(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.