AppB_Definitions-TMMcBH-Oct2014.docx

Appendix B

Definitions

Absent Treatment

Services performed by Christian Science practitioners for a person when the person is not physically present. Technically, “Absent Treatment” is an obsolete term. The current Christian Science terminology is “treatment through prayer and spiritual means,” which is employed by an authorized Christian Science practitioner either with the beneficiary being present or absent. However, to be considered for coverage under TRICARE, the beneficiary must be present physically when a Christian Science service is rendered, regardless of the terminology used.

Abuse

Any practice that is inconsistent with accepted sound fiscal, business, or professional practice which results in a TRICARE claim, unnecessary cost, or TRICARE payment for services or supplies that are:

1. Not within the concepts of medically necessary and appropriate care, as defined in the Regulation (32 CFR 199), or

2. That fail to meet professionally recognized standards for Health Care Providers (HCPs).

The term “abuse” includes deception or misrepresentation by a provider, or any person or entity acting on behalf of a provider in relation to a TRICARE claim.

Note: Unless a specific action is deemed gross and flagrant, a pattern of inappropriate practice will normally be required to find that abuse has occurred. Any practice or action that constitutes fraud, as defined by the Regulation (32 CFR 199), would also be abuse.

Access, Health Care

The ability to receive necessary health care services of high quality within the time frames, at the locations and from the providers that satisfy patient needs and desires. This is frequently associated with the contractor’s provision of network adequacy. Access to care standards are established in 32 CFR 199.17.

Access, Information

1. The availability of or the permission to consult records, archives, or manuscripts.

2. The ability and opportunity to obtain sensitive, classified, or administratively controlled information or records.

TRICARE Operations Manual 6010.56-M, February 1, 2008

Access Standards

TRICARE Operations Manual 6010.56-M, February 1, 2008 Appendix B

C-4, November 7, 2008

Beneficiary access standards broken into three categories, each defined as follows:

1. Urban. A five digit zip code in which the population density is greater than 3,000 persons per square mile.

2. Suburban. A five digit zip code in which the population density is between 1,000 and 3,000 persons per square mile.

3. Rural. A five digit zip code in which the population density is less than 1,000 persons per square mile.

As defined in 32 CFR 199.17:

(i) Under normal circumstances, enrollee travel time may not exceed 30 minutes from home to primary care delivery site unless a longer time is necessary because of the absence of providers (including providers not part of the network) in the area.

(ii) The wait time for an appointment for a well-patient visit or a specialty care referral shall not exceed four weeks; for a routine visit, the wait time for an appointment shall not exceed one week; and for an urgent care visit the wait time for an appointment shall generally not exceed 24 hours.

(iii) Emergency services shall be available and accessible to handle emergencies (and urgent care visits if not available from other primary care providers within the service area 24 hours a day, seven days a week.

(iv) The network shall include a sufficient number and mix of board certified specialists to meet reasonably the anticipated needs of enrollees. Travel time for specialty care shall not exceed one hour under normal circumstances, unless a longer time is necessary because of the absence of providers (including providers not part of the network) in the area. This requirement does not apply under the Specialized Treatment Services Program.

(v) Office waiting times in nonemergency circumstances shall not exceed 30 minutes, except when emergency care is being provided to patients, and the normal schedule is disrupted.

Action Plan

A contractor’s plan for achieving a goal through the use of specific resources based on a time- oriented schedule of activities.

Active Duty

Full-time duty in the Uniformed Services of the United States. It includes duty on the active list, full- time training duty, annual training duty, and attendance while in the active Military Service, at a school designated as a Service school by law or by the Secretary of the Military Department concerned.

Active Duty Member

A person on active duty in a Uniformed Service under a call or order that does not specify a period of 30 days or less.

Activities of Daily Living (ADL) (Respite Care Definition)

Care that consists of providing food (including special diets), clothing and shelter; personal hygiene services; observation and general monitoring; bowel training or management (unless abnormalities in bowel function are of a severity to result in a need for medical or surgical intervention in the absence of skilled services); safety precautions; general preventive procedures (such as turning to prevent bedsores); passive exercise; companionship; recreation; transportation; and other such elements of personal care that can reasonably be performed by an untrained adult with minimal instruction or supervision. ADL may also be referred to as “essentials of daily living”.

Adjunctive Dental Care

Dental care that is medically necessary in the treatment of an otherwise covered medical (not dental) condition, is an integral part of the treatment of such medical condition, and is essential to the control of the primary medical condition; or, is required in preparation for or as the result of dental trauma which may be or is caused by medically necessary treatment of an injury or disease (iatrogenic).

AAdjustmentt

A correction to the information in the TRICARE Encounter Data records (TEDs) and/or Beneficiary History Files (Hard Copy Files and Automated Beneficiary History and Deductible Files) related to a claim previously Processed To Completion (PTC). Adjustments include any recoupments, additional payment(s), all cancellations (total or partial), and corrections to statistical data, whether or not the changes result in changes to the financial data.

