(b)
Specific
definitions.
Abortion.
Abortion
means the intentional termination of a pregnancy by artificial means
done for a purpose other than that of producing a live birth. A
spontaneous, missed or threatened abortion or termination of an
ectopic (tubal) pregnancy are not included within the term “abortion”
as used herein.
Absent treatment.
Services performed by Christian
Science practitioners for a person when the person is physically present.
Note: Technically, “Absent Treatment”
is an obsolete term. The current Christian Science terminology is
“treatment through prayer and spiritual means,” which is employed
by an authorized Christian Science practitioner either with the
beneficiary being present or absent. However, to be considered for
coverage under CHAMPUS, the beneficiary must be present physically
when a Christian Science service is rendered, regardless of the
terminology used.
Abuse.
For the
purposes of this part, abuse is defined as any practice that is
inconsistent with accepted sound fiscal, business, or professional
practice which results in a CHAMPUS claim, unnecessary cost, or
CHAMPUS payment for services or supplies that are: (1) Not within
the concepts of medically necessary and appropriate care, as defined
in this part, or (2) that fail to meet professionally recognized
standards for health care providers. The term “abuse” includes deception
or misrepresentation by a provider, or any person or entity acting
on behalf of a provider in relation to a CHAMPUS claim.
Note: Unless a specific action is
deemed gross and flagrant, a pattern of inappropriate practice will
normally be required to find that abuse has occurred. Also, any
practice or action that constitutes fraud, as defined by this part, would
also be abuse.
Abused dependent.
An eligible spouse or child,
who meets the criteria in Sec. 199.3 of this part, of a former member who
received a dishonorable or bad-conduct discharge or was dismissed
from a Uniformed Service as a result of a court-martial conviction
for an offense involving physical or emotional abuse or was administratively
discharged as a result of such an offense, or of a member or former
member who has had their entitlement to receive retired pay terminated
because of misconduct involving physical or emotional abuse.
Accidental
injury.
Physical bodily injury resulting
from an external force, blow or fall, or the ingestion of a foreign body
or harmful substance, requiring immediate medical treatment. Accidental
injury also includes animal and insect bites and sunstrokes. For
the purpose of CHAMPUS, the breaking of a tooth or teeth does not
constitute a physical bodily injury.
Active
duty.
Full-time duty in the Uniformed
Services of the United States. It includes duty on the active list,
full-time training duty, annual training duty, and attendance while
in the active Military Service, at a school designated as a Service
school by law or by the Secretary of the Military Department concerned.
Active
duty member.
A person on active duty in
a Uniformed Service under a call or order that does not specify
a period of 30 days or less.
Activities
of daily living.
Care that consists of providing
food (including special diets), clothing, and shelter; personal hygiene
services; observation and general monitoring; bowel training or
management (unless abnormalities in bowel function are of a severity
to result in a need for medical or surgical intervention in the
absence of skilled services); safety precautions; general preventive
procedures (such as turning to prevent bedsores); passive exercise; companionship;
recreation; transportation; and such other elements of personal
care that reasonably can be performed by an untrained adult with
minimal instruction or supervision. Activities of daily living may
also be referred to as “essentials of daily living”.
Acupuncture.
The practice of inserting needles
into various body parts to pierce specific peripheral nerves for
the production of counter-irritation to relieve the discomfort of
pain, induce surgical anesthesia, or for other treatment purposes.
Note: Acupuncture is not covered
by CHAMPUS.
Adequate Medical Documentation,
Medical Treatment Records.
Adequate medical documentation
contains sufficient information to justify the diagnosis, the treatment
plan, and the services and supplies furnished. Under CHAMPUS, it
is required that adequate and sufficient clinical records be kept
by the health care provider(s) to substantiate that specific care
was actually and appropriately furnished, was medically necessary
and appropriate (as defined by this part), and to identify the individual(s)
who provided the care. All procedures billed must be documented
in the records. In determining whether medical records are adequate,
the records will be reviewed under the generally acceptable standards
such as the applicable Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) standards, the Peer Review Organization (PRO) standards
(and the provider’s state or local licensing requirements) and other
requirements specified by this part. In general, the documentation
requirements for a professional provider are not less in the outpatient
setting than the inpatient setting.
Adequate
medical documentation, mental health records.
Adequate
medical documentation provides the means for measuring the type,
frequency, and duration of active treatment mechanisms employed
and progress under the treatment plan. Under CHAMPUS, it is required
that adequate and sufficient clinical records be kept by the provider to
substantiate that specific care was actually and appropriately furnished,
was medically or psychologically necessary (as defined by this part),
and to identify the individual(s) who provided the care. Each service
provided or billed must be documented in the records. In determining
whether medical records are adequate, the records will be reviewed
under the generally acceptable standards (e.g., the standards of
an accrediting organization approved by the Director, and the provider’s
state or local licensing requirements) and other requirements specified
by this part. The psychiatric and psychological evaluations, physician
orders, the treatment plan, integrated progress notes (and physician
progress notes if separate from the integrated progress notes),
and the discharge summary are the more critical elements of the
mental health record. However, nursing and staff notes, no matter
how complete, are not a substitute for the documentation of services
by the individual professional provider who furnished treatment to
the beneficiary. In general, the documentation requirements of a
professional provider are not less in the outpatient setting than
the inpatient setting. Furthermore, even though a hospital that
provides psychiatric care may be accredited under The Joint Commission
(TJC) manual for hospitals rather than the behavioral health standards
manual, the critical elements of the mental health record listed
above are required for CHAMPUS claims.
Adjunctive
dental care.
Dental care which is medically
necessary in the treatment of an otherwise covered medical (not
dental) condition, is an integral part of the treatment of such
medical condition and is essential to the control of the primary
medical condition; or, is required in preparation for or as the
result of dental trauma which may be or is caused by medically necessary
treatment of an injury or disease (iatrogenic).
Admission.
The formal acceptance by a
CHAMPUS authorized institutional provider of a CHAMPUS beneficiary
for the purpose of diagnosis and treatment of illness, injury, pregnancy,
or mental disorder.
Adopted Child.
A child taken into one’s own
family by legal process and treated as one’s own child. In case
of adoption, CHAMPUS eligibility begins as of 12:01 a.m. of the
day of the final adoption decree.
Note: There is no CHAMPUS benefit
entitlement during any interim waiting period.
All-Inclusive
Per Diem Rate.
The OCHAMPUS determined rate
that encompasses the daily charge for inpatient care and, unless
specifically excepted, all other treatment determined necessary
and rendered as part of the treatment plan established for a patient,
and accepted by OCHAMPUS.
Allowable charge.
The CHAMPUS-determined level
of payment to physicians, other individual professional providers
and other providers, based on one of the approved reimbursement
methods set forth in Sec. 199.14 of this part. Allowable charge
also may be referred to as the CHAMPUS-determined reasonable charge.
Allowable
cost.
The CHAMPUS-determined level
of payment to hospitals or other institutions, based on one of the approved
reimbursement methods set fourth in Sec. 199.14 of this part. Allowable
cost may also be referred to as the CHAMPUS-determined reasonable
cost.
Ambulance.
A specially
designed vehicle for transporting the sick or injured that contains
a stretcher, linens, first aid supplies, oxygen equipment, and such
lifesaving equipment required by state and local law, and that is
staffed by personnel trained to provide first aid treatment.
Ambulatory
Payment Classifications (APCs).
Payment of services under the
TRICARE OPPS is based on grouping outpatient procedures and services
into ambulatory payment classification groups based on clinical
and resource homogeneity, provider concentration, frequency of service
and minimal opportunities for upcoding and code fragmentation. Nationally
established rates for each APC are calculated by multiplying the
APC’s relative weight derived from median costs for procedures assigned
to the APC group, scaled to the median cost of the APC group representing
the most frequently provided services, by the conversion factor.
Ambulatory
Surgery Center (ASC). Any
distinct entity that is classified by the Centers for Medicare and
Medicaid Services (CMS) as an Ambulatory Surgical Center (ASC) under
42 CFR part 416 and meets the applicable requirements established
by Sec. 199.6(b)(4)(x). Any ASC that would otherwise meet the CMS
classification as an ASC but does not have a participation agreement
with Medicare due to the nature of the patients they treat (e.g., pediatric)
must meet the applicable requirements established by Sec. 199.6(b)(4)(x)
in order to be a TRICARE authorized ASC. All ASCs must also enter
into participation agreements with TRICARE as required by Sec. 199.6(b)(4)(x)
in order to be an authorized TRICARE provider of ASC services. Additionally,
ASCs are prohibited from billing TRICARE beneficiaries for procedures
that are not included in Medicare’s ASC list of procedures allowable
for facility fee payment in an ASC setting, unless the beneficiary
agreed in advance in writing to pay for the non-covered services,
in accordance with the “hold harmless” provision under Sec. 199.6(b)(4)(x)(B)(1)(ii)
and (iii).
Amount in dispute.
The amount of money, determined
under this part, that CHAMPUS would pay for medical services and
supplies involved in an adverse determination being appealed if
the appeal were resolved in favor of the appealing party. See Sec.
199.10 for additional information concerning the determination of
“amount in dispute” under this part.
Anesthesia
services.
The administration of an anesthetic
agent by injection or inhalation, the purpose and effect of which
is to produce surgical anesthesia characterized by muscular relaxation,
loss of sensation, or loss of consciousness when administered by
or under the direction of a physician or dentist in connection with
otherwise covered surgery or obstetrical care, or shock therapy.
Anesthesia services do not include hypnosis or acupuncture.
Appealable
issue.
Disputed questions of fact
which, if resolved in favor of the appealing party, would result
in the authorization of CHAMPUS benefits, or approval as an authorized
provider in accordance with this part. An appealable issue does
not exist if no facts are in dispute, if no CHAMPUS benefits would
be payable, or if there is no authorized provider, regardless of
the resolution of any disputed facts. See Sec. 199.10 for additional
information concerning the determination of “appealable issue” under
this part.
Appealing party.
Any party to the initial determination
who files an appeal of an adverse determination or requests a hearing
under the provisions of this part.
Appropriate
medical care.
(i) Services performed
in connection with the diagnosis or treatment of disease or injury, pregnancy,
mental disorder, or well-baby care which are in keeping with the
generally accepted norms for medical practice in the United States;
(ii) The authorized
individual professional provider rendering the medical care is qualified
to perform such medical services by reason of his or her training
and education and is licensed or certified by the state where the service
is rendered or appropriate national organization or otherwise meets
CHAMPUS standards; and
(iii) The
services are furnished economically. For purposes of this part,
“economically” means that the services are furnished in the least
expensive level of care or medical environment adequate to provide
the required medical care regardless of whether or not that level
of care is covered by CHAMPUS.
Approved
teaching programs.
For purposes of CHAMPUS, an
approved teaching program is a program of graduate medical education
which has been duly approved in its respective specialty or subspecialty
by the Accreditation Council for Graduate Medical Education of the
American Medical Association, by the Committee on Hospitals of the Bureau
of Professional Education of the American Osteopathic Association,
by the Council on Dental Education of the American Dental Association,
or by the Council on Podiatry Education of the American Podiatry
Association.
Assistant Secretary of Defense
(Health Affairs).
An authority of the Assistant
Secretary of Defense (Health Affairs) includes any person designated
by the Assistant Secretary to exercise the authority involved.
Assistive
technology devices.
Equipment that generally does
not treat an underlying injury, illness, disease or their symptoms.
