FALLS CHURCH, Va. –
Have you recently come across a health care term and weren’t quite sure what it meant? It’s OK. Health care coverage is full of terms you may not know. To help you better understand your TRICARE benefit, here’s a list of commonly used health care terms and definitions.
“Having a basic knowledge of common health care terms that you may encounter as a TRICARE beneficiary will go a long way toward helping you make decisions that will benefit you and your family,” said TRICARE Health Plan Deputy Chief Curt Prichard.
Remember, there are different types of TRICARE health plans. So, depending on your plan, some of these terms may not apply. If you have questions, you should reach out to your health care provider or TRICARE contractor.
1. Network provider
This is any TRICARE-authorized provider that has signed a contract with one of the TRICARE regional contractors. Network providers have agreed to accept the contracted rate as payment in full for covered health care services and file claims for you. The TRICARE contractors have established provider networks in each region. To find a network provider near you, visit Find a Doctor. If you have TRICARE For Life, you can find a Medicare provider by searching the Medicare Provider Directory.
2. Non-network provider
This is a TRICARE-authorized provider who doesn’t have an agreement with TRICARE and may not file claims for you. There are two types of non-network providers: participating and nonparticipating. Participating providers may choose to participate on a claim-by-claim basis. They’ve agreed to accept payment directly from TRICARE. They’ve also agreed to accept the TRICARE-allowable charge (minus any applicable patient costs) as payment in full.
Non-participating providers haven’t agreed to file your claim. You may have to pay up front for services rendered and file your own claim. These providers also have a legal right to charge up to 15% above the TRICARE-allowable charge for services. You’re responsible for paying this amount, in addition to any applicable patient costs.
3. Primary care manager
With a TRICARE Prime plan, your health care is managed by a primary care manager (PCM). Your PCM is responsible for providing and coordinating a range of health care services—routine, nonemergency, and urgent health care—for you. Your PCM can be a provider at a military hospital or clinic or civilian TRICARE network provider. Or you could have a primary care provider under the US Family Health Plan.
This is when your PCM sends you to another provider for care. If you’re enrolled in a TRICARE Prime plan, you need a referral from your PCM to seek most specialty care. Your PCM will send a referral request to your regional contractor, who will process the referral. If you don’t get a referral from your PCM to visit a specialist, your care will be under the point-of-service (POS) option. By using the POS option, you’ll pay higher out-of-pocket-costs. Some TRICARE plans, including TRICARE Select, don’t require referrals for most health care services.
Sometimes, your TRICARE contractor must review a requested health care service or prescription drug to see if it’s medically necessary and appropriate, and is a TRICARE covered benefit. This is a pre-authorization and is different from a referral. Some health care services require pre-authorization before you receive them, regardless of your TRICARE plan. You can check for services that need pre-authorization on the TRICARE website or your regional contractor’s website. Without this approval, you could be responsible for the full cost of your care. Active duty service members need pre-authorizations for all inpatient and outpatient specialty services.
6. Medically necessary
TRICARE covers services or supplies that are medically necessary. Medically necessary refers to health care services or supplies that qualified medical professionals accept to be appropriate, reasonable, and adequate for the diagnosis and treatment of your condition. For care to be considered medically necessary, it must also be proven safe and effective, which must be established through reliable clinical trials, formal technology assessments, or positions from national medical organizations.
7. Covered Services
Covered services are the medical services or supplies that you’re eligible to receive under TRICARE. All medical services or supplies must be medically necessary and appropriate for the condition being treated. There are some services and supplies that aren’t covered under a health plan. These are known as exclusions. You can check the Covered Services page to see which services are covered by your health plan. To check coverage for your prescription drugs, search the TRICARE Formulary.
8. TRICARE Open Season
This is the annual period when you can enroll in or change your TRICARE health care coverage for the following year. Open season occurs each fall, beginning on the Monday of the second full week in November to the Monday of the second full week in December.
9. Qualifying Life Event
This is a certain change in your life that makes you eligible to enroll or change your TRICARE health plan outside of open season. As outlined in the TRICARE Qualifying Life Events Fact Sheet, examples of Qualifying Life Events (QLEs) include moving, retiring from active duty, getting married, and having a baby. These QLEs open a 90-day period for you and your family to make enrollment changes.
10. Other Health Insurance
This is any health insurance you have besides TRICARE. Other health insurance (OHI) can be through your employer or a private insurance program. TRICARE pays after most OHI. This means your OHI processes your claim first. Then, you or your doctor files a claim with TRICARE. By law, TRICARE pays after all other health insurance, except for Medicaid, TRICARE supplements, State Victims of Crime Compensation programs, or other federal government programs (for example, Indian Health Service). Tell your TRICARE contractor and doctors when you have other health insurance.
Want to learn more about health care? Understanding your medical costs is important, too. Check the Cost Terms page for a breakdown of costs terms and definitions. Remember, always ask if you don’t understand something your health care provider says or follow up with your TRICARE contractor.
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