TRICARE The Basics

1. TRICARE…  The Basics

2. TRICARE Prime TRICARE Standard/Extra TRICARE Prime Remote TRICARE Prime Remote for Active Duty Family Members

3. What is TRICARE? Unifomed Services “Medical Plan” 3 Options: PRIME EXTRA STANDARD

4. BASIC ACRONYMS/DEFINITIONS PCM HCF DCAO MTF BCAC NURSELINE PCM- Primary care managers are health care professionals who coordinate your medical care. By arranging all your medical care, your PCM will become an expert on your health and that of your family members. HCF- health care finder is a registered nurse or Physician’s Assistants who are employed by the TRICARE contractor. HCFs work with Primary Care managers to make specialty referral appointment with providers in the military treatment facility or civilian network. HCFs also authorize hospitalization and certain outpatient procedures. DCAO- Debt Collection Assistance Officers- provide priority assistance when presented documentation verifying that collection action has been started or that negative information is reflected on members credit report as a result of late or nonpayment for medical or dental care received through TRICARE MTF- medical treatment facility is a military hospital or clinic BCAC- beneficiary counseling and assistance coordinators, formerly referred to as Health Benefits Advisors, serve as members advocate and problem solver. They interface with the Medical Treatment Facility staff, managed care support contractors, and claims processors to resolve beneficiary concerns and questions regarding the TRICARE program. Nurseline- This line consists of specially trained nurses who will answer medical questions 24 hours a day, 7 days a week. The nurses provide advice on basic health care issues and aid in determining if immediate attention by a provider is warranted. This service is available in all regions. Call local TRICARE Service center PCM- Primary care managers are health care professionals who coordinate your medical care. By arranging all your medical care, your PCM will become an expert on your health and that of your family members. HCF- health care finder is a registered nurse or Physician’s Assistants who are employed by the TRICARE contractor. HCFs work with Primary Care managers to make specialty referral appointment with providers in the military treatment facility or civilian network. HCFs also authorize hospitalization and certain outpatient procedures. DCAO- Debt Collection Assistance Officers- provide priority assistance when presented documentation verifying that collection action has been started or that negative information is reflected on members credit report as a result of late or nonpayment for medical or dental care received through TRICARE MTF- medical treatment facility is a military hospital or clinic BCAC- beneficiary counseling and assistance coordinators, formerly referred to as Health Benefits Advisors, serve as members advocate and problem solver. They interface with the Medical Treatment Facility staff, managed care support contractors, and claims processors to resolve beneficiary concerns and questions regarding the TRICARE program. Nurseline- This line consists of specially trained nurses who will answer medical questions 24 hours a day, 7 days a week. The nurses provide advice on basic health care issues and aid in determining if immediate attention by a provider is warranted. This service is available in all regions. Call local TRICARE Service center

5. USEFUL WEBSITES www.manpower.usmc.mil www.tricare.osd.mil

6. TRICARE Prime What do you get with Prime? Priority ranking within the MHS. Guaranteed access such as travel time, a sufficient number of providers on staff to handle patient load, etc. TRICARE Prime enrollees will receive enhanced preventive services, referrals for specialty care, etc. Use of the MTF’s at no cost and a substantially reduced out-of-pocket costs for civilian care as compared to Extra and Standard. What does “priority” mean? The precedence in the system of who will be seen first. AD members, then AD Family Members enrolled in Prime, then all others. What does guaranteed access mean? Emergency services available and accessible within the service area 24 hrs/day, 7 days/week. Wait times for appointments: Urgent Care - shall not exceed one day. Routine - shall not exceed one week. Wellness - shall not exceed four weeks. Specialty Care - shall not exceed four weeks. What do you get with Prime? Priority ranking within the MHS. Guaranteed access such as travel time, a sufficient number of providers on staff to handle patient load, etc. TRICARE Prime enrollees will receive enhanced preventive services, referrals for specialty care, etc. Use of the MTF’s at no cost and a substantially reduced out-of-pocket costs for civilian care as compared to Extra and Standard. What does “priority” mean? The precedence in the system of who will be seen first. AD members, then AD Family Members enrolled in Prime, then all others. What does guaranteed access mean? Emergency services available and accessible within the service area 24 hrs/day, 7 days/week. Wait times for appointments: Urgent Care - shall not exceed one day. Routine - shall not exceed one week. Wellness - shall not exceed four weeks. Specialty Care - shall not exceed four weeks.

