TRICARE Manuals - Display Appendix A (Change 139, Jun 10, 2024) (2024)

TRICARE Operations Manual 6010.59-M, April 1, 2015

Appendix A

Definitions

Copyright:CPT only © 2006 American MedicalAssociation (or such other date of publication of CPT).All Rights Reserved.

Revision:C-131, December 14, 2023

The following definitions area mixture of TRICARE Regulatory definitions listed in 32CFR 199.2 and CFR 199.17,operationaldefinitions used by TRICARE personnel and contractors in the dailyadministration of the TRICARE Program, and terminology found inthe Health Insurance Portability and Accountability Act (HIPAA)of 1996. Regulatory definitions may not be changed or elaboratedupon without a regulatory change. Further explanations/elaborationsof TRICARE Regulatory definitions may be found in the TRICARE OperationsManual (TOM), TRICARE Policy Manual (TPM), TRICARE Reimbursem*nt Manual(TRM), and TRICARE Systems Manual (TSM) where appropriate. For acomplete listing of TRICARE Regulatory Definitions refer to 32CFR 199.2 and CFR 199.17.Included are acronyms for some of the words being defined. An acronymis a word formed from the first (or first few) letters of a seriesof words.

Absent Treatment (Definedin 32 CFR 199.2)

Services performed by ChristianScience practitioners for a person when the person is not physically present.Technically, “Absent Treatment” is an obsolete term. The currentChristian Science terminology is “treatment through prayer and spiritualmeans,” which is employed by an authorized Christian Science practitionereither with the beneficiary being present or absent. However, tobe considered for coverage under TRICARE, the beneficiary must bepresent physically when a Christian Science service is rendered,regardless of the terminology used.

Abuse (Defined in 32CFR 199.2)

Any practice that is inconsistentwith accepted sound fiscal, business, or professional practice which resultsin a TRICARE claim, unnecessary cost, or TRICARE payment for servicesor supplies that are:

1. Notwithin the concepts of medically necessary and appropriate care,as defined in the Regulation (32 CFR 199), or

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

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

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

Access, Health Care

The ability to receive necessaryhealth care services of high quality within specific time frames,at locations and from the providers that satisfy patient healthcare needs. This is frequently associated with the contractor’sprovision of network adequacy. Access to care standards are establishedin 32 CFR 199.17 and45 CFR 156.230. See the definition of “Access Standards” in thisappendix.

Access, Information

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

2. The abilityand opportunity to obtain sensitive, classified, or administrativelycontrolled information or records readily.

Access Standards (Definedin 32 CFR 199.17)

Preferred Provider Networks (PPNs)will have attributes of size composition, mix of providers and geographicaldistribution so that the networks, coupled with the Military MedicalTreatment Facility (MTF) capabilities, can adequately address thehealth care needs of the enrollees. Before offering enrollment inPrime to a beneficiary group, the Market/MTF Director (or otherauthorized person) will assure that the capabilities of the MTFplus PPN will meet the following access standards with respect tothe needs of the expected number of enrollees from the beneficiarygroup being offered enrollment:

1. Under normalcirc*mstances, enrollee travel time may not exceed 30 minutes fromhome to primary care delivery site unless a longer time is necessarybecause of the absence of providers (including providers not partof the network) in the area.

2. The wait timefor an appointment for a well-patient visit or a specialty carereferral shall not exceed four weeks; for a routine visit, the waittime for an appointment shall not exceed one week; and for an urgentcare visit the wait time for an appointment shall generally notexceed 24 hours.

2. Emergencyservices shall be available and accessible to handle emergencies(and urgent care visits if not available from other primary careproviders within the service area 24 hours a day, seven days a week.

3. The networkshall include a sufficient number and mix of board certified specialiststo meet reasonably the anticipated needs of enrollees. Travel timefor specialty care shall not exceed one hour under normal circ*mstances,unless a longer time is necessary because of the absence of providers (includingproviders not part of the network) in the area. This requirementdoes not apply under the Specialized Treatment Services Program.

4. Office waitingtimes in nonemergency circ*mstances shall not exceed 30 minutes,except when emergency care is being provided to patients, and thenormal schedule is disrupted.

Action Plan

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

Active Duty (Definedin 32 CFR 199.2)

Full-time duty in the UniformedServices of the United States (U.S.). It includes duty on the activelist, full-time training duty, annual training duty, and attendancewhile in the active Military Service, at a school designated asa Service school by law or by the Secretary of the Military Departmentconcerned.

Active Duty Member (Definedin 32 CFR 199.2)

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

Activities of Daily Living(ADL) (Defined in 32 CFR 199.2)

Care that consists of providingfood (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 resultin a need for medical or surgical intervention in the absence of skilledservices); safety precautions; general preventive procedures (suchas turning to prevent bedsores); passive exercise; companionship;recreation; transportation; and other such elements of personalcare that can reasonably be performed by an untrained adult withminimal instruction or supervision. ADL may also be referred toas “essentials of daily living”.

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

Adequate medical documentationprovides the means for measuring the type, frequency, and duration ofactive treatments mechanisms employed and progress under the treatmentplan. Under TRICARE, it is required that adequate and sufficientclinical records be kept be the provider to substantiate that specificcare was actually and appropriately furnished, was medically orpsychologically necessary (as defined in 32CFR 199.2), and to identify the individual(s) who providedthe care. Each service provided or billed must be documented inthe records. In determining whether medical records are adequate, therecords 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 otherrequirements specified in 32CFR 199. The psychiatric and psychologicalevaluations, physicians orders, the treatment plan, integrated progressnotes (and physician progress notes if separate from the integratedprogress notes), and the discharge summary are the more criticalelements of the mental health record. However, nursing and staffnotes, no matter how complete, are not a substitute for the documentationof services by the individual professional provider who furnishedtreatment to the beneficiary. In general, the documentation requirementof a professional provider are not less in the outpatient settingthan the inpatient setting. Furthermore, even though a hospitalthat provides psychiatric care may be accredited under The JointCommission (TJC) manual for hospitals rather than TJC behavioralhealth standards, the critical elements of the mental health recordlisted above are required for TRICARE claims.

Adjunctive Dental Care(Defined in 32 CFR 199.2)

Dental care that is medicallynecessary in the treatment of an otherwise covered medical (notdental) condition, is an integral part of the treatment of suchmedical condition, and is essential to the control of the primarymedical condition; or, is required in preparation for or as theresult of dental trauma which may be or is caused by medically necessarytreatment of an injury or disease (iatrogenic).

Adjustment

A correction to the informationin the TRICARE Encounter Data (TED) records and/or Beneficiary History Files(Hard Copy Files and Automated Beneficiary History and DeductibleFiles) related to a claim previously Processed To Completion (PTC).Adjustments include any recoupments, additional payment(s), allcancellations (total or partial), and corrections to statisticaldata, whether or not the changes result in changes to the financialdata.

Adjustment, IdentificationOf Receipt

An adjustmentmay be generated by a telephonic, written or personal inquiry, appealdecision, or as the result of a contractor’s internal review. Theadjustment is identified when the contractor’s staff determinesthe issue requires an additional payment, cancellation, or a changeto 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 reportingpurposes, with receipt of the payment by the contractor.

Administrative Efficiencies

Adherence to the TRICARE programand benefits, electronic claims processing, responsiveness to patientquestions and care coordination, timeliness of consult reportingback to referring providers.

Administrative Fee, Pharmacy

The offered price that representsall administrative charges relative to prescription, prior authorization andmedical necessity determination transaction processing.

All-Inclusive Per DiemRate (Defined in 32 CFR 199.2)

The TRICARE-determined ratethat encompasses the daily charge for inpatient care and, unless specificallyexcepted, all other treatment determined necessary and renderedas part of the treatment plan established for a patient and acceptedby TRICARE.

Allowable Charge (Definedin 32 CFR 199.2)

The TRICARE-determined levelof payment to institutions, physicians, and other categories ofindividual professional providers based on one of the approved reimbursem*ntmethods set forth in the 32 CFR 199.14.

Allowable Charge Complaint

A request for review of a contractordetermination of the allowable charge for covered services and suppliesfurnished under TRICARE. An allowable charge complaint does notfall within the meaning of an “appeal”, in the technical sense,but does require a careful review or reconsideration by the contractorof how the claim was processed to ensure accuracy of the paymentmade.

Allowable Charge Reduction

The difference between thereimbursem*nt determination made by a contractor and the amountbilled by the provider of care (prior to determination of applicablecost-shares and deductibles). This is also referred to in the industryas the contractual allowance.

Allowable Cost (Definedin 32 CFR 199.2)

The TRICARE-determined levelof payment to hospitals or other institutions, based on one of the approvedreimbursem*nt methods set forth in 32CFR 199.14. The allowable charge may also be referredto as the TRICARE-determined reasonable or allowable cost.

Amount In Dispute (Definedin 32 CFR 199.2)

The amount of money, determinedunder 32 CFR 199, that TRICARE will pay for medical services and suppliesinvolved in an adverse determination being appealed if the appealwere resolved in favor of the appealing party. See 32CFR 199.10 for additional information concerning the determinationof “amount in dispute” under the Regulation.

Appeal

A formal written request bya beneficiary, a participating provider, a provider denied authorized providerstatus under TRICARE, or a representative, to resolve a disputedquestion of fact. See 32 CFR 199.10 and 32 CFR199.12.

Appropriate Medical Care(Defined in 32 CFR 199.2)

Services that are:

1. Performed inconnection with the diagnosis or treatment of disease or injury,pregnancy, mental disorder, or well-baby care which are in keepingwith the generally accepted norms for medical practice in the U.S.;

2. Rendered byan authorized individual professional provider who is qualifiedto perform such medical services by reason of his or her trainingand education and is licensed or certified either by the state wherethe service is rendered or appropriate national organization, orwho otherwise meets TRICARE standards; and

3. Furnished economically.For the purposes of TRICARE, “economically” means that the servicesare furnished in the least expensive level of care or medical environmentadequate to provide the required medical care regardless of whetheror not that level of care is covered by TRICARE.

Armed Services (Definedin Title 10, United States Code, Section 101(a)(4))

The Army, Navy, Air Force,Marine Corps, Space Force, and Coast Guard.

Authorization For Care

The authorization determinationaddresses whether a particular service may be covered by TRICARE, includingwhether it appears necessary and appropriate in the context of thepatient’s diagnosis and circ*mstances.

Authorized Provider (Definedin 32 CFR 199.2)

A hospital or institutionalprovider, physician, or other individual professional provider,or other provider of services or supplies specifically authorizedto provide benefits under TRICARE in 32CFR 199.6.

Note:Providers not specificallylisted in 32 CFR 199.6 ordefined in 32 CFR 199.2 arenot considered authorized providers unless they have been includedin a TRICARE demonstration program.

Authorized Supplies,Pharmacy

Non-drugitems (usually used in conjunction with the administration of adrug) approved by the DoD Pharmacy and Therapeutic (P&T) [Committee]for inclusion in the formulary, and appearing on the formulary website at http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx.

Automated Data Processing(ADP)

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

Automated Data Processing(ADP) Backup System

A separate, off-site ADP systemwith similar operating capabilities which will be activated/usedin case of a major system failure, damage, or destruction. Thisincludes back-up data sets, software and hardware requirements,and trained personnel.

Balance Billing (Definedin 32 CFR 199.2)

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

Basic Program (Definedin 32 CFR 199.2)

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

Benchmark, Drug Price

The Average Wholesale Price(AWP) has long been the drug price benchmark for establishing reimbursem*ntpayment terms between payers, Pharmacy Benefit Managers (PBMs),and pharmacies. AWP as a benchmark has been going away. AWP is byno means the only price type available. Listed here, with briefdescriptions, are others that are available and may be used by theindustry for reimbursem*nt 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) -Center for Medicare and Medicaid Service (CMS) calculated pricefor Medicate Part B drugs;

Estimated Acquisition Cost(EAC) - Estimated cost of the product or the pharmacies’ usual and customarycharge;

Federal Upper Limit (FUL) -CMS calculation for the upper amount to be paid in aggregate formulti-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 individualeligible for benefits. The beneficiary, Sponsor, or representativeof the beneficiary, including the parent of a beneficiary under18 years of age, the beneficiary’s attorney, legal guardian or representativespecifically designated by the beneficiary may on his or her behalf regardingthe benefit at issue. An individual who is subject to the conflictof interest provisions of 32 CFR 199.10(a)(2)(i)(B), may not act asthe beneficiary’s representative under this section.

Beneficiary Counselingand Assistance Coordinators (BCACs)

Formerly referred to as HealthBenefit Advisors (HBAs), BCACs are individuals located at Uniformed Servicesmedical facilities or on occasion at other locations and assignedthe responsibility for providing TRICARE information, informationconcerning availability of care from the Uniformed Services DirectCare (DC) or Purchased Care Systems, and generally assisting beneficiariesor sponsors. The term also includes “Health Benefits Counselor.”

Beneficiary History File

A system of records consistingof any record or subsystem of records, whether hard copy, microformor automated, which reflects diagnosis, treatment, medical condition,family history records, correspondence, memorandum, or any otherpersonal information with respect to any individual, including allsuch records/reports acquired or utilized by the contractor in deliveryof health care services, in the development and processing of claims,or in performing any other functions under a TRICARE contract.

1. Hard Copy ClaimFiles.

2. AutomatedHistory Files. The electronically maintained record of a beneficiary’smedical care and related administrative data, including such dataon charges, payments, deductible status, services received, diagnoses,adjustments, etc.

Note:The term “TRICARE ContractorClaims Records” is used by the National Archives and Records Administration(NARA) “Medical/Dental Claims History files (formerly “BeneficiaryHistory and Deductibles Files”) includes but is not limited to “TRICAREContractor 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 ofmedical care or treatment received. Specifically, for the purposesof services and supplies covered by TRICARE, beneficiary liabilityincludes any annual deductible amount, cost-sharing amounts, or,when a provider does not submit a claim on a participating basison behalf of the beneficiary, amounts above the TRICARE-determinedallowable charge. Beneficiary liability also includes any expensesfor medical or related services and supplies not covered by TRICARE.

Benefit

Services, supplies, paymentamounts, 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 methodor technique that has consistently shown results superior to thoseachieved with other means, and that is used as a benchmark. In addition,a “best” practice can evolve to become better as improvements arediscovered.

Best Value Health Care

The delivery of high qualityclinical and other related services in the most economical mannerfor the Military Health System (MHS) that optimizes the DC systemwhile delivering the highest level of customer service.

Biotelemetry (Definedin 32 CFR 199.2)

A diagnostic or monitoringprocedure for the detection or measurement of human physiologic functionsfrom a distance using a biotelemetry device to remotely monitorvarious vital signs of ambulatory patients. Biotelemetry may alsobe referred to as remote physiologic monitoring of physiologic parameters.

Breach

A breach, as defined in Departmentof Defense Directive (DoDD) 5400.11 (2014), is a loss of control, compromise,unauthorized disclosure, unauthorized acquisition, unauthorizedaccess, or any similar term referring to situations where personsother than authorized users and for an other than authorized purposehave access or potential access to Personally Identifiable Information(PII)/Protected Health Information (PHI), whether in paper or electronicform. Breaches are classified as either possible or confirmed (seethe definition of “Possible Breach” and “Confirmed Breach” in this appendix)and as either cyber or non-cyber (i.e., involving either electronicPII/PHI or paper/oral PII/PHI).

Business Associate

1. A person ororganization that performs a function or activity on behalf of acovered 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 fulldefinition, refer to the 45 CFR 160.103, Definitions of HIPAA of1996.

Business Day

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

Capability Of A Provider

The scope of services the provideris both capable of performing and willing to perform under a TRICAREcontract. For example, a neurologist under TRICARE contract to performsleep studies may not be considered to have capability to performas a general neurology specialist.

Capacity Of A Provider

The amount of time or numberof services a provider is able to perform in conjunction with aTRICARE contract. For example, a Primary Care Physician (PCP), whosepractice is full has no available capacity for services.

Capitation

A payment arrangement for healthcare service providers. It pays a set amount for each enrolled person assignedto them, per period of time, whether or not that person seeks care.

Capped Rate

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

Care Coordination

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

Case Management (Definedin 32 CFR 199.2)

A collaborative process whichassesses, plans, implements, coordinates, monitors and evaluatesthe options and services required to meet an individual’s healthneeds, including mental health and Substance Use Disorder (SUD)needs, using communication and available resources to promote quality, cost-effectiveoutcomes.

Catastrophic Cap

The National Defense AuthorizationAct (NDAA) for Fiscal Years (FYs) 1988 and 1989 (Public Law 100-180)amended Title 10, USC, and established catastrophic loss protectionfor TRICARE beneficiary families on a Government fiscal year basis.The law placed fiscal year limits or catastrophic caps on beneficiaryliabilities for deductibles and cost-shares under the TRICARE BasicProgram. Specific guidance may be found in the TRM, Chapter 2, Section 2. NDAA for FY 2017 amendedTitle 10, USC to change calculations to a calendar year basis, beginningJanuary 1, 2018. The last quarter of calendar year 2017 was appliedto the FY 2017 calculations to bridge the gap.

Catchment Areas

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

Centers of Excellence

See definition for DefenseCenters of Excellence (CoE).

