1. Chapter 14 TRICARE and CHAMPVA
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2. Learning Objectives
Define pertinent TRICARE and CHAMPVA terminology and abbreviations.
State who is eligible for TRICARE.
Explain the differences of the TRICARE Standard government program.
List the circumstances when a nonavailability statement is necessary.
State the TRICARE fiscal year.
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3. Learning Objectives (cont’d.)
Name authorized providers who may treat a TRICARE Standard patient.
List the managed care features of TRICARE Extra.
State the managed care features of TRICARE Prime.
Explain TRICARE for Life benefits and those who are eligible individuals.
Name individuals eligible for TRICARE Plus.
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4. Learning Objectives (cont’d.)
Define individuals who may enroll in the TRICARE Prime Remote program.
Identify individuals who are eligible for CHAMPVA.
Describe how to process a claim for an individual who is covered by the TRICARE Standard program.
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5. Chapter 14
Lesson 14.1
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6. 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
CHAMPUS was created to fund comprehensive health benefits for military members and families.
CHAMPUS Prime, a managed care plan, was created to control escalating medical costs. Military members and dependents then had a choice of plans.
When TRICARE was created in 1994, options were expanded to include three choices.
What are the three regions of TRICARE in the U.S.? (Region West, Region North, Region South)
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7. 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)
Eligible family members need to be specific requirements to be covered under TRICARE.
What is a “beneficiary?” (An individual who qualifies for TRICARE)
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8. 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 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
A person retired from the military is a service retiree and remains in TRICARE until age 65. Then the person can join the TRICARE for Life program if Medicare-eligible.
No further family benefits are provided if an active duty service person served 4-6 years and then chose to leave the armed services.
CHAMPVA beneficiaries are not eligible for TRICARE.
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9. 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
No claims can be processed without prior DEERS registration.
A TRICARE beneficiary can check status at nearest personnel office or call DEERS’ toll-free number.
What is an “MTF?” (Military treatment facility)
What is a “catchment area?” (A specific geographic region defined by ZIP codes; based on an area of approximately 40 miles in radius surrounding each U.S. MTF)
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10. 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
Uniformed Services identification card necessary. Front and back should be copied.
If there is no military service hospital in the area, patient may be directed elsewhere.
Partnership program is an option for treatment by select civilian providers of care in a military hospital or military providers in a civilian facility.
Use of nonauthorized provider may result in nonpayment.
Authorized providers include MD, DO, DDS, DDM, DPM, certified nurse midwives, clinical social workers, etc.
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11. 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
Network provider is the physician providing care at contracted rates.
There is no annual fee to enroll in this PPO option.
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12. 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
PCM is the primary care manager. It is a physician.
Enrollment card or ID card is necessary but does not guarantee eligibility. The TRICARE Prime card must also be copied for the file.
TRICARE will not pay anything on a claim if the HMO has specialty services/providers but the patient goes outside the HMO for treatment.
A health benefits advisor (HBA) should be called to determine if an NAS is needed for a procedure done outside a military treatment facility (MTF).
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13. Differentiate benefit levels for ADFM and RFMS. (See illustration)
Fig (p. 473)
Compare and contrast the benefits in each TRICARE program: Standard, Prime, and Extra. (See illustration)
Differentiate benefit levels for ADFM and RFMS. (See illustration)
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14. Note annual deductibles in each plan. (See illustration)
Fig (p. 474)
Compare and contrast the benefits in each TRICARE program: Standard, Prime, and Extra. (See illustration)
Note annual deductibles in each plan. (See illustration)
Note medication costs/pharmacy benefits. (See illustration)
Describe how immunizations are covered in each plan. (See illustration)
Explain how durable medical equipment is covered in each plan. (See illustration)
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15. 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
Originally introduced as TRICARE Senior Prime.
For retirees, including guard and reservists, and spouses/survivors age 65 or older.
Not for dependent parents or in-laws.
Pays secondary to Medicare when they turn 65; must be eligible for Medicare Parts A and B.
All services and supplies must be benefits of Medicare or TRICARE to be covered.
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16. 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
Open to persons for care in military facilities but not enrolled in TRICARE Prime or commercial HMO.
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17. 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
ADSM is Active Duty Service Member.
Family members are not eligible, but they can enroll in TRICARE Prime, Standard, or Extra.
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18. 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
Inpatients at MTF not TRICARE eligible, such as parents/in-laws, are covered.
