The following definitions are a mixture
of TRICARE Regulatory definitions listed in
32 CFR 199.2 and
199.17,operational definitions used by TRICARE
personnel and contractors in the daily administration of the TRICARE
Program, and terminology found in the Health Insurance Portability
and Accountability Act (HIPAA) of 1996. Regulatory definitions may
not be changed or elaborated upon without a regulatory change. Further
explanations/elaborations of TRICARE Regulatory definitions may
be found in the TRICARE Operations Manual (TOM), TRICARE Policy
Manual (TPM), TRICARE Reimbursement Manual (TRM), and TRICARE Systems
Manual (TSM) where appropriate. For a complete listing of TRICARE
Regulatory Definitions refer to
32 CFR 199.2 and
199.17. Included are acronyms for some of the
words being defined. An acronym is a word for1med from the first
(or first few) letters of a series of words.
Absent Treatment (Defined in 32 CFR 199.2)Services
performed by Christian Science practitioners for a person when the
person is not physically present. Technically, “Absent Treatment”
is an obsolete term. The current Christian Science terminology is
“treatment through prayer and spiritual means,” which is employed
by an authorized Christian Science practitioner either with the
beneficiary being present or absent. However, to be considered for coverage
under TRICARE, the beneficiary must be present physically when a
Christian Science service is rendered, regardless of the terminology
used.
Abuse (Defined in 32 CFR 199.2)Any
practice that is inconsistent with accepted sound fiscal, business,
or professional practice which results in a TRICARE claim, unnecessary
cost, or TRICARE payment for services or supplies that are:
1. Not
within the concepts of medically necessary and appropriate care,
as defined in the Regulation (32 CFR 199), or
2. That
fail to meet professionally recognized standards for Health Care
Providers (HCPs).
The
term “abuse” includes deception or misrepresentation by a provider,
or any person or entity acting on behalf of a provider in relation
to a TRICARE claim.
Note: Unless a specific
action is deemed gross and flagrant, a pattern of inappropriate
practice will normally be required to find that abuse has occurred.
Any practice or action that constitutes fraud, as defined by the
Regulation (32 CFR 199), would also be abuse.
Access, Health CareThe ability to receive necessary health care services
of high quality within specific time frames, at locations and from
the providers that satisfy patient health care needs. This is frequently
associated with the contractor’s provision of network adequacy.
Access to care standards are established in
32 CFR 199.17 and 45 CFR 156.230. See the
definition of “Access Standards” in this appendix.
Access, Information1. The
availability and the permission to consult records, archives, or
manuscripts.
2. The ability and opportunity
to obtain sensitive, classified, or administratively controlled information
or records readily.
Access Standards (Defined in 32 CFR 199.17)Preferred
Provider Networks (PPNs) will have attributes of size composition,
mix of providers and geographical distribution so that the networks,
coupled with the Military Treatment Facility (MTF) capabilities,
can adequately address the health care needs of the enrollees. Before
offering enrollment in Prime to a beneficiary group, the MTF Commander/eMSM
Manager (or other authorized person) will assure that the capabilities
of the MTF plus PPN will meet the following access standards with
respect to the needs of the expected number of enrollees from the
beneficiary group being offered enrollment:
1. Under
normal circumstances, enrollee travel time may not exceed 30 minutes
from home to primary care delivery site unless a longer time is
necessary because of the absence of providers (including providers
not part of the network) in the area.
2. The
wait time for an appointment for a well-patient visit or a specialty
care referral shall not exceed four weeks; for a routine visit,
the wait time for an appointment shall not exceed one week; and
for an urgent care visit the wait time for an appointment shall
generally not exceed 24 hours.
3. Emergency
services shall be available and accessible to handle emergencies
(and urgent care visits if not available from other primary care
providers within the service area 24 hours a day, seven days a week.
4. The
network shall include a sufficient number and mix of board certified
specialists to meet reasonably the anticipated needs of enrollees.
Travel time for specialty care shall not exceed one hour under normal
circumstances, unless a longer time is necessary because of the
absence of providers (including providers not part of the network)
in the area. This requirement does not apply under the Specialized
Treatment Services Program.
5. Office
waiting times in nonemergency circumstances shall not exceed 30
minutes, except when emergency care is being provided to patients,
and the normal schedule is disrupted.
Action PlanA
contractor’s plan for achieving a goal through the use of specific
resources based on a time-oriented schedule of activities.
Active Duty (Defined in 32 CFR 199.2)Full-time
duty in the Uniformed Services of the United States (U.S.). It includes
duty on the active list, full-time training duty, annual training
duty, and attendance while in the active Military Service, at a school
designated as a Service school by law or by the Secretary of the
Military Department concerned.
Active Duty Member (Defined in 32 CFR 199.2)A
person on active duty in a Uniformed Service under a call or order
that does not specify a period of 30 days or less.
Activities of Daily Living (ADL) (Defined
in 32 CFR 199.2)Care that consists of providing food (including
special diets), clothing and shelter; personal hygiene services;
observation and general monitoring; bowel training or management
(unless abnormalities in bowel function are of a severity to result
in a need for medical or surgical intervention in the absence of skilled
services); safety precautions; general preventive procedures (such
as turning to prevent bedsores); passive exercise; companionship;
recreation; transportation; and other such elements of personal
care that can reasonably be performed by an untrained adult with
minimal instruction or supervision. ADL may also be referred to
as “essentials of daily living”.
Adequate Medical Documentation, Mental
Health Records (Defined in 32 CFR 199.2)Adequate medical documentation provides the means
for measuring the type, frequency, and duration of active treatments
mechanisms employed and progress under the treatment plan. Under
TRICARE, it is required that adequate and sufficient clinical records
be kept be the provider to substantiate that specific care was actually
and appropriately furnished, was medically or psychologically necessary
(as defined in
32 CFR 199.2),
and to identify the individual(s) who provided the care. Each service
provided or billed must be documented in the records. In determining
whether medical records are adequate, the records will be reviewed
under the general acceptable standards (e.g., standard of an accrediting organization
approved by the Director, and the provider’s state or local licensing
requirements) and other requirements specified in 32CFR 199. The
psychiatric and psychological evaluations, physicians orders, the
treatment plan, integrated progress notes (and physician progress
notes if separate from the integrated progress notes), and the discharge
summary are the more critical elements of the mental health record.
However, nursing and staff notes, no matter how complete, are not
a substitute for the documentation of services by the individual
professional provider who furnished treatment to the beneficiary.
In general, the documentation requirement of a professional provider
are not less in the outpatient setting than the inpatient setting.
Furthermore, even though a hospital that provides psychiatric care
may be accredited under The Joint Commission (TJC) manual for hospitals
rather than TJC behavioral health standards, the critical elements
of the mental health record listed above are required for TRICARE
claims.
Adjunctive Dental Care (Defined in 32 CFR 199.2)Dental
care that is medically necessary in the treatment of an otherwise
covered medical (not dental) condition, is an integral part of the
treatment of such medical condition, and is essential to the control of
the primary medical condition; or, is required in preparation for
or as the result of dental trauma which may be or is caused by medically
necessary treatment of an injury or disease (iatrogenic).
AdjustmentA
correction to the information in the TRICARE Encounter Data (TED)
records and/or Beneficiary History Files (Hard Copy Files and Automated
Beneficiary History and Deductible Files) related to a claim previously
Processed To Completion (PTC). Adjustments include any recoupments,
additional payment(s), all cancellations (total or partial), and
corrections to statistical data, whether or not the changes result
in changes to the financial data.
Adjustment, Identification Of ReceiptAn adjustment may be generated by a telephonic,
written or personal inquiry, appeal decision, or as the result of
a contractor’s internal review. The adjustment is identified when
the contractor’s staff determines the issue requires an additional
payment, cancellation, or a change to the Beneficiary History and
Deductible Files (see definition) or when notice is received from
DHA that an adjustment is required. In the case of recoupments,
the adjustment is “identified” for reporting purposes, with receipt of
the payment by the contractor.
Administrative EfficienciesAdherence to the TRICARE program and benefits,
electronic claims processing, responsiveness to patient questions
and care coordination, timeliness of consult reporting back to referring
providers.
Administrative Fee, PharmacyThe offered price that represents all administrative
charges relative to prescription, prior authorization and medical
necessity determination transaction processing.
All-Inclusive Per Diem Rate (Defined
in 32 CFR 199.2)The TRICARE-determined rate that encompasses the
daily charge for inpatient care and, unless specifically excepted,
all other treatment determined necessary and rendered as part of
the treatment plan established for a patient and accepted by TRICARE.
Allowable Charge (Defined in 32 CFR 199.2)The
TRICARE-determined level of payment to institutions, physicians,
and other categories of individual professional providers based
on one of the approved reimbursement methods set forth in the
32 CFR 199.14.
Allowable Charge ComplaintA request for review of a contractor determination
of the allowable charge for covered services and supplies furnished
under TRICARE. An allowable charge complaint does not fall within
the meaning of an “appeal”, in the technical sense, but does require
a careful review or reconsideration by the contractor of how the
claim was processed to ensure accuracy of the payment made.
Allowable Charge ReductionThe difference between the reimbursement determination
made by a contractor and the amount billed by the provider of care
(prior to determination of applicable cost-shares and deductibles).
This is also referred to in the industry as the contractual allowance.
Allowable Cost (Defined in 32 CFR 199.2)The
TRICARE-determined level of payment to hospitals or other institutions,
based on one of the approved reimbursement methods set forth in
32 CFR 199.14. The allowable charge may also
be referred to as the TRICARE-determined reasonable or allowable
cost.
Amount In Dispute (Defined in 32 CFR 199.2)The
amount of money, determined under 32 CFR 199, that TRICARE will
pay for medical services and supplies involved in an adverse determination
being appealed if the appeal were resolved in favor of the appealing
party. See
32 CFR 199.10 for
additional information concerning the determination of “amount in
dispute” under the Regulation.
AppealA formal
written request by a beneficiary, a participating provider, a provider
denied authorized provider status under TRICARE, or a representative,
to resolve a disputed question of fact. See
32 CFR 199.10 and
Chapter 12.
Appropriate Medical Care (Defined in 32 CFR 199.2)Services
that are:
1. Performed in connection with the diagnosis
or treatment of disease or injury, pregnancy, mental disorder, or
well-baby care which are in keeping with the generally accepted
norms for medical practice in the U.S.;
2. Rendered
by an authorized individual professional provider who is qualified
to perform such medical services by reason of his or her training
and education and is licensed or certified either by the state where
the service is rendered or appropriate national organization, or
who otherwise meets TRICARE standards; and
3. Furnished
economically. For the purposes of TRICARE, “economically” means
that the services are furnished in the least expensive level of
care or medical environment adequate to provide the required medical
care regardless of whether or not that level of care is covered
by TRICARE.
Authorization For CareThe authorization determination addresses whether
a particular service may be covered by TRICARE, including whether
it appears necessary and appropriate in the context of the patient’s
diagnosis and circumstances.
Authorized Provider (Defined in 32 CFR 199.2)A
hospital or institutional provider, physician, or other individual
professional provider, or other provider of services or supplies
specifically authorized to provide benefits under TRICARE in
32 CFR 199.6.
Note: Providers not specifically listed in
32 CFR 199.6 or defined in
32 CFR 199.2 are not considered authorized
providers unless they have been included in a TRICARE demonstration
program.
Authorized Supplies, PharmacyNon-drug items (usually used in conjunction with
the administration of a drug) approved by the DoD Pharmacy and Therapeutic
(P&T) [Committee] for inclusion in the formulary, and appearing
on the formulary web site at
http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx.
Automated Data Processing (ADP)A system for recording and processing data on magnetic
media, ADP cards, or any other method for mechanical/electronic
processing and manipulation or storage of data.
Automated Data Processing (ADP) Backup
SystemA separate, off-site ADP system
with similar operating capabilities which will be activated/used
in case of a major system failure, damage, or destruction. This
includes back-up data sets, software and hardware requirements,
and trained personnel.
Balance Billing (Defined in 32 CFR 199.2)A
provider seeking any payment, other than any payment relating to
applicable deductible and cost-sharing amounts, from a beneficiary
for TRICARE covered services for any amount in excess of the applicable
TRICARE allowable cost or charge.
Basic Program (Defined in 32 CFR 199.2)The
primary medical benefits authorized under Chapter 55 of Title 10,
United States Code (USC), and set forth in
32 CFR 199.4.
Benchmark, Drug PriceThe Average Wholesale Price (AWP) has long been
the drug price benchmark for establishing reimbursement payment
terms between payers, Pharmacy Benefit Managers (PBMs), and pharmacies. AWP
as a benchmark has been going away. AWP is by no means the only
price type available. Listed here, with brief descriptions, are
others that are available and may be used by the industry for reimbursement
purposes as AWP is being phased out:
• Actual Acquisition Cost (AAC) - Final price
paid by the pharmacy after subtraction of all discounts;
• Average Manufacturer Price (AMP) - Manufacturer
reported price for Medicaid drug rebate program;
• Average Sales Price (ASP) - Center for Medicare
and Medicaid Service (CMS) calculated price for Medicate Part B
drugs;
• Estimated
Acquisition Cost (EAC) - Estimated cost of the product or the pharmacies’
usual and customary charge;
• Federal Upper Limit (FUL) - CMS calculation
for the upper amount to be paid in aggregate for multi-source products;
• Maximum Allowable Cost (MAC) - Defined by
each payer for multi-source drugs;
• Manufacturer List Price (MLP) - Price listed
by the drug company;
• Wholesale Acquisition Cost (WAC) - List price
for a drug sold by a manufacturer to wholesaler, not including discounts.
BeneficiaryA
beneficiary is an individual eligible for benefits. The beneficiary,
Sponsor, or representative of the beneficiary, including the parent
of a beneficiary under 18 years of age, the beneficiary’s attorney,
legal guardian or representative specifically designated by the
beneficiary may on his or her behalf regarding the benefit at issue.
An individual who is subject to the conflict of interest provisions
of
32 CFR 199.10(a)(2)(i)(B), may not act as
the beneficiary’s representative under this section.
Beneficiary Counseling and Assistance
Coordinators (BCACs)Formerly referred
to as Health Benefit Advisors (HBAs), BCACs are individuals located
at Uniformed Services medical facilities or on occasion at other
locations and assigned the responsibility for providing TRICARE
information, information concerning availability of care from the
Uniformed Services Direct Care (DC) or Purchased Care Systems, and
generally assisting beneficiaries or sponsors. The term also includes
“Health Benefits Counselor.”
Beneficiary History FileA system of records consisting of any record or
subsystem of records, whether hard copy, microform or automated,
which reflects diagnosis, treatment, medical condition, family history
records, correspondence, memorandum, or any other personal information
with respect to any individual, including all such records/reports
acquired or utilized by the contractor in delivery of health care services,
in the development and processing of claims, or in performing any
other functions under a TRICARE contract.
1. Hard
Copy Claim Files.
2. Automated History Files.
The electronically maintained record of a beneficiary’s medical
care and related administrative data, including such data on charges,
payments, deductible status, services received, diagnoses, adjustments,
etc.
Note: The term “TRICARE Contractor Claims
Records” is used by the National Archives and Records Administration
(NARA) “Medical/Dental Claims History files (formerly “Beneficiary
History and Deductibles Files”) includes but is not limited to “TRICARE
Contractor claims Records.”
Beneficiary Liability (Defined in 32 CFR 199.2)The
legal obligation of a beneficiary, his or her estate, or responsible
family member to pay for the costs of medical care or treatment
received. Specifically, for the purposes of services and supplies
covered by TRICARE, beneficiary liability includes any annual deductible
amount, cost-sharing amounts, or, when a provider does not submit
a claim on a participating basis on behalf of the beneficiary, amounts
above the TRICARE-determined allowable charge. Beneficiary liability
also includes any expenses for medical or related services and supplies
not covered by TRICARE.
BenefitServices,
supplies, payment amounts, cost-shares and copayments authorized
by Public Law (PL) 89-614, 32 CFR 199, and outlined in the TPM and
the TRM.
Best PracticesA
best practice is a method or technique that has consistently shown
results superior to those achieved with other means, and that is
used as a benchmark. In addition, a “best” practice can evolve to
become better as improvements are discovered.
Best Value Health CareThe delivery of high quality clinical and other
related services in the most economical manner for the Military
Health System (MHS) that optimizes the DC system while delivering
the highest level of customer service.
BreachA breach, as defined in Department of Defense Directive
(DoDD) 5400.11 (2014), is a loss of control, compromise, unauthorized
disclosure, unauthorized acquisition, unauthorized access, or any
similar term referring to situations where persons other than authorized
users and for an other than authorized purpose have access or potential
access to Personally Identifiable Information (PII)/Protected Health
Information (PHI), whether in paper or electronic form. Breaches
are classified as either possible or confirmed (see the definition
of “Possible Breach” and “Confirmed Breach” in this appendix) and
as either cyber or non-cyber (i.e., involving either electronic
PII/PHI or paper/oral PII/PHI).
Business Associate1. A
person or organization that performs a function or activity on behalf
of a covered entity, but is not part of a covered entity’s workforce.
A business associate may also be a covered entity in it’s own right.
2. For
a full definition, refer to the 45 CFR 160.103, Definitions of HIPAA
of 1996.
Business DayFor
claims processing purposes, one business day is defined as the business
day following the day of transmission at the close of business at
the location of the receiving entity. A business workday is Monday
through Friday, excluding federal holidays.
Capability Of A ProviderThe scope of services the provider is both capable
of performing and willing to perform under a TRICARE contract. For
example, a neurologist under TRICARE contract to perform sleep studies
may not be considered to have capability to perform as a general
neurology specialist.
Capacity Of A ProviderThe amount of time or number of services a provider
is able to perform in conjunction with a TRICARE contract. For example,
a Primary Care Physician (PCP), whose practice is full has no available
capacity for services.
