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Preferred Provider Charge Station Installation Agreement

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					TRICARE Overseas Course
2) TOP



                                 TRICARE Overseas Course


                          TRICARE Overseas Program




                                            2
                                      Participant Guide




References
10 U.S.C.
32 CFR § 199.20
National Defense Authorization Act (NDAA)
TRICARE Policy Manual, Chapter 12
TRICARE Operations Manual
TRICARE Reimbursement Manual




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2) TOP




Participant Guide         March 2009   2
TRICARE Overseas Course
2) TOP




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                5.                  6.                            7.                  8.


                                  MAN                     SSSSSSSSSSE          $0 all all all all
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     Describe the TRICARE Overseas Program (TOP)
     Define overseas provider types
     Identify TOP options
     Describe provisions of the TOP options
     Locate TOP resources




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1.0 What is the TRICARE Overseas Program (TOP)?
        The TRICARE Overseas Program (TOP) is the Department of Defense’s (DoD’s) overseas
         managed health care program
        The TOP blends many TRICARE Program features while also allowing for the significant
         cultural differences unique to foreign countries and their health practices
           o Cultural differences may apply to things like, the location of care (provider comes to a
             patient’s home), or the way in which the care is provided, i.e., things commonly done
             by a provider class stateside may be performed by a physician assistant or physician
             overseas depending on the country

2.0 Overseas Area Offices
        Overseas is broken into three areas:
           o TRICARE Europe
             (Includes: Europe, Africa, Middle East, Azores, and Iceland)
           o TRICARE Pacific (Western Pacific)
             (Includes: Asia, Australia, New Zealand, and India)
           o TRICARE Latin America and Canada (TLAC)
             (Includes: Central and South America, the Caribbean Basin, Puerto Rico, Virgin
             Islands, and Canada)
        Toll-free TRICARE overseas service line (for all overseas locations): 1-888-777-8343




3.0 TOP Management
The Assistant Secretary of Defense for Health Affairs/Director of TMA has overall responsibility for
the TOP.


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4.0 TRICARE Area Office Directors
        TRICARE Area Office Directors or their designees are responsible for planning and
         delivering services to meet the health care needs of beneficiaries in their area of
         responsibility whether through the MTFs or memorandums of agreement with local host
         nation providers.
        Each TAO offers many of the services offered by a Stateside Managed Care Support
         Contractor (MCSC) or TRICARE Service Center (TSC) to include:
           o TOP enrollment assistance, utilization management, beneficiary support, and host
             nation provider education
           o Claims processing assistance
           o Seeking contract support for services necessary to satisfy requirements within their
             jurisdiction except for claims payment and processing responsibilities.
           o Contracting directly for support services or including new requirements in existing
             TMA contracts.
           o Host nation provider certification /recertification
        The TAO also serves as a primary contact and facilitator for TMA and the overseas claims
         processing contractor, Wisconsin Physician Services (WPS).

5.0 Military Treatment Facility (MTF) Commanders
        MTF Commanders are responsible for managing health care delivery for active duty
         personnel and TOP Prime enrollees, as well as for providing care for other Military Health
         System (MHS) beneficiaries who are eligible for care at MTFs.
        MTF Commanders, along with TAO Directors have the authority to seek new contracts to
         meet health care needs in their area of responsibility.
        MTF Commanders work directly with the TAO for network development, and local initiatives.

6.0 TOP Options

6.1 TOP Programs-Prime Benefits
        TOP Prime enrollment options include, enrollment to an overseas Military Treatment Facility
         (MTF) and TRICARE Global Remote Overseas (TGRO).
        TOP Prime offers overseas enrollees TRICARE Prime benefits to include access to primary
         care managers (PCMs), clinical preventative services, and specialty services.
        TGRO enrollees are eligible for aeromedical evacuation.
           o Aeromedical evacuation is only for urgent/emergency medically necessary care that is
             not available locally.
           o Aeromedical evacuation is coordinated through the International SOS call centers in
             either Singapore or Sydney, Australia.

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        TOP Prime has no enrollment fees and deductibles.
        Co-payments are waived except for TOP/TGRO-enrolled ADFMs who receive care under
         the Point of Service option and pharmacy services in U.S. territories where TRICARE Retail
         Pharmacies are available.

