(b)
Specific
definitions.
Abortion.
Abortion means
the intentional termination of a pregnancy by artificial means done
for a purpose other than that of producing a live birth. A spontaneous,
missed or threatened abortion or termination of an ectopic (tubal)
pregnancy are not included within the term “abortion” as used herein.
Absent treatment.
Services performed
by Christian Science practitioners for a person when the person is
physically present.
Note: 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 CHAMPUS, the beneficiary must be present physically
when a Christian Science service is rendered, regardless of the
terminology used.
Abuse.
For the purposes
of this part, abuse is defined as any practice that is inconsistent
with accepted sound fiscal, business, or professional practice which
results in a CHAMPUS claim, unnecessary cost, or CHAMPUS payment
for services or supplies that are: (1) Not within the concepts of
medically necessary and appropriate care, as defined in this part,
or (2) that fail to meet professionally recognized standards for
health care providers. 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 CHAMPUS 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.
Also, any practice or action that constitutes fraud, as defined
by this part, would also be abuse.
Abused dependent.
An eligible
spouse or child, who meets the criteria in Sec. 199.3 of this part,
of a former member who received a dishonorable or bad-conduct discharge
or was dismissed from a Uniformed Service as a result of a court-martial
conviction for an offense involving physical or emotional abuse
or was administratively discharged as a result of such an offense,
or of a member or former member who has had their entitlement to
receive retired pay terminated because of misconduct involving physical
or emotional abuse.
Accidental
injury.
Physical
bodily injury resulting from an external force, blow or fall, or
the ingestion of a foreign body or harmful substance, requiring
immediate medical treatment. Accidental injury also includes animal
and insect bites and sunstrokes. For the purpose of CHAMPUS, the
breaking of a tooth or teeth does not constitute a physical bodily
injury.
Active
duty.
Full-time
duty in the Uniformed Services of the United States. 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.
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.
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 such other
elements of personal care that reasonably can be performed by an untrained
adult with minimal instruction or supervision. Activities of daily
living may also be referred to as “essentials of daily living”.
Acupuncture.
The practice of inserting
needles into various body parts to pierce specific peripheral nerves
for the production of counter-irritation to relieve the discomfort
of pain, induce surgical anesthesia, or for other treatment purposes.
Note: Acupuncture is not covered by CHAMPUS.
Adequate Medical Documentation,
Medical Treatment Records.
Adequate medical documentation contains sufficient
information to justify the diagnosis, the treatment plan, and the
services and supplies furnished. Under CHAMPUS, it is required that
adequate and sufficient clinical records be kept by the health care
provider(s) to substantiate that specific care was actually and
appropriately furnished, was medically necessary and appropriate
(as defined by this part), and to identify the individual(s) who
provided the care. All procedures billed must be documented in the
records. In determining whether medical records are adequate, the
records will be reviewed under the generally acceptable standards
such as the applicable Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) standards, the Peer Review Organization (PRO) standards
(and the provider’s state or local licensing requirements) and other
requirements specified by this part. In general, the documentation
requirements for a professional provider are not less in the outpatient
setting than the inpatient setting.
Adequate medical documentation,
mental health records.
Adequate medical documentation provides the
means for measuring the type, frequency, and duration of active
treatment mechanisms employed and progress under the treatment plan.
Under CHAMPUS, it is required that adequate and sufficient clinical
records be kept by the provider to substantiate that specific care
was actually and appropriately furnished, was medically or psychologically
necessary (as defined by this part), 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 generally acceptable standards
(e.g., the standards of an accrediting organization approved by
the Director, and the provider’s state or local licensing requirements)
and other requirements specified by this part. The psychiatric and
psychological evaluations, physician 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
requirements 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 the behavioral health
standards manual, the critical elements of the mental health record
listed above are required for CHAMPUS claims.
Adjunctive dental care.
Dental care
which 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).
Admission.
The formal acceptance by a
CHAMPUS authorized institutional provider of a CHAMPUS beneficiary
for the purpose of diagnosis and treatment of illness, injury, pregnancy,
or mental disorder.
Adopted
Child.
A
child taken into one’s own family by legal process and treated as
one’s own child. In case of adoption, CHAMPUS eligibility begins
as of 12:01 a.m. of the day of the final adoption decree.
Note: There is no CHAMPUS benefit entitlement during
any interim waiting period.
All-Inclusive Per Diem Rate.
The OCHAMPUS
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 OCHAMPUS.
Allowable charge.
The CHAMPUS-determined
level of payment to physicians, other individual professional providers
and other providers, based on one of the approved reimbursement
methods set forth in Sec. 199.14 of this part. Allowable charge
also may be referred to as the CHAMPUS-determined reasonable charge.
Allowable cost.
The CHAMPUS-determined
level of payment to hospitals or other institutions, based on one
of the approved reimbursement methods set fourth in Sec. 199.14
of this part. Allowable cost may also be referred to as the CHAMPUS-determined
reasonable cost.
Ambulance.
A specially
designed vehicle for transporting the sick or injured that contains
a stretcher, linens, first aid supplies, oxygen equipment, and such
lifesaving equipment required by state and local law, and that is
staffed by personnel trained to provide first aid treatment.
Ambulatory Payment Classifications
(APCs).
Payment
of services under the TRICARE OPPS is based on grouping outpatient
procedures and services into ambulatory payment classification groups
based on clinical and resource homogeneity, provider concentration,
frequency of service and minimal opportunities for upcoding and
code fragmentation. Nationally established rates for each APC are calculated
by multiplying the APC’s relative weight derived from median costs
for procedures assigned to the APC group, scaled to the median cost
of the APC group representing the most frequently provided services,
by the conversion factor.
Amount
in dispute.
The
amount of money, determined under this part, that CHAMPUS would
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 Sec. 199.10 for additional information concerning the determination
of “amount in dispute” under this part.
Anesthesia services.
The administration
of an anesthetic agent by injection or inhalation, the purpose and
effect of which is to produce surgical anesthesia characterized
by muscular relaxation, loss of sensation, or loss of consciousness
when administered by or under the direction of a physician or dentist
in connection with otherwise covered surgery or obstetrical care,
or shock therapy. Anesthesia services do not include hypnosis or
acupuncture.
Appealable
issue.
Disputed
questions of fact which, if resolved in favor of the appealing party,
would result in the authorization of CHAMPUS benefits, or approval
as an authorized provider in accordance with this part. An appealable
issue does not exist if no facts are in dispute, if no CHAMPUS benefits would
be payable, or if there is no authorized provider, regardless of
the resolution of any disputed facts. See Sec. 199.10 for additional
information concerning the determination of “appealable issue” under
this part.
Appealing
party.
Any
party to the initial determination who files an appeal of an adverse
determination or requests a hearing under the provisions of this
part.
Appropriate
medical care.
(i) Services 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 United States;
(ii) The
authorized individual professional provider rendering the medical
care is qualified to perform such medical services by reason of
his or her training and education and is licensed or certified by
the state where the service is rendered or appropriate national
organization or otherwise meets CHAMPUS standards; and
(iii) The
services are furnished economically. For purposes of this part,
“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 CHAMPUS.
Approved
teaching programs.
For purposes of CHAMPUS, an approved teaching
program is a program of graduate medical education which has been
duly approved in its respective specialty or subspecialty by the
Accreditation Council for Graduate Medical Education of the American
Medical Association, by the Committee on Hospitals of the Bureau
of Professional Education of the American Osteopathic Association,
by the Council on Dental Education of the American Dental Association,
or by the Council on Podiatry Education of the American Podiatry
Association.
Assistant
Secretary of Defense (Health Affairs).
An authority of the Assistant
Secretary of Defense (Health Affairs) includes any person designated
by the Assistant Secretary to exercise the authority involved.
Assistive technology devices.
Equipment that
generally does not treat an underlying injury, illness, disease
or their symptoms. Assistive technology devices are authorized only
under the Extended Care Health Option (ECHO). Assistive technology
devices help an ECHO beneficiary overcome or remove a disability
and are used to increase, maintain, or improve the functional capabilities
of an individual. Assistive technology devices may include non-medical
devices but do not include any structural alterations (e.g., permanent
structure of wheelchair ramps or alterations to street curbs) service
animals (e.g., Seeing Eye dogs, hearing/handicapped assistance animals,
etc.) or specialized equipment and devices whose primary purpose
is to enable the individual to engage in sports or recreational
events. Assistive technology devices are authorized only under coverage
criteria determined by the Director, TRICARE Management Activity
to assist in the reduction of the disabling effects of a qualifying condition
for individuals eligible to receive benefits under the ECHO program,
as provided in Sec. 199.5.
Attending physician.
The physician
who has the primary responsibility for the medical diagnosis and treatment
of the patient. A consultant or an assistant surgeon, for example,
would not be an attending physician. Under very extraordinary circumstances,
because of the presence of complex, serious, and multiple, but unrelated,
medical conditions, a patient may have more than one attending physician concurrently
rendering medical treatment during a single period of time. An attending
physician also may be a teaching physician.
Augmentative communication device
(ACD).
