| Allowable Charge - The maximum amount TRICARE will pay for services. The allowable charge is also known as the TRICARE Maximum Allowable Charge (TMAC). |
Assignment (Medicare) - Assignment is an agreement between Medicare and doctors, other health care providers, and suppliers of health care equipment and supplies (like wheelchairs, oxygen, braces, and ostomy supplies). Doctors and suppliers who agree to accept assignment accept the Medicare-approved amount as payment in full for Part B services and supplies. You pay the coinsurance and deductible amounts.
If assignment isn't accepted, charges are often higher. This means you may pay more. In addition, you may have to pay the entire charge at the time of service. Medicare will then send you its share of the charge. There is a limit on the amount your doctors and providers can bill you. The highest amount of money you can be charged for a covered service by doctors and other health care providers who don’t accept assignment is called the limiting charge. The limit is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment.
There are three ways to handle assignment:- Always accept assignment, which means they participate in Medicare.
- Accept assignment on a case-by-case basis and accept it in this case.
- Never accept assignment, or choose not to accept assignment in this case.
Assignment doesn’t work with a private contract.
Note: Terms in red are defined in the Glossary section of the FAQ database.
For a list of participating physicians in your area, visit the Medicare Participating Physician Directory. For a list of participating suppliers in your area, visit the Medicare Participating Supplier Directory. |
| Authorization - A review determination made by a licensed professional nurse or other health care professional for requested services, procedures or admissions. Authorizations must be obtained prior to services being rendered or within 24 hours of an emergency admission. |
| Authorized Provider (TRICARE) - A TRICARE-authorized provider is a hospital or institutional provider, physician, or other individual professional provider, or other provider of services or supplies specifically authorized to provide benefits under TRICARE.
Authorized providers must have a state license and a national organization accreditation (if needed). Medicare-certified providers are considered TRICARE-authorized providers. TRICARE regional contractors are responsible for verifying a provider’s authorized status. If you see a provider who isn't TRICARE-authorized and can never be certified, you are responsible for the full cost of care.
A TRICARE-authorized (non-institutional) provider may charge more than the TRICARE maximum allowable charge for TRICARE-covered services. However, by law, the provider can’t charge more than 15% above the TRICARE maximum allowable charge.
There are two types of authorized providers: network and non-network.
Note: Terms in red are defined in the Glossary section of the FAQ database. |
| 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. Network providers and participating providers are prohibited from balance billing. Non-participating providers may charge up to 15% above the TRICARE allowable charge.
Note: Terms in red are defined in the Glossary section of the FAQ database. |
| Behavioral Health Services - Health services that include mental and emotional health, psychiatric care, addiction and substance abuse treatment. Services are provided by different kinds of providers, including certified counselors, psychiatrists, psychologists, neurologists and even family practice physicians. |
Beneficiary - A beneficiary is a person who is eligible for TRICARE benefits. Beneficiaries include:- Active duty service members and their families
- Retired service members and their families
- National Guard and Reserve members and their families
- Survivors/widows
- Certain former spouses
- Medal of Honor recipients and their families
Family members include spouses and unmarried natural children or stepchildren up to the age of 21 (or 23 if full-time students at accredited institutions of learning). Other beneficiary categories are listed in the TRICARE Eligibility section. |
| Beneficiary Counseling and Assistance Coordinator (BCAC) - Persons at military treatment facilities and TRICARE Service Centers who are available to answer questions, help solve health care-related problems and assist beneficiaries in obtaining medical care through TRICARE. BCACs were previously known as Health Benefits Advisors, or HBAs. Find a BCAC near you |
| Billed Charge - The total cost of care, without discounts or reduced fees from a provider. |
Catastrophic Cap - The maximum amount that a family will have to pay out-of-pocket per fiscal year (October 1-September 30), for TRICARE-covered medical services.
The cap applies to all covered services: annual deductibles, pharmacy copayments, annual enrollment fees and other cost shares based on TRICARE-allowable charges.
After you meet the catastrophic cap, TRICARE will pay your portion of the TRICARE-allowable amount for all covered services for the rest of the fiscal/enrollment year.
The catastrophic cap doesn't apply to services not covered by TRICARE or to any amount that non-participating providers may charge above the TRICARE maximum allowable charge.