6.2 TOP Standard
        Identical to TRICARE Standard benefits, deductibles, and cost-shares unchanged.
        Beneficiaries residing overseas and U.S. territories may be required to pay up front and file a
         claim for reimbursement.

6.3 TRICARE for Life (TOP TFL) Overseas (see Medicare-TRICARE module)
        TRICARE for Life (TFL) is available for dual-eligible TRICARE-Medicare beneficiaries
         enrolled in Medicare Part B.
        TOP TFL is first payer and will cost-share 75% of billed charges for TRICARE covered
         benefits.
           o The beneficiary is responsible for fiscal year deductibles of $150 for individuals and
             $300 for families and the remainder (25%) of the billed charges.
        TOP TFL cost-shares apply to civilian care provided. In locations where Medicare is
         available (Guam, American Samoa, and the Northern Mariana Islands), Medicare will be first
         payer and TFL will be second.

7.0 TRICARE Overseas Program-Prime

7.1 Eligibility

7.1.2 ADSM Eligibility for TOP Prime includes:
        Active duty service members (ADSMs)
        Certain National Guard/Reserve members


7.1.3 Command sponsored Active Duty Family Members (ADFMs) Eligibility
        ADFMs on PCS orders to accompany the sponsor to an overseas location.
        ADFMs on service funded orders to relocate overseas without the sponsor.
        National Guard/Reserve ADFMs are eligible for TOP Prime enrollment if the sponsor resided
         in a designated overseas location prior to activation/mobilization.
        In these cases, enrollment for National Guard/Reserve ADFMs will be based on the
         residential mailing address of the sponsor prior to activation/mobilization.

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7.1.4 Beneficiaries who are not eligible for TOP Prime enrollment
        TOP Prime enrollment is not available to the following beneficiary categories:
           o ADFMs living overseas, but not accompanied by their sponsor.
                   They remain eligible for TRICARE Standard, TRICARE Plus, or space-available
                    MTF care.
           o TRICARE-eligible retirees and their family members.
           o Survivors (regarded as Retirees)
           o NATO forces family members (ineligible for TOP)

7.2 Enrollment
        ADSMs who are permanently assigned overseas must enroll in the appropriate TOP Prime
         program.
        Reserve Component members called to active duty for more than 30 consecutive days with
         a final assignment to an overseas duty station for more than 179 days (as reflected on
         orders)
Note: RC members on duty in combatant theaters of operation with existing imbedded organic
medical treatment and support capabilities for healthcare are excluded.
        TOP Prime beneficiaries must enroll to:
           o Overseas Defense Medical Information System Identification (DMIS-ID) with
             assignment to an MTF Primary Care Manager (PCM).
           o TGRO Call Center when residing in an overseas remote area and enrolled to a remote
             overseas DMIS-ID.
        TOP Prime enrollment is effective the date the enrollment form is signed.

7.3 Family Member Enrollment Exceptions
        Eligibility for TOP Prime normally requires the family to be accompanied by the sponsor;
         therefore, a family member cannot:
           o Relocate within the overseas region.
           o Relocate to another overseas region.
           o Relocate from a location to an overseas region and transfer enrollment, with a few
             exceptions:
                   When the ADSM and command sponsored family members are enrolled in TOP
                    Prime or TGRO and the sponsor is reassigned on unaccompanied orders to a
                    location that does not permit family members, the family members can remain
                    enrolled at the current TOP Prime or TGRO site, as long as they remain command
                    sponsored.

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                   If the family member(s) do not relocate elsewhere during the sponsor’s PCS
                    move, then the family may remain enrolled in TOP Prime for a period based on the
                    length of the sponsor’s unaccompanied orders, but not to exceed two years. The
                    normal unaccompanied tour is 24 months or fewer.
                   If ADFMs are allowed to relocate under the sponsor’s PCS orders in accordance
                    with the Joint Federal Travel Regulation, or Noncombatant Evacuation Orders
                    without the sponsor to an overseas location supported by TOP Prime, then the
                    ADFMs are eligible for enrollment in the appropriate TOP Prime option consistent
                    with their orders.

