TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Overseas Program (TOP)
Chapter 24
Section 17
TRICAREOverseas Program (TOP) Prime Program
Revision:
1.0General
1.1TOP Primeis available to Service members (including Reserve Component (RC)members activated for more than 30 calendar days) who are on permanentassignment overseas in a location serviced by a Military MedicalTreatment Facility (MTF), Command-Sponsored Active Duty Family Members(ADFMs), accompanying the sponsor or on service orders, and certaintransitional survivors and Transitional Assistance Management Program (TAMP)-eligiblebeneficiaries according to the eligibility and enrollment provisionsof Section 5. TOP Prime offers enrollees accessto a Primary Care Manager (PCM), clinical preventative services,and specialty services.
Note:Command Sponsorship is definedin the Joint Travel Regulations (JTR), Appendix A at https://www.defensetravel.dod.mil/Docs/perdiem/JTR.pdf.
1.2TOP Prime has no enrollmentfees, and deductibles. Cost-shares are waived except for TOP PrimeADFMs who receive care under the Point of Service (POS) option,or who obtain pharmacy services in the 50 United States (US), theDistrict of Columbia, or US territories where the TRICARE Pharmacy(TPharm) contractor has established a retail pharmacy network. Waiverof copayment and deductibles under TOP Prime is subject to review/updating basedon enrollment status.
1.3Under TOP Prime, annual catastrophiccaps are calculated on calendar years. The enrollment year shall coincidewith the calendar year. Since deductibles and cost-shares are waivedfor TOP Prime enrollees, this policy will apply only to TOP Primeenrollees who incur out-of-pocket expenses.
2.0CONTRACTOR RESPONSIBILITIES
2.1TOP Prime enrollees shall selector have assigned to them PCMs according to guidelines establishedby the MTF Commander, TRICARE Area Office (TAO) Director, or designee.TOP Prime enrollment to a private sector care PCM may only occurwhen all available capacity in the MTF has been reached. The TOPPCM:
2.1.1May be an individual professionalprovider in an overseas MTF, other military treatment site, or other healthcare delivery arrangement that is part of the MTF. MTF PCMs maybe organized into teams for the purpose of ensuring patient continuityand accountability in the event that the individual’s assigned PCMis absent or unavailable.
2.1.2May bea private sector care primary care provider (internist, family practitioner,pediatrician, General Practitioner (GP), Obstetrician/Gynecologist(OB/GYN), Physician Assistant (PA), Nurse Practitioner (NP), orCertified Nurse Midwife (CNM) when determined by the TOP contractorto meet governing country rules and licensure requirements. See Section31 for additional provider certification requirementsin the Philippines.
2.1.3May also act as a Health CareFinder (HCF), when dual responsibility is necessary, as determinedby the MTF Commander or TAO Director.
2.2A TOPPrime enrollee must seek all his or her primary health care fromthe TOP PCM with the exception of care listed in Section 8. Ifthe TOP PCM is unable to provide the care, the TOP PCM is responsiblefor referring the enrollee to another primary care provider.
2.3TOP Primeenrollees must obtain appropriate referral/authorization for anynon-emergency care rendered by anyone other than the beneficiary’sPCM or another MTF provider. This provision applies regardless of wherethe care is rendered. MTFs may submit requests for retroactive authorizationsup to three business days after the care was rendered. After threebusiness days, the TAO Directors and/or Chief, TOP Office (TOPO)may direct retroactive authorizations on a case-by-case basis. Routinecare is generally not authorized while a TOP Prime enrollee is travelingout of their enrollment region; however, exceptions may be madefor unusual circ*mstances on a case-by-case basis with PCM referraland appropriate written justification from the referring MTF. Emergent/urgentcare does not require prior authorization; however, the beneficiaryshould contact their PCM and the TOP contractor as soon as possibleto arrange any necessary follow-up care.
2.4Failureto obtain a TOP PCM referral/authorization when one is requiredfor care may result in the service being paid under TOP Point ofService (POS) procedures for an ADFM with a deductible and cost-sharesfor outpatient services and cost-shares for inpatient services.
2.5The TOPPCM is responsible for notifying the TOP HCF that a referral isbeing made/requested. The TOP HCF will assist the TOP Prime enrolleeand other beneficiaries in locating an MTF or private sector careTOP network or non-network provider to provide the care, and toassist in scheduling an appointment upon request. The HCF will conducta benefit determination review and provide authorization for servicefor which the referral was made. If the contractor has no recordof referral/authorization, prior to denial/payment, the contractorshall follow the TOP POS rules, assuming the service is a coveredbenefit.
2.6TOP MTF PCMs may be delegatedauthority by the TOP MTF Commander to authorize referrals withinthe MTF. All referrals/authorizations to civilian private sectorcare providers and all referrals/authorization made by a TOP designatedprivate sector care PCM must be made through the TOP HCF and mustreceive an authorization.
