On Jan. 23, 2004, the Department of Health and Human

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1 A PUBLICATION FOR TRICARE PROVIDERS TRICARE Requires National Provider Identifier On Jan. 23, 2004, the Department of Health and Human Services (HHS) published the Health Insurance Portability and Accountability Act (HIPAA) Final Rule for the National Provider Identifier (NPI). This rule adopts the NPI as the standard unique identifier for health care providers. The rule became effective May 23, 2005, and affects both individual providers (e.g., physicians, nurse practitioners and pharmacists) and organizational providers (e.g., hospitals and pharmacies) who conduct HIPAA-standard electronic transactions. The goal of the NPI is to simplify the administration of the health care system and enable efficient electronic transmission of health information. Next year, beginning May 23, 2007, providers must use the NPI when conducting HIPAA-standard electronic transactions. However, even before May, health plans may require the NPI on paper claim forms (CMS-1500 by February 2007, and UB-04 by March 2007). Minnesota and Wisconsin will require the NPI on all paper claims. Providers who are associated with TRICARE should begin now to obtain their NPI. Providers can apply through a Web-based application or by submitting a paper application that can be found at A paper copy of the application can also be obtained by calling the NPI Enumerator at (TTY ). TRICARE will be collecting providers NPIs and adding them to provider records in preparation for the mandatory May 2007 implementation. By collecting NPIs in advance of the deadline, TRICARE will be better prepared to accept the NPI in HIPAA-standard electronic transactions, such as electronic claims or electronic eligibility queries. In the coming months, your regional TRICARE contractor, Health Net, will provide more information about how, where and when to submit your NPI, as well as other information related to NPI implementation. For More Information A Web site with the latest NPI information from HHS can be accessed at TRICARE-specific NPI information, as it becomes available, can be found at You can also send your TRICARE-related NPI questions to the TRICARE Management Activity HIPAA Office of Electronic Standards via at hipaamail@tma.osd.mil. From the Desk of the CMO Pedro N. Rivera, M.D. Chief Medical Officer Health Net Federal Services, Inc. The world is very different as our country continues at war and under the constant threat of terrorism. We are raising children under difficult conditions, and for the children of military families, this is an even more painful reality. There are more than 1.2 million military children ranging between birth and 23 years of age. Their lives are filled with the inherent danger of military operations, frequent moves, intermittent separation, the threat of a terrorist attack, and dramatic and graphic television coverage. Some indicators of potential difficulties include: preceding family dysfunction, behavioral health issues, special needs children, particular closeness to the deployed parent and recent family relocation with limited or no support systems in place. In addition to the details provided in the article, Children and Behavioral Health Care on page 3, I offer the following recommendations and information: 1) Ask military families about deployment of a family member or relatives. continued on page NE320202PRN0306L

2 From the Desk of the CMO continued from page 1 2) Assess the ability of the family to cope with the realities of their lives. 3) Direct families to available resources. Military children are subjected to an emotional cycle of deployment. The signs and symptoms that should alert us to potential problems vary with each age group. Among infants, irritability, difficulties with comforting by self or caregiver, sleep and eating disturbances are common indicators. Preschool and kindergarten children may start clinging to people, a favorite toy or a blanket. They may have periods of unexplained crying or tearfulness, may choose adults over same-age friends, may show increased violence toward people or things, start distancing themselves from people, become quieter, have difficulties eating and sleeping, and show regression in behaviors such as bed wetting. School aged children may, in addition to the above, present with changes in behavior, stomach aches, headaches, irritability, school problems, school avoidance and fights. Adolescents may, in addition to the above, begin acting out behaviors (trouble at school, home or the law), as well as present with low self-esteem and self-criticism, misdirected anger (excess anger over small incidents), depression and anxiety. They may tend to downplay their worries. For the deploying parent, it is recommended that they talk and share feelings with the child about separation, discuss ways to keep in touch, plan a special activity before deployment, swap important personal belongings with the child to keep during separation, and take family pictures and/or tape a favorite story. Communication with the deployed parent should be encouraged, and the deployed parent should be encouraged