7.4 Changes in eligibility
        When a beneficiary’s TRICARE eligibility status changes, eligibility for TOP Prime benefits
         may also change.
        Enrollment remains effective until:
           o Enrollee transfers enrollment to another region.
           o Enrollee disenrolls.
           o Enrollee becomes ineligible for TOP Prime or TRICARE coverage ends.

7.5 Enrollment
TOP Prime enrollment is not automatic.
        Eligible ADSMs/ADFMs must complete an enrollment form.
        Enrollment may be on an individual or family basis.
        TOP Prime enrollees will be provided an enrollment card through Defense Manpower Data
         Center (DMDC).
        TOP Prime enrollees pay no enrollment fees.
        Enrollment may occur at any time; enrollees are automatically re-enrolled each year until the
         end of their overseas tour, or the ADFM chooses to disenroll, or upon loss of eligibility.
        Parents of newborns and adoptees are required to take specific action to enroll the newborn
         or adoptee – see DEERS module.
Note: The above information does not apply in the case of a reservist who was called to active duty
for a period of 30 consecutive days or less, since the family members are not eligible for TOP
Prime.

7.6 TOP Prime Disenrollment
        TOP enrolled ADFMs may disenroll at any time.



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        Disenrollment is required within 60 days when beneficiaries (1) no longer lives within the
         TOP Prime region, (2) are not Command Sponsored or on orders (except for Transitional
         Survivors).
        Disenrollment is immediate when the beneficiary is no longer eligible for TOP Prime or
         TRICARE.
        Active duty family members (ADFMs) of sponsors E-5 and above, who voluntarily disenroll
         prior to their annual enrollment renewal date are not eligible to re-enroll for one year (12-
         month lock out), however the TAO has the authority to waive the 12 month lock-out in
         extraordinary circumstances.
        ADFMs of E1-E4 sponsors are exempt from the 12-month lockout.

7.7 Portability
        TOP enrollees must either transfer enrollment or disenroll within 60 days of the end of the
         overseas tour when:
           o The sponsor departs to a new permanent assignment
Note: When the sponsor or the ADFM is no longer eligible for TRICARE Prime or TRICARE
coverage, they are automatically disenrolled.
        The losing TOP region provides continuing coverage for up to 60 days until:
           o The enrollment has been transferred to the new location
           o The enrollee disenrolls
Note: When enrollment transfer or disenrollment has not been requested by the TOP Prime
enrollee by the 60th day, family members revert to TRICARE Standard coverage on the 61st day.
        ADSMs are never disenrolled from Prime

7.8 Receiving Care While Traveling in the United States
        When traveling in the United States, TOP Prime beneficiaries have the same patient priority
         at MTFs as Stateside TRICARE Prime enrollees.
        TOP Prime enrollees can also contact a TSC for information pertaining to TRICARE
         program options and Prime networks near their destination.




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        ADSMs who desire to receive any health care in the States must contact their PCM or
         TGRO call center for a referral and/or authorization.
        TOP Prime enrolled ADFMs are not required to obtain authorization for:
           o Non-urgent/emergency care, except for inpatient mental health care.
           o First eight outpatient mental health visits in an enrollment year. An authorization must
             be granted to receive the ninth outpatient mental health visit in an enrollment year.
        Beneficiaries should try to get routine care appointments done before traveling to the United
         States.

7.9 Receiving Care While Traveling Overseas
Stateside Prime-enrolled ADSMs/ADFMs seeking routine care from a host nation provider in TOP
Prime service areas or designated remote overseas should get a referral from their PCM first with
the understanding that they can expect to pay upfront for authorized care and file a reimbursement
claim with the claims processor where they are enrolled.




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7.10 Referrals and Authorizations (Overseas)

        Active Duty Service Members (ADSMs) and their eligible family members require a referral
         and authorization from their PCM before seeking care from a specialist for a diagnosis or
         treatment that their PCM cannot provide.
        They must have a referral and authorization from their PCM for routine, specialty, or inpatient
         care provided by anyone other than your PCM.
        If enrolled to a MTFs where services needed are unavailable, enrollees are referred to a
         qualified host nation provider.

        If the host nation provider does not speak English, bilingual MTF, or clinic patient liaisons
         may be available to interact with local providers and assist the beneficiary.
        Authorizations requirements may differ between TOP regions. Each TAO Director may
         require authorizations.
        Overseas Extended Care Health Option (ECHO) benefits must be authorized by the TAO
         Director or designee, prior to receiving the ECHO benefit.

