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INSUR {CBCS-CPC}
TRICARE and CHAMPVA
| Question | Answer |
|---|---|
| catastrophic cap | The maximum annual amount a TRICARE beneficiary must pay for deductible and cost share |
| CHAMPVA | Civilian Health & Medical Program of the Department of Veterans Affairs |
| CHAMPUS | Civilian Health & Medical Program of the Uniformed Services |
| cost-share | Coinsurance for a TRICARE or CHAMPVA beneficiary |
| (DEERS) Defense Enrollment Eligibility Reporting System | The worldwide database of TRICARE and CHAMPVA beneficiaries |
| (PCM) Primary Care Manager | Provider who coordinates and manages the care of TRICARE Prime beneficiaries |
| Prime Service Area | Geographic area designated to ensure medical readiness for active-duty members |
| Sponsor | The uniformed service member in a family qualified for TRICARE or CHAMPVA |
| TRICARE | is the Department of Defense's health insurance plan for military personnel and their families; formerly called CHAMPUS |
| TRICARE For Life | Program for beneficiaries who are both Medicare and TRICARE eligible |
| TRICARE Prime | The basic managed care health plan offered by TRICARE |
| TRICARE Select | The fee-for-service military health plan |
| TRICARE | insurance plan which includes managed care options; replaced CHAMPUS |
| TRICARE | contracts with civilian facilities and physicians to provide more extensive services to beneficiaries |
| TRICARE | Reserve & National Guard personnel become eligible when on active duty for more than 30 consecutive days or |
| TRICARE | Reserve & National Guard personnel become eligible when they retire from reserve status at age sixty |
| TRICARE | a regionally managed healthcare program serving approximately 9.6 million beneficiaries |
| TRICARE Uniformed Services | U.S. Army, Navy, Air Force, Marines, Coast Guard, Public Health Service, & National Oceanic & Atmospheric Administration |
| TRICARE beneficiary two groups | Group A and Group B |
| TRICARE Group B | includes sponsors enlisted or appointed on or after January 1, 2018 |
| TRICARE Group A | includes sponsor enlisted or appointed before January 1, 2018 |
| TRICARE Group A & Group B | have different enrollment fees and out-of-pocket costs |
| TRICARE | various branches of military service make decisions about eligibility |
| (DEERS) Defense Enrollment Eligibility Reporting System | information about patient eligibility is stored here |
| (DEERS) Defense Enrollment Eligibility Reporting System | sponsors may contact DEERS to verify eligibility |
| (DEERS) Defense Enrollment Eligibility Reporting System | providers may not contact DEERS directly because the information is protected by the Privacy Act |
| TRICARE | when a sponsor arrives for treatment, photocopies of both sides of their Military ID are made & the expiration date is validated |
| TRICARE | pays only for services rendered by authorized providers |
| TRICARE Regional Contractors | certify that authorized providers have met specific educational, licensing, & other requirements |
| TRICARE Providers | once authorized, a PIN is assigned and then they make the decision to participate |
| TRICARE Providers | those who participate agree to accept the TRICARE allowable charge as payment in full for services |
| TRICARE Participating Providers | are required to file claims on behalf of patients |
| Regional TRICARE contractor | sends payment directly to the provider, and the provider collects the patient's share of the charges |
| TRICARE Participating Providers | may appeal claim decisions |
| TRICARE Non-Participating Providers (nonPAR) | may not charge more than 115 percent of the allowable |
| cost-share | 20 or 25 percent; the TRICARE term for the coinsurance; that amount is the responsibility of the patient |
| TRICARE Non-Participating Providers (nonPAR) | once the claim has been submitted, TRICARE pays its portion of allowable charges |
| TRICARE | once the allowable charges have been paid by the nonPAR, this program mails the payment to the patient |
| cost-share | the patient is responsible for paying this to the provider; payment should be collected at the time of the visit |
| TRICARE Participating Providers | are paid on the amount specified in the Medicare Fee Schedule for most procedures |
