1. 15
TRICARE Medical Billing

2. Key Terms and Abbreviations
beneficiary
catastrophic cap
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
cost share

3. Key Terms and Abbreviations
Defense Enrollment Eligibility Reporting System (DEERS)
military treatment facility (MTF)
nonavailablilty statement (NAS)
Palmetto Government Benefits Administrators (PGBA)
primary care manager (PCM)
sponsor

4. Key Terms and Abbreviations
TRICARE
TRICARE Extra
TRICARE for Life (TFL)
TRICARE Prime
TRICARE Prime Remote (TPR)
TRICARE Reserve Retired (TRR)
TRICARE Reserve Select (TRS)
TRICARE Senior Prime

5. Key Terms and Abbreviations
TRICARE Standard
TRICARE Young Adult
Wisconsin Physicians Service (WPS)
TRICARE Young Adult (TYA)
Wisconsin Physicians Services (WPS)

6. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
15.1: Determine eligibility for TRICARE participants.
15.2: Identify different types of benefits available to veterans and their family members.

7. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
15.3: Submit claims to TRICARE using the CMS-1500 and the UB-40 (CMS-1450) forms.

8. 15.1: Determine eligibility for TRICARE participants.
TRICARE Eligibility
15.1: Determine eligibility for TRICARE participants.

9. 15.1: TRICARE Eligibility Determining TRICARE Eligibility
TRICARE is the U.S. Department of Defense medical entitlement program for eligible armed services beneficiaries: active-duty service members, retirees, family members, and survivors.

10. 15.1: TRICARE Eligibility Determining TRICARE Eligibility
An individual who qualifies for TRICARE is known as a beneficiary.
The active-duty service member is known as the sponsor.

11. 15.1: TRICARE Eligibility Determining TRICARE Eligibility
To be eligible for TRICARE, all armed services sponsors and family members must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS).

12. 15.1: TRICARE Eligibility Determining TRICARE Eligibility
At age 65, TRICARE beneficiaries become eligible for Medicare, and Medicare becomes the primary payer and TRICARE becomes the secondary coverage.

13. 15.1: TRICARE Eligibility Determining TRICARE Eligibility
No further family benefits are provided to service members who leave the armed services after 4 to 6 years of service.
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) beneficiaries are not eligible for TRICARE.

14. Benefits for Veterans and Their Family Members
15.2: Identify different types of benefits available to veterans and their family members.

15. 15.2: Benefits for Veterans and Their Family Members
Health Insurance Benefits for Veterans and Their Family Members
Certain veterans (such as retirees) and family members may be eligible for coverage through TRICARE or the Department of Veterans Affairs.

16. 15.2: Benefits for Veterans and Their Family Members
Health Insurance Benefits for Veterans and Their Family Members
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides healthcare coverage for veterans with 100% service-related disabilities and their families.

17. Submitting Claims to TRICARE
15.3: Submit claims to TRICARE using the CMS-1500 and the UB-40 (CMS-1450) forms.

18. 15.3: Submitting Claims to TRICARE
Filing TRICARE Claims
TRICARE claims must be submitted within 1 year of the date of service or date of patient discharge.
Claims can only be submitted by authorized providers who have been approved through the TRICARE credentialing process.

19. 15.3: Submitting Claims to TRICARE
Filing TRICARE Claims
Most TRICARE claims are filed electronically; otherwise, the CMS-1500 form is used for medical services, and the UB-04 form is used for hospital and other inpatient facility services.

20. 15.3: Submitting Claims to TRICARE
Filing TRICARE Claims
If paper claims are filed, the mailing address depends upon the provider’s geographic location.
Healthcare Common Procedure Coding System (HCPCS) codes are used to report services and supplies.
ICD-9-CM (or ICD-10-CM) codes are used to report diagnoses.

21. 15.3: Submitting Claims to TRICARE
Figure Information that must appear on submitted TRICARE claim forms>