Deck 15: Tricare Medical Billing

Question 1

The plan that provides benefits for veterans with 100% service-related disabilities and their families is:

A)TRICARE Standard.
B)TRICARE Extra.
C)TRICARE Prime.
D)CHAMPVA.

Answer 1

CHAMPVA.

Question 2

The TRICARE plan option that provides benefits using a fee-for-service, cost-sharing structure is:

A)TRICARE Standard.
B)TRICARE Extra.
C)TRICARE Prime.
D)CHAMPVA.

Answer 2

TRICARE Standard.

Question 3

An individual who qualifies for TRICARE is known as a(n):

A)member.
B)beneficiary.
C)sponsor.
D)enrollee.

Answer 3

beneficiary.

Question 4

The TRICARE preferred provider organization (PPO) plan option is:

A)TRICARE Standard.
B)TRICARE Extra.
C)TRICARE Prime.
D)CHAMPVA.

Question 5

Under TRICARE Standard, the group of beneficiaries that pays 25% cost share for outpatient services includes all of the following EXCEPT:

A)former spouses of active-duty service members.
B)retired service members and their families.
C)families of deceased personnel.
D)families of active-duty service members.

Question 6

An active-duty service member whose family is covered by a TRICARE plan is known as a(n):

A)member.
B)beneficiary.
C)sponsor.
D)enrollee.

Question 7

To be eligible for TRICARE, all sponsors and family members must be enrolled in DEERS, which stands for:

A)Department Electronic Enrollment Reporting System.
B)Department Early Enrollment Reporting System.
C)Defense Electronic Eligibility Reporting System.
D)Defense Enrollment Eligibility Reporting System.

Question 8

Authorized TRICARE providers include all of the following EXCEPT:

A)chiropractors.
B)doctors of dental medicine.
C)doctors of optometry.
D)psychologists.

Question 9

The TRICARE health maintenance organization (HMO) plan option is:

A)TRICARE Standard.
B)TRICARE Extra.
C)TRICARE Prime.
D)CHAMPVA.

Question 10

Under TRICARE Standard, the group of beneficiaries that pays 20% cost share for outpatient services includes:

A)former spouses of active-duty service members.
B)families of active-duty service members.
C)families of deceased personnel.
D)retirees from the military.

Question 11

Authorized nonphysician TRICARE providers include all of the following EXCEPT:

A)acupuncturists.
B)audiologists.
C)clinical social workers.
D)speech therapists.

Question 12

Which of the following services is covered under TRICARE Standard?

A)chiropractic care.
B)cosmetic surgery.
C)mental health care.
D)custodial care.

Question 13

The TRICARE Standard annual catastrophic cap (maximum amount beneficiaries are required to pay within 1 year) for retirees is:

A)$1,000.
B)$2,500.
C)$5,000.
D)$7,500.

Question 14

The TRICARE fiscal year begins on:

A)January 1.
B)July 1.
C)September 1.
D)October 1.

Question 15

The TRICARE fiscal year ends on:

A)January 31.
B)June 30.
C)September 30.
D)December 31.

Question 16

Under TRICARE, what does NAS stand for?

A)Nonavailability statement
B)Nonactive status
C)Nonauthorized service
D)No available surgeons

Question 17

If a TRICARE beneficiary receives services from a nonauthorized provider, the physician can bill:

A)only the usual, customary, and reasonable amount.
B)only the authorized contracted amount.
C)only the limiting charge.
D)any amount for the services.

Question 18

The TRICARE Standard annual catastrophic cap (maximum amount beneficiaries are required to pay within 1 year) for active-duty families is:

A)$1,000 per beneficiary.
B)$1,000 per family.
C)$7,500 per beneficiary.
D)$7,500 per family.

Question 19

When a TRICARE beneficiary needs treatment that is NOT available from a military treatment facility (MTF), the:

A)beneficiary will have to pay for the services.
B)services will not be covered.
C)beneficiary must obtain a nonavailability statement (NAS) to receive services from a civilian provider.
D)beneficiary can automatically receive services from a civilian provider.

Question 20

Services covered under TRICARE Standard include all of the following EXCEPT:

A)podiatry services.
B)durable medical equipment (DME).
C)mental health care.
D)routine physical examinations.

Question 21

Enrollment is NOT required for:

A)TRICARE Standard.
B)TRICARE Prime.
C)TRICARE Prime Remote.
D)CHAMPVA.

Question 22

In 1994, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) program name was changed to:

A)the Defense Enrollment Eligibility Reporting System (DEERS).
B)the Veteran's Administration (VA) Health Administration Center.
C)TRICARE.
D)CHAMPVA.

Question 23

For inpatient care at a civilian network facility, TRICARE Senior Prime/TFL beneficiaries pay:

A)$0.
B)$11 per day.
C)$11 per admission.
D)20% of the charges.

