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Mod 6 Chapter 14
Tricare & CHAMPVA
| Question | Answer |
|---|---|
| CHAMPUS, the acronym for Civilian Health and Medical Program of the Uniformed Services is now called | Tricare |
| an active duty service member is known as what? | sponsor |
| once retired, the former member, or sponsor, is called what? | service retiree |
| an individual who qualifies for TRICARE is known as what? | a beneficiary |
| a system for verifying an individual's TRICARE eligibility is called what? | DEERS - Defense Enrollment Eligibility Reporting System |
| when a beneficiary needs to be hospitalized at a civilian hospital and lives within a local radius to a uniformed services medical facility, the patient needs what type of authorization? | Non-availability statement |
| TRICARE standard and CHAMPVA beneficiary ID cards are issued to who: | dependents under 10 years of age and dependents of retirees |
| programs that allow tricare standard beneficiaries to receive treatment, services, or supplies from civilian providers are called what? | coopertive care and partnership programs |
| for patients whose sponsor is a rank E4 and below, the TRICARE standard deductible for outpatient care is how much per pt? per family? | $50 per pt/ $100 per family |
| for patients whose sponsor is a rank of E5 and above, the tricare standard deductible for outpatient care is how much per pt? per family? | $150 per pt/ $300 per family |
| for Tricare standard, dependents of active duty members pay what percentage for outpatient services after the deductible has been met? what percentage does tricare pay? | dependents pay 20%; tricare pays 80% of the allowable |
| for retired members or their dependents on tricare standard, what is the deductible per person? per family? | $150 per person/ $300 per family |
| for tricare standard, retired members or their dependents pay what percentage for outpatient services after the deductible has been met? what % does tricare pay? | member or dependent pays 25%/tricare pays 75% of the allowable |
| a voluntary tricare HMO type of option is known as what? | TRICARE Prime |
| CHAMPVA is the acronym for what? | Civilian Health and Medical Program of the Veterans Administration; now known as the Dept. of Veteran Affairs |
| those individuals who service in the US armed forces, finish their service, and are honorably discharged are known as what? | veteran |
| CHAMPVA is not an insurance program but is considered as what? | service benefit program |
| who is entitle to CHAMPVA medical benefits? 3. spouse or unmarried child of individual who died in the line of duty while in active service | 1. spouse or unmarried child of a veteran with a total permenant disability resulting from a service related injury 2. spouse or unmarried child of a veteran who died from service related disability |
| the public law establishing a person's right to review and contest inaccuracies in personal medical records is known as what? | the privacy act of 1974 |
| an organization that contracts with the government to process TRICARE and CHAMPVA health insurance claims is known as what? | a fiscal intermediary |
| time limit for submitting a tricare standard or champva claim for outpatient service is what? for inpatient is what? | within 1 year from date of service for outpatient / within 1 ye3ar of discharge from hospital for inpatient |
| The TRICARE fiscal year is what? | begins Oct 1 and ends Sept. 30 |
| a health care professional who helps a patient who is under the TRICARE standard program obtain preauthorization for care is called what? | health care finder (HCF) |
| TRICARE standard beneficiaries pay a certain amount each year for the cost share and annual deductible which is known as what? | catastrophic cap |
| to qualify for TRICARE for Life, a beneficiary must be what? | 1. a TRICARE beneficiary 2. elegible for Medicare Part A 3. enrolled in Medicare Part B |
| the time limit for filing a TRICARE standard claim is what? | within 1 year from the date a service is provided |
| true or false: medically necessary treatment needed for immediate illness or injury that would not result in further disability or death if not treated immediately is known as urgent care | true |
| true or false: TRICARE beneficiaries who use nonauthorized providers and receive medical services may be responsible for their entire bill | true |
| true or false: when an individual on TRICARE Prime shows you their ID card, it guarantees TRICARE eligibility | false |
| true or false: TRICARE Prime Remote is a program designed for military retirees and their families | false |
| true or false: beneficiaries of gthe CHAMPVA program have complete freedom of choice in selecting their civilian health care providers | true |
| Patient with other insurance besides TRICARE - whom is billed first? | other insurance first; tricare usually the 2nd payer when patient has other insurance |
| patient under age 65 with TRICARE and also has Medicare Part A & B - whom is billed first? | Medicare; tricare always 2nd payer to people under 65 that have Medicare |
