Glossary of Terms


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Abuse
The improper or excessive use of program benefits, resources, or services by providers or beneficiaries. Abuse can be either intentional or unintentional and can occur when:
  • Excessive or unnecessary services are used.
  • Services are not appropriate for the beneficiary’s condition.
  • A beneficiary uses an expired or voided identification card.
  • A more expensive treatment is rendered when a less expensive treatment would be as effective.
  • A provider or beneficiary files false or incorrect claims.
    • and/or
  • Billing or charging does not conform to TRICARE requirements.
Accepting Assignment
An accepting assignment is when a provider agrees to accept the TRICARE allowable charge(s), less any beneficiary cost-shares, copayments, or deductibles, as the full fee for care.
Allowable Charge, also TRICARE Allowable Charge
The term "allowable charge" is the maximum amount TRICARE will authorize for medical and other services furnished in an inpatient or outpatient setting. The allowable charge is normally the lowest of the actual billed charge or the allowable charge. For example, if the allowable charge for a service is $90 and the billed charge is $50, TRICARE will pay $50 (actual billed charge); if the billed charge is $100, TRICARE will pay $90 (the allowable charge). In the case of inpatient hospital payments, the diagnosis-related group (DRG) is the TRICARE allowable charge of the billed amount regardless.
Allowable Charge Review
An allowable charge review is a method by which a network provider may request a review of a claim he/she deems was paid at an inappropriate level.
Appeals Review
Method by which a non-network participating provider (i.e., one who has accepted assignment) may request a review of a claim he/she deems was paid at an inappropriate level.
Authorization
A review determination made by a licensed professional nurse or other health care professional for requested services, procedures, or admissions. Authorizations must be obtained prior to services being rendered or within 24 hours of an admission.
Authorized Provider
An authorized provider is a hospital or institutional provider, a physician or other individual professional provider, or other provider of services meeting specific educational, licensing, and other requirements. Authorized providers are not necessarily network providers. TRICARE will share costs if a beneficiary sees a provider of this type.
Balance Billing
A term used to describe when a provider bills a beneficiary for the rest of the charges. A beneficiary cannot be billed for the remainder or "balance" of the provider charges, after TRICARE (and other health insurance) has paid everything it’s going to pay. A beneficiary is not legally responsible for amounts above 15 percent of the TRICARE allowable charge, even if the provider is not network and does not accept assignment of benefits. Network providers are prohibited from balance billing.
Beneficiary
A person who is eligible for TRICARE benefits. Beneficiaries include active duty service members, active duty family members (ADFMs), retired service members and their families. Family members include spouses and unmarried natural or stepchildren up to the age of 21 (or 23 if full-time students at accredited institutions of learning). Other beneficiary categories are listed in the section entitled "Eligibility for TRICARE."
Beneficiary Counseling and Assistance Coordinators (BCACs)
Persons at military treatment facilities (MTFs) who are available to answer questions, help solve health care-related problems, and assist beneficiaries in obtaining medical care through TRICARE. BCACs were previously known as Health Benefits Advisors or HBAs.
BRAC Site
A military base that has been closed or targeted for closure by the Government’s Base Realignment and Closure Commission (BRAC).
Care Coordination
An approach to care management using proactive methods to optimize health outcomes and reduce risks of future complications over a short-term (two to six weeks) single episode of care. Prospective and concurrent reviews are used to identify current and future beneficiary needs.
Case Management
A collaborative process normally associated with multiple episodes of health care intervention that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a beneficiary’s complex health needs. This is accomplished through communication and available resources that promote quality, cost-effective outcomes.
Catastrophic Cap
The maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1–September 30). The catastrophic cap for active duty families is $1,000, and the catastrophic cap for all other TRICARE eligible families is $3,000.
Centers for Medicare and Medicaid Services (CMS)
The Federal agency that oversees all aspects of health care claims filing for Medicare (formerly known as the Health Care Financing Administration or HCFA).
Certified Provider
A certified provider is one that meets all the requirements to be a TRICARE-authorized provider and has been "certified" to provide services to TRICARE beneficiaries. "Authorized" and "certified" are interchangeable terms.
Copayment
The fixed amount a TRICARE Prime* enrollee will pay for care in the civilian provider network. Active duty service members and active duty family members are not required to pay copayments for services received from a network provider under TRICARE Prime.
A hospital or institutional provider, physician, or other individual professional provider of services or supplies specifically authorized by 32 CFR 199.6. Certified providers have been verified by TRICARE Management Activity (TMA) or TriWest to meet the standards of 32 CFR 199.6 and have been approved to provide services to TRICARE beneficiaries and receive government payment for services rendered to TRICARE beneficiaries.
