The following definitions are
a mixture of TRICARE Regulatory definitions listed in
32
CFR 199.2 and
CFR 199.17,operational
definitions used by TRICARE personnel and contractors in the daily
administration of the TRICARE Program, and terminology found in
the Health Insurance Portability and Accountability Act (HIPAA)
of 1996. Regulatory definitions may not be changed or elaborated
upon without a regulatory change. Further explanations/elaborations
of TRICARE Regulatory definitions may be found in the TRICARE Operations
Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual
(TRM), and TRICARE Systems Manual (TSM) where appropriate. For a
complete listing of TRICARE Regulatory Definitions refer to
32
CFR 199.2 and
CFR 199.17.
Included are acronyms for some of the words being defined. An acronym
is a word formed from the first (or first few) letters of a series
of words.
Absent Treatment (Defined
in 32 CFR 199.2)Services performed by Christian
Science practitioners for a person when the person is not physically present.
Technically, “Absent Treatment” is an obsolete term. The current
Christian Science terminology is “treatment through prayer and spiritual
means,” which is employed by an authorized Christian Science practitioner
either with the beneficiary being present or absent. However, to
be considered for coverage under TRICARE, the beneficiary must be
present physically when a Christian Science service is rendered,
regardless of the terminology used.
Abuse (Defined in 32
CFR 199.2)Any practice that is inconsistent
with accepted sound fiscal, business, or professional practice which results
in a TRICARE claim, unnecessary cost, or TRICARE payment for services
or supplies that are:
1. Not
within the concepts of medically necessary and appropriate care,
as defined in the Regulation (32 CFR 199), or
2. That fail to
meet professionally recognized standards for Health Care Providers
(HCPs).
The term
“abuse” includes deception or misrepresentation by a provider, or
any person or entity acting on behalf of a provider in relation
to a TRICARE claim.
Note: Unless a specific action is
deemed gross and flagrant, a pattern of inappropriate practice will
normally be required to find that abuse has occurred. Any practice
or action that constitutes fraud, as defined by the Regulation (32
CFR 199), would also be abuse.
Access, Health CareThe ability to receive necessary
health care services of high quality within specific time frames,
at locations and from the providers that satisfy patient health
care needs. This is frequently associated with the contractor’s
provision of network adequacy. Access to care standards are established
in
32 CFR 199.17 and
45 CFR 156.230. See the definition of “Access Standards” in this
appendix.
Access, Information1. The availability
and the permission to consult records, archives, or manuscripts.
2. The ability
and opportunity to obtain sensitive, classified, or administratively
controlled information or records readily.
Access Standards (Defined
in 32 CFR 199.17)Preferred Provider Networks (PPNs)
will have attributes of size composition, mix of providers and geographical
distribution so that the networks, coupled with the Military Medical
Treatment Facility (MTF) capabilities, can adequately address the
health care needs of the enrollees. Before offering enrollment in
Prime to a beneficiary group, the Market/MTF Director (or other
authorized person) will assure that the capabilities of the MTF
plus PPN will meet the following access standards with respect to
the needs of the expected number of enrollees from the beneficiary
group being offered enrollment:
1. Under normal
circumstances, enrollee travel time may not exceed 30 minutes from
home to primary care delivery site unless a longer time is necessary
because of the absence of providers (including providers not part
of the network) in the area.
2. The wait time
for an appointment for a well-patient visit or a specialty care
referral shall not exceed four weeks; for a routine visit, the wait
time for an appointment shall not exceed one week; and for an urgent
care visit the wait time for an appointment shall generally not
exceed 24 hours.
2. Emergency
services shall be available and accessible to handle emergencies
(and urgent care visits if not available from other primary care
providers within the service area 24 hours a day, seven days a week.
3. The network
shall include a sufficient number and mix of board certified specialists
to meet reasonably the anticipated needs of enrollees. Travel time
for specialty care shall not exceed one hour under normal circumstances,
unless a longer time is necessary because of the absence of providers (including
providers not part of the network) in the area. This requirement
does not apply under the Specialized Treatment Services Program.
4. Office waiting
times in nonemergency circumstances shall not exceed 30 minutes,
except when emergency care is being provided to patients, and the
normal schedule is disrupted.
Action PlanA contractor’s plan for achieving
a goal through the use of specific resources based on a time-oriented schedule
of activities.
Active Duty (Defined
in 32 CFR 199.2)Full-time duty in the Uniformed
Services of the United States (U.S.). It includes duty on the active
list, full-time training duty, annual training duty, and attendance
while in the active Military Service, at a school designated as
a Service school by law or by the Secretary of the Military Department
concerned.
Active Duty Member (Defined
in 32 CFR 199.2)A person on active duty in
a Uniformed Service under a call or order that does not specify
a period of 30 days or less.
Activities of Daily Living
(ADL) (Defined in 32 CFR 199.2)Care that consists of providing
food (including special diets), clothing and shelter; personal hygiene services;
observation and general monitoring; bowel training or management
(unless abnormalities in bowel function are of a severity to result
in a need for medical or surgical intervention in the absence of skilled
services); safety precautions; general preventive procedures (such
as turning to prevent bedsores); passive exercise; companionship;
recreation; transportation; and other such elements of personal
care that can reasonably be performed by an untrained adult with
minimal instruction or supervision. ADL may also be referred to
as “essentials of daily living”.
Adequate Medical Documentation,
Mental Health Records (Defined in 32
CFR 199.2)Adequate medical documentation
provides the means for measuring the type, frequency, and duration of
active treatments mechanisms employed and progress under the treatment
plan. Under TRICARE, it is required that adequate and sufficient
clinical records be kept be the provider to substantiate that specific
care was actually and appropriately furnished, was medically or
psychologically necessary (as defined in
32
CFR 199.2), and to identify the individual(s) who provided
the care. Each service provided or billed must be documented in
the records. In determining whether medical records are adequate, the
records will be reviewed under the general acceptable standards
(e.g., standard of an accrediting organization approved by the Director,
and the provider’s state or local licensing requirements) and other
requirements specified in 32CFR 199. The psychiatric and psychological
evaluations, physicians orders, the treatment plan, integrated progress
notes (and physician progress notes if separate from the integrated
progress notes), and the discharge summary are the more critical
elements of the mental health record. However, nursing and staff
notes, no matter how complete, are not a substitute for the documentation
of services by the individual professional provider who furnished
treatment to the beneficiary. In general, the documentation requirement
of a professional provider are not less in the outpatient setting
than the inpatient setting. Furthermore, even though a hospital
that provides psychiatric care may be accredited under The Joint
Commission (TJC) manual for hospitals rather than TJC behavioral
health standards, the critical elements of the mental health record
listed above are required for TRICARE claims.
Adjunctive Dental Care
(Defined in 32 CFR 199.2)Dental care that is medically
necessary in the treatment of an otherwise covered medical (not
dental) condition, is an integral part of the treatment of such
medical condition, and is essential to the control of the primary
medical condition; or, is required in preparation for or as the
result of dental trauma which may be or is caused by medically necessary
treatment of an injury or disease (iatrogenic).
AdjustmentA correction to the information
in the TRICARE Encounter Data (TED) records and/or Beneficiary History Files
(Hard Copy Files and Automated Beneficiary History and Deductible
Files) related to a claim previously Processed To Completion (PTC).
Adjustments include any recoupments, additional payment(s), all
cancellations (total or partial), and corrections to statistical
data, whether or not the changes result in changes to the financial
data.
Adjustment, Identification
Of ReceiptAn adjustment
may be generated by a telephonic, written or personal inquiry, appeal
decision, or as the result of a contractor’s internal review. The
adjustment is identified when the contractor’s staff determines
the issue requires an additional payment, cancellation, or a change
to the Beneficiary History and Deductible Files (see definition)
or when notice is received from DHA that an adjustment is required.
In the case of recoupments, the adjustment is “identified” for reporting
purposes, with receipt of the payment by the contractor.
Administrative EfficienciesAdherence to the TRICARE program
and benefits, electronic claims processing, responsiveness to patient
questions and care coordination, timeliness of consult reporting
back to referring providers.
Administrative Fee, PharmacyThe offered price that represents
all administrative charges relative to prescription, prior authorization and
medical necessity determination transaction processing.
All-Inclusive Per Diem
Rate (Defined in 32 CFR 199.2)The TRICARE-determined rate
that encompasses the daily charge for inpatient care and, unless specifically
excepted, all other treatment determined necessary and rendered
as part of the treatment plan established for a patient and accepted
by TRICARE.
Allowable Charge (Defined
in 32 CFR 199.2)The TRICARE-determined level
of payment to institutions, physicians, and other categories of
individual professional providers based on one of the approved reimbursement
methods set forth in the
32 CFR 199.14.
Allowable Charge ComplaintA request for review of a contractor
determination of the allowable charge for covered services and supplies
furnished under TRICARE. An allowable charge complaint does not
fall within the meaning of an “appeal”, in the technical sense,
but does require a careful review or reconsideration by the contractor
of how the claim was processed to ensure accuracy of the payment
made.
Allowable Charge ReductionThe difference between the
reimbursement determination made by a contractor and the amount
billed by the provider of care (prior to determination of applicable
cost-shares and deductibles). This is also referred to in the industry
as the contractual allowance.
Allowable Cost (Defined
in 32 CFR 199.2)The TRICARE-determined level
of payment to hospitals or other institutions, based on one of the approved
reimbursement methods set forth in
32
CFR 199.14. The allowable charge may also be referred
to as the TRICARE-determined reasonable or allowable cost.
Amount In Dispute (Defined
in 32 CFR 199.2)The amount of money, determined
under 32 CFR 199, that TRICARE will pay for medical services and supplies
involved in an adverse determination being appealed if the appeal
were resolved in favor of the appealing party. See
32
CFR 199.10 for additional information concerning the determination
of “amount in dispute” under the Regulation.
AppealA formal written request by
a beneficiary, a participating provider, a provider denied authorized provider
status under TRICARE, or a representative, to resolve a disputed
question of fact. See
32 CFR 199.10 and
32 CFR
199.12.
Appropriate Medical Care
(Defined in 32 CFR 199.2)Services that are:
1. Performed in
connection with the diagnosis or treatment of disease or injury,
pregnancy, mental disorder, or well-baby care which are in keeping
with the generally accepted norms for medical practice in the U.S.;
2. Rendered by
an authorized individual professional provider who is qualified
to perform such medical services by reason of his or her training
and education and is licensed or certified either by the state where
the service is rendered or appropriate national organization, or
who otherwise meets TRICARE standards; and
3. Furnished economically.
For the purposes of TRICARE, “economically” means that the services
are furnished in the least expensive level of care or medical environment
adequate to provide the required medical care regardless of whether
or not that level of care is covered by TRICARE.
Armed Services (Defined
in Title 10, United States Code, Section 101(a)(4))The Army, Navy, Air Force,
Marine Corps, Space Force, and Coast Guard.
Authorization For CareThe authorization determination
addresses whether a particular service may be covered by TRICARE, including
whether it appears necessary and appropriate in the context of the
patient’s diagnosis and circumstances.
Authorized Provider (Defined
in 32 CFR 199.2)A hospital or institutional
provider, physician, or other individual professional provider,
or other provider of services or supplies specifically authorized
to provide benefits under TRICARE in
32
CFR 199.6.
Note: Providers not specifically
listed in
32 CFR 199.6 or
defined in
32 CFR 199.2 are
not considered authorized providers unless they have been included
in a TRICARE demonstration program.
Authorized Supplies,
PharmacyNon-drug
items (usually used in conjunction with the administration of a
drug) approved by the DoD Pharmacy and Therapeutic (P&T) [Committee]
for inclusion in the formulary, and appearing on the formulary web
site at
http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx.
Automated Data Processing
(ADP)A system
for recording and processing data on magnetic media, ADP cards,
or any other method for mechanical/electronic processing and manipulation
or storage of data.
Automated Data Processing
(ADP) Backup SystemA separate, off-site ADP system
with similar operating capabilities which will be activated/used
in case of a major system failure, damage, or destruction. This
includes back-up data sets, software and hardware requirements,
and trained personnel.
Balance Billing (Defined
in 32 CFR 199.2)A provider seeking any payment,
other than any payment relating to applicable deductible and cost-sharing
amounts, from a beneficiary for TRICARE covered services for any
amount in excess of the applicable TRICARE allowable cost or charge.
Basic Program (Defined
in 32 CFR 199.2)The primary medical benefits
authorized under Chapter 55 of Title 10, United States Code (USC),
and set forth in
32 CFR 199.4.
Benchmark, Drug PriceThe Average Wholesale Price
(AWP) has long been the drug price benchmark for establishing reimbursement
payment terms between payers, Pharmacy Benefit Managers (PBMs),
and pharmacies. AWP as a benchmark has been going away. AWP is by
no means the only price type available. Listed here, with brief
descriptions, are others that are available and may be used by the
industry for reimbursement purposes as AWP is being phased out:
• Actual Acquisition Cost (AAC)
- Final price paid by the pharmacy after subtraction of all discounts;
• Average Manufacturer Price
(AMP) - Manufacturer reported price for Medicaid drug rebate program;
• Average Sales Price (ASP) -
Center for Medicare and Medicaid Service (CMS) calculated price
for Medicate Part B drugs;
• Estimated Acquisition Cost
(EAC) - Estimated cost of the product or the pharmacies’ usual and customary
charge;
• Federal Upper Limit (FUL) -
CMS calculation for the upper amount to be paid in aggregate for
multi-source products;
• Maximum Allowable Cost (MAC)
- Defined by each payer for multi-source drugs;
• Manufacturer List Price (MLP)
- Price listed by the drug company;
• Wholesale Acquisition Cost
(WAC) - List price for a drug sold by a manufacturer to wholesaler,
not including discounts.
BeneficiaryA beneficiary is an individual
eligible for benefits. The beneficiary, Sponsor, or representative
of the beneficiary, including the parent of a beneficiary under
18 years of age, the beneficiary’s attorney, legal guardian or representative
specifically designated by the beneficiary may on his or her behalf regarding
the benefit at issue. An individual who is subject to the conflict
of interest provisions of
32 CFR 199.10(a)(2)(i)(B), may not act as
the beneficiary’s representative under this section.
Beneficiary Counseling
and Assistance Coordinators (BCACs)Formerly referred to as Health
Benefit Advisors (HBAs), BCACs are individuals located at Uniformed Services
medical facilities or on occasion at other locations and assigned
the responsibility for providing TRICARE information, information
concerning availability of care from the Uniformed Services Direct
Care (DC) or Purchased Care Systems, and generally assisting beneficiaries
or sponsors. The term also includes “Health Benefits Counselor.”
Beneficiary History FileA system of records consisting
of any record or subsystem of records, whether hard copy, microform
or automated, which reflects diagnosis, treatment, medical condition,
family history records, correspondence, memorandum, or any other
personal information with respect to any individual, including all
such records/reports acquired or utilized by the contractor in delivery
of health care services, in the development and processing of claims,
or in performing any other functions under a TRICARE contract.
1. Hard Copy Claim
Files.
2. Automated
History Files. The electronically maintained record of a beneficiary’s
medical care and related administrative data, including such data
on charges, payments, deductible status, services received, diagnoses,
adjustments, etc.
Note: The term “TRICARE Contractor
Claims Records” is used by the National Archives and Records Administration
(NARA) “Medical/Dental Claims History files (formerly “Beneficiary
History and Deductibles Files”) includes but is not limited to “TRICARE
Contractor claims Records.”
Beneficiary Liability
(Defined in 32 CFR 199.2)The legal obligation of a beneficiary,
his or her estate, or responsible family member to pay for the costs of
medical care or treatment received. Specifically, for the purposes
of services and supplies covered by TRICARE, beneficiary liability
includes any annual deductible amount, cost-sharing amounts, or,
when a provider does not submit a claim on a participating basis
on behalf of the beneficiary, amounts above the TRICARE-determined
allowable charge. Beneficiary liability also includes any expenses
for medical or related services and supplies not covered by TRICARE.
BenefitServices, supplies, payment
amounts, cost-shares and copayments authorized by Public Law (PL)
89-614, 32 CFR 199, and outlined in the TPM and the TRM.
Best PracticesA best practice is a method
or technique that has consistently shown results superior to those
achieved with other means, and that is used as a benchmark. In addition,
a “best” practice can evolve to become better as improvements are
discovered.
Best Value Health CareThe delivery of high quality
clinical and other related services in the most economical manner
for the Military Health System (MHS) that optimizes the DC system
while delivering the highest level of customer service.
Biotelemetry (Defined
in 32 CFR 199.2)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.
BreachA breach, as defined in Department
of Defense Directive (DoDD) 5400.11 (2014), is a loss of control, compromise,
unauthorized disclosure, unauthorized acquisition, unauthorized
access, or any similar term referring to situations where persons
other than authorized users and for an other than authorized purpose
have access or potential access to Personally Identifiable Information
(PII)/Protected Health Information (PHI), whether in paper or electronic
form. Breaches are classified as either possible or confirmed (see
the definition of “Possible Breach” and “Confirmed Breach” in this appendix)
and as either cyber or non-cyber (i.e., involving either electronic
PII/PHI or paper/oral PII/PHI).
Business Associate1. A person or
organization that performs a function or activity on behalf of a
covered entity, but is not part of a covered entity’s workforce.
A business associate may also be a covered entity in it’s own right.
2. For a full
definition, refer to the 45 CFR 160.103, Definitions of HIPAA of
1996.
Business DayFor claims processing purposes,
one business day is defined as the business day following the day
of transmission at the close of business at the location of the
receiving entity. A business workday is Monday through Friday, excluding
Federal holidays.
Capability Of A ProviderThe scope of services the provider
is both capable of performing and willing to perform under a TRICARE
contract. For example, a neurologist under TRICARE contract to perform
sleep studies may not be considered to have capability to perform
as a general neurology specialist.
Capacity Of A ProviderThe amount of time or number
of services a provider is able to perform in conjunction with a
TRICARE contract. For example, a Primary Care Physician (PCP), whose
practice is full has no available capacity for services.
CapitationA payment arrangement for health
care service providers. It pays a set amount for each enrolled person assigned
to them, per period of time, whether or not that person seeks care.
Capped RateThe maximum per diem or all-inclusive
rate that TRICARE will allow for care.