7. TRICARE Prime Prime Terms: Primary Care Manager (PCM) Point -of-Service (POS) PCM- an Medical treatment facility provider (clinic) or network provider to whom a Marine is assigned for primary care services at the time of enrollment POS- an option under TRICARE Prime that allows members to self-refer for non-emergent health care services to any TRICARE authorized civilian provider. POS claims are subject to deductibles and cost sharesPCM- an Medical treatment facility provider (clinic) or network provider to whom a Marine is assigned for primary care services at the time of enrollment POS- an option under TRICARE Prime that allows members to self-refer for non-emergent health care services to any TRICARE authorized civilian provider. POS claims are subject to deductibles and cost shares

8. TRICARE Prime Enrollment Need to identify/select a Primary Care Manager (PCM) for each family member PCMs usually are assigned MTF or Civilian Network May be a Family Practitioner, Pediatrician, Internist, Flight Surgeon, sometimes an OB/Gyn May be a M.D., Physician Assistant, Nurse Practitioner, (Individual/Group/Team) If enrolled prior to the 20th, enrollment is effective the 1st of the following month. After the 20th, the 1st of the 2nd month. Once enrolled in Prime, re-enrollment is automatic, unless sponsor takes action to disenroll. A letter will be sent to the sponsor 15 days prior to the anniversary date or enrollment notifying them that unless they wish to disenroll, they will be automatically re-enrolled. No action is required to continue enrollment. There is no annual enrollment fee for AD or AD Family members for PRIME. All others pay an annual fee of $230 for individual or $460 for families. If enrolled prior to the 20th, enrollment is effective the 1st of the following month. After the 20th, the 1st of the 2nd month. Once enrolled in Prime, re-enrollment is automatic, unless sponsor takes action to disenroll. A letter will be sent to the sponsor 15 days prior to the anniversary date or enrollment notifying them that unless they wish to disenroll, they will be automatically re-enrolled. No action is required to continue enrollment. There is no annual enrollment fee for AD or AD Family members for PRIME. All others pay an annual fee of $230 for individual or $460 for families.

9. TRICARE Prime Enrollment Prime ID card/enrollee Always carry it with you! “Split” enrollment…family members enrolled in other TRICARE regions Prime follows you (portability) Your Prime ID card is like your American Express card - never leave home without it. Split enrollment involves different members of the same family enrolled with different TRICARE contractors. Each contractor maintains and tracks enrollment fees, co-payments, and other TRICARE enrollee information for the family members enrolled in its own area. A family will pay enrollment fees totaling no more than the TRICARE Prime family enrollment fee regardless of the enrollment locations of the family members. It is your responsibility to combine enrollment year catastrophic cap Prime moves with you when you move. Your Prime ID card is like your American Express card - never leave home without it. Split enrollment involves different members of the same family enrolled with different TRICARE contractors. Each contractor maintains and tracks enrollment fees, co-payments, and other TRICARE enrollee information for the family members enrolled in its own area. A family will pay enrollment fees totaling no more than the TRICARE Prime family enrollment fee regardless of the enrollment locations of the family members. It is your responsibility to combine enrollment year catastrophic cap Prime moves with you when you move.

