MBL102 Chapter 11 Tricare & Champva – Flashcards
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Name the uniformed service member in a family qualified for TRICARE
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sponsor
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Name the Dept. of Defense's health insurance plan for military personnel and their families
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TRICARE
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Where is information about TRICARE patient eligibility stored?
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DEERS
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What program did TRICARE replace?
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CHAMPUS
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Identify the two groups brought together by TRICARE to offer increased access to health care services
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military hospitals and a network of civilian facilities and providers
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Which of the following uniformed services is eligible for TRICARE without restrictions?
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Navy PHS NOAA ANSWER: all are eligible
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Why can't providers contact DEERS directly regarding sponsors?
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the information is protected by the HIPAA Privacy Act
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When creating TRICARE patient cases in a PMP, what information is included?
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the sponsor's grade, branch of service, and status
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What makes up the TRICARE system?
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all military hospitals, clinics, and treatment facilities
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Which of the following could make a decision about eligibility in TRICARE?
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the Army
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What should be checked on a patient's military id card to confirm it is valid?
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the expiration date
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TRICARE will only pay for services that are rendered by ________ providers
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authorized
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If a provider chooses not to participate in TRICARE, they may charge no more than _________ percent of the allowable charge
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115
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What is the TRICARE term for co-insurance??
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cost-share
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A non-participating provider in TRICARE sees a patient and provides services for three allowed charges that total $400. Calculate the maximum amount they may charge the patient
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$460
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A non-participating provider in TRICARE sees a patient and provides two services, one with an allowed charge of $120 and the other for $220. Calculate the maximum amount they may charge the patient
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$391
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A non-participating provider in TRICARE sees a patient and provides a service with an allowed charge of $200. However, the provider charges the patient $250 for the service. Determine what amount the patient must pay
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$230
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When does TRICARE fiscal year run?
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October 1 through September 30
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Who is responsible for the charges if a TRICARE managed care patient visits a provider who chooses not to join the TRICARE network?
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the patient
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Which of the following is NOT something that providers who participate with TRICARE agree to?
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participate for every patient, every time
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Services that are eligible for payment from TRICARE must meet all of the following criteria except ________________
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patients must be seen within 24 hours
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What is the term for the maximum amount TRICARE will pay for a procedure?
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TMAC
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The TRICARE program that offers fee-for-service coverage is _______________
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TRICARE Standard
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The TRICARE program that offers an HMO-like plan requiring no annual deductible is ________________
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TRICARE Prime
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The TRICARE program that offers an alternative managed care plan to TRICARE Prime with no annual enrollment fee is _____________
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TRICARE Extra
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The TRICARE program that offers benefits to active duty reservists is ______________
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TRICARE Reserve Select
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Patient cost share payments are subject to an annual _____________, a limit on the total medical expenses that beneficiaries are required to pay in one year
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catastrophic cap
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What is the TRICARE Standard annual cap for active duty families?
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$1000
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Once the catastrophic cap has been met, what percent of the additional charges for covered services for that coverage year will TRICARE pay?
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100 percent
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Which of the following services is generally NOT covered under TRICARE Standard?
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routine physical exams or foot care
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Who coordinates and manages the medical care of individuals after they enroll in TRICARE Prime?
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Primary Care Manger (PCM)
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Identify the electronic document that is used to state that a required service is not available at the nearby military treatment facility
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NAS
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Where do the medical services provided by TRICARE Standard occur?
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at civilian physician offices and at an MTF
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The husband of an active duty service member and an active duty service member have both arrived at an MTF. Who should be given priority?
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the active duty service member
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An active duty service member has an annual cap of $1000 under TRICARE Standard and receives treatment totaling $1400. Calculate how much the member must pay
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$1000
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What percent cost share do retirees pay for outpatient services under TRICARE Standard?
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25%
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What is the purpose of TRICARE Standard's annual catastrophic cap?
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to limit the maximum amount a TRICARE Standard sponsor will pay each year
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Which of the following services is not covered under TRICARE Standard?