The catastrophic cap for:- Active duty families is $1,000
- All other TRICARE-eligible families is $3,000.
For TRICARE Prime beneficiaries, the point of service cost shares and deductibles aren't applied to the catastrophic cap. The point of service cost share will remain at 50% of the TRICARE allowable charge even after the catastrophic cap is met. |
| Catchment Area - A defined geographic area served by a hospital, clinic, or dental clinic and delineated on the basis of such factors as population distribution, natural geographic boundaries, and transportation accessibility. For the Department of Defense (DoD) Components, those geographic areas are determined by the Assistant Secretary of Defense (Health Affairs) and are defined by a set of 5-digit zip codes, usually within an approximate 40-mile radius of military inpatient treatment facilities. |
| CHAMPUS - The former health care program established to provide health coverage for active duty family members and retirees and their family members. TRICARE was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. Benefits covered under CHAMPUS are now covered under TRICARE Standard.
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| Civilian Health and Medical Program of the Veterans Administration (CHAMPVA) - A health care program in which the Department of Veterans Affairs shares the cost of covered health care services and supplies with eligible beneficiaries. The program is managed by the Health Administration Center in Denver, Colorado. To be eligible for CHAMPVA, you can't be eligible for TRICARE. |
| COBRA - A health insurance plan which allows an employee who leaves a company to continue to be covered under the company's health plan, for a certain time period and under certain conditions. The name results from the fact that the program was created under the Consolidated Omnibus Reconciliation Act. The system is designed to prevent employees who are between jobs from experiencing a lapse in coverage. |
| Coinsurance (Medicare) - The amount you may be required to pay for services after you pay any plan deductibles. In the Original Medicare Plan, this is a percentage (like 20%) of the Medicare-approved amount. You have to pay this amount after you pay the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent.
Note: Terms in red are defined in the Glossary section of the FAQ database.
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| Continued Health Care Benefit Program (CHCBP) - The Continued Health Care Benefit Program (CHCBP) was established by the National Defense Authorization Act for FY 1993, and provides temporary continued healthcare benefits for certain former beneficiaries of the Military Health System. Coverage under the CHCBP is purchased on a premium basis. |
| Co-Payment - A co-payment (co-pay) is a fixed amount you pay if enrolled in the TRICARE Prime option and services are provided to you by a TRICARE authorized provider. Sometimes the terms co-payment and cost-share are used interchangeably. In fact, co-pays are a set amount based upon the service provided whereas cost-shares are a percentage based upon the TRICARE allowable charge. |
| Cost Share - The cost share is the percentage you pay out of pocket based upon the allowable charge on each claim. Your cost share amount depends upon your sponsor's status (active or retired) and whether services were provided by a network (contracted) or non-network TRICARE provider. |
| DD 2642 - The patient's request for medical payment. It is submitted by the beneficiary or sponsor requesting payment for services or supplies provided by civilian sources of medical care. |
| Deductible - The deductible is the amount you must first pay out of pocket each fiscal year for outpatient medical care before TRICARE begins sharing the cost. The amount you have contributed toward your deductible can be found on your TRICARE Explanation of Benefits (TEOB). The claims processor keeps track of your deductible and subtracts it from your claims during the fiscal year. The deductible is separate from, and in addition to, your cost share. |
| DEERS - The Defense Enrollment Eligibility Reporting System (DEERS) is a computerized data bank that lists all active and retired military members and their dependents if they meet the eligibility requirements. Active and retired military members are automatically listed but must take action to list their dependents and report any changes to family members' status (marriage, divorce, birth of a child, adoption, etc.) along with changes to mailing addresses. TRICARE contractors check DEERS before processing claims to make sure patients are eligible. You may contact DEERS at 1-800-538-9552. |
| Durable Medical Equipment (DME) - Durable Medical Equipment (DME) is purchased or rented medical equipment used for treatment of an injury or illness while medically necessary. DME may include wheelchairs, hospital beds, attachments, oxygen, respirators and medical supplies. DME purchases in excess of $500.00 or all rentals require pre-authorization. |
