatient care, if 

admission is required as part of the treatment. Please notify 

the MTF or International SOS if this is the case. 

■ Detailed Instructions 

■ Inclusions 

Note: If you have any questions about the medical care that is 

being authorized, please call International SOS before delivering 

service. 

Note: The authorization will indicate how long it is valid. 

Authorizations are typically valid for 90 days. If your treatment 

dates exceed the time the Authorization Form is valid, please 

contact International SOS or your local MTF to obtain a new 


Note: To access the full terms and conditions of the Authorization 

Form, please visit www.tricare-overseas.com. You may also 

contact your International SOS TOP Regional Call Center and 

press option #5 to request a copy of the terms and conditions. 

30



TRICARE AUTHORIZATION FORM 

FOR OUTPATIENT CARE 

TRICARE PRIME BENEFICIARY 

To: 

 

 

 

 

Tel: 

Fax: 

Authorization Number: 

Date: 14 April 2010 

Pages: 1 

SERVICE(S) REQUEST IN RESPECT OF: 

 

This is to confirm the Authorization for the above patient at for outpatient care. This Authorization is only valid 

between and . 

Priority 

Specialty 

Preliminary Diagnosis 

Number of Visits 

Scope 

Instructions: 

 

 

As per referral 

 

 

 

 

Inclusions: 

Further to medical information received, International SOS authorizes all reasonable, customary and necessary medical expenses 

within the scope of the approved authorization. 

Medical Reports: 

Please send a written medical report and discharge summary to the below addressee after this patient’s episode of care / 

procedure. Please follow any special arrangements you may have between you and the Military Treatment Facility (MTF). 

, Fax: 

 

SECTIoN 4 

Authorizations and Seeing 

TRICARE Patients 

Priority: 

For urgent medical appointments please return a copy of medical results within 24 hours. 

For routine appointments please return a copy of medical results within 10 calendar days. 

Important: 

An authorization is issued for requested services, procedures, or admissions that require medical necessity review prior to services 

being rendered. The terms of this Authorization are only applicable to the specific service provider indicated above and to this 

instance of service requested. 

Billing Instructions: 

If the Beneficiary has "other" healthcare coverage in addition to TRICARE, the "other" healthcare coverage is the Primary Insurer. 

All invoices must reach us within 12 calendar months from date of service to avoid denial of settlement. An itemized invoice 

accompanied with a duly completed Claim Form and a copy of this Authorization Form is to be sent to the following address. : 

 

 

For full terms and conditions of this Authorization Form, please refer to www.tricare-overseas.com . Alternatively, you may contact 

our office for a copy of the terms and conditions. 

Yours sincerely 

 

TRICARE Department 

31



Authorization Forms (continued) 

Authorizations for Cases of Pregnancy 

All care related to pregnancy and childbirth is covered by one 

referral from the MTF. Authorization Forms will be issued to for 

365 days to the OB/GYN or Medical Practitioner covering care. If 

any pregnancy and childbirth care (e.g., ultrasound scans) is to 

be conducted by other Providers, additonal Authorization Forms 

may be requested. The beneficiary or Provider should contact 

International SOS directly to request additional Authorization 

Forms. 

Patient Records and Privacy 

International SOS Network Providers must maintain medical 

health records for all TRICARE beneficiaries they treat. These 

records should be protected as stipulated by an addendum to 

the Mutual Cooperation Protocol. 

When possible, Network Providers should provide English 

language summaries of their records for inclusion in the patient’s 

U.S. military medical records. If you have any questions or need 

assistance in maintaining these records, please contact your TOP 

Regional Call Center or International SOS. 

Emergency Assistance Treatment and Authorizations and 

Payment 

If a TOP Prime or TOP Prime Remote beneficiary is unable to 

contact International SOS before receiving emergency care, then 

no Authorization Form or Authorization Number will be issued. 

The medical services rendered will be authorized retrospectively. 

Authorization Forms are not required to treat beneficiaries for 

Emergency Care. However, the words ‘Emergency Care’ or 

‘Emergency Room’ must be written on the Claim Form or Itemized 

Invoice so that these claims are processed without an 

Authorization Number. Please refer to the TOP Provider 

Emergency Care brief available at www.tricare-overseas.com 

for more information on how to receive retrospective authorization 

and submit your Emergency Care claims on behalf of TOP Prime 

or TOP Prime Remote beneficiaries. 

Clear and Legible Reporting: Issuing a Medical Report 

Following Patient Care 

After providing care to a TRICARE beneficiary, please send a 

medical report of your findings and/or treatment to the referring 

party. The Authorization Form will clearly indicate whether this 

should be returned to your local MTF (for TOP Prime 

beneficiaries) or International SOS (for TOP Prime Remote 

beneficiaries). 

Cultural Differences and Host 

Nation Patient Liaisons 

Health care delivery in the United States may vary from local 

overseas practices. Language is the most obvious and 

challenging difference. Even if your English language skills are 

considered strong, it is important that any care instructions are 

clear and fully understood by the patient. You should be aware, 

language differences may discourage some patients from asking 

questions when they don’t understand. 

U.S. patients may have a high degree of modesty and find 

cultural differences in personal privacy to be uncomfortable, 

particularly in the hospital setting. Curtains or privacy screens are 

expected in hospital rooms and examination rooms in the U.S., 

and U.S. patients may find it very difficult to undress (to any 

degree) without them. 

To help make care more comfortable for TRICARE beneficiaries, 

most MTFs use one or more host nation patient liaisons. These 

liaisons are fluent in English as well as the local language, and 

are familiar with how the host nation health care system works. 

Their primary role is to assist U.S. patients in a hospital setting. 

They may also be used to assist with particularly difficult 

outpatient situations. 

You may already have an existing relationship with your local host 

nation patient liaison. You can be assured that this relationship 

will not be interrupted or changed in any way with TOP. 

32



SECTIoN 5: 

Provider Claims Information 

As a TOP Host Nation Provider, you will be able to choose one of 

four methods for submitting your claims. A Standard U.S. Claim 

Form is required when submitting TRICARE claims for 

reimbursement. 

International SOS has designed its systems to support you with 

this process, by generating a partially completed Claim Form. 

You will receive this partially completed Claim Form with each 

authorization issued. This Claim Form must be submitted with an 

Itemized Invoice for services rendered. 

All Host Nation Providers will be required to submit a Standard 

U.S. Claim Form along with the invoice for reimbursement: 

■ Non-Institutional Providers will be required to submit a CMS 

1500 Claim Form (see Section 7) 

■ Institutional Providers (e.g., hospitals) will be required to 

submit a UB-04 Claim Form (see Section 7) 

International SOS’ TOP Provider Support Services staff will work 

with you to show you how to complete the Claim Form properly. 

Detailed step-by-step instructions and tools are available, to 

help simplify the process of filling out and submitting 

Claim Forms. 

Process for Submitting Claims 

You can submit your claim using any of the following four 

methods: 

1.) online Claim Submission: This is the preferred method for 

claims submission, as it significantly reduces the amount of 

time it takes for a claim to be received by our TOP Claims 

Processing Department and therefore can result in faster 

payments. Providers do not need to complete a paper Claim 

Form or produce an Itemized Invoice when using the Online 

Claim Submission method. After submitting your claim 

electronically, it can be tracked within 12 business hours. 

Note: A signed Electronic Data Interchange (EDI) Form must 

be submitted to International SOS before your claims can be 

submitted using the Online Claim Submission method. 

2.) Secure Message Transmission: This claims submission 

method allows Providers to upload and send their claims and 

invoices via a Secure Messaging System. Claim Forms 

submitted using Secure Message Transmission can be 

tracked within 15 days of receipt. Providers must still complete 

the appropriate paper Claim Form and produce an Itemized 

Invoice when using this method of submission. 

3.) Fax: This method should be used if the Provider does not 

have an Internet connection. This method will only work if the 

fax transmission is legible. Quality can be impacted by fax 

transmission and phone line connection. This method is also 

subject to overseas toll charges. 

Note: Fax submission is still faster than overseas mail. 

4.) overseas Mail: This method should be used only when the 

other three claims submission methods (above) are not 

available. Depending on where the Provider is located, using 

overseas mail can significantly increase the amount of time it 

takes for claims to be received by our TOP Claims Processor 

and therefore can result in delayed payment. 

The following table details the benefits of each claims submission 

method: 

Benefits of Each Claims Submission Method 

Preference Submission 

Method 

#1 

#2 

Online 

Claim 

Submission 

Secure 

Message 

Transmission 

#3 Fax 

#4 

Overseas 

Mail 

Internet 

Connection Cost Speed Tracking 

Claims 

Required 

Required 

Not 

Required 

Not 

Required 

None 

None 

$$ 

$ 

Received 

immediately 

Received 

immediately 

Received 

immediately 

Time it takes 

for claims to 

arrive depends 

on Provider’s 

location 

Within 

12 

business 

hours 

of 

receipt 

Within 

15 days 

of 

receipt 

Within 

15 days 

of 

receipt 

Within 

15 days 

of 

receipt 

SECTIoN 5 


33



Mail 

You can submit a Claim Form, along with the Itemized Invoice, 

by mail. Claim Forms and invoices can be sent in any language, 

in any currency. If you receive an Authorization Form from 

International SOS, the proper mailing address will be included 

on this form. 

For Active Duty Service Members (ADSM), all completed paper 

Claim Forms and Itemized Invoices can be mailed to: 


P.O. BOX 7968 

Madison, Wisconsin 53707-7968 

USA 

For all other beneficiaries in the Eurasia-Africa Region, all 

completed paper Claim Forms and Itemized Invoices can be 

mailed to: 


P.O. BOX 8976 


USA 

For all other beneficiaries in the Pacific Region and Latin America 

Region, all completed paper Claim Forms and Itemized Invoices 

can be mailed to: 


P.O. BOX 7985 


USA 

Web-based Claims Submission 

options 

There are two Web-based claims submission options available – 

Online Claim Submission and Secure Message Transmission. 

To use either of these options, you will need to register on the 

Provider Portal online at www.tricare-overseas.com to obtain a 

username and password. Additional information about how to 

register and use the Provider Portal can be found in Section 6 

(page 69) of this TOP Provider Manual. 

Note: Providers who do not have Internet access will need to 

submit their claims via overseas fax or overseas mail. 

Secure Message Transmission 

The first web-based option is Secure Message Transmission. 

Once you become a registered Provider on the 

www.tricare-overseas.com portal, you can upload a scanned 

copy of the completed paper Claim Form and Itemized Invoice. 

Below is the screen that will appear when you log onto 


Click here to submit 

claims using Secure 

Message Transmission. 

Note: Due to the lead time involved with overseas mail, 

submitting your claims via overseas mail may result in delayed 

payment. 

Fax 

Claim Forms and invoices can be faxed in any language, in any 

currency. 

You can submit a Claim Form, along with the Itemized Invoice, to 

the following fax number: +1-608-301-2251 

Note: All claims must be sent to this fax number, which is 

equipped to handle large volumes of faxes. 

Additionally, any claims-related correspondence can be faxed to: 

+1-608-301-2250 

Note: Claims sent to this correspondence fax number will not be 

processed for reimbursement. 

34



Secure Message Transmission: Compose a Message 

To send a message to the TOP Claims Customer Service 

Department, you can click the ‘Compose Message’ button. 

Selecting the ‘Compose Message’ button allows you to see 

a subset of message subjects to select: New Claim, Claim 

Status, General, Eligibility, or Appeals. Each message type 

has a set of input fields where you will supply information 

that will help the TOP Claims Customer Service Department 

assist in the resolution of your inquiry. 

{ 

Here you can see a record of other 

claims which have been previously 

sent and processed. 

SECTIoN 5 


Note: There is also the quick button option ‘Send New Claim’ to 

submit your claim via Secure Message Transmission directly. 

Full instructions on how to submit claims via Secure Message 

Transmission are included in this section, see page 37. 

35



The Secure Message Transmission method available through 

your secure account on www.tricare-overseas.com allows you 

to submit messages directly to the TRICARE Overseas Program 

(TOP) Customer Service department. 

To access your secure messages, select the ‘Secure Message’ 

button in the top navigation bar to be taken to your secure 

message inbox. Your Inbox is a record of inquiries you have 

made to the TRICARE Overseas Program via the secure 

messaging service and replies received from our Customer 

Service department. 

The Secure Message Inbox tab will display all messages 

currently in your secure message account. 

The Inbox view uses the following display format: 

■ Check Box: This box is used to mark messages for deletion. 

