TRICARE Reserve Select Handbook

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Glossary
Balance Billing
A term used to describe instances when a provider bills a beneficiary for the difference between billed charges and the TRICARE-allowable charge after TRICARE (and other health insurance ) has paid everything it’s going to pay. Participating providers are prohibited from balance billing. Nonparticipating providers may charge up to 15 percent above the TRICARE-allowable charge.
         
Beneficiary Counseling and Assistance Coordinator (BCAC)
Persons at military treatment facilities and TRICARE Regional Offices who are available to answer questions, help solve health care-related problems, and assist beneficiaries in obtaining medical care through TRICARE. Visit TRICARE's web site to locate a BCAC.
         
Catastrophic Cap
The maximum amount TRICARE beneficiaries are required to pay out of pocket for deductibles and cost-shares each federal fiscal year (October 1–September 30 ). The cap applies to all TRICARE-covered services based on TRICARE-allowable charges. Monthly premium payments and payments for non-covered services are not credited toward the catastrophic cap.
       
Continued Health Care Benefit Program (CHCBP)
A premium-based health care program you may purchase after loss of TRICARE eligibility if you qualify. The CHCBP offers temporary transitional health coverage and must be purchased within 30 days after TRICARE eligibility ends.
          
Covered Family Member
An eligible family member (see "Eligible Family Member" definition below ) enrolled in TRICARE Reserve Select.
       
Contingency Operation
“A military operation that (a) results in the call or order to, or retention of, active duty members of the uniformed services under section 688, 12301 (b), 12302, 12304, 12305, or 12406 of this title [10], chapter 15 of this title [10], or any other provision of law during a war or during a national emergency declared by the President or Congress.” Written calls or orders to active duty will specify if they are in support of a contingency operation.
      
Cost-share
A cost-share is the percentage or portion of costs that the beneficiary will pay for inpatient or outpatient care.
        
Deductible
The annual amount a TRICARE Reserve Select beneficiary must pay for covered outpatient benefits before TRICARE begins to share costs.
       
Defense Enrollment Eligibility Reporting System (DEERS)
A database of uniformed services members (sponsors), family members, and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS updated.  DEERS is the official system of record for TRICARE eligibility.
     
Eligible Family Member
Spouse, child, or unmarried person as specified in 10USC1072 (2)(A), (D), & (I) quoted below.
(A) spouse;
(D) a child who:
  (i) has not attained the age of 21;
  (ii) has not attained the age of 23, is enrolled in a full-time course of study at an institution of higher learning approved by the administering Secretary and is, or was at the time of the member’s or former member’s death, in fact dependent on the member or former member for over one-half of the child’s support; or
  (iii)

is incapable of self-support because of a mental or physical incapacity that
occurs while a dependent of a member or former member under clause (i) or (ii) and is, or was at the time of the member’s or former member’s death, in fact dependent on the member or former member for over one-half of the child’s support;
(I) an unmarried person who:
  (i) is placed in the legal custody of the member or former member as a result of an order of a court of competent jurisdiction in the United States (or a Territory or possession of the United States) for a period of at least 12 consecutive months;
  (ii) either:      
    (I) has not attained the age of 21;
    (II) has not attained the age of 23 and is enrolled in a full-time course of study at an institution of higher learning approved by the administering Secretary; or
    (III) is incapable of self support because of a mental or physical incapacity that occurred while the person was considered a dependent of the member or former member under this subparagraph pursuant to subclause (I) or (II);
  (iii) is dependent on the member or former member for over one-half of the
person’s support;
  (iv) resides with the member or former member unless separated by the necessity of
military service or to receive institutional care as a result of disability or
incapacitation or under such other circumstances as the administering Secretary
may by regulation prescribe; and
  (v) is not a dependent of a member or a former member under any other
subparagraph.
    
Explanation of Benefits (EOB)
A statement sent to beneficiaries showing that claims were processed and the amount paid to providers. If denied, an explanation of denial is provided.  (Refer to the Appendix section for samples of EOB statements.)
     
Military Treatment Facility (MTF)
A medical facility (hospital, clinic, etc.) owned and operated by the uniformed services usually located on or near a military base.
   
Negotiated Rate
The rate network providers and participating non-network providers have agreed to accept for covered services.
        
Network Provider (also known as TRICARE Network Provider)
TRICARE network providers have signed an agreement with Humana Military to provide care at a negotiated rate. Network providers handle claims for you.
         
Non-network Provider
Non-network, TRICARE-authorized providers have not signed an agreement with Humana Military and are therefore “out of network.” There are two types of non-network providers: participating and nonparticipating.
           
Nonparticipating Non-network Provider
Nonparticipating, non-network TRICARE-authorized providers have not agreed to accept the TRICARE-allowable charge or file your claims. Nonparticipating providers may charge you up to 15 percent above the TRICARE-allowable charge for services. This amount is your responsibility and will not be shared by TRICARE.
         
Other Health Insurance (OHI)
Any non-TRICARE health insurance that is not considered a supplement acquired through an employer, entitlement program, or other source. TRICARE pays second after all other health plans except for Medicaid, TRICARE supplements, the Indian Health Service, or other programs or plans as identified by the TRICARE Management Activity.
          
Participate on a Claim
When TRICARE-authorized providers participate on a claim, also known as “accepting assignment,” they agree to file the claim for you, to accept payment directly from TRICARE, and to accept the amount of the TRICARE-allowable charge, less any applicable patient cost-share paid by you, as payment in full for their services.
          
Participating Non-network Provider
Participating providers have agreed to file claims for you, to accept payment directly from TRICARE, and to accept the TRICARE-allowable charge, less any applicable patient cost-shares paid by you, as payment in full for their services. Providers may participate on a claim-by-claim basis, meaning they may choose to participate on one claim, but not another.
        
Prior Authorization
A process of reviewing certain medical, surgical, and behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered or within 24 hours of an emergency admission.
       
Regional Contractor
A TRICARE civilian partner who provides health care services and support in the TRICARE regions (Health Net Federal Services, Inc.; Humana Military Healthcare Services, Inc.; and TriWest Healthcare Alliance ).
          
Transitional Assistance Management Program (TAMP)
Transitional health care for certain uniformed services members (and eligible family members ) who separate from active duty.
             
TRICARE-allowable Charge
The maximum amount TRICARE will pay for services.
           
TRICARE-authorized Provider
A provider who meets TRICARE’s licensing and certification requirements and has been certified by TRICARE to provide care to TRICARE beneficiaries. If you see a provider who is not TRICARE-authorized and can never be certified, you are responsible for the full cost of care. TRICARE-authorized providers include doctors, hospitals, ancillary providers, (laboratories and radiology centers ) and pharmacies. There are two types of TRICARE-authorized providers: network and non-network.
              
TRICARE Network Provider
See Network Provider.
          
TRICARE Supplement
A health plan you may purchase specifically to supplement your TRICARE Reserve Select coverage. It will pay second after TRICARE. Employer-sponsored health insurance is not considered a TRICARE supplement.

             
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Last Update: November 2007