TRICARE Overseas Program Provider Manual

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
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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