Question 24

Under TRICARE Prime, a PCM is a:

A)primary care manager.
B)physician case manager.
C)preventive care manager.
D)physician consulting manager.

Question 25

TRICARE beneficiaries older than age 65 are eligible for TRICARE for Life if they have:

A)Medicare Part A coverage.
B)Medicare Part B coverage.
C)Medicare Parts A and B coverage.
D)no Medicare coverage.

Question 26

Under TRICARE, what does MTF stand for?

A)Medical treatment for forces
B)Military treatment facility
C)Military training families
D)Medical training facility

Question 27

Active-duty service members are NOT eligible to enroll in:

A)TRICARE Standard.
B)TRICARE Extra.
C)TRICARE Prime.
D)CHAMPVA.

Question 28

The cost share for TRICARE Extra enrollees includes a:

A)$0 deductible.
B)$150 deductible for an individual or $300 for a family.
C)$0 deductible and 20% of outpatient charges.
D)$250 deductible for an individual or $500 for a family.

Question 29

Under TRICARE Prime, the primary care manager provides all of the following services EXCEPT:

A)preventive care.
B)nonavailability statements when required.
C)care for routine illnesses.
D)referral to specialists.

Question 30

If a beneficiary has both TRICARE Senior Prime/TFL and Medicare, which plan is primary?

A)TRICARE is primary.
B)Medicare is primary.
C)The patient can select which is primary.
D)The provider can select which is primary.

Question 31

The TRICARE plan that offers a higher-cost, point-of-service option for care received from out-of-network providers is:

A)TRICARE Standard.
B)TRICARE Extra.
C)TRICARE Prime.
D)CHAMPVA.

Question 32

The copay for visits to civilian providers under TRICARE Prime is based on the:

A)type of service required.
B)type of physician providing services.
C)military rank of the sponsor.
D)number of dependent family members.

Question 33

TRICARE
Prime is a managed care plan that differs from TRICARE Standard in that:

A)beneficiaries are assigned a primary care manager (PCM).
B)more preventive services are covered.
C)fewer out-of-pocket costs must be paid by beneficiaries.
D)beneficiaries receive priority treatment at MTFs.

Question 34

Under the access standards for TRICARE Prime enrollees, appointment wait time for routine care should NOT exceed:

A)24 hours.
B)3 days.
C)7 days.
D)2 weeks.

Question 35

Under the access standards for TRICARE Prime enrollees, appointment wait time for wellness/preventive care should NOT exceed:

A)48 hours.
B)1 week.
C)2 weeks.
D)4 weeks.

Question 36

Under TRICARE Prime Remote, referrals to specialists are coordinated by the primary care manager (PCM) and the regional:

A)health care finder (HCF).
B)Department of Veterans Affairs (DVA).
C)military treatment facility (MTF).
D)primary care case manager (PCCM).

Question 37

Under the TRICARE Prime point-of-service option, charges for visits to non-network providers are:

A)not paid by TRICARE.
B)subject to a $6 or $12 copay.
C)paid 80% by TRICARE and 20% by the beneficiary.
D)paid 50% by TRICARE and 50% by the beneficiary.

Question 38

The TRICARE plan with the lowest out-of-pocket costs is:

A)TRICARE Standard.
B)TRICARE Extra.
C)TRICARE Prime.
D)CHAMPVA.

Question 39

The TRICARE Prime annual enrollment fee for retired service members is:

A)$0.
B)$260 for an individual or $520 for a family.
C)$300 for an individual or $600 for a family.
D)$520 for an individual or $1,040 for a family.

Question 40

Under the access standards for TRICARE Prime enrollees, appointment wait time for urgent care should NOT exceed:

A)24 hours.
B)48 hours.
C)72 hours.
D)7 days.

Question 41

Form Locator 1a, Insured's ID Number, should include the:

A)patient's Social Security number.
B)patient's TRICARE-issued ID number.
C)sponsor's Social Security number.
D)sponsor's military rank and number.

Question 42

The TRICARE regional healthcare finder (HCF) provides preventive services and care for routine illnesses or injuries.

Question 43

Under TRICARE Prime, visits to civilian network providers require a copayment dependent on the military rank of the sponsor.

Question 44

TRICARE claims must be submitted no later than:

A)30 days from the date of service.
B)90 days from the date of service.
C)6 months from the date of service.
D)1 year from the date of service.

Question 45

Due to confidentiality regulations, TRICARE claims examiners do NOT provide information to parents or guardians of minors in regard to healthcare services that are related to:

A)abortion.
B)alcoholism or drug abuse.
C)sexually transmitted disease.
D)all of the above.

