Chapter 16 TRICARE Copyright 2008 Delmar Learning All

Introduction • Health care program for: – Active military and their families – CHAMPUS

TRICARE • New program – Managed health care that joins health care resources to

Program Integrity Office • If one of these conditions applies to a authorized provider

Program Integrity Office • Fraud or abuse under TRICARE – Exclusion or suspension by

CHAMPVA • Civilian Health and Medical Program of the Department of Veterans Affairs –

CHAMPVA • Health Administration Center, administers the CHAMPVA program by: – Processing applications –

Eligibility for CHAMPVA • Spouse or child of the veteran who has been rated

Eligibility for CHAMPVA • Surviving spouse or child of a veteran who, at the

TRICARE Options • Prime – Military treatment facilities are the principal source of health

Features of TRICARE Prime • Guaranteed access to timely medical care • Priority for

Features of TRICARE Prime • Requires enrollment for one year • Retired military pay

Features of TRICARE Extra • Choice of any physician in the network • Less

Features of TRICARE Standard • Greatest flexibility in selecting health care providers • Most

Features of TRICARE Standard • Enrollment not required • TRICARE Extra can be used

Dual Medicare and TRICARE Eligibility • Beneficiaries eligible for Medicare Part A on the

Dual Medicare and TRICARE Eligibility • Family members of active-duty service members who are

Dual Medicare and TRICARE Eligibility • Beneficiaries under age 65 who are entitled to

TRICARE Supplemental Plans • Insurance policies offered by most military associations and some private

Special Handling 1. Always make a copy of the front and back of the

Special Handling 3. Ensure that the patient has obtained the necessary nonavailability statement for

Special Handling 4. Nonemergency inpatient mental health cases require preauthorization, and a nonavailability statement

Special Handling • TRICARE Mental health Treatment Reposts should be submitted to TRICARE every

Special Handling • Report should cover all following points: – – – Date treatment

Special Handling • Report should cover all following points: – Type and frequency of

Special Handling • A personal injury possible third-party liability statement is required for all

Special Handling • When filling a claim for services that fall under the special

Special Handling • Contact regional contractor’s representative – If there has been no response

Special Handling • For hospice claims – Enter “hospice claims” on the envelope to

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Introduction • Health care program for: – Active military and their families – CHAMPUS retirees and their families – Survivors of members of the uniformed services 2 Copyright © 2008 Delmar Learning. All rights reserved.

TRICARE • New program – Managed health care that joins health care resources to our uniformed services – Supplement programs with civilian health care – Provides access to high-quality service while supporting military operations 3 Copyright © 2008 Delmar Learning. All rights reserved.

Program Integrity Office • If one of these conditions applies to a authorized provider they can be excluded from the program: – Criminal conviction – Civil judgment involving fraud 4 Copyright © 2008 Delmar Learning. All rights reserved.

Program Integrity Office • Fraud or abuse under TRICARE – Exclusion or suspension by another federal, state, or local government agency – Participation in a conflict-of-interest situation – When it is in the best interest of the TRICARE program or its beneficiaries 5 Copyright © 2008 Delmar Learning. All rights reserved.

CHAMPVA • Civilian Health and Medical Program of the Department of Veterans Affairs – Wide-ranging health care program contribute to the costs of covered health care services and materials with eligible beneficiaries 6 Copyright © 2008 Delmar Learning. All rights reserved.

CHAMPVA • Health Administration Center, administers the CHAMPVA program by: – Processing applications – Determining eligibility – Authorizing benefits – Processing claims 7 Copyright © 2008 Delmar Learning. All rights reserved.

Eligibility for CHAMPVA • Spouse or child of the veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office. • Surviving spouse or child of a veteran who died from a VA-rated service connected disability. 8 Copyright © 2008 Delmar Learning. All rights reserved.

