Chapter 14 TRICARE and CHAMPVA Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2 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

3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. TRICARE 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)

4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. TRICARE Eligibility (cont’d.)  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 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

5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. TRICARE  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

6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. TRICARE Prime Remote  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

12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. TRICARE Hospice Program  Based on Medicare hospice program  Life expectancy is 6 months or less  Cannot also receive care under TRICARE basic programs

14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. CHAMPVA Program  1973 CHAMPVA created (Civilian Health and Medical Program of the Veterans 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 – not an insurance program

16Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. CHAMPVA Program (cont’d.)  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

17Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. HIPAA Compliance  Privacy Act of 1974  Individual has right to review own medical records maintained by a federal healthcare facility  If personal information is requested, the individual must be informed of purpose and use of the information

18Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. HIPAA Compliance (cont’d.)  Computer Matching and Privacy Protection Act of 1988  Government can verify information via computer matches  Patients must be made aware by providers of this information and how medical data can be disclosed

19Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure  TRICARE Standard administered by DOD (Department of Defense)  CHAMPVA administered by VA (Veterans Administration)  Claims must be:  Billed on CMS-1500 (08-05) form or electronically  Submitted to the correct fiscal intermediary  Filed within 1 year of service

20Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure (cont’d.)  TRICARE Extra and TRICARE Prime  No claim forms filed by beneficiary if care provided is in-network.  Providers must:  Use CMS-1500 (08-05) form or electronic system to submit claims  Submit claims to correct subcontractor  File within 1 year of service

21Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure (cont’d.)  TRICARE Prime Remote and Supplemental Health Care Program  Outpatient services are submitted with CMS-1500 (08-05) form or electronically  POS option and NAS requirement do not apply  Claims must be filed within 1 year of service

22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

23Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure (cont’d.)  TRICARE/CHAMPVA and Other Insurance  TRICARE/CHAMPVA usually pay as secondary payer if beneficiary has other health insurance  EOB copy from primary carrier should be attached to the completed CMS-1500 (08-05) claim form  Include copy of the physician’s complete itemized statement  Claim should then be sent to the local claims processor (fiscal intermediary)

24Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure (cont’d.)  For Medicaid:  TRICARE/CHAMPVA is primary  For Medicare:  TRICARE is secondary, if under 65 with Part A & Part B  CHAMPVA is secondary, if under 65 with Part A & Part B

25Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure (cont’d.)  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

26Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure (cont’d.)  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

27Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claims Procedure (cont’d.)  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

28Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. After Claim Submission  TRICARE  For each claim a summary payment voucher is issued to the patient  CHAMPVA  For each claim an explanation of benefits document is issued to the patient summarizing actions taken

29Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Quality Assurance  Quality assurance program  Continuous assessment of care, inpatient and outpatient  Grievance process for members and for providers  Providers notified if quality issue is identified and corrective recommendations are given

30Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claim Inquiries and Appeals  Appeal process  For providers to request that a denial of coverage be reconsidered  Or providers to request that amount paid on a submitted claim be reconsidered