TRICARE Standard Handbook Your guide to using TRICARE Standard and TRICARE Extra

Important Information TRICARE National Web site:

www.tricare.osd.mil

TRICARE Mail Order Pharmacy (Express Scripts):

1-866-DoD-TMOP (1-866-363-8667)

TRICARE Retail Pharmacy (Express Scripts):

1-866-DoD-TRRx (1-866-363-8779)

TRICARE North Region Contractor Health Net Federal Services, Inc. (Health Net):

1-877-TRICARE (1-877-874-2273)

Health Net Web site:

www.healthnetfederalservices.com

TRICARE South Region Contractor Humana Military Healthcare Services, Inc. (Humana Military): 1-800-444-5445 Humana Military Web site:

www.humana-military.com

TRICARE West Region Contractor TriWest Healthcare Alliance (TriWest):

1-888-TRIWEST (1-888-874-9378)

TriWest Web site:

www.triwest.com

TRICARE Overseas (TRICARE Europe,TRICARE Latin America and Canada, and TRICARE Pacific) Overseas Toll-Free Number:

1-888-777-8343

Overseas Web site:

www.tricare.osd.mil/overseas

An Important Note About TRICARE Program Changes At the time of printing, the information in this handbook is current. It is important to remember that TRICARE policies and benefits are governed by public law. Changes to TRICARE programs are continually made as public law is amended. For the most recent information, contact your regional contractor or local TRICARE Service Center. More information regarding TRICARE, including the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can be found online at: www.tricare.osd.mil

TRICARE Standard and TRICARE Extra Here are some examples where TRICARE Standard and TRICARE Extra may be the best option for you.

TRICARE Standard and TRICARE Extra are available to TRICARE beneficiaries who are not able to or choose not to enroll in one of the TRICARE Prime options. Enrollment is not required for TRICARE Standard and TRICARE Extra, which means there are no forms to fill out and no annual enrollment fees.

• You have an established relationship with a particular TRICAREauthorized civilian provider who is not a network provider, and you wish to continue receiving most of your care from that provider.

With TRICARE Standard and TRICARE Extra, you manage your own health care and have the freedom to seek care from any TRICARE authorized provider you choose. It is important that you understand these options, how they work, and the key differences between them, so that you receive the highest quality care that is the most convenient and cost effective.

• You prefer the freedom to schedule appointments with a network or nonnetwork provider without having to consult with a primary care manager first. • You live in an area where TRICARE Prime is not available. • You have employersponsored health insurance and prefer to use TRICARE Standard and TRICARE Extra as secondary coverage. This TRICARE Standard Handbook will explain the different types of TRICARE providers and outline in more detail the costs and requirements when using the TRICARE Standard and TRICARE Extra options. 1

Your TRICARE Regional Contractor We will regularly refer to your regional contractor throughout this handbook and describe differences in each region. In cases where there are regional differences, refer to the information specific to your region. The following are descriptions of each TRICARE region and contact information for each regional contractor.

WEST

NORTH SOUTH

TRICARE North Region

TRICARE West Region

The TRICARE North Region includes Connecticut, Delaware, the District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, Wisconsin, and portions of Iowa (Rock Island Arsenal area only), Missouri (St. Louis area only), and Tennessee (Ft. Campbell area only).

The TRICARE West Region includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding the Rock Island Arsenal area), Kansas, Minnesota, Missouri (excluding the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner only, including El Paso), Utah, Washington, and Wyoming.

Regional contractor

Health Net Federal Services, Inc. (Health Net)

Phone

1877TRICARE (18778742273)

Web site

www.healthnetfederalservices.com

The TRICARE South Region includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area), and Texas (excluding the El Paso area). Humana Military Healthcare Services, Inc. (Humana Military)

Phone

18004445445

Web site

www.humanamilitary.com

TriWest Healthcare Alliance (TriWest)

Phone

1888TRIWEST (18888749378)

Web site

www.triwest.com

Contact your regional contractor if you need assistance using TRICARE Standard and TRICARE Extra. Look in the mail for the TRICARE Standard Health Matters newsletter, an annual publication highlighting covered services, customer service options, news, and other important updates. You also can sign up for regular updates via email at www.tricare.osd.mil/tricaresubscriptions.

TRICARE South Region

Regional contractor

Regional contractor

Check the box marked “Subscribe” next to “TRICARE Standard Updates,” enter your email address, then select “Submit” at the bottom of the page. 2

Table of Contents 1.

Choosing TRICARE Standard and TRICARE Extra . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Plan Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

2.

Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Finding a Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 All Other Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Care at a Military Treatment Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Prior Authorization for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

3.

Covered Services, Limitations, and Exclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Clinical Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Behavioral Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Maternity Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Dental Programs Offered by TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

4.

Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Health Care Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Pharmacy Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Coordinating Benefits with Other Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 ThirdParty Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Debt Collection Assistance Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

5.

Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Getting Married or Divorced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Having a Baby or Adopting a Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Going to College . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Moving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Separating from the Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Retiring from Active Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Becoming Entitled to Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Deceased Sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Loss of Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

3

6.

Information and Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Beneficiary Counseling and Assistance Coordinators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Appealing a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Filing a Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Reporting Suspected Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

7.

Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

8.

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

9.

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 North Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 South Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

10. List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 11. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

For information about your patient rights and responsibilities, see the inside back cover of this handbook.

4

not the custodial parent after a divorce. Your DEERS information is important. Be sure to keep your DEERS records up to date.

Beneficiaries who are eligible to use TRICARE Standard and TRICARE Extra include:

To update DEERS:

• Active duty family members • Family members of National Guard and Reserve members on active duty for more than 30 consecutive days (under federal orders)

• Visit a uniformed services personnel office. Find one near you at www.dmdc.osd.mil/rsl. • Call 18005389552.

• Retired service members • Family members of retired service members

• Fax address changes to DEERS at 18316558317.

• Survivors

• Mail address changes to:

• Others (i.e., certain former spouses, Medal of Honor recipients, etc.)

Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA 939556771

Beneficiaries who are not eligible to use TRICARE Standard and TRICARE Extra include:

• Update addresses online at www.tricare.osd.mil/DEERS.

• Active duty service members • Activated National Guard and Reserve members

Medicare Eligibility

• Any beneficiary enrolled in one of the TRICARE Prime options. You must disenroll before using TRICARE Standard and TRICARE Extra.

TRICARE beneficiaries who also are eligible for Medicare are considered “dualeligible” and are covered under TRICARE For Life (TFL). Under TFL, TRICARE pays second after Medicare. When you are using TRICARE Standard or TRICARE Extra, these options will pay second after Medicare for services covered by both TRICARE and Medicare.

• Dependent parents and parentsinlaw Registering in DEERS You must be registered in the Defense Enrollment Eligibility Reporting System (DEERS) and have a valid uniformed services identification (ID) card to use TRICARE Standard and TRICARE Extra. Sponsors (i.e., active duty and retired service members) are responsible for ensuring that their spouse’s and children’s eligibility is always reflected correctly in DEERS. Once you are registered in DEERS, you will receive a uniformed services ID card that you will present when you seek care.

Retired service members, their family members, survivors, and others who are entitled to Medicare Part A coverage based on age, disability, or endstage renal disease must have Medicare Part B coverage to remain eligible for TRICARE. Active duty family members entitled to Medicare Part A are not required to have Medicare Part B coverage to remain eligible for TRICARE. However, when the active duty sponsor retires, the Medicareeligible family members must have Part A and Part B to remain eligible for TRICARE.

Children under age 10 generally can use a parent’s or guardian’s ID card, but they must be registered in DEERS. At age 10, the sponsor must obtain an ID card for the child. Children under age 10 should have ID cards of their own when in custody of a parent or guardian who is not eligible for TRICARE benefits or who is 5

SECTION 1

Eligibility

CHOOSING TRICARE STANDARD/TRICARE EXTRA

Choosing TRICARE Standard and TRICARE Extra

For information about purchasing Medicare Part B, visit www.ssa.gov or call 18007721213. For more information about TFL, please contact Wisconsin Physicians Service at 18667730404 or visit the TRICARE Web site at www.tricare.osd.mil/tfl.

Enrollment is not required for TRICARE Standard and TRICARE Extra—there are no enrollment forms to fill out and no enrollment fees. You may use TRICARE Standard and TRICARE Extra interchangeably as often as you like, but it’s important to understand the differences between the two.

Plan Overview

The key difference between TRICARE Standard and TRICARE Extra is in the providers that you use for care. With TRICARE Extra, you choose hospitals and providers within the TRICARE network and enjoy discounted costshares. With TRICARE Standard, you choose TRICARE authorized providers outside of the TRICARE network and pay higher costshares.

Active duty service members and activated National Guard and Reserve members* must enroll in TRICARE Prime or TRICARE Prime Remote. Active duty family members, retired service members and their families, survivors, and others have the choice of enrolling in TRICARE Prime or using TRICARE Standard and TRICARE Extra.

Figure 1.1 provides a quick comparison of the two options. We’ll discuss specific provider types later in this handbook. For detailed cost information, see the TRICARE: Summary of Beneficiary Costs flyer or contact your regional contractor.

* Activated National Guard and Reserve members will enroll in one of the TRICARE Prime options at their final duty station.

Comparison of TRICARE Standard and TRICARE Extra

Figure 1.1

TRICARE Standard1

TRICARE Extra

Provider Type

Not in network, but still a TRICARE authorized provider

In network

Outpatient costshare after deductible is met

Active Duty Families: 20% of the TRICARE allowable charge

Active Duty Families: 15% of the negotiated rate

Retirees, Their Families, and All Others: 25% of the TRICARE allowable charge

Retirees, Their Families, and All Others: 20% of the negotiated rate

You may be required to file your own TRICARE claims.

Network providers file claims for you.

Claims

1. Nonparticipating providers may also charge up to 15% above the TRICARE allowable charge. You are responsible for paying this amount. TRICARE will not pay it.

6

Getting Care Finding a Provider

Keep track of the type of providers you are seeing. Visits to a network provider (TRICARE Extra) will cost you less out of pocket, and the provider will file claims on your behalf. With a nonnetwork provider (TRICARE Standard), you’ll pay more out of pocket and may have to file your own claims.

Remember, you can use either a network or non network provider at any time. For example, if an orthopedic surgeon and a physical therapist are treating you, one could be a network provider and the other could be a nonnetwork provider.

TRICARE Provider Types

Figure 2.1

TRICARE-authorized Providers

• TRICAREauthorized providers are those who meet TRICARE’s licensing and certification requirements and have been certified by TRICARE to provide care to TRICARE beneficiaries. These include doctors, hospitals, ancillary providers (such as laboratories and radiology centers) and pharmacies. If you see a provider who is not TRICAREauthorized or can never be certified, you are responsible for the full cost of care. • There are two types of TRICAREauthorized providers: Network and Nonnetwork. Network Providers • Have a signed agreement with your regional contractor to provide care. • Agree to file claims and handle other paperwork for TRICARE beneficiaries. • You are using the TRICARE Extra option when you visit a network provider.

Non-network Providers • Do not have a signed agreement with your regional contractor. • There are two types of nonnetwork providers: Participating and Nonparticipating. Participating • Have agreed to file claims for TRICARE beneficiaries, to accept payment directly from TRICARE, and to accept the TRICARE allowable charge as payment in full for their services. • May participate on a claimby claim basis.

7

Nonparticipating • Have not agreed to accept the TRICARE allowable charge or file claims for TRICARE beneficiaries. • Have the legal right to charge beneficiaries up to 15% above the TRICARE allowable charge for services.

SECTION 2

To find a TRICARE network or nonnetwork provider, visit the provider locator online at www.tricare.osd.mil/ProviderDirectory. The regional contractors also have network provider directories on their Web sites to locate providers in each region. If you do not have Internet access, please call your regional contractor for assistance with locating a provider.

GETTING CARE

When using TRICARE Standard and TRICARE Extra, you may receive care from any TRICAREauthorized provider without a referral. Some services will require prior authorization (discussed later in this section). The following section describes the different types of providers. Figure 2.1 provides a brief overview of TRICARE provider types.

Emergency Care

Care at a Military Treatment Facility

TRICARE defines an emergency as a medical, maternity, or psychiatric condition that would lead a “prudent layperson” (someone with average knowledge of health and medicine) to believe that a serious medical condition exists, that the absence of medical attention would result in a threat to the patient’s life, limb, or eyesight, that the patient requires immediate medical treatment, or that the patient has painful symptoms requiring immediate attention to relieve suffering.

A military treatment facility (MTF) is a military hospital or clinic usually located on or near a military base. You may receive care at an MTF, but only on a spaceavailable basis. MTF appointments are limited, and you will have the lowest priority for receiving care at an MTF. See Figure 2.2 for MTF appointing priorities. MTF Appointing Priorities

1 2 3 4

If you require emergency care, call 911 or go to the nearest emergency room. If you are admitted, you may need to obtain authorization from your regional contractor.

Urgent Care

5

Urgent care is for an illness or injury that would not result in further disability or death if not treated immediately, but does require professional attention within 24 hours. You would require urgent care for conditions such as a sprain, sore throat, or rising temperature that have the potential to develop into an emergency if treatment is delayed longer than 24 hours. Urgent care is not the same as emergency care and you can schedule a “same day” urgent care appointment with a network or nonnetwork provider without a referral. Some services may require prior authorization (discussed later in this section).