| Fiscal Intermediary (FI) - Fiscal Intermediaries (FI) are privately held companies contracted by the government to handle all TRICARE claims for any given region. The government directs FIs through federal regulations and guidelines. At times a Fiscal Intermediary may subcontract Claims Processors to adjudicate claims. |
| Fiscal Year (FY) - The Fiscal Year (FY) for TRICARE benefits begins on October 1st and continues through September 30th of the following year. |
| HCFA 1500 - The health insurance claim form. It is submitted by individual professional providers of medical care or institutions billing professional services. |
| Health Benefits Advisor (HBA) - Health Benefits Advisors (HBA) are military personnel stationed at Military Treatment Facilities (MTF) who can assist you with on base appointments, Non-availability Statements (NAS) and understanding your benefits. The HBA has been renamed Beneficiary Counseling Assistance Coordinator (BCAC). |
| Health Care Finder (HCF) - Health Care Finders (HCF) are healthcare professionals, generally registered nurses, who can help you find needed care for services that require pre-authorization. They work with your Primary Care Manager (PCM) to locate the specialty care nearest you that you may require. Health Care Finders are located at TRICARE Service Centers (TSC) and can also assist with making medical appointments at a Military Treatment Facility. |
| Health Maintenance Organization (HMO) - An HMO is a health plan to which you pay a fixed premium for an assortment of medical services, usually including primary and preventive care. The primary purpose of an HMO is to coordinate care so as to eliminate unnecessary care and costs. HMOs typically have co-pays rather than cost shares. |
| Limiting Charge (Medicare) - In the Original Medicare Plan, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept assignment. The limiting charge is 15% over Medicare’s-approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.
Note: Terms in red are defined in the Glossary section of the FAQ database.
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| Managed Care - Managed Care is a concept under which an organization (like an HMO) delivers health care to enrolled members. It controls costs by closely supervising and reviewing the delivery of care. |
| Managed Care Support Contractor (MCSC) - Responsible for all civilian health care delivery to TRICARE beneficiaries outside the Military Treatment Facilities. |
| Medical or Psychological Necessity - TRICARE will consider payment for all necessary medical or psychological services which have been generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness. |
| Medicare Summary Notice (MSN) - The Medicare Summary Notice (MSN) is a statement sent by Medicare that is designed to alert you of claims that have been processed. The statement contains information about the submitted charges, the amount that Medicare paid, and the amount you may be responsible to pay. The MSN isn't a bill. These notices are sent by companies that handle bills for Medicare on a quarterly basis (every 90-day period), unless you are due a payment check from Medicare. If you are due payment from Medicare, the MSN will be mailed to you as your claims are processed.
If you have any questions or if you need an MSN for a particular claim before the quarterly mailing, call the phone number listed in the Customer Service Information box on the front of the MSN. |
| Medicare-Approved Amount - In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges. |
| Military Health System (MHS) - All aspects of health services for the Department of Defense. |
| Military Treatment Facilities (MTF) - Military Treatment Facilities (MTF) are hospitals, typically located on base, that provide medical or dental services to eligible beneficiaries. |
| Network Provider (TRICARE) - Network providers (individual or institutional) are TRICARE-authorized providers who signed an agreement with the regional contractors to provide care at a negotiated rate. Network providers agree to file the claims on behalf of the beneficiaries. Network providers are typically not available overseas. However, TRICARE network providers are available in Puerto Rico for active duty service members and their families enrolled in TRICARE Prime in Puerto Rico. Additionally, the TRICARE Global Remote Overseas contractor established TRICARE Global Remote Overseas provider networks in each overseas area.
Note: Terms in red are defined in the Glossary section of the FAQ database. |
| Nonavailability Statement (NAS) - A NAS is a certificate from a local military treatment facility (MTF) that states it can't provide the care that the patient needs. TRICARE Standard beneficiaries are required to obtain a NAS for inpatient mental health. With the exception of inpatient mental health care, the NAS requirement has been all but eliminated, except in limited circumstances when an MTF applies for a NAS waiver. MTFs may not apply for a NAS waiver for maternity, meaning the NAS requirement for maternity is removed completely. |
| Non-Network Provider (TRICARE) - Non-Network providers are TRICARE-authorized providers who don't have a signed agreement with the regional contractors to provide care at a negotiated rate. There are two types of non-network providers: participating and non-participating.
