J-1 Definitions v1.docx

Attachment J-1 Definitions

Additional definitions are located in the TRICARE Operations Manual (TOM), Appendix A.

Active Duty Service Member (ADSM) – A person on active duty in a Uniformed Service who is under a call or order that does not specify a period of 30 days or less. This contract only applies to the following Uniformed Services: The Army, Navy, Air Force, Marine Corps, Coast Guard, and uniformed members of the Commissioned Corps of the National Oceanographic and Atmospheric Administration (NOAA), and the Commissioned Corps of the Public Health Service (PHS).

Allowed Charge – Relative to network providers, the allowed charge for any procedure is the lower of: (1) the amount billed or (2) the amount under the network agreement that the network provider has agreed to accept as payment in full.

Anesthesia Services – The administration of an anesthetic agent by injection or inhalation. The purpose and effect of which is to produce surgical anesthesia characterized by muscular relaxation, loss of sensation, or loss of consciousness when administered by or under the direction of a physician or dentist in connection with otherwise covered surgery. Anesthesia services do not include hypnosis or acupuncture.

Assignment of Benefits - Acceptance by a non-network provider of payment directly from the insurer while reserving the right to charge the ADSM for any remaining amount of the fees for services which exceeds the prevailing fee allowance of the insurer.

Authorization - An authorization is required for all DTF referred care and care for which the remote ADSM cannot self-refer. ADDP authorizations are only approved by a Dental Treatment Facility, the DHA Dental Service Point of Contact, or the ADDP contractor.

Authorized Provider – A dentist, dental hygienist, or certified and licensed anesthetist specifically authorized to provide benefits under the Active Duty Dental Program (ADDP).

Average Allowed Charge – The average allowed charge is the mean across all procedures for a given code performed in a given three-digit zip code.

Balance Billing – When a provider seeks any payment, other than any payment relating to applicable allowable charge or for services outside of the authorization unless the ADSM agrees to pay prior to services being rendered.

Beneficiary Counseling and Assistance Coordinators (BCAC) – Individuals in the customer service community who address TRICARE and Military Health System issues and concerns. A directory of BCAC locations may be found on the TRICARE website at: http://www.tricare.mil/bcacdcao.

Billed Charge – The billed charge is equal to the undiscounted amount charged by a provider.

By Report – "By report" or "Report required" means dental procedures, which are authorized as benefits only in unusual circumstances requiring justification of exceptional conditions related to otherwise authorized procedures.

Continental United States (CONUS) – Includes the 50 United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands.

Contracting Officer – A Government employee having authority vested by a Contracting Officer’s Warrant to execute, administer, and terminate contracts and orders, and modifications thereto, which obligate Government funds and commit the Government to contractual terms and conditions.

Coordination of Benefits – A system to determine who the primary payer is and who the secondary payer is when more than one health and/or dental insurance coverage applies to a dental procedure. (TRICARE is always the primary payer for the ADDP.)

Covered Benefit – Dental procedure included in a dental benefit plan subject to plan limitations.

Covered Services – Dental procedure codes specified as a benefit in a dental benefits plan.

Denied Benefit – Dental procedure denied based on an enrollee’s dental plan limitations (e.g., a procedure that is allowed twice within a 12-month period would be denied if a claim was filed for a third time because of the dental plan limitations).

Denied Service – A dental procedure that is not a covered benefit under the dental benefit plan (e.g., teeth whitening is a service, but it is not a benefit covered by the ADDP dental benefits plan).

Dental Care – Services relating to the teeth and their supporting structures.

Dental Explanation of Benefits (DEOB) – The document prepared by insurance carriers, health care organizations, and TRICARE provided to enrollees and dentists explaining benefits determinations to include such information as: type of service received, the amount billed, the allowable charge, the cost share amount, services denied (with denial reasons), and application of annual and lifetime maximums.

