TRICARE Overseas Program Provider Manual

Transcription

1 R TRICARE Overseas Program

2 An Important Note About TRICARE Program Information: At the time of printing, the information in this TRICARE Overseas Program (TOP) is current. It is important to remember that TRICARE policies and benefits are governed by United States public law and federal regulations. Changes to TRICARE programs are continually made as public law and/or federal regulations are amended. For the most recent information, contact International SOS or visit More information regarding TRICARE, including the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can be found online at 2

3 Table of Contents SECTIoN 1: About International SoS and TRICARE overseas Program Introduction Letter About International SOS About Defense Health Agency and the Military Health System What is the TRICARE Overseas Program? TRICARE Overseas Program Overview International SOS TRICARE Contact Information Reporting Fraud and Abuse SECTIoN 2: TRICARE overseas Program Benefits Identifying TRICARE Patients and Validating Coverage Sample TOP Prime and TOP Prime Remote Enrollment Cards TOP Prime and TOP Prime Remote Eligibility TOP Prime TOP Prime Remote Other Covered Beneficiaries Beneficiaries on Active Duty for More Than 30 Days Beneficiaries on Active Duty for 30 Days or Less Beneficiaries Enrolled in the Continental U.S. (CONUS) Other Health Insurance TRICARE Pharmacy Program TRICARE Dental Program TOP Prime and TOP Prime Remote Beneficiary Covered Services TOP Prime and TOP Prime Remote Beneficiary Coverage Limitations TOP Prime and TOP Prime Remote Beneficiary Coverage Exclusions SECTIoN 3: International SoS Network Providers and Provider Credentialing What is a Network Provider? Becoming an International SOS Network Provider How to Become an International SOS Network Provider Network Provider Responsibilities Keeping Your Provider File Current Network Provider Quality Mission TOP Provider Support Services Access to Care Provider Credentialing Process Beneficiary Access to TOP Network Providers SECTIoN 4: Authorizations and Seeing TRICARE Patients How Are Patients Referred to You? TOP Prime and TOP Prime Remote Beneficiaries TOP Standard Beneficiaries Determining Patient Eligibility for Authorized Care Authorization Forms Authorization for Cases of Pregnancy Emergency Assistance Treatment and Authorizations and Payment Clear and Legible Reporting: Issuing a Medical Report Following Patient Care Patient Records and Privacy Cultural Differences and Host Nation Patient Liaisons

4 Table of Contents (continued) SECTIoN 5: Provider Claims Information Process for Submitting Claims Web-based Claims Submission Options Secure Message Transmission Online Claim Submission Claims for Services Rendered Before September 1, Claim Tracking and Monitoring Timely Filing of Claims Claim Reimbursement and Payment Required Criteria for Ensuring Payment of Claims Explanation of Benefits and Applicable Exchange Rate Information Transaction Fees Associated with Claim Reimbursement and Payments What if Both Non-Institutional & Institutional Providers Are Used for the Same Episode of Care and Billed Independently? What if a Beneficiary Does Not Show for an Appointment? Step-By-Step Instructions for Accurately Completing Claim Forms The Claims Process SECTIoN 6: The Provider Portal Registering to the Provider Portal Using the Provider Portal The Provider Dashboard Claim Status Patient Eligibility Manage Locations My Profile TRICARE Covered Benefits SECTIoN 7: TRICARE overseas Program Provider Forms Sample: CMS 1500 Claim Form Sample: UB-04 Claim Form Sample: International SOS Authorization Form Sample: EDI Agreement Form Sample: EFT Form for Providers Sample: EFT Form for Providers Who Use a Billing Agency SECTIoN 8: List of Acronyms Appendix TOP: Explanation of Benefits Denial Codes and Remarks

5 SECTIoN 1 About International SoS and the TRICARE overseas Program SECTIoN 1: About International SoS and the TRICARE overseas Program April 2011 Dear TRICARE Provider, International SOS Assistance, Inc. (International SOS) is proud to serve as the Department of Defense TRICARE Overseas Program (TOP) contractor, effective September 1, We are fully committed to delivering high-quality, readily available, and comprehensive health care services for the nearly half a million TRICARE beneficiaries, including deployed personnel, travelers, and retirees outside the 50 United States and the District of Columbia. International SOS remains focused on processing all claims and inquiries in a timely and accurate manner. Working together with you, our network of health care Providers who will be supporting us, we have created an efficient and timely cashless, claimless process for beneficiaries. International SOS has been serving a large population of this customer base since This manual describes the TRICARE program and requirements. It also provides important TOP Regional Call Center numbers and website information. International SOS is always here for you in case you need further assistance. We encourage you to visit for various Provider services, including covered services, how to submit claims for timely reimbursement, referrals and authorizations, credentialing and the benefits of becoming part of the TRICARE Provider Network. International SOS understands the value of services you provide to our Department of Defense military members and their families. We look forward to our continued successful relationships bringing the very best care to beneficiaries worldwide. Thank you for the very important role you play in helping us to achieve this goal. Kind regards, Kelley Harar Chief Operating Officer, TRICARE Overseas Program International SOS 5

6 Since 1998, International SOS has supported TRICARE in ensuring that Active Duty Service Members and their families receive the highest quality care, no matter where their work or travels take them. About International SoS International SOS ( is the world's leading medical and travel security risk services company. We care for clients across the globe, from more than 700 locations in 89 countries. Our expertise is unique: approximately 11,000 employees are led by 1,200 doctors and 200 security specialists. Teams work night and day to protect our members. Since 1998, International SOS has supported TRICARE in ensuring that Active Duty Service Members (ADSM) and their families receive the highest quality care, no matter where their work or travels take them. About Defense Health Agency and the Military Health System Defense Health Agency (DHA), the Defense Department activity that administers the health care plan for the uniformed services, retirees and their families, serves more than 9.5 million eligible beneficiaries worldwide in the Military Health System (MHS). The mission of the MHS is to enhance Department of Defense and national security by providing health support for the full range of military operations. The MHS provides quality medical care through a network of Providers, Military Treatment Facilities (MTF), medical clinics and dental clinics worldwide. What is the TRICARE overseas Program? TRICARE is a comprehensive health care program provided to active and retired members of the United States uniformed services, their spouses and children, survivors and certain other beneficiaries. On October 21, 2009, International SOS was selected by DHA as the contractor for the TRICARE Overseas Program (TOP) in locations outside the 50 United States and the District of Columbia. International SOS began delivering health care services on September 1, TOP is designed to enhance existing operations, improve Provider satisfaction and deliver high-quality, patient-centered care for nearly half a million beneficiaries overseas. For TRICARE beneficiaries living overseas, TOP will offer options including TOP Prime, TOP Prime Remote and TOP Standard as 6

7 SECTIoN 1 About International SoS and the TRICARE overseas Program well as TRICARE for Life, TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult. International SOS is developing a network of Providers primarily to support TOP Prime and TOP Prime Remote beneficiaries. We recognize that TOP Standard beneficiaries may also choose to seek care from some Network Providers. The TOP Prime program delivers the prime benefit to ADSM and their families in the three overseas areas: Eurasia-Africa, the Pacific, and Latin America and Canada. The TOP Prime Remote program delivers the prime benefit to ADSM and their families stationed in designated remote locations overseas. International SoS TRICARE Contact Information If you have any questions about claims, payments, how to become a Network Provider or credentialing and certification requirements, please contact your TOP Regional Call Center. Customer Service Phone Numbers Europe, Middle East & Africa TRICARE overseas Program overview Latin America and Canada Puerto Rico This TOP has been developed to provide you and your staff with basic, important information about the TRICARE Overseas Program (TOP). The manual will assist you in coordinating care for TOP beneficiaries. It contains detailed information about TOP programs, policies and procedures. Additional TOP program information can be found online by visiting Providers can also visit the TRICARE website at TRICARE program manuals are available in their entirety at the DHA Manuals website. Thank you for your commitment to the Department of Defense overseas military community. Asia-Pacific Australasia If a patient attends an appointment and you require assistance with determining eligibility, covered benefits, or receiving prior authorization for care, please contact the Medical Assistance lines below: Medical Assistance Phone Numbers Europe, Middle East & Africa Latin America and Canada Puerto Rico Asia-Pacific Australasia Visit for a full listing of toll free phone numbers by country. This website will be updated regularly, as additional information becomes available. 7

8 The following addresses are also available, for contacting your TOP Provider Support Services staff: Europe, Middle East & Africa Latin America and Canada Puerto Rico Asia-Pacific Additionally, Providers can inquire about specific claims issues by sending their questions to the International SOS TOP Claims Processing Department via the Web-based Secure Message Transmission function on the Provider Portal. Please see Section 6: The Provider Portal for additional information about accessing the Secure Message Inbox. Reporting Fraud and Abuse International SOS as part of the TRICARE Overseas Program is committed to detecting, correcting, and preventing health care fraud and abuse. Fraud happens when a person or organization takes action to deliberately deceive others to gain an unauthorized benefit. Health care abuse occurs when Providers supply services or products that are medically unnecessary or that do not meet professional standards. Write to the customer service department for TOP to report suspected fraud and abuse: ATTN: TRICARE Program Integrity 1717 W. Broadway PO Box 7635 Madison, Wisconsin USA You can also send an to reportit@wpsic.com or submit an electronic form posted on Be sure to provide as much information as possible. Fraud or abuse issues can also be reported directly to TRICARE by ing fraudline@dha.osd.mil. If you would like to obtain additional information about International SOS Program Integrity mission, please ToPProgramIntegrity@internationalsos.com. Program Integrity information is also available online at 8

9 SECTIoN 2: TRICARE overseas Program Benefits Identifying TRICARE Patients and Validating Coverage Sample ToP Prime and ToP Prime Remote Enrollment Cards SECTIoN 2 TRICARE overseas Program Benefits TRICARE is available to a range of members serving under the U.S. Department of Defense. It is important to remember that not all U.S. patients are TRICARE patients. Sample ToP Prime Enrollment Card Front of Card Because there are so many types of U.S. military patients who may seek care from you, it is critical to properly identify both the patient and their TRICARE status. TRICARE patients who seek care from you will have some way to prove that they are TRICARE eligible this can be a U.S. Military Identification Card, a written confirmation from the Military Treatment Facility (MTF), or an Authorization Form from International SOS. Generally, children under 10 will not have their own Military Identification Card. The parent s valid identification card is considered sufficient. TRICARE Prime Enrollment Cards are only valid when presented with a valid Military ID Card or Common Access Card (CAC). Please ensure that the names on both cards match, that the expiration date on the Military ID Card or CAC has not lapsed, and that the photo on this card accurately represents the patient. Back of Card If you have a concern about an individual patient, you may contact your TOP Regional Call Center for assistance 24/7. Providers are authorized and encouraged to photocopy both sides of a patient s Military ID Card or TRICARE Enrollment Card. Once the Provider is registered to the online Provider Portal available at they will also be able to check a patient s eligibility through the portal. Sample TOP Prime and TOP Prime Remote Enrollment Cards are included here for your reference. 9

10 Sample ToP Prime Remote Enrollment Card Front of Card ToP Prime and ToP Prime Remote Eligibility This section introduces several terms you may come across while treating TRICARE beneficiaries. TRICARE provides payment for covered services as long as the beneficiary is eligible and the care is properly authorized. Once a Provider agrees to participate, and they have agreed to provide cashless, claimless services to TOP Prime and TOP Prime Remote beneficiaries, they will submit the appropriate Standard U.S. Claim Forms on behalf of the beneficiaries and will provide medical services in line with TRICARE policy. Back of Card With the exception of emergency care and the first eight outpatient visits for behavioral health care, and one annual optometry screening (3 years and older), TOP Prime and TOP Prime Remote beneficiaries are eligible to receive cashless, claimless service from a Host Nation Provider. 1 It is important to remember that in most cases International SOS will provide you with an Authorization Form for TOP Prime and TOP Prime Remote beneficiaries. All other beneficiaries who are not TOP Prime or TOP Prime Remote are required to pay for service upfront and then file a TRICARE claim directly. As an International SOS Network Provider, you may choose to file claims on behalf of beneficiaries who are not TOP Prime or TOP Prime Remote, but are not required to do so. Active Duty Service Members (ADSM) are required to enroll in TOP Prime. Depending on where they are stationed overseas, they must enroll in one of the following two TOP Prime options: TOP Prime and TOP Prime Remote Active Duty Service Members (ADSM) will receive an enrollment card similar to the sample card graphic above. When presented with the beneficiary s Military ID Card or CAC, this is one method Providers can use to validate TRICARE eligibility. Note: Only TOP Prime and TOP Prime Remote beneficiaries will receive an enrollment card. Other TRICARE beneficiaries, such as TOP Standard, will not be issued an enrollment card. However, they will be given a Military ID Card or CAC. Therefore, the enrollment card is key for identifying those beneficiaries who are eligible for TOP Prime or TOP Prime Remote care. TOP Prime TOP Prime Remote Note: If you have any questions about how to determine beneficiary eligibility or the TOP option under which the beneficiary is covered, please contact your TOP Regional Call Center and select option #5 to speak with a member of your TOP Provider Support Services staff The TRICARE Overseas Program also operates in Puerto Rico, Guam, American Samoa, U.S. Virgin Islands and Northern Marianas.

11 ToP Prime TOP Prime beneficiaries live within a 40-mile radius of a U.S. MTF. These beneficiaries are required to seek care through their local MTF. If an MTF does not have the capability to provide treatment to the beneficiary, the assigned Primary Care Manager (or treating practitioner within the MTF) may refer the beneficiary to International SOS to find a Network Provider. International SOS will issue an Authorization Form to the Network Provider before care can be delivered. The medical oversight of the beneficiary s care still resides with the MTF Primary Care Manager or assigned host nation Primary Care Manager. All medical notes and consult findings should be sent back to the MTF or assigned host nation Primary Care Manager within 10 working days for routine consultation reports and within 24 hours for urgent consultation reports. ToP Prime Remote TOP Prime Remote beneficiaries live more than 40 miles away from an overseas U.S. MTF. TOP Prime Remote beneficiaries will receive their primary care from a Host Nation Provider who will serve as their Primary Care Physician. International SOS acts as the Primary Care Manager for all TOP Prime Remote Beneficiaries. International SOS manages all referrals and medical oversight of TOP Prime Remote beneficiaries living overseas. All medical notes and consult findings, including authorizations for referrals to secondary care or inpatient admissions should be discussed with International SOS. 11 The following table shows the various TOP options available by beneficiary type: Beneficiary Type Active Duty Service Members (ADSM) Active Duty Family Members 2 (ADFM) and transitional survivors Retired service members 4 and family members, survivors, Medal of Honor recipients, certain unremarried former spouse, and others who are registered in the Defense Enrollment Eligibility Reporting System (DEERS). 6 ToP Program options TOP Prime TOP Prime Remote TRICARE Active Duty Dental Program (ADDP) 1 TOP Prime TOP Prime Remote TOP Standard 3 TRICARE For Life (TFL) (if you have both Medicare Part A and Part B) 4 TRICARE Dental Program TRICARE Young Adult Program (TYA) 7 TOP Standard TFL (if you have both Medicare Part A and Part B) 4 TRICARE Retired Reserve 5 TYA 7 TRICARE Reserve Select Enhanced-Oversease TRICARE Retiree Dental Program TRICARE PLUS (depending on military hospital or clinical availability) SECTIoN 2 TRICARE overseas Program Benefits 1 The ADDP is only available in the United States and in U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). See page 13 for additional details about the TRICARE Dental Program. 2 Active Duty Family Members (ADFM) include the sponsor s TRICARE-eligible spouse and children. Unmarried children may remain TRICARE-eligible until age 21 (or age 23 if enrolled in a full-time course of study at an approved institution of higher learning, and if the sponsor provides 50 percent or more of the financial support, (but have not yet reached age 26). A disabled child may remain TRICARE-eligible beyond normal age limits. 3 ADFM who are not eligible for, or choose not to enroll in TOP Prime options may use TOP Standard. 4 Most beneficiaries who are entitled to Medicare Part A must have Medicare Part B to remain TRICARE-eligible. ADFMs who have Medicare Part A are not required to have Medicare Part B to remain eligible for TRICARE. However, once the sponsor reaches age 65, Medicare Part B must be in effect no later than the sponsor s retirement date to avoid a break in TRICARE coverage. 5 Retired service members and their family members are not eligible to enroll in TOP Prime options. They may be eligible to use TOP Standard or TRICARE for Life. Certain retired National Guard and Reserve members and their families may qualify to purchase TRICARE Retired Reserve coverage. 6 Individual eligibility is determined by DEERS. Beneficiaries are responsible for ensuring their information is current in this system. TRICARE claims for patients who are not listed as eligible in DEERS cannot be paid by International SOS. 7 The premium-based TRICARE Young Adult (TYA) program extends TRICARE coverage to certain qualified dependents until reaching age 26, and may be an option for adult children who age out of other TRICARE benefits. For more information, please visit

