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All Glossary Entries

Active Duty
Active Duty

A person currently serving in the uniformed services.

Adopted Child
Adopted Child

A child legally taken into your family and treated as your own. In the case of adoption, TRICARE eligibility begins as of 12:01 a.m. of the day of the final adoption decree. (Note: There is no TRICARE benefit entitlement during any interim waiting period.)

All-inclusive Per Diem Rate
All-inclusive Per Diem Rate

A negotiated rate that includes the daily charge for hospital care and unless specifically excepted, all other hospital treatment a patient needs.

Allowable Cost
Allowable Cost

TMA determines a level of payment to providers based on one of the approved reimbursement methods set forth in Chapter 14 of the TMA Regulations. "Allowable cost" is also called the "TMA-determined reasonable cost."

Amount Allowed
Amount Allowed

See TRICARE maximum allowable charge.

Amount Billed
Amount Billed

The amount billed on a claim is the provider's charge for healthcare treatment or supplies. The dollar amount varies depending on the physician, the area of the country and whether or not the provider is a certified (authorized) TRICARE provider who has agreed to charge certain rates.

Amount Paid by Beneficiary
Amount Paid by Beneficiary

Claim amount you pay after payment by other sources (other insurance companies) and by TRICARE. The amount you must pay includes your deductible, cost-shares and copayments.

Amount Paid by Government or Government Contractor
Amount Paid by Government or Government Contractor

Claim amount to be paid by the government and /or government contractor.

Amount Paid by Other Sources
Amount Paid by Other Sources

The claim amount to be paid by other sources such as other insurance companies.

Ancillary Providers
Ancillary Providers

Participating providers (other than doctors or hospitals) of such services as physical therapy, skilled nursing and home healthcare.

Ancillary Services
Ancillary Services

Necessary supplemental services (such as laboratory, radiology and physical therapy) you receive as part of appropriate medical treatment.

Appealable Issue
Appealable Issue

Appealable issues are disputed questions of fact. When an appeal is successful, TMA authorizes benefits or approves a provider as certified (authorized). If no TMA benefits would be payable or if there is no certified (authorized) provider, an appealable issue does not exist--regardless of how disputed facts are resolved.

Appealing Party
Appealing Party

TRICARE beneficiaries or the participating provider of services may appeal the initial decision on a claim. The beneficiary may appoint, in writing, a representative for the appeal or hearing. Only the beneficiary or provider receiving payment may appeal claims--no representative may be appointed.

Appeals Process (Reconsideration)
Appeals Process (Reconsideration)

In the appeals process, other healthcare professionals (peers) carefully review the Managed Care Support Contractor's (MCSC) decisions about healthcare services.

Authorization for Care
Authorization for Care

An authorization for care indicates that the treatment your provider requests for you is medically necessary, will be delivered in the appropriate setting, is a TMA and/or TRICARE benefit and will be cost-shared by DoD through its MCS contract.

Authorization to Disclose
Authorization to Disclose

Your formal permission that PGBA, LLC may show and discuss your healthcare claims with other people of your choice.

Average Length of Stay
Average Length of Stay

Average number of days a patient (excluding newborns) is in the hospital during a given period.

Balance Billing
Balance Billing

"Balance Billing" means the provider bills you for all charges not paid by TRICARE. The bill may include charges above the TRICARE maximum allowable charge, not covered by TRICARE or considered medically unnecessary. Your only responsibility is to pay the deductible, cost-share or copayment. EXCEPTION: an authorized non-participating provider can charge you 15 percent above the TRICARE maximum allowable charge. You must then pay the 15 percent in addition to your normal cost-share.

Base Realignment and Closure Site (BRAC)
Base Realignment and Closure Site (BRAC)

A BRAC site is a military base that has been closed or targeted for closure by the Base Realignment and Closure Commission. TMA may authorize additional healthcare benefits for you if you are living in the area when the base closes.

Beneficiary Counseling and Assistance Coordinator (BCAC)
Beneficiary Counseling and Assistance Coordinator (BCAC)

Military or government employee, usually located at the Military Treatment Facility (MTF), who can address healthcare issues and concerns. Formerly known as a Health Benefits Advisor (HBA). TMA's Web site explains how a BCAC can help you.

Beneficiary Service Representative (BSR)
Beneficiary Service Representative (BSR)

A Managed Care Support Contract (MCSC) employee, available by phone and in person at the TRICARE Service Centers (TSCs), who will discuss TRICARE benefits, questions and problems.