| Supplies and Services not subjected to Medicare limits | medical supplies, durable medical equipment, and ambulance services |
| (CMAC) CHAMPUS Maximum Allowable Charge | the Maximum amount TRICARE will pay for a procedure |
| TRICARE Participating Providers | are responsible for collecting the patients' deductibles and their cost-share portions of the charges |
| TRICARE Participating Providers | may also contract to become part of the TRICARE network |
| TRICARE Participating Providers | provide care to beneficiaries at contracted rates |
| TRICARE Participating Providers | serve patients in one of TRICARE's managed care plans |
| TRICARE Participating Providers | acts as participating providers on all TRICARE managed care programs claims |
| TRICARE Non-Participating Providers (nonPAR) | may still provide care to managed care patients; but TRICARE may not pay for the services |
| TRICARE Non-Participating Providers (nonPAR) | TRICARE may not pay for managed care services; and the patient may be 100% responsible for the charges |
| TRICARE Covered Services (Eligibility) | Medically necessary | Delivered at the appropriate level for the condition | Quality that meets professional medical standards |
| TRICARE Prime | a managed care plan similar to an HMO |
| TRICARE Prime | not all active-duty service members are required to enroll |
| TRICARE Prime | active-duty service members do not have the option of choosing from additional TRICARE options |
| (PCM) Primary Care Manager | may be a single military or civilian provider or a group of providers |
| TRICARE Prime | is available within Prime Service Areas |
| TRICARE Prime | available to those who live within 100 miles of a PCM |
| (MTF) Military Treatment Facility | Government facility providing medical services for members and dependents of the uniformed services |
| TRICARE Prime | available services vary by facility, & first priority is given to service members on active duty |
| TRICARE Prime | additional TRICARE programs are available for active-duty service members in remote locations & overseas |
| TRICARE Prime | individuals who are not active-duty family members must pay annual enrollment fees |
| TRICARE Prime | there is no deductible, and no payment is required for outpatient treatment at a military facility |
| TRICARE Prime | for active-duty family members, no payment is required for civilian network visits, but different copayments apply depending on the type of visit |
| catastrophic cap | a limit on the total medical expenses that beneficiaries are required to pay in one year |
| catastrophic cap | patient cost-share in the TRICARE programs are subject to this annual amount payment limit |
| catastrophic cap | TRICARE pays 100 percent of additional charges for covered services for that coverage year |
| TRICARE Prime | has a (POS) point-of-service option that patients may select |
| (POS) Point-of-Service Fees | active-duty service members are exempt, but their family members will be required to pay for certain types of services |
| TRICARE Prime | enrollees receive the majority of their healthcare services from military treatment facilities & receive priority |
| TRICARE Noncovered Services | cosmetic drugs, cosmetic surgery, and unproven (experimental) procedures or treatments |
| TRICARE Select | available to people who have verifiable eligibility through DEERS and who enroll annually |
| TRICARE Select | may receive care from any TRICARE authorized provider, whether the provider is network or non-network |
| TRICARE Select | referrals are not required, but prior authorization is necessary for some types of services |
| TRICARE Select | the sponsor's Military ID serves as proof of coverage |
| TRICARE Select | sponsors DO NOT receive a TRICARE wallet card |
| TRICARE Select | costs vary based on the sponsor's military status |
| TRICARE Select | all members pay an annual outpatient deductible & cost shares for covered services |
| TRICARE Select | sponsors who see a network provider are required to pay only a copayment and do not have to file any claims |
| TRICARE Select | visits to non-network providers must be paid in full by the sponsor |
| TRICARE Select | not available to active-duty service members |
| TRICARE Select | a popular option for people who live in an area where they cannot use TRICARE Prime |
| TRICARE Select | this program is available worldwide |
