TRICARE

Glossary of Terms

The following are a few important and commonly
used terms associated with military health care
Allowable Costs:
The maximum that will be paid to a participating provider. The allowable is based upon a CHAMPUS approved reimbursement method.
 
Authorized Provider:
A hospital, institution, physician or another professional who meets the licensing and certification requirements of the CHAMPUS regulation and is practicing within the scope of that license.
 
Balance Billing:
The practice of billing the beneficiary for the difference between the CHAMPUS allowable amount and the full charges of the provider.
 
Beneficiary:
An individual who is entitled to receive care at a medical facility (hospital,clinic)or through a health care provider.
Beneficiary Service Representative(BSR):
Beneficiary Service Representatives are employees of * Sierra Military Health Services responsible for assisting beneficiaries with enrollment,answering general beneficiary questions and providing details on the three benefits options available under TRICARE. BSRs will be located at every TSC.
Billed Charges:
The amount submitted by providers as their fee for services and supplies rendered to the beneficiary.
 
BRAC Site:
A military base that has been closed or targeted for closure by the Base Realignment and Closure Commission.
 
Case Management:
A collaborative process between the medical director, nurse reviewer and other key personnel to assess, plan, implement, coordinate, monitor and evaluate options and services to meet an individual's health needs through communications and available resources to promote quality, cost-effective outcomes. Catastrophic Cap: The upper limit on out-of-pocket expenses for CHAMPUS-covered medical bills which must be borne by the beneficiary during a fiscal year (Oct.1 through Sept. 30). Currently the limit is $1,000 for an active-duty family; $3,000 for non-active-duty Prime enrollees (per enrollment year); and $7,500 for all other CHAMPUS eligibles. Health care charges in excess of the CHAMPUS allowable do not count towards these caps. Catchment Area: Zip codes falling within a 40-mile radius of a Military Treatment Facility.
 
CHAMPUS:
The Civilian Health and Medical Program of the Uniformed Services is the Department of Defense's military health care program authorized by Congress in 1963 to provide health care services to the active duty dependents, retirees(under 65) and their dependents. CHAMPUS Reform Initiative(CRI) The CHAMPUS Reform Initiative was a managed care program implemented in 1988 to contain cost growth and improve services to beneficiaries.
 
Coordination of Benefits(COB):
The coordination of the payment of CHAMPUS benefits with the payment of benefits made by the double coverage so that there is not duplication of benefits paid between the double coverage plan and CHAMPUS.
 
Copayment:
A patient's share of costs for covered services, usually paid to the physician or provider at the time the care is rendered. TRICARE Prime copayments or cost-shares depend on the sponsor's military status and pay grade.
 
Cost-share:
The beneficiary's share of the cost for authorized care.
 
Covered Service:
A health care service that TRICARE will cover for a beneficiary.
 
Deductible:
The amount a beneficiary or his/her family must pay each year before TRICARE begins sharing the costs for health care services with the beneficiary.
 
DEERS:
The Defense Enrollment and Eligibility Reporting System. A data base used to verify beneficiary eligibility.
 
Department of Defense/Health Affairs(DoD/HA):
The division of the Department of Defense responsible for the operation and oversight of the U.S. Armed Forces' military health services system.
 
Dependent:
Any spouse or child of an active duty retired, deceased active-duty or retired person of the uniformed services.
 
Emergency Room:
A facility that handles medical situations that are "life or limb threatening" in nature and require immediate medical attention.
 
Enrollee:
A beneficiary, active duty or retired, who is enrolled in the TRICARE Prime program.
 
Enrollment Fee:
A fixed amount that retired beneficiaries and their family members are required to pay to enroll in the TRICARE Prime benefit plan.
 
Explanation of Benefits EOB):
A statement issued by the claims processor explaining how a claim was paid.
 
Health Benefits Advisor(HBA):
A federal government employee who helps beneficiaries with questions about CHAMPUS, care in the Military Treatment Facility and claims issues.
 
Health Care Finder(HCF):
Health Care Finders are registered nurses who are employees of * Sierra Military Health Services. HCFs primarily assist beneficiaries in locating network providers, providing referrals and helping to facilitate appointments for beneficiaries in certain circumstances. HCFs will be located at all TRICARE Service Centers in addition to 24 hour toll free telephone availability.
 
Health Care Financing Administration(HCFA):
HCFA was created to combine under one administration the oversight of the Medicare program, the federal portion of the Medicaid program and related quality assurance activities. Today, HCFA serves 68 million Americans through Medicare and Medicaid; approximately one quarter of the U.S. population.
 
Health Maintenance Organization(HMO):
An HMO is a "prepaid" plan (such as TRICARE Prime) that uses a highly qualified, select network of healthcare providers. An HMO usually offers a full range of services, and often emphasize preventive care.
 
Hospice:
An entity that provides supportive care to the terminally ill.
 
Lead Agent:
Lead Agents are military personnel responsible for oversight of a specific Managed Care Support(MCS) Region. A Lead Agent represents the interests of the MTFs in the MCS Region and will work with the contractor * Sierra Military Health Services for Region(1) to ensure that the needs and expectations of that Region are being satisfied.
 
Medicare:
The national health program through which certain medical and hospital expenses are paid for from Federal (mainly social security) funds. The program is open to individuals over the age of 65 and individuals with permanent disabilities.
 