Dental Hygienist – Practitioner in rendering complete oral prophylaxis services, applying medication, performing dental radiography, and providing dental education services with a certificate, associate degree, or bachelor’s degree in the field, and licensed by an appropriate authority.

Dental Readiness Classifications – The oral health status of uniformed personnel is classified into four categories.

· Class 1: Patients with current dental examination who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

· Class 2: Patients with current dental examination whose oral conditions are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable.

· Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

· Class 4: Patients who require periodic dental examinations or patients with unknown dental classification. Class 4 patients normally are not considered to be worldwide deployable.

Dental Service Point of Contact – A dentist assigned as the point of contact for all dental issues arising from care rendered to ADSMs in the civilian community and who review dental care for appropriateness. The Dental Service Point of Contact (DSPOC) positions are established within the DHA Dental Program Section to provide a means to identify, manage, and provide dental oversight of civilian dental care provided to ADSMs.

Dental Treatment Facility (DTF) – A facility operated by the military that provides dental care to ADSMs. DTFs have responsibility for management of all service members within their service areas even if that service member is not in the same branch of service as the base or post were assigned. DTFs also manage the care of non-active duty service members (e.g., Reservists) who have a dental Line of Duty (LOD) determination while in a drill or on active duty for less than 30 days.

Dentist – Doctor of Dental Medicine (D.M.D.) or Doctor of Dental Surgery (D.D.S.) or doctor with an equivalent dental degree, who is licensed to practice dentistry by an appropriate authority.

Diagnostic Services – Category of dental services including clinical oral examinations, radiographic examinations, and diagnostic laboratory tests and examinations provided in connection with other dental procedures authorized as ADDP benefits.

Emergency Care – Care which includes any treatment necessary to relieve pain, treat infection, control hemorrhaging, or repair broken fillings by placement of temporary or permanent fillings (not crowns). Root canal treatment and extractions may be needed to relieve the pain and infection. Crowns, implants, bridges and dentures work are not considered emergency care.

Endodontics – The etiology, prevention, diagnosis, and treatment of diseases and injuries affecting the dental pulp, tooth root, and periapical tissue.

Excludable Services – Excludable services are services that are not specifically excluded but are not covered because they are not medically necessary based on the circumstance.

Fraud – For purposes of the ADDP, fraud is defined as (1) a deception or misrepresentation by a provider, beneficiary, sponsor, or any person acting on behalf of a provider, sponsor, or beneficiary with the knowledge (or who had reason to know or should have known) that the deception or misrepresentation could result in some unauthorized ADDP benefit to self or some other person, or some unauthorized ADDP payment, or (2) a claim that is false or fictitious, or includes or is supported by any written statement which asserts a material fact which is false or fictitious, or includes or is supported by any written statement that (a) omits a material fact and (b) is false or fictitious as a result of such omission and (c) is a statement in which the person making, presenting, or submitting such statement has a duty to include such material fact. It is presumed that, if a deception or misrepresentation is established and an ADDP claim is filed, the person responsible for the claim had the requisite knowledge. This presumption is refutable only by substantial evidence. It is further presumed that the provider of the services is responsible for the actions of all individuals who file a claim on behalf of the provider (for example, billing clerks); this presumption may only be rebutted by clear and convincing evidence.

Geographical Area of Coverage:

· CONUS Service Area - The "CONUS" or "Continental United States" service area includes the fifty (50) United States, District of Columbia, U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and the Northern Mariana Islands..

· OCONUS Service Area - The "OCONUS" or "Outside the Continental United States" service area includes all other countries, island masses and territorial waters. Covered services provided on a civilian ship or vessel that is outside the territorial waters of the CONUS service area are considered covered under the OCONUS service area, regardless of the provider’s home address.

Inactive National Guard (ING) – The ING are personnel in an inactive status in the Ready Reserve, but not in the Selected Reserve. They are attached to a specific National Guard unit, who are required to muster once a year with their assigned unit, but do not participate in training activities.

