TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

The Department of Veterans Affairs and TRICARE

2011

Learning Objectives

Upon completion of today’s presentation, you should:

– Understand the basic facts about TRICARE – Have a general idea about TRICARE programs and

benefits – Be able to verify eligibility for TRICARE patients– Know the steps of the referral and authorization

process– Be able to locate the VA Learning Space

About TRICARE

TRICARE is• the worldwide health care program available to eligible

beneficiaries of the seven uniformed services—the U.S. Army, U.S. Navy, U.S. Air Force, U.S. Marine Corps, U.S. Coast Guard, Commissioned Corps of the U.S. Public Health Service and the Commissioned Corps of the National Oceanic and Atmospheric Administration, their families, retired service members and their families, survivors, certain former spouses and others.

• a tailored network of military and civilian health care professionals working together to foster, protect, sustain and restore health for those entrusted to their care.

TRICARE Oversight Responsibility

TRICARE Regions

TRICARE North

The TRICARE North Region includes the District of Columbia and the following states:

Connecticut

Delaware

Illinois

Indiana

Iowa (Rock Island Arsenal area only)

Kentucky

Maine

Maryland

Massachusetts

Michigan

Missouri (St. Louis area only)

New Hampshire

New Jersey

New York

North Carolina

Ohio

Pennsylvania

Rhode Island

Tennessee (Fort Campbell area only until March 31, 2012)

Vermont

Virginia

West Virginia

Wisconsin

TRICARE Also Serves Eligible Family Members

• Unmarried children of active duty, retired and reserve members

• Up to age 21 (or 23 if full-time student)• Past age 21—mental or physical incapacity• Unmarried children remain eligible even if parents

divorce or remarry• TRICARE Young Adult (TYA) Program• Family members under age 26 who meet the specific

qualifications of the premium-based TRICARE Young Adult program

Dual Eligibility – Veterans Affairs and TRICARE

Some TRICARE beneficiaries may be eligible for both Veterans Affairs (VA) and TRICARE benefits.

Care received at a VA facility for service-connected conditions must be received under VA benefits

If seeking care outside a VA facility for a TRICARE-covered benefit, beneficiaries are encouraged to complete the entire “episode of care” with that provider to ensure continuity of care and completion of the claims process.

Beneficiaries may choose to use the TRICARE benefit at a VA medical facility as long as the service is covered under TRICARE and is not for a service-connected condition.

Determination of Benefit and Reimbursement

A TRICARE beneficiary may be served under the following programs:

• VA Benefit – Beneficiaries with a service-connected disability are required to be treated under their VA benefits.

• TRICARE Benefit – Coverage for active duty service members, active duty family members, and non-active duty family members without a service-connected disability who are referred for specialty care to the VA because the VA facility is a TRICARE network provider. This referral may come from a civilian provider, military treatment facility (MTF) or in some cases, a VA primary care manager (PCM).

• VA/DoD Sharing Agreement – An agreement between an MTF and a VA facility to provide specialty care services not available at the MTF as outlined in the Sharing Agreement.

Note: When a patient presents for care, it is important to determine up-front which program will be utilized for treatment and how that care will eventually be reimbursed. These determinations will also affect which services may be offered.

Defense Enrollment Eligibility Reporting System (DEERS)

– A computerized databank that lists all eligible uniformed service personnel and their family members

– Official source for verifying eligibility and coverage, and maintaining the Uniformed Services Identification Card program and enrollment information

Verifying Eligibility for TRICARE Benefits

Online Eligibility Verification

To view general eligibility or eligibility for a specific procedure, diagnosis or service type you must register at www.myTRICARE.com.

