TRICARE Overseas Program Provider Manual

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TRICARE overseas Program Provider Manual 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.
TRICARE overseas Program Provider Manual 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 ■ TOP Prime Remote ■ TRICARE Active Duty Dental Program (ADDP) 1 ■ TOP Prime ■ TOP Prime Remote ■ 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 TRICARE overseas Program 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.
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TRICARE Overseas Program Provider Manual

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