Abuse
Abuse is defined as any practice that is inconsistent with accepted sound fiscal, business, or professional practice that results in a TRICARE claim, unnecessary cost, or TRICARE payment for services or supplies that are: (1) Not within the concepts of medically necessary and appropriate care, or (2) that fail to meet professionally recognized standards for health care providers. The term “abuse” includes deception or misrepresentation by a provider, or any person or entity acting on behalf of a provider, in relation to a TRICARE claim.
Note: Unless a specific action is deemed gross and flagrant, a pattern of inappropriate practice will normally be required to find that abuse has occurred. Also, any practice or action that constitutes fraud would be abuse.
Accepting Assignment
Accepting assignment refers to those instances when a provider agrees to accept the TRICARE-allowable charge(s).
Allowable Charge Review
An allowable charge review is a method by which a network provider may request a review of a claim he or she deems was paid at an inappropriate level.
Appeals Review
Method by which a non-network participating provider (i.e., one who has accepted assignment) may request a review of a denial of benefit coverage for services provided or proposed that are deemed not medically necessary.
Authorization
See the definition for prior authorization.
Authorization for Care
The determination that the requested treatment is medically necessary, delivered in the appropriate setting, a TRICARE benefit, and that the treatment will be cost-shared by the Department of Defense.
Authorized Provider
See the definition for TRICARE-authorized provider.
Balance Billing
A provider seeking any payment, other than any payment relating to applicable deductible and cost sharing amounts, from a beneficiary for TRICARE-covered services for any amount in excess of the applicable TRICARE allowable cost or charge.
Base Realignment and Closure Commission (BRAC) Site
A military base that has been closed or targeted for closure by the government BRAC.
Beneficiary
A beneficiary is a person who is eligible for TRICARE benefits. Beneficiaries include active duty family members and retired service members and their families. Family members include spouses and unmarried children, adopted children, or stepchildren up to the age of 21 (or 23 if full-time students at approved institutions of higher learning and the sponsor provides at least 50 percent of the financial support). Other beneficiary categories are listed in the TRICARE Eligibility section of this handbook.
Beneficiary Counseling and Assistance Coordinators (BCACs)
BCACs are 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. BCACs were previously known as Health Benefits Advisors, or HBAs. To locate a BCAC, visit
TRICARE's BCAC web page.
Care Coordination
An approach to care management using proactive methods to optimize health outcomes and reduce risks of future complications over a short-term (two to six weeks) single episode of care. Prospective and concurrent reviews are used to identify current and future beneficiary needs.
Case Management
Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes.
Catastrophic Cap
The maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1–September 30). Point-of-service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.
Catchment Area
Geographic areas determined by the Assistant Secretary of Defense (Health Affairs) that are defined by a set of five-digit ZIP codes, usually within an approximate 40-mile radius of a military inpatient treatment facility.
Note: Humana Military—and all other contractors responsible for administering TRICARE—is required to offer TRICARE Prime in each catchment area.
Centers for Medicare and Medicaid Services
The federal agency that oversees all aspects of health care claims filing for Medicare.
Certified Provider
See the definition for TRICARE-authorized provider.
CHAMPUS Maximum Allowable Charge (CMAC)
CMAC is a nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Scheduled amount. CMAC is the TRICARE-allowable charge for covered services when appropriately applied to services priced under CMAC.
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
CHAMPVA is the federal health benefits program for eligible family members of 100 percent totally and permanently disabled veterans. CHAMPVA is administered by the Department of Veterans Affairs and is a separate federal program from the Department of Defense TRICARE program. For questions regarding CHAMPVA, call 1-800-733-8387 or e-mail
hac.inq@va.gov.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
The health care program established to provide purchased health care coverage for active duty family members and retired service members and their family members outside the military’s direct care system. TRICARE Management Activity was organized as a separate office under the Assistant Secretary of Defense and replaced OCHAMPUS in 1994. The purchased care benefits authorized under the CHAMPUS law and regulations are now covered under TRICARE Standard.
ClaimCheck®
An automated claims-auditing system that verifies the clinical accuracy of claims.
CMS-1500
The CMS-1500 (version 08/05) claim form is used by most individual health care professionals (e.g., physicians) and non-institutional providers (e.g., suppliers) to bill TRICARE.
Concurrent Review/Continued Stay Review
Evaluation of a patient’s continued need for treatment and the appropriateness of current and proposed treatment, as well as the setting in which the treatment is being rendered or proposed. Concurrent review applies to all levels of care (including outpatient care). Concurrent reviews are generally performed when TRICARE is the primary payer. Concurrent reviews are referred for medical-director review when they indicate that criteria are not met.
