Introduction To TRICARE
Introduction to TRICARE Provider Orientation for Physicians & Facilities
Table of ContentsTRICARE and the South RegionsWhat is TRICAREThe TRICARE RegionsHumana Military’s RoleHumana Military Partners4689Maternity CareHospice CareOutpatient ServicesPhysical, Speech, and Occupational TherapyLimitations and Exclusions32333435361112131415Health Care Management and AdministrationReferrals and AuthorizationsMedical Records DocumentationUtilization ManagementFraud and Abuse38404142171819202122232425Claims and BillingHIPAA ComplianceHIPAA Code SetsBilling TipsElectronic Claims SubmissionElectronic Remittance Advice and ElectronicFunds TransferClaims AppealsReimbursement Methodologies4445464748495051Resources & Contact InformationOnline Self-Service for ProvidersProvider Resources5354Provider InformationRules and RegulationsCertificationCredentialingSpecialty Care and Emergency ResponsibilitiesBalance Billing and Hold HarmlessTRICARE OptionsVerifying EligibilityTRICARE and VeteransTRICARE PrimeTRICARE Standard and ExtraTRICARE for Life and MedicarePharmacySpecialty Medication Care Management ProgramCancer Clinic TrailsExtended Care Health OptionMedical CoveragePrior Authorization ListInpatient ServicesHospitalizationDischarge Planning272829312
TRICARE and the SouthRegion
What is TRICARE?TRICARE is the Department of Defense (DoD) worldwide health care program available toeligible beneficiaries in the uniformed services:–U.S. Army–U.S. Navy–U.S. Air Force–U.S. Marine Corps–U.S. Coast Guard–Commissioned Corps of the U.S. Public Health Service–Commissioned Corps of the National Oceanic and Atmospheric AdministrationTRICARE-eligible beneficiaries may include:–Active Duty Service Members (ADSMs)–Active Duty Family Members (ADFMs)–Retired service members and their families–National Guard and Reserve members and their families–Survivors–Certain former spouses and othersLearn more at Humana-Military.com.Introduction to TRICARE: TRICARE and the South Region
TRICARE Management Authority (TMA) Quadruple AimBetter Care:Defined as providing patientand family centered,compassionate, convenient,equitable, safe, always ofhighest qualityReadiness:Defined as ensuring the totalmilitary force Is medicallyready to deployBetter Health:Defined as reducinggenerators of ill health byencouraging healthybehaviors and decreasinglikelihood of Illness throughfocused prevention andincreased resilienceLower Cost::Defined as creating value byfocusing on quality,eliminating waste, andreducing unwarrantedvariation; considering totalcost of care over timeIntroduction to TRICARE: TRICARE and the South Region
TRICARE Regions:North, West and SouthIntroduction to TRICARE: TRICARE and the South Region
TRICARE South RegionIntroduction to TRICARE: TRICARE and the South Region
Humana Military’s Role Managed Care Support Contractor (MCSC) for the TRICARESouth Region since 1996 TRICARE Service Centers (TSCs) available to beneficiariesthroughout the South Region co-located where a military baseor post exists Serving approximately 3,000,000 eligible beneficiaries in theSouth Region aloneIntroduction to TRICARE: TRICARE and the South Region
Humana Military PartnersPGBA, LLC is Humana Military’s claims processing partner in the SouthRegion PGBA is a fiscal intermediary for the military’s TRICARE health benefitsprogram and is one of the largest subsidiaries of BlueCross BlueShieldof South CarolinaValueOptions , Inc. is Humana Military’s behavioral health partner inthe South Region ValueOptions is the nation’s largest independent behavioral healthcare and wellness company, specializing in management for allbehavioral health issues and mental health and chemical dependencydiagnosesIntroduction to TRICARE: TRICARE and the South Region
Provider Information
Rules and Regulations TRICARE providers must abide by the rules, procedures, policies and programrequirements specified in the TRICARE Provider Handbook provided as partof a network contract (The handbook is updated and re-issued to allproviders annually) An online version of the TRICARE Provider Handbook is available at HumanaMilitary.com TRICARE-related statutes are in Chapter 55 of Title 10 of the United StatesCode, which contains all statutes regarding the armed forces Find TRICARE manuals at http://manuals.tricare.osd.mil TRICARE Provider News, published quarterly, includes information aboutpolicy changes, timely notifications and implementation guidanceLearn more at Humana-Military.com.Introduction to TRICARE: Provider Information
