TRICARE Manuals - Display Chap 24 Sect 12 (Change 3, Apr 26, 2024) (2024)

1.0General

The TOP POC Program is a liaisonservice that assists remote site beneficiaries by facilitating timelyTRICARE claims filing and payment. As needed, the TOP POC Programshall assist the Services with coordinating the return travel forService members and TRICARE Prime enrolled Active Duty Family Members(ADFMs) after a medical evacuation.

2.0POC Designation

2.1DesignatedTOP POCs are established by the Uniformed Services, the DefenseIntelligence Agency (DIA), the Defense Security Assistance Agency(DSAA), or other organizations as established by the Government,with final approval by the TRICARE Area Office (TAO) Directors.

2.2Requests for POC designationshall be submitted in writing by the Commanding Officer of a military organizationalunit or location, Defense Attache Offices (DAOs), and Security AssistantOrganizations (SAOs) to the appropriate TAO Director. Requests forPOC designation shall include the POC’s name, anticipated date oftransfer/reassignment from the unit or location 24-hour commercialfax number, 24-hour commercial phone number, email address, anda valid and secure mailing address for pouch mail. The request shallindicate whether the individual is being designated as the primaryPOC or alternate POC (if any), along with the names of other POCsin the organization. The request should also indicate whether thePOC will be replacing a previously designated POC who is scheduledfor reassignment or transfer. POC designation is generally limitedto one primary POC and one or two alternate POCs per organization.If more than two alternate POCs are desired, the organization mustsubmit additional justification with the request.

2.3Upon receiptof a written request for POC designation, the TAO Director willreview the nomination for approval. After approval has been granted,the TAO Director will notify the TOP contractor of the POC designation. Thisnotification must be in writing and may be sent electronically orfaxed to the contractor, with a copy to the POC’s organization,the Defense Health Agency (DHA) Contracting Officer Representative(COR), and the DHA technical expert for overseas claims.

2.4POC designationsare not Uniformed Service-specific, nor is designation limited toa specific beneficiary category (e.g., Service member) or a specificTRICARE benefit category (e.g., medical, pharmacy, maternity).

2.5POC organizationsshall provide updated POC information to TAO Directors and the TOPcontractor as needed. Information updates for designated primary/alternatePOCs must be provided in a timely manner to avoid possible delaysin claims processing. Updates to POC’s commercial fax/phone numbers,email address, and mailing address shall be emailed directly tothe appropriate TAO Director as soon as the change occurs.

2.6Primaryand alternate POCs are responsible for notifying the appropriateTAO Director in writing of any pending reassignments or transfers.This written notification should indicate the POC’s projected dateof departure, the names of any remaining POCs in the organization,and whether a new POC will be designated as a replacement. If anew POC will be designated, the POC’s organization should requestdesignation as outlined in paragraph 2.2.

3.0GOVERNMENTRESPONSIBILITIES

3.1POCs shall assist TRICARE beneficiaries(including Service members) with the timely completion and filingof TOP claim forms. POCs shall secure and safeguard Protected HealthInformation (PHI), Personally Identifiable Information, and SensitiveInformation for TRICARE beneficiaries in accordance with Departmentof Defense (DoD) 5400.11-R, “Department of Defense Privacy Program”,May 14, 2007 and DoD Instruction 8500.2, “Information AssuranceImplementation”, February 6, 2003 and DoD Instruction (DoDI) 6025.18,“Privacy of Individually Identifiable Health Information in DoDPrograms,” December 2, 2009.

3.2POCs arenot authorized to sign as a claimant for any beneficiary’s claimother than the POC’s personal claim.

3.3As needed,the POCs shall assist Service members and Prime enrolled ADFMs withcoordinating their return travel after a medical evacuation andhospital discharge with the Service member or ADFM service representative.This shall include making the necessary phone calls and sendingemails to assist with the return travel. The POCs will assist tothe extent possible using the existing personnel. The Services’commands are still responsible for arranging and funding the returntravel.

3.4Each TAO shall develop anddistribute a region-specific POC Program booklet outlining specificPOC duties and responsibilities. Each TAO shall also develop andimplement region-specific POC training. POC booklets and trainingmaterials shall include instructions regarding the security requirementsidentified in paragraph 3.1 and other relevant securityinstructions. POCs shall use the current version of their region’sPOC booklet (and any additional training materials and sessions)as a guide in the performance of their POC duties.

