Getting out, military health issues - Marine Corps Times

Tricare Glossary

115 percent rule

Authorized health care providers who do not participate in Tricare still are limited in what they can charge military patients for services. Under federal law, authorized health care providers can charge no more than 15 percent above what Tricare allows to be charged.

For example, if Tricare Standard allows a maximum charge of $100 for a visit to an authorized specialist, the specialist cannot charge a Tricare Standard patient more than $115. The patient is responsible for the usual cost shares and deductible, and most also are responsible for the extra 15 percent charge.

Tricare pays the 15 percent for Tricare for Life users and for family members of reservists activated for more than 30 days.

Any patient billed more than 115 percent should show the provider the explanation of benefits or statement of how much Tricare will allow. If the provider does not correct the bill, the patient should contact the claims processor, who will ask the doctor to comply. If that fails, Tricare headquarters will contact the provider and ask for justification for the higher bill. Unless the higher bill can be justified, the doctor has 30 days to refund the excess charge or stop billing the patient. Health care providers who do not comply may lose their Tricare authorization.

Patients can waive this rule if they would like to stay with a particular doctor.

Appeal

When Tricare denies a claim, a beneficiary may take further action. If Tricare says the claim was denied as not medically necessary, the beneficiary first should ask the managed care contractor to reconsider. The request must be made within 90 days of the date on the denial statement and include a letter explaining why the beneficiary thinks the care should be covered, along with a copy of the denial statement.

The contractor’s second decision is due 30 days from the time the letter is received. If coverage again is denied based on medical necessity, the beneficiary has 90 days to appeal to the Tricare National Quality Monitoring contractor, a group independent of the managed care contractor that reviews the case and issues a decision.

That decision is final if the amount in dispute is less than $300. If the disputed amount is $300 or more, subsequent appeals may be filed with the Tricare Management Activity, Aurora, Colo.

When a claim is denied based on policy interpretation, the beneficiary or provider may first ask the contractor to reconsider. The request must be made within 90 days. Rejected claims may be appealed to the Tricare Management Activity if the amount is at least $50. A subsequent appeal may be made to that office if the disputed amount is at least $300.

Ultimately, a Tricare user can file a lawsuit to try to have the claim paid after all other appeals have been exhausted.

Authorized provider

Military patients should ask civilian doctors not in a Tricare Prime or Extra network if they are authorized providers under Tricare Standard. Seeing an unauthorized provider will result in the denial of claims, even if the treatment is a type normally covered by the program.

Catchment area

A catchment area is the hospital’s service area, generally defined by ZIP codes within 40 miles of a military hospital or clinic. It can extend nationwide for high-cost procedures.

Tricare Prime is available in the catchment areas, and Prime enrollees must follow the HMO’s rules. But catchment areas can affect Tricare users who aren’t enrolled in Prime. Before using Tricare Standard for civilian inpatient hospital care, active-duty family members, retirees and their family members living within the catchment area of a military hospital must check to see if it can provide the required treatment.

Claims

Tricare claims are handled by health insurance companies and claims adjustment firms under Defense Department contracts.

Families with private health insurance must submit claims to those companies first. When that insurer has paid, a claim then can be filed with the Tricare contractor for the state where the member lives.

Health care providers must file claims using HCFA Form 1500 (for individual providers) or UB-92 (for institutions) within 12 months of administering outpatient treatment or within 12 months of discharging someone from an inpatient facility.

DD Form 2642, for civilian outpatient treatment, can be obtained from many civilian hospitals, most military hospitals, a health benefits adviser or a Tricare contractor.

Contact Information

Anyone seeking more information about Tricare can contact a health benefits adviser or health care finder at the local base, or the Tricare contractor (claims processor) serving the area.

Information also is available at www.tricare.mil.

Deductibles

There is no deductible for inpatient treatment using Tricare at civilian hospitals.

Tricare Prime has no outpatient deductible if care is received at a military treatment facility or a civilian provider in the Prime network.

Under Prime’s Point-of-Service option, however, deductibles for outpatient care from providers not in the network are $300 for an individual and $600 for a family. After the Point-of-Service deductible is paid, Tricare will cover only 50 percent of the amount it allows to be charged.

Tricare Extra and Standard have annual deductibles for outpatient care. Deductibles are calculated by fiscal year, Oct. 1 to Sept. 30. With each new fiscal year, the deductible must be met again. An electronic system tracks how much each person or family has paid in co-payments and toward the annual deductible. Still, it’s a good idea to keep a copy of all medical bills.