TRICARE Certification TRICARE only reimburses appropriate covered services for eligible beneficiariesprovided by TRICARE-authorized providers TRICARE-authorized providers must meet TRICARE licensing and certificationstandards TRICARE-authorized providers must comply with regulations specific to their healthcare areas KePRO, the TRICARE Quality Monitoring Contractor (TQMC), must certifyfreestanding Partial Hospitalization Programs (PHPs), Residential Treatment Centers(RTCs) and Substance Use Disorder Rehabilitation Facilities (SUDRFs) Call 1-877-8416413 When a hospital is a TRICARE-authorized provider, the hospital’s PHP is also aTRICARE-authorized providerLearn more at Humana-Military.com.Introduction to TRICARE: Provider Information
TRICARE Credentialing To join the TRICARE network: A TRICARE-authorized provider must complete thecredentialing process and sign a contract with Humana Military or ValueOptions forbehavioral health Credentialing is also required for: Acute inpatient facilities, freestanding surgicalcenters, home health agencies and skilled nursing facilities Minimum credentialing criteria include:– Current signature and date on the application–Current, valid, unrestricted and unprobated state license–Current acceptable liability insurance–Ability to participate in federal health care programs, including Medicare, Medicaidand all other plans and programs that provide health benefits funded by the UnitedStates (excluding the Federal Employees Health Benefits Plan)–Acceptable accreditation status appropriate to the facilitySee pages 12 and 13 of TRICARE Provider Handbook.Introduction to TRICARE: Provider Information
Specialty Care and Emergency Care ResponsibilitiesSpecialty care may require prior authorization from Humana Military as well asreferrals from Primary Care Managers (PCMs) and/or Humana Military TRICARE Prime beneficiaries living within a 60-minute drive time of a MilitaryTreatment Facility (MTF) may be required to first seek specialty care, ancillary servicesand physical therapy at the MTF based on the Right Of First Refusal (ROFR) PCMs and specialty care providers must coordinate with Humana Military to obtainreferrals and prior authorizations Submitting a claim for an unauthorized service is subject to a penalty of up to 50percent of the TRICARE-allowable charge To avoid penalties, providers must notify Humana Military of any emergencyadmissions by visiting Humana-Military.com, calling 1-800-444-5445 or faxing 1-877548-1547See pages 14 and 15 of TRICARE Provider Handbook.Introduction to TRICARE: Provider Information
Balance Billing and the Hold Harmless Policy Network and participating non-network providers agree to accept the TRICARE-allowablecharge as payment in full for a covered service Providers may not bill TRICARE beneficiaries more than this amount for covered services Non-network, nonparticipating providers do not have to accept the TRICARE-allowable chargeand may bill patients for up to 15 percent above If patients have Other Health Insurance (OHI), providers must bill the OHI first. Providers may notcollect more than the billed charge from the OHI and TRICARE combined Balance billing limitations apply only to TRICARE-covered services Network providers must notify patients if TRICARE does not cover a service They may direct bill a beneficiary for excluded services based on the examples below:– If the beneficiary failed to inform the provider about his or her TRICARE coverage– If the beneficiary is aware that TRICARE does not cover the service and agrees to pay for theservices in advance by signing the TRICARE Non-Covered Services Waiver form, available onHumana Military’s websiteIf the TRICARE beneficiary has not signed the TRICARE Non-Covered Services Waiver form, he orshe is held harmless from financial liabilitySee page 15 of TRICARE Provider Handbook.Introduction to TRICARE: Provider Information
TRICARE Options