A
voice prosthesis as determined by the Secretary of Defense to be
necessary because of significant conditions resulting from trauma,
congenital anomalies, or disease. Also referred to as Speech Generating
Device.
Authorized
provider.
A
hospital or institutional provider, physician, or other individual
professional provider, or other provider of services or supplies
specifically authorized to provide benefits under CHAMPUS in Sec.
199.6 of this part.
Automobile
liability insurance.
Automobile liability insurance means insurance
against legal liability for health and medical expenses resulting
from personal injuries arising from operation of a motor vehicle. Automobile
liability insurance includes:
(1) Circumstances in
which liability benefits are paid to an injured party only when
the insured party’s tortious acts are the cause of the injuries;
and
(2) Uninsured
and underinsured coverage, in which there is a third-party tortfeasor
who caused the injuries (i.e., benefits are not paid on a no-fault
basis), but the insured party is not the tortfeasor.
Backup hospital.
A hospital which
is otherwise eligible as a CHAMPUS institutional provider and which is
fully capable of providing emergency care to a patient who develops
complications beyond the scope of services of a given category of
CHAMPUS-authorized freestanding institutional provider and which
is accessible from the site of the CHAMPUS-authorized freestanding
institutional provider within an average transport time acceptable
for the types of medical emergencies usually associated with the type
of care provided by the freestanding facility.
Balance billing.
A provider seeking
any payment, other than any payment relating to applicable deductible
and cost sharing amounts, from a beneficiary for CHAMPUS covered
services for any amount in excess of the applicable CHAMPUS allowable
cost or charge.
Bariatric
Surgery.
Surgical
procedures performed to treat co-morbid conditions associated with
morbid obesity. Bariatric surgery is based on two principles:
(1) Divert
food from the stomach to a lower part of the digestive tract where
the normal mixing of digestive fluids and absorption of nutrients
cannot occur (i.e., Malabsorptive surgical procedures); or
(2) Restrict
the size of the stomach and decrease intake (i.e., Restrictive surgical
procedures).
Basic
program.
The
primary medical benefits set forth in Sec. 199.4, generally referred
to as the Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS) as authorized under chapter 55 of title 10 United States
Code, were made available to eligible beneficiaries under this part.
Beneficiary.
An individual who has been
determined to be eligible for CHAMPUS benefits, as set forth in Sec.
199.3 of this part.
Beneficiary
liability.
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 CHAMPUS, 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 CHAMPUS-determined allowable cost or charge. Beneficiary liability
also includes any expenses for medical or related services and supplies
not covered by CHAMPUS.
Birthing
center.
A
health care provider which meets the applicable requirements established
by Sec. 199.6(b) of this part.
Birthing room.
A room and environment
designed and equipped to provide care, to accommodate support persons,
and within which a woman with a low-risk, normal, full-term pregnancy
can labor, deliver and recover with her infant.
Brace.
An orthopedic appliance or
apparatus (an orthosis) used to support, align, or hold parts of
the body in correct position. For the purposes of CHAMPUS, it does
not include orthodontic or other dental appliances.
CAHs.
A small facility that provides
limited inpatient and outpatient hospital services primarily in
rural areas and meets the applicable requirements established by
Sec. 199.6(b)(4)(xvi).
Capped
Rate.
The
maximum per diem or all-inclusive rate that CHAMPUS will allow for
care.
Case
management.
Case
management is 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 needs, using communication and available resources
to promote quality, cost effective outcomes.
Case-mix index.
Case-mix index
is a scale that measures the relative difference in resources intensity among
different groups receiving home health services.
Certified nurse-midwife.
An individual
who meets the applicable requirements established by Sec. 199.6(c)
of this part.
Certified
psychiatric nurse specialist.
A licensed, registered nurse who meets the
criteria in Sec. 199.6(c)(3)(iii)(G).
CHAMPUS DRG-Based Payment System.
A reimbursement
system for hospitals which assigns prospectively-determined payment
levels to each DRG based on the average cost of treating all CHAMPUS
patients in a given DRG.
CHAMPUS
fiscal intermediary.
An organization with which the Director, OCHAMPUS,
has entered into a contract for the adjudication and processing
of CHAMPUS claims and the performance of related support activities.
CHAMPUS Health Benefits Advisors
(HBAs).
Those
individuals located at Uniformed Services medical facilities (on
occasion at other locations) and assigned the responsibility for
providing CHAMPUS information, information concerning availability
of care from the Uniformed Services direct medical care system,
and generally assisting beneficiaries (or sponsors). The term also
includes “Health Benefits Counselor” and “CHAMPUS Advisor.”
Chemotherapy.
The administration
of approved antineoplastic drugs for the treatment of malignancies (cancer)
via perfusion, infusion, or parenteral methods of administration.
Child.
An unmarried child of a member
or former member, who meets the criteria (including age requirements)
in Sec. 199.3 of this part.
Chiropractor.
A practitioner
of chiropractic (also called chiropraxis); essentially a system
of therapeutics based upon the claim that disease is caused by abnormal
function of the nerve system. It attempts to restore normal function
of the nerve system by manipulation and treatment of the structures
of the human body, especially those of the spinal column.
Note: Services of chiropractors are not covered by CHAMPUS.
Christian science nurse.
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 exist two levels of Christian Science nurse
accreditation:
(i) 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 3-year course
of instruction and study.
(ii) 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 1-year course of instruction and study.
Christian Science practitioner.
An individual
who has been accredited as a Christian Science Practitioner for
the First Church, 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.
A sanatorium
either operated by the First Church of Christ, Scientist, or listed
and certified by the First Church of Christ, Scientist, Boston,
Massachusetts.
Chronic
medical condition.
A medical condition that is not curable, but
which is under control through active medical treatment. Such chronic
conditions may have periodic acute episodes and may require intermittent
inpatient hospital care. However, a chronic medical condition can
be controlled sufficiently to permit generally continuation of some
activities of persons who are not ill (such as work and school).
Chronic renal disease (CRD).
The end stage
of renal disease which requires a continuing course of dialysis
or a kidney transplantation to ameliorate uremic symptoms and maintain
life.
Clinical
psychologist.
A
psychologist, certified or licensed at the independent practice
level in his or her state, who meets the criteria in Sec. 199.6(c)(3)(iii)(A).
Clinical social worker.
An individual
who is licensed or certified as a clinical social worker and meets
the criteria listed in Sec. 199.6.
Clinically Meaningful Endpoints.
As used the
definition of reliable evidence in this paragraph (b) and Sec. 199.4(g)(15),
the term clinically meaningful endpoints means objectively measurable
outcomes of clinical interventions or other medical procedures,
expressed in terms of survival, severity of illness or condition,
extent of adverse side effects, diagnostic capability, or other
effect on bodily functions directly associated with such results.
Collateral visits.
Sessions with
the patient’s family or significant others for purposes of information gathering
or implementing treatment goals.
Combined daily charge.
A billing procedure
by an inpatient facility that uses an inclusive flat rate covering
all professional and ancillary charges without any itemization.
Complications of pregnancy.
One of the following,
when commencing or exacerbating during the term of the pregnancy:
(i) Caesarean
delivery; hysterotomy.
(ii) Pregnancy terminating
before expiration of 26 weeks, except a voluntary abortion.
(iii) False
labor or threatened miscarriage.
(iv) Nephritis or pyelitis
of pregnancy.
(v) Hyperemesis
gravidarum.
(vi) Toxemia.
(vii) Aggravation
of a heart condition or diabetes.
(viii) Premature rupture
of membrane.
(ix) Ectopic pregnancy.
(x) Hemorrhage.
(xi) Other
conditions as may be determined by the Director, OCHAMPUS, or a
designee.
Confinement.
That period
of time from the day of admission to a hospital or other institutional provider,
to the day of discharge, transfer, or separation from the facility,
or death. Successive admissions also may qualify as one confinement
provided not more than 60 days have elapsed between the successive
admissions, except that successive admissions related to a single
maternity episode shall be considered one confinement, regardless
of the number of days between admissions.
Conflict of Interest.
Includes any
situation where an active duty member (including a reserve member while
on active duty) or civilian employee of the United States Government,
through an official federal position, has the apparent or actual
opportunity to exert, directly or indirectly, any influence on the referral
of CHAMPUS beneficiaries to himself or herself or others with some
potential for personal gain or appearance of impropriety. For purposes
of this part, individuals under contract to a Uniformed Service
may be involved in a conflict of interest situation through the
contract position.
Congenital
anomaly.
A
condition existing at or from birth that is a significant deviation
from the common form or norm and is other than a common racial or
ethnic feature. For purposes of CHAMPUS, congenital anomalies do
not include anomalies relating to teeth (including malocclusion
or missing tooth buds) or structures supporting the teeth, or to
any form of hermaphroditism or sex gender confusion. Examples of
congenital anomalies are harelip, birthmarks, webbed fingers or
toes, or such other conditions that the Director, OCHAMPUS, or a
designee, may determine to be congenital anomalies.
Note: Also refer to Sec. 199.4(e)(7) of this part.
Consultation.
