TRICARE Manuals - Display Chap 16 Sect 1 (Change 1, Apr 5, 2024) (2024)

1.0INTRODUCTION

The TPR program provides healthcare to Active Duty Service Members (ADSMs), including Reserve Component (RC)members activated for more than 30 calendar days who meet the eligibilitycriteria specified in 32 CFR 199.16(e)(2) and are enrolled in theprogram. This chapter applies to operations of the TPR program inremote locations of the United States (US) and the District of Columbiawhile Chapter 24, Section 18 applies to operations ofthe TPR program outside of the US.

2.0ELIGIBILITY

2.1The contractorhas no responsibility for determining eligibility or for decidingin which geographic area of responsibility an ADSM will enroll.

2.2The GovernmentDesignated Authority (GDA) will furnish contractors with enrollmentinformation (refer to paragraph 3.0).

Note:ADSM Astronauts assigned tothe Johnson Space Center in Houston, Texas shall be enrolled inTPR.

3.0TPR PROGRAM UNITS

3.1The GDAwill supply the contractor with an electronic directory, updatedas needed, that lists, by geographical area of responsibility, thedesignated TPR ZIP codes for the contractor’s geographical areaof responsibility.

3.2The GDA will provide unit listingsto the contractor so the contractor can mail or email educational materialsto the units. In some instances, individual member listings (asopposed to units) may be provided.

4.0BENEFITS

4.1ADSMsenrolled in the TPR Program shall receive the benefits of TRICAREPrime, even in areas without contractor networks. Some covered benefits(see Section 2, paragraph 5.3) require review bySpecified Authorization Staff (SAS) (identified in Addendum A, paragraph 1.0) so they may identifyfitness-for-duty issues.

4.3The contractorshall deny claims from sanctioned or suspended providers (see Chapter 13, Section 5).

4.4SAS donot have the authority to overturn DHA or Department of Health andHuman Services (DHHS) provider exclusions. See Section 2 forreferral and authorization requirements.

4.5The contractormay, for services that would not have ordinarily been covered underTRICARE policy (including limitations and exclusions), authorizeservices for ADSMs only in accordance with the terms of a waiver approvedby the GDA, at the request of an authorized official of the UniformedService concerned. (Reference Health Affairs (HA) Policy 12-002“Use of Supplemental Health Care Program Funds for Non-Covered TRICARE HealthCare Services and the Waiver Process for Active Duty Service Members”).

4.6The contractorshall process claims for care provided to a ADSM who is not enrolledin TPR or who is not enrolled in TRICARE Prime at a Market/MilitaryMedical Treatment Facility (MTF) according to the applicable guidelinesof the Supplemental Health Care Program (SHCP) (Chapter17).

4.7The contractor shall implementappropriate measures to recognize SAS authorization in order to expediteclaims processing.

4.8SAS authorization shall bedeemed to constitute referral, authorization, and direction to bypassedits as appropriate to ensure payment of SAS-approved claims.

5.0SAS

5.1CertainUniformed Service controls and rules apply to ADSMs due to uniquemilitary readiness requirements. SAS (identified in Addendum A, paragraph 1.0) serves as liaisonamong the ADSM, the ADSM’s Uniformed Service, and the contractorfor managing the ADSM’s health care services.

5.2The contractorshall communicate, coordinate and collaborate with the SAS and theprimary care manager (PCM), if assigned, for the ADSM’s requiredexaminations.

5.3The SAS reviews referrals forproposed care as well as information about care already receivedin order to determine impact on an individual’s fitness-for-duty(see Section 2 and TRICARE Systems Manual (TSM), Chapter 1, Section 1.1, paragraph 11.0 forreferral, review and authorization procedures).

5.4The SASwill provide the protocol, procedures, and required documentationthrough the contractor to the provider for these examinations.

5.5For requiredcare that may not be obtainable in the civilian community, the SASwill refer the ADSM to a Market/MTF. Refer to Addendum A forthe addresses and telephone numbers of the SAS.

6.0APPEALPROCESS

6.1The contractor shall furnishthe enrollee with clear guidance for requesting a reconsiderationor filing an appeal with the SAS (see paragraph 6.4) on the Explanationof Benefits (EOB) or other appropriate document, if, at the directionof the SAS, the contractor denies authorization of care, or authorizationfor reimbursem*nt for a TPR enrollee’s health care services.

6.2The SASwill handle only those issues that involve SAS denials of authorizationor authorization for reimbursem*nt.

6.3The contractorshall process allowable charge issues, grievances, and other complaintsfrom beneficiaries.

6.4If theTPR enrollee disagrees with a denial rendered by the SAS, the firstlevel of appeal will be through the SAS who will coordinate theappeal as appropriate.

6.5The enrollee may initiate theappeal by contacting his or her SAS. If the SAS upholds the denial,the SAS will notify the enrollee of further appeal rights in accordancewith applicable regulations.

6.6If thedenial is overturned at any level, the SAS will notify the contractorand the ADSM.

6.7The contractor shall forwardall written inquiries and correspondence related to SAS denialsof authorization, or authorization for reimbursem*nt to the appropriateSAS within three business days of receipt.

6.8The contractorshall refer telephonic inquiries related to SAS denials to the appropriateSAS upon receipt of the inquiry.

7.0ACTIVEDUTY FAMILY MEMBERS (ADFMs) AND OTHERS

7.1TRICARE-eligiblefamily members accompanying ADSMs who are either eligible for orenrolled in the TPR program may enroll in the TRICARE Prime RemoteADFM (TPRADFM) program in accordance with Section 6.

7.2Enrollmentjurisdiction for the ADFMs may be based on the enrollment jurisdictionof the TPR enrolled ADSM per paragraph 8.7. This includes cross-geographicarea of responsibility enrollment (see Chapter 6, Section 1).

8.0TPRPROGRAM DIFFERENCES

In additionto the SHCP differences specified in Chapter 17, Section 1,the following differences apply to the TPR program:

8.1The contractorshall enroll a TPR-designated ADSM without a PCM assigned wherethe contractor has not established a network of PCMs in a remotearea.

8.2The ADSM without an assignedPCM will be able to use a local TRICARE-authorized provider forprimary health care services without review.

8.3The contractorshall process claims for TPR-enrolled ADSMs regardless if they havereceived a referral or authorization, provided the claim or caremeets all other TRICARE requirements (e.g., the care is medically necessary,a covered benefit of TRICARE an approved waiver is provided).

8.4AnnualADSM member re-enrollment is not required.

8.5If theUniformed Services determine that an ADSM is eligible for the TPRprogram, enrollment of the member is mandatory, unless there areService-specific issues that merit assignment to a military PCM,or if the ADSM elects to waive access standards and enrolls to aMarket/MTF (subject to Director approval).

8.6If ThirdParty Liability (TPL) is involved in a claim, ADSM claim paymentwill not be delayed during the development of TPL information fromthe ADSM.

8.7Enrollmentjurisdiction may be based on the location of the military work unitinstead of the ADSM’s residence. This is determined by the Services.