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Chapter 14 Tricare and Veterans health Care
Terms in this set (91)
active duty service member (ADSM)
An active member of the United States government military services (e.g., Army, Navy, Air Force, Marines, or Coast Guard).
An amount on which TRICARE figures the patient's cost-share for covered care. This is based on 75% to 80% of the allowable charge.
A physician or other individual authorized provider of care or a hospital or supplier approved by TRICARE to provide medical care and supplies.
An individual entitled to receive insurance policy or government program health care benefits. Also known as participant, subscriber, dependent, enrollee, or member.
The maximum dollar amount that a member has to pay under TRICARE or CHAMPVA in any fiscal year or enrollment period for covered medical bills.
In the TRICARE program, an area defined by zip codes, that is approximately 40 miles in radius surrounding each United States military treatment facility.
A term used when a patient is seen by a civilian physician or hospital for services cost-shared by TRICARE.
coordination of benefits
Two insurance carriers working together and coordinating the payment of their benefits so that there is no duplication of benefits paid between the primary and secondary insurance carriers. In TRICARE, the coordination of the payment of TRICARE benefits with the payment of benefits made by the double coverage plan so that there is no duplication of benefits paid between the double coverage plan and TRICARE; likewise applied to disability programs.
The portion of the allowable charges (20% or 25%) after the deductible has been met that the TRICARE patient is responsible for.
Defense Enrollment Eligibility Reporting System (DEERS)
An electronic database used to verify beneficiary eligibility for those individuals in the TRICARE programs.
department of veterans affairs
a government entity that oversees such issues and loans, health care and education for those who have been in the military
A sudden and unexpected medical condition, or the worsening of a condition, that poses a threat to life, limb, or sight, and requires immediate treatment to alleviate suffering (e.g., shortness of breath, chest pain, drug overdose).
health benefits advisors (HBA)
An individual at military hospitals or clinics who is there to help TRICARE beneficiaries obtain medical care through the military and through TRICARE.
health care finder (HCF)
health care professional, generally a registered nurse, who is located at TRICARE Service Centers to act as a liaison between military and civilian providers, verify eligibility, determine availability of services, coordinate care, assist the transfer of records, and perform first-level medical review.
medically (or psychologically) necessary
Medical or psychologic services considered appropriate care and generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness, injury, pregnancy, and mental disorders, or that are reasonable and adequate for well-baby care.
military treatment facility (MTF)
All uniformed service or health clinics; also known as military hospitals or uniformed services hospitals.
nonparticipating provider (non par)
A provider who decides not to accept the determined allowable charge from an insurance plan as the full fee for care. Payment goes directly to the patient in this case, and the patient is usually responsible for paying the bill in full.
other health insurance (OHI)
Health Care coverage for TRICARE beneficiaries through an employer, an association, or a private insurer. A student in the family may have a health care plan through school.
participating provider (par)
One who accepts TRICARE assignment. Payment in this case goes directly to the provider. The patient must still pay the cost-share outpatient deductible and the cost of care not covered by TRICARE.
A program that lets TRICARE-eligible individuals receive inpatient or outpatient treatment from civilian providers of care in a military hospital or from uniformed services providers of care in civilian facilities.
point-of-service (POS) option
individuals under the TRICARE program can choose to get TRICARE-covered non emergency services outside the prime network of providers without a referral from the primary care manager and without authorization from a health care finder.
A requirement of some health insurance plans to obtain permission for a service or procedure before it is done to see whether the insurance program agrees it is medically necessary.
primary care manager (PCM)
A physician who is responsible for coordinating and managing all of the TRICARE beneficiary's health care unless there is an emergency.
quality assurance program
A plan that continually assesses the effectiveness of inpatient and outpatient care in the TRICARE and CHAMPVA programs.
The head of a TRICARE region whose responsibility it is to provide beneficiaries with healthcare services and support in addition to what services are available at military treatment facilities (MTFs)
service benefit program
A program (e.g. TRICARE) that provides benefits without a contract guaranteeing the indemnification of an insured party against a specific loss; there are no premiums. TRICARE standard is considered a service benefit program.
Injury incurred by a service member while on active duty or incurred during reserve duty with a military unit.
service retiree (military retiree)
An individual who is retired from a career in the armed forces; also known as military retiree.
A PPO-type of TRICARE option in which the individual does not have to enroll or pay an annual fee. On a visit-by-visit basis, the individual may seek care from an authorized network provider and receive a discount on services and reduced cost-share (copayment).
For the Tricare program, the service person (active duty, retired, or deceased) whose relationship makes the patient (dependent) eligible for TRICARE.
A voluntary Hmo-type option for TRICARE beneficiaries.
summary payment voucher
The document the fiscal agent sends to the provider or beneficiary, showing the service received, allowable charges, amount billed, the amount TRICARE paid, how much deductible has been paid, and the patient's cost-share.
TRICARE for Life (TFL)
A health care program that offers additional TRICARE benefits as a supplementary payer to Medicare for uniformed services retirees, their spouses, and survivors age 65 years of age or older.
total, permanent services-connected disability
A total permanent disability incurred by a service member while on active duty.
