T-5TOM Appendix A.pdf

TRICARE Operations Manual 6010.59-M, June 1, 2020

Appendix A Definitions

Copyright: CPT only © 2006 American Medical Association (or such other date of publication of CPT).

All Rights Reserved.

Revision:

The following definitions are a mixture of TRICARE Regulatory definitions listed in 32 CFR

199.2 and 199.17,operational definitions used by TRICARE personnel and contractors in the daily administration of the TRICARE Program, and terminology found in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Regulatory definitions may not be changed or elaborated upon without a regulatory change. Further explanations/elaborations of TRICARE Regulatory definitions may be found in the TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), TRICARE Reimbursement Manual (TRM), and TRICARE Systems Manual (TSM) where appropriate. For a complete listing of TRICARE Regulatory Definitions refer to 32 CFR 199.2 and 199.17. Included are acronyms for some of the words being defined.

An acronym is a word for1med from the first (or first few) letters of a series of words.

Absent Treatment (Defined in 32 CFR 199.2)

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 (Defined in 32 CFR 199.2)

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 specific time frames, at locations and from the providers that satisfy patient health care needs. This is frequently associated with the contractor’s provision of an adequate network. Access to care standards are established in 32 CFR

199.17 and 45 CFR 156.230. See the definition of “Access Standards” in this appendix.

Access, Information

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

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

Access Standards (Defined in 32 CFR 199.17)

Preferred Provider Networks (PPNs) will have attributes of size composition, mix of providers and geographical distribution so that the networks, coupled with the Military Treatment Facility (MTF) capabilities, can adequately address the health care needs of the enrollees. Before offering enrollment in Prime to a beneficiary group, the Market Director/MTF Director (or other authorized person) will assure that the capabilities of the MTF plus PPN will meet the following access standards with respect to the needs of the expected number of enrollees from the beneficiary group being offered enrollment:

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

Accuracy (DHA Comms) A directory entry that contains correct information for all of the following data elements:

provider name, provider specialty, sub-specialty (if applicable), gender, work address, work fax number, and work telephone number for each service area.

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 (Defined in 32 CFR 199.2)

Full-time duty in the Uniformed Services of the United States (U.S.). 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 (Defined in 32 CFR 199.2)

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) (Defined in 32 CFR 199.2)

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”.

Adequate Medical Documentation, Mental Health Records (Defined in 32 CFR 199.2)

Adequate medical documentation provides the means for measuring the type, frequency, and duration of active treatments mechanisms employed and progress under the treatment plan.

Under TRICARE, it is required that adequate and sufficient clinical records be kept be the provider to substantiate that specific care was actually and appropriately furnished, was medically or psychologically necessary (as defined in 32 CFR 199.2), and to identify the individual(s) who provided the care. Each service provided or billed must be documented in the records. In determining whether medical records are adequate, the records will be reviewed under the general acceptable standards (e.g., standard of an accrediting organization approved by the Director, and the provider’s state or local licensing requirements) and other requirements specified in 32CFR 199. The psychiatric and psychological evaluations, physicians orders, the treatment plan, integrated progress notes (and physician progress notes if separate from the integrated progress notes), and the discharge summary are the more critical elements of the mental health record. However, nursing and staff notes, no matter how complete, are not a substitute for the documentation of services by the individual professional provider who furnished treatment to the beneficiary. In general, the documentation requirement of a professional provider are not less in the outpatient setting than the inpatient setting.

Furthermore, even though a hospital that provides psychiatric care may be accredited under The Joint Commission (JC) manual for hospitals rather than JC behavioral health standards, the critical elements of the mental health record listed above are required for TRICARE claims.

Adequate Network (Network Adequacy)

A network with a sufficient number of providers to meet access to care standards for Prime enrollees as defined in CFR 199.17(p)(5) (where providers are available).

Adjunctive Dental Care (Defined in 32 CFR 199.2)

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).

Adjustment

A correction to the information in the TRICARE Encounter Data (TED) records 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 DHA 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 Efficiencies

Adherence to the TRICARE program and benefits, electronic claims processing, responsiveness to patient questions and care coordination, timeliness of consult reporting back to referring providers.

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 (Defined in 32 CFR 199.2)

The TRICARE-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 and accepted by TRICARE.

Allowable Charge (Defined in 32 CFR 199.2)

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 32 CFR 199.14.