A deliberation
with a specialist physician, dentist, or qualified mental health
provider requested by the attending physician 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 physician of the findings of the consultant is
required.
Note: Staff consultations
required by rules and regulations of the medical staff of a hospital
or other institutional provider do not qualify as consultation
Consultation appointment.
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 opinion.
Consulting physician or dentist.
A physician
or dentist, other than the attending physician, who performs a consultation.
Conviction.
For purposes of this part,
“conviction” or “convicted” means that (1) a judgment of conviction
has been entered, or (2) there has been a finding of guilt by the
trier of fact, or (3) a plea of guilty or a plea of nolo
contendere has been accepted by a court of competent jurisdiction,
regardless of whether an appeal is pending.
Coordination of benefits.
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.
Corporate
services provider.
A health care provider that meets the applicable
requirements established by Sec. 199.6(f).
Cosmetic, reconstructive, or
plastic surgery.
Surgery that can be expected primarily to
improve the physical appearance of a beneficiary, or that is performed
primarily for psychological purposes, or that restores form, but
does not correct or improve materially a bodily function.
Cost-share.
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
fiscal year deductible or disallowed amounts) as set forth in Secs.
199.4(f) and 199.5(b) of this part. Cost-sharing may also be referred
to as “co-payment.”
Custodial
care.
The
term “custodial care” means 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
or are designed mainly to help the patient with the activities of
daily living.
Deceased member.
A person who,
at the time of his or her death, was an active duty member of a Uniformed
Service under a call or order that did not specify a period of 30
days or less.
Deceased
reservist.
A
reservist in a Uniformed Service who incurs or aggravates an injury,
illness, or disease, during, or on the way to or from, active duty
training for a period of 30 days or less or inactive duty training
and dies as a result of that specific injury, illness or disease.
Deceased retiree.
A person who,
at the time of his or her death, was entitled to retired or retainer
pay or equivalent pay based on duty in a Uniformed Service. For
purposes of this part, it also includes a person who died before
attaining age 60 and at the time of his or her death would have
been eligible for retired pay as a reservist but for the fact that
he or she was not 60 years of age, and had elected to participate
in the Survivor Benefit Plan established under 10 U.S.C. chapter
73.
Deductible.
Payment by an
individual beneficiary or family of a specific first dollar amount
of the TRICARE allowable amount for otherwise covered outpatient
services or supplies obtained in any program year. The dollar amount
of deductible per individual or family is calculated as specified
by law.
Deductible
certificate.
A
statement issued to the beneficiary (or sponsor) by a TRICARE contractor certifying
to deductible amounts satisfied by a beneficiary for any applicable
program year.
Defense
Enrollment Eligibility Reporting System (DEERS).
An automated system maintained
by the Department of Defense for the purpose 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 care facilities and for CHAMPUS.
Dental care.
Services relating to the teeth
and their supporting structures.
Dentist.
Doctor of Dental Medicine
(D.M.D.) or Doctor of Dental Surgery (D.D.S.) who is licensed to practice
dentistry by an appropriate authority.
Dependent.
Individuals whose relationship
to the sponsor (including NATO members who are stationed in or passing
through the United States on official business when authorized)
leads to entitlement to benefits under this part. (See Sec. 199.3
of this part for specific categories of dependents).
Deserter or desertion status.
A service member
is a deserter, or in a desertion status, when the Uniformed Service
concerned has made an administrative determination to that effect,
or the member’s period of unauthorized absence has resulted in a
court-martial conviction of desertion. Administrative declarations
of desertion normally are made when a member has been an unauthorized absentee
for over 30 days, but particular circumstances may result in an
earlier declaration. Entitlement to CHAMPUS benefits ceases as of
12:01 a.m. on the day following the day the desertion status is declared.
Benefits are not to be authorized for treatment received during
a period of unauthorized absence that results in a court-martial
conviction for desertion. Dependent eligibility for benefits is reestablished
when a deserter is returned to military control and continues, even
though the member may be in confinement, until any discharge is
executed. When a deserter status is later found to have been determined
erroneously, the status of deserter is considered never to have
existed, and the member’s dependents will have been eligible continuously
for benefits under CHAMPUS.
Diagnosis-Related Groups (DRGs).
Diagnosis-related
groups (DRGs) are a method of dividing hospital patients into clinically
coherent groups based on the 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.
Diagnostic
admission.
An
admission to a hospital or other authorized institutional provider,
or an extension of a stay in such a facility, primarily for the
purpose of performing diagnostic tests, examinations, and procedures.
Director.
The Director of the Defense
Health Agency, Director, TRICARE Management Activity, or Director,
Office of CHAMPUS. Any references to the Director, Office of CHAMPUS,
or OCHAMPUS, or TRICARE Management Activity, shall mean the Director,
Defense Health Agency (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 (Health Affairs).
Director, OCHAMPUS.
An authority
of the Director, OCHAMPUS includes any person designated by the Director,
OCHAMPUS to exercise the authority involved.
Director, TRICARE Management
Activity.
This
term includes the Director, TRICARE Management Activity, the official
sometimes referred to in this part as the Director, Office of CHAMPUS
(or OCHAMPUS), or any designee of the Director, TRICARE Management
Activity or the Assistant Secretary of Defense for Health Affairs
who is designated for purposes of an action under this part.
Doctor of Dental Medicine (D.M.D.).
A person who
has received a degree in dentistry, that is, that department of
the healing arts which is concerned with the teeth, oral cavity,
and associated structures.
Doctor of Medicine (M.D.).
A person who
has graduated from a college of allopathic medicine and who is entitled
legally to use the designation M.D.
Doctor of Osteopathy (D.O.).
A practitioner
of osteopathy, that is, a system of therapy based on the theory
that the body is capable of making its own remedies against disease
and other toxic conditions when it is in normal structural relationship
and has favorable environmental conditions and adequate nutrition.
It utilizes generally accepted physical, medicinal, and surgical
methods of diagnosis and therapy, while placing chief emphasis on
the importance of normal body mechanics and manipulative methods
of detecting and correcting faulty structure.
Domiciliary care.
The term “domiciliary
care” means care provided to a patient in an institution or homelike
environment because:
(1) Providing support
for the activities of daily living in the home is not available
or is unsuitable; or
(2) Members
of the patient’s family are unwilling to provide the care.
Donor.
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.
When a CHAMPUS
beneficiary also is enrolled in another insurance, medical service, or
health plan that duplicates all or part of a beneficiary’s CHAMPUS
benefits.
Double
coverage plan.
The
specific insurance, medical service, or health plan under which
a CHAMPUS beneficiary has entitlement to medical benefits that duplicate
CHAMPUS benefits in whole or in part. Double coverage plans do not
include:
(i) Medicaid.
(ii) Coverage
specifically designed to supplement CHAMPUS benefits.
(iii) Entitlement
to receive care from the Uniformed Services medical facilities;
(iv) Entitlement
to receive care from Veterans Administration medical care facilities;
or
(v) Part C of the Individuals with Disabilities
Education Act for services and items provided in accordance with
Part C of the IDEA that are medically or psychologically necessary
in accordance with the Individual Family Service Plan and that are
otherwise allowable under the CHAMPUS Basic Program or the Extended
Care Health Option (ECHO).
Dual
Compensation.
Federal
Law (5 U.S.C. 5536) prohibits active duty members or civilian employees
of the United States Government from receiving additional compensation
from the government above their normal pay and allowances. This
prohibition applies to CHAMPUS cost-sharing of medical care provided
by active duty members or civilian government employees to CHAMPUS
beneficiaries.
Duplicate
equipment.
An
item of durable equipment, durable medical equipment, or assistive technology
items, as defined in this section that serves the same purpose that
is served by an item of durable equipment, durable medical equipment,
or assistive technology item previously cost-shared by TRICARE.
For example, various models of stationary oxygen concentrators with
no essential functional differences are considered duplicate equipment,
whereas stationary and portable oxygen concentrators are not considered
duplicates of each other because the latter is intended to provide
the user with mobility not afforded by the former. Also, a manual
wheelchair and electric wheelchair, both of which otherwise meet
the definition of durable equipment or durable medical equipment,
would not be considered duplicates of each other if each is found
to provide an appropriate level of mobility. For the purpose of
this Part, durable equipment, durable medical equipment, or assistive
technology items that are essential in providing a fail-safe in-home
life support system or that replace in-like-kind an item of equipment
that is not serviceable due to normal wear, accidental damage, a
change in the beneficiary’s condition, or has been declared adulterated
by the U.S. FDA, or is being or has been recalled by the manufacturer
is not considered duplicate equipment.
Durable equipment.
Equipment that--
(1) Is
a medically necessary item, which can withstand repeated use;
(2) Is
primarily and customarily used to serve a medical purpose; and
(3) Is
generally not useful to an individual in the absence of an illness
or injury. It includes durable medical equipment as defined in Sec.
199.2, wheelchairs, iron lungs, and hospital beds. It does not include
equipment (including wheelchairs) used or designed primarily for
use in sports or recreational activities.
Durable medical equipment.
