chapter 14 tricare and veterans’ health care
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Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1
Chapter 14
TRICARE and Veterans’ Health Care
Insurance Handbook for the Medical Office
13th edition
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved
TRICARE and Veterans Health Administration (CHAMPVA) Overview
1. Define pertinent TRICARE and Veterans Health Administration (CHAMPVA) terminology and abbreviations.
2. State who is eligible for TRICARE.3. List the circumstances when a nonavailability
statement is necessary.4. Explain the benefits of the TRICARE Standard
government program.5. State the TRICARE fiscal year.
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Lesson 14.1
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TRICARE and Veterans Health Administration (CHAMPVA) Overview
(cont’d)6. Name authorized providers who may treat a
TRICARE Standard patient.7. List the managed care features of TRICARE
Extra.8. State the managed care features of TRICARE
Prime.9. Explain TRICARE for Life benefits and those
who are eligible individuals.10. Name individuals eligible for TRICARE Plus.
3
Lesson 14.1
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TRICARE and Veterans Health Administration (CHAMPVA) Overview
(cont’d)11. Define individuals who may enroll in the TRICARE
Prime Remote program.12. Identify individuals who are eligible for the
Veterans Health Administration program (CHAMPVA).
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Lesson 14.1
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History of TRICARE
1966 CHAMPUS created (Civilian Health and Medical Program of the Uniformed Services)
1988 CHAMPUS Prime created as managed care plan option
1994 TRICARE became new title with 3 options: TRICARE Standard (fee-for-service) TRICARE Extra (PPO) TRICARE Prime (HMO)
2005 TRICARE consolidated into 3 regions
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TRICARE Programs
Eligibility Active duty service members (Prime
Remote) Eligible family members of active duty
service members Military retirees and eligible family
members Surviving eligible family members of
deceased active or retired service members Wards and preadoptive children Former spouses of active or retired service
members (must meet requirements) 6
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TRICARE Programs
Eligibility Family members of active duty service
members who were court-martialed or separated from their families for abuse
Abused spouses/children of service members Spouses/children of NATO nation
representatives Reservists and National Guard members
activated for 30 or more consecutive days Disabled beneficiaries under 65 years with
Medicare A & B Medicare-eligible beneficiaries in TRICARE for
Life 7
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TRICARE Programs
Defense Enrollment Eligibility Reporting System (DEERS) A computerized database system that all
TRICARE-eligible persons must be enrolled in
Nonavailability Statement (NAS) Certification from a military hospital when it
cannot provide care 2003 not needed for individuals in the
catchment area about an MTF
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TRICARE Standard
ID card required for all dependents over age 10 Not limited to using network providers for
medically or psychologically necessary services
Care usually sought at military hospital closest to home or identified through Health Care Finder (HCF)
Authorized providers must be used Preauthorization necessary for specialty care,
hospitalization, and certain procedures Deductibles and copayments apply
9
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TRICARE Extra
ID card required for all dependents over age 10
PPO option Network provider must be used Preauthorization necessary and
coordinated by Health Care Finder for specialty care, hospitalization, and certain procedures
Deductibles and copayments apply
10
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TRICARE Prime
Voluntary HMO option with annual fee required
Minimum 12 months participation required PCM coordinates all care except emergencies Referral from Health Care Finder required for
use of non-network provider Preauthorization may be necessary for some
specialty care, hospitalization, and certain procedures
Copayments and deductibles apply
11
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TRICARE Reserve Select
Available to qualified members of the Selected Reserve and their families
Similar to TRICARE Standard and Extra
12
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TRICARE for Life
Supplementary payer to Medicare No separate ID card No referral or preauthorization
requirements Payment is based on the services
provided and coverage by both Medicare and TRICARE
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TRICARE Plus
ID card and DEERS enrollment required Enrollees use the military treatment
facility as source of primary care Same benefits as TRICARE Prime when
using military treatment facility Access to specialty providers at military
treatment facility not guaranteed
14