7.11 Referrals and Authorizations (Stateside)
TOP Prime-enrolled ADSMs require referrals and authorizations for all care sought while visiting
with the exception of urgent and emergency care.

7.12 Referrals are not required for:
        Emergency care:
            o TRICARE defines an emergency as a medical maternity, or psychiatric condition that
              would lead a “prudent layperson” (someone with average knowledge of health and
              medicine) to believe that a serious medical condition exists, or the absence of
              immediate medical attention would result in a threat to life, limb, or eyesight, or when
              the person has painful symptoms requiring immediate attention to relieve suffering.
        Urgent Care:
            o Urgent care is for an illness or injury that would not result in further disability or death
              if not treated immediately, but does require professional attention within 24 hours.
              Urgent care has the potential to develop into an emergency if treatment is delayed
              longer than 24 hours.
            o TOP Prime enrollees don't need authorization when seeking urgent care, regardless
              of their location.
        TGRO beneficiaries should coordinate urgent or emergency care with the TGRO Call
         Center.



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7.13 Referral Process:
         Referrals to host nation providers or referrals written by a TOP designated civilian PCMs,
          must be routed to the TRICARE Service Center or TGRO Call Center respectively.
         The TRICARE Service Center/TGRO Call Center conducts a benefit review and issues the
          appropriate care authorization.
         ADFMs referred to host nation provider care by the MTF should be prepared to pay first and
          file for reimbursement.
         TGRO-enrolled beneficiaries referred for specialty care by their host nation PCM or
          Embassy Clinic provider should contact the TGRO Call Center for authorizations and a
          guarantee of payment to avoid having to pay up front.


Note: TOP Clinic/MTF care authorizations are not portable to a Stateside Clinic/MTF. Likewise, a
care authorization from a Stateside Clinic/MTF is not portable to a TOP Clinic/MTF.

8.0 TOP Prime Costs

8.1 Active duty members and their families

 Enrollment Fees              Annual Deductibles          Co-payments

 $0                           $0                          $0


Note: ADSMs and ADFMs do not have to pay inpatient costs.

8.2 Catastrophic Cap
         The catastrophic cap is the maximum amount per fiscal year (October 1-September 30) a
          family pays out-of-pocket for TRICARE-covered services and supplies.
            o This is less of an issue for ADSMs and ADFMs using TOP Prime since they have few,
              if any out-of-pocket expenses.
            o It is more of a concern for TOP Standard ADFMs, retirees and their family members,
              and survivors living overseas.




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                            Active Duty Families

                            (This also applies to
                            ADFM using Standard)

 Catastrophic cap           $1,000 per family per
                            fiscal year


        Payments counted toward a beneficiary’s catastrophic cap include the following:
           o Enrollment fees (does not apply to overseas regions)
           o Deductibles
           o Co-payments
        Payments that do not count toward a beneficiary’s catastrophic cap include the following:
           o Payments for balance billing
           o Point of Service (POS) charges

8.3 Point-of-Service Option (POS)
        Provides TOP Prime ADFMs the freedom to self-refer to a TRICARE authorized civilian
         provider/host nation provider for TRICARE authorized non-emergency, specialty, and
         inpatient care
        When TOP Prime ADFMs choose to use the POS option, they incur increased deductibles
         and cost shares.
        Under POS, ADFM enrollees become responsible for 50% of the billed charge/covered
         charges after the POS deductible has been met.
Note: POS deductibles do not apply to inpatient services
        The POS option is not applicable for TOP ADFMs who receive care during temporary
         absences from an overseas area and during permanent transfer prior to enrollment in their
         new region.
           o The portability period is up to 60 days when returning to the States.
        POS deductibles and cost-sharing do not apply to the claims for care received by newborns
         and newly adopted children who are deemed enrolled in TOP Prime for the first 60/120 days
         or until an enrollment decision is made by the sponsor.
        POS deductibles and cost shares are NOT creditable to the enrollment/fiscal year
         catastrophic cap and are not limited by the cap.
        POS deductibles and cost shares do not apply if other health insurance (OHI) is involved.