Figure 2.2

Active duty service members Active duty family members enrolled in TRICARE Prime Retired service members, their families, and all others enrolled in TRICARE Prime Active duty family members NOT enrolled in TRICARE Prime Retired service members, their families, and all others NOT enrolled in TRICARE Prime

If you wish to receive care at an MTF, call first to see if the MTF can provide you with the care you need. Otherwise, seek care from a civilian network or nonnetwork provider.

Prior Authorization for Care You can access care from the TRICARE authorized provider you choose whenever you need it. Referrals are not required, but some services will require prior authorization. A prior authorization is a review of the requested health care service to determine if it is medically necessary at the requested level of care. Some providers may call the regional contractor to obtain prior authorization for you. If you have questions about authorization requirements, call your regional contractor or visit their Web site for assistance before seeking care.

All Other Care For all other care, such as routine physicals, ongoing treatment for a chronic condition, or visits to a specialist, you can schedule an appointment with a network or nonnetwork provider without a referral. Some services may require prior authorization (discussed later in this section).

8

The following services require prior authorization in all three TRICARE regions: • Adjunctive dental services • Home health services • Hospice care • Nonemergency inpatient admissions for substance use disorders or behavioral health • Outpatient behavioral health care beyond the eighth visit • Transplants—all solid organ and stem cell

Each regional contractor has additional prior authorization requirements. Visit your regional contractor’s Web site or call the tollfree number to learn about each region’s requirements, as they may change periodically.

9

SECTION 2

GETTING CARE

• TRICARE Extended Care Health Option services

Covered Services, Limitations, and Exclusions TRICARE Standard and TRICARE Extra cover most care that is medically necessary and considered proven. However, there are special rules or limits on certain types of care, while other types of care are not covered at all. This section is not intended to be allinclusive. Check with your regional contractor for additional information.

Outpatient Services Figure 3.1 provides coverage details for covered outpatient services. Note: This chart is not intended to be allinclusive. Outpatient Services: Coverage Details

Figure 3.1

Service

Description

Ambulance Services

Covers emergency transfers to or from a beneficiary’s home, accident scene, or other location to a hospital and transfers between hospitals; ambulance transfers from a hospitalbased emergency room to a hospital more capable of providing the required care; and transfers between a hospital or skilled nursing facility and another hospital based or freestanding outpatient therapeutic or diagnostic department/facility. Excludes ambulance service used instead of taxi service when the patient’s condition would have permitted use of regular private transportation; transport or transfer of a patient primarily for the purpose of having the patient nearer to home, family, friends, or personal physician; and Medicabs or ambicabs that function primarily as public passenger conveyances transporting patients to and from their medical appointments.

Ancillary Services

Certain diagnostic radiology and ultrasound; diagnostic nuclear medicine; pathology and laboratory services; and cardiovascular studies

Durable Medical Equipment (DME)

Generally covered if medically necessary and appropriate, and if prescribed by a physician for the specific use of the beneficiary. Duplicate items of DME that are essential to provide a failsafe, inhome, lifesupport system are covered. In this case, “duplicate” means an item that meets the definition of DME and serves the same purpose but may not be an exact duplicate of the original DME item. For example, a portable oxygen concentrator may be covered as a backup for a stationary oxygen generator.

Emergency Services

Emergency services are covered for medical, maternity, or psychiatric conditions that would lead a “prudent layperson” (someone with average knowledge of health and medicine) to believe that a serious medical condition exists; that the absence of medical attention would result in a threat to the patient’s life, limb, or eyesight; that the patient may be a danger to self or others and requires immediate medical treatment; or that the patient manifests painful symptoms requiring immediate palliative effort to relieve suffering.

Eye Examinations

• Active duty family members: One routine eye examination per year • Retired service members, their families, and others: Not covered after age 6

Home Health Care

Parttime or intermittent skilled nursing services and home health services; physical, speech, and occupational therapy; medical social services, and routine and nonroutine medical services. All care must be provided by a participating home health care agency and be authorized in advance by the regional contractor.

Individual Provider Services

Office visits; outpatient officebased medical and surgical care; consultation, diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathic manipulation; rehabilitation services (e.g., physical therapy, speech pathology services, and occupational therapy); and medical supplies used within the office.

10

Outpatient Services: Coverage Details (continued) Service

Description

Laboratory and Xray Services

Generally covered if prescribed by a physician. (Some exceptions apply, e.g., chemo sensitivity assays and bone density Xray studies for routine osteoporosis screening.)

Papanicolaou (Pap) Smear

Covered as either a diagnostic or routine preventive procedure. The HPV Pap test is not covered as a routine screening Pap smear.

Prosthetic Devices and Medical Supplies

Generally covered if prescribed by a physician and is directly related to a medical condition. Prosthetic devices must be FDAapproved.

Inpatient Services Figure 3.2 provides coverage details for covered inpatient services. Note: This chart is not intended to be allinclusive. Inpatient Services: Coverage Details

Figure 3.2

Service

Description

Hospitalization

Semiprivate room (and when medically necessary, special care units), general nursing, and hospital service. Includes inpatient physical and surgical services; meals (including special diets); drugs and medications while an inpatient; operating and recovery room; anesthesia; laboratory tests; Xrays and other radiology services; necessary medical supplies and appliances; and blood and blood products.

Figure 3.3 provides coverage details for covered clinical preventive services. Note: This chart is not intended to be allinclusive. Clinical Preventive Services: Coverage Details

Figure 3.3

Service

Description

Health Promotion and Disease Prevention Examinations

Office visits may be covered for the following services (subject to age and other criteria):

• Cancer screening examinations and services (breast cancer, cancer of female reproductive organs, colorectal cancer, and prostate cancer)

• Infectious diseases (Hepatitis B screening, human immunodeficiency virus [HIV] testing,) and preventive therapy when atrisk (tetanus, animal bite, Rh immune globulin, and exposure to certain infectious diseases, including tuberculosis)

• Genetic testing and counseling for certain clinical indications during pregnancy • Other: routine chest Xrays and electrocardiograms required for admission when a patient is scheduled to receive general anesthesia on an inpatient or outpatient basis Immunizations

Covered for ageappropriate dose of vaccines as recommended by the Centers for Disease Control and Prevention. Immunizations for active duty family members whose sponsors have permanent change of station orders to overseas locations also are covered.

11

SECTION 3

Clinical Preventive Services

COVERED SERVICES, LIMITATIONS, & EXCLUSIONS

Skilled Nursing Facility Semiprivate room; regular nursing services; meals, including special diets; physical, Care occupational, and speech therapy; drugs furnished by the facility; and necessary medical supplies and appliances. Unlike Medicare, unlimited number of days as medically necessary.

Clinical Preventive Services: Coverage Details (continued) Service

Description

Other Health Promotion and Disease Prevention Services

The following services may be covered if provided in connection with a visit for immunizations, Pap smears, mammograms, or examinations for colon and prostate cancer: • Cancer screening (testicular, skin, oral cavity, pharyngeal, and thyroid) • Infectious disease (tuberculosis screening, Rubella antibodies) • Cardiovascular disease (cholesterol screening, blood pressure screening) • Body measurements (height and weight) • Vision screening (only allowed under wellchild services) • Audiology screening (only allowed under wellchild services) • Counseling services expected of good clinical practice that are included with the appropriate office visit at no additional charge (dietary assessment and nutrition; physical activity and exercise; cancer surveillance; safe sexual practices; tobacco, alcohol, and substance abuse; promoting dental health; accident and injury prevention; and stress, bereavement, and suicide risk assessment)

School Physicals

Covered for children ages 511 if required in connection with school enrollment. Note: Annual sports physicals are not a covered benefit.

Wellchild Services

Covered from birth to age 6; includes visits, immunizations, and vision screening.

Behavioral Health Care Services

• Certified marriage and family therapists with a TRICARE participation agreement

You can receive your first eight behavioral health outpatient visits per fiscal year without prior authorization from your regional contractor. After the first eight visits, prior authorization is required. Remember to obtain care only from TRICARE network providers or TRICARE authorized nonnetwork providers. The following types of behavioral health providers may be authorized providers under TRICARE:

• Pastoral counselors—with physician referral and supervision • Mental health counselors—with physician referral and supervision • Licensed professional counselors—with physician referral and supervision If you are unsure which type of provider would best meet your needs, contact your regional contractor for assistance.

• Psychiatrists • Clinical psychologists • Certified psychiatric nurse specialists • Clinical social workers

12

Figure 3.4 provides coverage details for covered behavioral health care services. Note: This chart is not intended to be allinclusive. Behavioral Health Care Services: Coverage Details

Figure 3.4

Service

Description

Acute Inpatient Psychiatric Care

Acute inpatient psychiatric care may be covered on an emergency or nonemergency basis. Prior authorization from your regional contractor is required for all nonemergency inpatient admissions. In emergency situations, authorization is required for continued stay. Limitations • Patients age 19 and older are limited to 30 days per fiscal year.* • Patients age 18 and under are limited to 45 days per fiscal year.* • Inpatient admissions for substance use disorder detoxification and rehabilitation count toward the 30 or 45day limit.

Medication Management

If you are taking prescription medications for a behavioral health care condition, you must be under the care of a provider who is authorized to prescribe those medications. Your provider will manage the dosage and duration of your prescription to ensure you are receiving the best care possible.

Partial Hospitalization

Psychiatric partial hospitalization provides interdisciplinary therapeutic services at least three hours per day, five days a week, in any combination of day, evening, night, and weekend treatment programs. • Prior authorization from your regional contractor is required. • Facility must be TRICAREauthorized. • Partial hospitalization programs must agree to participate in TRICARE. Limitations

Covered when medically or psychologically necessary and provided in conjunction with otherwisecovered psychotherapy. Psychological tests are considered to be diagnostic services and are not counted against the limit of two psychotherapy visits per week. Limitations Testing and assessment is generally limited to six hours in a fiscal year. Exclusions Psychological testing is not covered for the following circumstances: • Academic placement • Job placement • Child custody disputes • General screening in the absence of specific symptoms • Teacher or parental referrals • Diagnosed specific learning disorders or learning disabilities

* Fiscal year is October 1September 30.

13

SECTION 3

Psychological Testing and Assessment

COVERED SERVICES, LIMITATIONS, & EXCLUSIONS

• Limited to 60 treatment days (whether a full or partialday treatment) in a fiscal year.* These 60 days are not offset or counted toward the 30 or 45day inpatient limit.

Behavioral Health Care Services: Coverage Details (continued) Service

Description

Psychotherapy

Prior authorization is required after the first eight behavioral health outpatient visits per beneficiary per fiscal year.* Covered psychotherapy includes: • Individual, conjoint, family, or group sessions • Collateral visits • Play therapy (This is a form of individual therapy used with children.) • Psychoanalysis (Prior authorization from your regional contractor is required.) Limitations • Outpatient psychotherapy is limited to a maximum of two sessions per week in any combination of individual, family, collateral, or group sessions and is not covered when the patient is an inpatient in an institution. • Inpatient psychotherapy is limited to five sessions per week in any combination of individual, family, collateral, or group sessions. The duration and frequency of care is dependent upon medical necessity.

Residential RTC care provides extended care for children and adolescents with psychological disorders Treatment Center that require continued treatment in a therapeutic environment. (RTC) Care • Unless therapeutically contraindicated, the family and/or guardian should actively participate in the continuing care of the patient either through direct involvement at the facility or geographically distant family therapy. • Facility must be TRICAREauthorized. • Prior authorization from your regional contractor is required. • RTC care is considered elective and will not be covered for emergencies. • Admission primarily for substanceuse rehabilitation is not authorized. • Care must be recommended and directed by a psychiatrist or clinical psychologist. Limitations • Limited to 150 days per fiscal year* (may be waived if determined to be medically or psychologically necessary.) Note: No qualified RTCs were available in overseas locations at time of printing. * Fiscal year is October 1September 30.

14

Behavioral Health Care Services: Coverage Details (continued) Service

Description

Treatment for Substance Use Disorders

A substance use disorder includes alcohol or drug abuse or dependence. TRICARE may cover services for the treatment of substance use disorders, including detoxification, rehabilitation, and outpatient group and family therapy. Emergency and inpatient hospital services are considered medically necessary only when the patient’s condition is such that the personnel and facilities of a hospital are required. Note: All treatment for substance use disorders requires prior authorization from your regional contractor. Coverage and Limitations • Benefit Period—Only three substance use disorder treatment benefit periods in a lifetime (waiver possible in accordance with policy criteria) are covered. A benefit period begins with the first date of covered treatment and ends 365 days later, regardless of the total services actually used within the benefit period. Emergency and inpatient hospital services for detoxification, stabilization, and for treatment of medical complications of substance use disorders do not count for purposes of establishing the beginning of a benefit period. • Detoxification—If chemical detoxification is needed but does not require the personnel or facilities of a general hospital setting, detoxification services are covered in addition to rehabilitative care. In a diagnosisrelated group (DRG)exempt facility, detoxification services are limited to seven days per year, unless the limit is waived. • Rehabilitation—Rehabilitation (residential or partial) is limited to 21 days per year or one inpatient stay in a facility subject to the DRGbased reimbursement system, per benefit period; you are limited to three benefit periods in your lifetime. All inpatient stays count toward the 30 or 45day inpatient limit. • Outpatient Care—Must be provided by an approved substance use disorder facility in a group setting. Coverage is limited up to 60 visits per fiscal year.* Individual outpatient care for substance use disorder is not covered.