Assistive technology devices are authorized only under the Extended
Care Health Option (ECHO). Assistive technology devices help an
ECHO beneficiary overcome or remove a disability and are used to
increase, maintain, or improve the functional capabilities of an
individual. Assistive technology devices may include non-medical
devices but do not include any structural alterations (e.g., permanent
structure of wheelchair ramps or alterations to street curbs) service
animals (e.g., Seeing Eye dogs, hearing/handicapped assistance animals,
etc.) or specialized equipment and devices whose primary purpose
is to enable the individual to engage in sports or recreational
events. Assistive technology devices are authorized only under coverage
criteria determined by the Director, TRICARE Management Activity
to assist in the reduction of the disabling effects of a qualifying
condition for individuals eligible to receive benefits under the
ECHO program, as provided in Sec. 199.5.
Attending
physician.
The physician who has the primary
responsibility for the medical diagnosis and treatment of the patient.
A consultant or an assistant surgeon, for example, would not be
an attending physician. Under very extraordinary circumstances,
because of the presence of complex, serious, and multiple, but unrelated,
medical conditions, a patient may have more than one attending physician
concurrently rendering medical treatment during a single period
of time. An attending physician also may be a teaching physician.
Augmentative
communication device (ACD).
A voice prosthesis as determined
by the Secretary of Defense to be necessary because of significant
conditions resulting from trauma, congenital anomalies, or disease.
Also referred to as Speech Generating Device.
Authorized
provider.
A hospital or institutional
provider, physician, or other individual professional provider,
or other provider of services or supplies specifically authorized
to provide benefits under CHAMPUS in Sec. 199.6 of this part.
Automobile
liability insurance.
Automobile liability insurance
means insurance against legal liability for health and medical expenses
resulting from personal injuries arising from operation of a motor
vehicle. Automobile liability insurance includes:
(1) Circumstances in
which liability benefits are paid to an injured party only when
the insured party’s tortious acts are the cause of the injuries;
and
(2) Uninsured
and underinsured coverage, in which there is a third-party tortfeasor
who caused the injuries (i.e., benefits are not paid on a no-fault
basis), but the insured party is not the tortfeasor.
Backup
hospital.
A hospital which is otherwise
eligible as a CHAMPUS institutional provider and which is fully capable
of providing emergency care to a patient who develops complications
beyond the scope of services of a given category of CHAMPUS-authorized
freestanding institutional provider and which is accessible from
the site of the CHAMPUS-authorized freestanding institutional provider
within an average transport time acceptable for the types of medical
emergencies usually associated with the type of care provided by
the freestanding facility.
Balance
billing.
A provider seeking any payment,
other than any payment relating to applicable deductible and cost
sharing amounts, from a beneficiary for CHAMPUS covered services
for any amount in excess of the applicable CHAMPUS allowable cost
or charge.
Bariatric Surgery.
Surgical procedures performed
to treat co-morbid conditions associated with morbid obesity. Bariatric
surgery is based on two principles:
(1) Divert food from
the stomach to a lower part of the digestive tract where the normal
mixing of digestive fluids and absorption of nutrients cannot occur
(i.e., Malabsorptive surgical procedures); or
(2) Restrict the size
of the stomach and decrease intake (i.e., Restrictive surgical procedures).
Basic
program.
The primary medical benefits
set forth in Sec. 199.4, generally referred to as the Civilian Health
and Medical Program of the Uniformed Services (CHAMPUS) as authorized
under chapter 55 of title 10 United States Code, were made available
to eligible beneficiaries under this part.
Beneficiary.
An individual who has been
determined to be eligible for CHAMPUS benefits, as set forth in
Sec. 199.3 of this part.
Beneficiary liability.
The legal obligation of a beneficiary,
his or her estate, or responsible family member to pay for the costs
of medical care or treatment received. Specifically, for the purposes
of services and supplies covered by CHAMPUS, beneficiary liability
includes any annual deductible amount, cost-sharing amounts, or,
when a provider does not submit a claim on a participating basis
on behalf of the beneficiary, amounts above the CHAMPUS-determined
allowable cost or charge. Beneficiary liability also includes any
expenses for medical or related services and supplies not covered
by CHAMPUS.
Birthing center.
A health care provider which
meets the applicable requirements established by Sec. 199.6(b) of
this part.
Biotelemetry.
A diagnostic or monitoring
procedure for the detection or measurement of human physiologic functions
from a distance using a biotelemetry device to remotely monitor
various vital signs of ambulatory patients. Biotelemetry may also
be referred to as remote physiologic monitoring of physiologic parameters.
See Sec. 199.4.
Birthing room.
A room and environment designed
and equipped to provide care, to accommodate support persons, and
within which a woman with a low-risk, normal, full-term pregnancy
can labor, deliver and recover with her infant.
Brace.
An orthopedic appliance or
apparatus (an orthosis) used to support, align, or hold parts of
the body in correct position. For the purposes of CHAMPUS, it does
not include orthodontic or other dental appliances.
CAHs.
A small facility that provides
limited inpatient and outpatient hospital services primarily in
rural areas and meets the applicable requirements established by
Sec. 199.6(b)(4)(xvi).
Cancer hospital. A specialty hospital
that is classified by CMS as a Cancer Hospital as specified in 42
CFR 412.23 and meets the applicable requirements established by
Sec. 199.6(b)(4)(i).
Capped
Rate.
The maximum per diem or all-inclusive
rate that CHAMPUS will allow for care.
Case management.
Case management is a collaborative
process which assesses, plans, implements, coordinates, monitors,
and evaluates the options and services required to meet an individual’s
health needs, including mental health and substance use disorder
needs, using communication and available resources to promote quality,
cost effective outcomes.
Case-mix index.
Case-mix index is a scale that
measures the relative difference in resources intensity among different
groups receiving home health services.
Certified
nurse-midwife.
An individual who meets the
applicable requirements established by Sec. 199.6(c) of this part.
Certified
psychiatric nurse specialist.
A licensed, registered nurse
who meets the criteria in Sec. 199.6(c)(3)(iii)(G).
CHAMPUS
DRG-Based Payment System.
A reimbursement system for
hospitals which assigns prospectively-determined payment levels
to each DRG based on the average cost of treating all CHAMPUS patients
in a given DRG.
CHAMPUS fiscal intermediary.
An organization with which
the Director, OCHAMPUS, has entered into a contract for the adjudication
and processing of CHAMPUS claims and the performance of related
support activities.
CHAMPUS Health Benefits Advisors
(HBAs).
Those individuals located at
Uniformed Services medical facilities (on occasion at other locations)
and assigned the responsibility for providing CHAMPUS information,
information concerning availability of care from the Uniformed Services
direct medical care system, and generally assisting beneficiaries
(or sponsors). The term also includes “Health Benefits Counselor”
and “CHAMPUS Advisor.”
Chemotherapy.
The administration of approved
antineoplastic drugs for the treatment of malignancies (cancer)
via perfusion, infusion, or parenteral methods of administration.
Child.
An unmarried child of a member
or former member, who meets the criteria (including age requirements)
in Sec. 199.3 of this part.
Children’s
hospital. A specialty hospital
that is classified by CMS as a Children’s Hospital as specified
in 42 CFR 412.23 and meets the applicable requirements established
by Sec. 199.6(b)(4)(i).
Chiropractor.
A practitioner of chiropractic
(also called chiropraxis); essentially a system of therapeutics
based upon the claim that disease is caused by abnormal function
of the nerve system. It attempts to restore normal function of the
nerve system by manipulation and treatment of the structures of
the human body, especially those of the spinal column.
Note: Services of chiropractors are
not covered by CHAMPUS.
Christian science nurse.
An individual who has been
accredited as a Christian Science Nurse by the Department of Care
of the First Church of Christ, Scientist, Boston, Massachusetts,
and listed (or eligible to be listed) in the Christian Science Journal
at the time the service is provided. The duties of Christian Science
nurses are spiritual and are nonmedical and nontechnical nursing
care performed under the direction of an accredited Christian Science practitioner.
There exist two levels of Christian Science nurse accreditation:
(i) Graduate
Christian Science nurse.
This accreditation is granted
by the Department of Care of the First Church of Christ, Scientist,
Boston, Massachusetts, after completion of a 3-year course of instruction
and study.
(ii) Practical
Christian Science nurse.
This accreditation is granted
by the Department of Care of the First Church of Christ, Scientist,
Boston, Massachusetts, after completion of a 1-year course of instruction
and study.
Christian Science practitioner.
An individual who has been
accredited as a Christian Science Practitioner for the First Church,
Scientist, Boston, Massachusetts, and listed (or eligible to be
listed) in the Christian Science Journal at the time the service
is provided. An individual who attains this accreditation has demonstrated
results of his or her healing through faith and prayer rather than
by medical treatment. Instruction is executed by an accredited Christian
Science teacher and is continuous.
Christian
Science sanatorium.
A sanatorium either operated
by the First Church of Christ, Scientist, or listed and certified
by the First Church of Christ, Scientist, Boston, Massachusetts.
Chronic
medical condition.
A medical condition that is
not curable, but which is under control through active medical treatment.
Such chronic conditions may have periodic acute episodes and may
require intermittent inpatient hospital care. However, a chronic
medical condition can be controlled sufficiently to permit generally continuation
of some activities of persons who are not ill (such as work and
school).
Chronic renal disease (CRD).
The end stage of renal disease
which requires a continuing course of dialysis or a kidney transplantation
to ameliorate uremic symptoms and maintain life.
Clinical
psychologist.
A psychologist, certified or
licensed at the independent practice level in his or her state,
who meets the criteria in Sec. 199.6(c)(3)(iii)(A).
Clinical
social worker.
An individual who is licensed
or certified as a clinical social worker and meets the criteria listed
in Sec. 199.6.
Clinically Meaningful Endpoints.
As used the definition of reliable
evidence in this paragraph (b) and Sec. 199.4(g)(15), the term clinically
meaningful endpoints means objectively measurable outcomes of clinical interventions
or other medical procedures, expressed in terms of survival, severity
of illness or condition, extent of adverse side effects, diagnostic
capability, or other effect on bodily functions directly associated
with such results.
Collateral visits.
Sessions with the patient’s
family or significant others for purposes of information gathering
or implementing treatment goals.
Combined
daily charge.
A billing procedure by an inpatient
facility that uses an inclusive flat rate covering all professional
and ancillary charges without any itemization.
Complications
of pregnancy.
One of the following, when
commencing or exacerbating during the term of the pregnancy:
(i) Caesarean delivery;
hysterotomy.
(ii) Pregnancy
terminating before expiration of 26 weeks, except a voluntary abortion.
(iii) False
labor or threatened miscarriage.
(iv) Nephritis or pyelitis
of pregnancy.
(v) Hyperemesis
gravidarum.
(vi) Toxemia.
(vii) Aggravation of
a heart condition or diabetes.
(viii) Premature rupture
of membrane.
(ix) Ectopic
pregnancy.
(x) Hemorrhage.
(xi) Other conditions
as may be determined by the Director, OCHAMPUS, or a designee.
Confinement.
That period of time from the
day of admission to a hospital or other institutional provider,
to the day of discharge, transfer, or separation from the facility,
or death. Successive admissions also may qualify as one confinement
provided not more than 60 days have elapsed between the successive
admissions, except that successive admissions related to a single
maternity episode shall be considered one confinement, regardless
of the number of days between admissions.
Conflict
of Interest.
Includes any situation where
an active duty member (including a reserve member while on active
duty) or civilian employee of the United States Government, through
an official federal position, has the apparent or actual opportunity
to exert, directly or indirectly, any influence on the referral
of CHAMPUS beneficiaries to himself or herself or others with some
potential for personal gain or appearance of impropriety. For purposes
of this part, individuals under contract to a Uniformed Service
may be involved in a conflict of interest situation through the
contract position.