Only use this box when you want to delete a message from 

your Inbox. You can select an individual message or multiple 

messages for deletion. Deletion of messages is permanent. 

■ Date: Date of last action on the email message. Date format is 

MM/DD/YYYY. By default, messages will display in your Inbox 

in the order of most recent date to oldest date. 

■ Subject: This field displays the message subject. The 

message subject is set to the inquiry type you select when 

composing the original message. Subject options include only 

the following: 

— New Claim 

— Claim Status 

— General 

— Eligibility 

— Appeal 

■ Status: The Status field will display one of the following two 

options: 

— Sent: These are messages you have composed and sent 

to the TRICARE Overseas Program that have not yet been 

viewed by our Customer Service department. 

— Received: The received status appears when your sent 

message has been reviewed by the Customer Service 

department. 

Note that the column heading can be clicked to sort the view of 

your Inbox by Date, Subject, or Status. 

The New Messages tab of the mailbox uses the same format as 

the Message Inbox tab, but will only display messages with a 

status of Sent, allowing you to see only those messages to which 

the Customer Service department has not yet replied. 

Your Inbox will store up to a maximum of 2,500 messages. To 

avoid potential issues with your secured mail account, be sure to 

manage your mail to not exceed this limit. 

36



Secure Message Transmission: New Claim 

The ‘Send New Claim’ button is used when you want to submit a claim (as an attachment) 

to the TOP Claims Processor using the Secure Message Transmission method. 

Note: A ‘New Claim’ message can be initiated by selecting the 

‘Send New Claim’ button OR by selecting the ‘Compose Message’ button 

and then choosing ‘New Claim’ as the message subject. 

When sending a new claim, you will see there is a notice 

informing you of what information you will need in order to 

successfully send a ‘New Claim’ via the Secure Message 

Transmission method. 

This includes: 

• Claim information: Such as provider location (e.g., 

country of origin, billed charges and currency). 

• Electronic Copy of a Signed Claim Form or Signed 

Claim Development Worksheet: You will need this to 

upload during the Secure Message Transmission process. 

• Patient Information: Including patient name, sponsor’s 

SSN, and beginning and ending dates of service. 

SECTIoN 5 


Once you have the information available, click the 

‘Get Started Sending a Secure Online Claim’ button 

at the bottom of the screen to begin the Secure 

Message Transmission process. 

37



Secure Message Transmission: New Claim/Claim Information 

Upload Attachments: 

You must upload at least one of the following: 

• UB-04 Claim Form 

• CMS 1500 Claim Form 

• Claim Development Worksheet 

*Attachments uploaded through the site, 

including the claim form or worksheet, must 

be in one of the file formats listed under the 

‘Attachments’ field. There are additional 

attachment fields available for uploading other 

documents to accompany your claim. These 

additional attachment fields are optional. 

The screen will update to display the data fields you need to fill in 

along with the basic claim summary data fields for uploading the 

claim form and any additional attachments you wish to provide. 

Note: All fields are required unless otherwise noted: 

■ Location: Select the physical location address where the 

service took place. 

■ Total Billed Charges: Enter the sum of all charges on the 

claim form or worksheet. 

■ Currency Type: Enter the name or code of the currency in 

which the claim charges are listed. Note: If the beneficiary has 

other health insurance, the claim will be paid in $USD (United 

States Dollars) regardless of the currency type listed here. 

■ Invoice Number: This is an optional field to enter your office’s 

internal tracking number for the claim or bill. 

When all necessary fields are entered and your attachments have 

been uploaded, click ‘Next’. 

38



Secure Message Transmission: Patient Information 

On the ‘Patient Information’ screen, you will be asked to provide the following patient 

information: 

• Sponsor Social Security Number (SSN): Select the patient’s benefit type from the drop 

down menu and then enter the corresponding benefit number in the text field to the right. 

• Patient First Name and Patient Last Name: Enter the patient’s first and last names in the 

corresponding fields. 

• Beginning Date of Service: Enter the earliest date of health care service as it is listed for 

the procedures being submitted on this claim. The date must be entered in MM/DD/YYYY 

format or you can click the calendar icon to select the date. 

• Ending Date of Service: Enter the last date of health care service as it is listed for the 

procedures being submitted on this claim. This date must be entered in the MM/DD/YYYY 

format or you can click the calendar icon to select the date. 

Click ‘Next.’ 

SECTIoN 5 


39



Secure Message Transmission: New Claim/Confirmation 

If you need to make changes to either the 

Claim Information section or the Patient 

Information section, click the ‘Edit’ button 

next to the section that requires changes. 

A Confirmation screen summarizing the data you entered will appear. 

Verify the information you provided. 

If all of the information is correct, click ‘Submit’ to send your claim to the TOP 

Claims Processor. 

When you click ‘Submit’ the screen will update to confirm that your TOP Claim has 

been successfully submitted via the Secure Message Transmission method. You 

will also receive an automated email response confirming your Secure Message 

Transmission. The automated email response will summarize the claim data you 

entered and will also provide you with the TOP claim number for your claim. The 

TOP claim number can be used to track the progress of your claim through the 

‘Claim Status and Claims Report’ functions available in your secured account area. 

Note: The ‘Secure Message Transmission’ function should only be used to submit 

ONE claim per each secure message. 

40



Claim Forms can be submitted in any language and invoices in 

any currency. Only one claim can be submitted per Secure 

Message Transmission transaction (the secure Provider portal 

will allow a maximum of 15MB total). 

The following formats are accepted: .doc, .xls, .jpg, .jpeg, .tf, .tiff 

or .pdf. 

The claim will be entered into the TOP Claims Processor’s system 

and can be tracked on the Secure Claims Portal using the 

patient’s name, the sponsor’s Social Security Number, DOD 

Benefits Number, DEERS Family ID, and DOB or Dates of 

Service. 

Claims will be available for you to review within 15 days of 

receipt. Secure Message Transmission through the Secure 

Claims Portal can be used to submit claims for TOP Prime and 


This transmission method can also be used if the Provider 

chooses to submit claims on behalf of TOP Standard 

beneficiaries. 

Note: Claims may not be emailed to International SOS directly. If 

Claim Forms and Itemized Invoices are emailed to International 

SOS directly, they will not be processed. 

online Claim Submission 

Note: Standard Web-based submission software packages such 

as PC-Ace require that all claims are submitted in U.S. Dollars. 

These packages are most suitable for Providers located in U.S. 

Territories familiar with Standard U.S. Claim Form procedures. 

For this reason, International SOS has developed a customized 

claims submission program, which is available on the un-secure 

Provider portal. User-friendly field descriptions and built-in 

prompts are used on this site to assist Providers in submitting 

claims. When using the ‘Online Claim’ submission option, 

claims can be tracked within 12 business hours of receipt. 

This portal also allows Providers to submit claims in certain 

foreign currencies. Using the Provider Portal to submit claims 

electronically is the recommended option for overseas Providers. 

This option significantly reduces the amount of time it takes to 

process payments. 

To use ‘Online Claim’ submission, you must first sign an 

Electronic Data Interchange (EDI) Agreement. The EDI Form is 

effectively a record of your signature on file for each claim that 

you submit through the portal. This form can be obtained from 

your International SOS TOP Provider Support Services staff, 

or it can be downloaded from www.tricare-overseas.com. 

A sample EDI Agreement Form can be found on page 105 of 

this TOP Provider Manual. 

All EDI Agreements are subject to acceptance by International 

SOS and Wisconsin Physicians Service (WPS). 

The second Web-based claims submission method is also 

available via the Secure Claims Portal on www.tricareoverseas.com. 

This portal has a custom-built ‘Online Claim’ submission option, 

which can be used to submit TOP Claims. 

Alternatively, Providers may download and submit claims using 

other Web-based submission software, such as PC-Ace. PC-Ace 

is available free of charge from International SOS. Please contact 

your TOP Regional Call Center and press option #5 to speak with 

a TOP Provider Support Services staff member to request this 

software. 

Claim Forms and Itemized Invoices are not required when 

submitting claims electronically through the Secure Claims Portal. 

Instead, Providers will be prompted to enter the claim data using 

ICD diagnosis codes and CPT procedure codes. These 

requirements vary slightly, depending on whether the claim is for 

an Institutional or Non-Institutional Provider. 

Finally, a clearing house or billing agency can be used for claims 

submission. In this case, it is the Provider’s responsibility to 

supply all required paperwork for accurate, complete processing 

of claims. If a clearing house or billing agency is used, a CMS 

1500 Form or a UB-04 Form is still required. 

Note: Please visit www.tricare-overseas.com/provider.htm to 

download a Computer Based Training Module on Web-based 

‘Online Claim’ submission of TOP claims. 

SECTIoN 5 


41



online Claim Submission: Select a Location 

The www.tricare-overseas.com Secure Claims Portal has field 

descriptions and built-in prompts that will assist you while entering 

the claim electronically. If you choose to submit claims using this 

website, you will see the following page after you log-in and click 

‘Online Claim.’ 

Your screen will update to display the ‘Online Claim’ submission 

page. 

The Select Location section of the page displays a ‘Submit Claim’ 

tab which lists all current locations for which you have an 

agreement for electronic claim submission. 

Click the radio button in the ‘Submit Online’ column that 

corresponds to the location where the medical services were 

rendered. 

Note: If you have a location on file with the TOP Claims Processor 

but do not have an electronic claims submission agreement for 

that location, you can see that location by clicking on the ‘Need 

Web Claim Submission Agreement’ tab. On that tab you can also 

request electronic claims submission by clicking on the ‘Sign Up’ 

link for those locations. 

If the location where the services were rendered does not 

appear on either the ‘Submit Online’ tab or the ‘Need Web 

Claim Submission Agreement’ tab, you can add the location 

by clicking the ‘Request a New Location’ link. 

42



online Claim Submission: Select a Patient 

Scroll down the page to the ‘Select Patient’ section. In this section, you can search for 

patients by using their TRICARE Sponsor Social Security Number (SSN) or DEERS Family 

ID as indicated on the patient’s Military ID card, which the patient should always carry 

with them. 

This search function will return a list of beneficiaries, their date of birth, and gender 

indicator based on the ID number. You can select the correct patient for your claim by 

clicking the ‘Radio’ button in front of their name. 

You have the alternative of selecting from a list of recent patients 

from claims you have submitted to the TOP Claims Processor. 

Click the ‘Choose from Recent Patients’ tab, select the letter that 

corresponds with the first letter of the patient's last name, and 

view a list of your recent TRICARE patients on screen. 

Note: If your search does not return any results, you will not be able to use the ‘Online 

Claim’ submission feature through www.tricare-overseas.com unless your patient is 

under 1 year of age. If your patient is a TRICARE beneficiary under 1 year of age and their 

name does not come up in a search result, select the ‘I am unable to find an eligible child 

under 1 year of age’ button and complete the First Name, Last Name and Date of Birth 

fields for this patient. 

Select the patient from this list by clicking the ‘Radio’ button in 

front of the patient's name. 

After selecting the patient for your claim, click ‘Next’. 

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online Claim Submission: Verify a Patient 

Please verify that this is the patient’s 

current and correct address. If you 

have a more current address for the 

patient, select the ‘Edit’ button next 

to the address and input the up-todate 

correct address you have on 

file. This will help expedite the claims 

process. 

The selected patient's name, date of birth, gender indicator and 

address will appear on the screen. 

Please verify that this is the patient that corresponds with your 

TOP Claim before proceeding. 

Note: If the TOP Claims Processor has information that indicates 

the patient may have Other Health Insurance (OHI) that should 

pay on the claim before TRICARE makes payment, you will 

receive a notice. If your patient does have OHI that should be 

paying, you will be responsible for entering the OHI payment 

information when completing the ‘Claim Information’ section. 

You have the option to attach an invoice number or code used by 

your office to identify this claim. To use this feature, enter your 

invoice or tracking number in the open field provided. A 

maximum of 20 characters are allowed for the invoice number. 

Note: Adding an invoice number or code will allow you to easily 

track this claim on the Secure Claims Portal as you will be able to 

use the invoice number or code to search for the claim and view 

its processing status. 

Once you’ve verified the patient data, click ‘Next.’ 

44



online Claim Submission: Enter Claim Information 

If you do not know the ICD diagnosis codes for the 

patient's diagnosis, you can use the ‘Code Lookup’ 

feature and search for the code by its description. 