Allowable Charge Complaint

A request for review of a contractor determination of the allowable charge for covered services and supplies furnished under TRICARE. An allowable charge complaint does not fall within the meaning of an “appeal”, in the technical sense, but does require a careful review or reconsideration by the contractor of how the claim was processed to ensure accuracy of the payment 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 (Defined in 32 CFR 199.2)

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

Amount In Dispute (Defined in 32 CFR 199.2)

The amount of money, determined under 32 CFR 199, that TRICARE will 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

199.10 and Chapter 12.

Appealable Issue (Defined in 32 CFR 199.2)

Disputed questions of fact which, if resolved in favor of the appealing party, would result in the authorization of TRICARE benefits, or approval as an authorized provider in accordance with this part. An appealable issue does not exist if no facts are in dispute, if no TRICARE benefits would be payable, or if there is no authorized provider, regardless of the resolution of any disputed facts.

See Sec. 199.10 for additional information concerning the determination of “appealable issue” under this part.

Appealing Party (Defined in 32 CFR 199.2)

Any party to the initial determination who files an appeal of an adverse determination or requests a hearing under the provisions of this part.

Appropriate Medical Care (Defined in 32 CFR 199.2)

Services that are:

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 U.S.;

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. For the purposes of TRICARE, “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.

Asynchronous Telehealth Asynchronous, or store and forward, telemedicine encounters transmit medical images or information in one direction at a time via electronic communications. Common types of asynchronous services include teleconsultations involving radiology, pathology, cardiology, and dermatology. Teleconsultation supports the delivery of healthcare at a distance via the asynchronous transmission of electronic medical information and associated or stand-alone digital images or video over a secure connection between healthcare providers for the purpose of obtaining an expert opinion or diagnostic support regarding the care of a patient. In the process of teleconsultation, the remote consultant does not interact directly with the patient. The consultant prepares and transmits comments, recommendations, or an official interpretation back to the referring provider for their review and consideration. A teleconsultation is not a traditional patient referral whereby patient care is transferred to the consultant.

Authorization

The authorization determination addresses whether a particular service may be covered by TRICARE, including whether it appears necessary and appropriate in the context of the patient’s diagnosis and circumstances.

Authorized Provider (Defined in 32 CFR 199.2)

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.

Note: Providers not specifically listed in 32 CFR 199.6 or defined in 32 CFR 199.2 are not considered authorized providers unless they have been 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 Pharmacy and Therapeutic (P&T) [Committee] for inclusion in the formulary, and appearing on the formulary web site at http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/ OTCDrugsSupplies.aspx.

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.

Automated Data Processing (ADP) Backup System

A separate, off-site ADP 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 (Defined in 32 CFR 199.2)

A provider seeking any payment, other than any payment relating to applicable deductible and cost- sharing amounts, from a beneficiary for TRICARE covered services for any amount in excess of the applicable TRICARE allowable cost or charge.

Basic Program (Defined in 32 CFR 199.2)

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

Behavioral Health

All-inclusive term that describes all aspects of mental health, substance use disorder, and associated physical and psychological health disorders. Behavioral health encompasses programs, processes of promoting general well-being, and preventing and intervening in mental health disorders. Mental disorders are defined in 32 CFR 199.2.

Benchmark, Drug Price

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;

http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx

• Average Manufacturer Price (AMP) - Manufacturer reported price for Medicaid drug rebate program;

• Average Sales Price (ASP) - Center for Medicare and Medicaid Service (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.

Beneficiary

A beneficiary is an individual eligible for benefits. The beneficiary, Sponsor, or representative of the beneficiary, including the parent of a beneficiary under 18 years of age, the beneficiary’s attorney, legal guardian or representative specifically designated by the beneficiary may on his or her behalf regarding the benefit at issue. An individual who is subject to the conflict of interest provisions of 32 CFR 199.10(a)(2)(i)(B), may not act as the beneficiary’s representative under this section.

Beneficiary Counseling and Assistance Coordinators (BCACs)

Formerly referred to as Health Benefit Advisors (HBAs), BCACs are individuals located at Uniformed Services medical facilities or on occasion at other locations and assigned the responsibility for providing TRICARE information, information concerning availability of care from the Uniformed Services Direct Care (DC) 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, family history records, correspondence, memorandum, or any other personal information with respect to any individual, including all such records/reports 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.

Medical Management Files: These records include the medical and mental health case files, all clinical history documentation, plans of care, treatment plans, case notes for beneficiaries past and present under Case Management (to include Extended Care Health Option (ECHO), ICMP-PEC and CCTP), ECHO Home Health Care (EHHC),case notes for beneficiaries past and present under Disease Management , claims and EOBs.