CHAMPUS Maximum Allowable Charge
The maximum amount TRICARE will cover for nationally established fees (i.e. fees for professional services). CMAC is the TRICARE allowable charge for covered services when appropriately applied to services priced under CMAC.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
The former health care program established to provide health coverage for active duty family members (ADFMs), retirees and their family members. TRICARE was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. Benefits covered under CHAMPUS are now covered under TRICARE Standard.
Civilian Health and Medical Program of the Veterans Administration (CHAMPVA)
A federal health benefits program for family members of 100-percent totally and permanently disabled veterans. CHAMPVA is administered by the Department of Veterans Affairs and is not associated with the TRICARE program. For questions regarding CHAMPVA, call 1-800-733-8387 or 1-303-331-7599.
Circumvention
A term used to describe inappropriate medical practices or actions that result in unnecessary multiple admissions of an individual.
ClaimCheck®
A customized, automated claims auditing system that verifies the clinical accuracy of professional claims.
CMS-1500
Formerly known as the HCFA-1500, the CMS has changed the name of its claim form to CMS-1500. Providers may continue to use HCFA-1500 forms they already have in stock, but will be required to order CMS-1500 forms when their supplies are exhausted. The form itself has not changed.
Concurrent Review
A review performed during the course of a beneficiary’s inpatient admission with the purpose of validating the appropriateness of the admission, level of care, medical necessity, and quality of care, as well as the information provided during earlier reviews. Additional functions performed include screening for case management and identification of discharge planning needs. The review may be conducted by telephone or on-site. Concurrent reviews are generally performed when TRICARE is the primary insurer. Concurrent reviews that indicate criteria are not met are referred for medical director review.
Copayment
The fixed amount a TRICARE Prime enrollee will pay for care in the civilian provider network. Active duty family members (ADFMs) are not required to make copayments.
Cost-Share
The percentage of the allowable charges a beneficiary will pay under TRICARE Extra and TRICARE Standard. The cost-share depends on the sponsor’s status—active duty or retired.
Credentialing
The process that evaluates and subsequently allows providers to participate in the TRICARE network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.
Current Procedural Terminology (CPT)
A systematic listing and coding of procedures and services performed by physicians. Each procedure or service is identified with a five-digit code. The use of CPT codes simplifies the reporting of services. With this coding and recording system, the procedure or service rendered by the physician is accurately identified.

* Includes TRICARE Prime Remote and TRICARE Prime Remote for Active Duty Family Members.
Deductible
The annual amount a TRICARE Extra or TRICARE Standard beneficiary must pay for covered outpatient benefits before TRICARE begins to share costs. TRICARE Prime and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) beneficiaries do not have an annual deductible, unless they are utilizing their point-of-service (POS) option.
Defense Enrollment Eligibility Reporting System (DEERS)
A system operated by the Department of Defense and used by TRICARE contractors to determine and confirm the eligibility of beneficiaries. Beneficiaries are responsible for maintaining the accuracy of their DEERS records and updating the system as necessary.
Diagnosis-Related Group (DRG)
A reimbursement methodology used for inpatient care in some hospitals.
Discharge Planning
A process that assesses requirements and the coordination of care for a beneficiary’s timely discharge from an acute inpatient setting to a post-care environment without need for additional military treatment facility (MTF) or civilian provider assistance.
Disease Management
A prospective, disease-specific approach to improving health care outcomes by providing education to beneficiaries through non-physician practitioners who specialize in targeted diseases.
ECHO
ECHO stands for "Extended Care Health Option." It is a supplement to the TRICARE basic program (Prime, Standard and Extra) and provides eligible active duty family members with an additional financial resource for the services and supplies they need to help reduce the disabling effects of the beneficiary’s qualifying condition.
Enrollee
A TRICARE-eligible beneficiary who has elected to enroll in TRICARE Prime, TRICARE Prime Remote (TPR), or TRICARE Prime Remote for Active Duty Family Members.
Explanation of Benefits (EOB)
A statement sent to beneficiaries showing that claims were processed and the amount paid to providers. If denied, an explanation of denial is provided.
Express Scripts, Inc.
The contractor responsible for providing a national network of civilian retail pharmacies for the TRICARE Retail Pharmacy Program, as well as for administering the national TRICARE Mail Order Pharmacy (TMOP) program (www.express-scripts.com).
Foreign Identification Number (FIN)
A permanent identification number assigned to a North Atlantic Treaty Organization (NATO) beneficiary by the appropriate national embassy. The number resembles a social security number (SSN) and most often starts with six or nine. TRICARE will not issue an authorization for treatment or services to NATO beneficiaries without a valid FIN.