To use the Code Lookup: 

• Click on ‘Code Lookup’ 

• The ‘Diagnosis Lookup’ pop-up box will appear 

• Type the description of the diagnosis in the box 

• Click the ‘Search’ button 

A list of descriptions containing your search word will 

appear. The ICD code corresponding to each 

description appears in the column to the left of the 

description. Find the diagnosis description for your 

claim and then click the code to the left to enter it into 

the Diagnosis field of the online claim form. 

The Claim Information page is where you begin entering the data 

about the health care encounter. Required fields are indicated 

with an asterisk. 

In the Diagnosis section, enter the ICD diagnosis codes that 

correspond to the reason the patient needed medical care. If you 

know the ICD code that represents the patient's diagnosis, it can 

be keyed directly into this field. 

Note: The Principal DX, or diagnosis, field is required for claims 

processing. There are seven additional fields for entering other 

diagnoses describing the patient's condition. These additional 

fields are optional. 

Select the ‘Assignment of Benefits’ indicator. Select ‘Yes’ if you 

want to receive reimbursement directly from TRICARE. 

If the patient made a payment to you for services on this claim 

prior to this claim being submitted, you must indicate their 

payment amount in the ‘Patient Paid’ field. The amount entered 

here should be given in the currency you will select below. 

However, if the patient has OHI, the ‘Patient Paid’ field must be 

completed in $USD (United States dollars). 

Note: This is a required field and must be completed, so if there 

is no patient payment prior to claim submission, enter zeroes 

(0000000) in these fields. 

In the field ‘Patient has Other Health Insurance (OHI)’, if the 

patient does not have another health insurance paying you for 

this claim (i.e., before TRICARE will pay), select ‘No’ and continue 

to the next section of the form. 

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45



If the patient does have another health insurance paying before 

TRICARE select ‘Yes.’ When you select ‘Yes’ the screen will 

update to display 3 additional fields to provide the payment 

information from the OHI: 

■ other Health Insurance Allowed – Enter the amount the OHI 

indicated as its ‘Allowed’ amount for the entire claim. Enter 

this amount in $USD (United States Dollars). 

■ other Health Insurance Paid – Enter the amount the OHI 

paid for the entire claim. Enter this amount in $USD (United 

States Dollars). 

■ other Health Insurance Payment Reason – The OHI will 

typically provide a code or comment explaining how they 

processed the claim. Click the ‘Look Up’ and from the pop-up 

box, select the reason that matches the OHI explanation. 

— Either Deductible, Copay/Cost Share, Non-Covered 

Service or Other. 

— Note: This is a required field when there is OHI, so if there 

is no payment reason from the OHI or if there isn’t one that 

matches these choices, select ‘Other.’ 

Be aware that claims transactions involving OHI must be 

conducted in $USD (United States Dollars). The currency type 

for the claim will default to $USD and cannot be changed. If you 

previously entered a patient payment amount in a currency other 

than $USD, please return to that field and enter the correct 

amount for $USD currency. 

You can select a currency type for the claims transaction from a 

drop down menu. 

However, if the claim transaction does include OHI, this option 

will not be available as the claim transaction with OHI must be 

in $USD. 

online Claim Submission: Claim Line Item Form 

To use the ‘Lookup’ feature: 

• Click on ‘Code Lookup’ 

• The CPT/HCPCS Lookup pop-up box will appear 

• Type the description of the procedure in the box 

• Click the ‘Search’ button 

A list of descriptions containing your search word will 

appear. The code corresponding to each description 

appears in the column to the left of the description. Find 

the diagnosis description for your claim and then click 

the code to the left to enter it into the CPT/ HCPCS field 

of the online claim form. 

46



The ‘Claim Line Item Form’ section is for entering the details about the 

medical services and/or supplies provided during the health care 

encounter. The ‘Claim Line Item Form’ section is not a summary 

section: you can enter multiple procedures per claim. Each procedure 

will have its own claim line. 

Note: Required fields are indicated with an asterisk. 

Begin by entering the dates of service for the procedure. Dates of 

service can be typed directly into the ‘From’ and ‘To’ fields or you can 

use the calendar icon to select the dates of service. 

Note: The required format for the ‘Dates of Service’ fields is Month, 

Day and Year. 

Enter the Current Procedural Terminology (CPT) code or the Health 

Care Procedure Coding System (HCPCS) code that represents the 

medical procedure or service that was performed. If you know the 

code representing the procedure or supply, you can type it directly 

into this field. 

The ‘Modifier’ field is used to enter 2 character codes that represent 

additional descriptors or clarifiers to the procedure performed. The 

modifier is not a required field and can be left blank. 

The ‘National Drug Code’ field is for listing the code the United States 

Food and Drug Administration assigns to any marketed prescription 

drug or insulin. This field is not required and should be left blank 

unless the medical procedure code entered in the CPT/HCPCS field 

represents a prescription drug or insulin. 

The ‘Anesthesia’ field should be checked ‘Yes’ only if the code 

entered in the CPT/HCPCS field represents anesthesia. If you 

selected ‘Yes’ here, the ‘Units’ field should be entered with the number 

of minutes anesthesia was administered. 

The ‘Units’ field is for entering the number of times the procedure in 

the CPT/HCPCS field was performed during the dates of service OR it 

should represent the number of units of the supply provided. 

Note: If the procedure or supply is a prescription or injection and the 

National Drug Code was also provided, enter the National Drug Code 

quantity in this field and not the HCPCS quantity. If you selected ‘Yes’ 

in the Anesthesia field, the number of units should be the number of 

minutes billed for anesthesia. 

The ‘Charges’ field is used to enter the amount you are billing for the 

procedure or service. Type the amount directly into these fields. 

Note: The amount entered in this field must be in the currency type 

selected in the ‘Claim Information’ section of the form. If the ‘Currency 

Type’ field displays $USD (United States dollars), the amount entered 

here must also be in $USD. 

The ‘Place of Service’ field is for entering the 2-digit code that 

describes the type of facility where the procedure was performed. If 

you know the correct code, it can be typed directly into this field. If 

you do not know the code, click the ‘Lookup’ button. A pop-up box 

with a list of descriptions will appear. The ‘Place of Service’ code 

corresponding to each description displays in a column to the left of 

the description. Select the code for the description that matched the 

location description to enter it into the ‘Online Claim Form.’ 

The ‘Service Location Zip Code’ field is an optional field, but if 

applicable enter the Zip Code of the location where the services were 

rendered in this field. This field only accepts Zip Codes in a 5-digit, allnumeric 

format. If your service location Zip Code does not meet the 

required format, leave this field blank. 

The ‘Provider’ field is a drop down menu of names of individuals on 

file for the ‘Provider Location’ you selected at the start of the ‘Online 

Claim’ submission process. Choose the name of the individual that 

performed the procedure or service given in the CPT/HCPCS field. If 

the name of the individual is not listed here, you can add them to the 

provider list for the location through the ‘Administration’ console OR if 

you cannot add them, you will not be able to include the procedures 

or services that person performed in your online claim submission. 

You have the option to provide comments or additional information to 

the line item you are currently entering. Click the ‘Insert Comment’ link 

to open a box that will allow you to enter up to 80 characters of text to 

accompany this procedure or service item. 

Once you have entered all required information for the procedure or 

service in the ‘Claim Line Item Form’ fields, click the ‘Add Line Item’ 

button to include the item in your claim. 

When you click the ‘Add Line Item’ button, the information for the 

procedure or service item in the ‘Line Item Form’ will move to the ‘Line 

Item List’ section, displaying all details you entered for the item. The 

‘Claim Line Item Form’ fields will reset to blank so that additional 

procedures or services can be entered on your claim. 

online Claim Submission: Line Item List 

The ‘Line Item List’ section will display all procedure or service items 

you have added to the claim, along with all details you entered for 

each item. If you need to correct or modify a line item, select the ‘Edit’ 

button for that item. If the line item should not be submitted with the 

claim, select the ‘Delete’ button for that item to completely remove it 

from the claim before submission. 

At the end of the ‘Line Item List’ section, the Total Charges are given 

for the claim. The total charges will be the sum of the charges in the 

currency type you selected for all line items you have added to the 

claim. 

Once you have completed entering line items to your claim, click the 

‘Next’ button 

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online Claim Submission: Review and Submit 

To end the ‘Online Claim’ submission transaction 

without submitting the form, click ‘Cancel.’ 

Note: Data will NOT be saved if you select ‘Cancel’. 

To make revisions, click the ‘Edit Claim Information’ 

button to return to the claim form and update your 

patient or claim information. 

To submit your claim for processing, click the ‘Submit 

Claim’ button. 

The ‘Review and Submit’ page gives you one additional chance 

to confirm all the data you have entered into the ‘Online Claim’ 

form (i.e., patient information, diagnosis and OHI data and all 

procedural information you’ve entered into the claim form). 

Note: When you click ‘Submit Claim’ the data will transmit to the 

TOP Claims Processor and you will not be able to make further 

changes. 

online Claim Submission: Claim Received 

If the ‘Online Claim’ submission is successful, you will see the 

‘Claim Received’ page. 

This page will summarize the currency selection and the total 

billed amount submitted on the TOP Claim. It will also provide you 

with a claim number. 

The claim number can be used to track the status of the TOP 

Claim using the ‘Claim Status’ feature. 

Note: It may take up to 12 business hours from submission for 

the claim to appear using the ‘Claim Status’ feature. Claims can 

be searched using the patient’s name, the sponsor’s Social 

Security Number of DOD Benefits Number, or by the Date of 

Service. 

48



Claims for Services Rendered 

Before September 1, 2010 

Effective September 1, 2010, all claims must be submitted using 

one of the International SOS submission methods outlined. This 

applies, even if treatment was provided for dates of service 

before September 1, 2010. 

For services delivered before September 1, 2010, a Claim Form 

and Itemized Invoice must be submitted. The correct Claim Form 

must be used, to ensure payment. 

CMS 1500 (Non-Institutional Providers) and UB-04 (Institutional 

Providers) Claim Forms can be downloaded at www.tricareoverseas.com. 

Detailed instructions for completing these forms 

can be found in Section 5 of this TOP Provider Manual. An online 

eLearning Module on how to properly fill out your Claim Forms is 

also available. Please contact your TOP Regional Call Center and 

select option #5 to request access details on the eLearning 

Module. 

Claim Tracking and Monitoring 

Once you become a registered user on the Provider Portal, you 

can track your claims online at www.tricare-overseas.com. 

After claims are submitted on this portal, they are entered into 

International SOS’ system. 

If you submitted your claims by overseas mail, overseas fax or 

Secure Message, you can view them online within 15 days of 

receipt. If you submitted your claims via Online Claim Submission 

using the Provider Portal, you can view them online within 

12 business hours. 

Providers can search for claims using the patient’s name, the 

sponsor’s Social Security Number or DOD Benefits Number, and 

DOB, or Dates of Service, or Claim Number. 

The claim status will indicate whether the claim is being 

processed and if it has been paid. If the claim has been paid, the 

claim status update will indicate how much has been paid or if 

the claim has been denied. Once the claim has been processed, 

the Provider will be able to view the Explanation of Benefits (EOB) 

for that claim online. 

Full instructions on using the Provider Portal ‘Dashboard’ features 

are included in Section 6 of this TOP Provider Manual, see pages 

77-85. 

Timely Filing of Claims 

All claims must be submitted within 1 year of the Date of Service. 

Claims must be date stamped/received by International SOS 

within 12 months of the last date of treatment in order to be 

reimbursed. Any claims exceeding this 12 month timely filing 

deadline will be declined. 

Claim Reimbursement and 

Payment 

Provider payments can be made in the following ways: 

■ By Check (Local Currency) 

■ Bank Draft (Local Currency) 

■ Electronic Fund Transfer (EFT) (Local Currency) 

Payments will be made in the currency in which the invoice is 

submitted, wherever possible. If the Provider submits an invoice in 

U.S. Dollars, payment will be made in U.S. Dollar check. If invoices 

are submitted in local currency, payment will be made by local 

currency bank draft, whenever possible. International SOS can 

make payments in over 100 currencies. If your currency is not 

available, payment will be made by U.S. Dollar check. Checks and 

bank drafts will be sent to the Provider by overseas mail. 

If Providers would like to receive payment via Electronic Funds 

Transfer (EFT), they must submit a request by completing and 

submitting an EFT Form. EFT Forms can be downloaded at 

www.tricare-overseas.com or you can contact your TOP 

Regional Call Center and select option #5 to speak to a TOP 

Provider Support Services staff member to obtain a form. 