Certification and Accreditation(C&A) Process

A processthat ensures the trust requirement is met for Information Systems(IS)/networks. Certification is the determination of the appropriatelevel of protection required for IS/networks. Certification also includesa comprehensive evaluation of the technical and non-technical securityfeatures and countermeasures required for each IS/network. Accreditationis the formal approval by the Government to operate the contractor’sIS/networks in a particular security mode using a prescribed setof safeguards at an acceptable level of risk. In addition, accreditationallows IS/networks to operate within the given operational environmentwith stated interconnections; and with appropriate level-of-protectionfor the specified period. The C&A requirements apply to allDoD IS/networks and contractor IS/networks that access, manage,store, or manipulate electronic IS data. Specific guidance may be foundin the TSM, Chapter 1.

Certification For Care

The determination that theprovider’s request for services (level of care, procedure, etc.)is consistent with pre-established health care criteria. Pre-certificationis the process performing a certification for care prior to renderingthe care.

Note:This isNOT synonymous with authorization for care.

Certified Provider

A hospital or institutionalprovider, physician, or other individual professional provider ofservices or supplies verified by DHA, or a designated contractor,to meet the provider standards outlined in 32CFR 199.6, and have been approved to provide servicesto TRICARE beneficiaries and receive Government payment for servicesrendered to TRICARE beneficiaries.

CHAMPUS Maximum AllowableCharge (CMAC)

A CMACis a nationally determined allowable charge level that is adjustedby locality indices and is equal to or greater than the MedicareFee Scheduled amount.

Civilian Health and MedicalProgram of the Department of Veterans Affairs (CHAMPVA)

A program of medical care forspouses and dependent children of disabled or deceased disabled veteranswho meet the eligibility requirements of the Department of VeteransAffairs (DVA)/Veterans Health Administration (VHA).

Change Order

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

Christian Science Nurse(Defined in 32 CFR 199.2)

An individual who has beenaccredited as a Christian Science Nurse by the Department of Careof the First Church of Christ, Scientist, Boston, Massachusetts,and listed (or eligible to be listed) in the Christian Science Journalat the time the service is provided. The duties of Christian Sciencenurses are spiritual and are nonmedical and nontechnical nursingcare performed under the direction of an accredited Christian Sciencepractitioner. There are two levels of Christian Science nurse accreditation:

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

2. Practical ChristianScience Nurse. This accreditation is granted by the Departmentof 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 beenaccredited as a Christian Science Practitioner for the First Churchof Christ, Scientist, Boston, Massachusetts, and listed (or eligibleto be listed) in the Christian Science Journal at the time the serviceis provided. An individual who attains this accreditation has demonstratedresults of his or her healing through faith and prayer rather thanby medical treatment. Instruction is executed by an accredited ChristianScience teacher and is continuous.

Christian Science Sanatorium(Defined in 32 CFR 199.2)

A sanatorium either operatedby the First Church of Christ, Scientist, or listed and certifiedby the First Church of Christ, Scientist, Boston, Massachusetts.

Claim

Any request for reimbursem*ntfor 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 electronicmedium.

Note:If twoor more forms for the same beneficiary are submitted together, theyshall constitute one claim unless they qualify for separate processingunder the claims splitting rules. (It is recognized that servicesmay be provided in situations in which no claims, as defined here,are generated. This does not relieve the contractor from collectingthe data necessary to fulfill the requirements of the TED Recordfor all care provided under the contract.)

Note:Any request for reimbursem*ntof a dispensed pharmaceutical agent or diabetic supply item. Forelectronic media claims, one prescription equals one claim. Forpaper claims, reimbursem*nt for multiple prescriptions may be requestedon a single paper claim.

Claim (Excluded)

Claims that:

Are retained at the discretionof the contractor for the external development of information necessaryto process the claim to completion; or

Require development for possibleThird Party Liability (TPL); or

Require intervention by anotherTRICARE Prime contractor; or

Require Government intervention(i.e., claims held for CMAC updates, claims held pending the issuanceof a policy change, etc.).

Claims where payment has beentemporarily suspended at Government direction pending the completionof fraud investigation in accordance with Chapter 13, Section 5.

Claim File

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

Claim Form

A fixed arrangement of captionedspaces designed for entering and extracting prescribed information, includingADP system forms.

Claim (Retained)

Any claim retained (held inthe contractor’s possession) for any reason that is not definedunder ‘Claim (Excluded)’.

Claims Cycle Time

That period of time, recordedin calendar days, from the receipt of a claim into the possession/custody ofthe contractor to the completion of all processing steps (see thedefinition of “Processed to Completion (or Final Disposition)” inthis appendix, and the TSM, Chapter 2, Section 2.4, “Date TED Record Processedto Completion”).

Claims Payment Data

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

Clean Claim

A claim that has no defect,impropriety (including a lack of any required substantiating documentation),or particular circ*mstance requiring special treatment externalto the contractor’s prepayment operation that prevents timely paymenton the claim.

Client Beneficiary

A beneficiary who receivesservices from a temporarily suspended provider, pharmacy, or entity.All payments to a client beneficiary for care or services renderedby a temporarily suspended provider, pharmacy, or entity shall beheld in temporary suspense (same as the temporarily suspended provider’s,pharmacy’s, or entity’s claims). A client beneficiary is NOT undertemporary suspense. Only the reimbursem*nt of claims for care receivedfrom a temporarily suspended provider, pharmacy, or entity shallbe held in temporary suspense. All other claims shall be paid inaccordance with the contract.

Clinical Quality Outcomes

The American College of MedicalQuality in its 2010 revision of its recommended Core Curriculumfor Medical Quality Management describes clinical outcomes as partof the definition of quality measures. These are:

1. StructuralMeasures - 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 givenoutcome, use of evidence-based clinical guidelines;

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

Clinical Support Agreement(CSA)

An arrangementrequested by the military, between an MTF/eMSM and the TRICARE contractorfor the contractor to provide needed clinical personnel at an MTF/eMSM.The arrangement must be formalized by modification to the TRICAREcontract prior to implementation of the provisions of the arrangement.

Code Set (HIPAA/PrivacyDefinition)

Any setof codes used to encode data elements, such as tables of terms,medical concepts, medical diagnostic codes, or medical procedurecodes. This includes both the codes and their descriptions, as outlinedin HIPAA of 1996.

Code Set MaintainingOrganization (HIPAA/Privacy Definition)

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

Combined Daily Charge(Defined in 32 CFR 199.2)

A billing procedure by an inpatientfacility that uses an inclusive flat rate covering all professionaland ancillary charges without any itemization.

Concurrent Review/ContinuedStay Review

Evaluationof a patient’s continued need for treatment, the appropriatenessof current and proposed treatment, as well as the setting in whichthe treatment is being rendered or proposed. Concurrent review appliesto all levels of care (including outpatient care).

Confidentiality Requirements

The procedures and controlsthat assure the privacy of personal medical information in compliance withthe Freedom of Information Act, the Comprehensive Alcohol Abuseand Alcoholism Prevention and Rehabilitation Act, the Privacy Act,and HIPAA of 1996.

Confirmed Breach

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

Conflict Of Interest(Defined in 32 CFR 199.2)

Includes any situation wherean active duty member (including a reserve member while on activeduty) or civilian employee of the U.S. Government, through an officialfederal position, has the apparent or actual opportunity to exert,directly or indirectly, any influence on the referral of TRICAREbeneficiaries to himself or herself or others with some potentialfor personal gain or appearance of impropriety. Individuals undercontract to a Uniformed Service may be involved in a conflict ofinterest situation through the contract position.

Consultation (Definedin 32 CFR 199.2)

A deliberation with a specialistphysician, dentist, or qualified mental health provider requestedby the attending TRICARE authorized provider primarily responsiblefor the medical care of the patient, with respect to the diagnosisor treatment in any particular case. A consulting physician or dentistor qualified mental health provider may perform a limited examinationof a given system or one requiring a complete diagnostic historyand examination. To qualify as a consultation, a written reportto the attending TRICARE authorized provider of the findings ofthe consultant is required.

Note:Staff consultations requiredby rules and regulations of the medical staff of a hospital or institutionalprovider do not qualify as consultations.

Consultation Appointment(Defined in 32 CFR 199.2)

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

Consulting Physicianor Dentist (Defined in 32 CFR 199.2)

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

Continued Health CareBenefit Program (CHCBP)

A TRICARE benefit program thatprovides temporary continued health care for certain former beneficiariesof the MHS. Coverage under the CHCBP is purchased on a premium basis.

Continuity of Care

Follow on of health care servicesfrom a specific individual professional provider as part of a specific procedureor service that was performed within the previous six months inorder to not disrupt therapy or repeat services.

Continuum of Care

All patient care services providedfrom “pre-conception to grave” across all types of settings. Requires integratingprocesses to maintain ongoing communication and documentation flowbetween the DC system and network.

Contract PerformanceEvaluation (CPE)

A reviewby DHA, of a contractor’s level of compliance with the terms andconditions of the contract. Usually, an operational audit performedby DHA staff that focuses on timeliness, accuracy, and responsivenessof the contractor in performing all aspects of the work requiredby the contract.

Contract Physician

A physician who has made contractualarrangements with a contractor to provide care or services to TRICAREbeneficiaries. A contract physician is a network provider who participateson all TRICARE claims.

Contracting Officer’sRepresentative (COR)

A Government representative,appointed in writing by the Contracting Officer (CO), who representsthe CO in the administration of technical matters involving contractrequirements.

Contractor

An organization with whichDHA has entered into a contract for delivery of and/or processingof payment for health care services, and the performance of relatedsupport activities, such as, pharmacy services, quality monitoringand/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 ofa copy of the claim, and age including total age in-house and agein a specific location.

Controlled Substances

Those medications which areincluded in one of the schedules of the Controlled Substances Actof 1970 and as amended.

Controlled UnclassifiedInformation (CUI)

Informationthat is not classified in accordance with national security directives,but that otherwise requires safeguarding or dissemination controlspursuant to and consistent with applicable law, regulations, andGovernment-wide policies.

Convenience Clinic (CC)

A CC is located in a retaillocation with a pharmacy whose purpose is to diagnose and treatnon-emergency illness or injury; and provide vaccinations, wellnessservices, and chronic disease monitoring.

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

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

Cost-Share (Defined in 32CFR 199.2)

The amount of money for whichthe beneficiary (or sponsor) is responsible in connection with otherwisecovered inpatient and outpatient services (other than the annualdeductible 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, Chapter2, and 32 CFR 199.17 foradditional cost-share information.

Correctional Institution(HIPAA Definition)

Any penalor correctional facility, jail, reformatory, detention center, workfarm, halfway house, or residential community program center operatedby, or under contract to, the U.S., a State, a territory, a politicalsubdivision of a State or territory, or an Indian tribe, for theconfinement or rehabilitation of persons charged with or convictedof a criminal offense or other persons held in lawful custody. Other personsheld in lawful custody includes juvenile offenders adjudicated delinquent,aliens detained awaiting deportation, persons committed to mentalinstitutions through the criminal justice system, witnesses, orothers awaiting charges or trial as defined in HIPAA of 1996.

Note:For the purposes of TRICARE,the term “correctional institution” includes military confinementfacilities but does not include internment facilities for enemyprisoners of war, retained personnel, civilian detainees and otherdetainees provided under the provisions of DoDD 2310.1 (reference(b)).

Covered Entity (HIPAADefinition)

Any businessentity that must comply with HIPAA regulations, which includes,health plans, health care clearinghouses, and HCPs. For the purposesof 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 planadministered by the DoD, the covered entity is the DoD Component(or subcomponent) that functions as the administrator of the healthplan.

Covered Functions (HIPAADefinition)

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

Credentialing

The process by which providersare allowed to participate in the network. This includes a reviewof the provider’s training, educational degrees, licensure, practicehistory, etc.

Credentials Package

Information required for allclinical personnel supplied by the contractor who will be workingin an Market/MTF. Similar information may be required for non-clinicalpersonnel. Complete information shall contain the following:

1. All documents,required per regulation/directive/instruction/policy which are neededto verify that the individual is certified/authorized/qualifiedto provide the proposed services at the involved facility. Thisshall include licensure from the jurisdiction in which the individualwill be practicing and a National Practitioner Data Bank (NPDB)query as specified by the facility.

2. A completeda Criminal History Background Check (CHBC), for all personnel requiredby law to have a CHBC prior to awarding of privileges or the deliveryof services with the following considerations:

If a CHBC has been initiated,but not completed, the Market/MTF Director has the authority toallow awarding of privileges and initiation of services if deliveredunder clinical supervision.

The mechanism for accomplishingthe CHBC may vary between Markets/MTFs and should be determinedduring phase-in/transition and be agreed to by the Market/MTF Director.

Regardless of the mechanismfor initiating and completing a CHBC, the cost shall be borne bythe contractor.

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

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

Custodial Care (Definedin 32 CFR 199.2)

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

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

2. Is/aredesigned mainly to help the patient with the ADLs.

Cybersecurity Incident

A cybersecurity incident isa violation or imminent threat of violation of computer securitypolicies, acceptable use policies, or standard security practices,with respect to electronic PII/PHI. A cybersecurity incident mayor may not involve a breach of PII/PHI. For example, a malware infection wouldbe 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 hasoccurred.

Cycle Time

The elapsed time, as expressedin days including any part of the first and last days counted astwo 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 addeddetail.

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 itis maintained/stored.

Data Aggregation

The combining of PHI by a businessassociate with the PHI received by the business associate in its capacityas a business associate of another covered entity, to permit dataanalyses that relate to the health care operations of the respectivecovered entities as outlined in HIPAA of 1996.

Data Condition (HIPAADefinition)

The circ*mstancesunder which a covered entity must use a particular data elementor segment as defined by HIPAA of 1996.

Data Content (HIPAA Definition)

All the data elements and codesets inherent to a transaction, and not related to the format ofthe transaction. Data elements that are related to the format arenot data content as defined by HIPAA of 1996.

Data Element (HIPAA Definition)

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

Data Repository

A single point of electronicstorage, established and maintained by the contractor that enablesthe Government to electronically access all data maintained by thecontractor relative to a TRICARE contract. This includes all claims/encounterdata, provider data, authorization, enrollment, and derived datacollected in relation to a TRICARE contract.

Data Set (HIPAA Definition)

A semantically meaningful unitof information exchanged between two parties to a transaction as definedby HIPAA of 1996.

Date Of Determination(Appeals)

The dateof completion appearing on the reconsideration determination, formalreview determination, or hearing final decision.

Days (Defined in 32CFR 199.2)

Calendar days.

Days Supply (Pharmacy)

The length of time a dispensedquantity of drug should last, based on directions for use with alimit as the First Data Bank recommended maximum daily dose (unlessspecifically altered by DoD).

Deductible (Defined in 32CFR 199.2)

Payment by the beneficiaryof the first $50 of the CHAMPUS determined allowable costs or chargesfor covered outpatient services or supplies provided in any onefiscal year; aggregate payment by two or more beneficiaries whosubmit claims for the first $100. Effective January 1, 2018, deductiblesare determined on a calendar year basis. Deductible amounts areoutlined in the TRM, Chapter 2.

Deductible Certificate

A statement issued to the beneficiary(or sponsor) by a TRICARE contractor certifying to the deductible amountssatisfied by a beneficiary for any applicable program year.

Defense Centers of Excellence(COEs)

CoEs focuson an associated group of clinical conditions and create value byachieving improvement in outcomes through clinical, educational,and research activities.

CoEs develop pathways of carecovering the clinical spectrum from prevention through reintegrationor transition.

Products of pathway of caredevelopment include:

Guidance regarding structureddocumentation (electronic health record);

Clinical practice guidelines;

Process and outcome measures;

Educational materials;

Innovation and identificationof research priorities; and,

Strategies for improving accessto care.

Defense Enrollment EligibilityReporting System (DEERS) (Defined in 32CFR 199.2)

An automated system maintainedby the DoD for the purposes of:

1. Enrolling members,former members and their dependents; and

2. Verifying members’,former members’, and their dependents’ eligibility for health carebenefits in the direct facilities and for TRICARE.

De-Identified Data

Health information that hasbeen rendered not individually identifiable by removal of specific identifiers,such as, individual or relatives or household members, names, addresses,employers, name or addressee, or geographic subdivisions smallerthan a State, and all elements of dates (except year) for datesdirectly related to an individual, telephone numbers, Social SecurityNumbers (SSNs), etc., as outlined in HIPAA of 1996.

Demonstration

A study or test project forthe purpose of trying alternative methods of payment for healthand medical services, cost-sharing by eligible beneficiaries, methodsof encouraging efficient and economical delivery of care, innovativeapproaches to delivery and financing services and prepayment forservices provided to a defined population. Following completionand evaluation of the test project, it may or may not become partof the program.

Descriptor (HIPAA Definition)

The text defining a code asdefined in HIPAA of 1996.

Designated Record Set

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

1. The medicalrecords and billing records about individuals maintained by or fora covered HCP;

2. Theenrollment, payment, claims adjudication, and case or medical managementrecord systems maintained by or for a health plan; or

3. Used, in wholeor in part, by or for the covered entity to make decisions aboutindividuals.

For purposes of this definition,the term record means any item, collection, or grouping of information thatincludes PHI and is maintained, collected, used, or disseminatedby or for a covered entity as described in HIPAA of 1996.

Designated Standard MaintenanceOrganization (DSMO)

An organization designatedby the Secretary of HHS under HIPAA of 1996 §162.910(a).

Diagnosis Related Groups(DRGs) (Defined in 32 CFR 199.2)

A method of dividing hospitalpatients into clinically coherent groups based on their consumptionof resources. Patients are assigned to the groups based on theirprincipal diagnosis (the reason for admission, determined afterstudy), secondary diagnoses, procedures performed, and the patient’s age,sex, and discharge status. See the TRM for more specific informationon DRGs.