| person with CHAMPVA and Medicaid - whom is billed first? | CHAMPVA - Medicaid is always the last billed |
| Name the 3 choices for TRICARE | 1. TRICARE standard (fee-for-service cost sharing option) 2. TRICARE extra (PPO type option) 3. TRICARE Prime (HMO option) |
| what does CHAMPUS stand for? | Civilian Health and Medical Program for the Uniformed Services |
| an individual who qualifies for TRICARE is known as what? | a beneficiary |
| active duty service member is called what? | sponsor |
| a person retired from a career in the military is known as what? | service retiree or military retiree |
| all TRICARE-eligible persons must be enrolled in what computerized database? | DEERS - Defense Enrollment Eligibility Reporting System - to verify benificiary eligibility |
| nonavailability statement | a certification from a military hospital stating that it cannot provide the care needed; if zip code falls within 40 mile radius of MTF must get this certification. |
| Military treatment facility (MTF) | a uniformed services hospital |
| catchment area | a specific geographic region defined by zip codes & based on an area of approx. 40 miles in radius surrounding each U.S. MTF. if zip falls outside the MTF service area then an NAS is not needed to seek civilian health care |
| what is the TRICARE fiscal year? | begins Oct 1 and ends Sept. 30 |
| catastrophic cap | amount beneficiary pays each year for the cost share and annual deductible; after this cap is reached TRICARE pays 100% of allowable charges for rest of the year. |
| true or false: nonparticipating providers may choose to accept TRICARE assignment on a case-by-case basis | true |
| true or false: assignment should always be accepted when the service member is transferring within 6 months because this avoids collection problems | true |
| TRICARE extra | a PPO in which the individual does not have to enroll or pay an annual fee; an unenrolled person automatically becomes TRICARE extra when care is rendered by a network provider; care by nonpar covered by TRICARE standard |
| TRICARE Prime | HMO type option; participation is optional but must enroll for a minimum of 1 year; active duty members automatically enrolled in this option and not eligible for standard or extra |
| primary care manager | physician that manages all aspects of the patient's health care under TRICARE Prime |
| TRICARE for life | a sypplementary payer to Medicare for uniformed service retirees, their spouses & survivors age 65 or older. |
| to qualify for TRICARE for life beneficiaries must be eligible for what and enrolled in what? | eligible for Medicare part A and enrolled in Medicare part B |
| true or false: beneficiaries who qualify for TFL need a TRICARE enrollment care | False - only need Medicare care and military ID card |
| TRICARE prime remote (TPR) | program designed for active duty service members who work and live more than 50 miles or 1 hour from a MTF; benefits are similar to TRICARE prime |
| what is CHAMPVA? | Civilian Health and Medical Program of the Veteran Administration - known as dept. of veteran affairs |
| Is CHAMPVA an insurance program or service benefit program? | service benefit program - there are no premiums |
| claims must be filed within what time frame from the date a service is provided? | 1 year |
| claims must be filed within what time frame from the patient's date of discharge from an inpatient facility? | 1 year |
| Who administers the TRICARE program | the Dept. of defense |
| where are TRICARE claims submitted? | to the TRICARE claims office nearest to the residence of the military sponsor |
| true or false: the beneficiary does not file any claim forms under TRICARE extra or TRICARE prime when using network providers. | true |
| providers must electronically submit claims to who for services given to TRICARE extra and prime members. | TRICARE subcontractors |
| true or false: primary care service claims are processed and paid under TRICARE prime remote without a referral or preauthorization from a network or nonnetwork provider | true |
| Claims for patients on active duty must be received by who and how? | must not be electronically submitted and must be received by the specific branch of service |
| claims for active duty patients are submitted to who? | Palmetto Government Benefits Administrators |
| Tricare/champva us usually the second payer when a beneficiary is enrolled in what? | other health insurance or civilian plan, or belongs to an HMO or PPO. |
| if a beneficiary has Medicaid which coverage is billed last? | Medicaid |
| true or false: tricare is considered secondary to Medicare for persons under age 65 who have Medicare Part A as a result of disability & who have enrolled in Medicare part B | true |
| true or false: champva is secondary payer to Medicare for persons under age 65 who are enrolled in MCare part A&B | true |
| for third-party involvement due to auto accident or injury, what are two options for reimbursement? | 1. statement of personal injury, possible third party liability must be send with claim 2. submit claim exclusively to the third party liability carrier |
| summary payment voucher | details the payment of a claim |
Created by:
mpeoples