Deck 11: Tricare and Champva

Question 1

When creating TRICARE patient cases in a PMP, what information is included?

A) the sponsor's grade, branch of service, and status
B) the sponsor's grade only
C) the sponsor's status and grade
D) the sponsor's branch of service only

Answer 1

the sponsor's grade, branch of service, and status

Question 2

Which organization is responsible for determining eligibility for the CHAMPVA program?

A) Primary Care Manager (PCM)
B) DEERS
C) Department of Veterans Affairs (VA)
D) Department of Defense

Answer 2

Department of Veterans Affairs (VA)

Question 3

Which of the following uniformed services is eligible for TRICARE without restrictions?

A) NOAA
B) PHS
C) all are eligible
D) Navy

Answer 3

all are eligible

Question 4

Who among the following providers may a CHAMPVA beneficiary use under the plan?

A) a provider who has signed a HIPAA agreement
B) a provider on the Medicare exclusion list
C) a provider who is not licensed to perform the service being delivered
D) a provider licensed to perform the service being delivered

Question 5

What makes up the TRICARE system?

A) all military hospitals only
B) all military hospitals, clinics, and treatment facilities
C) all military treatment facilities only
D) all military clinics and hospitals

Question 6

A nonparticipating provider in TRICARE sees a patient and provides two services, one with an allowed charge of $120 and the other for $220. Calculate the maximum amount they may charge the patient.

A) $391
B) $253
C) $220
D) $340

Question 7

A nonparticipating provider in TRICARE sees a patient and provides a service with an allowed charge of $200. However, the provider charges the patient $250 for the service. Determine what amount the patient must pay.

A) $230
B) $300
C) $200
D) $250

Question 8

Who is responsible for the costs of healthcare services not covered by CHAMPVA?

A) No one, CHAMPVA pays 100%.
B) the provider, as a write-off
C) the beneficiary
D) Medicare

Question 9

Which of the following is the uniformed services member in a family qualified for TRICARE?

A) insured
B) sponsor
C) enrollee
D) subscriber

Question 10

What must all enrollees in TRICARE for Life do?

A) be enrolled in Medicare Part B only
B) be enrolled in Medicare Part A & B and pay Part B premiums
C) be enrolled in Medicare Part A only
D) have Part A premiums deducted from their Social Security check

Question 11

If a provider chooses not to participate in TRICARE, they may charge no more than __________ percent of the allowable charge.

A) 115
B) 130
C) 100
D) 150

Question 12

All eligible beneficiaries in CHAMPVA possess a CHAMPVA Authorization Card, known as a(n)

A) A-Card.
B) Member Card.
C) C-Card.
D) User Card.

Question 13

Identify the correct order of payment when Medicaid and TRICARE for Life coverage exist simultaneously for one individual.

A) The order is not important, either TRICARE or Medicaid may pay first.
B) TRICARE pays first, and Medicaid covers the remaining expenses.
C) None of these are correct; an individual cannot have Medicaid and TRICARE for Life coverage.
D) Medicaid pays first, and TRICARE covers the remaining expenses.

Question 14

The husband of an active duty service member and an actual active duty service member have both arrived at a MTF. Who should be given priority?

A) neither is given priority
B) the husband of an active duty service member
C) the active duty service member
D) none of these; these individuals cannot seek treatment at an MTF

Question 15

A fee-for-service plan available to people who have verifiable eligibility through DEERS and who enroll annually is known as

A) Medicaid.
B) TRICARE Select.
C) TRICARE Prime.
D) Medicare.

Question 16

Which of the following may act as a PCM under TRICARE Prime?

A) group of providers only
B) military provider only
C) civilian provider only
D) military, civilian, or group provider

Question 17

Where are most CHAMPVA claims submitted?

A) the regional CHAMPVA claims processing center
B) the centralized CHAMPVA claims processing center
C) with the participating provider
D) with the primary care provider

Question 18

An active-duty service member has an annual catastrophic cap of $1,000 under TRICARE Prime and receives their first treatment of the year totaling $1,400. Calculate how much the member must pay.

A) $1,400
B) $1,050
C) $1,150
D) $1,000

Question 19

Once the catastrophic cap has been met, what percentage of the additional charges for covered services for that coverage year will TRICARE pay?