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POS Charges                                 Individual           Family

Deductible per fiscal year                  $300                 $600

Cost shares for outpatient claims           Limited to 50% of the billed charge/covered charges
                                            after POS deductible has been met

Cost shares for inpatient claims            50% of the billed charge/covered charges

For TRICARE Pacific, POS applies to TGRO ADFM enrollees (in all locations) and TOP Prime
ADFM enrollees in Guam, Japan, and Korea (only in the country to which they are enrolled)

50% cost share applies even after catastrophic cap for the enrollment/fiscal year has been met.
POS deductible and cost share do not apply if OHI is involved

9.0 TOP Standard

9.1 Eligibility
Available to all TRICARE-eligible beneficiaries, except active duty service members.

9.2 Enrollment
No enrollment forms or fees

9.3 MTF Access
        Beneficiaries may still receive care from a military treatment facility via TRICARE Plus or on
         a space-available basis.
        The MTF Commander determines space availability for TOP Standard beneficiaries.
        Space available care may be available to:
           o TOP Standard ADFMs
           o Retirees, their eligible family members, and Survivors, and eligible former spouses
           o Other DoD eligible beneficiaries, including contractors




10.0 TOP Standard Outpatient Costs
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   Enrollment fees                      Cost shares

   $0–Enrollment    not required
                                         ADFMs:
                                         Cost share – 20% of the covered costs after the deductible
   Show valid Uniformed Services         has been met
   ID card
                                         Retirees, their Family Members, Survivors, and Eligible
                                         Former Spouses:

                                         Cost share – 25% of the covered costs after the deductible
                                         has been met.
        Beneficiaries must pay cost shares and annual fiscal year deductibles.
            o Deductibles apply to outpatient care ONLY
            o The Government shares the cost for TRICARE-covered services only after the annual
              deductible is met.
        Beneficiaries typically are required to pay the entire billed charge first and file their own
         claims.
        TOP Standard is secondary coverage for retired service members who have OHI, to include
         employee sponsored or host nation insurance.

10.1 Deductibles

                              Annual Deductible for an             Annual Deductible for a Family
                              Individual

Active duty family            $50                                  $100
member of E-1 to E-4

Active duty family            $150                                 $300
member of E-5 and up;
and all others


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10.2 Catastrophic Cap

                    Active Duty Families Using       TRICARE Standard Retirees, their eligible
                    TRICARE Standard                 family members, Survivors, and eligible
                                                     Former Spouses

Catastrophic        $1,000 per family per fiscal     $3,000 per family per fiscal year (Oct. 1–Sep.
cap                 year (Oct. 1–Sep. 30)            30)


        The catastrophic cap is the maximum amount per fiscal year an eligible family (not individual
         beneficiary) pays for TRICARE-covered services or supplies.
        Payments counted toward a TOP Standard beneficiary’s catastrophic cap include:
           o Deductibles
           o Cost shares
           o Prescription co-payments
        Payments that do not count toward a beneficiary’s catastrophic cap include the following:
           o Payments for balance billing
           o POS charges

10.3 Inpatient Costs

Enrollment fees                   Cost shares

 $0–Enrollment not required        ADFMs:
                                   Per diem charge ($25 minimum charge per admission).
Show valid Uniformed               No separate cost share for separately billed professional
Services ID                       charges
 card
                                   Retirees, their Family Members, Survivors, and Eligible
                                   Former Spouses:


                                   25% cost-share of billed charges for institutional services,
                                   plus 25% cost share of covered costs for separately billed
                                   professional charges.


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10.4 Overseas TRICARE Standard (TOP Standard)
TOP Standard beneficiaries do not usually require a referral or authorization to be seen by a host
nation provider for a TRICARE covered service, as TOP Standard beneficiaries manage their own
care.
Note: A referral and authorization is required for the ninth outpatient mental health visit in an
enrollment year as well as any inpatient mental health stay.

10.5 Receiving care stateside
        All care may be sought from a MTF first, if available/feasible.
        TOP Standard beneficiaries don’t need preauthorization for urgent or emergency care when
         receiving care in the United States.
        Referrals are usually not required for TOP Standard ADFMs who receive care in the states;
         however, ADFMs receiving outpatient mental health care beyond the eighth visit require
         authorization.
        A referral and authorization is required for the ninth outpatient mental health visit in an
         enrollment year as well as any inpatient mental health stay.