Diagnostic and StatisticalManual of Mental Disorders (DSM)

A classification system ofcodes for mental illness developed by the American Psychiatric Association (APA).

Direct Data Entry (HIPAADefinition)

The directentry of data (for example, using dumb terminals or web browsers)that is immediately transmitted into a health plan’s computer, asdefined in HIPAA of 1996.

Direct Treatment Relationship(HIPAA Definition)

A treatmentrelationship between an individual and an HCP that is not an indirecttreatment relationship as defined under HIPAA of 1996. See the definitionof “Indirect Treatment Relationship” in this appendix.

Director

The Director of the DHA; Director, TRICARE ManagementActivity (TMA); or Director, Office of CHAMPUS (OCHAMPUS). Any referenceto the Director, Office of CHAMPUS, or OCHAMPUS, or TMA shall meanthe Director, DHA. Any reference to Director shall also includeany person designated by the Director to carry out a particularauthority. In addition, any authority of the Director may be exercisedby the Assistant Secretary of Defense for Health Affairs (ASD(HA)).

Director, Market

An individual responsible for:

The concept which integrateshealth care among the Uniformed Services by providing increased authorityincluding funding allocation, policy, and better maximization ofstaff skill sets; and

Oversight geographic areaswhere different Uniformed Services have overlapping service areas; and

The movement of workload andworkforce between or among medical treatment facilities, as applicable.

Director, Military MedicalTreatment Facility (MTF)

The individual responsiblefor overseeing a Uniformed Services hospital or clinic.

Director, TRICARE RegionalOffices (TROs)

An individualresponsible for:

1. Overseeingand ensuring there is an integrated health care delivery systemfor TRICARE beneficiaries in the region; and

2. Oversight ofthe management/monitoring of the daily administration of the TRICAREcontract/contractor(s) in the region; and

3. Managing thedaily activities of the TRO.

Disaster Response Duty

For purposes of TPM, Chapter 10, Section 10.1 only, the term “disasterresponse duty” means duty performed by a member of the NationalGuard in State status pursuant to an emergency declaration by theGovernor of the State (to include the four United States Territories,or with respect to the District of Columbia, the mayor of the Districtof Columbia) in response to a disaster or in preparation for an imminentdisaster.

Discharge Planning

The development of an individualizeddischarge health care plan for the patient prior to leaving an institutionto follow at home, with the aim of improving patient outcomes, reducingthe chance of unplanned readmission to an institution, and containingcosts.

Disclosure (HIPAA Definition)

The release, transfer, provisionof access to, or divulging in any other manner of information outsidethe entity holding the information as defined in HIPAA of 1996.

Distant Site

The “distant site” is wherethe physician or practitioner providing the professional serviceis located at the time the services are provided via an interactivetelecommunications system.

DoD Information

Information that is providedby the DoD to a non-DoD entity, or that is collected, developed,received, transmitted, used, or stored by a non-DoD entity in supportof an official DoD activity, where that information has not beencleared for public release.

Domiciliary Care (Definedin 32 CFR 199.2)

Care provided to a patientin an institution or home-like environment because:

1. Providing supportfor the ADLs in the home is not available or is unsuitable; or

2. Members ofthe patient’s family are unwilling to provide the care.

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

Donor (Defined in 32CFR 199.2)

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

Double Coverage (Definedin 32 CFR 199.2)

When a TRICARE beneficiaryalso is enrolled in another insurance, medical service, or healthplan that duplicates all or part of a beneficiary’s TRICARE benefits.

Double Coverage Plan(Defined in 32 CFR 199.2)

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

1. Medicaid.

2. Coverage specificallydesigned to supplement TRICARE benefits.

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

4. Entitlementto receive care from DVA/VHA medical care facilities; or

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

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

Dual Compensation (Definedin 32 CFR 199.2)

Federal law (5 USC 5536) prohibitsactive duty members or civilian employees of the U.S. Government fromreceiving additional compensation from the Government above theirnormal pay and allowances. This prohibition applies to TRICARE cost-sharingof medical care provided by active duty members or civilian Governmentemployees to TRICARE beneficiaries.

Edit Error (TEDs Only)

Errors found on TEDs (initialsubmissions, resubmissions, and adjustments/cancellation submissions) whichresult in non-acceptance of the records by DHA. These require correctionof the error by the contractor and resubmission of the correctedTED to DHA for acceptance.

Electronic Media (HIPAADefinition)

A modeof transferring/storing information that includes:

1. Electronicstorage material on which data may be recorded electronically, includingfor example devices in computers (hard drives) and any removable/transportabledigital memory medium, such as magnetic tape or disk, or digitalmemory card.

2. Transmissionmedia used to exchange information already in electronic storagemedia. Transmission media includes, for example, the Internet (theExtranet leased lines, dial-up lines, private networks, and thephysical movement of removable and transportable electronic storagemedia. Certain transmissions, including paper, via facsimile, andof voice, via telephone, are not considered to be transmissionsvia electronic media if the information being exchanged did notexist in electronic form immediately before the transmission.

Employment Records (Definedin DoD 5400.11-R, DoD Privacy Program)

Any item collection or groupingof information, whatever the storage media (paper, electronic, etc,) aboutan individual that is maintained by an entity subject to the DoDPrivacy Program Regulation including but not limited to an individual’seducation, financial transactions, medical history, criminal oremployment history, and that contains his or her name, or the identifyingnumber, symbol, or other identifying particular assigned to theindividual, such as a finger or voice print or a photograph. For morespecific information refer to the DoD Privacy Program Regulation.

Enrollment Fees

The amount required to be paidby some MHS beneficiaries eligible to enroll in and receive thebenefits of TRICARE Prime, TRICARE Select or other special TRICAREprograms.

Enrollment Plan

A process established by thecontractor to inform beneficiaries of the availability of the TRICAREPrime program, facilitate enrollment in the program, and maintainenrollment records. The plan must include actions for TRICARE Selectand must be approved by the Government. The contractor process mustbe approved by the Government.

Enrollment Records

Official documentation of abeneficiary’s registration (enrollment) for TRICARE Prime and maintained onthe DEERS.

Enrollment Transfer

A transfer of TRICARE enrollmentfrom one location or contractor to another:

1. Out-Of-Contract EnrollmentTransfer. An enrollment transfer between contractors, toinclude the Continental United States (CONUS) to CONUS, CONUS toOutside of the Continental United States (OCONUS), and OCONUS toCONUS. The term “contractors” also includes Designated Providers(DPs) under the Uniformed Services Family Health Plan (USFHP).

2. Within-Contract EnrollmentTransfer. An enrollment transfer within a TRICARE region,which involves a change of address and possibly a change of PrimaryCare Managers (PCMs), but not a change of contractors.

Entity (Defined in 32CFR 199.2)

An entity includes a corporation,trust, partnership, sole proprietorship or other kind of business enterprisethat is or may be eligible to receive reimbursem*nt either directlyor indirectly from TRICARE.

Episodes of Care (EOC)

Referrals are normally processedas “Episodes of Care.” An EOC is defined as “A treatment periodthat begins with the initial assessment, follow up interventionsand reassessments necessary to provide reasonable medical servicesrelated to a specific condition.” The episode includes associatedlab, radiology, Durable Medical Equipment (DME), and ancillary therapies(Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy(ST)), all of which are subject to the Right of First Refusal (ROFR)process. An episode of care generally involves evaluation and/ortreatment of one disease or condition and may allow for specialistto specialist (secondary) referrals. Episodes are generally categorizedas “evaluate (only)” or “evaluate and treat.”

Exclusion

Services and/or supplies notreimbursable under TRICARE. This includes otherwise covered services andsupplies provided to a TRICARE eligible beneficiary by a non-authorizedprovider/entity or a provider placed on “suspension” by a contractor.

Executive Director, TRICAREArea Office(s)

The individualresponsible for:

1. Overseeingand ensuring there is an integrated health care delivery systemfor TRICARE beneficiaries in the region; and

2. Oversightof the management/monitoring of the daily administration of theTRICARE contract/contractor(s) in the region; and

3.Managing the daily activities of the region.

Explanation Of Benefits(EOB)

An electronicor paper document prepared by insurance carriers, health care organizations,and TRICARE contractors to inform beneficiaries of the actions takenwith respect to a claim for health care coverage.

Explanation Of Benefits(EOB) Pharmacy

An electronicor paper document which provides a consolidated listing of prescriptionsfilled for the beneficiary over a specific period of time. The periodof time is dependent on printed request (quarterly) or online (userdefined).

Explanation Of Payment(EOP) Pharmacy

A documentprovided to either the beneficiary after paper claims are processedor network pharmacies for each payment cycle. This document describesthe action taken for each claim processed to a final determination(paid or denied). EOPs are not generated for beneficiaries processingclaims electronically at the point of sale.

Extraordinary PhysicalOr Psychological Condition

A complex physical or psychologicalclinical condition of such severity which results in the dependents ofa Service member being homebound. See TPM, Chapter9 for additional information.

Family Member

A family member is a dependentas defined in 10 USC 1072, who otherwise meets the requirementsto be an eligible beneficiary under the law.

Federal Records Center(FRCs)

Locationsestablished and maintained by the General Services Administration(GSA) at areas throughout the U.S. for the storage, processing,and servicing of non-current records for Government agencies.

Files Administration

The application of recordsmanagement techniques to filing practices to maintain records easilyand to retrieve them rapidly, to ensure their completeness, andto facilitate the disposition of noncurrent records.

Fiscal Year (FY)

The Federal Government’s 12month accounting period which currently runs from October 1 through September30 of the following year.

Format (HIPAA Definition)

Those data elements that provideor control the enveloping or hierarchical structure, or assist in identifyingdata content of, a transaction, as defined in HIPAA of 1996.

Former Member

An individual who is eligiblefor, or entitled to, retired pay, at age 60, for non-regular servicein accordance with Chapter 1223, Title 10, USC but has been dischargedand maintains no military affiliation. These former members, atage 60, and their eligible dependents are entitled to medical care, commissary,exchange, and MWR privileges. Under age 60, they and their eligibledependents are entitled to commissary, exchange, and MWR privilegesonly.

Formulary

A listing of pharmaceuticalsand other authorized supplies to be dispensed with appropriate prescriber’sorder from a particular POS. The formulary for any TRICARE contractwill be managed by the DoD Pharmacy and Therapeutics (P&T) Committeewith clinical guidance from the DoD Pharmacoeconomic Center (PEC).Applicable formulary information may be viewed on the TRICARE website at: http://www.health.mil/formulary.

Freedom Of Choice

The right to obtain medicalcare from any TRICARE-authorized source available, including TRICARE Prime,the DC and/or the MTF/eMSM systems, or obtain care from a providernot affiliated with the contractor and seek reimbursem*nt underthe terms and conditions of the TRICARE Standard (TRICARE Selectstarting January 1, 2018) Program (see definition).

Note:Beneficiaries who voluntarilyenroll in TRICARE Prime must be informed of any restrictions onfreedom of choice that may be applicable to enrollees as a resultof enrollment. Except for any limitations on freedom of choice thatare fully disclosed to the beneficiaries at the time of enrollment, freedomof choice provisions applicable to the TRICARE Standard (TRICARESelect starting January 1, 2018) Program shall be applicable toTRICARE Prime.

Freedom Of InformationAct (FOIA)

A lawenacted in 1967 as an amendment to the “Public Information” sectionof the Administrative Procedures Act, establishing provisions makinginformation available to the public. DHA and TRICARE contractorsare subject to these provisions.

Freestanding (Definedin 32 CFR 199.2)

Not “institution-affiliated”or “institution-based.”

Full Mobilization (DoDDefinition)

Expansionof the Active Armed Forces resulting from action by Congress andthe President to mobilize all Reserve Component (RC) units and individualsin the existing approved force structure, as well as retired militarypersonnel, and the resources needed for their support to meet therequirements of a war or other national emergency involving an externalthreat to the national security. Reserve personnel can be placedon active duty for the duration of the emergency plus six months.

Gag Clause

A provision that is includedin a professional provider’s agreement or contract with a managedcare organization; such as a Preferred Provider Organization (PPO)network or a Health Maintenance Organization (HMO) network, or third-partypayer that directly or indirectly prevents limits the ability of theHCP from being open with his/her patients about the terms of thepatient’s coverage and therapeutic treatment options, including,the risks, benefits and consequences of treatment or non-treatment,or the opportunity for the individual to refuse treatment and toexpress preferences about future treatment options.

Good Faith Payments (Definedin 32 CFR 199.2)

Those payments made to civiliansources of medical care who provided medical care to persons purportingto be eligible beneficiaries but who are determined later to beineligible for TRICARE benefits. (The ineligible person usuallypossesses an erroneous or illegal identification card.) To be consideredfor good faith payments, the civilian source of care must have exercisedreasonable precautions in identifying a person claiming to be aneligible beneficiary.

Grievance

A written complaint on a non-appealableissue which deals primarily with a perceived failure of a networkprovider, the Health Care Finder (HCF), or contractor or subcontractor,to furnish the level or quality of care expected by a beneficiary.

Grievance Process

A contractor developed andmanaged system for resolving beneficiary grievances.

Group A and B

With respect to beneficiarycost-sharing, deductibles and catastrophic cap, the NDAA 2017 divided beneficiariesenrolled in TRICARE Prime or TRICARE Select into two groups:

Group A (or grandfathered)beneficiaries: consists of sponsors and their family members whofirst became affiliated with a Uniformed Service through enlistmentor appointment before January 1, 2018.

Group B (or non-grandfathered)beneficiaries: consists of sponsors and their family members who firstbecame affiliated with a Uniformed Service through enlistment orappointment on or after January 1, 2018.

Effective January 1, 2018,enrollees in the TRICARE Reserve Select (TRS), TRICARE Retired Reserve(TRR), TRICARE Young Adult (TYA), or the CHCBP have Group B cost-shares,deductibles, and catastrophic caps, regardless of when the sponsorfirst became affiliated with a Uniformed Service through enlistmentor appointment.

Group Health Plan (GHP)

An employee welfare benefitplan (as defined in section 3(1) of the Employee Retirement Incomeand Security Act of 1974 (ERISA), 29 USC 1002(1)), including insuredand self-insured plans, to the extent that the plan provides medicalcare (as defined in section 2791(a)(2) of the Public Health ServiceAct (PHS Act), 42 USC 300gg-91(a)(2)), including items and servicespaid for as medical care, to employees or their dependents directlyor through insurance, reimbursem*nt, or otherwise, that:

1. Has 50 or moreparticipants (as defined in section 3(7) of ERISA, 29 USC 1002(7));or

2. Isadministered by an entity other than the employer that establishedand maintains the plan.

Health Care

The prevention, treatment andmanagement of illness and the preservation of mental and physicalwell being by qualified medical professionals. This includes butis not limited to, preventive, diagnostic, therapeutic, rehabilitative,maintenance, or palliative care, and counseling, service, assessment,or procedure with respect to the physical or mental condition, orfunctional status, of an individual or that affects the structureor function of the body; and the sale or dispensing of a drug, device,equipment, or other item in accordance with a prescription. As describedin HIPAA of 1996.

Health Care Clearinghouse(HIPAA Definition)

A publicor private entity, including a billing service, repricing company,community health management information system or community healthinformation system, and “value-added” networks and switches, thatdoes either of the following functions.

1. Processes orfacilitates the processing of health information received from anotherentity in a nonstandard format or containing nonstandard data contentinto standard data elements or a standard transaction.

2. Receives astandard transaction from another entity and processes or facilitatesthe processing of health information into nonstandard format ornonstandard data content for the receiving entity. As defined inHIPAA of 1996.

Health Care Common ProcedureCoding System (HCPCS)

Set of health care procedurecodes based on the American Medical Association’s (AMA’s) Current ProceduralTerminology (CPT).

Health Care Finder (HCF)

A person who manages and performsthe duties necessary to operate an HCF system.

Health Care Finder (HCF)System

A systemor mechanism, established by the contractor in each Prime ServiceArea (PSA) in the region, to facilitate referrals and other customerservice functions to assist beneficiaries in accessing health care tothe DC system and/or civilian providers.

Health Care Provider(HCP) (HIPAA Definition)

A provider of medical or healthservices, institutional or individual professional provider, andany other person or organization who furnishes, bills, or is paidfor health care in the normal course of business as defined in HIPAAof 1996.

Health Information (HIPAADefinition)

Any information,including genetic information, whether oral or recorded, in anyform or medium that:

1. Iscreated or received by a HCP, health plan, public health authority,employer, life insurer, school or university, or health care clearinghouse;and

2. Relatesto the past, present, or future physical or mental health or conditionof an individual; the provision of health care to an individual;or the past, present, or future payment for the provision of healthcare to an individual.

As defined in HIPAA of 1996.

Health Insurance Issuer(HIPAA Definition)

An insurancecompany, insurance service, or insurance organization (includingan HMO) that is licensed to engage in the business of insurancein a State and is subject to State Law that regulates insurance. Suchterm does not include a group health plan.

Health Maintenance Organization(HMO) (HIPAA Definition)

A federally qualified HMO,an organization recognized as an HMO under State law, or a similar organizationregulated for solvency under State law in the same manner and tothe same extent as such an HMO as defined in HIPAA of 1996.