Adjustment, Identification Of (Receipt)

An adjustment may be generated by a telephonic, written or personal inquiry, appeal decision, or as the result of a contractor’s internal review. The adjustment is identified when the contractor’s staff determines the issue requires an additional payment, cancellation, or a change to the Beneficiary History and Deductible Files (see definition) or when notice is received from Defense Health AgencyTRICARE Management Activity (DHATMA) that an adjustment is required. In the case of recoupments, the adjustment is “identified” for reporting purposes, with receipt of the payment by the contractor.

Administrative Fee, Pharmacy

The offered price that represents all administrative charges relative to prescription, prior authorization and medical necessity determination transaction processing.

All-Inclusive Per Diem Rate

The TMA-determined rate that encompasses the daily charge for inpatient care and, unless specifically excepted, all other treatment determined necessary and rendered as part of the treatment plan established for a patient.

Allowable Charge

The TRICARE-determined level of payment to institutions, physicians, and other categories of individual professional providers based on one of the approved reimbursement methods set forth in the TRICARE Reimbursement Manual (TRM). As used by TRICARE, the allowable charge shall be the lowest of the billed charge, the prevailing charge, or the maximum allowable prevailing charge. The TRICARE-determined level of payment to hospitals or other institutions, based on one of the approved reimbursement methods described in 32 CFR 199.14. The Allowable charget may also be referred to as the TRICARE-determined reasonable or allowable cost..

Allowable Charge Complaint

A request for review of a contractor determination of allowable charge for covered services and supplies furnished under TRICARE. The allowable charge complaint does not fall within the meaning of an “appeal”, in the technical sense, but does require a careful contractor review or reconsideration of the claim processing to ensure accuracy of the allowance made.

Allowable Charge Reduction

The difference between the reimbursement determination made by a contractor and the amount billed by the provider of care (prior to determination of applicable cost-shares and deductibles).

This is also referred to in the industry as the contractual allowance.

Allowable Cost

The TRICARE-determined level of payment to hospitals or other institutions, based on one of the approved reimbursement methods described in 32 CFR 199.14. Allowable cost may also be referred to as the TRICARE-determined reasonable cost.

Amount In Dispute

The amount of money, determined under 32 CFR 199, that TRICARE would pay for medical services and supplies involved in an adverse determination being appealed if the appeal were resolved in favor of the appealing party. See 32 CFR 199.10 for additional information concerning the determination of “amount in dispute” under the Regulation.

Appeal

A formal written request by a beneficiary, a participating provider, a provider denied authorized provider status under TRICARE, or a representative, to resolve a disputed question of fact. See 32 CFR 199 and the TRICARE Operations Manual (TOM).

Appropriate Medical Care

Services that have been:

1. Performed in connection with the diagnosis or treatment of disease or injury, pregnancy, mental disorder, or well-baby care which are in keeping with the generally accepted norms for medical practice in the United States;

2. Rendered by an authorized individual professional provider who is qualified to perform such medical services by reason of his or her training and education and is licensed or certified either by the state where the service is rendered or appropriate national organization, or who otherwise meets TRICARE standards; and

3. Furnished economically. “Economically” means that the services are furnished in the least expensive level of care or medical environment adequate to provide the required medical care regardless of whether or not that level of care is covered by TRICARE.

Authorization For Care

The determination that requested treatment is medically necessary, delivered in the appropriate setting, a TRICARE benefit, and that the treatment will be cost-shared by DoD through its contract. In managed care environments, this is most often accomplished prior to healthcare delivery, but can be accomplished concurrently in some circumstances and retroactively in rarer circumstances.

Authorized Provider

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 in 32 CFR

199.6. Any physician listed in 32 CFR 199.6 who holds a valid license to practice medicine in the state where he/she practices shall be an authorized provider. Providers not specifically listed in 32 CFR 199.6 are not considered authorized providers unless they are included in a TRICARE demonstration program.

Authorized Supplies, Pharmacy

Non-drug items (usually used in conjunction with the administration of a drug) approved by the DoD P&T Committee for inclusion in the formulary, and appearing on the formulary web site at http://www.pec.ha.osd.mil.

Automated Data Processing (ADP)

A system for recording and processing data on magnetic media, ADP cards, or any other method for mechanical/electronic processing and manipulation or storage of data.

Average Wholesale Price (AWP)

The wholesale list price of a drug, as published by First Data Bank. Most discounting formulas use AWP as a reference point (e.g., AWP - 18%) to determine actual cost. DSCP uses First Data Bank (FDB) to obtain access to this information.

Backup System

A separate, off-site automated data processing system with similar operating capabilities which will be activated/used in case of a major system failure, damage, or destruction. This includes back-up data sets, software and hardware requirements, and trained personnel.

