Upload
ruby-smith
View
229
Download
5
Embed Size (px)
Citation preview
Chapter 14Chapter 14
TRICARE and CHAMPVA TRICARE and CHAMPVA
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
History of TRICAREHistory of TRICARE 1966 CHAMPUS created (Civilian Health and 1966 CHAMPUS created (Civilian Health and
Medical Program of the Uniformed Services)Medical Program of the Uniformed Services) 1988 CHAMPUS Prime created as managed 1988 CHAMPUS Prime created as managed
care plan optioncare plan option 1994 TRICARE became new title with 3 1994 TRICARE became new title with 3
options:options: TRICARE Standard (fee-for-service)TRICARE Standard (fee-for-service) TRICARE Extra (PPO)TRICARE Extra (PPO) TRICARE Prime (HMO) TRICARE Prime (HMO)
2005 TRICARE consolidated into 3 regions2005 TRICARE consolidated into 3 regions
33Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE EligibilityTRICARE Eligibility
active duty service members (Prime Remote)active duty service members (Prime Remote) eligible family members of active duty service eligible family members of active duty service
membersmembers military retirees and eligible family members military retirees and eligible family members surviving eligible family members of surviving eligible family members of
deceased active or retired service membersdeceased active or retired service members wards and preadoptive childrenwards and preadoptive children former spouses of active or retired service former spouses of active or retired service
members (must meet requirements)members (must meet requirements)
44Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE Eligibility (cont’d.)TRICARE Eligibility (cont’d.) family members of active duty service members who family members of active duty service members who
were court-martialed or separated from their families were court-martialed or separated from their families for abusefor abuse
abused spouses/children of service members abused spouses/children of service members spouses/children of NATO representativesspouses/children of NATO representatives reservists and National Guard members activated for reservists and National Guard members activated for
30 or more consecutive days30 or more consecutive days disabled beneficiaries under 65 years with Medicare A disabled beneficiaries under 65 years with Medicare A
& B& B Medicare-eligible beneficiaries in TRICARE for LifeMedicare-eligible beneficiaries in TRICARE for Life
55Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE TRICARE
Defense Enrollment Eligibility Reporting Defense Enrollment Eligibility Reporting System (DEERS)System (DEERS) a computerized database system that all a computerized database system that all
TRICARE-eligible persons must be enrolled inTRICARE-eligible persons must be enrolled in Nonavailability Statement (NAS)Nonavailability Statement (NAS)
certification from a military hospital when it cannot certification from a military hospital when it cannot provide careprovide care
2003 not needed for individuals in the catchment 2003 not needed for individuals in the catchment area about an MTFarea about an MTF
66Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE StandardTRICARE Standard ID card required for all dependents over age 10ID card required for all dependents over age 10 Not limited to using network providers for medically Not limited to using network providers for medically
or psychologically necessary servicesor psychologically necessary services Care usually sought at military hospital closest to Care usually sought at military hospital closest to
home or identified through Health Care Finder (HCF)home or identified through Health Care Finder (HCF) Authorized providers must be used.Authorized providers must be used. Preauthorization necessary for specialty care, Preauthorization necessary for specialty care,
hospitalization, and certain procedureshospitalization, and certain procedures Deductibles and copayments applyDeductibles and copayments apply
77Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE ExtraTRICARE Extra
ID card required for all dependents over age 10ID card required for all dependents over age 10 PPO option PPO option Network provider must be used Network provider must be used Preauthorization necessary and coordinated by Preauthorization necessary and coordinated by
Health Care Finder for specialty care, Health Care Finder for specialty care, hospitalization, and certain procedureshospitalization, and certain procedures
Deductibles and copayments applyDeductibles and copayments apply
88Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE PrimeTRICARE Prime
Voluntary HMO option with annual fee required Voluntary HMO option with annual fee required Minimum 12 months participation requiredMinimum 12 months participation required PCM coordinates all care except emergenciesPCM coordinates all care except emergencies Referral from Health Care Finder required for Referral from Health Care Finder required for
use of non-network provideruse of non-network provider Preauthorization may be necessary for some Preauthorization may be necessary for some
specialty care, hospitalization, and certain specialty care, hospitalization, and certain proceduresprocedures
Copayments and deductibles applyCopayments and deductibles apply
99Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE for LifeTRICARE for Life
Supplementary payer to MedicareSupplementary payer to Medicare No separate ID card No separate ID card No referral or preauthorization requirementsNo referral or preauthorization requirements Payment is based on the services provided Payment is based on the services provided
and coverage by both Medicare and and coverage by both Medicare and TRICARETRICARE
1010Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE PlusTRICARE Plus
ID card and DEERS enrollment requiredID card and DEERS enrollment required Enrollees use the military treatment facility as Enrollees use the military treatment facility as
