FREQUENTLY ASKED QUESTIONS ABOUT USING TRICARE STANDARD IN PANAMA I’m seeing alarming information on some websites that make it sound like my health care benefits are being taken away. Is this true? No. There may be misinformation posted on non-government websites. We recommend you go to the TRICARE Area Office–Latin America and Canada official website for correct information at http://www.tricare.mil/TLAC/TAO.cfm.
I am a retiree and keep writing in on behalf of other beneficiaries trying to find out the status of their claim. I can’t get any information. Why? In accordance with the Privacy Act of 1974 and the Health Insurance Portability & Accountability Act (HIPAA) of 1996, we cannot provide to you the private information of another beneficiary without a signed Authorization for Disclosure of Medical or Dental Information form – commonly known as the HIPAA release form. Providers or individuals who have a question about their claim should be directed to the TRICARE Overseas Claims Processor, Wisconsin Physicians Service (WPS):
Phone: 1-608-301-2310/2311 or via the Web site: www.TRICARE4U.com. Correspondence should be sent to TRICARE Overseas, P.O. Box 7992, Madison, WI 53707-7992. May I go to any provider in Panama and use my TRICARE Standard benefit? All TRICARE Standard beneficiaries living in Panama may use any host nation provider for medical care in order to have their TRICARE claims paid. This is also true for of TRICARE Standard beneficiaries visiting Panama from the United States. What is a Participating Provider? The term participating provider refers to a provider who agrees to accept the TRICARE- allowed amount, plus the patient’s cost-share, as payment in full for the services. This is indicated by the provider checking “yes” in the appropriate block on claim form. Wisconsin Physicians Service (WPS) will send the check directly to the participating provider. The patient is only responsible for the cost-share which is identified on the Explanation of Benefits (EOB) which the patient receives from WPS. Providers may participate on a claim-by-claim basis. TRICARE Standard beneficiaries, who have chosen to live and receive health care in Panama, may be responsible for any difference between the TRICARE allowable amount and the billed amount unless they use the services of a participating provider, who agrees to accept the allowable amount plus the patient’s cost-share as payment in full for the services rendered. Beneficiaries are always encouraged to find those providers who agree to accept TRICARE-allowed amount as payment in full. Is there a list of Participating Providers? Because providers may choose to participate in TRICARE Standard on a claim-by-claim basis, it is impossible to maintain a list of TRICARE participating providers. A list of participating providers is not available or maintained by TRICARE Management Activity (TMA) or the overseas claims processor. Additionally, foreign providers may be unfamiliar with the term “participating provider.” We recommend that beneficiaries, prior to being seen, determine if a specific provider is willing to accept the TRICARE-allowed amount as payment in full, on that particular claim. Is proof of payment required for beneficiary submitted claims? TRICARE policy does not require proof of payment with all beneficiary submitted claims for reimbursement. On occasion, Wisconsin Physicians Service (WPS) may ask a beneficiary to provide additional information to assist TRICARE in processing a claim. If the provider was paid in cash, WPS may ask for proof of payment. Why is such a request necessary? The occasional request for proof of payment is necessary to validate the claim in order for TRICARE to fulfill its responsibility in safeguarding benefit dollars. TRICARE may require proof of payment in accordance with federal regulations, which may be found at Title 32 Code of Federal Regulations Section 199.4. Do US based private plans have a requirement for proof of paymentfor care received outside the continental United States? Research has established that proof of payment is routinely required for claims outside the United States for private plans as well as other federal programs. What do I need to submit with my claim if I have other health insurance (OHI)? By law, for both continental United States and overseas claims, OHI must be the first payer on any claim. Claims submitted to TRICARE claims processors must include an Explanation of Benefits (EOB) or similar documentation from the OHI provider to show what the OHI paid. We do understand that it can be challenging for beneficiaries in Panama to obtain the required documentation. Therefore, a form has been developed (Health Care Services or Supplies TRICARE Itemized/OHI Claim Checklist) which, when completed, signed by the provider, and accompanied by a properly completed claim form (DD 2642), will provide the necessary information to the overseas claims processor. The form is available on the TAO-Latin America and Canada website at http://www.tricare.mil/TLAC/TAO.cfm. How does TMA support efforts to combat TRICARE fraud overseas? TMA has established a fraud unit that is nationally recognized and has implemented contractual requirements for specialized fraud units for each TRICARE contractor. These fraud units routinely conduct reviews to detect fraudulent activities. In addition to the normal challenges faced when fighting health care fraud/abuse, overseas areas present special challenges of language, technology and other health care delivery factors that may have an impact on TMA’s fraud program. Since TRICARE reimbursement processes for foreign national providers and foreign national provider billing practices are not the same as for those in the United States, it is often difficult to determine fraud activities; however, every effort is made to combat fraud everywhere. TMA continually examines policies and procedures in order to modify claims processing requirements and aggressively institute additional claims processing controls, when needed, designed to reduce TRICARE fraud and protect taxpayer dollars. Where can I report fraud allegations? Although investigative details cannot be shared, all allegations are taken seriously and investigated. Fraud allegations can be reported to any of the addresses below: Program Integrity Office
