TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Overseas Program (TOP)
Chapter 24
Section 25
TRICAREOverseas Program (TOP) Supplemental Health Care Program (SHCP)
Revision:C-109, May 24, 2022
1.0general
1.1All TRICARErequirements regarding the SHCP shall apply to the TRICARE OverseasProgram (TOP) unless specifically changed, waived, or supersededby this section, TRICARE Policy Manual (TPM), Chapter12, or the TRICARE contract for health care support servicesoutside the 50 United States (U.S.) and the District of Columbia(hereinafter referred to as the “TOP Contract”). See Chapter17 for additional instructions.
1.2UniformedService members in an active duty status of greater than 30 days(also known as Service members) who are on permanent or officialduty assignment in a location outside the 50 U.S. and the Districtof Columbia must enroll in TRICARE Overseas Program (TOP) Primeor TOP Prime Remote. Service members in a temporary duty statusand enrolled elsewhere should not transfer their enrollment to TOPPrime or TOP Prime Remote unless it is medically appropriate andwill not cause enrollment eligibility disruption to family members’enrollment status. Service members are not CHAMPUS-eligible anddo not have the option to use TOP Select or the Point of Service(POS) option under TOP Prime or TOP Prime Remote. Uniformed Servicemembers who would normally receive care from a purchased care sectorprovider may be directed to transfer their care to a Military Treatment Facility(MTF). This applies to Service members and Uniformed Service membersnot in active duty status (Reserve Component (RC) members underLine of Duty (LOD) care). These controls ensure the maintenanceof required fitness-for-duty oversight for TOP Uniformed Servicemembers. Refer to Section 9 for claims processing instructions.
2.0Contractor Responsibilities
2.1Service members who are enrolledin TOP Prime shall follow the procedures outlined in Chapter17 for MTF-enrolled Service members, except that any referencesto the Defense Health Agency-Great Lakes (DHA-GL) should be replacedby a reference to the appropriate regional TRICARE Area Office (TAO)in all overseas locations except the U.S. Virgin Islands concerningLine of Duty Determinations and except for care delivered underthe National Department of Defense (DoD)/Department of VeteransAffairs (VA) Memorandum of Agreement (MOA) authorization requirements. See paragraph 2.3.3 forNational DoD/VA MOA authorization requirements. Service memberswho are enrolled in TOP Prime Remote must seek authorization fromthe TOP contractor for all non-emergent specialty and inpatientcare. Service members not enrolled in TOP who are on Temporary Additional Duty/TemporaryDuty (TAD/TDY), deployed, deployed on liberty, or in an authorizedleave status outside the 50 U.S. and the District of Columbia shallfollow referral/authorization guidelines for TOP Prime Remote enrollees.
2.2The TOP contractor shall ensurea benefit review is done on each SHCP referral and authorization.The TOP contractor shall return deferred-to-network referrals fornon-covered services with an explanation of why it was denied. TheTOP contractor shall not issue an authorization unless they obtaina copy of an approved waiver. The contractor shall deny all claimsfor TRICARE non-covered health care services. (Reference HealthAffairs (HA) Policy 12-002 “Use of Supplemental Health Care ProgramFunds for Non-Covered TRICARE Health Care Services and the WaiverProcess for Active Duty Service Members”).
2.2.1If the contractor determinesthat the requested service, supply, or equipment is not coveredby TRICARE policy and no Defense Health Agency (DHA)-approved waiveris provided, the contractor shall decline to file an authorizationand shall deny any received claims accordingly. If the request wasreceived as an MTF referral, the contractor shall notify the MTF(and enrolled MTF if different from the submitting MTF) of the declinedauthorization with explanation of the reason. If the request wasreceived as a referral from a civilian provider (for a remote Servicemember/non-enrolled Service member), the contractor shall notifythe civilian provider and the remote Service member/non-enrolledService member of the declined authorization with explanation ofthe reason. The notification to a civilian provider and the remoteService member/non-enrolled Service member shall explain the waiverprocess and provide contact information for the applicable UniformedServices Headquarters Point of Contact (POC)/Service Project Officersas listed in Chapter 17, Addendum A, paragraph 2.0. No notificationto the Specified Authorization Staff (SAS) is required.
2.2.2TRICARE benefits may not beextended for complications resulting from non-covered surgeriesand treatments performed outside the MTF for a Service member withoutan approved waiver. If the treatment is a non-covered TRICARE benefit,any follow-on care, including care for complications, will not becovered by TRICARE once the Service member separates from activeduty or retires (32 CFR 199.4(e)(9); TPM, Chapter 4, Sections 1.1 and 1.2). The Services will provide appropriate counselingthat such follow-on care is the member’s personal financial responsibilityupon separation or retirement.
