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An HMO is a health plan to which a beneficary pays a fixed premium for an assortment of medical services, usually including primary and preventive care. The primary purpose of an HMO is to coordinate care so as to eliminate unnecessary care and costs. HMOs typically have copays rather than cost-shares.
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Managed Care is a concept under which an organization (like an HMO) delivers health care to enrolled members. It controls costs by closely supervising and reviewing the delivery of care.
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TRICARE will consider payment for all necessary medical or psychological services which have been generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness.
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Military Treatment Facilities (MTF) are hospitals, clinics, etc., that are typically located on base and provide medical or dental services to eligible beneficiaries.
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A network provider is a healthcare professional who has signed an agreement with TRICARE stating, among other things, to accept assignment of benefit or the TRICARE Maximum Allowable Charge as payment in full. Network providers must file the claim on the patient's behalf.
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Authorizations may be needed for certain procedures. Typically, network or contracted TRICARE providers require authorizations to provide specialty or inpatient care. Prime beneficiaries require authorizations for specialty care provided out of the Primary Care Manager's office. Psychological and substance abuse care typically require authorization. Contact TriWest at 1-888-TRIWEST to determine if authorization is needed.
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A TRICARE-authorized provider is one whose provider status can be authorized by TRICARE as a legitimate provider of care, meeting specific educational, licensing, and other requirements. Authorized providers are not necessarily network providers. TRICARE will share costs for TRICARE-authorized procedures or services if a beneficiary sees a providers of this type, after the provider has become TRICARE-certified. A TRICARE-certified provider is TRICARE-authorized provider who has been certified by TriWest to provide services to TRICARE beneficiaries.
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Any person eligible for TRICARE benefits who is receiving care; the patient.
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A Beneficiary Counseling and Assistance Coordinator (BCAC) is a military or government employee, usually located at a Military Treatment Facility (MTF), who can address healthcare issues and concerns. Formerly known as a Health Benefits Advisor (HBA).
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The maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1 - September 30). Point of service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.
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CHAMPUS is the former name of the military healthcare program that is now TRICARE.
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A claims processor is the TRICARE designated contractor who processes medical claims for care received within a particular state or region. Customer Service areas are available to answer your questions regarding claim status.
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The fixed amount a TRICARE Prime program option enrollee will pay for care in the civilian provider network. Active duty family members enrolled in a TRICARE Prime program option are not required to make copayments.
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The percentage of the allowable charges a beneficiary will pay under TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select. The cost-share depends on the sponsor's status (active duty or retired).
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The annual amount a TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select beneficiary must pay for covered outpatient benefits before TRICARE begins to share costs. TRICARE Prime beneficiaries do not have an annual deductible, unless they are utilizing their point of service option.
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The Defense Enrollment Eligibility Reporting System (DEERS) is a computerized data bank that lists all active and retired military members and their dependents if they meet the eligibility requirements. Active and retired military members are automatically listed but must take action to list their dependents and report any changes to family members' status (marriage, divorce, birth of a child, adoption, etc.) along with changes to mailing addresses. TRICARE contractors check DEERS before processing claims to make sure patients are eligible. You may contact DEERS at 1-800-538-9552.
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Durable Medical Equipment (DME) is purchased or rented medical equipment used for treatment of an injury or illness while medically necessary. DME may include wheelchairs, hospital beds, attachments, oxygen, respirators and medical supplies. DME purchases in excess of $500.00 or all rentals require preauthorization.
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A statement sent to a beneficiary and the provider showing that a claim was processed and indicating the amount paid to the provider. The EOB includes dates of service, who provided a particular service, the allowable charge and the billed amount as well as deductible, copay, cost-share and catastrophic cap information. If denied, an explanation of denial is provided.
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Fiscal Intermediaries (FI) are privately held companies contracted by the government to handle all TRICARE claims for any given region. The government directs FIs through federal regulations and guidelines. At times a Fiscal Intermediary may subcontract Claims Processors to adjudicate claims.