Congenital anomaly.
A condition existing at or
from birth that is a significant deviation from the common form
or norm and is other than a common racial or ethnic feature. For
purposes of CHAMPUS, congenital anomalies do not include anomalies
relating to teeth (including malocclusion or missing tooth buds)
or structures supporting the teeth, or to any form of hermaphroditism
or sex gender confusion. Examples of congenital anomalies are harelip, birthmarks,
webbed fingers or toes, or such other conditions that the Director,
OCHAMPUS, or a designee, may determine to be congenital anomalies.
Note: Also refer to Sec. 199.4(e)(7)
of this part.
Consultation.
A deliberation with a specialist
physician, dentist, or qualified mental health provider requested
by the attending physician primarily responsible for the medical
care of the patient, with respect to the diagnosis or treatment
in any particular case. A consulting physician or dentist or qualified
mental health provider may perform a limited examination of a given
system or one requiring a complete diagnostic history and examination.
To qualify as a consultation, a written report to the attending
physician of the findings of the consultant is required.
Note: Staff consultations required
by rules and regulations of the medical staff of a hospital or other
institutional provider do not qualify as consultation
Consultation
appointment.
An appointment for evaluation
of medical symptoms resulting in a plan for management which may
include elements of further evaluation, treatment and follow-up
evaluation. Such an appointment does not include surgical intervention
or other invasive diagnostic or therapeutic procedures beyond the
level of very simply office procedures, or basic laboratory work
but rather provides the beneficiary with an authoritative opinion.
Consulting
physician or dentist.
A physician or dentist, other
than the attending physician, who performs a consultation.
Conviction.
For purposes of this part,
“conviction” or “convicted” means that (1) a judgment of conviction
has been entered, or (2) there has been a finding of guilt by the
trier of fact, or (3) a plea of guilty or a plea of nolo
contendere has been accepted by a court of competent jurisdiction,
regardless of whether an appeal is pending.
Coordination
of benefits.
The coordination, on a primary
or secondary payer basis, of the payment of benefits between two
or more health care coverages to avoid duplication of benefit payments.
Corporate
services provider.
A health care provider that
meets the applicable requirements established by Sec. 199.6(f).
Cosmetic,
reconstructive, or plastic surgery.
Surgery
that can be expected primarily to improve the physical appearance
of a beneficiary, or that is performed primarily for psychological
purposes, or that restores form, but does not correct or improve
materially a bodily function.
Cost-share.
The amount of money for which
the beneficiary (or sponsor) is responsible in connection with otherwise
covered inpatient and outpatient services (other than the annual
fiscal year deductible or disallowed amounts) as set forth in Secs.
199.4(f) and 199.5(b) of this part. Cost-sharing may also be referred
to as “co-payment.”
Custodial care.
The term “custodial care” means
treatment or services, regardless of who recommends such treatment
or services or where such treatment or services are provided, that:
(1) Can be rendered
safely and reasonably by a person who is not medically skilled;
or
(2) Is
or are designed mainly to help the patient with the activities of
daily living.
Deceased member.
A person who, at the time of
his or her death, was an active duty member of a Uniformed Service
under a call or order that did not specify a period of 30 days or
less.
Deceased reservist.
A reservist in a Uniformed
Service who incurs or aggravates an injury, illness, or disease,
during, or on the way to or from, active duty training for a period
of 30 days or less or inactive duty training and dies as a result
of that specific injury, illness or disease.
Deceased
retiree.
A person who, at the time of
his or her death, was entitled to retired or retainer pay or equivalent pay
based on duty in a Uniformed Service. For purposes of this part,
it also includes a person who died before attaining age 60 and at
the time of his or her death would have been eligible for retired
pay as a reservist but for the fact that he or she was not 60 years
of age, and had elected to participate in the Survivor Benefit Plan
established under 10 U.S.C. chapter 73.
Deductible.
Payment by an individual beneficiary
or family of a specific first dollar amount of the TRICARE allowable amount
for otherwise covered outpatient services or supplies obtained in
any program year. The dollar amount of deductible per individual
or family is calculated as specified by law.
Deductible
certificate.
A statement issued to the beneficiary
(or sponsor) by a TRICARE contractor certifying to deductible amounts
satisfied by a beneficiary for any applicable program year.
Defense
Enrollment Eligibility Reporting System (DEERS).
An automated
system maintained by the Department of Defense for the purpose of:
(1) Enrolling members,
former members and their dependents, and
(2) Verifying members’,
former members’ and their dependents’ eligibility for health care
benefits in the direct care facilities and for CHAMPUS.
Dental
care.
Services relating to the teeth
and their supporting structures.
Dentist.
Doctor of Dental Medicine (D.M.D.)
or Doctor of Dental Surgery (D.D.S.) who is licensed to practice dentistry
by an appropriate authority.
Dependent.
Individuals whose relationship
to the sponsor (including NATO members who are stationed in or passing
through the United States on official business when authorized)
leads to entitlement to benefits under this part. (See Sec. 199.3
of this part for specific categories of dependents).
Deserter
or desertion status.
A service member is a deserter,
or in a desertion status, when the Uniformed Service concerned has
made an administrative determination to that effect, or the member’s
period of unauthorized absence has resulted in a court-martial conviction
of desertion. Administrative declarations of desertion normally are
made when a member has been an unauthorized absentee for over 30
days, but particular circumstances may result in an earlier declaration.
Entitlement to CHAMPUS benefits ceases as of 12:01 a.m. on the day
following the day the desertion status is declared. Benefits are
not to be authorized for treatment received during a period of unauthorized
absence that results in a court-martial conviction for desertion.
Dependent eligibility for benefits is reestablished when a deserter
is returned to military control and continues, even though the member
may be in confinement, until any discharge is executed. When a deserter
status is later found to have been determined erroneously, the status
of deserter is considered never to have existed, and the member’s
dependents will have been eligible continuously for benefits under
CHAMPUS.
Diagnosis-Related Groups (DRGs).
Diagnosis-related groups (DRGs)
are a method of dividing hospital patients into clinically coherent
groups based on the consumption of resources. Patients are assigned
to the groups based on their principal diagnosis (the reason for
admission, determined after study), secondary diagnoses, procedures performed,
and the patient’s age, sex, and discharge status.
Diagnostic
admission.
An admission to a hospital
or other authorized institutional provider, or an extension of a stay
in such a facility, primarily for the purpose of performing diagnostic
tests, examinations, and procedures.
Director.
The Director of the Defense
Health Agency, Director, TRICARE Management Activity, or Director,
Office of CHAMPUS. Any references to the Director, Office of CHAMPUS,
or OCHAMPUS, or TRICARE Management Activity, shall mean the Director,
Defense Health Agency (DHA). Any reference to Director shall also
include any person designated by the Director to carry out a particular
authority. In addition, any authority of the Director may be exercised
by the Assistant Secretary of Defense (Health Affairs).
Director,
OCHAMPUS.
An authority of the Director,
OCHAMPUS includes any person designated by the Director, OCHAMPUS
to exercise the authority involved.
Director,
TRICARE Management Activity.
This term includes the Director,
TRICARE Management Activity, the official sometimes referred to
in this part as the Director, Office of CHAMPUS (or OCHAMPUS), or
any designee of the Director, TRICARE Management Activity or the
Assistant Secretary of Defense for Health Affairs who is designated for
purposes of an action under this part.
Doctor
of Dental Medicine (D.M.D.).
A person who has received a
degree in dentistry, that is, that department of the healing arts
which is concerned with the teeth, oral cavity, and associated structures.
Doctor
of Medicine (M.D.).
A person who has graduated
from a college of allopathic medicine and who is entitled legally
to use the designation M.D.
Doctor
of Osteopathy (D.O.).
A practitioner of osteopathy,
that is, a system of therapy based on the theory that the body is
capable of making its own remedies against disease and other toxic
conditions when it is in normal structural relationship and has
favorable environmental conditions and adequate nutrition. It utilizes
generally accepted physical, medicinal, and surgical methods of
diagnosis and therapy, while placing chief emphasis on the importance
of normal body mechanics and manipulative methods of detecting and
correcting faulty structure.
Domiciliary
care.
The term “domiciliary care”
means care provided to a patient in an institution or homelike environment
because:
(1) Providing
support for the activities of daily living in the home is not available
or is unsuitable; or
(2) Members
of the patient’s family are unwilling to provide the care.
Donor.
An individual who supplies
living tissue or material to be used in another body, such as a
person who furnishes a kidney for renal transplant.
Double
coverage.
When a CHAMPUS beneficiary
also is enrolled in another insurance, medical service, or health plan
that duplicates all or part of a beneficiary’s CHAMPUS benefits.
Double
coverage plan.
The specific insurance, medical
service, or health plan under which a CHAMPUS beneficiary has entitlement
to medical benefits that duplicate CHAMPUS benefits in whole or
in part. Double coverage plans do not include:
(i) Medicaid.
(ii) Coverage specifically
designed to supplement CHAMPUS benefits.
(iii) Entitlement
to receive care from the Uniformed Services medical facilities;
(iv) Entitlement to
receive care from Veterans Administration medical care facilities;
or
(v) Part C of the Individuals
with Disabilities Education Act for services and items provided
in accordance with Part C of the IDEA that are medically or psychologically
necessary in accordance with the Individual Family Service Plan
and that are otherwise allowable under the CHAMPUS Basic Program
or the Extended Care Health Option (ECHO).
Dual Compensation.
Federal Law (5 U.S.C. 5536)
prohibits active duty members or civilian employees of the United States
Government from receiving additional compensation from the government
above their normal pay and allowances. This prohibition applies
to CHAMPUS cost-sharing of medical care provided by active duty
members or civilian government employees to CHAMPUS beneficiaries.
Duplicate
equipment.
An item of durable equipment,
durable medical equipment, or assistive technology items, as defined
in this section that serves the same purpose that is served by an
item of durable equipment, durable medical equipment, or assistive
technology item previously cost-shared by TRICARE. For example,
various models of stationary oxygen concentrators with no essential
functional differences are considered duplicate equipment, whereas
stationary and portable oxygen concentrators are not considered
duplicates of each other because the latter is intended to provide
the user with mobility not afforded by the former. Also, a manual
wheelchair and electric wheelchair, both of which otherwise meet
the definition of durable equipment or durable medical equipment,
would not be considered duplicates of each other if each is found
to provide an appropriate level of mobility. For the purpose of
this Part, durable equipment, durable medical equipment, or assistive
technology items that are essential in providing a fail-safe in-home
life support system or that replace in-like-kind an item of equipment
that is not serviceable due to normal wear, accidental damage, a
change in the beneficiary’s condition, or has been declared adulterated
by the U.S. FDA, or is being or has been recalled by the manufacturer
is not considered duplicate equipment.
Durable
equipment.
Equipment that--
(1) Is a medically
necessary item, which can withstand repeated use;
(2) Is primarily and
customarily used to serve a medical purpose; and
(3) Is generally not
useful to an individual in the absence of an illness or injury.
It includes durable medical equipment as defined in Sec. 199.2,
wheelchairs, iron lungs, and hospital beds. It does not include
equipment (including wheelchairs) used or designed primarily for
use in sports or recreational activities.
Durable
medical equipment.
Durable equipment that is medically
appropriate to--
(1) Improve,
restore, or maintain the function of a malformed, diseased, or injured
body part or can otherwise minimize or prevent the deterioration
of the beneficiary’s function or condition; or
(2) Maximize
the beneficiary’s function consistent with the beneficiary’s physiological
or medical needs.
