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Beneficiary Online Handbook
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Previous Page Table of Contents
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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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Glossary of Terms
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Allowable Charge, also TRICARE Allowable Charge |
| The term “allowable charge” is the maximum amount TRICARE will authorize for medical and other services furnished in an inpatient or outpatient setting. The allowable charge is normally the lowest of the actual billed charge or the allowable charge. For example, if the allowable charge for a service is $90 and the billed charge is $50, TRICARE will pay $50 (actual billed charge); if the billed charge is $100, TRICARE will pay $90 (the allowable charge). In the case of inpatient hospital payments, the DRG is the TRICARE allowable charge of the billed amount regardless. |
Authorized Provider |
| An authorized provider is a hospital or institutional provider, a physician or other individual professional provider, or other provider of services, meeting specific educational, licensing, and other requirements. Authorized providers are not necessarily network providers. TRICARE will share costs if a beneficiary sees a provider of this type. |
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Balance Billing |
| A term used to describe when a provider bills a beneficiary for the rest of the charges. A beneficiary cannot be billed for the remainder or ‘balance’ of the provider charges after TRICARE (and other health insurance) has paid everything it’s going to pay. A beneficiary is not legally responsible for amounts above 15 percent of the TRICARE allowable charge, even if the provider is not network and does not accept assignment of benefits. Network providers are prohibited from balance billing. |
Beneficiary |
| A person who is eligible for TRICARE benefits. Beneficiaries include active duty service members, active duty family members (ADFMs), and retired service members and their families. Family members include spouses and unmarried natural or stepchildren up to the age of 21 (or 23 if full-time students at accredited institutions of learning). Other beneficiary categories are listed in the section titled “Eligibility for TRICARE.” |
Beneficiary Counseling and Assistance Coordinators (BCACs) |
| Persons at military treatment facilities (MTFs) who are available to answer questions, help solve health care-related problems, and assist beneficiaries in obtaining medical care through TRICARE. BCACs were previously known as Health Benefits Advisors or HBAs. |
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Catastrophic Cap |
| The maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1–September 30). The catastrophic cap for active duty families is $1,000, and the catastrophic cap for all other TRICARE eligible families is $3,000. |
Certified Provider |
| A certified provider is one that meets all the requirements to be a TRICARE-authorized provider and has been “certified” to provide services to TRICARE beneficiaries. “Authorized” and “certified” are interchangeable terms. |
Copayment |
| The fixed amount a TRICARE Prime* enrollee will pay for care in the civilian provider network. Active duty service members and active duty family members are not required to pay copayments for services received from a network provider under TRICARE Prime. |
Cost-Share |
| The percentage of the allowable charges a beneficiary will pay under TRICARE Extra and Standard. The cost-share depends on the sponsor’s status—active duty or retired. |
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Deductible |
| The annual amount a TRICARE Extra or TRICARE Standard beneficiary must pay for covered outpatient benefits before TRICARE begins to share costs. TRICARE Prime and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) beneficiaries do not have an annual deductible, unless they are utilizing their Point-of-Service (POS) option. |
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Enrollee |
| A TRICARE-eligible beneficiary who has elected to enroll in TRICARE Prime, TRICARE Prime Remote (TPR), TPRADFM, or the Uniformed Services Family Health Plan. |
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. |
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Health Care Finder (HCF) |
| Representatives who help locate TRICARE providers and applicable community, state, and federal health care resources for beneficiaries who require benefits and services beyond TRICARE. |
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Military Treatment Facility (MTF) |
| A medical facility operated by the military that may provide inpatient and/or ambulatory care to eligible TRICARE beneficiaries. MTF capabilities vary from limited acute care clinics to teaching and tertiary care medical centers. |
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Network Provider |
| A network provider is one who serves TRICARE beneficiaries by agreement as a member of the TRICARE Prime network or any other preferred provider network or by any other contractual agreement. A network provider accepts the negotiated rate as payment in full for services rendered. |