12 other Covered Beneficiaries Beneficiaries on Active Duty for More Than 30 Days If a beneficiary is activated for more than 30 consecutive days, they receive TRICARE benefits as an ADSM. The TRICARE-eligible family members who reside overseas with the ADSM sponsor receive coverage as Active Duty Family Members (ADFM) while the sponsor is activated. These ADFM are eligible to enroll in TOP Prime options if they are Command Sponsored (authorized by the U.S. Government to accompany their sponsor to the overseas location). If ADFM do not enroll in TOP Prime or TOP Prime Remote, they may choose to use TOP Standard, which does not require enrollment. Beneficiaries on Active Duty for 30 Days or Less National Guard and Reserve members serving overseas on orders for 30 days or less are not eligible for TRICARE active duty benefits. However, if the beneficiary is injured or becomes ill while traveling to or from annual training while on active duty, he/she is eligible for line-of-duty care. Beneficiaries may also seek emergency and urgent care while serving on their orders. Beneficiaries Enrolled in the Continental U.S. (CoNUS) For beneficiaries who are enrolled in a Continental U.S. (CONUS) TRICARE program and are traveling overseas, authorizations are needed for urgent care. Emergency care services can be delivered on a cashless, claimless basis without authorization. However, Providers are encouraged to call International SOS to coordinate care upfront. other Health Insurance As required by law, TRICARE can only pay after all other active insurance policies have paid their share. This includes National Health Insurance. As outlined below, proof of submitting the claim to the other health insurer (including any payment information) must be submitted with the Claim Form. If the patient has Other Health Insurance (OHI), you must claim payment from the OHI first. Once the OHI has processed and paid the claim, you can then seek reimbursement for any outstanding payments from TRICARE directly. If the OHI covers all costs associated with treating the beneficiary, then you will not need to submit a claim to TRICARE. Once the OHI has issued your payment, you must enter the amount paid in the relevant field on the corresponding Claim Form (field 29 on the CMS 1500 or field 54 on the UB-04 Claim Form). You may also submit a copy of the Explanation of Benefits (EOB) from the OHI, when submitting your Claim Form and Itemized Invoice. If the OHI has not made any payment, you must submit the EOB from the OHI to International SOS when submitting the claim. TRICARE Pharmacy Program TRICARE offers comprehensive prescription drug coverage and several options for filling prescriptions. The beneficiary is responsible for paying and claiming for their medications, unless the Pharmacy agrees to file claims on behalf of the beneficiary. Some Pharmacies may decide to offer cashless medical services to TRICARE beneficiaries. This means that the Provider will be responsible for submitting a completed Claim Form and Itemized Invoice to International SOS for reimbursement. Pharmacists will not require an Authorization Form to deliver this service. A TOP Pharmacy Pack is available for Pharmacies who decide to provide cashless medical services to TRICARE beneficiaries. The TOP Pharmacy Pack includes step-by-step instructions for the Pharmacist on how to complete the correct Claim Form as well as an information guide about formulary drug coverage. To request a TOP Pharmacy Pack, please contact your TOP Regional Call Center and press option #5 to speak with a member of your TOP Provider Support Services staff. To fill a prescription, TRICARE beneficiaries will need a written prescription and a TRICARE Prime Enrollment Card as well as a valid Military ID Card or CAC. When Providers write a prescription they are asked to include all of the information shown on Figure 2.1: 12

13 Figure 2.1 Name of the clinic Patient s name and date of birth Clinic Name Name of Provider Provider Street Provider Town Provider Telephone Date of Prescription Provider s name Provider s full address/phone number Date prescription is issued SECTIoN 2 TRICARE overseas Program Benefits Generic (chemical) name of the medication being prescribed. NOTE: Do not use the brand name Please include dosage instructions (e.g. Take 2 tablets 2x a day ) Attending physician s signature and name Name of Patient Patient DOB Generic (chemical) name of drug xxmg capsules, 30 Dosage instructions Refill: not to exceed 12 months Dr. Provider Dr. Provider Strength of the medication (e.g. 50mg tablets) Number of tablets required Please include the number of refills the patient may receive. This cannot cover more than a year. Provider s stamp Additional information about the TRICARE Pharmacy Program can be found online at or TRICARE Dental Program Active Duty Family Members ADFM enrolled in TOP Prime and TOP Prime Remote may receive their dental care under the TRICARE Dental Program. This is an optional program that requires enrollment. International SOS does not manage this care and cannot authorize these treatments. For additional information about the TRICARE Dental Program, please visit Active Duty Service Members International SOS coordinates dental care for ADSM enrolled in TOP Prime Remote only. Care will be referred to an International SOS Network Provider Dentist. 13 Note: The Network Provider Dentist will need to receive an Authorization Form from International SOS first, and will then need to file a claim for reimbursement, accordingly. TOP Prime ASDM dental care is covered by United Concordia (UCCI). TOP Prime ADSM will receive their dental care at the Dental Treatment Facility at the MTF. For more information, please visit ToP Prime and ToP Prime Remote Beneficiary Covered Services TRICARE covers most care that is medically necessary and considered proven. Some types of care are not covered at all, and there are special rules and limits for certain types of care. This section is not intended to be all-inclusive. TRICARE policies are very specific about which services are covered and which are not. It is in your best interest to take an active role in verifying coverage. If you have any questions about whether or not services are covered for the TOP Prime or TOP Prime Remote beneficiary you are seeing, please contact International SOS. Note: The following lists of services are subject to change. Please visit for a full list of covered services, limitations and exclusions.

14 outpatient Services: Coverage Details Figure 2.2 Service Ambulance Services Description The following ambulance services are covered: Emergency transfers from a beneficiary s home, accident scene, or other location to a hospital Transfers between hospitals Ambulance transfers from a hospital-based emergency room to a hospital more capable of providing the required care Transfers between a hospital or skilled nursing facility 1 and another hospital-based or freestanding outpatient therapeutic or diagnostic department/facility The following are excluded: Use of an ambulance service instead of taxi service when the patient s condition would have permitted use of regular private transportation Transport or transfer of a patient primarily for the purpose of having the patient nearer to home, family, friends, or personal physician Medicabs or ambicabs that function primarily as public passenger conveyances transporting patients to and from their medical appointments Note: Air or boat ambulance is only covered when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the beneficiary to the nearest hospital with appropriate facilities, and the patient s medical condition warrants speedy admission or is such that transfer by other means is not advisable. Durable Medical Equipment, Prosthetics, orthotics, and Supplies (DMEPoS) Emergency Services Generally covered if prescribed by a physician and if directly related to a medical condition. Covered DMEPOS generally includes: DMEPOS that are medically necessary and appropriate and prescribed by a physician for a beneficiary s specific use Duplicate DMEPOS items that are necessary to provide a fail-safe, in-home life-support system (In this case, duplicate means an item that meets the definition of DMEPOS and serves the same purpose but may not be an exact duplicate of the original DMEPOS item. For example, a portable oxygen concentrator may be covered as a backup for a stationary oxygen generator.) Note: Prosthetic devices must be U.S. Food and Drug Administration approved. TRICARE defines an emergency as a serious medical condition that the average person would consider to be a threat to life, limb, sight, or safety. However, most dental emergencies, such as going to the emergency room for a severe toothache, are not a covered medical benefit under TRICARE. Home Health Care 1 Covers part-time or intermittent skilled nursing services and home health care services for those confined to the home. (All care must be provided by a participating home health care agency and be authorized in advance by the regional contractor.) Individual Provider Services Covers office visits; outpatient, office-based medical and surgical care; consultation, diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathic manipulation; rehabilitation services (e.g., physical and occupational therapy and speech pathology services); and medical supplies used within the office. 1 Skilled nursing facility care and home health care services are only available in the United States and U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). 14

15 outpatient Services: Coverage Details (continued) Service Laboratory and X-ray Services Active Duty Service Member (ADSM) Respite Care Generally covered if prescribed by a physician. Description Covers respite care for ADSMs who are homebound as a result of a serious injury or illness incurred while serving on active duty; available if the ADSM s plan of care includes frequent interventions by the primary caregiver. 1 SECTIoN 2 TRICARE overseas Program Benefits The following respite care limits apply: Five days per calendar week Eight hours per calendar day Note: Respite care must be provided by a TRICARE-authorized home health care agency and requires prior authorization from your regional contractor and the ADSM s approving authority (i.e., referring military hospital or clinic). The ADSM is not required to be enrolled in the TRICARE Extended Care Health Option program to receive the respite benefit. 1 More than two interventions are required during the eight-hour period per day that the primary caregiver would normally be sleeping. Inpatient Services: Coverage Details Figure 2.3 Service Hospitalization (semi-private room/special care units when medically necessary) Skilled Nursing Facility Care 1 (semiprivate room) Description Covers general nursing; hospital, physician, and surgical services; meals (including special diets); drugs and medications; operating and recovery room care; anesthesia; laboratory tests; X-rays and other radiology services; medical supplies and appliances; and blood and blood products. Note: Surgical procedures designated inpatient only may only be covered when performed in an inpatient setting. Covers skilled nursing services; meals (including special diets); physical, occupational, and speech therapy; drugs furnished by the facility; and necessary medical supplies and appliances. (TRICARE covers an unlimited number of days as medically necessary.) 1 Skilled nursing facility care is only available in the United States and U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). 15

16 Clinical Preventive Service: Coverage Details Figure 2.4 Service Comprehensive Health Promotion and Disease Prevention Examinations Targeted Health Promotion and Disease Prevention Services Cancer Screenings Description A comprehensive clinical preventive exam is covered if it includes an immunization, Pap test, mammogram, colon cancer screening, or prostate cancer screening. School enrollment physicals for children ages 5 11 are also covered. Beneficiaries in each of the following age groups may receive one comprehensive clinical preventive exam without receiving an immunization, Pap test, mammogram, colon cancer screening, or prostate cancer screening (one exam per age group): 2 4, 5 11, 12 17, 18 39, and The screening examinations listed below may be covered if provided in conjunction with a comprehensive clinical preventive exam. The intent is to maximize preventive care. Colonoscopy: Average Risk: Individuals at average risk for colon cancer are covered once every 10 years beginning at age 50. Increased Risk: Once every five years for individuals with a first-degree relative diagnosed with a colorectal cancer or an adenomatous polyp before age 60, or in two or more first-degree relatives at any age. Optical colonoscopy should be performed beginning at age 40 or 10 years younger than the earliest affected relative, whichever is earlier. Once every 10 years, beginning at age 40, for individuals with a first-degree relative diagnosed with colorectal cancer or an adenomatous polyp at age 60 or older, or colorectal cancer diagnosed in two second-degree relatives. High Risk: Once every one to two years for individuals with a genetic or clinical diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) or individuals at increased risk for HNPCC. Optical colonoscopy should be performed beginning at age or 10 years younger than the earliest age of diagnosis, whichever is earlier. For individuals diagnosed with inflammatory bowel disease, chronic ulcerative colitis, or Crohn s disease, cancer risk begins to be significant eight years after the onset of pancolitis or years after the onset of left-sided colitis. For individuals meeting these risk parameters, optical colonoscopy should be performed every one to two years with biopsies for dysplasia. Fecal occult blood testing: Conduct testing annually starting at age 50. Breast Cancer: Clinical breast examination: For women under age 40, a clinical breast examination may be performed during a preventive health visit. For women age 40 and older, a clinical breast examination should be performed annually. Mammograms: Covered annually for all women beginning at age 40. Covered annually beginning at age 30 for women who have a 15 percent or greater lifetime risk of breast cancer (according to risk-assessment tools based on family history such as the Gail model, the Claus model, and the Tyrer-Cuzick model), or who have any of the following risk factors: History of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia Extremely dense breasts when viewed by mammogram Known BRCA1 or BRCA2 gene mutation First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves Radiation therapy to the chest between ages 10 and 30 History of Li-Fraumeni, Cowden, or hereditary diffuse gastric cancer syndrome, or a first-degree relative with a history of one of these syndromes Breast screening magnetic resonance imaging (MRI): Covered annually, in addition to the annual screening mammogram, beginning at age 30 for women who have a 20 percent or greater lifetime risk of breast cancer (according to risk assessment tools based on family history such as the Gail model, the Claus model, and the Tyrer-Cuzick model), or who have any of the following risk factors: Known BRCA1 or BRCA2 gene mutation First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves Radiation to the chest between ages 10 and 30 History of Li-Fraumeni, Cowden, or hereditary diffuse gastric cancer syndrome, or a first-degree relative with a history of one of these syndromes Proctosigmoidoscopy or sigmoidoscopy: Average Risk: Once every three to five years beginning at age 50. Increased Risk: Once every five years beginning at age 40 for individuals with a first-degree relative diagnosed with a colorectal cancer or an adenomatous polyp at age 60 or older, or two second-degree relatives diagnosed with colorectal cancer. High Risk: Annual flexible sigmoidoscopy, beginning at age 10 12, for individuals with known or suspected familial adenomatous polyposis. Prostate cancer: Perform a digital rectal exam and prostate-specific antigen screening annually for certain high-risk men ages and all men over age

17 Clinical Preventive Service: Coverage Details (continued) Service Cancer Screenings (continued) Description Routine Pap tests: Perform a Pap test annually for women starting at age 18 (younger if sexually active) or less often at patient and provider discretion (though not less than every three years). Human papillomavirus (HPV) DNA testing is covered as a cervical cancer screening only when performed in conjunction with a Pap test, and only for women age 30 and older. Skin cancer: Exams are covered at any age for a beneficiary who is at high risk due to family history or increased sun exposure. SECTIoN 2 TRICARE overseas Program Benefits Cardiovascular Diseases Cholesterol test (non-fasting): Testing is covered for a lipid panel at least once every five years, beginning at age 18. Blood pressure screening: Screening is covered annually for children (ages 3 6) and a minimum of every two years after age 6 (children and adults). Eye Examinations Well-child care coverage (infants and children up to age 6): Infants (until reaching age 3): Conduct one eye and vision screening at birth and at 6 months. Children (from age 3 until reaching age 6): Conduct a routine eye exam every two years. Active Duty Family Member (ADFM) children are covered for one routine eye exam annually. Adults and children (over age 6): Conduct a routine eye exam every two years. Active Duty Service Members (ADSM) and ADFMs receive one eye exam each year. Diabetic patients (any age): Eye exams are not limited. One eye exam per year is recommended. Note: ADSMs enrolled in TRICARE Prime must receive all vision care at military hospitals or clinics unless specifically referred by their primary care managers to civilian network providers, or to non-network providers if a network provider is not available. ADSMs enrolled in TRICARE Overseas Program Prime Remote may obtain periodic eye examinations from network providers without prior authorizations as needed to maintain fitness-for-duty status. Hearing Preventive hearing examinations are only allowed under the well-child care benefit. A newborn audiology screening should be performed on newborns before hospital discharge or within the first month after birth. Evaluative hearing tests may be performed at other ages during routine exams. Immunizations Infectious Disease Screening Patient and Parent Education Counseling School Physicals Well-Child Care (birth until reaching age 6) Age-appropriate doses of vaccines, including annual influenza vaccines, are covered as recommended by the Centers for Disease Control and Prevention (CDC). The HPV vaccine is a limited benefit and may be covered when the beneficiary has not been previously vaccinated or completed the vaccine series. Females: The HPV vaccine Gardasil (HPV4) or Cervarix (HPV2) is covered for females ages The series of injections must be completed prior to age 27 for coverage under TRICARE. Males: The HPV vaccine Gardasil (HPV4) is covered for all males ages and is covered for males ages who meet certain criteria. A single dose of the shingles vaccine Zostavax is covered for beneficiaries age 60 and older. Coverage is effective the date the recommendations are published in the CDC s Morbidity and Mortality Weekly Report. Refer to the CDC s Web site at for a current schedule of recommended vaccines. Note: Immunizations for ADFMs whose sponsors have permanent change-of-station orders to overseas locations are also covered. Immunizations for personal overseas travel are not covered. TRICARE covers screening for infectious diseases, including hepatitis B, rubella antibodies and HIV, and screening and/or prophylaxis for tetanus, rabies, hepatitis A and B, meningococcal meningitis, and tuberculosis. Counseling services expected of good clinical practice that are included with the appropriate office visit are covered at no additional charge for dietary assessment and nutrition; physical activity and exercise; cancer surveillance; safe sexual practices; tobacco, alcohol, and substance abuse; dental health promotion; accident and injury prevention; stress; bereavement; and suicide risk assessment. Covered for children ages 5 11 if required in connection with school enrollment. Note: Annual sports physicals are not covered. Covers routine newborn care; comprehensive health promotion and disease prevention exams; vision and hearing screenings; height, weight, and head circumference measurement; routine immunizations; and developmental and behavioral appraisal. TRICARE covers well-child care in accordance with American Academy of Pediatrics (AAP) and CDC guidelines. Your child can receive preventive care well-child visits as frequently as the AAP recommends, but no more than nine visits in two years. Visits for diagnosis or treatment of an illness or injury are covered separately under outpatient care. 17

18 Behavioral Health Care Services: outpatient Coverage Details Figure 2.5 Service outpatient Psychotherapy* (physician referral and supervision required when seeing licensed or certified mental health counselors and pastoral counselors) Description The following outpatient psychotherapy limits apply: Psychotherapy: Two sessions per week, in any combination of the following types: Individual (adult or child): 60 minutes per session; may extend to 120 minutes for crisis intervention Family or conjoint: 90 minutes per session; may extend to 180 minutes for crisis intervention Group: 90 minutes per session Collateral visits Up to 60 minutes per visit (Collateral visits are counted as individual psychotherapy sessions. Beneficiaries have the option of combining collateral visits with other individual or group psychotherapy visits.) Psychoanalysis Psychological Testing and Assessment Psychoanalysis differs from psychotherapy and requires prior authorization. After prior authorization is obtained, treatment must be given by approved providers who are specifically trained in psychoanalysis. Testing and assessment is generally covered when medically or psychologically necessary and provided in conjunction with otherwise-covered psychotherapy. Psychological tests are considered to be diagnostic services and are not counted toward the limit of two psychotherapy visits per week. Limitations: Testing and assessment is generally limited to six hours per fiscal year (FY 1 ). Any testing beyond six hours requires a review for medical necessity. Psychological testing must be medically necessary and not for educational purposes. Exclusions: Psychological testing is not covered for the following circumstances: Academic placement Job placement Child-custody disputes General screening in the absence of specific symptoms Teacher or parental referrals Testing to determine whether a beneficiary has a learning disability Diagnosed, specific learning disorders or learning disabilities Medication Management If you are taking prescription medications for a behavioral health condition, you must be under the care of a provider who is authorized to prescribe those medications. Your provider will manage the dosage and duration of your prescription to ensure you are receiving the best care possible. Medication-management appointments are medical appointments and do not count against the first eight outpatient behavioral health care visits per FY. 1 1 For ADFM, the first 8 outpatient visits per FY 1 do not require authorization. For ADSM, authorization is required for all behavioral health care. Also, certain clinical preventive services do not require authorization when received from a Network Provider. If you are unsure about covered services, please contact International SOS and press option #5 to speak with a member of the TOP Provider Support Services staff. 2 October 1- September