Fraud
An instance in which deliberate deceit is used by a provider to obtain payment for services not actually delivered or received, or by a beneficiary to claim program eligibility.
Health Care Financing Administration (HCFA)
The former name of the Centers for Medicare and Medicaid Services or CMS.
Health Care Finder (HCF)
Representatives who help locate TRICARE providers and applicable community, state, and federal health care resources for beneficiaries who require benefits and services beyond TRICARE.
Health Care Procedural Coding System (HCPCS)
A set of codes used by Medicare that describes services and procedures. HCPCS includes Current Procedural Terminology (CPT) codes for services not included in the normal CPT code list, such as durable medical equipment and ambulance service. While HCPCS is nationally defined, there is a provision for local use of certain codes.
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was introduced to improve portability and continuity of health insurance coverage in the group and individual markets; to combat waste, fraud, and abuse in health insurance and health care delivery; to promote the use of medical savings accounts; to improve access to long-term care services and coverage; to simplify the administration of health insurance; and for other purposes.
Health Management Strategic International (HMSI)
A company that has developed behavioral health review criteria for medical necessity reviews.
Initial Denial
Made only after second-level review if the care or treatment is not found to be medically necessary, reasonable, or at the appropriate level. The non-network, participating provider or beneficiary may request a reconsideration of the initial denial. See "Second-level Review" for clarification.
Managed Care
A concept under which an organization delivers health care to enrolled members and controls costs by closely supervising and reviewing the delivery of health care.
Managed Care Support Contractor (MCSC)
The Military Health System's (MHS') civilian health care partners who administer TRICARE in each of the TRICARE regions.
Medical Emergency
A medical condition manifesting itself by "acute symptoms of sufficient severity— including severe pain— such that a prudent layperson could reasonably expect the absence of medical attention to result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part." In the case of a pregnant woman, the danger should be considered to adversely affect the health of the woman or her unborn child. A provider qualified to furnish emergency services and those needed to evaluate or stabilize an emergency medical condition must furnish inpatient or outpatient emergency services.
Medically Necessary
Appropriate and necessary treatment of the beneficiary’s illness or injury according to accepted standards of medical practice and TRICARE policy. Medical necessity must be documented in clinical notes.
Military Treatment Facility (MTF)
A medical facility operated by the military that may provide inpatient and/or ambulatory care to eligible TRICARE beneficiaries. MTF capabilities vary from limited acute care clinics to teaching and tertiary care medical centers.
Network Provider
A network provider is one who serves TRICARE beneficiaries by agreement with your region’s contractor as a member of the TRICARE Prime network or any other preferred provider network or by any other contractual agreement. A network provider accepts the negotiated rate as payment in full for services rendered.
Nonavailability Statement (NAS)
A certification from an MTF that a specific health care service or procedure cannot be provided.
Non-network Provider
A non-network provider is one who has no contractual relationship to provide care to TRICARE beneficiaries, but is authorized to provide care to TRICARE beneficiaries. A non-network provider must be authorized. There are two types of non-network providers—"participating" and "nonparticipating."
Nonparticipating Provider
A nonparticipating provider is an authorized hospital, institutional provider, physician, or other provider that furnishes medical services (or supplies) to TRICARE beneficiaries, but who has not signed a contract with your regional contractor and does not agree to "accept assignment." A nonparticipating provider may balance bill.
North Atlantic Treaty Organization (NATO) Member
A member of a foreign NATO nation’s armed forces who is on active duty and who, in connection with official duties, is stationed in or passing through the U.S. The foreign NATO nations are Belgium, Canada, Czech Republic, Denmark, France, Federal Republic of Germany, Greece, Hungary, Iceland, Italy, Luxembourg, the Netherlands, Norway, Poland, Portugal, Spain, Turkey, and the United Kingdom.
Other Health Insurance (OHI)
Any non-TRICARE health insurance that is not considered a supplement. This insurance is acquired through an employer, entitlement program, or other source. Under federal law, TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, or other programs or plans as identified by TRICARE Management Activity (TMA).
Participating Provider
Providers who participate in TRICARE, also called "accepting assignment," and agree to accept the TRICARE-determined allowable cost or charge as the total charge for services—also known as the TRICARE allowable charge as the full fee for care. In the case of network providers, the negotiated rate is considered the full fee for care. Nonnetwork, individual providers may participate on a case-by-case basis. Providers may seek applicable copayments, costshares, and deductibles from the beneficiary. Hospitals that participate in Medicare must, by law, also participate in TRICARE for inpatient care. For outpatient care, they may or may not participate.
Peer Review Organization (PRO)
An organization charged with reviewing provider quality and medical necessity.
