27 terms
workbook questions ch 14&15
1. CHAMPUS, the acronym for Civilian Health and Medical Program of the Uniformed Services, is now
called TRICARE and was organized to control escalating medical costs and to standardize benefits for
active-duty families and military retirees.
called TRICARE and was organized to control escalating medical costs and to standardize benefits for
active-duty families and military retirees.
2. An active duty service member is known as a/an sponsor; once retired, this former member is called a/an
service retiree or military retiree
service retiree or military retiree
3. An individual who qualifies for TRICARE is known as a/an beneficiary
4. A system for verifying an individual's TRICARE eligibility is called Defense Enrollment Eligibility
Reporting System (DEERS)
Reporting System (DEERS)
5. Mrs. Hancock, a TRICARE beneficiary, lives two miles from a Uniformed Services Medical Treatment
Facility but needs to be hospitalized for mental healthcare services at Orlando Medical Center, a civilian
hospital. What type of authorization does she require? Nonavailability statement (NAS)
Facility but needs to be hospitalized for mental healthcare services at Orlando Medical Center, a civilian
hospital. What type of authorization does she require? Nonavailability statement (NAS)
6. TRICARE Standard and CHAMPVA beneficiary identification cards are issued to dependents 10 years
of age and older, survivors of active duty personnel, and retirees. Information must be obtained from
front and back of the card and placed on the health insurance claim form. (Note to instructor:
Emphasize to students that a photocopy of the beneficiary's card must be retained in the patient's
medical record because if a problem exists with coverage, payment will be made only if the provider
has a copy of the card.
of age and older, survivors of active duty personnel, and retirees. Information must be obtained from
front and back of the card and placed on the health insurance claim form. (Note to instructor:
Emphasize to students that a photocopy of the beneficiary's card must be retained in the patient's
medical record because if a problem exists with coverage, payment will be made only if the provider
has a copy of the card.
7. Programs that allow TRICARE Standard beneficiaries to receive treatment, services, or supplies from
civilian providers are called cooperative care and partnership
civilian providers are called cooperative care and partnership
8. For patients whose sponsor is a rank of E4 and below the TRICARE Standard deductible for outpatient
care is how much per patient? $50 Per family? $10
care is how much per patient? $50 Per family? $10
9. For patients whose sponsor is a rank of E5 and above the TRICARE Standard deductible for outpatient
care is how much per patient? $150 Per family? $30
care is how much per patient? $150 Per family? $30
10. For TRICARE Standard, dependents of active duty members pay what percentage for outpatient services
after the deductible has been met? 20% What percentage does TRICARE pay? 80
after the deductible has been met? 20% What percentage does TRICARE pay? 80
11. For retired members or their dependents on TRICARE Standard, what is their deductible responsibility for
outpatient services? Per person $150 Per family $30
outpatient services? Per person $150 Per family $30
12. For TRICARE Standard, retired members or their dependents pay what percentage for outpatient services
after the deductible has been met? 25% What percentage does TRICARE pay? 75
after the deductible has been met? 25% What percentage does TRICARE pay? 75
13. A voluntary TRICARE health maintenance organization type of option is known as TRICARE Prime
14. CHAMPVA is the acronym for Civilian Health and Medical Program of the Veterans
Administration, now known as the Department of Veterans Affairs
Administration, now known as the Department of Veterans Affairs
15. Those individuals who serve in the United States Armed Forces, finish their service, and are honorably
discharged are known as veterans
discharged are known as veterans
16. CHAMPVA is not an insurance program but is considered a/an service benefit program
17. Which individuals are entitled to CHAMPVA medical benefits?
a. husband, wife, or unmarried child of a veteran with a total disability, permanent in nature,
from a service-connected disability
b. 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
c. husband, wife, or unmarried child of an individual who died in the line of duty while on active
service
a. husband, wife, or unmarried child of a veteran with a total disability, permanent in nature,
from a service-connected disability
b. 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
c. husband, wife, or unmarried child of an individual who died in the line of duty while on active
service
18. 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
is known as the Privacy Act of 1974
19. An organization that contracts with the government to process TRICARE and CHAMPVA health
insurance claims is known as a/an fiscal intermediary (regional contractor)
insurance claims is known as a/an fiscal intermediary (regional contractor)
20. The time limit for submitting a TRICARE Standard or CHAMPVA claim for outpatient service is within
1 year from date service is provided; for inpatient service it is 1 year from patient's discharge from
hospital
1 year from date service is provided; for inpatient service it is 1 year from patient's discharge from
hospital
21. The TRICARE fiscal year
d. begins October 1 and ends September 30
d. begins October 1 and ends September 30
22. A healthcare professional who helps a patient who is under the TRICARE Standard program obtain
preauthorization for care is called a/an
b. healthcare finder (HCF)
preauthorization for care is called a/an
b. healthcare finder (HCF)
23. TRICARE Standard beneficiaries pay a certain amount each year for the cost-share and annual deductible
which is known a
a. catastrophic cap
which is known a
a. catastrophic cap
4. To qualify for TRICARE for Life (TFL), a beneficiary must be
a. a TRICARE beneficiary.