Individual Ready Reserve (IRR) – The IRR consists of those members of the Ready Reserve who are not in the Selected Reserve or the Inactive National Guard. Within the IRR of each reserve component there two types of mobilization categories:

· Mobilization Only Personnel – The IRR member volunteers for a specific service category or the member is selected for a specific category by the Secretary concerned, based upon the needs of the service and the grade and military skills of that member. An IRR mobilization member is eligible for benefits (other than pay and training) as are normally available to members of the Selected Reserve.

· Non-Mobilization Only Personnel - The IRR member is subject to being ordered to active duty involuntarily. An IRR non-mobilization member has limited benefits and is not entitled to the same benefits as a Selected Reserve member.

Initial Determination – A formal written decision on dental reimbursement or a request for a benefit pre-determination. Rejection of dental reimbursement or pre-determination, or of a request for benefit or provider authorization for failure to comply with administrative requirements, including failure to submit reasonably requested information, is not an initial determination. Responses to general or specific inquiries regarding dental benefits are not initial determinations.

Line of Duty (LOD) – Reserve Component members, to include the National Guard members, serving on duty 30 days or less are not eligible for DTF dental care except for emergencies. If a Reserve Component Member in an active duty status becomes injured or ill during training or duty related incident and requires dental treatment, they are only entitled to treatment for that injury or illness. The responsibility for determining eligibility for treatment rests with military medical authorities in accordance with published service regulations and Defense Health Agency guidance. The care may be received after a member is inactivated provided that the appropriate LOD documentation is on file; Defense Enrollment Eligibility Reporting System (DEERS) will not indicate eligibility.

Member Liability – The ADSM is liable for any expenses for services and supplies not covered, but for which the member has agreed in writing to pay. The ADSM, his/her estate, or responsible family member, has no legal obligation to pay for the costs of dental care or treatment received for covered services, and where required, services that were authorized.

Military Fixed Overseas Dental Treatment Facility (ODTF) - For the purposes of this contract, fixed ODTFs are Outside Continental United States (OCONUS) facilities that are staffed on a year-round basis and provide dental care to active duty members and their family members. Family members are seen on a space-available basis. Fixed ODTFs are sometimes referred to as “full-time.”

Network Provider – A dentist or dental hygienist who has agreed to accept the contractor's reasonable fee allowances or other fee arrangements as the total charge (even though less than the actual billed amount).

Non-Network Provider – A dentist or dental hygienist that furnished dental services to an ADSM, but who has not agreed to accept the insurer's fee allowances and applicable cost-share as the total charge for the services. A non-network provider relies on the ADSM for final responsibility for payment of his or her charge, but may accept payment (assignment of benefits) directly from the insurer or assist the ADSM in filing the claim for reimbursement by the dental plan contractor. Where the non-network provider does not accept payment directly from the insurer, the insurer pays the ADSM, not the provider. Use of a non-network provider must be pre-authorized by the contractor before non-emergency care is delivered.

Oral and Maxillofacial Surgery – Surgical procedures performed in the oral cavity or maxillofacial region.

Oral Surgeon – A person who has received a degree in dentistry and has completed residential training in oral and maxillofacial surgery, that is, that branch of the healing arts that deals with the diagnosis and the surgical correction and adjunctive treatment of diseases, injuries, and defects of the mouth, the jaws, and associated structures.

Orthodontics – The supervision, guidance, and correction of the growing or mature dentofacial structures, including those conditions that require movement of teeth or correction of malrelationships and malformations of their related structures and adjustment of relationships between and among teeth and facial bones by the application of forces and/or the stimulation and redirection of functional forces within the craniofacial complex.

Outside Continental United States (OCONUS) – includes all other countries, island masses and territorial waters not considered to be within the CONUS service area.

Party to the Initial Determination – An ADSM, network provider, and/or a provider seeking to become or remain an authorized ADDP provider whose interest have been adjudicated by the initial determination.