Note: Terms in red are defined in the Glossary section of the FAQ database. |
| Non-Participating Provider (Medicare) - A doctor or supplier who doesn't participate in Medicare. The doctor or supplier can choose to accept assignment on a case-by-case basis. |
| Non-Participating Provider (TRICARE) - Non-participating providers choose not to accept the TRICARE maximum allowable amount as payment in full for services provided. The provider may bill the beneficiary up to 15 percent above the TRICARE maximum allowable charge. This amount is the beneficiary’s responsibility. A non-participating provider expects payment from the beneficiary, rather than from TRICARE. In such cases, TRICARE pays the beneficiary, not the provider. |
| Other Health Insurance (OHI) - If the beneficiary has medical healthcare coverage besides TRICARE for themselves or any of their dependents, that coverage will be considered to be Other Health Insurance (OHI), and therefore a primary payer to TRICARE. TRICARE coordinates benefits (COB) to determine what, if any, TRICARE liability remains after the OHI has made payment. Supplemental insurance, Medicaid and Native American tribal insurances are considered to be secondary to TRICARE. |
| Part A (Medicare) - Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. |
| Part B (Medicare) - Medicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that aren't covered by Part A. |
| Participating Provider (Medicare) - A doctor or supplier who agrees to accept assignment on all Medicare claims. By accepting assignment, these doctors or suppliers agree to accept the Medicare-approved amount as payment in full. Medicare participating providers can’t try to collect more than the proper Medicare deductible and coinsurance amounts from you. |
| Participating Provider (TRICARE) -
Participating providers agree by signing and submitting a TRICARE claim form and indicating participation in the appropriate space on the claim form, to accept the TRICARE maximum allowable amount as payment in full for services provided. An institutional provider, in order to be an authorized provider under TRICARE, must be a participating provider for all claims. For outpatient care, hospitals may participate on a case-by-case basis. A skilled nursing facility or a home health agency, in order to be an authorized provider under TRICARE, must enter into a participation agreement with TRICARE for all claims. Individual providers may participate on a case-by-case basis.
Note: Terms in red are defined in the Glossary section of the FAQ database. |
Point of Service Option - The point of service (POS) option allows you to receive non-emergency care from any TRICARE-authorized provider without requesting a referral from your primary care manager. However, POS has higher out-of-pocket costs for care. The POS option is available to beneficiaries enrolled in TRICARE Prime, TRICARE Prime Remote, TRICARE Prime Remote for Active Duty Family Members, TRICARE Overseas Program Prime, and TRICARE Global Remote Overseas.
The POS option doesn't apply to:- Active duty service members
- Newborns or newly adopted children in the first 60 days after birth or adoption
- Emergency care
- Clinical preventive care received from a network provider
- First eight behavioral health care outpatient visits per FY (October 1–September 30) to a network provider
- Beneficiaries with other health insurance
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| Preferred Provider Organization (PPO) - A Preferred Provider Organization is a network of health care providers who provide services to patients at discounted rates or cost shares. |
| Primary Care Manager - A MTF provider or network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. 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 (USFHP). |
| Prime Service Area - A geographic area where TRICARE Prime benefits are offered. Regional contractors are required to establish a TRICARE Prime network in TRICARE Prime Service Areas. This includes all catchment areas, Base Realignment and Closure sites, a forty-mile radius around all military treatment facilities, and all additional areas proposed by the regional contractors. |
| Prior Authorization - A process of reviewing certain medical, surgical and behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered or within 24 hours of an emergency admission.
Visit your regional contractor's Web site or call them for a list of services requiring prior authorization.