TRICARE service center (TSC)
An office staffed by TRICARE Health Care Finders and beneficiary service representatives.
Medically necessary treatment that is required for illness or injury that would result in further disability or death if not treated immediately.
Any person who has served in the armed forces of the United States, especially in time of war; is no longer in the services; and has received an honorable discharged.
veterans health administration
formerly known as champva
Active Duty Service Member
Civilian Health and Medical Program of the Department of Veterans Affairs
Defense Enrollment Eligibility Reporting System
health administration center
health benefits advisor
health care finder
Military Health System
military treatment facility
nonparticipating (provider or physician)
primary care manager
other health insurance
Tricare for Life
POS option abv.
Tricare Management Activity
Supplemental Health Care Program
Tricare Prime Remote
Tricare Prime Remote for Active Duty Family Members
Tricare service center
Uniformed Services Family Health Plan
CHAMPUS, the acronym for Civilian Health and Medical Program of the Uniformed Services, is now called ___ and was organized to control escalating medical costs and to standardize benefits for active-duty families and military retirees.
An active duty service member is known as a/an ___; once retired, this former member is called a/an ___.
service retiree or military retiree.
An individual who qualifies for TRICARE is known as a/an ___.
A system for verifying an individual's TRICARE eligibility is called ___.
Defense Enrollment Eligibility Reporting System (DEERS).
Mrs. Hancock, a TRICARE beneficiary, lives two miles from a Uniformed Services Medical Treatment Facility but needs to be hospitalized for mental health care services at Orlando Medical Center, a civilian hospital. What type of authorization does she require?
Nonavailability statement (NAS).
TRICARE Standard and CHAMPVA beneficiary identification cards are issued to ___ and ___. Information must be obtained from of the card and placed on the health insurance claim form.
dependents 10 years of age and older, survivors of active duty personnel, and retirees. front and back
Programs that allow TRICARE Standard beneficiaries to receive treatment, services, or supplies from civilian providers are called ___ and ___.
cooperative care and partnership.
For patients whose sponsor is a rank of E4 and below the TRICARE Standard deductible for outpatient care is how much per patient? Per family?
For patients whose sponsor is a rank of E5 and above the TRICARE Standard deductible for outpatient care is how much per patient? $___ Per family? $___
For TRICARE Standard, dependents of active duty members pay what percentage for outpatient services after the deductible has been met? ___% What percentage does TRICARE pay? ___%
For retired members or their dependents on TRICARE Standard, what is their deductible responsibility for outpatient services? $___ Per family? $___
For TRICARE Standard, retired members or their dependents pay what percentage for outpatient services after the deductible has been met? ___% What percentage does TRICARE pay? ___%
A voluntary tricare health maintenance organization type of option is known as
CHAMPVA is the acronym for ___.
Civilian Health and Medical Program of the Veterans Administration, now known as the Department of Veterans Affairs.
Those individuals who serve in the United States Armed Forces, finish their service, and are honorably discharged are known as ___.
Veterans Health Administration CHAMPVA is not an insurance program but is considered a/an ___
service benefit program.
Which individuals are entitled to CHAMPVA medical benefits? ___
husband, wife, or unmarried child of a veteran with a total disability, permanent in nature, from a service-connected disability.
husband, wife, or unmarried child of a veteran who died because of service-connected disability or who, at the time of death, had a total disability, permanent in nature, resulting from a service-connected disability.
husband, wife, or unmarried child of an individual who died in the line of duty while on active service.
The public law establishing a person's right to review and contest inaccuracies in personal medical records
is known as the ___.
Privacy Act of 1974.
An organization that contracts with the government to process TRICARE and CHAMPVA health
insurance claims is known as a/an ___.
fiscal intermediary (regional contractor).
The time limit for submitting a TRICARE Standard or CHAMPVA claim for outpatient service is ___; for inpatient service it is ____.
within 1 year from date service is provided
1 year from patient's discharge from hospital
The TRICARE fiscal year ___.
begins October 1 and ends September 30.
A healthcare professional who helps a patient who is under the TRICARE Standard program obtain
preauthorization for care is called a/an ___.
health care finder (HCF).
TRICARE Standard beneficiaries pay a certain amount each year for the cost-share and annual deductible which is known as ___.
To qualify for TRICARE for Life (TFL), a beneficiary must be ___.
a TRICARE beneficiary.
eligible for Medicare Part A.
enrolled in Medicare Part B.
The time limit for submitting a TRICARE Standard claim for outpatient service is ___; for inpatient service it is ____.
within 1 year from date service is provided;
Medically necessary treatment needed for immediate illness or injury that would not result in further disability or death if not treated immediately is known as urgent care.
TRICARE beneficiaries who use non authorized providers and receive medical services may be
responsible for their entire bill.
When an individual on TRICARE Prime shows you his/her identification card, it guarantees
TRICARE Prime Remote (TPR) is a program designed for military retirees and their families.
Beneficiaries of the Veterans Health Administration (CHAMPVa) program have complete freedom of choice in selecting their civilian
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