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TRICARE AND CHAMPVA questions with complete verified solutions
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TRICARE AND CHAMPVA questions with complete verified solutions
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TRICARE AND CHAMPVA questionswith complete verified solutions
TRICARE
Government health program serving dependents of active-duty service
members, military retirees and their families, some former spouses, and
survivors of deceased military members.
TRICARE is the Department of Defense's health insurance plan for military
personnel and their families. TRICARE, which includes managed care
options, replaced the program known as the Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS). TRICARE is a regionally
managed health care program that brings the resources of military
hospitals together with a network of civilian facilities and providers to
offer increased access to health care services. All military treatment
facilities, including hospitals and clinics, are part of the TRICARE system.
TRICARE also contracts with civilian facilities and physicians to provide
more extensive services to beneficiaries.
Members of the following uniformed services and their families are
eligible for TRICARE: The Army, Navy, Air Force, Marine Corps, Coast
Guard, Public Health Service (PHS), and National Oceanic and Atmospheric
Administration (NOAA). Reserve and National Guard personnel become
eligible when on active duty for more than thirty consecutive days or when
they retire from reserve status at age sixty. The uniformed services
member is referred to as a sponsor, since the member's status makes
other family members eligible for TRICARE coverage.
TRICARE Claims
When a TRICARE patient arrives for treatment, the medical information
specialist photocopies both sides of the individual's military ID card and
checks the expiration date to confirm that coverage is still valid. Decisions
about eligibility are not made by TRICARE; the various branches of military
service make them. Information about patient eligibility is stored in the
Defense Enrollment Eligibility Reporting System (DEERS). Sponsors may
contact DEERS to verify eligibility; providers may NOT contact DEERS
directly because the information is protected by the Privacy Act.
TRICARE pays only for services rendered by authorized providers.
Authorized providers are certified by TRICARE regional contractors to have
met specific educational, licensing, and other requirements. Once
authorized, a provider is assigned a PIN and must decide whether to
,participate.
TRICARE participating providers file claims on behalf of patients, following
HIPAA regulations. Claims are filed with the regional contractor for that
region, based on the patient's home address, not the location of the
facility. Contact information for regional contractors is available on the
TRICARE website. The three administration regions for TRICARE are:
TRICARE North, TRICARE South, and TRICARE West. A fourth region covers
international claims.
Individuals file their own claims when services are received from
nonparticipating providers, using DD Form 2642, Patient's Request for
Medical Payment. A copy of the itemized bill from the provider must be
attached to the form.
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Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Now called the TRICARE program.
Sponsor
Uniformed service member in a family qualified for TRICARE or CHAMPVA.
Defense Enrollment Eligibility Reporting System (DEERS)
Worldwide database of TRICARE and CHAMPVA beneficiaries.
TRICARE Participating Providers
Providers who participate agree to accept the TRICARE allowable charge
as payment in full for services. Individual providers may decide whether to
, participate on a case-by-case basis. Participating providers are required to
file claims on behalf of patients. The regional TRICARE contractor sends
payment directly to the provider, and the provider collects the patient's
share of the charges. Only participating providers may appeal claim
decisions.
Nonparticipating Providers
A provider who chooses not to participate may not charge more than 115
percent of the allowable charge. If a provider bills more than 115 percent,
the patient may refuse to pay the excess amount. If a nonparticipating
provider charges more than 115 percent of the allowed charge, the patient
is NOT responsible for the amount that exceeded 115 percent of the
allowed amount. The difference would have to be written off by the
provider. The patient would pay the cost-share (either 20 or 25 percent) --
a TRICARE term for the coinsurance, the amount that is the responsibility
of the patient. Once the nonPAR provider submits the claim, TRICARE pays
its portion of the allowable charges, but instead of going directly to the
provider, the payment is mailed to the patient. The patient is responsible
for paying the provider. Payment should be collected at the time of the
visit.
Cost-Share
Coinsurance for a TRICARE or CHAMPVA beneficiary.
Reimbursement
Providers who participate in the basic TRICARE plan are paid the amount
specified in the Medicare Physician Fee Schedule for most procedures.
Medical supplies, durable medical equipment, and ambulance services are
not subject to Medicare limits. The maximum amount TRICARE will pay for
a procedure is known as the TRICARE Maximum Allowable Charge (TMAC).
Providers are responsible for collecting the patients' deductibles and their
cost-share portions of the charges.
The TRICARE Maximum Allowable Charge Table is located at:
www.tricare.mil/allowablecharges/
Network Providers
Providers who are authorized to treat TRICARE patients may also contract
to become part of the TRICARE network. These providers serve patients in
one of TRICARE's managed care plans. They agree to provide care to
beneficiaries at contracted rates and to act as participating providers on
all claims in TRICARE's managed care programs.
Nonnetwork Providers
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