Beneficiary (Bene)
Beneficiary (Bene)

A person eligible for medical benefits paid by the Department of Defense, either in a Military Treatment Facility (MTF) or other certified (authorized) TRICARE location.

Billed Charges
Billed Charges

The dollar amount that providers of service submit as their fee for service or supplies you have received.

Capital and Direct Medical Education (CAP DME)
Capital and Direct Medical Education (CAP DME)

PGBA, LLC pays this additional annual amount to hospitals. Capital and Direct Medical Education (CAP DME) is based on capital costs, the cost of medical education as reported to HCFA and the number of Diagnosis Related Group (DRG) days for TRICARE beneficiaries.

Case Management
Case Management

Through case management, Managed Care Support Contractors (MCSC) and Military Treatment Facilities (MTF) work together to coordinate healthcare to meet each person's needs. The goal is to provide access to high-quality, cost-effective healthcare by using available resources wisely.

Catastrophic Cap (Cat Cap)
Catastrophic Cap (Cat Cap)

A catastrophic cap is a maximum out-of-pocket expense a family will pay during a specified time period. After deductibles are reached, beneficiaries still must pay out-of-pocket expenses in the form of cost-shares and/or copayments. These expenses are accrued for a year. If at any time during that year the out-of-pocket maximum amount is reached, the family no longer will have out-of-pocket expenses (deductibles, cost-shares or copayments) on covered services for the rest of that year.

Catchment Area
Catchment Area

The area defined by U.S. Postal Service ZIP Codes within a 40-mile radius of a Military Treatment Facility (MTF).

CBSA
CBSA

CBSA is the acronym for Core-Based Statistical Area. The CBSA code should be used in block 39 of the UB-04 claim form for Home Health Agency Prospective Payment System (HHA/PPS) claims.

Charge
Charge

See Amount Billed.

Claim
Claim

A claim is any request for payment for services given to treat a disease or injury. The request may come from you (the beneficiary), your representative or a network or non-network provider. It may be submitted to a TRICARE FI/Contractor on any TRICARE-approved claim form or electronic media. Types of claims and/or data records include Institutional, Inpatient Professional Services, Outpatient Professional Services (Ambulatory), Drug, Dental and Extended Care Health Option (ECHO).

Claims Processor
Claims Processor

A company (such as PGBA, LLC) that adjudicates and processes TRICARE claims and provides customer service. Also known as a fiscal intermediary.

Concurrent Review and Continued Stay Review
Concurrent Review and Continued Stay Review

These two terms describe a Managed Care Support Contractor's (MCSC) review of services while they are being performed. "Concurrent Review" applies to any level of ongoing care (including outpatient care) to ensure the patient is progressing as expected. "Continued Stay Review" is an evaluation of whether or not a patient needs to stay in the hospital. A Registered Nurse usually performs these reviews using criteria approved by TMA.

Continued Health Care Benefit Program (CHCBP)
Continued Health Care Benefit Program (CHCBP)

Temporary healthcare benefits that may be purchased to cover the period immediately after a person is released from active duty. This program is not for retirees.

Continuity of Clinical Care
Continuity of Clinical Care

The provision of care by the same set of clinicians to a member over time or, if the same providers are not available over time, a way of providing appropriate clinical information in a timely fashion to the clinicians who continue to provide the same type and level of care.

Coordination of Benefits (COB)
Coordination of Benefits (COB)

When you have a health insurance policy in addition to TRICARE, your Other Health Insurance (OHI) pays for your healthcare first. TRICARE coverage is secondary. Through "Coordination of Benefits (COB)," TRICARE cooperates with your other insurance company to determine how to pay your claim.

Copayment (Copay)
Copayment (Copay)

The copayment is the portion of a claim or medical expense a Prime patient must pay out-of-pocket. This is a flat-dollar amount instead of a percentage of the total cost. You pay it directly to the provider for a prescription or medical service--usually at the same time you receive service.

Cost-share
Cost-share

The portion of the allowable charge for medical services that you pay.Your cost-share is one of your out-of-pocket expenses.

Covered Service
Covered Service

Covered services are healthcare services the government and Managed Care Support Contractors (MCSC) have agreed to pay for you. Some services must meet specific requirements before they will be paid.