Health Oversight Agency(HIPAA Definition)

An agencyor authority of the U.S., a State, a territory, a political subdivisionof a State or territory, or an Indian tribe, or a person or entityacting under a grant of authority from or contract with such public agency,including the employees or agents of such public agency or its contractorsor persons or entities to whom it has granted authority, that isauthorized by law to oversee the health care system (whether publicor private) or Government programs in which health information isnecessary to determine eligibility or compliance, or to enforcecivil rights laws for which health information is relevant as definedin HIPAA of 1996.

Note:The term “health oversightagency” includes any DoD Component authorized under applicable DoDRegulation to oversee the MHS, including with respect to mattersof quality of care, risk management, program integrity, financialmanagement, standards of conduct, or the effectiveness of the MHSin carrying out its mission.

Health Plan (HIPAA Definition)

An individual or group planthat provides or pays the cost of medical care. For a more detailed definitionrefer to HIPAA of 1996.

HIPAA Breach

An incident that satisfiesthe definition of a breach in 45 CFR 164.402 (HIPAA Breach Rule).

Homebound (Defined in 32CFR 199.2)

A beneficiary’s condition issuch that there exists a normal inability to leave home, and consequently, leavinghome would require considerable and taxing effort. Any absence ofan individual from the home attributable to the need to receivehealth care treatment including regular absences for the purposeof participating in rehabilitative, therapeutic, psychosocial, ormedical treatment in an adult daycare program that is licensed orcertified by a state, or accredited to furnish adult daycare servicesin the state shall not disqualify an individual from being consideredto be confined to home. Any other absence of an individual fromthe home shall not disqualify an individual if the absence is infrequentor of relatively short duration. For the purposes of the precedingsentence, any absence for the purpose of attending a religious serviceshall be deemed to be an absence of infrequent or short duration.Also, absences from the home for non-medical purposes, such as anoccasional trip to the barber, a walk around the block or a drive,would not necessarily negate the beneficiary’s homebound statusif the absences are undertaken on an infrequent basis and are ofrelatively short duration. An exception is made to the above homebounddefinitional criteria for beneficiaries under the age of 18 andthose receiving maternity care. The only homebound criteria forthese special beneficiary categories is written certification froma physician attesting to the fact that leaving home would placethe beneficiary at medical risk. In addition to the above absences,whether regular or infrequent, from the beneficiary’s primary homefor the purpose of attending an educational program in a publicor private school that is licensed and/or certified by a state,shall not negate the beneficiary’s homebound status. See also TPM, Chapter9 for additional information.

Hospital Day

An overnight stay at a hospital.Normally if the patient is discharged in less than 24 hours it wouldnot be considered an inpatient stay; however, if the patient wasadmitted and assigned to a bed and the intent of the hospital wasto keep the patient overnight, regardless of the actual Length-Of-Stay(LOS), the stay will be considered an inpatient stay and, therefore,a hospital day. For hospital stays exceeding 24 hours, the day ofadmission is considered a hospital day; the day of discharge isnot.

Immediate Family (Definedin 32 CFR 199.2)

The spouse, natural parent,child and sibling, adopted child and adoptive parent, stepparent,stepchild, grandparent, grandchild, stepbrother and stepsister,father-in-law, mother-in-law of the beneficiary, or provider, asappropriate. For purposes of this definition only, to determinewho may render services to a beneficiary, the step-relationshipcontinues to exist even if the marriage upon which the relationshipis based terminates through divorce or death of one of the parents.

Independent Laboratory(Defined in 32 CFR 199.2)

A freestanding laboratory approvedfor participation under Medicare and certified by the CMS.

Indirect Treatment Relationship(HIPAA Definition)

A relationshipbetween an individual and a HCP in which:

1. The HCP delivershealth care to the individual based on the orders of another HCP;and

2. TheHCP typically provides services or products, or reports the diagnosisor results associated with the health care, directly to anotherHCP, who provides the services or products or reports to the individual.

As defined in HIPAA of 1996.

Individual

The person who is the subjectof PHI as defined in HIPAA of 1996.

Individual Consideration(IC) Procedure

A service/treatmentnot routinely provided, is unusual, variable, or new and, as such,will require additional information from the provider of care, includingan adequate definition or description of the nature, extent andneed for the unusual service/treatment including the time, effort,and necessary equipment required. Any complexities related to theservice should also be identified.

Individually IdentifiableHealth Information (IIHI) (HIPAA Definition)

Information that is a subsetof health information, including demographic information collectedfrom an individual, and:

1. Iscreated or received by a HCP, health plan, employer, or health careclearinghouse; and

2. Relates tothe past, present, or future physical or mental health or conditionof an individual; the provision of health care to an individual;or the past, present, or future payment for the provision of healthcare to an individual; and

3. That identifiesthe individual; or

4. With respectto which there is a reasonable basis to believe the informationcan be used to identify the individual.

As defined in HIPAA of 1996.

Initial Determination(Defined in 32 CFR 199.2)

A formal written decision ona TRICARE claim, a request for benefit authorization, a requestby a provider for approval as an authorized TRICARE provider, ora decision disqualifying or excluding a provider as an authorizedprovider under TRICARE. Rejection of a claim or a request for benefitor provider authorization for failure to comply with administrativerequirements, including failure to submit reasonably requested information,is not an initial determination. Responses to general or specificinquiries regarding TRICARE benefits are not initial determinations.

Initial Payment

The first payment on a continuingclaim, such as a long-term institutional claim.

Inpatient (Defined in 32CFR 199.2)

A patient who has been admittedto a hospital or other authorized institution for bed occupancyfor purposes of receiving necessary medical care, with the reasonableexpectation that the patient will remain in the institution at least24 hours, and with the registration and assignment of an inpatient numberor designation. Institutional care in connection with in and out(ambulatory) surgery is not included within the meaning of inpatientwhether or not an inpatient number or designation is made by thehospital or other institution. If the patient has been receivedat the hospital, but death occurs before the actual admission occurs,an inpatient admission exists as if the patient had lived and had beenformally admitted.

Inpatient Care

Services/treatment providedto a person who has been admitted to a hospital or other authorized institution.

Inpatient RehabilitationFacility (IRF)

A facilityclassified by CMS as an IRF and meets the applicable requirementsestablished by 32 CFR 199.6(b)(4)(xx) (which includes therequirement to be a Medicare participating provider).

Inquiry

Requests for information orassistance made by or on behalf of a beneficiary, provider, thepublic, or the Government. Written inquiries may be made in anyformat (letter, memorandum, note attached to a claim, etc.). Allowablecharge complaints, grievances, and appeals are excluded from thisdefinition.

Institution-Affiliated(Defined in 32 CFR 199.2)

Related to a TRICARE authorizedinstitutional provider through a shared governing body but operating undera separate and distinct license or accreditation.

Institution-Based (Definedin 32 CFR 199.2)

Related to a TRICARE authorizedinstitutional provider through a shared governing body and operating undera common license and shared accreditation.

Institutional Provider

A HCP who meets the applicablerequirements established by 32 CFR 199.6.

Intensive OutpatientProgram (IOP)

A treatmentsetting capable of providing an organized day or evening programthat includes assessment, treatment, case management, and rehabilitationfor individuals not requiring 24-hour care for mental health disorders,to include SUDs, as appropriate for the individual patient. Theprogram structure is regularly scheduled, individualized, and sharesmonitoring and support with the patient’s family and support system.

Interactive TelecommunicationsSystem

Interactivetelecommunications systems are defined as multimedia communicationsmodalities that include, at a minimum, secure audio and video equipmentpermitting two-way, real-time services or consultations. This includessmartphones, tablet computers, and personal computers equipped with thenecessary camera and software to enable two-way, encrypted real-timeaudio and video interaction; as well as dedicated video conferencingand telemedicine systems.

Internal Control Number(ICN)

The uniquenumber assigned to a claim by the contractor to distinguish theclaim during processing, payment, and filing procedures. It is thenumber affixed to the face of each claim received and will, at a minimum,include the Julian date of receipt and a five digit sequence numberassigned by the contractor. Each TED must have a unique ICN. Forrecords generated from claims, it will be the ICN of the claim fromwhich it was generated. For a TED which is not generated from claims,it will be a unique number assigned by the contractor which willinclude the Julian date of the record’s creation and a five digitsequence number.

International Classificationof Diseases, 9th Edition, Clinical Modification (ICD-9-CM)

A technical reference, ICD-9-CM.Volumes 1 and 2 are a required reference and coding system for diagnosesand Volume 3 is required as a coding system for procedures in processingTRICARE claims for medical care with dates of service for outpatientservices or dates of discharge for inpatient services before themandated date, as directed by HHS, for ICD-10 implementation.

International Classificationof Diseases, 10th Edition, Clinical Modification (ICD-10-CM)

A technical reference, ICD-10-CM.It is a required reference and coding system for diagnoses in processingTRICARE claims for medical care with dates of service for outpatientservices or dates of discharge for inpatient services on or afterthe mandated date, as directed by HHS, for ICD-10 implementation.

International Classificationof Diseases, 10th Edition, Procedure Coding System (ICD-10-PCS)

A technical reference, ICD-10-PCS.It is a required reference and coding system for procedures in processingTRICARE claims for medical care with dates of discharge for inpatientservices on or after the mandated date, as directed by HHS, forICD-10 implementation.

Intervention, Pharmacy

A change in therapy resultingfrom the prospective drug utilization review process and contactwith the prescriber and/or the beneficiary because of allergy, clinicallysignificant interactions, duplicative therapy, or other reasons.

Intervention Report,Pharmacy

A formalaccount of prescriptions not dispensed or changes in therapy asa result of contact with prescriber's and/or beneficiaries becauseof allergies, clinically significant interactions, duplicative therapy,or other reasons. The formal account shall also contain the resultantchange in cost due to the intervention, if possible.

Investigational Drugs

New medicines or other substanceswhich have a physiological effect when ingested or otherwise introducedinto the body, that have not been approved for general use by theFDA but is under investigation and clinical trial regarding itssafety and efficacy first by clinical investigators and then by practicingphysician using subjects who have given informed consent to participate.

Laboratory And PathologicalServices (Defined in 32 CFR 199.2)

Laboratory and pathologicalexaminations (including machine diagnostic tests that produce hard-copy results)when necessary to, and rendered in connection with medical, obstetrical,or surgical diagnosis or treatment of an illness or injury, or inconnection with well-baby care.

Law Enforcement Official(HIPAA Definition)

An officeror employee of any agency or authority of the U.S., a State, a territory,a political subdivision of a State or territory, or an Indian tribe,who is empowered by law to:

1. Investigateor conduct an official inquiry into a potential violation of law;or

2. Prosecuteor otherwise conduct a criminal, civil, or administrative proceedingarising from an alleged violation of law.

For further details, referto HIPAA of 1996.

Legacy Identifier

A number used to identify uniqueproviders. These number include the six-digit Medicare ID number, UniquePhysician Identification Number (UPIN), 10-digit Ambulatory SurgeryCenter (ASC) number, Supplier Clearinghouse (NSC) number, OnlineSurvey Certification and Reporting (OSCAR) number, and DME suppliernumber. A legacy identification number is other than the uniqueNPI required by HIPAA of 1996 to be issued to each physician, supplierand other provider of health care and the Federal Tax IdentificationNumber (TIN). A Federal TIN is not considered a legacy identifierfor health care purposes as it’s primary purpose is to support IRS1099 reporting.

Limited Data Set (HIPAADefinition)

A semanticallymeaningful unit of information exchanged between two parties toa transaction that excludes direct identifiers of the individualor of relatives, employers, or household members of the individualwhich is considered to be PHI as defined in HIPAA of 1996.

Long-Term Care Hospital(LTCH)

A hospitalthat is classified by the CMS as an LTCH and meets the applicablerequirements established by 32 CFR 199.6(b)(4)(v) (which includes therequirement to be a Medicare participating provider).

Machine-Readable Records/Archives

The records and archives whoseinformational content is usually in code and has been recorded on media,such as magnetic disks, drums, tapes, punched paper cards, or punchedpaper tapes, accompanied by finding aids known as software documentation.The coded information is retrievable only by machine.

Maintain Or Maintenance(HIPAA Definition)

Activitiesnecessary to support the use of a standard adopted by the Secretaryof HHS, including technical corrections to an implementation specification,and enhancements, or expansion of a code set. This term excludesthe activities related to the adoption of a new standard or implementation specification,or modification to an adopted standard or implementation specification.

Major Diagnostic Category(MDC)

A groupof similar DRGs, such as all those effecting a given organ systemof the body formed by dividing all possible principal diagnosesfrom (ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDCcodes, like DRG codes, are primarily a claims and administrativedata element unique to the U.S. medical care reimbursem*nt system.DRG codes are also mapped, or grouped, into the MDC codes.

Managed Care SupportContractor (MCSC)

Civiliancontractor, under contract with the DoD, to work with, help supportand augment health care services available at the MTFs/eMSMs resultingin the establishment of an integrated system of health care deliverythat influences utilization of services, cost of services whilemeasuring performance. The contractor is required to assist militarypersonnel in the combining of the resources of the military’s directmedical care system, the TRICARE program and the contractor’s managedcare provider network and other services outlined in the contractto ensure a system that delivers value by giving TRICARE eligiblebeneficiaries access to quality, cost-effective health care.

Market (previously EnhancedMulti-Service Market (eMSM))

Concept which integrates healthcare among the Uniformed Services by providing increased authority includingfunding allocation, policy, and better maximization of staff skillsets. The concept is employed in geographic areas where differentUniformed Services have overlapping service areas. This concept providesthe MHS the ability for the movement of workload and workforce betweenor among the medical treatment facilities based on several factors,including overall size, medical mission, and graduate medical educationcapacity.

Marketing (HIPAA Definition)

Communication about a productor service to encourage recipients of the communication to purchase oruse the product or service as defined in HIPAA of 1996. See alsoDoD 6025.18R, DoD Health Information Privacy Regulation, for a listof specific exclusions to this definition.

Maximum Allowable PrevailingCharge

The TRICAREstate prevailing charges adjusted by the Medicare Economic Index(MEI) according to the methodology as set forth in Chapter16.

Maximum Defined DataSet (HIPAA Definition)

All required data elementsfor a particular standard based on a specific implementation specification.

Medicaid (Defined in 32CFR 199.2)

Those medical benefits authorizedunder Title XIX of the Social Security Act provided to welfare recipientsand the medically indigent through programs as administered by thevarious states.

Medical (Defined in 32CFR 199.2)

The generally used term whichpertains to the diagnosis and treatment of illness, injury, pregnancy, andmental disorders by trained and licensed or certified health professionals.For purposes of TRICARE, the term “medical” should be understoodto include “medical, psychological, surgical, and obstetrical,” unlessit is specifically stated that a more restrictive meaning is intended.

Medical/Dental ClaimsHistory File

Referto Beneficiary History File definition.

Medical Emergency (Definedin 32 CFR 199.2)

The sudden and unexpected onsetof a medical condition or the acute exacerbation of a chronic conditionthat is threatening to life, limb, or sight, and requires immediatemedical treatment or which manifests painful, symptomatology requiringimmediate palliative efforts to alleviate suffering. Medical emergenciesinclude heart attacks, cardiovascular accidents poisoning, convulsions,kidney stones, and such other acute medical conditions as may bedetermined to be medical emergencies by the Director, DHA or a designee.In the case of a pregnancy, a medical emergency must involve a suddenand unexpected medical complication that puts the mother, the baby,or both, at risk. Pain would not, however, qualify a maternity caseas an emergency, nor would incipient birth after the 34th week of gestation,unless an otherwise qualifying medical condition is present. Examplesof medical emergencies related to pregnancy or delivery are hemorrhage,ruptured membrane with prolapsed cord, placenta previa, abruptionplacenta, presence of shock or unconsciousness, suspected heart attackor stroke, or trauma (such as injuries received in an automobileaccident.

Medical Necessity Determination

A review to determine if therecommended health care services are reasonable for the diagnosisand treatment of illness, injury, pregnancy, mental disorders andadequate for well-baby care.

Medical Supplies AndDressings (Consumables) (Defined in 32CFR 199.2)

Necessary medical or surgicalsupplies (exclusive of DME) that do not withstand prolonged, repeated useand that are needed for the proper medical management of a conditionfor which benefits are otherwise authorized under TRICARE, on eitheran inpatient or outpatient basis. Examples include disposable syringesfor a diabetic, colostomy sets, irrigation sets, and ace bandages.

Medical Management

Contemporary practices in areassuch as Utilization Management (UM), Case Management (CM), care coordination,chronic care/Disease Management (DM), and the various additionalterms and models for managing the clinical and social needs of eligiblebeneficiaries to achieve the short and long term cost-effectivenessof the MHS while achieving the highest level of satisfaction amongMHS beneficiaries.

Medically or PsychologicallyNecessary (Defined in 32 CFR 199.2)

The frequency, extent and typesof medical services or supplies, which represent appropriate medical careand that are generally accepted by qualified professionals to bereasonable and adequate for the diagnosis and treatment of illness,injury, pregnancy, and mental disorders or that are reasonable and adequatefor well-baby care.

Medicare (Defined in 32CFR 199.2)

The medical benefits authorizedunder Title XVIII of the Social Security Act provided to persons65 or older, certain disabled persons, or persons with chronic renaldisease, through a national program administered by the Departmentof Health and Human Services (DHHS), Health Care Financing Administration(HCFA), Medicare Bureau.

Medicare Economic Index(MEI)

An indexused by Medicare to update physician fee levels in relation to annualchanges in the general economy for inflation, productivity, andchanges in specific health sector practice expenses factors includingmalpractice, personnel costs, rent, and other expenses.

