Chapter 14 TRICARE and Veterans’ Health Care

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1

Chapter 14

TRICARE and Veterans’ Health Care

Insurance Handbook for the Medical Office

13th edition

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved

TRICARE and Veterans Health Administration (CHAMPVA) Overview

1. Define pertinent TRICARE and Veterans Health Administration (CHAMPVA) terminology and abbreviations.

2. State who is eligible for TRICARE.3. List the circumstances when a nonavailability

statement is necessary.4. Explain the benefits of the TRICARE Standard

government program.5. State the TRICARE fiscal year.

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Lesson 14.1



(cont’d)6. Name authorized providers who may treat a

TRICARE Standard patient.7. List the managed care features of TRICARE

Extra.8. State the managed care features of TRICARE

Prime.9. Explain TRICARE for Life benefits and those

who are eligible individuals.10. Name individuals eligible for TRICARE Plus.

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Lesson 14.1



(cont’d)11. Define individuals who may enroll in the TRICARE

Prime Remote program.12. Identify individuals who are eligible for the

Veterans Health Administration program (CHAMPVA).

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Lesson 14.1


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

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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) 6


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 7


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

8


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

9


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

10


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

11


TRICARE Reserve Select

Available to qualified members of the Selected Reserve and their families

Similar to TRICARE Standard and Extra

12


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

13


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

14


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 15


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

16


TRICARE Hospice Program

Based on Medicare hospice program Life expectancy is 6 months or less Cannot also receive care under TRICARE

basic programs

17


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

18


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

19


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

20


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

21


Claims Procedure

TRICARE Extra and TRICARE Prime 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

22


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

23


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

24


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)

25


Claims Procedure

For Medicaid: 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

26


Claims Procedure

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

27


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

28


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

29


After Claim Submission

TRICARE For each claim a summary payment voucher

is issued to the patient

30


After Claim Submission

Veterans Health Administration For each claim an explanation of benefits

document is issued to the patient summarizing actions taken

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Questions?

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Documents

Chapter 14 TRICARE and Veterans’ Health Care