to send separate letters to each child. The non-deployed parent or guardian must maintain routines and discipline while being reassuring. They should listen, discuss feelings, answer questions honestly and dispel rumors; they should provide age-appropriate explanations, encourage communication and allow the child to talk. The parent should also monitor the amount of time the child watches news, discuss the news with the child, ask about what the child heard and what questions the child may have, provide reassurance and a sense of safety, and look for signs of fear and anxiety. Non-deployed parents need support as well. They have real issues related to the deployment and the risks to which the deployed family member is exposed. It is important they stay physically and mentally healthy. The reunification of the family can present challenges and requires preparation. Children and spouses have changed and family roles may have to be redefined. To successfully face and resolve all the challenges present through all the different phases of deployment, the family may need to use external resources. As their providers, we should be able to identify and support families in distress as well as be familiar with some of the resources available. For your benefit and use, some of them are included in the following lists. Military Family Centers: Army Community Service Centers (ACS), Family Service Center (FSC) (Navy, Marines, Coast Guard), Family Support Center (FSC) (Air Force). Resources within Military Installations: Family Centers, Family Support Groups, Legal Assistance Office, Chaplain s Office, Pediatric Clinic (primary care clinics), Mental Health Clinic, Social Work Services. These are services where they can get reliable information during deployments and have the opportunity to build relations with others who share common interests. The school system is another source of support and information for the family. Helpful Web Sites for Military Families: (American Academy of Pediatrics) (American Academy of Child and Adolescent Psychiatry) (Zero to Three) (The National Child Traumatic Stress Network) 2

3 Children and Behavioral Health Care Take a Proactive Stance May is National Mental Health Month, sponsored by the National Mental Health Association for the past 50 years. Nearly a decade ago, Childhood Depression Awareness Day was added to the observance to focus on the need for Americans to pay closer attention to children s behavioral health care needs. Today, that focus is as essential as ever. A December 2005 Substance Abuse and Mental Health Services Administration study found 9 percent of teenagers, nearly 2.2 million, experienced major depression in 2004 and fewer than half were treated. For military children, the risk is even more predominant. Children of active duty service members (ADSMs) are potentially at a higher risk to develop mental health conditions common among children in the general population, says Capt. Patricia Buss, Office of the Assistant Secretary of Defense. Conditions like attention-deficit hyperactivity disorder, depression, anxiety disorder and panic disorder can be exacerbated by the frequent moves required by the military lifestyle, particularly because children do not get the chance to develop a long-term support network of friends and family. Additionally, children of ADSMs who have been deployed may suffer extreme situational stress that can generate or add to these types of behavioral health problems. As a TRICARE provider, you should take extra care to watch for signs of depression, anxiety, compulsive behavior and other behavioral health problems in military children. When you see signs, there are a few things you should do: Advocate Using Eight Outpatient Visits Providers should direct children who may be suffering from any type of behavioral health problem toward treatment via the eight unmanaged behavioral health outpatient visits allowed by TRICARE Prime and TRICARE Prime Remote, Capt. Buss says. Just as with adult active duty family members, children are entitled to the first eight outpatient visits to a behavioral health care network provider per fiscal year without prior authorization. For TRICARE Prime beneficiaries, the provider must be a network provider, otherwise the beneficiary will incur additional charges under the point-of-service option. Beneficiaries may self-refer to behavioral health care network providers, with the exception of Licensed Professional Counselors (LPCs), Licensed Mental Health Counselors (LMHCs) and Pastoral Counselors. These providers also do not require prior authorization, but they do require a referral from a medical doctor. Even if you merely suspect that the child has a behavioral health problem, there is no obligation to continue treatment beyond this initial consultation, so it is important for the child to meet with a qualified provider. Too many children don t get the treatment they need and to which they are entitled. Direct Beneficiaries to the Right Provider If possible, help direct the child to an age-specific network provider who specializes in the type of disorder you believe he or she may have. If treatment is needed beyond the initial eight sessions, the child s behavioral health provider will need to submit a TRICARE Service Request/Notification Form to Health Net for prior authorization of sessions. When recommending an outpatient therapist for the child, be careful to select a provider in the TRICARE network, where available. If a network provider is not available, coordinate a referral with Health Net to a non-network provider. Otherwise, the family may incur additional charges under the TRICARE Prime point-of-service option. You can use the Find a Provider tool at to obtain a list of TRICARE providers in their area, or call Health Net toll-free at TRICARE. For more information about TRICARE s behavioral health care benefits, visit the Health Net Web site