1717 W Broadway
PO BOX 7927 or firstname.lastname@example.org
Madison, WI 53707 TRICARE Program Integrity Office
Aurora, CO 80011 or FRAUDLINE@tma.osd.mil Am I receiving a lesser benefit (being discriminated against) because I live overseas? TMA does not discriminate. TMA values the military service of all Uniformed Services retirees and makes every effort to provide consistency of TRICARE benefits worldwide. The TRICARE Standard benefit does not differ in either the covered benefits or beneficiary deductibles and cost shares, – no matter where a beneficiary may choose to retire. Some beneficiaries maintain that it is often difficult to find providers who will participate in TRICARE overseas. Depending on where one lives in the United States, however, finding a participating provider can also be difficult stateside. With respect to TRICARE For Life (TFL), even though Medicare benefits and providers are not available for U.S. retirees living abroad outside of U.S. Territories, the TFL benefits are available, with TMA providing the same benefit as TRICARE Standard. FREQUENTLY ASKED QUESTIONS REGARDING NEW CHAMPUS MAXIMUM ALLOWABLE CHARGES IN PANAMA What is changing with respect to reimbursement rates in Panama? A new fee schedule will be adopted in Panama. The new CHAMPUS Maximum Allowable Charges (CMAC) for non-ancillary professional service and inpatient per diem rates are available on our website at www.tricare.mil/tma/foreignfee.Reimbursement of ancillary services (radiology, pathology, clinical laboratory) will not change and will continue to be reimbursed at billed charges. When will the change to the new CMAC and inpatient per diem rates occur? The new rates will become effective in Panama on February 1, 2009. Who is affected by the CMAC and inpatient per diem change in Panama? The new rates will apply to both provider and beneficiary submitted claims for TRICARE Standard beneficiaries who receive services in Panama that fall under the jurisdiction of the overseas claims processor. Why are the rates being revised? The revised reimbursement amounts are an effort to get the most out of the health care dollar for the greatest number of beneficiaries and to minimize the flow of health care funds to a small percentage of high charging providers. Also, it provides greater program uniformity and consistency, ensuring that all providers are reimbursed under a system similar to what is in place in the United States. What is the benefit of revising the existing caps? The reimbursement methodology should control excessive charges and assist with ensuring medically necessary care, contributing to patient safety and quality of care. There have been numerous instances reported in which TRICARE beneficiaries were subjected to care that was not medically necessary and impacted patient safety, solely for the purpose of financial enrichment to the treating providers. TRICARE’s goal is to provide quality health care services for our military families at a cost-effective rate. Patient safety is of utmost concern. Will the new fee schedule change my annual deductibles and/or cost-shares for TRICARE Standard? The deductible and cost-share rates for TRICARE Standard beneficiaries will not change. Because a reduced rate will be adopted, your cost-share costs should also be reduced as a result. Your annual health care out-of-pocket costs remain capped at $3,000 in accordance with the TRICARE catastrophic cap policy. The TRICARE Standard benefit, as implemented by the Title 32 Code of Federal Regulations Part 199.4, does not differ in either the covered benefits or beneficiary cost shares, no matter where a beneficiary may choose to retire. Will the new fee schedule being implemented in Panama increase my out-of-pocket costs? To date, there is no evidence that the new fee schedule will significantly raise the health care costs for retiree beneficiaries living in the Philippines or Panama. It is possible TRICARE Standard beneficiaries’ out-of-pocket costs will increase. However, it is also possible that their out-of-pocket costs will decrease because the cost share will be based on a lower amount. Beneficiaries are always encouraged to find those providers who agree to accept the TRICARE-allowed amount as payment in full (participating providers). When a provider participates, he/she agrees to accept the TRICARE allowed amount, plus the patient’s cost-share, as payment in full for the services. This is indicated by the provider checking “yes” in the appropriate block on the claim form. Wisconsin Physicians Service (WPS) will send the check directly to the participating provider. The patient is only responsible for the cost-share which is identified on the Explanation of Benefits (EOB) which the patient receives from WPS. Providers may participate on a claim by claim basis. TRICARE Standard beneficiaries, who have chosen to live and receive health care in Panama, may be responsible for any difference between the TRICARE allowable amount and the billed amount unless they use the services of a participating provider who agrees to accept the allowable amount plus the patient’s cost-share as payment in full for the services. We recommend that beneficiaries, prior to being seen, determine if a specific provider is willing to participate on that particular claim. Will the new fee schedule reduce provider availability in the Philippines and Panama? Provider availability should not be affected, but it is possible that fewer providers may be willing to participate in TRICARE. Beneficiaries may need to pay up front and file for reimbursement. The effect of this change on beneficiary access to care will be closely monitored. How were the new rates developed? TRICARE Management Activity (TMA) constructed the inpatient per diem maximums and CHAMPUS maximum allowable charges for Panama using the maximum allowable amounts in the United States and adjusting them for the cost of living in Panama, as measured by the World Bank’s Purchasing Power Parity (PPP) measures. TMA believes that this is an appropriate method to set payment maximums in Panama.