Durable equipment
that is medically appropriate to--
(1) Improve, restore,
or maintain the function of a malformed, diseased, or injured body
part or can otherwise minimize or prevent the deterioration of the
beneficiary’s function or condition; or
(2) Maximize
the beneficiary’s function consistent with the beneficiary’s physiological
or medical needs.
Economic
interest.
(1) Any right, title, or share in the income, remuneration,
payment, or profit of a CHAMPUS-authorized provider, or of an individual
or entity eligible to be a CHAMPUS-authorized provider, resulting,
directly or indirectly, from a referral relationship; or any direct
or indirect ownership, right, title, or share, including a mortgage,
deed of trust, note, or other obligation secured (in whole or in
part) by one entity for another entity in a referral or accreditation
relationship, which is equal to or exceeds 5 percent of the total
property and assets of the other entity.
(2) A
referral relationship exists when a CHAMPUS beneficiary is sent,
directed, assigned or influenced to use a specific CHAMPUS-authorized
provider, or a specific individual or entity eligible to be a CHAMPUS-authorized
provider.
(3) An accreditation
relationship exists when a CHAMPUS-authorized accreditation organization evaluates
for accreditation an entity that is an applicant for, or recipient
of CHAMPUS-authorized provider status.
Emergency inpatient admission.
An unscheduled,
unexpected, medically necessary admission to a hospital or other
authorized institutional provider for treatment of a medical condition
meeting the definition of medical emergency and which is determined
to require immediate inpatient treatment by the attending physician.
Entity.
For purposes of Sec. 199.9(f)(1),
“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 CHAMPUS.
Essential Access Community Hospital
(EACH).
A
hospital that is designated by the Centers for Medicare and Medicaid
Services (CMS) as an EACH and meets the applicable requirements
established by Sec. 199.14(a)(7)(vi).
Extended Care Health Option
(ECHO).
The
TRICARE program of supplemental benefits for qualifying active duty
family members as described in Sec. 199.5.
External Partnership Agreement.
The External
Partnership Agreement is an agreement between a military treatment
facility commander and a CHAMPUS authorized institutional provider,
enabling Uniformed Services health care personnel to provide otherwise
covered medical care to CHAMPUS beneficiaries in a civilian facility
under the Military-Civilian Health Services Partnership Program. Authorized
costs associated with the use of the facility will be financed through
CHAMPUS under normal cost-sharing and reimbursement procedures currently
applicable under the basic CHAMPUS.
External Resource Sharing Agreement.
A type External
Partnership Agreement, established in the context of the TRICARE
program by agreement of a military medical treatment facility commander
and an authorized TRICARE contractor. External Resource Sharing
Agreements may incorporate TRICARE features in lieu of standard
CHAMPUS features that would apply to standard External Partnership Agreements.
Extramedical individual providers
of care.
Individuals
who do counseling or nonmedical therapy and whose training and therapeutic
concepts are outside the medical field, as specified in Sec. 199.6
of this part.
Extraordinary
physical or psychological condition.
A complex physical or psychological
clinical condition of such severity which results in the beneficiary
being homebound as defined in this section.
Facility charge.
The term “facility
charge” means the charge, either inpatient or outpatient, made by
a hospital or other institutional provider to cover the overhead
costs of providing the service. These costs would include building
costs, i.e. depreciation and interest; staffing costs; drugs and
supplies; and overhead costs, i.e., utilities, housekeeping, maintenance,
etc.
Former
member.
An
individual who is eligible for, or entitled to, retired pay, at
age 60, for non-Regular service in accordance with chapter 1223,
title 10, United States Code but who has been discharged and who
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.
Former
spouse.
A
former husband or wife of a Uniformed Service member or former member
who meets the criteria as set forth in Sec. 199.3(b)(2)(ii) of this
part.
Fraud.
For purposes
of this part, fraud is defined as (1) a deception or misrepresentation
by a provider, beneficiary, sponsor, or any person acting on behalf
of a provider, sponsor, or beneficiary with the knowledge (or who
had reason to know or should have known) that the deception or misrepresentation
could result in some unauthorized CHAMPUS benefit to self or some
other person, or some unauthorized CHAMPUS payment, or (2) a claim
that is false or fictitious, or includes or is supported by any
written statement which asserts a material fact which is false or
fictitious, or includes or is supported by any written statement
that (a) omits a material fact and (b) is false or fictitious as
a result of such omission and (c) is a statement in which the person
making, presenting, or submitting such statement has a duty to include
such material fact. It is presumed that, if a deception or misrepresentation
is established and a CHAMPUS claim is filed, the
person responsible for the claim had the requisite knowledge. This
presumption is rebuttable only by substantial evidence. It is further presumed
that the provider of the services is responsible for the actions
of all individuals who file a claim on behalf of the provider (for
example, billing clerks); this presumption may only be rebutted
by clear and convincing evidence.
Freestanding.
Not “institution-affiliated”
or “institution-based.”
Full-time
course of higher education.
A complete, progressive series of studies
to develop attributes such as knowledge, skill, mind, and character,
by formal schooling at a college or university, and which meets
the criteria set out in Sec. 199.3 of this part. To qualify as full-time,
the student must be carrying a course load of a minimum of 12 credit
hours or equivalent each semester.
General staff nursing service.
All nursing
care (other than that provided by private duty nurses) including,
but not limited to, general duty nursing, emergency room nursing,
recovery room nursing, intensive nursing care, and group nursing
arrangements performed by nursing personnel on the payroll of the
hospital or other authorized institution.
Good faith payments.
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 CHAMPUS 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.
Habilitation.
The provision
of functional capacity, absent from birth due to congenital anomaly
or developmental disorder, which facilitates performance of an activity
in the manner, or within the range considered normal, for a human
being.
Handicap.
For the purposes
of this part, the term “handicap” is synonymous with the term “disability.”
High-risk pregnancy.
A pregnancy
is high-risk when the presence of a currently active or previously treated
medical, anatomical, physiological illness or condition may create
or increase the likelihood of a detrimental effect on the mother,
fetus, or newborn and presents a reasonable possibility of the development
of complications during labor or delivery.
Homebound.
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 therapeutic, psychosocial, or medical treatment
in an adult day-care program that is licensed or certified by a
state, or accredited to furnish adult day-care services in the--state
shall not disqualify an individual from being considered to be confined
to his 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 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 the home would place the beneficiary at medical
risk. In addition to the above, absences, whether regular or infrequent,
from the beneficiary’s primary residence 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.
Home
health discipline.
One of six home health disciplines covered
under the home health benefit (skilled nursing services, home health
aide services, physical therapy services, occupational therapy services,
speech-language pathology services, and medical social services).
Home health market basket index.
An index that
reflects changes over time in the prices of an appropriate mix of
goods and services included in home health services.
Hospice care.
Hospice care
is a program which provides an integrated set of services and supplies designed
to care for the terminally ill. This type of care emphasizes palliative
care and supportive services, such as pain control and home care,
rather than cure-oriented services provided in institutions that
are otherwise the primary focus under CHAMPUS. The benefit provides
coverage for a humane and sensible approach to care during the last
days of life for some terminally ill patients.
Hospital, acute care (general
and special).
An
institution that meets the criteria as set forth in Sec. 199.6(b)(4)(i)
of this part.
Hospital,
psychiatric.
An
institution that meets the criteria as set forth in Sec. 199.6(b)(4)(ii)
of this part.
Illegitimate
child.
A
child not recognized as a lawful offspring; that is, a child born
of parents not married to each other.
Immediate family.
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.
A freestanding
laboratory approved for participation under Medicare and certified
by the Health Care Financing Administration.
Infirmaries.
Facilities operated by student
health departments of colleges and universities to provide inpatient
or outpatient care to enrolled students. When specifically approved
by the Director, OCHAMPUS, or a designee, a boarding school infirmary
also is included.
Initial
determination.
A
formal written decision on a CHAMPUS claim, a request for benefit authorization,
a request by a provider for approval as an authorized CHAMPUS provider,
or a decision disqualifying or excluding a provider as an authorized
provider under CHAMPUS. 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 CHAMPUS benefits are not initial determinations.
In-out surgery.
Surgery performed
in the outpatient department of a hospital or other institutional provider,
in a physician’s office or the office of another individual professional
provider, in a clinic, or in a “freestanding” ambulatory surgical
center which does not involve a formal inpatient admission for a period
of 24 hours or more.
Inpatient.
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 Rehabilitation Facility
(IRF).
A
facility classified by CMS as an IRF and meets the applicable requirements
established by Sec. 199.6(b)(4)(xx) (which includes the requirement
to be a Medicare participating provider).
Institution-affiliated.
Related to a
CHAMPUS-authorized institutional provider through a shared governing
body but operating under a separate and distinct license or accreditation.
Institution-based.
Related to a
CHAMPUS-authorized institutional provider through a shared governing body
and operating under a common license and shared accreditation.
Institutional provider.
A health care
provider which meets the applicable requirements established by Sec.
199.6(b) of this part.
Intensive
care unit (ICU).