Those receiving benefits are not responsible for any out-of-pocket expenses.
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19. Compare and contrast the benefits in TPR and SHCP. (See table)
Table 14.1 (p. 481)
Compare and contrast the benefits in TPR and SHCP. (See table)
Explain how these programs differ from TRICARE Prime. (See table)
Discuss the limitations of these programs. (See table)
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20. TRICARE Hospice Program
Based on Medicare hospice program
Life expectancy is 6 months or less
Cannot also receive care under TRICARE basic programs
If condition changes, hospice care option can be revoked and patient may again be eligible for TRICARE basic programs.
Guidelines should be followed to ensure that specific services are covered.
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21. 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
TRICARE will share the cost of covered services with an HMO if the listed criteria are met.
TRICA will not pay for services outside the HMO.
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22. 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
CHAMPVA is not an insurance program and there are no premiums. It is a service benefit program.
A veteran must have a total, permanent service-connected disability or must have died as a result of the injury/disability.
Disability must be permanent, not chronic and/or temporary.
Children are those unmarried under age 18, or under 23 if enrolled in an approved educational institution.
Discuss whether a 20-year-old, full-time college student qualifies if he/she marries.
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23. 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
Preauthorization is needed for dental services, hospice care, organ transplants, mental health treatment, and several other situations.
Discuss whether a widow who qualified for the CHAMPVA program continues to qualify if she remarries.
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24. Table 14.2 (p. 484)
CHAMPVA cost-share summary chart illustrates the benefit allocation for a beneficiary.
Describe what is meant by family services versus professional services listed under ambulatory services.
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25. Fig. 14-11 (pp. 493) in the textbook.
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26. Fig (pp. 492)
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27. Chapter 14
Lesson 14.2
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28. 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
See HIPAA Compliance Alert (p. 485) in the textbook.
Inaccuracies in medical records can be contested by the individual.
Direct access can be withheld if believed to be harmful to the individual.
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29. 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
Patients can access their own records with a written request.
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30. 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
Not subject to regulatory agencies that control the insurance business.
Fiscal intermediary is the claims processor or designated insurance contractor.
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31. 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
A contractor may grant exceptions from filing deadline, if there is a complete explanation of circumstances, all available documentation, and the denied claim is included with the request.
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32. 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
Claims for active duty patients must be sent to the specific branch of military service.
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33. 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
Medicare automatically forwards claims to TRICARE, after paying the first portion.
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34. 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)
Other insurance options include civilian health plan, HMO, PPO.
Two exceptions: plan administered under SS/Medicaid Title XIX and coverage designed to specifically supplement TRICARE benefits (e.g., Medigap).
EOB is the explanation of benefits.
Physician statement should include name, date of service, service description, fee, procedure codes, etc.
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35. 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
If under 65 with Medicare Part A, must be disabled to qualify for TRICARE.
Services covered by TRICARE but not covered by Medicare (e.g., prescriptions) are paid by TRICARE.
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36. 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
Beneficiary who refuses to claim benefits from other health insurance coverage risks denial of TRICARE benefits.
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37. 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
Third-party payer may result from auto accident or other injury.
If CMS-1500 (08-05) is filed without DD 2527, a request is made to complete it within 35 days, or the claim will be denied.
TRICARE may be able to recover costs from the third party, liable insurance carrier, or attorneys if involved.
ICD-9-CM codes are injury and poisoning, signaling the potential for litigation.
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38. 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
If the case is pending regarding whether it is truly a work-related injury or illness, then the claim might be sent to TRICARE/CHAMPVA for payment. The claims processor then files a lien for recovery after case settlement.
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39. 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
Summary payment voucher details the claim payment by the processor.
If provider receives direct payment, patient still receives copy of the voucher.
Explanation of benefits is issued to the patient even if provider is paid directly.
Exceptions to EOB issue by CHAMPVA are beneficiaries who receive DME or VA services from a CHAMPVA In-house Treatment Initiative (CITI).
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40. 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
Grievances can relate to the administrative process, the services provided, or the quality of care.
In TRICARE managed care programs, suspension or termination of a provider can result from noncompliance with corrective action plan or continued quality breaches.
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41. 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
Can the beneficiary appeal a claim? (No. Only a provider can appeal.)
Describe the process used by the beneficiary to appeal a claim. (See Ch. 9 for the appeals procedure.)
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