Eligibility for CHAMPVA • Surviving spouse or child of a veteran who, at the time death, was rated as permanently and totally disabled as the result of a service-connected disability. • Surviving spouse or child of a military member who died in the line of duty. 9 Copyright © 2008 Delmar Learning. All rights reserved.

TRICARE Options • Prime – Military treatment facilities are the principal source of health care under this option • Extra – Preferred provider organization option that costs less then TRICARE Prime or Standard • Standard – Fee-for-service option 10 Copyright © 2008 Delmar Learning. All rights reserved.

Features of TRICARE Prime • Guaranteed access to timely medical care • Priority for care at military treatment facilities • Assignment of a primary care manager • Lowest cost option of the three TRICARE options 11 Copyright © 2008 Delmar Learning. All rights reserved.

Features of TRICARE Prime • Requires enrollment for one year • Retired military pay an annual enrollment fee • Care sought outside of TRICARE Prime network is costly • May be unavailable in some TRICARE regions 12 Copyright © 2008 Delmar Learning. All rights reserved.

Features of TRICARE Extra • Choice of any physician in the network • Less costly than TRICIARE Standard • May be more expensive than TRICARE Prime • Annual enrollment is not required • Lower priority for care provided at MTFs 13 Copyright © 2008 Delmar Learning. All rights reserved.

Features of TRICARE Standard • Greatest flexibility in selecting health care providers • Most convenient when traveling or away from home • Potentially most expensive of all options 14 Copyright © 2008 Delmar Learning. All rights reserved.

Dual Medicare and TRICARE Eligibility • Beneficiaries eligible for Medicare Part A on the basis of age and who also purchase Medicare Part B coverage continue to be eligible for TRICARE • TRICARE is secondary to Medicare 16 Copyright © 2008 Delmar Learning. All rights reserved.

Dual Medicare and TRICARE Eligibility • Family members of active-duty service members who are eligible for Medicare also eligible for TRCIARE Prime, Extra, or Standard, whether or not they purchase Medicare Part B. 17 Copyright © 2008 Delmar Learning. All rights reserved.

Dual Medicare and TRICARE Eligibility • Beneficiaries under age 65 who are entitled to Medicare Part A because of disability or end-stage renal disease and who have purchased Medicare Part B are also eligible for TRICARE Prime, Extra, or Standard until they turn 65. 18 Copyright © 2008 Delmar Learning. All rights reserved.

TRICARE Supplemental Plans • Insurance policies offered by most military associations and some private firms. • Reimburse patients for medical expenses that must be paid after TRICARE reimburses government’s share of health care costs. 19 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling 1. Always make a copy of the front and back of the patient’s ID card. 2. Check to determine whether the patient knows the date of his or her next transfer. 20 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling 3. Ensure that the patient has obtained the necessary nonavailability statement for all nonemergency civilian inpatient care and specified outpatient surgeries if the sponsor lives within a catchment area. 21 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling • TRICARE Mental health Treatment Reposts should be submitted to TRICARE every 30 days for inpatient cases and on or about the 48 th outpatient visit and every 24 th visit thereafter. 23 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling • Report should cover all following points: – – – Date treatment began Age, sex, and marital status of patient Diagnosis and DSM axis information Presenting symptoms Historical data Prior treatment episodes 24 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling • Report should cover all following points: – Type and frequency of therapy – Explanation of any deviation from standard treatment for the diagnosis – Mental status and psychological testing – Progress of patient – Physical examination and/or pertinent laboratory date – Future plans and treatment goals 25 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling • A personal injury possible third-party liability statement is required for all injuries that have been assigned ICD-9 codes in the 800 to 959 range. – Do not forget the E-code for the cause 26 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling • When filling a claim for services that fall under the special handicap benefits: – Enter Dependent Disability Program at the top of the claim 27 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handling • For hospice claims – Enter “hospice claims” on the envelope to ensure the claim arrives at the regional carrier’s hospice desk 29 Copyright © 2008 Delmar Learning. All rights reserved.