TRICARE
Overview
taken from TriWest website
The terms TriWest and TRICARE are often used interchangeably, but each is distinctly different. It's easy to see why people may be confused—the names of both start with the same three letters and both have similar logos.
Created in the early 1990s, TRICARE is the U.S. Department of Defense (DoD) health care entitlement for active duty, Guard and Reserve and retired members of the military, and their eligible family members and survivors. TRICARE's objectives are to optimize the delivery of health care services at military treatment facilities and supplement that with access to civilian health care networks where necessary. TRICARE receives its funding as part of the annual federal defense budget, which is approved by Congress and signed by the President of the United States.
TriWest Healthcare Alliance is a privately held, Phoenix-based corporation that contracts with the DoD to administer TRICARE in the 21-state TRICARE West Region, and is monitored by the TRICARE Management Authority, a department within the DoD.
TRICARE is not an insurance plan, but rather a health care entitlement earned by our nation's military members for their service to this country. Likewise, TriWest is not an insurance company. TriWest is a contractor to the DoD that administers the TRICARE program in the 21-state West Region.
News/Updates
New Online Referral/Authorization Form Available to Providers
A new fill and print version of the TRICARE Patient Referral/Authorization Form has been developed to assist providers in completing the form. Providers are now able to complete all fields of the Referral/Authorization Form online, print the form, and submit it to TriWest via fax.
Please visit the Forms page on the Provider Connection at www.triwest.com/provider and click on the printer icon next to the TRICARE Patient Referral/Authorization form to access.
The online referral/authorization form is an optional alternative to handwritten forms.
Submitting Electronic Claims when Other Health Insurance (OHI) is Primary
Secondary and tertiary West Region claims can be submitted electronically through a clearinghouse, direct submission or www.triwest.com. The required information from the other health insurance (OHI) explanation of benefits (EOB) must be included in the claim submission.
Electronic submission of secondary or tertiary claims Web claims requires the primary payer allowed amount, paid amount, and the OHI Payment Reason code.
EDI (837P or 837I) claims transactions
In order to assure proper adjudication of claims containing primary payer involvement, it is strongly recommended that EDI claims include the primary payer amount allowed, paid amount, and reason if no prior payment is made on claims submitted. TRICARE follows the ASC X12 837 implementation guides for the needed elements to process.
The following outline provides the basic elements of the 837 needed for secondary and tertiary claims processing:
- Other Subscriber Information (SBR) – The 2320 loop is required when reporting other insurance, prior or otherwise. The multiple instances of SBRs breakdown multiple payers and the claim adjudication decisions.
- AMT Prior Payer Paid - The 837 implementation guide requires this element if claim adjudicated by prior payer.
- AMT - Allowed Amount – Allowed amounts can be provided at the AMT. However, if the AMT cannot be reported, the Claim Level Adjustments (CAS) segment is necessary to adjudicate.
- OI – Other Insurance Coverage Information – Required if 2320 loop is present.
To submit line level OHI information, refer to the WPS 837 Companion Guide which can be found in the Your EDI Connection area of www.triwest.com/provider.
Note: TriWest pays claims with OHI line-by-line. That means that if the other carrier pays on some lines and not others, TriWest will consider each service on its own merit. The TRICARE EOBs show the beneficiary responsibility. If it is ‘0’, the beneficiary cannot be billed. (See Figure 1 for an example of a two line claim with OHI.) The beneficiary has no out-of-pocket expenses.
Figure 1
|
Billed Amount |
OHI Allowable Amount |
OHI Paid |
OHI Beneficiary Liability |
TRICARE Allowable Amount |
TRICARE Paid |
|
Line 1 - $224 |
$200 |
$176 |
$24 |
$100 |
$24 |
|
Line 2 - $130 |
$97 |
$68 |
$29 |
$130 |
$29 |
|
Total - $354 |
$297 |
$244 |
$53 |
$230 |
$53 |
Posttraumatic Stress Disorder in Primary Care
Military members returning from deployment may experience Posttraumatic Stress Disorder (PTSD). PTSD may develop after exposure to extreme psychological trauma, defined as events that potentially cause a threat to life or physical integrity that produce fear, helplessness or horror (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association).