Credentialing
Credentialing

"Credentialing" means we review information about providers before they can bill TRICARE or join the network. We examine documentation (including licensure, certifications, insurance and malpractice history) and verify that all information is correct.

Criteria
Criteria

Criteria is statistical data that healthcare professionals use to help them decide when and what treatment is appropriate, where it should be given and who should give it.

Current Procedural Terminology 4th Edition (CPT-4)
Current Procedural Terminology 4th Edition (CPT-4)

Numerical codes corresponding to the procedures and services. The codes are listed in the Current Procedural Terminology Book-4th Edition (CPT-4). Also known as Level I HCPCS codes.

Date Billed
Date Billed

Date the institution or provider billed the Managed Care Support Contractor (MCSC) on a claim for services.

Date of Claim
Date of Claim

Date the TRICARE claims processor received the claim from a provider or institution.

Date of Service
Date of Service

Date the institution or provider gave the services and supplies.

Debt Collection Assistance Officer (DCAO)
Debt Collection Assistance Officer (DCAO)

Person who will help you resolve any outstanding debt collection issues arising from a TRICARE claim. TMA's Web site explains how the DCAO can help you.

Deductible
Deductible

In TRICARE Standard and Extra, your deductible is the portion of healthcare expenses you must pay out-of-pocket before any coverage applies. In TRICARE Prime, you do not have a deductible unless you receive care your Primary Care Manager (PCM) did not arrange. Then you must pay a deductible with the Point-of-Service (POS) option.

Defense Enrollment Eligibility Reporting System (DEERS)
Defense Enrollment Eligibility Reporting System (DEERS)

The government's computerized database listing all active duty and retired military sponsors and their dependents. We use DEERS to verify eligibility for TRICARE benefits.

Demonstration
Demonstration

Congressionally authorized pilot projects to improve access to care and save money. An example is the Department of Defense (DoD) Cancer Trials Demonstration Project.

Denial of Authorization
Denial of Authorization

The decision that proposed or already provided treatment will not be reimbursed by DoD.

Denial of Benefits
Denial of Benefits

Denial of benefits means that the DoD will not pay for the services billed on a claim. This happens when the services do not appear medically necessary, when the same care can be provided just as safely and effectively in a less costly setting or when the care is not covered under the patient's healthcare plan.

Diagnosis Related Group (DRG)
Diagnosis Related Group (DRG)

Diagnosis Related Group (DRG) is a system of classifying patients statistically. It compares the demographic, diagnostic and therapeutic characteristics of patients to their length of stay in the hospital and the amount of resources they use. The DRG's statistical classification of illnesses and injuries helps insurance companies determine ahead of time what payments are most likely appropriate.

Diagnosis (ICD-9 or Dx)
Diagnosis (ICD-9 or Dx)

A word or phrase describing a disease or problem for which you need, seek or receive healthcare. The numerical codes corresponding to the words are listed in the International Classification of Diseases, 9th Revision (ICD-9).

Direct Care
Direct Care

Medical care provided by Military Treatment Facilities (MTF).

Discharge Planning
Discharge Planning

In discharge planning, the Managed Care Support Contractor (MCSC) develops a care regimen for a patient leaving the hospital, including follow-up examinations and treatment.

Disengagement
Disengagement

Disengagement happens when the Military Treatment Facility (MTF) lacks the capability or the services necessary to provide treatment for a non-active duty patient for a single episode of care. Before disengagement, the MTF explains alternative sources of care and costs to the patient or the sponsor.

Disenrollment
Disenrollment

Disenrollment is termination of TRICARE Prime coverage. Voluntary disenrollment occurs when a member quits because he or she simply wants out. Involuntary disenrollment includes such cases as leaving the plan because of changing jobs.

Durable Medical Equipment (DME)
Durable Medical Equipment (DME)

Durable Medical Equipment (DME) is "durable" rather than "disposable"--that is, it can be used repeatedly--and is only used to care for a medical condition. Examples include wheelchairs and home hospital beds. Obtaining durable medical equipment may require authorization.

Elective Admission
Elective Admission

Elective Admission to a hospital is for medically necessary treatment that can be scheduled or planned.

Electronic Data Interchange (EDI)
Electronic Data Interchange (EDI)

Electronic Data Interchange (EDI) is an automated method of submitting claims for payment of medical services or supplies.

Electronic Remittance Advice (ERA)
Electronic Remittance Advice (ERA)

ERA allows providers to receive information concerning remits in an electronic format. ERA provides details on how claims were paid and/or why they were denied.

