When stationed overseas, Active Duty Service Members (ADSMs) and their families rely on the TRICARE Overseas Program (TOP) for their healthcare needs. Within TOP, both TOP Prime and TOP Prime Remote options operate as managed care programs, ensuring access to necessary medical services while managing costs. This guide will clarify how TRICARE managed care works for ADSMs under these programs.
TRICARE TOP Prime and TOP Prime Remote: Managed Care Essentials
For ADSMs enrolled in TOP Prime or TOP Prime Remote, managed care means accessing healthcare primarily through a Primary Care Manager (PCM) and utilizing a network of providers. This system is designed to minimize out-of-pocket expenses for beneficiaries while ensuring coordinated and comprehensive care.
When receiving care from military hospitals or clinics, or from network providers with appropriate referrals and prior authorizations, ADSMs face no out-of-pocket costs for covered services. This cost-effectiveness is a key benefit of the managed care aspect of TOP Prime and TOP Prime Remote.
To locate a network provider in your overseas location, you can utilize the provider search tool available at: http://www.tricare-overseas.com/beneficiaries/resources/provider-search. This tool is essential for navigating the network and ensuring you receive care within the managed care framework.
Opting for non-network, nonparticipating providers without proper authorization will require upfront payment, and you will need to file a claim for reimbursement. It’s crucial to understand that overseas non-network providers may not be limited in their billing, potentially leading to costs exceeding TRICARE’s allowable charges, for which you would be responsible.
The Point-of-Service (POS) option within TOP Prime (though not for ADSMs themselves) allows other beneficiaries to seek non-emergency care from any TRICARE-authorized provider without a referral, but with increased out-of-pocket expenses. Details about the POS option can be found at www.tricare.mil/pointofservice, although ADSMs should primarily focus on utilizing network providers to maximize the benefits of managed care.
Referrals and Prior Authorizations for ADSMs and ADFMs
A cornerstone of managed care within TRICARE TOP Prime and TOP Prime Remote is the requirement for referrals and prior authorizations, especially for specialist care. ADSMs require prior authorization for all inpatient and outpatient specialty care services. This process ensures that care is medically necessary and appropriately coordinated.
Active Duty Family Members (ADFMs) also require prior authorization for all inpatient and outpatient specialty care services, mirroring the requirements for ADSMs. Additionally, ADFMs need prior authorization for outpatient mental health care visits, including psychotherapy and substance use disorder (SUD) treatments. Certain treatments like psychoanalysis, electroconvulsive therapy, and Transcranial Magnetic Stimulation (TMS) have specific exceptions.
To assist beneficiaries in navigating the referral process, Referral Management personnel often serve as Patient Liaisons. These liaisons play a vital role in coordinating network appointments, inpatient admissions, after-hours transfers, translation services within the network, and managing consultation results from network providers. This support system enhances the managed care experience by providing personalized assistance.
Assistance for Non-Enrolled TRICARE Patients with USNH Referrals
Even for individuals not enrolled in TRICARE Prime at a specific US Naval Hospital (USNH), such as USNH Japan, referral management assistance may be available if the referral originates from a USNH provider. For those with TRICARE Select or non-TRICARE insurance who receive a referral from a primary care provider at USNH, the Referral Management Center (RMC) can assist in booking appointments with local providers.
In such cases, limited transportation and translation services might be offered for the initial appointment, depending on availability. However, subsequent transportation and translation become the patient’s responsibility. It’s important to note that these services are generally for patients utilizing the TRICARE network.
For other categories of patients eligible for care at USNH Yokosuka, such as NATO personnel or DoD-affiliated teachers, the TRICARE network restrictions maintained by International SOS may not apply, offering more flexibility in choosing providers.
Regardless of patient category, if USNH Yokosuka generates the initial referral, follow-up written translation services related to network care will be provided. Translated documents are then integrated into the patient’s electronic health record (AHLTA). However, RMC staff does not arrange care outside the International SOS network, and patients seeking such care are responsible for obtaining their own translation services.
Understanding Medical Bills within TRICARE Overseas
For those enrolled in TRICARE Prime overseas, all medically necessary costs incurred during hospitalization in Japanese facilities are typically covered by TRICARE. However, it’s important to note that TRICARE Prime generally does not cover extra charges for amenities like televisions, refrigerators, or private rooms unless deemed medically necessary. Patients might also need to purchase personal items from the hospital store at their own expense. For billing inquiries, the Health Benefits Advisor can be contacted.
If you have TRICARE Select or other insurance, be aware that Japanese hospitals usually cannot bill insurance companies directly. Patients are required to pay the full medical bill in Yen at the time of discharge and then file a claim for reimbursement with their insurance provider. While some hospitals accept credit cards, cash in Japanese Yen is the most widely accepted form of payment. Always obtain an itemized receipt for insurance claim purposes.
For extensive procedures or prolonged hospital stays, medical bills can be substantial. In such situations, consulting with both the hospital’s billing department and your insurance company is advisable to arrange payment plans. Some U.S.-based insurance companies may have Japanese agents to facilitate direct payments with Japanese hospitals, so checking with your insurer is recommended.
TRICARE While Traveling Overseas
For beneficiaries traveling between overseas regions or returning to the United States, understanding TRICARE program options during travel is essential. Detailed information about using TRICARE while traveling can be found at: http://www.tricare-overseas.com/beneficiaries/resources/traveling-beneficiaries. This resource is crucial for maintaining continuous healthcare coverage while mobile.
Birth Certificates and DEERS/TRICARE Enrollment for Newborns
For families welcoming newborns in Japanese hospitals, specific procedures for birth certificates and TRICARE enrollment must be followed. The Japanese hospital provides the birth certificate, partially completed in Japanese, requiring parents to fill in the remaining sections (also in Japanese). Assistance from a case manager is available for form completion if needed.
Submission of the completed birth certificate to the City Hall, along with parents’ passports or military IDs and marriage certificate, initiates the official registration. After processing, which takes approximately two hours, a Certificate of Acceptance of Birth Report (Shusshou jyuri shoumeisho) can be requested. This certificate is necessary for passport and Social Security number applications for the newborn and costs 300 yen per copy. Case managers can also provide English translations of this document.
To ensure continuous TRICARE coverage for newborns, prompt registration in the Defense Enrollment Eligibility Reporting System (DEERS) is crucial. DEERS enrollment is mandatory for TRICARE coverage, and it can be initiated even without a Social Security number, which can be updated later. Choosing a TRICARE health plan and enrolling the child completes the process. Assistance with DEERS and TRICARE enrollment is available at designated TRICARE offices.
In conclusion, TRICARE TOP Prime and TOP Prime Remote provide managed care solutions for ADSMs and their families stationed overseas. Understanding the referral processes, network utilization, billing procedures, and enrollment steps ensures beneficiaries can effectively navigate the system and access the healthcare benefits they are entitled to while minimizing out-of-pocket costs.