For additional information about covered and noncovered behavioral health care services and how to access care, contact your regional contractor.

MTF to find out what is on the formulary and for specific details about filling prescriptions at the MTF pharmacy. If you do not live near an MTF, this may not be your best option for filling prescriptions.

Pharmacy Services

TRICARE Mail Order Pharmacy

TRICARE offers comprehensive prescription drug coverage and several options for filling your prescriptions. To have a prescription filled, you’ll need a written prescription and a valid uniformed services ID card. Refer to the TRICARE: Summary of Beneficiary Costs flyer or www.tricare.osd.mil/pharmacy for pharmacy cost information.

The mailorder pharmacy is your least expensive option when not using the MTF. You may receive up to a 90day supply for most medications delivered to your home for a small copayment. Refills may be requested by mail, phone, or online. Express Scripts, Inc. (ESI), administers the mailorder pharmacy, and registering is easy. 1. Register online. Complete the registration form and follow the instructions available at www.expressscripts.com/TRICARE.

Military Treatment Facility Pharmacy Prescriptions may be filled (up to a 90day supply for most medications) at an MTF pharmacy at no cost as long as the medication is on the MTF formulary. You should contact the

2. Register by phone. Call 18663638667.

15

SECTION 3

* Fiscal year is October 1September 30.

COVERED SERVICES, LIMITATIONS, & EXCLUSIONS

• Family Therapy—Outpatient family therapy is covered beginning with the completion of rehabilitative care. You are covered for up to 15 visits in a benefit period.

Some drugs require prior authorization from ESI. For a general list of prescription drugs that are covered under TRICARE and for drugs requiring prior authorization or having quantity limits, visit www.tricare.osd.mil/pharmacy or call tollfree 1866DoDTRRx (18663638779) or 1866DoDTMOP (18663638667).

3. Register by mail. Download the form at www.expressscripts.com/TRICARE and mail it to: P.O. Box 52150, Phoenix, AZ 850729954. Include the written prescription and the appropriate copayment when you mail your registration. For faster processing of your mailorder prescription, you can register before placing your first order. Once you are registered, your provider can fax or call in your prescriptions.

Generic Drug Use Policy It is DoD policy to use generic medications, instead of brandname medications, whenever possible. Brandname drugs that have a generic equivalent may be dispensed only if the prescribing physician is able to justify medical necessity for use of the brandname drug in place of the generic equivalent. If a generic equivalent drug does not exist, the brandname drug will be dispensed at the brandname copayment. If you insist on having a prescription filled with a brandname drug that is not considered medically necessary, and when a generic equivalent is available, you will be responsible for paying the entire cost of the prescription out of pocket.

ESI will send your medications directly to your home within about 14 days after receiving your prescription. If you have prescription drug coverage from another health insurance plan, you can only use the mailorder pharmacy if the medication is not covered under the other plan or if you exceed the dollar limit of coverage under the other plan. TRICARE Retail Pharmacy Network You can have prescriptions filled (up to a 30day supply) at any pharmacy in the TRICARE retail pharmacy network for a small copayment. ESI also administers the retail pharmacy network. For more information or to locate a TRICARE network pharmacy near you, call 1866DoDTRRx (18663638779) or visit www.expressscripts.com/TRICARE.

Non-formulary Drugs Any drug in a therapeutic class determined to be not as relatively clinically effective or not as costeffective as other drugs in the class may be recommended for placement in the third, “nonformulary” tier. Drugs in the third tier are available to beneficiaries from the mailorder or retail pharmacies, but at a higher cost. You may be able to have nonformulary prescriptions filled at formulary costs if your provider can establish medical necessity.

Non-network Pharmacies Filling prescriptions at a nonnetwork pharmacy is the most expensive option. You may have to pay for the total amount first and then file a claim with ESI to receive a partial reimbursement after your deductible is met. (For pharmacy claims information, see the Claims section.)

To learn more about any medication and common drug interactions, to check for generic equivalents or to determine if a drug is classified as a nonformulary medication, visit the online TRICARE Formulary Search Tool at www.tricareformularysearch.org.

Quantity Limits and Prior Authorization TRICARE has established quantity limits on certain medications, which means the DoD will pay only for up to a specified quantity per 30, 60, or 90day supply. Quantity limits are applied to ensure the medications are safely and appropriately used. Exceptions to established quantity limits might be made if the prescribing provider is able to justify medical necessity.

For information on how to save money and make the most of your pharmacy benefit, visit www.tricare.osd.mil/pharmacy or call 1877DoDMEDS (18773636337).

16

Maternity Services

Dental Programs Offered by TRICARE

Prenatal care is important, and we strongly recommend that those who are pregnant, or who anticipate becoming pregnant, seek appropriate medical care. TRICARE Standard and TRICARE Extra cover maternity care, including prenatal care, delivery, and postpartum care. Newborns are covered separately.

TRICARE offers two dental programs—the TRICARE Dental Program (TDP) and the TRICARE Retiree Dental Program (TRDP). Each program is administered by a separate dental contractor and has its own monthly premiums and costshares.

Maternity Ultrasounds

TRICARE Dental Program

TRICARE covers medically necessary maternity ultrasounds separate from the global delivery fee. Doctors often perform medically necessary maternity ultrasounds at different times during pregnancy, and if your provider has reason for concern, TRICARE will cover the ultrasound. Specific conditions for which TRICARE will cover an ultrasound include the following:

The TDP is a voluntary dental insurance program available to eligible active duty family members and to members of the National Guard and Reserve and/or their families. United Concordia Companies, Inc., (United Concordia) currently administers the program. For TDP information, visit www.TRICAREdentalprogram.com or call United Concordia tollfree at 18008668499.

• Estimating gestational age • Evaluating fetal growth

TRICARE Retiree Dental Program

• Conducting a biophysical evaluation for fetal wellbeing

• Diagnosing or evaluating multiple gestations • Confirming cardiac activity • Evaluating maternal pelvic masses or uterine abnormalities • Evaluating suspected hydatidiform mole • Evaluating the fetus’s condition in late registrants for prenatal care Ultrasounds are not covered for routine screening or to determine the sex of the baby. Refer to your regional contractor’s Web site for additional details on maternity ultrasound coverage. If TRICARE coverage ends during pregnancy, TRICARE will not cover any remaining maternity costs unless your family qualifies for other TRICARE health coverage or has purchased the Continued Health Care Benefit Program (CHCBP). To ensure your newborn is covered by TRICARE, see “Having a Baby or Adopting a Child” in the Life Events section.

17

SECTION 3

• Defining the cause of vaginal bleeding

COVERED SERVICES, LIMITATIONS, & EXCLUSIONS

The TRDP is a voluntary dental insurance program available to retired service members and their eligible family members. Delta Dental Plan of California (Delta Dental) currently administers the program. For TRDP information, visit www.trdp.org or call Delta Dental tollfree at 18888388737.

• Evaluating a suspected ectopic pregnancy

Services or Procedures with Significant Limitations Below is a list of medical, surgical, and behavioral health care services that may not be covered unless exceptional circumstances exist. This list is not intended to be allinclusive. Check with your regional contractor for additional information. Services or Procedures with Significant Limitations

Figure 3.5

Service

Description

Abortions

Abortions are covered only when the life of the mother would be endangered if the pregnancy were carried to term. The attending physician must certify in writing that the abortion was performed because a lifethreatening condition existed. Medical documentation must be provided.

Cardiac and Pulmonary Rehabilitation

Both are covered only for certain indications. Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded.

Cosmetic, Plastic, or Reconstructive Surgery

Only covered when used to restore function, correct a serious birth defect, restore body form after a serious injury, improve appearance of a severe disfigurement, or after a medically necessary mastectomy.

Cranial Orthotic Device or Molding Helmet

Cranial orthotic devices are excluded for treatment of nonsynostic positional plagiocephaly.

Facility Charges for nonadjunctive Dental Services

Covered only to safeguard a patient’s life.

Dental Care and Dental Xrays

Both are covered only for adjunctive dental care (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical—not dental—condition).

Education and Training

Outpatient diabetic selfmanagement and training programs are covered when the services are provided by a TRICAREauthorized individual provider who also meets national standards for diabetes selfmanagement education programs recognized by the American Diabetes Association (ADA). The provider’s “Certificate of Recognition” from the ADA must accompany the claim for reimbursement.

Eyeglasses or Contact Lenses

Active duty service members may receive eyeglasses at MTFs at no cost. For all other beneficiaries, contact lenses and/or eyeglasses are only covered for treatment of: • Infantile glaucoma • Corneal or scleral lenses for treatment of keratoconus • Scleral lenses to retain moisture when normal tearing is not present or is inadequate • Corneal or scleral lenses to reduce corneal irregularities other than astigmatism • Intraocular lenses, contact lenses, or eyeglasses for loss of human lens function resulting from intraocular surgery, ocular injury, or congenital absence Note: Adjustments, cleaning, and repairs for eyeglasses are not covered

Food, Food Substitutes When used as the primary source of nutrition for enteral, parenteral, or oral nutritional or Supplements, or therapy. Intraperitoneal nutrition therapy is covered for malnutrition as a result of end Vitamins stage renal disease.

18

Services or Procedures with Significant Limitations (continued) Service

Description

Gastric Bypass

Gastric bypass, gastric stapling, or gastroplasty—to include vertical banded gastroplasty—is covered when one of the following conditions is met: 1. The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders, and severe arthritis of the weightbearing joints. 2. The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category. 3. The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).

Genetic Testing

Covered only under certain conditions.

Hearing Aids

Covered only for active duty family members who meet specific hearing loss requirements.

Intelligence Testing

Covered only when medically necessary for the diagnosis or treatment planning of covered psychiatric disorders.

Laser/LASIK/Refractive Covered only to relieve astigmatism following a corneal transplant. corneal surgery

Private Hospital Rooms

Not covered unless ordered for medical reasons or a semiprivate room is not available. Hospitals that are subject to the TRICARE diagnosisrelated group (DRG) payment system may provide the patient with a private room but will only receive the standard DRG amount. The hospital may bill the patient for the extra charges if the patient requests a private room.

Weight Reduction

Services and supplies related to obesity or weight reduction, whether surgical or nonsurgical, are excluded except for gastric bypass, gastric stapling, or gastroplasty procedures in connection with morbid obesity.

Exclusions

• Acupuncture • Air conditioners, humidifiers, dehumidifiers, and purifiers

In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder) or injury or for the diagnosis and treatment of pregnancy or wellbaby care. All services and supplies (including inpatient institutional costs) related to a noncovered condition or treatment, or provided by an unauthorized provider, are excluded.

• Artificial insemination, including invitro fertilization, gamete intrafallopian transfer, and all other such reproductive technologies • Autopsy services or postmortem examinations • Bariatric surgery, except as outlined under Gastric Bypass and Weight Reduction in Figure 3.5, “Services or Procedures with Significant Limitations” • Birth control/contraceptives (nonprescription) • Camps (e.g., weight loss)

The following specific services are excluded under any circumstance: This list is not intended to be allinclusive. Check your regional contractor’s Web site for additional information.

• Charges that providers may apply to missed or rescheduled appointments • Chiropractic care

19

SECTION 3

Covered only for beneficiaries with behavioral health disorder as a primary diagnosis, and the marital or couples therapy must be medically necessary.

COVERED SERVICES, LIMITATIONS, & EXCLUSIONS

Marital Therapy and/or Couples Counseling

• Clothing or shoes, even if required by virtue of an allergy • Counseling services that are not medically necessary in the treatment of a diagnosed medical condition. For example, educational counseling, vocational counseling, and counseling for socioeconomic purposes, stress management, lifestyle modification, etc. • Custodial care • Diagnostic admissions • Diagnostic tests to establish paternity of a child or tests to determine the sex of a fetus • Domiciliary care • Dyslexia treatment • Electrolysis • Elevators or chair lifts • Exercise equipment, spas, whirlpools, hot tubs, swimming pools, health club memberships, or other such charges or items

specialordered, custommade builtup shoes, or regular shoes later built up

• Experimental or unproven procedures

• Personal, comfort, or convenience items, such as beauty and barber services, radio, television, and telephone

• Foot care (routine) except those required as a result of a diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes

• Postpartum inpatient stay of a mother for purposes of staying with the newborn infant (usually primarily for the purpose of breastfeeding the infant) when the infant (but not the mother) requires the extended stay; or continued inpatient stay of a newborn infant primarily for purposes of remaining with the mother when the mother (but not the newborn infant) requires extended postpartum inpatient stay

• General exercise programs, even if recommended by a physician and regardless of whether rendered by an authorized provider • Inpatient stays: • For rest or rest cures • To control or detain a runaway child, whether or not admission is to an authorized institution

• Preventive care, such as routine annual or employmentrequested examinations; routine screening procedures; immunizations; except such preventive care, immunizations, and cancer screenings provided in the Clinical Preventive Services list (See “Clinical Preventive Services” earlier in this section.)