10. TRICARE Prime Portability…let’s talk! Prime Site-to-Prime Site “Transfer Enrollment” upon arrival Follow authorization rules in transit Same anniversary dates Enrollment fees transfer (All Others) Prime Site-to-Non-Prime Site Disenroll upon arrival (covered enroute) Non-Prime Site-to-Prime Site It’s decision time! Known as “portability”, you continue with the same enrollment period and anniversary date. Future enrollment fees paid on a quarterly basis will be paid to the gaining contractor. If you’re moving from a prime site to a non-prime site you must dis-enroll upon arrival. However, you are covered while you are in-transit. If you’re moving from a non-prime site to a prime site, it’s time to make that decision for you and your family. Use example…Known as “portability”, you continue with the same enrollment period and anniversary date. Future enrollment fees paid on a quarterly basis will be paid to the gaining contractor. If you’re moving from a prime site to a non-prime site you must dis-enroll upon arrival. However, you are covered while you are in-transit. If you’re moving from a non-prime site to a prime site, it’s time to make that decision for you and your family. Use example…

11. TRICARE Prime Getting care... Always call your chosen (or assigned) Primary Care Manager (PCM) first Military or Civilian Manage your TOTAL care When referred for care, the authorization process begins with the Primary Care Manager Via the Health Care Finder (HCF) What happens when you enroll? All TRICARE Prime enrollees designate, or have a PCM assigned to them at the time of enrollment. Each enrollee will be issued an ID card and the TRICARE Prime enrollees will also have access to a 24hr nurse advice line. The PCM is the assigned doctor that provides primary care services. He/she will arrange for the use of specialist care and inpatient care through an authorization and referral system. The PCM may be an individual doctor, a military provider, a military facility, a civilian clinic, an individual civilian provider, or Uniformed Services Family Health Plan. What happens when you enroll? All TRICARE Prime enrollees designate, or have a PCM assigned to them at the time of enrollment. Each enrollee will be issued an ID card and the TRICARE Prime enrollees will also have access to a 24hr nurse advice line. The PCM is the assigned doctor that provides primary care services. He/she will arrange for the use of specialist care and inpatient care through an authorization and referral system. The PCM may be an individual doctor, a military provider, a military facility, a civilian clinic, an individual civilian provider, or Uniformed Services Family Health Plan.

12. TRICARE Prime “Traveling-out-of-your-Area” Care Prime ID card Coverage Urgent care: Call PCM first! Emergency care: Notify MCSC No routine care when away from PCM! If it’s an emergency, go to the nearest Emergency Room and contact your PCM within 48 hours. If urgent care is required, contact PCM first. If it’s an emergency, go to the nearest Emergency Room and contact your PCM within 48 hours. If urgent care is required, contact PCM first.

13. TRICARE Standard/Extra Standard is what was formerly known as CHAMPUS. TRICARE Standard is available for all TRICARE eligible beneficiaries who elect not to enroll in prime. In general, TRICARE Standard/Extra covers most health care that is medically necessary. However, some types of care are not covered. TRICARE will not pay for unproven (used to be called investigational/experimental) medicine. Furthermore, TRICARE payments are prohibited for health care services that are “not medically or psychologically necessary”. Family members may see any participating civilian physician they choose, and the government will share the cost. There is no enrollment required. Your family may still seek treatment in a military hospital or clinic, but only on a space-available basis.Standard is what was formerly known as CHAMPUS. TRICARE Standard is available for all TRICARE eligible beneficiaries who elect not to enroll in prime. In general, TRICARE Standard/Extra covers most health care that is medically necessary. However, some types of care are not covered. TRICARE will not pay for unproven (used to be called investigational/experimental) medicine. Furthermore, TRICARE payments are prohibited for health care services that are “not medically or psychologically necessary”. Family members may see any participating civilian physician they choose, and the government will share the cost. There is no enrollment required. Your family may still seek treatment in a military hospital or clinic, but only on a space-available basis.