Care CoordinationA comprehensive method of client
assessment designed to identify client vulnerability, needs identification,
and client goals which results in the development plan of action
to produce an outcome that is desirable for the client. The goal
is to provide client advocacy, a system for coordinating client services,
and providing a systematic approach for evaluation of the effectiveness
of the client’s Life Plan.
Case Management (Defined
in 32 CFR 199.2)A collaborative process which
assesses, plans, implements, coordinates, monitors and evaluates
the options and services required to meet an individual’s health
needs, including mental health and Substance Use Disorder (SUD)
needs, using communication and available resources to promote quality, cost-effective
outcomes.
Catastrophic CapThe National Defense Authorization
Act (NDAA) for Fiscal Years (FYs) 1988 and 1989 (Public Law 100-180)
amended Title 10, USC, and established catastrophic loss protection
for TRICARE beneficiary families on a Government fiscal year basis.
The law placed fiscal year limits or catastrophic caps on beneficiary
liabilities for deductibles and cost-shares under the TRICARE Basic
Program. Specific guidance may be found in the TRM,
Chapter 2, Section 2. NDAA for FY 2017 amended
Title 10, USC to change calculations to a calendar year basis, beginning
January 1, 2018. The last quarter of calendar year 2017 was applied
to the FY 2017 calculations to bridge the gap.
Catchment AreasGeographic areas determined
by the Assistant Secretary of Defense (Health Affairs) (ASD(HA))
that are defined by a set of five digit zip codes, usually within
an approximate 40 mile radius of military inpatient treatment facility.
Centers of ExcellenceSee definition for Defense
Centers of Excellence (CoE).
Certification and Accreditation
(C&A) ProcessA process
that ensures the trust requirement is met for Information Systems
(IS)/networks. Certification is the determination of the appropriate
level of protection required for IS/networks. Certification also includes
a comprehensive evaluation of the technical and non-technical security
features and countermeasures required for each IS/network. Accreditation
is the formal approval by the Government to operate the contractor’s
IS/networks in a particular security mode using a prescribed set
of safeguards at an acceptable level of risk. In addition, accreditation
allows IS/networks to operate within the given operational environment
with stated interconnections; and with appropriate level-of-protection
for the specified period. The C&A requirements apply to all
DoD IS/networks and contractor IS/networks that access, manage,
store, or manipulate electronic IS data. Specific guidance may be found
in the TSM,
Chapter 1.
Certification For CareThe determination that the
provider’s request for services (level of care, procedure, etc.)
is consistent with pre-established health care criteria. Pre-certification
is the process performing a certification for care prior to rendering
the care.
Note: This is
NOT synonymous with authorization for care.
Certified ProviderA hospital or institutional
provider, physician, or other individual professional provider of
services or supplies verified by DHA, or a designated contractor,
to meet the provider standards outlined in
32
CFR 199.6, and have been approved to provide services
to TRICARE beneficiaries and receive Government payment for services
rendered to TRICARE beneficiaries.
CHAMPUS Maximum Allowable
Charge (CMAC)A CMAC
is a nationally determined allowable charge level that is adjusted
by locality indices and is equal to or greater than the Medicare
Fee Scheduled amount.
Civilian Health and Medical
Program of the Department of Veterans Affairs (CHAMPVA)A program of medical care for
spouses and dependent children of disabled or deceased disabled veterans
who meet the eligibility requirements of the Department of Veterans
Affairs (DVA)/Veterans Health Administration (VHA).
Change OrderA written directive from the
DHA Procuring Contracting Officer (PCO) to the contractor directing modifications,
within the general scope of the contract, as authorized by the “changes
clause” at FAR 52.243-1, Changes--Fixed Price.
Christian Science Nurse
(Defined in 32 CFR 199.2)An individual who has been
accredited as a Christian Science Nurse by the Department of Care
of the First Church of Christ, Scientist, Boston, Massachusetts,
and listed (or eligible to be listed) in the Christian Science Journal
at the time the service is provided. The duties of Christian Science
nurses are spiritual and are nonmedical and nontechnical nursing
care performed under the direction of an accredited Christian Science
practitioner. There are two levels of Christian Science nurse accreditation:
1. Graduate Christian
Science Nurse. This accreditation is granted by the Department
of Care of the First Church of Christ, Scientist, Boston, Massachusetts,
after completion of a three year course of instruction and study.
2. Practical Christian
Science Nurse. This accreditation is granted by the Department
of Care of the First Church of Christ, Scientist, Boston, Massachusetts,
after completion of a one year course of instruction and study.
Christian Science Practitioner
(Defined in 32 CFR 199.2)An individual who has been
accredited as a Christian Science Practitioner for the First Church
of Christ, Scientist, Boston, Massachusetts, and listed (or eligible
to be listed) in the Christian Science Journal at the time the service
is provided. An individual who attains this accreditation has demonstrated
results of his or her healing through faith and prayer rather than
by medical treatment. Instruction is executed by an accredited Christian
Science teacher and is continuous.
Christian Science Sanatorium
(Defined in 32 CFR 199.2)A sanatorium either operated
by the First Church of Christ, Scientist, or listed and certified
by the First Church of Christ, Scientist, Boston, Massachusetts.
ClaimAny request for reimbursement
for health care services rendered, received from a beneficiary,
a beneficiary’s representative, or a network or non-network provider,
by a contractor on any TRICARE-approved claim form or approved electronic
medium.
Note: If two
or more forms for the same beneficiary are submitted together, they
shall constitute one claim unless they qualify for separate processing
under the claims splitting rules. (It is recognized that services
may be provided in situations in which no claims, as defined here,
are generated. This does not relieve the contractor from collecting
the data necessary to fulfill the requirements of the TED Record
for all care provided under the contract.)
Note: Any request for reimbursement
of a dispensed pharmaceutical agent or diabetic supply item. For
electronic media claims, one prescription equals one claim. For
paper claims, reimbursement for multiple prescriptions may be requested
on a single paper claim.
Claim (Excluded)Claims that:
• Are retained at the discretion
of the contractor for the external development of information necessary
to process the claim to completion; or
• Require development for possible
Third Party Liability (TPL); or
• Require intervention by another
TRICARE Prime contractor; or
• Require Government intervention
(i.e., claims held for CMAC updates, claims held pending the issuance
of a policy change, etc.).
• Claims where payment has been
temporarily suspended at Government direction pending the completion
of fraud investigation in accordance with
Chapter 13, Section 5.
Claim FileThe collected records submitted
with or developed in the course of processing a single claim. It includes
the approved TRICARE claim form and may include attached bills,
medical records, records of telephone development, copies of correspondence
sent and received in connection with the claim, the EOB, and records
of adjustments to the claim. It may also include the records of
appeals and appeal actions. The claim file may be in microcopy,
hard copy, or in a combination of media.
Claim FormA fixed arrangement of captioned
spaces designed for entering and extracting prescribed information, including
ADP system forms.
Claim (Retained)Any claim retained (held in
the contractor’s possession) for any reason that is not defined
under ‘Claim (Excluded)’.
Claims Cycle TimeThat period of time, recorded
in calendar days, from the receipt of a claim into the possession/custody of
the contractor to the completion of all processing steps (see the
definition of “Processed to Completion (or Final Disposition)” in
this appendix, and the TSM,
Chapter 2, Section 2.4, “Date TED Record Processed
to Completion”).
Claims Payment DataThe record of information contained
on or derived from the processing of a claim or encounter.
Clean ClaimA claim that has no defect,
impropriety (including a lack of any required substantiating documentation),
or particular circumstance requiring special treatment external
to the contractor’s prepayment operation that prevents timely payment
on the claim.
Client BeneficiaryA beneficiary who receives
services from a temporarily suspended provider, pharmacy, or entity.
All payments to a client beneficiary for care or services rendered
by a temporarily suspended provider, pharmacy, or entity shall be
held in temporary suspense (same as the temporarily suspended provider’s,
pharmacy’s, or entity’s claims). A client beneficiary is NOT under
temporary suspense. Only the reimbursement of claims for care received
from a temporarily suspended provider, pharmacy, or entity shall
be held in temporary suspense. All other claims shall be paid in
accordance with the contract.
Clinical Quality OutcomesThe American College of Medical
Quality in its 2010 revision of its recommended Core Curriculum
for Medical Quality Management describes clinical outcomes as part
of the definition of quality measures. These are:
1. Structural
Measures - health care setting, appropriate equipment and supplies,
education, certification and experience of clinicians;
2. Process Measures
- actions taken and how well these were performed to achieve a given
outcome, use of evidence-based clinical guidelines;
3. Outcome Measures
- capture of changes in health status following the provision of
a set of healthcare processes and including the cost of delivering
the processes -- hospitalizations, physician office visits, or care
provided in post-acute care setting, patient satisfaction.
Clinical Support Agreement
(CSA)An arrangement
requested by the military, between an MTF/eMSM and the TRICARE contractor
for the contractor to provide needed clinical personnel at an MTF/eMSM.
The arrangement must be formalized by modification to the TRICARE
contract prior to implementation of the provisions of the arrangement.
Code Set (HIPAA/Privacy
Definition)Any set
of codes used to encode data elements, such as tables of terms,
medical concepts, medical diagnostic codes, or medical procedure
codes. This includes both the codes and their descriptions, as outlined
in HIPAA of 1996.
Code Set Maintaining
Organization (HIPAA/Privacy Definition)An organization that creates
and maintains the code sets adopted by the Secretary of Home Health Services
(HHS) for use in the transactions for which standards are adopted
as outlined in HIPAA of 1996.
Combined Daily Charge
(Defined in 32 CFR 199.2)A billing procedure by an inpatient
facility that uses an inclusive flat rate covering all professional
and ancillary charges without any itemization.
Concurrent Review/Continued
Stay ReviewEvaluation
of a patient’s continued need for treatment, the appropriateness
of current and proposed treatment, as well as the setting in which
the treatment is being rendered or proposed. Concurrent review applies
to all levels of care (including outpatient care).
Confidentiality RequirementsThe procedures and controls
that assure the privacy of personal medical information in compliance with
the Freedom of Information Act, the Comprehensive Alcohol Abuse
and Alcoholism Prevention and Rehabilitation Act, the Privacy Act,
and HIPAA of 1996.
Confirmed BreachAn incident in which it is
known that unauthorized access could occur. For example, if a laptop containing
PII/PHI is lost and the contractor knows that the PII/PHI is unencrypted,
then the contractor should classify and report the incident as a
confirmed breach, because unauthorized access could occur due to
the lack of encryption (the contractor knows this even without knowing
whether or not unauthorized access to the PII/PHI has actually occurred).
If the laptop is subsequently recovered and forensic investigation
reveals that files containing PII/PHI were never accessed, then
the possibility of unauthorized access can be ruled out, and the
contractor should re-classify the incident as a non-breach incident.
Conflict Of Interest
(Defined in 32 CFR 199.2)Includes any situation where
an active duty member (including a reserve member while on active
duty) or civilian employee of the U.S. Government, through an official
federal position, has the apparent or actual opportunity to exert,
directly or indirectly, any influence on the referral of TRICARE
beneficiaries to himself or herself or others with some potential
for personal gain or appearance of impropriety. Individuals under
contract to a Uniformed Service may be involved in a conflict of
interest situation through the contract position.
Consultation (Defined
in 32 CFR 199.2)A deliberation with a specialist
physician, dentist, or qualified mental health provider requested
by the attending TRICARE authorized provider primarily responsible
for the medical care of the patient, with respect to the diagnosis
or treatment in any particular case. A consulting physician or dentist
or qualified mental health provider may perform a limited examination
of a given system or one requiring a complete diagnostic history
and examination. To qualify as a consultation, a written report
to the attending TRICARE authorized provider of the findings of
the consultant is required.
Note: Staff consultations required
by rules and regulations of the medical staff of a hospital or institutional
provider do not qualify as consultations.
Consultation Appointment
(Defined in 32 CFR 199.2) An appointment for evaluation
of medical symptoms resulting in a plan for management which may include
elements of further evaluation, treatment and follow-up evaluation.
Such an appointment does not include surgical intervention or other
invasive diagnostic or therapeutic procedures beyond the level of
very simply office procedures, or basic laboratory work but rather
provides the beneficiary with an authoritative option.
Consulting Physician
or Dentist (Defined in 32 CFR 199.2)A physician or dentist, other
than the attending physician, who performs a consultation.
Continued Health Care
Benefit Program (CHCBP)A TRICARE benefit program that
provides temporary continued health care for certain former beneficiaries
of the MHS. Coverage under the CHCBP is purchased on a premium basis.
Continuity of CareFollow on of health care services
from a specific individual professional provider as part of a specific procedure
or service that was performed within the previous six months in
order to not disrupt therapy or repeat services.
Continuum of CareAll patient care services provided
from “pre-conception to grave” across all types of settings. Requires integrating
processes to maintain ongoing communication and documentation flow
between the DC system and network.
Contract Performance
Evaluation (CPE)A review
by DHA, of a contractor’s level of compliance with the terms and
conditions of the contract. Usually, an operational audit performed
by DHA staff that focuses on timeliness, accuracy, and responsiveness
of the contractor in performing all aspects of the work required
by the contract.
Contract PhysicianA physician who has made contractual
arrangements with a contractor to provide care or services to TRICARE
beneficiaries. A contract physician is a network provider who participates
on all TRICARE claims.
Contracting Officer’s
Representative (COR)A Government representative,
appointed in writing by the Contracting Officer (CO), who represents
the CO in the administration of technical matters involving contract
requirements.
ContractorAn organization with which
DHA has entered into a contract for delivery of and/or processing
of payment for health care services, and the performance of related
support activities, such as, pharmacy services, quality monitoring
and/or customer service.
Control Of ClaimsThe ability to identify individually,
locate, and count all claims in the custody of the contractor by location,
including those that may be being developed by physical return of
a copy of the claim, and age including total age in-house and age
in a specific location.
Controlled SubstancesThose medications which are
included in one of the schedules of the Controlled Substances Act
of 1970 and as amended.
Controlled Unclassified
Information (CUI)Information
that is not classified in accordance with national security directives,
but that otherwise requires safeguarding or dissemination controls
pursuant to and consistent with applicable law, regulations, and
Government-wide policies.
Convenience Clinic (CC)A CC is located in a retail
location with a pharmacy whose purpose is to diagnose and treat
non-emergency illness or injury; and provide vaccinations, wellness
services, and chronic disease monitoring.
Coordination Of Benefits
(COB) (Defined in 32 CFR 199.2)The coordination, on a primary
or secondary payer basis of the payment of benefits between two
or more health care coverages to avoid duplication of benefit payments.
Cost-Share (Defined in 32
CFR 199.2)The amount of money for which
the beneficiary (or sponsor) is responsible in connection with otherwise
covered inpatient and outpatient services (other than the annual
deductible or disallowed amounts) as set forth in
32 CFR 199.4(f) and
32 CFR 199.5(b).
Cost-sharing may also be referred to as “copayment.”
Correctional Institution
(HIPAA Definition)Any penal
or correctional facility, jail, reformatory, detention center, work
farm, halfway house, or residential community program center operated
by, or under contract to, the U.S., a State, a territory, a political
subdivision of a State or territory, or an Indian tribe, for the
confinement or rehabilitation of persons charged with or convicted
of a criminal offense or other persons held in lawful custody. Other persons
held in lawful custody includes juvenile offenders adjudicated delinquent,
aliens detained awaiting deportation, persons committed to mental
institutions through the criminal justice system, witnesses, or
others awaiting charges or trial as defined in HIPAA of 1996.
Note: For the purposes of TRICARE,
the term “correctional institution” includes military confinement
facilities but does not include internment facilities for enemy
prisoners of war, retained personnel, civilian detainees and other
detainees provided under the provisions of DoDD 2310.1 (reference
(b)).
Covered Entity (HIPAA
Definition)Any business
entity that must comply with HIPAA regulations, which includes,
health plans, health care clearinghouses, and HCPs. For the purposes
of HIPAA, HCPs include hospitals, physicians, and other caregivers.
See 45CFR Section 160.103 of HIPAA regulation for additional information.
Note: In the case of a health plan
administered by the DoD, the covered entity is the DoD Component
(or subcomponent) that functions as the administrator of the health
plan.
Covered Functions (HIPAA
Definition)Those
functions of a covered entity, the performance of which, makes the
entity a health plan or HCP as outlined in HIPAA of 1996.
CredentialingThe process by which providers
are allowed to participate in the network. This includes a review
of the provider’s training, educational degrees, licensure, practice
history, etc.
Credentials PackageInformation required for all
clinical personnel supplied by the contractor who will be working
in an Market/MTF. Similar information may be required for non-clinical
personnel. Complete information shall contain the following:
1. All documents,
required per regulation/directive/instruction/policy which are needed
to verify that the individual is certified/authorized/qualified
to provide the proposed services at the involved facility. This
shall include licensure from the jurisdiction in which the individual
will be practicing and a National Practitioner Data Bank (NPDB)
query as specified by the facility.
2. A completed
a Criminal History Background Check (CHBC), for all personnel required
by law to have a CHBC prior to awarding of privileges or the delivery
of services with the following considerations:
• If a CHBC has been initiated,
but not completed, the Market/MTF Director has the authority to
allow awarding of privileges and initiation of services if delivered
under clinical supervision.
• The mechanism for accomplishing
the CHBC may vary between Markets/MTFs and should be determined
during phase-in/transition and be agreed to by the Market/MTF Director.
• Regardless of the mechanism
for initiating and completing a CHBC, the cost shall be borne by
the contractor.
3. Medicare Provider
ID number/National Provider Identifier (NPI) number.
4. Evidence of compliance
(or scheduled compliance) with the Market/MTF specific requirements including
all local Employee Health Program (EHP), Federal Occupational Safety
Act and Health Act (OSHA), and Bloodborne Pathogens Program (BBP)
requirements.
Custodial Care (Defined
in 32 CFR 199.2)The treatment or services,
regardless of who recommends such treatment or services or where
such treatment or services are provided, that:
1. Can be rendered
safely and reasonably by a person who is not medically skilled;
or
2. Is/are
designed mainly to help the patient with the ADLs.
Cybersecurity IncidentA cybersecurity incident is
a violation or imminent threat of violation of computer security
policies, acceptable use policies, or standard security practices,
with respect to electronic PII/PHI. A cybersecurity incident may
or may not involve a breach of PII/PHI. For example, a malware infection would
be a possible breach if it could cause unauthorized access to PII/PHI.