| TRICARE Select | perfect for people who have other health insurance or who want to continue seeing a provider outside the TRICARE network |
| TRICARE For Life | acts as a SECONDARY payer to Medicare; Medicare pays first and TRICARE pays the remaining out of pocket expenses |
| Payers of Last Resort Providers | TRICARE and TRICARE For Life |
| TRICARE and TRICARE For Life | these providers are Payers of Last Resort EXCEPT when the patient also has Medicaid; if so, TRICARE pays before Medicaid |
| TRICARE For Life | available to individuals 65 & over who are eligible for both Medicare Part A, Part B & TRICARE |
| TRICARE For Life | enrollees in TRICARE who are 65 & over can continue to obtain medical services at military hospitals & clinics |
| TRICARE beneficiaries eligible for Medicare Part A | are required by law to enroll in Medicare Part B to retain their TRICARE benefits |
| TRICARE For Life | these claims are filed automatically; enrollees do not need to submit a paper claim |
| TRICARE For Life | Medicare pays its portion for Medicare covered services & automatically forwards the claim to WPS/TFL for processing |
| WPS/TFL | Wisconsin Physicians Service/TRICARE for Life; contractor in the U.S. and U.S. Territories |
| OHI | Other Health Insurance |
| (OHI) Other Health Insurance | the patient's claim does not automatically cross over to TRICARE; the patient must submit their claim to WPS/TFL |
| (OHI) Other Health Insurance [TRICARE Claim requirements] | Patient's Medicare Summary Notice | TRICARE paper claim DD Form 2642 | OHI's EOB statement |
| (OHI) Other Health Insurance [TRICARE Claim requirements] | must be mailed by the patient to: WPS/TRICARE For Life |
| TRICARE For Life | benefits are similar to those of a Medicare HMO with an emphasis on preventive & wellness services |
| TRICARE For Life | prescription drug benefits are also included |
| TRICARE For Life | all eligible enrollees in Part A & Part B are automatically enrolled in TRICARE For Life |
| TRICARE For Life | all eligible enrollees must have Part B premiums deducted from the Social Security check |
| TRICARE For Life | individuals already enrolled in a Medicare HMO may not participate |
| TRICARE For Life | other than Medicare costs; beneficiaries pay no enrollment fees & no cost share fees for inpatient or outpatient care |
| TRICARE For Life | treatment at a civilian network facility requires a copay |
| CHAMPVA | government health insurance program for the families of Veterans with 100% service-related disabilities |
| CHAMPVA | under the program, the Department of Veterans Affairs and the beneficiary share healthcare expenses |
| Veterans Health Care Eligibility Reform Act of 1996 | requires a veteran with a 100% disability to be enrolled in the program in order to receive benefits |
| Veterans Health Care Eligibility Reform Act of 1996 | prior to this legislation, enrollment was not required |
| Department of Veterans Affairs | is responsible for determining eligibility for the CHAMPVA program |
| CHAMPVA Eligible Beneficiaries | Dependents of a veteran who IS totally & permanently disable due to a service connected injury |
| CHAMPVA Eligible Beneficiaries | Dependents of a veteran who WAS totally & permanently disable due to a service connected condition at the time of death |
| CHAMPVA Eligible Beneficiaries | Survivor of a veteran who died as a result of a service related disability |
| CHAMPVA Eligible Beneficiaries | Survivor of a veteran who died in the line of duty |
| CHAMPVA Authorization Card | the provider's office checks this to determine eligibility |
| CHAMPVA Authorization Card | known as an A-Card |
| CHAMPVA Authorization Card | photocopies of the front and back are included in the patient's record |
| CHAMPVA Excluded Services | Medically unnecessary services & supplies | Experimental or investigational procedures | Custodial Care | (some) Dental care |
| CHAMPVA | some procedures must be approved in advance |
| CHAMPVA Preauthorization | is the responsibility of the patient; not of the provider |
| CHAMPVA Preauthorization Services | Mental Health/Substance Abuse | Organ/Bone marrow transplants | Dental care | Hospice | DME more than $300 |
| MTF | Military Treatment Facility |
| CHAMPVA | enrollees do not need to obtain nonavailability statements because they are not eligible to receive service in MTF's |