Preauthorization/Authorization/Referrals: This includes all those medical and mental health records generated within the health care services function involving preauthorization, authorization, referrals, beneficiary and provider denials letters, beneficiary and provider authorization letters, medical review, transition of care, peer review, concurrent review, and second level review performed by the medical directors, all UM appeal/reconsideration case files. These notes include copies of medical records and copies of prescriptions and other annotations that are maintained elsewhere in the original case files.

Mental Health Case Files: These files consist of all documents required in the processing of mental health claims. This series includes cases which have gone to peer review or have been denied at the contractor level. Peer reviews and all associated papers shall be filed in the case file, not kept separate.

1. Hard Copy Claim Files.

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.

Note: The term “TRICARE Contractor Claims Records” is used by the National Archives and Records Administration (NARA) “Medical/Dental Claims History files (formerly “Beneficiary History and Deductibles Files”) includes but is not limited to “TRICARE Contractor claims Records.”

Beneficiary Liability (Defined in 32 CFR 199.2)

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 charge.

Beneficiary liability also includes any expenses for medical or related services and supplies not covered by TRICARE.

Benefit

Services, supplies, payment amounts, cost-shares and copayments authorized by Public Law (PL) 89- 614, 32 CFR 199, and outlined in the TPM and the TRM.

Best Practices

A best practice is a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a “best” practice can evolve to become better as improvements are discovered.

Best Value Health Care

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

Breach

A breach, as defined in Department of Defense Directive (DoDD) 5400.11 (2014), is a loss of control, compromise, unauthorized disclosure, unauthorized acquisition, unauthorized access, or any similar term referring to situations where persons other than authorized users and for an other than authorized purpose have access or potential access to Personally Identifiable Information (PII)/ Protected Health Information (PHI), whether in paper or electronic form.

Breaches are classified as either possible or confirmed (see the definition of “Possible Breach” and “Confirmed Breach” in this appendix) and as either cyber or non-cyber (i.e., involving either electronic PII/PHI or paper/oral PII/ PHI).

Business Associate

1. A person or organization that performs a function or activity on behalf of a covered entity, but is not part of a covered entity’s workforce. A business associate may also be a covered entity in it’s own right.

2. For a full definition, refer to the 45 CFR 160.103, Definitions of HIPAA of 1996.

Business Day

For claims processing purposes, one business day is defined as the business day following the day of transmission at the close of business at the location of the receiving entity. A business workday is Monday through Friday, excluding federal holidays.

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 under TRICARE contract to perform 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 Manager (PCM), 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 Files (Records Management)

A file(s), regardless of media, containing material on a specific action, event, person, place, project, or other subjects. Sometimes referred to as a “project file” or a “transaction file.” Also a collection of such folders or other file units.

Case Management (Defined in 32 CFR 199.2)

A collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health needs, including mental health and Substance Use Disorder (SUD) needs, using communication and available resources to promote quality, cost-effective outcomes.

Catastrophic Cap

The National Defense Authorization Act (NDAA) for Fiscal Years (FYs) 1988 and 1989 (Public Law 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. NDAA for FY 2017 amended Title 10, USC to change calculations to a calendar year basis, beginning January 1, 2018. The last quarter of calendar year 2017 was applied to the FY 2017 calculations to bridge the gap.

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.

Centers of Excellence

See definition for Defense Centers of Excellence (CoE).

Certification and Accreditation (C&A) Process

A process that ensures the trust requirement is met for Information Systems (IS)/networks.

Certification is the determination of the appropriate level of protection required for IS/networks.

Certification also includes a comprehensive evaluation of the technical and non-technical security features and countermeasures required for each IS/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 IS/networks and contractor IS/networks that access, manage, store, or manipulate electronic IS data. Specific guidance may be found in the TSM, Chapter 1.

Certification For Care

The determination that the provider’s request for services (level of care, procedure, etc.) is consistent with pre-established health care 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

A hospital or institutional provider, physician, or other individual professional provider of services or supplies verified by DHA, or a designated contractor, to meet the provider standards outlined in 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)

A 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.

Civilian Health and Medical Program of the Department of Veterans Affairs

(CHAMPVA)

A program of medical care for spouses and dependent children of disabled or deceased disabled veterans who meet the eligibility requirements of the Department of Veterans Affairs (DVA)/Veterans Health Administration (VHA).