Medicare Subvention:
The proposed Medicare subvention program would reimburse the Department of Defense(DoD) for health care services provided through DoD facilities to retired military beneficiaries who are Medicare-eligible. If Medicare subvention were to be implemented,those individuals about to turn 65, who meet the requirements of a Medicare-eligible military beneficiary, would have the option of continuing their care through the TRICARE Prime program instead of being required to use Medicare.
 
Military Health System(MHS):
The total health care system of the United States uniformed services. MHS includes military treatment facilities (MTFs), as well as various programs in the civilian healthcare market, such as CHAMPUS.
 
Military Treatment Facility(MTF):
A DoD operated clinic or hospital located on a military base that renders care to military personnel, their dependents and military retirees and their dependents.
 
Network Provider:
A CHAMPUS certified network provider contracted to provide services to individuals enrolled in TRICARE Prime.
 
Non-Participating Provider:
A provider who decides not to accept the CHAMPUS-determined allowable charge as the full fee for care. Payment for the service goes directly to the patient in this case and the patient must pay the bill in full.
 
Other Healthcare Insurance(OHI):
Any non-CHAMPUS health insurance available to you or other members of your family through employment or other source.
 
Point-of-Service(POS):
For TRICARE Prime enrollees, you have what’s called a "point-of-service" (POS) option. This means that you can choose to get TRICARE-covered non-emergency services outside the Prime network of providers without a referral from your Primary Care Manager and without authorization from the Health Care Finder (HCF). However, if you choose to get care under the POS option, there’s an annual deductible (for both inpatient and outpatient care)of $300 for an individual and $600 for a family. After the deductible is satisfied, your cost-share will be 50 percent of the TRICARE allowable charge. Any additional charges by non-network providers are also your responsibility: up to 15 percent above the allowable charge, as permitted by law. POS cost-sharing may also apply to services you received from a Prime network provider if you didn’t get the required advance authorization for the care. Because of the increased costs associated with point-of-service care, you should seriously consider contacting your Primary Care Manager (PCM) to get authorization before getting care outside the network. The POS option does not apply to TRICARE Extra or TRICARE Standard.
 
Preferred Provider Organization(PPO):
A Preferred Provider Organization (such as TRICARE Extra)is a network of health care providers who agree to provide patient care at a discounted or fixed cost to a health plan or beneficiaries in order to be a part of the network of providers. Generally, customers have the ability to choose from any of the providers in the network.
 
Preventive Care:
Concept of health care in which an emphasis is placed on beneficiary education and on early detection of medical conditions. This usually includes encouraging routine physical examinations, diagnostic tests, immunizations and physical conditioning programs.
 
Primary Care Manager(PCM):
A Primary Care Manager (or provider) provides basic or general health care. Traditionally, these are family or internal medicine providers and pediatricians.
 
Quality Management Program:
The functions, including, but not limited to,credentialing and certification of providers, review and audit of medical and other records, outcome rate reviews,peer review and provider appeals and grievance procedures performed or required by an HMO, a payor or any other permitted person or entity to review and improve the quality of covered medical services rendered to beneficiaries.
 
Sponsor:
The member of the family who is or was in one of the uniformed services. CHAMPUS uses the Social Security Number (SSN) or authorization number of the sponsor or the veteran to identify claims.
 
TRICARE:
The triple-option Department of Defense health care program which relies on a commercial contractor to develop and manage a private sector network of healthcare providers and service. This network is utilized by CHAMPUS beneficiaries when care is not readily available in the Military Treatment Facility(MTF).
 
TRICARE EXTRA:
A preferred provider option through which, rather than an annual fee, a yearly deductible is charged. Health care is delivered through a network of civilian health care providers who accept payments from CHAMPUS and provide services at negotiated, discounted rates (seePPO).
 
TRICARE PRIME:
An HMO type plan in which enrollees receive health care through a Military Treatment Facilities PCM or a supporting network of civilian providers (see HMO).
 
TRICARE Service Center(TSC):
TRICARE Service Centers are offices located in or near an MTF which provide information about the TRICARE program. TSCs,which are operated by a private contractor such as * Sierra Military Health Services. TSCs will be staffed with Health Care Finders, Beneficiary service Representatives and other personnel to assist beneficiaries in facilitating access to care, enrolling in the TRICARE program and obtaining information about the program.
 
TRICARE STANDARD:
Also known as an Indemnity Plan, the Standard CHAMPUS program provides greater personal choice in the selection of a medical provider. A Fee-for-Service Plan, such as TRICARE STANDARD, requires higher individual out-of-pocket costs than one would pay under a managed care plan, including a PPO (Preferred Provider Organization) or an HMO (Health Maintenance Organization).
 
Utilization Management Program:
The functions, including but not limited to, prior referral authorization, prospective, concurrent, retrospective review, case management and discharge planning, performed or required by * Sierra Military Health Services, a payor, or any other permitted person or entity, to review and determine whether medical services or supplies which have been or will be provided to beneficiaries are covered under a benefit program and meet the criteria as medically necessary.
 
NOTE: See the Military Health System web page for an addition TRICARE Glossary.
* Sierra Military Health Services is a Northeast Region(1) TRICARE provider.

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