Economic interest.
(1) Any right, title,
or share in the income, remuneration, payment, or profit of a CHAMPUS-authorized
provider, or of an individual or entity eligible to be a CHAMPUS-authorized
provider, resulting, directly or indirectly, from a referral relationship;
or any direct or indirect ownership, right, title, or share, including
a mortgage, deed of trust, note, or other obligation secured (in
whole or in part) by one entity for another entity in a referral
or accreditation relationship, which is equal to or exceeds 5 percent
of the total property and assets of the other entity.
(2) A
referral relationship exists when a CHAMPUS beneficiary is sent,
directed, assigned or influenced to use a specific CHAMPUS-authorized
provider, or a specific individual or entity eligible to be a CHAMPUS-authorized provider.
(3) An accreditation
relationship exists when a CHAMPUS-authorized accreditation organization
evaluates for accreditation an entity that is an applicant for,
or recipient of CHAMPUS-authorized provider status.
Emergency
inpatient admission.
An unscheduled, unexpected,
medically necessary admission to a hospital or other authorized
institutional provider for treatment of a medical condition meeting
the definition of medical emergency and which is determined to require
immediate inpatient treatment by the attending physician.
Entity.
For purposes of Sec. 199.9(f)(1),
“entity” includes a corporation, trust, partnership, sole proprietorship
or other kind of business enterprise that is or may be eligible
to receive reimbursement either directly or indirectly from CHAMPUS.
Essential
Access Community Hospital (EACH).
A hospital
that is designated by the Centers for Medicare and Medicaid Services
(CMS) as an EACH and meets the applicable requirements established
by Sec. 199.14(a)(7)(vi).
Extended Care Health Option
(ECHO).
The TRICARE program of supplemental
benefits for qualifying active duty family members as described
in Sec. 199.5.
External Partnership Agreement.
The External Partnership Agreement
is an agreement between a military treatment facility commander
and a CHAMPUS authorized institutional provider, enabling Uniformed
Services health care personnel to provide otherwise covered medical
care to CHAMPUS beneficiaries in a civilian facility under the Military-Civilian
Health Services Partnership Program. Authorized costs associated
with the use of the facility will be financed through CHAMPUS under
normal cost-sharing and reimbursement procedures currently applicable
under the basic CHAMPUS.
External Resource Sharing Agreement.
A type External Partnership
Agreement, established in the context of the TRICARE program by
agreement of a military medical treatment facility commander and
an authorized TRICARE contractor. External Resource Sharing Agreements
may incorporate TRICARE features in lieu of standard CHAMPUS features
that would apply to standard External Partnership Agreements.
Extramedical
individual providers of care.
Individuals who do counseling
or nonmedical therapy and whose training and therapeutic concepts
are outside the medical field, as specified in Sec. 199.6 of this
part.
Extraordinary physical or psychological
condition.
A complex physical or psychological
clinical condition of such severity which results in the beneficiary
being homebound as defined in this section.
Facility
charge.
The term “facility charge”
means the charge, either inpatient or outpatient, made by a hospital
or other institutional provider to cover the overhead costs of providing
the service. These costs would include building costs, i.e. depreciation
and interest; staffing costs; drugs and supplies; and overhead costs,
i.e., utilities, housekeeping, maintenance, etc.
Former
member.
An individual who is eligible
for, or entitled to, retired pay, at age 60, for non-Regular service
in accordance with chapter 1223, title 10, United States Code but
who has been discharged and who maintains no military affiliation.
These former members, at age 60, and their eligible dependents are
entitled to medical care, commissary, exchange, and MWR privileges.
Under age 60, they and their eligible dependents are entitled to commissary,
exchange, and MWR privileges only.
Former
spouse.
A former husband or wife of
a Uniformed Service member or former member who meets the criteria
as set forth in Sec. 199.3(b)(2)(ii) of this part.
Fraud.
For purposes of this part,
fraud is defined as (1) a deception or misrepresentation by a provider,
beneficiary, sponsor, or any person acting on behalf of a provider,
sponsor, or beneficiary with the knowledge (or who had reason to
know or should have known) that the deception or misrepresentation
could result in some unauthorized CHAMPUS benefit to self or some
other person, or some unauthorized CHAMPUS payment, or (2) a claim
that is false or fictitious, or includes or is supported by any
written statement which asserts a material fact which is false or fictitious,
or includes or is supported by any written statement that (a) omits
a material fact and (b) is false or fictitious as a result of such
omission and (c) is a statement in which the person making, presenting,
or submitting such statement has a duty to include such material
fact. It is presumed that, if a deception or misrepresentation is established and a
CHAMPUS claim is filed, the person responsible for the claim had
the requisite knowledge. This presumption is rebuttable only by
substantial evidence. It is further presumed that the provider of
the services is responsible for the actions of all individuals who
file a claim on behalf of the provider (for example, billing clerks); this
presumption may only be rebutted by clear and convincing evidence.
Freestanding.
Not “institution-affiliated”
or “institution-based.”
Full-time course of higher
education.
A complete, progressive series
of studies to develop attributes such as knowledge, skill, mind,
and character, by formal schooling at a college or university, and
which meets the criteria set out in Sec. 199.3 of this part. To
qualify as full-time, the student must be carrying a course load
of a minimum of 12 credit hours or equivalent each semester.
General
staff nursing service.
All nursing care (other than
that provided by private duty nurses) including, but not limited
to, general duty nursing, emergency room nursing, recovery room
nursing, intensive nursing care, and group nursing arrangements
performed by nursing personnel on the payroll of the hospital or
other authorized institution.
Good faith
payments.
Those payments made to civilian
sources of medical care who provided medical care to persons purporting
to be eligible beneficiaries but who are determined later to be
ineligible for CHAMPUS benefits. (The ineligible person usually
possesses an erroneous or illegal identification card.) To be considered
for good faith payments, the civilian source of care must have exercised
reasonable precautions in identifying a person claiming to be an
eligible beneficiary.
Habilitation.
The provision of functional
capacity, absent from birth due to congenital anomaly or developmental disorder,
which facilitates performance of an activity in the manner, or within
the range considered normal, for a human being.
Handicap.
For the purposes of this part,
the term “handicap” is synonymous with the term “disability.”
High-risk
pregnancy.
A pregnancy is high-risk when
the presence of a currently active or previously treated medical, anatomical,
physiological illness or condition may create or increase the likelihood
of a detrimental effect on the mother, fetus, or newborn and presents
a reasonable possibility of the development of complications during
labor or delivery.
Homebound.
A beneficiary’s
condition is such that there exists a normal inability to leave
home and, consequently, leaving home would require considerable
and taxing effort. Any absence of an individual from the home attributable
to the need to receive health care treatment--including regular
absences for the purpose of participating in therapeutic, psychosocial,
or medical treatment in an adult day-care program that is licensed
or certified by a state, or accredited to furnish adult day-care
services in the--state shall not disqualify an individual from being
considered to be confined to his home. Any other absence of an individual
from the home shall not disqualify an individual if the absence
is infrequent or of relatively short duration. For purposes of the
preceding sentence, any absence for the purpose of attending a religious
service shall be deemed to be an absence of infrequent or short
duration. Also, absences from the home for non-medical purposes,
such as an occasional trip to the barber, a walk around the block
or a drive, would not necessarily negate the beneficiary’s homebound
status if the absences are undertaken on an infrequent basis and
are of relatively short duration. An exception is made to the above
homebound definitional criteria for beneficiaries under the age
of 18 and those receiving maternity care. The only homebound criteria
for these special beneficiary categories is written certification
from a physician attesting to the fact that leaving the home would
place the beneficiary at medical risk. In addition to the above, absences,
whether regular or infrequent, from the beneficiary’s primary residence
for the purpose of attending an educational program in a public
or private school that is licensed and/or certified by a state,
shall not negate the beneficiary’s homebound status.
Home health
discipline.
One of six home health disciplines
covered under the home health benefit (skilled nursing services,
home health aide services, physical therapy services, occupational
therapy services, speech-language pathology services, and medical
social services).
Home health market basket index.
An index that reflects changes
over time in the prices of an appropriate mix of goods and services
included in home health services.
Hospice
care.
Hospice care is a program which
provides an integrated set of services and supplies designed to
care for the terminally ill. This type of care emphasizes palliative
care and supportive services, such as pain control and home care,
rather than cure-oriented services provided in institutions that
are otherwise the primary focus under CHAMPUS. The benefit provides
coverage for a humane and sensible approach to care during the last
days of life for some terminally ill patients.
Hospital,
acute care (general and special).
An institution
that meets the criteria as set forth in Sec. 199.6(b)(4)(i) of this
part.
Hospital, psychiatric.
An institution that meets the
criteria as set forth in Sec. 199.6(b)(4)(ii) of this part.
Illegitimate
child.
A child not recognized as a
lawful offspring; that is, a child born of parents not married to
each other.
Immediate family.
The spouse, natural parent,
child and sibling, adopted child and adoptive parent, stepparent, stepchild,
grandparent, grandchild, stepbrother and stepsister, father-in-law,
mother-in-law of the beneficiary, or provider, as appropriate. For
purposes of this definition only, to determine who may render services
to a beneficiary, the step-relationship continues to exist even
if the marriage upon which the relationship is based terminates
through divorce or death of one of the parents.
Independent
laboratory.
A freestanding laboratory approved
for participation under Medicare and certified by the Health Care
Financing Administration.
Infirmaries.
Facilities operated by student
health departments of colleges and universities to provide inpatient
or outpatient care to enrolled students. When specifically approved
by the Director, OCHAMPUS, or a designee, a boarding school infirmary
also is included.
Initial determination.
A formal written decision on
a CHAMPUS claim, a request for benefit authorization, a request by
a provider for approval as an authorized CHAMPUS provider, or a
decision disqualifying or excluding a provider as an authorized
provider under CHAMPUS. Rejection of a claim or a request for benefit
or provider authorization for failure to comply with administrative
requirements, including failure to submit reasonably requested information,
is not an initial determination. Responses to general or specific
inquiries regarding CHAMPUS benefits are not initial determinations.
In-out
surgery.
Surgery performed in the outpatient
department of a hospital or other institutional provider, in a physician’s
office or the office of another individual professional provider,
in a clinic, or in a “freestanding” ambulatory surgical center which
does not involve a formal inpatient admission for a period of 24
hours or more.
Inpatient.
A patient
who has been admitted to a hospital or other authorized institution
for bed occupancy for purposes of receiving necessary medical care,
with the reasonable expectation that the patient will remain in
the institution at least 24 hours, and with the registration and
assignment of an inpatient number or designation. Institutional
care in connection with in and out (ambulatory) surgery is not included
within the meaning of inpatient whether or not an inpatient number
or designation is made by the hospital or other institution. If
the patient has been received at the hospital, but death occurs
before the actual admission occurs, an inpatient admission exists
as if the patient had lived and had been formally admitted.
Inpatient
Rehabilitation Facility (IRF).
A facility classified by CMS
as an IRF and meets the applicable requirements established by Sec.
199.6(b)(4)(xx) (which includes the requirement to be a Medicare
participating provider).
Institution-affiliated.
Related to a CHAMPUS-authorized
institutional provider through a shared governing body but operating
under a separate and distinct license or accreditation.
Institution-based.
Related to a CHAMPUS-authorized
institutional provider through a shared governing body and operating
under a common license and shared accreditation.
Institutional
provider.
A health care provider which
meets the applicable requirements established by Sec. 199.6(b) of
this part.
Intensive care unit (ICU).