A special segregated unit of a hospital in
which patients are concentrated by reason of serious illness, usually
without regard to diagnosis. Special lifesaving techniques and equipment
regularly and immediately are available within the unit, and patients
are under continuous observation by a nursing staff specially trained
and selected for the care of this type patient. The unit is maintained
on a continuing rather than an intermittent or temporary basis.
It is not a postoperative recovery room nor a postanesthesia room.
In some large or highly specialized hospitals, the ICUs may be further
refined for special purposes, such as for respiratory conditions,
cardiac surgery, coronary care, burn care, or neurosurgery. For
the purposes of CHAMPUS, these specialized units would be considered
ICUs if they otherwise conformed to the definition of an ICU.
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 substance use disorders, 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.
Intern.
A graduate of a medical or
dental school serving in a hospital in preparation to being licensed to
practice medicine or dentistry.
Internal Partnership Agreement.
The Internal
Partnership Agreement is an agreement between a military treatment
facility commander and a CHAMPUS-authorized civilian health care
provider which enables the use of civilian health care personnel
or other resources to provide medical care to CHAMPUS beneficiaries
on the premises of a military treatment facility under the Military-Civilian Health
Services Partnership Program. These internal agreements may be established
when a military treatment facility is unable to provide sufficient
health care services for CHAMPUS beneficiaries due to shortages
of personnel and other required resources.
Internal Resource Sharing Agreement.
A type of Internal
Partnership Agreement, established in the context of the TRICARE
program by agreement of a military medical treatment facility commander
and authorized TRICARE contractor. Internal Resource Sharing Agreements
may incorporate TRICARE features in lieu of standard CHAMPUS features
that would apply to standard Internal Partnership Agreements.
Item, Service, or Supply.
Includes (1)
any item, device, medical supply, or service claimed to have been provided
to a beneficiary (patient) and listed in an itemized claim for CHAMPUS
payment or a request for payment, or (2) in the case of a claim
based on costs, any entry or omission in a cost report, books of account,
or other documents supporting the claim.
Laboratory and pathological
services.
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.
Legitimized
child.
A
formerly illegitimate child who is considered legitimate by reason
of qualifying actions recognized in law.
Licensed practical nurse (L.P.N.).
A person who
is prepared specially in the scientific basis of nursing; who is
a graduate of a school of practical nursing; whose qualifications
have been examined by a state board of nursing; and who has been
authorized legally to practice as an L.P.N. under the supervision
of a physician.
Licensed
vocational nurse (L.V.N.)
A person who specifically is prepared in the
scientific basis or nursing; who is a graduate of a school of vocational
nursing; whose qualifications have been examined by a state board
of nursing; and who has been authorized legally to practice as a
L.V.N. under the supervision of a physician.
Long Term Care Hospital (LTCH).
A hospital that
is classified by the Centers for Medicare and Medicaid Services
(CMS) as an LTCH and meets the applicable requirements established
by Sec. 199.6(b)(4)(v) (which includes the requirement to be a Medicare
participating provider).
Low-risk
pregnancy.
A
pregnancy is low-risk when the basis for the ongoing clinical expectation
of a normal uncomplicated birth, as defined by reasonable and generally
accepted criteria of maternal and fetal health, is documented throughout
a generally accepted course of prenatal care.
Major life activity.
Breathing, cognition,
hearing, seeing, and age appropriate ability essential to bathing,
dressing, eating, grooming, speaking, stair use, toilet use, transferring,
and walking.
Marriage
and family therapist, certified.
An extramedical individual provider who meets
the requirements outlined in Sec. 199.6.
Maternity care.
Care and treatment
related to conception, delivery, and abortion, including prenatal and
postnatal care (generally through the 6th post-delivery week), and
also including treatment of the complications of pregnancy.
Medicaid.
Those medical benefits authorized
under Title XIX of the Social Security Act provided to welfare recipients
and the medically indigent through programs administered by the
various states.
Medical.
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 CHAMPUS, 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 emergency.
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 Director, OCHAMPUS, 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, abruptio placenta, presence
of shock or unconsciousness, suspected heart attack or stroke, or
trauma (such as injuries received in an automobile accident).
Medical supplies and dressings
(consumables).
Necessary
medical or surgical supplies (exclusive of durable medical equipment)
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 CHAMPUS, on either an inpatient or
outpatient basis. Examples include disposable syringes for a diabetic,
colostomy sets, irrigation sets, and ace bandages.
Medically or psychologically
necessary.
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.
Medically or psychologically
necessary preauthorization.
A pre (or prior) authorization for payment
for medical/surgical or psychological services based upon criteria
that are generally accepted by qualified professionals to be reasonable
for diagnosis and treatment of an illness, injury, pregnancy, and
mental disorder.
Medicare.
These 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 DHHS, Health Care Financing Administration, Medicare Bureau.
Medication assisted treatment
(MAT).
MAT
for diagnosed opioid use disorder 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.
Member.
An 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 disorder, to include
substance use disorder.
For purposes of the payment of CHAMPUS 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. A substance use disorder 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 Diagnostic and Statistical
Manual of Mental Disorders. “Conditions Not Attributable to a Mental
Disorder,” or V codes, are not considered diagnosable mental disorders.
Co-occurring mental and substance use disorders are common and assessment
should proceed as soon as it is possible to distinguish the substance
related symptoms from other independent conditions.
Mental health therapeutic absence.
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.
Missing in action (MIA).
A battle casualty
whose whereabouts and status are unknown, provided the absence appears
to be involuntary and the service member is not known to be in a
status of unauthorized absence.
Note: Claims for eligible CHAMPUS beneficiaries whose
sponsor is classified as MIA are processed as dependents of an active
duty service member.
Morbid
obesity.
A
body mass index (BMI) equal to or greater than 40 kilograms per
meter squared (kg/m2), or a BMI equal to or greater than 35 kg/m2
in conjunction with high-risk co-morbidities, which is based on
the guidelines established by the National Heart, Lung and Blood
Institute on the Identification and Management of Patients with
Obesity.
Note: Body mass index
is equal to weight in kilograms divided by height in meters squared.
Most-favored rate.
The lowest usual
charge to any individual or third-party payer in effect on the date of
the admission of a CHAMPUS beneficiary.
Natural childbirth.
Childbirth without
the use of chemical induction or augmentation of labor or surgical
procedures other than episiotomy or perineal repair.
Naturopath.
A person who practices naturopathy,
that is, a drugless system of therapy making use of physical forces
such as air, light, water, heat, and massage.
Note: Services of a naturopath are not covered by CHAMPUS.
NAVCARE clinics.
Contractor owned,
staffed, and operated primary clinics exclusively serving uniformed
services beneficiaries pursuant to contracts awarded by a Military
Department.
No-fault
insurance.
No-fault
insurance means an insurance contract providing compensation for
health and medical expenses relating to personal injury arising
from the operation of a motor vehicle in which the compensation
is not premised on whom may have been responsible for causing such
injury. No-fault insurance includes personal injury protection and
medical payments benefits in cases involving personal injuries resulting
from operation of a motor vehicle.
Nonavailability statement.
A certification
by a commander (or a designee) of a Uniformed Services medical treatment
facility, recorded on DEERS, generally for the reason that the needed
medical care being requested by a non-TRICARE Prime enrolled beneficiary
cannot be provided at the facility concerned because the necessary
resources are not available in the time frame needed.
Nonparticipating provider.
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 CHAMPUS beneficiary,
but who did not agree on the CHAMPUS claim form to participate or
to accept the CHAMPUS-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 CHAMPUS. In such cases, CHAMPUS pays the beneficiary or sponsor,
not the provider.
North
Atlantic Treaty Organization (NATO) member.
A 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 United States. The foreign NATO nations are Belgium, Canada,
Denmark, France, Federal Republic of Germany, Greece, Iceland, Italy,
Luxembourg, the Netherlands, Norway, Portugal, Spain, Turkey, and
the United Kingdom.
Not-for-profit
entity.
An
organization or institution owned and operated by one or more nonprofit corporations
or associations formed pursuant to applicable state laws, no part
of the net earnings of which inures, or may lawfully inure, to the
benefit of any private shareholder or individual.
Occupational therapist.
A person who
is trained specially in the skills and techniques of occupational therapy
(that is, the use of purposeful activity with individuals who are
limited by physical injury of illness, psychosocial dysfunction,
developmental or learning disabilities, poverty and cultural differences,
or the aging process in order to maximize independence, prevent
disability, and maintain health) and who is licensed to administer
occupational therapy treatments prescribed by a physician.
Off-label use of a drug or device.
A use other
than an intended use for which the prescription drug, biologic or
device is legally marketed under the Federal Food, Drug, and Cosmetic
Act or the Public Health Services Act. This includes any use that
is not included in the approved labeling for an approved drug, licensed
biologic, approved device or combination product; any use that is
not included in the cleared statement of intended use for a device
that has been determined by the Food and Drug Administration (FDA)
to be substantially equivalent to a legally marketed predicate device
and cleared for marketing; and any use of a device for which a manufacturer
or distributor would be required to seek pre-market review by the
FDA in order to legally include that use in the device’s labeling.
