TRICARE Prime Handbook - Navy Tribe

Table of Contents1.Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6TRICARE Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Your Primary Care Manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Enrollment Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82.Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Making an Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Access Standards for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Routine (Primary) Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Speciality Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Prior Authorizations for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Getting a Second Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Point of Service Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133.Covered Services, Limitations, and Exclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Clinical Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Behavioral Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Maternity Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Dental Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234.Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Health Care Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Pharmacy Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Coordinating Benefits with Other Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Third Party Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Debt Collection Assistance Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285.Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Getting Married or Divorced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Having a Baby or Adopting a Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Going to College . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Moving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Separating from the Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Retiring from Active Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Becoming Entitled to Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Deceased Sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Loss of Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .374

Beneficiary Counseling and Assistance Coordinators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Appealing a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Filing a Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Reporting Suspected Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .417.Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428.Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439.Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45North Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46South Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5010. List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5211. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53For information about your patient rights and responsibilities, see the inside back cover of thishandbook.5SECTION 1Information and Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38CHOOSING TRICARE STANDARD/TRICARE EXTRA6.

Getting StartedTRICARE Provider Typesby the uniformed services—usually located on ornear a military base. To locate an MTF near you,visit www.tricare.mil/mtf.TRICARE defines a provider as a person,business, or institution that provides health care.For example, a doctor, hospital, or ambulancecompany is a provider. Providers must beauthorized under TRICARE regulations and havetheir status certified by the regional contractorsto provide services to TRICARE beneficiaries.Civilian ProvidersFigure 1.1 explains the different types of civilianTRICARE providers.Military Treatment FacilitiesA military treatment facility (MTF) is a medicalfacility (hospital, clinic, etc.) owned and operatedTRICARE Provider TypesFigure 1.1TRICARE-authorized Providers A provider who meets TRICARE’s licensing and certification requirements and has been certified byTRICARE to provide care to TRICARE beneficiaries. TRICARE authorized providers include doctors,hospitals, ancillary providers (laboratories and radiology centers), and pharmacies. If you see a provider whois not TRICARE authorized, you are responsible for the full cost of care. There are two types of TRICARE authorized providers: Network and Non network.Network ProvidersNon-network Providers Network providers have a signedagreement with your regionalcontractor to provide care at anegotiated rate. Networkproviders file claims for you. Non network providers do not have a signed agreement with yourregional contractor and are therefore “out of network.” In most cases, youwill not receive care from non network providers unless approved by yourregional contractor. You may seek care from a non network provider in anemergency or if you are using the point of service (POS) option. You will receive most of yourcare from TRICARE networkproviders. There are two types of non network providers: Participating andNonparticipating.ParticipatingNonparticipating Participating* providers haveagreed to file claims for you, toaccept payment directly fromTRICARE and to accept theTRICARE allowable charge lessany applicable cost shares paid byyou as payment in full for theirservices. Nonparticipating providers havenot agreed to accept theTRICARE allowable charge orfile your claims. If you use thePOS option and seek care from anonparticipating provider, theprovider may charge you up to15% above the TRICAREallowable charge for services (inaddition to POS fees). Thisamount is your responsibility andwill not be shared by TRICARE. Using a participating provider isyour best option if you must visita non network provider. If you visit a nonparticipatingprovider, you may have to pay theprovider first and file a claim withTRICARE for reimbursement.*Providers may decide to participate on a claim by claim basis.6

GETTING CARESECTION 2Many Department of Veterans Affairs (VA) healthcare facilities participate in TRICARE as networkproviders. While VA facilities may or may notprovide primary care, many do provide specialtycare. Be sure to find out the VA facility’s status as aTRICARE network or non network provider beforeyou receive TRICARE covered health care at a VAfacility.SECTION 1A PSA must also have a substantial medicalcommunity to support most or all TRICAREPrime enrolled beneficiary medical needs.GETTING STARTEDDepartment of Veterans Affairs HealthCare FacilitiesOn-Call ProvidersPCMs are required to provide access to care 24hours a day, seven days a week. To cover allhours, your PCM may designate an on callprovider who will act on their behalf to supportyour health care needs. Therefore, theinformation, instructions, care, or carecoordination you receive from the on callprovider should be treated as if it was comingfrom your PCM.Note: Active duty service members who arereferred to a VA medical facility for aservice connected condition must receivehealth care benefits under the VA program.When an active duty service member with aservice connected condition is referred to/beingtreated by the VA, the Department of Defense(DoD) is still responsible for payment for thecare rendered.Changing Your Primary Care ManagerYou may change your PCM at any time providedthe new PCM is accepting new patients and yourrequest complies with local MTF guidelines.Once you have selected a new PCM from yourregional contractor’s provider directory(viewable online at each contractor’s Web site),complete a TRICARE Prime Enrollment andPCM Change Form with the new PCM’s nameand address.Some retired service members may be eligible forboth TRICARE and VA benefits (the VA offershealth care programs separate from TRICARE—refer to the VA Web site at www.va.gov for details),so you will have to choose which program youwant to use. When choosing between TRICAREand VA benefits, carefully compare the costs andthe financial demands of each option to make thebest decision.You only need to complete the portion of theform related to the PCM change. The changewill become effective once the application isreceived and processed by your regionalcontractor. You may also call your regionalcontractor to change your PCM. Once your PCMchange is processed, you will be mailed aconfirmation letter with the new PCM name andtelephone number.Your Primary Care ManagerWhen you enrolled in TRICARE Prime, youselected or were assigned a primary caremanager (PCM). Your PCM provides yourroutine health care and coordinates referrals forspecialty care that he or she cannot provide. YourPCM may be an MTF provider or a civilianTRICARE network provider within a Primeservice area (PSA).A PSA is a geographic area where TRICAREPrime benefits are offered. It’s typically ageographic area around an MTF and specificareas with a significant concentration ofuniformed service personnel and retirees andtheir families.7