Verifying EligibilityProviders must verify TRICARE eligibility prior to or at the time of service using validCommon Access Cards (CACs), uniformed services ID cards or eligibility authorizationletters A CAC or ID card alone does not prove eligibility Confirm eligibility by going to Humana-Military.com Use the sponsor’s Social Security Number (SSN) or DoD Benefits Number (DBN) toverify beneficiary eligibility(See Verifying Patient Eligibility Presentation for directions)Learn more at Humana-Military.com.Introduction to TRICARE: TRICARE Options
TRICARE and Veterans Affairs BenefitsCertain beneficiaries are eligible for both TRICARE and U.S. Department ofVeterans Affairs (VA) benefits programs, and they may choose which benefitsthey want to use Beneficiaries may seek TRICARE-covered services even if they receivedtreatment through the VA for the same medical condition during a previousepisode of care TRICARE does not duplicate payments made or authorized by the VA forservice-connected disability care For beneficiaries not eligible for Medicare, VA coverage is considered OHI,and TRICARE pays second to any out-of-pocket costs for VA servicesSee page 19 of TRICARE Provider Handbook.Introduction to TRICARE: TRICARE Options
TRICARE PrimeADSMs living and working in PSAs must enroll in TRICARE Prime Managed care option available in TRICARE Prime Services Areas (PSAs), requires aPrimary Care Manager (PCM) ADFMs can choose TRICARE Prime or use TRICARE Standard and if seeing networkproviders-TRICARE Extra PRIME typically requires referrals and/or authorizations for nonemergency careoutside of PCM office Military Treatment Facilities generally have beneficiaries enrolled to a PCM at thelocal (MTF) where possible MTFs have Right Of First Refusal TRICARE Prime beneficiaries must first seek care at the MTFSee pages 21 and 22 of TRICARE Provider Handbook.Introduction to TRICARE: TRICARE Options
TRICARE Standard and TRICARE ExtraTRICARE Standard: Fee-for-service option that allows beneficiaries to seek carefrom any TRICARE-authorized providerTRICARE Extra: Preferred provider option of TRICARE Standard that allowsbeneficiaries to reduce out of pocket cost by visiting network providers Available to all eligible beneficiaries except ADSMs Standard involves annual deductibles and cost-shares Does not require PCM assignment and allows beneficiaries to self-refer Standard requires certain services obtain prior authorization approval(inpatient admissions for substance abuse disorders and behavioral health,adjunctive dental care, home health services)See page 22 of TRICARE Provider Handbook.Introduction to TRICARE: TRICARE Options
TRICARE For Life and Medicare Eligibility TRICARE For Life (TFL) is Medicare wraparound coverage available to anyTRICARE beneficiary who has Medicare Part A and Medicare Part B ADFMs entitled to Medicare Part A do not have to have Medicare Part B to beTRICARE-eligible as long as the sponsor is on Active Duty Beneficiaries receiving disability benefits from the Social SecurityAdministration (SSA) are entitled to Medicare in the 25th month of receivingdisability payments When disability payments are suspended, beneficiaries must continue to payMedicare Part B premiums to remain eligible for TRICARE coverage Beneficiaries can seek care from any Medicare-participating provider,nonparticipating provider, opt-out provider, MTF (on a space-available basis)or a Veterans Affairs (VA) facilitySee pages 22 and 23 of TRICARE Provider Handbook.Introduction to TRICARE: TRICARE Options
TRICARE Pharmacy Program Comprehensive prescription drug coverage, administered by Express Scripts,Inc.All TRICARE beneficiaries are eligible Beneficiaries can fill prescriptions at MTF pharmacies, TRICARE PharmacyHome Delivery, TRICARE retail network pharmacies or non-network retailpharmacies TRICARE has established quantity limits on certain medications Some drugs require prior authorization from Express Scripts Visit http://pec.ha.osd.mil and select Formulary Search Tool to check forrestrictions on a medicationSee pages 25 through 26 of TRICARE Provider Handbook.Introduction to TRICARE: TRICARE Options
