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A P U B L I C AT I O N F O R T R I C A R E ® P R I M E B E N E F I C I A R I E S
If the condition is obviously life threatening or causing severe pain and distress, then the need for an ER is clear. TRICARE views an emergency as a medical, maternity or psychiatric condition you believe could threaten your life, limb or sight without immediate medical attention. Other emergencies include severe, painful symptoms requiring immediate attention, or when a person may be an immediate risk to self or others. If you or a family member experience any of the following symptoms, go to the ER immediately: • Chest pain or pressure • Uncontrolled bleeding • Sudden or severe pain • Coughing or vomiting blood • Difficulty breathing or shortness of breath • Sudden dizziness, weakness or changes in vision • Severe or persistent vomiting or diarrhea • Changes in mental status, such as confusion
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The Doctor is in ...
Urgent or Emergency? W. Bryan Gamble, M.D., FACS
Brigadier General, US Army Deputy Director, TRICARE Management Activity
f you or your child gets sick or injured, your first instinct may be to go to the emergency room (ER) right away or call 911. These are good instincts in an emergency, but many people use the ER when it is not an actual emergency. This contributes to long ER wait times, high costs and unnecessary medical care. Sometimes, using an urgent care clinic may be your best choice and can help responsibly preserve the TRICARE benefit for future generations of military families. It can be difficult to know whether an illness or injury is really an emergency, but the judgment is yours to make.
Cut Your Cholesterol for a Healthier Heart
eart disease is the number-one cause of death in the United States. High cholesterol can lead to heart disease. The good news is you can reduce your risk by lowering your cholesterol.
High cholesterol usually has no symptoms. That makes it important to get tested regularly. All adults age 20 and older should have their cholesterol checked at least once every five years.1 TRICARE Prime covers cholesterol tests at least once every five years beginning at age 20. People with diabetes, regardless of their age, should have their cholesterol checked at least once each year. Ask your doctor or visit www.tricare.mil to check on what is covered. You can take a confidential health risk assessment to learn about your risks such as high cholesterol. Visit www.hnfs.com and click on “I’m a Beneficiary,” then “Wellness” to get started.
If you have high cholesterol, ask your doctor what you can do to lower it. Your doctor might have you eat a hearthealthy diet, exercise, quit tobacco and avoid secondhand smoke. Even if your cholesterol numbers are good now, it is never too early to start heart-healthy habits to keep your cholesterol under control as you age. n
Inside This Issue ...
• Causes of Unexpected Point-of-Service Charges • Notice of Privacy Practices • Fighting Health Care Fraud and Abuse • Paying for Your TRICARE Benefit
An Important Note About TRICARE Program Information: At the time of printing, this information is current. It is important to remember that TRICARE policies and benefits are governed by public law and federal regulations. Changes to TRICARE programs are continually made as public law and/or federal regulations are amended. Military treatment facility guidelines and policies may be different than those outlined in this publication. For the most recent information, contact your TRICARE regional contractor, TRICARE Service Center, or local military treatment facility.
Causes of Unexpected Point-of-Service Charges
he point-of-service (POS) option, through which you can see any TRICARE-authorized provider without a referral, can be a great option for TRICARE Prime and TRICARE Prime Remote for Active Duty Family Member (TPRADFM) beneficiaries.1 The POS option provides TRICARE Prime beneficiaries with greater choice and easier access to any TRICARE-authorized provider without having to disenroll from TRICARE Prime. This option results in higher outof-pocket costs, or POS charges. These charges may apply if you do not follow the referral process properly. Here are some situations that may result in unexpected POS charges:
You or your specialist must contact your PCM to request a referral, and the PCM must submit the referral to Health Net. Follow-up care without an approved referral will cause the claim to process under POS. • Specialist visit without a referral—Most office visits outside the PCM’s office require a PCM referral and an authorization from Health Net. While PCMs submit most referrals to Health Net, network specialists are also responsible for submitting referrals for TRICARE Prime beneficiaries. To prevent unexpected POS charges, verify the referral is approved before getting care. • PCM assignment misconceptions—Beneficiaries sometimes lose track of their most current PCM assignment and may visit a provider that is not their assigned PCM. These are some common misconceptions: • “TRICARE will only assign the PCM I requested.” • “My PCM just moved across town, so I can still see him or her as my PCM.” • “My PCM left the group, so I can just go to another doctor in the group.” • “I called and got a list of PCMs. I thought I could use any PCM on the list.” You are assigned to either a PCM at a military treatment facility or a civilian provider. Even after your initial PCM assignment, your PCM may be changed by Health Net because of a provider move or network contract change. You will receive a letter anytime a PCM assignment or change occurs. You can view your referrals and PCM assignment online at www.myTRICARE.com. n
1. The POS option does not apply to active duty service members, children for the first 60 days following their birth or adoption, emergency care, beneficiaries with other health insurance or the first eight behavioral health outpatient visits per fiscal year (Oct. 1–Sept. 30) to a network provider for a medically diagnosed and covered condition.
• Urgent care without a primary care manager (PCM) referral—You need to contact your PCM before receiving urgent care services from a provider other than your PCM or at an urgent care facility. This applies even on weekends, after hours and while traveling. These requirements do not apply to emergency care or to TPRADFM beneficiaries with unassigned PCMs. Urgent care is when an illness or injury is serious enough to seek health care right away, but not so severe as to require emergency room care. Some examples include earache, joint sprain, muscle pull or urinary tract infection. If you do not contact your PCM or the regional contractor, Health Net Federal Services, LLC (Health Net), before going to an urgent care facility, POS charges may apply. Note: Beneficiaries enrolled to Joint Base McGuire-Dix-Lakehurst (87th Medical Group), Fort Lee (Kenner Army Health Clinic) and Naval Health Clinic Patuxent River should contact Health Net after hours or while traveling to obtain approval for urgent care services. • Preventive care follow-up visit without a referral—You can access most preventive care services through a network provider without a referral from your PCM or Health Net. However, if the preventive care provider discovers a condition or decides additional diagnostic tests are needed, the follow-up services will require a referral from your PCM.