Per Diem
A reimbursement methodology based on a per-day rate that is currently used for behavioral health institutions and partial hospitalization programs.
Point-of-Service (POS)
An option that allows a TRICARE Prime beneficiary to obtain medically necessary services—inside or outside the network— from someone other than his or her primary care manager, without first obtaining a referral or authorization. Utilizing the POS option results in a deductible and greater out-of- pocket expenses for the beneficiary.
Pre-Authorization
See the definition for Prior Authorization.
Preferred Provider Organization (PPO)
A network of health care providers who provide services to patients at discounted rates or cost-shares. TRICARE Extra is considered to be a Preferred Provider Organization option.
Primary Care Manager (PCM)
A TRICARE civilian network provider or military treatment facility (MTF) provider who provides primary care services to TRICARE beneficiaries. A PCM is either selected by the beneficiary or assigned by an MTF commander or his or her designated appointee. To the extent consistent with governing state rules and regulations, PCMs can include internal medicine physicians, family practitioners, pediatricians, general practitioners, obstetricians, gynecologists, physician assistants, nurse practitioners, or certified nurse midwives. Note: TRICARE Prime Remote beneficiaries may choose a TRICARE authorized provider if a network provider is not available.
Prime Service Area
Formerly was called catchment area defined to be within a 40-mile radius (determined by ZIP code) of a military treatment facility (MTF). It now also includes areas containing a high concentration of TRICARE beneficiaries and who are not within the catchment area of an MTF. TriWest is required to offer TRICARE Prime in each prime service area.
Prior Authorization
A review determination made by a licensed professional nurse or paraprofessional for requested services, procedures, or admissions. Prior authorizations must be obtained prior to services being rendered or within 24 hours of an admission.
Prospective Review
A screening process used to evaluate the medical necessity and appropriateness of a treatment or service proposed. The review is prospective (before the care or service is performed) and criteria-based. A registered nurse, physician assistant, or physician performs reviews. A first-level (i.e., prospective) review may result in an authorization of services or in a referral to second-level review. A prospective review never results in a denial of care or treatment.
Reconsideration or Appeal
A formal written request by an appropriate appealing party or an appointed representative to resolve a disputed statement of fact.
Referral
The process by which a primary care manager (PCM) refers a TRICARE Prime beneficiary to another professional or ancillary provider for specialized medical services, prior to those services being rendered.
Region
A geographic area determined by the Federal Government for civilian contracting of medical care and other services for TRICARE-eligible beneficiaries.
Regional Contractor
Civilian partners who provide health care services in the TRICARE regions (TriWest Healthcare Alliance, Health Net Federal Services, Inc., Humana Military Healthcare Services, Inc.).
Remittance Advice
A statement sent to providers showing that claims were processed and the amount for which the beneficiary is responsible. If denied, an explanation of denial is provided.
Reserve Component (RC)
The RC includes the Army National Guard, the Army Reserve, the Naval Reserve, the Marine Corps Reserve, the Air National Guard, the Air Force Reserve, and the U.S. Coast Guard Reserve.
Retrospective Review
A review of a beneficiary’s medical record that occurs after the services have been rendered.
Second-level Review
Cases that do not meet the prospective review screening criteria are referred for physician review at the second level.
Split Enrollment
Refers to multiple family members enrolled in TRICARE Prime in different TRICARE regions.
Sponsor
The active duty service member (ADSM) or retiree through whom family members are eligible for TRICARE.
Supplemental Insurance
Health benefit plans that are specifically designed to supplement TRICARE Standard benefits. Unlike other health insurance (OHI) plans, TRICARE supplemental plans are always secondary payers on TRICARE claims. These plans are frequently available from military associations and other private organizations and firms.
Tax Identification Number
A tax identification number is a number assigned by the State in which a business or entity is operated that identifies it for filing and paying taxes related to the business or entity.
Treatment Plan
A treatment plan is a multidisciplinary care plan for each beneficiary in active case management. It includes specific services to be delivered, the frequency of services, expected duration, community resources, military resources, all funding options, treatment goals, and assessment of the beneficiary environment. The plan is updated monthly and modified when appropriate. These plans are developed in collaboration with the attending physician and beneficiary or guardian.
TRICARE Prime Service Area
The geographic area where TRICARE Prime benefits are offered. This includes all catchment areas, Base Realignment and Closure (BRAC) sites, a forty-mile radius around all MTFs, and all additional areas proposed by the regional contractor.
TRICARE Service Centers (TSC)
A customer service presence located in or close by an MTF to assist all Military Health System beneficiaries, including traveling beneficiaries.
TriWest Hubs
Located throughout the TRICARE West Region and staffed with clinical personnel that work with providers by reviewing and responding to all referral or authorization requests.