Official formularies.
A book of official
standards for certain pharmaceuticals and preparations that are not
included in the U.S. Pharmacopeia.
Office-based opioid treatment.
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 office-based
opioid treatment (OBOT).
Opioid
Treatment Program.
Opioid Treatment Programs (OTPs) are service
settings for opioid treatment, either free standing or hospital
based, that adhere to the Department of Health and Human Services’ regulations
at 42 CFR part 8 and use medications indicated and approved by the
Food and Drug Administration. Treatment in OTPs provides 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 Department of Health and Human Services’
Substance Abuse and Mental Health Services Administration. 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,
OTPs.
Optometrist
(Doctor of Optometry).
A person trained and licensed to examine and
test the eyes and to treat visual defects by prescribing and adapting
corrective lenses and other optical aids, and by establishing programs
of exercises.
Oral
surgeon (D.D.S. or D.M.D.).
A person who has received a degree in dentistry
and who limits his or her practice to oral surgery, that is, that
branch of the healing arts that deals with the diagnosis and the surgical
correction and adjunctive treatment of diseases, injuries, and defects
of the mouth, the jaws, and associated structures.
Orthopedic shoes.
Shoes prescribed
by an orthopedic surgeon to effect changes in foot or feet position and
alignment and which are not an integral part of a brace.
Other allied health professionals.
Individual professional
providers other than physicians, dentists, or extramedical individual
providers, as specified in Sec. 199.6 of this part.
Other special institutional
providers.
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 this part; 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 the Joint Commission or other accrediting
organization approved by the Director 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.
Outpatient.
A patient who has not been
admitted to a hospital or other authorized institution as an inpatient.
Ownership or control interest.
For purposes
of Sec. 199.9(f)(1), a “person with an ownership or control interest”
is anyone who
(1) Has directly or
indirectly a 5 percent or more ownership interest in the entity;
or
(2) Is the owner of a whole or part interest in
any mortgage, deed of trust, note, or other obligation secured (in
whole or in part) by the entity or any of the property or assets
thereof, which whole or part interest is equal to or exceeds 5 percent
of the total property and assets of the entity; or
(3) Is
an officer or director of the entity if the entity is organized
as a corporation; or
(4) Is a partner in
the entity if the entity is organized as a partnership.
Partial hospitalization.
A 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.
A
CHAMPUS-authorized provider that is required, or has agreed by entering
into a CHAMPUS participation agreement or by act of indicating “accept
assignment” on the claim form, to accept the CHAMPUS-allowable amount
as the maximum total charge for a service or item rendered to a
CHAMPUS beneficiary, whether the amount is paid for fully by CHAMPUS
or requires cost-sharing by the CHAMPUS beneficiary.
Part-time or intermittent home
health aide and skilled nursing services.
Part-time or intermittent
means skilled nursing and home health aide services furnished any
number of days per week as long as they are furnished (combined)
less than 8 hours each day and 28 or fewer hours each week (or,
subject to review on a case-bay-case basis as to the need for care,
less than 8 hours each day and 35 or fewer hours per week).
Party to a hearing.
An appealing
party or parties and CHAMPUS.
Party to the initial determination.
Includes CHAMPUS
and also refers to a CHAMPUS beneficiary and a participating provider
of services whose interests have been adjudicated by the initial
determination. In addition, a provider who has been denied approval
as an authorized CHAMPUS provider is a party to that initial determination,
as is a provider who is disqualified or excluded as an authorized
provider under CHAMPUS, unless the provider is excluded based on
a determination of abuse or fraudulent practices or procedures under
another federal or federally funded program. See Sec. 199.10 for additional
information concerning parties not entitled to administrative review
under the CHAMPUS appeals and hearing procedures.
Pastoral counselor.
An extramedical
individual provider who meets the requirements outlined in Sec. 199.6.
Pharmaceutical Agent.
Drugs, biological
products, and medical devices under the regulatory authority of
the Food and Drug Administration.
Pharmacist.
A person who is trained specially
in the scientific basis of pharmacology and who is licensed to prepare
and sell or dispense drugs and compounds and to make up prescriptions
ordered by a physician.
Physical
medicine services or physiatry services.
The treatment of disease or
injury by physical means such as massage, hydrotherapy, or heat.
Physical therapist.
A person who
is trained specially in the skills and techniques of physical therapy (that
is, the treatment of disease by physical agents and methods such
as heat, massage, manipulation, therapeutic exercise, hydrotherapy,
and various forms of energy such as electrotherapy and ultrasound),
who has been authorized legally (that is, registered) to administer
treatments prescribed by a physician and who is entitled legally
to use the designation “Registered Physical Therapist.” A physical
therapist also may be called a physiotherapist.
Physician.
A person with a degree of
Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) who is licensed
to practice medicine by an appropriate authority.
Physician in training.
Interns, residents,
and fellows participating in approved postgraduate training programs
and physicians who are not in approved programs but who are authorized
to practice only in a hospital or other institutional provider setting,
e.g., individuals with temporary or restricted licenses, or unlicensed
graduates of foreign medical schools.
Podiatrist (Doctor of Podiatry
or Surgical Chiropody).
A person who has received a degree in podiatry (formerly
called chiropody), that is, that specialized field of the healing
arts that deals with the study and care of the foot, including its
anatomy, pathology, and medical and surgical treatment.
Preauthorization.
A decision issued
in writing, or electronically by the Director, TRICARE Management Activity,
or a designee, that TRICARE benefits are payable for certain services
that a beneficiary has not yet received. The term prior authorization
is commonly substituted for preauthorization and has the same meaning.
Prescription drugs and medicines.
Drugs and medicines
which at the time of use were approved for commercial marketing
by the U.S. Food and Drug Administration, and which, by law of the
United States, require a physician’s or dentist’s prescription,
except that it includes insulin for known diabetics whether or not
a prescription is required. Drugs grandfathered by the Federal Food,
Drug and Cosmetic Act of 1938 may be covered under CHAMPUS as if
FDA approved. Prescription drugs and medicines may also be referred
to as “pharmaceutical agents”.
Note: The fact that the U.S. Food and Drug Administration
has approved a drug for testing on humans would not qualify it within
this definition.
Preventive
care.
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
caregiver.
An
individual who renders to a beneficiary services to support the
activities of daily living (as defined in Sec. 199.2) and specific
services essential to the safe management of the beneficiary’s condition.
Primary payer.
The plan or
program whose medical benefits are payable first in a double coverage situation.
PRIMUS clinics.
Contractor owned,
staffed, and operated primary care clinics exclusively serving uniformed
services beneficiaries pursuant to contracts awarded by a Military
Department.
Private
room.
A
room with one bed that is designated as a private room by the hospital
or other authorized institutional provider.
Profound hearing loss (adults).
An “adult” (a
spouse as defined in section 32 CFR 199.3(b) of this part of a member
of the Uniformed Services on active duty for more than 30 days)
with a hearing threshold of:
(1) 40 dB HL or greater
in one or both ears when tested at 500, 1,000, 1,500, 2,000, 3,000,
or 4,000Hz; or
(2) 26
dB HL or greater in one or both ears at any three or more of those
frequencies; or
(3) A speech recognition
score less than 94 percent.
Profound
hearing loss (children).
A “child” (an unmarried child of an active
duty member who otherwise meets the criteria (including age requirements)
in 32 CFR 199.3 of this part) with a 26dB HL or greater hearing
threshold level in one or both ears when tested in the frequency
range at 500, 1,000, 2,000, 3,000 or 4,000 Hz.
Program year.
The 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 loss protection, etc.) on covered health care services
obtained or provided during the designated time period.
Progress notes.
Progress notes
are an essential component of the medical record wherein health
care personnel provide written evidence of ordered and supervised
diagnostic tests, treatments, medical procedures, therapeutic behavior
and outcomes. In the case of mental health care, progress notes
must include: the date of the therapy session; length of the therapy
session; a notation of the patient’s signs and symptoms; the issues,
pathology and specific behaviors addressed in the therapy session;
a statement summarizing the therapeutic interventions attempted
during the therapy session; descriptions of the response to treatment,
the outcome of the treatment, and the response to significant others;
and a statement summarizing the patient’s degree of progress toward
the treatment goals. Progress notes do not need to repeat all that
was said during a therapy session but must document a patient contact
and be sufficiently detailed to allow for both peer review and audits
to substantiate the quality and quantity of care rendered.
Prosthetic or Prosthetic device
(prosthesis).
A
prosthetic or prosthetic device (prosthesis) determined by the Secretary
of Defense to be necessary because of significant conditions resulting
from trauma, congenital anomalies, or diseases.
Prosthetic supplies.
Supplies that
are necessary for the effective use of a prosthetic or prosthetic
device.
Provider.
A hospital or
other institutional provider, a physician, or other individual professional provider,
or other provider of services or supplies as specified in Sec. 199.6
of this part.
Provider
exclusion and suspension.