When completing the EFT Form, please be sure to include the 

following information: 

■ Provider ID number 

■ The name of your bank and the name on the account 

■ Account number or IBAN number 

■ SWIFT code 

Please also include the currency in which you would like to 

receive payment. This must be the same as the currency in which 

you submit your claims. If any of these details is incomplete or 

missing, International SOS will not be able to process your EFT 

request. Once your EFT is set up, this will be your default method 

of payment. 

EFT is our recommended method of payment, as it reduces the 

amount of time it takes to receive payments. 

Remittance advice will be sent to the Provider in the form of an 

Explanation of Benefits (EOB). If the Provider receives payment 

by U.S. Dollar check or bank draft, the EOB will be sent to you by 

mail with the check or bank draft. If the Provider has an EFT set 

up, EOBs will be sent separately by mail. EOBs are also available 

to view online, on the Provider Portal available on www.tricareoverseas.com. 

Please see Section 6: The Provider Portal for 

additional information about viewing your EOB online. 

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Required Criteria for Ensuring 

Payment of Claims 

Providers can help to ensure that claims are processed (and 

payments made) in a timely manner, by making sure that the 

following minimum required fields are completed on their Claim 

Form, before it is submitted: 

CMS 1500: 

1. TRICARE Ticked 

2. Patient Name 

3. Patient Address 

4. Sponsor Name 

5. Sponsor’s Social Security Number or DOD Benefits Number 

6. Other Health Insurance (OHI) Details (if applicable) 

7. Patient Signature x2 and the date 

8. Diagnosis (if this cannot be written on the invoice) 

9. Authorization Number 

10. Federal Tax ID (Provider ID or TEPRV) 

11. Accept Assignment? YES 

12. Amount Paid by OHI or Beneficiary (if applicable) 

13. Provider Signature 

14. Provider Name and Billing Address 

UB-04: 

1. Provider Name and Billing Address 

2. Federal Tax ID (Provider ID or TEPRV) 

3. Patient Name 

4. Patient Address 

5. Other Health Insurance (OHI) Details (if applicable) 

6. Assignment of Benefits – YES 

7. Amount Paid by OHI or Beneficiary (if applicable) 

8. Sponsor Name 

9. Sponsor’s Social Security Number or DOD Benefits Number 

10. Authorization Number 

11. Diagnosis (if this cannot be written on the invoice) 

12. Provider Signature 

Providers must also ensure that the Itemized Invoice they submit 

contains all of the following information: 

■ Date of Service 

■ Letterhead Containing the Provider’s Name, Physical Address 

and Billing Address 

■ Invoice Number or Patient Account Number 

■ Corresponding Authorization Number (when required) prior to 

Treatment (this can be found on the Authorization Form) 

■ Patient Name 

■ Description of Diagnosis (if the diagnosis cannot be written on 

the invoice, please include this on the Claim Form) 

■ Breakdown of Services Rendered, Listing Corresponding 

Costs (and Taxes) and Overall Total Owed 

■ Invoice Currency 

Important: Claim Forms that are received without an invoice, or 

invoices that are received without a Claim Form will not be 

processed. The received document will be returned to the 

Provider. 

Note: If Providers would like to receive payment for claims in the 

fastest possible time, International SOS recommends using the 

Online Claim Submission option via the Provider Portal AND 

registering to receive EFT payments. This helps avoid the delays 

associated with overseas mailing times. 

Explanation of Benefits and 

Applicable Exchange Rate 

Information 

Remittance Advice is sent to the Provider in the form of an EOB. 

EOBs are sent to the Provider by mail however this information is 

also available to be viewed online via the Provider Portal. The 

electronic EOB is available on the same date the payment is 

issued. 

The EOB includes detailed information regarding any items that 

may have been denied for payment. It also includes important 

exchange rate data, which was used for issuing payment. 

Deductibles and co-payments that TOP Standard beneficiaries 

are responsible for paying will also be included on the EOB. 

According to TOP policy, the exchange rate applied will be the 

exchange rate valid on the last day of the ‘episode of care’ or last 

date of invoiced services. Citigroup is the standard exchange 

rate used by International SOS. 

If a claim is denied or not paid in full, a denial code will be 

assigned to that charge. An explanation of the denial codes 

is included on the last page of the EOB. A list of denial 

codes and their explanations is available online at 

www.tricare-overseas.com as well as in the Appendix of this 

TOP Provider Manual. 

You can also contact your TOP Regional Call Centre or submit a 

request via the Secure Message Transmission option on the 

Provider Portal. 

Note: Responses to Secure Messages transmitted via the 

Provider Portal will be sent to the Secure Message Inbox on the 

Provider Portal. Please see Section 6: The Provider Portal for 

additional information about accessing Secure Messages. 

50



Below are sample EOB statements for TOP Prime and TOP Prime Remote beneficiaries: 

Here are the Provider’s details. This 

is to whom the payment is made. 

The number in this corner will be a local 

toll free number which the Provider can 

call if they need assistance. 

® 

This is the Claim Number, also known as the 

Internal Control Number (ICN). 

The Check Number helps Providers match the payments that have been made to the Claims they have submitted. If the Provider has 

been paid by check, this number will correspond with the check number on the payment check. If the Provider has been paid by 

bank draft, this number will correspond with the number on the perforated record attached to the bank draft. If the Provider has been 

paid by Electronic Fund Transfer (EFT) up to six check numbers will appear in the payment line on the bank statement. 

® 

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This is the 

Check Number. 

51



® 

‘PT Resp’ means Patient’s Responsibility. 

TOP Prime beneficiaries receive a cashless 

service. Therefore, the deductibles and 

cost-shares are listed as $0.00. 

If any charges are denied, 

the denial code will be 

listed here. 

This is the total amount 

International SOS will 

reimburse. 

These are the dates of 

the ‘Episodes of Care’ as 

indicated on the invoice. 

These are the costs for 

the treatments the 

patient received. 

This is the total amount 


reimburse. 

These are the CPT 

procedure codes. 


translate the treatment 

details from the invoice 

into CPT codes. 

These are the costs that are allowed 

under the beneficiary’s TRICARE 

policy. If any payments are denied, a 

denial code will be indicated. An 

explanation of the code is given on the 

last page of the EOB. 

52



On the bottom half of the EOB, you will find the payment summary showing the amount International SOS will reimburse and the 

amount that is still outstanding. 

A brief explanation of the Denial Codes (if any) will appear here. A full list of Denial Codes is available in Host Nation 

Languages on www.tricare-overseas.com. No charges have been denied, therefore there are no denial codes listed here. 

Here, you will find the exchange rate that was used. Exchange rates will be in effect on the last date of service. International 

SOS uses Citigroup’s exchange rates. 

This is a sample TOP Standard beneficiary EOB 

If more than one invoice is submitted, or if a single invoice for multiple procedures is submitted with a single Claim Form, the EOB will 

appear as follows: 

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These are the dates for 

the ‘Episodes of Care’ 

indicated on the Itemized 

Invoice. 

These are the CPT 

procedure codes. 


translate the treatment 

details from the invoice 

into CPT codes. 

This EOB is for a Standard beneficiary and some of the services 

are not covered. Therefore, there is the total which is allowed 

under the policy; the amount the beneficiary must pay and the 

amount International SOS will reimburse. 

53



On the reverse side of the EOB will be additional information regarding Provider and beneficiary rights, as well as beneficiary 

co-payments, appeals process details and other information. 

54



The Bank Draft 

If the Provider is being paid by bank draft, it will be attached to the bottom of a letter, which will be sent to the Provider along with 

their EOB via overseas mail. 

This is the 

Check Number. 

123456 

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The bottom part of the bank draft letter is the bank draft itself. 

The beneficiary and Provider details are located at the top of the letter, along with the issue date, the amount being paid, a payment 

reference number and the Check Number. The Check Number corresponds with the Check Number on the bank draft, as well as the number 

on the EOB. 

55



Transaction Fees Associated with 

Claim Reimbursement and 

Payments 

International SOS is responsible for any costs associated with 

issuing payments, such as issuing checks and bank drafts, 

sending EFT payments (and related transaction fees), and 

sending the EOBs. Providers are responsible for all of the costs 

associated with receiving payments, such as depositing checks 

and bank drafts, collecting EFT payments, and exchanging 

payments into local currency. 

What if Both Non-Institutional and 

Institutional Providers Are Used for 

the Same ‘Episode of Care’ and 

Billed Independently? 

Two separate Claim Forms will be needed: one from the Non- 

Institutional Provider (CMS 1500) and one from the Institutional 

Provider (UB-04). 

Each entity that requests to receive payment independently must 

submit a separate Claim Form (CMS 1500 for Non-Institutional 

Providers or UB-04 for Institutional Providers) and an Itemized 

Invoice. 

Step-by-Step Instructions for 

Accurately Completing Claim 

Forms 

TOP Provider Support Services staff will work with you to show 

you how to complete each of the following Claim Forms properly. 

When you receive an International SOS Authorization Form, a 

pre-populated Claim Form will be sent to you simultaneously. If 

you do not receive an Authorization Form or if you need 

additional Claim Forms, these are available to be downloaded on 


Note: These Claim Forms will not be pre-populated. 

Full instructions on how to complete Claim Forms that have not 

been pre-populated are included in this TOP Provider Manual 

and are also available at www.tricare-overseas.com. 

Instructions on how to complete a pre-populated Claim Form are 

available at www.tricare-overseas.com. 

International SOS has also developed an eLearning Module to 

help you complete Claim Forms. Please contact your TOP 

Regional Call Center and press option #5 to request access to 

the eLearning Module. 

If needed, additional Claim Forms can be downloaded at 


What if a Beneficiary Does Not 

Show for an Appointment? 

TRICARE beneficiaries are directly responsible for paying noshow 

fees. You should invoice the patient directly for failing to 

cancel an appointment (without sufficient advance notice) or 

failing to show up for a scheduled appointment. 

56



The Claims Process 

Completing the CMS 1500 

PART 1 

Patient’s and 

Sponsor’s 

Details 

PART 2 

Patient’s Signature 

PART 3 

Diagnosis and 

Authorization 

Number 

PART 4 

Provider’s Details 

{{ 

{{ 

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The Pre-Populated Claim Form CMS 1500 

When you receive an 

Authorization Form from 

International SOS, you 

will also receive a 

pre-populated Claim Form. 

All the fields highlighted 

in purple will be 

pre-populated. All the 

fields highlighted in green 

can be left blank. 

You will only have to 

complete these few 

fields shown here in white. 

58



Part 1: Patient’s and Sponsor’s Details 

Always choose the 

TRICARE option. 

Please enter the patient’s 

DOB using the format 

MM DD YY and tick M or F to 

indicate the patient’s gender. 

Enter the sponsor’s ID number (10-digit DOD 

Benefit or 9-digit Social Security Number (SSN)) 

and name using the format Last Name, First 

Name, Middle Initial. This information will appear 

on the patient’s Military ID Card. 

Enter the patient’s name, 

using the format Last Name, 

First Name, Middle Initial and 

the patient’s full physical 

address including post code. 

Enter the patient’s relationship 

to the sponsor. 

Fields highlighted in green 

can be left blank 

Enter the sponsor’s 

full address if different than 

the patient’s. 

If the patient has OHI enter 

the name of the insured party 

using the format Last Name, 

First Name, Middle Initial, the 

policy number and in field 9d 

enter the name of the 

insurance plan. 

TRICARE is always the secondary 

payer. If the patient has OHI policy, 

tick ‘YES’ here and then 

complete 9, 9a and 9d. 

If the patient does not have OHI 

policy, section 9 can be left blank. 

Enter the sponsor’s DOB, 

using the format MM DD YY 

and indicate the sponsor’s 

gender marking either M for 

Male or F for Female. 

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Part 2: Patient’s Signature 

These two fields require the signature of the patient. 

• The patient and the insured party can be the same person. Even if the patient is not the Active Duty Service Member, the Active Duty Family 

Member is an eligible TRICARE beneficiary and considered the insured party. 

• The requirement for signature can be met by obtaining a ‘Signature on File’. This means the Provider will have the patient’s signature on file 

(collected at ‘registration’ at the Provider facility or at first appointment). 

• If the patient is incapable of signing or under 18 years of age, the parent or legal guardian’s signature will be kept on file. 

• Signature on File: International SOS will assist Providers with education on how to obtain this in the correct manner and which wording to 

include in collecting the signature. Providers will then simply write ‘Signature on File’ in BOTH fields and will not be required to obtain the 

beneficiary’s or insured’s signature when completing the Claim Form. 

