TRICARE Prime and TRICARE Prime Remote Handbook 2014

Question 1

National Guard and Reserve members called or ordered to active service for more than 30 consecutive days become eligible for TRICARE as active duty service members and their family members become eligible for TRICARE as active duty family members.

Answer 1

While on orders, you must live and work more than 50 miles (or approximately a one-hour drive) from the closest military hospital or clinic.

Question 2

For active duty service members (ADSMs) located in areas where TRICARE Prime is available, enrollment in TRICARE Prime is mandatory.

Answer 2

An enrollment action must be taken to ensure your Defense Enrollment Eligibility Reporting System (DEERS) enrollment data is current and claims are processed correctly.

Question 3

There are no enrollment fees for ADSMs and their family members.

Answer 3

Retired service members and their eligible family members, surviving spouses, eligible former spouses, and others pay TRICARE Prime enrollment fees.

Question 4

Eligible beneficiaries must be registered in DEERS and submit a TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form (DD Form 2876) to their regional contractors.

Answer 4

Enrollment forms received by your regional contractor by the 20th of the month become effective at the beginning of the following month

Question 5

If the application is received after the 20th of the month, coverage will become effective on the first day of the second month following the receipt of the enrollment form

Answer 5

To be eligible for TRICARE Prime Remote your home and work ZIP codes must be designated as TPR ZIP codes to indicate that you live and work more than 50 miles (or approximately a one-hour drive) from the closest military hospital or clinic.

Question 6

If you live or work within 50 miles of a military hospital or clinic, you will generally not be eligible for TPR.

Answer 6

If you choose not to enroll in TPRADFM, you will receive care under TRICARE Standard and TRICARE Extra, with applicable cost-shares and deductibles.

Question 7

You are considered an ADFM when your sponsor is on active duty orders.

Answer 7

The service point of contact (SPOC) coordinates
civilian health care for TPR-enrolled ADSMs of
the uniformed services.

Question 8

USFHP is available to ADFMs and retirees and

their family members until reaching age 65.

Answer 8

Beneficiaries age 65 and older who were enrolled
in USFHP on September 30, 2012, may continue
their USFHP enrollment.

Question 9

TRICARE Prime beneficiaries who live within a one-hour drive of a military hospital or clinic may be required to first seek specialty care, ancillary services (e.g., services from laboratories and radiology centers), and physical therapy at the military hospital or clinic.

Answer 9

You are encouraged to make initial contact with your new PCM within 30 days to establish yourself as a new patient.

Question 10

PCMs are required to provide services 24 hours a day, 7 days a week.

Answer 10

By law, TRICARE can only pay up to 20 percent of the TRICARE-allowable amount.

Question 11

Surviving beneficiaries and medically retired uniformed service members and their dependents will have their TRICARE Prime enrollment fees frozen at the rate in effect at the time they become survivors or medically retired and are enrolled in a TRICARE Prime option.

Answer 11

SSNs are being replaced with 10-digit DoD ID numbers.

Question 12

If you have DoD benefits (e.g., health care, commissary, exchange privileges), an 11-digit DoD Benefits Number (DBN) is also printed on the card.

Answer 12

The DBN is located above the bar code on the back of your uniformed services ID card or CAC.

Question 13

The ID card replacement process is expected to last several years until all current uniformed services ID cards are replaced as they come up for renewal.

Answer 13

Note: A health care provider photocopying your ID card or CAC for authorized purposes is legal.

Question 14

You do not need to make a special trip to have your uniformed services ID card updated until 30 days prior to expiration.

Answer 14

You may qualify for travel reimbursement if referred to specialty care that is more than 100 miles from your PCM’s office.

Question 15

If you are enrolled in TPR or TPRADFM and do not have an assigned PCM, you may seek care from any TRICARE-authorized provider.

Answer 15

However, in all emergencies, your PCM must be notified within 24 hours or on the next business day following admission to coordinate ongoing care and to ensure you receive proper authorization.

Question 16

If a military hospital or clinic is not available, prior authorization from your regional contractor is required before receiving nonemergency civilian care.

Answer 16

• The wait time for an urgent care appointment should not exceed 24 hours (one day).
• The wait time for a routine appointment should not exceed one week (seven days).

Question 17

• The travel time for a specialty care appointment should not exceed one hour.
• The wait time for a specialty care appointment or wellness visit should not exceed four weeks(28 days).

Answer 17

ADSMs require prior authorization for all inpatient and outpatient specialty services.

