Glossary
      

The improper or excessive use of program benefits, resources, or services by providers or beneficiaries. Abuse can be either intentional or unintentional and can occur when:

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

A review determination made by a licensed professional nurse or other health care professional for requested services, procedures, or admissions. Authorizations must be obtained prior to services being rendered or within 24 hours of an emergency admission.

Authorized Provider

See the definition for TRICARE-authorized provider.

Balance Billing

A term used to describe 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 is going to pay. Network providers are prohibited from balance billing.

Base Realignment and Closure Comission (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 natural children 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 TRICARE Eligibility section.

Beneficiary Counseling and Assistance Coordinators (BCACs)

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 directory.

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

A collaborative process normally associated with multiple episodes of health care intervention that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a beneficiary’s complex health needs. This is accomplished through communication and available resources that 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

Catchment areas are geographic areas that are defined by ZIP codes, usually within an approximate 40-mile radius of a military inpatient treatment facility. Eligible beneficiaries who reside within a catchment area may be required to receive certain services from the military treatment facility (MTF). 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 (CMS)

The federal agency that oversees all aspects of health care claims filing for Medicare (formerly known as the Health Care Financing Administration, or HCFA).

Certified Provider

See the definition for TRICARE-authorized provider.

CHAMPUS Maximum Allowable Charge (CMAC)

The amount TRICARE will cover for nationally established fees. CMAC is the TRICARE-allowable charge for covered services when appropriately applied to services priced under CMAC.

Circumvention

A term used to describe inappropriate medical practices or actions that result in unnecessary multiple admissions of an individual.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

The former health care program established to provide health care coverage for active duty family members and retirees and their family members. TRICARE was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. Benefits covered under CHAMPUS are now covered under TRICARE Standard.

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

The federal health benefits program for family members of 100 percent totally and permanently disabled veterans. CHAMPVA is also available to eligible beneficiaries under age 65. CHAMPVA is administered by the Department of Veterans Affairs and is not associated with the TRICARE program. For questions regarding CHAMPVA, call 1-800-733-8387 or e-mail to ha.inq@va.gov.

ClaimCheck®

An automated claims-auditing system that verifies the clinical accuracy of claims.

CMS-1500

As of January 1, 2008, the National Uniform Claim Committee required the use of the Centers for Medicare and Medicaid Services (CMS) Health Insurance Claim Form (version 08/05) to accommodate the reporting of the National Provider Identifier. The December 1990 version of the CMS-1500 claim form was discontinued and only the revised form is to be used after December 31, 2007. All rebilling of claims must use the revised form from January 1, 2008, forward, even though earlier submissions may have been on the December 1990 version of the CMS-1500 claim form.

Concurrent Review

A review performed during the course of a beneficiary’s inpatient admission with the purpose of validating the appropriateness of the admission, level of care, medical necessity, and quality of care, as well as the information provided during earlier reviews. Additional functions performed include screening for case management and identification of discharge planning needs. The review may be conducted by telephone or on site. Concurrent reviews are generally performed when TRICARE is the primary payer. Concurrent reviews that indicate criteria are not met are referred for medical director review.

Copayment

The fixed amount a TRICARE Prime program option enrollee will pay for care in the civilian provider network. Active duty family members enrolled in a TRICARE Prime program option are not required to make 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, TRICARE Extra, or TRICARE Reserve Select. The cost-share depends on the sponsor’s status—active duty or retired. Note: Extended Care Health Option services also have cost-shares, regardless of the beneficiary’s program option (including TRICARE Prime).

Credentialing

The process that evaluates and subsequently allows providers 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, TRICARE Extra, or TRICARE Reserve Select beneficiary must pay for covered outpatient benefits before TRICARE begins to share costs. TRICARE Prime beneficiaries do not have an annual deductible, unless they are utilizing their point of service option.

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. Refer to the TRICARE Eligibility section of this handbook for more information.

Designated Provider

Under the US Family Health Plan (USFHP), DPs, formerly known as uniformed services treatment facilities, are selected civilian medical facilities around the U.S. assigned to provide care to eligible 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 (DRG)

A reimbursement methodology used for inpatient care in some hospitals.

Discharge Planning

A process that assesses requirements and the coordination of care for a beneficiary’s timely discharge from an acute inpatient setting to a post-care environment without need for additional military treatment facility or civilian provider assistance.

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.

Enrollee

A TRICARE beneficiary who has elected to enroll in a TRICARE program option (e.g., TRICARE Prime, TRICARE Prime Remote, or TRICARE Prime Remote for Active Duty Family Members).

Explanation of Benefits

A statement sent to a beneficiary showing that a claim was processed and indicating the amount paid to providers. 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 active duty family members with an additional financial resource 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

An instance in which deliberate deceit is used by a provider to obtain payment for services not actually delivered or received, or by a beneficiary to claim program eligibility.