19 Behavioral Health Care Services: Inpatient Coverage Details Prior authorization is required for all nonemergency inpatient behavioral health care services. Psychiatric emergencies do not require prior authorization for inpatient admissions, but authorization is required for continued stay. Admissions resulting from psychiatric emergencies should be reported to the TOP contractor within 24 hours of admission or on the next business day, and must be reported within 72 hours of an admission. Authorization for continued stay is coordinated between the inpatient unit and the TOP contractor. Note: Active duty service members who receive care at military hospitals or clinics do not require prior authorization. Note: This figure is not all-inclusive and additional limitations on behavioral health care services may apply overseas. Figure 2.6 SECTIoN 2 TRICARE overseas Program Benefits Service Acute Inpatient Psychiatric Care Description May be covered on an emergency or nonemergency basis. Prior authorization from your regional contractor is required for all nonemergency inpatient admissions. In emergency situations, authorization is required for continued stay. Limitations: Patients age 19 and older: 30 days per fiscal year (FY 1 ) or in any single admission Patients age 18 and under: 45 days per FY 1 or in any single admission Inpatient admissions for substance use disorder detoxification and rehabilitation count toward the 30- or 45-day limit for acute inpatient psychiatric care. (Limitations may be waived if determined to be medically or psychologically necessary.) Psychiatric Partial Hospitalization Program (PHP) Psychiatric PHPs are treatment settings capable of providing interdisciplinary therapeutic services at least three hours a day, five days a week, in any combination of day, evening, night, and weekend treatment programs. The following rules apply: Prior authorization is required. PHP admissions are not considered emergencies. Facilities must be TRICARE-authorized. PHPs must have participation agreements with TRICARE. Limitations: PHP care is limited to 60 treatment days (whether full- or partial-day treatment) per FY 1. These 60 days are not offset by or counted toward the 30- or 45-day limit for acute inpatient psychiatric care. (Limitations may be waived if determined to be medically or psychologically necessary.) Residential Treatment Center (RTC) Care RTC care provides extended psychiatric care for children and adolescents with psychological disorders that require continued treatment in a therapeutic environment. The following rules apply: Facilities must be TRICARE-authorized. Unless therapeutically contraindicated, the family and/or guardian should actively participate in the continuing care of the patient through either direct involvement at the facility or geographically distant family therapy. Prior authorization is always required. RTC admissions are not considered emergencies. RTC care is considered elective and will not be covered for emergencies. Admission primarily for substance use rehabilitation is not authorized for psychiatric RTC care. In an emergency, psychiatric inpatient hospitalization must be sought first. Care must be recommended and directed by a psychiatrist or clinical psychologist. Limitations: Care is limited to 150 days per FY 1 or for a single admission. (Limitations may be waived if determined to be medically or psychologically necessary.) RTC care is only covered for patients until reaching age 21. RTC care does not count toward the 30- or 45-day inpatient limit. 1 October 1- September

20 Behavioral Health Care Services: Substance Use Disorder Services Figure 2.7 provides coverage details for covered substance use disorder services (up to three benefit periods per beneficiary, per lifetime). NoTE: This figure is not all-inclusive and additional limitations on substance use disorder services may apply overseas. Figure 2.7 Service Inpatient Detoxification Description TRICARE covers emergency and inpatient hospital services for the treatment of the acute phases of substance use withdrawal (detoxification) when the patient s condition requires the personnel and facilities of a hospital or substance use disorder rehabilitation facility (SUDRF). Limitations: Diagnosis-related group-exempt facility, services are limited to seven days per episode. Inpatient detoxification in a free-standing SUDRF counts toward the 30- or 45-day inpatient psychiatric care limit. SUDRF Rehabilitation Rehabilitation of a substance use disorder may occur in an inpatient (residential) or partial hospitalization setting. TRICARE covers 21 days of rehabilitation per benefit period in a TRICAREauthorized facility, whether in an inpatient or partial hospitalization facility or a combination of both. 1 Limitations: 21-day rehabilitation limit per episode Three episodes per lifetime Days for inpatient rehabilitation count toward the 30- or 45-day limit for acute inpatient psychiatric care (Limitations may be waived if determined to be medically or psychologically necessary.) SUDRF outpatient Care Outpatient substance use care must be provided by an approved SUDRF. Limitations: Individual or group therapy: Up to 60 visits per benefit period 1 Family therapy: Up to 15 visits per benefit period 1 Partial hospitalization program care: 21 treatment days per fiscal year 2 (Limitations may be waived if determined to be medically or psychologically necessary.) 1 A benefit period begins with the first day of covered treatments and ends 365 days later. Stay limitations for inpatient services may be waived if determined to be medically or psychologically necessary. 2 October 1- September 30. ToP Prime and ToP Prime Remote Beneficiary Coverage Limitations The following is a list of medical, surgical and behavioral health care services that may not be covered unless exceptional circumstances exist. This list is not intended to be all-inclusive. Please visit for a full list of covered services, limitations and exclusions. 20

21 Services or Procedures with Significant Limitations Figure 2.8 Service Botulinum Toxin Type A Injections Description Botulinum toxin type A injections for cosmetic procedures, myofascial pain, and fibromyalgia are not covered. Cost-sharing may apply for injections to treat severe primary axillary hyperhidrosis, dystonia-related blepharospasm or strabismus, cervical dystonia, cerebral palsy-related spasticity, or for the treatment of sialorrhea associated with Parkinson s disease. Botulinum toxin type A injections may also be cost-shared for prophylaxis of headaches in adult patients with chronic migraines, which is defined as 15 days or more per month with headache lasting four hours a day or longer. TRICARE may also consider off-label cost-sharing for Botox injections used to treat chronic anal fissure (if unresponsive to conservative therapeutic measures). SECTIoN 2 TRICARE overseas Program Benefits Breast Pumps Cardiac and Pulmonary Rehabilitation Cosmetic, Plastic or Reconstructive Surgery Cranial orthotic Device or Molding Helmet Dental Care and Dental X-rays Education and Training Eyeglasses or Contact Lenses Facility Charges for Non- Adjunctive Dental Services Food, Food Substitutes and Supplements, or Vitamins Heavy-duty, hospital-grade electric breast pumps (including services and supplies related to the use of the pump) for mothers of premature infants are covered. An electric breast pump is covered while the premature infant remains hospitalized during the immediate postpartum period. Hospital-grade electric breast pumps may also be covered after the premature infant is discharged from the hospital with a physician-documented medical reason. This documentation is also required for premature infants delivered in non-hospital settings. Breast pumps of any type, when used for reasons of personal convenience, are excluded even if prescribed by a physician. Both are covered only for certain indications. Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded. Surgery is only covered when used to restore function, correct a serious birth defect, restore body form after a serious injury, improve appearance of a severe disfigurement after cancer surgery, or reconstruct the breast after cancer surgery. Cranial orthotic devices are excluded for treatment of nonsynostic positional plagiocephaly. Both are covered only for adjunctive dental care (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical not dental condition). Prior authorization is required for adjunctive dental care. Education and training are covered under the TRICARE Extended Care Health Option (ECHO) and diabetic outpatient self-management training programs. Diabetic outpatient self-management training programs must be accredited by the American Diabetes Association. The provider s accreditation must accompany the claim for reimbursement. Active duty service members may receive eyeglasses at a militray hospital or clinic at no cost. For all other beneficiaries, the following are covered: Contact lenses and/or eyeglasses for treatment of infantile glaucoma Corneal or scleral lenses for treatment of keratoconus Scleral lenses to retain moisture when normal tearing is not present or is inadequate Corneal or scleral lenses to reduce corneal irregularities other than astigmatism Intraocular lenses, contact lenses, or eyeglasses for loss of human lens function resulting from intraocular surgery, ocular injury, or congenital absence Note: Adjustments, cleaning, and repairs for eyeglasses are not covered. Hospital and anesthesia charges related to routine dental care for children under age 5, or those with disabilities, may be covered in addition to dental care related to some medical conditions. Medically necessary nutrition formulas are covered when used as the primary source of nutrition for enteral, parenteral, or oral nutritional therapy. Intraperitoneal nutrition therapy is covered for malnutrition as a result of end-stage renal disease. Vitamins may be reimbursed when used as a specific treatment of a medical condition. Additionally, prenatal vitamins that require a prescription may be reimbursed for prenatal care only. 21

22 Services or Procedures with Significant Limitations (continued) Gastric Bypass Genetic Testing Hearing Aids Service Laser/LASIK/Refractive Corneal Surgery Private Hospital Rooms Shoes, Shoe Inserts, Shoe Modifications, and Arch Supports Description This procedure is covered for the treatment of morbid obesity under certain limited circumstances. Testing is covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient. Routine genetic testing is not covered. Hearing aids are covered only for active duty family members who meet specific hearing-loss requirements. Surgery is covered only to relieve astigmatism following a corneal transplant. Private rooms are not covered unless ordered for medical reasons or because a semi-private room is not available. Hospitals that are subject to the TRICARE diagnosis-related group (DRG) payment system may provide the patient with a private room but will receive only the standard DRG amount. The hospital may bill the patient for the extra charges if the patient requests a private room. Shoe and shoe inserts are covered only in very limited circumstances. Orthopedic shoes may be covered if they are a permanent part of a brace. For beneficiaries with diabetes, extra-depth shoes with inserts or custom-molded shoes with inserts may be covered. ToP Prime and ToP Prime Remote Beneficiary Coverage Exclusions In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including behavorial health disorders), injury, or for the diagnosis and treatment of pregnancy or well-child care. All services and supplies (including inpatient institutional costs) related to a non-covered condition or treatment, or provided by an unauthorized Provider, are excluded. The following specific services are excluded under all circumstances. This list is not intended to be all-inclusive. Please visit for a full list of covered services, limitations and exclusions. Abortion (except in cases where the life of the mother would be endangered if the pregnancy were carried to term or when the pregnancy is the result of rape or incest) Acupuncture (may be offered at some military hospitals or clinics and approved for certain active duty service members, but is not covered for care received by civilian providers) Alterations to living spaces Artificial insemination, including in vitro fertilization, gamete intrafallopian transfer, and all other such reproductive technologies (except in very limited circumstances for some wounded, ill, or injured service members) Autopsy services or post-mortem examinations Birth control/contraceptives (non-prescription) Camps (e.g., for weight loss) Charges that providers may apply to missed or rescheduled appointments Counseling services that are not medically necessary in the treatment of a diagnosed medical condition (e.g., educational, vocational, and socioeconomic counseling; stress management; or lifestyle modification) Custodial care Diagnostic admissions Domiciliary care Dyslexia treatment Electrolysis Elevators or chair lifts Exercise equipment, spas, whirlpools, hot tubs, swimming pools, health club memberships, or other such charges or items Experimental or unproven procedures (unless authorized under specific exceptions in the TRICARE regulations) 22

23 Foot care (routine), except if required as a result of a diagnosed, systemic medical disease affecting the lower limbs, such as severe diabetes General exercise programs, even if recommended by a physician and regardless of whether rendered by an authorized Provider Inpatient stays: For rest or rest cures To control or detain a runaway child, whether or not admission is to an authorized institution To perform diagnostic tests, examinations, and procedures that could have been and are performed routinely on an outpatient basis In hospitals or other authorized institutions above the appropriate level required to provide necessary medical care Learning disability services Medications: Drugs prescribed for cosmetic purposes Fluoride preparations Food supplements Homeopathic and herbal preparations Multivitamins Over-the-counter products (except insulin and diabetic supplies) Weight reduction products Megavitamins and orthomolecular psychiatric therapy Mind expansion and elective psychotherapy Naturopaths Non-surgical treatment of obesity or morbid obesity Personal, comfort, or convenience items, such as beauty and barber services, radio, television, and telephone Postpartum inpatient stay for a mother to stay with a newborn infant (usually primarily for the purpose of breast-feeding the infant) when the infant (but not the mother) requires the extended stay, or continued inpatient stay of a newborn infant primarily for purposes of remaining with the mother when the mother (but not the newborn infant) requires extended postpartum inpatient stay Preventive care, such as routine, annual, or employmentrequested physical examinations; routine screening procedures; or immunizations (except as provided under the clinical preventive services benefit. See Clinical Preventive Services earlier in this section.) Psychiatric treatment for sexual dysfunction Services and supplies: Provided under a scientific or medical study, grant, or research program Furnished or prescribed by an immediate family member For which the beneficiary has no legal obligation to pay or for which no charge would be made if the beneficiary or sponsor were not TRICARE-eligible Furnished without charge (i.e., cannot file claims for services provided free-of-charge) For the treatment of obesity, such as diets, weight-loss counseling, weight-loss medications, wiring of the jaw, or similar procedures (See Services or Procedures with Significant Limitations earlier in this section.) Inpatient stays directed or agreed to by a court or other governmental agency (unless medically necessary) Required as a result of occupational disease or injury for which any benefits are payable under a worker s compensation or similar law, whether such benefits have been applied for or paid (except if benefits provided under these laws have run out) That are (or are eligible to be) fully payable under another medical insurance or program, either private or governmental, such as coverage through employment or Medicare (in such instances, TRICARE is the last payer for any remaining charges) Sex changes or sexual inadequacy treatment (except for the treatment of ambiguous genitalia that has been documented to be present at birth) Sterilization reversal surgery Surgery performed primarily for psychological reasons (such as psychogenic surgery) Therapeutic absences from an inpatient facility (except when such absences are specifically included in a treatment plan approved by TRICARE) Transportation (except by ambulance) X-ray, laboratory, and pathological services and machine diagnostic tests not related to a specific illness or injury or a definitive set of symptoms (except for cancer-screening mammography, cancer screening, Pap tests, and other tests allowed under the clinical preventive services benefit) SECTIoN 2 TRICARE overseas Program Benefits 23

24 SECTIoN 3: International SoS Network Providers and Provider Credentialing What is a Network Provider? Network Providers are Providers who have entered into a formal agreement with International SOS, have signed a Mutual Cooperation Protocol Agreement and supplied International SOS with their full credentials. Network Providers have agreed to provide cashless, claimless services to TOP Prime and TOP Prime Remote beneficiaries, submit the appropriate Standard U.S. Claim Forms on behalf of the TRICARE beneficiaries they treat, and provide medical services in line with TRICARE policy. Network Providers are added to International SOS database of Providers and will always be our first choice when referring patients to the host nation network. Network Providers will also be continually published on which can be accessed by all TRICARE beneficiaries. If a Provider wishes to participate in TOP, but does not wish to sign a Mutual Protocol Agreement with International SOS, they may agree to participate without the contract. These Providers will still be required to provide cashless, claimless services to TOP Prime and TOP Prime Remote beneficiaries, submit the appropriate Standard U.S. Claim Forms on behalf of the beneficiaries they treat, and provide medical services in line with TRICARE policy. They will also be required to provide International SOS with their license. These Providers will not be published on Becoming an International SoS Network Provider Becoming an International SOS Network Provider benefits both Host Nation Providers and TOP beneficiaries. When TOP Prime and TOP Prime Remote beneficiaries are referred for host nation care, they are referred to one of International SOS Network Providers. Network Providers are always International SOS first choice of Providers. International SOS TOP Provider Support Services staff is available 24 hours a day, 365 days a year to assist Network Providers. In turn, Network Providers offer a number of benefits to TRICARE patients: Patients feel confident that they are receiving quality care, because Network Providers credentials have been reviewed. Beneficiaries are more comfortable, because their Provider can directly or indirectly communicate with them in English. TOP Prime and TOP Prime Remote beneficiaries can receive cashless, claimless health care. How to Become an International SoS Network Provider We encourage you to contact your International SOS TOP Regional Call Center and press option #5 to speak with a TOP Provider Support Services staff member on how to become a Network Provider. For a full list of phone numbers, see page 7 of this TOP or visit Your Network Coordinator will provide you with all the information you need, along with a Mutual Cooperation Protocol Agreement between you and International SOS. Once you have reviewed the document, provided the required information (including your credentials), and both parties have signed the Mutual Cooperation Protocol Agreement, you may become an International SOS Network Provider. Examples of credentials include a copy of professional license, proof of malpractice insurance (where applicable), fee schedules and other information. Network Provider Responsibilities A detailed list of Network Provider responsibilities can be found in the International SOS Mutual Cooperation Protocol Agreement. Network Providers are expected to follow the guidelines below: Do not discriminate based on sex, race, color, creed or religion. Communicate directly or indirectly with patients in English. Identify and assist TRICARE patients who seek emergency care and properly authorized routine and specialty care. 24

25 Maintain health records for TRICARE beneficiaries and, whenever possible, make English-language summaries of these records available for inclusion in the beneficiaries U.S. military medical records. Promptly return consultation results to the referring Military Treatment Facility (MTF). Note: Routine consultation reports should be returned within 10 working days, emergency consultation reports should be returned within 24 hours. Keeping Your Provider File Current International SOS TOP Provider Support Services staff is committed to keeping Network Provider files current and accurate. Reviewing this information on an annual basis helps prevent confusion and avoid problems. Listed below are events that will require a yearly update to your Network Provider file: The address from which you provide care changes. Your billing address or other billing information changes. Your phone, fax, or other contact information changes. Your office hours change. Your credentials change or are renewed. In the case of these events, please contact your TOP Network Executive using the addresses below, or you can refer to page 7 of this TOP for your TOP Regional Call Center numbers and select option #5. Europe, Middle East & Africa providerseurasiaafrica@internationalsos.com Network Provider Quality Mission International SOS is committed to delivering quality medical care to all beneficiaries living overseas. By becoming a Network Provider, you can be proud to know that you are part of this mission. International SOS works with you to understand how problems can be corrected or improved. We also work with you to develop a plan for avoiding quality- or service-related problems in the future. The Mutual Cooperation Protocol Agreement, together with our ongoing development and maintenance of the Network Providers, helps International SOS ensure our quality performance. From time to time, you may be contacted by International SOS or TRICARE directly, to assess and monitor your overall satisfaction with TOP, including service, accessibility, Provider education and other topics. ToP Provider Support Services A dedicated team of administrators, nurses and quality staff dedicated to the TRICARE Overseas Program are available to assist you. The team is responsible for working with Providers in their respective countries, building and maintaining relationships and answering questions in local languages about TOP covered services, authorizations and submitting claims for payment. SECTIoN 3 International SoS Network Providers & Provider Credentialing Latin America and Canada providerslatinamerica@internationalsos.com Puerto Rico provider.inquiries.pr@internationalsos.com Asia-Pacific providersasiapacific@internationalsos.com 25