• Laboratories: if the patient is not present, the laboratory should enter ‘Patient not Present’ on the line in both signature fields. 

• Ambulance Companies: Enter 'Patient Unable to Sign' on the line in both signature fields. 

IMPoRTANT NoTE: Both boxes must be signed and completed! 

An example ‘Signature on File’ letter: 

60



Part 3: Authorization Number 

If you are not able to include the diagnosis on the 

invoice, you can write it here. If the diagnosis is on 

the invoice, leave this field blank. The diagnosis can 

be a written description or an ICD or CPT Code. 

Please enter the appropriate 

Authorization Number. This can be 

found on the top right corner of the 


The rest of this information should be on the Itemized Invoice which must be submitted with the Claim Form. 



SECTIoN 5 


61



Emergency Care 

If the Provider is providing Emergency Care, they will not necessarily have an 

Authorization Number. In this case, the Provider should write the words 

‘Emergency Care’ in this section. 

EMERGENCY CARE 

62



Part 4: Provider’s Details 

The ‘Federal Tax ID Number’ is the 

Provider’s TRICARE ID Number 

(or TEPRV). Please enter this here. 

Always indicate ‘Yes’ here. This 

ensures that payment goes to the 

Provider. 

If the patient has OHI, it will be the primary payer 

for the claim. After the OHI has processed the 

claim, indicate here how much they have paid. 

Also include any payments the patient has made 

towards the claim. If TRICARE is the patient’s only 

health insurance plan, leave this field blank. 

This must be signed and 

dated by the Provider. 

This does not 

necessarily have to be 

the attending physician, 

but can be signed by an 

authorized person. 

Note: The Provider 

‘Signature on File’ 

procedure can be 

used here. 

Please enter the 

patient’s account 

number. This is 

generated by the 

Provider and 

should not be 

longer than 18 

digits long. 

Please enter 

the Provider’s 

name and full 

physical 

address. 




Provider’s full billing 

address if different to 

the physical address. 

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63



Completing the UB-04 

PART 1 

Provider’s Details 

{ 

{ 

{ { { 

PART 2 

Patient’s Details 

and Address 

PART 3 

This can be left 

blank as long as 

an Itemized 

Invoice is 

submitted 

PART 4 

Sponsor’s Details 

and Authorization 

Number 

PART 5 

Diagnosis and 

Provider Signature 

64



The Pre-Populated Claim Form UB-04 

When you receive 

an Authorization 

Form from 

International SOS, 

you will also 

receive a 

pre-populated 

Claim Form. 

All the fields 

highlighted in 

purple will be 

pre-populated. 

All the fields 

highlighted in 

green can be 

left blank. 

You will only have 

to complete these 

few fields shown 

here in white. 

SECTIoN 5 


65



Part 1: Provider’s Details 

Please enter the Patient’s account number. 

This is generated by the Provider and 

should not be longer than 18 digits long. 


Provider’s name 

and full physical 

address. 


Provider’s full billing 

address if different 

to the physical 

address. 

The ‘Federal Tax 

Number’ is the 

Provider’s TRICARE ID 

Number (or TEPRV). 

Please enter this here. 

Part 2: Patient’s Details and Address 

Enter the patient’s name, using the format Last 

Name, First Name, Middle Initial and the patient’s 

full physical address including post code. 


patient’s DOB 

using the format 

MM DD YY and 

write M or F to 

indicate the 

patient’s gender. 

Enter the 

sponsor’s name 

and full address 

if different than 

the patient’s. 

66



Part 3: This section can be left blank, as long as an Itemized Invoice is submitted 

This information should be on the Itemized Invoice which must be submitted with the Claim Form. 

Part 4: Sponsor’s Details and Authorization Number 

If the patient has OHI, enter the name 

of the insured party using the format 

Last Name, First Name, Middle Initial 

and the policy number. 

Always indicate ‘Y’ for ‘Yes’ 

here. This ensures that 

payment goes to the Provider. 

If the patient has OHI, it will be the primary payer for the claim. 

After the OHI has processed the claim, indicate here how 

much they have paid. Also include any payments the patient 

has made towards the claim. If TRICARE is the patient’s only 

health insurance plan, leave this field blank. 

SECTIoN 5 


Please enter the appropriate 

Authorization Number. This can 

be found on the top right corner 

of the Authorization Form. 

Enter the sponsor’s name using the format Last Name, First 

Name, Middle Initial and the sponsor’s ID number (SSN or the 

first 9 digits of the DOD Benefits Number). This information will 

appear on the patient’s Military ID Card. 

67



Emergency Care 

If the Provider is providing Emergency Care, they will not necessarily have an 

Authorization Number. In this case, the Provider should write the words 

‘Emergency Room’ in this section. 

EMERGENCY ROOM 

Part 5: Diagnosis and Provider Signature 

If you are not able to include the diagnosis on the invoice, you can 

write it here. If the diagnosis is on the invoice, leave this field blank. 

This must be signed and dated by the Provider. This does not necessarily have 

to be the attending physician, but can be signed by an authorized person. 

Note: The Provider ‘Signature on File’ procedure can be used here. 

68



SECTIoN 6: 

The Provider Portal 

Registering to the Provider Portal 

In order to access the Provider Portal on www.tricare-overseas.com the Provider will need to become a registered user first and set up a 

unique username and password. 

Note: Please visit www.tricare-overseas.com/provider.htm to download a Computer Based Training Module on Web-based Claim 

Submission options. 

To begin the registration process, go to the Providers section of www.tricare-overseas.com 

and click on ‘Register’. 

Your TRICARE overseas Program (ToP) Provider Number 

You will advance to the TOP 

Provider Number page. Enter 

your TOP Provider Number in the 

open field (this is a required 

field). If you do not know your 

TOP Provider Number, it can be 

found in your TRICARE Overseas 

Explanation of Benefits (EOB) 

(see example above). 

The Provider must enter their Provider ID Number (or TEPRV) – 

this is a number assigned to the Provider by International SOS 

and appears in the following format: DEU123456DEU A000. 

The Provider ID Number is indicated at the top of the Explanation 

of Benefits (EOB), which you may have received from 


If you have not yet received an EOB for a TRICARE beneficiary, 

please contact your TOP Regional Call Center and press option 

#5 to speak with a member of the TOP Provider Support Services 

team, who can provide you with your TOP Provider ID Number. 

After entering your TOP Provider ID Number, click ‘Next.’ 

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69



Provider Information 

The Provider must enter their 

contact information, including full 

name, and contact telephone 

number (optional). Providers will 

also be required to enter a valid 

email address where they can be 

contacted. Updates such as 

password information will be sent 

to this address. 

On the ‘Provider Information’ page you will enter the name and 

contact information of the TRICARE Overseas Program (TOP) 

Provider. All fields on this page are required for registration. 

■ Language Preference: The language preference field 

determines the site language when you have logged into your 

Secure Provider Claims Portal account. 

– Note: This preference can be changed at a later date 

in your personal profile. 

■ First Name: Enter the first name of the Provider. 

– Note: This field has a 25 character limit. 

■ Last Name: Enter the last name of the Provider. 

– Note: This field has a 35 character limit. 

■ Telephone Number: Enter the 3-digit international country 

code in the first field and the remaining digits of the contact 

telephone number in the second field. 

■ Email Address and Confirm Email Address: Enter the 

contact email address in the first field. Then validate the 

contact email address by entering it again in the ‘Confirm 

Email Address’ field. 

Providers located in the United States and U.S. territories will 

additionally be required to provide one of the following: 

■ License Number 

■ Medicare Certification Number 

■ National Provider Identifier 

Click ‘Next’ to continue the registration process. 

70



Provider Registration Type 

Choose the ‘Registration Type.’ 

Registration options are included on the drop down menu, and 

include the following: 

1.) Complete a secure instant registration on the site 

2.) Complete the registration process by mail 

To complete a secure instant registration on the site, Providers 

must have had a claim processed within the last 365 days with 

the TRICARE Overseas Program (TOP) Claims Processor. 

If this is your preferred method of registration, verify the 

registration drop down field displays the 'I would like to complete 

a secure instant registration' option. 

For ‘Secure Instant Registration’ Providers are required to enter a 

claim number (also known as the Internal Control Number (ICN)) 

from their TOP Explanation of Benefits (EOB) and the date of birth 

(DOB) of the patient on that claim. See diagram below. 

Note: Providers can use any claim number from within the last 365 days. 

Once you complete the required ‘Instant Registration’ fields, click ‘Next.’ 

If you have not submitted a claim to the TRICARE Overseas Program in the last 365 days, or if you prefer to complete registration by mail, 

choose the 'I would like to complete registration by mail' option from the drop down menu and click ‘Next.’ 

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71



Instant Registration: Account Username and Password 

Your password cannot contain spaces and cannot 

be the same as your first name, last name or the 

Username you have selected for your account. 

You can click on the ‘Password Rules’ button for the 

full list of requirements and regulations connected 

to passwords on www.tricare-overseas.com 

After choosing ‘Secure Instant Registration’, you will be taken to 

the ‘Username and Password’ page. 

The ‘Username’ page is where you will choose your account 

name and set up your account security. All fields on this page 

are required. 

Username: Enter the Username of your choice for your account. 

The Username must be a minimum of 5 characters long and 

cannot be more than 32 characters long. 

The site will validate your Username, displaying confirmation in 

green text if the Username you’ve selected is available for your 

account. The validation text will turn red if the Username you are 

trying to enter is already in use. 

72



Password: Enter the security password for your account. Your 

password must be a minimum of 9 characters long and must 

contain the following: 

■ 2 numbers 

■ Any 2 of the following special characters 

— ! exclamation point 

— @ at sign 

— # hashtag, pound sign, or number symbol 

— $ dollar sign 

— % percent sign 

— & ampersand 

— * asterisk 

— _ underscore 

— + plus sign 

— , comma 

— ? question mark 

■ 2 lower case characters 

■ 2 capital or upper case characters 

Confirm Password: Validate your chosen password by entering 

it a second time. 

Security Question: Select a security question from the options 

available in the drop down menu. 

Security Answer: Provide the answer to the security question 

you have just chosen. 

Note: Your security answer cannot be more than 32 characters 

in length. 

You must read the ‘Terms and Conditions’ 

and then click on the box next to this 

section, stating that you have read and 

accept the ‘Terms and Conditions’ before 

proceeding to the next step. 

Click ‘Next’ to continue. 

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73



Instant Registration: Confirmation 

If you wish to change 

any information prior to 

submission, click the 

‘Edit’ buttons here. 

If all the information is 

valid and correct, click 

the ‘Complete 

Registration’ button and 

you will be logged in to 

your new account on 

www.tricareoverseas.com 

Next, you will come to the Instant Registration ‘Confirmation’ 

page. This page displays the Provider information and Username 

and security question and answer you entered for your account. 

Note: Providers in the United States and U.S. territories will see 

an additional ‘Confirmation’ field with the License Number, 

Medicare Provider Number, or National Provider Identifier you 

entered on the ‘Provider Information’ page. 

74



Registration By Mail: Account Username and Password 

After choosing ‘Registration by Mail’, you will be taken to the 

‘Username’ page where you will set up some of the features for 

your account and account security. All fields on this page are 

required. 

Start by choosing the ‘Username’ for your account. 

The Username must be between 5 and 32 characters in length. 

The site will validate your Username, displaying confirmation in 

green text if the Username you want is available for your account. 

The validation text will turn red if the Username you are trying to 

enter is already in use. 

You will then choose a security question from the drop down 

menu. 

In the ‘Security Answer’ field, enter the answer to the question 

you selected. 

Note: Your security answer cannot be more than 32 characters 

in length. 

Click ‘Next.’ 

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75



Registration By Mail: Confirmation 

The website will display ‘Confirmation’ of the registration by 

displaying the name and address we have on file for the 

Provider number you’ve entered. 

By mail, the TOP Claims Customer Service Department will 

send to you (using the address displayed on screen) a 

password and instructions for logging in to your account on 

www.tricare-overseas.com 

The password and instructions should arrive within 7–10 

business days. 

You can then use these instructions and password to access 

your new account. 

76



Using the Provider Portal 

Using the Provider Portal: The Provider Dashboard 

The ‘Provider Dashboard’ is your landing page. It is the first page 

you will see after logging in to your secure account. The ‘Provider 

Dashboard’ provides you with a quick view of important Alerts 

and Announcements and also contains all your recent claims 

activity, including recent payment, returned claims, and pending 

claims. You can also check TRICARE beneficiary eligibility and 

Other Health Insurance from the ‘Provider Dashboard.’ 