Online Eligibility Verification

Deductibles/Out-of-Pocket CostsDeductibles/Out-of-Pocket Costs

Other Health InsuranceOther Health Insurance

Confirming Eligibility:Using the Common Access Card

Check the back of the identification (ID) card to verify eligibility for TRICARE

Look under the CIVILIAN field. It should say YES. If a beneficiary using TRICARE For Life (TFL) has

an ID card that reads “NO” in the CIVILIAN field, the beneficiary is still eligible to use TFL if entitled for Medicare Part A and enrolled in Medicare Part B.

Check the expiration date on the ID card in the EXP DATE field. If expired, the beneficiary will need to update his or her information in DEERS and get a new card.

Common Access Cards and Enrollment Cards

Although Common Access Cards (CACs) are valid uniformed service ID cards, they do NOT prove TRICARE eligibility.

Enrollment cards – used for certain plan options such as TRICARE Prime – should be presented at time of service but are not required to obtain care. The enrollment card contains important information for beneficiaries.

Each and every time a TRICARE beneficiary presents, you must verify the card bearer’s TRICARE eligibility by logging into Health Net’s website at www.hnfs.com or by calling Health Net’s interactive voice response (IVR) system at 877-TRICARE.

TRICARE Prime Enrollment Card

Front Back

• No longer includes a Social Security number• Should be presented with a military ID card

Common Access Card

• Does not include a Social Security number

• Includes a readable magnetic strip

Uniformed Services Military ID Card

• Credit card size

• Digital photograph image of the bearer

• Machine-readable data

• Printed identification and entitlement information

TRICARE Plans

TRICARE Standard

• Structured like an indemnity plan

• Eligibility based on DEERS

• Broadest choice of providers

• Highest out-of-pocket costs

• Deductible required

• Space available – lower priority access – at MTF

• Best option if beneficiary has other health insurance

• Prior authorization requirements apply

TRICARE Extra

• Similar to a preferred provider organization (PPO) plan

• Standard beneficiary utilizes a network provider and saves five percent

• Annual deductibles• Cost-shares• Self-referral by beneficiary to network provider• Prior authorization requirements apply• Beneficiaries show military ID card

TRICARE Prime

• Managed care option• Enrollment required• Fewer out-of-pocket costs• Select (or are assigned) a primary care manager

(PCM)• Care received at MTFs and in the civilian

preferred provider network• Guaranteed access standards• No claims to file• TRICARE Prime enrollment card and military ID

card required

Referrals

• The MTF is always the primary source of care for TRICARE Prime beneficiaries.

• A referral to a specialist is issued only if services are not available at the MTF.

• The MTF has right of first refusal to provide care for a TRICARE beneficiary.

• Complete the online authorization and referral submission form to submit a referral at www.hnfs.com

• TRICARE Standard beneficiaries do not require a referral regardless of the service area or location

Specialty Care Referrals

For TRICARE Prime beneficiaries:• The primary care manager (PCM) must initiate all referrals to

specialists and sub-specialists

• All TRICARE Prime beneficiaries, regardless of where they live, require a Health Net referral for most civilian specialty services

• Civilian PCMs are responsible for obtaining a approval number from Health Net prior to sending a beneficiary for specialty care

• Requirements listed at www.hnfs.com

Note: TRICARE Standard beneficiaries do not require a referral for specialty care.

Military Treatment FacilityRight of First Refusal

– Military treatment facilities (MTFs) are given right of first refusal for TRICARE Prime beneficiaries in order to optimize use of the MTFs

– Right of first refusal applies to inpatient admissions, specialty appointments and procedures requiring prior written authorization

– If the service is not available at the MTF within the appropriate access standards, then the beneficiary is referred to a TRICARE network provider

Authorizations

Authorizations are required for:

• Certain medical/surgical or behavioral health services, or procedures require Health Net review and approval to ensure medical necessity and appropriateness of care prior to services being provided.

• For example, certain behavioral health care, hospitalization, surgical/invasive or therapeutic procedures

To determine if a service requires a Health Net referral or prior authorization, visit www.hnfs.com.