Change Order

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

Christian Science Nurse (Defined in 32 CFR 199.2)

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 (Defined in 32 CFR 199.2)

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 (Defined in 32 CFR 199.2)

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

Any request for reimbursement for health care services rendered, 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.

Note: 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 TED record for all care provided under the contract.)

Note: 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, records of telephone development, copies of correspondence sent and received in connection with the claim, the EOB, and records of adjustments to the claim. It may also include the records 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 the definition of “Processed to Completion (or Final Disposition)” in this appendix, and the 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 Quality Management Program (CQMP)

The integrated processes, both clinical and administrative, that provide the framework for the contractor to objectively define and measure the quality of care received by beneficiaries.

Clinical Quality Outcomes

The American College of Medical Quality in their 2010 revision of their recommended Core Curriculum for Medical Quality Management describes clinical outcomes as part of the definition of quality measures. These are:

1. Structural Measures - health care setting, appropriate equipment and supplies, education, certification and experience of clinicians;

2. Process Measures - actions taken and how well these were performed to achieve a given outcome, use of evidence-based clinical guidelines;

3. Outcome Measures - capture of changes in health status following the provision of a set of healthcare processes and including the cost of delivering the processes -- hospitalizations, physician office visits, or care provided in post-acute care setting, patient satisfaction.

Clinical Support Agreement (CSA)

An arrangement requested by the military, between a Market/MTF and the TRICARE contractor for the contractor to provide needed clinical personnel at a Market/MTF. The arrangement must be formalized by modification to the TRICARE contract prior to implementation of the provisions of the arrangement.

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. This includes both the codes and their descriptions, as outlined in HIPAA of 1996.

Code Set Maintaining Organization (HIPAA/Privacy Definition)

An organization that creates and maintains the code sets adopted by the Secretary of Home Health Services (HHS) for use in the transactions for which standards are adopted as outlined in HIPAA of 1996.

Combined Daily Charge (Defined in 32 CFR 199.2)

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

Complaint

All forms of complaints, to include but not limited to phone calls, e-mails and written complaints.

Concurrent Review/Continued Stay Review

Evaluation of a patient’s continued need for treatment, 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 privacy of personal medical information in compliance with the Freedom of Information Act, the Comprehensive Alcohol Abuse and Alcoholism Prevention and Rehabilitation Act, the Privacy Act, and HIPAA of 1996.

Confirmed Breach

An incident in which it is known that unauthorized access could occur. For example, if a laptop containing PII/PHI is lost and the contractor knows that the PII/PHI is unencrypted, then the contractor should classify and report the incident as a confirmed breach, because unauthorized access could occur due to the lack of encryption (the contractor knows this even without knowing whether or not unauthorized access to the PII/PHI has actually occurred). If the laptop is subsequently recovered and forensic investigation reveals that files containing PII/PHI were never accessed, then the possibility of unauthorized access can be ruled out, and the contractor should re-classify the incident as a non- breach incident.

Conflict Of Interest (Defined in 32 CFR 199.2)

Includes any situation where an active duty member (including a reserve member while on active duty) or civilian employee of the U.S. Government, through an official federal position, has the apparent or actual opportunity to exert, directly or indirectly, any influence on the referral of TRICARE 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.

Connected Health (Telehealth)

• A generic term broadly referring to the support of patient or population health or health care via electronic means.

• Telehealth is a form of Connected Health.

Consultation (Defined in 32 CFR 199.2)

A deliberation with a specialist physician, dentist, or qualified mental health provider requested by the attending TRICARE authorized provider primarily responsible for the medical care of the patient, with respect to the diagnosis or treatment in any particular case. A consulting physician or dentist or qualified mental health provider may perform a limited examination of a given system or one requiring a complete diagnostic history and examination. To qualify as a consultation, a written report to the attending TRICARE authorized provider of the findings of the consultant is required.

Note: Staff consultations required by rules and regulations of the medical staff of a hospital or institutional provider do not qualify as consultations.

Consultation Appointment (Defined in 32 CFR 199.2)

An appointment for evaluation of medical symptoms resulting in a plan for management which may include elements of further evaluation, treatment and follow-up evaluation. Such an appointment does not include surgical intervention or other invasive diagnostic or therapeutic procedures beyond the level of very simply office procedures, or basic laboratory work but rather provides the beneficiary with an authoritative option.

Consulting Physician or Dentist (Defined in 32 CFR 199.2)

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

Content Management System (Records Management)

An application that provides capabilities for multiple users with different permission levels to manage content, data, or information.