A special segregated unit of
a hospital in which patients are concentrated by reason of serious
illness, usually without regard to diagnosis. Special lifesaving
techniques and equipment regularly and immediately are available
within the unit, and patients are under continuous observation by
a nursing staff specially trained and selected for the care of this
type patient. The unit is maintained on a continuing rather than
an intermittent or temporary basis. It is not a postoperative recovery
room nor a postanesthesia room. In some large or highly specialized
hospitals, the ICUs may be further refined for special purposes,
such as for respiratory conditions, cardiac surgery, coronary care,
burn care, or neurosurgery. For the purposes of CHAMPUS, these specialized
units would be considered ICUs if they otherwise conformed to the
definition of an ICU.
Intensive outpatient program
(IOP).
A treatment setting capable
of providing an organized day or evening program that includes assessment,
treatment, case management and rehabilitation for individuals not
requiring 24-hour care for mental health disorders, to include substance
use disorders, as appropriate for the individual patient. The program
structure is regularly scheduled, individualized and shares monitoring
and support with the patient’s family and support system.
Intern.
A graduate of a medical or
dental school serving in a hospital in preparation to being licensed
to practice medicine or dentistry.
Internal
Partnership Agreement.
The Internal Partnership Agreement
is an agreement between a military treatment facility commander
and a CHAMPUS-authorized civilian health care provider which enables
the use of civilian health care personnel or other resources to
provide medical care to CHAMPUS beneficiaries on the premises of
a military treatment facility under the Military-Civilian Health
Services Partnership Program. These internal agreements may be established
when a military treatment facility is unable to provide sufficient
health care services for CHAMPUS beneficiaries due to shortages
of personnel and other required resources.
Internal
Resource Sharing Agreement.
A type of Internal Partnership
Agreement, established in the context of the TRICARE program by
agreement of a military medical treatment facility commander and
authorized TRICARE contractor. Internal Resource Sharing Agreements
may incorporate TRICARE features in lieu of standard CHAMPUS features
that would apply to standard Internal Partnership Agreements.
Item,
Service, or Supply.
Includes (1) any item, device,
medical supply, or service claimed to have been provided to a beneficiary
(patient) and listed in an itemized claim for CHAMPUS payment or
a request for payment, or (2) in the case of a claim based on costs,
any entry or omission in a cost report, books of account, or other
documents supporting the claim.
Laboratory
and pathological services.
Laboratory and pathological
examinations (including machine diagnostic tests that produce hard-copy
results) when necessary to, and rendered in connection with medical,
obstetrical, or surgical diagnosis or treatment of an illness or
injury, or in connection with well-baby care.
Legitimized
child.
A formerly illegitimate child
who is considered legitimate by reason of qualifying actions recognized
in law.
Licensed practical nurse (L.P.N.).
A person who is prepared specially
in the scientific basis of nursing; who is a graduate of a school
of practical nursing; whose qualifications have been examined by
a state board of nursing; and who has been authorized legally to
practice as an L.P.N. under the supervision of a physician.
Licensed
vocational nurse (L.V.N.)
A person who specifically is
prepared in the scientific basis or nursing; who is a graduate of
a school of vocational nursing; whose qualifications have been examined
by a state board of nursing; and who has been authorized legally
to practice as a L.V.N. under the supervision of a physician.
Long Term
Care Hospital (LTCH).
A hospital that is classified
by the Centers for Medicare and Medicaid Services (CMS) as an LTCH
and meets the applicable requirements established by Sec. 199.6(b)(4)(v)
(which includes the requirement to be a Medicare participating provider).
Low-risk
pregnancy.
A pregnancy is low-risk when
the basis for the ongoing clinical expectation of a normal uncomplicated
birth, as defined by reasonable and generally accepted criteria
of maternal and fetal health, is documented throughout a generally
accepted course of prenatal care.
Major
life activity.
Breathing, cognition, hearing,
seeing, and age appropriate ability essential to bathing, dressing, eating,
grooming, speaking, stair use, toilet use, transferring, and walking.
Marriage
and family therapist, certified.
An extramedical individual
provider who meets the requirements outlined in Sec. 199.6.
Maternity
care.
Care and treatment related
to conception, delivery, and abortion, including prenatal and postnatal care
(generally through the 6th post-delivery week), and also including
treatment of the complications of pregnancy.
Medicaid.
Those medical benefits authorized
under Title XIX of the Social Security Act provided to welfare recipients
and the medically indigent through programs administered by the
various states.
Medical.
The generally
used term which pertains to the diagnosis and treatment of illness,
injury, pregnancy, and mental disorders by trained and licensed
or certified health professionals. For purposes of CHAMPUS, the
term “medical” should be understood to include “medical, psychological,
surgical, and obstetrical,” unless it is specifically stated that
a more restrictive meaning is intended.
Medical
emergency.
The sudden and unexpected onset
of a medical condition or the acute exacerbation of a chronic condition
that is threatening to life, limb, or sight, and requires immediate
medical treatment or which manifests painful symptomatology requiring
immediate palliative efforts to alleviate suffering. Medical emergencies
include heart attacks, cardiovascular accidents, poisoning, convulsions,
kidney stones, and such other acute medical conditions as may be
determined to be medical emergencies by the Director, OCHAMPUS,
or a designee. In the case of a pregnancy, a medical emergency must
involve a sudden and unexpected medical complication that puts the
mother, the baby, or both, at risk. Pain would not, however, qualify
a maternity case as an emergency, nor would incipient birth after
the 34th week of gestation, unless an otherwise qualifying medical condition
is present. Examples of medical emergencies related to pregnancy
or delivery are hemorrhage, ruptured membrane with prolapsed cord,
placenta previa, abruptio placenta, presence of shock or unconsciousness, suspected
heart attack or stroke, or trauma (such as injuries received in
an automobile accident).
Medical supplies and dressings
(consumables).
Necessary medical or surgical
supplies (exclusive of durable medical equipment) that do not withstand
prolonged, repeated use and that are needed for the proper medical management
of a condition for which benefits are otherwise authorized under
CHAMPUS, on either an inpatient or outpatient basis. Examples include
disposable syringes for a diabetic, colostomy sets, irrigation sets,
and ace bandages.
Medically or psychologically
necessary.
The frequency, extent, and
types of medical services or supplies which represent appropriate
medical care and that are generally accepted by qualified professionals
to be reasonable and adequate for the diagnosis and treatment of
illness, injury, pregnancy, and mental disorders or that are reasonable and
adequate for well-baby care.
Medically
or psychologically necessary preauthorization.
A pre
(or prior) authorization for payment for medical/surgical or psychological
services based upon criteria that are generally accepted by qualified
professionals to be reasonable for diagnosis and treatment of an
illness, injury, pregnancy, and mental disorder.
Medicare.
These medical benefits authorized
under Title XVIII of the Social Security Act provided to persons
65 or older, certain disabled persons, or persons with chronic renal
disease, through a national program administered by the DHHS, Health
Care Financing Administration, Medicare Bureau.
Medication
assisted treatment (MAT).
MAT for diagnosed opioid use
disorder is a holistic modality for recovery and treatment that
employs evidence-based therapy, including psychosocial treatments
and psychopharmacology, and FDA-approved medications as indicated
for the management of withdrawal symptoms and maintenance.
Member.
An individual who is affiliated
with a Service, either an active duty member, Reserve member, active
duty retired member, or Retired Reserve member. Members in a retired
status are not former members. Also referred to as the sponsor.
Mental
disorder, to include substance use disorder.
For purposes
of the payment of CHAMPUS benefits, a mental disorder is a nervous
or mental condition that involves a clinically significant behavioral
or psychological syndrome or pattern that is associated with a painful
symptom, such as distress, and that impairs a patient’s ability
to function in one or more major life activities. A substance use
disorder is a mental condition that involves a maladaptive pattern
of substance use leading to clinically significant impairment or
distress; impaired control over substance use; social impairment;
and risky use of a substance(s). Additionally, the mental disorder
must be one of those conditions listed in the current edition of
the Diagnostic and Statistical Manual of Mental Disorders. “Conditions Not
Attributable to a Mental Disorder,” or V codes, are not considered
diagnosable mental disorders. Co-occurring mental and substance
use disorders are common and assessment should proceed as soon as
it is possible to distinguish the substance related symptoms from
other independent conditions.
Mental
health therapeutic absence.
A therapeutically planned absence
from the inpatient setting. The patient is not discharged from the
facility and may be away for periods of several hours to several
days. The purpose of the therapeutic absence is to give the patient
an opportunity to test his or her ability to function outside the
inpatient setting before the actual discharge.
Missing
in action (MIA).
A battle casualty whose whereabouts
and status are unknown, provided the absence appears to be involuntary
and the service member is not known to be in a status of unauthorized
absence.
Note: Claims for eligible CHAMPUS
beneficiaries whose sponsor is classified as MIA are processed as
dependents of an active duty service member.
Morbid
obesity.
A body mass index (BMI) equal
to or greater than 40 kilograms per meter squared (kg/m2), or a
BMI equal to or greater than 35 kg/m2 in conjunction with high-risk
co-morbidities, which is based on the guidelines established by
the National Heart, Lung and Blood Institute on the Identification
and Management of Patients with Obesity.
Note: Body mass index is equal to
weight in kilograms divided by height in meters squared.
Most-favored
rate.
The lowest usual charge to
any individual or third-party payer in effect on the date of the admission
of a CHAMPUS beneficiary.
Natural childbirth.
Childbirth without the use
of chemical induction or augmentation of labor or surgical procedures
other than episiotomy or perineal repair.
Naturopath.
A person who practices naturopathy,
that is, a drugless system of therapy making use of physical forces
such as air, light, water, heat, and massage.
Note: Services of a naturopath are
not covered by CHAMPUS.
NAVCARE clinics.
Contractor owned, staffed,
and operated primary clinics exclusively serving uniformed services beneficiaries
pursuant to contracts awarded by a Military Department.
No-fault
insurance.
No-fault insurance means an
insurance contract providing compensation for health and medical
expenses relating to personal injury arising from the operation
of a motor vehicle in which the compensation is not premised on
whom may have been responsible for causing such injury. No-fault
insurance includes personal injury protection and medical payments
benefits in cases involving personal injuries resulting from operation
of a motor vehicle.
Nonavailability statement.
A certification by a commander
(or a designee) of a Uniformed Services medical treatment facility,
recorded on DEERS, generally for the reason that the needed medical
care being requested by a non-TRICARE Prime enrolled beneficiary
cannot be provided at the facility concerned because the necessary resources
are not available in the time frame needed.
Nonparticipating
provider.
A hospital or other authorized
institutional provider, a physician or other authorized individual
professional provider, or other authorized provider that furnished
medical services or supplies to a CHAMPUS beneficiary, but who did
not agree on the CHAMPUS claim form to participate or to accept
the CHAMPUS-determined allowable cost or charge as the total charge
for the services. A nonparticipating provider looks to the beneficiary
or sponsor for payment of his or her charge, not CHAMPUS. In such
cases, CHAMPUS pays the beneficiary or sponsor, not the provider.
North
Atlantic Treaty Organization (NATO) member.
A military
member of an armed force of a foreign NATO nation who is on active
duty and who, in connection with official duties, is stationed in
or passing through the United States. The foreign NATO nations are
Belgium, Canada, Denmark, France, Federal Republic of Germany, Greece, Iceland,
Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain, Turkey,
and the United Kingdom.
Not-for-profit entity.
An organization or institution
owned and operated by one or more nonprofit corporations or associations
formed pursuant to applicable state laws, no part of the net earnings
of which inures, or may lawfully inure, to the benefit of any private
shareholder or individual.