However, if the malware only affects data integrity or availability
(not confidentiality), then a non-breach cybersecurity incident has
occurred.
Cycle TimeThe elapsed time, as expressed
in days including any part of the first and last days counted as
two days, from the date a claim, piece of correspondence, grievance,
or appeal case was received by a contractor through the date (PTC).
See the definition of claims cycle time, in this appendix, for added
detail.
DataAny information collected,
derived, or created as a result of operations as a TRICARE contractor.
All data is the property of the Government regardless of where it
is maintained/stored.
Data AggregationThe combining of PHI by a business
associate with the PHI received by the business associate in its capacity
as a business associate of another covered entity, to permit data
analyses that relate to the health care operations of the respective
covered entities as outlined in HIPAA of 1996.
Data Condition (HIPAA
Definition)The circumstances
under which a covered entity must use a particular data element
or segment as defined by HIPAA of 1996.
Data Content (HIPAA Definition)All the data elements and code
sets inherent to a transaction, and not related to the format of
the transaction. Data elements that are related to the format are
not data content as defined by HIPAA of 1996.
Data Element (HIPAA Definition)The smallest named unit of
information in a transaction defined by HIPAA of 1996.
Data RepositoryA single point of electronic
storage, established and maintained by the contractor that enables
the Government to electronically access all data maintained by the
contractor relative to a TRICARE contract. This includes all claims/encounter
data, provider data, authorization, enrollment, and derived data
collected in relation to a TRICARE contract.
Data Set (HIPAA Definition)A semantically meaningful unit
of information exchanged between two parties to a transaction as defined
by HIPAA of 1996.
Date Of Determination
(Appeals)The date
of completion appearing on the reconsideration determination, formal
review determination, or hearing final decision.
Days (Defined in 32
CFR 199.2)Calendar days.
Days Supply (Pharmacy)The length of time a dispensed
quantity of drug should last, based on directions for use with a
limit as the First Data Bank recommended maximum daily dose (unless
specifically altered by DoD).
Deductible (Defined in 32
CFR 199.2)Payment by the beneficiary
of the first $50 of the CHAMPUS determined allowable costs or charges
for covered outpatient services or supplies provided in any one
fiscal year; aggregate payment by two or more beneficiaries who
submit claims for the first $100. Effective January 1, 2018, deductibles
are determined on a calendar year basis. Deductible amounts are
outlined in the TRM,
Chapter 2.
Deductible CertificateA statement issued to the beneficiary
(or sponsor) by a TRICARE contractor certifying to the deductible amounts
satisfied by a beneficiary for any applicable program year.
Defense Centers of Excellence
(COEs)CoEs focus
on an associated group of clinical conditions and create value by
achieving improvement in outcomes through clinical, educational,
and research activities.
• CoEs develop pathways of care
covering the clinical spectrum from prevention through reintegration
or transition.
• Products of pathway of care
development include:
• Guidance regarding structured
documentation (electronic health record);
• Clinical practice guidelines;
• Process and outcome measures;
• Educational materials;
• Innovation and identification
of research priorities; and,
• Strategies for improving access
to care.
Defense Enrollment Eligibility
Reporting System (DEERS) (Defined in 32
CFR 199.2)An automated system maintained
by the DoD for the purposes of:
1. Enrolling members,
former members and their dependents; and
2. Verifying members’,
former members’, and their dependents’ eligibility for health care
benefits in the direct facilities and for TRICARE.
De-Identified DataHealth information that has
been rendered not individually identifiable by removal of specific identifiers,
such as, individual or relatives or household members, names, addresses,
employers, name or addressee, or geographic subdivisions smaller
than a State, and all elements of dates (except year) for dates
directly related to an individual, telephone numbers, Social Security
Numbers (SSNs), etc., as outlined in HIPAA of 1996.
DemonstrationA study or test project for
the purpose of trying alternative methods of payment for health
and medical services, cost-sharing by eligible beneficiaries, methods
of encouraging efficient and economical delivery of care, innovative
approaches to delivery and financing services and prepayment for
services provided to a defined population. Following completion
and evaluation of the test project, it may or may not become part
of the program.
Descriptor (HIPAA Definition)The text defining a code as
defined in HIPAA of 1996.
Designated Record SetA group of records maintained
by or for a covered entity that is:
1. The medical
records and billing records about individuals maintained by or for
a covered HCP;
2. The
enrollment, payment, claims adjudication, and case or medical management
record systems maintained by or for a health plan; or
3. Used, in whole
or in part, by or for the covered entity to make decisions about
individuals.
For purposes of this definition,
the term record means any item, collection, or grouping of information that
includes PHI and is maintained, collected, used, or disseminated
by or for a covered entity as described in HIPAA of 1996.
Designated Standard Maintenance
Organization (DSMO)An organization designated
by the Secretary of HHS under HIPAA of 1996 §162.910(a).
Diagnosis Related Groups
(DRGs) (Defined in 32 CFR 199.2)A method of dividing hospital
patients into clinically coherent groups based on their consumption
of resources. Patients are assigned to the groups based on their
principal diagnosis (the reason for admission, determined after
study), secondary diagnoses, procedures performed, and the patient’s age,
sex, and discharge status. See the TRM for more specific information
on DRGs.
Diagnostic and Statistical
Manual of Mental Disorders (DSM)A classification system of
codes for mental illness developed by the American Psychiatric Association (APA).
Direct Data Entry (HIPAA
Definition)The direct
entry of data (for example, using dumb terminals or web browsers)
that is immediately transmitted into a health plan’s computer, as
defined in HIPAA of 1996.
Direct Treatment Relationship
(HIPAA Definition)A treatment
relationship between an individual and an HCP that is not an indirect
treatment relationship as defined under HIPAA of 1996. See the definition
of “Indirect Treatment Relationship” in this appendix.
DirectorThe Director of the DHA; Director, TRICARE Management
Activity (TMA); or Director, Office of CHAMPUS (OCHAMPUS). Any reference
to the Director, Office of CHAMPUS, or OCHAMPUS, or TMA shall mean
the Director, DHA. Any reference to Director shall also include
any person designated by the Director to carry out a particular
authority. In addition, any authority of the Director may be exercised
by the Assistant Secretary of Defense for Health Affairs (ASD(HA)).
Director, MarketAn individual responsible for:
• The concept which integrates
health care among the Uniformed Services by providing increased authority
including funding allocation, policy, and better maximization of
staff skill sets; and
• Oversight geographic areas
where different Uniformed Services have overlapping service areas; and
• The movement of workload and
workforce between or among medical treatment facilities, as applicable.
Director, Military Medical
Treatment Facility (MTF)The individual responsible
for overseeing a Uniformed Services hospital or clinic.
Director, TRICARE Regional
Offices (TROs)An individual
responsible for:
1. Overseeing
and ensuring there is an integrated health care delivery system
for TRICARE beneficiaries in the region; and
2. Oversight of
the management/monitoring of the daily administration of the TRICARE
contract/contractor(s) in the region; and
3. Managing the
daily activities of the TRO.
Disaster Response DutyFor purposes of TPM,
Chapter 10, Section 10.1 only, the term “disaster
response duty” means duty performed by a member of the National
Guard in State status pursuant to an emergency declaration by the
Governor of the State (to include the four United States Territories,
or with respect to the District of Columbia, the mayor of the District
of Columbia) in response to a disaster or in preparation for an imminent
disaster.
Discharge PlanningThe development of an individualized
discharge health care plan for the patient prior to leaving an institution
to follow at home, with the aim of improving patient outcomes, reducing
the chance of unplanned readmission to an institution, and containing
costs.
Disclosure (HIPAA Definition)The release, transfer, provision
of access to, or divulging in any other manner of information outside
the entity holding the information as defined in HIPAA of 1996.
Distant SiteThe “distant site” is where
the physician or practitioner providing the professional service
is located at the time the services are provided via an interactive
telecommunications system.
DoD InformationInformation that is provided
by the DoD to a non-DoD entity, or that is collected, developed,
received, transmitted, used, or stored by a non-DoD entity in support
of an official DoD activity, where that information has not been
cleared for public release.
Domiciliary Care (Defined
in 32 CFR 199.2)Care provided to a patient
in an institution or home-like environment because:
1. Providing support
for the ADLs in the home is not available or is unsuitable; or
2. Members of
the patient’s family are unwilling to provide the care.
Note: The terms “domiciliary” and
“custodial care” represent separate concepts and are not interchangeable.
Custodial care and domiciliary care are not covered under the TRICARE
programs or the Extended Care Health Option (ECHO).
Donor (Defined in 32
CFR 199.2)An individual who supplies
living tissue or material to be used in another body, such as a
person who furnishes a kidney for renal transplant.
Double Coverage (Defined
in 32 CFR 199.2)When a TRICARE beneficiary
also is enrolled in another insurance, medical service, or health
plan that duplicates all or part of a beneficiary’s TRICARE benefits.
Double Coverage Plan
(Defined in 32 CFR 199.2)The specific insurance, medical
service, or health plan under which a TRICARE beneficiary has entitlement
to medical benefits that duplicate TRICARE benefits in whole or
in part. Double coverage plans do not include:
1. Medicaid.
2. Coverage specifically
designed to supplement TRICARE benefits.
3. Entitlement
to receive care from the Uniformed Services medical care facilities;
or
4. Entitlement
to receive care from DVA/VHA medical care facilities; or
5. Entitlement
to receive care from Indian Health Services medical care facilities;
or
6. Services
and items provided under Part C (Infants and Toddlers with Disabilities)
of the Individuals With Disabilities Education Act (IDEA).
Dual Compensation (Defined
in 32 CFR 199.2)Federal law (5 USC 5536) prohibits
active duty members or civilian employees of the U.S. Government from
receiving additional compensation from the Government above their
normal pay and allowances. This prohibition applies to TRICARE cost-sharing
of medical care provided by active duty members or civilian Government
employees to TRICARE beneficiaries.
Edit Error (TEDs Only)Errors found on TEDs (initial
submissions, resubmissions, and adjustments/cancellation submissions) which
result in non-acceptance of the records by DHA. These require correction
of the error by the contractor and resubmission of the corrected
TED to DHA for acceptance.
Electronic Media (HIPAA
Definition)A mode
of transferring/storing information that includes:
1. Electronic
storage material on which data may be recorded electronically, including
for example devices in computers (hard drives) and any removable/transportable
digital memory medium, such as magnetic tape or disk, or digital
memory card.
2. Transmission
media used to exchange information already in electronic storage
media. Transmission media includes, for example, the Internet (the
Extranet leased lines, dial-up lines, private networks, and the
physical movement of removable and transportable electronic storage
media. Certain transmissions, including paper, via facsimile, and
of voice, via telephone, are not considered to be transmissions
via electronic media if the information being exchanged did not
exist in electronic form immediately before the transmission.
Employment Records (Defined
in DoD 5400.11-R, DoD Privacy Program)Any item collection or grouping
of information, whatever the storage media (paper, electronic, etc,) about
an individual that is maintained by an entity subject to the DoD
Privacy Program Regulation including but not limited to an individual’s
education, financial transactions, medical history, criminal or
employment history, and that contains his or her name, or the identifying
number, symbol, or other identifying particular assigned to the
individual, such as a finger or voice print or a photograph. For more
specific information refer to the DoD Privacy Program Regulation.
Enrollment FeesThe amount required to be paid
by some MHS beneficiaries eligible to enroll in and receive the
benefits of TRICARE Prime, TRICARE Select or other special TRICARE
programs.
Enrollment PlanA process established by the
contractor to inform beneficiaries of the availability of the TRICARE
Prime program, facilitate enrollment in the program, and maintain
enrollment records. The plan must include actions for TRICARE Select
and must be approved by the Government. The contractor process must
be approved by the Government.
Enrollment RecordsOfficial documentation of a
beneficiary’s registration (enrollment) for TRICARE Prime and maintained on
the DEERS.
Enrollment TransferA transfer of TRICARE enrollment
from one location or contractor to another:
1. Out-Of-Contract Enrollment
Transfer. An enrollment transfer between contractors, to
include the Continental United States (CONUS) to CONUS, CONUS to
Outside of the Continental United States (OCONUS), and OCONUS to
CONUS. The term “contractors” also includes Designated Providers
(DPs) under the Uniformed Services Family Health Plan (USFHP).
2. Within-Contract Enrollment
Transfer. An enrollment transfer within a TRICARE region,
which involves a change of address and possibly a change of Primary
Care Managers (PCMs), but not a change of contractors.
Entity (Defined in 32
CFR 199.2)An entity includes a corporation,
trust, partnership, sole proprietorship or other kind of business enterprise
that is or may be eligible to receive reimbursement either directly
or indirectly from TRICARE.
Episodes of Care (EOC)Referrals are normally processed
as “Episodes of Care.” An EOC is defined as “A treatment period
that begins with the initial assessment, follow up interventions
and reassessments necessary to provide reasonable medical services
related to a specific condition.” The episode includes associated
lab, radiology, Durable Medical Equipment (DME), and ancillary therapies
(Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy
(ST)), all of which are subject to the Right of First Refusal (ROFR)
process. An episode of care generally involves evaluation and/or
treatment of one disease or condition and may allow for specialist
to specialist (secondary) referrals. Episodes are generally categorized
as “evaluate (only)” or “evaluate and treat.”
ExclusionServices and/or supplies not
reimbursable under TRICARE. This includes otherwise covered services and
supplies provided to a TRICARE eligible beneficiary by a non-authorized
provider/entity or a provider placed on “suspension” by a contractor.
Executive Director, TRICARE
Area Office(s)The individual
responsible for:
1. Overseeing
and ensuring there is an integrated health care delivery system
for TRICARE beneficiaries in the region; and
2. Oversight
of the management/monitoring of the daily administration of the
TRICARE contract/contractor(s) in the region; and
3.
Managing the daily activities of the region.
Explanation Of Benefits
(EOB)An electronic
or paper document prepared by insurance carriers, health care organizations,
and TRICARE contractors to inform beneficiaries of the actions taken
with respect to a claim for health care coverage.
Explanation Of Benefits
(EOB) PharmacyAn electronic
or paper document which provides a consolidated listing of prescriptions
filled for the beneficiary over a specific period of time. The period
of time is dependent on printed request (quarterly) or online (user
defined).
Explanation Of Payment
(EOP) PharmacyA document
provided to either the beneficiary after paper claims are processed
or network pharmacies for each payment cycle. This document describes
the action taken for each claim processed to a final determination
(paid or denied). EOPs are not generated for beneficiaries processing
claims electronically at the point of sale.
Extraordinary Physical
Or Psychological ConditionA complex physical or psychological
clinical condition of such severity which results in the dependents of
a Service member being homebound. See TPM,
Chapter
9 for additional information.
Family MemberA family member is a dependent
as defined in 10 USC 1072, who otherwise meets the requirements
to be an eligible beneficiary under the law.
Federal Records Center
(FRCs)Locations
established and maintained by the General Services Administration
(GSA) at areas throughout the U.S. for the storage, processing,
and servicing of non-current records for Government agencies.
Files AdministrationThe application of records
management techniques to filing practices to maintain records easily
and to retrieve them rapidly, to ensure their completeness, and
to facilitate the disposition of noncurrent records.
Fiscal Year (FY)The Federal Government’s 12
month accounting period which currently runs from October 1 through September
30 of the following year.
Format (HIPAA Definition)Those data elements that provide
or control the enveloping or hierarchical structure, or assist in identifying
data content of, a transaction, as defined in HIPAA of 1996.
Former MemberAn individual who is eligible
for, or entitled to, retired pay, at age 60, for non-regular service
in accordance with Chapter 1223, Title 10, USC but has been discharged
and maintains no military affiliation. These former members, at
age 60, and their eligible dependents are entitled to medical care, commissary,
exchange, and MWR privileges. Under age 60, they and their eligible
dependents are entitled to commissary, exchange, and MWR privileges
only.
FormularyA listing of pharmaceuticals
and other authorized supplies to be dispensed with appropriate prescriber’s
order from a particular POS. The formulary for any TRICARE contract
will be managed by the DoD Pharmacy and Therapeutics (P&T) Committee
with clinical guidance from the DoD Pharmacoeconomic Center (PEC).
Applicable formulary information may be viewed on the TRICARE web
site at:
http://www.health.mil/formulary.
Freedom Of ChoiceThe right to obtain medical
care from any TRICARE-authorized source available, including TRICARE Prime,
the DC and/or the MTF/eMSM systems, or obtain care from a provider
not affiliated with the contractor and seek reimbursement under
the terms and conditions of the TRICARE Standard (TRICARE Select
starting January 1, 2018) Program (see definition).
Note: Beneficiaries who voluntarily
enroll in TRICARE Prime must be informed of any restrictions on
freedom of choice that may be applicable to enrollees as a result
of enrollment. Except for any limitations on freedom of choice that
are fully disclosed to the beneficiaries at the time of enrollment, freedom
of choice provisions applicable to the TRICARE Standard (TRICARE
Select starting January 1, 2018) Program shall be applicable to
TRICARE Prime.
Freedom Of Information
Act (FOIA)A law
enacted in 1967 as an amendment to the “Public Information” section
of the Administrative Procedures Act, establishing provisions making
information available to the public. DHA and TRICARE contractors
are subject to these provisions.
Freestanding (Defined
in 32 CFR 199.2)Not “institution-affiliated”
or “institution-based.”
Full Mobilization (DoD
Definition)Expansion
of the Active Armed Forces resulting from action by Congress and
the President to mobilize all Reserve Component (RC) units and individuals
in the existing approved force structure, as well as retired military
personnel, and the resources needed for their support to meet the
requirements of a war or other national emergency involving an external
threat to the national security. Reserve personnel can be placed
on active duty for the duration of the emergency plus six months.
Gag ClauseA provision that is included
in a professional provider’s agreement or contract with a managed
care organization; such as a Preferred Provider Organization (PPO)
network or a Health Maintenance Organization (HMO) network, or third-party
payer that directly or indirectly prevents limits the ability of the
HCP from being open with his/her patients about the terms of the
patient’s coverage and therapeutic treatment options, including,
the risks, benefits and consequences of treatment or non-treatment,
or the opportunity for the individual to refuse treatment and to
express preferences about future treatment options.
Good Faith Payments (Defined
in 32 CFR 199.2)Those payments made to civilian
sources of medical care who provided medical care to persons purporting
to be eligible beneficiaries but who are determined later to be
ineligible for TRICARE benefits. (The ineligible person usually
possesses an erroneous or illegal identification card.) To be considered
for good faith payments, the civilian source of care must have exercised
reasonable precautions in identifying a person claiming to be an
eligible beneficiary.