Balance Billing

The practice of a provider billing a beneficiary the difference between the TRICARE allowed amount and the billed charges on a claim. Participating providers and network providers may not collect from all sources an amount which exceeds the TRICARE allowed amount. Non-participating providers may not collect an amount which exceeds the balance billing limit (115% of the allowed charge). If the billed charge is less than the balance billing limit, then the billed charge is the maximum amount that can be collected by the non-participating provider. (See the TRICARE Reimbursement Manual (TRM), Chapter 3, Section 1.)

Basic Program

The primary medical benefits authorized under Chapter 55 of Title 10, United States Code (USC), and set forth in 32 CFR 199.4.

Benchmark, Drug Price

A TRICARE clerical and automated systems test using claims and other documents created or approved by TMA and processed by the contractor. The contractor’s output is compared to predetermined results prepared or approved by TMA to determine the accuracy, completeness and operational characteristics of the contractor’s clerical and automated systems components. The purpose of the benchmark is to identify clerical and automated systems deficiencies which must be corrected before claims can be processed in accordance with TMA requirements. The comprehensiveness of the benchmark will vary depending on the number and type of conditions tested.

The Average Wholesale Price (AWP) has long been the drug price benchmark for establishing reimbursement payment terms between payers, Pharmacy Benefit Managers (PBMs), and pharmacies. AWP as a benchmark has been going away. AWP is by no means the only price type available. Listed here, with brief descriptions, are others that are available and may be used by the industry for reimbursement purposes as AWP is being phased out:

Actual Acquisition Cost (AAC) – Final price paid by the pharmacy after subtraction of all discounts Average Manufacturer Price (AMP) – Manufacturer reported price for Medicaid drug rebate program Average Sales Price (ASP) – CMS calculated price for Medicate Part B drugs Estimated Acquisition Cost (EAC) – Estimated cost of the product or the pharmacies’ usual and customary charge Federal Upper Limit (FUL) – CMS calculation for the upper amount to be paid in aggregate for multi-source products Maximum Allowable Cost (MAC) – Defined by each payer for multi-source drugs Manufacturer List Price (MLP)- Price listed by the drug company Wholesale Acquisition Cost (WAC) – List price for a drug sold by a manufacturer to wholesaler, not including discounts

Benficiary Counseling and Assistance Coordinators (BCACs)

Formally referred to as Health benefit Advisors, BCACs are individuals located at Uniformed Services medical facilities (on occasion at other locations) and assigned the responsibility for providing TRICARE information, information concerning availability of care from the Uniformed Services direct medical care or purchased care systems, and generally assisting beneficiaries (or sponsors). The term also includes “Health Benefits Counselor.”

Beneficiary History File

A system of records consisting of any record or subsystem of records, whether hard copy, microform or automated, which reflects diagnosis, treatment, medical condition, or any other personal information with respect to any individual, including all such records acquired or utilized by the contractor in delivery of health care services, in the development and processing of claims, or in performing any other functions under a TRICARE contract.

1. Hard Copy Claim and Microform Files. These files may include:

• Claim forms (TRICARE or other claim form approved by DHA TMA)

• DoD Document (DD) Form 1251, Non-Availability Statement (NAS)

• Reports and related documentation pertaining to professional review of treatment

• Powers of Attorney

• Other Statements of Legal Guardianship

• Receipts (Itemized Bills)

• Other Insurance Payment Information (or EOB)

• Medical Reports (Mental illness case files, Durable Medical Equipment (DME), Medical Necessity Statement, Emergency Admission Statement, progress reports, nursing notes, operative reports, test results, etc.).

• Timely Filing Waiver

• Claim-Related Correspondence

• Appeals Case File

• Any other contractor developed documentation which is used for recording and documenting care and payment for care by network providers of care.

2. Automated History Files. The electronically maintained record of a beneficiary’s medical care and related administrative data, including such data on charges, payments, deductible status, services received, diagnoses, adjustments, etc.

Beneficiary Liability

The legal obligation of a beneficiary, his or her estate, or responsible family member to pay for the costs of medical care or treatment received. Specifically, for the purposes of services and supplies covered by TRICARE, beneficiary liability includes any annual deductible amount, cost-sharing amounts, or, when a provider does not submit a claim on a participating basis on behalf of the beneficiary, amounts above the TRICARE-determined allowable cost or charge. Beneficiary liability also includes any expenses for medical or related services and supplies not covered by TRICARE.

Benefit

C-1, March 13, 2008

The TRICARE benefit consists of those services, payment amounts, cost-shares and copayments authorized by Public Law (PL) 89-614, 32 CFR 199 and the TRICARE Policy Manual (TPM).

Best Value Health Care

The delivery of high quality clinical and other related services in the most economical manner for the MHS that optimizes the Direct Care (DC) system while delivering the highest level of customer service.

