Glossary of terms

Accepting assignment
Those instances when a provider agrees to accept the TRICARE allowable charge.

Authorization for care
The determination that the requested treatment is medically necessary, delivered in the appropriate setting, a TRICARE benefit and that the treatment will be cost-shared by the Department of Defense.

Base Realignment and Closure Commission (BRAC) Site
A military base that has been closed or targeted for closure by the government BRAC.

Beneficiary
A person who is eligible for TRICARE benefits. Beneficiaries include ADFMs and retired service members and their families. Family members include spouses and unmarried children, adopted children or stepchildren up to the age of 21 (or 23 if full-time students at approved institutions of higher learning and the sponsor provides at least 50 percent of the financial support). Find other beneficiary categories are listed in TRICARE Eligibility.

Beneficiary Counseling and Assistance Coordinators (BCAC)
Persons at military hospitals or clinics and Health Plan East Region offices, who are available to answer questions, help solve healthcare-related problems and assist beneficiaries in obtaining medical care through TRICARE. BCACs were previously known as Health Benefits Advisors (HBA).

Catastrophic cap
The maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given Fiscal Year (October 1 to September 30). Point-Of-Service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.

Catchment area
Geographic areas determined by the Assistant Secretary of Defense (Health Affairs) that are defined by a set of five-digit ZIP Codes, usually within an approximate 40-mile radius of a military inpatient treatment facility.

Note: Humana Military — and all other contractors responsible for administering TRICARE — is required to offer TRICARE Prime in each catchment area.

CHAMPUS Maximum Allowable Charge (CMAC)
The CHAMPUS (Civilian Health and Medicaid Program of the Uniformed Services) Maximum Allowable Charge is the maximum amount TRICARE will reimburse for nationally established procedure coding (i.e., codes for professional services). CMAC is the TRICARE allowable charge for covered services

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
The federal health benefits program for eligible family members of 100 percent totally and permanently disabled Veterans. CHAMPVA is administered by the Department of Veterans Affairs and is a separate federal program from the Department of Defense TRICARE program. For question regarding CHAMPVA, call (800) 733-8387 or email hac.inq@va.gov

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
The healthcare program established to provide purchased healthcare coverage for ADFMs and retired service members and their family members outside the military’s direct care system. DHA was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. The purchased care benefits authorized under the CHAMPUS law and regulations are now covered under TRICARE Select.

Corporate Services Provider (CSP)
A class of TRICARE-authorized providers consisting of institutional-based or freestanding corporations and foundations that render professional ambulatory or in-home care and technical diagnostic procedures.

Credentialing
The process by which providers are allowed to participate in the TRICARE network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.

Defense Enrollment Eligibility Reporting System (DEERS)
A database of uniformed services members (sponsors), family members and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS updated.

Refer to the TRICARE eligibility section for more information.

Designated Provider (DP)
Under the US Family Health Plan (USFHP), DPs (formerly known as uniformed services treatment facilities) are selected civilian medical facilities around the United States assigned to provide care to eligible and enrolled USFHP beneficiaries — including those who are age 65 and older — who live within the DP area. At these DPs, the USFHP provides TRICARE Prime benefits and cost-shares for eligible persons who enroll in USFHP, including those who are Medicare-eligible.

Disease management
A prospective, disease-specific approach to improving healthcare outcomes by providing education to beneficiaries through nonphysician practitioners who specialize in targeted diseases.

Extended Care Health Option (ECHO)
A supplemental program to the TRICARE basic program. It provides eligible and enrolled ADFMs with additional benefits for an integrated set of services and supplies designed to assist in the treatment and/ or reduction of the disabling effects of the beneficiary’s qualifying condition. Qualifying conditions may include moderate or severe intellectual disability, a serious physical disability or an extraordinary physical or psychological condition such that the beneficiary is homebound.

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 and most often starts with 6 or 9. TRICARE will not issue an authorization for treatment or services to NATO beneficiaries without a valid FIN.

Laboratory Developed Test (LDT)
A term used to refer to a certain class of In Vitro Diagnostics (IVD).

National Provider Identifier (NPI)
A 10-digit number used to identify providers in standard electronic transactions. It is a requirement of the Health Insurance Portability and Accountability Act of 1996. The National Plan and Provider Enumeration System (NPPES) assigns NPIs to providers.

Nonavailability Statement (NAS)
A certification by a commander (or a designee) of a uniformed services medical hospital or clinic recorded in DEERS, generally for the reason that the needed medical care being requested by a non-TRICARE

Prime enrolled beneficiary cannot be provided at the facility concerned because the necessary resources are not available in the time frame needed.

Outpatient Prospective Payment System (OPPS)
TRICARE OPPS is used to pay claims for hospital outpatient services. TRICARE OPPS is based on nationally established Ambulatory Payment Classification amounts and standardized for geographic wage differences that include operating and capital-related costs, which are directly related and integral to performing a procedure or furnishing a service in a hospital outpatient department. TRICARE OPPS became effective May 1, 2009.

Point Of Service (POS)
The option under TRICARE Prime that allows enrollees to self-refer for non-emergency healthcare services to any TRICARE-authorized civilian provider, in or out of the network. When Prime enrollees choose to use the POS option (i.e., to obtain non-emergency healthcare services from other than their PCMs or without a referral from their PCMs), all requirements applicable to TRICARE Select apply except the requirement for a NAS. POS claims are subject to deductibles and cost-shares even after the enrollment/Fiscal Year catastrophic cap has been met. The POS option is not available to ADSMs.

Primary Care Manager (PCM)
A military hospital or clinic provider, team of providers or a network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. Enrolled beneficiaries agree to initially seek all non-emergency, non-behavioral healthcare services from their PCMs.

Regional contractor
A civilian healthcare contractor of the Military Health System (MHS) that administers TRICARE in one of the TRICARE regions. As a regional contractor, Humana Military helps combine the service available at military hospitals or clinics with those offered by the TRICARE network of civilian hospitals and providers to meet the healthcare needs of the TRICARE beneficiaries.

Split enrollment
Split enrollment refers to multiple family members enrolled in TRICARE Prime under different TRICARE regions or regional contractors.

Sponsor
The ADSM, retiree or deceased service member or former service member through whom family members are eligible for TRICARE.

Supplemental Health Care Program (SHCP)
A program for eligible uniformed services members and other designated patients who require medical care that is not available at the military hospital or clinic upon the approval of the cognizant military hospital or clinic commander or the DHA director, as required, to be purchased from civilian providers under TRICARE payment rules.

Transitional Assistance Management Program (TAMP)
A program that provides 180 days of transitional healthcare benefits to help certain uniformed services members and their families transition to civilian life.

Designed for all beneficiaries to ensure a coordinated approach takes place across the continuum of care.

Provider tools and resources