Military Health System

Services performed by Christian Science practitioners for a person when the person is not physically present. Technically, “Absent Treatment” is an obsolete term. The current Christian Science terminology is “treatment through prayer and spiritual means,” which is employed by an authorized Christian Science practitioner either with the beneficiary being present or absent. However, to be considered for coverage under TRICARE, the beneficiary must be present physically when a Christian Science service is rendered, regardless of the terminology used.

Any practice that is inconsistent with accepted sound fiscal, business, or professional practice which results in a TRICARE claim, unnecessary cost, or TRICARE payment for services or supplies that are:

The term “abuse” includes deception or misrepresentation by a provider, or any person or entity acting on behalf of a provider in relation to a TRICARE claim.

The ability to receive necessary health care services of high quality within specific time frames, at locations and from the providers that satisfy patient health care needs. This is frequently associated with the contractor’s provision of network adequacy. Access to care standards are established in 32 CFR 199.17 and 45 CFR 156.230. See the definition of “Access Standards” in this appendix.

Preferred Provider Networks (PPNs) will have attributes of size composition, mix of providers and geographical distribution so that the networks, coupled with the Military Treatment Facility (MTF) capabilities, can adequately address the health care needs of the enrollees. Before offering enrollment in Prime to a beneficiary group, the MTF Commander/eMSM Manager (or other authorized person) will assure that the capabilities of the MTF plus PPN will meet the following access standards with respect to the needs of the expected number of enrollees from the beneficiary group being offered enrollment:

A contractor’s plan for achieving a goal through the use of specific resources based on a time-oriented schedule of activities.

Full-time duty in the Uniformed Services of the United States (U.S.). It includes duty on the active list, full-time training duty, annual training duty, and attendance while in the active Military Service, at a school designated as a Service school by law or by the Secretary of the Military Department concerned.

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.

Care that consists of providing food (including special diets), clothing and shelter; personal hygiene services; observation and general monitoring; bowel training or management (unless abnormalities in bowel function are of a severity to result in a need for medical or surgical intervention in the absence of skilled services); safety precautions; general preventive procedures (such as turning to prevent bedsores); passive exercise; companionship; recreation; transportation; and other such elements of personal care that can reasonably be performed by an untrained adult with minimal instruction or supervision. ADL may also be referred to as “essentials of daily living”.

Adequate medical documentation provides the means for measuring the type, frequency, and duration of active treatments mechanisms employed and progress under the treatment plan. Under TRICARE, it is required that adequate and sufficient clinical records be kept be the provider to substantiate that specific care was actually and appropriately furnished, was medically or psychologically necessary (as defined in 32 CFR 199.2), and to identify the individual(s) who provided the care. Each service provided or billed must be documented in the records. In determining whether medical records are adequate, the records will be reviewed under the general acceptable standards (e.g., standard of an accrediting organization approved by the Director, and the provider’s state or local licensing requirements) and other requirements specified in 32CFR 199. The psychiatric and psychological evaluations, physicians orders, the treatment plan, integrated progress notes (and physician progress notes if separate from the integrated progress notes), and the discharge summary are the more critical elements of the mental health record. However, nursing and staff notes, no matter how complete, are not a substitute for the documentation of services by the individual professional provider who furnished treatment to the beneficiary. In general, the documentation requirement of a professional provider are not less in the outpatient setting than the inpatient setting. Furthermore, even though a hospital that provides psychiatric care may be accredited under The Joint Commission (TJC) manual for hospitals rather than TJC behavioral health standards, the critical elements of the mental health record listed above are required for TRICARE claims.

Dental care that is medically necessary in the treatment of an otherwise covered medical (not dental) condition, is an integral part of the treatment of such medical condition, and is essential to the control of the primary medical condition; or, is required in preparation for or as the result of dental trauma which may be or is caused by medically necessary treatment of an injury or disease (iatrogenic).

A correction to the information in the TRICARE Encounter Data (TED) records and/or Beneficiary History Files (Hard Copy Files and Automated Beneficiary History and Deductible Files) related to a claim previously Processed To Completion (PTC). Adjustments include any recoupments, additional payment(s), all cancellations (total or partial), and corrections to statistical data, whether or not the changes result in changes to the financial data.

An adjustment may be generated by a telephonic, written or personal inquiry, appeal decision, or as the result of a contractor’s internal review. The adjustment is identified when the contractor’s staff determines the issue requires an additional payment, cancellation, or a change to the Beneficiary History and Deductible Files (see definition) or when notice is received from DHA that an adjustment is required. In the case of recoupments, the adjustment is “identified” for reporting purposes, with receipt of the payment by the contractor.

Adherence to the TRICARE program and benefits, electronic claims processing, responsiveness to patient questions and care coordination, timeliness of consult reporting back to referring providers.

The offered price that represents all administrative charges relative to prescription, prior authorization and medical necessity determination transaction processing.

The TRICARE-determined rate that encompasses the daily charge for inpatient care and, unless specifically excepted, all other treatment determined necessary and rendered as part of the treatment plan established for a patient and accepted by TRICARE.

The TRICARE-determined level of payment to institutions, physicians, and other categories of individual professional providers based on one of the approved reimbursement methods set forth in the 32 CFR 199.14.

A request for review of a contractor determination of the allowable charge for covered services and supplies furnished under TRICARE. An allowable charge complaint does not fall within the meaning of an “appeal”, in the technical sense, but does require a careful review or reconsideration by the contractor of how the claim was processed to ensure accuracy of the payment made.

The difference between the reimbursement determination made by a contractor and the amount billed by the provider of care (prior to determination of applicable cost-shares and deductibles). This is also referred to in the industry as the contractual allowance.

The TRICARE-determined level of payment to hospitals or other institutions, based on one of the approved reimbursement methods set forth in 32 CFR 199.14. The allowable charge may also be referred to as the TRICARE-determined reasonable or allowable cost.

The amount of money, determined under 32 CFR 199, that TRICARE will pay for medical services and supplies involved in an adverse determination being appealed if the appeal were resolved in favor of the appealing party. See 32 CFR 199.10 for additional information concerning the determination of “amount in dispute” under the Regulation.

A formal written request by a beneficiary, a participating provider, a provider denied authorized provider status under TRICARE, or a representative, to resolve a disputed question of fact. See 32 CFR 199.10 and Chapter 12.

Services that are:

The Army, Navy, Air Force, Marine Corps, Space Force, and Coast Guard.

The authorization determination addresses whether a particular service may be covered by TRICARE, including whether it appears necessary and appropriate in the context of the patient’s diagnosis and circumstances.

A hospital or institutional provider, physician, or other individual professional provider, or other provider of services or supplies specifically authorized to provide benefits under TRICARE in 32 CFR 199.6.

Non-drug items (usually used in conjunction with the administration of a drug) approved by the DoD Pharmacy and Therapeutic (P&T) [Committee] for inclusion in the formulary, and appearing on the formulary web site at http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx.

A system for recording and processing data on magnetic media, ADP cards, or any other method for mechanical/electronic processing and manipulation or storage of data.

A separate, off-site ADP system with similar operating capabilities which will be activated/used in case of a major system failure, damage, or destruction. This includes back-up data sets, software and hardware requirements, and trained personnel.

A provider seeking any payment, other than any payment relating to applicable deductible and cost-sharing amounts, from a beneficiary for TRICARE covered services for any amount in excess of the applicable TRICARE allowable cost or charge.

The primary medical benefits authorized under Chapter 55 of Title 10, United States Code (USC), and set forth in 32 CFR 199.4.

The Average Wholesale Price (AWP) has long been the drug price benchmark for establishing reimbursement payment terms between payers, Pharmacy Benefit Managers (PBMs), and pharmacies. AWP as a benchmark has been going away. AWP is by no means the only price type available. Listed here, with brief descriptions, are others that are available and may be used by the industry for reimbursement purposes as AWP is being phased out:

A beneficiary is an individual eligible for benefits. The beneficiary, Sponsor, or representative of the beneficiary, including the parent of a beneficiary under 18 years of age, the beneficiary’s attorney, legal guardian or representative specifically designated by the beneficiary may on his or her behalf regarding the benefit at issue. An individual who is subject to the conflict of interest provisions of 32 CFR 199.10(a)(2)(i)(B), may not act as the beneficiary’s representative under this section.

Formerly referred to as Health Benefit Advisors (HBAs), BCACs are individuals located at Uniformed Services medical facilities or on occasion at other locations and assigned the responsibility for providing TRICARE information, information concerning availability of care from the Uniformed Services Direct Care (DC) or Purchased Care Systems, and generally assisting beneficiaries or sponsors. The term also includes “Health Benefits Counselor.”

A system of records consisting of any record or subsystem of records, whether hard copy, microform or automated, which reflects diagnosis, treatment, medical condition, family history records, correspondence, memorandum, or any other personal information with respect to any individual, including all such records/reports acquired or utilized by the contractor in delivery of health care services, in the development and processing of claims, or in performing any other functions under a TRICARE contract.

The legal obligation of a beneficiary, his or her estate, or responsible family member to pay for the costs of medical care or treatment received. Specifically, for the purposes of services and supplies covered by TRICARE, beneficiary liability includes any annual deductible amount, cost-sharing amounts, or, when a provider does not submit a claim on a participating basis on behalf of the beneficiary, amounts above the TRICARE-determined allowable charge. Beneficiary liability also includes any expenses for medical or related services and supplies not covered by TRICARE.

Services, supplies, payment amounts, cost-shares and copayments authorized by Public Law (PL) 89-614, 32 CFR 199, and outlined in the TPM and the TRM.

A best practice is a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a “best” practice can evolve to become better as improvements are discovered.

The delivery of high quality clinical and other related services in the most economical manner for the Military Health System (MHS) that optimizes the DC system while delivering the highest level of customer service.

A breach, as defined in Department of Defense Directive (DoDD) 5400.11 (2014), is a loss of control, compromise, unauthorized disclosure, unauthorized acquisition, unauthorized access, or any similar term referring to situations where persons other than authorized users and for an other than authorized purpose have access or potential access to Personally Identifiable Information (PII)/Protected Health Information (PHI), whether in paper or electronic form. Breaches are classified as either possible or confirmed (see the definition of “Possible Breach” and “Confirmed Breach” in this appendix) and as either cyber or non-cyber (i.e., involving either electronic PII/PHI or paper/oral PII/PHI).

For claims processing purposes, one business day is defined as the business day following the day of transmission at the close of business at the location of the receiving entity. A business workday is Monday through Friday, excluding Federal holidays.

The scope of services the provider is both capable of performing and willing to perform under a TRICARE contract. For example, a neurologist under TRICARE contract to perform sleep studies may not be considered to have capability to perform as a general neurology specialist.

The amount of time or number of services a provider is able to perform in conjunction with a TRICARE contract. For example, a Primary Care Physician (PCP), whose practice is full has no available capacity for services.

A payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

The maximum per diem or all-inclusive rate that TRICARE will allow for care.