Note: There is a ‘What is My Dashboard?’ link available at the top 

of the dashboard page. You can click this link to view a quick 

explanation of the content and features available on the ‘Provider 

Dashboard.’ 

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77



Using the Provider Portal: The Provider Dashboard: Alerts and Announcements 

Check the ‘Alerts and Announcements’ box to see 

when your current password is scheduled to expire. 

You can click on the day-remaining link, which will 

take you to the ‘Password Update’ function in the 

Secure Provider Claims Portal. 

The first section of your ‘Provider Dashboard’ is a quick view of 

Alerts and Announcements. 

If you are an account administrator, in addition to password 

notifications you will see alerts for pending location approval 

requests and pending user requests. The location approval 

request and user request alerts are static – they will always 

display in your Alerts section. 

Each alert will be accompanied by a number indicating how 

many pending requests of each type there are. If there are no 

pending requests, the number field will display 0 (zero). The 

number field is a link you can click to take you to the 

administration page for each function. 

78



Using the Provider Portal: The Provider Dashboard: Notifications 

An Important Notifications page may appear as a splash screen when you first log in. 

These are important site-wide messages from the TOP Claims Customer Service Department. Topics range from changes in 

requirements in TRICARE Overseas Program policies and procedures to notices about www.tricare-overseas.com secure claims 

portal features and functionality. 

Be sure to review the notifications before closing the splash page. 

To close the notifications splash page, click OK or click the ‘X’ in the upper right-hand corner of the notification window. 

SECTIoN 6 


79



Using the Provider Portal: The Provider Dashboard: Check Patient Eligibility 

The ‘Check Patient Eligibility’ button can be found on the ‘Provider Dashboard’ and can be used as a quick link to begin a Beneficiary eligibility 

check. You can conduct a Beneficiary eligibility check using either the Sponsor Social Security Number (SSN) or DEERS Family ID. 

Once you make a selection, complete the remaining fields in this section and then click the ‘Submit’ button. 

The Beneficiary eligibility search will begin and then take you to the ‘Patient Eligibility’ page to view the results. 

80



Using the Provider Portal: The Provider Dashboard: Recent Payments View 

The ‘Provider Dashboard’ gives you immediate access to your 

most recent claims activity data in three convenient tabs: 

1. Recent Payments 

2. In-Process Claims 

3. Returned Claims 

The ‘Provider Dashboard’ defaults to the ‘Recent Payments’ tab, 

showing you data for your first registered location for the previous 

calendar week. You can use the ‘Location’ filter to choose another 

location if you have more than one registered location with 


You can also use the ‘View’ filter to choose an alternate time 

period of 30 days, 60 days, or 90 days. Each tab defaults to 50 

records per page. If you have more than 50 records, there will be 

a page selection and arrow navigation to allow you to move 

through multiple pages. 

Note: In each view the data can be sorted by clicking on the 

column heading. Displayed data cannot be sorted by the 

currency type. 

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81



Recent Payments: The Recent Payment view provides the following information: 

■ CHECK/EFT/ACH Number: Displays the number assigned to the check or electronic payment transaction made via either Electronic 

Fund Transfer (EFT) or Automated Clearing House (ACH). Electronic payment transaction numbers are preceded by an asterisk. 

■ Approval Date: This is the date the check was issued or the date the electronic payment was made. This appears in MM/DD/YYYY 

format. 

■ Payment Amount: This displays the full reimbursement amount made in the check or electronic payment transaction. 

■ Currency: Displays the code representing the currency in which the payment was made. 

■ View Claims: This field provides a link to a detailed view of all your claims that were part of that reimbursement. 

When you click on the ‘View Claims’ link, the screen will 

automatically update to display the ‘Claim View.’ 

The ‘Claim View’ provides the following details: 

■ EoB: This is a link to an image of your TRICARE Overseas 

Program (TOP) Explanation of Benefits (EOB) for the claim on 

this line. You will be able to view the EOB in either a summary 

payment format (.pdf document) or a detailed individual claim 

format (.html). 

■ Letters: If there was any correspondence or documentation 

attached to this claim transaction, the documentation can be 

viewed by clicking on the ‘Letters’ link. 

■ Invoice Number: If you added an office invoice or record 

number to your claim during the online claims submission 

process or when you submitted a claim via postal mail, this 

number will be displayed here. 

■ Date of Service: This field will display the earliest date of 

service on the claim. The date format is MM/DD/YYYY. 

■ Claim Number: This is the TOP control number assigned to 

your claim for processing and tracking on the Secure Claims 

Provider Portal. 

■ Patient Name: Displays the full name of the patient on the 

claim. 

■ Billed Amount: This field displays the sum of all charges that 

were submitted on this claim. 

■ Currency: This field displays the code representing the 

currency in which the claim transaction was processed. 

■ Provider Name: Displays the name of the individual provider 

or the facility name. 

■ Tax ID: Displays the 9-digit tax identification number of the 

Provider. For Providers outside the 50 United States and the 

U.S. territories, this is an identification number assigned to the 

Provider by the TRICARE Overseas Program. 

82



■ Paid by Government: This field displays the amount of 

payment the TRICARE benefit program covers and 

reimbursed or paid on the claim. 

■ Process Date: This field displays the date the claim 

processing was finalized in our system (i.e., by the TOP 

Claims Processor). 

You can also click the ‘Plus’ (+) symbol at the start of each line to expand additional details about the claim. 

Information about these additional claim details is available in the ‘Claim Status’ demonstration, also available on the Secure Provider 

Claims Portal. 

Clicking the ‘Back’ button will return you to the ‘Recent Payments’ dashboard summary view. 

SECTIoN 6 


83



Using the Provider Portal: The Provider Dashboard: In-Process Claims View 

In-Process Claims: In-Process Claims shows you the claims you 

have submitted and are currently being processed by the TOP 

Claims Customer Service Department. 

The ‘In-Process View’ provides the following information: 

■ Invoice Number: If you added an invoice or record number to 

your claim during the ‘Online Claims Submission’ process or 

when you submitted a claim via postal mail, this number will 

be displayed here. 

■ Date of Service: This field displays the earliest date of service 

on the claim. The date format is MM/DD/YYYY. 

■ Claim Number: This is the TRICARE Overseas Program 

control number assigned to your claim for processing and 

tracking on the Secure Claims Provider Portal. 

■ Patient Name: Displays the full name of the patient on the 

claim. 











Note: There is no expanded view for In-Process Claims. These 

claims are still being worked on by the TOP Claims Customer 

Service Department, so processing details are not yet available. 

84



Using the Provider Portal: The Provider Dashboard: Returned Claims View 

Returned Claims: The Returned Claims tab shows claims that 

you have submitted but were returned to you by the TOP Claims 

Customer Service Department because information was missing, 

which was needed for accurate claims processing and payment. 

The Returned Claims view provides the following information: 

■ Claim Number: This is the TRICARE Overseas Program 

control number assigned to your claim for processing and 

tracking on the Secure Claims Provider Portal. 

■ Patient Name: Displays the last name and first name of the 

patient on the claim. 











■ Date of Service: This field displays the earliest date of 

service on the claim. 

■ Invoice Number: If you added an invoice or record number to 

your claim during the ‘Online Claims Submission’ process or 

when you submitted a claim via postal mail, this number will 

be displayed here. 

■ Claim Status: This will display ‘Returned.’ 

You can also click the ‘Plus’ (+) symbol at the start of each line to 

expand additional details about the claim. Some additional 

information you will find in the expanded view includes the 

‘Reason Returned’ field, which is a brief summary explaining why 

the claim was returned to you, and a link to a .pdf version of the 

letter sent to you (along with the returned claim) explaining in 

detail why the claim was returned. 

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85



Claim Status 

Using the Provider Portal: Claim Status: Basic Search 

The ‘Basic Search’ allows you to 

search for your claim information 

by your registered locations, 

including an option for all 

locations. 

The default selection is 'All 

Locations' but you can select a 

specific location from the drop 

down menu. 

If the location you want to look up 

is not on the drop down menu, 

you can register this new location 

by selecting the 'Request a New 

Location' link. 

The ‘Claim Status’ function allows you to search for claim 

information and data for claims you have submitted to the TOP 

Claims Customer Service Department. 

Note: The ‘Claim Status’ function has a 500-claim limit for search 

returns and can only return claim data for the last 18 months 

(based on when the claim is processed). Please select the 

appropriate criteria to filter your search to improve search return 

and portal performance. 

Next, select the cross-reference search type you would like to 

perform. 

The choices here include: 

■ Patient Information: Selecting Patient Information allows you 

to input the data to find claims you submitted for a specific 

patient. Complete the following fields: 

— Sponsor Social Security Number (SSN): Enter the patient’s 

benefit eligibility number. 

— Patient First Name: Provide the patient’s first name. 

— Date of Birth: Enter the patient’s date of birth. The date 

format is MM/DD/YYYY. 

— Service Start/End Date: The system will default the service 

date fields to the last 30 days. If necessary, you can 

change this by typing new dates directly into these fields 

or by using the calendar icons to select new dates. 

— Claim Number: Selecting the Claim Number allows you to 

enter the full 14-digit number assigned to your claim and 

search for its status. Claim numbers are assigned 

immediately to your claims when you submit them using 

the Online Claims submission method on www.tricareoverseas.com 

■ Check Number: Selecting the Check Number allows you to 

enter the full 11-character check number and search for 

claims processed under that check. Check numbers will 

appear on your Electronic Funds Transfer (EFT) or Automated 

Clearing House (ACH) credit advice, your weekly claim 

summary reports, and your dashboard. You can also find the 

86



check number in the claim detail financial summary section. 

Note: When searching with an EFT or ACH check number, you must include the asterisk as the first character. 

■ Invoice Number: Selecting the Invoice Number allows you to search for a claim with the identification code you have assigned to the 

claim. The Invoice Number search works for claims you have submitted, for which you have also entered an invoice identification code. 

Note: The Invoice Number search is limited to 20 characters maximum. 

Note: There is a ‘Reset Search’ button which will clear the entire page of any inputs or selected options, if needed. 

Once you are satisfied with the search criteria entered, click the ‘Search’ button to perform the location and patient search. 

Using the Provider Portal: Claim Status: Advanced Search 

Selecting the ‘Advanced Search’ tab gives you several additional 

search options, which include: 

■ Individual Patient DEERS Family ID: Selecting this option 

allows you to search for a patient’s claim data by their 9-digit 

DEERS Family Identification Number. This option also requires 

that you enter the patient’s name, date of birth, and a selected 

date span for the claim search. 

■ Individual Patient DoD Benefits Number (DBN): Selecting 

this option allows you to search for a patient’s claim data by 

87 

their 10-digit DOD Benefits Number. This option also requires 

that you enter the patient’s name, date of birth, and a selected 

date span for the claim search. 

■ Process Date: Selecting this option allows you to enter a 

specific date and view all claims processed on that date. The 

date can be typed directly into the field in the MM/DD/YYYY 

format or it can be selected using the calendar icon. 

■ All Patients: Selecting this option allows you to search for 

and view claim data for all patients as cross-referenced with 

the selected provider location(s). 

SECTIoN 6 

The Provider Portal



Using the Provider Portal: Claim Status: Claim Search Results 

Near the top of the ‘Claim Search Results’ page is a notice 

asking if you would like to view any linked documentation 

in your ‘Search Results’ claim details. 

Note: You will need Adobe Reader. If you do not have 

Adobe Reader on your computer, you can download the 

program by clicking on the ‘Adobe Reader’ link. 

Immediately following the notice are buttons 

labeled ‘Edit Search’ or ‘New Search’. If the 

search you performed does not show the results 

you wanted, you can click ‘Edit Search’, which 

will take you back to the Claim Search screen 

where you previously entered your search 

criteria. Or you can click on ‘New Search’ which 

will take you to the blank Claim Search screen 

where you can enter your search criteria. 

The screen will update to display your search results. The number of results you receive for any search will depend on the type of claim 

search performed and the number of claims you have submitted to the TOP Claims Customer Service Department in the last 30 months 

(based on when the claim is processed). 

The criteria for the search you just performed will appear immediately above your ‘Claim Search Results’ so that you can verify if the 

search was performed with the criteria you intended. If the criteria shown are not correct, you can click the ‘Edit Search’ button to modify 

the criteria and perform a new search. 