26 Access to Care International SOS is committed to ensuring that TOP beneficiaries have access to quality care with suitable wait times and other standards of service delivery. Below is an overview of these standards and guidelines, as established by TRICARE policy. Element Wait Time for an Appointment office Waiting Times ToP Access to Care Standards Definition When a TRICARE beneficiary contacts you to make an appointment, you are expected to follow the guidelines below for seeing the patient: Well-patient Visit or Specialty Care Referral: 4 weeks Routine Visit: 1 week Urgent Care: 24 hours When a TRICARE beneficiary comes in for their appointment, the office waiting time to see their clinician can be no more than 30 minutes unless the clinician s schedule is disrupted because of a medical emergency. Service Standard Well-patient: 4 weeks Routine: 1 week Urgent: 24 hours No more than 30 minutes Provider Credentialing Process With 25 years of experience in international health care and medical assistance services, and operations in 70+ countries, International SOS understands that health care delivery differs significantly from country to country. Factors such as local country legislation and regulations are considered, as well as existing health care infrastructure and any unique challenges that may impact the delivery of care in a specific region. International SOS takes these differences into account, when reviewing Provider capabilities and determining eligibility to participate in TOP. Country-specific credentialing guidelines are used and we work with host nation licensing agencies, to maintain accurate and up-to-date information about local standards. Provider performance is monitored on an ongoing basis so that potential problems can be addressed before they impact beneficiary satisfaction and quality of care. Provider satisfaction surveys are also used to monitor your overall satisfaction with International SOS, including how accessible or helpful our call center and TOP Provider Support Services staff is in assisting with claims processing, Provider education, and other topics. The following credentialing items are required to become an International SOS Network Provider: Availability of Emergency Services Providers of emergency care services are expected to be available 24 hours a day, 7 days a week. Emergency care Providers are selected based on their abililty to meet this requirment. If your availability changes, you must notify us immediately. 24 hours a day / 7 days a week Note: If you have any questions or concerns about your ability to meet these standards and guidelines, please contact International SOS. 26

27 Criteria Signed Provider Agreement Meet the Standards for Authorization Standards An International SOS Provider Agreement (Mutual Cooperation Protocol) must be signed, in order to become a Network Provider. All health care services for TOP Prime and TOP Prime Remote beneficiaries are provided on an authorized basis. You will be expected to accept International SOS authorization for services, and agree to submit claims and invoices for payment to International SOS, through our subcontractor Wisconsin Physicians Service (WPS). You agree not to balance bill a TOP Prime or TOP Prime Remote beneficiary for uncovered services. Valid Malpractice Insurance (If Applicable) Licensure/Registration Evidence of Professional Qualifications and Experience You must have professional liability insurance, if this is required by the laws of your respective host nation. If you are a country, state, province, etc., entity Provider, and you are self-insured, then you are not required to have malpractice insurance. You must meet the requirements for licensure/registration as specified by your local governmental authority or licensing board. This includes having a valid license or registration in the host nation where you practice. You must be a graduate of an accredited program in health care sciences. This includes completing a certificate (residency) program, leading to certification in general medicine, family practice, gynecology, pediatrics, dentistry or other disciplines/specialties recognized by the applicable certifying agency in your country. SECTIoN 3 International SoS Network Providers & Provider Credentialing English Language Proficiency You must be able to proficiently communicate in English (both verbally and in writing), or to provide English translation and interpretation services at the time of service. Beneficiary Access to ToP Network Providers All Host Nation Providers with a signed Mutual Cooperation Protocol Agreement and approved credentials on file with International SOS will be published on and displayed for beneficiaries. The published list of Network Providers is matched with International SOS internal database, so it is important that you keep all of your information up-to-date. TRICARE beneficiaries using the website have the comfort of knowing that listed Providers are quality assured and recommended for care locally. Detailed information about referrals and authorizations is also included on this website, making Provider selection easier and more convenient for beneficiaries. Note: If you would not like your Provider information published, please contact your TOP Regional Call Center and select option #5 to speak with a member of the TOP Provider Support Services staff. 27

28 SECTIoN 4: Authorizations and Seeing TRICARE Patients Effective September 1, 2010, Providers will receive authorization from International SOS before providing care to TOP Prime and TOP Prime Remote beneficiaries. Prior authorization is required for certain procedures and inpatient hospital admissions, including patient rehabilitation and skilled nursing facilities. Authorizations are based on medical necessity and are not a guarantee of payment. This section explains the authorization process and what you can expect when seeing TRICARE patients. How Are Patients Referred to You? ToP Prime and ToP Prime Remote Beneficiaries TOP Prime and TOP Prime Remote beneficiaries should first visit their Primary Care Manager when seeking medical care. ToP Prime Beneficiaries: For TOP Prime beneficiaries, the Primary Care Manager is typically based at a Military Treatment Facility (MTF). If the MTF does not have the capability to provide the necessary care, they will refer the beneficiary to a Host Nation Provider. ToP Prime Remote Beneficiaries: International SOS acts as the Primary Care Manager for TOP Prime Remote beneficiaries and can authorize and refer these beneficiaries to Host Nation Providers for primary and secondary care. Host Nation Providers receive authorization directly from International SOS, to ensure that the services are covered. The authorization will be sent to the Network Provider via fax or secure . The beneficiary will also be informed when the authorization has been sent. TOP Prime and TOP Prime Remote beneficiaries may only receive care from a Network Provider. After the authorization has been issued, the beneficiary may contact the Network Provider directly to schedule an appointment. ToP Standard Beneficiaries TOP Standard beneficiaries may seek care from any Provider they prefer. They are required to pay and claim for any medical care they receive from a Host Nation Provider. Standard beneficiaries often prefer to seek care from a TOP Network Provider, because of the guaranteed quality of care they will receive. Host Nation Providers may offer to file a claim on behalf of the TOP Standard beneficiary and bill them for the balance owed. However, you are not required/obligated to do this. Additional information about submitting claims can be found in Section 5 of this TOP as well as online at Note: TOP Prime and TOP Prime Remote beneficiaries may come to your office without an Authorization Form. If a TRICARE beneficiary requests non-emergent health care at your facility without prior TRICARE authorization, the claims submitted for these services may be denied. Determining Patient Eligibility for Authorized Care You will receive an Authorization Form for TOP Prime and TOP Prime Remote beneficiaries that are eligible for cashless, claimless care under TOP. The authorization will state TRICARE Authorization Form in the title and specify whether the authorization is for a TOP Prime or TOP Prime Remote beneficiary. It will also specify what type of care is being authorized. Before an Authorization Form is issued, International SOS will verify the patient s eligibility to receive care from your facility. The Authorization Form will have a unique identification number (Authorization Number), which will be located on the top right section of the form. The Authorization Form will indicate the name and address of your facility, and will also contain the first name, surname and date of birth of the patient eligible for care. 28

29 To confirm a TRICARE beneficiary s eligibility, Providers should ask to see both of the following: TOP Prime Enrollment Card and U.S. Military ID or CAC It is important to verify that the name on both cards matches exactly, and that the photo on the U.S. Military ID Card or CAC accurately represents the patient. Providers should also check: The expiration date on the U.S. Military ID Card or CAC (to ensure that coverage is still valid) The sponsor s Social Security Number (this will always be in the same format: XXX-XX-XXXX) or the Department of Defense (DOD) Benefits Number (this can be found above the bar code on the back of the beneficiary s ID card and will be in the following format: XXXXXXXXX-XX). Only the first 9 digits of the DOD Benefits Number will be needed for the Provider to verify eligibility. You can also call your International SOS TOP Regional Call Center for assistance, if you are unsure. Note: International SOS will only issue a TRICARE Authorization Form for TOP Standard beneficiaries for the following types of medical care, which do require prior authorization: Adjunctive Dental Services Home Health Services Hospice Care Non-emergency Inpatient Admissions for Substance Use Disorders or Behavioral Health Care Outpatient Behavioral Health Care Visits Beyond 8th Visit per Fiscal Year (10/1-9/30) Transplants (all solid organ and stem cell) The TRICARE Standard Authorization Form will be issued to the MTF and the TOP Standard beneficiary. The TOP Standard beneficiary may give this to the Provider when they seek medical care. TOP Standard coverage is available to the family members of Active Duty Service Members (ADSM) living and working overseas. TOP Standard enrolled beneficiaries manage their own health care and also have the freedom to choose any Host Nation Provider they wish to see. TOP Standard beneficiaries receive reimbursable health care, after meeting their annual deductible payment and cost-sharing obligations. This means that the beneficiary will pay the first portion of costs toward health care services received each year (the annual deductible). After this portion is paid, the beneficiary is responsible to pay a certain percentage of each medical bill they receive TOP Standard beneficiaries who are Active Duty Family Members (ADFM) pay 20% of the total cost and Retirees 29 pay 25% of the total cost. Once the beneficiary has contributed over a determined limit (i.e., they reach their catastrophic cap), TRICARE will pay all medical costs for the remainder of the financial year. TOP Standard beneficiaries will not be issued a TRICARE Enrollment Card. They will only have a Military ID Card. As a Host Nation Provider under TOP, your commitment is to provide cashless, claimless services to TOP Prime and TOP Prime Remote beneficiaries only. You are not obligated to provide similar services to TOP Standard beneficiaries. Depending on your location, you may experience a large number of TOP Standard beneficiaries living and working in your region. If you decide to provide services to these beneficiaries, you may do so in one of the following two ways: Request TOP Standard beneficiaries to pay the cost of treatment upfront. This means the TOP Standard beneficiary will be personally responsible for claiming reimbursement from TRICARE. File the claim on behalf of the TOP Standard beneficiary (using the CMS 1500 for Non-Institutional Providers or UB-04 Claim Form for Institutional Providers) and bill the patient directly for the patient responsibility amount. Note: Providers should be prepared to collect required beneficiary cost shares at the time of service delivery. The most up-to-date beneficiary cost-share information can be found online at Providers registered to the Provider Portal can also check patient eligibility on by entering the sponsor s Social Security Number or DOD Benefits Number, and date of service. Additional information on understanding the Provider Portal can be found in Section 6 of this TOP. Based on your location, you may see TOP Prime, TOP Prime Remote and TOP Standard beneficiaries. TOP Standard beneficiaries are required to pay upfront and submit their claims for reimbursement. As a TRICARE Overseas Provider, you are not required to file claims on behalf of TOP Standard beneficiaries. If you would like to offer this service, you are responsible for ensuring that any cost shares or deductibles are collected from the TOP Standard beneficiary by your facility. Note: When submitting claims on behalf of TOP Standard beneficiaries, Providers must invoice for the full amount charged. If the Provider submits an invoice for only the balance (after the TOP Standard beneficiary has paid their deductible and cost share), International SOS will apply the deductible and cost share to the balance, as required by TRICARE policy. Therefore, International SOS will need the Itemized Invoice to reflect the full cost of medical care (i.e., the total invoiced amount). Please visit for additional information about how to handle TOP Standard claims for reimbursement. SECTIoN 4 Authorizations and Seeing TRICARE Patients

30 Authorization Forms International SOS will send an Authorization Form to you and the referring MTF along with a pre-populated Claim Form (see Section 5). The Authorization Form will include your contact information (as the Network Provider), the patient s name, date of birth, and instructions regarding the scope and validity of the authorization. The Authorization Form will also include the name of the MTF referring the care. A sample TRICARE Authorization Form is included on the following page, as well as in Section 7 of this TOP Provider Manual. A specific Authorization Form will be issued depending on whether a beneficiary is a TOP Prime or TOP Prime Remote patient. Authorization Forms will also vary depending on whether the beneficiary is receiving inpatient or outpatient care. A separate Authorization Form will be needed for TOP Prime Remote ADSM before receiving dental care. Below is a brief description about the fields you will find on an International SOS Authorization Form. You will need this information before delivering health care services. Priority Care this will either state Urgent or Routine Urgent: An appointment must be provided within 24 hours of the beneficiary s request for care. Note: For urgent care, medical results and any consult notes must be sent to the referring party, either the MTF or International SOS, within 24 hours. The referring party s contact details are indicated on the Authorization Form. Routine: An appointment must be provided within 1 week of the beneficiary s request for routine care and within 4 weeks of the beneficiary s request for specialty care. Note: For routine care, medical results and any consult notes must be sent to the referring party, either the MTF, the assigned Primary Care Manager (in Puerto Rico) or International SOS, within 10 days. Specialty required Preliminary diagnosis from referring physician Scope of care this will either state Evaluate or Evaluate and Treat Evaluate: You are authorized to evaluate only, using diagnostic tools such as laboratory tests, consultation, X-rays (to determine appropriate treatment). Evaluate and Treat: You are authorized to both evaluate and treat the patient. A separate Authorization Form will be provided for surgical procedures and inpatient care, if admission is required as part of the treatment. Please notify the MTF or International SOS if this is the case. Detailed Instructions Inclusions Note: If you have any questions about the medical care that is being authorized, please call International SOS before delivering service. Note: The authorization will indicate how long it is valid. Authorizations are typically valid for 90 days. If your treatment dates exceed the time the Authorization Form is valid, please contact International SOS or your local MTF to obtain a new Authorization Form. Note: To access the full terms and conditions of the Authorization Form, please visit You may also contact your International SOS TOP Regional Call Center and press option #5 to request a copy of the terms and conditions. 30

31 TRICARE AUTHORIZATION FORM FOR OUTPATIENT CARE TRICARE PRIME BENEFICIARY To: <<Provider Name>> <<Provider Address>> <<Provider City>> <<Provider Country>> Tel: <<Provider Phone Number>> Fax: <<Provider Fax>> Authorization Number: <<0NTL 22221>> Date: 14 April 2010 Pages: 1 SERVICE(S) REQUEST IN RESPECT OF: <<Beneficiary Name >> <<Beneficiary DOB>> This is to confirm the Authorization for the above patient at <<Provider Name>> for outpatient care. This Authorization is only valid between <<April >> and <<July >>. Priority Specialty Preliminary Diagnosis Number of Visits Scope Instructions: <<Routine/ Urgent>> <<Specialty Required>> As per referral <<Preliminary Diagnosis>> <<Number of allowed visits>> <<Evaluate and Treat>> <<Evaluate and Treat>> Inclusions: Further to medical information received, International SOS authorizes all reasonable, customary and necessary medical expenses within the scope of the approved authorization. Medical Reports: Please send a written medical report and discharge summary to the below addressee after this patient s episode of care / procedure. Please follow any special arrangements you may have between you and the Military Treatment Facility (MTF). <<International SOS>>, Fax: <<International SOS Fax Number>> <<International SOS Address>> SECTIoN 4 Authorizations and Seeing TRICARE Patients Priority: For urgent medical appointments please return a copy of medical results within 24 hours. For routine appointments please return a copy of medical results within 10 calendar days. Important: An authorization is issued for requested services, procedures, or admissions that require medical necessity review prior to services being rendered. The terms of this Authorization are only applicable to the specific service provider indicated above and to this instance of service requested. Billing Instructions: If the Beneficiary has "other" healthcare coverage in addition to TRICARE, the "other" healthcare coverage is the Primary Insurer. All invoices must reach us within 12 calendar months from date of service to avoid denial of settlement. An itemized invoice accompanied with a duly completed Claim Form and a copy of this Authorization Form is to be sent to the following address. : <<International SOS Claims Department>> <<Claims Department Address>> For full terms and conditions of this Authorization Form, please refer to Alternatively, you may contact our office for a copy of the terms and conditions. Yours sincerely <<TRICARE TEAM>> TRICARE Department 31

32 Authorization Forms (continued) Authorizations for Cases of Pregnancy All care related to pregnancy and childbirth is covered by one referral from the MTF. Authorization Forms will be issued to for 365 days to the OB/GYN or Medical Practitioner covering care. If any pregnancy and childbirth care (e.g., ultrasound scans) is to be conducted by other Providers, additonal Authorization Forms may be requested. The beneficiary or Provider should contact International SOS directly to request additional Authorization Forms. Patient Records and Privacy International SOS Network Providers must maintain medical health records for all TRICARE beneficiaries they treat. These records should be protected as stipulated by an addendum to the Mutual Cooperation Protocol. When possible, Network Providers should provide English language summaries of their records for inclusion in the patient s U.S. military medical records. If you have any questions or need assistance in maintaining these records, please contact your TOP Regional Call Center or International SOS. Emergency Assistance Treatment and Authorizations and Payment If a TOP Prime or TOP Prime Remote beneficiary is unable to contact International SOS before receiving emergency care, then no Authorization Form or Authorization Number will be issued. The medical services rendered will be authorized retrospectively. Authorization Forms are not required to treat beneficiaries for Emergency Care. However, the words Emergency Care or Emergency Room must be written on the Claim Form or Itemized Invoice so that these claims are processed without an Authorization Number. Please refer to the TOP Provider Emergency Care brief available at for more information on how to receive retrospective authorization and submit your Emergency Care claims on behalf of TOP Prime or TOP Prime Remote beneficiaries. Clear and Legible Reporting: Issuing a Medical Report Following Patient Care After providing care to a TRICARE beneficiary, please send a medical report of your findings and/or treatment to the referring party. The Authorization Form will clearly indicate whether this should be returned to your local MTF (for TOP Prime beneficiaries) or International SOS (for TOP Prime Remote beneficiaries). Cultural Differences and Host Nation Patient Liaisons Health care delivery in the United States may vary from local overseas practices. Language is the most obvious and challenging difference. Even if your English language skills are considered strong, it is important that any care instructions are clear and fully understood by the patient. You should be aware, language differences may discourage some patients from asking questions when they don t understand. U.S. patients may have a high degree of modesty and find cultural differences in personal privacy to be uncomfortable, particularly in the hospital setting. Curtains or privacy screens are expected in hospital rooms and examination rooms in the U.S., and U.S. patients may find it very difficult to undress (to any degree) without them. To help make care more comfortable for TRICARE beneficiaries, most MTFs use one or more host nation patient liaisons. These liaisons are fluent in English as well as the local language, and are familiar with how the host nation health care system works. Their primary role is to assist U.S. patients in a hospital setting. They may also be used to assist with particularly difficult outpatient situations. You may already have an existing relationship with your local host nation patient liaison. You can be assured that this relationship will not be interrupted or changed in any way with TOP. 32