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A NAS statement is a certificate from the local military treatment facility (MTF) that states it can't provide the care that the patient needs. TRICARE Standard beneficiaries are required to obtain a NAS for inpatient mental health. With the exception of inpateint mental health care, the NAS requirement has been all but eliminated, except in limited circumstances when an MTF applies for a NAS waiver. MTFs may not apply for a NAS waiver for maternity, meaning the NAS requiremnet for maternity is removed completely.
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Any non-TRICARE health insurance that is not considered a supplement is considered OHI. This insurance is acquired through an employer, entitlement program, or other source. Under federal law, TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, the Indian Health Service, or other programs or plans as identified by the TRICARE Management Activity.
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A Preferred Provider Organization is a network of healthcare providers who provide services to patients at discounted rates or cost shares.
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The Privacy Act of 1974 is a federal law that was established to provide a safeguard for individuals against invasion of personal privacy. The Federal Privacy Act imposes a legal responsibility on the Department of Defense and TRICARE Fiscal Intermediaries to assure that personal information about individuals collected by TRICARE is limited to that which is legally authorized and necessary.
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A doctor, hospital or other person or place that provides medical services and/or supplies.
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A referral is a request by the patient's Primary Care Manager (PCM) granting permission for the patient to seek specialty care outside of the PCM office.
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A defined geographic area served by a hospital, clinic, or dental clinic and delineated on the basis of such factors as population distribution, natural geographic boundaries, and transportation accessibility. For the Department of Defense (DoD) Components, those geographic areas are determined by the Assistant Secretary of Defense (Health Affairs) and are defined by a set of 5-digit ZIP codes, usually within an approximate 40-mile radius of military inpatient treatment facilities.
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Program administered by the Department of Defense (DoD) for the Department of Veterans Affairs that cost-shares for care delivered by civilian health providers to family members of totally disabled veterans that are eligible for retirement pay from a Uniformed Service of the United States.
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The MMSO helps ensure TRICARE members receive the health care services for which they are eligible. Located in Great Lakes, Ill., the MMSO serves as the centralized Tri-service point of contact, providing customer service, overseeing medical and dental care, and coordinating civilian health care services.
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A primary care manager is an MTF provider or network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. The PCM may be an individual doctor, a military provider, a military facility, a civilian clinic, an individual civilian provider, or Uniformed Services Family Health Plan (USFHP).
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A written confirmation that the requested PFPWD services or items are either not available from public facilities or are not adequate to meet the needs of the beneficiary’s qualifying condition. The PFPWD requires that public facilities be used first to the extent that they are available and adequate. The certification can be issued by the Commander of the MTF or an authorized administrator of the public facility. The certification is valid for 12 consecutive months from date of signature. A care-specific determination of public facility availability is conclusive and is not appealable.
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Situation where different members of the same family are enrolled with different TRICARE contractors. Each contractor maintains and tracks enrollment fees, copayments, and other TRICARE enrollee information for the family members enrolled in its own area.
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Ensures, with the support of the Surgeons General of the Military Departments, that Department of Defense (DoD) policy on health care is consistently, effectively and efficiently implemented throughout the Military Health System (MHS). The TMA is an activity of the Assistant Secretary of Defense (Health Affairs).
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Provides beneficiary enrollment, access to and referral for care, information on TRICARE options, information (including online access to the claims processing system for information about the status of a claim), assist beneficiaries with claim problems, and continuity of care services to all Military Health System beneficiaries. TSCs also fulfill the requirements of the Lead Agents (LAs).
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Medically necessary treatment that is required for illness or injury that would not result in further disability or death if not treated immediately, but treatment should not be put off. The illness or injury does require professional attention, and should be treated within 24 hours to avoid development of a situation in which further complications could result if treatment is not received.