Enrollment CardNon-Payment of Enrollment FeesIf you are required to pay enrollment fees andyou do not pay them when due, you will bedisenrolled from TRICARE Prime. Whendisenrolled for non payment, you are subject to a12 month lockout during which you will not bepermitted to re enroll in TRICARE Prime. Toavoid missing an appointment, learn aboutautomatic payment options in the TRICARE:Summary of Beneficiary Costs flyer or contactyour regional contractor.You and each enrolled family member willreceive his or her own TRICARE Primeenrollment card. Included with the card is a letteridentifying your PCM’s name and telephonenumber. Write your PCM’s name and telephonenumber on your card. TRICARE networkproviders may require you to show theenrollment card as well as your uniformedservices identification (ID) or Common AccessCard (CAC) at the time of service. YourTRICARE Prime enrollment effective date isprinted on this card.Becoming Medicare-Eligible at Age 65When you become entitled to premium freeMedicare Part A at age 65, you automaticallylose eligibility for TRICARE Prime andbecome eligible for TRICARE For Life (TFL)if you have Medicare Part B coverage. Visitwww.tricare.mil/tfl for more informationabout TFL.TRICARE: The World’s Best Health Carefor the World’s Best MilitaryTRICARE PRIMEELPName: John Q. SampleStatus: Active Duty SponsorPrimary Care Manager:Primary Care Manager Phone:Effective Date: 01 Jan 2000MASNote: If you are not entitled to premium freeMedicare Part A when you become age 65, youremain eligible for TRICARE Prime, Standard,and Extra, and you are not required to haveMedicare Part B coverage. You must present aSocial Security Administration Letter ofDisallowance to an ID card issuing facility toretain TRICARE coverage.Valid with presentation of current military ID cardContact your personnel office if any of the aboveinformation is incorrect.The TRICARE Prime enrollment card does notverify your eligibility for TRICARE. Only yourDEERS record can verify eligibility.DisenrollmentVoluntary DisenrollmentEnrollment in TRICARE Prime is continuous—you do not have to re enroll every year tomaintain coverage. Certain events will, however,cause you to be disenrolled from TRICAREPrime.If you choose to disenroll from TRICARE Primebefore the annual enrollment renewal date, youare subject to a 12 month lockout,* during whichyou will not be permitted to re enroll inTRICARE Prime. You must contact yourregional contractor to initiate a voluntarydisenrollment.Sponsor Status ChangeActive duty service members must enroll ineither TRICARE Prime or TRICARE PrimeRemote. Voluntary disenrollment is not anoption.Any change in the sponsor’s status (e.g.,retirement or National Guard and Reservemember deactivation) will cause you to bedisenrolled automatically from TRICARE Prime.If you will remain eligible for TRICARE Prime(after the status change), you should submit anew enrollment application to your regionalcontractor before the status change occurs toavoid a lapse in coverage.* The 12 month lockout provision does not apply to activeduty family members of sponsors grade E 1 through E 4.8

SECTION 29GETTING CAREIf your DEERS record is correct and you havelost eligibility, you may qualify for transitionalhealth care. See the Life Events, “Separatingfrom the Service” section for details abouttransitional health care options. You will receivea certificate of creditable coverage whenTRICARE eligibility is lost. See the Life Events,“Loss of Eligibility” section for moreinformation about the certificate of creditablecoverage.SECTION 1If you lose your TRICARE eligibility as shownin DEERS, your TRICARE Prime coverage willend automatically. If you believe you are stilleligible for TRICARE, you will need to updateyour DEERS record to re establish youreligibility. Once DEERS is updated, you mustre enroll in TRICARE Prime, or you will becovered under TRICARE Standard andTRICARE Extra.GETTING STARTEDLoss of Eligibility

