TRICARE and CHAMPVA: Revenue Cycle and Program Overview

1. TRICARE and CHAMPVA CHAPTER 11

2. See the ten-step Revenue Cycle figure (at the beginning of the chapter). • This chapter focuses on the following step: • Preregister patients • Establish financial responsibility • Check in patients • Review coding compliance • Review billing compliance • Check out patients • Prepare and transmit claims • Monitor payer adjudication • Generate patient statements • Follow up payments and collections Chapter 11: TRICARE and CHAMPVA

3. When you finish this chapter, you should be able to: 11.1 Discuss the eligibility requirements for TRICARE. 11.2 Compare TRICARE participating and nonparticipating providers. 11.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ. 11.4 Discuss the TRICARE for Life program. 11.5 Discuss the eligibility requirements for CHAMPVA. 11.6 Prepare accurate TRICARE and CHAMPVA claims. Learning Outcomes

4. Key Terms (1) • catastrophic cap • catchment area • Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) • Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) • cost-share • Defense Enrollment Eligibility Reporting System (DEERS) • Military Treatment Facility (MTF) • nonavailability statement (NAS) • Primary Care Manager (PCM) • sponsor • TRICARE

5. TRICARE Extra TRICARE for Life TRICARE Prime TRICARE Prime Remote TRICARE Reserve Select (TRS) TRICARE Standard TRICARE Young Adult (TYA) Key Terms (2)

6. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) • Now the TRICARE program • Not to be confused with CHAMPVA • TRICARE—government health program serving dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members 11.1 The TRICARE Program (1)

7. TRICARE eligibility • Members of the Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration and their families • Reserve and National Guard personnel become eligible when on active duty for more than thirty consecutive days or on retirement from reserve status at age sixty 11.1 The TRICARE Program (2)

8. Sponsor—uniformed service member in a family qualified for TRICARE or CHAMPVA Defense Enrollment Eligibility Reporting System (DEERS)—worldwide database of TRICARE and CHAMPVA beneficiaries At every visit: Photocopy or scan both sides of the individual’s military ID card and check the expiration date to confirm that coverage is still valid 11.1 The TRICARE Program (3)

9. Participating providers: • Accept the TRICARE allowable charge as payment in full for services • Are paid based on the Medicare Fee Schedule • Are required to file claims on behalf of patients • May appeal a decision • Nonparticipating providers: • May not charge more than 115 percent of the allowable charge • May not appeal a decision • TRICARE sends claim payment to patient (not provider) 11.2 Provider Participation and Nonparticipation (1)

10. Patients: • TRICARE pays its portion of the allowable charges directly to the patient • Patient responsible for paying the provider • Cost-share—term for coinsurance for a TRICARE or CHAMPVA beneficiary 11.2 Provider Participation and Nonparticipation (2)

11. TRICARE Standard—fee-for-service health plan • Replaced the old CHAMPUS program • Medical expenses are shared between TRICARE and the beneficiary • Most enrollees pay annual deductibles and cost-share percentages • Covered services examples: outpatient/inpatient care, diagnostic testing, lab/pathology services, drugs • Noncovered services examples: cosmetic surgery, routine physical examinations • Military Treatment Facility (MTF)—provider of medical services for members and dependents of the uniformed services 11.3 TRICARE Plans (1)

12. Catastrophic cap—maximum annual amount a TRICARE beneficiary must pay for deductible and cost-share for medical services • Catchment area—geographic area served by a hospital, clinic, or dental clinic • Nonavailability statement (NAS)—form required when a TRICARE member seeks medical services outside an MTF • Electronic document • TRICARE standard only requires NAS for outpatient prenatal and postpartum maternity care • Preauthorization may still be required 11.3 TRICARE Plans (2)

13. TRICARE Prime—basic managed care health plan • After enrollment, each individual is assigned a Primary Care Manager (PCM)—a provider who coordinates and manages the care of TRICARE beneficiaries • In addition to benefits offered by TRICARE Standard, Prime offers additional preventive care, including routine physical examinations • No deductible and no payment required for active-duty family members 11.3 TRICARE Plans (3)

14. TRICARE Prime Remote—health plan for TRICARE beneficiaries on remote assignment • No-cost healthcare through civilian providers • TRICARE Extra—managed care health plan that offers a network of civilian providers and facilities • Must receive healthcare services from a network of healthcare professionals 11.3 TRICARE Plans (4)

15. TRICARE Reserve Select (TRS)—TRICARE coverage for reservists and their covered family members • Premium-based health plan available for purchase • TRICARE Young Adult (TYA)—plan that restores TRICARE coverage to adult children up to age twenty-six after they lose their TRICARE coverage due to age • Premium-based health plan available for purchase 11.3 TRICARE Plans (5)

16. TRICARE for Life—program for beneficiaries who are both Medicare and TRICARE eligible • Individuals age sixty-five and over who are eligible for both Medicare and TRICARE may continue to receive healthcare at military treatment facilities • Must be enrolled in Medicare Parts A and B • Submit claim to primary insurance first (TRICARE for Life is a secondary payer) • Treatment at a civilian network facility requires a copay 11.4 TRICARE and Other Insurance Plans

17. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) • Program that shares healthcare costs for families of veterans with 100 percent service-connected disabilities and the surviving spouses and children of veterans who die from service-connected disabilities • Healthcare expenses are shared between the Department of Veterans Affairs (VA) and the beneficiary • Must check the CHAMPVA Authorization Card (called an “A-Card”) and photocopy front and back for EHR • Covers most necessary medical services • CHAMPVA is usually the secondary payer 11.5 CHAMPVA (1)

18. CHAMPVA for Life • Extends CHAMPVA benefits to spouses or dependents who are age sixty-five and over • Similar to TRICARE for Life • Must be enrolled in Medicare Parts A and B 11.5 CHAMPVA (2)

19. HIPAA and TRICARE • The MHS and TRICARE health plan are required to comply with the HIPAA Privacy Policy, Electronic Health Care Transactions and Code Sets requirements, and the Security Rule • TRICARE Fraud and Abuse • Program Integrity Office oversees fraud and abuse • OIG identifies and prosecutes cases • QIC performs quality and utilization review similar to Medicare • Fraud example: Changing date of service • Abuse example: Failing to maintain adequate financial records 11.6 Filing Claims (1)

20. Participating providers file TRICARE claims with the contractor for the region on behalf of patients • Individuals file their own TRICARE claims when services are received from nonparticipating providers • CHAMPVA claims • Most claims are filed by providers and submitted to the centralized CHAMPVA claims processing center • Claims must be filed within one year of the date of service or discharge • CHAMPVA pays equivalent to Medicare rates • CHAMPVA Maximum Allowable Charge (CMAC)—maximum amount CHAMPVA will pay for a service or procedure *end of presentation* 11.6 Filing Claims (2)