For reasons that are currently not understood, not everyone exposed to such trauma develops PTSD. Individuals with PTSD have these common traits:
- Frequently re-experience the traumatic event
- Experience persistent symptoms of increased arousal not present before the trauma
- Make efforts to avoid stimuli associated with the trauma
- Exhibit numbing of their general responsiveness
An individual suffering from PTSD will often first seek care from his or her primary care manager (PCM). According to the National Center for Posttraumatic Stress Disorder (NCPTSD), nearly half of all visits caused by a behavioral health issue are to a medical clinic or provider. Of these visits, 90 percent are to PCMs. It is important for PCMs to know the implications of PTSD so that the disorder can be identified and treated. Here are some examples of these implications from NCPTSD.
PTSD affects health – Neurochemical changes in the central nervous system, sleep deprivation, risky behavior (e.g., smoking, poor nutrition, substance abuse, anger and/or violence), and psychosocial problems can result in great biological strain on individuals with PTSD. It is not surprising that these individuals report higher rates of physical problems affecting the cardiovascular, pulmonary, neurological and gastrointestinal systems. The somatic symptoms of PTSD are frequently the presenting problems in primary care consultation.
PTSD affects utilization of services – Studies show that psychiatric problems such as PTSD, anxiety, depression and anger increase medical utilization rates. Some of the identified problems include difficulty in provider-patient communication, increase in somatization, reduction of patient compliance and collaboration in medical regimens.
PTSD is under-recognized by practitioners – Studies show that as with many anxiety disorders, most patients with PTSD are not identified and are therefore not receiving the appropriate education, counseling or referrals for mental-health evaluation.
What can healthcare providers do? – Practitioners often identify time constraints as a barrier to in-depth discussions about behavioral health issues. The NCPTSD states that "it is important to keep in mind that pressing someone into discussion of a traumatic event soon after exposure may have a detrimental effect on some traumatized individuals. Experts on traumatic stress emphasize that people have their own pace for processing trauma, and it is important for helpers to let survivors know that they should listen to and honor their own inner pace."
PTSD is treatable and with early intervention, the severity can be reduced. The good news is that PCMs don’t have to go it alone! There are professionals who specialize in the diagnosis and treatment of PTSD.
Here are some suggestions to help you in your efforts to assist these patients:
Ask about deployment – Routinely inquiring whether active duty service members or members of the National Guard and Reserve have recently returned from deployment to a combat zone can be useful in identifying those with PTSD.
Identify available resources – There are many existing resources including fact sheets, screening questionnaires, and videos on the TriWest Behavioral Health web portal or the NCPTSD Web site, http://www.ncptsd.va.gov/. TriWest also created A Provider’s Guide to TriWest’s Behavioral Health Resources that offers a quick snapshot of the numerous behavioral health resources available to providers.
Identify a PTSD Consultant – If your patient has TRICARE, call 1-888-TRIWEST (1-888-874-9378) and ask for the Behavioral Health Department. Another good place to start is your local Veterans Center, which can be found at www.vetcenter.va.gov .
Establish referral procedures – establishing these procedures ahead of time can save time and ensure quality referrals. The NCPTSD advises, "A few words indicating your awareness of their possible difficulties with stress, and supportively advising them that specialized services can be of great help, is almost always sufficient to motivate patients to accept this referral. You need not, and in most cases probably should not, attempt to take a detailed trauma history or make a diagnostic assessment of PTSD. This can be done by the PTSD clinician specialist."
Maintain ongoing contact with the PTSD Consultant – Once the referral is made, it is important to maintain contact with the PTSD consultant. Coordination of care often results in an improvement in patient compliance.
If you have questions regarding TRICARE beneficiaries’ benefits or resources or need further information, refer to the TriWest Behavioral Health web portal or please contact TriWest Healthcare Alliance at 1-888-TRIWEST (1-888-874-9378).
Upcoming Educational Seminars for TRICARE Providers
TriWest Healthcare Alliance will be hosting educational seminars from April to June of this year. The goal is to help TRICARE providers understand changes in policies and procedures that will greatly enhance TRICARE patient care, answer any questions they may have and help to simplify their administrative process. For a list of seminar dates, locations, and other details, please download the TriCare flyer. This is a semi-annual educational seminar; it is not for commercial purposes.
Sign Up to Receive TRICARE E-News at http://www.triwest.com/provider/frames.aspx?page=http://www.triwest.com/unauth/content/enews/subscribe/subscribe_prov.asp.
Fraud and Abuse
Please visit TriWest website to obtain more information on TRICARE fraud and abuse at http://www.triwest.com/provider/frames.aspx?page=%2Funauth%2Fapps%2Fsearch%2Fdefault.aspx%3F&search=fraud+and+abuse.