| (MTF) Military Treatment Facility | a Veterans Affairs hospital is not considered a MTF |
| CHAMPVA Participating Providers | does not contract with providers for most services |
| CHAMPVA | offers a maintained list of approved Mental Health Providers |
| CHAMPVA | beneficiaries can visit providers of their choice, as long as they are properly licensed & are not on the Medicare Exclusion List |
| CHAMPVA Participating Providers | are prohibited from charging more than the allowable amount |
| CHAMPVA Participating Providers | agree to accept payment and the patient's cost share as payment in full for services |
| CHAMPVA | most persons enrolled pay an annual deductible and a portion of their healthcare charges |
| CHAMPVA | some services are exempt from the deductible and cost share requirement |
| CHAMPVA | a patient's out of pocket costs are subject to a catastrophic cap of $3,000 per calendar year |
| CHAMPVA | pays claims for services at 100% for the rest of the year, once the beneficiary has paid $3,000 in medical bills for that year |
| CHAMPVA | pays equivalent to Medicare/TRICARE rates, in most cases |
| (CMAC) CHAMPVA Maximum Allowable Charge | the maximum amount paid for a procedure |
| CHAMPVA Outpatient Deductible | $50 per person up to $100 per family per calendar year, and a cost share 25 percent |
| CHAMPVA | cost share percentage is 75 percent |
| CHAMPVA | beneficiaries are responsible for the cost of healthcare services not covered |
| CHAMPVA | is almost always the SECONDARY payer; once the primary plan's RA is received, a copy is attached to the claim and filed |
| CHAMPVA as a Secondary Payer (exceptions) | Medicaid & supplemental policies purchased to cover deductibles, cost shares, and other services |
| CHAMPVA | insurance claims are first filed with the primary payer |
| CHAMPVA | persons under 65 who are eligible for Medicare benefits along with Parts A & B may also enroll |
| CHAMPVA for Life | extends benefits to spouses or dependents who are 65 and over |
| CHAMPVA for Life | benefits are payable after payment by Medicare or other 3rd party payers |
| CHAMPVA for Life | beneficiaries MUST be 65 or OLDER and MUST be enrolled in Medicare Parts A & B |
| CHAMPVA for Life | acts as the PRIMARY payer for services not covered by Medicare |
| TRICARE Claims | participating providers file claims on behalf of patients with the contractor for their region |
| TRICARE Claims | submitted to the regional contractor based on the patient's home address, not the location of the facility |
| TRICARE Regional Contractors | contact information is located on its website: www.tricare.mil |
| TRICARE Claims | individuals file their own claims when they receive services from nonPAR providers, using DD Form 2642 |
| DD Form 2642 | Patient's Request for Medical Payment |
| DD Form 2642 | a copy of the itemized bill from the provider must be attached |
| TRICARE National Administration Regions | TRICARE East | TRICARE West | TRICARE Overseas (covers international claims) |
| TRICARE Claims | outpatient claims must be filed within ONE year of the date that the service was provided |
| TRICARE Claims | inpatient claims must be filed ONE year from the date of discharge |
| Program Integrity Office | oversees the fraud and abuse program for TRICARE |
| Program Integrity Office | works with the Defense Criminal Investigative Services |
| (DCIS) Defense Criminal Investigative Services | identifies and prosecutes TRICARE fraud and abuse cases |
| TRICARE Providers | are subject to a quality & utilization review similar to the process used by Medicare |
| (QIC) Qualified Independent Contractor | reviews TRICARE claims, documentation, & records |
| TRICARE Fraud or Abuse | can result in sanctions, exclusion from the TRICARE program, or civil or criminal penalties |
| CHAMPVA Claims | providers file most of these claims & submit them to the centralized processing center in Denver, CO |
| VA Form 10-7959A | CHAMPVA Claim Form |
| CHAMPVA Claim Form (VA Form 10-7959A) | used when beneficiaries are filing their own claims |
| CHAMPVA Claims | must ALWAYS be accompanied by an itemized bill from the provider |
| CHAMPVA Claims | must be filed within ONE year of the date of service or discharge |
Created by:
VA_MedCod3r