Emergency
Emergency

An emergency is a sudden or unexpected condition or the acute worsening of a chronic condition that threatens life, limb or sight and requires immediate medical treatment to relieve suffering. Medical emergencies include heart attacks, poisoning, convulsions, kidney stones and other acute conditions. Pregnancy-related medical emergencies involve a sudden or unexpected medical complication that puts the mother, the baby or both at risk.

End Stage Renal Disease (ESRD) Treatment Facility
End Stage Renal Disease (ESRD) Treatment Facility

Facility that cares for patients with End Stage Renal Disease (ESRD).

Enrollment Portability
Enrollment Portability

Enrollment Portability allows TRICARE Prime enrollees to transfer healthcare coverage to another TRICARE Prime region.

Explanation of Benefits (EOB or TEOB)
Explanation of Benefits (EOB or TEOB)

When your claim for TRICARE coverage is paid or denied, you will receive a TRICARE Explanation of Benefits (TEOB). This statement shows you exactly how a claim was paid and tells you the reason when a claim is denied.

Extended Health Care Option (ECHO)
Extended Health Care Option (ECHO)

The Extended Health Care Option (ECHO) replaces the Program for Persons with Disabilities (PFPWD) benefit. It is a supplemental program to TRICARE and provides financial assistance to active duty family members (dependents). ECHO provides services and supplies to assist with a disabling condition when help is not available through public resources. ECHO provides medically necessary skilled services to eligible homebound beneficiaries whose needs exceed the limits of the Home Health Agency Prospective Payment System (HHA/PPS). ECHO Respite Care provides assistance to caregivers.

Fee-For-Service (FFS)
Fee-For-Service (FFS)

A method of paying practitioners service-by-service rather than a salary.

Fiscal Year (FY)
Fiscal Year (FY)

The Federal government's 12-month accounting period from 1 October to 30 September of the following year.

Fraud
Fraud

Fraud is defined as 1) a deception or misrepresentation by a provider, sponsor, or beneficiary or any person acting on behalf of a provider, sponsor, or beneficiary who knew, had reason to know or should have known that the deception or misrepresentation could result in unauthorized TMA payment. If a deception or misrepresentation is established and a TMA claim is filed, it is presumed the person responsible for the claim had the requisite knowledge. This presumption may be rebutted by substantial evidence. It is further presumed that the provider of the services is responsible for the actions of all individuals who file a claim on behalf of the provider (for example, billing clerks). This presumption may only be rebutted by clear and convincing evidence.

Grievance
Grievance

In a grievance, you express your dissatisfaction with a provider or service in writing.

Health Care Finder (HCF)
Health Care Finder (HCF)

Health Care Finders (HCFs) are available at TRICARE Service Centers (TSCs) to help you find the care you need. HCFs work with your Primary Care Manager (PCM) and make appointments for you with providers in the Military Treatment Facility (MTF) or contractor network. HCFs are generally registered nurses, and they may also authorize certain medical procedures, physician referrals, hospital admissions and other medically necessary treatments.

Health Care Procedure Coding System (HCPCS)
Health Care Procedure Coding System (HCPCS)

Numerical codes corresponding to medical procedures and services. The Health Care Procedure Coding System (HCPCS) includes CPT-4 codes, but also has Level II codes for services not included in the CPT-4 book, such as ambulance. While HCPCS is nationally defined, claims processors can create certain Level III codes in order to process claims for new services until national codes are updated.

Health Enrollment Assessment Review Form (HEAR)
Health Enrollment Assessment Review Form (HEAR)

A confidential questionnaire about your current health status and habits. The information helps your Primary Care Manager (PCM) develop a whole health plan for you.

Health Insurance Portability and Accountability Act (HIPAA)
Health Insurance Portability and Accountability Act (HIPAA)

The HIPAA Act of 1996 was passed to ensure patients' Protected Health Information (PHI), guard against healthcare fraud and abuse, and simplify communications in the healthcare industry. Find out more about HIPAA and how it affects you.

HHA/PPS
HHA/PPS

Home Health Agency Prospective Payment System

Hospice Program
Hospice Program

A program providing physical care and psychological support to terminally ill patients and their families or significant others, in both the home and hospital

ICD-9 Codes
ICD-9 Codes

ICD-9 Codes are a uniform system for coding and reporting the diagnoses of diseases and injuries. They are presented in the three-volume International Classification of Diseases, 9th Revision (ICD-9).