4 New Prior Authorization Requirements Set for TRICARE Beneficiaries Effective for dates of service on or after Feb. 1, 2006, the prior authorization* requirements listed on page 5 will be enforced, and authorization must be obtained prior to services being rendered. These requirements supersede the prior authorization requirements listed on pages of the North Region TRICARE Provider Handbook under Services Requiring Prior Authorization, as well as the prior authorization requirements listed on *A prior authorization or authorization is a process of reviewing certain medical, surgical and behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. Treatment for Post-Traumatic Stress Disorder As troops return from Iraq and Afghanistan, an increasing number of TRICARE beneficiaries are experiencing symptoms of post-traumatic stress disorder (PTSD). Military research shows that 17 percent of troops, including active duty and reserve, returning from the war show signs of behavioral health problems, which include PTSD. What Is PTSD? PTSD develops after exposure to extreme psychological trauma events that produce fear, helplessness or horror, such as a threat to life or physical integrity. Indirect trauma, e.g., seeing another person in a life-threatening situation, can trigger PTSD, as well. Not all trauma related to deployment is due to combat situations. Motor vehicle or other accidents can also lead to PTSD. the TRICARE Referrals and Prior Authorizations quick reference chart. Not everyone exposed to such trauma develops PTSD. Those who do, however, may re-experience the traumatic event as intrusive recollections, images, thoughts, dreams, dissociative flashbacks or intense reactions to situations that resemble an aspect of the traumatic event. Other less specific symptoms may also be present, such as increased arousal and startle response, difficulty sleeping, irritability and poor concentration. Many times there is guilt, coexisting depression and panic disorder. Some services that do not require prior authorization may have limitations in coverage or be excluded under the TRICARE program. View TRICARE Exclusions and Limitations on the Health Net Web site at Network provider non-compliance with the new requirements can result in a 10 percent penalty of the contracted rate on claims submitted without a required prior authorization. You can use the Prior Authorization Determination Tool, available on the Health Net Web site, to verify if a prior authorization is required by entering a valid Current Procedural Terminology (CPT) or Health Care Procedural Coding System (HCPCS) code for the service. You can obtain a prior authorization online through the Health Net Web site, or you can complete a TRICARE Service Request/Notification Form and fax your requests to Health Net at Do not include a fax cover sheet. Please fax each patient request separately. Be sure to submit requests a minimum of seven days prior to the anticipated date of service. Diagnosis and Treatment of PTSD Of those who have behavioral health problems returning from war, more than 65 percent say that they hesitate asking for help because it makes them feel weak. Therefore, communication with your military patients about their symptoms is often somewhat challenging. To assist you in approaching your military patients, recognizing symptoms and identifying treatment for their condition, the Veterans Health Administration (VHA) and the Department of Defense (DoD) have created clinical practice guidelines. These guidelines are available to you online at Getting PTSD Care for Your Patients continued on page 5 Active duty service members must always get a referral from their PCM for treatment of PTSD as it is critical for their care to be coordinated. All other beneficiaries, such as retirees and dependents, can access coverage for PTSD or other behavioral health problems through their behavioral health care benefits. Patients diagnosed with PTSD are eligible for behavioral health outpatient services, such as individual psychotherapy, group therapy, crisis intervention, family therapy and medication management. Other benefits may include psychological testing, inpatient treatment, substance abuse treatment and other services. 4