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custodial care
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Which of the following services is covered under TRICARE Standard?
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x-ray services
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Choose the best explanation of a catchment area
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a geographic area served by a hospital, clinic, or dental clinic
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What type of procedures require preauthorization under TRICARE Standard?
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arthroscopy
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Identify a scenario in which a NAS is still generally required
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for use in nonemergency inpatient medical health care services
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Which of the following may act as a PCM under TRICARE prime?
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military civilian, or group provider
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How much does a not active duty family member have to pay to join TRICARE Prime for an individual?
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$260
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Under TRICARE Prime, what payment is required for outpatient treatment at a military facility?
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there is no deductible or co-payment
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Which of the following statements is true regarding the cost of TRICARE Extra against TRICARE Prime and TRICARE Standard?
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TRICARE Extra costs more than TRICARE Prime, but less than TRICARE Standard
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The family deductible for TRICARE Extra costs ___________
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$300
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What percent do TRICARE Extra beneficiaries pay for civilian outpatient charges?
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15%
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Who is eligible for TRICARE Reserve Select?
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certain members of the National Guard and Reserve activates on or after Sept 11, 2001
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The TRICARE program that offers benefits to Medicare-eligible military retirees and family members is _____________
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TRICARE for Life
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Individuals age ________ and over who are eligible for Medicare and TRICARE are offered the opportunity to receive healthcare at a MTF through TRICARE for Life
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65
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Identify the correct order of payment when Medicare and TRICARE for Life coverage exist
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Medicare pays first, and TRICARE pays the remaining out of pocket expenses
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Identify the correct order of payment when Medicaid and TRICARE for Life coverage exist simultaneously for one individual
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TRICARE pays first, and Medicaid covers the remaining expenses
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TRICARE for Life benefits emphasize ____________
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preventive, wellness, and prescription drug services
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Determine the correct order of coverage between Medicare, Medicaid, and TRICARE for Life
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Medicare first, TRICARE second, Medicaid third
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What must all enrollees in TRICARE for Life do?
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be enrolled in Medicare Part A & B and pay premiums
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When TRICARE for Life beneficiaries receive treatment at a civilian network they must ______________
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pay a copay
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The program that offers benefits to veterans with 100 percent disability, as well as to their dependents or survivors, is _____________
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CHAMPVA
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Which organization is responsible for determining eligibility for the CHAMPVA program?
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Dept. of Veterans Affairs (VA)
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All eligible beneficiaries in CHAMPVA posses a CHAMPVA authorization card known as ___________
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A-Card
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Patients' out of pocket expenses are subject to a catastrophic cap of _____________ per calendar year under the CHAMPVA program
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$3000
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Which program extends CHAMPVA benefits to spouses or dependents who are age sixty five and over?
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CHAMPVA for Life
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Which of the following services is generally NOT covered by CHAMPVA?
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dental care
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Which party is responsible for obtaining preauthorization under CHAMPVA?
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the patient
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Who is not eligible for CHAMPVA?
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families of active duty members
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Identify the term that describes the maximum amount CHAMPVA will pay for a procedure
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CMAC
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Explain the terms with which providers who choose to participate in CHAMPVA must agree
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to accept CHAMPVA payment and the patient's cost share payment as payment in full for services
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Who among the following may a CHAMPVA beneficiary use under the plan?
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a provider licensed to perform the service being delivered
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In almost all cases, CHAMPVA is the ___________
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secondary payer
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What is the basis for the submission of TRICARE claims to the regional contractor?
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the patients' home address
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What regulations cover the CHAMPVA program?
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HIPAA
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Where are most CHAMPVA claims submitted?
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the centralized CHAMPVA claims processing center
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Identify the best practice for filing paper TRICARE claims
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check with each payer for specific information required on the form
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What does a qualifies independent contractor (QIC) ensure regarding TRICARE claims?
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that services were medically necessary and appropriate
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Which of the following examples demonstrates an abuse activity versus a fraudulent one?
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providing care that is inferior quality