14. TRICARE Standard/Extra TRICARE Standard (Same as CHAMPUS) Two Questions to always ask provider: First: Are you a TRICARE “authorized” provider? Second: Are you a “participating” provider? You have greater freedom of physician choice, but it can be expensive if you are seen by a non-participating provider or if you see a physician that is not an authorized provider. An authorized provider is one who meets certain educational, licensing and operational requirements. They are specifically authorized to provide benefits under TRICARE. They receive a TRICARE provider identification number. If a provider is not an authorized provider, there will be no cost-sharing by the government. That means 100% out of pocket expense for the beneficiary. A participating hospital or provider has agreed, by signing and submitting a TRICARE claim form and indicating participation in the appropriate space on the claim form, to accept the TRICARE-determined allowable cost or charge as the total charge, whether paid for fully by the TRICARE allowance or requiring cost-sharing by the beneficiary or sponsor. All network providers MUST be participating providers. Non-participating providers do not wish to participate in the TRICARE program and, therefore, will not accept the CHAMPUS Maximum Allowable Charge (CMAC) as payment in full for their services. In these cases, the beneficiary is responsible for all excess charges (the difference between what a nonparticipating provider bills and the CMAC) up to 115% of the CMAC.You have greater freedom of physician choice, but it can be expensive if you are seen by a non-participating provider or if you see a physician that is not an authorized provider. An authorized provider is one who meets certain educational, licensing and operational requirements. They are specifically authorized to provide benefits under TRICARE. They receive a TRICARE provider identification number. If a provider is not an authorized provider, there will be no cost-sharing by the government. That means 100% out of pocket expense for the beneficiary. A participating hospital or provider has agreed, by signing and submitting a TRICARE claim form and indicating participation in the appropriate space on the claim form, to accept the TRICARE-determined allowable cost or charge as the total charge, whether paid for fully by the TRICARE allowance or requiring cost-sharing by the beneficiary or sponsor. All network providers MUST be participating providers. Non-participating providers do not wish to participate in the TRICARE program and, therefore, will not accept the CHAMPUS Maximum Allowable Charge (CMAC) as payment in full for their services. In these cases, the beneficiary is responsible for all excess charges (the difference between what a nonparticipating provider bills and the CMAC) up to 115% of the CMAC.

15. TRICARE Standard/Extra TRICARE “Extra” You are TRICARE Standard!!! Use MCSC network visit-by-visit Shop the MCSC’s Provider Directory Incentive: Get discount on cost share! The only difference between Standard and Extra is the amount of cost share paid by the beneficiary. If you use a provider that is in the TRICARE network (TRICARE Extra), your cost share is 5% less than that of a provider not in the network (TRICARE Standard). Basically a PPO- preferred provider organizations You choose civilian physicians and specialists from a list of doctors who are part of the managed care support contractor’s network in that region. You can utilize network physicians on a visit-by-visit basis, and generally, you will not have to file any claim forms. As in Standard, you are entitled to use military medical facilities, but only on a space-available basis.The only difference between Standard and Extra is the amount of cost share paid by the beneficiary. If you use a provider that is in the TRICARE network (TRICARE Extra), your cost share is 5% less than that of a provider not in the network (TRICARE Standard). Basically a PPO- preferred provider organizations You choose civilian physicians and specialists from a list of doctors who are part of the managed care support contractor’s network in that region. You can utilize network physicians on a visit-by-visit basis, and generally, you will not have to file any claim forms. As in Standard, you are entitled to use military medical facilities, but only on a space-available basis.

16. TRICARE Standard/Extra You pay for Standard/Extra care like this... First, the Deductible (each Fiscal Year) Active Duty Family Member (ADFM) E-1 to E-4: $50 / individual & $100 / family E-5 & Up: $150/individual & $300 / family All Others $150 / individual & $300 / family ADFM’s of E-1 through E-4 pay a deductible of $50 for an individual, or $100 for 2 or more in the family. E-5 and up, and All Others pay, $150 for individual, and $300 for family per year. Deductibles apply to outpatient care only. TRICARE requires you to pay an annual deductible, per person or family deductible each fiscal year before they will pay. ADFM’s of E-1 through E-4 pay a deductible of $50 for an individual, or $100 for 2 or more in the family. E-5 and up, and All Others pay, $150 for individual, and $300 for family per year. Deductibles apply to outpatient care only. TRICARE requires you to pay an annual deductible, per person or family deductible each fiscal year before they will pay.