Business Associate (HIPAA/Privacy Definition)

1. A person who on behalf of a covered entity or of an organized health care arrangement in which the covered entity participates, but other than in the capacity of a member of the workforce of such covered entity or arrangement, performs, or assists in the performance of a function or activity involving the use or disclosure of Individually Identifiable Health Information (IIHI) or provides services to or for such covered entity, or to or for an organized health care arrangement in which the covered entity participates, where the provision of the service involves the disclosure of IIHI from such covered entity or arrangement, or from another business associate of such covered entity or arrangement to the person.

2. A covered entity participating in an organized health care arrangement that performs a function or activity for or on behalf of such organized health care arrangement, or that provides a service to or for such organized health care arrangement, does not, simply through the performance of such function or activity or the provision of such service, become a business associate of other covered entities participating in such organized health care arrangement.

3. A covered entity may be a business associate of another covered entity. For a full definition, refer to the Final Rule on Standards for Privacy of IIHI. Capability Of A Provider The scope of services the provider is both capable of performing and willing to perform under a TRICARE contract. For example, a neurologist who only performs sleep studies may not be considered to have capability to perform as a general neurology specialist.

Capacity Of A Provider

The amount of time or number of services a provider is able to perform in conjunction with a TRICARE contract. For example, a primary care physician whose practice is full has no available capacity for services.

Capped Rate

The maximum per diem or all-inclusive rate that TRICARE will allow for care.

Care Coordination

A comprehensive method of client assessment designed to identify client vulnerability, needs identification, and client goals which results in the development plan of action to produce an outcome that is desirable for the client. The goal is to provide client advocacy, a system for coordinating client services, and providing a systematic approach for evaluation of the effectiveness of the client’s Life Plan.

Case Management

A collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services to meet an individual’s health care needs using resources available to provide quality and cost-effective outcomes, which includes assisting in coordinating case management patients from on location to another. Case management is not restricted to catastrophic illnesses and injuries.

Catastrophic Cap

The National Defense Authorization Act for Fiscal Years 1988 and 1989 (PL 100-180) amended Title 10, USC, and established catastrophic loss protection for TRICARE beneficiary families on a government fiscal year basis. The law placed fiscal year limits or catastrophic caps on beneficiary liabilities for deductibles and cost-shares under the TRICARE Basic Program. Specific guidance may be found in the TRM, Chapter 2, Section 2.

Catchment Areas

Geographic areas determined by the Assistant Secretary of Defense (Health Affairs) (ASD(HA)) that are defined by a set of five digit zip codes, usually within an approximate 40 mile radius of military inpatient treatment facility.

Certification and Accreditation (C&A) Process

The C&A process ensures that the trust requirement is met for information systems and networks. Certification is the determination of the appropriate level of protection required for information systems/networks. Certification also includes a comprehensive evaluation of the technical and non- technical security features and countermeasures required for each system/network. Accreditation is the formal approval by the Government to operate the contractor’s IS/networks in a particular security mode using a prescribed set of safeguards at an acceptable level of risk. In addition, accreditation allows IS/networks to operate within the given operational environment with stated interconnections; and with appropriate level-of-protection for the specified period. The C&A requirements apply to all DoD ISs/networks and Contractor ISs/networks that access, manage, store, or manipulate electronic IS data. Specific guidance may be found in the TRICARE Systems Manual (TSM), Chapter 1.

Certification For Care

The determination that the provider’s request for care (level of care, procedure, etc.) is consistent with preestablished criteria. Pre-certification is the process performing a certification for care prior to rendering the care. (Note: This is NOT synonymous with authorization for care).

Certified Provider

C-108, September 19, 2013

A hospital or institutional provider, physician, or other individual professional provider of services or supplies specifically authorized by 32 CFR 199.6. Certified providers have been verified by DHATMA or a designated contractor to meet the standards of 32 CFR 199.6, and have been approved to provide services to TRICARE beneficiaries and receive Government payment for services rendered to TRICARE beneficiaries.

CHAMPUS Maximum Allowable Charge (CMAC)

CMAC is a nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Scheduled amount. Synonomous with TRICARE Maximum Allowable Charge (TMAC)

CHAMPVA

The Civilian Health and Medical Program of the Veterans Administration. This is a program of medical care for spouses and dependent children of disabled or deceased disabled veterans who meet the eligibility requirements of the DVA.

CHAMPVA Center (CVAC)

The component within the Department of Veterans Affairs (DVA), Health Administration Center (HAC) which processes all CHAMPVA claims.

Change Order

A written directive from the TMA DHA Procuring Contracting Officer (PCO) to the contractor directing changes within the general scope of the contract, as authorized by the “changes clause” at FAR 52.243-1, Changes--Fixed Price.

Christian Science Nurse

An individual who has been accredited as a Christian Science Nurse by the Department of Care of the First Church of Christ, Scientist, Boston, Massachusetts, and listed (or eligible to be listed) in the Christian Science Journal at the time the service is provided. The duties of Christian Science nurses are spiritual and are nonmedical and nontechnical nursing care performed under the direction of an accredited Christian Science practitioner. There are two levels of Christian Science nurse accreditation:

1. Graduate Christian Science Nurse. This accreditation is granted by the Department of Care of the First Church of Christ, Scientist, Boston, Massachusetts, after completion of a three year course of instruction and study.