The terms “exclusion” and “suspension”, when
referring to a provider under CHAMPUS, 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 CHAMPUS. The terms may be used interchangeably to refer to
a provider who has been denied status as an authorized CHAMPUS provider
based on (1) a criminal conviction or civil judgment involving fraud,
(2) an administrative finding of fraud or abuse under CHAMPUS, (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 the CHAMPUS or CHAMPUS beneficiaries to exclude or
suspend the provider.
Provider
termination.
When
a provider’s status as an authorized CHAMPUS 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 Sec.
199.6 of this part, to be an authorized CHAMPUS provider.
Psychiatric emergency.
A psychiatric
inpatient admission is an emergency when, based on a psychiatric evaluation
performed by a physician (or other qualified mental health care
professional with hospital admission authority), the patient is
at immediate risk of serious harm to self or others as a result
of a mental disorder and requires immediate continuous skilled observation
at the acute level of care.
Public facility.
A public authority
or entity legally constituted within a State (as defined in this
section) to administer, control or perform a service function for
public health, education or human services programs in a city, county,
or township, special district, or other political subdivision, or
such combination of political subdivisions or special districts
or counties as are recognized as an administrative agency for a
State’s public health, education or human services programs, or
any other public institution or agency having administrative control
and direction of a publicly funded health, education or human services
program.
Public
facility adequacy.
An available public facility shall be considered
adequate when the Director, OCHAMPUS, or designee, determines that
the quality, quantity, and frequency of an available service or item
otherwise allowable as a CHAMPUS benefit is sufficient to meet the
beneficiary’s specific disability related need in a timely manner.
Public facility availability.
A public facility
shall be considered available when the public facility usually and
customarily provides the requested service or item to individuals
with the same or similar disability related need as the otherwise
equally qualified CHAMPUS beneficiary.
Qualified accreditation organization.
A not-for-profit
corporation or a foundation that:
(1) Develops process
standards and outcome standards for health care delivery programs,
or knowledge standards and skill standards for health care professional
certification testing, using experts both from within and outside
of the health care program area or individual specialty to which
the standards are to be applied;
(2) Creates
measurable criteria that demonstrate compliance with each standard;
(3) Publishes
the organization’s standards, criteria and evaluation processes
so that they are available to the general public;
(4) Performs
on-site evaluations of health care delivery programs, or provides
testing of individuals, to measure the extent of compliance with
each standard;
(5) Provides on-site
evaluation or individual testing on a national or international
basis;
(6) Provides to evaluated programs and tested individuals
time-limited written certification of compliance with the organization’s
standards;
(7) Excludes certification
of any program operated by an organization which has an economic interest,
as defined in this section, in the accreditation organization or
in which the accreditation organization has an economic interest;
(8) Publishes
promptly the certification outcomes of each program evaluation or
individual test so that it is available to the general public; and
(9) Has
been found by the Director, OCHAMPUS, or designee, to apply standards,
criteria, and certification processes which reinforce CHAMPUS provider
authorization requirements and promote efficient delivery of CHAMPUS
benefits.
Qualified
mental health provider.
Psychiatrists or other physicians; clinical
psychologists, certified psychiatric nurse specialists, certified
clinical social workers, certified marriage and family therapists, TRICARE
certified mental health counselors, pastoral counselors under a
physician’s supervision, and supervised mental health counselors
under a physician’s supervision.
Radiation therapy services.
The treatment
of diseases by x-ray, radium, or radioactive isotopes when ordered
by the attending physician.
Rare Diseases.
TRICARE/CHAMPUS
defines a rare disease as any disease or condition that has a prevalence
of less than 200,000 persons in the United States.
Referral.
The act or an
instance of referring a TRICARE beneficiary to another authorized
provider to obtain necessary medical treatment. Generally, when
a referral is required to qualify health care as a covered benefit,
only a TRICARE-authorized physician may make such a referral unless
this regulation specifically allows another category of TRICARE-authorized
provider to make a referral as allowed within the scope of the provider’s
license. In addition to referrals which may be required for certain health
care to be a covered TRICARE benefit, the TRICARE Prime program
under Sec. 199.17 generally requires Prime enrollees to obtain a
referral for care through a primary care manager (PCM) or other authorized
care coordinator to avoid paying higher deductible and cost-sharing
for otherwise covered TRICARE benefits.
Registered nurse.
A person who
is prepared specially in the scientific basis of nursing, who is
a graduate of a school of nursing, and who is registered for practice
after examination by a state board of nurse examiners or similar
regulatory authority, who holds a current, valid license, and who
is entitled legally to use the designation R.N.
Rehabilitation.
The reduction
of an acquired loss of ability to perform an activity in the manner,
or within the range considered normal, for a human being.
Rehabilitative therapy.
Any rehabilitative
therapy that is necessary to improve, restore, or maintain function,
or to minimize or prevent deterioration of function, of a patient
and prescribed by a physician.
Reliable evidence.
(1) As
used in Sec. 199.4(g)(15), the term reliable evidence means only:
(i) Well
controlled studies of clinically meaningful endpoints, published
in refereed medical literature.
(ii) Published formal
technology assessments.
(iii) The
published reports of national professional medical associations.
(iv) Published
national medical policy organization positions; and
(v) The
published reports of national expert opinion organizations.
(2) The
hierarchy of reliable evidence of proven medical effectiveness,
established by (1) through (5) of this paragraph, is the order of
the relative weight to be given to any particular source. With respect
to clinical studies, only those reports and articles containing
scientifically valid data and published in the refereed medical
and scientific literature shall be considered as meeting the requirements
of reliable evidence. Specifically not included in the meaning of
reliable evidence are reports, articles, or statements by providers
or groups of providers containing only abstracts, anecdotal evidence
or personal professional opinions. Also not included in the meaning
of reliable evidence is the fact that a provider or a number of
providers have elected to adopt a drug, device, or medical treatment
or procedure as their personal treatment or procedure of choice
or standard of practice.
Representative.
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.
Reservist.
A person who is under an active
duty call or order to one of the Uniformed Services for a period
of 30 days or less or is on inactive training.
Resident (medical).
A graduate physician
or dentist who has an M.D. or D.O. degree, or D.D.S. or D.M.D. degree,
respectively, is licensed to practice, and who choose to remain
on the house staff of a hospital to get further training that will
qualify him or her for a medical or dental specialty.
Residential treatment center
(RTC).
A
facility (or distinct part of a facility) which meets the criteria
in Sec. 199.6(b)(4)(vii).
Respite
care.
Respite
care is short-term care for a patient in order to provide rest and
change for those who have been caring for the patient at home, usually
the patient’s family.
Retired
category.
Retirees
and their family members who are beneficiaries covered by 10 U.S.C.
1086(c), other than Medicare-eligible beneficiaries as described
in 10 U.S.C. 1086(d).
Retiree.
For ease of
reference in this part only, and except as otherwise specified in
this part, the term means 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.
Routine eye examinations.
The services
rendered in order to determine the refractive state of the eyes.
Sanction.
For purpose of Sec. 199.9,
“sanction” means a provider exclusion, suspension, or termination.
Secondary payer.
The plan or
program whose medical benefits are payable in double coverage situations
only after the primary payer has adjudicated the claim.
Semiprivate room.
A room containing
at least two beds. If a room is designated publicly as a semiprivate
accommodation by the hospital or other authorized institutional
provider and contains multiple beds, it qualifies as a semiprivate
room for the purposes of CHAMPUS.
Serious physical disability.
Any physiological
disorder or condition or anatomical loss affecting one or more body
systems which has lasted, or with reasonable certainty is expected
to last, for a minimum period of 12 contiguous months, and which
precludes the person with the disorder, condition or anatomical
loss from unaided performance of at least one Major Life Activity
as defined in this section.
Skilled nursing facility.
An institution
(or a distinct part of an institution) that meets the criteria as
set forth in Sec. 199.6(b)(4)(vi).
Skilled nursing services.
Skilled nursing
services includes application of professional nursing services and
skills by an RN, LPN, or 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.
Sole community hospital (SCH).
A hospital that
is designated by CMS as an SCH and meets the applicable requirements
established by Sec. 199.6(b)(4)(xvii).
Spectacles, eyeglasses, and
lenses.
Lenses,
including contact lenses, that help to correct faulty vision.
Speech generating device (SGD).
See Augmentative
Communication Device.
Sponsor.
A member or
former member of a Uniformed Service upon whose status his or her dependents’
eligibility for CHAMPUS is based. A sponsor also includes a person
who, while a member of the Uniformed Services and after becoming
eligible to be retired on the basis of years of service, has his or
her eligibility to receive retired pay terminated as a result of
misconduct involving abuse of a spouse or dependent child. It also
includes NATO members who are stationed in or passing through the
United States on official business when authorized. It also includes
individuals eligible for CHAMPUS under the Transitional Assistance
Management Program.
Spouse.
A lawful husband
or wife, who meets the criteria in Sec. 199.3 of this part, regardless
of whether or not dependent upon the member or former member for
his or her own support.
State.
For purposes
of this part, 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 United
States.
State
victims of crime compensation programs.
Benefits available to victims
of crime under the Violent Crime Control and Law Enforcement Act.