Medication Assisted Treatment(MAT)

MAT fordiagnosed SUD is a holistic modality for recovery and treatmentthat employs evidence-based therapy, including psychosocial treatmentsand psychopharmacology, and FDA-approved medications as indicatedfor the management of withdrawal symptoms and maintenance.

Medication Error (FDADefinition)

Any preventableevent that may cause or lead to inappropriate medication use orpatient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be relatedto professional practice, health care products, procedures, andsystems, including prescribing, order communication, product labelingpackaging, and nomenclature, compounding, dispensing, distribution,administration, education, monitoring and use as defined by theFDA.

Mental Disorder, To IncludeSUD

For purposes of the paymentof TRICARE benefits, a mental disorder is a nervous or mental condition thatinvolves a clinically significant behavioral or psychological syndromeor pattern that is associated with a painful symptom, such as distress,and that impairs a patient’s ability to function in one or more majorlife activities. An SUD is a mental condition that involves a maladaptivepattern of substance use leading to clinically significant impairmentor distress; impaired control over substance use; social impairment;and risky use of a substance(s). Additionally, the mental disordermust be one of those conditions listed in the current edition ofthe DSM. “Conditions Not Attributable to a Mental Disorder,” or V codes,or ICD-10-CM Z codes, are not considered diagnosablemental disorders.

Member

An individual who is affiliatedwith a Service, either an active duty member, reserve member, active dutyretired member, or retired reserve member. Members in a retiredstatus are not former members. Also referred to as the sponsor.

Mental Health TherapeuticAbsence (Defined in 32 CFR 199.2)

A therapeutically planned absencefrom the inpatient setting. The patient is not discharged from the facilityand may be away for periods of several hours to several days. Thepurpose of the therapeutic absence is to give the patient an opportunityto test his or her ability to function outside the inpatient settingbefore the actual discharge.

Military Health System(MHS) Beneficiary

Any individualwho is eligible to receive treatment in an Market/MTF. Eligibilityis determined by the Uniformed Services and is reported on DEERS.

Note:The categories of MHS beneficiariesshall be broadly interpreted unless otherwise specifically restricted.(For example: Authorized parents and parents-in-law are not eligiblefor TRICARE Program, but may receive treatment in an Market/MTF (ona space available basis) and may access the Nurse Advise Line (NAC)).

Military Medical TreatmentFacility (MTF)

A UniformedServices hospital or clinic.

Military Medical TreatmentFacility (MTF) Director

The individual responsiblefor overseeing a Uniformed Services hospital or clinic.

Market/Military MedicalTreatment Facility (MTF) Optimization

Filling every appointment andbed available within the MTF or in the Market based on the capacityand capabilities of the Market/MTF and the Market’s/MTF’s readiness/trainingrequirements, as defined by the Market/MTF Director before referralto outside civilian providers.

Military Medical TreatmentFacility (MTF)-Referred Care

Medical care or services/suppliesrequired by a patient that are not available at the MTF or in the Market areaand therefore must be provided by an outside civilian provider.Such care requires an Market/MTF referral for the civilian medicalcare.

Mobilization Plan - TRICARE

A detailed proposal designedto ensure the Government’s ability to continue to meet the healthcare needs of the TRICARE-eligible beneficiaries in the event ofa military mobilization that precludes the use of all or parts ofthe military DC system for provision of care to TRICARE-eligiblebeneficiaries.

Monthly Pro-Rating

A calculation process for determiningthe amount of the enrollment fee to be credited to a new enrollmentperiod. For example, if a beneficiary pays their annual enrollmentfee, in total, on January 1, (the first day of their enrollmentperiod) and a change in status occurs on February 15. The beneficiary willreceive credit for 10 months of the enrollment fee. The beneficiarywill lose that portion of the enrollment fee that would have coveredthe period from February 15 through February 28.

Most-Favored Rate (Definedin 32 CFR 199.2)

The lowest usual charge toany individual or third-party payer in effect on the date of theadmission of a TRICARE beneficiary.

National AppropriateCharge Level

The chargelevel established from a 1991 national appropriate charge file developedfrom July 1986 - June 1987 claims data, by applying appropriateMEI updates through 1990, and prevailing charge cuts, freeze orMEI updates for 1991 as discussed in the September 6, 1991, FinalRule.

National Conversion Factor(NCF)

A mathematicalrepresentation of what is currently being paid for similar servicesnationally. The factor is based on the national allowable chargesactually in use.

National Disaster MedicalSystem (NDMS)

A Federallycoordinated framework that augments the nation’s medical responsecapability. The primary purpose of the NDMS is to supplement anintegrated national medical response for assisting state and localauthorities in dealing with medical impacts of major peacetime disastersand to provide support to the military and the DVA/VHA medical systemsin caring for casualties evacuated back to the U.S. from overseasarmed conventional conflict. The NDMS framework involves privatesector hospitals located throughout the U.S. that will provide carefor victims of any incident that exceeds the medical care capabilityof any affected state, region, or federal medical care system. Formore detailed information see NDMS at the DHHS web site.

National Prevailing ChargeLevel

A ratethat does not exceed the amount equivalent to the eightieth (80th)percentile of billed charges made for similar services during a12 month base period.

National Provider Identifier(NPI) (HIPAA Definition)

A 10-digit number assignedto all HCPs mandated by HIPAA of 1996. These numbers are to be usedfor all financial and administrative transactions. The 10-digitnumber, containing checksum, prevents technical errors during datatransmission. The number doesn’t have built-in correlation withany other identifier associated with the provider.

Negotiated (Discounted)Rate

An amountthat represents the reimbursable amount that a provider agrees toaccept for covered services.

Network

The providers or facilities(owned, leased, or arranged) the TRICARE contractor has contractedwith to provide health care services to TRICARE eligible beneficiariesat a pre-negotiated rate as the total charge for services providedby the provider and to file claims for beneficiaries. The agreementsfor health care delivery made between the MTF and the eMSM and theTRICARE contractor are also included in this definition.

Network Care

Health care services and suppliesprovided by providers and facilities (owned, leased, arranged) the TRICAREcontractor has contracted with to provide necessary treatment toTRICARE eligible beneficiaries.

Network Inadequacy

Insufficient TRICARE contractorcontracted providers to meet the access standards required by the TRICAREcontract.

Network Provider

An individual or institutionalprovider that has contracted with a TRICARE contractor to providecare to TRICARE eligible beneficiaries, usually at a discountedrate.

Note:All networkproviders MUST be participating providers.

Non-Appealable Issue

Denial of benefits based ona fact or condition outside the scope of responsibility of DHA andthe TRICARE contractor.

Note:For example, the establishmentof eligibility is a Uniformed Service responsibility and if the servicehas not established that eligibility, neither DHA nor a TRICAREcontractor may review the action. Similarly, late claim filing,late appeal filing, amount of allowable charge (the contractor mustverify it was properly applied and calculated), and services orsupplies specifically excluded by law or regulation, such as routinedental care, clothing, routine vision care, etc., are matters subjectto legislative action or regulatory rule making not appealable underTRICARE. TRICARE contractors shall not make a determination thatan issue is not appealable except as specified in Chapter13 and 32 CFR 199.10.

Non-Claim Health CareData

Informationcaptured by the TRICARE contractor to complete the required TEDrecord for care rendered to TRICARE beneficiaries in those contractorowned, operated and/or subcontracted facilities where there is noclaim submitted by the provider of care.

Non-Compliant, Pharmacy

Action which results in a medicationbeing returned to stock for various reasons such as the medication wasnot picked by the patient within the given 10 day grace period,pharmacy/physician cancelled the prescription, etc.

Note:A subsequent reversal is automaticallysent to Pharmacy Data Transaction Service (PDTS) which will resultin the removal of the prescription fill from the patient profile.A reversed or adjusted TED record is also submitted to DHA resultingin a financial credit to the Government.

Non-Current Records

Documents that are no longerrequired in the conduct of current business and therefore can be retrievedby an archival repository or destroyed.

Non-Department Mentalhealth Care Provider

For the purposes of establishinga mental health care provider readiness designation as mandatedby the National Defense and Authorization Act (NDAA) for FiscalYear (FY) 2016 Section 717, a non-Department mental health careprovider is a health care provider who specializes in mental health,is not a health care provider of the DoD at a facility of the Department,and provides health care to members of the Armed Forces. It includespsychiatrists, psychologists, psychiatric nurses, social workers,mental health counselors, marriage and family therapists, and othermental health care providers designated by the Secretary of Defense.

Non-DoD Information System(IS)

An ISthat is not owned, controlled, or operated by the DoD, and is notused or operated by a contractor or other non-DoD entity exclusivelyon behalf of the DoD.

Non-DoD TRICARE Beneficiaries

A special category of individualssponsored by non-DoD Uniformed Services (the Commissioned Corps ofthe U.S. Public Health Service (USPHS), the U.S. Coast Guard, andthe Commissioned Corps of the National Oceanic and Atmospheric Administration(NOAA)) who are eligible for TRICARE.

Non-Network Care

Services and supplies receivedfrom a civilian provider authorized to provide health care but hasno contractual relationship with the TRICARE contractor.

Non-Network Provider

An individual or institutionalprovider that not has contracted with a TRICARE contractor to provide careto TRICARE eligible beneficiaries at a discounted rate.

Non-Participating Provider(Defined in 32 CFR 199.2)

A hospital or other authorizedinstitutional provider, a physician or other authorized individual professionalprovider, or other authorized provider that furnished medical servicesor supplies to a TRICARE beneficiary, but who did not agree on theTRICARE claim form to participate or to accept the TRICARE-determinedallowable cost or charge as the total charge for the services. Anonparticipating provider looks to the beneficiary or sponsor forpayment of his or her charge, not TRICARE. In such cases, TRICAREpays the beneficiary or sponsor, not the provider.

Non-Prime TRICARE Beneficiaries

Individuals, eligible for theTRICARE Program, who are not enrolled in the TRICARE Prime program.

North Atlantic TreatyOrganization (NATO) Member

A military member of an armedforce of a foreign NATO nation who is on active duty and who, in connectionwith official duties, is stationed in or passing through the U.S.For a list of member nations, see https://www.nato.int/cps/ie/natohq/topics_52044.htm.

Office-Based Opioid Treatment(OBOT)

TRICARE authorized providersacting within the scope of their licensure or certification to prescribe outpatientsupplies of the medication to assist in withdrawal management (detoxification)and/or maintenance of opioid use disorder, as regulated by 42 CFRPart 8, addressing OBOT.

Open Enrollment Period

The yearly period when non-activeduty beneficiaries can enroll in or change their TRICARE enrolled plancoverage for the following calendar program year. The open enrollmentperiod for TRICARE begins on the Monday of the second full weekin November to the Monday of the second full week in December ofeach calendar year. See TPM, Chapter 10, Section 2.1.

Opioid Treatment Program(OTP)

OTPs areservice settings for opioid treatment, either freestanding or hospital-based,that adhere to the DHHS’ regulations at 42 CFR Part 8 and use medicationsindicated and approved by DHA. OTPs provide a comprehensive, individuallytailored program of medication therapy integrated with psychosocial andmedical treatment and support services that address factors affectingeach patient, as certified by the Center for Substance Abuse Treatment(CSAT) of the DHHS’ Substance Abuse and Mental Health Services Administration(SAMHSA). Treatment in OTPs can include management of withdrawal symptoms(detoxification) from opioids and medically supervised withdrawalfrom maintenance medications. Patients receiving care for substanceuse and co-occurring disorders care can be referred to, or otherwiseconcurrently enrolled in, OTP.

Organized Health CareArrangement (HIPAA Definition)

1. A clinicallyintegrated care setting in which individuals typically receive healthcare from more than one HCP;

2. An organizedsystem of health care in which more than one covered entity participates,and in which the participating covered entities hold themselvesout to the public as participating in a joint arrangement and participatein joint activities such as utilization review, quality assessmentand improvement activities, or payment activities.

3. A group healthplan and a health insurance issuer or HMO with respect to such grouphealth plan, but only with respect to PHI created or received bysuch health insurance issuer or HMO that relates to individualswho are or who have been participants or beneficiaries in such grouphealth plan;

4. A group healthplan and one or more other group health plans each of which aremaintained by the same plan sponsor; or

5. The group healthplans described in paragraph 4 of this definition and health insuranceissuers or HMOs with respect to such group health plans, but onlywith respect to PHI created or received by such health insuranceissuers or HMOs that relates to individuals who are or have beenparticipants or beneficiaries in any of such group health plans.

For full details refer to HIPAAof 1996.

Originating Site

The originating site is wherethe beneficiary is located at the time the services are providedvia an interactive telecommunications system. The originating sitemust be either (a) where an otherwise authorized TRICARE providernormally offers professional medical or psychological services,such as the office of a TRICARE authorized individual professionalprovider (e.g., physician’s office), (b) a TRICARE authorized institutionalprovider, or (c) a patient’s home or other secure location as outlinedin this policy.

Other Health Insurance(OHI)

Alternateor additional health plan coverage other than TRICARE. This doesnot include Medicare or supplemental insurance plans.

Other Special InstitutionalProviders (Defined in 32 CFR 199.2)

Certain specialized medicaltreatment facilities, either inpatient or outpatient, other thanthose specifically defined, that provide courses of treatment prescribedby a doctor of medicine or osteopathy; when the patient is underthe supervision of a doctor of medicine or osteopathy during theentire course of the inpatient admission or the outpatient treatment;when the type and level of care and services rendered by the institutionare otherwise authorized in 32 CFR 199; when the facility meetsall licensing or other certification requirements that are extantin the jurisdiction in which the facility is located geographically;which is accredited by an accrediting organization approved by the Director,DHA if an appropriate accreditation program for the given type offacility is available; and which is not a nursing home, intermediatefacility, halfway house, home for the aged, or other institutionof similar purpose.

Out-Of-Area Care

Treatment received by TRICAREeligible beneficiaries while traveling outside their TRICARE region.

Out-Of-Network Care

See definition for Non-networkCare.

Out-Of-Region Beneficiaries

Individuals who resides inone TRICARE region but receives care within another TRICARE region.

Over-The-Counter (OTC)Medications

Drugsthat by law can be sold to a consumer without a prescription froma health care professional.

Note:OTC drugs/items covered bythe TRICARE Pharmacy (TPharm) benefit (see https://www.tricare.mil/CoveredServices/Pharmacy/Drugs/OTCDrugsSupplies.aspx forcovered items) will be reimbursed by the TPharm contractor whenpurchased with or without a prescription, as long as the purchasewas from a retail pharmacy. Covered OTC’s purchased without a prescriptionfrom a medical supply house or venue other than a retail pharmacywill be processed for reimbursem*nt by the TRICARE regional contractor.

Partial Hospitalization

A treatment setting capableof providing an interdisciplinary program of medically monitored therapeuticservices, to include management of withdrawal symptoms, as medicallyindicated. Services may include day, evening, night, and weekendtreatment programs which employ an integrated, comprehensive, andcomplementary schedule of recognized treatment approaches. Partial hospitalizationis a time-limited, ambulatory, active treatment program that offerstherapeutically intensive, coordinated, and structured clinicalservices within a stable therapeutic environment. Partial hospitalizationis an appropriate setting for crisis stabilization, treatment ofpartially stabilized mental disorders, to include substance disorders,and a transition from an inpatient program when medically necessary.

Participating Provider(Defined in 32 CFR 199.2)

A TRICARE authorized providerthat is required, or has agreed by entering into a TRICARE participation agreementor by an act of indicating “accept assignment” on the TRICARE claimform to accept the TRICARE-allowable amount as the maximum totalcharge for a service or item rendered to a TRICARE beneficiary,whether the amount is paid for fully by TRICARE or requires cost-sharingby the TRICARE beneficiary.

Note:This is another term for anon-network provider previously defined in this section.

Partnership for Peace(PfP)

The PfPStatus of Forces Agreement (SOFA) is a multilateral agreement betweenNATO member states and countries participating in the PfP program.It deals with the status of foreign forces while present on theterritory of another state. See https://www.nato.int/cps/en/natolive/topics_50349.htm fora more detailed definition and https://www.nato.int/cps/en/natohq/51288.htm fora list of current countries.

Patient Harm

A fraudulent or abusive practicedirectly causing a patient who is undergoing treatment for a disease, injury,or medical (or dental) condition to suffer actual physical injuryor acceleration of an underlying condition. The determination thatpatient harm has occurred must be based on the opinion of a qualifiedmedical or dental provider or pharmacist in the case of pharmacyclaims. Refer to Chapter 13 foradditional information.

Patient Profile, Pharmacy

A complete record for eachbeneficiary receiving prescriptions under the TRICARE program including: name,address, telephone number, date of birth, gender, patient identificationnumber (sponsor’s SSN and DEERS dependent suffix), DEERS Identifier,service sponsorship, status category, chronic medical conditions(diagnosis code), allergies and adverse drug experiences, past medicationhistory, prescriptions dispensed, non-receipt of prescriptions,status on interventions and prescription problems resolved, priorauthorizations approved or denied, and any other information suppliedby the beneficiary in the patient data form or updates.

Pending Claim, Correspondence,Or Appeal

The claim/correspondence/appealcase has been received but has not been processed to final disposition.

Performance Standard

Government approved and developedcriteria measuring specific aspects of a contractor’s executionof a TRICARE contract.

