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VA/TRICARE Business Practices

VA/TRICARE Business Practices. TRICARE Basics. Prime (HMO) Requires enrollment Primary Care Manager Requires authorization for outside care Extra (Preferred Provider Network) Requires authorization for inpatient/certain procedures. TRICARE Basics.

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VA/TRICARE Business Practices

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  1. VA/TRICARE Business Practices

  2. TRICARE Basics • Prime (HMO) • Requires enrollment • Primary Care Manager • Requires authorization for outside care • Extra (Preferred Provider Network) • Requires authorization for inpatient/certain procedures

  3. TRICARE Basics • TRICARE Standard (Fee for Service) • Requires authorization for inpatient/certain procedures • TRICARE For Life (Medicare eligible) • Medicare eligible TRICARE beneficiaries • Must purchase Medicare Part B • No additional authorizations required • Acts as first payor to VA

  4. Managed Care Support Contractors • Health Services and Support Contractors in TRICARE contracts • Establish eligibility and TRICARE status • Referrals and authorizations • Establish Provider networks • Provider network training • Claims processing (New National Contract) • Marketing (New National Contract)

  5. Types of TRICARE Providers • TRICARE Provider (Non Participating) • Accepts TRICARE at CMAC • Can bill at 15% over CMAC • No contract or agreement signed • Preferred (Network) Provider • Signed agreement to provide certain services • Bill at negotiated rate • (Example: CMAC less 10%)

  6. TRICARE Contractors • Health Net Federal Services North Region • Humana Military Healthcare Services South Region • TriWest Healthcare Alliance Corp. West Region

  7. VA Responsibilities • Establish TRICARE eligibility and TRICARE status • Register patient into VistA • Eligibility and Insurance information • Obtain authorizations for Prime patients • Obtain required authorizations for Extra and Standard Patients • Bill TRICARE • Bill Patient Co-pays and deductibles • Follow up on TRICARE bills

  8. Eligibility • Veteran • TRICARE • Dual Eligible Veteran • Active Duty

  9. Dual Eligible Veterans • Individuals that are eligible for VA and TRICARE benefits: • Must be treated as a veteran if seeking care for a service connected condition • Do Not bill TRICARE • May use either Veteran or TRICARE benefits if seeking care for a non service connected condition (Veteran choice) • Must use that benefit for the complete episode of care

  10. Patient Registration: TRICARE • Patient Type: TRICARE • Veteran (Y/N)?: No • Primary Eligibility Code: TRICARE/CHAMPUS • Secondary Eligibility Code: • Period of Service: Other/Non Veteran

  11. Patient Registration: Veteran Primary/TRICARE Secondary • Patient Type: NSC Veteran • Veteran (Y/N)?: Yes • Primary Eligibility Code: Appropriate Veteran Code (SC <50%, NSC, etc.) • Secondary Eligibility Code: TRICARE/CHAMPUS • Period of Service: Veteran’s appropriate Period of Service (WWII, PGW, etc.)

  12. Patient Registration: Active Duty • Patient Type: Active Duty • Veteran (Y/N)?: No • Primary Eligibility Code: Sharing Agreement • Secondary Eligibility Code:TRICARE/CHAMPUS • Period of Service: Service Name Active Duty

  13. Insurance Data Screen • Covered by Health Insurance: Yes • Insurance Company Name: TRICARE • Group Name: • Prime, Extra, Standard or TFL • Type of Plan: CHAMPUS • Whose Insurance: Other • Subscriber ID: TRICARE ID # • Name of Insured: Name of TRICARE sponsor • Insured’s SSN: Sponsor’s SSN

  14. Making Appointments • No TRICARE appointment type in VistA • Use Sharing Agreement as appointment type for a TRICARE patient • Use Sharing Agreement as appointment type for a dual eligible veteran using TRICARE benefits

  15. Billing Basics • Bill to the Fiscal Intermediary where the TRICARE patient lives or is stationed at the time of service • Active Duty do not pay co-payments or deductibles • TRICARE pays after primary insurance • TFL pays VA as primary insurance • TMAC billing rates are at http://vaww1.va.gov/vadod/index.cfm

  16. Billing and Payment • Biller creates and authorizes the TRICARE bill • Accounts Receivable Technician • Audits bill • Receives/analyzes EOB from TRICARE • Processes payment • Initiates appeal if necessary • Biller creates and authorizes patient bill for co-payment and deductible

  17. Additional Information • TRICARE and VA Training Guide http://vaww.vistau.med.va.gov/vistau/ tricare/default.htm • VHA Handbook DoD Health Care Resources Sharing (to be published) • Managed Care Support Contractor Provider Relations Department • http://www.tricare.osd.mil

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