Copayment
The fixed amount a TRICARE Prime enrollee will pay for care in the civilian provider network. TRICARE Prime active duty service members and active duty family members are not required to pay copayments.
Corporate Services Provider
A class of TRICARE-authorized providers consisting of institutional-based or freestanding corporations and foundations that render professional ambulatory or in-home care and technical diagnostic procedures.
Cost-Share
The percentage of the allowable charges a beneficiary will pay under TRICARE Standard and TRICARE Extra. The cost share depends on the sponsor’s status—active duty or retired.
Credentialing
The process by which providers are allowed to participate in the TRICARE network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.
Current Procedural Terminology (CPT®)
A systematic listing and coding of procedures and services performed by physicians. Each procedure or service is identified with a five-digit code. The use of CPT codes simplifies the reporting of services. With this coding and recording system, the procedure or service rendered by the physician is accurately identified.
Deductible
The annual amount a TRICARE Standard and TRICARE Extra, TRICARE For Life, TRICARE Reserve Select, or TRICARE Retired Reserve beneficiary must pay for covered outpatient benefits per fiscal year before TRICARE begins to share costs. TRICARE Prime beneficiaries do not have an annual deductible, unless they are using their point-of-service option.
Defense Enrollment Eligibility Reporting System (DEERS)
A database of uniformed service members (sponsors), family members, and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS updated. Refer to the TRICARE Eligibility section of this handbook for more information.
Designated Provider (DP)
Under the US Family Health Plan (USFHP), DPs, formerly known as uniformed services treatment facilities, are selected civilian medical facilities around the United States assigned to provide care to eligible and enrolled USFHP beneficiaries—including those who are age 65 and older—who live within the DP area. At these DPs, the USFHP provides TRICARE Prime benefits and cost-shares for eligible persons who enroll in USFHP, including those who are Medicare-eligible.
Diagnosis-Related Group
A reimbursement methodology used for inpatient care in some hospitals.
Discharge Planning
The development of an individualized discharge plan for the patient prior to leaving an institution for home, with the aim of improving patient outcomes, reducing the chance of unplanned readmission to an institution, and containing costs.
Disease Management
A prospective, disease-specific approach to improving health care outcomes by providing education to beneficiaries through non-physician practitioners who specialize in targeted diseases.
Emergency Care
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 eyesight, or when the 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 to self or others.
Enrollee
A TRICARE beneficiary who has elected to enroll in one of the TRICARE program enrollment-based options (e.g., TRICARE Prime, TRICARE Prime Remote, TRICARE Prime Remote for Active Duty Family Members, US Family Health Plan, Extended Care Health Option).
Explanation of Benefits (EOB)
A statement sent to a beneficiary showing that a claim was processed and indicating the amount paid to the provider. If denied, an explanation of denial is provided.
Extended Care Health Option (ECHO)
ECHO is a supplemental program to the TRICARE basic program. It provides eligible and enrolled active duty family members with additional benefits for an integrated set of services and supplies designed to assist in the treatment and/or reduction of the disabling effects of the beneficiary’s qualifying condition. Qualifying conditions may include moderate or severe mental retardation, a serious physical disability, or an extraordinary physical or psychological condition such that the beneficiary is homebound.
Foreign Identification Number (FIN)
A permanent identification number assigned to a North Atlantic Treaty Organization (NATO) beneficiary by the appropriate national embassy. The number resembles a Social Security number and most often starts with six or nine. TRICARE will not issue an authorization for treatment or services to NATO beneficiaries without a valid FIN.
Fraud
Fraud is defined as (1) a deception or misrepresentation by a provider, beneficiary, sponsor, or any person acting on behalf of a provider, sponsor, or beneficiary with the knowledge (or who had reason to know or should have known) that the deception or misrepresentation could result in some unauthorized TRICARE benefit to self or some other person, or some unauthorized TRICARE payment, or (2) a claim that is false or fictitious, or includes or is supported by any written statement that asserts a material fact that is false or fictitious, or includes or is supported by any written statement that (a) omits a material fact and (b) is false or fictitious as a result of such omission and (c) is a statement in which the person making, presenting, or submitting such statement has a duty to include such material fact. It is presumed that, if a deception or misrepresentation is established and a TRICARE claim is filed, the person responsible for the claim had the requisite knowledge. This presumption is rebuttable only by substantial evidence. It is further presumed that the provider of the services is responsible for the actions of all individuals who file a claim on behalf of the provider (e.g., billing clerks); this presumption may only be rebutted by clear and convincing evidence.