The ‘Location’ filter gives you the option to sort your ‘Claim Search Results’ by Tax ID and Zip Code. 

Note: There is a paging index that allows you to advance through multiple pages of ‘Claim Search Results.’ Click a page number to 

advance to that page or use the arrows to navigate through the ‘Claim Search Results’ one page at a time. 

88



The ‘Claim Search Results’ box will list all claims that fit the 

criteria you selected for the search. The immediate search results 

display the following fields for each claim returned in the search: 

■ Expand/Contract: This button allows you to display and hide 

additional details and functions for the claim specific to that 

‘Claim Search Result’ line. 

■ Explanation of Benefits (EoB): If an EOB has been 

generated for the claim, an icon linking to an Adobe .pdf 

version of the EOB will appear in this field. 

■ Letters: If additional documentation has been generated by 

the TOP Claims Customer Service Department while 

processing your claim, an icon linking to an Adobe .pdf 

version of this documentation will appear in this field. 

■ Invoice Number: This field will display your office Invoice 

Number for the claim if you provided one during the Online 

Claims submission process or for a claim that you have 

submitted via postal mail. 

■ Date of Service: This field displays the end date for services 

listed on the claim. This field displays in the MM/DD/YYYY 

format. 

■ Claim Number: This field displays the 14-digit claim control 

number assigned to your claim when it was received by the 

TOP Claims Customer Service Department. 

■ Patient Name: This field displays the last name and first name 

of the patient on the claim. 

■ Claim Status: This field displays the current status of your 

claim (i.e., where the claim is in the process of being handled 

by the TOP Claims Customer Service Department). Possible 

‘Claim Status’ values include: 

■ Currency: This field displays the currency code in which the 

claim the claim transaction was processed. 

Note: A currency code does not indicate there was a payment 

on the claim. 

■ Process Date: This field will display the date on which the 

TOP Claims Customer Service Department took final action on 

the claim. If the claim status is In-Process, this field will be left 

blank. The date displays in the MM/DD/YYYY format. 

Note: You can expand a claim's record to see more details about 

how the claim was processed. Click the ‘Plus’ (+) symbol at the 

start of the record line to view the summary payment details. 

The expanded record's payment details are presented in 4 

columns: 

■ The first two columns detail the financial information for the 

claim: 

— The billed amount, the ‘Paid by Government’ amount, to 

whom the payment was directed (if a payment was made), 

and any beneficiary liability. 

— The third column gives the information for the Provider of 

services on record for the claim, including the individual or 

facility name and address. 

— The fourth column lists the check details, including the 

check or EFT transaction number, the issue date, and the 

payee (i.e., individual or facility recipient) of the payment. 

Clicking the ‘Full Claim Detail’ button gives you access to patient 

detail information and claim line item detail information. 

Note: Claim line item detail information is not available for claims 

that are labeled ‘In-Process.’ 

— In-Process 

— Payment 

— No Payment 

— Adjustment 

— Reissue 

— Credit 



■ Paid by Government: This field displays the amount of 

payment the TRICARE benefit program covers and 

reimbursed or paid on the claim to the Provider and/or patient. 

This field will display all zeroes (00000) if the claim is In- 

Process or No Payment could be made on the claim. 

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Using the Provider Portal: Claim Status: Claim Search Details 

Historical details for each of these 

items include: 

- Eligibility 

- Other Health Insurance 

- Out-of-Pocket Expenses 

- Primary Care Manager 

Clicking the ‘Plus’ (+) symbol to expand the ‘Patient Eligibility’ section will allow you to see the patient's eligibility and benefit information 

corresponding to the dates of service of the claim. 

The eligibility record will display any records of any insurance program the beneficiary may have in addition to TRICARE and the dates 

that insurance program is effective. Out-of-Pocket expenses are also detailed here. 

Note: Financial values here will be up-to-date with the most recent claim processed for the beneficiary, but ‘In-Process’ claim values will 

not have been calculated against these benefits. Also, please note that all values appearing here are given in $USD (United States 

Dollars). 

Current Primary Care Manager information will be given in the third column. 

90



Using the Provider Portal: Claim Status: Claim Search Details 

Clicking the ‘Plus’ (+) symbol to expand the ‘Claim Line Items’ 

section allows you to see details for each service, procedure or 

supply you billed for on the claim. 

Details will be listed using the following fields: 

■ Service Description: Displays the code and partial 

description for the service, procedure, or supply. 

■ Reason Code: This is a 3-character code indicating 

message from the TOP Claims Customer Service Department 

explaining claim processing actions take for that service, 

procedure or supply. You can select the code to view its 

explanation. 

■ Start Date, Date of Service, and End Date of Service: The 

dates you provided to indicate the beginning and end of the 

procedure. 

■ Billed Amount: The amount you charged for the service, 

procedure or supply. 

■ Allowed Amount: The amount TRICARE deems the 

maximum amount for the service, procedure or supply. 

■ Units: The number of times the procedure was performed or 

the supply provided during the dates of service. 

■ Invoice Number: This field will display your office Invoice 

Number for the claim if you provided one during the Online 

Claims submission process or for a claim that you have 

submitted via postal mail. 

■ Provider of Service: This field will list the name of the 

assigned individual Provider or facility that delivered the 

medical care on behalf of the beneficiary. 

Note: ‘Claim Line Item Details’ will not be available on claims that 

are labeled ‘In-Process.’ 

Full instructions on how to submit claims via ‘Online Claim 

Submission’ are included in Section 5 of this TOP Provider 

Manual (see pages 33-48). 

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91



Using the Provider Portal: Claims Report 

To access the ‘Claims Report’ select 

the ‘Claims Report’ button in the 

navigation bar. This button will take 

you to the ‘Claims Report’ menu 

page (shown left). 

The ‘Claims Report’ page 

displays the selection criteria 

for building your report. 

The ‘Claims Report’ function available through the Secure Claims 

Provider Portal on www.tricare-overseas.com allows you to 

create a report of claims associated with your account up to 9 

weeks in the past. 

Criterion #1: 

The first criterion on the ‘Claims Report’ page is ‘Select Claim 

Status.’ Click the ‘Radio’ icon that corresponds with the status 

type you would like to view on your report. You can select one of 

the following: 

— Processed 

— In-Process 

— Returned 

— All 

You have the additional option to display individual charges in 

your report by clicking the check box marked ‘Display Individual 

Charges,’ but please note this will only apply to Processed claims 

(i.e., not to claims labeled ‘In-Process’ or ‘Returned.’). 

Criterion #2: 

The second criterion is the ‘Report Date Range.’ 

Note: If you have selected ‘In-Process’ as the status type, all 

‘In-Process’ claims will display regardless of the date and the 

‘Report Date Range’ option will not be available to select. 

From the drop down menu, choose one of the following: 

■ This Week: This option is defined as being from the previous 

Sunday to the current day of the week. When selecting this 

92



option, the ‘From’ and ‘To’ date range fields will automatically 

fill with the corresponding dates and will not be available to 

change. 

■ Yesterday: This option is defined as the date prior to the 

current date you are running the ‘Claims Report’. When 

selecting this option, the ‘From’ and ‘To’ date range fields will 

automatically fill with the corresponding dates and will not be 

available to change. 

■ Last Week: This option is defined as being from Sunday to 

Saturday of the week prior to the current week. When 

selecting this option the ‘From’ and ‘To’ date range fields will 

automatically fill with the corresponding dates and will not be 

available to change. 

■ Select Date Range: This option allows you to enter the ‘From’ 

and ‘To’ date fields. You can select a span of 7 days within the 

last 9 weeks to view a ‘Claims Report. 

Criterion #3: 

The third criterion is to select the Provider. You have the option to 

select either a single/specific Individual Provider or Institutional 

Facility for reporting claims data. Or, you can select all Providers 

added to the account for reporting claims data. 

Next, select a ‘View Option’ for your report. The ‘View Option’ sets 

a sort order for how your claims data will display in the report. 

From the drop down menu, choose one of the following: 

— Check Number 

— Account or Invoice Number 

— Patient Name 

— Sponsor Number 

Note: Sorting the view by ‘Check Number’ is not an option when 

the report's claim status is either ‘In-Process’ or ‘Returned’, as 

there is no check generated for these statuses. Account or 

Invoice Number will only display if you have entered an invoice 

number through the Online Claim submission process. 

Once you have selected the criteria for your ‘Claims Report,’ click 

‘View Report’ to see your claim data in .html format (i.e., 

displayed as a web page). 

Or, you can click ‘Export to Excel’ to have your ‘Claims Report’ 

data display in Microsoft Excel. To use this option, you must have 

Microsoft Excel installed on your computer. 

The ‘Reset All’ button will set all criteria fields to their default 

values, thereby removing any selections you may have made 

prior to clicking the button. 

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93



Using the Provider Portal: Claims Report: View Report 

■ Removed claims will display the following claim-specific 

information: 

(Note: Actual field order will depend on the view 

option selected) 




— Claim Number 

— Dates of Service 

— Reason for Return 

■ Processed claims display the following summary 

information: 

(Note: Actual field order will depend on the view 

option selected) 

The reports are formatted as follows: 

■ Claim dates of service are displayed in the month/day/year 

format. The month will be the first 3 characters of the 

alphabetic spelling and the year will be in a 4-digit format. 

■ All currency values are displayed in the Provider's local 

currency and are displayed without a currency symbol or 

indicator. The 3-byte currency code will appear in the report 

header. 

■ In .html or web page format, claims data will be separated by 

the Provider attributed to the claim. In Excel format, each 

Provider and their corresponding claim data will display on a 

separate tab. 

■ In-Process claims will display the following claim-specific 

information: 

(Note: Actual field order will depend on the 

view option selected) 




— TOP Claim Number 


— Amount Billed 

— Check Number 

— Processed Date 

— Check Amount 




— Claim Number 



— Amount Allowed 

— Patient Owes 

— Paid to Patient 

— Paid to Provider 

— Denial Flag (Y or N) 

■ If the ‘Display Individual Charges’ option was selected for 

processed claims, the following fields will display as 

applicable to the claim and line: 

— Line Item 

— Procedure Code 

— Revenue Code 

— Number of Services 



— Amount Allowed 

— Patient Offset 

— Provider Offset 

— Paid by Patient 

— OHI Paid 

— OHI Patient Owes 

— Reject 

94



Patient Eligibility 

Using the Provider Portal: Patient Eligibility 

The ‘Check Patient Eligibility’ button can be found on the 

navigation bar (see above). 

You can conduct a Beneficiary eligibility check using either the 

Sponsor Social Security Number (SSN) or DEERS Family ID. 

Once you make a selection, complete the remaining fields in this 

section and then click the ‘Submit’ button. The Beneficiary 

eligibility search will begin and then take you to the ‘Patient 

Eligibility’ page to view the results. 

Full instructions on how to submit claims via ‘Secure Message 

Transmission’ are included in Section 5 of this TOP Provider 

Manual (see pages 35-41). 

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95



Manage Locations 

Using the Provider Portal: Manage My Locations 

You can add one or more locations in order to view payments, 

claims, send secure messages and submit Online Claims. 

In order to add one or more locations, you will need to have one 

claim number along with the corresponding patient ‘Date of Birth’ 

for that claim number, for the location you wish to add. 

After the location is successfully added, you will be able to view 

recent payments, claims, send secure messages and submit 

Online Claims. 

To add a location, click ‘Request Location Access’ which will then 

ask you to enter the 9-digit tax identification number (first 9 digits 

of the TEPRV) and zip code. 

Then click ‘Search’. 

A list will display of locations that are available to add. 

You will then need to click the ‘Self Authorize For Instant Access’ 

button, which will prompt you to enter the claim number and 

‘Date of Birth’ for the patient on that claim number (for the 

location being requested). After the information has been entered 

and is verified, you will receive a message stating that the 

location was successfully added. 

96



Using the Provider Portal: My Profile 

You can make any changes to your 

Provider Profile by clicking on 

‘Personal Information’. Update the 

information in this section and then 

click ‘Save’ to make the updates. 

You can change your language 

preference by clicking on the 

‘Language Preference’ button. 

Once you’re finished making your 

selection, click ‘Save’ to make the 

update. 

You can change your password and/or 

update your security question and 

answer. Click the ‘Password Security 

Question’ button and when completed, 

click ‘Save’ to make the updates. 

