Medical Insurance Chapter16 PPTAW

Slide 1
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Chapter 14
TRICARE and
CHAMPVA
Slide 2
Learning Objectives
State who is eligible for TRICARE
and CHAMPVA.
Define pertinent TRICARE and
CHAMPVA terminology and
abbreviations.
Enumerate the differences between
TRICARE Prime and Extra and the
TRICARE Standard programs.
Slide 3
Learning Objectives (cont’d.)
Identify the difference between the
TRICARE program and CHAMPVA.
Name various forms used with
these federal health care programs.
List the circumstances when a non-
availability statement is necessary.
Describe how to process a claim for
an individual who is covered by the
TRICARE Standard program.
Slide 4
Chapter 14
Lesson 14.1
Slide 5
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
Slide 6
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)
Slide 7
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
Slide 8
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
Slide 9
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 co-payments apply.
Slide 10
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 co-payments apply.
Slide 11
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.
 Co-payments and deductibles apply.
Slide 12
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Slide 14
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.
Slide 15
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
Slide 16
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
Slide 17
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 co-payments if
military treatment facility initiates
referral
Slide 18
Slide 19
TRICARE Hospice
Program
based on Medicare hospice
program
life expectancy is six months or
less
cannot also receive care under
TRICARE basic programs
Slide 20
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
Slide 21
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
Slide 22
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.
Slide 23
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Slide 26
Chapter 14
Lesson 14.2
Slide 27
HIPAA Compliance
Privacy Act of 1974
Individual has right to review own
medical records maintained by a
federal health care facility.
If personal information is
requested, the individual must be
informed of purpose and use of the
information.
Slide 28
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.
Slide 29
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 one year of service
Slide 30
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 one year of service
Slide 31
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 one year
of service.
Slide 32
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.
Slide 33
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).
Slide 34
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
Slide 35
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
Slide 36
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.
Slide 37
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.
Slide 38
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
Slide 39
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
Slide 40
Claim Inquiries and
Appeals
Appeal process
for providers to request that a denial
of coverage be reconsidered
for providers to request that amount
paid on a submitted claim be
reconsidered
Slide 41

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Civilian provider submits claims to

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