33 SECTIoN 5: Provider Claims Information As a TOP Host Nation Provider, you will be able to choose one of four methods for submitting your claims. A Standard U.S. Claim Form is required when submitting TRICARE claims for reimbursement. International SOS has designed its systems to support you with this process, by generating a partially completed Claim Form. You will receive this partially completed Claim Form with each authorization issued. This Claim Form must be submitted with an Itemized Invoice for services rendered. All Host Nation Providers will be required to submit a Standard U.S. Claim Form along with the invoice for reimbursement: Non-Institutional Providers will be required to submit a CMS 1500 Claim Form (see Section 7) Institutional Providers (e.g., hospitals) will be required to submit a UB-04 Claim Form (see Section 7) International SOS TOP Provider Support Services staff will work with you to show you how to complete the Claim Form properly. Detailed step-by-step instructions and tools are available, to help simplify the process of filling out and submitting Claim Forms. Process for Submitting Claims You can submit your claim using any of the following four methods: 1.) online Claim Submission: This is the preferred method for claims submission, as it significantly reduces the amount of time it takes for a claim to be received by our TOP Claims Processing Department and therefore can result in faster payments. Providers do not need to complete a paper Claim Form or produce an Itemized Invoice when using the Online Claim Submission method. After submitting your claim electronically, it can be tracked within 12 business hours. Note: A signed Electronic Data Interchange (EDI) Form must be submitted to International SOS before your claims can be submitted using the Online Claim Submission method. 2.) Secure Message Transmission: This claims submission method allows Providers to upload and send their claims and invoices via a Secure Messaging System. Claim Forms submitted using Secure Message Transmission can be tracked within 15 days of receipt. Providers must still complete the appropriate paper Claim Form and produce an Itemized Invoice when using this method of submission. 3.) Fax: This method should be used if the Provider does not have an Internet connection. This method will only work if the fax transmission is legible. Quality can be impacted by fax transmission and phone line connection. This method is also subject to overseas toll charges. Note: Fax submission is still faster than overseas mail. 4.) overseas Mail: This method should be used only when the other three claims submission methods (above) are not available. Depending on where the Provider is located, using overseas mail can significantly increase the amount of time it takes for claims to be received by our TOP Claims Processor and therefore can result in delayed payment. The following table details the benefits of each claims submission method: Benefits of Each Claims Submission Method Preference Submission Method #1 #2 Online Claim Submission Secure Message Transmission #3 Fax #4 Overseas Mail Internet Connection Cost Speed Tracking Claims Required Required Not Required Not Required None None $$ $ Received immediately Received immediately Received immediately Time it takes for claims to arrive depends on Provider s location Within 12 business hours of receipt Within 15 days of receipt Within 15 days of receipt Within 15 days of receipt SECTIoN 5 Provider Claims Information 33

34 Mail You can submit a Claim Form, along with the Itemized Invoice, by mail. Claim Forms and invoices can be sent in any language, in any currency. If you receive an Authorization Form from International SOS, the proper mailing address will be included on this form. For Active Duty Service Members (ADSM), all completed paper Claim Forms and Itemized Invoices can be mailed to: TRICARE overseas Program P.O. BOX 7968 Madison, Wisconsin USA For all other beneficiaries in the Eurasia-Africa Region, all completed paper Claim Forms and Itemized Invoices can be mailed to: TRICARE overseas Program P.O. BOX 8976 Madison, Wisconsin USA For all other beneficiaries in the Pacific Region and Latin America Region, all completed paper Claim Forms and Itemized Invoices can be mailed to: TRICARE overseas Program P.O. BOX 7985 Madison, Wisconsin USA Web-based Claims Submission options There are two Web-based claims submission options available Online Claim Submission and Secure Message Transmission. To use either of these options, you will need to register on the Provider Portal online at to obtain a username and password. Additional information about how to register and use the Provider Portal can be found in Section 6 (page 69) of this TOP. Note: Providers who do not have Internet access will need to submit their claims via overseas fax or overseas mail. Secure Message Transmission The first web-based option is Secure Message Transmission. Once you become a registered Provider on the portal, you can upload a scanned copy of the completed paper Claim Form and Itemized Invoice. Below is the screen that will appear when you log onto Click here to submit claims using Secure Message Transmission. Note: Due to the lead time involved with overseas mail, submitting your claims via overseas mail may result in delayed payment. Fax Claim Forms and invoices can be faxed in any language, in any currency. You can submit a Claim Form, along with the Itemized Invoice, to the following fax number: Note: All claims must be sent to this fax number, which is equipped to handle large volumes of faxes. Additionally, any claims-related correspondence can be faxed to: Note: Claims sent to this correspondence fax number will not be processed for reimbursement. 34

35 Secure Message Transmission: Compose a Message To send a message to the TOP Claims Customer Service Department, you can click the Compose Message button. Selecting the Compose Message button allows you to see a subset of message subjects to select: New Claim, Claim Status, General, Eligibility, or Appeals. Each message type has a set of input fields where you will supply information that will help the TOP Claims Customer Service Department assist in the resolution of your inquiry. { Here you can see a record of other claims which have been previously sent and processed. SECTIoN 5 Provider Claims Information Note: There is also the quick button option Send New Claim to submit your claim via Secure Message Transmission directly. Full instructions on how to submit claims via Secure Message Transmission are included in this section, see page

36 The Secure Message Transmission method available through your secure account on allows you to submit messages directly to the TRICARE Overseas Program (TOP) Customer Service department. To access your secure messages, select the Secure Message button in the top navigation bar to be taken to your secure message inbox. Your Inbox is a record of inquiries you have made to the TRICARE Overseas Program via the secure messaging service and replies received from our Customer Service department. The Secure Message Inbox tab will display all messages currently in your secure message account. The Inbox view uses the following display format: Check Box: This box is used to mark messages for deletion. Only use this box when you want to delete a message from your Inbox. You can select an individual message or multiple messages for deletion. Deletion of messages is permanent. Date: Date of last action on the message. Date format is MM/DD/YYYY. By default, messages will display in your Inbox in the order of most recent date to oldest date. Subject: This field displays the message subject. The message subject is set to the inquiry type you select when composing the original message. Subject options include only the following: New Claim Claim Status General Eligibility Appeal Status: The Status field will display one of the following two options: Sent: These are messages you have composed and sent to the TRICARE Overseas Program that have not yet been viewed by our Customer Service department. Received: The received status appears when your sent message has been reviewed by the Customer Service department. Note that the column heading can be clicked to sort the view of your Inbox by Date, Subject, or Status. The New Messages tab of the mailbox uses the same format as the Message Inbox tab, but will only display messages with a status of Sent, allowing you to see only those messages to which the Customer Service department has not yet replied. Your Inbox will store up to a maximum of 2,500 messages. To avoid potential issues with your secured mail account, be sure to manage your mail to not exceed this limit. 36

37 Secure Message Transmission: New Claim The Send New Claim button is used when you want to submit a claim (as an attachment) to the TOP Claims Processor using the Secure Message Transmission method. Note: A New Claim message can be initiated by selecting the Send New Claim button OR by selecting the Compose Message button and then choosing New Claim as the message subject. When sending a new claim, you will see there is a notice informing you of what information you will need in order to successfully send a New Claim via the Secure Message Transmission method. This includes: Claim information: Such as provider location (e.g., country of origin, billed charges and currency). Electronic Copy of a Signed Claim Form or Signed Claim Development Worksheet: You will need this to upload during the Secure Message Transmission process. Patient Information: Including patient name, sponsor s SSN, and beginning and ending dates of service. SECTIoN 5 Provider Claims Information Once you have the information available, click the Get Started Sending a Secure Online Claim button at the bottom of the screen to begin the Secure Message Transmission process. 37

38 Secure Message Transmission: New Claim/Claim Information Upload Attachments: You must upload at least one of the following: UB-04 Claim Form CMS 1500 Claim Form Claim Development Worksheet *Attachments uploaded through the site, including the claim form or worksheet, must be in one of the file formats listed under the Attachments field. There are additional attachment fields available for uploading other documents to accompany your claim. These additional attachment fields are optional. The screen will update to display the data fields you need to fill in along with the basic claim summary data fields for uploading the claim form and any additional attachments you wish to provide. Note: All fields are required unless otherwise noted: Location: Select the physical location address where the service took place. Total Billed Charges: Enter the sum of all charges on the claim form or worksheet. Currency Type: Enter the name or code of the currency in which the claim charges are listed. Note: If the beneficiary has other health insurance, the claim will be paid in $USD (United States Dollars) regardless of the currency type listed here. Invoice Number: This is an optional field to enter your office s internal tracking number for the claim or bill. When all necessary fields are entered and your attachments have been uploaded, click Next. 38

39 Secure Message Transmission: Patient Information On the Patient Information screen, you will be asked to provide the following patient information: Sponsor Social Security Number (SSN): Select the patient s benefit type from the drop down menu and then enter the corresponding benefit number in the text field to the right. Patient First Name and Patient Last Name: Enter the patient s first and last names in the corresponding fields. Beginning Date of Service: Enter the earliest date of health care service as it is listed for the procedures being submitted on this claim. The date must be entered in MM/DD/YYYY format or you can click the calendar icon to select the date. Ending Date of Service: Enter the last date of health care service as it is listed for the procedures being submitted on this claim. This date must be entered in the MM/DD/YYYY format or you can click the calendar icon to select the date. Click Next. SECTIoN 5 Provider Claims Information 39

40 Secure Message Transmission: New Claim/Confirmation If you need to make changes to either the Claim Information section or the Patient Information section, click the Edit button next to the section that requires changes. A Confirmation screen summarizing the data you entered will appear. Verify the information you provided. If all of the information is correct, click Submit to send your claim to the TOP Claims Processor. When you click Submit the screen will update to confirm that your TOP Claim has been successfully submitted via the Secure Message Transmission method. You will also receive an automated response confirming your Secure Message Transmission. The automated response will summarize the claim data you entered and will also provide you with the TOP claim number for your claim. The TOP claim number can be used to track the progress of your claim through the Claim Status and Claims Report functions available in your secured account area. Note: The Secure Message Transmission function should only be used to submit ONE claim per each secure message. 40

41 Claim Forms can be submitted in any language and invoices in any currency. Only one claim can be submitted per Secure Message Transmission transaction (the secure Provider portal will allow a maximum of 15MB total). The following formats are accepted:.doc,.xls,.jpg,.jpeg,.tf,.tiff or.pdf. The claim will be entered into the TOP Claims Processor s system and can be tracked on the Secure Claims Portal using the patient s name, the sponsor s Social Security Number, DOD Benefits Number, DEERS Family ID, and DOB or Dates of Service. Claims will be available for you to review within 15 days of receipt. Secure Message Transmission through the Secure Claims Portal can be used to submit claims for TOP Prime and TOP Prime Remote beneficiaries. This transmission method can also be used if the Provider chooses to submit claims on behalf of TOP Standard beneficiaries. Note: Claims may not be ed to International SOS directly. If Claim Forms and Itemized Invoices are ed to International SOS directly, they will not be processed. online Claim Submission Note: Standard Web-based submission software packages such as PC-Ace require that all claims are submitted in U.S. Dollars. These packages are most suitable for Providers located in U.S. Territories familiar with Standard U.S. Claim Form procedures. For this reason, International SOS has developed a customized claims submission program, which is available on the un-secure Provider portal. User-friendly field descriptions and built-in prompts are used on this site to assist Providers in submitting claims. When using the Online Claim submission option, claims can be tracked within 12 business hours of receipt. This portal also allows Providers to submit claims in certain foreign currencies. Using the Provider Portal to submit claims electronically is the recommended option for overseas Providers. This option significantly reduces the amount of time it takes to process payments. To use Online Claim submission, you must first sign an Electronic Data Interchange (EDI) Agreement. The EDI Form is effectively a record of your signature on file for each claim that you submit through the portal. This form can be obtained from your International SOS TOP Provider Support Services staff, or it can be downloaded from A sample EDI Agreement Form can be found on page 105 of this TOP. All EDI Agreements are subject to acceptance by International SOS and Wisconsin Physicians Service (WPS). The second Web-based claims submission method is also available via the Secure Claims Portal on This portal has a custom-built Online Claim submission option, which can be used to submit TOP Claims. Alternatively, Providers may download and submit claims using other Web-based submission software, such as PC-Ace. PC-Ace is available free of charge from International SOS. Please contact your TOP Regional Call Center and press option #5 to speak with a TOP Provider Support Services staff member to request this software. Claim Forms and Itemized Invoices are not required when submitting claims electronically through the Secure Claims Portal. Instead, Providers will be prompted to enter the claim data using ICD diagnosis codes and CPT procedure codes. These requirements vary slightly, depending on whether the claim is for an Institutional or Non-Institutional Provider. Finally, a clearing house or billing agency can be used for claims submission. In this case, it is the Provider s responsibility to supply all required paperwork for accurate, complete processing of claims. If a clearing house or billing agency is used, a CMS 1500 Form or a UB-04 Form is still required. Note: Please visit to download a Computer Based Training Module on Web-based Online Claim submission of TOP claims. SECTIoN 5 Provider Claims Information 41

42 online Claim Submission: Select a Location The Secure Claims Portal has field descriptions and built-in prompts that will assist you while entering the claim electronically. If you choose to submit claims using this website, you will see the following page after you log-in and click Online Claim. Your screen will update to display the Online Claim submission page. The Select Location section of the page displays a Submit Claim tab which lists all current locations for which you have an agreement for electronic claim submission. Click the radio button in the Submit Online column that corresponds to the location where the medical services were rendered. Note: If you have a location on file with the TOP Claims Processor but do not have an electronic claims submission agreement for that location, you can see that location by clicking on the Need Web Claim Submission Agreement tab. On that tab you can also request electronic claims submission by clicking on the Sign Up link for those locations. If the location where the services were rendered does not appear on either the Submit Online tab or the Need Web Claim Submission Agreement tab, you can add the location by clicking the Request a New Location link. 42

43 online Claim Submission: Select a Patient Scroll down the page to the Select Patient section. In this section, you can search for patients by using their TRICARE Sponsor Social Security Number (SSN) or DEERS Family ID as indicated on the patient s Military ID card, which the patient should always carry with them. This search function will return a list of beneficiaries, their date of birth, and gender indicator based on the ID number. You can select the correct patient for your claim by clicking the Radio button in front of their name. You have the alternative of selecting from a list of recent patients from claims you have submitted to the TOP Claims Processor. Click the Choose from Recent Patients tab, select the letter that corresponds with the first letter of the patient's last name, and view a list of your recent TRICARE patients on screen. Note: If your search does not return any results, you will not be able to use the Online Claim submission feature through unless your patient is under 1 year of age. If your patient is a TRICARE beneficiary under 1 year of age and their name does not come up in a search result, select the I am unable to find an eligible child under 1 year of age button and complete the First Name, Last Name and Date of Birth fields for this patient. Select the patient from this list by clicking the Radio button in front of the patient's name. After selecting the patient for your claim, click Next. SECTIoN 5 Provider Claims Information 43

44 online Claim Submission: Verify a Patient Please verify that this is the patient s current and correct address. If you have a more current address for the patient, select the Edit button next to the address and input the up-todate correct address you have on file. This will help expedite the claims process. The selected patient's name, date of birth, gender indicator and address will appear on the screen. Please verify that this is the patient that corresponds with your TOP Claim before proceeding. Note: If the TOP Claims Processor has information that indicates the patient may have Other Health Insurance (OHI) that should pay on the claim before TRICARE makes payment, you will receive a notice. If your patient does have OHI that should be paying, you will be responsible for entering the OHI payment information when completing the Claim Information section. You have the option to attach an invoice number or code used by your office to identify this claim. To use this feature, enter your invoice or tracking number in the open field provided. A maximum of 20 characters are allowed for the invoice number. Note: Adding an invoice number or code will allow you to easily track this claim on the Secure Claims Portal as you will be able to use the invoice number or code to search for the claim and view its processing status. Once you ve verified the patient data, click Next. 44

