WorkersComp/Tricare

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TRICARE'S two main objectives

Accessibility and Affordability

TRICARE serves __#__ regions

Three

The individual responsible for oversight of all healthcare delivery activities within his or her region

Regional Director or Lead Agent

Name of total healthcare system of the U.S. uniformed services

Military Health System

TRICARE is administered by:

The Department of Defense

The main purpose of TRICARE Management Activity (TMA) is to:

Enhance the performance of TRICARE worldwide

Computerized data bank that lists all active and retired military service members

DEERS

TRICARE-eligible individuals are referred to as:

Beneficiaries

Fee for service option offered by TRICARE which has basically the same benefits as the original CHAMPUS program

TRICARE Standard

TRICARE option similar to preferred provider organization-type managed care

TRICARE Extra

CHAMPVA is managed by:

The VA'S HAC

CHAMPVA eligibility can be lost if certain demographic changes occur such as:

Widow remarrying, Divorcing the sponsor, Become eligible for Medicare

CHAMPVA is the last payer after all other third-party payers have met their obligations except for:

Medicaid and CHAMPVA Supplemental Insurance

The deadline for filing military claims

One Year

The annual catastrophic cap for CHAMPVA

$3000

T/F: Sponsor's relationship to the beneficiary creates eligibility under TRICARE.

True

T/F: Military retirees and their family members are not eligible for TRICARE.

False

T/F: TRICARE pays for only their allowed services, supplies, and procedures.

True

T/F: There is no "cost sharing" under TRICARE regulations.

False

T/F: Active duty personnel are not CHAMPUS-eligible and are automatically enrolled in TRICARE Standard.

False

T/F: TRICARE Prime is a health maintenance organization type managed care option in which MTFs are the principal source of healthcare.

True

T/F: Under TRICARE Prime's point of service (POS) option, enrollees are allowed to recieve healthcare services only from providers within the POS network.

False

T/F: Under TRICARE for Life, TRICARE pays Medicare deductibles and coinsurance or copayment amounts up to 115% of Medicare-allowable charges.

True

T/F: Eligibility for patients claiming TRICARE and CHAMPVA coverage should be verified immediately.

True

T/F: TRICARE participating providers (PARs) must accept the TRICARE allowable charge as payment in full for the healthcare services provided and cannot balance bill.

True

T/F: Patients using TRICARE Standard are usually responsible for submitting their own claims.

True

T/F: In the case of nonparticipating providers (nonPARs), TRICARE Standard patients must file their own claims; however the reimbursement check is sent to the provider.

False

T/F: Even though electronic claims submission is preferred by most major carriers, military carriers still prefer paper claims.

False

T/F: The deadline for submitting military claims varies from region to region.

False (One Year)

Three basic plans available under the TRICARE program:

TRICARE Prime, TRICARE Standard, TRICARE Extra

Service member, whether in active duty, retired, or deceased is called

Sponsor

Purpose of a nonavailability statement

Indicates that care is unavailable from the MTF

How the health insurance professional can verify eligibility for benefits under one of the military's healthcare programs

Military ID, TRICARE Prime ID - Verify Immediately

Workers' compensation got its start in the 1800s in

Germany

In workers' compensation insurance, the premiums are paid by:

The employer

The federal program that establishes workers' compensation for nonmilitary federal government employees is known as:

Federal Employment Compensation Act (FECA)

The federal program that establishes workers' compensation for railroad workers engaged in interstate commerce is known as:

Federal Employment Liability Act (FELA)

An individual responsible for investigatingand resolving workers' complaints against the employer or insurance companythat is denying the benefits is is called:

Ombudsman

The time limit for filing a workers' compensation claim is established by

Individual state statutes

An injury or illness that is job related typically must be reported to the employer

Time limits vary from state to state

A patients inability to perform normal job duties at the previous level of expertise as a result of being absent from work is called

Job deconditioning

After the initial attending physician report has been filed, periodic updates must be provided to the employer/insurer, called:

Progress reports or Supplemental reports

The type of insurance that replaces a portion of earned income when an individual is unable to perform the requirements of his or her job because of non-job-related injury or illness is called:

Disability Insurance

The maximum amount of benefits that can be recieved in a specific time period is called:

Benefit Cap

The federal act established in 1990 that protects the civil rights of individuals with the disabilites is called the:

Americans with Disabilities Act (ADA)

The examining body that determines if an applicant qualifies for SSDI is the:

State Disability Determination unit

The method of determining whether or not an individual is eligible for SSI benefits is through a:

Financial means test

The program that provides greater choice in selecting the providers and rehabilitation services disabled individuals need to help them keep working or return to work is called:

Ticket to Work

T/F: Employers must purchase workers' compensation policies from the state in which their business operates.

True

T/F: In the US, any employee who is injured on the job or develops an employment-related illness that prevents the individual from working is likely to be eligible to collect workers' compensation benefits.

True

T/F: If an employee is injured on the job, the employer can be penalized if the cause of injury or illness was due to the employer being conspicuously negligent.

True

T/F: Most state workers' compensation laws include coverage for injuries sustained while an employee is commuting to and from work.

False

T/F: If a workers' compensation claim is denied, the worker may file a claim with his or her health insurance carrier only after all workers' compensation appeals have been exhausted.

True

T/F: The first thing an injured employee must do is call his or her family physician.

False

T/F: Workers' compensation claims must be submitted on the universal CMS-1500 claim form.

False

T/F: As long as a workers' compensation claim is pending, the provider cannot bill the patient.

True

T/F: Workers' compensation patients are not required to sign a release of information form for a claim form to be filed.

True

T/F: An individual may recieve benefits from only one federal disability program even if he or she meets all the eligibility requirements for serveral.

False

T/F: The SSI program provides monthly cash payments to low-income aged, blind, and disabled individuals.

True

T/F: The CDC Disability and Health Team's focus is promoting safe workplace procedures.

False

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