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UHI Ch 16


CHAMPUS TRICARE was originally called
active duty members provides medical care for families of
West, North, South There are 3 TRICARE regions in the U.S.
any of the 7 uniformed services ( Air Force, Army, Coast Guard, Marine Corps, National Oceanic & Atmospheric Administration, Navy, Public Health Service) Eligible members include
the patient's SS# ID # is
Military Health Services System (MHSS) the healthcare system of the U.S. military service
if a non-participating provider
115% Physicians can not charge more than __________ of the allowable charge
TRICARE contractors Claims are submitted to
1 year timely filing for TRICARE is
MTF (Military Treatment Facility) facility who provides care to eligible TRICARE beneficiaries
NAS (Non-Availability Statement) electronic document required if there is no facility nearby
Healthcare finders RN or PA who assists in obtaining preauthorization & referrals in a military treatment facility
TMA (TRICARE Management Activity) office responsible for surveillance of fraud & abuse activities
CHAMPVA Civilian health & medical program of the department of veterans affairs
dependents of a vet who is totally 100% disabled, survivors of a vet who dies as a result of service-related disability, survivors of a vet who died in the line of duty Eligibility
MEDICAID & supplemental Secondary except for
TRICARE Prime, TRICARE Remote, TRICARE For Life, TRICARE Extra, TRICARE Standard, TRICARE Reserve 6 TRICARE plans
TRICARE Prime semilar to an HMO; no deductible; no outpatient treatment; eligibility-active duty, family members of active duty sponsors, retirees & their family members who are under the age of 65; activated when seeking medical care without prior approval
PCM (Primary Care Manager) provider who manages the care of TRICARE beneficiaries
TRICARE Remote service members & their families on assignment are provided services at no cost
50 must live & work no more than _____ miles from the nearest facility
catastrophic cap benefit protects beneficiaries from financial loss due to serious illness; out-of-pocket cost for active members & families: $1000; out-of-pocket cost for retirees & families: $3000
TRICARE Extra managed care plans; civilian facility provides majority of the care; deductible - $150 for individuals & $300 for family; pays 15% of outpatient; enrollees save 5% by using network providers
TRICARE Reserve reservists; dependents may be eligible after personal made active after 30+ days; National Guard; reserve duty eligibility
TRICARE Standard "fee for service plan"; greatest flexibility; out-of-pocket are higher; most convenient when traveling; most expensive of all options (out-of-pocket for active: $1000 and $3000 for retirees)
TRICARE for Life 65+ dual MEDICARE; similar to MEDICARE but no HMO; Second to MEDICARE; must have Part A & B MEDICARE
payers of last resort TRICARE & TRICARE for Life are __________ except when the patient also has MEDICAID
DEERS (Defense Enrollment Eligibility Reporting System) a computer system that contains up-to-date defense department workforce personnel information; eligibility reporting system
fiscal year runs from Oct 1 of one year to Sep 30 of the next
Program Integrity (PI) Office responsible for the surveillance of fraud & abuse activities worldwide involving purchased care for beneficiaries in the military healthcare system
allowable fee TRICARE follows the principles of the RBRVS system but has made some adjustments to the geographic regions & assigned a slightly higher conversion factor
PCM (Primary Care Manager) a doctor assigned to a sponsor & is part of the TRICARE provider network
CHAMPUS (Civilian Health And Medical Program of the Uniformed Service) now called TRICARE Standard; created in 1966; was implemented in 1967
deductible amount for which the pt is financially responsible before an insurance policy provides coverage
CHAMPVA (the Civilian Health And Medical Program of the department of Veterans Affairs) a comprehensive health care program for which the Department of Veterans Affairs (VA) shares costs of covered health care services & supplies with eligible beneficiaries
TRICARE healthcare program for active duty members of the military & their qualified family members, eligible retirees & their qualified family members, & eligible survivors of members of the uniformed service
MHSS (Military Health Services System) the entire healthcare system of the U.S. Uniformed services & includes MTFs as well as various programs in the civilian healthcare market
HCF (Health Care Finder) a registered nurse or physician assistant who assists primary care providers with preauthorizations & referrals to healthcare services in a military treatment facility or civilian provider network
fee schedule allowable fee
case management coordinates health care services
DD form 2642 you file own claim with what form
no availability claim what do you file if more than 50 miles from a facility
LA (lead agents) commanders of selected MTFs (Military Treatment Facilities) are selected as __________ for the TRICARE regions
HA (Health Affairs) refers to the Office of the Assistant Secretary of Defense for Health Affairs, which is responsible for both military & peacetime health care
TRICARE sponsors uniformed service personnel who are either active duty, retired, or deceased
TRICARE beneficiaries include sponsors & dependents of sponsors
TSCs (TRICARE Service Centers) business offices staffed by one or more beneficiary services representatives & health care finders who assist TRICARE sponsors with health care needs & answer questions about the program
BSR (Beneficiary Services Representative) provides information about using TRICARE, & assists with other matters affecting access to health care (e.g., appointment scheduling)
nurse advisors available 24/7 for advice & assistance with treatment alternatives & to discuss whether a sponsor should see a provider based on a discussion of symptoms
BCACs (Beneficiary Counseling & Assistance Coordinators) located at MTFs, & they are available to answer questions, help solve health care-related problems, & assist beneficiaries in obtaining medical care through TRICARE
DCAOs (Debt Collection Assistance Officers) located at MTFs to assist beneficiaries in resolving health care collection-related issues
critical pathway the sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment
practice guidelines decision-making tools used by providers to determine appropriate health care for specific clinical circumstances
discharge planning assesses requirements so that arrangements can be made for the appropriate & timely discharge of patients from acute care or outpatient settings
CAC (Common Access Card) an identification card issued by the Department of Defense (DoD); always make a copy of the front & back
demonstration project or pilot tests & establishes the feasibility of implementing a new program during a trial period, after which the program is evaluated, modified, and/or abandoned
OHI (Other Health Insurance) if the pt has __________, attach the remittance advice to the TRICARE claim
Created by: Stacey_Gantt5