Common use of ENROLLMENT PROCESSING Clause in Contracts

ENROLLMENT PROCESSING. 3.1 TOP Prime and TOP Prime Remote are available to Active Duty Service Members (ADSMs) and certain ADFMs in overseas locations as described below. These programs are similar, but not identical, to TRICARE Prime and TRICARE Prime Remote (TPR)/TRICARE Prime Remote for ADFMs (TPRADMs) in the United States (U.S.). TOP Prime enrollees shall normally be enrolled to an Military Treatment Facility (MTF) Primary Care Manager (PCM), but enrollment to a purchased care sector PCM may be authorized when MTF capacity is reached. TOP Prime enrollment procedures shall be established in the Statements of Responsibilities (SORs) between the TOP contractor and the MTF Commander. TOP Prime Remote enrollees shall be enrolled to a remote Defense Medical Information System (DMIS) code with assignment to a purchased care sector PCM or to the TOP contractor, according to the specific regional enrollment procedures established in the SORs between the contractor and the TRICARE Area Office (TAO) Directors. 3.2 Unless a specific exception exists, enrollment to TOP Prime or TOP Prime Remote is available only to ADSMs who are permanently assigned overseas, and to ADFMs who are Command Sponsored and accompanying their sponsor on his/her overseas tour, or on orders in an overseas location (see paragraph 5.1 for additional information regarding Command Sponsorship). This includes activated Reserve Component (RC) ADSMs who are on orders to an overseas location for more than 30 days, and their Command Sponsored ADFMs who accompany the RC member on his/ her overseas tour or are on orders in an overseas location. 3.3 Non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for TOP Prime or TOP Prime Remote enrollment in any overseas location. This long-standing limitation derives from the limited number and capacity of MTFs and staff in overseas locations, coupled with their mission-critical requirement to provide Prime coverage for ADSMs as their first priority, and to Command Sponsored ADFMs as their second priority. ADFMs who are not Command Sponsored or on military orders as described in this section will be covered by TOP Standard (for services received through December 31, 2017). Effective January 1, 2018, a beneficiary not enrolled in Prime must be enrolled in Select (subject to any grace period during calendar year 2018) with services received on or after January 1, 2018, covered by Select. (see Section

ENROLLMENT PROCESSING. 3.1 TOP Prime and TOP Prime Remote are available to Active Duty Service Members (ADSMs) and certain ADFMs in overseas locations as described below. These programs are similar, but not identical, to TRICARE Prime and TRICARE Prime Remote (TPR)/TRICARE Prime Remote for ADFMs (TPRADMs) in the United States (U.S.). TOP Prime enrollees shall normally be enrolled to an Military Treatment Facility (MTF) Primary Care Manager (PCM), but enrollment to a purchased care sector host nation PCM may be authorized when MTF capacity is reached. TOP Prime enrollment procedures shall be established in the Statements of Responsibilities Memorandum Of Understanding (SORsMOU) between the TOP contractor and the MTF Commander. TOP Prime Remote enrollees shall be enrolled to a remote Defense Medical Information System (DMIS) code with assignment to a purchased care sector host nation PCM or to the TOP contractor, according to the specific regional enrollment procedures established in the SORs MOUs between the contractor and the TRICARE Area Office (TAO) Directors. 3.2 Unless a specific exception exists, enrollment to TOP Prime or TOP Prime Remote is available only to ADSMs who are permanently assigned overseas, and to ADFMs who are Command Sponsored and accompanying their sponsor on his/her overseas tour, or on orders in an overseas location (see paragraph 5.1 for additional information regarding Command Sponsorship). This includes activated Reserve Component (RC) ADSMs who are on orders to an overseas location for more than 30 days, and their Command Sponsored ADFMs who accompany the RC member on his/ her overseas tour or are on orders in an overseas location. 3.3 Non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for TOP Prime or TOP Prime Remote enrollment in any overseas location. This long-standing limitation derives from the limited number and capacity of MTFs and staff in overseas locations, coupled with their mission-critical requirement to provide Prime coverage for ADSMs as their first priority, and to Command Sponsored ADFMs as their second priority. ADFMs who are not Command Sponsored or on military orders as described in this section will be covered by TOP Standard (see Section 19). 