GrievanceA written complaint on a non-appealable
issue which deals primarily with a perceived failure of a network
provider, the Health Care Finder (HCF), or contractor or subcontractor,
to furnish the level or quality of care expected by a beneficiary.
Grievance ProcessA contractor developed and
managed system for resolving beneficiary grievances.
Group A and BWith respect to beneficiary
cost-sharing, deductibles and catastrophic cap, the NDAA 2017 divided beneficiaries
enrolled in TRICARE Prime or TRICARE Select into two groups:
• Group A (or grandfathered)
beneficiaries: consists of sponsors and their family members who
first became affiliated with a Uniformed Service through enlistment
or appointment before January 1, 2018.
• Group B (or non-grandfathered)
beneficiaries: consists of sponsors and their family members who first
became affiliated with a Uniformed Service through enlistment or
appointment on or after January 1, 2018.
Effective January 1, 2018,
enrollees in the TRICARE Reserve Select (TRS), TRICARE Retired Reserve
(TRR), TRICARE Young Adult (TYA), or the CHCBP have Group B cost-shares,
deductibles, and catastrophic caps, regardless of when the sponsor
first became affiliated with a Uniformed Service through enlistment
or appointment.
Group Health Plan (GHP)An employee welfare benefit
plan (as defined in section 3(1) of the Employee Retirement Income
and Security Act of 1974 (ERISA), 29 USC 1002(1)), including insured
and self-insured plans, to the extent that the plan provides medical
care (as defined in section 2791(a)(2) of the Public Health Service
Act (PHS Act), 42 USC 300gg-91(a)(2)), including items and services
paid for as medical care, to employees or their dependents directly
or through insurance, reimbursement, or otherwise, that:
1. Has 50 or more
participants (as defined in section 3(7) of ERISA, 29 USC 1002(7));
or
2. Is
administered by an entity other than the employer that established
and maintains the plan.
Health CareThe prevention, treatment and
management of illness and the preservation of mental and physical
well being by qualified medical professionals. This includes but
is not limited to, preventive, diagnostic, therapeutic, rehabilitative,
maintenance, or palliative care, and counseling, service, assessment,
or procedure with respect to the physical or mental condition, or
functional status, of an individual or that affects the structure
or function of the body; and the sale or dispensing of a drug, device,
equipment, or other item in accordance with a prescription. As described
in HIPAA of 1996.
Health Care Clearinghouse
(HIPAA Definition)A public
or private entity, including a billing service, repricing company,
community health management information system or community health
information system, and “value-added” networks and switches, that
does either of the following functions.
1. Processes or
facilitates the processing of health information received from another
entity in a nonstandard format or containing nonstandard data content
into standard data elements or a standard transaction.
2. Receives a
standard transaction from another entity and processes or facilitates
the processing of health information into nonstandard format or
nonstandard data content for the receiving entity. As defined in
HIPAA of 1996.
Health Care Common Procedure
Coding System (HCPCS)Set of health care procedure
codes based on the American Medical Association’s (AMA’s) Current Procedural
Terminology (CPT).
Health Care Finder (HCF)A person who manages and performs
the duties necessary to operate an HCF system.
Health Care Finder (HCF)
SystemA system
or mechanism, established by the contractor in each Prime Service
Area (PSA) in the region, to facilitate referrals and other customer
service functions to assist beneficiaries in accessing health care to
the DC system and/or civilian providers.
Health Care Provider
(HCP) (HIPAA Definition)A provider of medical or health
services, institutional or individual professional provider, and
any other person or organization who furnishes, bills, or is paid
for health care in the normal course of business as defined in HIPAA
of 1996.
Health Information (HIPAA
Definition)Any information,
including genetic information, whether oral or recorded, in any
form or medium that:
1. Is
created or received by a HCP, health plan, public health authority,
employer, life insurer, school or university, or health care clearinghouse;
and
2. Relates
to the past, present, or future physical or mental health or condition
of an individual; the provision of health care to an individual;
or the past, present, or future payment for the provision of health
care to an individual.
As defined in HIPAA of 1996.
Health Insurance Issuer
(HIPAA Definition)An insurance
company, insurance service, or insurance organization (including
an HMO) that is licensed to engage in the business of insurance
in a State and is subject to State Law that regulates insurance. Such
term does not include a group health plan.
Health Maintenance Organization
(HMO) (HIPAA Definition)A federally qualified HMO,
an organization recognized as an HMO under State law, or a similar organization
regulated for solvency under State law in the same manner and to
the same extent as such an HMO as defined in HIPAA of 1996.
Health Oversight Agency
(HIPAA Definition)An agency
or authority of the U.S., a State, a territory, a political subdivision
of a State or territory, or an Indian tribe, or a person or entity
acting under a grant of authority from or contract with such public agency,
including the employees or agents of such public agency or its contractors
or persons or entities to whom it has granted authority, that is
authorized by law to oversee the health care system (whether public
or private) or Government programs in which health information is
necessary to determine eligibility or compliance, or to enforce
civil rights laws for which health information is relevant as defined
in HIPAA of 1996.
Note: The term “health oversight
agency” includes any DoD Component authorized under applicable DoD
Regulation to oversee the MHS, including with respect to matters
of quality of care, risk management, program integrity, financial
management, standards of conduct, or the effectiveness of the MHS
in carrying out its mission.
Health Plan (HIPAA Definition)An individual or group plan
that provides or pays the cost of medical care. For a more detailed definition
refer to HIPAA of 1996.
HIPAA BreachAn incident that satisfies
the definition of a breach in 45 CFR 164.402 (HIPAA Breach Rule).
Homebound (Defined in 32
CFR 199.2)A beneficiary’s condition is
such that there exists a normal inability to leave home, and consequently, leaving
home would require considerable and taxing effort. Any absence of
an individual from the home attributable to the need to receive
health care treatment including regular absences for the purpose
of participating in rehabilitative, therapeutic, psychosocial, or
medical treatment in an adult daycare program that is licensed or
certified by a state, or accredited to furnish adult daycare services
in the state shall not disqualify an individual from being considered
to be confined to home. Any other absence of an individual from
the home shall not disqualify an individual if the absence is infrequent
or of relatively short duration. For the purposes of the preceding
sentence, any absence for the purpose of attending a religious service
shall be deemed to be an absence of infrequent or short duration.
Also, absences from the home for non-medical purposes, such as an
occasional trip to the barber, a walk around the block or a drive,
would not necessarily negate the beneficiary’s homebound status
if the absences are undertaken on an infrequent basis and are of
relatively short duration. An exception is made to the above homebound
definitional criteria for beneficiaries under the age of 18 and
those receiving maternity care. The only homebound criteria for
these special beneficiary categories is written certification from
a physician attesting to the fact that leaving home would place
the beneficiary at medical risk. In addition to the above absences,
whether regular or infrequent, from the beneficiary’s primary home
for the purpose of attending an educational program in a public
or private school that is licensed and/or certified by a state,
shall not negate the beneficiary’s homebound status. See also TPM,
Chapter
9 for additional information.
Hospital DayAn overnight stay at a hospital.
Normally if the patient is discharged in less than 24 hours it would
not be considered an inpatient stay; however, if the patient was
admitted and assigned to a bed and the intent of the hospital was
to keep the patient overnight, regardless of the actual Length-Of-Stay
(LOS), the stay will be considered an inpatient stay and, therefore,
a hospital day. For hospital stays exceeding 24 hours, the day of
admission is considered a hospital day; the day of discharge is
not.
Immediate Family (Defined
in 32 CFR 199.2)The spouse, natural parent,
child and sibling, adopted child and adoptive parent, stepparent,
stepchild, grandparent, grandchild, stepbrother and stepsister,
father-in-law, mother-in-law of the beneficiary, or provider, as
appropriate. For purposes of this definition only, to determine
who may render services to a beneficiary, the step-relationship
continues to exist even if the marriage upon which the relationship
is based terminates through divorce or death of one of the parents.
Independent Laboratory
(Defined in 32 CFR 199.2)A freestanding laboratory approved
for participation under Medicare and certified by the CMS.
Indirect Treatment Relationship
(HIPAA Definition)A relationship
between an individual and a HCP in which:
1. The HCP delivers
health care to the individual based on the orders of another HCP;
and
2. The
HCP typically provides services or products, or reports the diagnosis
or results associated with the health care, directly to another
HCP, who provides the services or products or reports to the individual.
As defined in HIPAA of 1996.
IndividualThe person who is the subject
of PHI as defined in HIPAA of 1996.
Individual Consideration
(IC) ProcedureA service/treatment
not routinely provided, is unusual, variable, or new and, as such,
will require additional information from the provider of care, including
an adequate definition or description of the nature, extent and
need for the unusual service/treatment including the time, effort,
and necessary equipment required. Any complexities related to the
service should also be identified.
Individually Identifiable
Health Information (IIHI) (HIPAA Definition)Information that is a subset
of health information, including demographic information collected
from an individual, and:
1. Is
created or received by a HCP, health plan, employer, or health care
clearinghouse; and
2. Relates to
the past, present, or future physical or mental health or condition
of an individual; the provision of health care to an individual;
or the past, present, or future payment for the provision of health
care to an individual; and
3. That identifies
the individual; or
4. With respect
to which there is a reasonable basis to believe the information
can be used to identify the individual.
As defined in HIPAA of 1996.
Initial Determination
(Defined in 32 CFR 199.2)A formal written decision on
a TRICARE claim, a request for benefit authorization, a request
by a provider for approval as an authorized TRICARE provider, or
a decision disqualifying or excluding a provider as an authorized
provider under TRICARE. Rejection of a claim or a request for benefit
or provider authorization for failure to comply with administrative
requirements, including failure to submit reasonably requested information,
is not an initial determination. Responses to general or specific
inquiries regarding TRICARE benefits are not initial determinations.
Initial PaymentThe first payment on a continuing
claim, such as a long-term institutional claim.
Inpatient (Defined in 32
CFR 199.2)A patient who has been admitted
to a hospital or other authorized institution for bed occupancy
for purposes of receiving necessary medical care, with the reasonable
expectation that the patient will remain in the institution at least
24 hours, and with the registration and assignment of an inpatient number
or designation. Institutional care in connection with in and out
(ambulatory) surgery is not included within the meaning of inpatient
whether or not an inpatient number or designation is made by the
hospital or other institution. If the patient has been received
at the hospital, but death occurs before the actual admission occurs,
an inpatient admission exists as if the patient had lived and had been
formally admitted.
Inpatient CareServices/treatment provided
to a person who has been admitted to a hospital or other authorized institution.
Inpatient Rehabilitation
Facility (IRF)A facility
classified by CMS as an IRF and meets the applicable requirements
established by
32 CFR 199.6(b)(4)(xx) (which includes the
requirement to be a Medicare participating provider).
InquiryRequests for information or
assistance made by or on behalf of a beneficiary, provider, the
public, or the Government. Written inquiries may be made in any
format (letter, memorandum, note attached to a claim, etc.). Allowable
charge complaints, grievances, and appeals are excluded from this
definition.
Institution-Affiliated
(Defined in 32 CFR 199.2)Related to a TRICARE authorized
institutional provider through a shared governing body but operating under
a separate and distinct license or accreditation.
Institution-Based (Defined
in 32 CFR 199.2)Related to a TRICARE authorized
institutional provider through a shared governing body and operating under
a common license and shared accreditation.
Institutional ProviderA HCP who meets the applicable
requirements established by
32 CFR 199.6.
Intensive Outpatient
Program (IOP)A treatment
setting capable of providing an organized day or evening program
that includes assessment, treatment, case management, and rehabilitation
for individuals not requiring 24-hour care for mental health disorders,
to include SUDs, as appropriate for the individual patient. The
program structure is regularly scheduled, individualized, and shares
monitoring and support with the patient’s family and support system.
Interactive Telecommunications
SystemInteractive
telecommunications systems are defined as multimedia communications
modalities that include, at a minimum, secure audio and video equipment
permitting two-way, real-time services or consultations. This includes
smartphones, tablet computers, and personal computers equipped with the
necessary camera and software to enable two-way, encrypted real-time
audio and video interaction; as well as dedicated video conferencing
and telemedicine systems.
Internal Control Number
(ICN)The unique
number assigned to a claim by the contractor to distinguish the
claim during processing, payment, and filing procedures. It is the
number affixed to the face of each claim received and will, at a minimum,
include the Julian date of receipt and a five digit sequence number
assigned by the contractor. Each TED must have a unique ICN. For
records generated from claims, it will be the ICN of the claim from
which it was generated. For a TED which is not generated from claims,
it will be a unique number assigned by the contractor which will
include the Julian date of the record’s creation and a five digit
sequence number.
International Classification
of Diseases, 9th Edition, Clinical Modification (ICD-9-CM)A technical reference, ICD-9-CM.
Volumes 1 and 2 are a required reference and coding system for diagnoses
and Volume 3 is required as a coding system for procedures in processing
TRICARE claims for medical care with dates of service for outpatient
services or dates of discharge for inpatient services before the
mandated date, as directed by HHS, for ICD-10 implementation.
International Classification
of Diseases, 10th Edition, Clinical Modification (ICD-10-CM)A technical reference, ICD-10-CM.
It is a required reference and coding system for diagnoses in processing
TRICARE claims for medical care with dates of service for outpatient
services or dates of discharge for inpatient services on or after
the mandated date, as directed by HHS, for ICD-10 implementation.
International Classification
of Diseases, 10th Edition, Procedure Coding System (ICD-10-PCS)A technical reference, ICD-10-PCS.
It is a required reference and coding system for procedures in processing
TRICARE claims for medical care with dates of discharge for inpatient
services on or after the mandated date, as directed by HHS, for
ICD-10 implementation.
Intervention, PharmacyA change in therapy resulting
from the prospective drug utilization review process and contact
with the prescriber and/or the beneficiary because of allergy, clinically
significant interactions, duplicative therapy, or other reasons.
Intervention Report,
PharmacyA formal
account of prescriptions not dispensed or changes in therapy as
a result of contact with prescriber's and/or beneficiaries because
of allergies, clinically significant interactions, duplicative therapy,
or other reasons. The formal account shall also contain the resultant
change in cost due to the intervention, if possible.
Investigational DrugsNew medicines or other substances
which have a physiological effect when ingested or otherwise introduced
into the body, that have not been approved for general use by the
FDA but is under investigation and clinical trial regarding its
safety and efficacy first by clinical investigators and then by practicing
physician using subjects who have given informed consent to participate.
Laboratory And Pathological
Services (Defined in 32 CFR 199.2)Laboratory and pathological
examinations (including machine diagnostic tests that produce hard-copy results)
when necessary to, and rendered in connection with medical, obstetrical,
or surgical diagnosis or treatment of an illness or injury, or in
connection with well-baby care.
Law Enforcement Official
(HIPAA Definition)An officer
or employee of any agency or authority of the U.S., a State, a territory,
a political subdivision of a State or territory, or an Indian tribe,
who is empowered by law to:
1. Investigate
or conduct an official inquiry into a potential violation of law;
or
2. Prosecute
or otherwise conduct a criminal, civil, or administrative proceeding
arising from an alleged violation of law.
For further details, refer
to HIPAA of 1996.
Legacy IdentifierA number used to identify unique
providers. These number include the six-digit Medicare ID number, Unique
Physician Identification Number (UPIN), 10-digit Ambulatory Surgery
Center (ASC) number, Supplier Clearinghouse (NSC) number, Online
Survey Certification and Reporting (OSCAR) number, and DME supplier
number. A legacy identification number is other than the unique
NPI required by HIPAA of 1996 to be issued to each physician, supplier
and other provider of health care and the Federal Tax Identification
Number (TIN). A Federal TIN is not considered a legacy identifier
for health care purposes as it’s primary purpose is to support IRS
1099 reporting.
Limited Data Set (HIPAA
Definition)A semantically
meaningful unit of information exchanged between two parties to
a transaction that excludes direct identifiers of the individual
or of relatives, employers, or household members of the individual
which is considered to be PHI as defined in HIPAA of 1996.
Long-Term Care Hospital
(LTCH)A hospital
that is classified by the CMS as an LTCH and meets the applicable
requirements established by
32 CFR 199.6(b)(4)(v) (which includes the
requirement to be a Medicare participating provider).
Machine-Readable Records/ArchivesThe records and archives whose
informational content is usually in code and has been recorded on media,
such as magnetic disks, drums, tapes, punched paper cards, or punched
paper tapes, accompanied by finding aids known as software documentation.
The coded information is retrievable only by machine.
Maintain Or Maintenance
(HIPAA Definition)Activities
necessary to support the use of a standard adopted by the Secretary
of HHS, including technical corrections to an implementation specification,
and enhancements, or expansion of a code set. This term excludes
the activities related to the adoption of a new standard or implementation specification,
or modification to an adopted standard or implementation specification.
Major Diagnostic Category
(MDC)A group
of similar DRGs, such as all those effecting a given organ system
of the body formed by dividing all possible principal diagnoses
from (ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDC
codes, like DRG codes, are primarily a claims and administrative
data element unique to the U.S. medical care reimbursement system.
DRG codes are also mapped, or grouped, into the MDC codes.
Managed Care Support
Contractor (MCSC)Civilian
contractor, under contract with the DoD, to work with, help support
and augment health care services available at the MTFs/eMSMs resulting
in the establishment of an integrated system of health care delivery
that influences utilization of services, cost of services while
measuring performance. The contractor is required to assist military
personnel in the combining of the resources of the military’s direct
medical care system, the TRICARE program and the contractor’s managed
care provider network and other services outlined in the contract
to ensure a system that delivers value by giving TRICARE eligible
beneficiaries access to quality, cost-effective health care.
Market (previously Enhanced
Multi-Service Market (eMSM))Concept which integrates health
care among the Uniformed Services by providing increased authority including
funding allocation, policy, and better maximization of staff skill
sets. The concept is employed in geographic areas where different
Uniformed Services have overlapping service areas. This concept provides
the MHS the ability for the movement of workload and workforce between
or among the medical treatment facilities based on several factors,
including overall size, medical mission, and graduate medical education
capacity.
Marketing (HIPAA Definition)Communication about a product
or service to encourage recipients of the communication to purchase or
use the product or service as defined in HIPAA of 1996. See also
DoD 6025.18R, DoD Health Information Privacy Regulation, for a list
of specific exclusions to this definition.