Capped RateThe
maximum per diem or all-inclusive rate that TRICARE will allow for
care.
Care CoordinationA
comprehensive method of client assessment designed to identify client
vulnerability, needs identification, and client goals which results
in the development plan of action to produce an outcome that is
desirable for the client. The goal is to provide client advocacy,
a system for coordinating client services, and providing a systematic
approach for evaluation of the effectiveness of the client’s Life Plan.
Case Management (Defined in 32 CFR 199.2)A
collaborative process which assesses, plans, implements, coordinates,
monitors and evaluates the options and services required to meet
an individual’s health needs, including mental health and Substance
Use Disorder (SUD) needs, using communication and available resources
to promote quality, cost-effective outcomes.
Catastrophic CapThe
National Defense Authorization Act (NDAA) for Fiscal Years (FYs)
1988 and 1989 (Public Law 100-180) amended Title 10, USC, and established
catastrophic loss protection for TRICARE beneficiary families on
a Government fiscal year basis. The law placed fiscal year limits
or catastrophic caps on beneficiary liabilities for deductibles
and cost-shares under the TRICARE Basic Program. Specific guidance
may be found in the TRM,
Chapter 2, Section 2. NDAA for FY 2017 amended
Title 10, USC to change calculations to a calendar year basis, beginning
January 1, 2018. The last quarter of calendar year 2017 was applied
to the FY 2017 calculations to bridge the gap.
Catchment AreasGeographic
areas determined by the Assistant Secretary of Defense (Health Affairs)
(ASD(HA)) that are defined by a set of five digit zip codes, usually
within an approximate 40 mile radius of military inpatient treatment
facility.
Centers of ExcellenceSee definition for Defense Centers of Excellence
(CoE).
Certification and Accreditation (C&A)
ProcessA process that ensures the trust
requirement is met for Information Systems (IS)/networks. Certification is
the determination of the appropriate level of protection required
for IS/networks. Certification also includes a comprehensive evaluation
of the technical and non-technical security features and countermeasures
required for each IS/network. Accreditation is the formal approval
by the Government to operate the contractor’s IS/networks in a particular
security mode using a prescribed set of safeguards at an acceptable
level of risk. In addition, accreditation allows IS/networks to
operate within the given operational environment with stated interconnections;
and with appropriate level-of-protection for the specified period.
The C&A requirements apply to all DoD IS/networks and contractor IS/networks
that access, manage, store, or manipulate electronic IS data. Specific
guidance may be found in the TSM,
Chapter 1.
Certification For CareThe determination that the provider’s request for
services (level of care, procedure, etc.) is consistent with pre-established
health care criteria. Pre-certification is the process performing
a certification for care prior to rendering the care.
Note: This is NOT synonymous with authorization for
care.
Certified ProviderA
hospital or institutional provider, physician, or other individual
professional provider of services or supplies verified by DHA, or
a designated contractor, to meet the provider standards outlined
in
32 CFR 199.6,
and have been approved to provide services to TRICARE beneficiaries
and receive Government payment for services rendered to TRICARE
beneficiaries.
CHAMPUS Maximum Allowable Charge (CMAC)A CMAC is a nationally determined allowable charge
level that is adjusted by locality indices and is equal to or greater
than the Medicare Fee Scheduled amount.
Civilian Health and Medical Program of
the Department of Veterans Affairs (CHAMPVA)A
program of medical care for spouses and dependent children of disabled
or deceased disabled veterans who meet the eligibility requirements
of the Department of Veterans Affairs (DVA).
Change OrderA
written directive from the DHA Procuring Contracting Officer (PCO)
to the contractor directing modifications, within the general scope
of the contract, as authorized by the “changes clause” at FAR 52.243-1,
Changes--Fixed Price.
Christian Science Nurse (Defined in 32 CFR 199.2)An
individual who has been accredited as a Christian Science Nurse
by the Department of Care of the First Church of Christ, Scientist,
Boston, Massachusetts, and listed (or eligible to be listed) in
the Christian Science Journal at the time the service is provided.
The duties of Christian Science nurses are spiritual and are nonmedical
and nontechnical nursing care performed under the direction of an accredited
Christian Science practitioner. There are two levels of Christian
Science nurse accreditation:
1. Graduate
Christian Science Nurse. This accreditation is granted by
the Department of Care of the First Church of Christ, Scientist,
Boston, Massachusetts, after completion of a three year course of instruction
and study.
2. Practical Christian
Science Nurse. This accreditation is granted by the Department
of Care of the First Church of Christ, Scientist, Boston, Massachusetts,
after completion of a one year course of instruction and study.
Christian Science Practitioner (Defined
in 32 CFR 199.2)An individual who has been accredited as a Christian
Science Practitioner for the First Church of Christ, Scientist,
Boston, Massachusetts, and listed (or eligible to be listed) in
the Christian Science Journal at the time the service is provided.
An individual who attains this accreditation has demonstrated results of
his or her healing through faith and prayer rather than by medical
treatment. Instruction is executed by an accredited Christian Science
teacher and is continuous.
Christian Science Sanatorium (Defined
in 32 CFR 199.2)A sanatorium either operated by the First Church
of Christ, Scientist, or listed and certified by the First Church
of Christ, Scientist, Boston, Massachusetts.
ClaimAny
request for reimbursement for health care services rendered, received
from a beneficiary, a beneficiary’s representative, or a network
or non-network provider, by a contractor on any TRICARE-approved
claim form or approved electronic medium.
Note: If two or more forms for the same beneficiary
are submitted together, they shall constitute one claim unless they
qualify for separate processing under the claims splitting rules.
(It is recognized that services may be provided in situations in
which no claims, as defined here, are generated. This does not relieve
the contractor from collecting the data necessary to fulfill the
requirements of the TED record for all care provided under the contract.)
Note: Any request for reimbursement of a dispensed pharmaceutical
agent or diabetic supply item. For electronic media claims, one
prescription equals one claim. For paper claims, reimbursement for
multiple prescriptions may be requested on a single paper claim.
Claim FileThe
collected records submitted with or developed in the course of processing
a single claim. It includes the approved TRICARE claim form and
may include attached bills, medical records, records of telephone
development, copies of correspondence sent and received in connection
with the claim, the EOB, and records of adjustments to the claim.
It may also include the records of appeals and appeal actions. The
claim file may be in microcopy, hard copy, or in a combination of
media.
Claim FormA
fixed arrangement of captioned spaces designed for entering and
extracting prescribed information, including ADP system forms.
Claims Cycle TimeThat
period of time, recorded in calendar days, from the receipt of a
claim into the possession/custody of the contractor to the completion
of all processing steps (see the definition of “Processed to Completion
(or Final Disposition)” in this appendix, and the TSM,
Chapter 2, Section 2.4, “Date TED Record Processed
to Completion”).
Claims Payment DataThe record of information contained on or derived
from the processing of a claim or encounter.
Clinical Quality OutcomesThe American College of Medical Quality in their
2010 revision of their recommended Core Curriculum for Medical Quality
Management describes clinical outcomes as part of the definition
of quality measures. These are:
1. Structural
Measures - health care setting, appropriate equipment and supplies,
education, certification and experience of clinicians;
2. Process
Measures - actions taken and how well these were performed to achieve
a given outcome, use of evidence-based clinical guidelines;
3. Outcome
Measures - capture of changes in health status following the provision
of a set of healthcare processes and including the cost of delivering
the processes -- hospitalizations, physician office visits, or care
provided in post-acute care setting, patient satisfaction.
Clinical Support Agreement (CSA)An arrangement requested by the military, between
an MTF/eMSM and the TRICARE contractor for the contractor to provide
needed clinical personnel at an MTF/eMSM. The arrangement must be
formalized by modification to the TRICARE contract prior to implementation
of the provisions of the arrangement.
Code Set (HIPAA/Privacy Definition)Any set of codes used to encode data elements,
such as tables of terms, medical concepts, medical diagnostic codes,
or medical procedure codes. This includes both the codes and their
descriptions, as outlined in HIPAA of 1996.
Code Set Maintaining Organization (HIPAA/Privacy
Definition)An organization that creates
and maintains the code sets adopted by the Secretary of Home Health Services
(HHS) for use in the transactions for which standards are adopted
as outlined in HIPAA of 1996.
Combined Daily Charge (Defined in 32 CFR 199.2)A
billing procedure by an inpatient facility that uses an inclusive
flat rate covering all professional and ancillary charges without
any itemization.
Concurrent Review/Continued Stay ReviewEvaluation of a patient’s continued need for treatment,
the appropriateness of current and proposed treatment, as well as
the setting in which the treatment is being rendered or proposed.
Concurrent review applies to all levels of care (including outpatient
care).
Confidentiality RequirementsThe procedures and controls that assure the privacy
of personal medical information in compliance with the Freedom of
Information Act, the Comprehensive Alcohol Abuse and Alcoholism
Prevention and Rehabilitation Act, the Privacy Act, and HIPAA of
1996.
Confirmed BreachAn
incident in which it is known that unauthorized access could occur.
For example, if a laptop containing PII/PHI is lost and the contractor
knows that the PII/PHI is unencrypted, then the contractor should
classify and report the incident as a confirmed breach, because
unauthorized access could occur due to the lack of encryption (the
contractor knows this even without knowing whether or not unauthorized
access to the PII/PHI has actually occurred). If the laptop is subsequently
recovered and forensic investigation reveals that files containing
PII/PHI were never accessed, then the possibility of unauthorized
access can be ruled out, and the contractor should re-classify the
incident as a non-breach incident.
Conflict Of Interest (Defined in 32 CFR 199.2)Includes
any situation where an active duty member (including a reserve member
while on active duty) or civilian employee of the U.S. Government,
through an official federal position, has the apparent or actual
opportunity to exert, directly or indirectly, any influence on the
referral of TRICARE beneficiaries to himself or herself or others
with some potential for personal gain or appearance of impropriety. Individuals
under contract to a Uniformed Service may be involved in a conflict
of interest situation through the contract position.
Consultation (Defined in 32 CFR 199.2)A
deliberation with a specialist physician, dentist, or qualified
mental health provider requested by the attending TRICARE authorized
provider primarily responsible for the medical care of the patient,
with respect to the diagnosis or treatment in any particular case.
A consulting physician or dentist or qualified mental health provider may
perform a limited examination of a given system or one requiring a
complete diagnostic history and examination. To qualify as a consultation,
a written report to the attending TRICARE authorized provider of
the findings of the consultant is required.
Note: Staff consultations required by rules and regulations
of the medical staff of a hospital or institutional provider do
not qualify as consultations.
Consultation Appointment (Defined in 32 CFR 199.2) An
appointment for evaluation of medical symptoms resulting in a plan
for management which may include elements of further evaluation,
treatment and follow-up evaluation. Such an appointment does not
include surgical intervention or other invasive diagnostic or therapeutic
procedures beyond the level of very simply office procedures, or
basic laboratory work but rather provides the beneficiary with an
authoritative option.
Consulting Physician or Dentist (Defined
in 32 CFR 199.2)A physician or dentist, other than the attending
physician, who performs a consultation.
Continued Health Care Benefit Program
(CHCBP)A TRICARE benefit program that
provides temporary continued health care for certain former beneficiaries
of the MHS. Coverage under the CHCBP is purchased on a premium basis.
Continuity of CareFollow
on of health care services from a specific individual professional
provider as part of a specific procedure or service that was performed
within the previous six months in order to not disrupt therapy or
repeat services.
Continuum of CareAll
patient care services provided from “pre-conception to grave” across
all types of settings. Requires integrating processes to maintain
ongoing communication and documentation flow between the DC system
and network.
Contract Performance Evaluation (CPE)A review by DHA, of a contractor’s level of compliance
with the terms and conditions of the contract. Usually, an operational
audit performed by DHA staff that focuses on timeliness, accuracy,
and responsiveness of the contractor in performing all aspects of
the work required by the contract.
Contract PhysicianA
physician who has made contractual arrangements with a contractor
to provide care or services to TRICARE beneficiaries. A contract
physician is a network provider who participates on all TRICARE claims.
Contracting Officer’s Representative
(COR)A Government representative, appointed
in writing by the Contracting Officer (CO), who represents the CO
in the administration of technical matters involving contract requirements.
ContractorAn
organization with which DHA has entered into a contract for delivery
of and/or processing of payment for health care services, and the
performance of related support activities, such as, pharmacy services,
quality monitoring and/or customer service.
Control Of ClaimsThe
ability to identify individually, locate, and count all claims in
the custody of the contractor by location, including those that
may be being developed by physical return of a copy of the claim,
and age including total age in-house and age in a specific location.
Controlled SubstancesThose medications which are included in one of
the schedules of the Controlled Substances Act of 1970 and as amended.
Controlled Unclassified Information (CUI)Information that is not classified in accordance
with national security directives, but that otherwise requires safeguarding
or dissemination controls pursuant to and consistent with applicable
law, regulations, and Government-wide policies.
Coordination Of Benefits (COB) (Defined
in 32 CFR 199.2)The coordination, on a primary or secondary payer
basis of the payment of benefits between two or more health care
coverages to avoid duplication of benefit payments.
Cost-Share (Defined in 32 CFR 199.2)The
amount of money for which the beneficiary (or sponsor) is responsible
in connection with otherwise covered inpatient and outpatient services
(other than the annual deductible or disallowed amounts) as set
forth in
32 CFR 199.4(f) and
32 CFR 199.5(b). Cost-sharing may also be
referred to as “copayment.”
Correctional Institution (HIPAA Definition)Any penal or correctional facility, jail, reformatory,
detention center, work farm, halfway house, or residential community
program center operated by, or under contract to, the U.S., a State,
a territory, a political subdivision of a State or territory, or
an Indian tribe, for the confinement or rehabilitation of persons
charged with or convicted of a criminal offense or other persons
held in lawful custody. Other persons held in lawful custody includes
juvenile offenders adjudicated delinquent, aliens detained awaiting
deportation, persons committed to mental institutions through the
criminal justice system, witnesses, or others awaiting charges or
trial as defined in HIPAA of 1996.
Note: For the purposes of TRICARE, the term “correctional
institution” includes military confinement facilities, but does
not include internment facilities for enemy prisoners of war, retained personnel,
civilian detainees and other detainees provided under the provisions
of DoDD 2310.1 (reference (b)).
Covered Entity (HIPAA Definition)Any business entity that must comply with HIPAA regulations,
which includes, health plans, health care clearinghouses, and HCPs.
For the purposes of HIPAA, HCPs include hospitals, physicians, and
other caregivers. See 45CFR Section 160.103 of HIPAA regulation
for additional information.
Note: In the case of
a health plan administered by the DoD, the covered entity is the
DoD Component (or subcomponent) that functions as the administrator
of the health plan.
Covered Functions (HIPAA Definition)Those functions of a covered entity, the performance
of which, makes the entity a health plan or HCP as outlined in HIPAA
of 1996.
CredentialingThe
process by which providers are allowed to participate in the network.
This includes a review of the provider’s training, educational degrees,
licensure, practice history, etc.
Credentials PackageInformation required for all clinical personnel
supplied by the contractor who will be working in an MTF/eMSM. Similar
information may be required for non-clinical personnel. Complete
information shall contain the following:
1. All
documents, required per regulation/directive/instruction/policy
which are needed to verify that the individual is certified/authorized/qualified
to provide the proposed services at the involved facility. This
shall include licensure from the jurisdiction in which the individual
will be practicing and a National Practitioner Data Bank (NPDB)
query as specified by the facility.
2. A
completed a Criminal History Background Check (CHBC), for all personnel
required by law to have a CHBC prior to awarding of privileges or
the delivery of services with the following considerations:
• If
a CHBC has been initiated, but not completed, the MTF Commander/eMSM
Manager has the authority to allow awarding of privileges and initiation
of services if delivered under clinical supervision.
• The mechanism for
accomplishing the CHBC may vary between MTFs/eMSMs and should be
determined during phase-in/transition and be agreed to by the MTF
Commander/eMSM Manager.
• Regardless of the
mechanism for initiating and completing a CHBC, the cost shall be
borne by the contractor.
3. Medicare
Provider ID number/National Provider Identifier (NPI) number.
4. Evidence
of compliance (or scheduled compliance) with the MTF/eMSM specific
requirements including all local Employee Health Program (EHP),
Federal Occupational Safety Act and Health Act (OSHA), and Bloodborne
Pathogens Program (BBP) requirements.
Custodial Care (Defined in 32 CFR 199.2)The
treatment or services, regardless of who recommends such treatment
or services or where such treatment or services are provided, that:
1. Can
be rendered safely and reasonably by a person who is not medically
skilled; or
2. Is/are designed mainly
to help the patient with the ADLs.
Cybersecurity IncidentA cybersecurity incident is a violation or imminent
threat of violation of computer security policies, acceptable use
policies, or standard security practices, with respect to electronic
PII/PHI. A cybersecurity incident may or may not involve a breach
of PII/PHI. For example, a malware infection would be a possible
breach if it could cause unauthorized access to PII/PHI. However,
if the malware only affects data integrity or availability (not
confidentiality), then a non-breach cybersecurity incident has occurred.
Cycle TimeThe
elapsed time, as expressed in calendar days including any part of
the first and last days counted as two days, from the date a claim,
piece of correspondence, grievance, or appeal case was received
by a contractor through the date (PTC). See the definition of claims
cycle time, in this appendix, for added detail.
DataAny information
collected, derived, or created as a result of operations as a TRICARE
contractor. All data is the property of the Government regardless
of where it is maintained/stored.
Data AggregationThe
combining of PHI by a business associate with the PHI received by
the business associate in its capacity as a business associate of
another covered entity, to permit data analyses that relate to the health
care operations of the respective covered entities as outlined in
HIPAA of 1996.