Occupational
therapist.
A person who is trained specially
in the skills and techniques of occupational therapy (that is, the
use of purposeful activity with individuals who are limited by physical
injury of illness, psychosocial dysfunction, developmental or learning
disabilities, poverty and cultural differences, or the aging process
in order to maximize independence, prevent disability, and maintain
health) and who is licensed to administer occupational therapy treatments
prescribed by a physician.
Off-label
use of a drug or device.
A use other than an intended
use for which the prescription drug, biologic or device is legally
marketed under the Federal Food, Drug, and Cosmetic Act or the Public
Health Services Act. This includes any use that is not included
in the approved labeling for an approved drug, licensed biologic,
approved device or combination product; any use that is not included
in the cleared statement of intended use for a device that has been
determined by the Food and Drug Administration (FDA) to be substantially
equivalent to a legally marketed predicate device and cleared for
marketing; and any use of a device for which a manufacturer or distributor
would be required to seek pre-market review by the FDA in order
to legally include that use in the device’s labeling.
Official
formularies.
A book of official standards
for certain pharmaceuticals and preparations that are not included in
the U.S. Pharmacopeia.
Office-based opioid treatment.
TRICARE authorized providers
acting within the scope of their licensure or certification to prescribe
outpatient supplies of the medication to assist in withdrawal management (detoxification)
and/or maintenance of opioid use disorder, as regulated by 42 CFR
part 8, addressing office-based opioid treatment (OBOT).
Opioid
Treatment Program.
Opioid Treatment Programs (OTPs)
are service settings for opioid treatment, either free standing
or hospital based, that adhere to the Department of Health and Human
Services’ regulations at 42 CFR part 8 and use medications indicated
and approved by the Food and Drug Administration. Treatment in OTPs provides
a comprehensive, individually tailored program of medication therapy
integrated with psychosocial and medical treatment and support services
that address factors affecting each patient, as certified by the
Center for Substance Abuse Treatment (CSAT) of the Department of
Health and Human Services’ Substance Abuse and Mental Health Services
Administration. Treatment in OTPs can include management of withdrawal
symptoms (detoxification) from opioids and medically supervised
withdrawal from maintenance medications. Patients receiving care
for substance use and co-occurring disorders care can be referred
to, or otherwise concurrently enrolled in, OTPs.
Optometrist
(Doctor of Optometry).
A person trained and licensed
to examine and test the eyes and to treat visual defects by prescribing
and adapting corrective lenses and other optical aids, and by establishing
programs of exercises.
Oral surgeon (D.D.S. or D.M.D.).
A person who has received a
degree in dentistry and who limits his or her practice to oral surgery,
that is, that branch of the healing arts that deals with the diagnosis
and the surgical correction and adjunctive treatment of diseases,
injuries, and defects of the mouth, the jaws, and associated structures.
Orthopedic
shoes.
Shoes prescribed by an orthopedic
surgeon to effect changes in foot or feet position and alignment
and which are not an integral part of a brace.
Other
allied health professionals.
Individual professional providers
other than physicians, dentists, or extramedical individual providers,
as specified in Sec. 199.6 of this part.
Other
special institutional providers.
Certain specialized medical
treatment facilities, either inpatient or outpatient, other than
those specifically defined, that provide courses of treatment prescribed
by a doctor of medicine or osteopathy; when the patient is under
the supervision of a doctor of medicine or osteopathy during the
entire course of the inpatient admission or the outpatient treatment;
when the type and level of care and services rendered by the institution
are otherwise authorized in this part; when the facility meets all
licensing or other certification requirements that are extant in
the jurisdiction in which the facility is located geographically;
which is accredited by the Joint Commission or other accrediting
organization approved by the Director if an appropriate accreditation
program for the given type of facility is available; and which is
not a nursing home, intermediate facility, halfway house, home for
the aged, or other institution of similar purpose.
Outpatient.
A patient who has not been
admitted to a hospital or other authorized institution as an inpatient.
Ownership
or control interest.
For purposes of Sec. 199.9(f)(1),
a “person with an ownership or control interest” is anyone who
(1) Has directly or
indirectly a 5 percent or more ownership interest in the entity;
or
(2) Is the owner of
a whole or part interest in any mortgage, deed of trust, note, or
other obligation secured (in whole or in part) by the entity or
any of the property or assets thereof, which whole or part interest
is equal to or exceeds 5 percent of the total property and assets
of the entity; or
(3) Is
an officer or director of the entity if the entity is organized
as a corporation; or
(4) Is
a partner in the entity if the entity is organized as a partnership.
Partial
hospitalization.
A treatment setting capable
of providing an interdisciplinary program of medically monitored
therapeutic services, to include management of withdrawal symptoms,
as medically indicated. Services may include day, evening, night
and weekend treatment programs which employ an integrated, comprehensive and
complementary schedule of recognized treatment approaches. Partial
hospitalization is a time-limited, ambulatory, active treatment
program that offers therapeutically intensive, coordinated, and
structured clinical services within a stable therapeutic environment.
Partial hospitalization is an appropriate setting for crisis stabilization,
treatment of partially stabilized mental disorders, to include substance
disorders, and a transition from an inpatient program when medically
necessary.
Participating provider.
A CHAMPUS-authorized provider
that is required, or has agreed by entering into a CHAMPUS participation
agreement or by act of indicating “accept assignment” on the claim
form, to accept the CHAMPUS-allowable amount as the maximum total
charge for a service or item rendered to a CHAMPUS beneficiary,
whether the amount is paid for fully by CHAMPUS or requires cost-sharing
by the CHAMPUS beneficiary.
Part-time
or intermittent home health aide and skilled nursing services.
Part-time or intermittent means
skilled nursing and home health aide services furnished any number
of days per week as long as they are furnished (combined) less than
8 hours each day and 28 or fewer hours each week (or, subject to
review on a case-bay-case basis as to the need for care, less than
8 hours each day and 35 or fewer hours per week).
Party
to a hearing.
An appealing party or parties
and CHAMPUS.
Party to the initial determination.
Includes CHAMPUS and also refers
to a CHAMPUS beneficiary and a participating provider of services
whose interests have been adjudicated by the initial determination.
In addition, a provider who has been denied approval as an authorized
CHAMPUS provider is a party to that initial determination, as is
a provider who is disqualified or excluded as an authorized provider
under CHAMPUS, unless the provider is excluded based on a determination
of abuse or fraudulent practices or procedures under another federal
or federally funded program. See Sec. 199.10 for additional information
concerning parties not entitled to administrative review under the
CHAMPUS appeals and hearing procedures.
Pastoral
counselor.
An extramedical individual
provider who meets the requirements outlined in Sec. 199.6.
Pharmaceutical
Agent.
Drugs, biological products,
and medical devices under the regulatory authority of the Food and
Drug Administration.
Pharmacist.
A person
who is trained specially in the scientific basis of pharmacology
and who is licensed to prepare and sell or dispense drugs and compounds
and to make up prescriptions ordered by a physician.
Physical
medicine services or physiatry services.
The treatment
of disease or injury by physical means such as massage, hydrotherapy,
or heat.
Physical therapist.
A person who is trained specially
in the skills and techniques of physical therapy (that is, the treatment
of disease by physical agents and methods such as heat, massage,
manipulation, therapeutic exercise, hydrotherapy, and various forms
of energy such as electrotherapy and ultrasound), who has been authorized legally
(that is, registered) to administer treatments prescribed by a physician
and who is entitled legally to use the designation “Registered Physical
Therapist.” A physical therapist also may be called a physiotherapist.
Physician.
A person with a degree of Doctor
of Medicine (M.D.) or Doctor of Osteopathy (D.O.) who is licensed
to practice medicine by an appropriate authority.
Physician
in training.
Interns, residents, and fellows
participating in approved postgraduate training programs and physicians
who are not in approved programs but who are authorized to practice
only in a hospital or other institutional provider setting, e.g.,
individuals with temporary or restricted licenses, or unlicensed
graduates of foreign medical schools.
Podiatrist
(Doctor of Podiatry or Surgical Chiropody).
A person
who has received a degree in podiatry (formerly called chiropody),
that is, that specialized field of the healing arts that deals with
the study and care of the foot, including its anatomy, pathology,
and medical and surgical treatment.
Preauthorization.
A decision issued in writing,
or electronically by the Director, TRICARE Management Activity,
or a designee, that TRICARE benefits are payable for certain services
that a beneficiary has not yet received. The term prior authorization
is commonly substituted for preauthorization and has the same meaning.
Prescription
drugs and medicines.
Drugs and medicines which at
the time of use were approved for commercial marketing by the U.S.
Food and Drug Administration, and which, by law of the United States,
require a physician’s or dentist’s prescription, except that it
includes insulin for known diabetics whether or not a prescription
is required. Drugs grandfathered by the Federal Food, Drug and Cosmetic
Act of 1938 may be covered under CHAMPUS as if FDA approved. Prescription
drugs and medicines may also be referred to as “pharmaceutical agents”.
Note: The fact that the U.S. Food
and Drug Administration has approved a drug for testing on humans
would not qualify it within this definition.
Preventive
care.
Diagnostic and other medical
procedures not related directly to a specific illness, injury, or definitive
set of symptoms, or obstetrical care, but rather performed as periodic
health screening, health assessment, or health maintenance.
Primary
caregiver.
An individual who renders to
a beneficiary services to support the activities of daily living
(as defined in Sec. 199.2) and specific services essential to the
safe management of the beneficiary’s condition.
Primary
payer.
The plan or program whose medical
benefits are payable first in a double coverage situation.
PRIMUS
clinics.
Contractor owned, staffed,
and operated primary care clinics exclusively serving uniformed
services beneficiaries pursuant to contracts awarded by a Military
Department.
Private room.
A room with one bed that is
designated as a private room by the hospital or other authorized institutional
provider.
Profound hearing loss (adults).
An “adult” (a spouse as defined
in section 32 CFR 199.3(b) of this part of a member of the Uniformed
Services on active duty for more than 30 days) with a hearing threshold
of:
(1) 40 dB HL or greater
in one or both ears when tested at 500, 1,000, 1,500, 2,000, 3,000,
or 4,000Hz; or
(2) 26
dB HL or greater in one or both ears at any three or more of those
frequencies; or
(3) A
speech recognition score less than 94 percent.
Profound
hearing loss (children).
A “child” (an unmarried child
of an active duty member who otherwise meets the criteria (including
age requirements) in 32 CFR 199.3 of this part) with a 26dB HL or
greater hearing threshold level in one or both ears when tested
in the frequency range at 500, 1,000, 2,000, 3,000 or 4,000 Hz.
Program
year.
The appropriate year (e.g.,
calendar year, fiscal year, rolling 12-month period, etc.) specified
in the administration of TRICARE programs for application of unique
requirements or limitations (e.g., enrollment fees, deductibles,
catastrophic loss protection, etc.) on covered health care services
obtained or provided during the designated time period.
Progress
notes.
Progress notes are an essential
component of the medical record wherein health care personnel provide
written evidence of ordered and supervised diagnostic tests, treatments,
medical procedures, therapeutic behavior and outcomes. In the case
of mental health care, progress notes must include: the date of
the therapy session; length of the therapy session; a notation of
the patient’s signs and symptoms; the issues, pathology and specific
behaviors addressed in the therapy session; a statement summarizing
the therapeutic interventions attempted during the therapy session;
descriptions of the response to treatment, the outcome of the treatment, and
the response to significant others; and a statement summarizing
the patient’s degree of progress toward the treatment goals. Progress
notes do not need to repeat all that was said during a therapy session
but must document a patient contact and be sufficiently detailed
to allow for both peer review and audits to substantiate the quality
and quantity of care rendered.