Maximum Allowable Prevailing
ChargeThe TRICARE
state prevailing charges adjusted by the Medicare Economic Index
(MEI) according to the methodology as set forth in
Chapter
16.
Maximum Defined Data
Set (HIPAA Definition)All required data elements
for a particular standard based on a specific implementation specification.
Medicaid (Defined in 32
CFR 199.2)Those medical benefits authorized
under Title XIX of the Social Security Act provided to welfare recipients
and the medically indigent through programs as administered by the
various states.
Medical (Defined in 32
CFR 199.2)The generally used term which
pertains to the diagnosis and treatment of illness, injury, pregnancy, and
mental disorders by trained and licensed or certified health professionals.
For purposes of TRICARE, the term “medical” should be understood
to include “medical, psychological, surgical, and obstetrical,” unless
it is specifically stated that a more restrictive meaning is intended.
Medical/Dental Claims
History FileRefer
to Beneficiary History File definition.
Medical Emergency (Defined
in 32 CFR 199.2)The sudden and unexpected onset
of a medical condition or the acute exacerbation of a chronic condition
that is threatening to life, limb, or sight, and requires immediate
medical treatment or which manifests painful, symptomatology requiring
immediate palliative efforts to alleviate suffering. Medical emergencies
include heart attacks, cardiovascular accidents poisoning, convulsions,
kidney stones, and such other acute medical conditions as may be
determined to be medical emergencies by the Director, DHA or a designee.
In the case of a pregnancy, a medical emergency must involve a sudden
and unexpected medical complication that puts the mother, the baby,
or both, at risk. Pain would not, however, qualify a maternity case
as an emergency, nor would incipient birth after the 34th week of gestation,
unless an otherwise qualifying medical condition is present. Examples
of medical emergencies related to pregnancy or delivery are hemorrhage,
ruptured membrane with prolapsed cord, placenta previa, abruption
placenta, presence of shock or unconsciousness, suspected heart attack
or stroke, or trauma (such as injuries received in an automobile
accident.
Medical Necessity DeterminationA review to determine if the
recommended health care services are reasonable for the diagnosis
and treatment of illness, injury, pregnancy, mental disorders and
adequate for well-baby care.
Medical Supplies And
Dressings (Consumables) (Defined in 32
CFR 199.2)Necessary medical or surgical
supplies (exclusive of DME) that do not withstand prolonged, repeated use
and that are needed for the proper medical management of a condition
for which benefits are otherwise authorized under TRICARE, on either
an inpatient or outpatient basis. Examples include disposable syringes
for a diabetic, colostomy sets, irrigation sets, and ace bandages.
Medical ManagementContemporary practices in areas
such as Utilization Management (UM), Case Management (CM), care coordination,
chronic care/Disease Management (DM), and the various additional
terms and models for managing the clinical and social needs of eligible
beneficiaries to achieve the short and long term cost-effectiveness
of the MHS while achieving the highest level of satisfaction among
MHS beneficiaries.
Medically or Psychologically
Necessary (Defined in 32 CFR 199.2)The frequency, extent and types
of medical services or supplies, which represent appropriate medical care
and that are generally accepted by qualified professionals to be
reasonable and adequate for the diagnosis and treatment of illness,
injury, pregnancy, and mental disorders or that are reasonable and adequate
for well-baby care.
Medicare (Defined in 32
CFR 199.2)The medical benefits authorized
under Title XVIII of the Social Security Act provided to persons
65 or older, certain disabled persons, or persons with chronic renal
disease, through a national program administered by the Department
of Health and Human Services (DHHS), Health Care Financing Administration
(HCFA), Medicare Bureau.
Medicare Economic Index
(MEI)An index
used by Medicare to update physician fee levels in relation to annual
changes in the general economy for inflation, productivity, and
changes in specific health sector practice expenses factors including
malpractice, personnel costs, rent, and other expenses.
Medication Assisted Treatment
(MAT)MAT for
diagnosed SUD is a holistic modality for recovery and treatment
that employs evidence-based therapy, including psychosocial treatments
and psychopharmacology, and FDA-approved medications as indicated
for the management of withdrawal symptoms and maintenance.
Medication Error (FDA
Definition)Any preventable
event that may cause or lead to inappropriate medication use or
patient harm while the medication is in the control of the health
care professional, patient, or consumer. Such events may be related
to professional practice, health care products, procedures, and
systems, including prescribing, order communication, product labeling
packaging, and nomenclature, compounding, dispensing, distribution,
administration, education, monitoring and use as defined by the
FDA.
Mental Disorder, To Include
SUD
For purposes of the payment
of TRICARE benefits, a mental disorder is a nervous or mental condition that
involves a clinically significant behavioral or psychological syndrome
or pattern that is associated with a painful symptom, such as distress,
and that impairs a patient’s ability to function in one or more major
life activities. An SUD is a mental condition that involves a maladaptive
pattern of substance use leading to clinically significant impairment
or distress; impaired control over substance use; social impairment;
and risky use of a substance(s). Additionally, the mental disorder
must be one of those conditions listed in the current edition of
the DSM. “Conditions Not Attributable to a Mental Disorder,” or V codes,
or ICD-10-CM Z codes, are not considered diagnosable
mental disorders.
MemberAn individual who is affiliated
with a Service, either an active duty member, reserve member, active duty
retired member, or retired reserve member. Members in a retired
status are not former members. Also referred to as the sponsor.
Mental Health Therapeutic
Absence (Defined in 32 CFR 199.2)A therapeutically planned absence
from the inpatient setting. The patient is not discharged from the facility
and may be away for periods of several hours to several days. The
purpose of the therapeutic absence is to give the patient an opportunity
to test his or her ability to function outside the inpatient setting
before the actual discharge.
Military Health System
(MHS) BeneficiaryAny individual
who is eligible to receive treatment in an Market/MTF. Eligibility
is determined by the Uniformed Services and is reported on DEERS.
Note: The categories of MHS beneficiaries
shall be broadly interpreted unless otherwise specifically restricted.
(For example: Authorized parents and parents-in-law are not eligible
for TRICARE Program, but may receive treatment in an Market/MTF (on
a space available basis) and may access the Nurse Advise Line (NAC)).
Military Medical Treatment
Facility (MTF)A Uniformed
Services hospital or clinic.
Military Medical Treatment
Facility (MTF) Director
The individual responsible
for overseeing a Uniformed Services hospital or clinic.
Market/Military Medical
Treatment Facility (MTF) OptimizationFilling every appointment and
bed available within the MTF or in the Market based on the capacity
and capabilities of the Market/MTF and the Market’s/MTF’s readiness/training
requirements, as defined by the Market/MTF Director before referral
to outside civilian providers.
Military Medical Treatment
Facility (MTF)-Referred CareMedical care or services/supplies
required by a patient that are not available at the MTF or in the Market area
and therefore must be provided by an outside civilian provider.
Such care requires an Market/MTF referral for the civilian medical
care.
Mobilization Plan - TRICAREA detailed proposal designed
to ensure the Government’s ability to continue to meet the health
care needs of the TRICARE-eligible beneficiaries in the event of
a military mobilization that precludes the use of all or parts of
the military DC system for provision of care to TRICARE-eligible
beneficiaries.
Monthly Pro-RatingA calculation process for determining
the amount of the enrollment fee to be credited to a new enrollment
period. For example, if a beneficiary pays their annual enrollment
fee, in total, on January 1, (the first day of their enrollment
period) and a change in status occurs on February 15. The beneficiary will
receive credit for 10 months of the enrollment fee. The beneficiary
will lose that portion of the enrollment fee that would have covered
the period from February 15 through February 28.
Most-Favored Rate (Defined
in 32 CFR 199.2)The lowest usual charge to
any individual or third-party payer in effect on the date of the
admission of a TRICARE beneficiary.
National Appropriate
Charge LevelThe charge
level established from a 1991 national appropriate charge file developed
from July 1986 - June 1987 claims data, by applying appropriate
MEI updates through 1990, and prevailing charge cuts, freeze or
MEI updates for 1991 as discussed in the September 6, 1991, Final
Rule.
National Conversion Factor
(NCF)A mathematical
representation of what is currently being paid for similar services
nationally. The factor is based on the national allowable charges
actually in use.
National Disaster Medical
System (NDMS)A Federally
coordinated framework that augments the nation’s medical response
capability. The primary purpose of the NDMS is to supplement an
integrated national medical response for assisting state and local
authorities in dealing with medical impacts of major peacetime disasters
and to provide support to the military and the DVA/VHA medical systems
in caring for casualties evacuated back to the U.S. from overseas
armed conventional conflict. The NDMS framework involves private
sector hospitals located throughout the U.S. that will provide care
for victims of any incident that exceeds the medical care capability
of any affected state, region, or federal medical care system. For
more detailed information see NDMS at the DHHS web site.
National Prevailing Charge
LevelA rate
that does not exceed the amount equivalent to the eightieth (80th)
percentile of billed charges made for similar services during a
12 month base period.
National Provider Identifier
(NPI) (HIPAA Definition)A 10-digit number assigned
to all HCPs mandated by HIPAA of 1996. These numbers are to be used
for all financial and administrative transactions. The 10-digit
number, containing checksum, prevents technical errors during data
transmission. The number doesn’t have built-in correlation with
any other identifier associated with the provider.
Negotiated (Discounted)
RateAn amount
that represents the reimbursable amount that a provider agrees to
accept for covered services.
NetworkThe providers or facilities
(owned, leased, or arranged) the TRICARE contractor has contracted
with to provide health care services to TRICARE eligible beneficiaries
at a pre-negotiated rate as the total charge for services provided
by the provider and to file claims for beneficiaries. The agreements
for health care delivery made between the MTF and the eMSM and the
TRICARE contractor are also included in this definition.
Network CareHealth care services and supplies
provided by providers and facilities (owned, leased, arranged) the TRICARE
contractor has contracted with to provide necessary treatment to
TRICARE eligible beneficiaries.
Network InadequacyInsufficient TRICARE contractor
contracted providers to meet the access standards required by the TRICARE
contract.
Network ProviderAn individual or institutional
provider that has contracted with a TRICARE contractor to provide
care to TRICARE eligible beneficiaries, usually at a discounted
rate.
Note: All network
providers MUST be participating providers.
Non-Appealable IssueDenial of benefits based on
a fact or condition outside the scope of responsibility of DHA and
the TRICARE contractor.
Note: For example, the establishment
of eligibility is a Uniformed Service responsibility and if the service
has not established that eligibility, neither DHA nor a TRICARE
contractor may review the action. Similarly, late claim filing,
late appeal filing, amount of allowable charge (the contractor must
verify it was properly applied and calculated), and services or
supplies specifically excluded by law or regulation, such as routine
dental care, clothing, routine vision care, etc., are matters subject
to legislative action or regulatory rule making not appealable under
TRICARE. TRICARE contractors shall not make a determination that
an issue is not appealable except as specified in
Chapter
13 and
32 CFR 199.10.
Non-Claim Health Care
DataInformation
captured by the TRICARE contractor to complete the required TED
record for care rendered to TRICARE beneficiaries in those contractor
owned, operated and/or subcontracted facilities where there is no
claim submitted by the provider of care.
Non-Compliant, PharmacyAction which results in a medication
being returned to stock for various reasons such as the medication was
not picked by the patient within the given 10 day grace period,
pharmacy/physician cancelled the prescription, etc.
Note: A subsequent reversal is automatically
sent to Pharmacy Data Transaction Service (PDTS) which will result
in the removal of the prescription fill from the patient profile.
A reversed or adjusted TED record is also submitted to DHA resulting
in a financial credit to the Government.
Non-Current RecordsDocuments that are no longer
required in the conduct of current business and therefore can be retrieved
by an archival repository or destroyed.
Non-Department Mental
health Care ProviderFor the purposes of establishing
a mental health care provider readiness designation as mandated
by the National Defense and Authorization Act (NDAA) for Fiscal
Year (FY) 2016 Section 717, a non-Department mental health care
provider is a health care provider who specializes in mental health,
is not a health care provider of the DoD at a facility of the Department,
and provides health care to members of the Armed Forces. It includes
psychiatrists, psychologists, psychiatric nurses, social workers,
mental health counselors, marriage and family therapists, and other
mental health care providers designated by the Secretary of Defense.
Non-DoD Information System
(IS)An IS
that is not owned, controlled, or operated by the DoD, and is not
used or operated by a contractor or other non-DoD entity exclusively
on behalf of the DoD.
Non-DoD TRICARE BeneficiariesA special category of individuals
sponsored by non-DoD Uniformed Services (the Commissioned Corps of
the U.S. Public Health Service (USPHS), the U.S. Coast Guard, and
the Commissioned Corps of the National Oceanic and Atmospheric Administration
(NOAA)) who are eligible for TRICARE.
Non-Network CareServices and supplies received
from a civilian provider authorized to provide health care but has
no contractual relationship with the TRICARE contractor.
Non-Network ProviderAn individual or institutional
provider that not has contracted with a TRICARE contractor to provide care
to TRICARE eligible beneficiaries at a discounted rate.
Non-Participating Provider
(Defined in 32 CFR 199.2)A hospital or other authorized
institutional provider, a physician or other authorized individual professional
provider, or other authorized provider that furnished medical services
or supplies to a TRICARE beneficiary, but who did not agree on the
TRICARE claim form to participate or to accept the TRICARE-determined
allowable cost or charge as the total charge for the services. A
nonparticipating provider looks to the beneficiary or sponsor for
payment of his or her charge, not TRICARE. In such cases, TRICARE
pays the beneficiary or sponsor, not the provider.
Non-Prime TRICARE BeneficiariesIndividuals, eligible for the
TRICARE Program, who are not enrolled in the TRICARE Prime program.
North Atlantic Treaty
Organization (NATO) MemberA military member of an armed
force of a foreign NATO nation who is on active duty and who, in connection
with official duties, is stationed in or passing through the U.S.
For a list of member nations, see
https://www.nato.int/cps/ie/natohq/topics_52044.htm.
Office-Based Opioid Treatment
(OBOT)
TRICARE authorized providers
acting within the scope of their licensure or certification to prescribe outpatient
supplies of the medication to assist in withdrawal management (detoxification)
and/or maintenance of opioid use disorder, as regulated by 42 CFR
Part 8, addressing OBOT.
Open Enrollment PeriodThe yearly period when non-active
duty beneficiaries can enroll in or change their TRICARE enrolled plan
coverage for the following calendar program year. The open enrollment
period for TRICARE begins on the Monday of the second full week
in November to the Monday of the second full week in December of
each calendar year. See TPM,
Chapter 10, Section 2.1.
Opioid Treatment Program
(OTP)OTPs are
service settings for opioid treatment, either freestanding or hospital-based,
that adhere to the DHHS’ regulations at 42 CFR Part 8 and use medications
indicated and approved by DHA. OTPs provide a comprehensive, individually
tailored program of medication therapy integrated with psychosocial and
medical treatment and support services that address factors affecting
each patient, as certified by the Center for Substance Abuse Treatment
(CSAT) of the DHHS’ Substance Abuse and Mental Health Services Administration
(SAMHSA). Treatment in OTPs can include management of withdrawal symptoms
(detoxification) from opioids and medically supervised withdrawal
from maintenance medications. Patients receiving care for substance
use and co-occurring disorders care can be referred to, or otherwise
concurrently enrolled in, OTP.
Organized Health Care
Arrangement (HIPAA Definition)1. A clinically
integrated care setting in which individuals typically receive health
care from more than one HCP;
2. An organized
system of health care in which more than one covered entity participates,
and in which the participating covered entities hold themselves
out to the public as participating in a joint arrangement and participate
in joint activities such as utilization review, quality assessment
and improvement activities, or payment activities.
3. A group health
plan and a health insurance issuer or HMO with respect to such group
health plan, but only with respect to PHI created or received by
such health insurance issuer or HMO that relates to individuals
who are or who have been participants or beneficiaries in such group
health plan;
4. A group health
plan and one or more other group health plans each of which are
maintained by the same plan sponsor; or
5. The group health
plans described in paragraph 4 of this definition and health insurance
issuers or HMOs with respect to such group health plans, but only
with respect to PHI created or received by such health insurance
issuers or HMOs that relates to individuals who are or have been
participants or beneficiaries in any of such group health plans.
For full details refer to HIPAA
of 1996.
Originating SiteThe originating site is where
the beneficiary is located at the time the services are provided
via an interactive telecommunications system. The originating site
must be either (a) where an otherwise authorized TRICARE provider
normally offers professional medical or psychological services,
such as the office of a TRICARE authorized individual professional
provider (e.g., physician’s office), (b) a TRICARE authorized institutional
provider, or (c) a patient’s home or other secure location as outlined
in this policy.
Other Health Insurance
(OHI)Alternate
or additional health plan coverage other than TRICARE. This does
not include Medicare or supplemental insurance plans.
Other Special Institutional
Providers (Defined in 32 CFR 199.2)Certain specialized medical
treatment facilities, either inpatient or outpatient, other than
those specifically defined, that provide courses of treatment prescribed
by a doctor of medicine or osteopathy; when the patient is under
the supervision of a doctor of medicine or osteopathy during the
entire course of the inpatient admission or the outpatient treatment;
when the type and level of care and services rendered by the institution
are otherwise authorized in 32 CFR 199; when the facility meets
all licensing or other certification requirements that are extant
in the jurisdiction in which the facility is located geographically;
which is accredited by an accrediting organization approved by the Director,
DHA if an appropriate accreditation program for the given type of
facility is available; and which is not a nursing home, intermediate
facility, halfway house, home for the aged, or other institution
of similar purpose.
Out-Of-Area CareTreatment received by TRICARE
eligible beneficiaries while traveling outside their TRICARE region.
Out-Of-Network CareSee definition for Non-network
Care.
Out-Of-Region BeneficiariesIndividuals who resides in
one TRICARE region but receives care within another TRICARE region.
Over-The-Counter (OTC)
MedicationsDrugs
that by law can be sold to a consumer without a prescription from
a health care professional.
Note: OTC drugs/items covered by
the TRICARE Pharmacy (TPharm) benefit (see
https://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx for
covered items) will be reimbursed by the TPharm contractor when
purchased with or without a prescription, as long as the purchase
was from a retail pharmacy. Covered OTC’s purchased without a prescription
from a medical supply house or venue other than a retail pharmacy
will be processed for reimbursement by the TRICARE regional contractor.