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TRICARE Prime Remote Program
For active duty service members only Must live at least 50 miles from military
treatment facility Same benefits as TRICARE Prime No prior authorization for routine primary
care PCM coordinates all care except
emergencies No out-of-pocket expenses for in-network
services 15
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Supplemental Health Care Program
For active duty service members and other designated patients
Enables beneficiaries to be referred to civilian providers when needed
No deductibles or copayments if military treatment facility initiates referral
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TRICARE Hospice Program
Based on Medicare hospice program Life expectancy is 6 months or less Cannot also receive care under TRICARE
basic programs
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TRICARE and HMO Coverage
Provider must meet TRICARE provider certification standards
Type of care must be a TRICARE benefit and medically necessary
TRICARE does not pay for emergency services received outside the normal HMO service area
18
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Veterans Health Administration Program
1973 CHAMPVA created (Civilian Health and Medical Program of the Veterans Administration)
Now called the Veterans Health Administration
For spouses and dependent children of veterans with total, permanent disability
Must not be eligible for TRICARE Standard or Medicare A
Service benefit program
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Veterans Health Administration Program
ID card required for all dependents over age 10
Benefits similar to TRICARE Standard for dependents of retired and deceased military personnel
Freedom of choice in selecting civilian providers
Preauthorization needed for some services
20
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Claims Procedure
TRICARE Standard administered by DOD (Department of Defense)
Veterans Health Administration program administered by VA (Veterans Administration)
Claims must be: Billed on CMS-1500 (02-12) form or
electronically Submitted to the correct fiscal intermediary Filed within 1 year of service
21
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Claims Procedure
TRICARE Extra and TRICARE Prime No claim forms filed by beneficiary if care
provided is in-network Providers must:
Use CMS-1500 (02-12) form or electronic system to submit claims
Submit claims to correct subcontractor File within 1 year of service
22
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Claims Procedure
TRICARE Prime Remote and Supplemental Health Care Program
Outpatient services are submitted with CMS-1500 (02-12) form or electronically
POS option and NAS requirement do not apply
Claims must be filed within 1 year of service
23
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Claims Procedure
TRICARE for Life Civilian provider submits claims to
Medicare to pay first and then the claim is submitted to TRICARE for the remainder
24
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Claims Procedure
TRICARE/Veterans Health Administration and Other Insurance TRICARE/Veterans Health Administration
usually pay as secondary payer if beneficiary has other health insurance
EOB copy from primary carrier should be attached to the completed CMS-1500 (02-12) claim form
Include copy of the physician’s complete itemized statement
Claim should then be sent to the local claims processor (fiscal intermediary)
25
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Claims Procedure
For Medicaid: TRICARE/Veterans Health Administration is
primary For Medicare:
TRICARE is secondary, if under 65 with Part A & Part B
Veterans Health Administration is secondary, if under 65 with Part A & Part B
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Claims Procedure
Coordination of benefits Needed for situations with dual coverage so
there is no duplication of benefits paid TRICARE pays the lower of:
Amount of TRICARE allowable charges after other plan has paid benefits
Amount TRICARE would have paid as primary
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Claims Procedure
For third-party liability: TRICARE form DD 2527 is submitted with
regular claim form CMS-1500 (08-05) Provider can submit claims only to third-
party liability carrier for reimbursement If ICD-9-CM code between 800–999, claims
processor may request completion of form DD 2527
28
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Claims Procedure
For Workers’ Compensation: TRICARE/CHAMPVA billed when workers’
compensation benefits are exhausted Beneficiary with work-related injury or
illness must file the claim with the workers’ compensation carrier
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After Claim Submission
TRICARE For each claim a summary payment voucher
is issued to the patient
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After Claim Submission
Veterans Health Administration For each claim an explanation of benefits
document is issued to the patient summarizing actions taken
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