Periodontics – The examination, diagnosis, and treatment of diseases affecting the surrounding and supporting structures of the teeth.

Prevailing Charge – The charges submitted by certain dental providers which fall within the range of charges that are most frequently used in a state for a particular procedure or service. The top of the range establishes the maximum amount ADDP will authorize for payments of a given procedure or service, except where unusual circumstances or dental complications warrant an additional charge.

Preventive Services – Dental care services to prevent dental disease, including traditional prophylaxis, scaling deposits from teeth, polishing teeth, and topical application of fluoride to teeth, sealants, etc.

Prosthodontics – The diagnosis, planning, making, insertion, adjustment, refinement, and repair of artificial devices intended for the replacement of missing teeth, deficient teeth that cannot be corrected with direct restorations, and associated tissues.

Provider – A dentist, dental hygienist, or certified and licensed anesthetist, or other individual professional provider, or other provider of services or supplies in accordance with 32 CFR 199.2. This term, when used in relation to OCONUS service area providers, may include other recognized professions authorized to furnish care under laws of that particular territory, possession or country.

Ready Reserve – The Ready Reserve consists of units or Reserves, or both, liable for active duty. The Ready Reserve comprises military members of the Reserve and National Guard that consists of three reserve component subcategories: (1) Selected Reserve, (2) Individual Ready Reserve, and (3) Inactive National Guard.

Referral – The act or an instance of referring an ADSM from a Dental Treatment Facility to a civilian provider for dental care. ADDP referrals may only be made by the Dental Treatment Facility.

Remote Active Duty Service Member – An active duty service member who works and lives more than 50 miles from a military Dental Treatment Facility. This also includes eligible members enrolled in TRICARE Prime Remote, uniformed members of NOAA, Early Activation reserve component members, Foreign Forces members in CONUS geographic regions, Line of Duty members, Wounded Warriors and certain Reserve component members under TAMP.

Residual Claim – A claim for dental care services rendered during the dental care delivery period of the contract, but processed during the Phase-Out period of that contract when that contractor is no longer providing dental care delivery (i.e. the contract has been transitioned to another contractor).

Restorative Services – Restoration of teeth including those procedures commonly described as amalgam restorations, resin restorations, pin retention, and stainless steel crowns for primary teeth.

Retained Claims – Claims retained by the contractor for processing to completion or development.

Routine Care – Covered benefits for remote ADSMs that do not require authorization which includes diagnostic (exams and X-rays), preventive (cleanings), routine restorations (amalgam or composite fillings), and single tooth extractions that does not exceed $750 per appointment. It does not include crowns nor other specialty care.

Routine Care Appointment – A routine appointment is for care such as a 6-month, annual exam and preventive services (i.e. prophylaxis and application of fluoride).

Sealants – A material designed for application on specified teeth to seal the surface irregularities to prevent ingress of oral fluids, food, and debris in order to prevent tooth decay.

Selected Reserve (SelRes) – The Selected Reserve consist of those units and individuals within the Ready Reserve designated by their respective Services and approved by the Chairman of the Joint Chiefs of Staff as so essential to initial wartime missions that they have priority over all other Reserves.

Service Point of Contact (SPOC) – Serves as a centralized service point of contact and is the primary POC for respective service headquarters and commands.

Specialty Care – Other dental care (e.g., prosthodontics, implantology, periodontics, oral surgery, orthodontics, endodontics, orofacial pain) or diagnostic procedure not considered emergency or routine care.

TRICARE OCONUS Preferred Dentist (TOPD) - A dentist who has signed an agreement with the ADDP contractor agreeing to abide to the applicable credentialing requirements and standards of care for the country in which they practice; submit claims directly to the contractor for authorized and/or covered services rendered to beneficiaries; and to collect only the applicable cost-share amount from the beneficiary. Active Duty Service Members (ADSMs) do not have cost shares or co-pays. TOPDs are not network providers.