Partial HospitalizationA treatment setting capable
of providing an interdisciplinary program of medically monitored therapeutic
services, to include management of withdrawal symptoms, as medically
indicated. Services may include day, evening, night, and weekend
treatment programs which employ an integrated, comprehensive, and
complementary schedule of recognized treatment approaches. Partial hospitalization
is a time-limited, ambulatory, active treatment program that offers
therapeutically intensive, coordinated, and structured clinical
services within a stable therapeutic environment. Partial hospitalization
is an appropriate setting for crisis stabilization, treatment of
partially stabilized mental disorders, to include substance disorders,
and a transition from an inpatient program when medically necessary.
Participating Provider
(Defined in 32 CFR 199.2)A TRICARE authorized provider
that is required, or has agreed by entering into a TRICARE participation agreement
or by an act of indicating “accept assignment” on the TRICARE claim
form to accept the TRICARE-allowable amount as the maximum total
charge for a service or item rendered to a TRICARE beneficiary,
whether the amount is paid for fully by TRICARE or requires cost-sharing
by the TRICARE beneficiary.
Note: This is another term for a
non-network provider previously defined in this section.
Partnership for Peace
(PfP)The PfP
Status of Forces Agreement (SOFA) is a multilateral agreement between
NATO member states and countries participating in the PfP program.
It deals with the status of foreign forces while present on the
territory of another state. See
https://www.nato.int/cps/en/natolive/topics_50349.htm for
a more detailed definition and
https://www.nato.int/cps/en/natohq/51288.htm for
a list of current countries.
Patient HarmA fraudulent or abusive practice
directly causing a patient who is undergoing treatment for a disease, injury,
or medical (or dental) condition to suffer actual physical injury
or acceleration of an underlying condition. The determination that
patient harm has occurred must be based on the opinion of a qualified
medical or dental provider or pharmacist in the case of pharmacy
claims. Refer to
Chapter 13 for
additional information.
Patient Profile, PharmacyA complete record for each
beneficiary receiving prescriptions under the TRICARE program including: name,
address, telephone number, date of birth, gender, patient identification
number (sponsor’s SSN and DEERS dependent suffix), DEERS Identifier,
service sponsorship, status category, chronic medical conditions
(diagnosis code), allergies and adverse drug experiences, past medication
history, prescriptions dispensed, non-receipt of prescriptions,
status on interventions and prescription problems resolved, prior
authorizations approved or denied, and any other information supplied
by the beneficiary in the patient data form or updates.
Pending Claim, Correspondence,
Or AppealThe claim/correspondence/appeal
case has been received but has not been processed to final disposition.
Performance StandardGovernment approved and developed
criteria measuring specific aspects of a contractor’s execution
of a TRICARE contract.
Pharmacoeconomic Center
(PEC)An activity
under the DoD Pharmacy Operations Division (POD) with the mission
to improve the clinical, economic, and humanistic outcomes of drug
therapy in support of the readiness and managed care missions of
the MHS. The PEC is comprised of pharmacists, physicians, and pharmacy
technicians from each of the three services, as well as civilian
pharmacists and support personnel who monitor drug usage, and cost
trends, and performs analysis to support DoD formulary management
and national pharmaceutical contracts, and clinical practice guidelines.
Pharmacy and Therapeutics
(P&T) CommitteeA DoD chartered committee with
representatives from MTF/eMSM providers and MTF/eMSM pharmacists.
The P&T Committee’s primary role is establishing and maintaining
the DoD Uniform Formulary for the purchased care system and the
DC system (MTFs/eMSMs).
Pharmacy Data Transaction
Service (PDTS)A bi-directional
data transaction service that provides a pharmaceutical data warehouse
and electronically transmits encrypted prescription data using the
National Council of Prescription Drug Program (NCPDP) standards
to the pharmacy contractor. The PDTS provides the capability to
perform Prospective Drug Utilization Review (ProDUR) and houses
prior authorization/medical necessity history by integrating pharmacy
data from all three points of service (DC, mail order, and retail
pharmacies) with increased clinical screening and medication-related
outcomes.
Pharmacy Operations Center
(POC)The DoD
organization responsible for Tier I and Tier II (systems and software)
support of the PDTS project. The POC:
1. Resolves ProDUR
POS conflicts between MTFs/eMSM and the TPharm contractor;
2. Monitors quantity
limits (which are cumulative between all three POSs);
3. Issues NCPDP
provider numbers for DC pharmacies; and
4. Maintains “lock
out” and “include” databases for closed class and mandatory use
requirements contracts.
Point Of Service (POS)
OptionAllows
TRICARE Prime enrollees and TRICARE Prime Remote for Active Duty
Family Members (TPRADFMs) enrollees to receive non-emergent health
care services from any TRICARE authorized civilian provider, in
or out of the network without requesting a referral from a PCM.
Using this benefit results in the beneficiary incurring more out
of pocket expenses. For further details, refer to the TRM,
Chapter 2, Section 3.
Possible BreachAn incident where the possibility
of unauthorized access is suspected (or should be suspected) and
has not been ruled out. For example, if a laptop containing PII/PHI
is lost, and the contractor does not initially know whether or not
the PII/PHI was encrypted, then the incident must initially be classified
as a possible breach, because it is impossible to rule out the possibility
of unauthorized access to the PII/PHI. In contrast, that possibility
can be ruled out immediately, and a possible breach has not occurred, when
misdirected postal mail is returned unopened in its original packaging.
However, if the intended recipient informs the contractor that an
expected package has not been received, then a possible breach exists
until and unless the unopened package is returned to the contractor.
In determining whether unauthorized access should be suspected,
the contractor shall consider at least the following factors:
• How the event was discovered;
• Did the information stay within
the covered entity’s control;
• Was the information actually
accessed/viewed; and
• Ability to ensure containment
(e.g., recovered, destroyed, or deleted).
Preauthorization (Defined
in 32 CFR 199.2)A decision issued in writing
or electronically by the Director, Defense Health Agency (DHA),
or a designee, that TRICARE benefits may be payable for certain
services that a beneficiary has not yet received. The term prior
authorization is substituted for preauthorization and has the same
meaning.
A more
comprehensive review process for certain services to determine that
requested treatment may be covered as medically necessary, delivered
at the appropriate setting, and is a TRICARE benefit before services
are rendered to the beneficiary. Preauthorizations are required
for certain services per the TOM,
Chapter 7, Section 2,
A preauthorization request may be submitted by the beneficiary or
provider and is not required prior to a Primary Care Manager (PCM)
(physician) issuing a beneficiary a referral for specialty services
from a network provider.
Preferred Provider Organization
(PPO)A type
of health plan that has contracts with a network of doctors, hospitals
and other health care professionals to provide services to plan
beneficiaries at a reduced rate.
PrescriberA physician or other individual
professional provider of services specifically authorized to write
a prescription for medications or supplies in accordance with all
applicable federal and state laws.
PrescriptionA legal order from an authorized
prescriber to dispense pharmaceuticals or other authorized supplies.
Prevailing ChargeA rate submitted by certain
non-institutional providers which fall within the range of rates
that are most frequently used in a state for a particular health
care procedure or service. The top of the range establishes the
maximum amount TRICARE will authorize for payments of a given health
care procedure or service, except where unusual circumstances or
medical complications warrant an additional charge. The calculation
methodology and use is determined according to the reimbursement
instructions outlined in the TRM.
Preventive Care (Defined
in 32 CFR 199.2)Diagnostic and other medical
procedures not related directly to a specific illness, injury, or
definitive set of symptoms, or obstetrical care, but rather performed
as periodic health screening, health assessment, or health maintenance.
Primary CareThe initial medical care given
by a HCP to a patient especially, as part of regular ambulatory
care, and sometimes followed by referral to other medical providers.
Primary Caregiver (Defined
in 32 CFR 199.2)An individual who renders to
a beneficiary services to support the ADL as defined in
32
CFR 199.2 and specific services essential to the safe
management of the beneficiary’s condition.
Primary Care Manager
(PCM)A HCP
a patient sees first for their health care needs responsible for
providing and coordinating the patient’s care, maintaining the patient’s
health record and when necessary refers the patient for specialty
care.
Primary Payer (Defined
in 32 CFR 199.2)The plan or program whose medical
benefits are payable first in a double coverage situation.
Prime ContractorThe main individual or organization
that has a contract with the owner of the contract and has full responsibility
for its completion/execution and may employ (and manage) one or
more subcontractors to carry out specific parts of the contract.
Prime EnrolleeAn Individual who has signed
up to receive health care under the TRICARE Prime option.
Prime Service Area (PSA)PSAs are areas in which the
contractor offers enrollment in TRICARE Prime in compliance with
the travel time access standard. PSAs encompass the entire area
of all the ZIP codes lying within or intersected by the 40 mile
radius around enrolling MTFs/eMSMs (both hospitals and clinics)
and Base Realignment and Closure (BRAC) sites. Zip codes enclosed
entirely within a PSA’s boundary shall also be included. For BRAC
sites, the 40 mile radius shall be determined based on the physical
address of the former MTF location. If the former MTF address is
no longer valid, the 40 mile radius shall be determined from the geographic
center of the BRAC site zip code as of the date of contract award.
Prior Authorization,
Medical CareSee definition
for Preauthorization.
Prior Authorization,
PharmacyPre-approval
required for the filling of certain drugs ordered by a HCP.
Note: Criteria, developed by the
DoD P&T Committee, will be provided by the to the contractor for
use in the filling of certain drugs. However, the contractor will
be responsible for developing pre-approval criteria for quantity
limit override, etc.
Priority CorrespondenceOfficial communications, received
by mail, faxes, e-mail, cables, telexes and other media of record, received
by the contractor from the Office of the Assistant Secretary of
Defense (Health Affairs) (OASD(HA)), DHA, and any elected or appointed,
federal, state, local, foreign, and tribal officials and Members
of Congress and Governors, or any other correspondence designated
for priority status by the contractor’s management.
Privacy Act, 5 USC 552a
(Records Maintained on Individuals)Federal Law which established
a Code of Fair Information Practice that governs the collection, maintenance,
use and dissemination of personally identifiable information about
individuals that is maintained in systems of records by federal
agencies. The law prohibits the disclosure of a System Of Records
(SOR) without the written consent of the individual. Additionally,
the law provides the individual with a means by which to seek access
for amendment of their records, and set forth various agencies record
keeping requirements.
Privacy Act, 5 USC 552a
System of Records (SOR)A group of records containing
PHI and PII maintained by or on behalf of the DoD where PHI and
PII in the records is specifically retrieved by personal identifiers.
Processed To Completion
(PTC)A date/time
frame when specific portions of claims processing work has been
completed, resolved or received a final disposition. Under the TRICARE
MCSCs there are specific dates/time frames for:
1. Claims. Claims
are considered PTC, for workload reporting and payment record coding
purposes, when all claims received in the current and prior months
have been processed to the point where the following actions have
resulted:
• All services and supplies on
the claim have been adjudicated, payment has been determined on the
basis of covered services/supplies and allowable charges applied
to deductible and/or denied, and
• Payment, deductible application
or denial action has been posted to ADP history.
2. Correspondence. Correspondence
is considered PTC, when the final reply is mailed to the individual(s)
submitting the written inquiry or when the inquiry is fully answered
by telephone.
3.
Telephonic Inquiry. A telephonic inquiry is considered PTC
or resolved, when the final reply is provided by either telephone
or letter. A final telephone reply means that the caller’s inquiry
has been fully responded to, there are no unanswered issues remaining,
and no additional call-backs are necessary. If the contractor must
take a subsequent action to correct a problem or address an issue raised
during the telephone call, the telephone inquiry is considered resolved
when the contractor identifies the need for the subsequent action,
and so notifies the inquirer. For example, if a claim requires adjustment
as a result of a telephone inquiry, the call is resolved when the
contractor initiates the claim adjustment and the inquirer is so
notified (i.e., it is not necessary to keep the call open until the
actual processing of the claim adjustment occurs).
4. Appeals. Final
disposition of an appeal case occurs when the previous decision
by the contractor is either reaffirmed, reversed, or partially reversed
and the decision is mailed.
Procuring Contracting
Officer (PCO)A Federal
employee with specific contracting authorization having ultimate
authority and responsibility for the Governments’ side for the contract
execution regardless of whatever additional support team may be
outlined in the contract. The Government employee is responsible
for overseeing the contract from start to finish, including the
drawing up the procurement package, Request for Proposal (RFP) and
contract award, as well as administration during the contracts life
cycle.
Profiled AmountAn amount that is the lower
of the prevailing charge or the maximum allowable prevailing charge.
Program Integrity SystemA software system for detecting
overutilization or fraud and abuse.
Program YearThe appropriate year (e.g.,calendar
year, fiscal year, rolling 12-month period, etc.) specified in the administration
of TRICARE programs for application of unique requirements or limitations
(e.g., enrollment fees, deductibles, catastrophic lose protection,
etc.) on covered health care services obtained or provided during
the designated time period.
Prospective Drug Utilization
Review (ProDUR)A process
used to identify any potential medication problems that may occur,
based on a patient’s current prescription, applicable patient profile
information, and medication history, prior to the point of dispensing.
ProDUR is used to detect over-utilization, under-utilization, therapeutic
duplication, drug-disease complications, drug interactions, incorrect
dosages and duration of therapy.
Prospective ReviewPrior assessment of a request
for treatment before the treatment is rendered to determine if the treatment
is appropriate for the patient. Another term for preauthorization.
Protected Health Information
(PHI) (HIPAA Definition)1. IIHI that is:
a. Transmitted
by electronic media;
b. Maintained
in electronic media; or
c. Transmitted
or maintained in any other form or medium.
Note: Sometimes referred to as Electronic
Protected Health Information (ePHI).
2. PHI excludes
IIHI in:
a. Education
records covered by the Family Educational Right and Privacy Act,
as amended, 20 USC 1232g;
b. Records described
at 20 USC 1232g(a)(4)(B)(iv); and
c. Employment
records held by a covered entity in its role as an employer.
d. Regarding a
person who has been deceased for more than 50 years.
Note: As defined in HIPAA of 1996.
Provider (Defined in 32
CFR 199.2)A hospital or other institutional
provider, a physician or other individual professional provider,
or other provider of services or supplies in accordance with
32
CFR 199.6.
Provider Exclusion And
Suspension (Defined in 32 CFR 199.2)The terms “exclusion” and “suspension”,
when referring to a provider under TRICARE, both mean the denial
of status as an authorized provider, resulting in items, services,
or supplies furnished by the provider not being reimbursed, directly
or indirectly, under TRICARE. The terms may be used interchangeably
to refer to a provider who has been denied status as an authorized
TRICARE provider based on:
1. A criminal
conviction or civil judgment involving fraud;
2. An administrative
finding of fraud or abuse under TRICARE;
3. An administrative
finding that the provider has been excluded or suspended by another
agency of the Federal Government, a state, or a local licensing
authority;
4. An
administrative finding that the provider has knowingly participated
in a conflict of interest situation; or
5. An administrative
finding that it is in the best interests of TRICARE or TRICARE beneficiaries
to exclude or suspend the provider.
Provider NetworkA group of HCPs with which
a managed care contractor has made contractual or other arrangements with
to provide health care at a discounted rate.
Provider Termination
(Defined in 32 CFR 199.2)When a provider’s status as
an authorized TRICARE provider is ended, other than through exclusion
or suspension, based on a finding that the provider does not meet
the qualifications, as set forth in
32
CFR 199.6 to be an authorized TRICARE provider.
Psychotherapy Notes (HIPAA
Definition)Notes
recorded (in any medium) by a HCP who is a mental health professional
documenting or analyzing the contents of conversation during a private
counseling session or a group, joint, or family counseling session
and that are separated from the rest of the individual’s medical
record. Psychotherapy notes excludes medication prescription and
monitoring, counseling session start and stop times, the modalities
and frequencies of treatment furnished, results of clinical tests,
and any summary of the following items: diagnosis, functional status,
the treatment plan, symptoms, prognosis, and progress to date, as
defined in HIPAA of 1996.
Public Health Authority
(HIPAA Definition)An agency
or authority of the U.S., a state, a territory, a political subdivision
of a state or territory, or an Indian tribe, that is responsible
for public health matters as part of its official mandate as well
as a person or entity acting under a grant of authority from or
under a contract with a public health agency, as defined in HIPAA
of 1996.
Note: The term
“public health authority” includes any DoD Component authorized
under applicable DoD regulation to carry out public health activities,
including medical surveillance activities under DoD Directive 6490.2.
Qualified Mental Health
Provider
Psychiatrists or other physicians,
clinical psychologists, Certified Psychiatric Nurse Specialists
(CPNSs), Certified Clinical Social Workers (CCSWs), certified marriage
and family therapists, TRICARE Certified Mental Health Counselors
(TCMHCs), pastoral counselors under a physician’s supervision, and supervised
mental health counselors under a physician’s supervision.
Qualifying Life Event
(QLE)A change
in a beneficiary’s situation, like getting married, having a baby,
or losing health coverage, that allows a beneficiary to enroll in
or change their TRICARE health plan coverage outside of the annual open
enrollment period. See TPM,
Chapter 10, Section 2.1, for a list of authorized
QLEs.
Quality Assurance (QA),
PharmacyA process
for developing controls to prevent mistakes in the dispensing of
drugs. QA is the responsibility of both the pharmacy and the contractor.
Quality Assurance ProgramA system-wide process established
and maintained by the contractor to monitor and evaluate the quality
of patient health care and clinical performance.
Quality Control, PharmacyProcesses and procedures employed
to ensure that pharmaceuticals are dispensed accurately and timely.
These should be employees by both the contractor and the pharmacy.
Quality ImprovementAn approach to quality management
that builds upon traditional quality assurance methods by emphasizing:
1. The organization
and systems (rather than individuals);
2. The need for
objective data with which to analyze and improve processes; and
3. The ideal that
systems and performance can always improve even when high standards
appear to have been met.
Receipt Of Claim, Correspondence
Or AppealDelivery
of a claim, correspondence, or appeal into the custody of the contractor
by the post office or other party.
ReconsiderationAn appeal to a contractor of
an initial determination issued by the contractor.