Student status.
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.
Substance use disorder rehabilitation
facility (SUDRF).
A facility or a distinct part of a facility
that meets the criteria in Sec. 199.6(b)(4)(xiv).
Supervised mental health counselor.
An extramedical
individual provider who meets the requirements outlined in Sec.
199.6.
Supplemental
insurance plan.
A health insurance policy or other health
benefit plan offered by a private entity to a CHAMPUS 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 CHAMPUS due to program limitations,
or beneficiary liabilities imposed by law. CHAMPUS recognizes two
types of supplemental plans, general indemnity plans, and those
offered through a direct service health maintenance organization
(HMO).
(1) An indemnity supplemental
insurance plan must meet all of the following criteria:
(i) It
provides insurance coverage, regulated by state insurance agencies,
which is available only to beneficiaries of CHAMPUS.
(ii) is
premium based and all premiums relate only to the CHAMPUS supplemental
coverage.
(iii) Its
benefits for all covered CHAMPUS beneficiaries are predominantly
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.
(iv) It
provides insurance reimbursement by making payment directly to the
CHAMPUS beneficiary or to the participating provider.
(v) 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 or cost-shares.
(2)
A
supplemental insurance plan offered by a Health Maintenance Organization
(HMO) must meet all of the following criteria:
(i) The HMO must be
authorized and must operate under relevant provisions of state law.
(ii) The
HMO supplemental plan must be premium based and all premiums must
relate only to CHAMPUS supplemental coverage.
(iii) The
HMO’s benefits, above those which are directly reimbursed by CHAMPUS,
must be limited predominantly to services not covered by CHAMPUS
and CHAMPUS deductible and cost-share amounts.
(iv) The
HMO must provide services directly to CHAMPUS beneficiaries through
its affiliated providers who, in turn, are reimbursed by CHAMPUS.
(v) The
HMO’s premium structure must be designed so that no overall reduction
in the amount of the beneficiary deductibles or cost-shares will
result.
Suppliers
of portable X-ray services.
A supplier that meets the conditions of coverage
of the Medicare program, set forth in the Medicare regulations (42
CFR 405.1411 through 405.1416 (as amended)) or the Medicaid program
in the state in which the covered service is provided.
Surgery.
Medically appropriate operative
procedures, including related preoperative and postoperative care;
reduction of fractures and dislocations; injections and needling
procedures of the joints; laser surgery of the eye; and those certain
procedures listed in Sec. 199.4(c)(2)(i) of this part.
Surgical assistant.
A physician
(or dentist or podiatrist) who assists the operating surgeon in
the performance of a covered surgical service when such assistance
is certified as necessary by the attending surgeon, when the type
of surgical procedure being performed is of such complexity and seriousness
as to require a surgical assistant, and when interns, residents,
or other house staff are not available to provide the surgical assistance
services in the specialty area required.
Suspension of claims processing.
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 CHAMPUS beneficiary pending action
by the Director, OCHAMPUS, or a designee, in a case of suspected
fraud or abuse. The action may include the administrative remedies
provided for in Sec. 199.9 or any other Department of Defense issuance
(e.g. DoD issuances implementing the Program Fraud Civil Remedies
Act), case development or investigation by OCHAMPUS, or referral
to the Department of Defense-Inspector General or the Department
of Justice for action within their cognizant jurisdictions.
Teaching physician.
A teaching physician
is any physician whose duties include providing medical training
to physicians in training within a hospital or other institutional
provider setting.
Third-party
billing agent.
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
payer.
Third-payer
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 worker’s 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
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
described in Sec. 199.8(c)(2) of this part, TRICARE payment may
be authorized to be paid in advance of adjudication of the claim
by certain third-party payers. TRICARE advance payments will not
be made when a third-party provider is determined to be a primary
medical insurer under Sec. 199.8(c)(3) of this part.
Timely filing.
The filing of
CHAMPUS claims within the prescribed time limits as set forth in
Sec. 199.7 of this part.
Transitional
Assistance Management Program (TAMP).
The program established under
10 U.S.C. Sec. 1145(a) and Sec. 199.3(e) of this part.
Treatment plan.
A detailed description
of the medical care being rendered or expected to be rendered a
CHAMPUS beneficiary seeking approval for inpatient and other benefits
for which preauthorization is required as set forth in Sec. 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 current International Statistical Classification
of Diseases and Related Health Problems (ICD) or current Diagnostic
and Statistical Manual of Mental Disorders (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 CHAMPUS patient 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.
TRICARE certified mental health
counselor.
An
allied health professional who meets the requirements outlined in
Sec. 199.6.
TRICARE
Extra.
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.
The
Medicare wraparound coverage option of the TRICARE program made
available to an eligible beneficiary by reason of 10 U.S.C. 1086(d).
TRICARE Hospital Outpatient
Prospective Payment System (OPPS).
OPPS is a hospital outpatient prospective
payment system, based on nationally established APC payment amounts
and standardized for geographic wage differences that includes operating
and capital-related costs that are directly related and integral
to performing a procedure or furnishing a service in a hospital
outpatient department.
TRICARE
Prime.
The
managed care otion of the TRICARE program established under Sec.
199.17.
TRICARE
program.
The
program establish under Sec. 199.17.
TRICARE Reserve Select.
The program
established under 10 U.S.C. 1076d and Sec. 199.24 of this Part.
TRICARE Retired Reserve.
The program
established under 10 U.S.C. 1076e and Sec. 199.25.
TRICARE Select.
The self-managed,
preferred-provider network option under the TRICARE Program established
by 10 U.S.C. 1075 and Sec. 199.17 to replace TRICARE Extra and Standard
after December 31, 2017.
TRICARE
Standard.
The
TRICARE program made available prior to January 1, 2018, covering
health benefits contracted for under the authority of 10 U.S.C.
section 1079(a) or 1086(a) and subject to the same rates and conditions
as apply to persons covered under those section.
TRICARE Young Adult.
The program
authorized by and described in Sec. 199.26 of this part.
Uniform HMO benefit.
The health care
benefit established by Sec. 199.18.
Uniformed Services.
The Army, Navy,
Air Force, Marine Corps, Coast Guard, Commissioned Corps of the USPHS,
and the Commissioned Corps of the NOAA.
Veteran.
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
dependents are eligible for benefits under CHAMPUS.
Waiver of benefit limits.
Extension of
current benefit limitations under the Case Management Program, of
medical care, services, and/or equipment, not otherwise a benefit
under the TRICARE/CHAMPUS program.
Well-child care.
A specific program
of periodic health screening, developmental assessment, and routine
immunization for dependents under six years of age.
Widow or Widower.
A person who
was a spouse at the time of death of a member or former member and
who has not remarried.
Worker’s
compensation benefits.
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.
X-ray services.
An x-ray examination
from which an x-ray film or other image is produced, ordered by the
attending physician when necessary and rendered in connection with
a medical or surgical diagnosis or treatment of an illness or injury,
or in connection with maternity or well-baby care.
[51 FR 24008, Jul 1, 1986, as amended at
64 FR 46134, Aug 24, 1999; 66 FR 40606, Aug 3, 2001; 66 FR 45172,
Aug 28, 2001; 67 FR 18826, Apr 17, 2002; 67 FR 40602, Jun 13, 2002;
68 FR 6618, Feb 10, 2003; 68 FR 23032, Apr 30, 2003; 68 FR 32361,
May 30, 2003; 68 FR 44880, Jul 31, 2003; 69 FR 17048, Apr 1, 2004; 69
FR 44946, Jul 28, 2004; 69 FR 51563, Aug 20, 2004; 69 FR 60554,
Oct 12, 2004; 70 FR 12802, Mar 16, 2005; 70 FR 61377, Oct 24, 2005;
71 FR 31944, Jun 2, 2006; 71 FR 35532, Jun 21, 2006; 71 FR 47092,
Aug 16, 2006; 72 FR 46383, Aug 20, 2007; 73 FR 74964, Dec 10, 2008;
74 FR 44755, Aug 31, 2009; 75 FR 47455, Aug 6, 2010; 75 FR 47458,
Aug 6, 2010; 76 FR 8297, Feb 14, 2011; 76 FR 23483, Apr 27, 2011;
77 FR 38178, Jun 27, 2012; 78 FR 12954, Feb 26, 2013; 78 FR 48309,
Aug 8, 2013; 79 FR 41641, Jul 17, 2014; 78 FR 78711, Dec 31, 2014;
81 FR 61085, Sep 2, 2016; 82 FR 45445, Sep 29, 2017; 82 FR 61692,
Dec 29, 2017; 84 FR 4333, Feb 15, 2019; 85 FR 15065,
Mar 17, 2020]
1. At 66 FR 45172, Aug 28, 2001, Sec. 199.2,
was amended in part by revising the definition of “Director, OCHAMPUS”.
However, this amendment could not be incorporated due to inaccurate
amendatory instruction.
2. For Federal Register citations affecting
Sec. 199.2, see the List of CFR Sections Affected, which appears
in the Finding Aids section of the printed volume and at www.fdsys.gov.