2. Practical Christian Science Nurse. This accreditation is granted by the Department of Care of the First Church of Christ, Scientist, Boston, Massachusetts, after completion of a one year course of instruction and study.

Christian Science Practitioner

An individual who has been accredited as a Christian Science Practitioner for the First Church of Christ, Scientist, Boston, Massachusetts, and listed (or eligible to be listed) in the Christian Science Journal at the time the service is provided. An individual who attains this accreditation has demonstrated results of his or her healing through faith and prayer rather than by medical treatment. Instruction is executed by an accredited Christian Science teacher and is continuous.

Christian Science Sanatorium

A sanatorium either operated by the First Church of Christ, Scientist, or listed and certified by the First Church of Christ, Scientist, Boston, Massachusetts.

Claim

1. Any request for payment for health care services rendered which is received from a beneficiary, a beneficiary’s representative, or a network or non-network provider by a contractor on any TRICARE-approved claim form or approved electronic medium. If two or more forms for the same beneficiary are submitted together, they shall constitute one claim unless they qualify for separate processing under the claims splitting rules. (It is recognized that services may be provided in situations in which no claims, as defined here, are generated. This does not relieve the contractor from collecting the data necessary to fulfill the requirements of the TRICARE Encounter Data (TED) for all care provided under the contract.)

2. Any request for reimbursement of a dispensed pharmaceutical agent or diabetic supply item. For electronic media claims, one prescription equals one claim. For paper claims, reimbursement for multiple prescriptions may be requested on a single paper claim.

Claim File

The collected records submitted with or developed in the course of processing a single claim. It includes the approved TRICARE claim form and may include attached bills, medical records, record of telephone development, copies of correspondence sent and received in connection with the claim, the EOB, and record of adjustments to the claim. It may also include the record of appeals and appeal actions. The claim file may be in microcopy, hard copy, or in a combination of media.

Claim Form

A fixed arrangement of captioned spaces designed for entering and extracting prescribed information, including ADP system forms.

Claims Cycle Time

That period of time, recorded in calendar days, from the receipt of a claim into the possession/ custody of the contractor to the completion of all processing steps (See “Processed to Completion (or Final Disposition)” in this Appendix, and TSM, Chapter 2, Section 2.4, “Date TED Record Processed to Completion”).

Claims Payment Data

The record of information contained on or derived from the processing of a claim or encounter.

Clinical Support Agreement (CSA)

An agreement, executed by a contract action under a Managed Care Support (MCS) contract, that is/was undertaken at the behest of an MTF Commander and which requires a contractor to provide needed clinical personnel at an MTF.

Code Set (HIPAA/Privacy Definition)

Any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. A code set includes the codes and descriptors of the codes.

Code Set Maintaining Organization (HIPAA/Privacy Definition)

An organization that creates and maintains the code sets adopted by the Secretary (HHS) for use in the transactions for which standards are adopted.

Combined Daily Charge (HIPAA/Privacy Definition)

A billing procedure by an inpatient facility that uses an inclusive flat rate covering all professional and ancillary charges without any itemization.

Concurrent Review/Continued Stay Review

Evaluation of a patient’s continued need for treatment and the appropriateness of current and proposed treatment, as well as the setting in which the treatment is being rendered or proposed. Concurrent review applies to all levels of care (including outpatient care).

Confidentiality Requirements

The procedures and controls that assure the confidentiality of medical information in compliance with the Freedom of Information Act, the Comprehensive Alcohol Abuse and Alcoholism Prevention and Rehabilitation Act, and the Privacy Act.

Conflict Of Interest

Includes any situation where an active duty member (including a reserve member while on active duty) or civilian employee of the United States Government, through an official federal position, has the apparent or actual opportunity to exert, directly or indirectly, any influence on the referral of MHS beneficiaries to himself or herself or others with some potential for personal gain or appearance of impropriety. Individuals under contract to a Uniformed Service may be involved in a conflict of interest situation through the contract position.

Consulting Physician Or Dentist

A physician or dentist, other than the attending physician, who performs a consultation.

Continued Health Care Benefit Program (CHCBP)

The CHCBP provides temporary continued health care benefits for certain former beneficiaries of the Military Health System (MHS). Coverage under the CHCBP is purchased on a premium basis.

Continuity of Care

Follow on of health care services from a specific specialist as part of a specific procedure or service that was performed within the previous six months in order to not disrupt therapy or repeat services.

Continuum of Care

All patient care services provided from “pre-conception to grave” across all types of settings. Requires integrating processes to maintain ongoing communication and documentation flow between the DC system and network.

Contract Data Requirements List (CDRL)

List of management reports and deliverables required by the contract. The contractor uses the CDRL for direction, schedule, and format guidance.