Grievance

A grievance is a written complaint or concern from a TRICARE beneficiary or a provider on a non-appealable issue. Grievances address issues of perceived failure 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 they are entitled.

Health Care Financing Administration (HCFA)

The former name of the federal agency that oversees all aspects of health claims filing for Medicare. The agency is now known as the Centers for Medicare and Medicaid Services.

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.

Health Management Strategies International

A company that has developed behavioral health review criteria for medical necessity reviews.

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 introduced 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 concept 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 partner 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.

Medical Emergency

A medical condition manifesting itself by acute symptoms of sufficient severity—including severe pain—such that a prudent layperson could reasonably expect the absence of medical attention to result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. In the case of a pregnant woman, the danger should be considered to adversely affect the health of the woman or her unborn child.

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.

Military Treatment Facility (MTF)

An MTF is a medical facility (hospital, clinic, etc.) owned and operated by the uniformed services and usually located on or near a military base.

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 (HIPAA).

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 those TRICARE Standard beneficiaries using TRICARE Extra (the preferred provider option).

Nonavailability Statement (NAS)

A NAS is a certification from a military treatment facility stating 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 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 nonparticipating provider is a TRICARE-authorized hospital, institutional provider, physician, or other provider that furnishes medical services (or supplies) to TRICARE beneficiaries, but does not agree to accept the TRICARE-allowable charge or file claims for TRICARE beneficiaries.

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 Belgium, Bulgaria, Canada, Czech Republic, Denmark, Estonia, France, Federal Republic of 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 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 per-day rate that is currently used for behavioral health institutions and partial hospitalization programs.

Point of Service (POS)

An option that allows a TRICARE Prime or TRICARE Prime Remote for Active Duty Family Members beneficiary to obtain medically necessary services—inside or outside the TRICARE 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. The POS option is not available to active duty service members.

Pre-Authorization

See the definition for Prior Authorization.

Preferred Provider Organization (PPO)

A network of health care providers who provide services to patients at discounted rates or cost-shares. TRICARE Extra is considered to be a PPO option.

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.

Prime Service Area (PSA)

A PSA is an area that has been defined and mapped in proximity to military treatment facilities (MTFs), Base Realignment and Closure Commission (BRAC) installations, and in other predetermined areas. Minimum government standards for MTF PSAs and BRAC PSAs are geographically defined by ZIP codes that create an approximate 40-mile radius from the MTF or BRAC installation.

Prior Authorization

A process of reviewing certain medical, surgical, and behavioral health care services to ensure medical necessity and appropriateness of care prior to services being rendered or within 24 hours of an emergency admission.

Prospective Review

A screening process used to evaluate the medical necessity and appropriateness of a treatment or service proposed. The review is prospective (before the care or service is performed) and criteria-based. 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 or Appeal

A formal written request by an appropriate appealing party or an appointed representative to resolve a disputed statement of fact.

Referral

The process of sending a patient to another professional provider (physician or psychologist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Referrals are always required for active duty service members (except in the case of an emergency) for services provided by a civilian provider, other than the primary care manager.

Region

A geographic area determined by the federal 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 (RSA)

There are two types of RSAs. External RSAs are arrangements that allow military providers to render medical services to TRICARE beneficiaries in civilian network medical facilities. Internal RSAs are arrangements that allow civilian providers into the military treatment facility system to render medical services to TRICARE beneficiaries.

Retrospective Review

A review of a beneficiary’s medical record that occurs after the services have been rendered.

Second-Level Review

Cases that do not meet the prospective review screening criteria are referred for medical director review at the second level.

Social Security Number (SSN)

AN SSN is a number assigned by the federal government for the purposes of identifying a specific individual and taxpayer.

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 or retiree 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). Because services are not available at the MTF, these beneficiaries must be referred to a civilian provider.

Supplemental Insurance

Supplemental insurance includes health benefit plans that are specifically designed to supplement TRICARE Standard benefits. Unlike other health insurance 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.

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 Care

Transitional care is a program that is designed for all beneficiaries to assure a coordinated approach takes places across the continuum of care.

Treatment Plan

A treatment plan is a multidisciplinary care plan for each beneficiary in active case management. It includes specific services to be delivered, the frequency of services, expected duration, community resources, military resources, all funding options, treatment goals, and assessment of the beneficiary environment. The plan is updated monthly and modified when appropriate. These plans are developed in collaboration with the attending physician and beneficiary or guardian.

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 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 provider who meets TRICARE’s licensing and certification requirements and has been authorized by TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers include doctors, hospitals, ancillary providers (such as laboratory and radiology providers), and pharmacies.

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 HIPAA 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.