Data Condition (HIPAA Definition)The circumstances under which a covered entity
must use a particular data element or segment as defined by HIPAA
of 1996.
Data Content (HIPAA Definition)All the data elements and code sets inherent to
a transaction, and not related to the format of the transaction.
Data elements that are related to the format are not data content
as defined by HIPAA of 1996.
Data Element (HIPAA Definition)The smallest named unit of information in a transaction
defined by HIPAA of 1996.
Data RepositoryA
single point of electronic storage, established and maintained by
the contractor that enables the Government to electronically access
all data maintained by the contractor relative to a TRICARE contract.
This includes all claims/encounter data, provider data, authorization,
enrollment, and derived data collected in relation to a TRICARE
contract.
Data Set (HIPAA Definition)A semantically meaningful unit of information exchanged
between two parties to a transaction as defined by HIPAA of 1996.
Date Of Determination (Appeals)The date of completion appearing on the reconsideration
determination, formal review determination, or hearing final decision.
Days (Defined in 32 CFR 199.2)Calendar
days.
Days Supply (Pharmacy)The length of time a dispensed quantity of drug
should last, based on directions for use with a limit as the First
Data Bank recommended maximum daily dose (unless specifically altered
by DoD).
Deductible (Defined in 32 CFR 199.2)Payment
by the beneficiary of the first $50 of the CHAMPUS determined allowable
costs or charges for covered outpatient services or supplies provided
in any one fiscal year; aggregate payment by two or more beneficiaries
who submit claims for the first $100. Effective January 1, 2018,
deductibles are determined on a calendar year basis. Deductible
amounts are outlined in the TRM,
Chapter 2.
Deductible CertificateA statement issued to the beneficiary (or sponsor)
by a TRICARE contractor certifying to the deductible amounts satisfied
by a beneficiary for any applicable program year.
Defense Centers of Excellence (COEs)CoEs focus on an associated group of clinical conditions
and create value by achieving improvement in outcomes through clinical,
educational, and research activities.
• CoEs
develop pathways of care covering the clinical spectrum from prevention
through reintegration or transition.
• Products
of pathway of care development include:
• Guidance
regarding structured documentation (electronic health record);
• Clinical
practice guidelines;
• Process
and outcome measures;
• Educational
materials;
• Innovation and
identification of research priorities; and,
• Strategies
for improving access to care.
Defense Enrollment Eligibility Reporting
System (DEERS) (Defined in 32 CFR 199.2)An automated system maintained by the DoD for the
purposes of:
1. Enrolling members,
former members and their dependents; and
2. Verifying
members’, former members’, and their dependents’ eligibility for
health care benefits in the direct facilities and for TRICARE.
De-Identified DataHealth
information that has been rendered not individually identifiable
by removal of specific identifiers, such as, individual or relatives
or household members, names, addresses, employers, name or addressee,
or geographic subdivisions smaller than a State, and all elements
of dates (except year) for dates directly related to an individual,
telephone numbers, Social Security Numbers (SSNs), etc., as outlined
in HIPAA of 1996.
DemonstrationA
study or test project for the purpose of trying alternative methods
of payment for health and medical services, cost-sharing by eligible
beneficiaries, methods of encouraging efficient and economical delivery
of care, innovative approaches to delivery and financing services
and prepayment for services provided to a defined population. Following
completion and evaluation of the test project, it may or may not
become part of the program.
Descriptor (HIPAA Definition)The text defining a code as defined in HIPAA of
1996.
Designated Record SetA group of records maintained by or for a covered
entity that is:
1. The medical records
and billing records about individuals maintained by or for a covered
HCP;
2. The enrollment, payment,
claims adjudication, and case or medical management record systems maintained
by or for a health plan; or
3. Used,
in whole or in part, by or for the covered entity to make decisions
about individuals.
For
purposes of this definition, the term record means any item, collection,
or grouping of information that includes PHI and is maintained,
collected, used, or disseminated by or for a covered entity as described
in HIPAA of 1996.
Designated Standard Maintenance Organization
(DSMO)An organization designated by
the Secretary of HHS under HIPAA of 1996 §162.910(a).
Diagnosis Related Groups (DRGs) (Defined
in 32 CFR 199.2)A method of dividing hospital patients into clinically
coherent groups based on their consumption of resources. Patients
are assigned to the groups based on their principal diagnosis (the
reason for admission, determined after study), secondary diagnoses,
procedures performed, and the patient’s age, sex, and discharge
status. See the TRM for more specific information on DRGs.
Diagnostic and Statistical Manual of
Mental Disorders (DSM)A classification
system of codes for mental illness developed by the American Psychiatric
Association (APA).
Direct Data Entry (HIPAA Definition)The direct entry of data (for example, using dumb
terminals or web browsers) that is immediately transmitted into
a health plan’s computer, as defined in HIPAA of 1996.
Direct Treatment Relationship (HIPAA
Definition)A treatment relationship
between an individual and a HCP that is not an indirect treatment
relationship as defined under HIPAA of 1996. See the definition
of “Indirect Treatment Relationship” in this appendix.
DirectorThe
Director of the DHA; Director, TRIICARE Management Activity (TMA);
or Director, Office of CHAMPUS (OCHAMPUS). Any reference to the
Director, Office of CHAMPUS, or OCHAMPUS, or TMA shall mean the
Director, DHA. Any reference to Director shall also include any
person designated by the Director to carry out a particular authority.
In addition, any authority of the Director may be exercised by the
Assistant Secretary of Defense for Health Affairs (ASD(HA)).
Director, TRICARE Regional Offices (TROs)An individual responsible for:
1. Overseeing
and ensuring there is an integrated health care delivery system
for TRICARE beneficiaries in the region; and
2. Oversight
of the management/monitoring of the daily administration of the
TRICARE contract/contractor(s) in the region; and
3. Managing
the daily activities of the TRO.
Disaster Response DutyFor purposes of TPM,
Chapter 10, Section 10.1 only, the term “disaster
response duty” means duty performed by a member of the National
Guard in State status pursuant to an emergency declaration by the
Governor of the State (to include the four United States Territories,
or with respect to the District of Columbia, the mayor of the District
of Columbia) in response to a disaster or in preparation for an imminent
disaster.
Discharge PlanningThe
development of an individualized discharge health care plan for
the patient prior to leaving an institution to follow at home, with
the aim of improving patient outcomes, reducing the chance of unplanned
readmission to an institution, and containing costs.
Disclosure (HIPAA Definition)The release, transfer, provision of access to,
or divulging in any other manner of information outside the entity
holding the information as defined in HIPAA of 1996.
Distant SiteThe
“distant site” is where the physician or practitioner providing
the professional service is located at the time the services are
provided via an interactive telecommunications system.
DoD InformationInformation
that is provided by the DoD to a non-DoD entity, or that is collected,
developed, received, transmitted, used, or stored by a non-DoD entity
in support of an official DoD activity, where that information has
not been cleared for public release.
Domiciliary Care (Defined in 32 CFR 199.2)Care
provided to a patient in an institution or home-like environment
because:
1. Providing support for the ADLs in the home
is not available or is unsuitable; or
2. Members
of the patient’s family are unwilling to provide the care.
Note: The terms “domiciliary” and “custodial care” represent
separate concepts and are not interchangeable. Custodial care and
domiciliary care are not covered under the TRICARE programs or the
Extended Care Health Option (ECHO).
Donor (Defined in 32 CFR 199.2)An
individual who supplies living tissue or material to be used in
another body, such as a person who furnishes a kidney for renal
transplant.
Double Coverage (Defined in 32 CFR 199.2)When
a TRICARE beneficiary also is enrolled in another insurance, medical
service, or health plan that duplicates all or part of a beneficiary’s
TRICARE benefits.
Double Coverage Plan (Defined in 32 CFR 199.2)The
specific insurance, medical service, or health plan under which
a TRICARE beneficiary has entitlement to medical benefits that duplicate
TRICARE benefits in whole or in part. Double coverage plans do not
include:
1. Medicaid.
2. Coverage
specifically designed to supplement TRICARE benefits.
3. Entitlement
to receive care from the Uniformed Services medical care facilities;
or
4. Entitlement to receive
care from DVA medical care facilities; or
5. Entitlement
to receive care from Indian Health Services medical care facilities;
or
6. Services and items
provided under Part C (Infants and Toddlers with Disabilities) of
the Individuals With Disabilities Education Act (IDEA).
Dual Compensation (Defined in 32 CFR 199.2)Federal
law (5 USC 5536) prohibits active duty members or civilian employees
of the U.S. Government from receiving additional compensation from
the Government above their normal pay and allowances. This prohibition
applies to TRICARE cost-sharing of medical care provided by active
duty members or civilian Government employees to TRICARE beneficiaries.
Edit Error (TEDs Only)Errors found on TEDs (initial submissions, resubmissions,
and adjustments/cancellation submissions) which result in non-acceptance
of the records by DHA. These require correction of the error by
the contractor and resubmission of the corrected TED to DHA for
acceptance.
Electronic Media (HIPAA Definition)A mode of transferring/storing information that
includes:
1. Electronic storage material on which data
may be recorded electronically, including for example devices in
computers (hard drives) and any removable/transportable digital
memory medium, such as magnetic tape or disk, or digital memory
card.
2. Transmission media
used to exchange information already in electronic storage media. Transmission
media includes, for example, the Internet (the Extranet leased lines,
dial-up lines, private networks, and the physical movement of removable
and transportable electronic storage media. Certain transmissions,
including paper, via facsimile, and of voice, via telephone, are
not considered to be transmissions via electronic media if the information
being exchanged did not exist in electronic form immediately before
the transmission.
Employment Records (Defined in DoD 5400.11-R,
DoD Privacy Program)Any item collection
or grouping of information, whatever the storage media (paper, electronic,
etc,) about an individual that is maintained by an entity subject
to the DoD Privacy Program Regulation including but not limited
to an individual’s education, financial transactions, medical history,
criminal or employment history, and that contains his or her name,
or the identifying number, symbol, or other identifying particular
assigned to the individual, such as a finger or voice print or a
photograph. For more specific information refer to the DoD Privacy
Program Regulation.
Enhanced Multi-Service Markets (eMSM)Concept which integrates health care among the
Uniformed Services by providing increased authority including funding
allocation, policy, and better maximization of staff skill sets.
The concept is employed in geographic areas where at least two medical
hospitals or clinics from different Uniformed Services have overlapping
service areas. They are considered enhanced because of several factors,
including overall size, medical mission, and graduate medical education
capacity and because they allow for the movement of workload and
workforce between or among the medical treatment facilities.
Enrollment FeesThe
amount required to be paid by some MHS beneficiaries eligible to
enroll in and receive the benefits of TRICARE Prime, TRICARE Select or
other special TRICARE programs.
Enrollment PlanA
process established by the contractor to inform beneficiaries of
the availability of the TRICARE Prime program, facilitate enrollment
in the program, and maintain enrollment records. The plan must include actions
for TRICARE Select and must be approved by the Government. The contractor
process must be approved by the Government.
Enrollment RecordsOfficial
documentation of a beneficiary’s registration (enrollment) for TRICARE
Prime and maintained on the DEERS.
Enrollment TransferA transfer of TRICARE enrollment from one location
or contractor to another:
1. Out-Of-Contract
Enrollment Transfer. An enrollment transfer between contractors,
to include the Continental United States (CONUS) to CONUS, CONUS
to Outside of the Continental United States (OCONUS), and OCONUS
to CONUS. The term “contractors” also includes Designated Providers
(DPs) under the Uniformed Services Family Health Plan (USFHP).
2. Within-Contract
Enrollment Transfer. An enrollment transfer within a TRICARE
region, which involves a change of address and possibly a change
of Primary Care Managers (PCMs), but not a change of contractors.
Entity (Defined in 32 CFR 199.2)An
entity includes a corporation, trust, partnership, sole proprietorship
or other kind of business enterprise that is or may be eligible
to receive reimbursement either directly or indirectly from TRICARE.
Episodes of Care (EOC)Referrals are normally processed as “Episodes of
Care.” An EOC is defined as “A treatment period that begins with
the initial assessment, follow up interventions and reassessments
necessary to provide reasonable medical services related to a specific
condition.” The episode includes associated lab, radiology, Durable
Medical Equipment (DME), and ancillary therapies (Physical Therapy
(PT), Occupational Therapy (OT), Speech Therapy (ST)), all of which
are subject to the Right of First Refusal (ROFR) process. An episode
of care generally involves evaluation and/or treatment of one disease
or condition and may allow for specialist to specialist (secondary)
referrals. Episodes are generally categorized as ”evaluate (only)”
or “evaluate and treat.”
ExclusionServices
and/or supplies not reimbursable under TRICARE. This includes otherwise
covered services and supplies provided to a TRICARE eligible beneficiary
by a non-authorized provider/entity or a provider placed on “suspension”
by a contractor.
Explanation Of Benefits (EOB)An electronic or paper document prepared by insurance
carriers, health care organizations, and TRICARE contractors to
inform beneficiaries of the actions taken with respect to a claim
for health care coverage.
Extraordinary Physical Or Psychological
ConditionA complex physical or psychological
clinical condition of such severity which results in the dependents of
a Service member being homebound. See TPM,
Chapter 9 for
additional information.
Federal Records Center (FRCs)Locations established and maintained by the General
Services Administration (GSA) at areas throughout the U.S. for the
storage, processing, and servicing of non-current records for Government agencies.
Files AdministrationThe application of records management techniques
to filing practices to maintain records easily and to retrieve them
rapidly, to ensure their completeness, and to facilitate the disposition
of noncurrent records.
Fiscal Year (FY)The
Federal Government’s 12 month accounting period which currently
runs from October 1 through September 30 of the following year.
Format (HIPAA Definition)Those data elements that provide or control the
enveloping or hierarchical structure, or assist in identifying data
content of, a transaction, as defined in HIPAA of 1996.
Former MemberAn
individual who is eligible for, or entitled to, retired pay, at
age 60, for non-regular service in accordance with Chapter 1223,
Title 10, USC but has been discharged and maintains no military affiliation.
These former members, at age 60, and their eligible dependents are
entitled to medical care, commissary, exchange, and MWR privileges.
Under age 60, they and their eligible dependents are entitled to
commissary, exchange, and MWR privileges only.
FormularyA
listing of pharmaceuticals and other authorized supplies to be dispensed
with appropriate prescriber’s order from a particular POS. The formulary
for any TRICARE contract will be managed by the DoD Pharmacy and
Therapeutics (P&T) Committee with clinical guidance from the
DoD Pharmacoeconomic Center (PEC). Applicable formulary information
may be viewed on the TRICARE web site at:
http://www.health.mil/formulary.
Freedom Of ChoiceThe
right to obtain medical care from any TRICARE-authorized source
available, including TRICARE Prime, the DC and/or the MTF/eMSM systems,
or obtain care from a provider not affiliated with the contractor
and seek reimbursement under the terms and conditions of the TRICARE
Standard (TRICARE Select starting January 1, 2018) Program (see
definition).
Note: Beneficiaries
who voluntarily enroll in TRICARE Prime must be informed of any
restrictions on freedom of choice that may be applicable to enrollees
as a result of enrollment. Except for any limitations on freedom
of choice that are fully disclosed to the beneficiaries at the time
of enrollment, freedom of choice provisions applicable to the TRICARE
Standard (TRICARE Select starting January 1, 2018) Program shall
be applicable to TRICARE Prime.
Freedom Of Information Act (FOIA)A law enacted in 1967 as an amendment to the “Public
Information” section of the Administrative Procedures Act, establishing
provisions making information available to the public. DHA and TRICARE contractors
are subject to these provisions.
Freestanding (Defined in 32 CFR 199.2)Not
“institution-affiliated” or “institution-based.”
Full Mobilization (DoD Definition)Expansion of the Active Armed Forces resulting
from action by Congress and the President to mobilize all Reserve
Component (RC) units and individuals in the existing approved force
structure, as well as retired military personnel, and the resources
needed for their support to meet the requirements of a war or other
national emergency involving an external threat to the national
security. Reserve personnel can be placed on active duty for the
duration of the emergency plus six months.
Gag ClauseA
provision that is included in a professional provider’s agreement
or contract with a managed care organization; such as a Preferred
Provider Organization (PPO) network or a Health Maintenance Organization
(HMO) network, or third-party payer that directly or indirectly
prevents limits the ability of the HCP from being open with his/her
patients about the terms of the patient’s coverage and therapeutic
treatment options, including, the risks, benefits and consequences
of treatment or non-treatment, or the opportunity for the individual
to refuse treatment and to express preferences about future treatment
options.
Good Faith Payments (Defined in 32 CFR 199.2)Those
payments made to civilian sources of medical care who provided medical
care to persons purporting to be eligible beneficiaries but who
are determined later to be ineligible for TRICARE benefits. (The
ineligible person usually possesses an erroneous or illegal identification
card.) To be considered for good faith payments, the civilian source
of care must have exercised reasonable precautions in identifying
a person claiming to be an eligible beneficiary.
GrievanceA
written complaint on a non-appealable issue which deals primarily
with a perceived failure of a network provider, the Health Care
Finder (HCF), or contractor or subcontractor, to furnish the level
or quality of care expected by a beneficiary.
Grievance ProcessA
contractor developed and managed system for resolving beneficiary
grievances.
Group A and BWith
respect to beneficiary cost-sharing, deductibles and catastrophic
cap, the NDAA 2017 divided beneficiaries enrolled in TRICARE Prime
or TRICARE Select into two groups:
• Group A (or grandfathered)
beneficiaries: consists of sponsors and their family members who
first became affiliated with a Uniformed Service through enlistment
or appointment before January 1, 2018.
• Group B (or non-grandfathered) beneficiaries:
consists of sponsors and their family members who first became affiliated
with a Uniformed Service through enlistment or appointment on or
after January 1, 2018.
