Chapter 3 -Lesson 8, 9, 10,  

CHAMPVA and CHAMPUS

CHAMPVA is a program very similar to CHAMPUS. However, it has different eligibility requirements. CHAMPVA was established in 1973. The following people are eligible for CHAMPVA health care coverage.

Note: A child is defined as being under the age of 18 regardless of dependent status, or under the age of 23 if child is enrolled in an approved course of higher education.

Coverage of CHAMPUS and CHAMPVA

CHAMPUS gives the beneficiaries a wide range of health care options. Beneficiaries receive coverage for hospitalization, outpatient care, maternity related expenses, skilled nursing facility care, treatment of mental illness and alcoholism, physician expenses and many other services. Each service is covered according to guidelines set forth by the 2 programs. As a medical claims specialist, it is important that you contact the nearest military treatment facility to get more detailed information. You should talk to the health benefits advisor. That person should pass along the name of fiscal intermediary for your billing area.

A fiscal intermediary is an organization that contracts with the government to handle CHAMPUS and CHAMPVA claims. These organizations usually have 3 year contracts, so they can change relatively often. Be sure you have up to date information. Having the correct information makes filing claims easier.

Filing CHAMPUS and CHAMPVA claims

Whether you are filing a CHAMPUS or a CHAMPVA claim, you will need to follow the same basic steps. The first thing to do before a procedure is performed, is to determine if pre-authorization is needed. Pre-authorization gives the insurance provider a chance to look at a proposed treatment and determine if it is reasonable for the condition. If you fail to get pre-authorization for a procedure that requires it, benefits can be reduced or the claim might be denied entirely.

After determining the pre-authorization requirement, the next step is to see if non availability statement is needed.

The Non availability Statement

If the patient is seeking treatment at a nonmilitary facility, CHAMPUS and CHAMPVA might require a non availability statement. The non availability statement (NAS) is required for all CHAMPUS and CHAMPVA beneficiaries who live within 40 miles of a military care facility, but are seeking treatment at a civilian hospital. The NAS certifies that the procedure the patient is seeking is not available at the military facility. Currently, NAS filing is completely electronic. The billing specialist forwards the NAS to the military facility, who then has someone enter the information into DEERS.

The NAS is not required before visiting a physician. It is not required before visiting a physician. It is required before procedures are actually performed.

Filing Claims

Now that you've checked for NAS and pre authorization requirements, you are ready to file the claim. The procedure for this is similar to any other claim. However, you will need to fill out some additional forms and determine whether or not the doctors you work for have accepted assignments from CHAMPUS and CHAMPVA.

Claims for Physicians Who HAVE Accepted Assignment

A physician who agrees to accept assignment is known as a participating provider. Participating providers agree to accept the allowable charge established by CHAMPUS and CHAMPVA.

The allowable charge is the lowest of the following amounts:

The provider may collect the annual deductible and the cost-share from the insured. Then the provider bills CHAMPUS or CHAMPVA. Cost-share is the word CHAMPUS and CHAMPVA use for coinsurance. The provider agrees not to bill for the difference between his customary charge and the allowable charge established by CHAMPUS and CHAMPVA.

Beneficiaries pay a specified amount each year, called the catastrophic cap, for their annual deductible has paid the specified amount, CHAMPUS and CHAMPVA then pay 100% of allowable charges for the remainder of that year. The catastrophic cap is reset each year, as is the deductible.

Once a beneficiary has met his or her deductible or maximum financial outlay, you should attach a note to the bill indicating this situation. This will hasten the reimbursement process.

For physicians who have accepted assignment, once the claim is completed and processed by the fiscal intermediary, payment is sent directly to the physician.

Claims for Physicians Who Have NOT Accepted Assignment

Physicians who do not accept assignment, nonparticipating physicians, bill CHAMPUS or CHAMPVA for their customary costs. The limit for any charge collected from a patient, however, is 115%. That means the physician may not charge patients more than 15 percent higher than the CHAMPUS and CHAMPVA allowable charge.