5 New Prior Authorization Requirements Set for TRICARE Beneficiaries continued from page 4 TRICARE North Region Prior Authorization Requirements Effective for dates of service on or after Feb. 1, 2006 For active duty service members (ADSMs) and TRICARE Prime Remote (TPR) ADSMs Inpatient and outpatient services from a civilian network or non-network provider Exception: Ancillary services within the following code ranges do not require prior authorization when the care has been referred by the ADSM s primary care manager (PCM) or specialist to a network provider: - Diagnostic radiology and ultrasound services CPT code range through Diagnostic nuclear medicine services CPT code range through Pathology and laboratory services CPT code range through Cardiovascular studies CPT code range through ADSM care is typically provided at a military treatment facility (MTF), which authorizes care. However, TPR ADSMs are often not located near an MTF and may need care from a civilian (network or non-network) provider. All ADSMs must also notify Health Net of emergency room services within 24 hours or the next business day of care being received. For TRICARE Prime and TRICARE Prime Remote For Active Duty Family Members (TPRADFM) Adjunctive dental care 1 including: - Craniofacial and maxillofacial procedures - Dental procedures not related to the basic dental benefit Durable medical equipment (DME): - Durable medical equipment purchase greater than or equal to $2,000 - Durable medical equipment rental for all DME categorized by CMS as Capped Rentals - Payment Class: Capped Rental Items These are DME items that do not fall under any of the other DME payment categories. They are generally expensive items that have historically been routinely rented. Extended Care Health Option (ECHO) services 1 Home health services, including home infusion 1 Hospice 1 Inpatient admissions: - All elective acute inpatient admissions - Emergency medical/surgical and behavioral health inpatient admissions require notification to Health Net within 24 hours of admission or the next business day. Non-network provider services Obstetrical services including global maternity and high-risk maternity Oral surgery Psychiatric services 1 : - All non-emergency inpatient admissions for substance abuse or behavioral health - Psychotherapy after the initial eight outpatient visits - Psychoanalysis - Intensive outpatient treatment programs, partial hospitalization programs and residential treatment center programs Rehabilitation: - Occupational, physical and speech therapy Transplants 1 : - All solid organ and stem cell transplants 1 These prior authorization requirements also apply to TRICARE Reserve Select (TRS), TRICARE Standard and TRICARE Extra beneficiaries, as well as those with other health insurance (excluding ADSMs and TPR ADSMs). For TRICARE dual-eligible beneficiaries (including TRICARE For Life) TRICARE dual-eligible beneficiaries (those with Medicare Part B coverage and TRICARE coverage that includes TRICARE For Life beneficiaries) do not require a prior authorization from Health Net for health care services. These beneficiaries should follow Medicare rules for services requiring authorization

6 Focus On... Magnetic Resonance Imaging of the Lumbosacral Spine Health Net s Clinical Quality Management department conducted a focused review on magnetic resonance imaging (MRI) of the lumbosacral (LS) spine to ascertain the level of evaluation and conservative treatment attempted by primary care providers prior to referring patients with low back pain for MRI. The random sample consisted of 103 TRICARE Prime beneficiaries with no other health insurance, who had an MRI procedure performed within the timeframe of Oct. 1, 2004, to Dec. 31, 2004, and presented with a principal diagnosis of lumbago. The standards of measurement utilized for this review included the Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Adult Spine, as published in the American College of Radiology Practice Guidelines (2001, Res. 13) and the VHA/DoD Clinical Practice Guidelines for the Management of Low Back Pain or Sciatica in the Primary Care Setting (May, 1999). MRI of the LS spine studies may be misleading if not closely correlated with clinical history, clinical examination and physiological tests according to the guidelines. Key Findings A key finding of this retrospective review was that the majority of the medical records did not consistently document the rationale for MRI, such as failed trials of conservative therapies and re-evaluation of symptoms after four to six weeks. The primary care provider s account of a comprehensive history and physical assessment, to rule out other serious problems, is valuable in avoiding early referral for MRI, as well as increasing the reliability of the test interpretation. Documentation in the medical record was identified as a target area for improvement. Notations such as taking nonsteroidal anti-inflammatories for four weeks without improvement or attending physical therapy sessions for six weeks without improvement provide clear evidence to support the referral for MRI. Other key areas for demonstrating documentation, which follows the treatment guidelines, may include instruction of progressive range of motion exercises, modified light activity, education in self care, and work-related ergonomic evaluation. Coverage and Authorization MRI and MRI with contrast media are covered benefits under TRICARE when medically necessary, appropriate and the standard of care (TRICARE Policy Manual, Chapter 5, Section 1.1, IV A). As of Feb. 1, 2006, Health Net no longer requires prior authorization review for MRI: Current Procedural Terminology (CPT) codes 72148, and Medical record documentation of assessment and treatment to accepted guidelines and standards will be as important as ever to demonstrate appropriate use of this tool in absence of prior review for medical necessity. 6