People who buy prescription drugs at retail stores that are not part of the Tricare network also pay deductibles of $150 for an individual or $300 for a family. Enlisted members in paygrades E-4 and below pay lower deductibles: $50 for an individual, $100 for a family. Prime enrollees pay the point-of-service deductible.

Tricare waives the deductibles for family members of reservists who are called to active duty for more than 30 days.

Dental — inpatient

For dental care related to hospitalization, patients must get approval from the Tricare contractor for their area before receiving treatment. Send a statement from a doctor — if one is involved — about the condition, along with a statement from the dentist saying what care is needed, why and how much it will cost. Requests should be made at least 30 days before scheduled treatment.

Hospice care

Hospice care provides various kinds of home and inpatient care for terminally ill patients. Tricare offers a hospice benefit that gives patients with six months or less to live several episodes of care: two initial 90-day periods and an unlimited number of subsequent 60-day periods.

Patients revert to Tricare Standard coverage when not using hospice care. While enrolled in this program, patients waive entitlement to other Tricare reimbursement related to the terminal illness, except for services from an attending doctor.

The hospice benefit has no deductible.

Inpatient

An inpatient is someone who is lodged and fed in a hospital or clinic while receiving treatment.

Nonavailability

In late 2003, Tricare eliminated a major hurdle for Standard and Extra patients needing inpatient medical care. Previously, they were required to first check with their local military facility to see if the care could be obtained there. If not, they were issued a nonavailability statement and could seek the care at a civilian facility. The 2003 change did away with that requirement and allowed beneficiaries to get inpatient care at civilian hospitals without getting prior approval from a military facility.

However, beneficiaries who use Standard or Extra and want to receive nonemergency inpatient mental health care at a civilian facility still must first check with the nearby military hospital to see if the care can be provided there. If it cannot, the hospital will issue the nonavailability statement allowing the patient to use a civilian facility.

If a patient receives inpatient mental health care without obtaining the nonavailability statement, Tricare won’t share the costs unless there are extenuating circumstances that prevented someone from getting a nonavailability statement.

Patients do not need nonavailability statements if they have Medicare or another health insurance that pays first.

By law, a military hospital can ask the Defense Department to still allow it to require the nonavailability statements for specific medical treatments. But the military cannot require Standard and Extra patients to receive obstetric care at military hospitals and clinics. As a result, military hospitals have taken steps to improve their maternity care to attract customers.

Prime participants do not have to get nonavailability statements for any kind of care. People enrolled in Prime must consult their primary care manager to learn where they can be treated.

Other insurance

People who have health coverage in addition to Tricare must file claims first with that plan, which is the primary payer.

Payment from the primary plan plus Tricare may cover 100 percent of the bill, even after applying the usual cost-sharing requirements. Tricare will not pay anything if coverage by the first payer exceeds Tricare’s maximum allowable charge.

Tricare users eligible for Medicare are in a similar situation: Medicare must be used before Medicare will pay benefits.

Federal law establishes the order of payment. There are two exceptions:

•When the second coverage is Medicaid, Tricare pays first.

•When the patient’s other insurance is specifically designated as a Tricare supplemental plan, Tricare pays first.

Claims for job-related illnesses and injuries are paid by workers’ compensation programs and are not covered by Tricare Standard. When workers’ compensation is exhausted, Tricare benefits can be used.

Former spouses who normally are eligible for Tricare lose these benefits when they are covered by an employer-sponsored health plan.

Outpatient

When patients are treated at a hospital or clinic but leave the same day, they are considered outpatients.

Participant

A doctor who participates in Tricare accepts as full payment the amount Tricare allows for the particular service or supply. A doctor who does not participate is refusing to accept what Tricare allows as payment in full.

Doctors who are not in Tricare networks are free to decide when or if they will participate in Tricare Standard. The fact that doctors agree to accept Standard rates for one procedure does not obligate them to do so the next time a patient receives care.

Even if the doctor does participate, that does not mean a patient will get free care. The patient still must pay the deductible, co-payment or cost share and any service or supply not covered by Tricare.

Preauthorization

Certain surgical, diagnostic and treatment procedures require preauthorization from the managed care contractor before care in order for Tricare to pay for it. Check with local contractors for details.

Medical specialists sometimes disagree on what care is necessary and appropriate. Often, it comes down to this: Tricare will pay if the patient or physician can prove the treatment is medically necessary.

Did You Know?

Under federal law, even if an authorized health care provider chooses not to participate in Tricare, they still cannot charge patients more than 15 percent above what Tricare normally allows for a given medical service or procedure.