A comprehensive method of client assessment designed to identify client vulnerability, needs identification, and client goals which results in the development plan of action to produce an outcome that is desirable for the client. The goal is to provide client advocacy, a system for coordinating client services, and providing a systematic approach for evaluation of the effectiveness of the client’s Life Plan.

A collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health needs, including mental health and Substance Use Disorder (SUD) needs, using communication and available resources to promote quality, cost-effective outcomes.

The National Defense Authorization Act (NDAA) for Fiscal Years (FYs) 1988 and 1989 (Public Law 100-180) amended Title 10, USC, and established catastrophic loss protection for TRICARE beneficiary families on a Government fiscal year basis. The law placed fiscal year limits or catastrophic caps on beneficiary liabilities for deductibles and cost-shares under the TRICARE Basic Program. Specific guidance may be found in the TRM, Chapter 2, Section 2. NDAA for FY 2017 amended Title 10, USC to change calculations to a calendar year basis, beginning January 1, 2018. The last quarter of calendar year 2017 was applied to the FY 2017 calculations to bridge the gap.

Geographic areas determined by the Assistant Secretary of Defense (Health Affairs) (ASD(HA)) that are defined by a set of five digit zip codes, usually within an approximate 40 mile radius of military inpatient treatment facility.

See definition for Defense Centers of Excellence (CoE).

A process that ensures the trust requirement is met for Information Systems (IS)/networks. Certification is the determination of the appropriate level of protection required for IS/networks. Certification also includes a comprehensive evaluation of the technical and non-technical security features and countermeasures required for each IS/network. Accreditation is the formal approval by the Government to operate the contractor’s IS/networks in a particular security mode using a prescribed set of safeguards at an acceptable level of risk. In addition, accreditation allows IS/networks to operate within the given operational environment with stated interconnections; and with appropriate level-of-protection for the specified period. The C&A requirements apply to all DoD IS/networks and contractor IS/networks that access, manage, store, or manipulate electronic IS data. Specific guidance may be found in the TSM, Chapter 1.

The determination that the provider’s request for services (level of care, procedure, etc.) is consistent with pre-established health care criteria. Pre-certification is the process performing a certification for care prior to rendering the care.

A hospital or institutional provider, physician, or other individual professional provider of services or supplies verified by DHA, or a designated contractor, to meet the provider standards outlined in 32 CFR 199.6, and have been approved to provide services to TRICARE beneficiaries and receive Government payment for services rendered to TRICARE beneficiaries.

A CMAC is a nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Scheduled amount.

A program of medical care for spouses and dependent children of disabled or deceased disabled veterans who meet the eligibility requirements of the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA).

A written directive from the DHA Procuring Contracting Officer (PCO) to the contractor directing modifications, within the general scope of the contract, as authorized by the “changes clause” at FAR 52.243-1, Changes--Fixed Price.

An individual who has been accredited as a Christian Science Nurse by the Department of Care of the First Church of Christ, Scientist, Boston, Massachusetts, and listed (or eligible to be listed) in the Christian Science Journal at the time the service is provided. The duties of Christian Science nurses are spiritual and are nonmedical and nontechnical nursing care performed under the direction of an accredited Christian Science practitioner. There are two levels of Christian Science nurse accreditation:

An individual who has been accredited as a Christian Science Practitioner for the First Church of Christ, Scientist, Boston, Massachusetts, and listed (or eligible to be listed) in the Christian Science Journal at the time the service is provided. An individual who attains this accreditation has demonstrated results of his or her healing through faith and prayer rather than by medical treatment. Instruction is executed by an accredited Christian Science teacher and is continuous.

A sanatorium either operated by the First Church of Christ, Scientist, or listed and certified by the First Church of Christ, Scientist, Boston, Massachusetts.

Any request for reimbursement for health care services rendered, received from a beneficiary, a beneficiary’s representative, or a network or non-network provider, by a contractor on any TRICARE-approved claim form or approved electronic medium.

Claims that:

The collected records submitted with or developed in the course of processing a single claim. It includes the approved TRICARE claim form and may include attached bills, medical records, records of telephone development, copies of correspondence sent and received in connection with the claim, the EOB, and records of adjustments to the claim. It may also include the records of appeals and appeal actions. The claim file may be in microcopy, hard copy, or in a combination of media.

A fixed arrangement of captioned spaces designed for entering and extracting prescribed information, including ADP system forms.

Any claim retained (held in the contractor’s possession) for any reason that is not defined under ‘Claim (Excluded)’.

That period of time, recorded in calendar days, from the receipt of a claim into the possession/custody of the contractor to the completion of all processing steps (see the definition of “Processed to Completion (or Final Disposition)” in this appendix, and the TSM, Chapter 2, Section 2.4, “Date TED Record Processed to Completion”).

The record of information contained on or derived from the processing of a claim or encounter.

A claim that has no defect, impropriety (including a lack of any required substantiating documentation), or particular circumstance requiring special treatment external to the contractor’s prepayment operation that prevents timely payment on the claim.

A beneficiary who receives services from a temporarily suspended provider, pharmacy, or entity. All payments to a client beneficiary for care or services rendered by a temporarily suspended provider, pharmacy, or entity shall be held in temporary suspense (same as the temporarily suspended provider’s, pharmacy’s, or entity’s claims). A client beneficiary is NOT under temporary suspense. Only the reimbursement of claims for care received from a temporarily suspended provider, pharmacy, or entity shall be held in temporary suspense. All other claims shall be paid in accordance with the contract.

The American College of Medical Quality in its 2010 revision of its recommended Core Curriculum for Medical Quality Management describes clinical outcomes as part of the definition of quality measures. These are:

An arrangement requested by the military, between an MTF/eMSM and the TRICARE contractor for the contractor to provide needed clinical personnel at an MTF/eMSM. The arrangement must be formalized by modification to the TRICARE contract prior to implementation of the provisions of the arrangement.

Any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions, as outlined in HIPAA of 1996.

An organization that creates and maintains the code sets adopted by the Secretary of Home Health Services (HHS) for use in the transactions for which standards are adopted as outlined in HIPAA of 1996.

A billing procedure by an inpatient facility that uses an inclusive flat rate covering all professional and ancillary charges without any itemization.

Evaluation of a patient’s continued need for treatment, the appropriateness of current and proposed treatment, as well as the setting in which the treatment is being rendered or proposed. Concurrent review applies to all levels of care (including outpatient care).

The procedures and controls that assure the privacy of personal medical information in compliance with the Freedom of Information Act, the Comprehensive Alcohol Abuse and Alcoholism Prevention and Rehabilitation Act, the Privacy Act, and HIPAA of 1996.

An incident in which it is known that unauthorized access could occur. For example, if a laptop containing PII/PHI is lost and the contractor knows that the PII/PHI is unencrypted, then the contractor should classify and report the incident as a confirmed breach, because unauthorized access could occur due to the lack of encryption (the contractor knows this even without knowing whether or not unauthorized access to the PII/PHI has actually occurred). If the laptop is subsequently recovered and forensic investigation reveals that files containing PII/PHI were never accessed, then the possibility of unauthorized access can be ruled out, and the contractor should re-classify the incident as a non-breach incident.

Includes any situation where an active duty member (including a reserve member while on active duty) or civilian employee of the U.S. Government, through an official federal position, has the apparent or actual opportunity to exert, directly or indirectly, any influence on the referral of TRICARE beneficiaries to himself or herself or others with some potential for personal gain or appearance of impropriety. Individuals under contract to a Uniformed Service may be involved in a conflict of interest situation through the contract position.

A deliberation with a specialist physician, dentist, or qualified mental health provider requested by the attending TRICARE authorized provider primarily responsible for the medical care of the patient, with respect to the diagnosis or treatment in any particular case. A consulting physician or dentist or qualified mental health provider may perform a limited examination of a given system or one requiring a complete diagnostic history and examination. To qualify as a consultation, a written report to the attending TRICARE authorized provider of the findings of the consultant is required.

An appointment for evaluation of medical symptoms resulting in a plan for management which may include elements of further evaluation, treatment and follow-up evaluation. Such an appointment does not include surgical intervention or other invasive diagnostic or therapeutic procedures beyond the level of very simply office procedures, or basic laboratory work but rather provides the beneficiary with an authoritative option.

A physician or dentist, other than the attending physician, who performs a consultation.

A TRICARE benefit program that provides temporary continued health care for certain former beneficiaries of the MHS. Coverage under the CHCBP is purchased on a premium basis.

Follow on of health care services from a specific individual professional provider as part of a specific procedure or service that was performed within the previous six months in order to not disrupt therapy or repeat services.

All patient care services provided from “pre-conception to grave” across all types of settings. Requires integrating processes to maintain ongoing communication and documentation flow between the DC system and network.

A review by DHA, of a contractor’s level of compliance with the terms and conditions of the contract. Usually, an operational audit performed by DHA staff that focuses on timeliness, accuracy, and responsiveness of the contractor in performing all aspects of the work required by the contract.

A physician who has made contractual arrangements with a contractor to provide care or services to TRICARE beneficiaries. A contract physician is a network provider who participates on all TRICARE claims.

A Government representative, appointed in writing by the Contracting Officer (CO), who represents the CO in the administration of technical matters involving contract requirements.

An organization with which DHA has entered into a contract for delivery of and/or processing of payment for health care services, and the performance of related support activities, such as, pharmacy services, quality monitoring and/or customer service.

The ability to identify individually, locate, and count all claims in the custody of the contractor by location, including those that may be being developed by physical return of a copy of the claim, and age including total age in-house and age in a specific location.

Those medications which are included in one of the schedules of the Controlled Substances Act of 1970 and as amended.

Information that is not classified in accordance with national security directives, but that otherwise requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations, and Government-wide policies.

A CC is located in a retail location with a pharmacy whose purpose is to diagnose and treat non-emergency illness or injury; and provide vaccinations, wellness services, and chronic disease monitoring.

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.

The amount of money for which the beneficiary (or sponsor) is responsible in connection with otherwise covered inpatient and outpatient services (other than the annual deductible or disallowed amounts) as set forth in 32 CFR 199.4(f) and 32 CFR 199.5(b). Cost-sharing may also be referred to as “copayment.”

Any penal or correctional facility, jail, reformatory, detention center, work farm, halfway house, or residential community program center operated by, or under contract to, the U.S., a State, a territory, a political subdivision of a State or territory, or an Indian tribe, for the confinement or rehabilitation of persons charged with or convicted of a criminal offense or other persons held in lawful custody. Other persons held in lawful custody includes juvenile offenders adjudicated delinquent, aliens detained awaiting deportation, persons committed to mental institutions through the criminal justice system, witnesses, or others awaiting charges or trial as defined in HIPAA of 1996.

Any business entity that must comply with HIPAA regulations, which includes, health plans, health care clearinghouses, and HCPs. For the purposes of HIPAA, HCPs include hospitals, physicians, and other caregivers. See 45CFR Section 160.103 of HIPAA regulation for additional information.

Those functions of a covered entity, the performance of which, makes the entity a health plan or HCP as outlined in HIPAA of 1996.

The process by which providers are allowed to participate in the network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.