7 TRICARE Reference Room Understanding TRICARE Provider Types Can Help Coordinate Quality, Cost-Effective Care for Your TRICARE Patients As a TRICARE provider, you are integral to coordinating TRICARE beneficiaries health care. At times, you may need to refer your TRICARE patients to another provider for an x-ray, lab test or other specialty service. Part of successful coordination of care begins with understanding the types of TRICARE providers to which your TRICARE patients may be referred. To receive payment from TRICARE for services rendered to a TRICARE beneficiary, a provider must be authorized under the TRICARE Regulation and must have their authorized status verified or certified by Health Net. When you refer your TRICARE patient to a specialty provider, it is important to understand the differences between provider types and financial liability that may impact your patient. Here are some brief descriptions that should help you understand the types of TRICARE providers. TRICARE Authorized or Certified Providers An authorized or certified provider is a provider who meets TRICARE s licensing and certification requirements and has been authorized by TRICARE to provide care to TRICARE beneficiaries. If a TRICARE beneficiary sees a health care provider who is not TRICARE-authorized/certified, the beneficiary will be responsible for the full cost of care. For this reason, you should avoid referring TRICARE patients to a provider who is not TRICARE-authorized/certified. TRICARE-authorized/certified providers can be either network or non-network providers. Did you know? Health care providers who are active duty service members or civilian Federal Government employees are generally not authorized to also be TRICARE providers in civilian facilities. Under federal dual compensation statutes, they are prohibited from receiving pay for services in civilian facilities from TRICARE. Only TRICARE-authorized/ certified civilian providers may receive reimbursement from TRICARE. Network Providers Network providers are TRICARE-authorized/certified physicians, hospitals, ancillary facilities and pharmacies who have a contractual relationship with Health Net or MHN Inc. (MHN), to provide care to TRICARE beneficiaries for a negotiated rate. Civilian network providers are required to file claims and other paperwork on behalf of TRICARE beneficiaries. TRICARE network providers provide care to beneficiaries enrolled in TRICARE Prime or using TRICARE Extra. Military treatment facility (MTF) providers are considered TRICARE network providers. Additionally, some Veterans Affairs (VA) facilities have agreed to serve as network providers. Check with Health Net about referring your patients to MTFs or VA facilities. Non-network Providers Non-network providers do not have a contractual relationship with Health Net or MHN, but they are still TRICAREauthorized/certified providers. There are two types of non-network providers: participating and nonparticipating. Participating A participating non-network provider agrees to accept the CHAMPUS maximum allowable charge (CMAC) plus any applicable cost-shares and copayments collected from the beneficiary as the total charge for services. Participating providers may also submit claims for beneficiaries. Non-network providers may participate in TRICARE on a claim-by-claim basis. Nonparticipating A nonparticipating non-network provider does not agree to accept the CMAC, and generally, nonparticipating providers do not file claims for beneficiaries. Nonparticipating providers may charge TRICARE beneficiaries up to 15 percent above the CMAC for services. The 15 percent will not be reimbursed by TRICARE, so beneficiaries are advised not to seek care from nonparticipating non-network providers. Non-network providers provide services to TRICARE Standard beneficiaries. If you are referring and coordinating care for a TRICARE Prime beneficiary, try to avoid referring them to a non-network provider. If unavoidable, coordinate with Health Net to obtain the necessary authorization. continued on page

