Chapter 16

1. Chapter 16 TRICARE

2. Introduction • Health care program for: • Active military and their families • CHAMPUS retirees and their families • Survivors of members of the uniformed services

3. 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

4. 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

5. 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

6. 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

7. CHAMPVA • Health Administration Center, administers the CHAMPVA program by: • Processing applications • Determining eligibility • Authorizing benefits • Processing claims

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. Features of TRICARE Standard • Enrollment not required • TRICARE Extra can be used • Space-available care in MTFs is a provision

16. 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

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

18. 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.

19. 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.

20. 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.

21. 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.

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

23. Special Handling • TRICARE Mental health Treatment Reposts should be submitted to TRICARE every 30 days for inpatient cases and on or about the 48th outpatient visit and every 24th visit thereafter.

24. 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

25. 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

26. 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

27. 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

28. Special Handling • Contact regional contractor’s representative • If there has been no response within 45 days of filling the claim.

29. Special Handling • For hospice claims • Enter “hospice claims” on the envelope to ensure the claim arrives at the regional carrier’s hospice desk