• To perform diagnostic tests, examinations, and procedures that could have been and are performed routinely on an outpatient basis • In hospitals or other authorized institutions above the appropriate level required to provide necessary medical care

• Psychiatric treatment for sexual dysfunction

• Laparoscopic adjustable gastric banding (Lap Band procedure)

• Services and supplies:

• Learning disability services

• Provided under a scientific or medical study, grant, or research program

• Megavitamins and orthomolecular psychiatric therapy

• Furnished or prescribed by an immediate family member

• Mind expansion and elective psychotherapy

• For which the beneficiary has no legal obligation to pay or for which no charge would be made if the beneficiary or sponsor was not eligible under TRICARE

• Naturopaths • Orthopedic shoes (except if an integral part of a brace), arch supports, shoe inserts, and other supportive devices for the feet, including 20

• Furnished without charge (e.g., cannot file claims for services provided freeofcharge) • For the treatment of obesity, except as outlined in Services or Procedures with Significant Limitations. Diets, weight loss counseling, weight loss medications, wiring of the jaw, or similar procedures are excluded. • Including inpatient stays, directed or agreed to by a court or other governmental agency (unless medically necessary) • Required as a result of occupational disease or injury for which any benefits are payable under a worker’s compensation or similar law, whether such benefits have been applied for or paid, except if benefits provided under such laws are exhausted • That are (or are eligible to be) fully payable under another medical insurance or program, either private or governmental, such as coverage through employment or Medicare (TRICARE will be secondary for any remaining charges.)

• Sterilization reversal surgery • “Stop smoking” regimens • Surgery performed primarily for psychological reasons (such as psychogenic) • Therapeutic absences from an inpatient facility, except when such absences are specifically included in a treatment plan approved by TRICARE • Transportation except by ambulance • Travel, even if prescribed by a physician to obtain medical care • Xray, laboratory, and pathological services and machine diagnostic tests not related to a specific illness or injury or a definitive set of symptoms except for cancer screening mammography, cancer screening, Pap tests, and other tests allowed under the Clinical Preventive Services benefit

21

SECTION 3

COVERED SERVICES, LIMITATIONS, & EXCLUSIONS

• Sex changes or sexual inadequacy treatment (However, treatment of ambiguous genitalia which has been documented to be present at birth is covered.)

Claims Health Care Claims

• Charge for each service • Diagnosis (If the diagnosis is not on the bill, be sure to complete block 8a on the form.)

If you are using the TRICARE Extra option, your provider will submit claims on your behalf. If you are using the TRICARE Standard option, you may be required to submit your own health care claims. Claims should be submitted to the claims processor in the region in which you live.

Be sure to complete all 12 blocks of the form correctly and sign it. Note: Providers submit inpatient facility claims. You may be required to pay up front for services if you see a nonnetwork TRICARE authorized provider who chooses not to participate on the claim. In this case, TRICARE will reimburse you directly for the TRICARE allowable charge minus any applicable deductible and costshare. Remember that nonparticipating providers may charge you up to 15 percent above the TRICARE allowable charge for services in addition to your costshare and/or deductible.

Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge. To file a claim, obtain and fill out a DD Form 2642 Patient’s Request for Medical Payment. Forms and instructions are available to download from the TRICARE Web site at www.tricare.osd.mil/claims or your regional contractor’s Web site. You can also visit a TRICARE Service Center (TSC) or a military treatment facility (MTF). If you have claims questions, call your regional contractor.

Send your claims to the claims processor for the region in which you live. If you receive care while traveling, file TRICARE claims based on where you live, not where you received care. Be sure to keep a copy of the paperwork for your records. Figure 4.1 lists regional claims processing information.

When filing a claim, attach a readable copy of the provider’s bill to the claim form, making sure it contains the following: • Sponsor’s Social Security number (SSN) (Eligible former spouses should use their social security number.) • Provider’s name and address (If more than one provider’s name is on the bill, circle the name of the person who treated you.)

You may call your regional contractor, visit your regional contractor’s Web site, or visit the TRICARE Web site at www.tricare.osd.mil/claims for claims processing information.

• Date and place of each service • Description of each service or supply furnished

Regional Claims Processing Information

Figure 4.1

TRICARE North Region

TRICARE South Region

TRICARE West Region

Send claims to: Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE P.O. Box 870140 Surfside Beach, SC 295879740

Send claims to: TRICARE South Region Claims Department P.O. Box 7031 Camden, SC 290207031

Send claims to: West Region Claims P.O. Box 77028 Madison, WI 537977028

Check the status of your claim at www.myTRICARE.com or www.healthnetfederalservices.com.

Check the status of your claim at www.myTRICARE.com or at www.humanamilitary.com.

22

Check the status of your claim at www.triwest.com.

Pharmacy Claims

If you have OHI, you’ll need to follow the OHI’s rules for filing claims and file the claim with them first. If there is an amount your OHI does not cover, you can file the claim with TRICARE for reimbursement. It is important to follow the requirements of your OHI. If your OHI denies a claim for failure to follow their rules, such as obtaining care without authorization or using a nonnetwork provider, TRICARE may also deny your claim.

If you have other health insurance (OHI) with pharmacy coverage or if you fill prescriptions at a nonnetwork pharmacy, you’ll need to submit pharmacy claims to Express Scripts, Inc. (ESI), for payment. Before reimbursement is granted for nonnetwork pharmacy claims, you must meet an annual TRICARE deductible. Pharmacy claims must be filed within one year of the date of service. To file a pharmacy claim, obtain and fill out a DD Form 2642 Patient’s Request for Medical Payment. Prescription claims require the following information for each drug:

Keep your regional contractor and health care providers informed about your OHI so that they can coordinate your benefits and help ensure that there is no delay (or denial) in the payment of your claims.

• Name of the patient

How TRICARE Calculates Payment with OHI

• Name, strength, date filled, days supply, quantity dispensed, and price of each drug

TRICARE regulations require coordination of benefits with OHI coverage. Due to these regulations, TRICARE does not always pay the OHI copayment or the balance remaining after the OHI pays. However, your liability is usually eliminated. Payment calculations differ by provider status as detailed below.

• National Drug Code, if available • Prescription number of each drug • Name and address of the pharmacy • Name and address of the prescribing physician Forms and instructions are available to download at www.tricare.osd.mil/claims or at www.tricare.osd.mil/pharmacy/claims.cfm.

TRICARE Network Individual/Group Providers and Most Inpatient Facilities If your OHI pays more than the TRICARE allowed amount, then no payment is authorized, the charge is considered paid in full, and the provider may not bill you. Otherwise, TRICARE pays the lesser of:

Mail the claim to: Express Scripts, Inc. TRICARE Claims P.O. Box 66518 St. Louis, MO 631666518

• The allowed amount minus the OHI payment Call 1866DoDTRRx (18663638779) with questions about filing a pharmacy claim.

• The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copayment/deductible)

TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs/plans as identified by the TRICARE Management Activity (TMA).

TRICARE pays the lesser of: • The billed amount minus the OHI payment • The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copayment/deductible) 23

SECTION 4

Non-Network Individual/Group Providers that Accept TRICARE Assignment (Participating)

CLAIMS

Coordinating Benefits with Other Health Insurance

Individual/Group Providers that Don’t Accept TRICARE Assignment (Nonparticipating)

or unless you exceed the dollar limit of coverage under the other plan. When you have OHI, the rules of that insurer apply. You should call ESI at 1866DoDTRRx (18663638779) for specific instructions about filing pharmacy claims if you have OHI.

Nonparticipating providers may only bill you up to 15 percent above the TRICARE allowable charge. If your OHI paid more than 115 percent of the TRICARE allowable charge, then no TRICARE payment is authorized, the charge is considered paid in full, and the provider may not bill you. Otherwise, TRICARE pays the lesser of:

Third-Party Liability The Federal Medical Care Recovery Act allows TRICARE to be reimbursed for its costs of treatment if you are injured in an accident that was caused by someone else. The DD Form 2527 Statement of Personal Injury Third Party Liability Form will be sent to you if a claim appears to have thirdparty liability involvement. Within 35 calendar days, you must complete and sign this form and follow the directions for returning the form to the appropriate claims processor. The DD Form 2527 is available to download at www.tricare.osd.mil/claims or from your regional contractor’s Web site.

• 115 percent of the allowed amount minus the OHI payment • The amount TRICARE would have paid without OHI • The beneficiary’s liability (OHI copay/deductible) Staff Model Health Maintenance Organizations (HMO), Group HMOs, and Other Capitated OHI Plan Providers If you are enrolled in one of these OHI plans, the provider/group either works directly for the HMO or is paid a monthly/annual amount rather than a fee for each service performed. In these plans you may only receive a copayment receipt, and an itemized bill or explanation of benefits (EOB) may not be available.

Explanation of Benefits A TRICARE explanation of benefits (EOB) is not a bill. It is an itemized statement that shows what action TRICARE has taken on your claims. An EOB is for your information and files.

In these cases, you can submit a DD Form 2642 Patient’s Request for Medical Payment with a copy of the receipt. For processing, the copay is considered the billed amount. Deductibles and costshares are applied, and you may only receive partial reimbursement of your HMO copay.

After reviewing the EOB, you have the right to appeal certain decisions regarding your claims and must do so in writing within 90 days of the date of the EOB notice. (For more information about appeals, see the Information and Assistance section.) You should keep EOBs with your health insurance records for reference.

Pharmacy Claims (Processed by ESI) For a sample of the EOB in your region along with instructions for reading the EOB, see the following figure numbers in the Appendix section:

When using OHI, the OHI is the first payer for pharmacy coverage. You may then be eligible for full or partial reimbursement from TRICARE for outofpocket costs, including copayments. If you have OHI, you should use a retail pharmacy under your private insurer that is also in the TRICARE retail network to avoid paying the TRICARE nonnetwork deductible. You may not use the mail order pharmacy if you have prescription drug coverage from OHI, unless the medication is not covered under the other plan,

• North Region: Figure 9.1 • South Region: Figure 9.2 • West Region: Figure 9.3

24

Debt Collection Assistance Officers Debt Collection Assistance Officers (DCAO) are located at MTFs and at TRICARE Regional Offices (TRO) to assist you in resolving health care collectionrelated issues. Contact a DCAO if you have received a negative credit rating or have been sent to a collection agency due to an issue related to TRICARE services.

25

SECTION 4

CLAIMS

When you visit a DCAO for assistance, you must bring or submit documentation associated with a collection action or adverse credit rating, including debt collection letters, EOB statements, and medical/dental bills from providers. The more information you can provide, the faster the DCAO will be able to determine the cause of the problem. The DCAO will research your claim, provide you with a written resolution of your collection problem, and inform the collection agency that action is being taken to resolve the issue. DCAOs cannot provide legal advice or repair your credit rating, but they can help you through the debt collection process by providing documentation for the collection or creditreporting agency to explain the circumstances relating to the debt. To find a DCAO near you, visit the DCAO directory online at www.tricare.osd.mil/bcacdcao.

Life Events Divorce

TRICARE Standard and TRICARE Extra continue to provide health coverage for you and your family as you experience major life events. You will, however, need to take specific actions to make sure you remain eligible for TRICARE. With every life event listed in this section, the first step is to update your information in the Defense Enrollment Eligibility Reporting System (DEERS).

In the case of a divorce, sponsors must report to DEERS that the former spouse is no longer eligible for TRICARE. You will need a copy of the divorce decree to update DEERS. Children After a divorce, children (biological and adopted) remain eligible for TRICARE up to age 21 (or age 23 if enrolled in college full time and the sponsor provides at least 50 percent of the financial support) as long as their information is kept up to date in DEERS. While children normally do not get their own uniformed services ID card until age 10, children under age 10 should have an ID card of their own when they are in custody of a parent or guardian who is not eligible for TRICARE benefits or who is not the custodial parent after a divorce. Please check with DEERS for eligibility criteria. Patient privacy may be a factor for divorced parents attempting to obtain information about received health care services. Contact your regional contractor for assistance. Note: Children with a disability may remain eligible for TRICARE beyond the normal age limits. Please contact DEERS to verify what documentation is needed to extend coverage.

To update DEERS: • Visit a uniformed services personnel office. Find one near you at www.dmdc.osd.mil/rsl. • Call 18005389552. • Fax address changes to DEERS at 18316558317. • Mail the address change to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA 939556771 • Update addresses online at www.tricare.osd.mil/DEERS. Read the following sections to learn what to do when you get married, have a child, move, retire, and more.

Former Spouses Certain former spouses are eligible to continue TRICARE Standard and TRICARE Extra coverage if the following requirements are met:

Getting Married or Divorced Marriage

1. Must not remarry (If they remarry, the loss of benefits remains applicable even if remarriage ends in death or divorce.)

It is extremely important that active duty and retired sponsors register their new spouses in DEERS to ensure they are eligible for TRICARE. To register a new spouse, the sponsor will need to provide a copy of the marriage certificate to the nearest uniformed services ID cardissuing facility. Once the spouse is registered in DEERS, he or she will receive a uniformed services ID card and will be eligible for TRICARE. When accessing care, providers will ask to see the ID card.

2. Must not be covered by an employer sponsored health plan 3. Must not be the former spouse of a North Atlantic Treaty Organization or “Partners for Peace” nation member 4. Must meet the requirements of one of the three situations in Figure 5.1 on the following page.