17. TRICARE Standard/Extra After Deductible is Met, THEN... Pay Cost Share Active Duty Family Member (ADFM) Standard: 20% Extra: 15% All Others Standard: 25% Extra: 20% The cost share is the amount a beneficiary must pay for covered inpatient and outpatient services (other than the deductible, the annual TRICARE Prime enrollment fee or disallowed amount.) Disallowed charges are any charges related to non-covered service or a charge for a service not related to the diagnosis or treatment provided. ADFMs pay a 20% cost share under standard, and save 5% by utilizing a TRICARE Extra provider. All Others pay 25% for standard and 20% for extra.The cost share is the amount a beneficiary must pay for covered inpatient and outpatient services (other than the deductible, the annual TRICARE Prime enrollment fee or disallowed amount.) Disallowed charges are any charges related to non-covered service or a charge for a service not related to the diagnosis or treatment provided. ADFMs pay a 20% cost share under standard, and save 5% by utilizing a TRICARE Extra provider. All Others pay 25% for standard and 20% for extra.

18. TRICARE Standard/Extra Plus, with Standard (not Extra) you pay balance billing costs for care from non-participating providers To avoid balance billing: - Ask if provider will participate (may or may not) - Or use network provider (Extra) Here’s where it can get even more expensive. Balance billing is the practice of billing the beneficiary for whatever amount the insurance company does not cover (the “balance” of the charges). Federal law says you aren’t legally responsible for any amount in excess of 15% above the TRICARE/CHAMPUS allowable charge (CMAC).Here’s where it can get even more expensive. Balance billing is the practice of billing the beneficiary for whatever amount the insurance company does not cover (the “balance” of the charges). Federal law says you aren’t legally responsible for any amount in excess of 15% above the TRICARE/CHAMPUS allowable charge (CMAC).

19. TRICARE Standard/Extra Maximum your family will pay for TRICARE covered services (Catastrophic Cap) ADFM (per SSN): $1000 / fiscal year All Others (per SSN): $3000 / fiscal year Here are the catastrophic caps under Standard/Extra. $1,000 for ADFM and $3000 for All Others.Here are the catastrophic caps under Standard/Extra. $1,000 for ADFM and $3000 for All Others.

20. TRICARE Standard/Extra Non-Availability Statements (NAS) Still need NAS for inpatient care When you live within 40 miles of MTF Except If you have other health insurance Emergency admission NAS’s are no longer required for outpatient care. NAS’s can be required for inpatient care if you live within 40 miles of an MTF unless you have other health insurance or it is am emergency admission. When you have OHI, TRICARE pays after all other plans except for certain TRICARE supplements. TRICARE does not require NAS for emergency treatment, but the attending physician must certify that the episode was a true emergency. Only MTFs are authorized to issue NAS’s - not clinics. An NAS certifies a specific medical service is not available within a specified geographic boundary (catchment area) of the beneficiary’s residence. The beneficiary is responsible for knowing if a NAS is required. A NAS must be submitted with all claims. If you do not get a non-availability statement before you get inpatient care from a civilian, TRICARE Standard may not share your costs.NAS’s are no longer required for outpatient care. NAS’s can be required for inpatient care if you live within 40 miles of an MTF unless you have other health insurance or it is am emergency admission. When you have OHI, TRICARE pays after all other plans except for certain TRICARE supplements. TRICARE does not require NAS for emergency treatment, but the attending physician must certify that the episode was a true emergency. Only MTFs are authorized to issue NAS’s - not clinics. An NAS certifies a specific medical service is not available within a specified geographic boundary (catchment area) of the beneficiary’s residence. The beneficiary is responsible for knowing if a NAS is required. A NAS must be submitted with all claims. If you do not get a non-availability statement before you get inpatient care from a civilian, TRICARE Standard may not share your costs.