Effective
January 1, 2018, enrollees in the TRICARE Reserve Select (TRS),
TRICARE Retired Reserve (TRR), TRICARE Young Adult (TYA), or the
CHCBP have Group B cost-shares, deductibles, and catastrophic caps,
regardless of when the sponsor first became affiliated with a Uniformed
Service through enlistment or appointment.
Group Health Plan (GHP)An employee welfare benefit plan (as defined in
section 3(1) of the Employee Retirement Income and Security Act
of 1974 (ERISA), 29 USC 1002(1)), including insured and self-insured
plans, to the extent that the plan provides medical care (as defined
in section 2791(a)(2) of the Public Health Service Act (PHS Act),
42 USC 300gg-91(a)(2)), including items and services paid for as
medical care, to employees or their dependents directly or through
insurance, reimbursement, or otherwise, that:
1. Has
50 or more participants (as defined in section 3(7) of ERISA, 29
USC 1002(7)); or
2. Is administered by
an entity other than the employer that established and maintains
the plan.
Health CareThe
prevention, treatment and management of illness and the preservation
of mental and physical well being by qualified medical professionals.
This includes but is not limited to, preventive, diagnostic, therapeutic,
rehabilitative, maintenance, or palliative care, and counseling,
service, assessment, or procedure with respect to the physical or
mental condition, or functional status, of an individual or that affects
the structure or function of the body; and the sale or dispensing
of a drug, device, equipment, or other item in accordance with a
prescription. As described in HIPAA of 1996.
Health Care Clearinghouse (HIPAA Definition)A public or private entity, including a billing
service, repricing company, community health management information
system or community health information system, and “value-added” networks
and switches, that does either of the following functions.
1. Processes
or facilitates the processing of health information received from
another entity in a nonstandard format or containing nonstandard
data content into standard data elements or a standard transaction.
2. Receives
a standard transaction from another entity and processes or facilitates
the processing of health information into nonstandard format or
nonstandard data content for the receiving entity. As defined in
HIPAA of 1996.
Health Care Common Procedure Coding System
(HCPCS)Set of health care procedure
codes based on the American Medical Association’s (AMA’s) Current Procedural
Terminology (CPT).
Health Care Finder (HCF)A person who manages and performs the duties necessary
to operate an HCF system.
Health Care Finder (HCF) SystemA system or mechanism, established by the contractor
in each Prime Service Area (PSA) in the region, to facilitate referrals
and other customer service functions to assist beneficiaries in
accessing health care to the DC system and/or civilian providers.
Health Care Provider (HCP) (HIPAA Definition)A provider of medical or health services, institutional
or individual professional provider, and any other person or organization
who furnishes, bills, or is paid for health care in the normal course
of business as defined in HIPAA of 1996.
Health Information (HIPAA Definition)Any information, including genetic information,
whether oral or recorded, in any form or medium that:
1. Is
created or received by a HCP, health plan, public health authority,
employer, life insurer, school or university, or health care clearinghouse;
and
2. Relates to the past,
present, or future physical or mental health or condition of an
individual; the provision of health care to an individual; or the
past, present, or future payment for the provision of health care
to an individual.
As defined
in HIPAA of 1996.
Health Insurance Issuer (HIPAA Definition)An insurance company, insurance service, or insurance
organization (including an HMO) that is licensed to engage in the
business of insurance in a State and is subject to State Law that
regulates insurance. Such term does not include a group health plan.
Health Maintenance Organization (HMO)
(HIPAA Definition)A federally qualified
HMO, an organization recognized as an HMO under State law, or a
similar organization regulated for solvency under State law in the
same manner and to the same extent as such an HMO as defined in
HIPAA of 1996.
Health Oversight Agency (HIPAA Definition)An agency or authority of the U.S., a State, a
territory, a political subdivision of a State or territory, or an Indian
tribe, or a person or entity acting under a grant of authority from
or contract with such public agency, including the employees or
agents of such public agency or its contractors or persons or entities
to whom it has granted authority, that is authorized by law to oversee
the health care system (whether public or private) or Government
programs in which health information is necessary to determine eligibility
or compliance, or to enforce civil rights laws for which health
information is relevant as defined in HIPAA of 1996.
Note: The term “health oversight agency” includes any
DoD Component authorized under applicable DoD Regulation to oversee
the MHS, including with respect to matters of quality of care, risk management,
program integrity, financial management, standards of conduct, or
the effectiveness of the MHS in carrying out its mission.
Health Plan (HIPAA Definition)An individual or group plan that provides or pays
the cost of medical care. For a more detailed definition refer to
HIPAA of 1996.
HIPAA BreachAn
incident that satisfies the definition of a breach in 45 CFR 164.402
(HIPAA Breach Rule).
Homebound (Defined in 32 CFR 199.2)A
beneficiary’s condition is such that there exists a normal inability
to leave home, and consequently, leaving home would require considerable
and taxing effort. Any absence of an individual from the home attributable
to the need to receive health care treatment including regular absences
for the purpose of participating in rehabilitative, therapeutic,
psychosocial, or medical treatment in an adult daycare program that
is licensed or certified by a state, or accredited to furnish adult
daycare services in the state shall not disqualify an individual
from being considered to be confined to home. Any other absence
of an individual from the home shall not disqualify an individual
if the absence is infrequent or of relatively short duration. For
the purposes of the preceding sentence, any absence for the purpose
of attending a religious service shall be deemed to be an absence
of infrequent or short duration. Also, absences from the home for
non-medical purposes, such as an occasional trip to the barber,
a walk around the block or a drive, would not necessarily negate
the beneficiary’s homebound status if the absences are undertaken
on an infrequent basis and are of relatively short duration. An
exception is made to the above homebound definitional criteria for
beneficiaries under the age of 18 and those receiving maternity
care. The only homebound criteria for these special beneficiary
categories is written certification from a physician attesting to
the fact that leaving home would place the beneficiary at medical
risk. In addition to the above absences, whether regular or infrequent,
from the beneficiary’s primary home for the purpose of attending
an educational program in a public or private school that is licensed
and/or certified by a state, shall not negate the beneficiary’s
homebound status. See also TPM,
Chapter 9 for
additional information.
Hospital DayAn
overnight stay at a hospital. Normally if the patient is discharged
in less than 24 hours it would not be considered an inpatient stay;
however, if the patient was admitted and assigned to a bed and the intent
of the hospital was to keep the patient overnight, regardless of
the actual Length-Of-Stay (LOS), the stay will be considered an
inpatient stay and, therefore, a hospital day. For hospital stays
exceeding 24 hours, the day of admission is considered a hospital
day; the day of discharge is not.
Immediate Family (Defined in 32 CFR 199.2)The
spouse, natural parent, child and sibling, adopted child and adoptive
parent, stepparent, stepchild, grandparent, grandchild, stepbrother
and stepsister, father-in-law, mother-in-law of the beneficiary,
or provider, as appropriate. For purposes of this definition only,
to determine who may render services to a beneficiary, the step-relationship
continues to exist even if the marriage upon which the relationship
is based terminates through divorce or death of one of the parents.
Independent Laboratory (Defined in 32 CFR 199.2)A
freestanding laboratory approved for participation under Medicare
and certified by the CMS.
Indirect Treatment Relationship (HIPAA
Definition)A relationship between an
individual and a HCP in which:
1. The HCP delivers health
care to the individual based on the orders of another HCP; and
2. The
HCP typically provides services or products, or reports the diagnosis
or results associated with the health care, directly to another
HCP, who provides the services or products or reports to the individual.
As defined in HIPAA of 1996.
IndividualThe
person who is the subject of PHI as defined in HIPAA of 1996.
Individual Consideration (IC) ProcedureA service/treatment not routinely provided, is
unusual, variable, or new and, as such, will require additional
information from the provider of care, including an adequate definition
or description of the nature, extent and need for the unusual service/treatment
including the time, effort, and necessary equipment required. Any
complexities related to the service should also be identified.
Individually Identifiable Health Information
(IIHI) (HIPAA Definition)Information
that is a subset of health information, including demographic information
collected from an individual, and:
1. Is created or received
by a HCP, health plan, employer, or health care clearinghouse; and
2. Relates
to the past, present, or future physical or mental health or condition
of an individual; the provision of health care to an individual;
or the past, present, or future payment for the provision of health
care to an individual; and
3. That
identifies the individual; or
4. With
respect to which there is a reasonable basis to believe the information
can be used to identify the individual.
As defined in HIPAA of 1996.
Initial Determination (Defined in 32 CFR 199.2)A
formal written decision on a TRICARE claim, a request for benefit
authorization, a request by a provider for approval as an authorized
TRICARE provider, or a decision disqualifying or excluding a provider
as an authorized provider under TRICARE. Rejection of a claim or
a request for benefit or provider authorization for failure to comply
with administrative requirements, including failure to submit reasonably
requested information, is not an initial determination. Responses
to general or specific inquiries regarding TRICARE benefits are
not initial determinations.
Initial PaymentThe
first payment on a continuing claim, such as a long-term institutional
claim.
Inpatient (Defined in 32 CFR 199.2)A
patient who has been admitted to a hospital or other authorized
institution for bed occupancy for purposes of receiving necessary
medical care, with the reasonable expectation that the patient will remain
in the institution at least 24 hours, and with the registration
and assignment of an inpatient number or designation. Institutional
care in connection with in and out (ambulatory) surgery is not included
within the meaning of inpatient whether or not an inpatient number
or designation is made by the hospital or other institution. If
the patient has been received at the hospital, but death occurs before
the actual admission occurs, an inpatient admission exists as if
the patient had lived and had been formally admitted.
Inpatient CareServices/treatment
provided to a person who has been admitted to a hospital or other
authorized institution.
Inpatient Rehabilitation Facility (IRF)A facility classified by CMS as an IRF and meets
the applicable requirements established by
32 CFR 199.6(b)(4)(xx) (which includes the
requirement to be a Medicare participating provider).
InquiryRequests
for information or assistance made by or on behalf of a beneficiary,
provider, the public, or the Government. Written inquiries may be
made in any format (letter, memorandum, note attached to a claim,
etc.). Allowable charge complaints, grievances, and appeals are
excluded from this definition.
Institution-Affiliated (Defined in 32 CFR 199.2)Related
to a TRICARE authorized institutional provider through a shared
governing body but operating under a separate and distinct license
or accreditation.
Institution-Based (Defined in 32 CFR 199.2)Related
to a TRICARE authorized institutional provider through a shared
governing body and operating under a common license and shared accreditation.
Institutional ProviderA HCP who meets the applicable requirements established
by
32 CFR 199.6.
Intensive Outpatient Program (IOP)A treatment setting capable of providing an organized
day or evening program that includes assessment, treatment, case
management, and rehabilitation for individuals not requiring 24-hour
care for mental health disorders, to include SUDs, as appropriate
for the individual patient. The program structure is regularly scheduled,
individualized, and shares monitoring and support with the patient’s family
and support system.
Interactive Telecommunications SystemInteractive telecommunications systems are defined
as multimedia communications modalities that include, at a minimum,
secure audio and video equipment permitting two-way, real-time services
or consultations. This includes smartphones, tablet computers, and
personal computers equipped with the necessary camera and software
to enable two-way, encrypted real-time audio and video interaction;
as well as dedicated video conferencing and telemedicine systems.
Internal Control Number (ICN)The unique number assigned to a claim by the contractor
to distinguish the claim during processing, payment, and filing
procedures. It is the number affixed to the face of each claim received
and will, at a minimum, include the Julian date of receipt and a
five digit sequence number assigned by the contractor. Each TED
must have a unique ICN. For records generated from claims, it will
be the ICN of the claim from which it was generated. For a TED which
is not generated from claims, it will be a unique number assigned
by the contractor which will include the Julian date of the record’s
creation and a five digit sequence number.
International Classification of Diseases,
9th Edition, Clinical Modification (ICD-9-CM)A
technical reference, ICD-9-CM. Volumes 1 and 2 are a required reference
and coding system for diagnoses and Volume 3 is required as a coding
system for procedures in processing TRICARE claims for medical care
with dates of service for outpatient services or dates of discharge
for inpatient services before the mandated date, as directed by
HHS, for ICD-10 implementation.
International Classification of Diseases,
10th Edition, Clinical Modification (ICD-10-CM)A technical reference, ICD-10-CM. It is a required
reference and coding system for diagnoses in processing TRICARE
claims for medical care with dates of service for outpatient services
or dates of discharge for inpatient services on or after the mandated
date, as directed by HHS, for ICD-10 implementation.
International Classification of Diseases,
10th Edition, Procedure Coding System (ICD-10-PCS)A technical reference, ICD-10-PCS. It is a required
reference and coding system for procedures in processing TRICARE
claims for medical care with dates of discharge for inpatient services
on or after the mandated date, as directed by HHS, for ICD-10 implementation.
Intervention, PharmacyA change in therapy resulting from the prospective
drug utilization review process and contact with the prescriber
and/or the beneficiary because of allergy, clinically significant
interactions, duplicative therapy, or other reasons.
Intervention Report, PharmacyA formal account of prescriptions not dispensed
or changes in therapy as a result of contact with prescriber's and/or
beneficiaries because of allergies, clinically significant interactions,
duplicative therapy, or other reasons. The formal account shall
also contain the resultant change in cost due to the intervention,
if possible.
Investigational DrugsNew medicines or other substances which have a
physiological effect when ingested or otherwise introduced into
the body, that have not been approved for general use by the Food
and Drug Administration (FDA) but is under investigation and clinical
trial regarding its safety and efficacy first by clinical investigators
and then by practicing physician using subjects who have given informed
consent to participate.
Laboratory And Pathological Services
(Defined in 32 CFR 199.2)Laboratory and pathological examinations (including
machine diagnostic tests that produce hard-copy results) when necessary
to, and rendered in connection with medical, obstetrical, or surgical
diagnosis or treatment of an illness or injury, or in connection
with well-baby care.
Law Enforcement Official (HIPAA Definition)An officer or employee of any agency or authority
of the U.S., a State, a territory, a political subdivision of a
State or territory, or an Indian tribe, who is empowered by law
to:
1. Investigate or conduct an official inquiry
into a potential violation of law; or
2. Prosecute
or otherwise conduct a criminal, civil, or administrative proceeding
arising from an alleged violation of law.
For further details, refer to HIPAA of 1996.
Legacy IdentifierA
number used to identify unique providers. These number include the
six-digit Medicare ID number, Unique Physician Identification Number
(UPIN), 10-digit Ambulatory Surgery Center (ASC) number, Supplier
Clearinghouse (NSC) number, Online Survey Certification and Reporting
(OSCAR) number, and DME supplier number. A legacy identification
number is other than the unique NPI required by HIPAA of 1996 to
be issued to each physician, supplier and other provider of health
care and the Federal Tax Identification Number (TIN). A Federal
TIN is not considered a legacy identifier for health care purposes as
it’s primary purpose is to support IRS 1099 reporting.
Limited Data Set (HIPAA Definition)A semantically meaningful unit of information exchanged
between two parties to a transaction that excludes direct identifiers
of the individual or of relatives, employers, or household members
of the individual which is considered to be PHI as defined in HIPAA
of 1996.
Long-Term Care Hospital (LTCH)A hospital that is classified by the CMS as an
LTCH and meets the applicable requirements established by
32 CFR 199.6(b)(4)(v) (which includes the
requirement to be a Medicare participating provider).
Machine-Readable Records/ArchivesThe records and archives whose informational content
is usually in code and has been recorded on media, such as magnetic
disks, drums, tapes, punched paper cards, or punched paper tapes, accompanied
by finding aids known as software documentation. The coded information
is retrievable only by machine.
Maintain Or Maintenance (HIPAA Definition)Activities necessary to support the use of a standard
adopted by the Secretary of HHS, including technical corrections
to an implementation specification, and enhancements, or expansion
of a code set. This term excludes the activities related to the
adoption of a new standard or implementation specification, or modification
to an adopted standard or implementation specification.
Major Diagnostic Category (MDC)A group of similar DRGs, such as all those effecting
a given organ system of the body formed by dividing all possible
principal diagnoses from (ICD-9-CM) into 25 mutually exclusive diagnosis
areas. MDC codes, like DRG codes, are primarily a claims and administrative
data element unique to the U.S. medical care reimbursement system.
DRG codes are also mapped, or grouped, into the MDC codes.
Managed Care Support Contractor (MCSC)Civilian contractor, under contract with the DoD,
to work with, help support and augment health care services available
at the MTFs/eMSMs resulting in the establishment of an integrated
system of health care delivery that influences utilization of services,
cost of services while measuring performance. The contractor is
required to assist military personnel in the combining of the resources
of the military’s direct medical care system, the TRICARE program
and the contractor’s managed care provider network and other services
outlined in the contract to ensure a system that delivers value
by giving TRICARE eligible beneficiaries access to quality, cost-effective
health care.
Marketing (HIPAA Definition)Communication about a product or service to encourage
recipients of the communication to purchase or use the product or
service as defined in HIPAA of 1996. See also DoD 6025.18R, DoD
Health Information Privacy Regulation, for a list of specific exclusions
to this definition.
Maximum Allowable Prevailing ChargeThe TRICARE state prevailing charges adjusted by
the Medicare Economic Index (MEI) according to the methodology as
set forth in
Chapter 16.
Maximum Defined Data Set (HIPAA Definition)All required data elements for a particular standard
based on a specific implementation specification.
Medicaid (Defined in 32 CFR 199.2)Those
medical benefits authorized under Title XIX of the Social Security
Act provided to welfare recipients and the medically indigent through
programs as administered by the various states.
Medical (Defined in 32 CFR 199.2)The
generally used term which pertains to the diagnosis and treatment
of illness, injury, pregnancy, and mental disorders by trained and
licensed or certified health professionals. For purposes of TRICARE, the
term “medical” should be understood to include “medical, psychological,
surgical, and obstetrical,” unless it is specifically stated that
a more restrictive meaning is intended.