Contract Performance Evaluation (CPE)

The review by TMA, of a contractor’s level of compliance with the terms and conditions of the contract. Usually, an operational audit performed by TMA staff focuses on timeliness, accuracy, and responsiveness of the contractor in performing all aspects of the work required by the contract.

Contract Physician

A physician who has made contractual arrangements with a contractor to provide care or services to TRICARE beneficiaries. A contract physician is a network provider who participates on all TRICARE claims.

Contracting Officer's Representative (COR)

A government representative, appointed in writing by the contracting officer, who represents the contracting officer in technical matters.

Contractor

An organization with which DHATMA has entered into a contract for delivery of and/or processing of payment for health care services, performance of related support activities such as pharmacy services, quality monitoring or customer service.

Control Of Claims

The ability to identify individually, locate, and count all claims in the custody of the contractor by location, including those that may be being developed by physical return of a copy of the claim, and age including total age in-house and age in a specific location.

Controlled Substances

Those medications which are included in one of the schedules of the Controlled Substances Act of 1970 and as amended.

Coordination Of Benefits (COB)

A system to require collection of other health insurance benefits before making any TRICARE benefit payment, except for Medicaid, in compliance with requirements specified in 32 CFR 199 and the TRM.

Copayment

See the definition for “cost-share.”

Cost Effective Provider Network Areas

Areas in which provider networks can be developed where the discounts received from providers and the effects of Utilization Management activities are greater than or equal to the administrative costs associated with maintaining the Provider Network and accomplishing all additional marketing, education, enrollment, and related administrative activities.

Cost-Share

The amount a beneficiary must pay for covered inpatient and outpatient services (other than the deductible. It includes copayments, , the annual TRICARE Prime enrollment fee, the balance billing amount, or disallowed amounts) as set forth in 32 CFR 199.4, 199.5, and 199.17. Active Duty Service Members (ADSMs) have no financial liability for the authorized health care services they receive. They do not pay cost- shares, deductibles, enrollment fees, or balance billed amounts. Active Duty Family Members are also not required to make copayments. The contractor shall reimburse the full amount that a provider can collect, including any amount over CMAC up to the balance billing limit. Under TRICARE, cost-shares are expressed as either coinsurance or copayment. See the TRM, Chapter 2, for additional information.

Correctional Institution (HIPAA/Privacy Definition)

Any penal or correctional facility, jail, reformatory, detention center, work farm, halfway house, or residential community program center operated by, or under contract to, the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, for the confinement or rehabilitation of persons charged with or convicted of a criminal offense or other persons held in lawful custody. Other persons held in lawful custody includes juvenile offenders adjudicated delinquent, aliens detained awaiting deportation, persons committed to mental institutions through the criminal justice system, witnesses, or others awaiting charges or trial. The term “correctional institution” includes military confinement facilities, but does not include internment facilities for enemy prisoners of war, retained personnel, civilian detainees and other detainees provided under the provisions of DoDD 2310.1 (reference (b)).

Covered Entity (HIPAA/Privacy Definition)

A health plan, health care clearinghouse or health care provider who transmits any health information in electronic form in connection with a transaction. In the case of a health plan administered by the Department of Defense, the covered entity is the DoD Component (or subcomponent) that functions as the administrator of the health plan.

Definitions

For details refer to the Transaction and Code Sets Regulation and the Standards for Privacy of IIHI Regulation.

Covered Functions (HIPAA/Privacy Definition)

Those functions of a covered entity the performance of which makes the entity a health plan or health care provider.

Credentialing

The process by which providers are allowed to participate in the network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.

Credentials Package

Credentials packages are required for all clinical personnel supplied by the contractor who will be working in an MTF. Similar packages may be required for non-clinical personnel. The credentials package shall contain the following information.

1. All documents, verified per regulation/directive/instruction/policy, which are needed in order for the individual to provide the proposed services at the involved facility. This will include licensure from the jurisdiction in which the individual will be practicing and a National Practitioner Data Bank (NPDB) query as specified by the facility.

2. Credentials files for all personnel required by law to have a Criminal History Background Check (CHBC) will contain documentation showing that the required CHBC has been completed prior to awarding of privileges or the delivery of services.

• If a CHBC has been initiated, but not completed, the MTF commander has the authority to allow awarding of privileges and initiation of services if delivered under clinical supervision.

• The mechanism for accomplishing the CHBC may vary between MTFs and should be determined during phase-in/transition and be agreed to by the MTF Commander.

• Regardless of the mechanism for initiating and completing a CHBC, the cost shall be borne by the contractor.

3. TRICARE Provider ID number when provider is of a type which is recognized by TRICARE. Medicare Provider ID number when provider is of a type recognized by Medicare.

4. Evidence of compliance (or scheduled compliance) with the MTF specific requirements including all local Employee Health Program (EHP), Federal Occupational Safety Act and Health Act (OSHA), and Bloodborne Pathogens Program (BBP) requirements.