45 online Claim Submission: Enter Claim Information If you do not know the ICD diagnosis codes for the patient's diagnosis, you can use the Code Lookup feature and search for the code by its description. To use the Code Lookup: Click on Code Lookup The Diagnosis Lookup pop-up box will appear Type the description of the diagnosis in the box Click the Search button A list of descriptions containing your search word will appear. The ICD code corresponding to each description appears in the column to the left of the description. Find the diagnosis description for your claim and then click the code to the left to enter it into the Diagnosis field of the online claim form. The Claim Information page is where you begin entering the data about the health care encounter. Required fields are indicated with an asterisk. In the Diagnosis section, enter the ICD diagnosis codes that correspond to the reason the patient needed medical care. If you know the ICD code that represents the patient's diagnosis, it can be keyed directly into this field. Note: The Principal DX, or diagnosis, field is required for claims processing. There are seven additional fields for entering other diagnoses describing the patient's condition. These additional fields are optional. Select the Assignment of Benefits indicator. Select Yes if you want to receive reimbursement directly from TRICARE. If the patient made a payment to you for services on this claim prior to this claim being submitted, you must indicate their payment amount in the Patient Paid field. The amount entered here should be given in the currency you will select below. However, if the patient has OHI, the Patient Paid field must be completed in $USD (United States dollars). Note: This is a required field and must be completed, so if there is no patient payment prior to claim submission, enter zeroes ( ) in these fields. In the field Patient has Other Health Insurance (OHI), if the patient does not have another health insurance paying you for this claim (i.e., before TRICARE will pay), select No and continue to the next section of the form. SECTIoN 5 Provider Claims Information 45

46 If the patient does have another health insurance paying before TRICARE select Yes. When you select Yes the screen will update to display 3 additional fields to provide the payment information from the OHI: other Health Insurance Allowed Enter the amount the OHI indicated as its Allowed amount for the entire claim. Enter this amount in $USD (United States Dollars). other Health Insurance Paid Enter the amount the OHI paid for the entire claim. Enter this amount in $USD (United States Dollars). other Health Insurance Payment Reason The OHI will typically provide a code or comment explaining how they processed the claim. Click the Look Up and from the pop-up box, select the reason that matches the OHI explanation. Either Deductible, Copay/Cost Share, Non-Covered Service or Other. Note: This is a required field when there is OHI, so if there is no payment reason from the OHI or if there isn t one that matches these choices, select Other. Be aware that claims transactions involving OHI must be conducted in $USD (United States Dollars). The currency type for the claim will default to $USD and cannot be changed. If you previously entered a patient payment amount in a currency other than $USD, please return to that field and enter the correct amount for $USD currency. You can select a currency type for the claims transaction from a drop down menu. However, if the claim transaction does include OHI, this option will not be available as the claim transaction with OHI must be in $USD. online Claim Submission: Claim Line Item Form To use the Lookup feature: Click on Code Lookup The CPT/HCPCS Lookup pop-up box will appear Type the description of the procedure in the box Click the Search button A list of descriptions containing your search word will appear. The code corresponding to each description appears in the column to the left of the description. Find the diagnosis description for your claim and then click the code to the left to enter it into the CPT/ HCPCS field of the online claim form. 46

47 The Claim Line Item Form section is for entering the details about the medical services and/or supplies provided during the health care encounter. The Claim Line Item Form section is not a summary section: you can enter multiple procedures per claim. Each procedure will have its own claim line. Note: Required fields are indicated with an asterisk. Begin by entering the dates of service for the procedure. Dates of service can be typed directly into the From and To fields or you can use the calendar icon to select the dates of service. Note: The required format for the Dates of Service fields is Month, Day and Year. Enter the Current Procedural Terminology (CPT) code or the Health Care Procedure Coding System (HCPCS) code that represents the medical procedure or service that was performed. If you know the code representing the procedure or supply, you can type it directly into this field. The Modifier field is used to enter 2 character codes that represent additional descriptors or clarifiers to the procedure performed. The modifier is not a required field and can be left blank. The National Drug Code field is for listing the code the United States Food and Drug Administration assigns to any marketed prescription drug or insulin. This field is not required and should be left blank unless the medical procedure code entered in the CPT/HCPCS field represents a prescription drug or insulin. The Anesthesia field should be checked Yes only if the code entered in the CPT/HCPCS field represents anesthesia. If you selected Yes here, the Units field should be entered with the number of minutes anesthesia was administered. The Units field is for entering the number of times the procedure in the CPT/HCPCS field was performed during the dates of service OR it should represent the number of units of the supply provided. Note: If the procedure or supply is a prescription or injection and the National Drug Code was also provided, enter the National Drug Code quantity in this field and not the HCPCS quantity. If you selected Yes in the Anesthesia field, the number of units should be the number of minutes billed for anesthesia. The Charges field is used to enter the amount you are billing for the procedure or service. Type the amount directly into these fields. Note: The amount entered in this field must be in the currency type selected in the Claim Information section of the form. If the Currency Type field displays $USD (United States dollars), the amount entered here must also be in $USD. The Place of Service field is for entering the 2-digit code that describes the type of facility where the procedure was performed. If you know the correct code, it can be typed directly into this field. If you do not know the code, click the Lookup button. A pop-up box with a list of descriptions will appear. The Place of Service code corresponding to each description displays in a column to the left of the description. Select the code for the description that matched the location description to enter it into the Online Claim Form. The Service Location Zip Code field is an optional field, but if applicable enter the Zip Code of the location where the services were rendered in this field. This field only accepts Zip Codes in a 5-digit, allnumeric format. If your service location Zip Code does not meet the required format, leave this field blank. The Provider field is a drop down menu of names of individuals on file for the Provider Location you selected at the start of the Online Claim submission process. Choose the name of the individual that performed the procedure or service given in the CPT/HCPCS field. If the name of the individual is not listed here, you can add them to the provider list for the location through the Administration console OR if you cannot add them, you will not be able to include the procedures or services that person performed in your online claim submission. You have the option to provide comments or additional information to the line item you are currently entering. Click the Insert Comment link to open a box that will allow you to enter up to 80 characters of text to accompany this procedure or service item. Once you have entered all required information for the procedure or service in the Claim Line Item Form fields, click the Add Line Item button to include the item in your claim. When you click the Add Line Item button, the information for the procedure or service item in the Line Item Form will move to the Line Item List section, displaying all details you entered for the item. The Claim Line Item Form fields will reset to blank so that additional procedures or services can be entered on your claim. online Claim Submission: Line Item List The Line Item List section will display all procedure or service items you have added to the claim, along with all details you entered for each item. If you need to correct or modify a line item, select the Edit button for that item. If the line item should not be submitted with the claim, select the Delete button for that item to completely remove it from the claim before submission. At the end of the Line Item List section, the Total Charges are given for the claim. The total charges will be the sum of the charges in the currency type you selected for all line items you have added to the claim. Once you have completed entering line items to your claim, click the Next button SECTIoN 5 Provider Claims Information 47

48 online Claim Submission: Review and Submit To end the Online Claim submission transaction without submitting the form, click Cancel. Note: Data will NOT be saved if you select Cancel. To make revisions, click the Edit Claim Information button to return to the claim form and update your patient or claim information. To submit your claim for processing, click the Submit Claim button. The Review and Submit page gives you one additional chance to confirm all the data you have entered into the Online Claim form (i.e., patient information, diagnosis and OHI data and all procedural information you ve entered into the claim form). Note: When you click Submit Claim the data will transmit to the TOP Claims Processor and you will not be able to make further changes. online Claim Submission: Claim Received If the Online Claim submission is successful, you will see the Claim Received page. This page will summarize the currency selection and the total billed amount submitted on the TOP Claim. It will also provide you with a claim number. The claim number can be used to track the status of the TOP Claim using the Claim Status feature. Note: It may take up to 12 business hours from submission for the claim to appear using the Claim Status feature. Claims can be searched using the patient s name, the sponsor s Social Security Number of DOD Benefits Number, or by the Date of Service. 48

49 Claims for Services Rendered Before September 1, 2010 Effective September 1, 2010, all claims must be submitted using one of the International SOS submission methods outlined. This applies, even if treatment was provided for dates of service before September 1, For services delivered before September 1, 2010, a Claim Form and Itemized Invoice must be submitted. The correct Claim Form must be used, to ensure payment. CMS 1500 (Non-Institutional Providers) and UB-04 (Institutional Providers) Claim Forms can be downloaded at Detailed instructions for completing these forms can be found in Section 5 of this TOP. An online elearning Module on how to properly fill out your Claim Forms is also available. Please contact your TOP Regional Call Center and select option #5 to request access details on the elearning Module. Claim Tracking and Monitoring Once you become a registered user on the Provider Portal, you can track your claims online at After claims are submitted on this portal, they are entered into International SOS system. If you submitted your claims by overseas mail, overseas fax or Secure Message, you can view them online within 15 days of receipt. If you submitted your claims via Online Claim Submission using the Provider Portal, you can view them online within 12 business hours. Providers can search for claims using the patient s name, the sponsor s Social Security Number or DOD Benefits Number, and DOB, or Dates of Service, or Claim Number. The claim status will indicate whether the claim is being processed and if it has been paid. If the claim has been paid, the claim status update will indicate how much has been paid or if the claim has been denied. Once the claim has been processed, the Provider will be able to view the Explanation of Benefits (EOB) for that claim online. Full instructions on using the Provider Portal Dashboard features are included in Section 6 of this TOP, see pages Timely Filing of Claims All claims must be submitted within 1 year of the Date of Service. Claims must be date stamped/received by International SOS within 12 months of the last date of treatment in order to be reimbursed. Any claims exceeding this 12 month timely filing deadline will be declined. Claim Reimbursement and Payment Provider payments can be made in the following ways: By Check (Local Currency) Bank Draft (Local Currency) Electronic Fund Transfer (EFT) (Local Currency) Payments will be made in the currency in which the invoice is submitted, wherever possible. If the Provider submits an invoice in U.S. Dollars, payment will be made in U.S. Dollar check. If invoices are submitted in local currency, payment will be made by local currency bank draft, whenever possible. International SOS can make payments in over 100 currencies. If your currency is not available, payment will be made by U.S. Dollar check. Checks and bank drafts will be sent to the Provider by overseas mail. If Providers would like to receive payment via Electronic Funds Transfer (EFT), they must submit a request by completing and submitting an EFT Form. EFT Forms can be downloaded at or you can contact your TOP Regional Call Center and select option #5 to speak to a TOP Provider Support Services staff member to obtain a form. When completing the EFT Form, please be sure to include the following information: Provider ID number The name of your bank and the name on the account Account number or IBAN number SWIFT code Please also include the currency in which you would like to receive payment. This must be the same as the currency in which you submit your claims. If any of these details is incomplete or missing, International SOS will not be able to process your EFT request. Once your EFT is set up, this will be your default method of payment. EFT is our recommended method of payment, as it reduces the amount of time it takes to receive payments. Remittance advice will be sent to the Provider in the form of an Explanation of Benefits (EOB). If the Provider receives payment by U.S. Dollar check or bank draft, the EOB will be sent to you by mail with the check or bank draft. If the Provider has an EFT set up, EOBs will be sent separately by mail. EOBs are also available to view online, on the Provider Portal available on Please see Section 6: The Provider Portal for additional information about viewing your EOB online. SECTIoN 5 Provider Claims Information 49

50 Required Criteria for Ensuring Payment of Claims Providers can help to ensure that claims are processed (and payments made) in a timely manner, by making sure that the following minimum required fields are completed on their Claim Form, before it is submitted: CMS 1500: 1. TRICARE Ticked 2. Patient Name 3. Patient Address 4. Sponsor Name 5. Sponsor s Social Security Number or DOD Benefits Number 6. Other Health Insurance (OHI) Details (if applicable) 7. Patient Signature x2 and the date 8. Diagnosis (if this cannot be written on the invoice) 9. Authorization Number 10. Federal Tax ID (Provider ID or TEPRV) 11. Accept Assignment? YES 12. Amount Paid by OHI or Beneficiary (if applicable) 13. Provider Signature 14. Provider Name and Billing Address UB-04: 1. Provider Name and Billing Address 2. Federal Tax ID (Provider ID or TEPRV) 3. Patient Name 4. Patient Address 5. Other Health Insurance (OHI) Details (if applicable) 6. Assignment of Benefits YES 7. Amount Paid by OHI or Beneficiary (if applicable) 8. Sponsor Name 9. Sponsor s Social Security Number or DOD Benefits Number 10. Authorization Number 11. Diagnosis (if this cannot be written on the invoice) 12. Provider Signature Providers must also ensure that the Itemized Invoice they submit contains all of the following information: Date of Service Letterhead Containing the Provider s Name, Physical Address and Billing Address Invoice Number or Patient Account Number Corresponding Authorization Number (when required) prior to Treatment (this can be found on the Authorization Form) Patient Name Description of Diagnosis (if the diagnosis cannot be written on the invoice, please include this on the Claim Form) Breakdown of Services Rendered, Listing Corresponding Costs (and Taxes) and Overall Total Owed Invoice Currency Important: Claim Forms that are received without an invoice, or invoices that are received without a Claim Form will not be processed. The received document will be returned to the Provider. Note: If Providers would like to receive payment for claims in the fastest possible time, International SOS recommends using the Online Claim Submission option via the Provider Portal AND registering to receive EFT payments. This helps avoid the delays associated with overseas mailing times. Explanation of Benefits and Applicable Exchange Rate Information Remittance Advice is sent to the Provider in the form of an EOB. EOBs are sent to the Provider by mail however this information is also available to be viewed online via the Provider Portal. The electronic EOB is available on the same date the payment is issued. The EOB includes detailed information regarding any items that may have been denied for payment. It also includes important exchange rate data, which was used for issuing payment. Deductibles and co-payments that TOP Standard beneficiaries are responsible for paying will also be included on the EOB. According to TOP policy, the exchange rate applied will be the exchange rate valid on the last day of the episode of care or last date of invoiced services. Citigroup is the standard exchange rate used by International SOS. If a claim is denied or not paid in full, a denial code will be assigned to that charge. An explanation of the denial codes is included on the last page of the EOB. A list of denial codes and their explanations is available online at as well as in the Appendix of this TOP. You can also contact your TOP Regional Call Centre or submit a request via the Secure Message Transmission option on the Provider Portal. Note: Responses to Secure Messages transmitted via the Provider Portal will be sent to the Secure Message Inbox on the Provider Portal. Please see Section 6: The Provider Portal for additional information about accessing Secure Messages. 50

51 Below are sample EOB statements for TOP Prime and TOP Prime Remote beneficiaries: Here are the Provider s details. This is to whom the payment is made. The number in this corner will be a local toll free number which the Provider can call if they need assistance. This is the Claim Number, also known as the Internal Control Number (ICN). The Check Number helps Providers match the payments that have been made to the Claims they have submitted. If the Provider has been paid by check, this number will correspond with the check number on the payment check. If the Provider has been paid by bank draft, this number will correspond with the number on the perforated record attached to the bank draft. If the Provider has been paid by Electronic Fund Transfer (EFT) up to six check numbers will appear in the payment line on the bank statement. SECTIoN 5 Provider Claims Information This is the Check Number. 51

52 PT Resp means Patient s Responsibility. TOP Prime beneficiaries receive a cashless service. Therefore, the deductibles and cost-shares are listed as $0.00. If any charges are denied, the denial code will be listed here. This is the total amount International SOS will reimburse. These are the dates of the Episodes of Care as indicated on the invoice. These are the costs for the treatments the patient received. This is the total amount International SOS will reimburse. These are the CPT procedure codes. International SOS will translate the treatment details from the invoice into CPT codes. These are the costs that are allowed under the beneficiary s TRICARE policy. If any payments are denied, a denial code will be indicated. An explanation of the code is given on the last page of the EOB. 52

53 On the bottom half of the EOB, you will find the payment summary showing the amount International SOS will reimburse and the amount that is still outstanding. A brief explanation of the Denial Codes (if any) will appear here. A full list of Denial Codes is available in Host Nation Languages on No charges have been denied, therefore there are no denial codes listed here. Here, you will find the exchange rate that was used. Exchange rates will be in effect on the last date of service. International SOS uses Citigroup s exchange rates. This is a sample TOP Standard beneficiary EOB If more than one invoice is submitted, or if a single invoice for multiple procedures is submitted with a single Claim Form, the EOB will appear as follows: SECTIoN 5 Provider Claims Information These are the dates for the Episodes of Care indicated on the Itemized Invoice. These are the CPT procedure codes. International SOS will translate the treatment details from the invoice into CPT codes. This EOB is for a Standard beneficiary and some of the services are not covered. Therefore, there is the total which is allowed under the policy; the amount the beneficiary must pay and the amount International SOS will reimburse. 53

54 On the reverse side of the EOB will be additional information regarding Provider and beneficiary rights, as well as beneficiary co-payments, appeals process details and other information. 54

55 The Bank Draft If the Provider is being paid by bank draft, it will be attached to the bottom of a letter, which will be sent to the Provider along with their EOB via overseas mail. This is the Check Number SECTIoN 5 Provider Claims Information The bottom part of the bank draft letter is the bank draft itself. The beneficiary and Provider details are located at the top of the letter, along with the issue date, the amount being paid, a payment reference number and the Check Number. The Check Number corresponds with the Check Number on the bank draft, as well as the number on the EOB. 55

56 Transaction Fees Associated with Claim Reimbursement and Payments International SOS is responsible for any costs associated with issuing payments, such as issuing checks and bank drafts, sending EFT payments (and related transaction fees), and sending the EOBs. Providers are responsible for all of the costs associated with receiving payments, such as depositing checks and bank drafts, collecting EFT payments, and exchanging payments into local currency. What if Both Non-Institutional and Institutional Providers Are Used for the Same Episode of Care and Billed Independently? Two separate Claim Forms will be needed: one from the Non- Institutional Provider (CMS 1500) and one from the Institutional Provider (UB-04). Each entity that requests to receive payment independently must submit a separate Claim Form (CMS 1500 for Non-Institutional Providers or UB-04 for Institutional Providers) and an Itemized Invoice. Step-by-Step Instructions for Accurately Completing Claim Forms TOP Provider Support Services staff will work with you to show you how to complete each of the following Claim Forms properly. When you receive an International SOS Authorization Form, a pre-populated Claim Form will be sent to you simultaneously. If you do not receive an Authorization Form or if you need additional Claim Forms, these are available to be downloaded on Note: These Claim Forms will not be pre-populated. Full instructions on how to complete Claim Forms that have not been pre-populated are included in this TOP and are also available at Instructions on how to complete a pre-populated Claim Form are available at International SOS has also developed an elearning Module to help you complete Claim Forms. Please contact your TOP Regional Call Center and press option #5 to request access to the elearning Module. If needed, additional Claim Forms can be downloaded at What if a Beneficiary Does Not Show for an Appointment? TRICARE beneficiaries are directly responsible for paying noshow fees. You should invoice the patient directly for failing to cancel an appointment (without sufficient advance notice) or failing to show up for a scheduled appointment. 56