Pharmacoeconomic Center(PEC)

An activityunder the DoD Pharmacy Operations Division (POD) with the missionto improve the clinical, economic, and humanistic outcomes of drugtherapy in support of the readiness and managed care missions ofthe MHS. The PEC is comprised of pharmacists, physicians, and pharmacytechnicians from each of the three services, as well as civilianpharmacists and support personnel who monitor drug usage, and costtrends, and performs analysis to support DoD formulary managementand national pharmaceutical contracts, and clinical practice guidelines.

Pharmacy and Therapeutics(P&T) Committee

A DoD chartered committee withrepresentatives from MTF/eMSM providers and MTF/eMSM pharmacists.The P&T Committee’s primary role is establishing and maintainingthe DoD Uniform Formulary for the purchased care system and theDC system (MTFs/eMSMs).

Pharmacy Data TransactionService (PDTS)

A bi-directionaldata transaction service that provides a pharmaceutical data warehouseand electronically transmits encrypted prescription data using theNational Council of Prescription Drug Program (NCPDP) standardsto the pharmacy contractor. The PDTS provides the capability toperform Prospective Drug Utilization Review (ProDUR) and housesprior authorization/medical necessity history by integrating pharmacydata from all three points of service (DC, mail order, and retailpharmacies) with increased clinical screening and medication-relatedoutcomes.

Pharmacy Operations Center(POC)

The DoDorganization responsible for Tier I and Tier II (systems and software)support of the PDTS project. The POC:

1. Resolves ProDURPOS conflicts between MTFs/eMSM and the TPharm contractor;

2. Monitors quantitylimits (which are cumulative between all three POSs);

3. Issues NCPDPprovider numbers for DC pharmacies; and

4. Maintains “lockout” and “include” databases for closed class and mandatory userequirements contracts.

Point Of Service (POS)Option

AllowsTRICARE Prime enrollees and TRICARE Prime Remote for Active DutyFamily Members (TPRADFMs) enrollees to receive non-emergent healthcare services from any TRICARE authorized civilian provider, inor out of the network without requesting a referral from a PCM.Using this benefit results in the beneficiary incurring more outof pocket expenses. For further details, refer to the TRM, Chapter 2, Section 3.

Possible Breach

An incident where the possibilityof unauthorized access is suspected (or should be suspected) andhas not been ruled out. For example, if a laptop containing PII/PHIis lost, and the contractor does not initially know whether or notthe PII/PHI was encrypted, then the incident must initially be classifiedas a possible breach, because it is impossible to rule out the possibilityof unauthorized access to the PII/PHI. In contrast, that possibilitycan be ruled out immediately, and a possible breach has not occurred, whenmisdirected postal mail is returned unopened in its original packaging.However, if the intended recipient informs the contractor that anexpected package has not been received, then a possible breach existsuntil and unless the unopened package is returned to the contractor.In determining whether unauthorized access should be suspected,the contractor shall consider at least the following factors:

How the event was discovered;

Did the information stay withinthe covered entity’s control;

Was the information actuallyaccessed/viewed; and

Ability to ensure containment(e.g., recovered, destroyed, or deleted).

Preauthorization (Definedin 32 CFR 199.2)

A decision issued in writingor electronically by the Director, Defense Health Agency (DHA),or a designee, that TRICARE benefits may be payable for certainservices that a beneficiary has not yet received. The term priorauthorization is substituted for preauthorization and has the samemeaning.

A morecomprehensive review process for certain services to determine thatrequested treatment may be covered as medically necessary, deliveredat the appropriate setting, and is a TRICARE benefit before servicesare rendered to the beneficiary. Preauthorizations are requiredfor certain services per the TOM, Chapter 7, Section 2,A preauthorization request may be submitted by the beneficiary orprovider and is not required prior to a Primary Care Manager (PCM)(physician) issuing a beneficiary a referral for specialty servicesfrom a network provider.

Preferred Provider Organization(PPO)

A typeof health plan that has contracts with a network of doctors, hospitalsand other health care professionals to provide services to planbeneficiaries at a reduced rate.

Prescriber

A physician or other individualprofessional provider of services specifically authorized to writea prescription for medications or supplies in accordance with allapplicable federal and state laws.

Prescription

A legal order from an authorizedprescriber to dispense pharmaceuticals or other authorized supplies.

Prevailing Charge

A rate submitted by certainnon-institutional providers which fall within the range of ratesthat are most frequently used in a state for a particular healthcare procedure or service. The top of the range establishes themaximum amount TRICARE will authorize for payments of a given healthcare procedure or service, except where unusual circ*mstances ormedical complications warrant an additional charge. The calculationmethodology and use is determined according to the reimbursem*ntinstructions outlined in the TRM.

Preventive Care (Definedin 32 CFR 199.2)

Diagnostic and other medicalprocedures not related directly to a specific illness, injury, ordefinitive set of symptoms, or obstetrical care, but rather performedas periodic health screening, health assessment, or health maintenance.

Primary Care

The initial medical care givenby a HCP to a patient especially, as part of regular ambulatorycare, and sometimes followed by referral to other medical providers.

Primary Caregiver (Definedin 32 CFR 199.2)

An individual who renders toa beneficiary services to support the ADL as defined in 32CFR 199.2 and specific services essential to the safemanagement of the beneficiary’s condition.

Primary Care Manager(PCM)

A HCPa patient sees first for their health care needs responsible forproviding and coordinating the patient’s care, maintaining the patient’shealth record and when necessary refers the patient for specialtycare.

Primary Payer (Definedin 32 CFR 199.2)

The plan or program whose medicalbenefits are payable first in a double coverage situation.

Prime Contractor

The main individual or organizationthat has a contract with the owner of the contract and has full responsibilityfor its completion/execution and may employ (and manage) one ormore subcontractors to carry out specific parts of the contract.

Prime Enrollee

An Individual who has signedup to receive health care under the TRICARE Prime option.

Prime Service Area (PSA)

PSAs are areas in which thecontractor offers enrollment in TRICARE Prime in compliance withthe travel time access standard. PSAs encompass the entire areaof all the ZIP codes lying within or intersected by the 40 mileradius around enrolling MTFs/eMSMs (both hospitals and clinics)and Base Realignment and Closure (BRAC) sites. Zip codes enclosedentirely within a PSA’s boundary shall also be included. For BRACsites, the 40 mile radius shall be determined based on the physicaladdress of the former MTF location. If the former MTF address isno longer valid, the 40 mile radius shall be determined from the geographiccenter of the BRAC site zip code as of the date of contract award.

Prior Authorization,Medical Care

See definitionfor Preauthorization.

Prior Authorization,Pharmacy

Pre-approvalrequired for the filling of certain drugs ordered by a HCP.

Note:Criteria, developed by theDoD P&T Committee, will be provided by the to the contractor foruse in the filling of certain drugs. However, the contractor willbe responsible for developing pre-approval criteria for quantitylimit override, etc.

Priority Correspondence

Official communications, receivedby mail, faxes, e-mail, cables, telexes and other media of record, receivedby the contractor from the Office of the Assistant Secretary ofDefense (Health Affairs) (OASD(HA)), DHA, and any elected or appointed,federal, state, local, foreign, and tribal officials and Membersof Congress and Governors, or any other correspondence designatedfor priority status by the contractor’s management.

Privacy Act, 5 USC 552a(Records Maintained on Individuals)

Federal Law which establisheda Code of Fair Information Practice that governs the collection, maintenance,use and dissemination of personally identifiable information aboutindividuals that is maintained in systems of records by federalagencies. The law prohibits the disclosure of a System Of Records(SOR) without the written consent of the individual. Additionally,the law provides the individual with a means by which to seek accessfor amendment of their records, and set forth various agencies recordkeeping requirements.

Privacy Act, 5 USC 552aSystem of Records (SOR)

A group of records containingPHI and PII maintained by or on behalf of the DoD where PHI andPII in the records is specifically retrieved by personal identifiers.

Processed To Completion(PTC)

A date/timeframe when specific portions of claims processing work has beencompleted, resolved or received a final disposition. Under the TRICAREMCSCs there are specific dates/time frames for:

1. Claims. Claimsare considered PTC, for workload reporting and payment record codingpurposes, when all claims received in the current and prior monthshave been processed to the point where the following actions haveresulted:

All services and supplies onthe claim have been adjudicated, payment has been determined on thebasis of covered services/supplies and allowable charges appliedto deductible and/or denied, and

Payment, deductible applicationor denial action has been posted to ADP history.

2. Correspondence. Correspondenceis considered PTC, when the final reply is mailed to the individual(s)submitting the written inquiry or when the inquiry is fully answeredby telephone.

3.Telephonic Inquiry. A telephonic inquiry is considered PTCor resolved, when the final reply is provided by either telephoneor letter. A final telephone reply means that the caller’s inquiryhas been fully responded to, there are no unanswered issues remaining,and no additional call-backs are necessary. If the contractor musttake a subsequent action to correct a problem or address an issue raisedduring the telephone call, the telephone inquiry is considered resolvedwhen the contractor identifies the need for the subsequent action,and so notifies the inquirer. For example, if a claim requires adjustmentas a result of a telephone inquiry, the call is resolved when thecontractor initiates the claim adjustment and the inquirer is sonotified (i.e., it is not necessary to keep the call open until theactual processing of the claim adjustment occurs).

4. Appeals. Finaldisposition of an appeal case occurs when the previous decisionby the contractor is either reaffirmed, reversed, or partially reversedand the decision is mailed.

Procuring ContractingOfficer (PCO)

A Federalemployee with specific contracting authorization having ultimateauthority and responsibility for the Governments’ side for the contractexecution regardless of whatever additional support team may beoutlined in the contract. The Government employee is responsiblefor overseeing the contract from start to finish, including thedrawing up the procurement package, Request for Proposal (RFP) andcontract award, as well as administration during the contracts lifecycle.

Profiled Amount

An amount that is the lowerof the prevailing charge or the maximum allowable prevailing charge.

Program Integrity System

A software system for detectingoverutilization or fraud and abuse.

Program Year

The appropriate year (e.g.,calendaryear, fiscal year, rolling 12-month period, etc.) specified in the administrationof TRICARE programs for application of unique requirements or limitations(e.g., enrollment fees, deductibles, catastrophic lose protection,etc.) on covered health care services obtained or provided duringthe designated time period.

Prospective Drug UtilizationReview (ProDUR)

A processused to identify any potential medication problems that may occur,based on a patient’s current prescription, applicable patient profileinformation, and medication history, prior to the point of dispensing.ProDUR is used to detect over-utilization, under-utilization, therapeuticduplication, drug-disease complications, drug interactions, incorrectdosages and duration of therapy.

Prospective Review

Prior assessment of a requestfor treatment before the treatment is rendered to determine if the treatmentis appropriate for the patient. Another term for preauthorization.

Protected Health Information(PHI) (HIPAA Definition)

1. IIHI that is:

a. Transmittedby electronic media;

b. Maintainedin electronic media; or

c. Transmittedor maintained in any other form or medium.

Note:Sometimes referred to as ElectronicProtected Health Information (ePHI).

2. PHI excludesIIHI in:

a. Educationrecords covered by the Family Educational Right and Privacy Act,as amended, 20 USC 1232g;

b. Records describedat 20 USC 1232g(a)(4)(B)(iv); and

c. Employmentrecords held by a covered entity in its role as an employer.

d. Regarding aperson who has been deceased for more than 50 years.

Note:As defined in HIPAA of 1996.

Provider (Defined in 32CFR 199.2)

A hospital or other institutionalprovider, a physician or other individual professional provider,or other provider of services or supplies in accordance with 32CFR 199.6.

Provider Exclusion AndSuspension (Defined in 32 CFR 199.2)

The terms “exclusion” and “suspension”,when referring to a provider under TRICARE, both mean the denialof status as an authorized provider, resulting in items, services,or supplies furnished by the provider not being reimbursed, directlyor indirectly, under TRICARE. The terms may be used interchangeablyto refer to a provider who has been denied status as an authorizedTRICARE provider based on:

1. A criminalconviction or civil judgment involving fraud;

2. An administrativefinding of fraud or abuse under TRICARE;

3. An administrativefinding that the provider has been excluded or suspended by anotheragency of the Federal Government, a state, or a local licensingauthority;

4. Anadministrative finding that the provider has knowingly participatedin a conflict of interest situation; or

5. An administrativefinding that it is in the best interests of TRICARE or TRICARE beneficiariesto exclude or suspend the provider.

Provider Network

A group of HCPs with whicha managed care contractor has made contractual or other arrangements withto provide health care at a discounted rate.

Provider Termination(Defined in 32 CFR 199.2)

When a provider’s status asan authorized TRICARE provider is ended, other than through exclusionor suspension, based on a finding that the provider does not meetthe qualifications, as set forth in 32CFR 199.6 to be an authorized TRICARE provider.

Psychotherapy Notes (HIPAADefinition)

Notesrecorded (in any medium) by a HCP who is a mental health professionaldocumenting or analyzing the contents of conversation during a privatecounseling session or a group, joint, or family counseling sessionand that are separated from the rest of the individual’s medicalrecord. Psychotherapy notes excludes medication prescription andmonitoring, counseling session start and stop times, the modalitiesand frequencies of treatment furnished, results of clinical tests,and any summary of the following items: diagnosis, functional status,the treatment plan, symptoms, prognosis, and progress to date, asdefined in HIPAA of 1996.

Public Health Authority(HIPAA Definition)

An agencyor authority of the U.S., a state, a territory, a political subdivisionof a state or territory, or an Indian tribe, that is responsiblefor public health matters as part of its official mandate as wellas a person or entity acting under a grant of authority from orunder a contract with a public health agency, as defined in HIPAAof 1996.

Note:The term“public health authority” includes any DoD Component authorizedunder applicable DoD regulation to carry out public health activities,including medical surveillance activities under DoD Directive 6490.2.

Qualified Mental HealthProvider

Psychiatrists or other physicians,clinical psychologists, Certified Psychiatric Nurse Specialists(CPNSs), Certified Clinical Social Workers (CCSWs), certified marriageand family therapists, TRICARE Certified Mental Health Counselors(TCMHCs), pastoral counselors under a physician’s supervision, and supervisedmental health counselors under a physician’s supervision.

Qualifying Life Event(QLE)

A changein a beneficiary’s situation, like getting married, having a baby,or losing health coverage, that allows a beneficiary to enroll inor change their TRICARE health plan coverage outside of the annual openenrollment period. See TPM, Chapter 10, Section 2.1, for a list of authorizedQLEs.

Quality Assurance (QA),Pharmacy

A processfor developing controls to prevent mistakes in the dispensing ofdrugs. QA is the responsibility of both the pharmacy and the contractor.

Quality Assurance Program

A system-wide process establishedand maintained by the contractor to monitor and evaluate the qualityof patient health care and clinical performance.

Quality Control, Pharmacy

Processes and procedures employedto ensure that pharmaceuticals are dispensed accurately and timely.These should be employees by both the contractor and the pharmacy.

Quality Improvement

An approach to quality managementthat builds upon traditional quality assurance methods by emphasizing:

1. The organizationand systems (rather than individuals);

2. The need forobjective data with which to analyze and improve processes; and

3. The ideal thatsystems and performance can always improve even when high standardsappear to have been met.

Receipt Of Claim, CorrespondenceOr Appeal

Deliveryof a claim, correspondence, or appeal into the custody of the contractorby the post office or other party.

Reconsideration

An appeal to a contractor ofan initial determination issued by the contractor.

Records

All books, papers, maps, photographs,machine readable materials, or other documentary materials, regardlessof physical form or characteristics, made or received by an agencyof the U.S. Government under Federal law or in connection with thetransaction of public business or appropriate for presentation bythat agency or its legitimate successor as evidence of the organization,functions, policies, decisions, procedures, operations, or otheractivities of the Government.

Also any item, collection,or grouping of information about a beneficiary which is maintained, collected,used or disseminated, by TRICARE or a TRICARE contractor, including,but not limited to his or her education, financial transactions,medical history, and criminal or employment history, and which containsthe beneficiary’s name or identifying number, symbol or other personalidentifiers.

Records Management

The area of general administrativemanagement concerned with achieving economy and efficiency in thecreation, use and maintenance, and disposition of records. Includedin the fulfilling of archival requirements and ensuring effectivedocumentation.

Referral (Defined in 32CFR 199.2)

The act or an instance of referringa TRICARE beneficiary to another authorized provider to obtain necessarymedical treatment. Generally, when a referral is required to qualifyhealth care as a covered benefit, only a TRICARE-authorized physicianmay make such a referral unless 32 CFR 199 specifically allows anothercategory of TRICARE-authorized provider to make a referral as allowedwithin the scope of the provider’s license. In addition to referralswhich may be required for certain health care to be a covered TRICAREbenefit, the TRICARE Prime program under 32CFR 199.17 generally requires Prime enrollees to obtaina referral for care through a PCM or other authorized care coordinatorto avoid paying higher deductible and cost-sharing for otherwisecovered TRICARE benefits.

A referral is a request fromone physician to another to assume responsibility for managementof one or more of a patient’s specified problems. A consult is arequest from one physician to another for an advisory opinion. Referralsand/or consults written by MTF/eMSM or Civilian TRICARE providersare sent to the Contractor for authorization or preauthorization(if needed per TOM, Chapter 7, Section 2).A PCM (physician) does not require a preauthorization/authorizationfrom the Contractor to generate a referral or consult to/from anetwork provider.

Referral Management

Process by which all referralswritten by the MTF/eMSM authorized providers and network and non-networkproviders are tracked for care coordination, patient safety, andaccountability. The referral management process ends when the referringprovider is provided the clear and legible report, informed thepatient did not use/activate their referral, or if the referralwas denied by the contractor.