Definitions

Custodial Care Prior To December 28, 2001

Care rendered to a patient:

1. Who is disabled mentally or physically and such disability is expected to continue and be prolonged, and

2. Who requires a protected, monitored, or controlled environment whether in an institution of in the home, and

3. Who requires assistance to support the essentials of daily living, and

4. Who is not under active and specific medical, surgical, or psychiatric treatment that will reduce the disability to the extent necessary to enable the patient to function outside the protected, monitored, or controlled environment.

A custodial care determination is not precluded by the fact that a patient is under the care of a supervising or attending physician and that services are being ordered and prescribed to support and generally maintain the patient’s condition, or provide for the patient’s comfort, or ensure the manageability of the patient. Further, a custodial care determination is not precluded because the ordered and prescribed services and supplies are being provided by an RN, LPN, or LVN.

Note: The determination of custodial care in no way implies that the care being rendered is not required by the patient; it only means that it is the kind of care that is not covered under TRICARE. A program of physical and mental rehabilitation which is designed to reduce a disability is not custodial care as long as the objective of the program is a reduced level of care.

Custodial Care After December 28, 2001

The treatment or services, regardless of who recommends such treatment or services or where such treatment or services are provided, that can be rendered safely and reasonably by a person who is not medically skilled or is or are designed mainly to help the patient with the activities of daily living.

Cycle Time

The elapsed time, as expressed in calendar days (including any part of the first and last days counted as two days), from the date a claim, piece of correspondence, grievance, or appeal case was received by a contractor through the date PTC. (See claims cycle time for added detail.)

Data

Any information collected, derived, or created as a result of operations as a TRICARE contractor. All data is the property of the Government regardless of where it is maintained/stored.

Definitions

Data Aggregation (HIPAA/Privacy Definition)

The combining of Protected Health Information (PHI) by a business associate with the PHI received by the business associate in its capacity as a business associate of another covered entity, to permit data analyses that relate to the health care operations of the respective covered entities.

Data Condition (HIPAA/Privacy Definition)

The circumstances under which a covered entity must use a particular data element or segment.

Data Content (HIPAA/Privacy Definition)

The data elements and code sets inherent to a transaction, and not related to the format of the transaction. Data elements that are related to the format are not data content.

Data Element (HIPAA/Privacy Definition)

The smallest named unit of information in a transaction.

Data Repository

A single point of electronic storage, established and maintained by the contractor, that enables the Government to electronically access all data maintained by the contractor relative to a TRICARE contract. This includes all claims/encounter data, provider data, authorization, enrollment, and derived data collected in relation to a TRICARE contract.

Data Set (HIPAA/Privacy Definition)

A semantically meaningful unit of information exchanged between two parties to a transaction.

Date Of Determination (Appeals)

The date of completion appearing on the reconsideration determination, formal review determination, or hearing final decision.

Days

CCalendar days unless otherwise indicated as business days.

Days Supply

The number of days that the dispensed quantity of drug should last, based on directions for use with a limit as the First Data Bank recommended maximum daily dose (unless specifically altered by DoD).

Deductible

C-1, March 13, 2008

The statutory requirement for payment by the beneficiary of an initial specified dollar amount of the TRICARE-determined allowable costs or charges for covered outpatient services or supplies provided in any one fiscal year.

Example 1: Under TRICARE Standard and TRICARE Extra, the deductible is $50 (for family members of sponsors in pay grade E-4 and below) or $150.00 (for family members of sponsors in pay grades above E-4, and retirees and their family members) For a family, the aggregate payment of $100 (for family members of sponsors in pay grade E-4 and below) or $300.00 (for family members of sponsors in pay grades above E-4, and retirees and their family members) by two or more beneficiaries will satisfy the deductible requirement.

Example 2: For TRICARE Prime enrollees, under the Point-of-Service option, the deductible is $300 for individuals, $600 for a family.

Defense Enrollment Eligibility Reporting System (DEERS)

The computer-based enrollment/eligibility system for verifying entitlement to health care services. See the 32 CFR 199 definition and the TSM, for specific information concerning DEERS.

Defense Health Agency (DHA)

The DoD organization responsible for managing the TRICARE contracts and day-to-day operations of the TRICARE program.

Defense Health Agency, Great Lakes, IL (DHA-GL); formerly the Military Medical Support Office (MMSO))

A shared service that provides health care authorization support for service members in areas remote from MTFs in the United States including TRICARE Prime Remote and Reserve Component service members with a Line of Duty condition. Provides health care authorization support for service members across all areas of the United States for non-enrolled service members and service members with Traumatic Brain Injury (TBI), Spinal Cord Injury (SCI), and Blindness being treated at a Veterans Administration Medical Center under the DoD/VA Memorandum of Agreement (MOA).

De-Identified Data (HIPAA/Privacy Definition)

Health information that has been rendered not IIHI by removal of identifiers of the individual or of relatives, employers, or household members of the individual, such as names, geographic subdivisions smaller than a State, all elements of dates (except year) for dates directly related to an individual, telephone numbers, Social Security Numbers, etc. For full details refer to the DoD Health Information Privacy Regulation.