Grievance
A grievance is a written complaint or concern from a TRICARE beneficiary or a provider on a non-appealable issue. Grievances address health care-related concerns by any member of the health care delivery team—including TRICARE military providers, Humana Military, or Humana Military subcontractor personnel—to provide appropriate and timely health care services, access to care, quality of care, or level of care or service to which the beneficiary or provider feels he or she is entitled.
Healthcare Common Procedure Coding System (HCPCS)
A set of codes used by Medicare that describes services and procedures. HCPCS includes Current Procedural Terminology (CPT®) codes for services not included in the normal CPT code list, such as durable medical equipment and ambulance service. While HCPCS is nationally defined, there is a provision for local use of certain codes.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA was enacted to improve portability and continuity of health insurance coverage in the group and individual markets; to combat waste, fraud, and abuse in health insurance and health care delivery; to promote the use of medical savings accounts; to improve access to long-term care services and coverage; to simplify the administration of health insurance; and for other purposes.
Initial Denial
Made only after second-level review if the care or treatment is not found to be medically necessary, reasonable, or at the appropriate level. The non-network, participating provider or beneficiary may appeal the initial denial. For more information, see the definition for second-level review.
Managed Care
A health care system under which an organization delivers health care to enrolled members and controls costs by closely supervising and reviewing the delivery of health care.
Managed Care Support Contractor (MCSC)
An MCSC is a civilian health care contractor of the Military Health System that administers TRICARE in one of the TRICARE regions. An MCSC (Humana Military is an MCSC) helps combine the services available at military treatment facilities with those offered by the TRICARE network of civilian hospitals and providers to meet the health care needs of the TRICARE beneficiaries.
Medically Necessary
Appropriate and necessary treatment of the beneficiary’s illness or injury according to accepted standards of medical practice and TRICARE policy. Medical necessity must be documented in clinical notes.
Medicare
The Centers for Medicare and Medicaid Services manages Medicare. Medicare is a health insurance program for people age 65 or older; people under age 65 with certain disabilities; people with endstage renal disease; and people with amyotrophic lateral sclerosis (Lou Gehrig’s) disease. Medicare Part A is hospital insurance. Medicare Part B is medical insurance.
Military Treatment Facility (MTF)
An MTF is a medical facility (hospital, clinic, etc.) owned and operated by one of the component services of the Department of Defense (e.g., U.S. Army, U.S. Navy, U.S. Air Force) and usually located on or near a military installation.
National Drug Code (NDC)
The U.S. Food and Drug Administration (FDA) requires companies engaged in the manufacture, preparation, propagation, compounding, or processing of a drug product to register with the FDA and provide a list of all drugs manufactured for commercial distribution. Drug products are identified and reported using a unique three-segment number called the NDC. NDCs can be found on the Drug Registration and Listing System published by the FDA.
National Guard and Reserve
The National Guard and Reserve includes the Army National Guard, the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air National Guard, the Air Force Reserve, and the Coast Guard Reserve.
National Provider Identifier (NPI)
The NPI is a 10-digit number used to identify providers in standard electronic transactions. It is a requirement of the Health Insurance Portability and Accountability Act of 1996.
Network Provider
A network provider is a professional or institutional provider who has a contractual relationship with the managed care support contractor to provide care. A network provider agrees to file claims and handle other paperwork for TRICARE beneficiaries, and typically administers care to TRICARE Prime beneficiaries and TRICARE Standard beneficiaries using TRICARE Extra (the preferred provider option).
Nonavailability Statement (NAS)
A certification by a commander (or a designee) of a uniformed services medical treatment facility, recorded in DEERS, generally for the reason that the needed medical care being requested by a non-TRICARE Prime enrolled beneficiary cannot be provided at the facility concerned because the necessary resources are not available in the time frame needed.
Non-Network Provider
A non-network provider is one who has no contractual relationship with the managed care support contractor, but is authorized to provide care to TRICARE beneficiaries. There are two types of non-network providers—participating and nonparticipating.
Nonparticipating Provider
A hospital or other authorized institutional provider, a physician or other authorized individual professional provider, or other authorized provider that furnished medical services or supplies to a TRICARE beneficiary, but who did not agree on the TRICARE claim form to participate or to accept the TRICARE-determined allowable cost or charge as the total charge for the services. A nonparticipating provider looks to the beneficiary or sponsor for payment of his or her charge, not TRICARE. In such cases, TRICARE pays the beneficiary or sponsor, not the provider.