3.4 Enrollment may occur at any time after TOP eligibility has been established, and normally remains effective during the overseas tour of the sponsor. Annual re-enrollment is not required for services received through December 31TOP Prime or TOP Prime Remote. Once enrolled, 2017beneficiaries remain enrolled in these programs until they disenroll; transfer enrollment to another TRICARE region/program; lose eligibility for TRICARE, TOP Prime, or TPR; or until the 61st calendar day following the end of the overseas tour (see paragraph 12.5). 3.5 The TOP contractor shall perform all enrollment-related activities for TOP Prime, TOP Prime Remote, TRICARE Plus, TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), and TRICARE Retired Reserve (TRR) in overseas locations. These activities include validation of eligibility, enrollment, re-enrollment, disenrollment, transfers, updating information in DEERS, clearing enrollment discrepancies, assign or change PCM, collecting Other Health Insurance (OHI) information, and related enrollment functions. The contractor shall use the approved TRICARE Enrollment Application for enrollment activities and shall reproduce the form as necessary to ensure ready availability to all potential enrollees. Enrollment shall be accomplished within five working days of receipt of a complete TRICARE Enrollment Application. 3.6 Enrollments for TOP Prime or TOP Prime Remote are effective on the date the enrollment form is signed (and appropriate Command Sponsorship orders are received, when applicable), unless a retroactive enrollment has been authorized by the TAO Director or designee. For TOP emergency cases that should be placed under immediate case management, TOP MTF commanders and/or the TAO Directors may approve exceptions on a case-by-case basis for retroactive TOP enrollment. Except for administrative errors, the effective date for retroactive enrollments shall not be earlier than the first day of the month that the application is submitted (see the TPM, Chapter 10, Section 2.1). Effective January • A signed enrollment application includes those with (1) an original signature, 2018(2) an electronic signature offered by and collected by the contractor, or (3) the self attestation by the beneficiary when using the Beneficiary Web Enrollment (BWE) system. An ADSM or ADFM signature is not required to make enrollment changes when using the Enrollment Portability process outlined in Chapter 6, Section 2, paragraph 1.4. A signature from an ADSM, although desired, is not required to complete Prime enrollment as enrollment in Prime is mandatory per TPM, Chapter 10, Section 2.1, paragraph 1.1. 3.7 The contractor shall follow guidance from the TAO Directors and the MTFs regarding PCM assignment when enrolling beneficiaries into TOP Prime. The MTF enrollment area encompasses a beneficiary not 40-mile radius or a one-hour drive time from the MTF. TOP Prime Remote beneficiaries will be enrolled to the appropriate DMIS code for the beneficiary’s remote overseas location. TOP Prime Remote enrollees in Canada will follow guidance applicable to the U.S. and Canada Reciprocal Health Care Agreement, and may be assigned to a Canadian Forces Health Facility for their primary care. 3.8 Newborns/adoptees are deemed to be enrolled for 60 days following birth/adoption when one other family member, to include the sponsor, is enrolled in TOP Prime/TOP Prime must Remote. Parents of newborns/adoptees are required to take specific action to enroll the newborn/adoptee within 60 calendar days of birth/adoption. For newborns and newly adopted children who are deemed enrolled, Point of Service (POS) cost-sharing does not apply through the deemed enrollment period, or until an enrollment decision is made by a responsible representative, whichever is earlier. If the newborn/adoptee is not formally enrolled to TOP Prime or TOP Prime Remote during the 60-day period, the newborn/adoptee will revert to TRICARE Standard effective the 61st day, unless the deemed enrollment period has been waived. TAO Directors may extend the deemed enrollment period for newborns/adoptees up to 120 days on a case-by-case or regional basis. TAO Directors shall advise TRICARE Management Activity (TMA) Contracting Officer (CO) in writing when a region-wide enrollment waiver has been authorized. The TMA CO will notify the TOP contractor of any waivers to the 60-day deemed enrollment period in writing at the time the waiver is implemented, and this information shall be enrolled in Select incorporated into the Memorandum of Understanding (subject MOU) between the contractor and the TAO Director(s). 3.9 The provisions of Chapter 6, Section 1 and the TPM, Chapter 10, Section 2.1 regarding Prime enrollment fees shall not apply to any grace period during calendar year 2018) TOP Prime or TOP Prime Remote. There are no enrollment fees associated with services received on TOP Prime or after January 1, 2018, covered by Select. (see SectionTOP Prime Remote.