21. TRICARE Standard/Extra Maternity Non-Availability Statements NAS required for all maternity care including birthing centers home delivery Issued once pregnancy is confirmed by MTF

22. TRICARE Standard/Extra What monies go towards catastrophic cap? Deductibles Cost-shares * Note: For balance billing situations, monies paid over CMAC are not applied to catastrophic cap

23. When does MHS care change/end for AD? Retirement May choose TRICARE Prime or TRICARE Standard/Extra as Retiree Separate from Service Active Duty & TRICARE Check with personnel to find out exactly what the mbr is entitled to Check with personnel to find out exactly what the mbr is entitled to

24. TRICARE PrimeRemote

25. TRICARE Prime RemotePurpose Provide easier access to civilian health care for remotely assigned Active Duty Service Members (ADSMs) & certain Active Duty Family Members (ADFM’s) Reduces hassles and separation from family Assists Unit Commanders by keeping ADSMs on the job Continues to ensure fitness for duty ADFM’s MUST RESIDE with the ADSM to obtain eligibility for TPRFM The TPR benefit became effective 1 October 2001. The TPRADFM has not been implemented yet. This will effect recruiters, I&I, reservists.The TPR benefit became effective 1 October 2001. The TPRADFM has not been implemented yet. This will effect recruiters, I&I, reservists.

26. New program…new acronyms!! MMSO - Military Medical Support Office SPOC - Service Point of Contact MMSO- Military Medical Support Office-the joint services organization responsible for reviewing specialty and inpatient care requests and claims for impact on fitness-for-duty. MMSO is also responsible for approving certain medical services not covered under TRICARE that are necessary to maintain fitness for duty and/or retention on active duty. The SPOCs for Marine Corps, Navy, Army, and Air Force active duty service members are assigned to the MMSO. SPOC- the uniformed services office or individual responsible for coordinating civilian health care for active duty service members who receive care under the TRICARE Prime Remote program. The SPOC reviews requests for specialty and inpatient care to determine impact on the ADSM’s fitness for duty; determines whether the ADSM shall receive care related to fitness for duty at a MTF or civilian provider; initiates/coordinates medical evaluation boards; arranges transportation for hospitalized service members when necessary; and provides overall health care management for the active duty Marine SPOC only deals with Service member not family members. MMSO- Military Medical Support Office-the joint services organization responsible for reviewing specialty and inpatient care requests and claims for impact on fitness-for-duty. MMSO is also responsible for approving certain medical services not covered under TRICARE that are necessary to maintain fitness for duty and/or retention on active duty. The SPOCs for Marine Corps, Navy, Army, and Air Force active duty service members are assigned to the MMSO. SPOC- the uniformed services office or individual responsible for coordinating civilian health care for active duty service members who receive care under the TRICARE Prime Remote program. The SPOC reviews requests for specialty and inpatient care to determine impact on the ADSM’s fitness for duty; determines whether the ADSM shall receive care related to fitness for duty at a MTF or civilian provider; initiates/coordinates medical evaluation boards; arranges transportation for hospitalized service members when necessary; and provides overall health care management for the active duty Marine SPOC only deals with Service member not family members.

27. Eligibility Active Duty Service Members (ADSMs) Includes Reservists or National Guard Members on orders to Active Duty for greater than 30 days TPR areas are designated by zip codes Must work and live in TPR designated areas If you’re unsure whether or not you meet this criteria, go to the TRICARE web site under the TPR section and it will ask you to provide your zip codes, once this is complete it well tell you whether or not you are TPR or notIf you’re unsure whether or not you meet this criteria, go to the TRICARE web site under the TPR section and it will ask you to provide your zip codes, once this is complete it well tell you whether or not you are TPR or not

28. Eligibility Active Duty Family Members: ADFM’s MUST reside with the ADSM Must enroll in Prime even if none available ADFM’s get same benefit as those residing in “Prime Network” areas “Waived Charges” benefit in place These areas were established as a pilot program to see how the benefit would apply down the road for all benes’. The networks were put in place to ensure that the ADFM’s would have a PCM (provider) to see and get their healthcare through. A “waived charges” benefit for active duty prime remote family members will remain in effect until the September 2002 implementation of the new TRICARE Prime Remote for Active Duty Family Members program. The interim waived charges benefit, which is retroactive to Oct. 30, 2000, waives cost shares, copayments and deductibles for active duty family members who accompany their sponsors on assignment to remote locations, and reside with those sponsors. As of right now, TPRADFM is on hold and we will hopefully have a date soon on implementation but waived charges will remain in effect. Once approved a MARADMIN will follow.These areas were established as a pilot program to see how the benefit would apply down the road for all benes’. The networks were put in place to ensure that the ADFM’s would have a PCM (provider) to see and get their healthcare through. A “waived charges” benefit for active duty prime remote family members will remain in effect until the September 2002 implementation of the new TRICARE Prime Remote for Active Duty Family Members program. The interim waived charges benefit, which is retroactive to Oct. 30, 2000, waives cost shares, copayments and deductibles for active duty family members who accompany their sponsors on assignment to remote locations, and reside with those sponsors. As of right now, TPRADFM is on hold and we will hopefully have a date soon on implementation but waived charges will remain in effect. Once approved a MARADMIN will follow.