Immediate Family
Immediate Family

Healthcare providers may not deliver services to members of their immediate family. Immediate family is defined as the spouse, natural parent, child and sibling, adopted child and adoptive parent, stepparent, stepchild, grandparent, grandchild, stepbrother and stepsister, father-in-law or mother-in-law of the beneficiary or provider, as appropriate. The step-relationship continues to exist even if the marriage upon which the relationship is based ends through divorce or death of one of the parents.

Level of Care
Level of Care

The level of care is the degree of services needed to improve a patient's condition quickly and effectively, with the least risk. The level describes the seriousness or "intensity" of care. The more serious or intensive the care, the more costly it is.

Licensure
Licensure

A state's legal permission for a healthcare professional to practice or a hospital to operate in that state. Licensure is based on specific state requirements for healthcare practitioners and institutional providers.

Managed Care Support Contractor (MCSC)
Managed Care Support Contractor (MCSC)

The government selects a civilian healthcare organization to serve as the Managed Care Support Contractor (MCSC) for TRICARE in a specific region. This contractor supplements all military direct care for TRICARE beneficiaries in the region. The contractor also provides managed care support to TRICARE Prime members and organizes the Preferred Provider Network (PPN).

Medically Necessary
Medically Necessary

The term "medically necessary" describes the kinds of services and supplies healthcare professionals need to diagnose and treat illness or injury properly. It also applies to how long and how much a patient needs such services and supplies to receive essential medical care.

Medicare Summary Notice (MSN)
Medicare Summary Notice (MSN)

This is also known as a Medicare Explanation of Benefits. This statement shows you exactly how a claim was paid and tells you the reason when a claim is denied.

Military Health System (MHS)
Military Health System (MHS)

The total healthcare system of the U.S.uniformed services. The Military Health System (MHS) includes Military Treatment Facilities (MTF) as well as various programs for civilian healthcare, like TRICARE.

Military Medical Support Office (MMSO)
Military Medical Support Office (MMSO)

The MMSO helps to ensure TRICARE members receive the health care services for which they are eligible. The MMSO, located in Great Lakes, Illinois serves as the centralized Tri-service point of contact, providing customer service, overseeing medical and dental care, and coordinating civilian health care services.

Military Treatment Facility (MTF)
Military Treatment Facility (MTF)

A military facility that provides medical and/or dental care to eligible people.

National Drug Code (NDC)
National Drug Code (NDC)

Drug products are identified and reported using a three-segment number called a National Drug Code (NDC). An NDC is a universal product identifier for human drugs.

National Practitioner Data Bank (NPDB)
National Practitioner Data Bank (NPDB)

Congress set up the National Practitioner Data Bank (NPDB) to collect information about physicians and dentists in one place.The data bank contains "reportable" information, including malpractice litigation claims, DEA offenses, Medicare/Medicaid sanctions and disciplinary actions by state medical boards or the military.

National Provider Identifier (NPI)
National Provider Identifier (NPI)

National Provider Identifier (NPI) is a 10-digit identification number that the federal government assigns to healthcare providers. It is one of the simplifications of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) intended to reduce fraud and improve the efficiency of the healthcare system.

National Quality Monitoring Contractor (NQMC)
National Quality Monitoring Contractor (NQMC)

A national contractor, responsible to DoD and TMA, that performs third level reconsiderations when payment denials are appealed.

Neonate
Neonate

An infant from birth to 4 weeks (28 days) of age.

Network Providers
Network Providers

The network providers are a group of military and civilian healthcare providers who have agreed to provide services or supplies to TRICARE Prime and Extra beneficiaries at a negotiated rate. The TRICARE network includes doctors, hospitals, pharmacies and other healthcare professionals. Network providers handle claims and other paperwork for you, and the claims processor pays them directly. Network providers adhere to TRICARE standards of quality and follow other requirements of the TRICARE Program.

Non-Acute Days
Non-Acute Days

Non-acute days are days in the hospital that are not medically necessary or that have not been documented as necessary by a physician. As a result, reimbursement for those days in a hospital is denied.

Nonavailability Statement (NAS)
Nonavailability Statement (NAS)

A Nonavailability Statement (NAS) certifies that the nonemergency inpatient mental healthcare cannot be provided at the Military Treatment Facility (MTF). Therefore, a standard beneficiary can seek care from a civilian provider.