RecordsAll books, papers, maps, photographs,
machine readable materials, or other documentary materials, regardless
of physical form or characteristics, made or received by an agency
of the U.S. Government under Federal law or in connection with the
transaction of public business or appropriate for presentation by
that agency or its legitimate successor as evidence of the organization,
functions, policies, decisions, procedures, operations, or other
activities of the Government.
Also any item, collection,
or grouping of information about a beneficiary which is maintained, collected,
used or disseminated, by TRICARE or a TRICARE contractor, including,
but not limited to his or her education, financial transactions,
medical history, and criminal or employment history, and which contains
the beneficiary’s name or identifying number, symbol or other personal
identifiers.
Records ManagementThe area of general administrative
management concerned with achieving economy and efficiency in the
creation, use and maintenance, and disposition of records. Included
in the fulfilling of archival requirements and ensuring effective
documentation.
Referral (Defined in 32
CFR 199.2)The act or an instance of referring
a TRICARE beneficiary to another authorized provider to obtain necessary
medical treatment. Generally, when a referral is required to qualify
health care as a covered benefit, only a TRICARE-authorized physician
may make such a referral unless 32 CFR 199 specifically allows another
category of TRICARE-authorized provider to make a referral as allowed
within the scope of the provider’s license. In addition to referrals
which may be required for certain health care to be a covered TRICARE
benefit, the TRICARE Prime program under
32
CFR 199.17 generally requires Prime enrollees to obtain
a referral for care through a PCM or other authorized care coordinator
to avoid paying higher deductible and cost-sharing for otherwise
covered TRICARE benefits.
A referral is a request from
one physician to another to assume responsibility for management
of one or more of a patient’s specified problems. A consult is a
request from one physician to another for an advisory opinion. Referrals
and/or consults written by MTF/eMSM or Civilian TRICARE providers
are sent to the Contractor for authorization or preauthorization
(if needed per TOM,
Chapter 7, Section 2).
A PCM (physician) does not require a preauthorization/authorization
from the Contractor to generate a referral or consult to/from a
network provider.
Referral ManagementProcess by which all referrals
written by the MTF/eMSM authorized providers and network and non-network
providers are tracked for care coordination, patient safety, and
accountability. The referral management process ends when the referring
provider is provided the clear and legible report, informed the
patient did not use/activate their referral, or if the referral
was denied by the contractor.
RegionA geographic area determined
by the Government for civilian contracting of medical care and other services
for TRICARE-eligible beneficiaries.
Regional Review Authority
(RRA)An entity
responsible for performing Peer Review Organization (PRO) functions.
Under TRICARE the contractor shall be responsible for performing
the duties of the RRA.
ReliantsRefers to a subset of TRICARE
eligible beneficiaries who are dependent on TRICARE and not the
DC system or OHI for the coverage/reimbursement of vaccines under
the well-child and preventive benefits. This includes, but is not
limited to: All TRICARE Active Duty Family Members (ADFMs) not enrolled
to a DC PCM who are reliant on TRICARE as their primary form of
insurance, and retirees and their family members who do not have
OHI and are not dependent on the DC system but are dependent on
TRICARE as their primary form of insurance.
Representative (Defined
in 32 CFR 199.2)Any person who has been appointed
by a party to the initial determination as counsel or advisor and who
is otherwise eligible to serve as the counsel or advisor of the
party to the initial determination, particularly in connection with
a hearing.
Required By Law (HIPAA
Definition)A mandate
contained in law that compels a covered entity to make a use or
disclosure of PHI and that is enforceable in a court of law. Required
by law includes, but is not limited to, court orders and court-ordered
warrants; subpoenas or summons issued by a court, grand jury, a
governmental or tribal inspector general, or an administrative body
authorized to require the production of information; a civil or
an authorized investigative demand; Medicare conditions of participation
with respect to HCPs participating in the program; and statutes
or regulations that require the production of information, including
statutes or regulations that require such information if payment
is sought under a Government program providing public benefits as
defined in HIPAA of 1996.
Note: For TRICARE required by law
also includes any mandate contained in a DoD Regulation that mandates
a covered entity (or other person functioning under the authority
of a covered entity) to make a use or disclosure and is enforceable
in a court of law. The attribute of being enforceable in a court
of law means that in a court or court-martial proceeding, a person
required by the mandate to comply would be held to have a legal
duty to comply or, in the case of noncompliance, to have had a legal
duty to have complied. Required by law also includes any DoD regulation
requiring the production of information necessary to establish eligibility
for reimbursement or coverage under TRICARE.
Research (HIPAA Definition)A systematic investigation,
including research, development, testing, and evaluation, designed
to develop or contribute to generalizable knowledge as defined in
HIPAA of 1996.
ResidenceFor purposes of TRICARE, “residence”
is the dwelling place of the beneficiary for day-to-day living.
A temporary living place during periods of temporary duty or during
a period of confinement, such as a Residential Treatment Center
(RTC), does not constitute a residence. In the case of minor children,
the residence of the custodial parent(s) or the legal guardian shall
be deemed the residence of the child. In the case of incompetent
adult beneficiaries, the residence of the legal guardian shall be
deemed the residence of such beneficiary. Under split enrollment,
when a dependent resides away from home while attending school,
their residence shall be where they are domiciled.
Residential Treatment
Center (RTC)A facility
or distinct part of a facility which meets the criteria in
32 CFR 199.6(b)(4)(vii).
Residual ClaimA claim for health care services
rendered during the health care delivery period of one contract,
but processed under a different (incoming) contract.
Resource Sharing Agreement
(External) (Defined in 32 CFR 199.2)A type of external Partnership
Agreement established in the context of the TRICARE Program by agreement
of the MTF Director and an authorized TRICARE contractor. External
resource sharing agreements may incorporate TRICARE features in
lieu of standard TRICARE features that would apply to stand external
Partnership Agreements.
Respite Care (Defined
in 32 CFR 199.2)Short-term care for a patient
in order to provide rest and change for primary caregivers who have
been caring for the patient at home, usually the patient’s family.
Note: Although this is usually the
patient’s family, it may be a relative or friend who assists the member
with their ADL. Respite care consists of providing skilled and non-skilled
services to a beneficiary such that in the absence of the primary
caregiver, management of the beneficiary’s qualifying condition
and safety are provided. Respite care services are provided exclusively
to the Service member beneficiary.
1. Qualifying Condition
For Receipt Of Respite Benefits. For the purposes of receiving
respite benefits, a qualifying condition is defined as a serious
injury or illness resulting in or based on the clinical assessment
of the member’s provider or case management team that will result
in a physical disability, or an extraordinary physical or psychological
condition.
2.
Limitations On Respite Benefits:
• The services performed by the
primary caregiver are those that can be performed safely and effectively
by the average non-medical person without direct supervision of an HCP
after the primary caregiver has been trained by appropriate medical
personnel.
• Respite care services are limited
to a maximum of eight hours per day, five days per week.
ResubmissionsA group of TED records submitted
to DHA to correct those TED claims and adjustments which generated
edit errors when originally processed by DHA. These groups of records
will be identified by the batch number and resubmission in the TED
Header Record.
Retention PeriodThe length of time for particular
documents/records (normally a series) are to be kept.
Retiree (Defined in 32
CFR 199.2)A member or former member of
a Uniformed Service who is entitled to retired, retainer, or equivalent pay
based on duty in a Uniformed Service.
Retired CategoryRetirees and their family members
who are beneficiaries covered by 10 USC 1086(c), other than Medicare-eligible
beneficiaries as described in 10 USC 1086(d).
Retrospective Drug Utilization
ReviewA process
of appraising and reconsidering the usage of drugs to determine
the effectiveness of drug treatment after a medication is dispensed.
The process includes evaluation for therapeutic appropriateness,
over-utilization and under-utilization, therapeutic duplication,
drug-disease contraindications, drug interactions, incorrect dosage
and /or duration of therapy.
Retrospective ReviewA post-treatment assessment
of care already delivered. The assessment evaluates the appropriateness of
care and conformance to pre-established criteria for utilization.
The purpose for this type of assessment may be to validate utilization
decisions made and/or to validate payment made for care provided
(by examining the actual record of treatment).
Returned ClaimA bill of health care services
the contractor returns to the sender because there is missing information that
is needed for processing, and the missing information cannot be
obtained from in-house sources.
ReversedStatus of claim once a reversal
transaction is transmitted for the removal of the PAID claim from
a patient’s profile.
Routine CorrespondenceAll communications received
by mail, faxes cables, telexes, and other media or record, is not
designated as Priority Mail.
Routine UseWith respect to the disclosure
of a record from a Privacy Act System of Records (SOR) 5 USC, 552a,
the use of a record for a purpose that is compatible for which it
was information collected. See also Defense Privacy and Civil Liberties
Office’s (DPCLO’s) published list of blanket routine uses for sharing
PII.
Same Day ReferralThe act or instance of referring
a TRICARE beneficiary to another authorized provider to obtain necessary
medical treatment within 24 hours of a request for care. This includes
immediate (STAT), 24 hours (As Soon As Possible (ASAP)), and Today
referral priority requests from the Composite Health Care System
(CHCS).
Sanction (Defined in 32
CFR 199.2)For the purposes of
32
CFR 199.9, “sanction” means a provider exclusion, suspension,
or termination.
Secondary Payer (Defined
in 32 CFR 199.2)The plan or program whose medical
benefits are payable in double coverage situations only after the primary
payer has adjudicated the claim.
Secretary Of Health And
Human Services (HHS)The head of the U.S. DHHS concerned
with health matters.
Segment (HIPAA Definition)A group of related data elements
in a transaction as defined in HIPAA of 1996.
Seventy-Two Hour ReferralThe act or instance of referring
a TRICARE beneficiary to another authorized provider to obtain necessary
medical treatment within 72 hours of a request for care.
Skilled Nursing Facility
(SNF) (Defined in 32 CFR 199.2)An institution (or a distinct
part of an institution) that meets the criteria as set forth in
32
CFR 199.6.
Skilled Nursing Service
(Defined in 32 CFR 199.2)Skilled nursing services includes
application of professional nursing services and skills by and Registered
Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Vocational
Nurse (LVN) that are required to be performed under the general
supervision/direction of a TRICARE authorized physician to ensure
the safety of the patient and achieve the medically desired result
in accordance with accepted standards of practice.
Note: Skilled nursing services are
other than those services that provide primarily support for the Activities
of Daily Living (ADL) or that could be performed by an untrained
adult with minimum instruction or supervision.
Special ChecksChecks issued outside the normal
processing workflow for the purpose of expediting payment of a claim
for benefits.
Special InquiriesRequests for information under
the Freedom of Information Act, Privacy Act, and the news media.
Also includes requests received for surveys, audits, and requests
by Government agencies including DoD agencies, entities other than
DHA and Congressional Committees.
Specialty CareSpecialized medical services
provided by a physician specialist.
Specified Authorization
Staff (SAS)/Defense Health Agency-Great Lakes (DHA-GL) (formerly Military
Medical Support Office (MMSO))A Joint Services Organization
responsible for reviewing specialty and inpatient care requests
and claims for impact on fitness-for-duty. SAS/DHA-GL is also responsible
for approving certain medical services not covered under TRICARE
that are necessary to maintain fitness for duty and/or retention
on active duty. The SASs for Army, Navy, Marine Corps, and Air Force
Service members are assigned to the DHA-GL. For more information,
see
Chapter 17 for
additional information.
Split-BillingThe division of a medical claim
for service provided into two or more parts. Claims may be split
to divide work between clients, payers or for reimbursement to different
service providers for performing a shared service. Such claims may
or may not require Coordination of Benefits. (COB)
Split EnrollmentA TRICARE Prime option which
allows an entire family to enroll in TRICARE Prime even if part
of the family is living in another TRICARE region.
SponsorAn active duty member, retiree,
or deceased active duty member or retiree, of a Uniformed Service upon
whose status his or her family members’ eligibility for TRICARE
is based. See also
32 CFR 199.2 for a
more complete definition.
Spouse (Defined in 32
CFR 199.2)A lawful husband or wife, who
meets the criteria in
32 CFR 199.3,
regardless of whether or not dependent upon the active duty member
or retiree.
StakeholdersAny party who has a direct interest
in the success of a business concern. For TRICARE purposes, stakeholders
include the DoD, the Director, TROs, Market/MTF Directors, DHA,
the MHS, and all employees thereof, contractors, elected officials,
and MHS beneficiaries.
Standard Transaction
(HIPAA Definition)A transaction
that complies with the applicable standard adopted by HIPAA.
Start Of ServiceThe date a contractor officially
begins delivery of health care services, processing claims, and/or delivery
of other services in a production environment, as specified in the
contract requirements.
State (Defined in 32
CFR 199.2)For the purposes of the 32
CFR 199, any of the several states, the District of Columbia, the Commonwealth
of Puerto Rico, the Commonwealth of the Northern Mariana Islands,
and each territory and possession of the U.S.
State (HIPAA Definition)1. For a health
plan established or regulated by Federal law, State has the meaning
set forth in the applicable section of the USC for such health plan.
2. Each of the
several states, the District of Columbia, Puerto Rico, the U.S.
Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
Statement of Responsibilities
(SOR)A communication
document that is intended to identify key processes and points of
interaction between the MTF and the contractor or the TAO and the
contractor. It does not repeat contract requirements, nor is it
used to modify any contract requirement.
Student Status (Defined
in 32 CFR 199.2)A dependent of a member or
former member of a Uniformed Service who has not passed his or her 23rd
birthday and is enrolled in a full-time course of study in an institution
of higher learning.
SubcontractorAn individual or in many cases
a business that signs a contract to perform part or all of the obligations of
another’s contract. This includes but is not limited to enrolled
program health benefits business entities at whatever level of the
contract organization they exist. It does not include institutional
or non-institutional providers of health care. This definition does
not exclude business entities that are not specifically addressed
herein but whose legal status within the contract organization establishes
them as subcontractors because that term may be otherwise defined
in the Federal Acquisition Regulation (FAR).
Note: In determining whether a business
entity is a network first tier subcontractor, consideration is given
as to whether or not the entity providing the designated services
acts as a broker of care; i.e., the entity itself obtains the medical
coverage needed by in turn contracting with institutional and non-institutional
providers. Implicit in the determination is size of the offered
network; i.e., does this entity provide a large number of contracted
providers for a large geographical area?
Subcontractor (HIPAA
Definition)A person
to whom a business associate delegates a function, activity, or
service other than in the capacity of a member of the workforce
of such business associate.
SubcontractsThe contractual assignment
of elements of requirements to another organization or person for purposes
of TRICARE. Unless otherwise specified in the contract, the term
also includes purchase orders, with changes and/or modifications
thereto.
Substance Use Disorder
Rehabilitation Facility (SUDRF)A facility or a distinct part
of a facility that meets the criteria in
32 CFR 199.6(b)(4)(xiv).
Summary Health Information
(HIPAA Definition)Information
that may be IIHI, and:
1. That summarizes
the claims history, claims expenses, or type of claims experienced
by individuals for whom a plan sponsor has provided health benefits
under a group health plan; and
2. From which
the information has been deleted, except that the geographic information
may be aggregated to the level of a five digit zip code.
As defined in HIPAA of 1996.
Supplemental CareMedical care received by Service
members of the Uniformed Services and other designated patients pursuant
to an MTF/eMSM referral (MTF/eMSM Referred Care). Supplemental Health
Care also includes specific episodes of Service member non-referred
civilian care, both emergent and authorized non-emergent care (non-MTF/eMSM
Referred Care).
Supplemental FundsFunds used to pay for supplemental
care.
Supplemental Insurance
Plan (Defined in 32 CFR 199.2)A health insurance policy or
other health benefit plan offered by a private entity to a TRICARE beneficiary,
that primarily is designed, advertised, marketed, or otherwise held
out as providing payment for expenses incurred for services and
items that are not reimbursed under TRICARE due to program limitations
or beneficiary liabilities imposed by law. TRICARE recognizes two
types of supplemental plans, general indemnity plans and those offered
through a direct service HMO.
1. An indemnity
supplemental insurance plan must meet all the following criteria:
a. It provides
insurance coverage, regulated by the state insurance agencies, which
is only available only to beneficiaries of TRICARE.
b. It is premium
based and all premiums relate only to the TRICARE supplemental coverage.
c. Its benefits
for all covered TRICARE beneficiaries are predominately limited
to non-covered services, to the deductible and cost-shared portions
of the pre-determined allowable charges and/or to amounts exceeding
the allowable charges for covered services.
d. It provides
insurance reimbursement by making payment directly to the TRICARE
beneficiary or to the participating provider.
e. It does not
operate in a manner which results in lower deductibles or cost-shares
than those imposed by law, or that waives the legally imposed deductibles
and cost-shares.
2. A supplemental
insurance plan offered by a HMO must meet all of the following criteria:
a. The HMO must
be authorized and must operate under relevant provisions of state
law.
b. The
HMO supplemental plan must be premium based and all premiums must
relate only to TRICARE supplemental coverage.
c. The HMO’s benefits,
above those which are directly reimbursed by TRICARE, must be limited predominantly
to services not covered by TRICARE and TRICARE deductible and cost-share
amounts.
d. The
HMO must provide services directly to TRICARE beneficiaries through
its affiliated providers, who in turn, are reimbursed by TRICARE.
e. The HMO’s premium
structure must be designed so that no overall reduction to the amount
of the beneficiary deductibles or cost-shares will result.
Suspension Of Claims
Processing (Defined in 32 CFR 199.2)The temporary suspension of
processing (to protect the Government’s interests) of claims for
care furnished by a specific provider (whether the claims are submitted
by the provider or beneficiary) or claims submitted by or on behalf
of a specific TRICARE beneficiary pending action by the Director,
DHA, or a designee, in a case of suspected fraud or abuse. The action
may include administrative remedies provided for in
32
CFR 199.9 or any other DoD issuance (e.g., DoD issuances
implementing the Program Fraud Civil Remedies Act), case development
or investigation by DHA, or referral to the DoD-Inspector General
(IG) or the Department of Justice (DOJ) for action within their
cognizant jurisdictions.
Telephonic Consultations
(32 CFR 199.2)A covered consultation service
conducted via a 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
(32 CFR 199.2)A covered service provided
via a telephone call between a beneficiary who is an established
patient and a TRICARE-authorized provider.