26

• Must have been married to the same member or former member for at least 20 years, and at least 20 of those years must have been creditable in determining the member’s eligibility for retirement pay.

1

• If the date of the final decree of divorce or annulment was on or after February 1, 1983, the former spouse is eligible for TRICARE coverage of health care that is received after the date of the divorce or annulment. • If the date of the final decree is before February 1, 1983, the former spouse is eligible for TRICARE coverage of health care received on or after January 1, 1985. • Eligibility continues as long as the preceding requirements continue to be met. • Must have been married to the same military member or former member for at least 20 years, and at least 15—but less than 20—of those married years must have been creditable in determining the member’s eligibility for retirement pay.

2

• If the date of the final decree of divorce or annulment is before April 1, 1985, the former spouse is eligible only for care received on or after January 1, 1985, or the date of the decree, whichever is later. • Eligibility continues as long as the preceding requirements continue to be met. However, if the date of the final divorce decree or annulment is on or after April 1, 1985, but before September 29, 1988, the former spouse is eligible for care received from the date of the decree until December 31, 1988, or two years from the date of the decree, whichever is later.

3

• Must have been married to the same military member or former member for at least 20 years, and at least 15—but less than 20—of those married years must have been creditable in determining the member’s eligibility for retirement pay. • If the date of the final decree of divorce or annulment is on or after September 29, 1988, the former spouse is eligible only for care received for one year from the date of the decree.

member is enrolled in TRICARE Prime, the child is automatically covered by TRICARE Prime for the first 60 days. If you wish to keep your child in TRICARE Prime, you must submit a TRICARE Prime Enrollment Application to your regional contractor within 60 days of birth for continuous TRICARE Prime coverage.

When a former spouse is eligible for TRICARE coverage, he or she must change his or her personal information in DEERS so that his or her name and Social Security number (SSN) is listed as the primary contact. The former spouse’s TRICARE eligibility will be shown in DEERS under his or her SSN.

On the 61st day, if you have not enrolled your child in TRICARE Prime, he or she will automatically be covered under TRICARE Standard and TRICARE Extra until 365 days after his or her birth or adoption. On day 366, if you have not registered your child in DEERS, DEERS will show “loss of eligibility,” and he or she will no longer be able to receive TRICARE benefits until they are registered in DEERS. If you register your child in DEERS within the first 365 days, TRICARE Standard and TRICARE Extra coverage is continuous.

Having a Baby or Adopting a Child Register your newborn or adopted child in DEERS as soon as possible. To register your child, you need a certificate of live birth or adoption. Note: The document does not need to be a certified copy of the official birth certificate. It can be a certificate of live birth authenticated by either the attending physician or other responsible party from the hospital. Children are covered as TRICARE Prime beneficiaries for 60 days after birth or adoption, when at least one other person in the family is enrolled in TRICARE Prime. Therefore, if the sponsor is on active duty (and active duty sponsors must be enrolled in TRICARE Prime or TRICARE Prime Remote), or another family

If no family member is enrolled in TRICARE Prime at the time of your child’s birth or adoption, he or she is automatically covered by TRICARE Standard and TRICARE Extra. Coverage will be continuous as long as you register your child in DEERS within 365 days of birth. 27

SECTION 5

Figure 5.1

LIFE EVENTS

Eligibility Requirements for Former Spouses

Going to College

Traveling Overseas When traveling overseas, you can use the TRICARE Standard option and receive care from any host nation provider. The TRICARE Overseas Program Standard option is similar to the stateside program, including costshares and deductibles. You may have to pay for care up front and file a claim for reimbursement with your regional contractor when you return to your stateside region.

Your children remain eligible for TRICARE up to age 21 (or age 23 if enrolled in college full time and the sponsor provides at least 50 percent of the financial support) as long as their information is kept up to date in DEERS. To extend benefits for your college student beyond his or her 21st birthday, call the nearest uniformed services ID cardissuing facility for further assistance. Representatives there will be able to advise you about the documentation needed to update DEERS and extend coverage.

Contact the TRICARE Area Office (TAO) for the overseas area where you are traveling or the nearest American Embassy Health Unit for assistance finding a host nation provider. Visit http://usembassy.state.gov for a list of every American Embassy or Consular Office worldwide. Note: The TRICARE Extra option is not available overseas.

TRICARE Standard and TRICARE Extra provide continuous coverage when your child goes to college. Coverage remains the same, but your child will need to find a new provider. Advise your son or daughter to save any receipts they have in case you need to file a claim for reimbursement. TRICARE benefits end when your college student reaches age 23 or when fulltime student status ends, whichever comes first. For example, if your child turns 23 on January 3rd but doesn’t graduate until May, coverage ends at midnight on January 2nd. Note: Children with a disability may remain eligible for TRICARE beyond the normal limits.

Traveling Traveling within the United States If you seek care from a network provider, the provider will file the claim with your regional contractor on your behalf. If you seek care from a TRICAREauthorized nonnetwork provider, you may have to pay up front, save your receipts, and file the claim with your regional contractor. Claims are always filed with the regional contractor in your home region, not with the regional contractor in the area in which you are traveling.

28

TRICARE Europe

TLAC

TRICARE Pacific

Comm.: 011496302677432

Comm.: 17067872424

Comm.: 011816117432036

DSN: 4967432

DSN: 7732424

DSN: 6432036

Tollfree: 18887778343

Tollfree: 18887778343

Remote Sites: 0116563389277 Tollfree: 18887778343

Fax

Comm.: 011496302676374

17067873024

DSN: 4966374

Comm.: 011816117432037 DSN: 6432037

Email

[email protected]

[email protected]

[email protected]

Online

www.europe.tricare.osd.mil

www.tricare.osd.mil/tlac

www.tricare.osd.mil/pacific

TRICARE Overseas Areas

All you’ll need is the written prescription and your uniformed services ID card. Refilling a prescription originally filled at another MTF is at the discretion of the MTF you are visiting.

• TRICARE Europe includes Europe, Africa, and the Middle East. • TRICARE Latin America and Canada (TLAC) includes Central and South America, the Caribbean Basin, Canada, Puerto Rico, and the Virgin Islands.

TRICARE Mail Order Pharmacy If you will be staying away from home for a longer period of time, you can plan ahead to receive prescriptions though the TRICARE mail order pharmacy. Provide ESI with your temporary address so prescriptions can be mailed to you at your travel destination. Note: The mailorder option is not available overseas unless you have an APO or FPO address. Call tollfree 18663638667 or visit www.expressscripts.com/TRICARE for assistance.

• TRICARE Pacific includes Guam, Japan, Korea, Asia, New Zealand, India, and Western Pacific remote countries. Figure 5.2 lists contact information for the TAO in each overseas area. Filling Prescriptions on the Road We recommend that you have all your prescriptions filled before you travel, but there are several options for filling prescriptions on the road.

Non-Network Pharmacy If there is no other option, you also can have prescriptions filled at any nonnetwork retail pharmacy. Having prescriptions filled at a nonnetwork pharmacy is the most expensive option. If you do, you’ll have to pay in full when you have your prescriptions filled, then file a claim with TRICARE for partial reimbursement after your deductible is met.

TRICARE Retail Network Pharmacy You can have prescriptions filled at any TRICARE retail network pharmacy. The TRICARE retail pharmacy network has more than 53,000 retail pharmacies in the United States, Puerto Rico, Guam, and the U.S. Virgin Islands. To locate a network pharmacy, call tollfree 18663638779 or visit www.expressscripts.com/TRICARE.

Filling Prescriptions Overseas Your pharmacy coverage is limited overseas. We recommend that you have all your prescriptions filled before you travel overseas.

Military Treatment Facility Pharmacy If you’re near an MTF while traveling, you can have a new prescription filled free of charge if the medication is on the MTF formulary and the pharmacy stocks the medication you need.

• TRICARE retail network pharmacies are located only in the United States, Puerto Rico, Guam, and the U.S. Virgin Islands. 29

SECTION 5

Phone

Figure 5.2

LIFE EVENTS

TRICARE Area Office Contact Information

TRICARE Overseas Areas

• To use the mailorder pharmacy overseas, you must have an APO or FPO address.

• TRICARE Europe includes Europe, Africa, and the Middle East.

• The prescription must be from a U.S. licensed provider. • TRICARE Standard deductibles apply at host nation pharmacies.

• TLAC includes Central and South America, the Caribbean Basin, Canada, Puerto Rico, and the Virgin Islands.

Moving

• TRICARE Pacific includes Guam, Japan, Korea, Asia, New Zealand, India, and Western Pacific Remote countries.

Moving within the United States

Figure 5.2 on the previous page lists contact information for the TAO in each overseas area.

Whether you are moving to another area within the same TRICARE region or to a different TRICARE region, moving with TRICARE Standard and TRICARE Extra is easy. All you need to do is update your personal information in DEERS, find a new provider, and continue to receive care when you need it.

Separating from the Service If your active duty sponsor separates from the uniformed services, TRICARE coverage may or may not continue, depending on the circumstances of the separation. TRICARE offers two transitional health care options—the Transitional Assistance Management Program (TAMP) and the Continued Health Care Benefit Program (CHCBP)—that offer temporary coverage until you have a new health plan.

To find a provider, visit the provider locator online at www.tricare.osd.mil/ProviderDirectory. The regional contractors also have network provider directories on their Web sites to locate providers in the respective regions. If you move to a new region, learn who your new regional contractor is and where to file your claims. See the Claims section for details.

Transitional Assistance Management Program TAMP provides 180 days of transitional health care benefits to certain uniformed service members and their families, if the active duty sponsor is:

Moving Overseas You can use the TRICARE Standard option and receive care from any host nation provider overseas. The TRICARE Overseas Program Standard option is similar to the stateside program, including costshares and deductibles. Contact the TAO for the overseas area where you are moving or the nearest American Embassy Health Unit for assistance finding a host nation provider. Visit http://usembassy.state.gov for a list of every American Embassy or Consular Office worldwide. Note: The TRICARE Extra option is not available overseas.

1. Involuntarily separating from active duty under honorable conditions 2. A member of the National Guard or Reserves separating from active duty after a period of more than 30 consecutive days in support of a contingency operation 3. Separating from active duty following involuntary retention (stoploss) in support of a contingency operation 4. Separating from active duty following a voluntary agreement to stay on active duty for less than one year in support of a contingency operation

There are some limitations in health care services and pharmacy coverage overseas. Check with the TAO for details. You can request a copy of the TRICARE Beneficiary Handbook for your overseas area.

30

Continued Health Care Benefit Program The CHCBP is a premiumbased health care program administered by Humana Military Health Care Services, Inc., (Humana Military). CHCBP offers temporary transitional health coverage (1836 months) after TRICARE eligibility ends. Service members and certain family members can purchase CHCBP within 60 days of loss of eligibility for either regular TRICARE or TAMP coverage.

Because your status also changes to that of a family member of a retired service member, the costshares and catastrophic cap for TRICARE Standard and TRICARE Extra will increase. There are also other program changes. Here’s a quick glance at some of the changes in TRICARE Standard and TRICARE Extra that you’ll experience when your active duty sponsor retires:

CHCBP acts as a bridge between military health benefits and your new civilian health plan. CHCBP benefits are comparable to TRICARE Standard with the same benefits, providers, and program rules. The main difference is that you pay premiums to participate. To purchase CHCBP, you must enroll within 60 days of your loss of TRICARE eligibility. Contact Humana Military for more information about CHCBP by visiting www.humanamilitary.com/chcbp/main.htm or by calling 18004445445.

Outpatient Costshares

• Increases to the retired family rates

Catastrophic Cap

• Increases to the retired family rate

Health Care Services

• Annual eye exams no longer covered • Hearing aids no longer covered

Medicare eligibility

Contact your regional contractor or a beneficiary counseling and assistance coordinator (BCAC) to discuss your family’s eligibility for either of these programs. You also can visit www.tricare.osd.mil for details about either program.

• Must purchase Medicare Part B to remain eligible for TRICARE

See the TRICARE: Summary of Beneficiary Costs flyer for additional details about inpatient costshare increases. You should look at your health care options together and determine which option best meets your family’s needs after you retire.

Additionally, some members of the National Guard or Reserve may be eligible for TRICARE Reserve Select (TRS) upon separating from active duty. Visit www.tricare.osd.mil/reserve/reserveselect/index.cfm for information.

31

SECTION 5

If your active duty sponsor will soon retire, he or she will experience a “change in status” from active duty to retired. When your sponsor’s status is updated in DEERS, you will receive a new uniformed services ID card showing the new “retired” status. With the new “retired service member” status, your sponsor will have new health care options. Until they retire, they are enrolled in either TRICARE Prime or TRICARE Prime Remote. As retired service members, they can choose to reenroll in TRICARE Prime, or they can use TRICARE Standard and TRICARE Extra.

LIFE EVENTS

Retiring from Active Duty

If you qualify for coverage under TAMP, you will have 180 days of transitional health benefits after the sponsor separates. During this 180day period, you may enroll in TRICARE Prime if you reside in a TRICARE Prime Service Area, or you will be covered under TRICARE Standard and TRICARE Extra. Rules and processes for these programs will apply. Your costs will be the same as those for active duty family members.

Becoming Entitled to Medicare

During this time, family members are referred to as “transitional survivors.”