Continued Health Care Benefit Program (CHCBP)

A TRICARE benefit program that provides temporary continued health care for certain former beneficiaries of the MHS. Coverage under the CHCBP is purchased on a premium basis.

Continuity of Care

Follow on of health care services from a specific individual professional provider or care team 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. For certain conditions, continuity of care may last up to one year.

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 Performance Evaluation (CPE)

A review by DHA, of a contractor’s level of compliance with the terms and conditions of the contract. Usually, an operational audit performed by DHA staff that 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 (CO), who represents the CO in the administration of technical matters involving contract requirements.

Contractor

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

Contractor Records (Records Management)

All data produced and maintained by a contractor for DHA.

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.

Controlled Unclassified Information (CUI)

Information that is not classified in accordance with national security directives, but that otherwise requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations, and Government-wide policies.

Coordination Of Benefits (COB) (Defined in 32 CFR 199.2)

The coordination, on a primary or secondary payer basis of the payment of benefits between two or more health care coverages to avoid duplication of benefit payments.

Cost-Share (Defined in 32 CFR 199.2)

The amount of money for which the beneficiary (or sponsor) is responsible in connection with otherwise covered inpatient and outpatient services (other than the annual deductible or disallowed amounts) as set forth in 32 CFR 199.4(f) and 32 CFR 199.5(b). Cost-sharing may also be referred to as “copayment.”

Note: See also TRM, Chapter 2, and 32 CFR 199.17 for additional cost-share information.

Correctional Institution (HIPAA 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 U.S., 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 as defined in HIPAA of 1996.

Note: For the purposes of TRICARE, 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 Definition)

Any business entity that must comply with HIPAA regulations, which includes, health plans, health care clearinghouses, and HCPs. For the purposes of HIPAA, HCPs include hospitals, physicians, and other caregivers. See 45CFR Section 160.103 of HIPAA regulation for additional information.

Note: In the case of a health plan administered by the DoD, the covered entity is the DoD Component (or subcomponent) that functions as the administrator of the health plan.

Covered Functions (HIPAA Definition)

Those functions of a covered entity, the performance of which, makes the entity a health plan or HCP as outlined in HIPAA of 1996.

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

Information required for all clinical personnel supplied by the contractor who will be working in a Market/MTF. Similar information may be required for non-clinical personnel. Complete information shall contain the following:

1. All documents, required per regulation/directive/instruction/policy which are needed to verify that the individual is certified/authorized/qualified to provide the proposed services at the involved facility. This shall 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. A completed a Criminal History Background Check (CHBC), for all personnel required by law to have a CHBC prior to awarding of privileges or the delivery of services with the following considerations:

• If a CHBC has been initiated, but not completed, the Market Director/MTF Director 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 Markets/MTFs and should be determined during phase-in/transition and be agreed to by the Market Director/MTF Director.

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

3. Medicare Provider ID number/National Provider Identifier (NPI) number.

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

Custodial Care (Defined in 32 CFR 199.2)

The treatment or services, regardless of who recommends such treatment or services or where such treatment or services are provided, that:

1. Can be rendered safely and reasonably by a person who is not medically skilled; or

2. Is/are designed mainly to help the patient with the ADLs.

Cybersecurity Incident

A cybersecurity incident is a violation or imminent threat of violation of computer security policies, acceptable use policies, or standard security practices, with respect to electronic PII/PHI. A cybersecurity incident may or may not involve a breach of PII/PHI. For example, a malware infection would be a possible breach if it could cause unauthorized access to PII/PHI.

However, if the malware only affects data integrity or availability (not confidentiality), then a non-breach cybersecurity incident has occurred.

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 the definition of claims cycle time, in this appendix, 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.

Data Aggregation

The combining of 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 as outlined in HIPAA of 1996.

Data Condition (HIPAA Definition)

The circumstances under which a covered entity must use a particular data element or segment as defined by HIPAA of 1996.

Data Content (HIPAA Definition)

All 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 as defined by HIPAA

Data Element (HIPAA Definition)

The smallest named unit of information in a transaction defined by HIPAA of 1996.

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 Definition)

A semantically meaningful unit of information exchanged between two parties to a transaction as defined by HIPAA of 1996.

Date Of Determination (Appeals)

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

Days (Defined in 32 CFR 199.2)

Calendar days.

Days Supply (Pharmacy)

The length of time a 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 (Defined in 32…