Notice of Privacy Practices
he Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives individuals the right to be informed of the privacy practices of their health plans and those of most of their health care providers, as well as to be informed of their individual rights with respect to their protected health information. Health plans and covered health care providers are required to develop and distribute a Notice of Privacy Practices (NoPP) that provides a clear explanation of these rights and
practices. The NoPP is intended to make individuals aware of privacy issues and concerns, encourage them to exercise their rights and prompt them to have discussions with their health care plan administrators and health care providers. You may view the Military Health System NoPP at www.tricare.mil/tma/privacy. For other privacy concerns, you may contact the Health Net Federal Services, LLC Privacy Compliance Office at firstname.lastname@example.org. n
The Doctor is in ...
Urgent or Emergency?
… continued from page 1
for authorization. You can find contact information for your regional contractor at www.tricare.mil/contacts. According to the Urgent Care Association of America, 57 percent of visits to an urgent care facility have a wait time of 15 minutes or less. By comparison, the Centers for Disease Control and Prevention reports only 22 percent of visits to an emergency room have wait times of 15 minutes or less. Getting urgent care instead of visiting the ER can also save money. ERs are required to run expensive diagnostic tests that may not be necessary if your condition is less serious. Being judicious with your health care spending can make your household budget go further, and cost-efficient urgent care will help protect your TRICARE benefit in these uncertain financial times. It’s a good idea to be aware of nearby urgent care facilities in the TRICARE network, just as you would with the closest ER. To find an urgent care facility near you in the TRICARE network, visit www.tricare.mil/findaprovider and select the search tool for your regional contractor. n
Correction: “The Doctor is in” column that ran in the Health Matters Winter 2012 newsletter was written by Barclay P. Butler, Ph.D. The article did not identify Dr. Butler as the author and as Director, Department of Defense/Department of Veterans Affairs Interagency Program Office.
You do not need authorization for emergency care before receiving treatment. However, if you’re enrolled in a TRICARE Prime plan you must contact your primary care manager (PCM) or regional contractor within 24 hours or the next business day after you receive emergency care. Urgent care is when an illness or injury is serious enough to seek health care right away, but not so severe as to require emergency room care. Some examples include earache, toothache, joint sprain, muscle pull or urinary tract infection. You can get urgent care from your PCM or from an urgent care center if your PCM is inaccessible. Urgent care can be quicker, with a lower cost and better results, compared to a crowded ER that may require unnecessary tests or hospital stays. Many urgent care centers are open after normal business hours and on the weekend, so you can go at a time that fits with your schedule, or when a health problem warrants. If you have TRICARE Prime, you need to get prior authorization from your PCM or your regional contractor to avoid additional costs for visiting an urgent care center. If you are traveling, you need to contact your home region
Fighting Health Care Fraud and Abuse
ealth care fraud and abuse cost American taxpayers billions of dollars each year. TRICARE and Health Net Federal Services, LLC (Health Net) are committed to ensuring you receive care from trustworthy providers and that taxpayer money is used appropriately.
• If you notice any differences between the services reflected on your EOB and the services you received, call the toll-free number listed on the EOB. Differences do not always indicate fraud, but they can indicate mistakes that may result in improper claims reimbursement from TRICARE or cause your medical record to be incorrect. If you have any concerns about your medical record, you should follow up with your health care provider to ensure the services you received are reflected properly. To learn more about how TRICARE and Health Net combat fraud and abuse, visit the TRICARE Fraud & Abuse website at www.tricare.mil/fraud or visit www.hnfs.com. To report fraud or abuse regarding the TRICARE Pharmacy Program, contact Express Scripts, Inc. at 1-800-332-5455, ext. 367079, or by e-mail at email@example.com. n
What Are Fraud and Abuse?
Health care fraud is intentional deception or misrepresentation that enables someone to obtain an unauthorized benefit or payment. Health care abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards. You are an important partner in the ongoing fight against fraud and abuse within the TRICARE program.
How You Can Help:
• Always review the explanation of benefits (EOB) you receive after health care services. The EOB should list the services and supplies you received.
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“TRICARE” is a registered trademark of the TRICARE Management Activity. All rights reserved.
Paying for Your TRICARE Benefit
Automatic Payment Options
xcept for the initial payment, TRICARE Prime enrollment fees must be paid with a credit card or an automatic monthly payment option. Learn about automatic payment options on the Health Net Federal Services, LLC (Health Net) website by visiting www.hnfs.com and clicking on “I’m a Beneficiary,” then selecting the “Enrollment” tab and choosing the “Change My Payment Method” page.
Updated Enrollment Fees
Effective Oct. 1, 2012, enrollment fees for TRICARE Prime changed. Enrollment fees for TRICARE Reserve Select, TRICARE Retired Reserve and TRICARE Young Adult changed on Jan. 1, 2013. For updated fee amounts, visit the Health Net “Make a Payment” page and click on the specific plan type.
Insufficient Funds Fee
Health Net assesses a $20 administrative fee for enrollment fee payments that are unsuccessful because of insufficient or unavailable funds. Beneficiaries will be billed the $20 administrative fee along with the outstanding payment amount, and payment received will be first applied to the $20 fee, with the remaining amount applied to the enrollment fee. n
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