Information required for all clinical personnel supplied by the contractor who will be working in an MTF/eMSM. Similar information may be required for non-clinical personnel. Complete information shall contain the following:

The treatment or services, regardless of who recommends such treatment or services or where such treatment or services are provided, that:

A cybersecurity incident is a violation or imminent threat of violation of computer security policies, acceptable use policies, or standard security practices, with respect to electronic PII/PHI. A cybersecurity incident may or may not involve a breach of PII/PHI. For example, a malware infection would be a possible breach if it could cause unauthorized access to PII/PHI. However, if the malware only affects data integrity or availability (not confidentiality), then a non-breach cybersecurity incident has occurred.

The elapsed time, as expressed in calendar days including any part of the first and last days counted as two days, from the date a claim, piece of correspondence, grievance, or appeal case was received by a contractor through the date (PTC). See the definition of claims cycle time, in this appendix, for added detail.

Any information collected, derived, or created as a result of operations as a TRICARE contractor. All data is the property of the Government regardless of where it is maintained/stored.

The combining of PHI by a business associate with the PHI received by the business associate in its capacity as a business associate of another covered entity, to permit data analyses that relate to the health care operations of the respective covered entities as outlined in HIPAA of 1996.

The circumstances under which a covered entity must use a particular data element or segment as defined by HIPAA of 1996.

All the data elements and code sets inherent to a transaction, and not related to the format of the transaction. Data elements that are related to the format are not data content as defined by HIPAA of 1996.

The smallest named unit of information in a transaction defined by HIPAA of 1996.

A single point of electronic storage, established and maintained by the contractor that enables the Government to electronically access all data maintained by the contractor relative to a TRICARE contract. This includes all claims/encounter data, provider data, authorization, enrollment, and derived data collected in relation to a TRICARE contract.

A semantically meaningful unit of information exchanged between two parties to a transaction as defined by HIPAA of 1996.

The date of completion appearing on the reconsideration determination, formal review determination, or hearing final decision.

Calendar days.

The length of time a dispensed quantity of drug should last, based on directions for use with a limit as the First Data Bank recommended maximum daily dose (unless specifically altered by DoD).

Payment by the beneficiary of the first $50 of the CHAMPUS determined allowable costs or charges for covered outpatient services or supplies provided in any one fiscal year; aggregate payment by two or more beneficiaries who submit claims for the first $100. Effective January 1, 2018, deductibles are determined on a calendar year basis. Deductible amounts are outlined in the TRM, Chapter 2.

A statement issued to the beneficiary (or sponsor) by a TRICARE contractor certifying to the deductible amounts satisfied by a beneficiary for any applicable program year.

CoEs focus on an associated group of clinical conditions and create value by achieving improvement in outcomes through clinical, educational, and research activities.

An automated system maintained by the DoD for the purposes of:

Health information that has been rendered not individually identifiable by removal of specific identifiers, such as, individual or relatives or household members, names, addresses, employers, name or addressee, or geographic subdivisions smaller than a State, and all elements of dates (except year) for dates directly related to an individual, telephone numbers, Social Security Numbers (SSNs), etc., as outlined in HIPAA of 1996.

A study or test project for the purpose of trying alternative methods of payment for health and medical services, cost-sharing by eligible beneficiaries, methods of encouraging efficient and economical delivery of care, innovative approaches to delivery and financing services and prepayment for services provided to a defined population. Following completion and evaluation of the test project, it may or may not become part of the program.

The text defining a code as defined in HIPAA of 1996.

A group of records maintained by or for a covered entity that is:

For purposes of this definition, the term record means any item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for a covered entity as described in HIPAA of 1996.

An organization designated by the Secretary of HHS under HIPAA of 1996 §162.910(a).

A method of dividing hospital patients into clinically coherent groups based on their consumption of resources. Patients are assigned to the groups based on their principal diagnosis (the reason for admission, determined after study), secondary diagnoses, procedures performed, and the patient’s age, sex, and discharge status. See the TRM for more specific information on DRGs.

A classification system of codes for mental illness developed by the American Psychiatric Association (APA).

The direct entry of data (for example, using dumb terminals or web browsers) that is immediately transmitted into a health plan’s computer, as defined in HIPAA of 1996.

A treatment relationship between an individual and a HCP that is not an indirect treatment relationship as defined under HIPAA of 1996. See the definition of “Indirect Treatment Relationship” in this appendix.

The Director of the DHA; Director, TRIICARE Management Activity (TMA); or Director, Office of CHAMPUS (OCHAMPUS). Any reference to the Director, Office of CHAMPUS, or OCHAMPUS, or TMA shall mean the Director, DHA. Any reference to Director shall also include any person designated by the Director to carry out a particular authority. In addition, any authority of the Director may be exercised by the Assistant Secretary of Defense for Health Affairs (ASD(HA)).

An individual responsible for:

For purposes of TPM, Chapter 10, Section 10.1 only, the term “disaster response duty” means duty performed by a member of the National Guard in State status pursuant to an emergency declaration by the Governor of the State (to include the four United States Territories, or with respect to the District of Columbia, the mayor of the District of Columbia) in response to a disaster or in preparation for an imminent disaster.

The development of an individualized discharge health care plan for the patient prior to leaving an institution to follow at home, with the aim of improving patient outcomes, reducing the chance of unplanned readmission to an institution, and containing costs.

The release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information as defined in HIPAA of 1996.

The “distant site” is where the physician or practitioner providing the professional service is located at the time the services are provided via an interactive telecommunications system.

Information that is provided by the DoD to a non-DoD entity, or that is collected, developed, received, transmitted, used, or stored by a non-DoD entity in support of an official DoD activity, where that information has not been cleared for public release.

Care provided to a patient in an institution or home-like environment because:

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.

When a TRICARE beneficiary also is enrolled in another insurance, medical service, or health plan that duplicates all or part of a beneficiary’s TRICARE benefits.

The specific insurance, medical service, or health plan under which a TRICARE beneficiary has entitlement to medical benefits that duplicate TRICARE benefits in whole or in part. Double coverage plans do not include:

Federal law (5 USC 5536) prohibits active duty members or civilian employees of the U.S. Government from receiving additional compensation from the Government above their normal pay and allowances. This prohibition applies to TRICARE cost-sharing of medical care provided by active duty members or civilian Government employees to TRICARE beneficiaries.

Errors found on TEDs (initial submissions, resubmissions, and adjustments/cancellation submissions) which result in non-acceptance of the records by DHA. These require correction of the error by the contractor and resubmission of the corrected TED to DHA for acceptance.

A mode of transferring/storing information that includes:

Any item collection or grouping of information, whatever the storage media (paper, electronic, etc,) about an individual that is maintained by an entity subject to the DoD Privacy Program Regulation including but not limited to an individual’s education, financial transactions, medical history, criminal or employment history, and that contains his or her name, or the identifying number, symbol, or other identifying particular assigned to the individual, such as a finger or voice print or a photograph. For more specific information refer to the DoD Privacy Program Regulation.

Concept which integrates health care among the Uniformed Services by providing increased authority including funding allocation, policy, and better maximization of staff skill sets. The concept is employed in geographic areas where at least two medical hospitals or clinics from different Uniformed Services have overlapping service areas. They are considered enhanced because of several factors, including overall size, medical mission, and graduate medical education capacity and because they allow for the movement of workload and workforce between or among the medical treatment facilities.

The amount required to be paid by some MHS beneficiaries eligible to enroll in and receive the benefits of TRICARE Prime, TRICARE Select or other special TRICARE programs.

A process established by the contractor to inform beneficiaries of the availability of the TRICARE Prime program, facilitate enrollment in the program, and maintain enrollment records. The plan must include actions for TRICARE Select and must be approved by the Government. The contractor process must be approved by the Government.

Official documentation of a beneficiary’s registration (enrollment) for TRICARE Prime and maintained on the DEERS.

A transfer of TRICARE enrollment from one location or contractor to another:

An entity includes a corporation, trust, partnership, sole proprietorship or other kind of business enterprise that is or may be eligible to receive reimbursement either directly or indirectly from TRICARE.

Referrals are normally processed as “Episodes of Care.” An EOC is defined as “A treatment period that begins with the initial assessment, follow up interventions and reassessments necessary to provide reasonable medical services related to a specific condition.” The episode includes associated lab, radiology, Durable Medical Equipment (DME), and ancillary therapies (Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST)), all of which are subject to the Right of First Refusal (ROFR) process. An episode of care generally involves evaluation and/or treatment of one disease or condition and may allow for specialist to specialist (secondary) referrals. Episodes are generally categorized as ”evaluate (only)” or “evaluate and treat.”

Services and/or supplies not reimbursable under TRICARE. This includes otherwise covered services and supplies provided to a TRICARE eligible beneficiary by a non-authorized provider/entity or a provider placed on “suspension” by a contractor.

An electronic or paper document prepared by insurance carriers, health care organizations, and TRICARE contractors to inform beneficiaries of the actions taken with respect to a claim for health care coverage.

An electronic or paper document which provides a consolidated listing of prescriptions filled for the beneficiary over a specific period of time. The period of time is dependent on printed request (quarterly) or online (user defined).

A document provided to either the beneficiary after paper claims are processed or network pharmacies for each payment cycle. This document describes the action taken for each claim processed to a final determination (paid or denied). EOPs are not generated for beneficiaries processing claims electronically at the point of sale.

A complex physical or psychological clinical condition of such severity which results in the dependents of a Service member being homebound. See TPM, Chapter 9 for additional information.

Locations established and maintained by the General Services Administration (GSA) at areas throughout the U.S. for the storage, processing, and servicing of non-current records for Government agencies.

The application of records management techniques to filing practices to maintain records easily and to retrieve them rapidly, to ensure their completeness, and to facilitate the disposition of noncurrent records.

The Federal Government’s 12 month accounting period which currently runs from October 1 through September 30 of the following year.

Those data elements that provide or control the enveloping or hierarchical structure, or assist in identifying data content of, a transaction, as defined in HIPAA of 1996.

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, USC but has been discharged and maintains no military affiliation. These former members, at age 60, and their eligible dependents are entitled to medical care, commissary, exchange, and MWR privileges. Under age 60, they and their eligible dependents are entitled to commissary, exchange, and MWR privileges only.

A listing of pharmaceuticals and other authorized supplies to be dispensed with appropriate prescriber’s order from a particular POS. The formulary for any TRICARE contract will be managed by the DoD Pharmacy and Therapeutics (P&T) Committee with clinical guidance from the DoD Pharmacoeconomic Center (PEC). Applicable formulary information may be viewed on the TRICARE web site at: http://www.health.mil/formulary.

The right to obtain medical care from any TRICARE-authorized source available, including TRICARE Prime, the DC and/or the MTF/eMSM systems, or obtain care from a provider not affiliated with the contractor and seek reimbursement under the terms and conditions of the TRICARE Standard (TRICARE Select starting January 1, 2018) Program (see definition).

A law enacted in 1967 as an amendment to the “Public Information” section of the Administrative Procedures Act, establishing provisions making information available to the public. DHA and TRICARE contractors are subject to these provisions.