Specialty Medication Care Management ProgramSeeks to improve beneficiaries’ health through continuous health evaluation,ongoing monitoring, assessment of educational needs and management ofmedication use Provides monthly refill reminder calls, scheduled deliveries, specialtyconsultations with a nurse or pharmacist, and access to proactive, clinicallybased services for specific diseases Patients who receive medications through TRICARE Pharmacy Home Deliveryreceive these services at no additional cost, and participation is voluntary Specialty medications are usually high-cost; self-administered; injectable, oralor infused drugs that treat serious chronic conditions They typically require special storage and handling, are not readily availableat local pharmacies and may have side effects that require pharmacist and/ornurse monitoringIntroduction to TRICARE: TRICARE Options
Cancer Clinical TrialsParticipation in cancer clinical trials became a permanent TRICARE benefit April 1,2008Three types of National Cancer Institute (NCI) clinical trials:–Phase I: Beneficiaries may be eligible to participate in Phase I trials if they meet certainrequirements–Phase II: Beneficiaries may participate in these trials, which study the safety and efficacy of anagent or intervention on a particular type of cancer and evaluate its effect on the human body–Phase III: Beneficiaries may participate in these trials, which compare promising newtreatments for a particular type of cancer against standard approaches TRICARE cost-shares all medical care and testing required to determine eligibility foran NCI-sponsored trial Participation in NCI clinical trials requires prior authorization Providers must contact a case manager before beginning any evaluation or treatmentSee page 28 of TRICARE Provider Handbook.Introduction to TRICARE: TRICARE Options
TRICARE Extended Care Health Option (ECHO)Provides services to ADFMs who qualify based on specific mental or physicaldisabilities Offers an integrated set of services and supplies beyond those provided bybasic TRICARE programs Only available to those registered in the Exceptional Family Member Program(EFMP) Qualifying conditions:–Moderate or severe mental retardation–Serious physical disability–Multiple disabilities affecting separate body systemsAlso available to children under age three diagnosed with a neuromusculardevelopmental condition or other condition expected to precede diagnosis ofa condition listed aboveSee page 29 of TRICARE Provider Handbook.Introduction to TRICARE: TRICARE Options
Medical Coverage
Prior Authorization List for the South RegionIntroduction to TRICARE: Medical Coverage
Inpatient Services Hospital, general nursing, physician and surgical services Meals, including special diets Drugs and medications Operating and recovery room care Anesthesia Laboratory tests, X-ray services and other radiology services Medical supplies and appliances Blood and blood products Semiprivate rooms and special care units if medically necessary Surgical procedures designated as “inpatient only” only when performed in an inpatient setting Skilled nursing facility care Bariatric surgery Behavioral health care services, including acute inpatient psychiatric care, partial hospitalizationprogram care, residential treatment center care and substance abuse servicesSee page 37 of TRICARE Provider Handbook.Introduction to TRICARE: Medical Coverage
HospitalizationAll non-urgent hospital admissions require prior authorization Humana Military must be notified of all emergency inpatient admissionswithin 24 hours or the next business day A Last Covered Date (LCD) is assigned at time of approval for inpatientmedical/surgical non-active duty admissions The LCD is the last day of the inpatient admission to be paid the full allowableamount Hospitals must request extensions of approved days when needed Financial penalties will be applied to claim reimbursement for anyunauthorized day(s)Introduction to TRICARE: Medical Coverage
An Important Message from TRICAREIntroduction to TRICARE: Medical Coverage
HospitalizationDischarge planning: Helps eliminate barriers that may disrupt a timely discharge from the acutecare setting Discharge planning begins on admission review and continues throughoutthe hospital stay Includes arranging for services such as home health care and durable medicalequipment needed after dischargeProprietary to Humana Military - not to be disclosed