Medical/Dental Claims History FileRefer to Beneficiary History File definition.
Medical Emergency (Defined in 32 CFR 199.2)The
sudden and unexpected onset of a medical condition or the acute
exacerbation of a chronic condition that is threatening to life,
limb, or sight, and requires immediate medical treatment or which manifests
painful, symptomatology requiring immediate palliative efforts to
alleviate suffering. Medical emergencies include heart attacks,
cardiovascular accidents poisoning, convulsions, kidney stones,
and such other acute medical conditions as may be determined to
be medical emergencies by the TRICARE Director, or a designee. In
the case of a pregnancy, a medical emergency must involve a sudden
and unexpected medical complication that puts the mother, the baby,
or both, at risk. Pain would not, however, qualify a maternity case
as an emergency, nor would incipient birth after the 34th week of gestation,
unless an otherwise qualifying medical condition is present. Examples
of medical emergencies related to pregnancy or delivery are hemorrhage,
ruptured membrane with prolapsed cord, placenta previa, abruption
placenta, presence of shock or unconsciousness, suspected heart attack
or stroke, or trauma (such as injuries received in an automobile
accident.
Medical Necessity DeterminationA review to determine if the recommended health
care services are reasonable for the diagnosis and treatment of
illness, injury, pregnancy, mental disorders and adequate for well-baby
care.
Medical Supplies And Dressings (Consumables)
(Defined in 32 CFR 199.2)Necessary medical or surgical supplies (exclusive
of DME) that do not withstand prolonged, repeated use and that are
needed for the proper medical management of a condition for which
benefits are otherwise authorized under TRICARE, on either an inpatient
or outpatient basis. Examples include disposable syringes for a
diabetic, colostomy sets, irrigation sets, and ace bandages.
Medical ManagementContemporary
practices in areas such as Utilization Management (UM), Case Management
(CM), care coordination, chronic care/Disease Management (DM), and
the various additional terms and models for managing the clinical
and social needs of eligible beneficiaries to achieve the short
and long term cost-effectiveness of the MHS while achieving the
highest level of satisfaction among MHS beneficiaries.
Medically or Psychologically Necessary
(Defined in 32 CFR 199.2)The frequency, extent and types of medical services
or supplies, which represent appropriate medical care and that are
generally accepted by qualified professionals to be reasonable and
adequate for the diagnosis and treatment of illness, injury, pregnancy,
and mental disorders or that are reasonable and adequate for well-baby
care.
Medicare (Defined in 32 CFR 199.2)The
medical benefits authorized under Title XVIII of the Social Security
Act provided to persons 65 or older, certain disabled persons, or
persons with chronic renal disease, through a national program administered
by the Department of Health and Human Services (DHHS), Health Care
Financing Administration (HCFA), Medicare Bureau.
Medicare Economic Index (MEI)An index used by Medicare to update physician fee
levels in relation to annual changes in the general economy for
inflation, productivity, and changes in specific health sector practice
expenses factors including malpractice, personnel costs, rent, and
other expenses.
Medication Assisted Treatment (MAT)MAT for diagnosed SUD is a holistic modality for
recovery and treatment that employs evidence-based therapy, including
psychosocial treatments and psychopharmacology, and FDA-approved
medications as indicated for the management of withdrawal symptoms
and maintenance.
Medication Error (FDA Definition)Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication
is in the control of the health care professional, patient, or consumer.
Such events may be related to professional practice, health care
products, procedures, and systems, including prescribing, order
communication, product labeling packaging, and nomenclature, compounding, dispensing,
distribution, administration, education, monitoring and use as defined
by the FDA.
Mental Disorder, To Include SUD
For purposes of the payment of TRICARE benefits,
a mental disorder is a nervous or mental condition that involves
a clinically significant behavioral or psychological syndrome or
pattern that is associated with a painful symptom, such as distress,
and that impairs a patient’s ability to function in one or more major
life activities. An SUD is a mental condition that involves a maladaptive
pattern of substance use leading to clinically significant impairment
or distress; impaired control over substance use; social impairment;
and risky use of a substance(s). Additionally, the mental disorder
must be one of those conditions listed in the current edition of
the DSM. “Conditions Not Attributable to a Mental Disorder,” or V codes,
or ICD-10-CM Z codes, are not considered diagnosable
mental disorders.
MemberAn
individual who is affiliated with a Service, either an active duty
member, reserve member, active duty retired member, or retired reserve
member. Members in a retired status are not former members. Also
referred to as the sponsor.
Mental Health Therapeutic Absence (Defined
in 32 CFR 199.2)A therapeutically planned absence from the inpatient
setting. The patient is not discharged from the facility and may
be away for periods of several hours to several days. The purpose
of the therapeutic absence is to give the patient an opportunity
to test his or her ability to function outside the inpatient setting
before the actual discharge.
Military Health System (MHS) BeneficiaryAny individual who is eligible to receive treatment
in an MTF/eMSM. Eligibility is determined by the Uniformed Services
and is reported on DEERS.
Note: The categories
of MHS beneficiaries shall be broadly interpreted unless otherwise specifically
restricted. (For example: Authorized parents and parents-in-law
are not eligible for TRICARE Program, but may receive treatment
in an MTF/eMSM (on a space available basis) and may access the Nurse
Advise Line (NAC)).
Military Treatment Facility (MTF)A Uniformed Services hospital or clinic.
Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (eMSM) OptimizationFilling
every appointment and bed available within the MTF or in the eMSM
based on the capacity and capabilities of the MTF/eMSM and the MTF’s/eMSM’s
readiness/training requirements, as defined by the MTF Commander/eMSM
Manager before referral to outside civilian providers.
Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (eMSM)-Referred CareMedical
care or services/supplies required by a patient that are not available
at the MTF or in the eMSM area and therefore must be provided by
an outside civilian provider. Such care requires an MTF/eMSM referral
for the civilian medical care.
Mobilization Plan - TRICAREA detailed proposal designed to ensure the Government’s
ability to continue to meet the health care needs of the TRICARE-eligible
beneficiaries in the event of a military mobilization that precludes
the use of all or parts of the military DC system for provision
of care to TRICARE-eligible beneficiaries.
Monthly Pro-RatingA
calculation process for determining the amount of the enrollment
fee to be credited to a new enrollment period. For example, if a
beneficiary pays their annual enrollment fee, in total, on January
1, (the first day of their enrollment period) and a change in status
occurs on February 15. The beneficiary will receive credit for 10
months of the enrollment fee. The beneficiary will lose that portion
of the enrollment fee that would have covered the period from February
15 through February 28.
Most-Favored Rate (Defined in 32 CFR 199.2)The
lowest usual charge to any individual or third-party payer in effect
on the date of the admission of a TRICARE beneficiary.
National Appropriate Charge LevelThe charge level established from a 1991 national
appropriate charge file developed from July 1986 - June 1987 claims
data, by applying appropriate MEI updates through 1990, and prevailing
charge cuts, freeze or MEI updates for 1991 as discussed in the
September 6, 1991, Final Rule.
National Conversion Factor (NCF)A mathematical representation of what is currently
being paid for similar services nationally. The factor is based
on the national allowable charges actually in use.
National Disaster Medical System (NDMS)A Federally coordinated framework that augments
the nation’s medical response capability. The primary purpose of
the NDMS is to supplement an integrated national medical response
for assisting state and local authorities in dealing with medical
impacts of major peacetime disasters and to provide support to the
military and the DVA medical systems in caring for casualties evacuated
back to the U.S. from overseas armed conventional conflict. The
NDMS framework involves private sector hospitals located throughout
the U.S. that will provide care for victims of any incident that
exceeds the medical care capability of any affected state, region,
or federal medical care system. For more detailed information see
NDMS at the DHHS web site.
National Prevailing Charge LevelA rate that does not exceed the amount equivalent
to the eightieth (80th) percentile of billed charges made for similar
services during a 12 month base period.
National Provider Identifier (NPI) (HIPAA
Definition)A 10-digit number assigned
to all HCPs mandated by HIPAA of 1996. These numbers are to be used
for all financial and administrative transactions. The 10-digit
number, containing checksum, prevents technical errors during data
transmission. The number doesn’t have built-in correlation with
any other identifier associated with the provider.
Negotiated (Discounted) RateAn amount that represents the reimbursable amount
that a provider agrees to accept for covered services.
NetworkThe
providers or facilities (owned, leased, or arranged) the TRICARE
contractor has contracted with to provide health care services to
TRICARE eligible beneficiaries at a pre-negotiated rate as the total charge
for services provided by the provider and to file claims for beneficiaries.
The agreements for health care delivery made between the MTF and
the eMSM and the TRICARE contractor are also included in this definition.
Network CareHealth
care services and supplies provided by providers and facilities
(owned, leased, arranged) the TRICARE contractor has contracted
with to provide necessary treatment to TRICARE eligible beneficiaries.
Network InadequacyInsufficient
TRICARE contractor contracted providers to meet the access standards
required by the TRICARE contract.
Network ProviderAn
individual or institutional provider that has contracted with a
TRICARE contractor to provide care to TRICARE eligible beneficiaries,
usually at a discounted rate.
Note: All network providers MUST be participating providers.
Non-Appealable IssueDenial of benefits based on a fact or condition
outside the scope of responsibility of DHA and the TRICARE contractor.
Note: For example, the establishment of eligibility
is a Uniformed Service responsibility and if the service has not
established that eligibility, neither DHA nor a TRICARE contractor
may review the action. Similarly, late claim filing, late appeal
filing, amount of allowable charge (the contractor must verify it was
properly applied and calculated), and services or supplies specifically
excluded by law or regulation, such as routine dental care, clothing,
routine vision care, etc., are matters subject to legislative action
or regulatory rule making not appealable under TRICARE. TRICARE
contractors shall not make a determination that an issue is not
appealable except as specified in
Chapter 13 and
32 CFR 199.10.
Non-Claim Health Care DataInformation captured by the TRICARE contractor
to complete the required TED record for care rendered to TRICARE
beneficiaries in those contractor owned, operated and/or subcontracted
facilities where there is no claim submitted by the provider of
care.
Non-Compliant, PharmacyAction which results in a medication being returned
to stock for various reasons such as the medication was not picked
by the patient within the given 10 day grace period, pharmacy/physician
cancelled the prescription, etc.
Note: A subsequent reversal is automatically sent to
Pharmacy Data Transaction Service (PDTS) which will result in the
removal of the prescription fill from the patient profile. A reversed
or adjusted TED record is also submitted to DHA resulting in a financial
credit to the Government.
Non-Current RecordsDocuments that are no longer required in the conduct
of current business and therefore can be retrieved by an archival
repository or destroyed.
Non-Department Mental health
Care ProviderFor
the purposes of establishing a mental health care provider readiness
designation as mandated by the National Defense and Authorization
Act (NDAA) for Fiscal Year (FY) 2016 Section 717, a non-Department
mental health care provider is a health care provider who specializes
in mental health, is not a health care provider of the DoD at a
facility of the Department, and provides health care to members
of the Armed Forces. It includes psychiatrists, psychologists, psychiatric
nurses, social workers, mental health counselors, marriage and family
therapists, and other mental health care providers designated by
the Secretary of Defense.
Non-DoD Information System (IS)An IS that is not owned, controlled, or operated
by the DoD, and is not used or operated by a contractor or other
non-DoD entity exclusively on behalf of the DoD.
Non-DoD TRICARE BeneficiariesA special category of individuals sponsored by
non-DoD Uniformed Services (the Commissioned Corps of the U.S. Public
Health Service (USPHS), the U.S. Coast Guard, and the Commissioned
Corps of the National Oceanic and Atmospheric Administration (NOAA))
who are eligible for TRICARE.
Non-Network CareServices
and supplies received from a civilian provider authorized to provide
health care but has no contractual relationship with the TRICARE
contractor.
Non-Network ProviderAn individual or institutional provider that not
has contracted with a TRICARE contractor to provide care to TRICARE
eligible beneficiaries at a discounted rate.
Non-Participating Provider (Defined in 32 CFR 199.2)A
hospital or other authorized institutional provider, a physician
or other authorized individual professional provider, or other authorized
provider that furnished medical services or supplies to a TRICARE
beneficiary, but who did not agree on the TRICARE claim form to
participate or to accept the TRICARE-determined allowable cost or
charge as the total charge for the services. A nonparticipating provider
looks to the beneficiary or sponsor for payment of his or her charge,
not TRICARE. In such cases, TRICARE pays the beneficiary or sponsor,
not the provider.
Non-Prime TRICARE BeneficiariesIndividuals, eligible for the TRICARE Program,
who are not enrolled in the TRICARE Prime program.
North Atlantic Treaty Organization (NATO)
MemberA military member of an armed
force of a foreign NATO nation who is on active duty and who, in connection
with official duties, is stationed in or passing through the U.S. For
a list of member nations, see
https://www.nato.int/cps/ie/natohq/topics_52044.htm.
Office-Based Opioid Treatment (OBOT)
TRICARE authorized providers acting within
the scope of their licensure or certification to prescribe outpatient
supplies of the medication to assist in withdrawal management (detoxification)
and/or maintenance of opioid use disorder, as regulated by 42 CFR
Part 8, addressing OBOT.
Open Enrollment PeriodThe yearly period when non-active duty beneficiaries
can enroll in or change their TRICARE enrolled plan coverage for
the following calendar program year. The open enrollment period
for TRICARE begins on the Monday of the second full week in November
to the Monday of the second full week in December of each calendar
year. See TPM,
Chapter 10, Section 2.1.
Opioid Treatment Program (OTP)OTPs are service settings for opioid treatment,
either freestanding or hospital-based, that adhere to the DHHS’
regulations at 42 CFR Part 8 and use medications indicated and approved
by DHA. OTPs provide a comprehensive, individually tailored program
of medication therapy integrated with psychosocial and medical treatment
and support services that address factors affecting each patient,
as certified by the Center for Substance Abuse Treatment (CSAT)
of the DHHS’ Substance Abuse and Mental Health Services Administration
(SAMHSA). Treatment in OTPs can include management of withdrawal symptoms
(detoxification) from opioids and medically supervised withdrawal
from maintenance medications. Patients receiving care for substance
use and co-occurring disorders care can be referred to, or otherwise
concurrently enrolled in, OTP.
Organized Health Care Arrangement (HIPAA
Definition)1. A clinically integrated
care setting in which individuals typically receive health care
from more than one HCP;
2. An
organized system of health care in which more than one covered entity
participates, and in which the participating covered entities hold
themselves out to the public as participating in a joint arrangement
and participate in joint activities such as utilization review,
quality assessment and improvement activities, or payment activities.
3. A
group health plan and a health insurance issuer or HMO with respect
to such group health plan, but only with respect to PHI created
or received by such health insurance issuer or HMO that relates
to individuals who are or who have been participants or beneficiaries
in such group health plan;
4. A
group health plan and one or more other group health plans each
of which are maintained by the same plan sponsor; or
5. The
group health plans described in paragraph
4 of
this definition and health insurance issuers or HMOs with respect
to such group health plans, but only with respect to PHI created
or received by such health insurance issuers or HMOs that relates
to individuals who are or have been participants or beneficiaries
in any of such group health plans.
For
full details refer to HIPAA of 1996.
Originating SiteThe
originating site is where the beneficiary is located at the time
the services are provided via an interactive telecommunications
system. The originating site must be either (a) where an otherwise authorized
TRICARE provider normally offers professional medical or psychological
services, such as the office of a TRICARE authorized individual
professional provider (e.g., physician’s office), (b) a TRICARE authorized
institutional provider, or (c) a patient’s home or other secure
location as outlined in this policy.
Other Health Insurance (OHI)Alternate or additional health plan coverage other
than TRICARE. This does not include Medicare or supplemental insurance
plans.
Other Special Institutional Providers
(Defined in 32 CFR 199.2)Certain specialized medical treatment facilities,
either inpatient or outpatient, other than those specifically defined,
that provide courses of treatment prescribed by a doctor of medicine
or osteopathy; when the patient is under the supervision of a doctor
of medicine or osteopathy during the entire course of the inpatient
admission or the outpatient treatment; when the type and level of care
and services rendered by the institution are otherwise authorized
in 32 CFR 199; when the facility meets all licensing or other certification
requirements that are extant in the jurisdiction in which the facility
is located geographically; which is accredited by an accrediting
organization approved by the Director, DHA if an appropriate accreditation
program for the given type of facility is available; and which is
not a nursing home, intermediate facility, halfway house, home for
the aged, or other institution of similar purpose.
Out-Of-Area CareTreatment
received by TRICARE eligible beneficiaries while traveling outside
their TRICARE region.
Out-Of-Network CareSee definition for Non-network Care.
Out-Of-Region BeneficiariesIndividuals who resides in one TRICARE region but
receives care within another TRICARE region.
Over-The-Counter (OTC) MedicationsDrugs that by law can be sold to a consumer without
a prescription from a health care professional.
Note: OTC drugs/items covered by the TRICARE Pharmacy
(TPharm) benefit (see
https://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx for covered
items) will be reimbursed by the TPharm contractor when purchased
with or without a prescription, as long as the purchase was from
a retail pharmacy. Covered OTC’s purchased without a prescription
from a medical supply house or venue other than a retail pharmacy
will be processed for reimbursement by the TRICARE regional contractor.
Partial HospitalizationA treatment setting capable of providing an interdisciplinary
program of medically monitored therapeutic services, to include
management of withdrawal symptoms, as medically indicated. Services may
include day, evening, night, and weekend treatment programs which
employ an integrated, comprehensive, and complementary schedule
of recognized treatment approaches. Partial hospitalization is a
time-limited, ambulatory, active treatment program that offers therapeutically intensive,
coordinated, and structured clinical services within a stable therapeutic
environment. Partial hospitalization is an appropriate setting for
crisis stabilization, treatment of partially stabilized mental disorders,
to include substance disorders, and a transition from an inpatient
program when medically necessary.