source of primary caresource of primary care Same benefits as TRICARE Prime when Same benefits as TRICARE Prime when
using military treatment facilityusing military treatment facility Access to specialty providers at military Access to specialty providers at military
treatment facility not guaranteedtreatment facility not guaranteed
1111Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE Prime RemoteTRICARE Prime Remote
For active duty service members onlyFor active duty service members only Must live at least 50 miles from military Must live at least 50 miles from military
treatment facilitytreatment facility Same benefits as TRICARE PrimeSame benefits as TRICARE Prime No prior authorization for routine primary care No prior authorization for routine primary care PCM coordinates all care except PCM coordinates all care except
emergenciesemergencies No out-of-pocket expenses for in-network No out-of-pocket expenses for in-network
servicesservices
1212Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Supplemental Health Care Supplemental Health Care ProgramProgram
For active duty service members and other For active duty service members and other designated patientsdesignated patients
Enables beneficiaries to be referred to civilian Enables beneficiaries to be referred to civilian providers when neededproviders when needed
No deductibles or copayments if military No deductibles or copayments if military treatment facility initiates referraltreatment facility initiates referral
1313Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE Hospice ProgramTRICARE Hospice Program
Based on Medicare hospice programBased on Medicare hospice program Life expectancy is 6 months or lessLife expectancy is 6 months or less Cannot also receive care under TRICARE Cannot also receive care under TRICARE
basic programsbasic programs
1414Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
TRICARE and HMO CoverageTRICARE and HMO Coverage
Provider must meet TRICARE provider Provider must meet TRICARE provider certification standardscertification standards
Type of care must be a TRICARE benefit and Type of care must be a TRICARE benefit and medically necessarymedically necessary
TRICARE does not pay for emergency TRICARE does not pay for emergency services received outside the normal HMO services received outside the normal HMO service areaservice area
1515Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
CHAMPVA ProgramCHAMPVA Program
1973 CHAMPVA created (Civilian Health and 1973 CHAMPVA created (Civilian Health and Medical Program of the Veterans Medical Program of the Veterans Administration)Administration)
For spouses and dependent children of For spouses and dependent children of veterans with total, permanent disability veterans with total, permanent disability
Must not be eligible for TRICARE Standard or Must not be eligible for TRICARE Standard or Medicare AMedicare A
Service benefit program – not an insurance Service benefit program – not an insurance programprogram
1616Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
CHAMPVA Program (cont’d.)CHAMPVA Program (cont’d.)
ID card required for all dependents over age 10ID card required for all dependents over age 10 Benefits similar to TRICARE Standard for Benefits similar to TRICARE Standard for
dependents of retired and deceased military dependents of retired and deceased military personnelpersonnel
Freedom of choice in selecting civilian providersFreedom of choice in selecting civilian providers Preauthorization needed for some servicesPreauthorization needed for some services
1717Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
HIPAA ComplianceHIPAA Compliance
Privacy Act of 1974Privacy Act of 1974 Individual has right to review own medical Individual has right to review own medical
records maintained by a federal healthcare records maintained by a federal healthcare facilityfacility
If personal information is requested, the If personal information is requested, the individual must be informed of purpose and individual must be informed of purpose and use of the informationuse of the information
1818Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
HIPAA Compliance (cont’d.)HIPAA Compliance (cont’d.)
Computer Matching and Privacy Protection Computer Matching and Privacy Protection Act of 1988Act of 1988
Government can verify information via Government can verify information via computer matchescomputer matches
Patients must be made aware by providers of Patients must be made aware by providers of this information and how medical data can be this information and how medical data can be discloseddisclosed
1919Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims ProcedureClaims Procedure
TRICARE Standard administered by DOD TRICARE Standard administered by DOD (Department of Defense)(Department of Defense)
CHAMPVA administered by VA (Veterans CHAMPVA administered by VA (Veterans Administration)Administration)
Claims must be: Claims must be: Billed on CMS-1500 (08-05) form or electronicallyBilled on CMS-1500 (08-05) form or electronically Submitted to the correct fiscal intermediarySubmitted to the correct fiscal intermediary Filed within 1 year of service Filed within 1 year of service
2020Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims Procedure (cont’d.)Claims Procedure (cont’d.)
TRICARE Extra and TRICARE PrimeTRICARE Extra and TRICARE Prime No claim forms filed by beneficiary if care provided No claim forms filed by beneficiary if care provided
is in-network.is in-network. Providers must: Providers must:
Use CMS-1500 (08-05) form or electronic system Use CMS-1500 (08-05) form or electronic system to submit claimsto submit claims
Submit claims to correct subcontractorSubmit claims to correct subcontractor File within 1 year of serviceFile within 1 year of service
2121Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims Procedure (cont’d.)Claims Procedure (cont’d.)