ENROLLMENT PROCESSING. 3.1 TOP Prime and TOP Prime Remote are available to Active Duty Service Members (ADSMs) and certain ADFMs in overseas locations as described below. These programs are similar, but not identical, to TRICARE Prime and TRICARE Prime Remote (TPR)/TRICARE Prime Remote for ADFMs (TPRADMs) in the United States (U.S.). TOP Prime enrollees shall normally be enrolled to an a Military Treatment Facility (MTF) Primary Care Manager (PCM), but enrollment to a purchased care sector PCM may be authorized when MTF capacity is reached. TOP Prime enrollment procedures shall be established in the Statements of Responsibilities (SORs) between the TOP contractor and the MTF CommanderDirector. TOP Prime Remote enrollees shall be enrolled to a remote Defense Medical Information System (DMIS) code with assignment to a purchased care sector PCM or to the TOP contractor, according to the specific regional enrollment procedures established in the SORs between the contractor and the TRICARE Area Office (TAO) Directors. 3.2 Unless a specific exception exists, enrollment to TOP Prime or TOP Prime Remote is available only to ADSMs who are permanently assigned overseas, and to ADFMs who are Command Sponsored and accompanying their sponsor on his/her overseas tour, or on orders in an overseas location (see paragraph 5.1 for additional information regarding Command Sponsorship). This includes activated Reserve Component (RC) ADSMs who are on orders to an overseas location for more than 30 days, and their Command Sponsored ADFMs who accompany the RC member on his/ her overseas tour or are on orders in an overseas location. 3.3 Non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for TOP Prime or TOP Prime Remote enrollment in any overseas location. This long-standing limitation derives from the limited number and capacity of MTFs and staff in overseas locations, coupled with their mission-critical requirement to provide Prime coverage for ADSMs as their first priority, and to Command Sponsored ADFMs as their second priority. ADFMs who are not Command Sponsored or on military orders as described in this section will be covered by TOP Standard (for services received through December 31, 2017). Effective January 1, 2018, a beneficiary not enrolled in Prime must be enrolled in Select (subject to any grace period during calendar year 2018) with services received on or after January 1, 2018, covered by Select. (see Section

ENROLLMENT PROCESSING. 3.1 TOP Prime and TOP Prime Remote are available to Active Duty Service Members (ADSMs) and certain ADFMs in overseas locations as described below. These programs are similar, but not identical, to TRICARE Prime and TRICARE Prime Remote (TPR)/TRICARE Prime Remote for ADFMs (TPRADMs) in the United States (U.S.). TOP Prime enrollees shall normally be enrolled to an Military Treatment Facility (MTF) Primary Care Manager (PCM), but enrollment to a purchased care sector host nation PCM may be authorized when MTF capacity is reached. TOP Prime enrollment procedures shall be established in the Statements of Responsibilities Memorandum Of Understanding (SORsMOU) between the TOP contractor and the MTF Commander. TOP Prime Remote enrollees shall be enrolled to a remote Defense Medical Information System (DMIS) code with assignment to a purchased care sector host nation PCM or to the TOP contractor, according to the specific regional enrollment procedures established in the SORs MOUs between the contractor and the TRICARE Area Office (TAO) Directors. 3.2 Unless a specific exception exists, enrollment to TOP Prime or TOP Prime Remote is available only to ADSMs who are permanently assigned overseas, and to ADFMs who are Command Sponsored and accompanying their sponsor on his/her overseas tour, or on orders in an overseas location (see paragraph 5.1 for additional information regarding Command Sponsorship). This includes activated Reserve Component (RC) ADSMs who are on orders to an overseas location for more than 30 days, and their Command Sponsored ADFMs who accompany the RC member on his/ her overseas tour or are on orders in an overseas location. 3.3 Non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for TOP Prime or TOP Prime Remote enrollment in any overseas location. This long-standing limitation derives from the limited number and capacity of MTFs and staff in overseas locations, coupled with their mission-critical requirement to provide Prime coverage for ADSMs as their first priority, and to Command Sponsored ADFMs as their second priority. ADFMs who are not Command Sponsored or on military orders as described in this section will be covered by TOP Standard (see Section 19). 3.4 Enrollment may occur at any time after TOP eligibility has been established, and normally remains effective during the overseas tour of the sponsor. Annual re-enrollment is not required for services received through December 31TOP Prime or TOP Prime Remote. Once enrolled, 2017). Effective January 1, 2018, a beneficiary not beneficiaries remain enrolled in these programs until they disenroll; transfer enrollment to another TRICARE region/program; lose eligibility for TRICARE, TOP Prime, or TPR; or until the 61st calendar day following the end of the overseas tour (see paragraph 12.5). 