Other Health Insurance (OHI)
Other Health Insurance (OHI)

Any source of healthcare coverage you have other than TRICARE. Other Health Insurance (OHI) includes group employers, associations or private insurers. OHI does not include TRICARE Supplemental Insurance or Medicaid.

Out-of-Pocket Expense
Out-of-Pocket Expense

The amount of money you must pay. This includes your enrollment fees, cost-shares, deductibles, copayments, and any extra expenses incurred when you use your Point-of-Service (POS) option or visit an authorized, non-participating provider.

Outpatient Prospective Payment System (OPPS)
Outpatient Prospective Payment System (OPPS)

OPPS is a prospective payment system for reimbursement of hospital outpatient services. Providers must follow all Medicare specific coding requirements in order to receive TRICARE reimbursement under OPPS.

Point-of-Service Option (POS)
Point-of-Service Option (POS)

This special type of coverage applies only when a member of TRICARE Prime receives non-emergency care not coordinated by his or her Primary Care Manager (PCM). The Point-of-Service (POS) option allows a Prime member the freedom of choosing. However, when using this option, the member must also pay cost-share and deductibles.

Portability
Portability

See Enrollment Portability.

Primary Care Manager (PCM)
Primary Care Manager (PCM)

In TRICARE Prime, your Primary Care Manager (PCM) is your principal provider for routine medical needs. Your PCM refers you for tests or specialty care and monitors the quality of care you receive. Usually PCMs are physicians, but some are physician assistants, nurse practitioners and independent duty corps members practicing under the supervision of a physician. When your PCM coordinates your care, you enjoy maximum Prime coverage benefits.

Prior Authorization or Pre-Authorization (Pre-Auth)
Prior Authorization or Pre-Authorization (Pre-Auth)

For certain procedures, you must obtain authorization before you receive healthcare in order to be reimbursed by TRICARE. This authorization indicates the care or procedure is medically necessary and the proposed location for delivery of that care is appropriate. Preauthorization does not prevent the possibility that a later review of the medical record will result in a different determination. The preferred location for care is the Military Treatment Facility (MTF).

Prospective Review
Prospective Review

A prospective review evaluates a request for medical treatment before you receive the treatment. This usually occurs when your provider requests non-emergency admission to a hospital or specific procedures that require pre-treatment certification and authorization.

Provider Network
Provider Network

The Provider Network is an organization of providers who agree to accept the TRICARE maximum allowable charge as payment in full and submit claims for you. The Managed Care Support Contractor (MCSC) coordinates the provider networks in each region.

Provider, authorized, non-participating
Provider, authorized, non-participating

TRICARE-certified (authorized) non-network providers can either accept assignment or choose not to accept assignment on a claim by claim basis. If they do not accept assignment, they may bill you up to 115% of TRICARE maximum allowable charge for services.

Provider, authorized, participating
Provider, authorized, participating

TRICARE-certified (authorized) healthcare providers who agree to accept the TRICARE maximum allowable charge and submit claim forms for you.

Provider, non-authorized, non-participating
Provider, non-authorized, non-participating

Healthcare providers who are not TRICARE-certified (authorized). When you visit a non-authorized, non-participating provider you are responsible for the entire bill.

Recredentialing
Recredentialing

Periodically, we review the credentials of our contracted healthcare providers. We analyze current information to verify that they continue to meet TRICARE standards.

Referral
Referral

In TRICARE Prime, your Primary Care Manager (PCM) gives you a referral to a specialist when you need medical care that your PCM does not offer.

Regional Director
Regional Director

The Regional Director (Formerly known as Lead Agent)is responsible for administering a TRICARE Health Service Region. The Regional Director may also be the commander of a major medical facility located in the area. The Regional Director's office works with the other Military Treatment Facility (MTF) commanders within the region to develop an integrated plan for delivering healthcare to beneficiaries.

Resource Sharing
Resource Sharing

With resource sharing, a Military Treatment Facility (MTF) commmander and a Managed Care Support Contractor (MCSC) agree to provide or share equipment, supplies, facilities or staff. This program improves the MTF's capabilities to provide you with the care you need.

Retiree
Retiree

A member or former member of a Uniformed Service who is entitled to retired, retainer or equivalent pay and other benefits based on duty in a Uniformed Service.