Demonstration

A study or test project with respect to alternative methods of payment for health and medical services, cost-sharing by eligible beneficiaries, methods of encouraging efficient and economical delivery of care, innovative approaches to delivery and financing services and prepayment for services provided to a defined population. Following completion and evaluation of the test project, it may or may not become part of the program.

Descriptor (HIPAA/Privacy Definition)

The text defining a code.

Designated Record Set (HIPAA/Privacy Definition)

A group of records maintained by or for a covered entity that is:

1. The medical records and billing records about individuals maintained by or for a covered health care provider;

Definitions

information that includes PHI and is maintained, collected, used, or disseminated by or for a covered entity.

Designated Standard Maintenance Organization (DSMO) (HIPAA/Privacy Definition)

An organization designated by the Secretary (HHS) under §162.910(a) of the Transaction and Code Sets Regulation.

Diagnosis Related Groups (DRGs)

A categorization of hospital patients into clinically coherent groups based on their consumption of resources. Patients are assigned to the groups based on their principal diagnosis (the reason for admission, determined after study), secondary diagnoses, procedures performed, and the patient’s age, sex, and discharge status. A reimbursement system using DRGs assigns payment levels to each DRG based on the average cost of treating all patients in a given DRG.

Direct Data Entry (HIPAA/Privacy Definition)

The direct entry of data (for example, using dumb terminals or web browsers) that is immediately transmitted into a health plan’s computer.

Direct Treatment Relationship (HIPAA/Privacy Definition)

A treatment relationship between an individual and a health care provider that is not an indirect treatment relationship as defined under the DoD Health Information Privacy Regulation.

Discharge Planning

The development of an individualized discharge plan for the patient prior to leaving an institution for home, with the aim of improving patient outcomes, reducing the chance of unplanned readmission to an institution, and containing costs.

Disclosure (HIPAA/Privacy Definition)

The release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.

Domiciliary Care

Care provided to a patient in an institution or home-like environment because (1) providing support for the activities for daily living in the home is not available or is unsuitable; or (2) members of the patient’s family are unwilling to provide the care.

Definitions

Note: The terms “domiciliary” and “custodial care” represent separate concepts and are not interchangeable. Custodial care and domiciliary care are not covered under the TRICARE Prime, Extra, or Standard programs or the Extended Care Health Option (ECHO).

Donor

An individual who supplies living tissue or material to be used in another body, such as a person who furnishes a kidney for renal transplant.

Double Coverage

Enrollment by a TRICARE beneficiary in another insurance, medical service, or health plan that duplicates all or part of a beneficiary’s TRICARE benefits.

Double Coverage Plan

The specific insurance, medical service, or health plan under which a TRICARE beneficiary has entitlement to medical benefits that duplicate TRICARE benefits in whole or in part. Double coverage plans do not include:

1. Medicaid.

2. Coverage specifically designed to supplement TRICARE benefits.

3. Entitlement to receive care from the Uniformed Services medical care facilities; or

4. Entitlement to receive care from Department of Veterans Affairs (DVA) medical care facilities;

or

5. Entitlement to receive care from Indian Health Services medical care facilities; or

6. Services and items provided under Part C (Infants and Toddlers with Disabilities) of the Individuals With Disabilities Education Act (IDEA).

DSM III

A technical reference, Diagnostic and Statistical Manual of Mental Disorders, Third Edition.

DSM IV

A technical reference, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Dual Compensation

Federal law (5 USC 5536) prohibits active duty members or civilian employees of the United States Government from receiving additional compensation from the Government above their normal pay and allowances. This prohibition applies to TRICARE cost-sharing of medical care provided by active duty members or civilian Government employees to TRICARE beneficiaries.

Edit Error (TEDs Only)

C-60, November 15, 2011

Errors found on TEDs (initial submissions, resubmissions, and adjustments/cancellation submissions) which result in nonacceptance of the records by TMADHA. These require correction of the error by the contractor and resubmission of the corrected TED to TMA DHA for acceptance.

Electronic Media (HIPAA/Privacy Definition)

The mode of electronic transmission. It includes the Internet (wide-open), Extranet (using Internet technology to link a business with information only accessible to collaborating parties), leased lines, dial-up lines, private networks, and those transmissions that are physically moved from one location to another using magnetic tape, disk, or compact disk media.

Employment Records (HIPAA/Privacy Definition)

Records that include health information and that:

1. Are maintained by a component of the Department of Defense or other entity subject to the DoD Health Information Privacy Regulation;

2. Are about an individual who is (or seeks or sought to become) a member of the uniformed services, employee of the United States Government, employee of a Department of Defense contractor, or person with a comparable relationship to the Department of Defense; and

3. Are not maintained in connection with carrying out any covered function under the DoD Health Information Privacy…