Not “institution-affiliated” or “institution-based.”

Expansion of the Active Armed Forces resulting from action by Congress and the President to mobilize all Reserve Component (RC) units and individuals in the existing approved force structure, as well as retired military personnel, and the resources needed for their support to meet the requirements of a war or other national emergency involving an external threat to the national security. Reserve personnel can be placed on active duty for the duration of the emergency plus six months.

A provision that is included in a professional provider’s agreement or contract with a managed care organization; such as a Preferred Provider Organization (PPO) network or a Health Maintenance Organization (HMO) network, or third-party payer that directly or indirectly prevents limits the ability of the HCP from being open with his/her patients about the terms of the patient’s coverage and therapeutic treatment options, including, the risks, benefits and consequences of treatment or non-treatment, or the opportunity for the individual to refuse treatment and to express preferences about future treatment options.

Those payments made to civilian sources of medical care who provided medical care to persons purporting to be eligible beneficiaries but who are determined later to be ineligible for TRICARE benefits. (The ineligible person usually possesses an erroneous or illegal identification card.) To be considered for good faith payments, the civilian source of care must have exercised reasonable precautions in identifying a person claiming to be an eligible beneficiary.

A written complaint on a non-appealable issue which deals primarily with a perceived failure of a network provider, the Health Care Finder (HCF), or contractor or subcontractor, to furnish the level or quality of care expected by a beneficiary.

A contractor developed and managed system for resolving beneficiary grievances.

With respect to beneficiary cost-sharing, deductibles and catastrophic cap, the NDAA 2017 divided beneficiaries enrolled in TRICARE Prime or TRICARE Select into two groups:

An employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income and Security Act of 1974 (ERISA), 29 USC 1002(1)), including insured and self-insured plans, to the extent that the plan provides medical care (as defined in section 2791(a)(2) of the Public Health Service Act (PHS Act), 42 USC 300gg-91(a)(2)), including items and services paid for as medical care, to employees or their dependents directly or through insurance, reimbursement, or otherwise, that:

The prevention, treatment and management of illness and the preservation of mental and physical well being by qualified medical professionals. This includes but is not limited to, preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and the sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription. As described in HIPAA of 1996.

A public or private entity, including a billing service, repricing company, community health management information system or community health information system, and “value-added” networks and switches, that does either of the following functions.

Set of health care procedure codes based on the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT).

A person who manages and performs the duties necessary to operate an HCF system.

A system or mechanism, established by the contractor in each Prime Service Area (PSA) in the region, to facilitate referrals and other customer service functions to assist beneficiaries in accessing health care to the DC system and/or civilian providers.

A provider of medical or health services, institutional or individual professional provider, and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business as defined in HIPAA of 1996.

Any information, including genetic information, whether oral or recorded, in any form or medium that:

As defined in HIPAA of 1996.

An insurance company, insurance service, or insurance organization (including an HMO) that is licensed to engage in the business of insurance in a State and is subject to State Law that regulates insurance. Such term does not include a group health plan.

A federally qualified HMO, an organization recognized as an HMO under State law, or a similar organization regulated for solvency under State law in the same manner and to the same extent as such an HMO as defined in HIPAA of 1996.

An agency or authority of the U.S., a State, a territory, a political subdivision of a State or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is authorized by law to oversee the health care system (whether public or private) or Government programs in which health information is necessary to determine eligibility or compliance, or to enforce civil rights laws for which health information is relevant as defined in HIPAA of 1996.

An individual or group plan that provides or pays the cost of medical care. For a more detailed definition refer to HIPAA of 1996.

An incident that satisfies the definition of a breach in 45 CFR 164.402 (HIPAA Breach Rule).

A beneficiary’s condition is such that there exists a normal inability to leave home, and consequently, leaving home would require considerable and taxing effort. Any absence of an individual from the home attributable to the need to receive health care treatment including regular absences for the purpose of participating in rehabilitative, therapeutic, psychosocial, or medical treatment in an adult daycare program that is licensed or certified by a state, or accredited to furnish adult daycare services in the state shall not disqualify an individual from being considered to be confined to home. Any other absence of an individual from the home shall not disqualify an individual if the absence is infrequent or of relatively short duration. For the purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. Also, absences from the home for non-medical purposes, such as an occasional trip to the barber, a walk around the block or a drive, would not necessarily negate the beneficiary’s homebound status if the absences are undertaken on an infrequent basis and are of relatively short duration. An exception is made to the above homebound definitional criteria for beneficiaries under the age of 18 and those receiving maternity care. The only homebound criteria for these special beneficiary categories is written certification from a physician attesting to the fact that leaving home would place the beneficiary at medical risk. In addition to the above absences, whether regular or infrequent, from the beneficiary’s primary home for the purpose of attending an educational program in a public or private school that is licensed and/or certified by a state, shall not negate the beneficiary’s homebound status. See also TPM, Chapter 9 for additional information.

An overnight stay at a hospital. Normally if the patient is discharged in less than 24 hours it would not be considered an inpatient stay; however, if the patient was admitted and assigned to a bed and the intent of the hospital was to keep the patient overnight, regardless of the actual Length-Of-Stay (LOS), the stay will be considered an inpatient stay and, therefore, a hospital day. For hospital stays exceeding 24 hours, the day of admission is considered a hospital day; the day of discharge is not.

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.

A freestanding laboratory approved for participation under Medicare and certified by the CMS.

A relationship between an individual and a HCP in which:

As defined in HIPAA of 1996.

The person who is the subject of PHI as defined in HIPAA of 1996.

A service/treatment not routinely provided, is unusual, variable, or new and, as such, will require additional information from the provider of care, including an adequate definition or description of the nature, extent and need for the unusual service/treatment including the time, effort, and necessary equipment required. Any complexities related to the service should also be identified.

Information that is a subset of health information, including demographic information collected from an individual, and:

As defined in HIPAA of 1996.

A formal written decision on a TRICARE claim, a request for benefit authorization, a request by a provider for approval as an authorized TRICARE provider, or a decision disqualifying or excluding a provider as an authorized provider under TRICARE. Rejection of a claim or a request for benefit or provider authorization for failure to comply with administrative requirements, including failure to submit reasonably requested information, is not an initial determination. Responses to general or specific inquiries regarding TRICARE benefits are not initial determinations.

The first payment on a continuing claim, such as a long-term institutional claim.

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.

Services/treatment provided to a person who has been admitted to a hospital or other authorized institution.

A facility classified by CMS as an IRF and meets the applicable requirements established by 32 CFR 199.6(b)(4)(xx) (which includes the requirement to be a Medicare participating provider).

Requests for information or assistance made by or on behalf of a beneficiary, provider, the public, or the Government. Written inquiries may be made in any format (letter, memorandum, note attached to a claim, etc.). Allowable charge complaints, grievances, and appeals are excluded from this definition.

Related to a TRICARE authorized institutional provider through a shared governing body but operating under a separate and distinct license or accreditation.

Related to a TRICARE authorized institutional provider through a shared governing body and operating under a common license and shared accreditation.

A HCP who meets the applicable requirements established by 32 CFR 199.6.

A treatment setting capable of providing an organized day or evening program that includes assessment, treatment, case management, and rehabilitation for individuals not requiring 24-hour care for mental health disorders, to include SUDs, as appropriate for the individual patient. The program structure is regularly scheduled, individualized, and shares monitoring and support with the patient’s family and support system.

Interactive telecommunications systems are defined as multimedia communications modalities that include, at a minimum, secure audio and video equipment permitting two-way, real-time services or consultations. This includes smartphones, tablet computers, and personal computers equipped with the necessary camera and software to enable two-way, encrypted real-time audio and video interaction; as well as dedicated video conferencing and telemedicine systems.

The unique number assigned to a claim by the contractor to distinguish the claim during processing, payment, and filing procedures. It is the number affixed to the face of each claim received and will, at a minimum, include the Julian date of receipt and a five digit sequence number assigned by the contractor. Each TED must have a unique ICN. For records generated from claims, it will be the ICN of the claim from which it was generated. For a TED which is not generated from claims, it will be a unique number assigned by the contractor which will include the Julian date of the record’s creation and a five digit sequence number.

A technical reference, ICD-9-CM. Volumes 1 and 2 are a required reference and coding system for diagnoses and Volume 3 is required as a coding system for procedures in processing TRICARE claims for medical care with dates of service for outpatient services or dates of discharge for inpatient services before the mandated date, as directed by HHS, for ICD-10 implementation.

A technical reference, ICD-10-CM. It is a required reference and coding system for diagnoses in processing TRICARE claims for medical care with dates of service for outpatient services or dates of discharge for inpatient services on or after the mandated date, as directed by HHS, for ICD-10 implementation.

A technical reference, ICD-10-PCS. It is a required reference and coding system for procedures in processing TRICARE claims for medical care with dates of discharge for inpatient services on or after the mandated date, as directed by HHS, for ICD-10 implementation.

A change in therapy resulting from the prospective drug utilization review process and contact with the prescriber and/or the beneficiary because of allergy, clinically significant interactions, duplicative therapy, or other reasons.

A formal account of prescriptions not dispensed or changes in therapy as a result of contact with prescriber's and/or beneficiaries because of allergies, clinically significant interactions, duplicative therapy, or other reasons. The formal account shall also contain the resultant change in cost due to the intervention, if possible.

New medicines or other substances which have a physiological effect when ingested or otherwise introduced into the body, that have not been approved for general use by the FDA but is under investigation and clinical trial regarding its safety and efficacy first by clinical investigators and then by practicing physician using subjects who have given informed consent to participate.

Laboratory and pathological 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.

An officer or employee of any agency or authority of the U.S., a State, a territory, a political subdivision of a State or territory, or an Indian tribe, who is empowered by law to:

For further details, refer to HIPAA of 1996.

A number used to identify unique providers. These number include the six-digit Medicare ID number, Unique Physician Identification Number (UPIN), 10-digit Ambulatory Surgery Center (ASC) number, Supplier Clearinghouse (NSC) number, Online Survey Certification and Reporting (OSCAR) number, and DME supplier number. A legacy identification number is other than the unique NPI required by HIPAA of 1996 to be issued to each physician, supplier and other provider of health care and the Federal Tax Identification Number (TIN). A Federal TIN is not considered a legacy identifier for health care purposes as it’s primary purpose is to support IRS 1099 reporting.

A semantically meaningful unit of information exchanged between two parties to a transaction that excludes direct identifiers of the individual or of relatives, employers, or household members of the individual which is considered to be PHI as defined in HIPAA of 1996.

A hospital that is classified by the CMS as an LTCH and meets the applicable requirements established by 32 CFR 199.6(b)(4)(v) (which includes the requirement to be a Medicare participating provider).

The records and archives whose informational content is usually in code and has been recorded on media, such as magnetic disks, drums, tapes, punched paper cards, or punched paper tapes, accompanied by finding aids known as software documentation. The coded information is retrievable only by machine.

Activities necessary to support the use of a standard adopted by the Secretary of HHS, including technical corrections to an implementation specification, and enhancements, or expansion of a code set. This term excludes the activities related to the adoption of a new standard or implementation specification, or modification to an adopted standard or implementation specification.