Region

A geographic area determinedby the Government for civilian contracting of medical care and other servicesfor TRICARE-eligible beneficiaries.

Regional Review Authority(RRA)

An entityresponsible for performing Peer Review Organization (PRO) functions.Under TRICARE the contractor shall be responsible for performingthe duties of the RRA.

Reliants

Refers to a subset of TRICAREeligible beneficiaries who are dependent on TRICARE and not theDC system or OHI for the coverage/reimbursem*nt of vaccines underthe well-child and preventive benefits. This includes, but is notlimited to: All TRICARE Active Duty Family Members (ADFMs) not enrolledto a DC PCM who are reliant on TRICARE as their primary form ofinsurance, and retirees and their family members who do not haveOHI and are not dependent on the DC system but are dependent onTRICARE as their primary form of insurance.

Representative (Definedin 32 CFR 199.2)

Any person who has been appointedby a party to the initial determination as counsel or advisor and whois otherwise eligible to serve as the counsel or advisor of theparty to the initial determination, particularly in connection witha hearing.

Required By Law (HIPAADefinition)

A mandatecontained in law that compels a covered entity to make a use ordisclosure of PHI and that is enforceable in a court of law. Requiredby law includes, but is not limited to, court orders and court-orderedwarrants; subpoenas or summons issued by a court, grand jury, agovernmental or tribal inspector general, or an administrative bodyauthorized to require the production of information; a civil oran authorized investigative demand; Medicare conditions of participationwith respect to HCPs participating in the program; and statutesor regulations that require the production of information, includingstatutes or regulations that require such information if paymentis sought under a Government program providing public benefits asdefined in HIPAA of 1996.

Note:For TRICARE required by lawalso includes any mandate contained in a DoD Regulation that mandatesa covered entity (or other person functioning under the authorityof a covered entity) to make a use or disclosure and is enforceablein a court of law. The attribute of being enforceable in a courtof law means that in a court or court-martial proceeding, a personrequired by the mandate to comply would be held to have a legalduty to comply or, in the case of noncompliance, to have had a legalduty to have complied. Required by law also includes any DoD regulationrequiring the production of information necessary to establish eligibilityfor reimbursem*nt or coverage under TRICARE.

Research (HIPAA Definition)

A systematic investigation,including research, development, testing, and evaluation, designedto develop or contribute to generalizable knowledge as defined inHIPAA of 1996.

Residence

For purposes of TRICARE, “residence”is the dwelling place of the beneficiary for day-to-day living.A temporary living place during periods of temporary duty or duringa period of confinement, such as a Residential Treatment Center(RTC), does not constitute a residence. In the case of minor children,the residence of the custodial parent(s) or the legal guardian shallbe deemed the residence of the child. In the case of incompetentadult beneficiaries, the residence of the legal guardian shall bedeemed the residence of such beneficiary. Under split enrollment,when a dependent resides away from home while attending school,their residence shall be where they are domiciled.

Residential TreatmentCenter (RTC)

A facilityor distinct part of a facility which meets the criteria in 32 CFR 199.6(b)(4)(vii).

Residual Claim

A claim for health care servicesrendered during the health care delivery period of one contract,but processed under a different (incoming) contract.

Resource Sharing Agreement(External) (Defined in 32 CFR 199.2)

A type of external PartnershipAgreement established in the context of the TRICARE Program by agreementof the MTF Director and an authorized TRICARE contractor. Externalresource sharing agreements may incorporate TRICARE features inlieu of standard TRICARE features that would apply to stand externalPartnership Agreements.

Respite Care (Definedin 32 CFR 199.2)

Short-term care for a patientin order to provide rest and change for primary caregivers who havebeen caring for the patient at home, usually the patient’s family.

Note:Although this is usually thepatient’s family, it may be a relative or friend who assists the memberwith their ADL. Respite care consists of providing skilled and non-skilledservices to a beneficiary such that in the absence of the primarycaregiver, management of the beneficiary’s qualifying conditionand safety are provided. Respite care services are provided exclusivelyto the Service member beneficiary.

1. Qualifying ConditionFor Receipt Of Respite Benefits. For the purposes of receivingrespite benefits, a qualifying condition is defined as a seriousinjury or illness resulting in or based on the clinical assessmentof the member’s provider or case management team that will resultin a physical disability, or an extraordinary physical or psychologicalcondition.

2.Limitations On Respite Benefits:

The services performed by theprimary caregiver are those that can be performed safely and effectivelyby the average non-medical person without direct supervision of an HCPafter the primary caregiver has been trained by appropriate medicalpersonnel.

Respite care services are limitedto a maximum of eight hours per day, five days per week.

Resubmissions

A group of TED records submittedto DHA to correct those TED claims and adjustments which generatededit errors when originally processed by DHA. These groups of recordswill be identified by the batch number and resubmission in the TEDHeader Record.

Retention Period

The length of time for particulardocuments/records (normally a series) are to be kept.

Retiree (Defined in 32CFR 199.2)

A member or former member ofa Uniformed Service who is entitled to retired, retainer, or equivalent paybased on duty in a Uniformed Service.

Retired Category

Retirees and their family memberswho are beneficiaries covered by 10 USC 1086(c), other than Medicare-eligiblebeneficiaries as described in 10 USC 1086(d).

Retrospective Drug UtilizationReview

A processof appraising and reconsidering the usage of drugs to determinethe effectiveness of drug treatment after a medication is dispensed.The process includes evaluation for therapeutic appropriateness,over-utilization and under-utilization, therapeutic duplication,drug-disease contraindications, drug interactions, incorrect dosageand /or duration of therapy.

Retrospective Review

A post-treatment assessmentof care already delivered. The assessment evaluates the appropriateness ofcare and conformance to pre-established criteria for utilization.The purpose for this type of assessment may be to validate utilizationdecisions made and/or to validate payment made for care provided(by examining the actual record of treatment).

Returned Claim

A bill of health care servicesthe contractor returns to the sender because there is missing information thatis needed for processing, and the missing information cannot beobtained from in-house sources.

Reversed

Status of claim once a reversaltransaction is transmitted for the removal of the PAID claim froma patient’s profile.

Routine Correspondence

All communications receivedby mail, faxes cables, telexes, and other media or record, is notdesignated as Priority Mail.

Routine Use

With respect to the disclosureof a record from a Privacy Act System of Records (SOR) 5 USC, 552a,the use of a record for a purpose that is compatible for which itwas information collected. See also Defense Privacy and Civil LibertiesOffice’s (DPCLO’s) published list of blanket routine uses for sharingPII.

Same Day Referral

The act or instance of referringa TRICARE beneficiary to another authorized provider to obtain necessarymedical treatment within 24 hours of a request for care. This includesimmediate (STAT), 24 hours (As Soon As Possible (ASAP)), and Todayreferral priority requests from the Composite Health Care System(CHCS).

Sanction (Defined in 32CFR 199.2)

For the purposes of 32CFR 199.9, “sanction” means a provider exclusion, suspension,or termination.

Secondary Payer (Definedin 32 CFR 199.2)

The plan or program whose medicalbenefits are payable in double coverage situations only after the primarypayer has adjudicated the claim.

Secretary Of Health AndHuman Services (HHS)

The head of the U.S. DHHS concernedwith health matters.

Segment (HIPAA Definition)

A group of related data elementsin a transaction as defined in HIPAA of 1996.

Seventy-Two Hour Referral

The act or instance of referringa TRICARE beneficiary to another authorized provider to obtain necessarymedical treatment within 72 hours of a request for care.

Skilled Nursing Facility(SNF) (Defined in 32 CFR 199.2)

An institution (or a distinctpart of an institution) that meets the criteria as set forth in 32CFR 199.6.

Skilled Nursing Service(Defined in 32 CFR 199.2)

Skilled nursing services includesapplication of professional nursing services and skills by and RegisteredNurse (RN), Licensed Practical Nurse (LPN), or Licensed VocationalNurse (LVN) that are required to be performed under the generalsupervision/direction of a TRICARE authorized physician to ensurethe safety of the patient and achieve the medically desired resultin accordance with accepted standards of practice.

Note:Skilled nursing services areother than those services that provide primarily support for the Activitiesof Daily Living (ADL) or that could be performed by an untrainedadult with minimum instruction or supervision.

Special Checks

Checks issued outside the normalprocessing workflow for the purpose of expediting payment of a claimfor benefits.

Special Inquiries

Requests for information underthe Freedom of Information Act, Privacy Act, and the news media.Also includes requests received for surveys, audits, and requestsby Government agencies including DoD agencies, entities other thanDHA and Congressional Committees.

Specialty Care

Specialized medical servicesprovided by a physician specialist.

Specified AuthorizationStaff (SAS)/Defense Health Agency-Great Lakes (DHA-GL) (formerly MilitaryMedical Support Office (MMSO))

A Joint Services Organizationresponsible for reviewing specialty and inpatient care requestsand claims for impact on fitness-for-duty. SAS/DHA-GL is also responsiblefor approving certain medical services not covered under TRICAREthat are necessary to maintain fitness for duty and/or retentionon active duty. The SASs for Army, Navy, Marine Corps, and Air ForceService members are assigned to the DHA-GL. For more information,see Chapter 17 foradditional information.

Split-Billing

The division of a medical claimfor service provided into two or more parts. Claims may be splitto divide work between clients, payers or for reimbursem*nt to differentservice providers for performing a shared service. Such claims mayor may not require Coordination of Benefits. (COB)

Split Enrollment

A TRICARE Prime option whichallows an entire family to enroll in TRICARE Prime even if partof the family is living in another TRICARE region.

Sponsor

An active duty member, retiree,or deceased active duty member or retiree, of a Uniformed Service uponwhose status his or her family members’ eligibility for TRICAREis based. See also 32 CFR 199.2 for amore complete definition.

Spouse (Defined in 32CFR 199.2)

A lawful husband or wife, whomeets the criteria in 32 CFR 199.3,regardless of whether or not dependent upon the active duty memberor retiree.

Stakeholders

Any party who has a direct interestin the success of a business concern. For TRICARE purposes, stakeholdersinclude the DoD, the Director, TROs, Market/MTF Directors, DHA,the MHS, and all employees thereof, contractors, elected officials,and MHS beneficiaries.

Standard Transaction(HIPAA Definition)

A transactionthat complies with the applicable standard adopted by HIPAA.

Start Of Service

The date a contractor officiallybegins delivery of health care services, processing claims, and/or deliveryof other services in a production environment, as specified in thecontract requirements.

State (Defined in 32CFR 199.2)

For the purposes of the 32CFR 199, any of the several states, the District of Columbia, the Commonwealthof Puerto Rico, the Commonwealth of the Northern Mariana Islands,and each territory and possession of the U.S.

State (HIPAA Definition)

1. For a healthplan established or regulated by Federal law, State has the meaningset forth in the applicable section of the USC for such health plan.

2. Each of theseveral states, the District of Columbia, Puerto Rico, the U.S.Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

Statement of Responsibilities(SOR)

A communicationdocument that is intended to identify key processes and points ofinteraction between the MTF and the contractor or the TAO and thecontractor. It does not repeat contract requirements, nor is itused to modify any contract requirement.

Student Status (Definedin 32 CFR 199.2)

A dependent of a member orformer member of a Uniformed Service who has not passed his or her 23rdbirthday and is enrolled in a full-time course of study in an institutionof higher learning.

Subcontractor

An individual or in many casesa business that signs a contract to perform part or all of the obligations ofanother’s contract. This includes but is not limited to enrolledprogram health benefits business entities at whatever level of thecontract organization they exist. It does not include institutionalor non-institutional providers of health care. This definition doesnot exclude business entities that are not specifically addressedherein but whose legal status within the contract organization establishesthem as subcontractors because that term may be otherwise definedin the Federal Acquisition Regulation (FAR).

Note:In determining whether a businessentity is a network first tier subcontractor, consideration is givenas to whether or not the entity providing the designated servicesacts as a broker of care; i.e., the entity itself obtains the medicalcoverage needed by in turn contracting with institutional and non-institutionalproviders. Implicit in the determination is size of the offerednetwork; i.e., does this entity provide a large number of contractedproviders for a large geographical area?

Subcontractor (HIPAADefinition)

A personto whom a business associate delegates a function, activity, orservice other than in the capacity of a member of the workforceof such business associate.

Subcontracts

The contractual assignmentof elements of requirements to another organization or person for purposesof TRICARE. Unless otherwise specified in the contract, the termalso includes purchase orders, with changes and/or modificationsthereto.

Substance Use DisorderRehabilitation Facility (SUDRF)

A facility or a distinct partof a facility that meets the criteria in 32 CFR 199.6(b)(4)(xiv).

Summary Health Information(HIPAA Definition)

Informationthat may be IIHI, and:

1. That summarizesthe claims history, claims expenses, or type of claims experiencedby individuals for whom a plan sponsor has provided health benefitsunder a group health plan; and

2. From whichthe information has been deleted, except that the geographic informationmay be aggregated to the level of a five digit zip code.

As defined in HIPAA of 1996.

Supplemental Care

Medical care received by Servicemembers of the Uniformed Services and other designated patients pursuantto an MTF/eMSM referral (MTF/eMSM Referred Care). Supplemental HealthCare also includes specific episodes of Service member non-referredcivilian care, both emergent and authorized non-emergent care (non-MTF/eMSMReferred Care).

Supplemental Funds

Funds used to pay for supplementalcare.

Supplemental InsurancePlan (Defined in 32 CFR 199.2)

A health insurance policy orother health benefit plan offered by a private entity to a TRICARE beneficiary,that primarily is designed, advertised, marketed, or otherwise heldout as providing payment for expenses incurred for services anditems that are not reimbursed under TRICARE due to program limitationsor beneficiary liabilities imposed by law. TRICARE recognizes twotypes of supplemental plans, general indemnity plans and those offeredthrough a direct service HMO.

1. An indemnitysupplemental insurance plan must meet all the following criteria:

a. It providesinsurance coverage, regulated by the state insurance agencies, whichis only available only to beneficiaries of TRICARE.

b. It is premiumbased and all premiums relate only to the TRICARE supplemental coverage.

c. Its benefitsfor all covered TRICARE beneficiaries are predominately limitedto non-covered services, to the deductible and cost-shared portionsof the pre-determined allowable charges and/or to amounts exceedingthe allowable charges for covered services.

d. It providesinsurance reimbursem*nt by making payment directly to the TRICAREbeneficiary or to the participating provider.

e. It does notoperate in a manner which results in lower deductibles or cost-sharesthan those imposed by law, or that waives the legally imposed deductiblesand cost-shares.

2. A supplementalinsurance plan offered by a HMO must meet all of the following criteria:

a. The HMO mustbe authorized and must operate under relevant provisions of statelaw.

b. TheHMO supplemental plan must be premium based and all premiums mustrelate only to TRICARE supplemental coverage.

c. The HMO’s benefits,above those which are directly reimbursed by TRICARE, must be limited predominantlyto services not covered by TRICARE and TRICARE deductible and cost-shareamounts.

d. TheHMO must provide services directly to TRICARE beneficiaries throughits affiliated providers, who in turn, are reimbursed by TRICARE.

e. The HMO’s premiumstructure must be designed so that no overall reduction to the amountof the beneficiary deductibles or cost-shares will result.

Suspension Of ClaimsProcessing (Defined in 32 CFR 199.2)

The temporary suspension ofprocessing (to protect the Government’s interests) of claims forcare furnished by a specific provider (whether the claims are submittedby the provider or beneficiary) or claims submitted by or on behalfof a specific TRICARE beneficiary pending action by the Director,DHA, or a designee, in a case of suspected fraud or abuse. The actionmay include administrative remedies provided for in 32CFR 199.9 or any other DoD issuance (e.g., DoD issuancesimplementing the Program Fraud Civil Remedies Act), case developmentor investigation by DHA, or referral to the DoD-Inspector General(IG) or the Department of Justice (DOJ) for action within theircognizant jurisdictions.

Telephonic Consultations(32 CFR 199.2)

A covered consultation serviceconducted via a telephone call between TRICARE-authorized providers, includinga verbal and written report to the patient’s treating/requestingphysician or other TRICARE-authorized provider.

Telephonic Office Visits(32 CFR 199.2)

A covered service providedvia a telephone call between a beneficiary who is an establishedpatient and a TRICARE-authorized provider.

Telepresenter

A telepresenter is an individualat the originating site (when the originating site is other thanthe patient’s home) who has the necessary skills, training, and/orclinical background (e.g., Licensed Practical Nurse (LPN), RegisteredNurse (RN), trained medical technician, etc.) to operate the telemedicinetechnology and facilitate examinations under the direction of theprovider at the distant site. For example, a nurse may use a deviceconnected to a telemedicine system, such as a digital stethoscopeor otoscope, in order to provide diagnostically relevant imagery,sound, or other data/information about the patient to the distantprovider in real time.

Termination

The removal of a provider asan authorized TRICARE provider based on a finding that the providerdoes not meet the qualifications established by 32CFR 199.6 to be an authorized TRICARE provider. This includesthose categories of providers who have signed specific participationagreements.

Third-Party Billing Agent(Defined in 32 CFR 199.2)

Any entity that acts on behalfof a provider to prepare, submit, and monitor claims, excludingthose entities that act solely as a collection agency.