Before You File a Claim

There are a few things you should check before you get into the actual filing of CHAMPUS or CHAMPVA claims. First, you need to photocopy the patient's identification card for the program (either CHAMPUS or CHAMPVA). Be sure to copy both sides of the card.

After you complete the form for the claim, you submit it to the fiscal intermediary for the state in which service was performed. If your claim service has clients from different states, make sure you are submitting the form to the correct fiscal intermediary.

Another thing to make sure of is the order of submission. In most cases, CHAMPUS and CHAMPVA are primary programs and you bill them first. But when a patient has insurance through another provider, that provider becomes the primary carrier and is billed first. (This rule applies unless the separate insurance is through Medicaid or is specifically designed to supplement CHAMPUS benefits.)

Cases involving Worker's Compensation (on-the-job injuries), third-party liability or automobile accidents are all filed with different insurance carriers. Worker's compensation cases are filed with the compensation insurance company. Third-party liability means someone else is obligated to pay for injuries. Automobile accidents are covered by automobile insurance companies.

In the case of third-party liability, you have two options. You may file CHAMPUS form DD2527 (Statement of Personal Injury -- Possible Third-Party Liability) with the regular claim. This allows CHAMPUS to look at the claim and consider the possibility of recovering money from the third party. Or you may submit all claims directly to the third-party insurance company. After a claim is settled, CHAMPUS and CHAMPVA send the patient and physician an explanation of benefits.

The Claim Form

The basic claim form used to file CHAMPUS and CHAMPVA claims is the HCFA-1500 form. We will show you specifically how to fill out this claim form later in the course.

You must file a CHAMPUS or CHAMPVA claim within one year of the date of service.

With health care costs rising, many insurance companies have turned to managed care. CHAMPUS is no exception. Its managed care system is called TRICARE.

TRICARE

TRICARE is the Department of Defense's regional managed care program. It is currently being implemented across the United States, and by late 1997, it will be available in 49 states. Alaska is currently not planned to be included. As its name suggests, TRICARE has three parts: TRICARE Standard, TRICARE Extra and TRICARE Prime.

TRICARE STANDARD

TRICARE Standard is the new name for CHAMPUS. TRICARE Standard allows the greatest amount of freedom for beneficiaries, giving them the opportunity to choose from a wide variety of health care providers. However, it continues to have the highest potential of out-of-pocket expenses because patients pay deductibles and cost share (currently, CHAMPUS patients pay 25% of allowable charges, plus charges that are up to 15 percent above the CHAMPUS allowable charge). Under standard CHAMPUS, the current annual cap on out-of-pocket expenses is $7500.

TRICARE EXTRA

Not as flexible as TRICARE Standard but less restrictive than TRICARE Prime. TRICARE Extra does not require a patient to enroll in the program, but rather allows a case-by-case use. Patients can choose to use prime providers (see below) for a reduced copayment. Instead of sharing 25% of the cost, patients are only required to share 20% of the cost. In addition, patients don't have to worry about any charges above the allowable charge because prime providers do not charge more than the allowable amount. The annual deductible still applies to TRICARE Extra users.

TRICARE PRIME

The third and most restrictive program is TRICARE Prime. Similar to an HMO, families enrolled under TRICARE Prime can choose to enroll for one year (renewable enrollment). There is a fee for enrollment for retirees, but not for active-duty families.

After enrollment, the family receives its health care through prime providers, a network of participating physicians. Those who enroll in TRICARE Prime are treated by a personal primary care manager, who is selected by the enrolled family. Treatment, whenever possible, is received in a military facility. However, there are civilian prime providers. When a TRICARE Prime enrollee uses a civilian facility, the person is required to pay a copayment at the time of service. However, annual out-of-pocket expenses are capped at $3000.

If patients receive care from providers outside the prime provider network, they must pay an increased deductible and cost-share (currently 50%).

With any TRICARE treatment, the provider must file the insurance claim within six months of the date of service.

Worker's Compensation

As we alluded to in the previous section, it is a special insurance situation when someone is injured during the course of his or her job. When a worker is injured, the case is covered by a worker's compensation program. Workers compensation programs pay for medical expenses incurred by the worker injured on the job. They also pay benefits for lost wages and permanent disabilities suffered due to job-related injuries or illnesses.