A group of similar DRGs, such as all those effecting a given organ system of the body formed by dividing all possible principal diagnoses from (ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDC codes, like DRG codes, are primarily a claims and administrative data element unique to the U.S. medical care reimbursement system. DRG codes are also mapped, or grouped, into the MDC codes.

Civilian contractor, under contract with the DoD, to work with, help support and augment health care services available at the MTFs/eMSMs resulting in the establishment of an integrated system of health care delivery that influences utilization of services, cost of services while measuring performance. The contractor is required to assist military personnel in the combining of the resources of the military’s direct medical care system, the TRICARE program and the contractor’s managed care provider network and other services outlined in the contract to ensure a system that delivers value by giving TRICARE eligible beneficiaries access to quality, cost-effective health care.

Communication about a product or service to encourage recipients of the communication to purchase or use the product or service as defined in HIPAA of 1996. See also DoD 6025.18R, DoD Health Information Privacy Regulation, for a list of specific exclusions to this definition.

The TRICARE state prevailing charges adjusted by the Medicare Economic Index (MEI) according to the methodology as set forth in Chapter 16.

All required data elements for a particular standard based on a specific implementation specification.

Those medical benefits authorized under Title XIX of the Social Security Act provided to welfare recipients and the medically indigent through programs as administered by the various states.

The generally used term which pertains to the diagnosis and treatment of illness, injury, pregnancy, and mental disorders by trained and licensed or certified health professionals. For purposes of TRICARE, the term “medical” should be understood to include “medical, psychological, surgical, and obstetrical,” unless it is specifically stated that a more restrictive meaning is intended.

Refer to Beneficiary History File definition.

The sudden and unexpected onset of a medical condition or the acute exacerbation of a chronic condition that is threatening to life, limb, or sight, and requires immediate medical treatment or which manifests painful, symptomatology requiring immediate palliative efforts to alleviate suffering. Medical emergencies include heart attacks, cardiovascular accidents poisoning, convulsions, kidney stones, and such other acute medical conditions as may be determined to be medical emergencies by the TRICARE Director, or a designee. In the case of a pregnancy, a medical emergency must involve a sudden and unexpected medical complication that puts the mother, the baby, or both, at risk. Pain would not, however, qualify a maternity case as an emergency, nor would incipient birth after the 34th week of gestation, unless an otherwise qualifying medical condition is present. Examples of medical emergencies related to pregnancy or delivery are hemorrhage, ruptured membrane with prolapsed cord, placenta previa, abruption placenta, presence of shock or unconsciousness, suspected heart attack or stroke, or trauma (such as injuries received in an automobile accident.

A review to determine if the recommended health care services are reasonable for the diagnosis and treatment of illness, injury, pregnancy, mental disorders and adequate for well-baby care.

Necessary medical or surgical supplies (exclusive of DME) that do not withstand prolonged, repeated use and that are needed for the proper medical management of a condition for which benefits are otherwise authorized under TRICARE, on either an inpatient or outpatient basis. Examples include disposable syringes for a diabetic, colostomy sets, irrigation sets, and ace bandages.

Contemporary practices in areas such as Utilization Management (UM), Case Management (CM), care coordination, chronic care/Disease Management (DM), and the various additional terms and models for managing the clinical and social needs of eligible beneficiaries to achieve the short and long term cost-effectiveness of the MHS while achieving the highest level of satisfaction among MHS beneficiaries.

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.

The medical benefits authorized under Title XVIII of the Social Security Act provided to persons 65 or older, certain disabled persons, or persons with chronic renal disease, through a national program administered by the Department of Health and Human Services (DHHS), Health Care Financing Administration (HCFA), Medicare Bureau.

An index used by Medicare to update physician fee levels in relation to annual changes in the general economy for inflation, productivity, and changes in specific health sector practice expenses factors including malpractice, personnel costs, rent, and other expenses.

MAT for diagnosed SUD is a holistic modality for recovery and treatment that employs evidence-based therapy, including psychosocial treatments and psychopharmacology, and FDA-approved medications as indicated for the management of withdrawal symptoms and maintenance.

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use as defined by the FDA.

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.

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.

Any individual who is eligible to receive treatment in an MTF/eMSM. Eligibility is determined by the Uniformed Services and is reported on DEERS.

A Uniformed Services hospital or clinic.

Filling every appointment and bed available within the MTF or in the eMSM based on the capacity and capabilities of the MTF/eMSM and the MTF’s/eMSM’s readiness/training requirements, as defined by the MTF Commander/eMSM Manager before referral to outside civilian providers.

Medical care or services/supplies required by a patient that are not available at the MTF or in the eMSM area and therefore must be provided by an outside civilian provider. Such care requires an MTF/eMSM referral for the civilian medical care.

A detailed proposal designed to ensure the Government’s ability to continue to meet the health care needs of the TRICARE-eligible beneficiaries in the event of a military mobilization that precludes the use of all or parts of the military DC system for provision of care to TRICARE-eligible beneficiaries.

A calculation process for determining the amount of the enrollment fee to be credited to a new enrollment period. For example, if a beneficiary pays their annual enrollment fee, in total, on January 1, (the first day of their enrollment period) and a change in status occurs on February 15. The beneficiary will receive credit for 10 months of the enrollment fee. The beneficiary will lose that portion of the enrollment fee that would have covered the period from February 15 through February 28.

The lowest usual charge to any individual or third-party payer in effect on the date of the admission of a TRICARE beneficiary.

The charge level established from a 1991 national appropriate charge file developed from July 1986 - June 1987 claims data, by applying appropriate MEI updates through 1990, and prevailing charge cuts, freeze or MEI updates for 1991 as discussed in the September 6, 1991, Final Rule.

A mathematical representation of what is currently being paid for similar services nationally. The factor is based on the national allowable charges actually in use.

A Federally coordinated framework that augments the nation’s medical response capability. The primary purpose of the NDMS is to supplement an integrated national medical response for assisting state and local authorities in dealing with medical impacts of major peacetime disasters and to provide support to the military and the DVA/VHA medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflict. The NDMS framework involves private sector hospitals located throughout the U.S. that will provide care for victims of any incident that exceeds the medical care capability of any affected state, region, or federal medical care system. For more detailed information see NDMS at the DHHS web site.

A rate that does not exceed the amount equivalent to the eightieth (80th) percentile of billed charges made for similar services during a 12 month base period.

A 10-digit number assigned to all HCPs mandated by HIPAA of 1996. These numbers are to be used for all financial and administrative transactions. The 10-digit number, containing checksum, prevents technical errors during data transmission. The number doesn’t have built-in correlation with any other identifier associated with the provider.

An amount that represents the reimbursable amount that a provider agrees to accept for covered services.

The providers or facilities (owned, leased, or arranged) the TRICARE contractor has contracted with to provide health care services to TRICARE eligible beneficiaries at a pre-negotiated rate as the total charge for services provided by the provider and to file claims for beneficiaries. The agreements for health care delivery made between the MTF and the eMSM and the TRICARE contractor are also included in this definition.

Health care services and supplies provided by providers and facilities (owned, leased, arranged) the TRICARE contractor has contracted with to provide necessary treatment to TRICARE eligible beneficiaries.

Insufficient TRICARE contractor contracted providers to meet the access standards required by the TRICARE contract.

An individual or institutional provider that has contracted with a TRICARE contractor to provide care to TRICARE eligible beneficiaries, usually at a discounted rate.

Denial of benefits based on a fact or condition outside the scope of responsibility of DHA and the TRICARE contractor.

Information captured by the TRICARE contractor to complete the required TED record for care rendered to TRICARE beneficiaries in those contractor owned, operated and/or subcontracted facilities where there is no claim submitted by the provider of care.

Action which results in a medication being returned to stock for various reasons such as the medication was not picked by the patient within the given 10 day grace period, pharmacy/physician cancelled the prescription, etc.

Documents that are no longer required in the conduct of current business and therefore can be retrieved by an archival repository or destroyed.

For the purposes of establishing a mental health care provider readiness designation as mandated by the National Defense and Authorization Act (NDAA) for Fiscal Year (FY) 2016 Section 717, a non-Department mental health care provider is a health care provider who specializes in mental health, is not a health care provider of the DoD at a facility of the Department, and provides health care to members of the Armed Forces. It includes psychiatrists, psychologists, psychiatric nurses, social workers, mental health counselors, marriage and family therapists, and other mental health care providers designated by the Secretary of Defense.

An IS that is not owned, controlled, or operated by the DoD, and is not used or operated by a contractor or other non-DoD entity exclusively on behalf of the DoD.

A special category of individuals sponsored by non-DoD Uniformed Services (the Commissioned Corps of the U.S. Public Health Service (USPHS), the U.S. Coast Guard, and the Commissioned Corps of the National Oceanic and Atmospheric Administration (NOAA)) who are eligible for TRICARE.

Services and supplies received from a civilian provider authorized to provide health care but has no contractual relationship with the TRICARE contractor.

An individual or institutional provider that not has contracted with a TRICARE contractor to provide care to TRICARE eligible beneficiaries at a discounted rate.

A hospital or other authorized institutional provider, a physician or other authorized individual professional provider, or other authorized provider that furnished medical services or supplies to a TRICARE beneficiary, but who did not agree on the TRICARE claim form to participate or to accept the TRICARE-determined allowable cost or charge as the total charge for the services. A nonparticipating provider looks to the beneficiary or sponsor for payment of his or her charge, not TRICARE. In such cases, TRICARE pays the beneficiary or sponsor, not the provider.

Individuals, eligible for the TRICARE Program, who are not enrolled in the TRICARE Prime program.

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 U.S. For a list of member nations, see https://www.nato.int/cps/ie/natohq/topics_52044.htm.

The yearly period when non-active duty beneficiaries can enroll in or change their TRICARE enrolled plan coverage for the following calendar program year. The open enrollment period for TRICARE begins on the Monday of the second full week in November to the Monday of the second full week in December of each calendar year. See TPM, Chapter 10, Section 2.1.

OTPs are service settings for opioid treatment, either freestanding or hospital-based, that adhere to the DHHS’ regulations at 42 CFR Part 8 and use medications indicated and approved by DHA. OTPs provide a comprehensive, individually tailored program of medication therapy integrated with psychosocial and medical treatment and support services that address factors affecting each patient, as certified by the Center for Substance Abuse Treatment (CSAT) of the DHHS’ Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment in OTPs can include management of withdrawal symptoms (detoxification) from opioids and medically supervised withdrawal from maintenance medications. Patients receiving care for substance use and co-occurring disorders care can be referred to, or otherwise concurrently enrolled in, OTP.

For full details refer to HIPAA of 1996.

The originating site is where the beneficiary is located at the time the services are provided via an interactive telecommunications system. The originating site must be either (a) where an otherwise authorized TRICARE provider normally offers professional medical or psychological services, such as the office of a TRICARE authorized individual professional provider (e.g., physician’s office), (b) a TRICARE authorized institutional provider, or (c) a patient’s home or other secure location as outlined in this policy.

