Chapter 16
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| TRICARE Standard | greatest freedom in selection and most expensive of TRICARE plans
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| There are.....TRICARE regions in the U.S. and .....for a total of four regions | 1) three
2) one overseas
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| All active duty members are not eligible for | TRICARE Extra because they are automatically enrolled on TRICARE Prime
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| The Health Affairs Office is responsible for | both military readiness and peacetime health care
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| Catastrophic Cap Benefit | protects beneficiaries who are the victims of medical malpractice from devastating financial loss
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| TMA office | responsible for quality health care provided to members of the military and their families
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| Primary Care Manager (PCM) | Physician who is part of the TRICARE provider network; assigned to sponsor
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| TRICARE sponsors | uniformed service personnel; can be classified as active duty, retired or deceased
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| TRICARE has three health care options | 1) TRICARE Standard
2) TRICARE Prime
3) TRICARE Extra
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| Business offices that assist TRICARE sponsors with healthcare needs are | referred to as TRICARE Service Centers
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| CHAMPVA | always pays after Medicare
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| Nurse advisors are available for | advice and assistance with treatment alternatives
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| The Health Administration Center administers the CHAMPVA program by | 1)processing applications,
2)determining eligibility,
3)authorizing benefits and
4)processing claims
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| Beneficiary Counseling and Assistance Coordinators (BCACs) used to be called | Health Benefit Advisors (HBA)
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| TRICARE case management coordinates and monitors | a beneficiary's healthcare options and services
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| Someone who assists primary care providers (PCPs) with preauthorization and referrals is called | a health care finder
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| TRICARE's main office is located in | Colorado
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| TRICARE used to be called | CHAMPUS
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| Retired Reserve Component service members are | eligible for retirement pay at age 60
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| The Army, Navy and Air Force are | all covered by TRICARE
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| MTF | Military Treatment Facility
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| There are......Tricare regions in the United States | four(4)
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| Doctors assigned to sponsors and part of the TRICARE network are called | Primary Care Managers
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| A preauthorization is | an official approval obtained from a health care finder before certain specialty procedures and inpatient care can be given
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| A referral is | a request for a member to receive treatment from another provider
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| The following are eligible for TRICARE Prime | 1) Retirees and their family members who are under the age of 65
2) Active duty personnel
3) Family members of active duty personnel
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| The following are benefits offered under TRICARE Prime | 1) Guaranteed access to timely medical care
2) Assignment of primary care manager
3) Priority care at military treatment facilites
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| When a person has CHAMPVA and Medicare | CHAMPVA always pays after Medicare
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| The entire healthcare system of the U.S. uniformed services is | referred to as the Military Health Services System
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| The Program Integrity Office is responsible for | surveillance of fraud and abuse activities
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| Catchment Area | Region defined by code boundaries within a 40-mile radius of an MTF (military treatment facility)
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| The nurse or doctor who helps Primary care providers with preauthorization is referred to as a | health care finder
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| Decision-making tools that are used to decide appropriate health care for specific circumstances are called | practice guidelines
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| TRICARE for Life | provides Medicare wrap-around coverage
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| Beneficiary Services Representatives | provide beneficiaries information about using TRICARE
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| When an MTF is unable to provide needed care | they issue the patient an "non-availability statement"
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| TRICARE Prime is | a managed care option for military that is similar to HMOs
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| Critical Pathway | a sequence of activities that results in cost-effective course of treatment
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| The fiscal year | runs from October 1 through September 30
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| Demonstration Project | tests and establishes the feasibility of starting a new program
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| MTF | Military Treatment Facility; healthcare facility operated by the military
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| Lead Agents | federal health care team created to work with military treatment facility commanders
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| Catastrophic Cap Benefit | out-of-pocket costs for covered services
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| It is the responsibility of Primary Care Manager to | 1) Provide non-emergency care to eligible beneficiaries
2) Arrange referrals for specialty care if needed
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| The following are circumstances which would exclude TRICARE-authorized providers form program participation | 1) Criminal conviction or civil judgment involving fraud
2) Fraud or abuse under TRICARE
3) Exclusion or suspension by another federal, state or local government agency
4) Participation in a conflict of interest situation
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| (continued)The following are circumstances which would exclude TRICARE-authorized providers form program participation (continued) | 5) When it is in the best interest of the TRICARE program or its beneficiaries
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| TRICARE Prime guarantees enrollees access to care | urgent care within one day and less urgent care within one week
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| Tricare Extra features include | 1) Choice of any physician in the network
2) Less expensive than TRICARE Standard
3) May be more expensive than TRICARE Prime
4) Annual enrollment is not required
5) Low priority for care provided at military treatment facilities
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