North Atlantic Treaty Organization (NATO) Member
A member of a foreign NATO nation’s armed forces who is on active duty and who, in connection with official duties, is stationed in or passing through the United States. The foreign NATO nations are Albania, Belgium, Bulgaria, Canada, Croatia, Czech Republic, Denmark, Estonia, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Lithuania, Luxembourg, the Netherlands, Norway, Poland, Portugal, Romania, Spain, Slovakia, Slovenia, Turkey, and the United Kingdom.
Other Health Insurance (OHI)
Any non-TRICARE health insurance that is not considered a supplement is considered OHI. 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 the TRICARE Management Activity.
Outpatient Prospective Payment System (OPPS)
TRICARE OPPS is used to pay claims for hospital outpatient services. TRICARE OPPS is based on nationally established Ambulatory Payment Classification payment amounts and standardized for geographic wage differences that include operating and capital-related costs, which are directly related and integral to performing a procedure or furnishing a service in a hospital outpatient department. TRICARE OPPS became effective May 1, 2009.
Participating Provider
A provider who has agreed to file claims for TRICARE beneficiaries, accept payment directly from TRICARE, and accept the TRICARE-allowable charge as payment in full for services rendered. Non-network providers may participate on a claim-by-claim basis. Providers may seek payment of applicable copayments, cost-shares, and deductibles from the beneficiary. After May 1, 2009, under the outpatient prospective payment system (OPPS), all hospitals that are Medicare-participating providers must, by law, also participate in TRICARE for inpatient and outpatient care. Refer to Chapter 13 of the
TRICARE's Reimbursement Manual for additional details on the OPPS.
Peer Review Organization
An organization charged with reviewing provider quality and medical necessity.
Per Diem
A reimbursement methodology based on a perday rate that is currently used for behavioral health institutions and partial hospitalization programs.
Point of Service (POS)
The option under TRICARE Prime that allows enrollees to self refer for nonemergent health care services to any TRICARE-authorized civilian provider, in or out of the network. When Prime enrollees choose to use the POS option (i.e., to obtain nonemergent health care services from other than their primary care managers [PCMs] or without a referral from their PCMs), all requirements applicable to TRICARE Standard, apply except the requirement for a Nonavailability Statement. POS claims are subject to deductibles and cost-shares (refer to definitions in this glossary) even after the enrollment/fiscal year catastrophic cap has been met. The POS option is not available to active duty service members.
Pre-Authorization
See the definition for prior authorization.
Preferred Provider Organization (PPO)
An organization of providers who, through contractual agreements with the contractor, have agreed to provide services to TRICARE beneficiaries at reduced rates and to file TRICARE claims on behalf of the beneficiaries and accept TRICARE assignment on all TRICARE claims. The preferred provider agreements may call for some other form of reimbursement to providers, but in no case will an eligible beneficiary receiving services from a preferred provider be required to file a TRICARE claim or pay more than the allowable charge cost-share for services received.
Primary Care Manager (PCM)
A military treatment facility provider or team of providers or a network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. Enrolled beneficiaries agree to initially seek all nonemergency, non-mental health care services from their PCMs.
Prime Service Area (PSA)
The geographic area where TRICARE Prime benefits are offered. This includes all catchment areas, Base Realignment and Closure Commission sites, a 40-mile radius around all military treatment facilities, and all additional areas proposed by the regional managed care support contractor.
Prior Authorization
A decision issued in writing, or electronically by the Director, TRICARE Management Activity, or a designee, that TRICARE benefits are payable for certain services that a beneficiary has not yet received. May also be referred to as pre-authorization.
Note: Definition is distinct from “referral.”
Prospective Review
Evaluation of a provider’s request for treatment of a patient before the treatment is delivered. This typically involves a provider requesting admission (nonemergent) or requesting selected procedures that require pretreatment certification and authorization for reimbursement. A registered nurse, physician assistant, behavioral health clinician, or physician performs reviews. A first-level (i.e., prospective) review may result in an authorization of services or in a referral to second-level review. A first-level review never results in a denial of care or treatment.
Protected Health Information (PHI)
PHI is any individually identifiable health information that relates to a patient’s past, present, or future physical or behavioral health and related health care services. PHI may include demographics, documentation of symptoms, examination and test results, diagnoses, and treatments.
Reconsideration
An appeal to a contractor of an initial determination issued by the contractor.
Referral
The act or an instance of referring a TRICARE beneficiary to another authorized provider to obtain necessary medical treatment. Under TRICARE, only a physician may make referrals.
Note: Definition is distinct from “prior authorization.”