57 The Claims Process Completing the CMS 1500 PART 1 Patient s and Sponsor s Details PART 2 Patient s Signature PART 3 Diagnosis and Authorization Number PART 4 Provider s Details {{ {{ SECTIoN 5 Provider Claims Information 57

58 The Pre-Populated Claim Form CMS 1500 When you receive an Authorization Form from International SOS, you will also receive a pre-populated Claim Form. All the fields highlighted in purple will be pre-populated. All the fields highlighted in green can be left blank. You will only have to complete these few fields shown here in white. 58

59 Part 1: Patient s and Sponsor s Details Always choose the TRICARE option. Please enter the patient s DOB using the format MM DD YY and tick M or F to indicate the patient s gender. Enter the sponsor s ID number (10-digit DOD Benefit or 9-digit Social Security Number (SSN)) and name using the format Last Name, First Name, Middle Initial. This information will appear on the patient s Military ID Card. Enter the patient s name, using the format Last Name, First Name, Middle Initial and the patient s full physical address including post code. Enter the patient s relationship to the sponsor. Fields highlighted in green can be left blank Enter the sponsor s full address if different than the patient s. If the patient has OHI enter the name of the insured party using the format Last Name, First Name, Middle Initial, the policy number and in field 9d enter the name of the insurance plan. TRICARE is always the secondary payer. If the patient has OHI policy, tick YES here and then complete 9, 9a and 9d. If the patient does not have OHI policy, section 9 can be left blank. Enter the sponsor s DOB, using the format MM DD YY and indicate the sponsor s gender marking either M for Male or F for Female. SECTIoN 5 Provider Claims Information Fields highlighted in green can be left blank 59

60 Part 2: Patient s Signature These two fields require the signature of the patient. The patient and the insured party can be the same person. Even if the patient is not the Active Duty Service Member, the Active Duty Family Member is an eligible TRICARE beneficiary and considered the insured party. The requirement for signature can be met by obtaining a Signature on File. This means the Provider will have the patient s signature on file (collected at registration at the Provider facility or at first appointment). If the patient is incapable of signing or under 18 years of age, the parent or legal guardian s signature will be kept on file. Signature on File: International SOS will assist Providers with education on how to obtain this in the correct manner and which wording to include in collecting the signature. Providers will then simply write Signature on File in BOTH fields and will not be required to obtain the beneficiary s or insured s signature when completing the Claim Form. Laboratories: if the patient is not present, the laboratory should enter Patient not Present on the line in both signature fields. Ambulance Companies: Enter 'Patient Unable to Sign' on the line in both signature fields. IMPoRTANT NoTE: Both boxes must be signed and completed! An example Signature on File letter: 60

61 Part 3: Authorization Number If you are not able to include the diagnosis on the invoice, you can write it here. If the diagnosis is on the invoice, leave this field blank. The diagnosis can be a written description or an ICD or CPT Code. Please enter the appropriate Authorization Number. This can be found on the top right corner of the Authorization Form. The rest of this information should be on the Itemized Invoice which must be submitted with the Claim Form. Fields highlighted in green can be left blank SECTIoN 5 Provider Claims Information 61

62 Emergency Care If the Provider is providing Emergency Care, they will not necessarily have an Authorization Number. In this case, the Provider should write the words Emergency Care in this section. EMERGENCY CARE 62

63 Part 4: Provider s Details The Federal Tax ID Number is the Provider s TRICARE ID Number (or TEPRV). Please enter this here. Always indicate Yes here. This ensures that payment goes to the Provider. If the patient has OHI, it will be the primary payer for the claim. After the OHI has processed the claim, indicate here how much they have paid. Also include any payments the patient has made towards the claim. If TRICARE is the patient s only health insurance plan, leave this field blank. This must be signed and dated by the Provider. This does not necessarily have to be the attending physician, but can be signed by an authorized person. Note: The Provider Signature on File procedure can be used here. Please enter the patient s account number. This is generated by the Provider and should not be longer than 18 digits long. Please enter the Provider s name and full physical address. Fields highlighted in green can be left blank Please enter the Provider s full billing address if different to the physical address. SECTIoN 5 Provider Claims Information 63

64 Completing the UB-04 PART 1 Provider s Details { { PART 2 Patient s Details and Address PART 3 This can be left blank as long as an Itemized Invoice is submitted PART 4 Sponsor s Details and Authorization Number PART 5 Diagnosis and Provider Signature { {{ 64

65 The Pre-Populated Claim Form UB-04 When you receive an Authorization Form from International SOS, you will also receive a pre-populated Claim Form. All the fields highlighted in purple will be pre-populated. All the fields highlighted in green can be left blank. You will only have to complete these few fields shown here in white. SECTIoN 5 Provider Claims Information 65

66 Part 1: Provider s Details Please enter the Patient s account number. This is generated by the Provider and should not be longer than 18 digits long. Please enter the Provider s name and full physical address. Please enter the Provider s full billing address if different to the physical address. The Federal Tax Number is the Provider s TRICARE ID Number (or TEPRV). Please enter this here. Part 2: Patient s Details and Address Enter the patient s name, using the format Last Name, First Name, Middle Initial and the patient s full physical address including post code. Please enter the patient s DOB using the format MM DD YY and write M or F to indicate the patient s gender. Enter the sponsor s name and full address if different than the patient s. 66

67 Part 3: This section can be left blank, as long as an Itemized Invoice is submitted This information should be on the Itemized Invoice which must be submitted with the Claim Form. Part 4: Sponsor s Details and Authorization Number If the patient has OHI, enter the name of the insured party using the format Last Name, First Name, Middle Initial and the policy number. Always indicate Y for Yes here. This ensures that payment goes to the Provider. If the patient has OHI, it will be the primary payer for the claim. After the OHI has processed the claim, indicate here how much they have paid. Also include any payments the patient has made towards the claim. If TRICARE is the patient s only health insurance plan, leave this field blank. SECTIoN 5 Provider Claims Information Please enter the appropriate Authorization Number. This can be found on the top right corner of the Authorization Form. Enter the sponsor s name using the format Last Name, First Name, Middle Initial and the sponsor s ID number (SSN or the first 9 digits of the DOD Benefits Number). This information will appear on the patient s Military ID Card. 67

68 Emergency Care If the Provider is providing Emergency Care, they will not necessarily have an Authorization Number. In this case, the Provider should write the words Emergency Room in this section. EMERGENCY ROOM Part 5: Diagnosis and Provider Signature If you are not able to include the diagnosis on the invoice, you can write it here. If the diagnosis is on the invoice, leave this field blank. This must be signed and dated by the Provider. This does not necessarily have to be the attending physician, but can be signed by an authorized person. Note: The Provider Signature on File procedure can be used here. 68

69 SECTIoN 6: The Provider Portal Registering to the Provider Portal In order to access the Provider Portal on the Provider will need to become a registered user first and set up a unique username and password. Note: Please visit to download a Computer Based Training Module on Web-based Claim Submission options. To begin the registration process, go to the Providers section of and click on Register. Your TRICARE overseas Program (ToP) Provider Number You will advance to the TOP Provider Number page. Enter your TOP Provider Number in the open field (this is a required field). If you do not know your TOP Provider Number, it can be found in your TRICARE Overseas Explanation of Benefits (EOB) (see example above). The Provider must enter their Provider ID Number (or TEPRV) this is a number assigned to the Provider by International SOS and appears in the following format: DEU123456DEU A000. The Provider ID Number is indicated at the top of the Explanation of Benefits (EOB), which you may have received from International SOS. If you have not yet received an EOB for a TRICARE beneficiary, please contact your TOP Regional Call Center and press option #5 to speak with a member of the TOP Provider Support Services team, who can provide you with your TOP Provider ID Number. After entering your TOP Provider ID Number, click Next. SECTIoN 6 The Provider Portal 69

70 Provider Information The Provider must enter their contact information, including full name, and contact telephone number (optional). Providers will also be required to enter a valid address where they can be contacted. Updates such as password information will be sent to this address. On the Provider Information page you will enter the name and contact information of the TRICARE Overseas Program (TOP) Provider. All fields on this page are required for registration. Language Preference: The language preference field determines the site language when you have logged into your Secure Provider Claims Portal account. Note: This preference can be changed at a later date in your personal profile. First Name: Enter the first name of the Provider. Note: This field has a 25 character limit. Last Name: Enter the last name of the Provider. Note: This field has a 35 character limit. Telephone Number: Enter the 3-digit international country code in the first field and the remaining digits of the contact telephone number in the second field. Address and Confirm Address: Enter the contact address in the first field. Then validate the contact address by entering it again in the Confirm Address field. Providers located in the United States and U.S. territories will additionally be required to provide one of the following: License Number Medicare Certification Number National Provider Identifier Click Next to continue the registration process. 70

71 Provider Registration Type Choose the Registration Type. Registration options are included on the drop down menu, and include the following: 1.) Complete a secure instant registration on the site 2.) Complete the registration process by mail To complete a secure instant registration on the site, Providers must have had a claim processed within the last 365 days with the TRICARE Overseas Program (TOP) Claims Processor. If this is your preferred method of registration, verify the registration drop down field displays the 'I would like to complete a secure instant registration' option. For Secure Instant Registration Providers are required to enter a claim number (also known as the Internal Control Number (ICN)) from their TOP Explanation of Benefits (EOB) and the date of birth (DOB) of the patient on that claim. See diagram below. Note: Providers can use any claim number from within the last 365 days. Once you complete the required Instant Registration fields, click Next. If you have not submitted a claim to the TRICARE Overseas Program in the last 365 days, or if you prefer to complete registration by mail, choose the 'I would like to complete registration by mail' option from the drop down menu and click Next. SECTIoN 6 The Provider Portal 71

72 Instant Registration: Account Username and Password Your password cannot contain spaces and cannot be the same as your first name, last name or the Username you have selected for your account. You can click on the Password Rules button for the full list of requirements and regulations connected to passwords on After choosing Secure Instant Registration, you will be taken to the Username and Password page. The Username page is where you will choose your account name and set up your account security. All fields on this page are required. Username: Enter the Username of your choice for your account. The Username must be a minimum of 5 characters long and cannot be more than 32 characters long. The site will validate your Username, displaying confirmation in green text if the Username you ve selected is available for your account. The validation text will turn red if the Username you are trying to enter is already in use. 72

73 Password: Enter the security password for your account. Your password must be a minimum of 9 characters long and must contain the following: 2 numbers Any 2 of the following special characters! exclamation at sign # hashtag, pound sign, or number symbol $ dollar sign % percent sign & ampersand * asterisk _ underscore + plus sign, comma? question mark 2 lower case characters 2 capital or upper case characters Confirm Password: Validate your chosen password by entering it a second time. Security Question: Select a security question from the options available in the drop down menu. Security Answer: Provide the answer to the security question you have just chosen. Note: Your security answer cannot be more than 32 characters in length. You must read the Terms and Conditions and then click on the box next to this section, stating that you have read and accept the Terms and Conditions before proceeding to the next step. Click Next to continue. SECTIoN 6 The Provider Portal 73

74 Instant Registration: Confirmation If you wish to change any information prior to submission, click the Edit buttons here. If all the information is valid and correct, click the Complete Registration button and you will be logged in to your new account on Next, you will come to the Instant Registration Confirmation page. This page displays the Provider information and Username and security question and answer you entered for your account. Note: Providers in the United States and U.S. territories will see an additional Confirmation field with the License Number, Medicare Provider Number, or National Provider Identifier you entered on the Provider Information page. 74

75 Registration By Mail: Account Username and Password After choosing Registration by Mail, you will be taken to the Username page where you will set up some of the features for your account and account security. All fields on this page are required. Start by choosing the Username for your account. The Username must be between 5 and 32 characters in length. The site will validate your Username, displaying confirmation in green text if the Username you want is available for your account. The validation text will turn red if the Username you are trying to enter is already in use. You will then choose a security question from the drop down menu. In the Security Answer field, enter the answer to the question you selected. Note: Your security answer cannot be more than 32 characters in length. Click Next. SECTIoN 6 The Provider Portal 75

76 Registration By Mail: Confirmation The website will display Confirmation of the registration by displaying the name and address we have on file for the Provider number you ve entered. By mail, the TOP Claims Customer Service Department will send to you (using the address displayed on screen) a password and instructions for logging in to your account on The password and instructions should arrive within 7 10 business days. You can then use these instructions and password to access your new account. 76

77 Using the Provider Portal Using the Provider Portal: The Provider Dashboard The Provider Dashboard is your landing page. It is the first page you will see after logging in to your secure account. The Provider Dashboard provides you with a quick view of important Alerts and Announcements and also contains all your recent claims activity, including recent payment, returned claims, and pending claims. You can also check TRICARE beneficiary eligibility and Other Health Insurance from the Provider Dashboard. Note: There is a What is My Dashboard? link available at the top of the dashboard page. You can click this link to view a quick explanation of the content and features available on the Provider Dashboard. SECTIoN 6 The Provider Portal 77

78 Using the Provider Portal: The Provider Dashboard: Alerts and Announcements Check the Alerts and Announcements box to see when your current password is scheduled to expire. You can click on the day-remaining link, which will take you to the Password Update function in the Secure Provider Claims Portal. The first section of your Provider Dashboard is a quick view of Alerts and Announcements. If you are an account administrator, in addition to password notifications you will see alerts for pending location approval requests and pending user requests. The location approval request and user request alerts are static they will always display in your Alerts section. Each alert will be accompanied by a number indicating how many pending requests of each type there are. If there are no pending requests, the number field will display 0 (zero). The number field is a link you can click to take you to the administration page for each function. 78

79 Using the Provider Portal: The Provider Dashboard: Notifications An Important Notifications page may appear as a splash screen when you first log in. These are important site-wide messages from the TOP Claims Customer Service Department. Topics range from changes in requirements in TRICARE Overseas Program policies and procedures to notices about secure claims portal features and functionality. Be sure to review the notifications before closing the splash page. To close the notifications splash page, click OK or click the X in the upper right-hand corner of the notification window. SECTIoN 6 The Provider Portal 79

80 Using the Provider Portal: The Provider Dashboard: Check Patient Eligibility The Check Patient Eligibility button can be found on the Provider Dashboard and can be used as a quick link to begin a Beneficiary eligibility check. You can conduct a Beneficiary eligibility check using either the Sponsor Social Security Number (SSN) or DEERS Family ID. Once you make a selection, complete the remaining fields in this section and then click the Submit button. The Beneficiary eligibility search will begin and then take you to the Patient Eligibility page to view the results. 80

81 Using the Provider Portal: The Provider Dashboard: Recent Payments View The Provider Dashboard gives you immediate access to your most recent claims activity data in three convenient tabs: 1. Recent Payments 2. In-Process Claims 3. Returned Claims The Provider Dashboard defaults to the Recent Payments tab, showing you data for your first registered location for the previous calendar week. You can use the Location filter to choose another location if you have more than one registered location with You can also use the View filter to choose an alternate time period of 30 days, 60 days, or 90 days. Each tab defaults to 50 records per page. If you have more than 50 records, there will be a page selection and arrow navigation to allow you to move through multiple pages. Note: In each view the data can be sorted by clicking on the column heading. Displayed data cannot be sorted by the currency type. SECTIoN 6 The Provider Portal 81

82 Recent Payments: The Recent Payment view provides the following information: CHECK/EFT/ACH Number: Displays the number assigned to the check or electronic payment transaction made via either Electronic Fund Transfer (EFT) or Automated Clearing House (ACH). Electronic payment transaction numbers are preceded by an asterisk. Approval Date: This is the date the check was issued or the date the electronic payment was made. This appears in MM/DD/YYYY format. Payment Amount: This displays the full reimbursement amount made in the check or electronic payment transaction. Currency: Displays the code representing the currency in which the payment was made. View Claims: This field provides a link to a detailed view of all your claims that were part of that reimbursement. When you click on the View Claims link, the screen will automatically update to display the Claim View. The Claim View provides the following details: EoB: This is a link to an image of your TRICARE Overseas Program (TOP) Explanation of Benefits (EOB) for the claim on this line. You will be able to view the EOB in either a summary payment format (.pdf document) or a detailed individual claim format (.html). Letters: If there was any correspondence or documentation attached to this claim transaction, the documentation can be viewed by clicking on the Letters link. Invoice Number: If you added an office invoice or record number to your claim during the online claims submission process or when you submitted a claim via postal mail, this number will be displayed here. Date of Service: This field will display the earliest date of service on the claim. The date format is MM/DD/YYYY. Claim Number: This is the TOP control number assigned to your claim for processing and tracking on the Secure Claims Provider Portal. Patient Name: Displays the full name of the patient on the claim. Billed Amount: This field displays the sum of all charges that were submitted on this claim. Currency: This field displays the code representing the currency in which the claim transaction was processed. Provider Name: Displays the name of the individual provider or the facility name. Tax ID: Displays the 9-digit tax identification number of the Provider. For Providers outside the 50 United States and the U.S. territories, this is an identification number assigned to the Provider by the TRICARE Overseas Program. 82

83 Paid by Government: This field displays the amount of payment the TRICARE benefit program covers and reimbursed or paid on the claim. Process Date: This field displays the date the claim processing was finalized in our system (i.e., by the TOP Claims Processor). You can also click the Plus (+) symbol at the start of each line to expand additional details about the claim. Information about these additional claim details is available in the Claim Status demonstration, also available on the Secure Provider Claims Portal. Clicking the Back button will return you to the Recent Payments dashboard summary view. SECTIoN 6 The Provider Portal 83