Participating Provider (Defined in 32 CFR 199.2)A
TRICARE authorized provider that is required, or has agreed by entering
into a TRICARE participation agreement or by an act of indicating
“accept assignment” on the TRICARE claim form to accept the TRICARE-allowable
amount as the maximum total charge for a service or item rendered
to a TRICARE beneficiary, whether the amount is paid for fully by
TRICARE or requires cost-sharing by the TRICARE beneficiary.
Note: This is another term for a non-network provider
previously defined in this section.
Partnership for Peace (PfP)The PfP Status of Forces Agreement (SOFA) is a
multilateral agreement between NATO member states and countries
participating in the PfP program. It deals with the status of foreign
forces while present on the territory of another state. See
https://www.nato.int/cps/en/natolive/topics_50349.htm for
a more detailed definition and
https://www.nato.int/cps/en/natohq/51288.htm for
a list of current countries.
Patient HarmA
fraudulent or abusive practice directly causing a patient who is
undergoing treatment for a disease, injury, or medical (or dental)
condition to suffer actual physical injury or acceleration of an
underlying condition. The determination that patient harm has occurred
must be based on the opinion of a qualified medical or dental provider
or pharmacist in the case of pharmacy claims. Refer to
Chapter 13 for additional information.
Patient Profile, PharmacyA complete record for each beneficiary receiving
prescriptions under the TRICARE program including: name, address,
telephone number, date of birth, gender, patient identification
number (sponsor’s SSN and DEERS dependent suffix), DEERS Identifier,
service sponsorship, status category, chronic medical conditions
(diagnosis code), allergies and adverse drug experiences, past medication
history, prescriptions dispensed, non-receipt of prescriptions,
status on interventions and prescription problems resolved, prior
authorizations approved or denied, and any other information supplied
by the beneficiary in the patient data form or updates.
Pending Claim, Correspondence, Or AppealThe claim/correspondence/appeal case has been received
but has not been processed to final disposition.
Performance StandardGovernment approved and developed criteria measuring
specific aspects of a contractor’s execution of a TRICARE contract.
Pharmacoeconomic Center (PEC)An activity under the DoD Pharmacy Operations Division
(POD) with the mission to improve the clinical, economic, and humanistic
outcomes of drug therapy in support of the readiness and managed care
missions of the MHS. The PEC is comprised of pharmacists, physicians,
and pharmacy technicians from each of the three services, as well
as civilian pharmacists and support personnel who monitor drug usage,
and cost trends, and performs analysis to support DoD formulary
management and national pharmaceutical contracts, and clinical practice
guidelines.
Pharmacy and Therapeutics (P&T) CommitteeA DoD chartered committee with representatives
from MTF/eMSM providers and MTF/eMSM pharmacists. The P&T Committee’s
primary role is establishing and maintaining the DoD Uniform Formulary
for the purchased care system and the DC system (MTFs/eMSMs).
Pharmacy Data Transaction Service (PDTS)A bi-directional data transaction service that
provides a pharmaceutical data warehouse and electronically transmits
encrypted prescription data using the National Council of Prescription
Drug Program (NCPDP) standards to the pharmacy contractor. The PDTS
provides the capability to perform Prospective Drug Utilization
Review (ProDUR) and houses prior authorization/medical necessity
history by integrating pharmacy data from all three points of service
(DC, mail order, and retail pharmacies) with increased clinical
screening and medication-related outcomes.
Pharmacy Operations Center (POC)The DoD organization responsible for Tier I and
Tier II (systems and software) support of the PDTS project. The
POC:
1. Resolves ProDUR POS conflicts between MTFs/eMSM
and the TPharm contractor;
2. Monitors
quantity limits (which are cumulative between all three POSs);
3. Issues
NCPDP provider numbers for DC pharmacies; and
4. Maintains
“lock out” and “include” databases for closed class and mandatory
use requirements contracts.
Point Of Service (POS) OptionAllows TRICARE Prime enrollees and TRICARE Prime
Remote for Active Duty Family Members (TPRADFMs) enrollees to receive
non-emergent health care services from any TRICARE authorized civilian
provider, in or out of the network without requesting a referral
from a PCM. Using this benefit results in the beneficiary incurring
more out of pocket expenses. For further details, refer to the TRM,
Chapter 2, Section 3.
Possible BreachAn
incident where the possibility of unauthorized access is suspected
(or should be suspected) and has not been ruled out. For example,
if a laptop containing PII/PHI is lost, and the contractor does
not initially know whether or not the PII/PHI was encrypted, then
the incident must initially be classified as a possible breach,
because it is impossible to rule out the possibility of unauthorized
access to the PII/PHI. In contrast, that possibility can be ruled
out immediately, and a possible breach has not occurred, when misdirected
postal mail is returned unopened in its original packaging. However,
if the intended recipient informs the contractor that an expected
package has not been received, then a possible breach exists until
and unless the unopened package is returned to the contractor. In
determining whether unauthorized access should be suspected, the
contractor shall consider at least the following factors:
• How the event was
discovered;
• Did the information
stay within the covered entity’s control;
• Was
the information actually accessed/viewed; and
• Ability
to ensure containment (e.g., recovered, destroyed, or deleted).
Preauthorization (Defined in 32 CFR 199.2)A
decision issued in writing or electronically by the Director, Defense
Health Agency (DHA), or a designee, that TRICARE benefits may be payable
for certain services that a beneficiary has not yet received. The
term prior authorization is substituted for preauthorization and
has the same meaning.
A more comprehensive
review process for certain services to determine that requested
treatment may be covered as medically necessary, delivered at the
appropriate setting, and is a TRICARE benefit before services are
rendered to the beneficiary. Preauthorizations are required for
certain services per the TOM,
Chapter 7, Section 2,
A preauthorization request may be submitted by the beneficiary or
provider and is not required prior to a Primary Care Manager (PCM)
(physician) issuing a beneficiary a referral for specialty services
from a network provider.
Preferred Provider Organization (PPO)A type of health plan that has contracts with a
network of doctors, hospitals and other health care professionals
to provide services to plan beneficiaries at a reduced rate.
PrescriberA
physician or other individual professional provider of services
specifically authorized to write a prescription for medications
or supplies in accordance with all applicable federal and state
laws.
PrescriptionA
legal order from an authorized prescriber to dispense pharmaceuticals
or other authorized supplies.
Prevailing ChargeA
rate submitted by certain non-institutional providers which fall
within the range of rates that are most frequently used in a state
for a particular health care procedure or service. The top of the
range establishes the maximum amount TRICARE will authorize for
payments of a given health care procedure or service, except where
unusual circumstances or medical complications warrant an additional
charge. The calculation methodology and use is determined according
to the reimbursement instructions outlined in the TRM.
Preventive Care (Defined in 32 CFR 199.2)Diagnostic
and other medical procedures not related directly to a specific
illness, injury, or definitive set of symptoms, or obstetrical care,
but rather performed as periodic health screening, health assessment, or
health maintenance.
Primary CareThe
initial medical care given by a HCP to a patient especially, as
part of regular ambulatory care, and sometimes followed by referral
to other medical providers.
Primary Caregiver (Defined in 32 CFR 199.2)An
individual who renders to a beneficiary services to support the
ADL as defined in
32 CFR 199.2 and specific
services essential to the safe management of the beneficiary’s condition.
Primary Care Manager (PCM)A HCP a patient sees first for their health care
needs responsible for providing and coordinating the patient’s care,
maintaining the patient’s health record and when necessary refers
the patient for specialty care.
Primary Payer (Defined in 32 CFR 199.2)The
plan or program whose medical benefits are payable first in a double
coverage situation.
Prime ContractorThe
main individual or organization that has a contract with the owner
of the contract and has full responsibility for its completion/execution
and may employ (and manage) one or more subcontractors to carry
out specific parts of the contract.
Prime EnrolleeAn
Individual who has signed up to receive health care under the TRICARE
Prime option.
Prime Service Area (PSA)PSAs are areas in which the contractor offers enrollment
in TRICARE Prime in compliance with the travel time access standard.
PSAs encompass the entire area of all the ZIP codes lying within
or intersected by the 40 mile radius around enrolling MTFs/eMSMs
(both hospitals and clinics) and Base Realignment and Closure (BRAC)
sites. Zip codes enclosed entirely within a PSA’s boundary shall
also be included. For BRAC sites, the 40 mile radius shall be determined
based on the physical address of the former MTF location. If the
former MTF address is no longer valid, the 40 mile radius shall
be determined from the geographic center of the BRAC site zip code
as of the date of contract award.
Prior Authorization, Medical CareSee definition for Preauthorization.
Prior Authorization, PharmacyPre-approval required for the filling of certain
drugs ordered by a HCP.
Note: Criteria, developed
by the DoD P&T Committee, will be provided by the to the contractor for
use in the filling of certain drugs. However, the contractor will
be responsible for developing pre-approval criteria for quantity
limit override, etc.
Priority CorrespondenceOfficial communications, received by mail, faxes,
e-mail, cables, telexes and other media of record, received by the
contractor from the Office of the Assistant Secretary of Defense
(Health Affairs) (OASD(HA)), DHA, and any elected or appointed,
federal, state, local, foreign, and tribal officials and Members
of Congress and Governors, or any other correspondence designated
for priority status by the contractor’s management.
Privacy Act, 5 USC 552a (Records Maintained
on Individuals)Federal Law which established
a Code of Fair Information Practice that governs the collection, maintenance,
use and dissemination of personally identifiable information about
individuals that is maintained in systems of records by federal
agencies. The law prohibits the disclosure of a System Of Records
(SOR) without the written consent of the individual. Additionally,
the law provides the individual with a means by which to seek access
for amendment of their records, and set forth various agencies record
keeping requirements.
Privacy Act, 5 USC 552a System of Records
(SOR)A group of records containing PHI
and PII maintained by or on behalf of the DoD where PHI and PII
in the records is specifically retrieved by personal identifiers.
Processed To Completion (PTC)A date/time frame when specific portions of claims
processing work has been completed, resolved or received a final
disposition. Under the TRICARE MCSCs there are specific dates/time
frames for:
1. Claims. Claims are considered
PTC, for workload reporting and payment record coding purposes, when
all claims received in the current and prior months have been processed
to the point where the following actions have resulted:
• All
services and supplies on the claim have been adjudicated, payment
has been determined on the basis of covered services/supplies and
allowable charges applied to deductible and/or denied, and
• Payment, deductible
application or denial action has been posted to ADP history.
2. Correspondence. Correspondence
is considered PTC, when the final reply is mailed to the individual(s)
submitting the written inquiry or when the inquiry is fully answered
by telephone.
3. Telephonic Inquiry. A
telephonic inquiry is considered PTC or resolved, when the final
reply is provided by either telephone or letter. A final telephone
reply means that the caller’s inquiry has been fully responded to,
there are no unanswered issues remaining, and no additional call-backs
are necessary. If the contractor must take a subsequent action to
correct a problem or address an issue raised during the telephone
call, the telephone inquiry is considered resolved when the contractor identifies
the need for the subsequent action, and so notifies the inquirer.
For example, if a claim requires adjustment as a result of a telephone
inquiry, the call is resolved when the contractor initiates the
claim adjustment and the inquirer is so notified (i.e., it is not
necessary to keep the call open until the actual processing of the
claim adjustment occurs).
4. Appeals. Final
disposition of an appeal case occurs when the previous decision
by the contractor is either reaffirmed, reversed, or partially reversed
and the decision is mailed.
Procuring Contracting Officer (PCO)A Federal employee with specific contracting authorization
having ultimate authority and responsibility for the Governments’
side for the contract execution regardless of whatever additional support
team may be outlined in the contract. The Government employee is
responsible for overseeing the contract from start to finish, including
the drawing up the procurement package, Request for Proposal (RFP)
and contract award, as well as administration during the contracts
life cycle.
Profiled AmountAn
amount that is the lower of the prevailing charge or the maximum
allowable prevailing charge.
Program Integrity SystemA software system for detecting overutilization
or fraud and abuse.
Program YearThe
appropriate year (e.g.,calendar year, fiscal year, rolling 12-month
period, etc.) specified in the administration of TRICARE programs
for application of unique requirements or limitations (e.g., enrollment
fees, deductibles, catastrophic lose protection, etc.) on covered
health care services obtained or provided during the designated
time period.
Prospective Drug Utilization Review (ProDUR)A process used to identify any potential medication
problems that may occur, based on a patient’s current prescription,
applicable patient profile information, and medication history,
prior to the point of dispensing. ProDUR is used to detect over-utilization,
under-utilization, therapeutic duplication, drug-disease complications,
drug interactions, incorrect dosages and duration of therapy.
Prospective ReviewPrior
assessment of a request for treatment before the treatment is rendered
to determine if the treatment is appropriate for the patient. Another
term for preauthorization.
Protected Health Information (PHI) (HIPAA
Definition)1. IIHI that is:
a. Transmitted
by electronic media;
b. Maintained in electronic
media; or
c. Transmitted or maintained
in any other form or medium.
Note: Sometimes referred to as Electronic Protected
Health Information (ePHI).
2. PHI excludes IIHI in:
a. Education
records covered by the Family Educational Right and Privacy Act,
as amended, 20 USC 1232g;
b. Records
described at 20 USC 1232g(a)(4)(B)(iv); and
c. Employment
records held by a covered entity in its role as an employer.
d. Regarding
a person who has been deceased for more than 50 years.
Note: As defined in HIPAA of 1996.
Provider (Defined in 32 CFR 199.2)A
hospital or other institutional provider, a physician or other individual
professional provider, or other provider of services or supplies
in accordance with
32 CFR 199.6.
Provider Exclusion And Suspension (Defined
in 32 CFR 199.2)The terms “exclusion” and “suspension”, when referring
to a provider under TRICARE, both mean the denial of status as an
authorized provider, resulting in items, services, or supplies furnished
by the provider not being reimbursed, directly or indirectly, under
TRICARE. The terms may be used interchangeably to refer to a provider
who has been denied status as an authorized TRICARE provider based
on:
1. A criminal conviction or civil judgment
involving fraud;
2. An administrative finding
of fraud or abuse under TRICARE;
3. An
administrative finding that the provider has been excluded or suspended
by another agency of the Federal Government, a state, or a local
licensing authority;
4. An administrative finding
that the provider has knowingly participated in a conflict of interest situation;
or
5. An administrative finding
that it is in the best interests of TRICARE or TRICARE beneficiaries
to exclude or suspend the provider.
Provider NetworkA
group of HCPs with which a managed care contractor has made contractual
or other arrangements with to provide health care at a discounted
rate.
Provider Termination (Defined in 32 CFR 199.2)When a provider’s status as an authorized TRICARE
provider is ended, other than through exclusion or suspension, based
on a finding that the provider does not meet the qualifications,
as set forth in
32 CFR 199.6 to
be an authorized TRICARE provider.
Psychotherapy Notes (HIPAA Definition)Notes recorded (in any medium) by a HCP who is
a mental health professional documenting or analyzing the contents
of conversation during a private counseling session or a group,
joint, or family counseling session and that are separated from
the rest of the individual’s medical record. Psychotherapy notes
excludes medication prescription and monitoring, counseling session
start and stop times, the modalities and frequencies of treatment
furnished, results of clinical tests, and any summary of the following
items: diagnosis, functional status, the treatment plan, symptoms,
prognosis, and progress to date, as defined in HIPAA of 1996.
Public Health Authority (HIPAA Definition)An agency or authority of the U.S., a state, a
territory, a political subdivision of a state or territory, or an Indian
tribe, that is responsible for public health matters as part of
its official mandate as well as a person or entity acting under
a grant of authority from or under a contract with a public health
agency, as defined in HIPAA of 1996.
Note: The term “public health authority” includes any
DoD Component authorized under applicable DoD regulation to carry
out public health activities, including medical surveillance activities under
DoD Directive 6490.2.
Qualified Mental Health Provider
Psychiatrists or other physicians, clinical
psychologists, Certified Psychiatric Nurse Specialists (CPNSs), Certified
Clinical Social Workers (CCSWs), certified marriage and family therapists,
TRICARE Certified Mental Health Counselors (TCMHCs), pastoral counselors
under a physician’s supervision, and supervised mental health counselors
under a physician’s supervision.
Qualifying Life Event (QLE)A change in a beneficiary’s situation, like getting
married, having a baby, or losing health coverage, that allows a
beneficiary to enroll in or change their TRICARE health plan coverage
outside of the annual open enrollment period. See TPM,
Chapter 10, Section 2.1, for a list of authorized
QLEs.
Quality Assurance (QA), PharmacyA process for developing controls to prevent mistakes
in the dispensing of drugs. QA is the responsibility of both the
pharmacy and the contractor.
Quality Assurance ProgramA system-wide process established and maintained
by the contractor to monitor and evaluate the quality of patient
health care and clinical performance.
Quality Control, PharmacyProcesses and procedures employed to ensure that
pharmaceuticals are dispensed accurately and timely. These should
be employees by both the contractor and the pharmacy.
Quality ImprovementAn approach to quality management that builds upon
traditional quality assurance methods by emphasizing:
1. The
organization and systems (rather than individuals);
2. The
need for objective data with which to analyze and improve processes;
and
3. The ideal that systems
and performance can always improve even when high standards appear
to have been met.
Receipt Of Claim, Correspondence Or AppealDelivery of a claim, correspondence, or appeal
into the custody of the contractor by the post office or other party.
ReconsiderationAn
appeal to a contractor of an initial determination issued by the
contractor.