Retrospective Review
Retrospective Review

An evaluation to determine if the care received was appropriate and within TRICARE standards. By examining the actual record of treatment, the retrospective review validates utilization decisions made during the review process and/or validates payment for the care.

Skilled Care
Skilled Care

"Skilled Care" describes medical services that must be performed by or under the direct supervision of a Registered Nurse or licensed professional, such as a physical therapist or occupational therapist.

Special Checks
Special Checks

The Managed Care Support Contractor (MCSC) may issue checks outside the normal workflow for very high dollar claims and other very unusual circumstances.

Specialist
Specialist

A doctor other than a Primary Care Manager (PCM), usually contracted with TRICARE, who provides professional services your PCM does not offer. Your PCM must refer you to the specialist.

Specialized Treatment Services Facilities (STSF)
Specialized Treatment Services Facilities (STSF)

For certain high technology or high cost procedures, you may be referred to a Specialized Treatment Services Facility (STSF). The government has established regional, multi-regional and national STSFs. If you choose not to use an STSF when one is designated and available, you will be responsible for a higher portion or all of the cost of the care.

Split Enrollment
Split Enrollment

Split Enrollment allows family members to enroll in Prime even if they do not live together in the same TRICARE region. Be sure to follow the rules for this program carefully because different Managed Care Support Contractors (MCSC) are responsible for different regions.

Sponsor
Sponsor

The person who has TRICARE benefits because of his or her own military service status rather than the status of another person.

Supplemental Health Care Program (SHCP)
Supplemental Health Care Program (SHCP)

Under the Supplemental Health Care Program (SHCP), active duty members may receive referrals and authorization to use civilian healthcare providers.

Third Party Liability (TPL)
Third Party Liability (TPL)

Third Party Liability (TPL) is the responsibility of another party for damages to the injured TRICARE beneficiary. When we review a claim, any indication of the following will result in the assumption that TPL is present: (1) Any automobile accident; (2) Statements that indicate another party may be held accountable for damages; (3) Name of an attorney listed on the DD Form 2527 (Third Party Liability Form).

Transitional Assistance Management Program (TAMP)
Transitional Assistance Management Program (TAMP)

The Transitional Assistance Management Program (TAMP) offers transitional TRICARE coverage to certain separating active duty members and their eligible family members. Care is available for a limited time.

TRICARE
TRICARE

TRICARE (formerly CHAMPUS) is the Health Services and Support program for DoD beneficiaries. Through the three TRICARE programs (Standard, Extra and Prime), Military Treatment Facilities (MTF) and civilian providers work as partners to help control the overall cost of healthcare. TRICARE is administered by regional Managed Care Support Contractors (MCSC) to provide you with an appropriate balance of cost, access and quality.

TRICARE Contractor
TRICARE Contractor

The government selects a civilian healthcare organization to serve as Managed Care Support Contractor (MCSC) for TRICARE in a specific region. This contractor supplements all military direct care for TRICARE beneficiaries in the region. The contractor also provides health services and support to TRICARE Prime members and organizes the Preferred Provider Network (PPN).

TRICARE Explanation of Benefits (TEOB)
TRICARE Explanation of Benefits (TEOB)

The TRICARE Explanation of Benefits (TEOB) shows exactly how and why a claim was or was not paid. It is also called an "EOB."

TRICARE Extra
TRICARE Extra

As a TRICARE Standard beneficiary, you can participate in TRICARE Extra simply by choosing to see a provider in the Preferred Provider Network (PPN). TRICARE Extra does not require enrollment, and you enjoy a lower cost-share by using a network provider.

TRICARE For Life (TFL)
TRICARE For Life (TFL)

A Medicare supplement entitlement for Medicare-eligible military retirees and their dependents over 65 who are enrolled in Medicare Part B. TRICARE For Life (TFL) became effective October 1, 2001.

TRICARE Mail Order Pharmacy Program (TMOP)
TRICARE Mail Order Pharmacy Program (TMOP)

A convenient pharmacy benefit for eligible beneficiaries. You can enjoy a three-month supply per copayment on most prescriptions. Certain restrictions apply. Please visit the Express Scripts Web site for further information.

TRICARE Maximum Allowable Charge
TRICARE Maximum Allowable Charge

The dollar amount TMA allows on a claim for services and supplies. The government sets a base rate, then adjusts it to determine what is allowed. Adjustment amounts vary depending on the provider, the area of the country and whether or not the provider is TRICARE-certified (authorized) and has agreed to charge certain rates.

