4 Learning Objectives (cont d.)

Transcription

1 1 2 Learning Objectives Define pertinent TRICARE and CHAMPVA terminology and abbreviations. State who is eligible for TRICARE. Explain the differences of the TRICARE Standard government program. List the circumstances when a nonavailability statement is necessary. State the TRICARE fiscal year. 3 Learning Objectives (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. ividuals. Name individuals eligible for TRICARE Plus. 4 Learning Objectives (cont d.) 5 Define individuals who may enroll in the TRICARE Prime Remote program. Identify individuals who are eligible for CHAMPVA. Describe how to process a claim for an individual who is covered by the TRICARE Standard program. 6 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 for-service) TRICARE Extra (PPO) TRICARE Prime (HMO) 2005 TRICARE consolidated into 3 regions 7 TRICARE 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) r 8 TRICARE Eligibility (cont d.) 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 c days disabled beneficiaries under 65 years with Medicare A & B Medicare-eligible eligible beneficiaries in TRICARE for Life 9 TRICARE

2 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 10 TRICARE Standard 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 11 TRICARE Extra 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 12 TRICARE Prime 13 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 network provider Preauthorization may be necessary for some specialty care, hospitalization, and certain procedures Copayments and deductibles apply 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 M and TRICARE 16 TRICARE Plus ID card and DEERS enrollment required Enrollees use the military treatment facility as source of primary ry care Same benefits as TRICARE Prime when using military treatment facility Access to specialty providers at military treatment facility not guaranteed 17 TRICARE Prime Remote For active duty service members only

3 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 of-pocket expenses for in-network network services 18 Supplemental Health Care Program 19 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 20 TRICARE Hospice Program Based on Medicare hospice program Life expectancy is 6 months or less Cannot also receive care under TRICARE basic programs 21 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 22 CHAMPVA Program 1973 CHAMPVA created (Civilian Health and Medical Program of the Veterans 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 23 CHAMPVA Program (cont d.) 24 Benefits similar to TRICARE Standard for dependents of retired and a deceased military personnel Freedom of choice in selecting civilian providers Preauthorization needed for some services HIPAA Compliance Privacy Act of 1974 Individual has right to review own medical records maintained by a federal healthcare facility If personal information is requested, the individual must be informed of purpose and use of the information

4 29 HIPAA Compliance (cont d.) Computer Matching and Privacy Protection Act of 1988 Government can verify information via computer matches Patients must be made aware by providers of this information and how medical data can be disclosed 30 Claims Procedure TRICARE Standard administered by DOD (Department of Defense) CHAMPVA administered by VA (Veterans Administration) Claims must be: Billed on CMS-1500 (08-05) 05) form or electronically Submitted to the correct fiscal intermediary Filed within 1 year of service 31 Claims Procedure (cont d.) TRICARE Extra and TRICARE Prime No claim forms filed by beneficiary if care provided is in-network. network. Providers must: Use CMS-1500 (08-05) 05) form or electronic system to submit claims Submit claims to correct subcontractor File within 1 year of service 32 Claims Procedure (cont d.) TRICARE Prime Remote and Supplemental Health Care Program Outpatient services are submitted with CMS-1500 (08-05) 05) form or electronically POS option and NAS requirement do not apply Claims must be filed within 1 year of service 33 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 34 Claims Procedure (cont d.) TRICARE/CHAMPVA and Other Insurance TRICARE/CHAMPVA usually pay as secondary payer if beneficiary has s other health insurance EOB copy from primary carrier should be attached to the completed d CMS-1500 (08-05) 05) claim form Include copy of the physician s s complete itemized statement Claim should then be sent to the local claims processor (fiscal intermediary) 35 Claims Procedure (cont d.) For Medicaid: TRICARE/CHAMPVA is primary For Medicare: TRICARE is secondary, if under 65 with Part A & Part B CHAMPVA is secondary, if under 65 with Part A & Part B 36 Claims Procedure (cont d.) Coordination of benefits needed for situations with dual coverage so there is no duplication ion 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

5 37 Claims Procedure (cont d.) For third-party liability: TRICARE form DD 2527 is submitted with regular claim form CMS-1500 (08-05) 05) Provider can submit claims only to third-party liability carrier for reimbursement If ICD-9-CM CM code between , claims processor may request completion of form DD Claims Procedure (cont d.) For Workers Compensation: TRICARE/CHAMPVA billed when workers compensation benefits are exhausted Beneficiary with work-related related injury or illness must file the claim with the workers compensation carrier 39 After Claim Submission TRICARE For each claim a summary payment voucher is issued to the patient CHAMPVA For each claim an explanation of benefits document is issued to the patient summarizing actions taken 40 Quality Assurance Quality assurance program Continuous assessment of care, inpatient and outpatient Grievance process for members and for providers Providers notified if quality issue is identified and corrective recommendations are given 41 Claim Inquiries and Appeals Appeal process For providers to request that a denial of coverage be reconsidered ed Or providers to request that amount paid on a submitted claim be reconsidered