TRICARE

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School

Technical University of Mombasa *

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RESEARCH P

Subject

Health Science

Date

Nov 24, 2024

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docx

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Uploaded by MateFieldWalrus14

1 Compensation Student’s Name University Affiliation Course Name Instructor’s Name Assignment Due Date

2 Compensation Identify the different components of TRICARE billing and different types of benefits available to active duty members, veterans, and their family members. Over the years the military and their families have struggled to afford their medical care and this has triggered the United States Congress to develop the Civil Health and Medical Program of the Uniformed Services which is currently referred to as TRICARE (Vines, Braceland, Rollins, & Miller, 2013, p. 440). TRICARE has come to the rescue of the forces because they are offering various services to active force members and their families and it is necessary for medical billers and coders to understand the personal requirements for qualification, benefit coverage and other plan regulations for a successful and precise billing procedure. Active members of the forces are referred to as sponsors while those who are legible for TRICARE are known as beneficiaries. There are various plans that are available for different active duty members and they include, TRICARE Standard which is a free for service scheme, TRICARE Prime is the HMO plan and TRICARE Senior Prime is offered for members aged 65 years and above who qualify for Medicare. TRICARE also has another pack of plans that they offer to incorporate the active force families and give PPO solutions for issues through non- military providers. Legends who have disabilities that they suffered 100% in the line of duty do not qualify for TRICARE but instead they are served through CHAMPVA. There are some fundamental backgrounds of the system that the medical billers and coders need to understand in the delivery of their services. They first need to understand the timely filing requirements, the qualification verification process through Defense Enrollment Eligibility Reporting System.

3 They need an understanding of what services are covered under which plan and who are covered. They also need to be conversant with the procedures of filing claims for every plan that is offered by the system. Understand the history of workers’ compensation and distinguish between federal workers’ compensation and state workers’ compensation The Office of Worker’s Compensation Programs is responsible for compensating all employees working under federal agencies. Other workers are compensated based on the statutes set if their places of work and they differ from state to state (Vines, Braceland, Rollins, & Miller, 2013, p. 440). It is necessary for medical billers and coders to understand the statutes of their state so that it can enable them to code and bill with the dictated boundaries. There are two ways of filing claims, claims can be filed manual or electronically and the two procedures and the manual process demands more oversight ("Billing Workers’ Compensation | Medical Billing and Coding U," 2017). The claim filing process the progress note must be attached to a Work Status Report and deep explanation in completing the CMS-1500 form is needed to eliminate denial. Fraud is a major issue when dealing with workers’ compensation claims and that is why it is important for medical billers and coders to be informed of all the requirements and procedures involved. At the time of developing and presenting claims and backup details it is important to highlight which services were offered to make sure they are accurately matched to the billing codes. The most common medical provider fraud plans are creative coding and upcoding. Explain the importance of the Explanation of Benefits and Electronic Remittance Advice Forms.

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