TRICARE Overseas Program Provider Manual

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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: 12
TRICARE overseas Program Provider Manual 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 TRICARE overseas Program 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. ToP Prime and ToP Prime Remote 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.
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