TelepresenterA telepresenter is an individual
at the originating site (when the originating site is other than
the patient’s home) who has the necessary skills, training, and/or
clinical background (e.g., Licensed Practical Nurse (LPN), Registered
Nurse (RN), trained medical technician, etc.) to operate the telemedicine
technology and facilitate examinations under the direction of the
provider at the distant site. For example, a nurse may use a device
connected to a telemedicine system, such as a digital stethoscope
or otoscope, in order to provide diagnostically relevant imagery,
sound, or other data/information about the patient to the distant
provider in real time.
TerminationThe removal of a provider as
an authorized TRICARE provider based on a finding that the provider
does not meet the qualifications established by
32
CFR 199.6 to be an authorized TRICARE provider. This includes
those categories of providers who have signed specific participation
agreements.
Third-Party Billing Agent
(Defined in 32 CFR 199.2)Any entity that acts on behalf
of a provider to prepare, submit, and monitor claims, excluding
those entities that act solely as a collection agency.
Third-Party Liability
(TPL) ClaimsReimbursements
to the Government that arise when medical care is provided to an
entitled beneficiary for treatment or injury or illness caused under
circumstances creating tort liability legally requiring a third
person to pay damages for that care. The Government pursues repayment
for the care provided to the beneficiary under the provisions and
authority of the Federal Medical Care Recovery Act (FMCRA) (42 USC
paragraphs 2651-2653).
Third-Party Liability
(TPL) RecoveryThe recovery
by the Government of expenses incurred for medical care provided
to an entitled beneficiary in the treatment of injuries or illness
caused by a third-party who is liable in tort for damages to the
beneficiary. Such recoveries can be made from the liable third-party
directly or from a liability insurance policy (e.g., automobile
liability policy or homeowners insurance) covering the liable third-party.
TPL recoveries are made under the authority of the FMCRA (42 USC
paragraph 2651 et sec). Other potential sources of recovery in favor
of the Government in TPL situations include, but are not limited
to, no fault or uninsured motorist insurance, medical payments provisions
of insurance policies, and workers compensation plans. Recoveries
from such other sources are made under the authority of 10 USC paragraphs
10790, 1086(g), and 1095b.)
Third-Party Payer (Defined
in 32 CFR 199.2)Third-party means an entity
that provides an insurance, medical service, or health plan by contract
or agreement, including an automobile liability insurance or no
fault insurance carrier and a workers compensation program or plan,
and any other plan or program (e.g., homeowners insurance) that
is designed to provide compensation or coverage for expenses incurred
by a beneficiary for medical services or supplies. For the purposes
of the definition of “third-party payer,” an insurance medical service
or health plan includes a preferred provider organization, an insurance
plan described as Medicare supplemental insurance, and a personal
injury protection plan or medical payments benefit plan for personal
injuries resulting from the operation of a motor vehicle.
Note: TRICARE is secondary payer
to all third-party payers. Under limited circumstances in
32
CFR 199.8, TRICARE payment may be authorized to be paid
in advance of adjudication of the claim by certain third-party payers.
TRICARE advance payment will not be made when a third-party provider
is determined to be a primary medical insurer under
32
CFR 199.8.
Timely FilingThe submitting of TRICARE claims
within the prescribed time limits as set forth in
32
CFR 199.7 and the requirements of the TRICARE contract.
Toll-Free TelephonesHaving or using a direct line
or number for a call that is not charged to the caller. Under the
TRICARE contract all telephone calls are considered toll-free for
the purposes of measuring the standards contained in
Chapter 1, Section 3, paragraph 3.4.
Trading Partner Agreement
(HIPAA Definition)An agreement
related to the exchange of information in electronic transactions,
whether the agreement is distinct or part of a larger agreement,
between each party to the agreement. (For example, a trading partner
agreement may specify, among other things, the duties and responsibilities of
each party to the agreement in conducting a standard transaction.)
As defined in HIPAA of 1996.
Transaction (HIPAA Definition)The transmission of information
between two parties to carry out financial or administrative activities related
to health care. It includes the following types of information transmissions:
1. Health care
claims or equivalent encounter information.
2. Health care
payment and remittance advice.
3. Coordination
of benefits.
4. Health
care claims status.
5. Enrollment
and disenrollment in a health plan.
6. Eligibility
for a health plan.
7. Health plan
premium payments.
8. Referral
certification and authorization.
9. First report
of injury.
10. Health
claims attachments.
11. Other transactions
that may be prescribed by regulation.
Transfer ClaimsA bill received by a contractor
for services received and billed from another contractor’s jurisdiction. See
Chapter
8 for processing requirements related to these types of
claims.
Note: Claims
for Service members which are sent to the appropriate Uniformed
Service are not considered to be “transfer claims.”
TransitionThe process of changing contractors
or contract in a Government designated service area. Transition begins
with the Notice of Award to the incoming contractor and is formally
completed with the close out procedures of the outgoing contractor,
several months after the start work date.
Transitional Patients
Or CasesBeneficiaries
for whom active care is in progress on the date of a contractor’s
start work date.
Note: If the care being provided
is for covered services, the contractor is financially responsible for
the portion of care delivered on or after the contractor’s start
work date.
Treatment (HIPAA Definition)The provision, coordination,
or management of health care and related services by one or more
HCPs, including the coordination or management of health care by
a HCP with a third-party; consultation between HCPs relating to
a patient; or the referral of a patient for health care from one
HCP to another.
Treatment EncounterThe smallest meaningful unit
of health care utilization: One provider rendering one service to
one beneficiary.
Treatment Plan (Defined
in 32 CFR 199.2)A detailed description of the
medical care being rendered or expected to be rendered a TRICARE beneficiary
seeking approval for inpatient and other benefits for which preauthorization
is required as set forth in
32 CFR 199.4(b).
Medical care described in the plan must meet the requirements of
medical and psychological necessity. A treatment plan must include,
at a minimum, a diagnosis (either the current edition of the ICD-CM,
or the current edition of the DSM); detailed reports of prior treatment, medical
history, family history, social history, and physical examination;
diagnostic test results; consultant’s reports (if any); proposed
treatment by type (such as surgical, medical, and psychiatric);
a description of who is or will be providing treatment (by discipline
or specialty); anticipated frequency, medications, and specific
goals of treatment; type of inpatient facility required and why
(including length of time the related inpatient stay will be required);
and prognosis. If the treatment plan involves the transfer of a
TRICARE beneficiary from a hospital or another inpatient facility,
medical records related to that inpatient stay also are required
as a part of the treatment plan documentation.
TriageThe process of determining the
priority of patients’ treatment based on the severity of their condition.
Note: For the
TRICARE Program this function is performed by the contractor’s 24-hour
telephone Nurse Advice Line (NAL).
TRICAREThe DoD’s managed health care
program for Service members and their families, retirees and their families,
survivors, and other TRICARE-eligible beneficiaries. TRICARE is
a blend of the military’s DC system of hospitals and clinics and
civilian providers. Through December 31, 2017, TRICARE offers three options:
TRICARE Standard Plan, TRICARE Extra Plan, and TRICARE Prime Plan
(see definitions in this section and in
32
CFR 199.17). Beginning January 1, 2018, TRICARE offers
three options: TRICARE Prime, TRICARE Select, and TRICARE For Life
(TFL) (see definitions in this appendix and in
32
CFR 199.2).
TRICARE Area Office (TAO)The management organization
responsible for overseeing an integrated health care delivery system within
one of the three designated TRICARE overseas regional zones.
TRICARE Beneficiary
An individual determined by
the Uniformed Services to be eligible for TRICARE benefits, as set
forth in
32 CFR 199.3.
TRICARE ContractorAn organization with which
DHA has entered into a binding agreement for:
1. The delivery
of and/or processing of payment for health care services through
contracted providers;
2. The processing
of claims for health care services received from non-network providers;
and
3. The
performance of related support activities.
TRICARE Encounter Data
(TED)A data
set of information required for all care received/delivered under
the contract and provided by the contractor in a Government-specified
format and submitted to DHA via a telecommunication network. The
information in the data set can be described in the following broad
categories:
1. Beneficiary
identification.
2. Provider
identification.
3. Health
information:
• Place and type of service
• Diagnosis and treatment-related
data
• Units of service (admissions,
days, visits, etc.)
4. Related financial
information.
TRICARE Encounter Data
(TED) Record Transmittal SummaryA single record which identifies
the submitting contractor and summarizes, for transmittal purposes, the
number of records and the financial information contained within
the associated “batch” of TED records.
TRICARE Extra (Defined
in 32 CFR 199.2)The preferred-provider option
of the TRICARE program made available prior to January 1, 2018,
under which TRICARE Standard beneficiaries may obtain discounts
on cost-sharing as a result of using TRICARE network providers.
TRICARE For Life (TFL)
(Defined in 32 CFR 199.2)The Medicare wraparound coverage
option of the TRICARE program made available to an eligible beneficiary
by reason of 10 USC 1086(d).
TRICARE Operations Manual
(TOM) (6010.59-M)A DHA
authored book which provides instructions and requirements for claims
processing and health care delivery under TRICARE.
TRICARE Pharmacy (TPharm)
Benefits ProgramA plan
to provide outpatient prescription drugs through military pharmacies,
TRICARE Pharmacy Home Delivery, and TRICARE retail network and non-network
pharmacies.
TRICARE Policy Manual
(TPM) (6010.60-M)A DHA
authored book which provides the description of TRICARE Program
benefits, adjudication guidance, policy interpretations, and decisions
for use in determining benefits under the TRICARE Program.
TRICARE PlusA primary care program offered
at some military hospitals and clinics for beneficiaries not enrolled
in TRICARE Prime. Beneficiaries are enrolled with a Primary Care
Coordinator (PCC) at an MTF/eMSM. MTFs/eMSMs may limit enrollment
based on capability and capacity. There is no enrollment fee.
Note: These MTF/eMSM enrollees are
to receive primary care appointments within the TRICARE Prime access
standards. TRICARE Plus “enrollment” will be annotated in DEERS
and the MTF’s/eMSM’s Electronic Medical Records. When a TRICARE
Plus enrollee receives care from civilian providers, TRICARE Standard/Extra
rules will apply (through December 31, 2017). For services payable
by Medicare, Medicare rules will apply, with TRICARE as second payer
for TRICARE covered services and supplies. Specialty care in the
MTF/eMSM will be on referrals from the primary care provider or
on a self-referral basis. TRICARE Plus enrollees are not guaranteed
specialty care appointments within the TRICARE Prime access standards.
TRICARE Prime (Defined
in 32 CFR 199.2)The managed care option of
the TRICARE program established under
32
CFR 199.17.
TRICARE Prime Remote
(TPR) ProgramA managed
care option under TRICARE designed to provide health care services
to Service members and command sponsored family members assigned
to remote locations in the U.S.
TRICARE Prime Remote
(TPR) Work UnitA uniformed
services group whose members have to be designated by the Military
Services to be eligible to enroll in the TPR Program.
TRICARE Program (Defined
in 32 CFR 199.2)A program established under
the
32 CFR 199.17.
TRICARE Quality Management
Contract (TQMC)A national-level
contractor responsible to the DoD and DHA that performs second level reconsiderations
for payment denials and focused retrospective quality of care reviews.
TRICARE Retired ReserveThe program established under
10 USC 1076e and
32 CFR 199.25.
TRICARE Regional Office
(TRO)The management
organization responsible for overseeing an integrated Tri-Services
health care delivery system within one of the designated TRICARE
regions.
TRICARE Regulation (Defined
in 32 CFR 199.2)This regulation prescribes
guidelines and policies for the administration of the TRICARE Program
for the Army, Navy, Air Force, Marine Corps, Coast Guard, Commissioned
Corps of the USPHS, and the Commissioned Corps of the NOAA. It includes
the guidelines and policies for the administration of the TRICARE
Program.
TRICARE Reimbursement
Manual (TRM) (6010.61-M)A DHA authored book which provides
and outlines payment methodologies under the TRICARE Program.
TRICARE RepresentativeA highly qualified individual
knowledgeable about TRICARE responsible for providing information
and assistance to providers, whether network or non-network, to
Beneficiary Counseling and Assistance Coordinators (BCACs) in their
service area and to Congressional offices.
TRICARE SelectThe self-managed, preferred
provider network option under the TRICARE program established by
10 USC 1075 and
32 CFR 199.17 to
replace TRICARE Extra and Standard after December 31, 2017.
TRICARE StandardThe TRICARE program made available
prior to January 1, 2018, under which the basic program of health care
benefits generally referred to as CHAMPUS was made available to
eligible beneficiaries under 32 CFR 199.
TRICARE Systems Manual
(TSM) (7950.3-M)A DHA
authored book which provides ADP instructions and requirements for
contractors who use the TEDs system for reporting data to DHA.
Unbundled (Or Fragmented)
BillingA form
of procedure code manipulation which involves a provider separately
billing the component parts of a procedure instead of billing only
the single procedure code which represents the entire comprehensive
procedure.
Uniform FormularyA list of brand name and generic
drugs and supplies available for dispensing.
Note: PL 106-65, NDAA for FY 2000,
Section 701, mandated that the DoD develop a uniform formulary to
be applied across all POSs within the TRICARE system. Pharmaceuticals
and other supplies authorized for dispensing will be in accordance
with TRICARE policy and the Uniform Formulary. Recommendations for
the design, structure and composition of the Uniform Formulary are
developed by the DoD P&T Committee, with comments by the Uniform
Formulary Beneficiary Advisory Panel, and provided to the Executive
Director, DHA for approval and implementation.
Uniform HMO Benefit (Defined
in 32 CFR 199.2)The health care benefit established
by
32 CFR 199.18.
Uniformed Services (Defined
in Title 10, United States Code, Section 101(a)(5))The Army, Navy, Air Force,
Marine Corps, Space Force, Coast Guard, Commissioned Corps of the
USPHS, and the Commissioned Corps of the NOAA.
Uniformed Services Clinic
(USC)An MHS
clinic that delivers primary health care to Service members.
Uniformed Services Family
Health Plan (USFHP)A DoD health plan option that
offers TRICARE Prime to individuals who reside in the geographic
service area of a USFHP DP who are eligible to receive care in medical
MTFs/eMSMs (except Service members). This includes those individuals
over age 65 who, except for their eligibility for Medicare benefits,
would have been eligible for TRICARE benefits. DPs under the USFHP
were previously known as “Uniformed Services Family Treatment Facilities”
(USTFs) and are former USPHS hospitals. The service areas of the USFHP
DPs are listed at
https://www.usfhp.com on
the world wide web and in the Catchment Area Directory.
United States (U.S.)Territory made up of the 50
federated states, American Samoa, the District of Columbia, Johnston Island,
Guam, Wake, Midway Islands, Northern Marianas and the U.S. Virgin
Islands.
United States Public
Health Service (USPHS)An agency within the DHHS which
has a Commissioned Corps which are classified as members of the “Uniformed
Services.”
Unprocessable TRICARE
Encounter Data (TED)TED records transmitted by
the contractor to DHA and received in such condition that the basic
record identifier information is not readable on the TRICARE data
system, i.e., header incorrect, electronic records garbled, etc.
Unproven Drugs, Devices,
And Medical Treatments Or ProceduresDrugs, devices, medical treatments
or procedures are considered unproven if:
1. FDA approval
is required and has not been given;
2. If the device
is a FDA Category A Investigational Device Exemption (IDE);
3. If there is
no reliable evidence which documents that the treatment or procedure
has been the subject of well-controlled studies of clinically meaningful
endpoints which have determined its maximum tolerated dose, its
toxicity, its safety, and its efficacy as compared with the standard
means of treatment or diagnosis;
4. If the reliable
evidence shows that the consensus among experts regarding the treatment
or procedure is that further studies or clinical trials are necessary
to determine its maximum tolerated dose, its safety, or its effectiveness
as compared with the standard means of treatment or diagnosis.
For further clarification see
32
CFR 199.4.
Urgent CareMedically necessary treatment
that is required for a sudden illness or injury that is not life
threatening, but does require immediate professional attention to
avoid further complications resulting from non-treatment. Treatment
is usually performed outside an Emergency Room (ER) setting.
Urgent Care Center (UCC)
A TRICARE authorized UCC is
a qualified corporate services provider under
32 CFR 199.6(f) with a location distinct from
a hospital Emergency Room (ER), an office, or a clinic; and whose
purpose is to diagnose and treat illness or injury for unscheduled,
ambulatory patients seeking immediate medical attention.
Use (HIPAA Definition)IIHI which involves sharing,
employment, application, utilization, examination, or analysis of
such information within an entity that maintains such information.”
Utilization CriteriaSpecific guidelines that must
be met in order to ensure that medically necessary and appropriate treatment
is being provided. Criteria to use for screening.
Utilization ManagementA set of techniques used to
manage health care costs by influencing patient care decision-making through
case-by-case assessment of the appropriateness and medical necessity
of care either prior to, during, or after provision of care. Utilization
management also includes the systematic evaluation of individual
and group utilization patterns to determine the effectiveness of
the employed utilization management techniques and to develop modifications
to the utilization management system designed to address aberrances
identified through the evaluation.
Utilization ReviewA process for monitoring the
use, delivery, quality, medical necessity, and cost-effectiveness
of health care services especially those provided by medical community.
Validated Date and DiagnosisThe date a DoD physician (military
or civil service) validates the diagnosis of a service-related condition and
validates that the condition can be resolved within 180 days.
Veteran (Defined in 38
CFR §3.1(d) and 32 CFR 199.2)A person who served in the
active military, naval, or air service, and who was discharged or
released therefrom under conditions other than dishonorable.
Note: Unless the veteran is eligible
for “retired pay,” “retirement pay,” or “retainer pay,” which refers
to payments of a continuing nature and are payable at fixed intervals
from the Government for military service neither the veteran nor
his or her family members are eligible for benefits under TRICARE.
Widow Or Widower (Defined
in 32 CFR 199.2)A person who was a spouse at
the time of death of the active duty member or retiree and who has
not remarried.
WorkdayAny day on which full-time
business can be conducted. See the definition of “Business Day”
in this appendix.
Worker's Compensation
Benefits (Defined in 32 CFR 199.2)Medical benefits available
under any worker’s compensation law (including the Federal Employees Compensation
Act), occupational disease law, employers liability law, or any
other legislation of similar purpose, or under the maritime doctrine
of maintenance, wages, and cure.
Workforce (HIPAA Definition)Employees, volunteers, trainees,
and other persons whose conduct, in the performance of work for
a covered entity is under the direct control of such entity, whether
or not they are paid by the covered entity or business associate
as defined in HIPAA of 1996.