3.5Questionsregarding specific POC duties and responsibilities shall be addressedto the appropriate TAO for resolution.

4.0TOPCONTRACTOR RESPONSIBILITIES

The TOP contractor shall:

4.1Maintaina current listing of POCs, in coordination with the TAOs.

4.2AssistDHA staff, TAO staff, POCs, Uniformed Services, TRICARE beneficiaries,and private sector care providers with information on the completionand filing of TRICARE claims.

4.3Providea dedicated P.O. Box, fax number, and email address for the receiptof TOP claims and correspondence from all designated POCs. The faxnumber must be able to receive data 24 hours a day, seven days aweek (24/7).

4.4Develop procedures for thecoordination, control, tracking, and processing of health care claimsthat are submitted by POCs in accordance with established standardsfor the PHI/Personally Identifiable Information (PII). This includes,but is not limited to, microcopying/imaging of claims upon receipt,storage/maintenance of the claim and all related correspondence,verification of beneficiary eligibility for TRICARE benefits, developmentof claims for missing information, processing of claims, and issuanceof foreign drafts/US dollar checks/Explanation of Benefits (EOB).

4.5Contactthe appropriate POC (via phone, fax or email) when additional informationis needed to process a claim submitted by that POC. The TOP contractorshall pend the claim for 14 calendar days following POC notification.If the requested information is not received by the contractor bythe Close Of Business (COB) on the 14th calendar day following POCnotification, the contractor shall deny the claim.

4.6Acceptonly faxed claims/inquiries/information faxed by an officially designatedprimary or alternate POC. Electronic mail may also be used for TOPinquiries/information, subject to all applicable privacy rules.

4.7ReportPOC inquiries (including fax, email, and letters) as routine correspondenceas outlined in Chapter 1, Section 3.

4.8Pay allbeneficiary-submitted claims for TRICARE covered drugs dispensedby a US embassy health clinic to the beneficiary. The contractorshall not make payments directly to an embassy health clinic.

4.9Use prioritypouch mail to mail foreign drafts/US dollar checks/EOBs for claimssubmitted via POCs. Priority pouch mail must be sent to the appropriatePOC’s location, unless a single point of dispersal for all paymentshas been established for that country. In those locations wherea single point of dispersal has been established for all paymentsfor that country, the TOP contractor shall batch payments/EOBs bycountry and mail the payments/EOBs in pouches to the designatedpoint of dispersal at least once every five business days. Paymentsand EOBs that are placed in pouch mail shall be placed in sealedseparate envelopes by individual beneficiary/private sector careprovider for POC distribution. Pouch mail shall normally be sentvia overnight mail delivery; however, if overnight mail serviceis not available or is not timely in a foreign location, the contractorshall use the most expeditious means available.

4.10Reportunresolved claims problems or issues between the POC and the contractorto the TAO Director and the DHA COR.

4.11Followthe inquiry process outlined in this section for POC requests forclaims status update and for POC requests for changes to mail, faxnumbers, etc.

4.12Upon receipt of a POC inquiryand once the inquiry is completed, fax the response back to theperson identified as the POC. The TOP contractor shall follow thefaxed POC inquiry with a phone call, if necessary.

Note:POCs also assist TRICARE DentalProgram (TDP) beneficiaries with the submission of dental claims.POC responsibilities for TDP claims are described in the POC Programbooklet. The TOP contractor is not responsible for processing dentalclaims, except for adjunctive dental services as identified in theTRICARE Policy Manual (TPM), Chapter 8, Section 13.1 and remote Servicemember claims in accordance with Section 10.POC-submitted TDP claims that are misdirected to the TOP contractorshall be returned to the appropriate POC.

Note:Professional services renderedby a US embassy health clinic are not covered by TRICARE/TOP. Those servicesare covered under International Cooperative Administrative SupportServices (ICASS) agreements. Embassy providers (acting as PrimaryCare Managers (PCMs)) may refer TOP enrollees to private sectorcare providers; these claims shall be processed per TOP policy andprocedures.