Prosthetic
or Prosthetic device (prosthesis).
A prosthetic
or prosthetic device (prosthesis) determined by the Secretary of
Defense to be necessary because of significant conditions resulting
from trauma, congenital anomalies, or diseases.
Prosthetic
supplies.
Supplies that are necessary
for the effective use of a prosthetic or prosthetic device.
Provider.
A hospital or other institutional
provider, a physician, or other individual professional provider,
or other provider of services or supplies as specified in Sec. 199.6
of this part.
Provider exclusion and suspension.
The terms “exclusion” and “suspension”,
when referring to a provider under CHAMPUS, both mean the denial
of status as an authorized provider, resulting in items, services,
or supplies furnished by the provider not being reimbursed, directly
or indirectly, under CHAMPUS. The terms may be used interchangeably
to refer to a provider who has been denied status as an authorized
CHAMPUS provider based on (1) a criminal conviction or civil judgment
involving fraud, (2) an administrative finding of fraud or abuse
under CHAMPUS, (3) an administrative finding that the provider has
been excluded or suspended by another agency of the Federal Government,
a state, or a local licensing authority, (4) an administrative finding
that the provider has knowingly participated in a conflict of interest
situation, or (5) an administrative finding that it is in the best interests
of the CHAMPUS or CHAMPUS beneficiaries to exclude or suspend the
provider.
Provider termination.
When a provider’s status as
an authorized CHAMPUS provider is ended, other than through exclusion
or suspension, based on a finding that the provider does not meet
the qualifications, as set forth in Sec. 199.6 of this part, to
be an authorized CHAMPUS provider.
Psychiatric
emergency.
A psychiatric inpatient admission
is an emergency when, based on a psychiatric evaluation performed
by a physician (or other qualified mental health care professional
with hospital admission authority), the patient is at immediate
risk of serious harm to self or others as a result of a mental disorder
and requires immediate continuous skilled observation at the acute
level of care.
Public facility.
A public authority or entity
legally constituted within a State (as defined in this section)
to administer, control or perform a service function for public
health, education or human services programs in a city, county,
or township, special district, or other political subdivision, or
such combination of political subdivisions or special districts
or counties as are recognized as an administrative agency for a
State’s public health, education or human services programs, or
any other public institution or agency having administrative control
and direction of a publicly funded health, education or human services
program.
Public facility adequacy.
An available public facility
shall be considered adequate when the Director, OCHAMPUS, or designee,
determines that the quality, quantity, and frequency of an available
service or item otherwise allowable as a CHAMPUS benefit is sufficient
to meet the beneficiary’s specific disability related need in a
timely manner.
Public facility availability.
A public facility shall be
considered available when the public facility usually and customarily
provides the requested service or item to individuals with the same
or similar disability related need as the otherwise equally qualified
CHAMPUS beneficiary.
Qualified accreditation organization.
A not-for-profit corporation
or a foundation that:
(1) Develops
process standards and outcome standards for health care delivery
programs, or knowledge standards and skill standards for health
care professional certification testing, using experts both from
within and outside of the health care program area or individual
specialty to which the standards are to be applied;
(2) Creates
measurable criteria that demonstrate compliance with each standard;
(3) Publishes the organization’s
standards, criteria and evaluation processes so that they are available
to the general public;
(4) Performs
on-site evaluations of health care delivery programs, or provides
testing of individuals, to measure the extent of compliance with
each standard;
(5) Provides
on-site evaluation or individual testing on a national or international
basis;
(6) Provides to evaluated
programs and tested individuals time-limited written certification
of compliance with the organization’s standards;
(7) Excludes certification
of any program operated by an organization which has an economic
interest, as defined in this section, in the accreditation organization
or in which the accreditation organization has an economic interest;
(8) Publishes promptly
the certification outcomes of each program evaluation or individual
test so that it is available to the general public; and
(9) Has been found
by the Director, OCHAMPUS, or designee, to apply standards, criteria,
and certification processes which reinforce CHAMPUS provider authorization
requirements and promote efficient delivery of CHAMPUS benefits.
Qualified
mental health provider.
Psychiatrists or other physicians;
clinical psychologists, certified psychiatric nurse specialists,
certified clinical social workers, certified marriage and family
therapists, TRICARE certified mental health counselors, pastoral
counselors under a physician’s supervision, and supervised mental
health counselors under a physician’s supervision.
Radiation
therapy services.
The treatment of diseases by
x-ray, radium, or radioactive isotopes when ordered by the attending
physician.
Rare Diseases.
TRICARE/CHAMPUS defines a rare
disease as any disease or condition that has a prevalence of less than
200,000 persons in the United States.
Referral.
The act or an instance of referring
a TRICARE beneficiary to another authorized provider to obtain necessary
medical treatment. Generally, when a referral is required to qualify
health care as a covered benefit, only a TRICARE-authorized physician
may make such a referral unless this regulation specifically allows
another category of TRICARE-authorized provider to make a referral
as allowed within the scope of the provider’s license. In addition to
referrals which may be required for certain health care to be a
covered TRICARE benefit, the TRICARE Prime program under Sec. 199.17
generally requires Prime enrollees to obtain a referral for care
through a primary care manager (PCM) or other authorized care coordinator
to avoid paying higher deductible and cost-sharing for otherwise
covered TRICARE benefits.
Registered nurse.
A person who is prepared specially
in the scientific basis of nursing, who is a graduate of a school of
nursing, and who is registered for practice after examination by
a state board of nurse examiners or similar regulatory authority,
who holds a current, valid license, and who is entitled legally
to use the designation R.N.
Rehabilitation.
The reduction of an acquired
loss of ability to perform an activity in the manner, or within
the range considered normal, for a human being.
Rehabilitative
therapy.
Any rehabilitative therapy
that is necessary to improve, restore, or maintain function, or
to minimize or prevent deterioration of function, of a patient and
prescribed by a physician.
Reliable
evidence.
(1) As used in Sec.
199.4(g)(15), the term reliable evidence means only:
(i) Well controlled
studies of clinically meaningful endpoints, published in refereed
medical literature.
(ii) Published
formal technology assessments.
(iii) The
published reports of national professional medical associations.
(iv) Published national
medical policy organization positions; and
(v) The published reports
of national expert opinion organizations.
(2) The
hierarchy of reliable evidence of proven medical effectiveness,
established by (1) through (5) of this paragraph, is the order of
the relative weight to be given to any particular source. With respect
to clinical studies, only those reports and articles containing
scientifically valid data and published in the refereed medical
and scientific literature shall be considered as meeting the requirements
of reliable evidence. Specifically not included in the meaning of
reliable evidence are reports, articles, or statements by providers
or groups of providers containing only abstracts, anecdotal evidence
or personal professional opinions. Also not included in the meaning of
reliable evidence is the fact that a provider or a number of providers
have elected to adopt a drug, device, or medical treatment or procedure
as their personal treatment or procedure of choice or standard of
practice.
Representative.
Any person who has been appointed
by a party to the initial determination as counsel or advisor and
who is otherwise eligible to serve as the counsel or advisor of
the party to the initial determination, particularly in connection
with a hearing.
Reservist.
A person
who is under an active duty call or order to one of the Uniformed
Services for a period of 30 days or less or is on inactive training.
Resident
(medical).
A graduate physician or dentist
who has an M.D. or D.O. degree, or D.D.S. or D.M.D. degree, respectively,
is licensed to practice, and who choose to remain on the house staff
of a hospital to get further training that will qualify him or her
for a medical or dental specialty.
Residential
treatment center (RTC).
A facility (or distinct part
of a facility) which meets the criteria in Sec. 199.6(b)(4)(vii).
Respite
care.
Respite care is short-term
care for a patient in order to provide rest and change for those
who have been caring for the patient at home, usually the patient’s
family.
Retired category.
Retirees and their family members
who are beneficiaries covered by 10 U.S.C. 1086(c), other than Medicare-eligible
beneficiaries as described in 10 U.S.C. 1086(d).
Retiree.
For ease of reference in this
part only, and except as otherwise specified in this part, the term
means a member or former member of a Uniformed Service who is entitled
to retired, retainer, or equivalent pay based on duty in a Uniformed
Service.
Routine eye examinations.
The services rendered in order
to determine the refractive state of the eyes.
Sanction.
For purpose of Sec. 199.9,
“sanction” means a provider exclusion, suspension, or termination.
Secondary
payer.
The plan or program whose medical
benefits are payable in double coverage situations only after the
primary payer has adjudicated the claim.
Semiprivate
room.
A room containing at least
two beds. If a room is designated publicly as a semiprivate accommodation
by the hospital or other authorized institutional provider and contains
multiple beds, it qualifies as a semiprivate room for the purposes
of CHAMPUS.
Serious physical disability.
Any physiological disorder
or condition or anatomical loss affecting one or more body systems
which has lasted, or with reasonable certainty is expected to last,
for a minimum period of 12 contiguous months, and which precludes
the person with the disorder, condition or anatomical loss from
unaided performance of at least one Major Life Activity as defined
in this section.
Skilled nursing facility.
An institution (or a distinct
part of an institution) that meets the criteria as set forth in
Sec. 199.6(b)(4)(vi).
Skilled nursing services.
Skilled nursing services includes
application of professional nursing services and skills by an RN,
LPN, or LVN, that are required to be performed under the general
supervision/direction of a TRICARE-authorized physician to ensure
the safety of the patient and achieve the medically desired result
in accordance with accepted standards of practice.
Sole community
hospital (SCH).
A hospital that is designated
by CMS as an SCH and meets the applicable requirements established
by Sec. 199.6(b)(4)(xvii).
Spectacles,
eyeglasses, and lenses.
Lenses, including contact lenses,
that help to correct faulty vision.
Speech
generating device (SGD).
See Augmentative Communication
Device.
Sponsor.
A member
or former member of a Uniformed Service upon whose status his or
her dependents’ eligibility for CHAMPUS is based. A sponsor also
includes a person who, while a member of the Uniformed Services
and after becoming eligible to be retired on the basis of years
of service, has his or her eligibility to receive retired pay terminated
as a result of misconduct involving abuse of a spouse or dependent
child. It also includes NATO members who are stationed in or passing
through the United States on official business when authorized.
It also includes individuals eligible for CHAMPUS under the Transitional
Assistance Management Program.
Spouse.
A lawful husband or wife, who
meets the criteria in Sec. 199.3 of this part, regardless of whether
or not dependent upon the member or former member for his or her
own support.
State.
For purposes
of this part, any of the several States, the District of Columbia,
the Commonwealth of Puerto Rico, the Commonwealth of the Northern
Mariana Islands, and each territory and possession of the United
States.
State victims of crime compensation
programs.
Benefits available to victims
of crime under the Violent Crime Control and Law Enforcement Act.
Student
status.
A dependent of a member or
former member of a Uniformed Service who has not passed his or her 23rd
birthday, and is enrolled in a full-time course of study in an institution
of higher learning.
Substance use disorder rehabilitation
facility (SUDRF).
A facility or a distinct part
of a facility that meets the criteria in Sec. 199.6(b)(4)(xiv).
Supervised
mental health counselor.
An extramedical individual
provider who meets the requirements outlined in Sec. 199.6.
Supplemental
insurance plan.
A health insurance policy or
other health benefit plan offered by a private entity to a CHAMPUS
beneficiary, that primarily is designed, advertised, marketed, or
otherwise held out as providing payment for expenses incurred for
services and items that are not reimbursed under CHAMPUS due to
program limitations, or beneficiary liabilities imposed by law.