11.0 Types of Charges

11.1 Billed Charges
        A billed charge is the total cost of care without discounts or reduced fees from a provider.
        All TOP beneficiary claims for overseas health care shall be based upon the billed charges.
        Exceptions to billed charges are:
           o Professional services such as physicians’ charges in the Philippines (subject to the
             foreign fee schedule)
           o Prescription drugs

11.1.2 Billed Charge Example:
        A TOP Standard beneficiary sees a host nation provider for dermatology appointment.
        The provider charges $50 for the service.
        The Standard beneficiary pays the full amount and files a reimbursement claim.



11.1.3 To further illustrate:
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             o $50 = Provider billed charge for the dermatology appointment
             o The beneficiary paid the full amount charged by the provider and filed a claim with
               WPS
             o $50 = TRICARE approved billed charge
             o After the appropriate annual deductible and cost shares (20% or 25%) are deducted
               from the billed charge of $50, the remaining amount is paid to the beneficiary


11.2 Co-pay
A co-pay is a fixed dollar amount paid out of pocket paid by eligible beneficiaries for medical and
some pharmacy expenses
Note: Active duty service members have no co-pays

11.3 Deductible
        The amount the beneficiary must pay toward outpatient medical care during each fiscal year
         before TRICARE begins sharing the cost of medical care.
        The deductible is separate from, and in addition to, the cost share.

11.4 Cost Share
        The cost share is the percentage of the TRICARE allowable charge (billed charges
         overseas) that a beneficiary must pay for TRICARE-covered medical services or supplies
         after the deductible has been met.
           o Includes medical services or supplies under the Extended Care Health Option
             (ECHO).

11.5 Catastrophic Cap
The catastrophic cap is the maximum amount per fiscal year an eligible family (not individual
beneficiary) pays for TRICARE-covered services or supplies.

11.6 Balance Billing (applies to Stateside regions and Puerto Rico)
        A term used to describe when a provider bills a beneficiary for the difference between billed
         charges and the TRICARE allowable charge after TRICARE (and other health insurance, if
         applicable) has paid everything it will pay.
        Participating providers are prohibited from balance billing. Non-participating providers may
         charge up to 15 percent above the TRICARE allowable charge.
        Balance billing provisions do not apply to TOP beneficiary claims paid as billed charges.



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12.0 Types of Overseas Providers

                                                                                                     NON-AUTHORIZED
                                                     AUTHORIZED                                         PROVIDER
     TAO Europe                                       PROVIDER
                                                   (TRICARE CERTIFIED)
                                                                                                           TRICARE
                                                                                                         CANNOT PAY
          PREFERRED
           PROVIDER
           NETWORK
                                   TAO Europe                  TAO Pacific                            TAO LAC
                                                                                                      (TOP Puerto Rico Prime)


          PREFERRED                                                                                      NETWORK &
           PROVIDER              PARTNERSHIP               MOU                 Non-Network              NON-NETWORK
             MOU                   PROVIDER              PROVIDER               PROVIDER                 PROVIDERS


                                  SIGNS INTERNAL         May SIGN Internal
          SIGNS MOU                                                             Participating &          PARTICIPATING &
                                  AGREEMENT with        MOU Agreement with
                                                                               Non-Participating        NON-PARTICIPATING
          AGREEMENT                                            MTF
                                       MTF


                                                       ACCEPTS/Does Not         Accepts/Does not        ACCEPTS/DOES NOT
    ACCEPTS TRICARE               ACCEPTS TRICARE
                                                        Accept TRICARE          Accept TRICARE           ACCEPT TRICARE
    BILLED CHARGES                   PAYMENT                                        Payment
                                                           Payment                                          PAYMENT




          FILES CLAIM               FILES CLAIM          FILES/Does Not file   Files/Does not file      FILES/DOES NOT FILE
          FOR MEMBER                FOR MEMBER          CLAIM FOR MEMBER       Claim for members        CLAIM FOR MEMBERS




                                                                                         Source: CFR 199.6 – Authorized Providers
 As of 4/10/2008                                                                                                                1


          There are no Network providers overseas, with the following exceptions:
                   o The TRICARE Prime Puerto Rico Contract (TPRC) provides a civilian provider
                     network to facilitate the health care services not available at military clinics on the
                     island.
                   o The TAO Europe region offers a Preferred Provider Network. This type of network is
                     unique to TAO Europe.