Question 46

The claims processor for all TRICARE Senior Prime/TRICARE for Life claims is:

A)Blue Cross/Blue Shield.
B)the Veteran's Administration (VA) Health Administration Center.
C)the Wisconsin Physicians Service (WPS).
D)dependent on the location of the provider.

Question 47

If a TRICARE Standard beneficiary receives care from a provider who does NOT accept assignment, he or she is responsible for the provider's additional charges up to 115% of the allowable charge.

Question 48

Under TRICARE Standard, if care is available from a military treatment facility (MTF) but the patient prefers to receive similar care at a civilian facility, he or she can do so after obtaining a nonavailability statement (NAS).

Question 49

The TRICARE claims processor for the northern region of the United States is:

A)Blue Cross/Blue Shield.
B)Health Net Federal Services, Inc.
C)the Veteran's Administration (VA) Health Administration Center.
D)the Wisconsin Physicians Service (WPS).

Question 50

Paper claims for CHAMPVA may be submitted to:

A)Blue Cross/Blue Shield.
B)the Veteran's Administration (VA) Health Administration Center.
C)the Wisconsin Physicians Service (WPS).
D)This is dependent on the location of the provider.

Question 51

If a Veteran's Administration (VA) facility cannot provide necessary medical care for a veteran, an authorization for services will specify all of the following EXCEPT the:

A)provider the patient must see.
B)medical services that the VA approves.
C)length of period of treatment.
D)amount the VA will pay.

Question 52

Which claim form must physician offices use to submit claims to TRICARE?

A)CMS-1450
B)CMS-1500
C)UB-04
D)CMS-5100

Question 53

The CHAMPVA program is administered by the:

A)Centers for Medicare and Medicaid Services (CMS).
B)Department of Defense (DoD).
C)Veteran's Administration (VA) Health Administration Center.
D)Veteran's Administration (VA) hospital network.

Question 54

An individual who qualifies for TRICARE coverage is known as a sponsor.

Question 55

For inpatient care at a military facility, TRICARE Senior Prime/TFL beneficiaries pay:

A)$0.
B)$11 per day.
C)$11 per admission.
D)20% of the charges.

Question 56

TRICARE beneficiaries who use nonauthorized providers may be responsible for paying their entire bill.

Question 57

The TRICARE program covers active-duty service members, retirees, family members, and survivors of eligible armed services members.

Question 58

A doctor of osteopathy is considered an authorized service provider for TRICARE.

Question 59

Under TRICARE Standard, most enrollees pay an annual deductible but no cost share for outpatient charges.

Question 60

All active-duty uniformed services members are required to enroll in one of the TRICARE Prime plan options.

Question 61

TRICARE Extra is more expensive than TRICARE Prime but less costly than TRICARE Standard.

Question 62

Nonavailability statements are valid for 12 months after they are issued.

Question 63

TRICARE Standard and TRICARE Extra are available to beneficiaries throughout the United States and overseas.

Question 64

Penalties or interest charges can be billed to a beneficiary by a physician due to TRICARE's failure to make payment on a timely basis.

Question 65

If treatment is NOT available at a military treatment facility (MTF), a TRICARE beneficiary must obtain a(n) __________ statement before receiving services from a civilian provider.

Question 66

The Department of Defense (DoD) medical entitlement program for uniformed services beneficiaries is __________ .

Question 67

The TRICARE plan that is similar to an HMO and requires care to be coordinated by a primary care manager (PCM) is __________ .

Question 68

TRICARE Standard __________

Question 69

TRICARE Senior Prime/TRICARE for Life acts as the primary payer when the covered individual also has Medicare coverage.

Question 70

Active-duty service members who are assigned to permanent duty in a location that is at a distance from sources of military healthcare can obtain services through __________ .

Question 71

When the covered beneficiary is responsible for a portion of the total healthcare costs, this is known as cost __________ .

Question 72

The program that provides medical care for veterans with 100% service-related disabilities is __________ .

Question 73

Under the TRICARE Prime plan, the provider who coordinates and manages a patient's medical care is referred to as the __________ manager.

Question 74

All armed services sponsors and family members must be enrolled in the __________ Reporting System to be eligible for TRICARE.

Question 75

Contractors who process TRICARE claims do NOT provide information to parents of minors when the healthcare services provided are related to drug abuse.

Question 76

Once a TRICARE Standard member has reached an annual catastrophic cap, the beneficiary pays 100% of additional charges for that year.

Question 77

What are the seven health plans available to individuals who are eligible for TRICARE benefits?

Question 78

Priority access to military treatment facilities (MTFs) is given to TRICARE Standard and TRICARE Extra beneficiaries.

Question 79

The primary care manager (PCM) under TRICARE Prime may be a single military or civilian provider or a group of providers.

Question 80

Prescription drug benefits are included in TRICARE Senior Prime/TRICARE for Life.