When you or another family member becomes entitled to Medicare A—due to age, disability, or endstage renal disease—TRICARE becomes the second payer after Medicare. To remain eligible for TRICARE, you must have Medicare Part B coverage (except for active duty family members). TRICARE beneficiaries that have Medicare Part A and Part B coverage are covered under TRICARE For Life (TFL).

During the transitional survivor period, you may enroll in TRICARE Prime, if available. If you choose not to enroll in TRICARE Prime, you will be covered automatically by TRICARE Standard and TRICARE Extra. If TRICARE Prime is not available, surviving spouses will be eligible to enroll in TRICARE Prime Remote for Active Duty Family Members for a threeyear period, and surviving children are eligible to enroll until age 21 or 23. Your TRICARE coverage will continue uninterrupted as long as your information is correct in DEERS. At the end of the threeyear transition, TRICARE eligibility continues for the surviving spouse at the retired family member rates. If the surviving spouse is enrolled in TRICARE Prime during the transitional survivor period and wants to continue coverage after three years, the spouse will need to submit a new enrollment application to the regional contractor along with the appropriate enrollment fees.

If you are becoming entitled to Medicare due to age (65 and over), you will receive a letter from DEERS 90 days before your 65th birthday. The letter will tell you that your benefits are about to change, that you must have Medicare Part B coverage, and that you will begin using TFL. For additional details, contact Wisconsin Physicians Service at 18667730404 or visit the TRICARE Web site at www.tricare.osd.mil/tfl.

Deceased Sponsor TRICARE coverage continues for eligible family members whose sponsor dies—whether on active duty or if retired. Surviving spouses will remain eligible for TRICARE as long as they do not remarry. In the case of remarriage, surviving spouse status cannot be regained later, even if the surviving spouse later divorces or the new spouse dies.

Following the Death of a Retired Service Member When a retired service member dies, family members remain eligible for TRICARE Standard and TRICARE Extra with no changes as long as information is kept up to date in DEERS. Surviving spouses will remain eligible for TRICARE as long as they do not remarry. In the case of remarriage, surviving spouse status cannot be regained later, even if the surviving spouse later divorces or the new spouse dies.

Children remain eligible until they turn age 21 (or 23 if enrolled in college full time and you, the parent, provide more than 50 percent of your child’s financial support). Note: Children with a disability may be eligible for TRICARE beyond the normal limits.

Children remain eligible up to age 21 (or to age 23 if the child is enrolled full time in college and you, the parent, provide more than 50 percent of your child’s financial support). Note: Children with a disability may remain eligible for TRICARE beyond the normal limits.

Following the Death of an Active Duty Service Member When an active duty sponsor dies, the surviving spouse remains eligible for TRICARE at the active duty family member rates for a threeyear period, and the surviving children remain eligible for TRICARE at the active duty family member rates until age 21, or age 23 if enrolled full time in a postsecondary education program.

32

• Sponsor’s name and Social Security number

Upon loss of TRICARE eligibility, each family member will automatically receive a certificate of creditable coverage. The certificate of creditable coverage is a document that serves as evidence of prior health care coverage under TRICARE so that you cannot be excluded from a new health plan for preexisting conditions.

• Name of person for whom the certificate is requested • Reason for the request • Name and address to whom and where the certificate should be sent • Signature of the requester You cannot request a certificate by phone. If there is an urgent need for a certificate of creditable coverage, fax your request to the DSO at 18316558317 and/or request that DSO fax the certificate to a particular number.

Examples of when certificates may be issued include the following: • Upon separation of the sponsor from active duty, a certificate will be issued to the sponsor listing all eligible family members. • Upon the loss of eligibility for a dependent child (age 21, or 23 if a fulltime student), a certificate will be issued to the dependent child.

Additional information is available at www.tricare.osd.mil/certificate.

• Upon loss of coverage after divorce, a certificate will be issued to the former spouse, as soon as the information is updated in DEERS. Certificates automatically reflect the most recent period of continuous coverage under TRICARE. Certificates issued upon request of a beneficiary reflect each period of continuous coverage under TRICARE that ended within the 24 months prior to the date of loss of eligibility. Each certificate identifies the name of the sponsor or family member for whom it is issued, the dates TRICARE coverage began and ended, and the certificate issue date. Send your written request for a certificate of creditable coverage to the Defense Manpower Data Center Support Office (DSO) at the following address: Defense Manpower Data Center Support Office Attn: Certificate of Creditable Coverage 400 Gigling Road Seaside, CA 939556771

33

SECTION 5

The request must include the following:

LIFE EVENTS

Loss of Eligibility

Information and Assistance Beneficiary Counseling and Assistance Coordinators

regarding the payment of your claims. You also may appeal the denial of a requested authorization of services even though no care has been provided and no claim submitted.

Beneficiary counseling and assistance coordinators (BCAC) can help you with TRICARE and Military Health System inquiries and concerns and can advise you about obtaining health care. BCACs are located at military treatment facilities (MTF) and at the TRICARE Regional Offices (TRO). To locate a BCAC near you, visit www.tricare.osd.mil/bcacdcao for an online directory.

There are some things you may not appeal. For example, you may not appeal the denial of a service provided by an individual not eligible for TRICARE certification (e.g., a chiropractor). When services are denied based on a medical necessity or a benefit decision, you automatically are notified in writing. The notification will include an explanation of what was denied or why a payment was reduced and the reasoning behind that decision.

Appealing a Decision If you believe a service or claim was improperly denied, in whole or in part, you (or another appropriate party) may file an appeal. An appeal must involve an appealable issue. For example, you have the right to appeal TRICARE decisions

Appeal Requirements Your appeal must meet the requirements listed in Figure 6.1.

TRICARE Appeal Requirements

Figure 6.1

An appropriate appealing party must submit the appeal. Proper appealing parties include: • You, the beneficiary • Your custodial parent (if you are a minor) or your guardian • A person appointed in writing by you to represent you for the purpose of the appeal

1

• An attorney filing on your behalf • Nonnetwork participating providers If a physician or other party is going to submit the appeal, you must complete and sign an “Appointment of Representative and Authorization to Disclose Information” form, which is available on your regional contractor’s Web site. If the appeal is submitted without this form, it will not be processed. Note: Network providers are not appropriate appealing parties (unless appointed by you in writing).

2

The appeal must be in writing. See Figure 6.2 for addresses to submit different types of appeals. The issue in dispute must be an appealable issue. The following are nonappealable issues: • Allowable charges

3

• Eligibility • Denial of nonavailability statements (NAS) for inpatient behavioral health care • Denial of services from an unauthorized provider • Denial of treatment plan when an alternative treatment plan is selected

4

The appeal must be filed in a timely manner. An appeal must be filed within 90 days after the date on the EOB or denial notification letter.

5

There must be an amount in dispute to file an appeal. In the case involving an appeal of a denial of an authorization in advance of receiving the actual services, the amount in dispute is deemed to be the estimated TRICARE allowable charge for the services requested. There is no minimum amount in dispute necessary to request a reconsideration.

34

Filing an Appeal

A description of the issue or concern must include:

Appeals must be filed with your regional contractor within particular deadlines. If you are not satisfied with a decision rendered on an appeal, there are further levels of appeal. For specific information about filing an appeal in your region, contact your regional contractor.

• The specific issue in dispute • A copy of the previous denial determination notice • Any appropriate supporting documents Send your appeal to your regional contractor. See Figure 6.2 for regional appeals filing information.

A grievance is a written complaint about a concern on a nonappealable issue regarding a perceived failure by any member of the health care delivery team—including TRICARE authorized providers, military providers, regional contractors, or subcontractor personnel—to provide appropriate and timely health care services, access, or quality, or to deliver the proper level of care or service.

Appeals should contain the following information: • Beneficiary’s name, address, and telephone number • Sponsor’s Social Security number (SSN) • Beneficiary’s date of birth

The grievance process allows full opportunity to report in writing any concern or complaint regarding health care quality or service.

• Beneficiary’s or appealing party’s signature

Regional Appeals Filing Information

Figure 6.2

TRICARE North Region

TRICARE South Region

TRICARE West Region

Claims Appeals:

Claims Appeals:

Claims Appeals:

Health Net Federal Services, Inc. c/o PGBA LLC/TRICARE Claims Appeals P.O. Box 870148 Surfside Beach, SC 295879748

TRICARE South Region Appeals P.O. Box 202002 Florence, SC 295022002

TriWest Healthcare Alliance Claims Appeals P.O. Box 86508 Phoenix, AZ 85080

Claims Appeals Fax: 18884582554 Prior Authorization Appeals: Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE Authorization Appeals P.O. Box 870142 Surfside Beach, SC 295879742 Prior Authorization Appeals Fax: 18888813622

Prior Authorization Appeals: Humana Military Healthcare Services Attn: Clinical Appeals P.O. Box 740044 Louisville, KY 402019973 Behavioral Health Appeals: ValueOptions Behavioral Health Attn: Appeals and Reconsideration Department P.O. Box 551138 Jacksonville, FL 322551138

35

Prior Authorization Appeals: TriWest Healthcare Alliance Claims Appeals P.O. Box 86508 Phoenix, AZ 85080

SECTION 6

Filing a Grievance

INFORMATION AND ASSISTANCE

Prior authorization denial appeals may be either expedited or nonexpedited, depending on the urgency of the situation. You or an appointed representative must file an expedited appeal within three calendar days after receipt of the initial denial. A nonexpedited review of a denial must be filed no later than 90 days after receipt of the initial denial.

• Beneficiary’s signature

Any TRICARE civilian or military provider, TRICARE beneficiary, sponsor, parent or guardian, or other representative of an eligible dependent child may file a grievance. Your regional contractor is responsible for the investigation and resolution of all grievances. Grievances are resolved no later than 60 days from receipt. Following resolution, the party who submitted the grievance will be notified of the review completion.

• A description of the issue or concern that must include: • The date and time of the event • Name of the provider(s) and/or person(s) involved • Location of the event (address) • The nature of the concern or complaint • Details describing the event or issue • Any appropriate supporting documents

Grievances may include such issues as: • The quality of health care or services aspects like accessibility, appropriateness, level, continuity or timeliness of care, effectiveness, or outcome

File your grievance with your regional contractor. See Figure 6.3 for regional grievance filing information.

• The demeanor or behavior of providers and their staff

Reporting Suspected Fraud and Abuse

• The performance of any part of the health care delivery system

Fraud happens when a person or organization deliberately deceives others to gain some sort of unauthorized benefit. Health care abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards.

• Practices related to patient safety When filing a grievance, include the following information: • The beneficiary’s name, address, and telephone number

You are an important partner in the ongoing fight against fraud and abuse with your most effective tool being your Explanation of Benefits (EOB).

• Sponsor’s SSN • Beneficiary’s date of birth

Regional Grievance Filing Information

Figure 6.3

TRICARE North Region

TRICARE South Region

TRICARE West Region

All grievances should be addressed to:

Submit your grievance in writing to the nearest location:

All grievances should be addressed to:

Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE Grievance P.O. Box 870150 Surfside Beach, SC 295879750

Regional Grievance Coordinator Humana Military Healthcare Services 8123 Datapoint Drive Suite 400 San Antonio, TX 78229

TriWest Healthcare Alliance Attn: Customer Relations Dept. P.O. Box 86036 Phoenix, AZ 85080

Submit online at: www.healthnetfederalservices.com Submit by fax: 18883176155

For behavioral health care concerns, send your information to: Grievance Specialist ValueOptions P.O. Box 551188 Jacksonville, FL 322551188

36

Report suspected fraud and abuse to your regional contractor. See Figure 6.4 for details. To report fraud or abuse regarding the pharmacy program, contact ESI:

Since an EOB is a tangible statement of services/supplies received, it is one of the first lines of defense against health care fraud. Each EOB provides a tollfree number to call if you have questions about services you believe are billed fraudulently. You also can access the TRICARE Program Integrity Web site www.tricare.osd.mil/fraud for direct links to each contractor fraud and abuse reporting office. Through your regional contractor’s Web site, you can use claims tools to view your EOBs, claims history and track TRICARE costs paid. We strongly encourage you to read your EOBs carefully.

Phone: 18003325455 Email: fraudtip@expressscripts.com You also can report any fraud or abuse issues directly to TRICARE at [email protected].

TRICARE North Region

TRICARE South Region

TRICARE West Region

• Call 18009776761

• Call 18003331620

• Call 18885849378

• Send an email message to: [email protected]

• Report online at www.humanamilitary.com.

• Fax 16025642458

• Report online at www.healthnetfederalservices.com.

• Mail information to:

• Mail information to: Health Net Federal Services, Inc. Attn: Program Integrity P.O. Box 870147 Surfside Beach, SC 295879747

Humana Military Healthcare Services Attn: Program Integrity 500 W. Main Street, 19th floor Louisville, KY 40202

37

• Report online at www.triwest.com.