12.1 Authorized Providers
          An authorized provider is a doctor or other individual provider of care, hospital, or supplier
           licensed by the state, accredited by a national organization, meets other standards of the
           medical community, or is authorized/certified by TRICARE to provide benefits under
           TRICARE.
          If the provider is not authorized or deemed TRICARE certified, TRICARE will not pay the bill.
           Beneficiaries should always check with the TAO or TSC first before receiving treatment.



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        To help TLAC beneficiaries, always check with the TSC to validate provider status, or
         International SOS at 1-800-834-5514 (all other TAO-Pacific regions)

12.2 Host Nation Providers

A Host Nation Provider is a healthcare provider that is certified by the host nation/native country to
practice medicine within the host country.

12.3 Pacific area providers consist of:
        PCMs
        Specialty Providers
        Hospitals
        Ancillary/Outpatient Services
        Behavioral Health Service Providers
        Dental Providers

12.4 Primary Care Managers (PCMs)
        PCMs are selected by a TOP enrolled beneficiary or assigned by an MTF, the TAO, or their
         designee.
        PCMs may only be an individual professional provider.
        PCMs may be organized into teams to support patient continuity and accountability if the
         individual’s assigned PCM is absent or unavailable.
Note: For the purposes of referral management and authorization for TRICARE Prime
episodes of care, the TRICARE Global Remote Overseas Call Centers are considered PCMs..

12.5 PCMs may be any of the following:
        Internist, family practitioner, pediatrician, general practitioner, obstetrician/gynecologist,
         physician assistant, nurse practitioner, or certified nurse midwives when determined by the
         MTF commander, TAO Director, or designee, to meet governing country rules and licensure.

13.0 Getting Care http://www.tricare.mil/tma/pacific/

13.1 TAO-Pacific Web Site
        MHS personnel and beneficiaries will find this website useful for finding MTFs and host
         nation providers.




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    

13.2 Considerations when seeking care
        The three most important topics to keep in mind are:
           o TRICARE Overseas Program (TOP) eligibility
           o Provider availability
           o Payment for services

13.3 Finding a TRICARE-Approved Provider
        To find TRICARE-approved host nation providers in TOP regions, beneficiaries may contact
         the local TRICARE Service Center for assistance.
        MHS personnel and beneficiaries may also access the “Find a Provider” site by:
           o Selecting the “Find a Provider” tab on the TAO-Pacific website, or
                www.tricare.mil/tma/pacific/pacificFindProvider.aspx




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13.4 Finding TGRO Providers




        When trying to find providers in TGRO areas, Point of Contacts (POCs) and beneficiaries
         may either:
           o Select the hyperlink displayed at the bottom of the “Find a Provider” webpage; or
                http://www.internationalsos.com/private/tricare/pacific/

14.0 Receiving Care Overseas
MTF Care                                          Non-MTF Care

TOP Prime                                         TRICARE Global Remote Overseas (TGRO)

TRICARE Plus (at some MTFs)                       TRICARE Standard (includes TFL)

Space Available                                   Aeromedical Evacuation (urgent/emergency

15.0 TRICARE GLOBAL REMOTE OVERSEAS (TGRO)
        Standardizes TRICARE Prime coverage across overseas regions to provide quality medical
         care at remote locations from TRICARE-approved healthcare providers while reducing
         administrative costs for the Government.
        Provides routine, urgent, and emergency medical services and dental services for ADSMs
        Provides routine, urgent, and emergency medical services for ADFMs
           o ADFMs may receive dental coverage through the TRICARE Dental Program (TDP)
           o ADFMs must still have command sponsorship and accompany their sponsor to the
             remote overseas location to enroll in TGRO.
Note: See TGRO Module for complete details

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16.0 The Women, Infants, and Children Overseas Program (WIC)
        WIC Overseas is designed to provide nutrition counseling and supplement the families with
         additional nutritional food items.
        The WIC Overseas Program provides several important benefits including the following:
        Nutritious food that will contribute to a healthier diet
        Education on nutrition and proper diet
        Tips on how to prepare a balanced meal
        Nutrition and health screening
        Access to other resources to lead a healthy life
        Participants receive redeemable food coupons called “drafts” for specified foods and
         quantities.
            o Drafts can be redeemed only for specific food items at commissaries and NEXMARTs
              overseas.