b. eligible for Medicare Part A.
c. enrolled in Medicare Part B.....D... all of the above
a. a TRICARE beneficiary.
b. eligible for Medicare Part A.
c. enrolled in Medicare Part B.....D... all of the above
25. The time limit for filing a TRICARE Standard claim iS
b. within 1 year from the date a service is provide
b. within 1 year from the date a service is provide
26. T 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.
27. T RICARE beneficiaries who use nonauthorized providers and receive medical services may be
responsible for their entire bill.
28. F When an individual on TRICARE Prime shows you his/her identification card, it guarantees
TRICARE eligibility.
29. F TRICARE Prime Remote (TPR) is a program designed for military retirees and their families.
30. T Beneficiaries of the CHAMPVA program have complete freedom of choice in selecting their civilian
healthcare providers
disability or death if not treated immediately is known as urgent care.
27. T RICARE beneficiaries who use nonauthorized providers and receive medical services may be
responsible for their entire bill.
28. F When an individual on TRICARE Prime shows you his/her identification card, it guarantees
TRICARE eligibility.
29. F TRICARE Prime Remote (TPR) is a program designed for military retirees and their families.
30. T Beneficiaries of the CHAMPVA program have complete freedom of choice in selecting their civilian
healthcare providers
CHAPTER 15
CHAPTER 15
1. Name two kinds of statutes under workers' compensation.
a. federal compensation laws
b. state compensation law
a. federal compensation laws
b. state compensation law
2. An unexpected, unintended event that occurs at a particular time and place, causing injury to an individual
not of his or her own making, is called a/an accident
not of his or her own making, is called a/an accident
3. Maria Cardoza works in a plastics manufacturing company and inhales some fumes that cause bronchitis.
Because this condition is associated with her employment, it is called a/an occupational illness. Optional
answer: industrial or workers' compensation illness
Because this condition is associated with her employment, it is called a/an occupational illness. Optional
answer: industrial or workers' compensation illness
4. Name the federal workers' compensation acts that cover workers.
a. Workmen's Compensation Law of the District of Columbia
b. Federal Coal Mine Health and Safety Act
c. Federal Employees' Compensation Act
d. Longshoremen's and Harbor Workers' Compensation AcT
a. Workmen's Compensation Law of the District of Columbia
b. Federal Coal Mine Health and Safety Act
c. Federal Employees' Compensation Act
d. Longshoremen's and Harbor Workers' Compensation AcT
5. State compensation laws that require each employer to accept its provisions and provide for specialized
benefits for employees who are injured at work are called compulsory law
benefits for employees who are injured at work are called compulsory law
6. State compensation laws that may be accepted or rejected by the employer are known as elective law
7. State five methods used for funding workers' compensation.
a. monopolistic state or provincial fund
b. qualification of employers as self-insurers
c. territorial fund
d. competitive state fund
e. private insurance companieS
a. monopolistic state or provincial fund
b. qualification of employers as self-insurers
c. territorial fund
d. competitive state fund
e. private insurance companieS
8. Who pays the workers' compensation insurance premiums? Employers
10. When an employee with a preexisting condition is injured at work and the injury produces a disability
greater than what would have been caused by the second injury alone, the benefits are derived from a/an
subsequent or second-injury fund
greater than what would have been caused by the second injury alone, the benefits are derived from a/an
subsequent or second-injury fund
11. Name jobs that may not be covered by workers' compensation insurance.
a. domestic or casual employees d. charity workers
b. laborers e. gardeners
c. babysitters f. newspaper vendors or distributor
a. domestic or casual employees d. charity workers
b. laborers e. gardeners
c. babysitters f. newspaper vendors or distributor
14. List five types of workers' compensation benefits.
a. medical treatment
b. temporary disability indemnity
c. permanent disability indemnity
d. death benefits
e. rehabilitation benefitS
a. medical treatment
b. temporary disability indemnity
c. permanent disability indemnity
d. death benefits
e. rehabilitation benefitS
15. Who can treat an industrial injury? Medical doctor, osteopath, dentist, or chiropractor
16. What are three types of workers' compensation claims and the differences among them?
a. Nondisability claim: Person is injured or ill, is treated, and goes back to work. No disability
from his or her job.
