TRICARE Overseas Program Provider Manual

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TRICARE overseas Program Provider Manual 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 TOP Prime Remote beneficiaries. 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? ToP Prime and ToP Prime Remote 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
TRICARE overseas Program Provider Manual 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
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