Maternity CareTRICARE covers medical services related to prenatal care, labor and delivery,and postpartum care PCM must submit a referral prior to the beneficiary’s first obstetricsappointment The referral begins with the first prenatal visit and is valid through 42 daysafter birth PCM must request prior authorization for delivery in a civilian inpatientfacility or birthing center PCM must notify Humana Military of any hospitalization or observationduring pregnancy TRICARE covers medically necessary fetal ultrasounds See handbook for a list of specific coverage and limitationsSee page 38 of TRICARE Provider Handbook.Introduction to TRICARE: Medical Coverage
Hospice CareFour levels of care: Continuous home care, general hospice inpatient care,inpatient respite care and routine home care Care only begins with a doctor’s order and requires prior authorizationHospice care is provided in three benefit periods: The first two are 90 dayseach, and the final period comprises an unlimited number of 60-day periods(each requires recertification of terminal illness)Care may include: Physician services, nursing care, counseling, medicalequipment, supplies, medications, medical social services, physical andoccupational services, speech and language pathology, and hospice shortterm acute patient careOnly includes room and board if patient is receiving inpatient or respite careSee page 39 of TRICARE Provider Handbook.Introduction to TRICARE: Medical Coverage
Outpatient ServicesTRICARE covers: Adjunctive dental care Ambulance services Durable Medical Equipment (DME), prosthetics, orthotics and supplies Home health care Laboratory and X-ray services Individual provider services Behavioral health services, including outpatient psychotherapy, psychologicaltesting and assessment, medication management, Telemental HealthProgram and Smoking Cessation ProgramSee page 35 of TRICARE Provider Handbook.Introduction to TRICARE: Medical Coverage
Physical, Speech and Occupational TherapyTherapy services are a covered benefit Referral requests are submitted by the PCM or a qualified specialist such asan Orthopedic Surgeon for PT The number of therapy visits are approved based on the diagnosis andtreatment, with additional visits allowed with the appropriatedocumentation PT, ST, and OT are considered “Allied Health” providers and are notcredentialedIntroduction to TRICARE: Medical Coverage
Limitations and Exclusions To determine if a specific service is a covered benefit or coverage is limited,check the current list of noncovered services on the No Government PayProcedure Code List at www.tricare.mil/nogovernmentpayTRICARE Provider Handbook references:– Med/Surg limitations–Med/Surg exclusions–Behavioral health limitations and exclusionsIntroduction to TRICARE: Medical Coverage
TRICARE Provider Handbook . provided as part of a network contract (The handbook is updated and re-issued to all providers annually) An online version of the . TRICARE Provider Handbook. is available at Humana-Mi
Handbook Your guide to TRICARE programs, policies and procedures 2015 TRICARE Provider Handbook — South Region An important note about TRICARE Program information The TRICARE Provider Handbook will assist you in delivering TRICARE benefits and services. The handbook
Enroll new family member(s) in TRICARE (active duty), TRICARE Reserve Select (Reserve members) or other health insurance plan. Review the handout "TRICARE Overview" for more information. Visit www.tricare.mil to find out more about your options. Counselor: Note that TRICARE Prime and TRIC
East Region 2020 TRICARE PROVIDER HANDBOOK 7 Search What is TRICARE TRICARE is the Department of Defense’s (DoD) worldwide healthcare program available to
TRICARE Reserve Select (TRS): TRICARE Reserve Select (TRS) is a premium based, worldwide health plan that qualified Selected Reserve members and ualified members and survivors: - Comprehensive health coverage similar to TRICARE Standard and TRICARE Extra (in the Untied Stares) or the
September 2013. Important Information. TRICARE Web Site: www.tricare.mil. TRICARE For Life
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.
Welcome to the Fort Campbell area. Whether you are moving here as part of a Permanent Change of Station (PCS), moving here as a retiree, or recently married and new to TRICARE, you must call TRICARE and let them know you are here! Fort Campbell is located within the TRICARE East Region. You can call TRICARE at 1-800-444-5445 to
Register for TRICARE Pharmacy Home Delivery, find a TRICARE retail network pharmacy, or find information on how to save money and make the most of your pharmacy benefit. Express Scripts, Inc.
