TRICARE
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| CHAMPUS | TRICARE was originally called
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| active duty members | provides medical care for families of
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| West, North, South | There are 3 TRICARE regions in the U.S.
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| any of the 7 uniformed services ( Air Force, Army, Coast Guard, Marine Corps, National Oceanic & Atmospheric Administration, Navy, Public Health Service) | Eligible members include
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| the patient's SS# | ID # is
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| Military Health Services System (MHSS) | the healthcare system of the U.S. military service
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| if a non-participating provider
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| 115% | Physicians can not charge more than __________ of the allowable charge
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| TRICARE contractors | Claims are submitted to
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| 1 year | timely filing for TRICARE is
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| MTF (Military Treatment Facility) | facility who provides care to eligible TRICARE beneficiaries
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| NAS (Non-Availability Statement) | electronic document required if there is no facility nearby
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| Healthcare finders | RN or PA who assists in obtaining preauthorization & referrals in a military treatment facility
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| TMA (TRICARE Management Activity) | office responsible for surveillance of fraud & abuse activities
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| CHAMPVA | Civilian health & medical program of the department of veterans affairs
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| 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
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| MEDICAID & supplemental | Secondary except for
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| TRICARE Prime, TRICARE Remote, TRICARE For Life, TRICARE Extra, TRICARE Standard, TRICARE Reserve | 6 TRICARE plans
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| 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
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| PCM (Primary Care Manager) | provider who manages the care of TRICARE beneficiaries
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| TRICARE Remote | service members & their families on assignment are provided services at no cost
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| 50 | must live & work no more than _____ miles from the nearest facility
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| 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
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| 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
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| TRICARE Reserve | reservists; dependents may be eligible after personal made active after 30+ days; National Guard; reserve duty eligibility
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| 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)
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| TRICARE for Life | 65+ dual MEDICARE; similar to MEDICARE but no HMO; Second to MEDICARE; must have Part A & B MEDICARE
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| payers of last resort | TRICARE & TRICARE for Life are __________ except when the patient also has MEDICAID
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| MEDICAID | TRICARE pays before
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| DEERS (Defense Enrollment Eligibility Reporting System) | a computer system that contains up-to-date defense department workforce personnel information; eligibility reporting system
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| fiscal year | runs from Oct 1 of one year to Sep 30 of the next
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| Program Integrity (PI) Office | responsible for the surveillance of fraud & abuse activities worldwide involving purchased care for beneficiaries in the military healthcare system
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| 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
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| PCM (Primary Care Manager) | a doctor assigned to a sponsor & is part of the TRICARE provider network
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| CHAMPUS (Civilian Health And Medical Program of the Uniformed Service) | now called TRICARE Standard; created in 1966; was implemented in 1967
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| deductible | amount for which the pt is financially responsible before an insurance policy provides coverage
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| 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
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| 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
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| 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
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| 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
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| fee schedule | allowable fee
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| case management | coordinates health care services
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| DD form 2642 | you file own claim with what form
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| no availability claim | what do you file if more than 50 miles from a facility
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| LA (lead agents) | commanders of selected MTFs (Military Treatment Facilities) are selected as __________ for the TRICARE regions
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| 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
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| TRICARE sponsors | uniformed service personnel who are either active duty, retired, or deceased
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| TRICARE beneficiaries | include sponsors & dependents of sponsors
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| 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
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| BSR (Beneficiary Services Representative) | provides information about using TRICARE, & assists with other matters affecting access to health care (e.g., appointment scheduling)
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| 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
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| 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
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| DCAOs (Debt Collection Assistance Officers) | located at MTFs to assist beneficiaries in resolving health care collection-related issues
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| critical pathway | the sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment
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| practice guidelines | decision-making tools used by providers to determine appropriate health care for specific clinical circumstances
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| discharge planning | assesses requirements so that arrangements can be made for the appropriate & timely discharge of patients from acute care or outpatient settings
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| CAC (Common Access Card) | an identification card issued by the Department of Defense (DoD); always make a copy of the front & back
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| 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
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| OHI (Other Health Insurance) | if the pt has __________, attach the remittance advice to the TRICARE claim
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Stacey_Gantt5
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