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97



TRICARE Covered Benefits 

Providers can check to see which medical care services are covered for each type of TRICARE Beneficiary by visiting 

www.tricare.mil/coveredservices 

You can fill in the fields in the ‘Answer Three Questions’ section at the top of this page to customize the search results and change the 

profile of the TRICARE Beneficiary. 

For Question #2, you can select the country in which the Beneficiary is located. This will assist in determining which TRICARE Plan he or 

she is using. 

Once you have selected the customized profile, you can then click on ‘See What’s Covered’ to bring up a list of TRICARE Covered 

Services, in alphabetical order. 

98



TRICARE Covered Benefits: See What’s Covered 

Once the ‘See What’s Covered’ page opens, you can use the drop down menu to search for the particular treatment or medical service 

you are looking for. In the example below, ‘Birth Control’ was selected from the drop down menu. Details regarding covered services and 

the relevant exclusions (if any) will appear. 

You can also click any of the links in the ‘Most Viewed Topics’ section (top right) to obtain more information regarding related topics. 

SECTIoN 6 


99



SECTIoN 7: 

TRICARE overseas Program Provider Forms 

Sample: CMS 1500 Claim Form 

100



SECTIoN 7 


Provider Forms 

Sample: CMS 1500 Claim Form (continued) 

101



Sample: UB-04 Claim Form 

102



SECTIoN 7 



Sample: UB-04 Claim Form (continued) 

103



Sample: International SoS Authorization Form 

TRICARE AUTHORIZATION FORM 

FOR OUTPATIENT CARE 

TRICARE PRIME BENEFICIARY 

To: 

 

 

 

 

Tel: 

Fax: 

Authorization Number: 

Date: 14 April 2010 

Pages: 1 

SERVICE(S) REQUEST IN RESPECT OF: 

 

This is to confirm the Authorization for the above patient at for outpatient care. This Authorization is only valid 

between and . 

Priority 

Specialty 

Preliminary Diagnosis 

Number of Visits 

Scope 

Instructions: 

 

 

As per referral 

 

 

 

 

Inclusions: 

Further to medical information received, International SOS authorizes all reasonable, customary and necessary medical expenses 

within the scope of the approved authorization. 

Medical Reports: 

Please send a written medical report and discharge summary to the below addressee after this patient’s episode of care / 

procedure. Please follow any special arrangements you may have between you and the Military Treatment Facility (MTF). 

, Fax: 

 

Priority: 

For urgent medical appointments please return a copy of medical results within 24 hours. 

For routine appointments please return a copy of medical results within 10 calendar days. 

Important: 

An authorization is issued for requested services, procedures, or admissions that require medical necessity review prior to services 

being rendered. The terms of this Authorization are only applicable to the specific service provider indicated above and to this 

instance of service requested. 

Billing Instructions: 

If the Beneficiary has "other" healthcare coverage in addition to TRICARE, the "other" healthcare coverage is the Primary Insurer. 

All invoices must reach us within 12 calendar months from date of service to avoid denial of settlement. An itemized invoice 

accompanied with a duly completed Claim Form and a copy of this Authorization Form is to be sent to the following address. : 

 

 

For full terms and conditions of this Authorization Form, please refer to www.tricare-overseas.com . Alternatively, you may contact 

our office for a copy of the terms and conditions. 

Yours sincerely 

 

TRICARE Department 

104



SECTIoN 7 



Sample: EDI (Electronic Data Interchange) Agreement Form 

105



Sample: EFT (Electronic Funds Transfer) Form for Providers 

Electronic Funds Transfer (EFT) Claim Payment Request 

If you are expecting to receive all your payments directly, please complete your bank details. 

If you are processing all of your invoices through a billing agency or a corporate entity, please send them form to provide us with 

their bank details and a list of providers billing through them. 

PROVIDER INFORMATION: 

Do you use a billing agency? Yes / No (If Yes, please request your Billing Agency to complete the EFT Form for Billing Agency) 

TRICARE ID Number 

City 

Country 

Provider Name 

State 

Zip / Postal Code 

BANK DETAILS: 

Please provide details of the Account Holder – including Account Holder’s Street Address 

Account Holder Name 

Street Address 

Country 

Bank Name 

Bank ID Code (Swift, FED, 

ABA, etc.) 

Bank Street Address 

Bank State/ Country 

Tel Number 


Full Bank Account 

Number (IBAN) 

Bank City 

Bank Zip / Postal 

Code 

INTERMEDIARY BANK DETAILS: 


Intermediary Bank Name 


State / Country 

Bank Swift Code 

Tel Number 

City 


PAYMENT INFORMATION: 

Wire_____________________ (specify currency) 

Authorization (Signature and Date Required) 

_________________________ (Bank Accountholder) hereby authorizes International SOS and/or its dedicated Agents to make 

payments of any benefits payable to us by crediting the payments to my account at the bank or financial institution named above. I 

agree to notify in writing of any change relating to the information provided on this form or of a withdrawal of this authorization. 

I agree that if, for any reason unearned payments are deposited into my account, I will immediately repay the full amount of any 

such payments. I further agree that if I do not immediately repay such unearned payments, I will be liable for all costs of collection. 

These costs include reasonable attorney’s fees, incurred by International SOS and/or its dedicated Agents in the collection of such 

payments. 

In the case of any overpayment of benefits to my account, I agree that International SOS may debit my account for such 

overpayment, without further authorization from me. 

All bank charges incurred by our organization are our responsibility. 

Signature Title Date 

Organization Name 

Please email this form back to: Europe, Middle East & Africa providerseurasiaafrica@internationalsos.com 

Asia Pacific 




Puerto Rico 


106



SECTIoN 7 



Sample: EFT Form for Providers Who Use a Billing Agency 

Billing Agency - Electronic Funds Transfer (EFT) Claim Payment Request 

If you use the services of a billing agency to submit claims on your behalf for TOP beneficiary claims, please request that your billing 

agency completes and returns this form along with your Mutual Cooperation Protocol. 

BILLING AGENCY INFORMATION: 

TRICARE ID Number 

City 

Country 

Billing Agency Name 

State 


BANK DETAILS: 


Account Holder Name 


Country 

Bank Name 

Bank ID Code (Swift, FED, 

ABA, etc.) 

Bank Street Address 

Bank State/ Country 

Tel Number 


Full Bank Account 

Number (IBAN) 

Bank City 

Bank Zip / Postal 

Code 

INTERMEDIARY BANK DETAILS: 


Intermediary Bank Name 


State / Country 

Bank Swift Code 

Tel Number 

City 


PAYMENT INFORMATION: 

Wire_____________________ (specify currency) 

Authorization (Signature and Date Required) 

_________________________ (Bank Accountholder) hereby authorizes International SOS and/or its dedicated Agents to make 

payments of any benefits payable to us by crediting the payments to my account at the bank or financial institution named above. I 

agree to notify in writing of any change relating to the information provided on this form or of a withdrawal of this authorization. 

I agree that if, for any reason unearned payments are deposited into my account, I will immediately repay the full amount of any 

such payments. I further agree that if I do not immediately repay such unearned payments, I will be liable for all costs of collection. 

These costs include reasonable attorney’s fees, incurred by International SOS and/or its dedicated Agents in the collection of such 

payments. 

In the case of any overpayment of benefits to my account, I agree that International SOS may debit my account for such 

overpayment, without further authorization from me. 

All bank charges incurred by our organization are our responsibility. 

Signature Title Date 

Organization Name 

Please email this form back to: Europe, Middle East & Africa providerseurasiaafrica@internationalsos.com 

Asia Pacific 




Puerto Rico 


107



SECTIoN 8: 

List of Acronyms 

AAP 

ADFM 

ADSM 

CAC 

CDC 

CoNUS 

CPT 

DHA 

DMEPoS 

DoB 

DoD 

DRG 

ECHo 

EDI 

EFT 

EoB 

FY 

HPV 

ICD 

ICN 

MHS 

MRI 

oHI 

SSN 

TFL 

ToP 

TRR 

TRS 

TYA 

UCCI 

WPS 

American Academy of Pediatrics 

Active Duty Family Member 

Active Duty Service Member 

Common Access Card 

Centers for Disease Control 

Continental United States 

Current Procedural Terminology 

Defense Health Agency 

Durable Medical Equipment, Prosthetics, Orthontics and Supplies 

Date of Birth 

Department of Defense 

Diagnosis-related Group 

TRICARE Extended Health Care Option 

Electronic Data Interchange 

Electronic Fund Transfer 

Explanation of Benefits 

Fiscal Year 

Human Papillomavirus 

International Classification of Diseases 

Internal Control Number 

Military Health System 

Magnetic Resonance Imaging 

Other Health Insurance 

Social Security Number 

TRICARE for Life 

TRICARE Overseas Program 

TRICARE Retired Reserve 

TRICARE Reserve Select 

TRICARE Young Adult Program 

United Concordia Companies, Inc. 

Wisconsin Physicians Service 

108



Appendix 

ToP: Explanation of Benefits Denial Codes and Remarks 

Code Description Additional Information 

003 

See Item Five on Reverse. If you are not satisfied with our determination, you have 

the right to request a review within 90 days of the date of this notice. 

SECTIoN 8 / APPENDIX 

Acronyms 

004 Non-prescription drug – see Item Four on Reverse. 

008 Routine X-ray not covered – see Item Four on Reverse. 

009 Non-covered routine eye examination – see Item Four on Reverse. 

010 Routine lab not covered – see Item Four on Reverse. 

013 Eyeglasses/lenses not covered – see Item Four on Reverse. 

014 Routine foot care not covered – see Item Four on Reverse. 

018 Provider not TRICARE-authorized for this service. 

019 Personal comfort item not covered – see Item Four on Reverse. 

020 This charge included in a paid service. 

This is used when the Provider is 

billing for a procedure that is 

already accounted for in another 

procedure. For example, removal 

of cerumen (ear wax) is included in 

the office visit charge. 

027 Authorized service limits exceeded – see Item Four on Reverse. 

028 Requested Information Not Received. 

030 Service Filed After Time Limit. 

032 Non-covered Services. 

033 Duplicate of Services Previously Claimed (Manual). 

Services billed are not a covered 

service according to TRICARE 

Policy. 

Upon manual review, it was 

determined this charge is a 

duplicate and has been paid 

previously on another line/claim. 

109



ToP: Explanation of Benefits Denial Codes and Remarks (continued) 


044 Duplicate of services previously claimed (system). 

045 Applied to deductible – see Item Six on Reverse. 

049 Authorization not on file. Contact your HBA. 

050 Insufficient Diagnosis – see Item Four on Reverse. 

056 Chiropractic services not covered. 

059 Obesity not a covered diagnosis – see Item Four on Reverse. 

067 Medical need not documented. 

070 Patient not eligible. Per DEERS, patient is not eligible. 

072 

Claim requires drug name, strength and quantity. See Item Two on Reverse for 

time limit to send requested information. 

074 Sponsor not on DEERS. 

075 Patient not on DEERS. 

077 Dependent patient not on DEERS. 

080 ID card or eligibility expired on DEERS. 

083 Insufficient information received. 

126 Level of care billed not substantiated. 

Information requested (such as 

medical records) were insufficient 

to support the care/request. 

Upon review, it was determined 

that the charges billed were for 

more services than what was 

actually provided. For example, 

Provider is billing for a new patient 

office visit when we have already 

paid a new patient office visit for 

the same Provider. So, the Provider 

should have been billing as an 

established patient office visit. 

110



ToP: Explanation of Benefits Denial Codes and Remarks (continued) 


132 Services must be billed by Provider of care. 

Claim is being submitted by 

another Provider on behalf of the 

Provider that rendered care. For 

example, St. Mary’s submits the 

claim for Meriter. 

135 Provider is not TRICARE-authorized. 

136 Services denied because we cannot determine primary insurance payment. 

Need Explanation of Benefits from 

Other Health Insurance. 

APPENDIX 

160 Procedure code submitted not payable for this service/beneficiary. 

173 Documentation does not support the frequency of visits billed. 

219 

236 

Diagnosis code is missing or invalid. Your claim will be reconsidered upon timely 

receipt of information. 

Your claim was denied because we did not receive the EOBs from all your primary 

insurances. 

There is more than one active 

health insurance on file. Need 

EOBs from ALL active Other Health 

Insurances. 

308 Authorization not attached. Contact local command personnel or nearest MTF. 

Services required an authorization 

and there is not one on file. 

327 Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC). 

111

R 

International SOS Assistance, Inc. 

www.tricare-overseas.com 

Worldwide reach Human touch

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