All this is provided by the worker's employer. By law, all employers are required to carry worker's compensation coverage. Federal employees with job-related injuries are covered by the federal program called FECA. FECA, which stands for the Federal Employee's Compensation Act, covers two classifications of on-the-job injuries -- traumatic and occupational illness.

The traumatic injury is an injury caused by a specific event or series of events during a single workday. Falling off a ladder and breaking an arm is an example of a traumatic injury. An occupational illness is a condition caused by continued exposure to the workplace. Respiratory trouble due to dust inhaled for years in a mine is considered an occupational illness.

State programs provide coverage for people who are not federal employees. Each program varies from state to state, so you need to contact you state's compensation board or commission to get accurate, up-to-date information.

This information should include the forms required to file worker's compensation claims, where to find these forms, where to send completed claims, who chooses the physician, what the filing deadlines are and how reimbursement is determined (the fee schedule).

Also make sure you receive a list of all regulations regarding worker's compensation in your state. For example, you should find out if the physician needs to sign all forms, or is a stamp or photocopy acceptable?

Filing a Worker's Compensation Claim

The first thing to remember is to check every bill that comes by you to see if it is for a work-related injury. All other insurance companies will refuse a claim that is covered by worker's compensation. You must file with worker's compensation (often referred to as worker's comp) first.

Let's look at the process for FECA. FECA requires a different form for each class of claim - either Form CA-1 for a traumatic injury or Form CA-2 for an occupational illness. These forms must be filled out by the patient and filed with the patient's employer. It is important to make sure this step is completed; otherwise, benefits might be reduced.

After the employer receives either Form CA-1 or Form CA-2, the employer completes Form C-16, which authorizes treatment for the first 60 days. This authorization applies only to the first treating physician. The first treating physician is the doctor who first diagnosed and treated the injury. You need to attach form CA-16 to the insurance claim form you file.

In order to file a worker's compensation claim, you need to fill out form HCFA-1500. We'll show you how to do this later on. As you can see, the HCFA-1500 is a commonly used, important form. This form is filed with the Office of Worker's Compensation Programs (OWCA), a part of the United States Department of Labor.

In addition to the normal claim form and the CA-16 form, OWCA requires other documentation for a job-related injury. Here's a list of the information the employee must submit to file a claim.

Facts About Filing a Worker's Compensation Claim

The injured employee must submit this information to OWCA:

After receiving the necessary information, OWCA will assign a case file number to the case. This number is important because it must be included on all documents you submit to the OWCA.

Many times you will need to file progress reports stating the degree of recovery achieved by the patient. These progress reports usually go out when a person's situation changes and, therefore, the level of care changes. This report also includes the physician's opinion regarding the patient's availability for work, an estimate of future recovery and the extent of permanent loss or disability.

A Note About Patient Records

A regular patient might come to see the doctor for a worker's compensation-covered injury. You must set up a separate file for all worker's compensation activity. Do not include any of the worker's compensation items in the patient's normal file. This will help keep records accurate and also separate job-related injuries from injuries unrelated to the job.

Disability Insurance

When a person is unable to work, that person might be eligible for disability benefits. Unlike worker's compensation, people with disability insurance need not suffer job-related injuries or illnesses to be eligible for coverage.

Disability insurance programs are offered by the federal government, some states and some private insurance carriers. Disability insurance is usually paid for through payroll deductions. For a program to cover a person with a disability, the disability must be defined as a legal disability, rather than a medical disability.

A medical disability is a condition that disables the person, such as severe back injury.

A legal disability is one that meets the requirements of the particular program. For example, in the Social Security Disability program, a legal disability is one that prevents the worker from doing any work, and the condition is expected to last for a year or more, or to cause the worker's death.

As a medical claims and billing specialist, you won't have to actually file claims with disability insurance carriers, but you might have to assist in putting records together to enable the patient to file. These records include the following:

You must have permission from the patient to release this information to anyone, including insurance companies. Be sure you have a signed release form.

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