RecordsAll
books, papers, maps, photographs, machine readable materials, or
other documentary materials, regardless of physical form or characteristics,
made or received by an agency of the U.S. Government under Federal
law or in connection with the transaction of public business or
appropriate for presentation by that agency or its legitimate successor
as evidence of the organization, functions, policies, decisions,
procedures, operations, or other activities of the Government.
Also any item, collection, or grouping of information
about a beneficiary which is maintained, collected, used or disseminated,
by TRICARE or a TRICARE contractor, including, but not limited to
his or her education, financial transactions, medical history, and
criminal or employment history, and which contains the beneficiary’s
name or identifying number, symbol or other personal identifiers.
Records ManagementThe
area of general administrative management concerned with achieving
economy and efficiency in the creation, use and maintenance, and
disposition of records. Included in the fulfilling of archival requirements
and ensuring effective documentation.
Referral (Defined in 32 CFR 199.2)The
act or an instance of referring a TRICARE beneficiary to another
authorized provider to obtain necessary medical treatment. Under
TRICARE, only a physician may make referrals.
A referral is a request from one physician to another
to assume responsibility for management of one or more of a patient’s
specified problems. A consult is a request from one physician to
another for an advisory opinion. Referrals and/or consults written
by MTF/eMSM or Civilian TRICARE providers are sent to the Contractor
for authorization or preauthorization (if needed per TOM,
Chapter 7, Section 2). A PCM (physician) does
not require a preauthorization/authorization from the Contractor
to generate a referral or consult to/from a network provider.
Referral ManagementProcess by which all referrals written by the MTF/eMSM
authorized providers and network and non-network providers are tracked
for care coordination, patient safety, and accountability. The referral management
process ends when the referring provider is provided the clear and
legible report, informed the patient did not use/activate their
referral, or if the referral was denied by the contractor.
RegionA geographic
area determined by the Government for civilian contracting of medical
care and other services for TRICARE-eligible beneficiaries.
Regional Review Authority (RRA)An entity responsible for performing Peer Review
Organization (PRO) functions. Under TRICARE the contractor shall
be responsible for performing the duties of the RRA.
ReliantsRefers
to a subset of TRICARE eligible beneficiaries who are dependent
on TRICARE and not the DC system or OHI for the coverage/reimbursement
of vaccines under the well-child and preventive benefits. This includes,
but is not limited to: All TRICARE Active Duty Family Members (ADFMs)
not enrolled to a DC PCM who are reliant on TRICARE as their primary
form of insurance, and retirees and their family members who do
not have OHI and are not dependent on the DC system but are dependent
on TRICARE as their primary form of insurance.
Representative (Defined in 32 CFR 199.2)Any
person who has been appointed by a party to the initial determination
as counsel or advisor and who is otherwise eligible to serve as
the counsel or advisor of the party to the initial determination, particularly
in connection with a hearing.
Required By Law (HIPAA Definition)A mandate contained in law that compels a covered
entity to make a use or disclosure of PHI and that is enforceable
in a court of law. Required by law includes, but is not limited
to, court orders and court-ordered warrants; subpoenas or summons
issued by a court, grand jury, a governmental or tribal inspector
general, or an administrative body authorized to require the production
of information; a civil or an authorized investigative demand; Medicare
conditions of participation with respect to HCPs participating in
the program; and statutes or regulations that require the production
of information, including statutes or regulations that require such
information if payment is sought under a Government program providing
public benefits as defined in HIPAA of 1996.
Note: For TRICARE required by law also includes any
mandate contained in a DoD Regulation that mandates a covered entity
(or other person functioning under the authority of a covered entity)
to make a use or disclosure and is enforceable in a court of law.
The attribute of being enforceable in a court of law means that
in a court or court-martial proceeding, a person required by the
mandate to comply would be held to have a legal duty to comply or,
in the case of noncompliance, to have had a legal duty to have complied.
Required by law also includes any DoD regulation requiring the production
of information necessary to establish eligibility for reimbursement
or coverage under TRICARE.
Research (HIPAA Definition)A systematic investigation, including research,
development, testing, and evaluation, designed to develop or contribute
to generalizable knowledge as defined in HIPAA of 1996.
ResidenceFor
purposes of TRICARE, “residence” is the dwelling place of the beneficiary
for day-to-day living. A temporary living place during periods of
temporary duty or during a period of confinement, such as a Residential Treatment Center (RTC),
does not constitute a residence. In the case of minor children,
the residence of the custodial parent(s) or the legal guardian shall
be deemed the residence of the child. In the case of incompetent
adult beneficiaries, the residence of the legal guardian shall be
deemed the residence of such beneficiary. Under split enrollment,
when a dependent resides away from home while attending school,
their residence shall be where they are domiciled.
Residential Treatment Center (RTC)A facility or distinct part of a facility which
meets the criteria in
32 CFR 199.6(b)(4)(vii).
Residual ClaimA
claim for health care services rendered during the health care delivery
period of one contract, but processed under a different (incoming)
contract.
Resource Sharing Agreement (External)
(Defined in 32 CFR 199.2)A type of external Partnership Agreement established
in the context of the TRICARE Program by agreement of the MTF Commander
and an authorized TRICARE contractor. External resource sharing agreements
may incorporate TRICARE features in lieu of standard TRICARE features
that would apply to stand external Partnership Agreements.
Respite Care (Defined in 32 CFR 199.2)Short-term
care for a patient in order to provide rest and change for primary
caregivers who have been caring for the patient at home, usually
the patient’s family.
Note: Although this
is usually the patient’s family, it may be a relative or friend
who assists the member with their ADL. Respite care consists of
providing skilled and non-skilled services to a beneficiary such
that in the absence of the primary caregiver, management of the
beneficiary’s qualifying condition and safety are provided. Respite
care services are provided exclusively to the Service member beneficiary.
1. Qualifying
Condition For Receipt Of Respite Benefits. For the purposes
of receiving respite benefits, a qualifying condition is defined
as a serious injury or illness resulting in, or based on the clinical
assessment of the member’s provider or case management team that
will result in a physical disability, or an extraordinary physical
or psychological condition.
2. Limitations
On Respite Benefits:
• The services performed by the primary caregiver
are those that can be performed safely and effectively by the average
non-medical person without direct supervision of a HCP after the primary
caregiver has been trained by appropriate medical personnel.
• Respite care services are limited to a maximum
of eight hours per calendar day, five days per calendar week.
ResubmissionsA
group of TED records submitted to DHA to correct those TED claims
and adjustments which generated edit errors when originally processed
by DHA. These groups of records will be identified by the batch
number and resubmission in the TED Header Record.
Retention PeriodThe
length of time for particular documents/records (normally a series)
are to be kept.
Retiree (Defined in 32 CFR 199.2)A
member or former member of a Uniformed Service who is entitled to
retired, retainer, or equivalent pay based on duty in a Uniformed
Service.
Retired CategoryRetirees
and their family members who are beneficiaries covered by 10 USC
1086(c), other than Medicare-eligible beneficiaries as described
in 10 USC 1086(d).
Retrospective Drug Utilization ReviewA process of appraising and reconsidering the usage
of drugs to determine the effectiveness of drug treatment after
a medication is dispensed. The process includes evaluation for therapeutic appropriateness,
over-utilization and under-utilization, therapeutic duplication,
drug-disease contraindications, drug interactions, incorrect dosage
and /or duration of therapy.
Retrospective ReviewA post-treatment assessment of care already delivered.
The assessment evaluates the appropriateness of care and conformance
to pre-established criteria for utilization. The purpose for this
type of assessment may be to validate utilization decisions made
and/or to validate payment made for care provided (by examining
the actual record of treatment).
Returned ClaimA
bill of health care services the contractor returns to the sender
because there is missing information that is needed for processing,
and the missing information cannot be obtained from in-house sources.
ReversedStatus
of claim once a reversal transaction is transmitted for the removal
of the PAID claim from a patient’s profile.
Routine CorrespondenceAll communications received by mail, faxes cables,
telexes, and other media or record, is not designated as Priority
Mail.
Routine UseWith
respect to the disclosure of a record from a Privacy Act System
of Records (SOR) 5 USC, 552a, the use of a record for a purpose
that is compatible for which it was information collected. See also
Defense Privacy and Civil Liberties Office’s (DPCLO’s) published
list of blanket routine uses for sharing PII.
Same Day ReferralThe
act or instance of referring a TRICARE beneficiary to another authorized
provider to obtain necessary medical treatment within 24 hours of
a request for care. This includes immediate (STAT), 24 hours (As
Soon As Possible (ASAP)), and Today referral priority requests from
the Composite Health Care System (CHCS).
Sanction (Defined in 32 CFR 199.2)For
the purposes of
32 CFR 199.9,
“sanction” means a provider exclusion, suspension, or termination.
Secondary Payer (Defined in 32 CFR 199.2)The
plan or program whose medical benefits are payable in double coverage
situations only after the primary payer has adjudicated the claim.
Secretary Of Health And Human Services
(HHS)The head of the U.S. DHHS concerned
with health matters.
Segment (HIPAA Definition)A group of related data elements in a transaction
as defined in HIPAA of 1996.
Seventy-Two Hour ReferralThe act or instance of referring a TRICARE beneficiary
to another authorized provider to obtain necessary medical treatment
within 72 hours of a request for care.
Skilled Nursing Facility (SNF) (Defined
in 32 CFR 199.2)An institution (or a distinct part of an institution)
that meets the criteria as set forth in
32 CFR 199.6.
Skilled Nursing Service (Defined in 32 CFR 199.2)Skilled
nursing services includes application of professional nursing services
and skills by and Registered Nurse (RN), Licensed Practical Nurse
(LPN), or Licensed Vocational Nurse (LVN) that are required to be
performed under the general supervision/direction of a TRICARE authorized
physician to ensure the safety of the patient and achieve the medically
desired result in accordance with accepted standards of practice.
Note: Skilled nursing services are other than those
services that provide primarily support for the Activities of Daily
Living (ADL) or that could be performed by an untrained adult with
minimum instruction or supervision.
Special ChecksChecks
issued outside the normal processing workflow for the purpose of
expediting payment of a claim for benefits.
Special InquiriesRequests
for information under the Freedom of Information Act, Privacy Act,
and the news media. Also includes requests received for surveys,
audits, and requests by Government agencies including DoD agencies,
entities other than DHA and Congressional Committees.
Specialty CareSpecialized
medical services provided by a physician specialist.
Specified Authorization Staff (SAS)/Defense
Health Agency-Great Lakes (DHA-GL) (formerly Military Medical Support
Office (MMSO))A Joint Services Organization
responsible for reviewing specialty and inpatient care requests
and claims for impact on fitness-for-duty. SAS/DHA-GL is also responsible
for approving certain medical services not covered under TRICARE
that are necessary to maintain fitness for duty and/or retention
on active duty. The SASs for Army, Navy, Marine Corps, and Air Force
Service members are assigned to the DHA-GL. For more information,
see
Chapter 17 for additional information.
Split-BillingThe
division of a medical claim for service provided into two or more
parts. Claims may be split to divide work between clients, payers
or for reimbursement to different service providers for performing a
shared service. Such claims may or may not require Coordination
of Benefits. (COB)
Split EnrollmentA
TRICARE Prime option which allows an entire family to enroll in
TRICARE Prime even if part of the family is living in another TRICARE
region.
SponsorAn
active duty member, retiree, or deceased active duty member or retiree,
of a Uniformed Service upon whose status his or her family members’
eligibility for TRICARE is based. See also
32 CFR 199.2 for a more complete definition.
Spouse (Defined in 32 CFR 199.2)A
lawful husband or wife, who meets the criteria in
32 CFR 199.3, regardless of whether or not dependent
upon the active duty member or retiree.
StakeholdersAny
party who has a direct interest in the success of a business concern.
For TRICARE purposes, stakeholders include the DoD, the Director,
TROs, MTF Commanders/eMSM Managers, DHA, the MHS, and all employees
thereof, contractors, elected officials, and MHS beneficiaries.
Standard Transaction (HIPAA Definition)A transaction that complies with the applicable
standard adopted by HIPAA.
Start Of ServiceThe
date a contractor officially begins delivery of health care services,
processing claims, and/or delivery of other services in a production
environment, as specified in the contract requirements.
State (Defined in 32 CFR 199.2)For
the purposes of the 32 CFR 199, any of the several states, the District
of Columbia, the Commonwealth of Puerto Rico, the Commonwealth of
the Northern Mariana Islands, and each territory and possession
of the U.S.
State (HIPAA Definition)1. For
a health plan established or regulated by Federal law, State has
the meaning set forth in the applicable section of the USC for such
health plan.
2. Each of the several
states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands,
Guam, American Samoa, and the Northern Mariana Islands.
Student Status (Defined in 32 CFR 199.2)A
dependent of a member or former member of a Uniformed Service who
has not passed his or her 23rd birthday, and is enrolled in a full-time
course of study in an institution of higher learning.
SubcontractorAn
individual or in many cases a business that signs a contract to
perform part or all of the obligations of another’s contract. This
includes but is not limited to enrolled program health benefits
business entities at whatever level of the contract organization
they exist. It does not include institutional or non-institutional
providers of health care. This definition does not exclude business
entities that are not specifically addressed herein but whose legal
status within the contract organization establishes them as subcontractors
because that term may be otherwise defined in the Federal Acquisition
Regulation (FAR).
Note: In determining
whether a business entity is a network first tier subcontractor,
consideration is given as to whether or not the entity providing
the designated services acts as a broker of care; i.e., the entity
itself obtains the medical coverage needed by in turn contracting
with institutional and non-institutional providers. Implicit in
the determination is size of the offered network; i.e., does this
entity provide a large number of contracted providers for a large
geographical area?
Subcontractor (HIPAA Definition)A person to whom a business associate delegates
a function, activity, or service other than in the capacity of a
member of the workforce of such business associate.
SubcontractsThe
contractual assignment of elements of requirements to another organization
or person for purposes of TRICARE. Unless otherwise specified in
the contract, the term also includes purchase orders, with changes
and/or modifications thereto.
Substance Use Disorder Rehabilitation
Facility (SUDRF)A facility or a distinct
part of a facility that meets the criteria in
32 CFR 199.6(b)(4)(xiv).
Summary Health Information (HIPAA Definition)Information that may be IIHI, and:
1. That
summarizes the claims history, claims expenses, or type of claims
experienced by individuals for whom a plan sponsor has provided
health benefits under a group health plan; and
2. From
which the information has been deleted, except that the geographic
information may be aggregated to the level of a five digit zip code.
As defined in HIPAA of 1996.
Supplemental CareMedical
care received by Service members of the Uniformed Services and other
designated patients pursuant to an MTF/eMSM referral (MTF/eMSM Referred
Care). Supplemental Health Care also includes specific episodes
of Service member non-referred civilian care, both emergent and
authorized non-emergent care (non-MTF/eMSM Referred Care).
Supplemental FundsFunds
used to pay for supplemental care.
Supplemental Insurance Plan (Defined
in 32 CFR 199.2)A health insurance policy or other health benefit
plan offered by a private entity to a TRICARE beneficiary, that
primarily is designed, advertised, marketed, or otherwise held out
as providing payment for expenses incurred for services and items
that are not reimbursed under TRICARE due to program limitations
or beneficiary liabilities imposed by law. TRICARE recognizes two
types of supplemental plans, general indemnity plans and those offered
through a direct service HMO.
1. An
indemnity supplemental insurance plan must meet all the following
criteria:
a. It provides insurance coverage, regulated
by the state insurance agencies, which is only available only to
beneficiaries of TRICARE.
b. It
is premium based and all premiums relate only to the TRICARE supplemental
coverage.
c. Its benefits for all
covered TRICARE beneficiaries are predominately limited to non-covered services,
to the deductible and cost-shared portions of the pre-determined
allowable charges and/or to amounts exceeding the allowable charges
for covered services.
d. It provides insurance
reimbursement by making payment directly to the TRICARE beneficiary
or to the participating provider.
e. It
does not operate in a manner which results in lower deductibles
or cost-shares than those imposed by law, or that waives the legally
imposed deductibles and cost-shares.
2. A
supplemental insurance plan offered by a HMO must meet all of the
following criteria:
a. The HMO must be authorized
and must operate under relevant provisions of state law.
b. The
HMO supplemental plan must be premium based and all premiums must
relate only to TRICARE supplemental coverage.
c. The
HMO’s benefits, above those which are directly reimbursed by TRICARE,
must be limited predominantly to services not covered by TRICARE
and TRICARE deductible and cost-share amounts.
d. The
HMO must provide services directly to TRICARE beneficiaries through
its affiliated providers, who in turn, are reimbursed by TRICARE.
e. The
HMO’s premium structure must be designed so that no overall reduction
to the amount of the beneficiary deductibles or cost-shares will
result.
Suspension Of Claims Processing (Defined
in 32 CFR 199.2)The temporary suspension of processing (to protect
the Government’s interests) of claims for care furnished by a specific
provider (whether the claims are submitted by the provider or beneficiary)
or claims submitted by or on behalf of a specific TRICARE beneficiary
pending action by the Director, DHA, or a designee, in a case of
suspected fraud or abuse. The action may include administrative
remedies provided for in
32 CFR 199.9 or
any other DoD issuance (e.g., DoD issuances implementing the Program Fraud
Civil Remedies Act), case development or investigation by DHA, or
referral to the DoD-Inspector General (IG) or the Department of
Justice (DOJ) for action within their cognizant jurisdictions.
TelepresenterA
telepresenter is an individual at the originating site (when the
originating site is other than the patient’s home) who has the necessary
skills, training, and/or clinical background (e.g., Licensed Practical
Nurse (LPN), Registered Nurse (RN), trained medical technician,
etc.) to operate the telemedicine technology and facilitate examinations
under the direction of the provider at the distant site. For example,
a nurse may use a device connected to a telemedicine system, such
as a digital stethoscope or otoscope, in order to provide diagnostically
relevant imagery, sound, or other data/information about the patient
to the distant provider in real time.