CHAMPUS recognizes two types of supplemental plans, general indemnity
plans, and those offered through a direct service health maintenance
organization (HMO).
(1) An
indemnity supplemental insurance plan must meet all of the following
criteria:
(i) It provides insurance
coverage, regulated by state insurance agencies, which is available
only to beneficiaries of CHAMPUS.
(ii) is premium based
and all premiums relate only to the CHAMPUS supplemental coverage.
(iii) Its
benefits for all covered CHAMPUS beneficiaries are predominantly
limited to non-covered services, to the deductible and cost-shared
portions of the pre-determined allowable charges, and/or to amounts
exceeding the allowable charges for covered services.
(iv) It provides insurance
reimbursement by making payment directly to the CHAMPUS beneficiary
or to the participating provider.
(v) It does not operate
in a manner which results in lower deductibles or cost-shares than
those imposed by law, or that waives the legally imposed deductibles
or cost-shares.
(2)
A
supplemental insurance plan offered by a Health Maintenance Organization
(HMO) must meet all of the following criteria:
(i) The HMO must be
authorized and must operate under relevant provisions of state law.
(ii) The HMO supplemental
plan must be premium based and all premiums must relate only to
CHAMPUS supplemental coverage.
(iii) The
HMO’s benefits, above those which are directly reimbursed by CHAMPUS,
must be limited predominantly to services not covered by CHAMPUS
and CHAMPUS deductible and cost-share amounts.
(iv) The HMO must provide
services directly to CHAMPUS beneficiaries through its affiliated
providers who, in turn, are reimbursed by CHAMPUS.
(v) The
HMO’s premium structure must be designed so that no overall reduction
in the amount of the beneficiary deductibles or cost-shares will
result.
Suppliers of portable X-ray
services.
A supplier that meets the conditions
of coverage of the Medicare program, set forth in the Medicare regulations
(42 CFR 405.1411 through 405.1416 (as amended)) or the Medicaid
program in the state in which the covered service is provided.
Surgery.
Medically appropriate operative
procedures, including related preoperative and postoperative care; reduction
of fractures and dislocations; injections and needling procedures
of the joints; laser surgery of the eye; and those certain procedures
listed in Sec. 199.4(c)(2)(i) of this part.
Surgical
assistant.
A physician (or dentist or
podiatrist) who assists the operating surgeon in the performance
of a covered surgical service when such assistance is certified
as necessary by the attending surgeon, when the type of surgical
procedure being performed is of such complexity and seriousness
as to require a surgical assistant, and when interns, residents,
or other house staff are not available to provide the surgical assistance
services in the specialty area required.
Suspension
of claims processing.
The temporary suspension of
processing (to protect the government’s interests) of claims for
care furnished by a specific provider (whether the claims are submitted
by the provider or beneficiary) or claims submitted by or on behalf
of a specific CHAMPUS beneficiary pending action by the Director,
OCHAMPUS, or a designee, in a case of suspected fraud or abuse.
The action may include the administrative remedies provided for in
Sec. 199.9 or any other Department of Defense issuance (e.g. DoD
issuances implementing the Program Fraud Civil Remedies Act), case
development or investigation by OCHAMPUS, or referral to the Department
of Defense-Inspector General or the Department of Justice for action
within their cognizant jurisdictions.
Teaching
physician.
A teaching physician is any
physician whose duties include providing medical training to physicians
in training within a hospital or other institutional provider setting.
Telephonic
consultations.
A covered consultation service
conducted via telephone call between TRICARE-authorized providers,
including a verbal and written report to the patient’s treating/requesting
physician or other TRICARE-authorized provider.
Telephonic
office visits.
A covered service provided
via a telephone call between a beneficiary who is an established patient
and a TRICARE-authorized provider. See Sec. 199.4.
Third-party
billing agent.
Any entity that acts on behalf
of a provider to prepare, submit and monitor claims, excluding those
entities that act solely as a collection agency.
Third-party
payer.
Third-payer means an entity
that provides an insurance, medical service, or health plan by contract
or agreement, including an automobile liability insurance or no
fault insurance carrier and a worker’s compensation program or plan,
and any other plan or program (e.g., homeowners insurance) that
is designed to provide compensation or coverage for expenses incurred
by a beneficiary for medical services or supplies. For purposes
of the definition of “third-party payer,” an insurance, medical
service, or health plan includes a preferred provider organization,
an insurance plan described as Medicare supplemental insurance,
and a personal injury protection plan or medical payments benefit
plan for personal injuries resulting from the operation of a motor vehicle.
Note: TRICARE is secondary payer
to all third-party payers. Under limited circumstances described
in Sec. 199.8(c)(2) of this part, TRICARE payment may be authorized
to be paid in advance of adjudication of the claim by certain third-party
payers. TRICARE advance payments will not be made when a third-party
provider is determined to be a primary medical insurer under Sec.
199.8(c)(3) of this part.
Timely filing.
The filing of CHAMPUS claims
within the prescribed time limits as set forth in Sec. 199.7 of
this part.
Transitional Assistance Management
Program (TAMP).
The program established under
10 U.S.C. Sec. 1145(a) and Sec. 199.3(e) of this part.
Treatment
plan.
A detailed description of the
medical care being rendered or expected to be rendered a CHAMPUS beneficiary
seeking approval for inpatient and other benefits for which preauthorization
is required as set forth in Sec. 199.4(b). Medical care described
in the plan must meet the requirements of medical and psychological necessity.
A treatment plan must include, at a minimum, a diagnosis (either
current International Statistical Classification of Diseases and
Related Health Problems (ICD) or current Diagnostic and Statistical
Manual of Mental Disorders (DSM)); detailed reports of prior treatment,
medical history, family history, social history, and physical examination;
diagnostic test results; consultant’s reports (if any); proposed
treatment by type (such as surgical, medical, and psychiatric);
a description of who is or will be providing treatment (by discipline
or specialty); anticipated frequency, medications, and specific
goals of treatment; type of inpatient facility required and why (including
length of time the related inpatient stay will be required); and
prognosis. If the treatment plan involves the transfer of a CHAMPUS
patient from a hospital or another inpatient facility, medical records
related to that inpatient stay also are required as a part of the
treatment plan documentation.
TRICARE
certified mental health counselor.
An allied
health professional who meets the requirements outlined in Sec.
199.6.
TRICARE Extra.
The preferred provider option
of the TRICARE program made available prior to January 1, 2018, under
which TRICARE Standard beneficiaries may obtain discounts on cost
sharing as a result of using TRICARE network providers.
TRICARE
for Life.
The Medicare wraparound coverage
option of the TRICARE program made available to an eligible beneficiary
by reason of 10 U.S.C. 1086(d).
TRICARE
Hospital Outpatient Prospective Payment System (OPPS).
OPPS is a hospital outpatient
prospective payment system, based on nationally established APC
payment amounts and standardized for geographic wage differences that
includes operating and capital-related costs that are directly related
and integral to performing a procedure or furnishing a service in
a hospital outpatient department.
TRICARE
Prime.
The managed care otion of the
TRICARE program established under Sec. 199.17.
TRICARE
program.
The program establish under
Sec. 199.17.
TRICARE Reserve Select.
The program established under
10 U.S.C. 1076d and Sec. 199.24 of this Part.
TRICARE
Retired Reserve.
The program established under
10 U.S.C. 1076e and Sec. 199.25.
TRICARE
Select.
The self-managed, preferred-provider
network option under the TRICARE Program established by 10 U.S.C.
1075 and Sec. 199.17 to replace TRICARE Extra and Standard after
December 31, 2017.
TRICARE Standard.
The TRICARE program made available
prior to January 1, 2018, covering health benefits contracted for
under the authority of 10 U.S.C. section 1079(a) or 1086(a) and
subject to the same rates and conditions as apply to persons covered
under those section.
TRICARE Young Adult.
The program authorized by and
described in Sec. 199.26 of this part.
Uniform
HMO benefit.
The health care benefit established
by Sec. 199.18.
Uniformed Services.
The Army, Navy, Air Force,
Marine Corps, Coast Guard, Commissioned Corps of the USPHS, and the
Commissioned Corps of the NOAA.
Veteran.
A person who served in the
active military, naval, or air service, and who was discharged or
released therefrom under conditions other than dishonorable.
Note: Unless the veteran is eligible
for “retired pay,” “retirement pay,” or “retainer pay,” which refers
to payments of a continuing nature and are payable at fixed intervals
from the government for military service neither the veteran nor
his or her dependents are eligible for benefits under CHAMPUS.
Waiver
of benefit limits.
Extension of current benefit
limitations under the Case Management Program, of medical care,
services, and/or equipment, not otherwise a benefit under the TRICARE/CHAMPUS
program.
Well-child care.
A specific program of periodic
health screening, developmental assessment, and routine immunization
for dependents under six years of age.
Widow
or Widower.
A person who was a spouse at
the time of death of a member or former member and who has not remarried.
Worker’s
compensation benefits.
Medical benefits available
under any worker’s compensation law (including the Federal Employees
Compensation Act), occupational disease law, employers liability
law, or any other legislation of similar purpose, or under the maritime
doctrine of maintenance, wages, and cure.
X-ray
services.
An x-ray examination from which
an x-ray film or other image is produced, ordered by the attending physician
when necessary and rendered in connection with a medical or surgical
diagnosis or treatment of an illness or injury, or in connection
with maternity or well-baby care.
[51 FR 24008, Jul 1, 1986,
as amended at 64 FR 46134, Aug 24, 1999; 66 FR 40606, Aug 3, 2001;
66 FR 45172, Aug 28, 2001; 67 FR 18826, Apr 17, 2002; 67 FR 40602,
Jun 13, 2002; 68 FR 6618, Feb 10, 2003; 68 FR 23032, Apr 30, 2003;
68 FR 32361, May 30, 2003; 68 FR 44880, Jul 31, 2003; 69 FR 17048,
Apr 1, 2004; 69 FR 44946, Jul 28, 2004; 69 FR 51563, Aug 20, 2004;
69 FR 60554, Oct 12, 2004; 70 FR 12802, Mar 16, 2005; 70 FR 61377,
Oct 24, 2005; 71 FR 31944, Jun 2, 2006; 71 FR 35532, Jun 21, 2006;
71 FR 47092, Aug 16, 2006; 72 FR 46383, Aug 20, 2007; 73 FR 74964,
Dec 10, 2008; 74 FR 44755, Aug 31, 2009; 75 FR 47455, Aug 6, 2010;
75 FR 47458, Aug 6, 2010; 76 FR 8297, Feb 14, 2011; 76 FR 23483,
Apr 27, 2011; 77 FR 38178, Jun 27, 2012; 78 FR 12954, Feb 26, 2013;
78 FR 48309, Aug 8, 2013; 79 FR 41641, Jul 17, 2014; 78 FR 78711,
Dec 31, 2014; 81 FR 61085, Sep 2, 2016; 82 FR 45445, Sep 29, 2017;
82 FR 61692, Dec 29, 2017; 84 FR 4333, Feb 15, 2019; 85 FR 15065,
Mar 17, 2020; 87 FR 33013, Jun 1, 2022; 88 FR 19855,
Apr 4, 2023]
1. At 66 FR 45172, Aug 28,
2001, Sec. 199.2, was amended in part by revising the definition
of “Director, OCHAMPUS”. However, this amendment could not be incorporated
due to inaccurate amendatory instruction.
2. For Federal Register citations
affecting Sec. 199.2, see the List of CFR Sections Affected, which
appears in the Finding Aids section of the printed volume and at
www.fdsys.gov.