Alternate or additional health plan coverage other than TRICARE. This does not include Medicare or supplemental insurance plans.

Certain specialized medical treatment facilities, either inpatient or outpatient, other than those specifically defined, that provide courses of treatment prescribed by a doctor of medicine or osteopathy; when the patient is under the supervision of a doctor of medicine or osteopathy during the entire course of the inpatient admission or the outpatient treatment; when the type and level of care and services rendered by the institution are otherwise authorized in 32 CFR 199; when the facility meets all licensing or other certification requirements that are extant in the jurisdiction in which the facility is located geographically; which is accredited by an accrediting organization approved by the Director, DHA if an appropriate accreditation program for the given type of facility is available; and which is not a nursing home, intermediate facility, halfway house, home for the aged, or other institution of similar purpose.

Treatment received by TRICARE eligible beneficiaries while traveling outside their TRICARE region.

See definition for Non-network Care.

Individuals who resides in one TRICARE region but receives care within another TRICARE region.

Drugs that by law can be sold to a consumer without a prescription from a health care professional.

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.

A TRICARE authorized provider that is required, or has agreed by entering into a TRICARE participation agreement or by an act of indicating “accept assignment” on the TRICARE claim form to accept the TRICARE-allowable amount as the maximum total charge for a service or item rendered to a TRICARE beneficiary, whether the amount is paid for fully by TRICARE or requires cost-sharing by the TRICARE beneficiary.

The PfP Status of Forces Agreement (SOFA) is a multilateral agreement between NATO member states and countries participating in the PfP program. It deals with the status of foreign forces while present on the territory of another state. See https://www.nato.int/cps/en/natolive/topics_50349.htm for a more detailed definition and https://www.nato.int/cps/en/natohq/51288.htm for a list of current countries.

A fraudulent or abusive practice directly causing a patient who is undergoing treatment for a disease, injury, or medical (or dental) condition to suffer actual physical injury or acceleration of an underlying condition. The determination that patient harm has occurred must be based on the opinion of a qualified medical or dental provider or pharmacist in the case of pharmacy claims. Refer to Chapter 13 for additional information.

A complete record for each beneficiary receiving prescriptions under the TRICARE program including: name, address, telephone number, date of birth, gender, patient identification number (sponsor’s SSN and DEERS dependent suffix), DEERS Identifier, service sponsorship, status category, chronic medical conditions (diagnosis code), allergies and adverse drug experiences, past medication history, prescriptions dispensed, non-receipt of prescriptions, status on interventions and prescription problems resolved, prior authorizations approved or denied, and any other information supplied by the beneficiary in the patient data form or updates.

The claim/correspondence/appeal case has been received but has not been processed to final disposition.

Government approved and developed criteria measuring specific aspects of a contractor’s execution of a TRICARE contract.

An activity under the DoD Pharmacy Operations Division (POD) with the mission to improve the clinical, economic, and humanistic outcomes of drug therapy in support of the readiness and managed care missions of the MHS. The PEC is comprised of pharmacists, physicians, and pharmacy technicians from each of the three services, as well as civilian pharmacists and support personnel who monitor drug usage, and cost trends, and performs analysis to support DoD formulary management and national pharmaceutical contracts, and clinical practice guidelines.

A DoD chartered committee with representatives from MTF/eMSM providers and MTF/eMSM pharmacists. The P&T Committee’s primary role is establishing and maintaining the DoD Uniform Formulary for the purchased care system and the DC system (MTFs/eMSMs).

A bi-directional data transaction service that provides a pharmaceutical data warehouse and electronically transmits encrypted prescription data using the National Council of Prescription Drug Program (NCPDP) standards to the pharmacy contractor. The PDTS provides the capability to perform Prospective Drug Utilization Review (ProDUR) and houses prior authorization/medical necessity history by integrating pharmacy data from all three points of service (DC, mail order, and retail pharmacies) with increased clinical screening and medication-related outcomes.

The DoD organization responsible for Tier I and Tier II (systems and software) support of the PDTS project. The POC:

Allows TRICARE Prime enrollees and TRICARE Prime Remote for Active Duty Family Members (TPRADFMs) enrollees to receive non-emergent health care services from any TRICARE authorized civilian provider, in or out of the network without requesting a referral from a PCM. Using this benefit results in the beneficiary incurring more out of pocket expenses. For further details, refer to the TRM, Chapter 2, Section 3.

An incident where the possibility of unauthorized access is suspected (or should be suspected) and has not been ruled out. For example, if a laptop containing PII/PHI is lost, and the contractor does not initially know whether or not the PII/PHI was encrypted, then the incident must initially be classified as a possible breach, because it is impossible to rule out the possibility of unauthorized access to the PII/PHI. In contrast, that possibility can be ruled out immediately, and a possible breach has not occurred, when misdirected postal mail is returned unopened in its original packaging. However, if the intended recipient informs the contractor that an expected package has not been received, then a possible breach exists until and unless the unopened package is returned to the contractor. In determining whether unauthorized access should be suspected, the contractor shall consider at least the following factors:

A decision issued in writing or electronically by the Director, Defense Health Agency (DHA), or a designee, that TRICARE benefits may be payable for certain services that a beneficiary has not yet received. The term prior authorization is substituted for preauthorization and has the same meaning.

A more comprehensive review process for certain services to determine that requested treatment may be covered as medically necessary, delivered at the appropriate setting, and is a TRICARE benefit before services are rendered to the beneficiary. Preauthorizations are required for certain services per the TOM, Chapter 7, Section 2, A preauthorization request may be submitted by the beneficiary or provider and is not required prior to a Primary Care Manager (PCM) (physician) issuing a beneficiary a referral for specialty services from a network provider.

A type of health plan that has contracts with a network of doctors, hospitals and other health care professionals to provide services to plan beneficiaries at a reduced rate.

A physician or other individual professional provider of services specifically authorized to write a prescription for medications or supplies in accordance with all applicable federal and state laws.

A legal order from an authorized prescriber to dispense pharmaceuticals or other authorized supplies.

A rate submitted by certain non-institutional providers which fall within the range of rates that are most frequently used in a state for a particular health care procedure or service. The top of the range establishes the maximum amount TRICARE will authorize for payments of a given health care procedure or service, except where unusual circumstances or medical complications warrant an additional charge. The calculation methodology and use is determined according to the reimbursement instructions outlined in the TRM.

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.

The initial medical care given by a HCP to a patient especially, as part of regular ambulatory care, and sometimes followed by referral to other medical providers.

An individual who renders to a beneficiary services to support the ADL as defined in 32 CFR 199.2 and specific services essential to the safe management of the beneficiary’s condition.

A HCP a patient sees first for their health care needs responsible for providing and coordinating the patient’s care, maintaining the patient’s health record and when necessary refers the patient for specialty care.

The plan or program whose medical benefits are payable first in a double coverage situation.

The main individual or organization that has a contract with the owner of the contract and has full responsibility for its completion/execution and may employ (and manage) one or more subcontractors to carry out specific parts of the contract.

An Individual who has signed up to receive health care under the TRICARE Prime option.

PSAs are areas in which the contractor offers enrollment in TRICARE Prime in compliance with the travel time access standard. PSAs encompass the entire area of all the ZIP codes lying within or intersected by the 40 mile radius around enrolling MTFs/eMSMs (both hospitals and clinics) and Base Realignment and Closure (BRAC) sites. Zip codes enclosed entirely within a PSA’s boundary shall also be included. For BRAC sites, the 40 mile radius shall be determined based on the physical address of the former MTF location. If the former MTF address is no longer valid, the 40 mile radius shall be determined from the geographic center of the BRAC site zip code as of the date of contract award.

See definition for Preauthorization.

Pre-approval required for the filling of certain drugs ordered by a HCP.

Official communications, received by mail, faxes, e-mail, cables, telexes and other media of record, received by the contractor from the Office of the Assistant Secretary of Defense (Health Affairs) (OASD(HA)), DHA, and any elected or appointed, federal, state, local, foreign, and tribal officials and Members of Congress and Governors, or any other correspondence designated for priority status by the contractor’s management.

Federal Law which established a Code of Fair Information Practice that governs the collection, maintenance, use and dissemination of personally identifiable information about individuals that is maintained in systems of records by federal agencies. The law prohibits the disclosure of a System Of Records (SOR) without the written consent of the individual. Additionally, the law provides the individual with a means by which to seek access for amendment of their records, and set forth various agencies record keeping requirements.

A group of records containing PHI and PII maintained by or on behalf of the DoD where PHI and PII in the records is specifically retrieved by personal identifiers.

A date/time frame when specific portions of claims processing work has been completed, resolved or received a final disposition. Under the TRICARE MCSCs there are specific dates/time frames for:

A Federal employee with specific contracting authorization having ultimate authority and responsibility for the Governments’ side for the contract execution regardless of whatever additional support team may be outlined in the contract. The Government employee is responsible for overseeing the contract from start to finish, including the drawing up the procurement package, Request for Proposal (RFP) and contract award, as well as administration during the contracts life cycle.

An amount that is the lower of the prevailing charge or the maximum allowable prevailing charge.

A software system for detecting overutilization or fraud and abuse.

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 lose protection, etc.) on covered health care services obtained or provided during the designated time period.

A process used to identify any potential medication problems that may occur, based on a patient’s current prescription, applicable patient profile information, and medication history, prior to the point of dispensing. ProDUR is used to detect over-utilization, under-utilization, therapeutic duplication, drug-disease complications, drug interactions, incorrect dosages and duration of therapy.

Prior assessment of a request for treatment before the treatment is rendered to determine if the treatment is appropriate for the patient. Another term for preauthorization.

A hospital or other institutional provider, a physician or other individual professional provider, or other provider of services or supplies in accordance with 32 CFR 199.6.

The terms “exclusion” and “suspension”, when referring to a provider under TRICARE, both mean the denial of status as an authorized provider, resulting in items, services, or supplies furnished by the provider not being reimbursed, directly or indirectly, under TRICARE. The terms may be used interchangeably to refer to a provider who has been denied status as an authorized TRICARE provider based on:

A group of HCPs with which a managed care contractor has made contractual or other arrangements with to provide health care at a discounted rate.

When a provider’s status as an authorized TRICARE provider is ended, other than through exclusion or suspension, based on a finding that the provider does not meet the qualifications, as set forth in 32 CFR 199.6 to be an authorized TRICARE provider.

Notes recorded (in any medium) by a HCP who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date, as defined in HIPAA of 1996.

An agency or authority of the U.S., a state, a territory, a political subdivision of a state or territory, or an Indian tribe, that is responsible for public health matters as part of its official mandate as well as a person or entity acting under a grant of authority from or under a contract with a public health agency, as defined in HIPAA of 1996.

A change in a beneficiary’s situation, like getting married, having a baby, or losing health coverage, that allows a beneficiary to enroll in or change their TRICARE health plan coverage outside of the annual open enrollment period. See TPM, Chapter 10, Section 2.1, for a list of authorized QLEs.

A process for developing controls to prevent mistakes in the dispensing of drugs. QA is the responsibility of both the pharmacy and the contractor.