Nonavailability Statement (NAS) |
| A certification from an MTF that a specific health care service or procedure cannot be provided. |
Non-network Provider |
| A non-network provider is one who has no contractual relationship to provide care to TRICARE beneficiaries, but is authorized to provide care to TRICARE beneficiaries. A non-network provider must be authorized. There are two types of non-network providers—”participating” and “nonparticipating." |
Nonparticipating Provider |
| A nonparticipating provider is an authorized hospital, institutional provider, physician, or other provider that furnishes medical services (or supplies) to TRICARE beneficiaries, but who has not signed a contract with your regional contractor and does not agree to “accept assignment.” A nonparticipating provider may balance bill. |
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Other Health Insurance (OHI) |
| Any non-TRICARE health insurance that is not considered a supplement. This insurance is acquired through an employer, entitlement program, or other source. Under federal law, TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, or other programs or plans as identified by TRICARE Management Activity (TMA). |
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Participating Provider |
| Providers who participate in TRICARE, also called “accepting assignment,” and who agree to accept the TRICARE-determined allowable cost or charge as the total charge for services—also known as the TRICARE allowable charge as the full fee for care. In the case of network providers, the negotiated rate is considered the full fee for care. Non-network, individual providers may participate on a case-by-case basis. Providers may seek applicable copayments, costshares, and deductibles from the beneficiary.Hospitals that participate in Medicare must, by law, also participate in TRICARE for inpatient care. For outpatient care, they may or may not participate. |
Point of Service (POS) |
| An option that allows a TRICARE Prime beneficiary to obtain medically necessary services—inside or outside the network— from someone other than his or her primary care manager, without first obtaining a referral or authorization. Utilizing the POS option results in a deductible and greater out-of-pocket expenses for the beneficiary. |
Pre-Authorization |
| See the definition for Prior Authorization. |
Primary Care Manager (PCM) |
| A TRICARE civilian network provider or military treatment facility (MTF) provider who provides primary care services to TRICARE beneficiaries. A PCM is either selected by the beneficiary or assigned by an MTF commander or his or her designated appointee. To the extent consistent with governing state rules and regulations, PCMs can include internal medicine physicians, family practitioners, pediatricians, general practitioners, obstetricians, gynecologists, physician assistants, nurse practitioners, or certified nurse midwives. |
Note: TPR and TPRADFM beneficiaries may choose a TRICARE-authorized provider if a network provider is not available. |
Prime Service Area |
| Formerly was called catchment area defined to be within a 40-mile radius (determined by ZIP code) of a military treatment facility (MTF). It now also includes areas containing a high concentration of TRICARE beneficiaries who are not within the catchment area of an MTF. Humana Military is required to offer TRICARE Prime in each prime service area. |
Prior Authorization |
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A review determination made by a licensed professional nurse or paraprofessional for requested services, procedures, or admissions. Prior authorizations must be obtained prior to services being rendered or within 24 hours of an admission.
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Referral |
| The process by which a primary care manager (PCM) refers a TRICARE Prime beneficiary to another professional or ancillary provider for specialized medical services, prior to those services being rendered. |
Regional Contractors |
| TRICARE Civilian partners who provide health care services and support in the TRICARE regions (TriWest Healthcare Alliance, Health Net Federal Services, Inc., and Humana Military Healthcare Services, Inc.). |
Reserve Component (RC) |
| The RC includes the Army National Guard, the Army Reserve, the Naval Reserve, the Marine Corps Reserve, the Air National Guard, the Air Force Reserve, and the U.S. Coast Guard Reserve. |
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Split Enrollment |
| Refers to multiple family members enrolled in TRICARE Prime in different TRICARE regions. |
Sponsor |
| The active duty service member (ADSM) or retiree through whom family members are eligible for TRICARE. |
Supplemental Insurance |
| Health benefit plans that are specifically designed to supplement TRICARE Standard benefits. Unlike other health insurance (OHI) plans, TRICARE supplemental plans are always secondary payers on TRICARE claims. These plans are frequently available from military associations and other private organizations and firms. |
*Includes TRICARE Prime Remote and TRICARE Prime Remote for Active Duty Family Members. |
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