SECTION 6

Figure 6.4

INFORMATION AND ASSISTANCE

Regional Fraud and Abuse Reporting Information

Acronyms ADA BCAC CAC CHCBP DCAO DEERS DME DoD DRG DSO EOB ESI IRR MTF NAS NATO OHI PFP RTC SNF SSN TAMP TAO TDP TFL TLAC TMA TMOP TRDP TRO TRRx TRS TSC WPS

American Diabetes Association Beneficiary Counseling and Assistance Coordinator Common Access Card Continued Health Care Benefit Program Debt Collection Assistance Officer Defense Enrollment Eligibility Reporting System Durable Medical Equipment Department of Defense Diagnosisrelated Group Defense Manpower Data Center Support Office Explanation of Benefits Express Scripts, Inc. Individual Ready Reserve Military Treatment Facility Nonavailability Statement North Atlantic Treaty Organization Other Health Insurance Partners for Peace Residential Treatment Center Skilled Nursing Facility Social Security Number Transitional Assistance Management Program TRICARE Area Office TRICARE Dental Program TRICARE For Life TRICARE Latin America and Canada TRICARE Management Activity TRICARE Mail Order Pharmacy TRICARE Retiree Dental Program TRICARE Regional Office TRICARE Retail Pharmacy TRICARE Reserve Select TRICARE Service Center Wisconsin Physicians Service

38

Glossary Balance Billing A term used to describe when a provider bills a beneficiary for the difference between billed charges and the TRICARE allowable charge after TRICARE (and other health insurance) has paid everything it’s going to pay. Participating providers are prohibited from balance billing. Nonparticipating providers may charge up to 15 percent above the TRICARE allowable charge.

Debt Collection Assistance Officer (DCAO) Persons located at military treatment facilities and TRICARE Regional Offices to assist you in resolving health care collection related issues. Contact a DCAO if you have received a negative credit rating or have been sent to a collection agency due to an issue related to TRICARE services. Defense Enrollment Eligibility Reporting System (DEERS) A database of uniformed services members (sponsors), family members, and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS updated.

Beneficiary Counseling and Assistance Coordinator (BCAC) Persons at military treatment facilities and TRICARE Regional Offices who are available to answer questions, help solve health carerelated problems, and assist beneficiaries in obtaining medical care through TRICARE. To locate a BCAC near you, visit www.tricare.osd.mil/bcacdcao.

Explanation of Benefits (EOB) A statement sent to beneficiaries showing that claims were processed and the amount paid to providers. If denied, an explanation of denial is provided.

GLOSSARY

SECTION 8

Continued Health Care Benefit Program (CHCBP) A premiumbased health care program you may purchase after loss of TRICARE eligibility if you qualify. The CHCBP offers temporary transitional health coverage and must be purchased within 60 days after TRICARE eligibility ends.

SECTION 7

Military Treatment Facility (MTF) A military treatment facility is a medical facility operated by the military.

ACRONYMS

Catastrophic Cap The maximum outofpocket expenses for which TRICARE beneficiaries are responsible for deductibles and costshares based on allowed charges for services and supplies received in a given fiscal year (October 1September 30).

Negotiated Rate The rate network providers and participating nonnetwork providers have agreed to accept for covered services. Network Provider Network providers have a signed agreement with your regional contractor to provide care at a negotiated rate. Network providers handle claims for you. You are using the TRICARE Extra option when you visit a network provider.

Cost-share A costshare is the percentage or portion of costs that the beneficiary will pay for inpatient or outpatient care.

Non-network Provider Nonnetwork providers do not have a signed agreement with your regional contractor and are therefore “out of network.” You are using the TRICARE Standard option when you visit a nonnetwork provider. There are two types of nonnetwork providers: participating and nonparticipating. 39

Nonparticipating Non-network Provider Nonparticipating providers have not agreed to accept the TRICARE allowable charge or file your claims. Nonparticipating providers may charge you up to 15 percent above the TRICARE allowable charge for services. This amount is your responsibility and will not be shared by TRICARE.

Regional Contractor A TRICARE civilian partner who provides health care services and support in the TRICARE regions (Health Net Federal Services, Inc.; Humana Military Healthcare Services, Inc.; and TriWest Healthcare Alliance). Transitional Assistance Management Program (TAMP) Transitional health care for certain uniformed services members (and eligible family members) who separate from active duty.

Other Health Insurance (OHI) Any nonTRICARE health insurance that is not considered a supplement acquired through an employer, entitlement program, or other source. TRICARE pays second after all other health plans except for Medicaid, TRICARE supplements, the Indian Health Service, or other programs or plans as identified by the TRICARE Management Activity.

TRICARE Allowable Charge The maximum amount TRICARE will pay for services. TRICARE-authorized Provider A provider who meets TRICARE’s licensing and certification requirements and has been certified by TRICARE to provide care to TRICARE beneficiaries. If you see a provider who is not TRICAREauthorized or can never be certified, you are responsible for the full cost of care. TRICARE authorized providers include doctors, hospitals, ancillary providers (such as laboratory and radiology providers), and pharmacies. There are two types of TRICAREauthorized providers: network and nonnetwork.

Participate on a Claim When providers participate on a claim, also known as “accepting assignment,” they agree to file the claim for the patient, to accept payment directly from TRICARE, and to accept the amount of the TRICARE allowable charge, less any applicable patient costshare paid by you, as payment in full for their services. Participating Non-network Provider Participating providers have agreed to file claims for you, to accept payment directly from TRICARE, and to accept the TRICARE allowable charge plus applicable costshares paid by you as payment in full for their services. Providers may participate on a claimbyclaim basis.

TRICARE Supplement A health plan you may purchase specifically to supplement your TRICARE Standard and TRICARE Extra coverage. It will pay second after TRICARE. A TRICARE supplement is not employersponsored health insurance.

Prior Authorization A review determination made by a licensed professional nurse or paraprofessional for requested services, procedures, or admissions. Prior authorizations must be obtained prior to services being rendered or within 24 hours of an admission. Visit your regional contractor’s Web site or call them for a list of services requiring prior authorization.

40

Sample Explanation of Benefit Statements The following pages list figures and reference details for each regional contractor’s explanation of benefits (EOB) statements. • North Region: Figure 9.1 • South Region: Figure 9.2 • West Region: Figure 9.3

41

SECTION 9

APPENDIX

Appendix

North Region Explanation of Benefits Statement Sample

Figure 9.1

TRICARE NORTH REGION CLAIMS

December 30, 2005

WWW.HEALTHNETFEDERALSERVICES.COM

12/14/2005

75.00

50.61

75.00

50.61

75.00 50.61 24.39

1, 2, 3, 4, 5

2005

51.00

50.61

2 - GREAT NEWS! PGBA IS MAKING TRICARE EASIER. YOU CAN NOW VIEW THE STATUS OF YOUR CLAIMS AT WWW.MYTRICARE.COM FOR MORE INFORMATION VISIT OUR WEB SITE TODAY. 3 - PLEASE ALLOW UP TO 30 DAYS FOR YOUR CLAIMS TO PROCESS. 4 - $51.00 HAS BEEN APPLIED TOWARD THE CATASTROPHIC CAP OF $1000.00. 5 - AMOUNT ALLOWED IS BASED ON A DISCOUNT AGREEMENT. (1-877-874-2273)

42

1. PGBA, LLC—PGBA processes all TRICARE claims for the region where you live.

14. Claim Summary—Here we give you a detailed explanation of the action we took on your claim. You will find the following totals: amount billed, amount approved by TRICARE, noncovered amount, amount (if any) that you have already paid to the provider, amount your primary health insurance paid (if TRICARE is your secondary insurance), benefits we have paid to the provider, benefits we have paid to the beneficiary. A Check Number will appear here only if a check accompanies your EOB.

2. Regional Contractor—The name “Health Net Federal Services” and the Health Net logo will appear here. 3. Date of Notice—PGBA prepared your TRICARE EOB on this date. 4. Sponsor SSN/Sponsor Name—We process your claim using the Social Security number of the military service member (active duty, retired, or deceased) who is your TRICARE sponsor.

15. Beneficiary Liability Summary—You may be responsible for a portion of the fee your doctor has charged. If so, you’ll see that amount itemized here. It will include any charges that we have applied to your annual deductible and any costshare or copayment you must pay.

5. Beneficiary Name—The patient who received medical care and for whom this claim was filed. 6. Mailto Name and Address—We mail the TRICARE EOB directly to the patient (or patient’s parent or guardian) at the address given on the claim. (Note: Be sure your doctor has updated your records with your current address.)

16. Patient Responsibility—The total amount you owe for this claim. 17. Benefit Period Summary—This section shows how much of the individual and family annual deductible and maximum out ofpocket expense you have met to date. We calculate your annual deductible and maximum outofpocket expense by fiscal year. See the Fiscal Year Beginning date in this section for the first date of the fiscal year.

7. Benefits Were Payable To—This field will appear only if your doctor accepts assignment. This means the doctor accepts the TRICARE maximum allowable charge as payment in full for the services you received. 8. Claim Number—We assign each claim a unique number. This helps us keep track of the claim as it is processed. It also helps us find the claim quickly whenever you call or write us with questions or concerns.

18. Remarks—Explanations of the codes or numbers listed in See Remarks will appear here.

9. Service Provided By/Date of Services— This section lists who provided your medical care, the number of services and the procedure codes, as well as the date you received the care.

19. TollFree Telephone Number—Questions about your TRICARE explanation of benefits? Please call PGBA tollfree at 1877TRICARE (18778742273). Our professional customer service representatives will gladly assist you.

10. Services Provided—This section describes the medical services you received and how many services are itemized on your claim. It also lists the specific procedure codes that doctors, hospitals, and labs use to identify the specific medical services you received. 11. Amount Billed—Your doctor, hospital, or lab charged this fee for the medical services you received. 12. TRICARE Approved—This is the amount TRICARE approves for the services you received. 43

SECTION 9

13. See Remarks—If you see a code or a number here, look at the Remarks section (18) for more information about your claim.

APPENDIX

How to Read Your TRICARE EOB for the North Region

South Region Explanation of Benefits Statement Sample

44

Figure 9.2

1. PGBA, LLC—PGBA processes all TRICARE claims for the region where you live.

13. See Remarks—If you see a code or a number here, look at the Remarks section (17) for more information about your claim.

2. Regional Contractor—The name “Humana Military” and the Humana Military logo will appear here.

14. Claim Summary—Here we give you a detailed explanation of the action we took on your claim. You will find the following totals: amount billed, amount approved by TRICARE, noncovered amount, amount that you have already paid to the provider (if any), amount your primary health insurance paid (if TRICARE is your secondary insurance), benefits we have paid to the provider, and benefits we have paid to the beneficiary. A check number will appear here only if a check accompanies your EOB.

3. Date of Notice—PGBA prepared your TRICARE EOB on this date. 4. Sponsor SSN/Sponsor Name—We process your claim using the Social Security number (SSN) of the military service member (active duty, retired, or deceased) who is your TRICARE sponsor. For security reasons, only the last four digits of your sponsor’s SSN will appear on the EOB. 5. Beneficiary Name—The patient who received medical care and for whom this claim was filed.

15. Beneficiary Liability Summary—You may be responsible for a portion of the fee your doctor has charged. If so, you’ll see that amount itemized here. It will include any charges that we have applied to your annual deductible and any costshare or copayment you must pay.

6. Mailto Name and Address—We mail the EOB directly to the patient (or patient’s parent or guardian) at the address given on the claim. (Note: Be sure your doctor has updated your records with your current address.)

16. Benefit Period Summary—This section shows how much of the individual and family annual deductible and maximum outofpocket expense you have met to date. We calculate your annual deductible and maximum outofpocket expense by fiscal year. See the Fiscal Year Beginning date in this section for the first date of the fiscal year.

7. Benefits Were Payable To—This field will appear only if your doctor accepts assignment. This means the doctor accepts the TRICARE allowable charge as payment in full for the services you received. 8. Claim Number—We assign each claim a unique number. This helps us keep track of the claim as it is processed. It also helps us find the claim quickly whenever you call or write us with questions or concerns.

17. Remarks—Explanations of the codes or numbers listed in the “See Remarks” section will appear here. 18. TollFree Telephone Number—If you have questions about your TRICARE explanation of benefits, please call PGBA at this tollfree number. Our professional customer service representatives will gladly assist you.

9. Service Provided By/Date of Services— This section lists who provided your medical care, the number of services, and the procedure codes, as well as the date you received the care. 10. Services Provided—This section describes the medical services you received and how many services are itemized on your claim. It also lists the specific procedure codes that doctors, hospitals, and labs use to identify the specific medical services you received. 11. Amount Billed—Your doctor, hospital, or lab charged this fee for the medical services you received.

45

SECTION 9

12. TRICARE Approved—This is the amount TRICARE approves for the services you received.

APPENDIX

How to Read Your TRICARE EOB for the South Region

West Region Explanation of Benefits Statement Sample

46

Figure 9.3

14. Beneficiary Share—You may be responsible for a portion of the fee your doctor has charged. If so, you’ll see that amount itemized here. It will include any charges that we have applied to your annual deductible and any costshare or copayment you must pay.

1. Mailto Name and Address—We mail the TRICARE EOB directly to the patient (or patient’s parent or guardian) at the address given on the claim. (Note: Be sure your doctor has updated your records with your current address.) 2. Date of Notice—The date we prepared your TRICARE EOB.

15. Out of Pocket Expense—This section shows how much of the individual and family annual deductible and maximum outofpocket expense you have met to date. We calculate your annual deductible and maximum outofpocket expense by fiscal year. See the Fiscal Year Beginning date in this section for the first date of the fiscal year.

