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Insurance Handbook for the Medical Office

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1 Insurance Handbook for the Medical Office
13th edition Chapter 14 TRICARE and Veterans’ Health Care

2 TRICARE and Veterans Health Administration (CHAMPVA) Overview
Lesson 14.1 TRICARE and Veterans Health Administration (CHAMPVA) Overview Define pertinent TRICARE and Veterans Health Administration (CHAMPVA) terminology and abbreviations. State who is eligible for TRICARE. List the circumstances when a nonavailability statement is necessary. Explain the benefits of the TRICARE Standard government program. State the TRICARE fiscal year.

3 TRICARE and Veterans Health Administration (CHAMPVA) Overview (cont’d)
Lesson 14.1 TRICARE and Veterans Health Administration (CHAMPVA) Overview (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.

4 TRICARE and Veterans Health Administration (CHAMPVA) Overview (cont’d)
Lesson 14.1 TRICARE and Veterans Health Administration (CHAMPVA) Overview (cont’d) Define individuals who may enroll in the TRICARE Prime Remote program. Identify individuals who are eligible for the Veterans Health Administration program (CHAMPVA).

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 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)

6 TRICARE Programs 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.)

7 TRICARE Programs Eligibility
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. Veterans Health Administration beneficiaries are not eligible for TRICARE.

8 TRICARE Programs 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.)

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 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.

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 copayments apply Network provider is the physician providing care at contracted rates. There is no annual fee to enroll in this PPO option.

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 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).

12 TRICARE Reserve Select
Available to qualified members of the Selected Reserve and their families Similar to TRICARE Standard and Extra Enrollees must not be eligible for or enrolled in the Federal Employee Health Benefits (FEHB) program or currently covered under FEHB. TRICARE Reserve Select (TRS) can include Army National Guard, Army Reserve, Navy Reserve, Marine Corps Reserve, Air National Guard, Air Force Reserve, and Coast Guard Reserve.

13 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.

14 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.

15 TRICARE Prime Remote Program
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.

16 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. See Table 14-1 to compare and contrast the benefits in TPR and SHCP.

17 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.

18 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. TRICARE will not pay for services outside the HMO.

19 Veterans Health Administration Program
1973 CHAMPVA created (Civilian Health and Medical Program of the Veterans Administration) Now called the Veterans Health 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.

20 Veterans Health Administration Program
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.

21 Claims Procedure TRICARE Standard administered by DOD (Department of Defense) Veterans Health Administration program administered by VA (Veterans Administration) Claims must be: Billed on CMS-1500 (02-12) 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. Regional contractor, or fiscal intermediary, is the claims processor or designated insurance contractor.

22 Claims Procedure TRICARE Extra and TRICARE Prime Providers must:
No claim forms filed by beneficiary if care provided is in-network Providers must: Use CMS-1500 (02-12) 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.

23 Claims Procedure TRICARE Prime Remote and Supplemental Health Care Program Outpatient services are submitted with CMS-1500 (02-12) 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.

24 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.

25 Claims Procedure TRICARE/Veterans Health Administration and Other Insurance TRICARE/Veterans Health Administration usually pay as secondary payer if beneficiary has other health insurance EOB copy from primary carrier should be attached to the completed CMS-1500 (02-12) 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.

26 Claims Procedure For Medicaid: For Medicare:
TRICARE/Veterans Health Administration is primary For Medicare: TRICARE is secondary, if under 65 with Part A & Part B Veterans Health Administration 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.

27 Claims Procedure Coordination of benefits TRICARE pays the lower of:
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.

28 Claims Procedure 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 (02-12) 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.

29 Claims Procedure 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.

30 After Claim Submission
TRICARE For each claim a summary payment voucher is issued to the patient Summary payment voucher details the claim payment by the processor. If provider receives direct payment, patient still receives copy of the voucher.

31 After Claim Submission
Veterans Health Administration For each claim an explanation of benefits document is issued to the patient summarizing actions taken Explanation of benefits is issued to the patient even if provider is paid directly.

32 Questions?

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