29. EligibilityAm I Eligible? Two Ways to Check Check TRICARE Prime Remote Web Site: “http://www.tricare.osd.mil/remote/” Provides Eligibility Information Based on Work and Home Zip Codes Call Toll-Free Beneficiary Information Line for Local Region

30. Enrollment ADSM and ADFM’s Complete Regional Enrollment Form. Available from Unit or Call Contractor’s Toll-Free Number Sends to Regional Address Provided by the Contractor

31. Getting Care Selecting A Provider...Two Options: 1. Choose a Primary Care Manager (PCM) from the Network (if available) 2. If No Network Providers, Select Any TRICARE-Authorized Provider from the Community Must be A Primary Care Provider Examples Include: Family Practice, Internal Medicine, General Practice or OB/GYN The reason for PCP is because you may reside in an area where providers will not accept TRICARE at all TPRADFM’s began 1 October 2001The reason for PCP is because you may reside in an area where providers will not accept TRICARE at all TPRADFM’s began 1 October 2001

32. Finding a TRICARE Authorized Provider Visit the TRICARE Web Site at http://www.tricare.osd.mil/ProviderDirectory/ Call the Regional contractor for assistance Ask the provider when you call to make an appointment - “Are you an authorized TRICARE provider?”

33. Primary Care Services See your PCM or Primary Care Provider Prior-authorization is Not Required for Primary Care Services Prior authorization is not required because it is routine care with your PCMPrior authorization is not required because it is routine care with your PCM

34. Primary Care ServicesExamples Routine health services (sick call) Laboratory tests X-rays Immunizations Hearing tests/routine eye exams Breast Exams and mammography Pap Smears Prostate/early Cancer diagnosis exams

35. Specialty Carefor the ADSM Pre-authorization is Required for All Specialty Care Your PCM (or You) Must Call the Health Care Finder (HCF) for Pre-authorization The HCF Will Check with MMSO to Ensure Care Does Not Require A “Fitness for Duty” Evaluation by A Military Provider You Will Receive Approval for Civilian Care or Referral to a Military Facility in 2 Working Days (sooner, if urgent) You may be given the authorization to receive the care, but you may have to travel a distance to see a military provider for Fitness for duty or possible Med Board proceedingsYou may be given the authorization to receive the care, but you may have to travel a distance to see a military provider for Fitness for duty or possible Med Board proceedings

36. Pre-Authorization Requirements Specialty Care Routine maternity care Physical therapy Mental Health services Family Counseling Smoking cessation program All Require Pre-authorization! This ONLY applies to the ADSMThis ONLY applies to the ADSM

37. Filing Medical Claims Network and Participating Providers will file claims For Non-Participating Providers, ADSMs may have to file claim But...ADSMs will be FULLY reimbursed for authorized out-of-pocket costs

38. Filing Medical Claims When filing Medical Claims on your own, you must have the following documents: Completed DD Form 2642 (CHAMPUS Claim Form) available on TRICARE web site Itemized medical bill Proof of payment All forms can be downloaded off the TRICARE web siteAll forms can be downloaded off the TRICARE web site

39. Filing Medical Claims All claims (regardless of who files the claim) will generate an “Explanation of Benefits (EOB)” to the ADSM Information on the EOB Includes: Amount of Billed Charges CMAC (CHAMPUS Maximum Allowable Charge) Amount Paid to the Provider or reimbursed to the ADSM

40. QUESTIONS???