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| Privacy Act - The Privacy Act of 1974 is a federal law that was established to provide a safeguard for individuals against invasion of personal privacy. The Federal Privacy Act imposes a legal responsibility on the Department of defense and TRICARE Fiscal Intermediaries to assure that personal information about individuals collected by TRICARE is limited to that which is legally authorized and necessary. |
| Private Contract (Medicare) - A contract between you and a doctor, podiatrist, dentist, or optometrist who has decided not to offer services through the Medicare program (opted out). There are no limits on what you can be charged for services under a private contract. You must pay the full amount of the bill. TRICARE won’t pay anything for services under a private contract. |
| Provider - A provider is a hospital or other institutional provider of medical care or services, a physician or other individual professional provider, or other provider of services or supplies. |
| Public Facility-Use Certificate - A written confirmation that the requested PFPWD services or items are either not available from public facilities or are not adequate to meet the needs of the beneficiary’s qualifying condition. The PFPWD requires that public facilities be used first to the extent that they are available and adequate. The certification can be issued by the Commander of the MTF or an authorized administrator of the public facility. The certification is valid for 12 consecutive months from date of signature. A care-specific determination of public facility availability is conclusive and is not appealable. |
| Referral - A referral is a request by the patient's Primary Care Manager (PCM) granting permission for the patient to seek specialty care outside of the PCM office. |
| Service Point of Contact (SPOC) - The Uniformed Services office or individual responsible for coordinating civilian health care for Active Duty Service Members (ADSMs) who receive care under the TRICARE Prime Remote (TPR) program. |
| Split Enrollment - Situation where different members of the same family are 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. |
| Sponsor - A sponsor is the person who served in the uniformed services, whether active duty or retired, who makes you eligible for TRICARE. The sponsor's Social Security number serves as the group or policy number. |
| Supplemental Insurance - Supplemental insurance generally pays most, or all, of whatever is remaining after TRICARE has made payment. These plans are frequently available from military associations and other private organizations. |
| Third Party Liability - Medical services that may be a result of a third party must first be reviewed for liability before TRICARE can consider payment. A Third Party Liability (TPL) form must be completed which explains whether or not another party may be responsible for making payment before TRICARE. |
| TRICARE Extra - TRICARE Extra refers to care provided to a patient by a network, or contracted provider. Beneficiaries do not have to enroll for Extra benefits. By seeing a network provider patients pay reduced cost shares for care (5% less) and have an annual deductible. |
| TRICARE For Life - Patients eligible for TRICARE who are age 65 or older are considered to be TRICARE For Life (TFL) beneficiaries. These beneficiaries must be Medicare eligible and purchasing Part B. TRICARE will pay after Medicare if there is no Medicare Supplemental coverage. |
| TRICARE Management Activity (TMA) - Ensures, with the support of the Surgeons General of the Military Departments, that Department of Defense (DoD) policy on health care is consistently, effectively and efficiently implemented throughout the Military Health System (MHS). The TMA is an activity of the Assistant Secretary of Defense (Health Affairs). |
| TRICARE Prime - TRICARE Prime is the managed health care program for military families. Prime operates similarly to an HMO, under which one enrolls for a year at a time, and agrees to seek healthcare providers and institutions set up by the TRICARE contractor in the appropriate region. The Prime program requires obtaining a pre-authorization and/or referral for specialty care. |
| TRICARE Service Center (TSC) - Provides beneficiary enrollment, access to and referral for care, information on TRICARE options, information (including on-line access to the claims processing system for information about the status of a claim), assist beneficiaries with claim problems, and continuity of care services to all Military Health System beneficiaries. TSCs also fulfill the requirements of the Lead Agents (LAs). |
| TRICARE Standard - TRICARE Standard (formerly known as CHAMPUS) provides core healthcare benefits. Standard allows beneficiaries to see any TRICARE authorized non-network civilian provider. Patients pay an annual deductible and a cost share. |
| Uniformed Services Family Health Plan (USFHP) - US Family Health Plan is an extra TRICARE Prime option that is available to family members of active-duty military and retirees and their eligible family members regardless of their age. The Plan is provided through not-for-profit healthcare systems in six areas of the country. Eligibles of all ages who live in the six service areas can enroll.
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| Urgent Care - Medically necessary treatment that is required for illness or injury that would not result in further disability or death if not treated immediately, but treatment should not be put off. The illness or injury does require professional attention, and should be treated within 24 hours to avoid development of a situation in which further complications could result if treatment is not received. |
| What is “Obesity"? - TRICARE defines morbid obesity as when the body weight is 100 pounds over ideal weight for height and bone structure, according to the most current Metropolitan Life Table, and the beneficiary a severe medical conditions that has a higher death rate due to the morbid obesity; or, the body weight is 200 percent or more of ideal weight for height and bone structure. |