b. Temporary disability claim: Person is injured or ill and cannot work at his or her job and is off
work for a period of time.
c. Permanent disability claim: Person is injured or ill and cannot work, and the problem results in
permanent injury or illness
a. Nondisability claim: Person is injured or ill, is treated, and goes back to work. No disability
from his or her job.
b. Temporary disability claim: Person is injured or ill and cannot work at his or her job and is off
work for a period of time.
c. Permanent disability claim: Person is injured or ill and cannot work, and the problem results in
permanent injury or illness
17. Weekly temporary disability payments are based on a percentage of the employee's earnings at the time
of the injury or illness
of the injury or illness
18. After suffering an industrial injury, Mr. Fields is in a treatment program in which he is given real work
tasks for building strength and endurance. This form of therapy is called work hardeninG
tasks for building strength and endurance. This form of therapy is called work hardeninG
19. When an industrial case reaches the time for rating the disability, this is accomplished by what state
agency? The state's industrial accident commission or workers' compensation board
agency? The state's industrial accident commission or workers' compensation board
20. May an injured person appeal his or her case if he or she is not satisfied with the rating? Yes. If so, to
whom does he or she appeal? Workers' Compensation Appeals Board or Industrial Accident
Commission
whom does he or she appeal? Workers' Compensation Appeals Board or Industrial Accident
Commission
21. When fraud or abuse is suspected in a workers' compensation case, the physician should report the
situation to the insurance carrier
situation to the insurance carrier
22. Explain third-party subrogation. A third party is responsible for the injury (person is injured by an
outside party)
outside party)
23. When an individual suffers a work-related injury or illness, the employer must complete and send a form
called a/an Employer's Report of Occupational Injury or Illness to the insurance company and
workers' compensation state offices, and if the employee is sent to a physician's office for medical care,
the employer must complete a form called a/an Medical Service Order that authorizes the physician to
treat the employeE
called a/an Employer's Report of Occupational Injury or Illness to the insurance company and
workers' compensation state offices, and if the employee is sent to a physician's office for medical care,
the employer must complete a form called a/an Medical Service Order that authorizes the physician to
treat the employeE
24. Employers are required to meet health and safety standards for their employees under federal and state
statutes known as
a. Occupational Safety and Health Administration (OSHA) Act of 1970
statutes known as
a. Occupational Safety and Health Administration (OSHA) Act of 1970
25. The process of carrying on a lawsuit is calleD
b. litigatioN
b. litigatioN
26. A proceeding during which an attorney questions a witness who answers under oath but not in open court
is called a/a
is called a/a
27. The legal promise of a patient to satisfy a debt to the physician from proceeds received from a litigated
case is termed a/aN
c. lien
case is termed a/aN
c. lien
28. When a physician treats an industrial injury, he or she must complete a First Treatment Medical Report or
Doctor's First Report of Occupational Injury or Illness and send it to the following:
a. insurance carrier
b. employer
c. state workers' compensation office
D. all of the above
Doctor's First Report of Occupational Injury or Illness and send it to the following:
a. insurance carrier
b. employer
c. state workers' compensation office
D. all of the above
29. T The first thing an employee should do after he or she is injured on the job is to notify his or her
employer or immediate supervisor.
30. F A roofer takes his girlfriend to a roofing job and she is injured. She is covered under workers'
compensation insurance.
31. F A stamped physician's signature is acceptable on the Doctor's First Report of Occuupational Injury or
Illness form.
32. T In a workers' compensation case, bills should be submitted monthly or at the time of termination of
treatment, and a claim becomes delinquent after a time frame of 45 days.
33. T If an individual seeks medical care for a workers' compensation injury from another state, the state's
regulations are followed in which the injured person's claim was originally filed.
34. T When a patient arrives at a medical office and says he or she was hurt at work, verify insurance
information with the benefits coordinator for the employer
employer or immediate supervisor.
30. F A roofer takes his girlfriend to a roofing job and she is injured. She is covered under workers'
compensation insurance.
31. F A stamped physician's signature is acceptable on the Doctor's First Report of Occuupational Injury or
Illness form.
32. T In a workers' compensation case, bills should be submitted monthly or at the time of termination of
treatment, and a claim becomes delinquent after a time frame of 45 days.
33. T If an individual seeks medical care for a workers' compensation injury from another state, the state's
regulations are followed in which the injured person's claim was originally filed.
34. T When a patient arrives at a medical office and says he or she was hurt at work, verify insurance
information with the benefits coordinator for the employer