Getting CareAdditionally, it is important to understand yourprovider’s specific policies regarding cancelledor missed appointments. Some providers chargea missed appointment fee, which is not coveredby TRICARE. Please be sure to notify yourprovider’s office within the appropriate time,usually 24 to 48 hours prior, if you will not beable to make your scheduled appointment.You receive routine or primary health care fromyour primary care manager (PCM), and yourPCM will refer you to a specialist for necessaryspecialty care. You are guaranteed access to carewithin specific time frames, and you may qualifyfor a travel reimbursement if referred to specialtycare that is more than 100 miles from yourPCM’s office. This section explains these andother details about using TRICARE Prime.Emergency CareMaking an AppointmentTRICARE defines an emergency as a medical,maternity, or psychiatric condition that wouldlead a “prudent layperson” (someone withaverage knowledge of health and medicine) tobelieve that a serious medical condition exists, orthe absence of immediate medical attentionwould result in a threat to life, limb, or eyesight,or when the person has painful symptomsrequiring immediate attention to relievesuffering. If you need emergency care, go to thenearest emergency room or call 911. It isimportant that you know the emergencytelephone numbers in your area. Take a minute tolook these numbers up and write them here or onthe inside front cover of this book.Contact your PCM’s office directly to make anappointment. There is no need to contact yourregional contractor to schedule appointments.Access Standards for CareThere are certain access standards for care. The wait time for an urgent care appointmentshould not exceed 24 hours (one day). The wait time for a routine appointment shouldnot exceed one week (seven days). The wait time for a specialty care appointmentor wellness visit should not exceed four weeks(28 days).Emergency Assistance:These access standards begin at the time of yourcall to or contact with the provider. It isimportant to contact your provider as soon aspossible. At times, appointments may not beavailable within the time frames listed above dueto high demand for specialty care services. If theprovider does not have appointments availablewithin the access standards, you can choose toschedule the earliest available appointment withthe provider or contact your regional contractorfor assistance in locating another provider.Ambulance:Poison Control: 1 800 222 1222You do not need to call your PCM or regionalcontractor before receiving emergency medicalcare. However, in all emergency situations, youmust notify your PCM within 24 hours, or thenext business day, so that ongoing care can becoordinated, and to ensure you receive properauthorization for care.You should have access to a PCM whose officeis within 30 minutes of your home under normalcircumstances. Specialty care should be availablewithin one hour from your home. See the sectiontitled, Specialty Care far From Home forinformation about travel reimbursement if youare referred for specialty care more than 100miles from your PCM’s office.10

Urgent Carenon network provider without a referral fromyour PCM, you will be utilizing the POS option,resulting in higher out of pocket costs. See theTRICARE: Summary of Beneficiary Costs flyerto learn about POS fees.Urgent care is for an illness or injury that wouldnot result in further disability or death if nottreated immediately, but does requireprofessional attention within 24 hours. Youwould require urgent care for conditions such asa sprain, sore throat, or rising temperature thathave the potential to develop into an emergencyif treatment is delayed longer than 24 hours.Routine (Primary) CareRoutine (primary) care includes general officevisits for the treatment of symptoms, chronic oracute illnesses and diseases, and follow up carefor an ongoing medical condition. Routine carealso includes preventive care measures to helpkeep you healthy. You will receive most of yourroutine or primary care from your PCM.Referrals for Specialty CareVisit your regional contractor’s Web site orcall the toll free number to learn about region specific referral requirements and for detailsabout obtaining referrals.You do not need a referral to visit your PCM. Ifyour PCM is unable to provide the care needed,he or she will refer you to another provider. Ifyou receive any routine care without a referralfrom your PCM, you will be utilizing the POSoption, resulting in higher out of pocket costs.See the TRICARE: Summary of BeneficiaryCosts flyer to learn about POS fees.If you live near an MTF and are referred forspecialty care, inpatient admissions, orprocedures requiring prior authorization, yourregional contractor will attempt to coordinateyour care at the MTF first. When the servicesare not available at the MTF, the care will becoordinated with a TRICARE network provider.Services That Do Not RequireReferralsSpecialty to Specialty ReferralsSome services may be obtained without a PCMreferral. These include clinical preventiveservices and the first eight outpatient behavioralhealth care visits per fiscal year (October 1 September 30). When seeking clinical preventiveservices or behavioral health care, you must usea network provider. If you seek care from aIf your PCM refers you to a specialist whowould like to refer you to another specialist, thespecialist will need to contact your PCM. YourPCM or the specialist will contact your regionalcontractor to obtain authorization for additionalspecialty care, when necessary.11SECTION 3There are times when you will need to see aspecialist for a diagnosis or treatment that yourPCM cannot provide. Your PCM will providereferrals to access services from specialtyproviders and will coordinate the referral requestwith your regional contractor, when necessary. Ifyou receive specialty care without a referral fromyour PCM, you will be utilizing the POS option,resulting in higher out of pocket costs. See theTRICARE: Summary of Beneficiary Costs flyerto learn about POS fees.COVERED S

At the time of printing,the information in this handbook is current.It is important to remember that TRICARE policies and benefits are governed by public law.Changes to TRICARE programs are continually made as public law is amended.For the most recent information,contact your regional contractor or local TRICARE Service Center.