How to Code and Process Military Medical Claims

By Karen Smiley from Medical Billing and Coding For Dummies

Medical coding for current and former military personnel follows certain fee schedules through two separate programs: Tricare, which funds medical claims for active military and their dependents, and CHAMPUS VA, which funds medical care for spouses and dependents of veterans killed or injured in the line of duty.

How to code for Tricare medical claims

Tricare, funded by the U.S. Department of Defense, is the healthcare system used by active military personnel and their dependents.

Different Tricare programs address the needs of specific segments of the military:

Tricare Standard: Active duty military, retired active duty military, reserve military retirees, and eligible family members use Tricare Standard. These members can use any civilian healthcare provider and usually have a co-insurance responsibility and a deductible.
Tricare Prime: Tricare Prime serves the same segment of the military population that Tricare Standard does, except that Tricare Prime is more restrictive. Tricare Prime patients are allowed to seek treatment only from network providers. All active military are required to enroll in Tricare Prime, but for eligible dependents, it’s a less expensive option.
Tricare for Life: Tricare for Life is essentially a Medicare supplement available to retirees who were formally Tricare members that became Medicare eligible. (Go to “Looking at Medicare supplement policies” for info.)

To put it in insurance terms, think of Tricare Standard as the military equivalent of a PPO. Tricare Prime, which is more restrictive, is the equivalent of an HMO. Think of Tricare for Life as a Medicare supplement policy.

In the United States, Tricare benefits are administered through regional contractors known as Tricare North, Tricare South, and Tricare West. Overseas claims are processed through the Tricare Overseas Program.

Tricare follows the same claim editing programs that Medicare uses, and it pays according to Tricare fee schedules. A provider who treats a Tricare patient can expect the claim to process per the appropriate fee schedule; in return, Tricare trusts the provider to accept the fee schedule pricing and not to send the balance to the patient to pay (a practice called balance billing), regardless of a network contract.

The fee schedules are updated regularly; you can access them through the Tricare web portals.

How to code for CHAMPUS VA medical claims

CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) VA patients are those who are not eligible for Tricare: spouses or dependents of veterans disabled in the line of duty and surviving spouses of veterans who had been disabled or died from a service-connected disability.

Occasionally a surviving spouse or child of a military member killed in the line of duty may have CHAMPUS VA, but normally they are eligible for Tricare.

CHAMPUS VA plans are always secondary when another payer exists. When CHAMPUS VA is the primary payer, it functions mostly like an HMO. Always verify patient coverage prior to any scheduled encounters to secure any necessary referrals or prior authorization for treatment.

In prior years, both active and retired military beneficiaries and their dependents were treated exclusively at military facilities. Due to budget restrictions, the Department of Defense started to contract with civilian providers for their members’ healthcare needs. This program was originally known as CHAMPUS. Later, CHAMPUS became CHAMPUS VA, which is now funded by the Veterans Administration.