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A non-participating provider is a TRICARE-certified hospital, institutional provider physician, or other provider that furnishes medical services (or supplies) to TRICARE beneficiaries but who has not signed a contract and does not agree to accept the TRICARE-allowable charge or file claims for TRICARE beneficiaries.
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A participating provider is a provider who has agreed to file claims for TRICARE beneficiaries, accept payment directly from TRICARE, and accept the TRICARE-allowable charge as payment in full for services rendered. Non-network providers may participate on a claim-by-claim basis. Providers may seek payment of applicable copayments, cost-shares, and deductibles from the beneficiary. After May 1, 2009, under the outpatient prospective payment systems (OPPS), all hospitals that are Medicare-participating providers must, by law, also participate in TRICARE for inpatient and outpatient care.
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TRICARE figures the allowable charge from all professional (non-institutional) providers' charges nationwide, with adjustments for specific localities, over the last year. The claims processor can verify the allowable amount for specific services per TRICARE guidelines. The allowable charge is also known as the TRICARE Maximum Allowable Charge (TMAC).
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Medical services that may be a result of a third party must first be reviewed for liability before TRICARE can consider payment. A Third Party Liability (TPL) form must be completed which explains whether or not another party may be responsible for making payment before TRICARE.
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TRICARE Prime is a managed care option offered in TRICARE Prime Service Areas (PSAs). TRICARE Prime enrollees receive most of their care from an assigned primary care manager (PCM) at a Military Treatment Facility, if available, or from the TRICARE network. The PCM provides and coordinates care, maintains patient medical records, and refers patients to specialists, if necessary. Specialty care referred by the PCM must be approved in advance by TriWest Healthcare Alliance Corp. Primary care is provided by the assigned PCM unless the PCM issues a referral.
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TRICARE Extra is available to all TRICARE eligible beneficiaries except ADSMs. Beneficiaries are responsible for fiscal year deductible and cost-shares. Beneficiaries may see any TRICARE-authorized provider they choose, and TRICARE will share the cost of covered services with the beneficiaries after deductible are met. TRICARE Extra is a preferred provider option. Beneficiaries choose a doctor, hospital, or other medical provider within the TRICARE provider network. By choosing a network provider, the beneficiary's out-of-pocket costs are reduced.
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TRICARE Standard is available to all TRICARE eligible beneficiaries except ADSMs. Beneficiaries are responsible for fiscal year deductible and cost-shares. Beneficiaries may see any TRICARE-authorized provider they choose, and TRICARE will share the cost of covered services with the beneficiaries after deductible are met. TRICARE Standard is a fee-for-service option.
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TRICARE For Life (TFL) is TRICARE's Medicare-wraparound coverage available worldwide to TRICARE beneficiaries regardless of age, provided they are entitled to premium-free Medicare Part A and also have Medicare Part B. TFL is available to all TRICARE/Medicare dual-eligible beneficiaries, including retired members of the National Guard and Reserve who are in receipt of retired pay, family members, widows/widowers, and certain former spouses. Dependent parents and parents-in-law are not eligible for TFL. TFL coverage is effective the same day that a beneficiary's Medicare Part B coverage becomes effective.
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The TRICARE form for Patient's Request for Medical Payment. This form is submitted by the beneficiary or sponsor requesting payment for services or supplies provided by civilian sources of medical care.
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Responsible for all civilian health care delivery to TRICARE beneficiaries outside the Military Treatment Facilities.
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All aspects of health services for the Department of Defense.
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Network providers may only bill TRICARE beneficiaries for applicable deductible, copayment, or cost-sharing amounts, but may not bill for charges that exceed contractually agreed upon payment rates. Because network providers have contractually agreed to adhere to these provisions, TRICARE beneficiaries will be referred first to a network provider. Any provider who is uncertain about the amount that may be billed to a TRICARE beneficiary may call TriWest at 1-888-TRIWEST (1-888-874-9478).