2.3The provisions of Chapter17 are changed for the TOP as follows:
2.3.1The provisions of Chapter 17, Section 2, paragraph 2.0 (UniformedServices Family Health Plan (USFHP)) are not applicable to the TOPcontract. USFHP services are not available outside the 50 U.S. andthe District of Columbia.
2.3.2Except for the claims for Servicemember care provided under the National DoD/VA MOA, the provisionsof Chapter 17, Section 3, paragraph 1.2.1 areapplicable for TOP. Service member claims for covered benefits submittedto the TOP contractor for which an authorization is not on fileare to be processed and paid as if an authorization is on file.Claims for non-covered services shall be denied. The TOP contractorshall provide the MTF with a report (in accordance with the CDRL),for all claims processed and paid with no authorization and alldenied claims for non-covered services.
2.3.3Theprovisions of Chapter 17, Section 2, paragraph 3.1 regardingclaims for care provided under the National DoD/VA MOA for SpinalCord Injury (SCI), Traumatic Brain Injury (TBI), Blind Rehabilitation,and Polytrauma are applicable to the TOP and shall be processedin accordance with Chapter 17, Section 2, paragraph 3.1.3. Suchcare will be authorized by the DHA-GL for Service members underthis MOA.
2.3.4Theprovisions of Section 6, paragraph 5.0 and Chapter 8, Section 5 apply to TOP SHCP referrals.Additionally, when MTFs submit a referral request for purchasedcare services for a non-AD sub-population beneficiary eligible forSHCP, the MTF shall utilize the required data elements identified in Chapter 8, Section 5, paragraph 6.1 and shallannotate the referral with “SHCP” in line item 12, “Review Comment”.This will ensure that SHCP claims for eligible non-AD sub-populationbeneficiaries are properly adjudicated.
Note:Circ*mstances where supplementalfunds may be used to reimburse for care rendered by non-Governmentalhealth care providers to non-active duty patients are limited tothose where a MTF provider orders the needed health care servicesfrom civilian sources for a patient, and the MTF provider maintainsfull clinical responsibility for the episode of care. This meansthat the patient is not disengaged from the MTF that is providingthe care. See Chapter 17, Section 1.
2.4When a Service member leavesa remote TOP assignment as a result of Permanent Change of Station(PCS) or other service-related change of duty status, the followingapplies in support of medical record accumulation:
2.4.1For Service members leavingremote TOP assignment in Puerto Rico, the PCM shall provide a completecopy of medical records, to include copies of specialty and ancillarycare documentation, to Service members within 30 calendar days ofthe Service member’s request for the records. The Service membermay also request copies of medical care documentation (specialtycare visits and discharge summaries) on an ongoing, Episode of Care(EOC) basis.
2.4.2For Servicemembers leaving remote TOP assignments from all overseas areas otherthan Puerto Rico, Service members in those locations should requestmedical records from the purchased care sector provider(s) who providedhealth care services during the Service member’s tour of duty. TheseService members may also request copies of medical care documentation(specialty care visits and discharge summaries) on an ongoing, EOCbasis.
2.4.3Recordsprovided by purchased care sector providers in languages other thanEnglish may be submitted to the TOP contractor for translation intoEnglish according to the terms of the contract.
2.4.4Network purchased care sectorproviders shall be reimbursed for medical records photocopying andpostage costs incurred at the rates established in their networkprovider participation agreements. Non-network purchased care sectorproviders shall be reimbursed for medical records photocopying andpostage costs on the basis of billed charges unless the Government hasdirected a lower reimbursem*nt rate. Service members who have paidfor copied records and applicable postage costs shall be reimbursedfor the full amount paid to ensure they have no out-of-pocket expenses.All providers and/or Service members must submit a claim form, withthe charges clearly identified, to the contractor for reimbursem*nt.
Note:The purpose of copying medicalrecords is to assist the Service member in maintaining accurateand current medical documentation. The contractor shall not makepayment to a purchased care sector provider who photocopies medicalrecords to support the adjudication of a claim.
2.4.5The provisions of Chapter 17, Section 3, paragraph 1.1.8 arenot applicable to the TOP. SHCP funds may not be used to pay foroverseas purchased sector care for foreign military members or their families.The TOP contractor shall deny any MTF referrals and claims for suchcare.
2.5Provisionof Respite Care For The Benefit of Seriously Ill or Injured ActiveDuty Members
2.5.1The provisionsof Chapter 17, Section 3 and the TRICARE SystemsManual (TSM), Chapter 2, Sections 2.8 and 6.4 regarding respite care for seriously illor injured Service members are applicable in locations outside the50 U.S. and the District of Columbia where TRICARE-authorized HomeHealth Agencies (HHAs) have been established.
2.5.2The respite care benefit isapplicable to Service members enrolled to TOP Prime, TOP Prime Remote,and to any Service member referred by an overseas MTF or TAO.
2.5.3All normal Service member authorizationand case management requirements for the TOP apply to the Servicemember respite care benefit.
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