A system-wide process established and maintained by the contractor to monitor and evaluate the quality of patient health care and clinical performance.

Processes and procedures employed to ensure that pharmaceuticals are dispensed accurately and timely. These should be employees by both the contractor and the pharmacy.

An approach to quality management that builds upon traditional quality assurance methods by emphasizing:

Delivery of a claim, correspondence, or appeal into the custody of the contractor by the post office or other party.

An appeal to a contractor of an initial determination issued by the contractor.

All books, papers, maps, photographs, machine readable materials, or other documentary materials, regardless of physical form or characteristics, made or received by an agency of the U.S. Government under Federal law or in connection with the transaction of public business or appropriate for presentation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the Government.

Also any item, collection, or grouping of information about a beneficiary which is maintained, collected, used or disseminated, by TRICARE or a TRICARE contractor, including, but not limited to his or her education, financial transactions, medical history, and criminal or employment history, and which contains the beneficiary’s name or identifying number, symbol or other personal identifiers.

The area of general administrative management concerned with achieving economy and efficiency in the creation, use and maintenance, and disposition of records. Included in the fulfilling of archival requirements and ensuring effective documentation.

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 32 CFR 199 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 32 CFR 199.17 generally requires Prime enrollees to obtain a referral for care through a PCM or other authorized care coordinator to avoid paying higher deductible and cost-sharing for otherwise covered TRICARE benefits.

A referral is a request from one physician to another to assume responsibility for management of one or more of a patient’s specified problems. A consult is a request from one physician to another for an advisory opinion. Referrals and/or consults written by MTF/eMSM or Civilian TRICARE providers are sent to the Contractor for authorization or preauthorization (if needed per TOM, Chapter 7, Section 2). A PCM (physician) does not require a preauthorization/authorization from the Contractor to generate a referral or consult to/from a network provider.

Process by which all referrals written by the MTF/eMSM authorized providers and network and non-network providers are tracked for care coordination, patient safety, and accountability. The referral management process ends when the referring provider is provided the clear and legible report, informed the patient did not use/activate their referral, or if the referral was denied by the contractor.

A geographic area determined by the Government for civilian contracting of medical care and other services for TRICARE-eligible beneficiaries.

An entity responsible for performing Peer Review Organization (PRO) functions. Under TRICARE the contractor shall be responsible for performing the duties of the RRA.

Refers to a subset of TRICARE eligible beneficiaries who are dependent on TRICARE and not the DC system or OHI for the coverage/reimbursement of vaccines under the well-child and preventive benefits. This includes, but is not limited to: All TRICARE Active Duty Family Members (ADFMs) not enrolled to a DC PCM who are reliant on TRICARE as their primary form of insurance, and retirees and their family members who do not have OHI and are not dependent on the DC system but are dependent on TRICARE as their primary form of insurance.

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.

A mandate contained in law that compels a covered entity to make a use or disclosure of PHI and that is enforceable in a court of law. Required by law includes, but is not limited to, court orders and court-ordered warrants; subpoenas or summons issued by a court, grand jury, a governmental or tribal inspector general, or an administrative body authorized to require the production of information; a civil or an authorized investigative demand; Medicare conditions of participation with respect to HCPs participating in the program; and statutes or regulations that require the production of information, including statutes or regulations that require such information if payment is sought under a Government program providing public benefits as defined in HIPAA of 1996.

A systematic investigation, including research, development, testing, and evaluation, designed to develop or contribute to generalizable knowledge as defined in HIPAA of 1996.

For purposes of TRICARE, “residence” is the dwelling place of the beneficiary for day-to-day living. A temporary living place during periods of temporary duty or during a period of confinement, such as a Residential Treatment Center (RTC), does not constitute a residence. In the case of minor children, the residence of the custodial parent(s) or the legal guardian shall be deemed the residence of the child. In the case of incompetent adult beneficiaries, the residence of the legal guardian shall be deemed the residence of such beneficiary. Under split enrollment, when a dependent resides away from home while attending school, their residence shall be where they are domiciled.

A facility or distinct part of a facility which meets the criteria in 32 CFR 199.6(b)(4)(vii).

A claim for health care services rendered during the health care delivery period of one contract, but processed under a different (incoming) contract.

A type of external Partnership Agreement established in the context of the TRICARE Program by agreement of the MTF Commander and an authorized TRICARE contractor. External resource sharing agreements may incorporate TRICARE features in lieu of standard TRICARE features that would apply to stand external Partnership Agreements.

Short-term care for a patient in order to provide rest and change for primary caregivers who have been caring for the patient at home, usually the patient’s family.

A group of TED records submitted to DHA to correct those TED claims and adjustments which generated edit errors when originally processed by DHA. These groups of records will be identified by the batch number and resubmission in the TED Header Record.

The length of time for particular documents/records (normally a series) are to be kept.

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.

Retirees and their family members who are beneficiaries covered by 10 USC 1086(c), other than Medicare-eligible beneficiaries as described in 10 USC 1086(d).

A process of appraising and reconsidering the usage of drugs to determine the effectiveness of drug treatment after a medication is dispensed. The process includes evaluation for therapeutic appropriateness, over-utilization and under-utilization, therapeutic duplication, drug-disease contraindications, drug interactions, incorrect dosage and /or duration of therapy.

A post-treatment assessment of care already delivered. The assessment evaluates the appropriateness of care and conformance to pre-established criteria for utilization. The purpose for this type of assessment may be to validate utilization decisions made and/or to validate payment made for care provided (by examining the actual record of treatment).

A bill of health care services the contractor returns to the sender because there is missing information that is needed for processing, and the missing information cannot be obtained from in-house sources.

Status of claim once a reversal transaction is transmitted for the removal of the PAID claim from a patient’s profile.

All communications received by mail, faxes cables, telexes, and other media or record, is not designated as Priority Mail.

With respect to the disclosure of a record from a Privacy Act System of Records (SOR) 5 USC, 552a, the use of a record for a purpose that is compatible for which it was information collected. See also Defense Privacy and Civil Liberties Office’s (DPCLO’s) published list of blanket routine uses for sharing PII.

The act or instance of referring a TRICARE beneficiary to another authorized provider to obtain necessary medical treatment within 24 hours of a request for care. This includes immediate (STAT), 24 hours (As Soon As Possible (ASAP)), and Today referral priority requests from the Composite Health Care System (CHCS).

For the purposes of 32 CFR 199.9, “sanction” means a provider exclusion, suspension, or termination.

The plan or program whose medical benefits are payable in double coverage situations only after the primary payer has adjudicated the claim.

The head of the U.S. DHHS concerned with health matters.

A group of related data elements in a transaction as defined in HIPAA of 1996.

The act or instance of referring a TRICARE beneficiary to another authorized provider to obtain necessary medical treatment within 72 hours of a request for care.

An institution (or a distinct part of an institution) that meets the criteria as set forth in 32 CFR 199.6.

Skilled nursing services includes application of professional nursing services and skills by and Registered Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Vocational Nurse (LVN) that are required to be performed under the general supervision/direction of a TRICARE authorized physician to ensure the safety of the patient and achieve the medically desired result in accordance with accepted standards of practice.

Checks issued outside the normal processing workflow for the purpose of expediting payment of a claim for benefits.

Requests for information under the Freedom of Information Act, Privacy Act, and the news media. Also includes requests received for surveys, audits, and requests by Government agencies including DoD agencies, entities other than DHA and Congressional Committees.

Specialized medical services provided by a physician specialist.

A Joint Services Organization responsible for reviewing specialty and inpatient care requests and claims for impact on fitness-for-duty. SAS/DHA-GL is also responsible for approving certain medical services not covered under TRICARE that are necessary to maintain fitness for duty and/or retention on active duty. The SASs for Army, Navy, Marine Corps, and Air Force Service members are assigned to the DHA-GL. For more information, see Chapter 17 for additional information.

The division of a medical claim for service provided into two or more parts. Claims may be split to divide work between clients, payers or for reimbursement to different service providers for performing a shared service. Such claims may or may not require Coordination of Benefits. (COB)

A TRICARE Prime option which allows an entire family to enroll in TRICARE Prime even if part of the family is living in another TRICARE region.

An active duty member, retiree, or deceased active duty member or retiree, of a Uniformed Service upon whose status his or her family members’ eligibility for TRICARE is based. See also 32 CFR 199.2 for a more complete definition.

A lawful husband or wife, who meets the criteria in 32 CFR 199.3, regardless of whether or not dependent upon the active duty member or retiree.

Any party who has a direct interest in the success of a business concern. For TRICARE purposes, stakeholders include the DoD, the Director, TROs, MTF Commanders/eMSM Managers, DHA, the MHS, and all employees thereof, contractors, elected officials, and MHS beneficiaries.

A transaction that complies with the applicable standard adopted by HIPAA.

The date a contractor officially begins delivery of health care services, processing claims, and/or delivery of other services in a production environment, as specified in the contract requirements.

For the purposes of the 32 CFR 199, any of the several states, the District of Columbia, the Commonwealth of Puerto Rico, the Commonwealth of the Northern Mariana Islands, and each territory and possession of the U.S.

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.

An individual or in many cases a business that signs a contract to perform part or all of the obligations of another’s contract. This includes but is not limited to enrolled program health benefits business entities at whatever level of the contract organization they exist. It does not include institutional or non-institutional providers of health care. This definition does not exclude business entities that are not specifically addressed herein but whose legal status within the contract organization establishes them as subcontractors because that term may be otherwise defined in the Federal Acquisition Regulation (FAR).

A person to whom a business associate delegates a function, activity, or service other than in the capacity of a member of the workforce of such business associate.

The contractual assignment of elements of requirements to another organization or person for purposes of TRICARE. Unless otherwise specified in the contract, the term also includes purchase orders, with changes and/or modifications thereto.

A facility or a distinct part of a facility that meets the criteria in 32 CFR 199.6(b)(4)(xiv).

Information that may be IIHI, and:

As defined in HIPAA of 1996.

Medical care received by Service members of the Uniformed Services and other designated patients pursuant to an MTF/eMSM referral (MTF/eMSM Referred Care). Supplemental Health Care also includes specific episodes of Service member non-referred civilian care, both emergent and authorized non-emergent care (non-MTF/eMSM Referred Care).

Funds used to pay for supplemental care.

A health insurance policy or other health benefit plan offered by a private entity to a TRICARE beneficiary, that primarily is designed, advertised, marketed, or otherwise held out as providing payment for expenses incurred for services and items that are not reimbursed under TRICARE due to program limitations or beneficiary liabilities imposed by law. TRICARE recognizes two types of supplemental plans, general indemnity plans and those offered through a direct service HMO.

The temporary suspension of processing (to protect the Government’s interests) of claims for care furnished by a specific provider (whether the claims are submitted by the provider or beneficiary) or claims submitted by or on behalf of a specific TRICARE beneficiary pending action by the Director, DHA, or a designee, in a case of suspected fraud or abuse. The action may include administrative remedies provided for in 32 CFR 199.9 or any other DoD issuance (e.g., DoD issuances implementing the Program Fraud Civil Remedies Act), case development or investigation by DHA, or referral to the DoD-Inspector General (IG) or the Department of Justice (DOJ) for action within their cognizant jurisdictions.