TRICARE Prime Remote and Supplemental TRICARE Prime Remote and Supplemental Health Care ProgramHealth Care Program
Outpatient services are submitted with CMS-1500 Outpatient services are submitted with CMS-1500 (08-05) form or electronically(08-05) form or electronically
POS option and NAS requirement do not applyPOS option and NAS requirement do not apply Claims must be filed within 1 year of serviceClaims must be filed within 1 year of service
2222Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims ProcedureClaims Procedure
TRICARE for LifeTRICARE for Life Civilian provider submits claims to Medicare Civilian provider submits claims to Medicare
to pay first and then the claim is submitted to to pay first and then the claim is submitted to TRICARE for the remainderTRICARE for the remainder
2323Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims Procedure (cont’d.)Claims Procedure (cont’d.)
TRICARE/CHAMPVA and Other InsuranceTRICARE/CHAMPVA and Other Insurance TRICARE/CHAMPVA usually pay as secondary TRICARE/CHAMPVA usually pay as secondary
payer if beneficiary has other health insurancepayer if beneficiary has other health insurance EOB copy from primary carrier should be attached EOB copy from primary carrier should be attached
to the completed CMS-1500 (08-05) claim formto the completed CMS-1500 (08-05) claim form Include copy of the physician’s complete itemized Include copy of the physician’s complete itemized
statement statement Claim should then be sent to the local claims Claim should then be sent to the local claims
processor (fiscal intermediary)processor (fiscal intermediary)
2424Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims Procedure (cont’d.)Claims Procedure (cont’d.)
For Medicaid: For Medicaid: TRICARE/CHAMPVA is primaryTRICARE/CHAMPVA is primary
For Medicare:For Medicare: TRICARE is secondary, if under 65 with Part A & TRICARE is secondary, if under 65 with Part A &
Part BPart B CHAMPVA is secondary, if under 65 with Part A & CHAMPVA is secondary, if under 65 with Part A &
Part BPart B
2525Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims Procedure (cont’d.)Claims Procedure (cont’d.)
Coordination of benefitsCoordination of benefits needed for situations with dual coverage so there needed for situations with dual coverage so there
is no duplication of benefits paidis no duplication of benefits paid TRICARE pays the lower of:TRICARE pays the lower of:
amount of TRICARE allowable charges after other amount of TRICARE allowable charges after other plan has paid benefitsplan has paid benefits
amount TRICARE would have paid as primary amount TRICARE would have paid as primary
2626Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims Procedure (cont’d.)Claims Procedure (cont’d.)
For third-party liability:For third-party liability: TRICARE form DD 2527 is submitted with regular TRICARE form DD 2527 is submitted with regular
claim form CMS-1500 (08-05)claim form CMS-1500 (08-05) Provider can submit claims only to third-party Provider can submit claims only to third-party
liability carrier for reimbursementliability carrier for reimbursement If ICD-9-CM code between 800 – 999, claims If ICD-9-CM code between 800 – 999, claims
processor may request completion of form DD processor may request completion of form DD 25272527
2727Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claims Procedure (cont’d.)Claims Procedure (cont’d.)
For Workers’ Compensation:For Workers’ Compensation: TRICARE/CHAMPVA billed when workers’ TRICARE/CHAMPVA billed when workers’
compensation benefits are exhaustedcompensation benefits are exhausted Beneficiary with work-related injury or illness must Beneficiary with work-related injury or illness must
file the claim with the workers’ compensation file the claim with the workers’ compensation carriercarrier
2828Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
After Claim SubmissionAfter Claim Submission
TRICARE TRICARE For each claim a summary payment voucher is For each claim a summary payment voucher is
issued to the patientissued to the patient CHAMPVACHAMPVA
For each claim an explanation of benefits For each claim an explanation of benefits document is issued to the patient summarizing document is issued to the patient summarizing actions taken actions taken
2929Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Quality AssuranceQuality Assurance
Quality assurance program Quality assurance program Continuous assessment of care, inpatient and Continuous assessment of care, inpatient and
outpatientoutpatient Grievance process for members and for providersGrievance process for members and for providers Providers notified if quality issue is identified and Providers notified if quality issue is identified and
corrective recommendations are givencorrective recommendations are given
3030Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Claim Inquiries and AppealsClaim Inquiries and Appeals
Appeal process Appeal process For providers to request that a denial of coverage For providers to request that a denial of coverage
be reconsideredbe reconsidered Or providers to request that amount paid on a Or providers to request that amount paid on a
submitted claim be reconsidered submitted claim be reconsidered