Chapter 14 TRICARE and CHAMPVA Elsevier items and derived items © 2010, 2008 by Saunders, an...

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


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)


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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



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


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



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)



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



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



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



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


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


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


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

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