A telepresenter is an individual at the originating site (when the originating site is other than the patient’s home) who has the necessary skills, training, and/or clinical background (e.g., Licensed Practical Nurse (LPN), Registered Nurse (RN), trained medical technician, etc.) to operate the telemedicine technology and facilitate examinations under the direction of the provider at the distant site. For example, a nurse may use a device connected to a telemedicine system, such as a digital stethoscope or otoscope, in order to provide diagnostically relevant imagery, sound, or other data/information about the patient to the distant provider in real time.

The removal of a provider as an authorized TRICARE provider based on a finding that the provider does not meet the qualifications established by 32 CFR 199.6 to be an authorized TRICARE provider. This includes those categories of providers who have signed specific participation agreements.

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.

Reimbursements to the Government that arise when medical care is provided to an entitled beneficiary for treatment or injury or illness caused under circumstances creating tort liability legally requiring a third person to pay damages for that care. The Government pursues repayment for the care provided to the beneficiary under the provisions and authority of the Federal Medical Care Recovery Act (FMCRA) (42 USC paragraphs 2651-2653).

The recovery by the Government of expenses incurred for medical care provided to an entitled beneficiary in the treatment of injuries or illness caused by a third-party who is liable in tort for damages to the beneficiary. Such recoveries can be made from the liable third-party directly or from a liability insurance policy (e.g., automobile liability policy or homeowners insurance) covering the liable third-party. TPL recoveries are made under the authority of the FMCRA (42 USC paragraph 2651 et sec). Other potential sources of recovery in favor of the Government in TPL situations include, but are not limited to, no fault or uninsured motorist insurance, medical payments provisions of insurance policies, and workers compensation plans. Recoveries from such other sources are made under the authority of 10 USC paragraphs 10790, 1086(g), and 1095b.)

Third-party means an entity that provides an insurance, medical service, or health plan by contract or agreement, including an automobile liability insurance or no fault insurance carrier and a workers compensation program or plan, and any other plan or program (e.g., homeowners insurance) that is designed to provide compensation or coverage for expenses incurred by a beneficiary for medical services or supplies. For the purposes of the definition of “third-party payer,” an insurance medical service or health plan includes a preferred provider organization, an insurance plan described as Medicare supplemental insurance, and a personal injury protection plan or medical payments benefit plan for personal injuries resulting from the operation of a motor vehicle.

The submitting of TRICARE claims within the prescribed time limits as set forth in 32 CFR 199.7 and the requirements of the TRICARE contract.

Having or using a direct line or number for a call that is not charged to the caller. Under the TRICARE contract all telephone calls are considered toll-free for the purposes of measuring the standards contained in Chapter 1, Section 3, paragraph 3.4.

An agreement related to the exchange of information in electronic transactions, whether the agreement is distinct or part of a larger agreement, between each party to the agreement. (For example, a trading partner agreement may specify, among other things, the duties and responsibilities of each party to the agreement in conducting a standard transaction.) As defined in HIPAA of 1996.

The transmission of information between two parties to carry out financial or administrative activities related to health care. It includes the following types of information transmissions:

A bill received by a contractor for services received and billed from another contractor’s jurisdiction. See Chapter 8 for processing requirements related to these types of claims.

The process of changing contractors or contract in a Government designated service area. Transition begins with the Notice of Award to the incoming contractor and is formally completed with the close out procedures of the outgoing contractor, several months after the start work date.

Beneficiaries for whom active care is in progress on the date of a contractor’s start work date.

The provision, coordination, or management of health care and related services by one or more HCPs, including the coordination or management of health care by a HCP with a third-party; consultation between HCPs relating to a patient; or the referral of a patient for health care from one HCP to another.

The smallest meaningful unit of health care utilization: One provider rendering one service to one beneficiary.

A detailed description of the medical care being rendered or expected to be rendered a TRICARE beneficiary seeking approval for inpatient and other benefits for which preauthorization is required as set forth in 32 CFR 199.4(b). Medical care described in the plan must meet the requirements of medical and psychological necessity. A treatment plan must include, at a minimum, a diagnosis (either the current edition of the ICD-CM, or the current edition of the DSM); detailed reports of prior treatment, medical history, family history, social history, and physical examination; diagnostic test results; consultant’s reports (if any); proposed treatment by type (such as surgical, medical, and psychiatric); a description of who is or will be providing treatment (by discipline or specialty); anticipated frequency, medications, and specific goals of treatment; type of inpatient facility required and why (including length of time the related inpatient stay will be required); and prognosis. If the treatment plan involves the transfer of a TRICARE beneficiary from a hospital or another inpatient facility, medical records related to that inpatient stay also are required as a part of the treatment plan documentation.

The process of determining the priority of patients treatment based on the severity of their condition.

The DoD’s managed health care program for Service members and their families, retirees and their families, survivors, and other TRICARE-eligible beneficiaries. TRICARE is a blend of the military’s DC system of hospitals and clinics and civilian providers. Through December 31, 2017, TRICARE offers three options: TRICARE Standard Plan, TRICARE Extra Plan, and TRICARE Prime Plan (see definitions in this section and in 32 CFR 199.17). Beginning January 1, 2018, TRICARE offers three options: TRICARE Prime, TRICARE Select, and TRICARE For Life (TFL) (see definitions in this appendix and in 32 CFR 199.2).

An organization with which DHA has entered into a binding agreement for:

A data set of information required for all care received/delivered under the contract and provided by the contractor in a Government-specified format and submitted to DHA via a telecommunication network. The information in the data set can be described in the following broad categories:

A single record which identifies the submitting contractor and summarizes, for transmittal purposes, the number of records and the financial information contained within the associated “batch” of TED records.

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.

The Medicare wraparound coverage option of the TRICARE program made available to an eligible beneficiary by reason of 10 USC 1086(d).

A DHA authored book which provides instructions and requirements for claims processing and health care delivery under TRICARE.

A plan to provide outpatient prescription drugs through military pharmacies, TRICARE Pharmacy Home Delivery, and TRICARE retail network and non-network pharmacies.

A DHA authored book which provides the description of TRICARE Program benefits, adjudication guidance, policy interpretations, and decisions for use in determining benefits under the TRICARE Program.

A primary care program offered at some military hospitals and clinics for beneficiaries not enrolled in TRICARE Prime. Beneficiaries are enrolled with a Primary Care Coordinator (PCC) at an MTF/eMSM. MTFs/eMSMs may limit enrollment based on capability and capacity. There is no enrollment fee.

The managed care option of the TRICARE program established under 32 CFR 199.17.

A managed care option under TRICARE designed to provide health care services to Service members and command sponsored family members assigned to remote locations in the U.S.

A uniformed services group whose members have to be designated by the Military Services to be eligible to enroll in the TPR Program.

A program established under the 32 CFR 199.17.

A national-level contractor responsible to the DoD and DHA that performs second level reconsiderations for payment denials and focused retrospective quality of care reviews.

The program established under 10 USC 1076e and 32 CFR 199.25.

The management organization responsible for overseeing an integrated Tri-Services health care delivery system within one of the designated TRICARE regions.

This regulation prescribes guidelines and policies for the administration of the TRICARE Program for the Army, Navy, Air Force, Marine Corps, Coast Guard, Commissioned Corps of the USPHS, and the Commissioned Corps of the NOAA. It includes the guidelines and policies for the administration of the TRICARE Program.

A DHA authored book which provides and outlines payment methodologies under the TRICARE Program.

A highly qualified individual knowledgeable about TRICARE responsible for providing information and assistance to providers, whether network or non-network, to Beneficiary Counseling and Assistance Coordinators (BCACs) in their service area and to Congressional offices.

The self-managed, preferred provider network option under the TRICARE program established by 10 USC 1075 and 32 CFR 199.17 to replace TRICARE Extra and Standard after December 31, 2017.

The TRICARE program made available prior to January 1, 2018, under which the basic program of health care benefits generally referred to as CHAMPUS was made available to eligible beneficiaries under 32 CFR 199.

A DHA authored book which provides ADP instructions and requirements for contractors who use the TEDs system for reporting data to DHA.

A form of procedure code manipulation which involves a provider separately billing the component parts of a procedure instead of billing only the single procedure code which represents the entire comprehensive procedure.

A list of brand name and generic drugs and supplies available for dispensing.

The health care benefit established by 32 CFR 199.18.

The Army, Navy, Air Force, Marine Corps, Space Force, Coast Guard, Commissioned Corps of the USPHS, and the Commissioned Corps of the NOAA.

An MHS clinic that delivers primary health care to Service members.

A DoD health plan option that offers TRICARE Prime to individuals who reside in the geographic service area of a USFHP DP who are eligible to receive care in medical MTFs/eMSMs (except Service members). This includes those individuals over age 65 who, except for their eligibility for Medicare benefits, would have been eligible for TRICARE benefits. DPs under the USFHP were previously known as “Uniformed Services Family Treatment Facilities” (USTFs) and are former USPHS hospitals. The service areas of the USFHP DPs are listed at http://usfhp.net on the world wide web and in the Catchment Area Directory.

Territory made up of the 50 federated states, American Samoa, the District of Columbia, Johnston Island, Guam, Wake, Midway Islands, Northern Marianas and the U.S. Virgin Islands.

An agency within the DHHS which has a Commissioned Corps which are classified as members of the “Uniformed Services.”

TED records transmitted by the contractor to DHA and received in such condition that the basic record identifier information is not readable on the TRICARE data system, i.e., header incorrect, electronic records garbled, etc.

Drugs, devices, medical treatments or procedures are considered unproven if:

For further clarification see 32 CFR 199.4.

Medically necessary treatment that is required for a sudden illness or injury that is not life threatening, but does require immediate professional attention to avoid further complications resulting from non-treatment. Treatment is usually performed outside an Emergency Room (ER) setting.

IIHI which involves sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information.”

Specific guidelines that must be met in order to ensure that medically necessary and appropriate treatment is being provided. Criteria to use for screening.

A set of techniques used to manage health care costs by influencing patient care decision-making through case-by-case assessment of the appropriateness and medical necessity of care either prior to, during, or after provision of care. Utilization management also includes the systematic evaluation of individual and group utilization patterns to determine the effectiveness of the employed utilization management techniques and to develop modifications to the utilization management system designed to address aberrances identified through the evaluation.

A process for monitoring the use, delivery, quality, medical necessity, and cost-effectiveness of health care services especially those provided by medical community.

The date a DoD physician (military or civil service) validates the diagnosis of a service-related condition and validates that the condition can be resolved within 180 days.

A person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable.

A person who was a spouse at the time of death of the active duty member or retiree and who has not remarried.

Any day on which full-time business can be conducted. See the definition of “Business Day” in this appendix.

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.

Employees, volunteers, trainees, and other persons whose conduct, in the performance of work for a covered entity is under the direct control of such entity, whether or not they are paid by the covered entity or business associate as defined in HIPAA of 1996.