What is a TRICARE Prime Service Area?
A TRICARE Prime Service Area is the geographic area where TRICARE Prime benefits are offered. This includes all predetermined areas, including Base Realignment and Closure Commission sites, and a 40-mile radius around all military treatment facilities (MTFs).
Who determines TRICARE reimbursement rates?
Congress passed the Defense Appropriations Act establishing the uniform payment system for the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), called the CHAMPUS maximum allowable charge (CMAC). The TRICARE Enabling Statute (Title 10, United States Code, Chapter 55) authorizes the Secretary of Defense the authority to set the reimbursement rates for health care services provided to TRICARE beneficiaries. Those rates are set in accordance with the same reimbursement rules that apply to payments for similar services under Medicare (Title XVIII of the Social Security Act [Title 42, United States Code, Section 1395]) to the extent practicable within the Military Health System. Refer to the TRICARE Reimbursement Methodologies section of this handbook for more information. See “Glossary of Terms” for more information about CMAC versus TRICARE-allowable charges.
What types of procedures require prior authorization?
Procedures that require prior authorization vary by beneficiary type. Refer to the Health Care Management and Administration section of this handbook for more information about the rules for prior authorization and how to obtain a list of procedures requiring prior authorization.
Does TRICARE provide case management?
Humana Military Healthcare Services, Inc. (Humana Military), offers case management for beneficiaries with complex cases. See the Health Care Management and Administration section of this handbook for more information.
How is the care of maternity patients managed?
Military medicine focuses on family-centered care before, during, and after childbirth. MTFs in the South Region are committed to being responsive to maternity patients and flexible to their needs. They offer:
- An extended military “family” that is knowledgeable about the separation aspects of military life
- A family-centered-care approach that ensures new military families get the best possible personalized, coordinated maternity care.
Expectant mothers are encouraged to visit
TRICARE's "Having a Baby" web section when deciding where to obtain maternity care. Refer to the Medical Coverage section of this handbook for details on maternity care coverage.
Does TRICARE offer programs for persons with disabilities?
Yes, but only for certain beneficiaries. The TRICARE Extended Care Health Option (ECHO) provides covered non-medical benefits to qualified dependants of active duty service members (ADSMs). See details about TRICARE ECHO in the TRICARE Program Options section of this handbook.
How does TRICARE define an emergency?
TRICARE defines an emergency as a medical, maternity, or psychiatric condition that would lead a “prudent lay person” (someone with average knowledge of health and medicine) to believe that a serious medical condition exists, or that the absence of immediate medical attention would result in a threat to life, limb,or sight, or when a person has painful symptoms requiring immediate attention to relieve suffering. This includes situations where a person is in severe pain or is at immediate risk of serious harm to self or others.
If a TRICARE Prime, TRICARE Prime Remote (TPR), or TRICARE Prime Remote for Active Duty Family Members (TPRADFM) patient (including active duty service members) is admitted following emergency care, does that admission require prior authorization?
Humana Military must be notified within 24 hours or the next business day of an emergency inpatient admission. Non-emergent hospital admissions must also be approved by the primary care manager (PCM) or the admission may only be covered under the TRICARE Prime point-of-service option (POS).
Note: Separate rules apply for ADSMs. The Military Medical Support Office (MMSO) is responsible for coordination and management of civilian emergent and non-emergent hospital admissions. Refer to the Welcome to TRICARE and the South Region section of this handbook for MMSO contact information.
Does TRICARE allow outpatient observation stays?
Up to 48 hours of outpatient observation services are allowed for physicians to evaluate, stabilize, and treat patients for whom a full admission is not clear. If after 48 hours it becomes apparent that the patient must continue as an inpatient, authorization for the inpatient admission must be obtained. For details on how the TRICARE outpatient prospective payment system affects outpatient observation stays, refer to the
TRICARE Reimbursement Manual, Chapter 13.
Do TRICARE Prime, TPR, and TPRADFM beneficiaries have coverage outside of this region?
Emergencies are covered for TRICARE Prime, TPR, and TPRADFM beneficiaries when traveling away from home, whether they are in or out of their TRICARE regions. However, keep in mind:
- Humana Military must be notified within 24 hours, or the next business day, of an emergency inpatient hospital admission.
- Nonemergency care, including urgent care, must be approved by the beneficiary’s PCM and authorized by Humana Military, when necessary, to ensure maximum TRICARE coverage.
- Routine, out-of-region care for TRICARE Prime, TPR, and TPRADFM enrollees may be covered under the POS option.
Where does my office file TRICARE claims?
PGBA, LLC, is Humana Military’s partner for claims processing.
Note: TRICARE For Life (TFL) claims are processed by Wisconsin Physicians Service/TFL. Refer to the Claims Processing and Billing Information section of this handbook for more information on filing claims.
How do I order current TRICARE marketing and educational materials?
Providers can view and print the latest
TRICARE materials, including manuals and
TRICARE Provider News publications. The same materials are available on the
TRICARE Smart Site.
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