Claims
The contractor for claims
Who is PGBA?
Beneficiary type we primarily appoint for.
What is a Prime beneficiary?
The document to send a patient to another specialist.
What is a referral?
Criteria for an authorized provider
What is must meet TRICARE licensing and certification requirements?
Model for all other TRICARE plans
What is Prime and Select?
The Explanation of Benefits
What is EOB?
Involved in post-surgical care and overall beneficiary's care experience
Who is Clinical Quality Management?
We will not appoint for this beneficiary.
Who is the sponsor?
Neurologist, craniologist, proctologist
What are specialist?
Used to know when an authorization or referral is required
What is the RADS tool?
Where to find help in ensuring forms are completed correctly
What is tricare.mil/patient resources/claims?
We will only appoint this
What is Utilization Management
Will not file claims
What is a non-network, non-participating provider?
Used to help beneficiaries choose a doctor
What is the Provider Directory?
Claim processed for a beneficiary under Prime who received care without a referral
What is Point of Service?
After appointment is set, document appointment details here
What is done in both CareRadius and Salesforce?
We appoint to a non-network provider
What is only when all network providers have been exhausted?
A non-network participating provider
What is will accept on a case-by-case basis?
Who are the TRICARE for Life and pharmacy contractors?
Tricare pays first
What is medicaid?
Confirmation following immediately after HIPAA verification
What is confirm the beneficiary is not a part of ECHO/CM/DM programs?
Medical Management search(es) available in CareRadius
What is Member and Authorization/Referral search?
Ensures high-quality, cost-effective providers are available within our beneficiaries drivetime
What is Value Based Steerage Model?
All enrollment transactions start here
What is DOES enrollment tab?