16.1 Eligibility
        All members of the Uniformed Services, civilian employees of a military department.
        Contractors of the Department of Defense living overseas and their family members may be
         eligible to participate in the WIC Overseas program.
        Eligible families whose gross income falls at or below 185 percent of the U.S. poverty
         income guidelines may be eligible if the woman, her infants, or children are determined to be
         at nutritional risk for medical or dietary reasons.
        Pregnant women are eligible throughout their pregnancy and up to 6 weeks after birth, or
         when the pregnancy ends.
        Breastfeeding women can continue to use the program until the infant’s first birthday, and
         non-breastfeeding women can use it for up to 6 months after the child’s birth.

16.2 Approved Food List
        Nutritional counselors provide approved food lists that specify what types, brands, and
         quantities of foods can be purchased using WIC Overseas drafts.
        The following food items are generally available through the WIC Overseas program:
            o Iron-fortified infant formula and infant cereal
            o Iron-fortified adult cereal
            o Vitamin C-rich fruit and/or vegetable juice
            o Eggs
            o Milk
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           o Cheese
           o Peanut butter
           o Dried beans or peas
           o Canned tuna
           o Vitamin A-rich vegetables

16.3 WIC Overseas Program Office Locations
        The WIC Overseas Program offices are located in Belgium, Central America, England,
         Germany, Iceland, Italy, Japan, Korea, Netherlands, Portugal, Spain, Turkey
        Please check with the local base or installation telephone operator to obtain the WIC
         Overseas office listing in the area
        For more information about the WIC Overseas program and program contacts, please visit
         the Web site at: www.tricare.mil/Wic/.

17.0 Reciprocal Health Care Agreements
The United States entered into agreements with other countries to provide reciprocal health care for
active duty personnel and their dependents.
Note: For more information, go to: http://www.tricare.mil/foreignforces/

18.0 TRICARE Overseas Resources


TRICARE Area Office-Pacific:
Toll-free: 1-888-777-8343
011-81-6117-43-2036
DSN: 643-2036
Remote Sites: 011-65-6-338-9277
Fax: 011-81-611-743-2037
DSN Fax: 643-2037
TPAO.CSC@med.navy.mil

TRICARE Area Office-Europe:
Toll-free: 1-888-777-8343
011-49-6302-67-7432
DSN: 496-7432
Fax: 011-49-6302-67-6374
DSN Fax: 496-6374
teurope@europe.tricare.osd.mil



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TRICARE Area Office-Latin America and Canada:
TAO-LAC, Building 38716, 38th Alley
Ft Gordon, GA 30905-5650
Toll-free: 1-888-777-8343
1-706-787-2424
DSN: 773-2424
Fax: 1-706-787-3024
taolac@tma.osd.mil


International SOS:
www.internationalsos.com




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Summary




     Describe the TRICARE Overseas Program (TOP)
     Define overseas provider types
     Identify TOP options
     Describe provisions of the TOP options
     Locate TOP resources




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Appendix 1: Medical Matrix Homework
                           TOP PRIME           TRICARE GLOBAL        STANDARD
                                              REMOTE OVERSEAS
                                                  PROGRAM
                                                FOR AD & ADFM


                      AD           ADFM         AD     ADFM     AD     ADFM        RET



  Enrollment
  Required



  Command
  Sponsorship



  Enrollment Fee




  PCM Assigned




  Co-pays




  Cost-shares




  Inpatient Costs




  Mental Health
  Inpatient Costs




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  Catastrophic
  Cap



  Deductibles




  Claims




  MTF Access




  Portable




  Overseas
  Access



  Civilian
  Equivalent



  Advantages




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Brainteaser Answer Key


   1.    Go long
   2.    Sailing over the 7 seas
   3.    Apartment
   4.    Neon light
   5.    Split second timing
   6.    Man overboard
   7.    Tennessee
   8.    Free for all




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DOCUMENT INFO
Description: Preferred Provider Charge Station Installation Agreement document sample