3. Sponsor SSN/Sponsor Name—We process your claim using the Social Security number of the military service member (active duty, retired, or deceased) who is your TRICARE sponsor. 4. Patient Name—The patient who received medical care and for whom this claim was filed.

16. Remark Codes—Explanations of the codes or numbers listed in Remarks (12) will appear here.

5. Claim Number—We assign each claim a unique number. This helps us keep track of the claim as it is processed. It also helps us find the claim quickly whenever you call or write us with questions or concerns.

17. Paid To—The name of the provider or facility who the claim was paid to. 18. Regional Contractor— The name “TriWest Healthcare Alliance” and the TriWest logo will appear here.

6. Check Number—A Check Number will appear here only if a check accompanies your EOB. 7. TollFree Number/Web Address—How you can reach us (TriWest) if you have questions. 8. Service Provided By—Who provided your medical care, the number and type of services and the procedure codes 9. Date of Services—The date you received the care. 10. Amount Billed—Your doctor, hospital, or lab charged this fee for the medical services you received. 11. TRICARE Allowed—This is the amount TRICARE approves for the services you received. 12. Remarks—If you see a code or a number here, look at the Remark Codes section (16) for more information about your claim. 13. Claim Summary—Here we give you a detailed explanation of the action we took on your claim. You will find the following totals: amount billed, amount approved by TRICARE, noncovered amount, amount (if any) that you have already paid to the provider, amount your primary health insurance paid (if TRICARE is your secondary insurance), benefits we have paid 47

SECTION 9

to the provider, benefits we have paid to the beneficiary.

APPENDIX

How to Read Your TRICARE EOB for the West Region

List of Tables Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure

1.1 2.1 2.2 3.1 3.2 3.3 3.4 3.5 4.1 5.1 5.2 6.1 6.2 6.3 6.4 9.1 9.2 9.3

Comparison of TRICARE Standard and TRICARE Extra . . . . . . . . . . . . . . . . . .6 TRICARE Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 MTF Appointing Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Outpatient Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Inpatient Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Clinical Preventive Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . .11 Behavioral Health Care Services: Coverage Details . . . . . . . . . . . . . . . . . . . . .13 Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . .18 Regional Claims Processing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Eligibility Requirements for Former Spouses . . . . . . . . . . . . . . . . . . . . . . . . . .27 TRICARE Area Office Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . .29 TRICARE Appeal Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Regional Appeals Filing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Regional Grievance Filing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Regional Fraud and Abuse Reporting Information . . . . . . . . . . . . . . . . . . . . . . .37 North Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . .42 South Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . .44 West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . .46

Note: This list also includes samples represented as a graphic in this book.

48

Index A

Continued Health Care Benefit Program (CHCBP), 17, 3031, 3839 Copayment, 1516, 2324, 43, 45, 47 Cosmetic surgery, 18 Costshare, 39 Couples counseling, 19 Covered services, 2, 10, 39 Custodial parent, 5, 26, 34

Abortion, 18 Accident, 10, 12, 24 Active duty family member, 32 Active duty service member, 32 Acupuncture, 19 Adjunctive dental, 9, 18 Adopting, 17, 27 Allergy tests, 10 Ambulance, 10, 21 Ancillary services, 10 Anesthesia, 11 Annual deductible, 43, 45, 47 Appeal, 24, 3435, 48 Artificial insemination, 19 Autopsy, 19

D

Eligibility, 5, 2627, 3134, 39, 48 Emergency care, 8 Endstage renal disease, 5, 18, 32 Enrollment, 1, 6, 27, 32 Examination, 1012, 1920 Exclusions, 10, 13, 19 Explanation of benefits (EOB), 24, 36, 3839, 4146, 48 Express Scripts, Inc. (ESI), 15, 23, 38 Eye examination, 10, 31 Eyeglasses, 18

C Camps, 19 Cancer screening, 1112, 21 Cardiac rehabilitation, 18 Catastrophic cap, 31, 39 Certificate of Creditable Coverage, 33 Claims, 67, 16, 2124, 28, 30, 3435, 37, 3940, 43, 45, 48, 53 Clinic, 8 Clinical preventive services, 1112, 2021, 48 College, 26, 28, 32 Colorectal cancer, 11 Common Access Card (CAC), 38 Contact lenses, 18 Contingency operation, 30

F Food, 18 Former spouses, 5, 22, 2627, 48 Fraud and abuse, 3637, 48 G Gastric bypass, 19 Generic drug use policy, 16 49

SECTION 11

E

INDEX

Behavioral health care, 9, 1215, 18, 34, 36, 48 Beneficiary, 56, 10, 1415, 20, 3031, 3334, 36, 39, 43, 45, 47 Beneficiary counseling and assistance coordinators, 31, 34, 38 Birth, 12, 21, 27 Birth control, 19 Birth defect, 18 Blood products, 11 Blood pressure screening, 12 Brace, 20 Breast cancer, 11 Breast reconstruction, 18 Breastfeeding, 20

SECTION 10

B

LIST OF TABLES

Debt Collection Assistance Officers (DCAO), 25, 3839 Defense Enrollment Eligibility Reporting System (DEERS), 5, 26, 3839 Defense Manpower Data Center Support Office (DSO), 5, 26, 33, 38 Delta Dental Plan of California, 17 Denial, 23, 3435, 39 Dental care, 18 Dental programs, 17 Detoxification, 13, 15 Disability, 5, 20, 26, 28, 32 Divorce, 2627, 33 Drug abuse, 15 Dualeligible beneficiaries, 5 Durable medical equipment (DME), 10, 38 Dyslexia, 20

Network pharmacies, 29 Network provider, 1, 67, 12, 28, 34, 39 Newborn, 17, 20, 27 Nonavailability statement (NAS), 34, 38 Nonemergency, 9, 13 Nonformulary drugs, 16 Nonnetwork pharmacies, 16, 23, 29 Nonnetwork provider, 1, 78, 12, 23, 28, 3940 Nonparticipating provider, 67, 22, 24, 3940 Nonsynostic positional plagiocephaly, 18

Generic medication, 16 Genetic testing, 11, 19 Grievance, 3536, 48 H Hearing Aids, 19, 31 Hepatitis B screening, 11 Human immunodeficiency virus (HIV), 11 Home health services, 910 Hospice care, 9 Hospitalization, 11

O

I

K

Obesity, 19, 21 Occupational therapy, 10 Orthomolecular psychiatric therapy, 20 Orthopedic shoes, 20 Osteopathic manipulation, 10 Other health insurance, 23, 38, 40 Outofpocket costs, 7, 16, 24, 47 Outpatient behavioral health, 9, 12 Outpatient care, 15, 39 Outpatient psychotherapy, 14 Outpatient services, 1011, 48

Keratoconus, 18

P

L

Pap smear, 1112 Parenteral, 18 Partial hospitalization, 13 Participating provider, 7, 2223, 34, 3940 Pastoral counselor, 12 Pharmacy, 1516, 2324, 2930, 3738 Physical examination, 8, 12 Physical therapy, 10 Plastic surgery, 18 Postpartum, 17, 20 Pregnancy, 11, 1719 Prenatal, 17 Prescriptions, 13, 1516, 2324, 2930 Prior authorization, 79, 1216, 35, 40 Prostate cancer, 1112 Prosthetic, 11 Psychiatrist, 12, 14 Psychoanalysis, 14 Psychogenic, 21 Psychological testing, 13 Psychologist, 12, 14 Psychotherapy, 1314, 20 Pulmonary rehabilitation, 18

Immunizations, 1112, 20 Indian Health Service, 23, 40 Infant, 20 Infantile glaucoma, 18 Inpatient admissions, 9, 13 Inpatient behavioral health care, 34 Inpatient psychotherapy, 14 Inpatient services, 11, 48 Intelligence testing, 19

Laboratory services, 10 LASIK, 19 Learning disability, 20 Licensed professional counselors, 12 Limitations, 10, 1315, 1819, 30, 48 M Mammograms, 12 Marital therapy, 19 Marriage, 26 Maternity services, 17 Maternity ultrasounds, 17 Medicabs, 10 Medical necessity, 14, 16, 34 Medicare, 5, 11, 21, 3132 Medicare Part A, 5, 32 Medicare Part B, 56, 3132 Medication management, 13 Military treatment facility, 8, 15, 29, 3839 Molding helmet, 18 Moving, 30 N

Q

National Guard and Reserve, 56, 17 Naturopaths, 20

Quantity limits, 16 50

R

TRICARE Extra, 12, 56, 10, 17, 22, 2628, 3032, 3940, 48 TRICARE For Life, 5, 32, 38 TRICARE formulary search tool, 16 TRICARE Latin America and Canada (TLAC), 29, 38 TRICARE Mail Order Pharmacy, 15, 29, 38 TRICARE Management Activity (TMA), 23, 38, 40 TRICARE Pacific, 2930 TRICARE Prime, 1, 56, 8, 27, 3132 TRICARE Prime Remote, 6, 27, 3132 TRICARE regional contractor, 2 TRICARE Regional Office (TRO), 25, 3839 TRICARE Reserve Select (TRS), 31, 38 TRICARE Retail Pharmacy (TRRx), 16, 29, 38 TRICARE Retiree Dental Program (TRDP), 17, 38 TRICARE Service Center (TSC), 22, 38 TRICARE Standard, 12, 57, 10, 17, 22, 2628, 3032, 3940, 48 TRICAREauthorized provider, 7, 40 Tuberculosis, 11, 12

Radiology, 7, 1011, 40 Reconsideration, 3435 Reconstructive surgery, 18 Referral, 78, 1213 Refractive corneal surgery, 18 Regional contractor, 2, 610, 1215, 1718, 2224, 2728, 3032, 3437, 3941, 43, 45, 47 Rehabilitation, 10, 1315, 18 Reimbursement, 1516, 18, 2324, 2829 Residential Treatment Center (RTC), 14, 38 Retired service member, 5, 8, 10, 17, 3132 Retiring from active duty, 31 Rubella, 12 S School physicals, 12 Separating from service/active duty, 3031 Sexual dysfunction, 20 Shoe inserts, 20 Skilled nursing facility, 1011, 38 Social Security Number (SSN), 22, 27, 33, 35, 38, 43, 45, 47 Sore throat, 8 Specialist, 8, 10, 12, 36 Speech therapy, 11 Sponsor, 5, 11, 22, 2628, 3033, 3536, 39, 43, 45, 47 Sprain, 8 Stem cell, 9 Stress management, 20 Substance abuse, 12 Substance use disorder, 9, 13, 15 Suicide, 12 Supplements, 18, 23, 40 Surgical care, 10 Survivors, 56, 32

U

Vaccines, 11 Vitamins, 18, 20 W Weight reduction, 19 Wellchild services, 12 Wisconsin Physicians Service (WPS), 6, 38

T Tetanus, 11 Thirdparty liability, 24 Transitional Assistance Management Program (TAMP), 30, 38, 40 Transplant, 9, 19 Traveling, 22, 2829 TRICARE allowable charge, 67, 24, 34, 3940, 45 TRICARE Area Office (TAO), 28, 38, 48 TRICARE Dental Program, 17, 38 TRICARE Europe, 2930

X Xray, 11, 18, 21

51

SECTION 11

V

INDEX

Ultrasound, 10, 17 Uniformed services identification (ID) card, 5, 15, 26, 2829, 31 United Concordia Companies, Inc., 17 Urgent care, 8

Notes

52

Patient Bill of Rights and Responsibilities As a patient in the military health system, you have the right to:

As a patient in the military health system, you have the responsibility to:

• Receive accurate, easy-to-understand information to help you make informed decisions about TRICARE programs, medical professionals, and facilities.

• Maximize healthy habits, such as exercising, not smoking, and maintaining a healthy diet.

• Have a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care. • Access emergency health care services when and where the need arises. • Receive and review information about diagnosis, treatment, and the progress of your condition, and to fully participate in all decisions related to your health care or to be represented by family members, conservators, or other duly appointed representatives. • Receive considerate, respectful care from all members of the health care system without discrimination based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment. • Communicate with health care providers in confidence and to have the confidentiality of your health care information protected.You also have the right to review, copy, and request amendments to your medical records.

• Be involved in health care decisions, which means working with providers in developing and carrying out agreed-upon treatment plans, disclosing relevant information, and clearly communicating your wants and needs. • Be knowledgeable about TRICARE coverage and program options. You also have the responsibility to: • Show respect for other patients and health care workers. • Make a good-faith effort to meet financial obligations. • Use the disputed claims process when there is a disagreement. • Report wrongdoing and fraud to appropriate resources or legal authorities.

• Have a fair and efficient process for resolving differences with your health plan, health care providers, and the institutions that serve them. For more information about your rights, visit www.tricare.osd.mil/Patientrights/default.cfm

Please provide feedback on this handbook at: http://www.tricare.mil/evaluations/feedback Printed: August 2006

www.tricare.osd.mil

TRICARE North Region Health Net Federal Services, Inc. www.healthnetfederalservices.com 1-877-TRICARE (1-877-874-2273) TRICARE South Region Humana Military Healthcare Services, Inc. www.humana-military.com 1-800-444-5445

HA520801BET0806L

TRICARE West Region TriWest Healthcare Alliance www.triwest.com 1-888-TRIWEST (1-888-874-9378)