TRICARE Prime
TRICARE Prime

TRICARE Prime works like a civilian Health Maintenance Organization (HMO) to control costs. You are assigned a Primary Care Manager (PCM) at the Military Treatment Facility (MTF). (In some areas, PCMs are civilian network providers.) Your PCM handles all of your routine healthcare. When you need care your PCM does not offer, he or she will give you a referral. Then the Managed Care Support Contractors (MCSC) finds the most appropriate provider and location for your additional care. With TRICARE Prime, you enjoy expanded healthcare benefits in addition to the core benefits. You also have the freedom to choose civilian providers (at a higher cost) when you use the Point-of-Service (POS) option.

TRICARE Prime Network Providers
TRICARE Prime Network Providers

TRICARE Prime Network Providers have signed a contract with the Managed Care Support Contractor (MCSC) agreeing to offer healthcare services and supplies to beneficiaries at a negotiated rate. These providers also submit claims for beneficiaries.

TRICARE Prime Remote (TPR)
TRICARE Prime Remote (TPR)

A special version of the TRICARE benefit for active duty service members and their eligible family members who live and work a great distance from military installations.

TRICARE Region
TRICARE Region

A TRICARE region is a geographical location defined by states and ZIP codes. In each region, a Managed Care Support Contractor (MCSC) organizes the provider network and oversees healthcare.

TRICARE Service Center (TSC)
TRICARE Service Center (TSC)

At the TRICARE Service Center (TSC), you'll find the information you need about TRICARE, Prime enrollment, Health Care Finder (HCF) services and more--all in one place.

TRICARE Standard
TRICARE Standard

TRICARE Standard (also known as "the old CHAMPUS program") provides core healthcare benefits. Standard allows you to see any TRICARE-certified (authorized) non-network civilian providers. You pay an annual deductible and a 25% cost-share of covered treatment and services.

TRICARE Summary Payment Voucher
TRICARE Summary Payment Voucher

Also known as a remittance notice or advice, this statement shows providers how TRICARE claims pay.

TRICARE Supplemental Insurance
TRICARE Supplemental Insurance

TRICARE Supplemental Insurance generally pays what's left over after TRICARE Standard pays your covered benefits. Such a policy may cover certain cost-share amounts.

UB-04
UB-04

Is the claim form hospitals use to send a bill to the claims processor. The UB-04 replaced the UB-92 on March 1, 2007. (UB-92 forms are no longer accepted as of January 1, 2008).

Unbundling or Fragmentation
Unbundling or Fragmentation

"Unbundling" or "fragmentation" means a provider bills or reports the separate parts of a procedure instead of the entire comprehensive procedure. This practice can be considered fraudulent.

Unremarried Former Spouse
Unremarried Former Spouse

A unremarried former spouse of a TRICARE beneficiary who was married for more than twenty years. Find out more of changes in unremarried former spouse benefits.

Urgent Admissions
Urgent Admissions

Urgent admissions are for situations requiring immediate medical attention and hospital admission, but that do not endanger life or permanent health as long as the patient receives care within a reasonable period of time.

Urgent Care
Urgent Care

Urgent care is medical attention for a condition that, while not life or limb-threatening, could become more serious if not treated. For example, eye or ear infections and suspected bladder infections usually require urgent care.

Usual, Customary and Reasonable
Usual, Customary and Reasonable

Insurance companies use a complex fee schedule based on what is "usual, customary and reasonable" to determine payment of a provider's charges.

Utilization Management
Utilization Management

Managed Care Support Contractors (MCSC) and Military Treatment Facilities (MTF) work together to ensure the optimum balance of healthcare access, quality and cost. They coordinate patient care and assist clinicians and members in using medical resources appropriately. Utilization management includes prior authorization, concurrent review, retrospective review, discharge planning and case management.

VA DoD SHARING
VA DoD SHARING

Through VA/DoD Sharing, you use your local Military Treatment Facility (MTF) and VA before seeing a civilian provider. This program holds down healthcare costs by ensuring maximum use of DoD and VA facilities within the same geographical area.

XPressClaim
XPressClaim

Developed by PGBA, LLC, XPressClaim is a secure, streamlined Web-based system that allows providers to submit TRICARE CMS 1500-08/05 claims and UB04 claim forms. In most cases, you'll receive instant results. XPressClaim is the fastest way available to get TRICARE claims processed, and it's free.



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