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UHI Ch 16
TRICARE
| Answer | Question |
|---|---|
| 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 |
| MEDICAID | TRICARE pays before |
| 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
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