Third-Party Liability(TPL) Claims

Reimbursem*ntsto the Government that arise when medical care is provided to anentitled beneficiary for treatment or injury or illness caused undercirc*mstances creating tort liability legally requiring a thirdperson to pay damages for that care. The Government pursues repaymentfor the care provided to the beneficiary under the provisions andauthority of the Federal Medical Care Recovery Act (FMCRA) (42 USCparagraphs 2651-2653).

Third-Party Liability(TPL) Recovery

The recoveryby the Government of expenses incurred for medical care providedto an entitled beneficiary in the treatment of injuries or illnesscaused by a third-party who is liable in tort for damages to thebeneficiary. Such recoveries can be made from the liable third-partydirectly or from a liability insurance policy (e.g., automobileliability policy or homeowners insurance) covering the liable third-party.TPL recoveries are made under the authority of the FMCRA (42 USCparagraph 2651 et sec). Other potential sources of recovery in favorof the Government in TPL situations include, but are not limitedto, no fault or uninsured motorist insurance, medical payments provisionsof insurance policies, and workers compensation plans. Recoveriesfrom such other sources are made under the authority of 10 USC paragraphs10790, 1086(g), and 1095b.)

Third-Party Payer (Definedin 32 CFR 199.2)

Third-party means an entitythat provides an insurance, medical service, or health plan by contractor agreement, including an automobile liability insurance or nofault insurance carrier and a workers compensation program or plan,and any other plan or program (e.g., homeowners insurance) thatis designed to provide compensation or coverage for expenses incurredby a beneficiary for medical services or supplies. For the purposesof the definition of “third-party payer,” an insurance medical serviceor health plan includes a preferred provider organization, an insuranceplan described as Medicare supplemental insurance, and a personalinjury protection plan or medical payments benefit plan for personalinjuries resulting from the operation of a motor vehicle.

Note:TRICARE is secondary payerto all third-party payers. Under limited circ*mstances in 32CFR 199.8, TRICARE payment may be authorized to be paidin advance of adjudication of the claim by certain third-party payers.TRICARE advance payment will not be made when a third-party provideris determined to be a primary medical insurer under 32CFR 199.8.

Timely Filing

The submitting of TRICARE claimswithin the prescribed time limits as set forth in 32CFR 199.7 and the requirements of the TRICARE contract.

Toll-Free Telephones

Having or using a direct lineor number for a call that is not charged to the caller. Under theTRICARE contract all telephone calls are considered toll-free forthe purposes of measuring the standards contained in Chapter 1, Section 3, paragraph 3.4.

Trading Partner Agreement(HIPAA Definition)

An agreementrelated to the exchange of information in electronic transactions,whether the agreement is distinct or part of a larger agreement,between each party to the agreement. (For example, a trading partneragreement may specify, among other things, the duties and responsibilities ofeach party to the agreement in conducting a standard transaction.)As defined in HIPAA of 1996.

Transaction (HIPAA Definition)

The transmission of informationbetween two parties to carry out financial or administrative activities relatedto health care. It includes the following types of information transmissions:

1. Health careclaims or equivalent encounter information.

2. Health carepayment and remittance advice.

3. Coordinationof benefits.

4. Healthcare claims status.

5. Enrollmentand disenrollment in a health plan.

6. Eligibilityfor a health plan.

7. Health planpremium payments.

8. Referralcertification and authorization.

9. First reportof injury.

10. Healthclaims attachments.

11. Other transactionsthat may be prescribed by regulation.

Transfer Claims

A bill received by a contractorfor services received and billed from another contractor’s jurisdiction. See Chapter8 for processing requirements related to these types ofclaims.

Note:Claimsfor Service members which are sent to the appropriate UniformedService are not considered to be “transfer claims.”

Transition

The process of changing contractorsor contract in a Government designated service area. Transition beginswith the Notice of Award to the incoming contractor and is formallycompleted with the close out procedures of the outgoing contractor,several months after the start work date.

Transitional PatientsOr Cases

Beneficiariesfor whom active care is in progress on the date of a contractor’sstart work date.

Note:If the care being providedis for covered services, the contractor is financially responsible forthe portion of care delivered on or after the contractor’s startwork date.

Treatment (HIPAA Definition)

The provision, coordination,or management of health care and related services by one or moreHCPs, including the coordination or management of health care bya HCP with a third-party; consultation between HCPs relating toa patient; or the referral of a patient for health care from oneHCP to another.

Treatment Encounter

The smallest meaningful unitof health care utilization: One provider rendering one service toone beneficiary.

Treatment Plan (Definedin 32 CFR 199.2)

A detailed description of themedical care being rendered or expected to be rendered a TRICARE beneficiaryseeking approval for inpatient and other benefits for which preauthorizationis required as set forth in 32 CFR 199.4(b).Medical care described in the plan must meet the requirements ofmedical and psychological necessity. A treatment plan must include,at a minimum, a diagnosis (either the current edition of the ICD-CM,or the current edition of the DSM); detailed reports of prior treatment, medicalhistory, family history, social history, and physical examination;diagnostic test results; consultant’s reports (if any); proposedtreatment by type (such as surgical, medical, and psychiatric);a description of who is or will be providing treatment (by disciplineor specialty); anticipated frequency, medications, and specificgoals of treatment; type of inpatient facility required and why(including length of time the related inpatient stay will be required);and prognosis. If the treatment plan involves the transfer of aTRICARE beneficiary from a hospital or another inpatient facility,medical records related to that inpatient stay also are requiredas a part of the treatment plan documentation.

Triage

The process of determining thepriority of patients’ treatment based on the severity of their condition.

Note:For theTRICARE Program this function is performed by the contractor’s 24-hourtelephone Nurse Advice Line (NAL).

TRICARE

The DoD’s managed health careprogram for Service members and their families, retirees and their families,survivors, and other TRICARE-eligible beneficiaries. TRICARE isa blend of the military’s DC system of hospitals and clinics andcivilian providers. Through December 31, 2017, TRICARE offers three options:TRICARE Standard Plan, TRICARE Extra Plan, and TRICARE Prime Plan(see definitions in this section and in 32CFR 199.17). Beginning January 1, 2018, TRICARE offersthree options: TRICARE Prime, TRICARE Select, and TRICARE For Life(TFL) (see definitions in this appendix and in 32CFR 199.2).

TRICARE Area Office (TAO)

The management organizationresponsible for overseeing an integrated health care delivery system withinone of the three designated TRICARE overseas regional zones.

TRICARE Beneficiary

An individual determined bythe Uniformed Services to be eligible for TRICARE benefits, as setforth in 32 CFR 199.3.

TRICARE Contractor

An organization with whichDHA has entered into a binding agreement for:

1. The deliveryof and/or processing of payment for health care services throughcontracted providers;

2. The processingof claims for health care services received from non-network providers;and

3. Theperformance of related support activities.

TRICARE Encounter Data(TED)

A dataset of information required for all care received/delivered underthe contract and provided by the contractor in a Government-specifiedformat and submitted to DHA via a telecommunication network. Theinformation in the data set can be described in the following broadcategories:

1. Beneficiaryidentification.

2. Provideridentification.

3. Healthinformation:

Place and type of service

Diagnosis and treatment-relateddata

Units of service (admissions,days, visits, etc.)

4. Related financialinformation.

TRICARE Encounter Data(TED) Record Transmittal Summary

A single record which identifiesthe submitting contractor and summarizes, for transmittal purposes, thenumber of records and the financial information contained withinthe associated “batch” of TED records.

TRICARE Extra (Definedin 32 CFR 199.2)

The preferred-provider optionof the TRICARE program made available prior to January 1, 2018,under which TRICARE Standard beneficiaries may obtain discountson cost-sharing as a result of using TRICARE network providers.

TRICARE For Life (TFL)(Defined in 32 CFR 199.2)

The Medicare wraparound coverageoption of the TRICARE program made available to an eligible beneficiaryby reason of 10 USC 1086(d).

TRICARE Operations Manual(TOM) (6010.59-M)

A DHAauthored book which provides instructions and requirements for claimsprocessing and health care delivery under TRICARE.

TRICARE Pharmacy (TPharm)Benefits Program

A planto provide outpatient prescription drugs through military pharmacies,TRICARE Pharmacy Home Delivery, and TRICARE retail network and non-networkpharmacies.

TRICARE Policy Manual(TPM) (6010.60-M)

A DHAauthored book which provides the description of TRICARE Programbenefits, adjudication guidance, policy interpretations, and decisionsfor use in determining benefits under the TRICARE Program.

TRICARE Plus

A primary care program offeredat some military hospitals and clinics for beneficiaries not enrolledin TRICARE Prime. Beneficiaries are enrolled with a Primary CareCoordinator (PCC) at an MTF/eMSM. MTFs/eMSMs may limit enrollmentbased on capability and capacity. There is no enrollment fee.

Note:These MTF/eMSM enrollees areto receive primary care appointments within the TRICARE Prime accessstandards. TRICARE Plus “enrollment” will be annotated in DEERSand the MTF’s/eMSM’s Electronic Medical Records. When a TRICAREPlus enrollee receives care from civilian providers, TRICARE Standard/Extrarules will apply (through December 31, 2017). For services payableby Medicare, Medicare rules will apply, with TRICARE as second payerfor TRICARE covered services and supplies. Specialty care in theMTF/eMSM will be on referrals from the primary care provider oron a self-referral basis. TRICARE Plus enrollees are not guaranteedspecialty care appointments within the TRICARE Prime access standards.

TRICARE Prime (Definedin 32 CFR 199.2)

The managed care option ofthe TRICARE program established under 32CFR 199.17.

TRICARE Prime Remote(TPR) Program

A managedcare option under TRICARE designed to provide health care servicesto Service members and command sponsored family members assignedto remote locations in the U.S.

TRICARE Prime Remote(TPR) Work Unit

A uniformedservices group whose members have to be designated by the MilitaryServices to be eligible to enroll in the TPR Program.

TRICARE Program (Definedin 32 CFR 199.2)

A program established underthe 32 CFR 199.17.

TRICARE Quality ManagementContract (TQMC)

A national-levelcontractor responsible to the DoD and DHA that performs second level reconsiderationsfor payment denials and focused retrospective quality of care reviews.

TRICARE Retired Reserve

The program established under10 USC 1076e and 32 CFR 199.25.

TRICARE Regional Office(TRO)

The managementorganization responsible for overseeing an integrated Tri-Serviceshealth care delivery system within one of the designated TRICAREregions.

TRICARE Regulation (Definedin 32 CFR 199.2)

This regulation prescribesguidelines and policies for the administration of the TRICARE Programfor the Army, Navy, Air Force, Marine Corps, Coast Guard, CommissionedCorps of the USPHS, and the Commissioned Corps of the NOAA. It includesthe guidelines and policies for the administration of the TRICAREProgram.

TRICARE Reimbursem*ntManual (TRM) (6010.61-M)

A DHA authored book which providesand outlines payment methodologies under the TRICARE Program.

TRICARE Representative

A highly qualified individualknowledgeable about TRICARE responsible for providing informationand assistance to providers, whether network or non-network, toBeneficiary Counseling and Assistance Coordinators (BCACs) in theirservice area and to Congressional offices.

TRICARE Select

The self-managed, preferredprovider network option under the TRICARE program established by10 USC 1075 and 32 CFR 199.17 toreplace TRICARE Extra and Standard after December 31, 2017.

TRICARE Standard

The TRICARE program made availableprior to January 1, 2018, under which the basic program of health carebenefits generally referred to as CHAMPUS was made available toeligible beneficiaries under 32 CFR 199.

TRICARE Systems Manual(TSM) (7950.3-M)

A DHAauthored book which provides ADP instructions and requirements forcontractors who use the TEDs system for reporting data to DHA.

Unbundled (Or Fragmented)Billing

A formof procedure code manipulation which involves a provider separatelybilling the component parts of a procedure instead of billing onlythe single procedure code which represents the entire comprehensiveprocedure.

Uniform Formulary

A list of brand name and genericdrugs and supplies available for dispensing.

Note:PL 106-65, NDAA for FY 2000,Section 701, mandated that the DoD develop a uniform formulary tobe applied across all POSs within the TRICARE system. Pharmaceuticalsand other supplies authorized for dispensing will be in accordancewith TRICARE policy and the Uniform Formulary. Recommendations forthe design, structure and composition of the Uniform Formulary aredeveloped by the DoD P&T Committee, with comments by the UniformFormulary Beneficiary Advisory Panel, and provided to the ExecutiveDirector, DHA for approval and implementation.

Uniform HMO Benefit (Definedin 32 CFR 199.2)

The health care benefit establishedby 32 CFR 199.18.

Uniformed Services (Definedin Title 10, United States Code, Section 101(a)(5))

The Army, Navy, Air Force,Marine Corps, Space Force, Coast Guard, Commissioned Corps of theUSPHS, and the Commissioned Corps of the NOAA.

Uniformed Services Clinic(USC)

An MHSclinic that delivers primary health care to Service members.

Uniformed Services FamilyHealth Plan (USFHP)

A DoD health plan option thatoffers TRICARE Prime to individuals who reside in the geographicservice area of a USFHP DP who are eligible to receive care in medicalMTFs/eMSMs (except Service members). This includes those individualsover age 65 who, except for their eligibility for Medicare benefits,would have been eligible for TRICARE benefits. DPs under the USFHPwere previously known as “Uniformed Services Family Treatment Facilities”(USTFs) and are former USPHS hospitals. The service areas of the USFHPDPs are listed at https://www.usfhp.com onthe world wide web and in the Catchment Area Directory.

United States (U.S.)

Territory made up of the 50federated states, American Samoa, the District of Columbia, Johnston Island,Guam, Wake, Midway Islands, Northern Marianas and the U.S. VirginIslands.

United States PublicHealth Service (USPHS)

An agency within the DHHS whichhas a Commissioned Corps which are classified as members of the “UniformedServices.”

Unprocessable TRICAREEncounter Data (TED)

TED records transmitted bythe contractor to DHA and received in such condition that the basicrecord identifier information is not readable on the TRICARE datasystem, i.e., header incorrect, electronic records garbled, etc.

Unproven Drugs, Devices,And Medical Treatments Or Procedures

Drugs, devices, medical treatmentsor procedures are considered unproven if:

1. FDA approvalis required and has not been given;

2. If the deviceis a FDA Category A Investigational Device Exemption (IDE);

3. If there isno reliable evidence which documents that the treatment or procedurehas been the subject of well-controlled studies of clinically meaningfulendpoints which have determined its maximum tolerated dose, itstoxicity, its safety, and its efficacy as compared with the standardmeans of treatment or diagnosis;

4. If the reliableevidence shows that the consensus among experts regarding the treatmentor procedure is that further studies or clinical trials are necessaryto determine its maximum tolerated dose, its safety, or its effectivenessas compared with the standard means of treatment or diagnosis.

For further clarification see 32CFR 199.4.

Urgent Care

Medically necessary treatmentthat is required for a sudden illness or injury that is not lifethreatening, but does require immediate professional attention toavoid further complications resulting from non-treatment. Treatmentis usually performed outside an Emergency Room (ER) setting.

Urgent Care Center (UCC)

A TRICARE authorized UCC isa qualified corporate services provider under 32 CFR 199.6(f) with a location distinct froma hospital Emergency Room (ER), an office, or a clinic; and whosepurpose is to diagnose and treat illness or injury for unscheduled,ambulatory patients seeking immediate medical attention.

Use (HIPAA Definition)

IIHI which involves sharing,employment, application, utilization, examination, or analysis ofsuch information within an entity that maintains such information.”

Utilization Criteria

Specific guidelines that mustbe met in order to ensure that medically necessary and appropriate treatmentis being provided. Criteria to use for screening.

Utilization Management

A set of techniques used tomanage health care costs by influencing patient care decision-making throughcase-by-case assessment of the appropriateness and medical necessityof care either prior to, during, or after provision of care. Utilizationmanagement also includes the systematic evaluation of individualand group utilization patterns to determine the effectiveness ofthe employed utilization management techniques and to develop modificationsto the utilization management system designed to address aberrancesidentified through the evaluation.

Utilization Review

A process for monitoring theuse, delivery, quality, medical necessity, and cost-effectivenessof health care services especially those provided by medical community.

Validated Date and Diagnosis

The date a DoD physician (militaryor civil service) validates the diagnosis of a service-related condition andvalidates that the condition can be resolved within 180 days.

Veteran (Defined in 38CFR §3.1(d) and 32 CFR 199.2)

A person who served in theactive military, naval, or air service, and who was discharged orreleased therefrom under conditions other than dishonorable.

Note:Unless the veteran is eligiblefor “retired pay,” “retirement pay,” or “retainer pay,” which refersto payments of a continuing nature and are payable at fixed intervalsfrom the Government for military service neither the veteran norhis or her family members are eligible for benefits under TRICARE.

Widow Or Widower (Definedin 32 CFR 199.2)

A person who was a spouse atthe time of death of the active duty member or retiree and who hasnot remarried.

Workday

Any day on which full-timebusiness can be conducted. See the definition of “Business Day”in this appendix.

Worker's CompensationBenefits (Defined in 32 CFR 199.2)

Medical benefits availableunder any worker’s compensation law (including the Federal Employees CompensationAct), occupational disease law, employers liability law, or anyother legislation of similar purpose, or under the maritime doctrineof maintenance, wages, and cure.

Workforce (HIPAA Definition)

Employees, volunteers, trainees,and other persons whose conduct, in the performance of work fora covered entity is under the direct control of such entity, whetheror not they are paid by the covered entity or business associateas defined in HIPAA of 1996.

- END -

TRICARE Manuals - Display Appendix A (Change 139, Jun 10, 2024) (2024)

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