3.5 The TOP contractor shall perform all enrollment-related activities for TOP Prime, TOP Prime must Remote, TRICARE Plus, TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), and TRICARE Retired Reserve (TRR) in overseas locations. These activities include validation of eligibility, enrollment, re-enrollment, disenrollment, transfers, updating information in DEERS, clearing enrollment discrepancies, assign or change PCM, collecting Other Health Insurance (OHI) information, and related enrollment functions. The contractor shall use the approved TRICARE enrollment request options for enrollment activities. Enrollment shall be accomplished within five working days of receipt of a complete TRICARE enrollment request. 3.6 Enrollments for TOP Prime or TOP Prime Remote are effective on the date the enrollment request is received (and appropriate Command Sponsorship orders are received or attested to, when applicable), unless a retroactive enrollment has been authorized by the TAO Director or designee. For telephonic enrollments, the TOP contractor will collect the Military Sponsor’s Order Number and date on the orders and document in the contractor’s call notes. By providing the Order Number and date on the orders, the Sponsor and/or ADFM attests to command sponsorship. For TOP emergency cases that should be placed under immediate case management, TOP MTF commanders and/or the TAO Directors may approve exceptions on a case-by-case basis for retroactive TOP enrollment. Except for administrative errors, the effective date for retroactive enrollments shall not be earlier than the first day of the month that the application is submitted (see the TPM, Chapter 10, Section 2.1).‌ • An official signed enrollment request includes those with (1) an original signature, (2) an electronic signature offered by and collected by the contractor, or (3) a verbal consent provided via telephone and documented in the contractor’s call notes. A signature is not required to make enrollment changes by phone as long as the verbal request is documented. A signature from an ADSM is never required to complete Prime enrollment as enrollment in Prime is mandatory per TPM, Chapter 10, Section 2.1, paragraph 1.1. 3.7 The contractor shall follow guidance from the TAO Directors and the MTFs regarding PCM assignment when enrolling beneficiaries into TOP Prime. The MTF enrollment area encompasses a 40-mile radius or a one-hour drive time from the MTF. TOP Prime Remote beneficiaries will be enrolled to the appropriate DMIS code for the beneficiary’s remote overseas location. TOP Prime Remote enrollees in Select Canada will follow guidance applicable to the U.S. and Canada Reciprocal Health Care Agreement, and may be assigned to a Canadian Forces Health Facility for their primary care. 3.8 Newborns/adoptees are deemed to be enrolled for 60 days following birth/adoption when one other family member, to include the sponsor, is enrolled in TOP Prime/TOP Prime Remote. Parents of newborns/adoptees are required to take specific action to enroll the newborn/adoptee within 60 calendar days of birth/adoption. For newborns and newly adopted children who are deemed enrolled, Point of Service (subject to any grace period during calendar year 2018POS) with services cost-sharing does not apply through the deemed enrollment period, or until an enrollment decision is made by a responsible representative, whichever is earlier. If the newborn or adoptee is formally enrolled in TOP Prime or TOP Prime Remote within the 60-day period, the date of enrollment will be the date the enrollment request is received on or after January 1, 2018, covered by Select. (see Sectionper paragraph 3.

ENROLLMENT PROCESSING. 3.1 TOP Prime and TOP Prime Remote are available to Active Duty Service Members (ADSMs) and certain ADFMs in overseas locations as described below. These programs are similar, but not identical, to TRICARE Prime and TRICARE Prime Remote (TPR)/TRICARE Prime Remote for ADFMs (TPRADMs) in the United States (U.S.). TOP Prime enrollees shall normally be enrolled to an Military Treatment Facility (MTF) Primary Care Manager (PCM), but enrollment to a purchased care sector PCM may be authorized when MTF capacity is reached. TOP Prime enrollment procedures shall be established in the Statements of Responsibilities (SORs) between the TOP contractor and the MTF Commander. TOP Prime Remote enrollees shall be enrolled to a remote Defense Medical Information System (DMIS) code with assignment to a purchased care sector PCM or to the TOP contractor, according to the specific regional enrollment procedures established in the SORs between the contractor and the TRICARE Area Office (TAO) Directors. 3.2 Unless a specific exception exists, enrollment to TOP Prime or TOP Prime Remote is available only to ADSMs who are permanently assigned overseas, and to ADFMs who are Command Sponsored and accompanying their sponsor on his/her overseas tour, or on orders in an overseas location (see paragraph 5.1 for additional information regarding Command Sponsorship). This includes activated Reserve Component (RC) ADSMs who are on orders to an overseas location for more than 30 days, and their Command Sponsored ADFMs who accompany the RC member on his/ her overseas tour or are on orders in an overseas location. 