Claims
The contractor for claims
Who is PGBA?
When an out-of-network provider bills the beneficiary for the difference between their full charge and what TRICARE allows
What is Balance Billing?
TRICARE Plan, similar to a HMO. Beneficiaries have a PCM assigned and have lower out of pocket costs
What is TRICARE Prime?
Tool used to determine if a referral or authorization is needed
What is the RADS tool?
The appointment access to care standard for ROUTINE CARE?
What is 1 week (7days)?
The Explanation of Benefits
What is EOB?
The maximum amount of money a beneficiary must pay each year for TRICARE-covered services
What is the catastrophic cap?
TRICARE Plan, similar to a PPO. Beneficiaries can self-refer to any TRICARE Authorized provider with a referral without referral.
What is TRICARE Select?
System used to view beneficiary and provider information and to document calls
What is Salesforce?
30 min drive time
What is drive time access standard for primary (routine)?
Where to find help in ensuring forms are completed correctly
What is tricare.mil/patient resources/claims?
Extra charges TRICARE Prime beneficiaries pay when they get care from an out-of-network provider without a referral
What is Point Of Service Fees?
Pogram that provides financial assistance to beneficiaries with special needs for services not covered by the regular TRICARE program
What is ECHO?
System used to view and make changes to referrals authorizations
What is CareRadius?
1-888-874-9378
What is the phone number for TRICARE West Region (Triwest)?
Claim processed for a beneficiary under Prime who received care without a referral
What is Point of Service?
A set dollar amount the beneficiary pays for a covered medical service or prescription
What is a copayment
Premium based plan that provides temporary coverage when TRICARE eligibility is lost
What is Continued Health Care Benefit Program?
Tool utilized to determine what MTFs are available to a beneficiary, in their area, for PCM assignment
What is the MTF Assist Tool?
Express Scripts
Who is the TRICARE Pharmacy contractor?
DD Form 2642
What is the Beneficiary Claim form?
The amount a beneficiary pays out-of-pocket each year before TRICARE begins sharing the cost of care
What is the Annual Deductible?
Provides 180 days of TRICARE benefits to help beneficiaries transition their healthcare after separating from active duty
What is Transitional Assistance Management Program?
Tool used to locate providers.
What is the Provider Directory?
All enrollment transactions start here
What is DOES enrollment tab?