Business Tools for Providers at www.hnfs.com

• Patient eligibility verification

• Network provider directory

• Electronic forms

• Catastrophic cap and deductible queries

• Real-time electronic claims submission

• Claims status check

• Electronic funds transfer

• Secure email inquiries

Web Tools for Providers

Prior Authorization, Referral and Benefit Tool– Check if a prior authorization or referral is required

Online Authorization and Referral Submission– Submit your requests at www.hnfs.com

Check the status of a prior authorization or referral– Register at www.myTRICARE.com to get prior

authorization and referral status

Providers

Provider Section

Check Authorization and ReferralRequirements Online

Authorization and Referral Requirements

Referral Requirements Table

Prior Authorization

Referral, Prior Authorization and Inpatient Notification Requirements Guide

Referral Requirements Table

Prior Authorization Requirements Table

Submit an Authorization or Referral Online

Submit an Authorization orReferral Online (Continued)

Service Request/Notification FormOnline Submittal

Check Status ofAuthorizations and Referrals

Summary

DetailsDetails

Clearly Legible Reports (CLR)

– Specialty providers are required to submit clearly legible specialty care consultation or referral reports, operative reports and discharge summaries to the MTF within seven days.

– In urgent and emergency situations, a preliminary report of a specialty care consultation should be submitted within 24 hours.

Note: Upon receipt of an approved referral or authorization from Health Net, providers will receive a letter that contains the secure fax line number for coordinating the CLR with the MTF.

Release of Medical Records

– Unless a signature is on file, specialty care providers must request TRICARE Prime beneficiaries sign an Authorization to Disclose Information form at every office visit, allowing release of protected health information (PHI).

– This includes ancillary services associated with each visit whereby the PCM, civilian and/or the MTF Commander are designated to receive medical records.

Release of Medical Records

Per VA Privacy Office: – If TRICARE and its contractors are seeking the

individual patient medical records for payment purposes, there is legal authority for the Veterans Health Administration authorizing release of PHI to the DoD TRICARE contractor.

– For an urgent care visit, the records should be given to the beneficiary at the time of the visit.

– If requested in writing, Veterans Affairs Medical Centers are required to release PHI for review, usually in support of National Center for Quality Management.

TRICARE and Other Health Insurance

• TRICARE is the secondary payer except for Medicaid, TRICARE supplements and the Indian Health Service or other programs or plans as identified by TRICARE Management Activity.

• Beneficiaries with OHI are not required to obtain referrals or prior authorizations for covered services, except for adjunctive dental care, TRICARE Extended Care Health Option (formerly the Program for Persons with Disabilities), behavioral health care services and transplants.

• Providers are encouraged to ask beneficiaries about OHI to coordinate benefits.

Provider Resources

TRICARE Provider website — www.TRICARE.mil/provider.asp– National TRICARE information—regulatory guidance, policies and

procedures

– TRICARE program options and features

– Main resource for TRICARE information

TRICARE Online—www.TRICAREonline.com– Department of Defense Internet portal

– Interactive health care services and information

– Military treatment facility and provider Web pages

– Links to health care information

Health Net Federal Services Customer Service Line

877-TRICARE (877-874-2273)

• Offers extended hours:

7 a.m. to 7 p.m. Eastern time

6 a.m. to 6 p.m. Central time

• Interactive Voice Response (IVR) feature: 24-hour, seven days-a-week access to self-service options, including claims status, eligibility inquiries and TRICARE allowable charge rates.

PGBA–Health Net’s Claims Processor

• PGBA is Health Net’s partner for claims processing in the TRICARE North Region

• Both the Health Net and PGBA websites offer many online claims customer service features:

• Health Net—www.hnfs.com

• PGBA—www.myTRICARE.com

• All network provider claims must be filed electronically

Provider Section

VA Learning Space

To provide a world-class health system that meets all wartime and peacetime health care needs for active duty and retired military and their families.

TRICARE’s Vision

Thank you.

Questions ?