A) 100 percent
B) 80 percent
C) 75 percent
D) 85 percent

Question 20

Explain the terms with which providers who choose to participate in CHAMPVA must agree.

A) accept what they pay as payment in full and write off any remaining cost share
B) to accept the catastrophic cap per patient, meaning they will receive no more than $1,000 per patient per calendar year, regardless of what services they provide
C) not to charge more than 125% of the CHAMPVA allowable amounts
D) to accept CHAMPVA payment and the patient's cost-share payment as payment in full for services

Question 21

Under TRICARE Prime, what payment is required for outpatient treatment at a military facility?

A) there is no deductible or copayment
B) a payment for visiting a military facility
C) coinsurance
D) deductible payment

Question 22

Identify the best practice for filing paper TRICARE claims.

A) Check the NUCC instructions.
B) Check with the QIC.
C) None of these are correct.
D) Check with each payer for specific information required on the form.

Question 23

What should be checked on a patient's military ID card to confirm if it is valid?

A) the expiration date
B) the individual's branch of the military
C) the individual's PCP
D) the sponsor's grade

Question 24

Which of the following services is covered under TRICARE Prime?

A) unproven treatments
B) cosmetic surgery
C) experimental procedures
D) x-ray services

Question 25

Who is responsible for the charges if a TRICARE managed care patient visits a provider who chooses not to join the TRICARE network?

A) the patient
B) the provider
C) TRICARE
D) the payer

Question 26

Who is not eligible for CHAMPVA?

A) families of active duty members
B) survivors of a veteran who died in the line of duty
C) dependents of a veteran who is totally and permanently disabled due to a service-connected condition
D) survivors of a veteran who died as a result of a service-related disability

Question 27

Which of the following examples demonstrates an abuse activity versus a fraudulent one?

A) providing care that is of inferior quality
B) altering CPT codes to increase the amount of payment to the provider
C) billing more than once for the same service
D) changing dates of service, frequency of service, or names of recipients

Question 28

Individuals age__________ and over who are eligible for both Medicare and TRICARE are offered the opportunity to receive health care at a MTF through TRICARE for Life.

A) 55
B) 70
C) 60
D) 65

Question 29

A nonparticipating provider in TRICARE sees a patient and provides services for three allowed charges that total $400. Calculate the maximum amount they may charge the patient.

A) $400
B) $500
C) $340
D) $460

Question 30

Which of the following could make a decision about eligibility in TRICARE?

A) TRICARE
B) the individual's PCP
C) the Army
D) DEERS

Question 31

Which of the following services is generally not covered by CHAMPVA?

A) surgical procedures
B) dental care
C) hospital services
D) hospice services

Question 32

What is the TRICARE term for coinsurance?

A) capitation
B) allowable charge
C) copayment
D) cost-share

Question 33

Where is information about TRICARE patient eligibility stored?

A) DEERS
B) CHAMPUS
C) PHS
D) CHAMPVA

Question 34

Which party is responsible for obtaining preauthorization under CHAMPVA?

A) the PCP
B) the provider
C) the patient
D) the VA

Question 35

What regulations cover the CHAMPVA, MHS, and TRICARE programs?

A) HIPAA
B) CHAMPUS
C) DEERS
D) TRICARE

Question 36

The TRICARE program that offers an HMO-like plan requiring no annual deductible is

A) TRICARE Standard.
B) TRICARE Prime.
C) TRICARE Reserve Select.
D) TRICARE Extra.

Question 37

What is the basis for the submission of TRICARE claims to the regional contractor?

A) the patient's home address
B) the location of the facility
C) the physician's office address
D) the patient's work address

Question 38

What does a qualified independent contractor (QIC) ensure regarding TRICARE claims?

A) that procedures have only one diagnosis code
B) that all claims be processed and paid
C) that care was up to ethical medical standards
D) that services were medically necessary and appropriate

Question 39

What is the purpose of TRICARE Prime annual catastrophic cap?

A) to eliminate government spending by making the patient responsible for 50% co-share
B) to limit the maximum reimbursement a provider will receive each year
C) to limit the maximum amount a sponsor will pay each year
D) to limit the maximum benefit a sponsor will receive each year

Question 40

Which of the following services is generally not covered under TRICARE Prime?

