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Insurance handbook for the medical office chp 14
Terms in this set (59)
History of TRICARE
1. 1966 CHAMPUS created (Civilian Health and Medical Program of the Uniformed Services)
2.1988 CHAMPUS Prime created as managed care plan option
3.1994 TRICARE became new title with 3 options:
A.TRICARE Standard (fee-for-service)
B.TRICARE Extra (PPO)
C.TRICARE Prime (HMO)
4.2005 TRICARE consolidated into 3 regions
CHAMPUS was created to
fund comprehensive health benefits for military members and families
, a managed care plan, was created to control escalating medical costs. Military members and dependents then had a choice of plans.
What are the three regions of TRICARE in the U.S.?
Region West, Region North, Region South)
1.active duty service members (Prime Remote)
2.eligible family members of active duty service members
3.military retirees and eligible family members
4.surviving eligible family members of deceased active or retired service members
5.wards and preadoptive children
6.Former spouses of active or retired service members (must meet requirements)
7.family members of active duty service members who were court-martialed or separated from their families for abuse
8.abused spouses/children of service members
spouses/children of NATO nation representatives
9.reservists and National Guard members activated for 30 or more consecutive days
10.disabled beneficiaries under 65 years with Medicare A & B
11.Medicare-eligible beneficiaries in TRICARE for Life
What is a "beneficiary?"
individual who qualifies for TRICARE)
A person retired from the military is a service retiree and remains in TRICARE until age 65. Then
the person can join the TRICARE for Life program if Medicare-eligible.
No further family benefits are provided if an active duty service person served 4-6 years and then chose to leave the armed services.
CHAMPVA beneficiaries are not eligible for TRICARE.
Defense Enrollment Eligibility Reporting System (DEERS)
a computerized database system that all TRICARE-eligible persons must be enrolled in
Nonavailability Statement (NAS)
1.certification from a military hospital when it cannot provide care
2.2003 not needed for individuals in the catchment area about an MTF
No claims can be processed without prior DEERS registration
A TRICARE beneficiary can check status at
nearest personnel office or call DEERS' toll-free number.
What is an "MTF?"
military treatment facility)
What is a "catchment area?"
(a specific geographic region defined by ZIP codes; based on an area of approximately 40 miles in radius surrounding each U.S. MTF.)
1.ID card required for all dependents over age 10.
2.Not limited to using network providers for medically or psychologically necessary services.
3.Care usually sought at military hospital closest to home or identified through Health Care Finder (HCF).
4.Authorized providers must be used.
5.Preauthorization necessary for specialty care, hospitalization, and certain procedures.
6.Deductibles and co-payments apply.
Uniformed Services identification card necessary
Front and back should be copied.
If there is no military service hospital in the area,
patient may be directed elsewhere
Partnership program is
an option for treatment by select civilian providers of care in a military hospital or military providers in a civilian facility.
Use of nonauthorized provider may result in
Authorized providers include
MD, DO, DDS, DDM, DPM, certified nurse midwives, clinical social workers, etc.
1.ID card required for all dependents over age 10.
3.Network provider must be used.
5.Preauthorization necessary and coordinated by Health Care Finder for specialty care, hospitalization, and certain procedures.
6.Deductibles and co-payments apply.
no annual fee to enroll in this PPO option.
1.1Voluntary HMO option with annual fee required.
2.Minimum 12 months participation required.
3.PCM coordinates all care except emergencies.
4.Referral from Health Care Finder required for use of non-network provider.
5.Preauthorization may be necessary for some specialty care, hospitalization, and certain procedures.
6.Co-payments and deductibles apply.
PCM is the
the primary care manager. It is a physician
Enrollment card or ID card is necessary but does not
guarantee eligibility. The TRICARE Prime card must also be copied for the file.
TRICARE will not pay anything on a claim if
the HMO has specialty services/providers but the patient goes outside the HMO for treatment.
A health benefits advisor (HBA) should be called to determine if
an NAS is needed for a procedure done outside a military treatment facility (MTF).
Describe how immunizations are covered in each plan.
Explain how durable medical equipment is covered in each plan
TRICARE for Life
1.supplementary payer to Medicare
2.no separate ID card
3.no referral or preauthorization requirements
4.Payment is based on the services provided and coverage by both Medicare and TRICARE.
TRICARE for Life
For retirees, including guard and reservists, and spouses/survivors age 65 or older.
dependent parents or in-laws
Pays secondary to
Medicare when they turn 65; must be eligible for Medicare Parts A and B.
All services and supplies must be benefits
of Medicare or TRICARE to be covered
Open to persons for care in military facilities but not enrolled in TRICARE Prime or commercial HMO
1.ID card and DEERS enrollment required.
2.Enrollees use the military treatment facility as source of primary care.
3.same benefits as TRICARE Prime when using military treatment facility
4.access to specialty providers at military treatment facility not guaranteed
TRICARE Prime Remote
1.for active duty service members only
2.must live at least 50 miles from military treatment facility
3.same benefits as TRICARE Prime
4.no prior authorization for routine primary care
5.PCM coordinates all care except emergencies.
6.no out-of-pocket expenses for in-network services
7.Family members are not eligible, but they can enroll in TRICARE Prime, Standard, or Extra.