Region
A geographic area determined by the government for civilian contracting of medical care and other services for TRICARE-eligible beneficiaries.
Remittance Advice
A statement sent to providers showing that claims were processed and the amount for which the beneficiary is responsible. If denied, an explanation of denial is provided.
Resource Sharing Agreement
This is an agreement between the contractor and individual military treatment facility (MTF) commanders to provide or share equipment, supplies, facilities, physicians, nurses, or other trained staff who are under contract with, or employed by, the contractor for work in MTFs (internal resource sharing) for the purpose of enhancing the capabilities of MTFs to provide needed patient care to beneficiaries. Resource sharing may also occur when the MTF commander and the contractor agree to place an MTF provider in a civilian facility (external resource sharing).
Retrospective Review
Evaluation of care already delivered to determine appropriateness of care and conformance to pre-established criteria for utilization. The purpose for this type of review may be to validate utilization decisions made during the review process and/or to validate payment made for care provided by examining the actual record of treatment.
Second-Level Review
Cases that do not meet the prospective review screening criteria are referred for medical director review at the second level.
Split Enrollment
Split enrollment refers to multiple family members enrolled in TRICARE Prime under different TRICARE regions or managed care support contractors.
Sponsor
The sponsor is the active duty service member, retiree, or deceased service member or former service member through whom family members are eligible for TRICARE.
Supplemental Health Care Program (SHCP)
The SHCP is a program for eligible uniformed service members and other designated patients who require medical care that is not available at the military treatment facility (MTF) upon the approval of the cognizant MTF commander or the Director, TRICARE Management Activity, as required, to be purchased from civilian providers under TRICARE payment rules.
Supplemental Insurance Plan
A health insurance policy or other health benefit plan offered by a private entity to a TRICARE beneficiary that primarily is designed, advertised, marketed, or otherwise held out as providing payment for expenses incurred for services and items that are not reimbursed under TRICARE due to program limitations, or beneficiary liabilities imposed by law. TRICARE recognizes two types of supplemental plans, general indemnity plans, and those offered through a direct service health maintenance organization.
Tax Identification Number (TIN)
A TIN is a number assigned by the state in which a business or entity is operated that identifies it for filing and paying taxes related to the business or entity.
Transitional Assistance Management Program (TAMP)
TAMP provides 180 days of transitional health care benefits to help certain uniformed services members and their families transition to civilian life.
Transitional Care
Transitional care is designed for all beneficiaries to assure a coordinated approach takes place across the continuum of care.
Treatment Plan
A detailed description of the medical care being rendered or expected to be rendered to a TRICARE beneficiary seeking approval for inpatient benefits for which prior authorization is required. A treatment plan must include, at a minimum, a diagnosis (either ICD-9-CM or DSM-III); detailed reports of prior treatment, medical history, family history, social history, and physical examination; diagnostic test results; consultant’s reports (if any); proposed treatment by type (such as surgical, medical, and psychiatric); a description of who is or will be providing treatment (by discipline or specialty); anticipated frequency, medications, and specific goals of treatment; type of inpatient facility required and why (including length of time the related inpatient stay will be required); and prognosis. If the treatment plan involves the transfer of a TRICARE patient from a hospital or another inpatient facility, medical records related to that inpatient stay also are required as a part of the treatment-plan documentation.
TRICARE-Allowable Charge
The TRICARE-allowable charge (also called 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 lesser of the actual billed charge and 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 diagnosis-related group rate is the TRICARE-allowable charge, regardless of the billed amount. For network providers, the allowable charge is the lesser of the contracted rate and the maximum amount TRICARE would authorize if the service had been furnished by a non-network participating provider.
TRICARE-Authorized Provider
A hospital or institutional provider, physician, or other individual professional provider, or other provider of services or supplies specifically authorized to provide benefits under TRICARE.
TRICARE Prime Service Area
See the definition for Prime Service Area.
UB-04
The CMS-1450 form (also known as the UB-92) has been replaced with the UB-04 form. The UB-04 form is used by hospitals and other institutional providers to bill government and commercial health plans; it must be used exclusively for institutional billing beginning January 1, 2008. The UB-04 data set accommodates the National Provider Identifier and incorporates a number of other important changes and improvements. It also is Health Insurance Portability and Accountability Act of 1996-compliant.
Urgent Care
Urgent care is medically necessary treatment required for an illness or injury that would not result in further disability or death if not treated immediately. The illness or injury does require professional attention, and should be treated within 24 hours to avoid development of a situation in which further complications could result if treatment is not received.
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