TRICARE Overseas Program Provider Manual

TRICARE overseas Program
Provider Manual
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:
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