Active Duty Service Member.
Supplemental Health Care Program
1.for active duty service members and other designated patients
2.enables beneficiaries to be referred to civilian providers when needed
3.no deductibles or co-payments if military treatment facility initiates referral
4.Inpatients at MTF not TRICARE eligible, such as parents/in-laws, are covered.
5.Those receiving benefits are not responsible for any out-of-pocket expenses.
TRICARE Hospice Program
1.based on Medicare hospice program
2.life expectancy is six months or less
3.cannot also receive care under TRICARE basic programs
4.If condition changes, hospice care option can be revoked and patient may again be eligible for TRICARE basic programs.
5.Guidelines should be followed to ensure that specific services are covered.
TRICARE and HMO Coverage
1.provider must meet TRICARE provider certification standards
2.type of care must be a TRICARE benefit and medically necessary
3.TRICARE does not pay for emergency services received outside the normal HMO service area
4.TRICARE will share the cost of covered services with an HMO if the listed criteria are met
1.1973 CHAMPVA created (Civilian Health and Medical Program of the Veterans Administration)
2.for spouses and dependent children of veterans with total, permanent disability
must not be eligible for TRICARE Standard or Medicare A
3.service benefit program
4.CHAMPVA is not an insurance program and there are no premiums. It is a service benefit program.
5.A veteran must have a total, permanent service-connected disability or must have died as a result of the injury/disability.
6.Disability must be permanent, not chronic and/or temporary.
7.Children are those unmarried under age 18, or under 23 if enrolled in an approved educational institution.
8.ID card required for all dependents over age 10.
9.Benefits similar to TRICARE Standard for dependents of retired and deceased military personnel.
10.Freedom of choice in selecting civilian providers
11.Preauthorization needed for some
Preauthorization is needed for
dental services, hospice care, organ transplants, mental health treatment, and several other situations.
Discuss whether a widow who qualified for the CHAMPVA program continues to qualify if she remarries
Describe what is meant by family services versus professional services listed under ambulatory services.
1.Privacy Act of 1974
2.Individual has right to review own medical records maintained by a federal health care facility.
3.If personal information is requested, the individual must be informed of purpose and use of the information.
4.Computer Matching and Privacy Protection Act of 1988
5.Government can verify information via computer matches.
6.Patients must be made aware by providers of this information and how medical data can be disclosed.
Patients can access their own records with a written request.
1.TRICARE Standard administered by DOD (Department of Defense).
2.CHAMPVA administered by VA (Veterans Administration).
3.Claims must be:
A. billed on CMS-1500 (08-05) form or electronically
B.submitted to the correct fiscal intermediary
C.filed within one year of service
4.TRICARE Extra and TRICARE Prime
A.No claim forms filed by beneficiary if care provided is in-network.
A.use CMS-1500 (08-05) form or electronic system to submit claims
B.submit claims to correct subcontractor
C.file within one year of service
1.TRICARE Prime Remote and Supplemental Health Care Program
2.Outpatient services are submitted with CMS-1500 (08-05) form or electronically.
3.POS option and NAS requirement do not apply.
4.Claims must be filed within one year of service.
5.Claims for active duty patients must be sent to the specific branch of military service.
6.TRICARE for Life
7.Civilian provider submits claims to Medicare to pay first and then the claim is submitted to TRICARE for the remainder.
Fiscal intermediary is the
claims processor or designated insurance contractor.
Medicare automatically forwards claims to TRICARE, after paying the first portion.
TRICARE/CHAMPVA and Other Insurance
A.TRICARE/CHAMPVA usually pay as secondary payer if beneficiary has other health insurance.
B.EOB copy from primary carrier should be attached to the completed CMS-1500 (08-05) claim form.
C.include copy of the physician's complete itemized statement
D.Claim should then be sent to the local claims processor (fiscal intermediary).
Other insurance options include
civilian health plan, HMO, PPO.
Physician statement should include
name, date of service, service description, fee, procedure codes, etc.
TRICARE/CHAMPVA is primary
TRICARE is secondary, if under 65 with Part A & Part B
CHAMPVA is secondary, if under 65 with Part A & Part B
If under 65 with Medicare Part A, must be disabled to qualify for TRICARE.
Services covered by TRICARE but not covered by Medicare (e.g. prescriptions) are paid by TRICARE.
If CMS-1500 (08-05) is filed without DD 2527, a
request is made to complete it within 35 days, or the claim will be denied.
For third-party liability:
TRICARE form DD 2527 is submitted with regular claim form CMS-1500 (08-05).
Provider can submit claims only to third-party liability carrier for reimbursement.
If ICD-9-CM code between 800 - 999, claims processor may request completion of form DD 2527
TRICARE may be able to recover costs from the third party, liable insurance carrier, or attorneys if involved.
For Workers' Compensation:
TRICARE/CHAMPVA billed when workers' compensation benefits are exhausted.
Beneficiary with work-related injury or illness must file the claim with the workers' compensation carrier.
If the case is pending regarding whether it is truly work-related injury or illness, then the claim might be sent to TRICARE/CHAMPVA for payment. The claims processor then files a lien for recovery after case settlement.
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