2.7The TOP contractor shall ensurethat all authorized services for TOP Prime enrollees are providedon a cashless, claimless basis. The contractor shall implement guaranteeof payment or other business arrangements to ensure that TOP Primeenrollees are not required to pay up front at the time servicesare rendered by a private sector care provider.
2.8Cashless,claimless provisions do not apply to self-referred care that wouldnormally require authorization.
2.9In accordancewith the Statement of Responsibilities (SOR), MTFs will determineif they have the capability and capacity to provide needed specialtyinpatient care. Submission of an MTF referral shall signify that thereferring MTF has determined that the care cannot be provided bythe direct care system within the TRICARE access standards. In PuertoRico, the local MTF must have the opportunity to review each referralfrom a private sector care PCM to determine if the MTF has the capabilityand capacity to provide the care. Specific language regarding thisprocess shall be incorporated into each SOR with all MTFs with PuertoRico.
2.10For TOP Prime enrollees whoare traveling in the 50 US or the District of Columbia, the TOPcontractor and the TAO Directors will encourage/direct TOP beneficiariesto utilize stateside MTFs and TRICARE network providers wheneverpossible. If MTF care is unavailable, beneficiaries shall be providedwith information regarding the nearest available network provider(s)who can assist the beneficiary. Non-network providers should onlybe used when MTF or network care is not available.
2.11ADFMsenrolled in TOP Prime may obtain urgent care from any authorizedprovider without a PCM (if assigned) referral or overseas contractorauthorization. In order to ensure the urgent care visit will becashless/claimless, the ADFMs enrolled to TOP Prime should contactthe TOP contractor to obtain an authorization. Without this authorization,overseas providers may request payment upfront (overseas providersmay bill above the TRICARE allowable amount without any limits)and the beneficiary will then have to submit a claim for reimbursem*nt.
3.0POSOPTION
3.1TOP Prime-enrolled ADFMs arerequired to follow established referral/authorization proceduresprior to obtaining specialty care to avoid the application of POScost-shares and deductibles. This includes all self-referred, non-emergencyoutpatient specialty medical services and all inpatient care (includinginpatient mental health care), except for outpatient mental healthand Substance Use Disorder (SUD) visits, ancillary services, anddrugs. TOP Prime ADFMs who self-refer to a civilian provider otherthan their PCM shall have their claims processed as POS.
3.2POS cost-sharesand deductibles shall not apply to claims for care received by newborns/adoptees duringthe deemed enrollment period.
3.3Self-referred,non-emergency, non-urgent, specialty, or inpatient care providedto a TOP Prime enrollee by a network or non-network private sectorcare provider, which is not either provided/referred by the beneficiary’s PCMor specifically authorized may be reimbursed only under the TOPPrime POS option if it is a TRICARE benefit. Services which arenot a TRICARE benefit shall be denied.
3.4POS cost-sharingand deductible amounts do not apply if a TOP Prime enrollee hasOther Health Insurance (OHI) that provides primary coverage. TheOHI must be primary under the provisions of the TRICARE Reimbursem*ntManual (TRM), Chapter 4, Section 1, and documentation thatthe other insurance processed the claim and the exact amount paidmust be submitted with the TOP claim.TRICARE OHI provisions applyfor this type of claim.
3.5The POS option does not applyto Service member overseas/stateside care.
3.6The TOPcontractor shall adjust TOP Prime copayments when TOP PCMs or HCFsdo not follow established referral/authorization procedures. Forexample, if the contractor processes a claim without evidence of anauthorization and/or a referral under POS provisions, and the contractorlater verifies that the PCM or other appropriate provider referredthe beneficiary for the care, the contractor shall adjust the claimunder TOP Prime provisions. The contractor need not identify pastclaims, however, the contractor shall adjust these claims as they arebrought to their attention.
3.7On a case-by-casebasis, following stabilization of the patient, the MTF Commandermay require a TOP Prime beneficiary to transfer to the MTF. TheMTF Commander shall provide written notice to the beneficiary (or responsibleparty) advising them of the impending transfer to a TOP networkfacility/MTF. If a TOP Prime-enrolled ADFM elects to remain in anon-network facility following notification of an impending transferto another facility, TOP POS cost-sharing will begin 24 hours followingreceipt of the written notice. The MTF Commander may not requirea transfer until such time as the transfer is deemed medically safe.
3.8See theTRM, Chapter 2, Section 5 for the deductible andcost-share amounts which apply to all TOP Prime POS claims for healthcare services.
3.9POS deductible and cost-sharingdo not apply to the claims for care received by certain newbornand newly adopted children during the deemed enrollment period.See Section 5 for additional guidance regarding deemedenrollment for newborns/adoptees.
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