3.3 Non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for TOP Prime or TOP Prime Remote enrollment in any overseas location. This long-standing limitation derives from the limited number and capacity of MTFs and staff in overseas locations, coupled with their mission-critical requirement to provide Prime coverage for ADSMs as their first priority, and to Command Sponsored ADFMs as their second priority. ADFMs who are not Command Sponsored or on military orders as described in this section will be covered by TOP Standard (see Section 19). 3.4 Enrollment may occur at any time after TOP eligibility has been established, and normally remains effective during the overseas tour of the sponsor. Annual re-enrollment is not required for services received through December 31TOP Prime or TOP Prime Remote. Once enrolled, 2017). Effective January 1, 2018, a beneficiary not beneficiaries remain enrolled in these programs until they disenroll; transfer enrollment to another TRICARE region/program; lose eligibility for TRICARE, TOP Prime, or TPR; or until the 61st calendar day following the end of the overseas tour (see paragraph 12.5). 3.5 The TOP contractor shall perform all enrollment-related activities for TOP Prime, TOP Prime must Remote, TRICARE Plus, TRICARE Young Adult (TYA), TRICARE Reserve Select (TRS), and TRICARE Retired Reserve (TRR) in overseas locations. These activities include validation of eligibility, enrollment, re-enrollment, disenrollment, transfers, updating information in DEERS, clearing enrollment discrepancies, assigning or changing PCMs, collecting Other Health Insurance (OHI) information, and related enrollment functions. The contractor shall use the approved TRICARE enrollment request options for enrollment activities. Enrollment shall be accomplished within five working days of receipt of a complete TRICARE enrollment request. Note: Overseas insurance plans such as German Statutory Health Insurance, Japanese National Insurance (JNI), Philippines Phil Health, and Australian Medicare, etc., are considered OHI. 3.6 Enrollments for TOP Prime or TOP Prime Remote are effective on the date the enrollment request is received (and appropriate Command Sponsorship orders are received or attested to, when applicable), unless a retroactive enrollment has been authorized by the TAO Director or designee. For telephonic enrollments, the TOP contractor will collect the Military Sponsor’s Order Number and date on the orders and document in the contractor’s call notes. By providing the Order Number and date on the orders, the Sponsor and/or ADFM attests to command sponsorship. For TOP emergency cases that should be placed under immediate case management, TOP MTF commanders and/or the TAO Directors may approve exceptions on a case-by-case basis for retroactive TOP enrollment. Except for administrative errors, the effective date for retroactive enrollments shall not be earlier than the first day of the month that the application is submitted (see the TPM, Chapter 10, Section 2.1).‌ • An official signed enrollment request includes those with (1) an original signature, (2) an electronic signature offered by and collected by the contractor, or (3) a verbal consent provided via telephone and documented in the contractor’s call notes. A signature is not required to make enrollment changes by phone as long as the verbal request is documented. A signature from an ADSM is never required to complete Prime enrollment as enrollment in Prime is mandatory per TPM, Chapter 10, Section 2.1, paragraph 1.1. 3.7 The contractor shall follow guidance from the TAO Directors and the MTFs regarding PCM assignment when enrolling beneficiaries into TOP Prime. The MTF enrollment area encompasses a 40-mile radius or a one-hour drive time from the MTF. TOP Prime Remote beneficiaries will be enrolled to the appropriate DMIS code for the beneficiary’s remote overseas location. TOP Prime Remote enrollees in Select Canada will follow guidance applicable to the U.S. and Canada Reciprocal Health Care Agreement, and may be assigned to a Canadian Forces Health Facility for their primary care. 3.8 Newborns/adoptees in all overseas locations are deemed to be enrolled for 120 days following birth/adoption when one other family member, to include the sponsor, is enrolled in TOP Prime/TOP Prime Remote. Parents of newborns/adoptees are required to take specific action to enroll the newborn/adoptee within 60 calendar days of birth/adoption. For newborns and newly adopted children who are deemed enrolled, Point of Service (subject to any grace period during calendar year 2018POS) with services cost-sharing does not apply through the deemed enrollment period, or until an enrollment decision is made by a responsible representative, whichever is earlier. If the newborn or adoptee is formally enrolled in TOP Prime or TOP Prime Remote within the 120-day period, the date of enrollment will be the date the enrollment request is received on or after January 1, 2018, covered by Select. (see Sectionper paragraph 3.