Question 18

An additional fitness-for-duty review is required for maternity care, physical therapy, behavioral health care services, and family counseling.

Answer 18

The TRICARE point-of-service (POS) option
gives you the freedom, at an additional cost, to receive nonemergency health care services from any TRICARE-authorized provider without requesting a referral from your PCM.

Question 19

Except in emergencies, active duty service
members (ADSMs) must have a referral and prior authorization before seeking behavioral health care outside of a military hospital or clinic.

Answer 19

Prior authorization from the regional contractor is required for all nonemergency inpatient behavioral health care services.

Question 20

Psychiatric emergencies do not require prior authorization for admission to an inpatient unit, but the regional contractor must
authorize continued stay.

Answer 20

TRICARE covers three substance use disorder treatment benefit periods in a lifetime and one per benefit period. A benefit period begins with the first date
of the covered treatment and ends 365 days later.

Question 21

Below are three ways to help you get the necessary assistance to break the smoking cycle:
• TRICARE-covered smoking-cessation
medications
• TRICARE’s Smoking Quitline is a telephone
support and referral service with trained
smoking-cessation coaches
• The Department of Defense’s Web site,
www.ucanquit2.org, provides education
and a wide range of tools to help you become
tobacco-free

Answer 21

Covered smoking-cessation medications are available at no cost through TRICARE Pharmacy Home Delivery and at military pharmacies

Question 22

Smoking-cessation counseling is covered for all TRICARE beneficiaries age 18 and older who are not Medicare-eligible and who reside and receive counseling in the 50 United States or the District
of Columbia.

Answer 22

A comprehensive clinical preventive examination is covered if it includes
an immunization, Pap test, mammogram, colon cancer screening, or prostate cancer
screening.

Question 23

Review Chart on Pgs 18-21

Answer 23

TRICARE does not cover routine ultrasound screening. Only medically necessary maternity ultrasounds are covered by
TRICARE.

Question 24

TRICARE Extended Care Health Option (ECHO) provides supplemental health and non-health care services to active duty family members who qualify based on specific mental or physical disabilities.

Answer 24

In the United States and U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands), claims must be filed within one year of either the date of service or the date of inpatient discharge.

Question 25

Overseas, claims must be filed within three years of either the date of service or the date of inpatient discharge. You must submit proof of payment with overseas claims.

Answer 25

To file a claim, obtain and complete a TRICARE
DoD/CHAMPUS Medical Claim—Patient’s
Request for Medical Payment (DD Form 2642).

Question 26

You must submit proof of payment with all claims for care received overseas. Proof of payment is necessary for TRICARE to validate claims and safeguard benefit dollars.

Answer 26

Review chart on pg 27

Question 27

If an emergency occurs, call 911 or go to the nearest emergency room and notify your PCM or the local TRICARE Overseas Program (TOP) Regional CallCenter (if overseas) within 24 hours or on the next business day.

Answer 27

If you do not enroll your child in a TRICARE

Prime option by day 61, he or she will be covered under TRICARE Standard and TRICARE Extra.

Question 28

If your child is not registered in DEERS within one year after the date of birth, DEERS will show “loss of eligibility,” and your child will lose all TRICARE coverage until he or she is registered in DEERS.

Answer 28

Note: You must complete DEERS registration
before you enroll your child in TRICARE Prime
or TPRADFM.

Question 29

If you plan to travel for more than 60 days,

you may choose to transfer your TRICARE Prime enrollment to the new TRICARE region where you will be living.

Answer 29

If you move to an area where TRICARE Prime
is not available (same or new region), you must
disenroll from TRICARE Prime.

Question 30

If you are eligible under TAMP and have a newly diagnosed medical condition that is related to your active duty service, you may qualify for the TCSRC program, which provides 180 days of care for your condition with no out-of-pocket costs.

Answer 30

Continued Health Care Benefit Program

(CHCBP) offers temporary transitional health coverage (18–36 months) after TRICARE eligibility ends.

Question 31

If you decide to reenroll in TRICARE Prime,
you must submit your DD Form 2876 to your
regional contractor prior to your retirement date; otherwise, the 20th-of-the-month rule may apply.

Answer 31

Retirees and their dependents who are entitled to premium-free Medicare Part A must also have Medicare Part B to remain TRICARE-eligible regardless of their age or place of residence.

Question 32

To avoid a break in TRICARE coverage, ADSMs and ADFMs must sign up for Medicare Part B before their sponsor’s active duty status ends.

Answer 32

END