A) diagnostic testing
B) experimental treatments
C) mental health
D) dental care

Question 41

Identify the term that describes the maximum amount CHAMPVA will pay for a procedure.

A) CMAC
B) PCM
C) MTF
D) TMAC

Question 42

Why can't providers contact DEERS directly regarding sponsors?

A) the information is protected by the HIPAA Privacy Act
B) there is no contact person at DEERS; it is only a database
C) the information is protected by the HIPAA Security Act
D) the information is protected by the HIPAA Code Set

Question 43

What is the TRICARE program annual catastrophic cap for active-duty families?

A) $5,000
B) $1,000
C) $3,000
D) $500

Question 44

What is the term for the maximum amount TRICARE will pay for a procedure?

A) MTF
B) catastrophic cap
C) cost-share
D) TMAC

Question 45

Services that are eligible for payment from TRICARE must meet all of the following criteria except

A) medically necessary.
B) patients must be seen within 24 hours.
C) delivered at the appropriate level for the condition.
D) quality that meets professional medical standards.

Question 46

When TRICARE for Life beneficiaries receive treatment at a civilian network they must

A) pay a copay.
B) make payments toward a deductible.
C) pay coinsurance.
D) have no deductible or copay.

Question 47

Identify the correct order of payment when Medicare and TRICARE for Life coverage exist.

A) None of these are correct; an individual cannot have Medicare and TRICARE for Life coverage.
B) The order is not important, either TRICARE or Medicare may pay first.
C) TRICARE pays first, and Medicare pays the remaining out-of-pocket expenses.
D) Medicare pays first, and TRICARE pays the remaining out-of-pocket expenses.

Question 48

Geographic areas in the US that are designated to ensure medical readiness for active-duty members are known as

A) PCM (Primary Care Manger)
B) PSA (Prime Service Areas)
C) POS (point of service)
D) MTF (Military Treatment Facility)

Question 49

TRICARE will pay only for services that are rendered by __________ providers.

A) authorized
B) hospital
C) military
D) civilian

Question 50

TRICARE programs are subject to an annual __________, a limit on the total medical expenses that beneficiaries are required to pay in one year.

A) catastrophic cap
B) allowable charge
C) beneficiary limit
D) expense quota

Question 51

Which of the following is not something that providers who participate with TRICARE agree to?

A) Participate for every patient, every time.
B) Appeal claims on behalf of the patient.
C) File claims on behalf of patients.
D) Accept the TRICARE allowable charge as payment in full for services.

Question 52

Determine the correct order of coverage between Medicare, Medicaid, and TRICARE for Life.

A) Medicare first, TRICARE second, Medicaid third
B) Medicare first, Medicaid second, TRICARE third
C) TRICARE first, Medicare second, Medicaid third
D) Medicaid first, Medicare second, TRICARE third

Question 53

Patients' out-of-pocket expenses are subject to a catastrophic cap of __________ per calendar year under the CHAMPVA program.

A) $500
B) $1,000
C) $3,000
D) $5,000

Question 54

Which of the following services are covered under TRICARE Prime?

A) all of these
B) maternity care
C) outpatient care
D) surgery

Question 55

How much does a not active-duty family member have to pay to join TRICARE Prime for an individual?

A) $578.16
B) $1,000
C) $0
D) $289.08

Question 56

The TRICARE program that offers benefits to Medicare-eligible military retirees and family members is

A) TRICARE Extra.
B) CHAMPUS.
C) TRICARE for Life.
D) TRICARE Standard.

Question 57

In almost all cases, CHAMPVA is the

A) secondary payer.
B) only payer.
C) tertiary payer.
D) primary payer.

Question 58

TRICARE for Life benefits emphasize

A) preventive, wellness, and prescription drug services.
B) preventive services only.
C) wellness services only.
D) prescription drug benefits and wellness services.

Question 59

Identify the two groups brought together by TRICARE to offer increased access to health care services.

A) military hospitals and a network of civilian facilities and providers
B) military bases and local hospitals
C) a network of Medicaid and Medicare providers
D) military hospitals and the Medicare network of providers