TerminationThe
removal of a provider as an authorized TRICARE provider based on
a finding that the provider does not meet the qualifications established
by
32 CFR 199.6 to
be an authorized TRICARE provider. This includes those categories
of providers who have signed specific participation agreements.
Third-Party Billing Agent (Defined in 32 CFR 199.2)Any
entity that acts on behalf of a provider to prepare, submit, and
monitor claims, excluding those entities that act solely as a collection
agency.
Third-Party Liability (TPL) ClaimsReimbursements to the Government that arise when
medical care is provided to an entitled beneficiary for treatment
or injury or illness caused under circumstances creating tort liability
legally requiring a third person to pay damages for that care. The
Government pursues repayment for the care provided to the beneficiary
under the provisions and authority of the Federal Medical Care Recovery
Act (FMCRA) (42 USC paragraphs 2651-2653).
Third-Party Liability (TPL) RecoveryThe recovery by the Government of expenses incurred
for medical care provided to an entitled beneficiary in the treatment
of injuries or illness caused by a third-party who is liable in
tort for damages to the beneficiary. Such recoveries can be made
from the liable third-party directly or from a liability insurance
policy (e.g., automobile liability policy or homeowners insurance)
covering the liable third-party. TPL recoveries are made under the
authority of the FMCRA (42 USC paragraph 2651 et sec). Other potential
sources of recovery in favor of the Government in TPL situations
include, but are not limited to, no fault or uninsured motorist
insurance, medical payments provisions of insurance policies, and
workers compensation plans. Recoveries from such other sources are
made under the authority of 10 USC paragraphs 10790, 1086(g), and
1095b.)
Third-Party Payer (Defined in 32 CFR 199.2)Third-party
means an entity that provides an insurance, medical service, or
health plan by contract or agreement, including an automobile liability
insurance or no fault insurance carrier and a workers compensation
program or plan, and any other plan or program (e.g., homeowners
insurance) that is designed to provide compensation or coverage
for expenses incurred by a beneficiary for medical services or supplies.
For the purposes of the definition of “third-party payer,” an insurance
medical service or health plan includes a preferred provider organization,
an insurance plan described as Medicare supplemental insurance,
and a personal injury protection plan or medical payments benefit plan
for personal injuries resulting from the operation of a motor vehicle.
Note: TRICARE is secondary payer to all third-party
payers. Under limited circumstances in
32 CFR 199.8, TRICARE payment may be authorized
to be paid in advance of adjudication of the claim by certain third-party
payers. TRICARE advance payment will not be made when a third-party
provider is determined to be a primary medical insurer under
32 CFR 199.8.
Timely FilingThe
submitting of TRICARE claims within the prescribed time limits as
set forth in
32 CFR 199.7 and
the requirements of the TRICARE contract.
Toll-Free TelephonesHaving or using a direct line or number for a call
that is not charged to the caller. Under the TRICARE contract all
telephone calls are considered toll-free for the purposes of measuring
the standards contained in
Chapter 1, Section 3, paragraph 3.4.
Trading Partner Agreement (HIPAA Definition)An agreement related to the exchange of information
in electronic transactions, whether the agreement is distinct or
part of a larger agreement, between each party to the agreement.
(For example, a trading partner agreement may specify, among other
things, the duties and responsibilities of each party to the agreement
in conducting a standard transaction.) As defined in HIPAA of 1996.
Transaction (HIPAA Definition)The transmission of information between two parties
to carry out financial or administrative activities related to health
care. It includes the following types of information transmissions:
1. Health
care claims or equivalent encounter information.
2. Health
care payment and remittance advice.
3. Coordination
of benefits.
4. Health care claims
status.
5. Enrollment and disenrollment
in a health plan.
6. Eligibility for a health
plan.
7. Health plan premium
payments.
8. Referral certification
and authorization.
9. First report of injury.
10. Health
claims attachments.
11. Other transactions
that may be prescribed by regulation.
Transfer ClaimsA
bill received by a contractor for services received and billed from
another contractor’s jurisdiction. See
Chapter 8 for
processing requirements related to these types of claims.
Note: Claims for Service members which are sent to the
appropriate Uniformed Service are not considered to be “transfer
claims.”
TransitionThe
process of changing contractors or contract in a Government designated
service area. Transition begins with the Notice of Award to the
incoming contractor and is formally completed with the close out
procedures of the outgoing contractor, several months after the
start work date.
Transitional Patients Or CasesBeneficiaries for whom active care is in progress
on the date of a contractor’s start work date.
Note: If the care being provided is for covered services,
the contractor is financially responsible for the portion of care
delivered on or after the contractor’s start work date.
Treatment (HIPAA Definition)The provision, coordination, or management of health
care and related services by one or more HCPs, including the coordination
or management of health care by a HCP with a third-party; consultation between
HCPs relating to a patient; or the referral of a patient for health
care from one HCP to another.
Treatment EncounterThe smallest meaningful unit of health care utilization:
One provider rendering one service to one beneficiary.
Treatment Plan (Defined in 32 CFR 199.2)A
detailed description of the medical care being rendered or expected
to be rendered a TRICARE beneficiary seeking approval for inpatient and
other benefits for which preauthorization is required as set forth
in
32 CFR 199.4(b). Medical care described in
the plan must meet the requirements of medical and psychological
necessity. A treatment plan must include, at a minimum, a diagnosis
(either the current edition of the ICD-CM, or the current edition
of the DSM); detailed reports of prior treatment, medical history,
family history, social history, and physical examination; diagnostic
test results; consultant’s reports (if any); proposed treatment
by type (such as surgical, medical, and psychiatric); a description
of who is or will be providing treatment (by discipline or specialty);
anticipated frequency, medications, and specific goals of treatment;
type of inpatient facility required and why (including length of
time the related inpatient stay will be required); and prognosis.
If the treatment plan involves the transfer of a TRICARE beneficiary from
a hospital or another inpatient facility, medical records related
to that inpatient stay also are required as a part of the treatment
plan documentation.
TriageThe
process of determining the priority of patients treatment based
on the severity of their condition.
Note: For the TRICARE Program this function is performed
by the contractor’s 24 hour telephone Nurse Advice Line (NAL).
TRICAREThe
DoD’s managed health care program for Service members and their
families, retirees and their families, survivors, and other TRICARE-eligible
beneficiaries. TRICARE is a blend of the military’s DC system of
hospitals and clinics and civilian providers. Through December 31,
2017, TRICARE offers three options: TRICARE Standard Plan, TRICARE
Extra Plan, and TRICARE Prime Plan (see definitions in this section
and in
32 CFR 199.17). Beginning
January 1, 2018, TRICARE offers three options: TRICARE Prime, TRICARE
Select, and TRICARE For Life (TFL) (see definitions in this appendix
and in
32 CFR 199.2).
TRICARE Beneficiary
An individual determined by the Uniformed Services
to be eligible for TRICARE benefits, as set forth in
32 CFR 199.3.
TRICARE ContractorAn
organization with which DHA has entered into a binding agreement
for:
1. The delivery of and/or processing of payment
for health care services through contracted providers;
2. The
processing of claims for health care services received from non-network
providers; and
3. The performance of
related support activities.
TRICARE Encounter Data (TED)A data set of information required for all care
received/delivered under the contract and provided by the contractor
in a Government-specified format and submitted to DHA via a telecommunication network.
The information in the data set can be described in the following
broad categories:
1. Beneficiary identification.
2. Provider
identification.
3. Health information:
• Place
and type of service
• Diagnosis and treatment-related
data
• Units
of service (admissions, days, visits, etc.)
4. Related
financial information.
TRICARE Encounter Data (TED) Record Transmittal
SummaryA single record which identifies
the submitting contractor and summarizes, for transmittal purposes, the
number of records and the financial information contained within
the associated “batch” of TED records.
TRICARE Extra (Defined in 32 CFR 199.2)The
preferred-provider option of the TRICARE program made available
prior to January 1, 2018, under which TRICARE Standard beneficiaries
may obtain discounts on cost-sharing as a result of using TRICARE
network providers.
TRICARE For Life (TFL) (Defined in 32 CFR 199.2) The
Medicare wraparound coverage option of the TRICARE program made
available to an eligible beneficiary by reason of 10 USC 1086(d).
TRICARE Operations Manual (TOM) (6010.59-M)A DHA authored book which provides instructions
and requirements for claims processing and health care delivery
under TRICARE.
TRICARE Pharmacy (TPharm) Benefits ProgramA plan to provide outpatient prescription drugs
through military pharmacies, TRICARE Pharmacy Home Delivery, and
TRICARE retail network and non-network pharmacies.
TRICARE Policy Manual (TPM) (6010.60-M)A DHA authored book which provides the description
of TRICARE Program benefits, adjudication guidance, policy interpretations,
and decisions for use in determining benefits under the TRICARE Program.
TRICARE PlusA
primary care program offered at some military hospitals and clinics
for beneficiaries not enrolled in TRICARE Prime. Beneficiaries are
enrolled with a Primary Care Coordinator (PCC) at an MTF/eMSM. MTFs/eMSMs
may limit enrollment based on capability and capacity. There is
no enrollment fee.
Note: These MTF/eMSM
enrollees are to receive primary care appointments within the TRICARE Prime
access standards. TRICARE Plus “enrollment” will be annotated in
DEERS and the MTF’s/eMSM’s Electronic Medical Records. When a TRICARE
Plus enrollee receives care from civilian providers, TRICARE Standard/Extra
rules will apply (through December 31, 2017). For services payable
by Medicare, Medicare rules will apply, with TRICARE as second payer
for TRICARE covered services and supplies. Specialty care in the
MTF/eMSM will be on referrals from the primary care provider or
on a self-referral basis. TRICARE Plus enrollees are not guaranteed
specialty care appointments within the TRICARE Prime access standards.
TRICARE Prime (Defined in 32 CFR 199.2)The
managed care option of the TRICARE program established under
32 CFR 199.17.
TRICARE Prime Remote (TPR) ProgramA managed care option under TRICARE designed to
provide health care services to Service members and command sponsored
family members assigned to remote locations in the U.S.
TRICARE Prime Remote (TPR) Work UnitA uniformed services group whose members have to
be designated by the Military Services to be eligible to enroll
in the TPR Program.
TRICARE Program (Defined in 32 CFR 199.2)A
program established under the
32 CFR 199.17.
TRICARE Quality Management Contract (TQMC)A national-level contractor responsible to the
DoD and DHA that performs second level reconsiderations for payment
denials and focused retrospective quality of care reviews.
TRICARE Retired ReserveThe program established under 10 USC 1076e and
32 CFR 199.25.
TRICARE Regional Office (TRO)The management organization responsible for overseeing
an integrated Tri-Services health care delivery system within one
of the designated TRICARE regions.
TRICARE Regulation (Defined in 32 CFR 199.2)This
regulation prescribes guidelines and policies for the administration
of the TRICARE Program for the Army, Navy, Air Force, Marine Corps,
Coast Guard, Commissioned Corps of the USPHS, and the Commissioned
Corps of the NOAA. It includes the guidelines and policies for the
administration of the TRICARE Program.
TRICARE Reimbursement Manual (TRM) (6010.61-M)A DHA authored book which provides and outlines
payment methodologies under the TRICARE Program.
TRICARE RepresentativeA highly qualified individual knowledgeable about
TRICARE responsible for providing information and assistance to
providers, whether network or non-network, to Beneficiary Counseling
and Assistance Coordinators (BCACs) in their service area and to
Congressional offices.
TRICARE SelectThe
self-managed, preferred provider network option under the TRICARE
program established by 10 USC 1075 and
32 CFR 199.17 to
replace TRICARE Extra and Standard after December 31, 2017.
TRICARE StandardThe
TRICARE program made available prior to January 1, 2018, under which
the basic program of health care benefits generally referred to
as CHAMPUS was made available to eligible beneficiaries under 32 CFR
199.
TRICARE Systems Manual (TSM) (7950.3-M)A DHA authored book which provides ADP instructions
and requirements for contractors who use the TEDs system for reporting
data to DHA.
Unbundled (Or Fragmented) BillingA form of procedure code manipulation which involves
a provider separately billing the component parts of a procedure
instead of billing only the single procedure code which represents
the entire comprehensive procedure.
Uniform FormularyA
list of brand name and generic drugs and supplies available for
dispensing.
Note: PL 106-65, NDAA
for FY 2000, Section 701, mandated that the DoD develop a uniform formulary
to be applied across all POSs within the TRICARE system. Pharmaceuticals
and other supplies authorized for dispensing will be in accordance
with TRICARE policy and the Uniform Formulary. Recommendations for
the design, structure and composition of the Uniform Formulary are
developed by the DoD P&T Committee, with comments by the Uniform
Formulary Beneficiary Advisory Panel, and provided to the Executive
Director, DHA for approval and implementation.
Uniform HMO Benefit (Defined in 32 CFR 199.2)The
health care benefit established by
32 CFR 199.18.
Uniformed Services (Defined in 32 CFR 199.2)The
Army, Navy, Air Force, Marine Corps, Coast Guard, Commissioned Corps
of the USPHS, and the Commissioned Corps of the NOAA.
Uniformed Services Clinic (USC)An MHS clinic that delivers primary health care
to Service members.
Uniformed Services Family Health Plan
(USFHP)A DoD health plan option that
offers TRICARE Prime to individuals who reside in the geographic
service area of a USFHP DP who are eligible to receive care in medical
MTFs/eMSMs (except Service members). This includes those individuals
over age 65 who, except for their eligibility for Medicare benefits,
would have been eligible for TRICARE benefits. DPs under the USFHP
were previously known as “Uniformed Services Family Treatment Facilities”
(USTFs) and are former USPHS hospitals. The service areas of the USFHP
DPs are listed at
http://usfhp.net on
the world wide web and in the Catchment Area Directory.
United States (U.S.)Territory made up of the 50 federated states, American
Samoa, the District of Columbia, Johnston Island, Guam, Wake, Midway
Islands, Northern Marianas and the U.S. Virgin Islands.
United States Public Health Service (USPHS)An agency within the DHHS which has a Commissioned
Corps which are classified as members of the “Uniformed Services.”
Unprocessable TRICARE Encounter Data
(TED)TED records transmitted by the
contractor to DHA and received in such condition that the basic
record identifier information is not readable on the TRICARE data
system, i.e., header incorrect, electronic records garbled, etc.
Unproven Drugs, Devices, And Medical
Treatments Or ProceduresDrugs, devices,
medical treatments or procedures are considered unproven if:
1. FDA
approval is required and has not been given;
2. If
the device is a FDA Category A Investigational Device Exemption
(IDE);
3. If there is no reliable
evidence which documents that the treatment or procedure has been
the subject of well-controlled studies of clinically meaningful
endpoints which have determined its maximum tolerated dose, its
toxicity, its safety, and its efficacy as compared with the standard
means of treatment or diagnosis;
4. If
the reliable evidence shows that the consensus among experts regarding
the treatment or procedure is that further studies or clinical trials
are necessary to determine its maximum tolerated dose, its safety,
or its effectiveness as compared with the standard means of treatment
or diagnosis.
For further
clarification see
32 CFR 199.4.
Urgent CareMedically
necessary treatment that is required for a sudden illness or injury
that is not life threatening, but does require immediate professional
attention to avoid further complications resulting from non-treatment.
Treatment is usually performed outside an Emergency Room (ER) setting.
Urgent Care Center (UCC)
A TRICARE authorized UCC is a qualified corporate
services provider under
32 CFR 199.6(f) with
a location distinct from a hospital Emergency Room (ER), an office,
or a clinic; and whose purpose is to diagnose and treat illness
or injury for unscheduled, ambulatory patients seeking immediate
medical attention.
Use (HIPAA Definition)IIHI which involves sharing, employment, application,
utilization, examination, or analysis of such information within
an entity that maintains such information.”
Utilization CriteriaSpecific guidelines that must be met in order to
ensure that medically necessary and appropriate treatment is being
provided. Criteria to use for screening.
Utilization ManagementA set of techniques used to manage health care
costs by influencing patient care decision-making through case-by-case
assessment of the appropriateness and medical necessity of care
either prior to, during, or after provision of care. Utilization
management also includes the systematic evaluation of individual
and group utilization patterns to determine the effectiveness of
the employed utilization management techniques and to develop modifications
to the utilization management system designed to address aberrances
identified through the evaluation.
Utilization ReviewA
process for monitoring the use, delivery, quality, medical necessity,
and cost-effectiveness of health care services especially those
provided by medical community.
Validated Date and DiagnosisThe date a DoD physician (military or civil service)
validates the diagnosis of a service-related condition and validates
that the condition can be resolved within 180 days.
Veteran (Defined in 32 CFR 199.2)A
person who served in the active military, naval, or air service,
and who was discharged or released therefrom under conditions other
than dishonorable.
Note: Unless the veteran
is eligible for “retired pay,” “retirement pay,” or “retainer pay,”
which refers to payments of a continuing nature and are payable
at fixed intervals from the Government for military service neither
the veteran nor his or her family members are eligible for benefits
under TRICARE.
Widow Or Widower (Defined in 32 CFR 199.2)A
person who was a spouse at the time of death of the active duty
member or retiree and who has not remarried.
WorkdayAny
day on which full-time business can be conducted. See the definition
of “Business Day” in this appendix.
Worker's Compensation Benefits (Defined
in 32 CFR 199.2)Medical benefits available under any worker’s compensation
law (including the Federal Employees Compensation Act), occupational
disease law, employers liability law, or any other legislation of
similar purpose, or under the maritime doctrine of maintenance,
wages, and cure.
Workforce (HIPAA Definition)Employees, volunteers, trainees, and other persons
whose conduct, in the performance of work for a covered entity is
under the direct control of such entity, whether or not they are
paid by the covered entity or business associate as defined in HIPAA
of 1996.