84 Using the Provider Portal: The Provider Dashboard: In-Process Claims View In-Process Claims: In-Process Claims shows you the claims you have submitted and are currently being processed by the TOP Claims Customer Service Department. The In-Process View provides the following information: Invoice Number: If you added an invoice or record number to your claim during the Online Claims Submission process or when you submitted a claim via postal mail, this number will be displayed here. Date of Service: This field displays the earliest date of service on the claim. The date format is MM/DD/YYYY. Claim Number: This is the TRICARE Overseas Program control number assigned to your claim for processing and tracking on the Secure Claims Provider Portal. Patient Name: Displays the full name of the patient on the claim. Billed Amount: This field displays the sum of all charges that were submitted on this claim. Currency: This field displays the code representing the currency in which the claim transaction was processed. Provider Name: Displays the name of the individual provider or the facility name. Tax ID: Displays the 9-digit tax identification number of the Provider. For Providers outside the 50 United States and the U.S. territories, this is an identification number assigned to the Provider by the TRICARE Overseas Program. Note: There is no expanded view for In-Process Claims. These claims are still being worked on by the TOP Claims Customer Service Department, so processing details are not yet available. 84

85 Using the Provider Portal: The Provider Dashboard: Returned Claims View Returned Claims: The Returned Claims tab shows claims that you have submitted but were returned to you by the TOP Claims Customer Service Department because information was missing, which was needed for accurate claims processing and payment. The Returned Claims view provides the following information: Claim Number: This is the TRICARE Overseas Program control number assigned to your claim for processing and tracking on the Secure Claims Provider Portal. Patient Name: Displays the last name and first name of the patient on the claim. Billed Amount: This field displays the sum of all charges that were submitted on this claim. Currency: This field displays the code representing the currency in which the claim transaction was processed. Provider Name: Displays the name of the individual provider or the facility name. Tax ID: Displays the 9-digit tax identification number of the Provider. For Providers outside the 50 United States and the U.S. territories, this is an identification number assigned to the Provider by the TRICARE Overseas Program. Date of Service: This field displays the earliest date of service on the claim. Invoice Number: If you added an invoice or record number to your claim during the Online Claims Submission process or when you submitted a claim via postal mail, this number will be displayed here. Claim Status: This will display Returned. You can also click the Plus (+) symbol at the start of each line to expand additional details about the claim. Some additional information you will find in the expanded view includes the Reason Returned field, which is a brief summary explaining why the claim was returned to you, and a link to a.pdf version of the letter sent to you (along with the returned claim) explaining in detail why the claim was returned. SECTIoN 6 The Provider Portal 85

86 Claim Status Using the Provider Portal: Claim Status: Basic Search The Basic Search allows you to search for your claim information by your registered locations, including an option for all locations. The default selection is 'All Locations' but you can select a specific location from the drop down menu. If the location you want to look up is not on the drop down menu, you can register this new location by selecting the 'Request a New Location' link. The Claim Status function allows you to search for claim information and data for claims you have submitted to the TOP Claims Customer Service Department. Note: The Claim Status function has a 500-claim limit for search returns and can only return claim data for the last 18 months (based on when the claim is processed). Please select the appropriate criteria to filter your search to improve search return and portal performance. Next, select the cross-reference search type you would like to perform. The choices here include: Patient Information: Selecting Patient Information allows you to input the data to find claims you submitted for a specific patient. Complete the following fields: Sponsor Social Security Number (SSN): Enter the patient s benefit eligibility number. Patient First Name: Provide the patient s first name. Date of Birth: Enter the patient s date of birth. The date format is MM/DD/YYYY. Service Start/End Date: The system will default the service date fields to the last 30 days. If necessary, you can change this by typing new dates directly into these fields or by using the calendar icons to select new dates. Claim Number: Selecting the Claim Number allows you to enter the full 14-digit number assigned to your claim and search for its status. Claim numbers are assigned immediately to your claims when you submit them using the Online Claims submission method on Check Number: Selecting the Check Number allows you to enter the full 11-character check number and search for claims processed under that check. Check numbers will appear on your Electronic Funds Transfer (EFT) or Automated Clearing House (ACH) credit advice, your weekly claim summary reports, and your dashboard. You can also find the 86

87 check number in the claim detail financial summary section. Note: When searching with an EFT or ACH check number, you must include the asterisk as the first character. Invoice Number: Selecting the Invoice Number allows you to search for a claim with the identification code you have assigned to the claim. The Invoice Number search works for claims you have submitted, for which you have also entered an invoice identification code. Note: The Invoice Number search is limited to 20 characters maximum. Note: There is a Reset Search button which will clear the entire page of any inputs or selected options, if needed. Once you are satisfied with the search criteria entered, click the Search button to perform the location and patient search. Using the Provider Portal: Claim Status: Advanced Search Selecting the Advanced Search tab gives you several additional search options, which include: Individual Patient DEERS Family ID: Selecting this option allows you to search for a patient s claim data by their 9-digit DEERS Family Identification Number. This option also requires that you enter the patient s name, date of birth, and a selected date span for the claim search. Individual Patient DoD Benefits Number (DBN): Selecting this option allows you to search for a patient s claim data by 87 their 10-digit DOD Benefits Number. This option also requires that you enter the patient s name, date of birth, and a selected date span for the claim search. Process Date: Selecting this option allows you to enter a specific date and view all claims processed on that date. The date can be typed directly into the field in the MM/DD/YYYY format or it can be selected using the calendar icon. All Patients: Selecting this option allows you to search for and view claim data for all patients as cross-referenced with the selected provider location(s). SECTIoN 6 The Provider Portal

88 Using the Provider Portal: Claim Status: Claim Search Results Near the top of the Claim Search Results page is a notice asking if you would like to view any linked documentation in your Search Results claim details. Note: You will need Adobe Reader. If you do not have Adobe Reader on your computer, you can download the program by clicking on the Adobe Reader link. Immediately following the notice are buttons labeled Edit Search or New Search. If the search you performed does not show the results you wanted, you can click Edit Search, which will take you back to the Claim Search screen where you previously entered your search criteria. Or you can click on New Search which will take you to the blank Claim Search screen where you can enter your search criteria. The screen will update to display your search results. The number of results you receive for any search will depend on the type of claim search performed and the number of claims you have submitted to the TOP Claims Customer Service Department in the last 30 months (based on when the claim is processed). The criteria for the search you just performed will appear immediately above your Claim Search Results so that you can verify if the search was performed with the criteria you intended. If the criteria shown are not correct, you can click the Edit Search button to modify the criteria and perform a new search. The Location filter gives you the option to sort your Claim Search Results by Tax ID and Zip Code. Note: There is a paging index that allows you to advance through multiple pages of Claim Search Results. Click a page number to advance to that page or use the arrows to navigate through the Claim Search Results one page at a time. 88

89 The Claim Search Results box will list all claims that fit the criteria you selected for the search. The immediate search results display the following fields for each claim returned in the search: Expand/Contract: This button allows you to display and hide additional details and functions for the claim specific to that Claim Search Result line. Explanation of Benefits (EoB): If an EOB has been generated for the claim, an icon linking to an Adobe.pdf version of the EOB will appear in this field. Letters: If additional documentation has been generated by the TOP Claims Customer Service Department while processing your claim, an icon linking to an Adobe.pdf version of this documentation will appear in this field. Invoice Number: This field will display your office Invoice Number for the claim if you provided one during the Online Claims submission process or for a claim that you have submitted via postal mail. Date of Service: This field displays the end date for services listed on the claim. This field displays in the MM/DD/YYYY format. Claim Number: This field displays the 14-digit claim control number assigned to your claim when it was received by the TOP Claims Customer Service Department. Patient Name: This field displays the last name and first name of the patient on the claim. Claim Status: This field displays the current status of your claim (i.e., where the claim is in the process of being handled by the TOP Claims Customer Service Department). Possible Claim Status values include: Currency: This field displays the currency code in which the claim the claim transaction was processed. Note: A currency code does not indicate there was a payment on the claim. Process Date: This field will display the date on which the TOP Claims Customer Service Department took final action on the claim. If the claim status is In-Process, this field will be left blank. The date displays in the MM/DD/YYYY format. Note: You can expand a claim's record to see more details about how the claim was processed. Click the Plus (+) symbol at the start of the record line to view the summary payment details. The expanded record's payment details are presented in 4 columns: The first two columns detail the financial information for the claim: The billed amount, the Paid by Government amount, to whom the payment was directed (if a payment was made), and any beneficiary liability. The third column gives the information for the Provider of services on record for the claim, including the individual or facility name and address. The fourth column lists the check details, including the check or EFT transaction number, the issue date, and the payee (i.e., individual or facility recipient) of the payment. Clicking the Full Claim Detail button gives you access to patient detail information and claim line item detail information. Note: Claim line item detail information is not available for claims that are labeled In-Process. In-Process Payment No Payment Adjustment Reissue Credit Billed Amount: This field displays the sum of all charges that were submitted on this claim. Paid by Government: This field displays the amount of payment the TRICARE benefit program covers and reimbursed or paid on the claim to the Provider and/or patient. This field will display all zeroes (00000) if the claim is In- Process or No Payment could be made on the claim. SECTIoN 6 The Provider Portal 89

90 Using the Provider Portal: Claim Status: Claim Search Details Historical details for each of these items include: - Eligibility - Other Health Insurance - Out-of-Pocket Expenses - Primary Care Manager Clicking the Plus (+) symbol to expand the Patient Eligibility section will allow you to see the patient's eligibility and benefit information corresponding to the dates of service of the claim. The eligibility record will display any records of any insurance program the beneficiary may have in addition to TRICARE and the dates that insurance program is effective. Out-of-Pocket expenses are also detailed here. Note: Financial values here will be up-to-date with the most recent claim processed for the beneficiary, but In-Process claim values will not have been calculated against these benefits. Also, please note that all values appearing here are given in $USD (United States Dollars). Current Primary Care Manager information will be given in the third column. 90

91 Using the Provider Portal: Claim Status: Claim Search Details Clicking the Plus (+) symbol to expand the Claim Line Items section allows you to see details for each service, procedure or supply you billed for on the claim. Details will be listed using the following fields: Service Description: Displays the code and partial description for the service, procedure, or supply. Reason Code: This is a 3-character code indicating message from the TOP Claims Customer Service Department explaining claim processing actions take for that service, procedure or supply. You can select the code to view its explanation. Start Date, Date of Service, and End Date of Service: The dates you provided to indicate the beginning and end of the procedure. Billed Amount: The amount you charged for the service, procedure or supply. Allowed Amount: The amount TRICARE deems the maximum amount for the service, procedure or supply. Units: The number of times the procedure was performed or the supply provided during the dates of service. Invoice Number: This field will display your office Invoice Number for the claim if you provided one during the Online Claims submission process or for a claim that you have submitted via postal mail. Provider of Service: This field will list the name of the assigned individual Provider or facility that delivered the medical care on behalf of the beneficiary. Note: Claim Line Item Details will not be available on claims that are labeled In-Process. Full instructions on how to submit claims via Online Claim Submission are included in Section 5 of this TOP Provider Manual (see pages 33-48). SECTIoN 6 The Provider Portal 91

92 Using the Provider Portal: Claims Report To access the Claims Report select the Claims Report button in the navigation bar. This button will take you to the Claims Report menu page (shown left). The Claims Report page displays the selection criteria for building your report. The Claims Report function available through the Secure Claims Provider Portal on allows you to create a report of claims associated with your account up to 9 weeks in the past. Criterion #1: The first criterion on the Claims Report page is Select Claim Status. Click the Radio icon that corresponds with the status type you would like to view on your report. You can select one of the following: Processed In-Process Returned All You have the additional option to display individual charges in your report by clicking the check box marked Display Individual Charges, but please note this will only apply to Processed claims (i.e., not to claims labeled In-Process or Returned. ). Criterion #2: The second criterion is the Report Date Range. Note: If you have selected In-Process as the status type, all In-Process claims will display regardless of the date and the Report Date Range option will not be available to select. From the drop down menu, choose one of the following: This Week: This option is defined as being from the previous Sunday to the current day of the week. When selecting this 92

93 option, the From and To date range fields will automatically fill with the corresponding dates and will not be available to change. Yesterday: This option is defined as the date prior to the current date you are running the Claims Report. When selecting this option, the From and To date range fields will automatically fill with the corresponding dates and will not be available to change. Last Week: This option is defined as being from Sunday to Saturday of the week prior to the current week. When selecting this option the From and To date range fields will automatically fill with the corresponding dates and will not be available to change. Select Date Range: This option allows you to enter the From and To date fields. You can select a span of 7 days within the last 9 weeks to view a Claims Report. Criterion #3: The third criterion is to select the Provider. You have the option to select either a single/specific Individual Provider or Institutional Facility for reporting claims data. Or, you can select all Providers added to the account for reporting claims data. Next, select a View Option for your report. The View Option sets a sort order for how your claims data will display in the report. From the drop down menu, choose one of the following: Check Number Account or Invoice Number Patient Name Sponsor Number Note: Sorting the view by Check Number is not an option when the report's claim status is either In-Process or Returned, as there is no check generated for these statuses. Account or Invoice Number will only display if you have entered an invoice number through the Online Claim submission process. Once you have selected the criteria for your Claims Report, click View Report to see your claim data in.html format (i.e., displayed as a web page). Or, you can click Export to Excel to have your Claims Report data display in Microsoft Excel. To use this option, you must have Microsoft Excel installed on your computer. The Reset All button will set all criteria fields to their default values, thereby removing any selections you may have made prior to clicking the button. SECTIoN 6 The Provider Portal 93

94 Using the Provider Portal: Claims Report: View Report Removed claims will display the following claim-specific information: (Note: Actual field order will depend on the view option selected) Account or Invoice Number Patient Name Sponsor Number Claim Number Dates of Service Reason for Return Processed claims display the following summary information: (Note: Actual field order will depend on the view option selected) The reports are formatted as follows: Claim dates of service are displayed in the month/day/year format. The month will be the first 3 characters of the alphabetic spelling and the year will be in a 4-digit format. All currency values are displayed in the Provider's local currency and are displayed without a currency symbol or indicator. The 3-byte currency code will appear in the report header. In.html or web page format, claims data will be separated by the Provider attributed to the claim. In Excel format, each Provider and their corresponding claim data will display on a separate tab. In-Process claims will display the following claim-specific information: (Note: Actual field order will depend on the view option selected) Account or Invoice Number Patient Name Sponsor Number TOP Claim Number Dates of Service Amount Billed Check Number Processed Date Check Amount Account or Invoice Number Patient Name Sponsor Number Claim Number Dates of Service Amount Billed Amount Allowed Patient Owes Paid to Patient Paid to Provider Denial Flag (Y or N) If the Display Individual Charges option was selected for processed claims, the following fields will display as applicable to the claim and line: Line Item Procedure Code Revenue Code Number of Services Dates of Service Amount Billed Amount Allowed Patient Offset Provider Offset Paid by Patient OHI Paid OHI Patient Owes Reject 94

95 Patient Eligibility Using the Provider Portal: Patient Eligibility The Check Patient Eligibility button can be found on the navigation bar (see above). You can conduct a Beneficiary eligibility check using either the Sponsor Social Security Number (SSN) or DEERS Family ID. Once you make a selection, complete the remaining fields in this section and then click the Submit button. The Beneficiary eligibility search will begin and then take you to the Patient Eligibility page to view the results. Full instructions on how to submit claims via Secure Message Transmission are included in Section 5 of this TOP Provider Manual (see pages 35-41). SECTIoN 6 The Provider Portal 95

96 Manage Locations Using the Provider Portal: Manage My Locations You can add one or more locations in order to view payments, claims, send secure messages and submit Online Claims. In order to add one or more locations, you will need to have one claim number along with the corresponding patient Date of Birth for that claim number, for the location you wish to add. After the location is successfully added, you will be able to view recent payments, claims, send secure messages and submit Online Claims. To add a location, click Request Location Access which will then ask you to enter the 9-digit tax identification number (first 9 digits of the TEPRV) and zip code. Then click Search. A list will display of locations that are available to add. You will then need to click the Self Authorize For Instant Access button, which will prompt you to enter the claim number and Date of Birth for the patient on that claim number (for the location being requested). After the information has been entered and is verified, you will receive a message stating that the location was successfully added. 96

97 Using the Provider Portal: My Profile You can make any changes to your Provider Profile by clicking on Personal Information. Update the information in this section and then click Save to make the updates. You can change your language preference by clicking on the Language Preference button. Once you re finished making your selection, click Save to make the update. You can change your password and/or update your security question and answer. Click the Password Security Question button and when completed, click Save to make the updates. SECTIoN 6 The Provider Portal 97

98 TRICARE Covered Benefits Providers can check to see which medical care services are covered for each type of TRICARE Beneficiary by visiting You can fill in the fields in the Answer Three Questions section at the top of this page to customize the search results and change the profile of the TRICARE Beneficiary. For Question #2, you can select the country in which the Beneficiary is located. This will assist in determining which TRICARE Plan he or she is using. Once you have selected the customized profile, you can then click on See What s Covered to bring up a list of TRICARE Covered Services, in alphabetical order. 98

99 TRICARE Covered Benefits: See What s Covered Once the See What s Covered page opens, you can use the drop down menu to search for the particular treatment or medical service you are looking for. In the example below, Birth Control was selected from the drop down menu. Details regarding covered services and the relevant exclusions (if any) will appear. You can also click any of the links in the Most Viewed Topics section (top right) to obtain more information regarding related topics. SECTIoN 6 The Provider Portal 99

100 SECTIoN 7: TRICARE overseas Program Provider Forms Sample: CMS 1500 Claim Form 100

101 SECTIoN 7 TRICARE overseas Program Provider Forms Sample: CMS 1500 Claim Form (continued) 101

102 Sample: UB-04 Claim Form 102

103 SECTIoN 7 TRICARE overseas Program Provider Forms Sample: UB-04 Claim Form (continued) 103