8 Your Central Role in the Consumer Bill of Rights As a health care provider, and more importantly as a TRICARE provider, you know the central role you play in understanding and complying with the federal government s Consumer Bill of Rights and Responsibilities. Drafted in 1998, the purpose of the Bill is threefold: To build consumer confidence in the health care system by facilitating ways consumers can actively participate To support the importance of a good relationship between health care providers and patients To support consumers in improving their health by providing them with rights and responsibilities For your convenience, here is a review of two Bill of Rights chapters that are of utmost importance to TRICARE providers. Participation in Treatment Decisions As a provider, you know how patient participation in treatment decisions can lead to better treatment as well as higher patient satisfaction. You also know patients often have to make vital decisions when they re not in optimal condition to do so. That s why you can make a big difference by clearly explaining all treatment options including the alternative of no treatment as well as the risks, benefits and consequences of each option. TRICARE beneficiaries must be properly informed in advance and in writing of specific services or procedures that are not covered under TRICARE. For beneficiaries to be held financially responsible for non-covered services, they must sign a Request for Non-Covered Services form or equivalent before services are provided. The form is available on the Health Net Web site at Respect and Nondiscrimination A good relationship between you and the patient is based on mutual respect. Consumers have the right to considerate, respectful and nondiscriminatory care from their doctors, health plan representatives and other health care providers. A number of health care industry surveys uncovered dissatisfaction among patients who felt they were not being treated with respect. Reasons ranged from poor communications, such as inadequate information about their condition, to feeling rushed or ignored. Not only did consumers express a desire for medical providers to be respectful of their time, but they also expressed a desire for emotional support to relieve fear and anxiety. How do you best show respect to a patient? Guidelines from the Bill of Rights suggest providing the patient with the following: Your assurance that disrespect or discrimination of any kind from your office is not tolerated Information regarding existing laws prohibiting disrespectful or discriminatory treatment Enough time to fully discuss their concerns and questions Reasonable assistance to overcome language (including limited English proficiency), cultural, physical or communication barriers A timely notice and explanation of changes in fees or billing practices An explanation and apology for delays that are unavoidable For more information on the Consumer Bill of Rights and Responsibilities, visit TRICARE Reference Room continued from page 7 Online Provider Directories An easy way to find out if a provider is network, non-network or non-authorized is to consult the TRICARE online provider directories: To check a provider s TRICARE network status, visit Health Net s provider directory at To check a provider s TRICARE-authorized/certified status, visit the TRICARE Standard Directory at For more information about TRICARE provider types or if you want to know how to become a network provider, visit or call TRICARE. 8

9 Billing for Assistant Surgeon Services An assistant surgeon for TRICARE purposes includes any physician, dentist, podiatrist, certified physician assistant (PA), nurse practitioner (NP) or certified nurse midwife, acting within the scope of his or her license, who actively assists the operating surgeon in the performance of a TRICAREcovered surgical service. Note that this definition requires an active assist with the procedure or service, not just a passive presence. TRICARE covers assistant surgeon services when the services are considered medically necessary and meet the following criteria: The complexity of the surgical procedure warrants an assistant surgeon rather than a surgical nurse or other operating room personnel. Interns, residents or other hospital staff are unavailable at the time of the surgery. All assistant surgeon claims are subject to ClaimCheck auditing. ClaimCheck validates that the surgical procedure(s) performed require the services of an assistant surgeon. Standby assistant surgeon services are not reimbursed when the assistant surgeon does not actively participate in the surgery. How to Bill Properly for Timely Payment To ensure timely payment, be sure to complete Box 24D on the CMS-1500 claim form with the modifier that best describes the assistant surgeon services. Modifier Modifier 80 Modifier 81 Modifier 82 Description Billing PA and NP Services When a provider bills for a procedure or service performed by a PA, TRICARE policy requires that the supervising or employing physician bill the procedure or service as a separately identified line item (e.g., PA Office Visit) and use the PA s provider number. The supervising or employing physician of a PA must be an authorized TRICARE provider. NPs may bill on their own behalf and use their NP provider number for procedures or services they perform. Used to designate that the assistant surgeon provided service in a facility without a teaching program. Used to designate a minimum assistant surgeon. Typically used when the services provided are only required for a short or discreet time period during the procedure. Used by the assistant surgeon when a qualified resident surgeon is not available. Health Information Privacy Notification Requirement In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Section C of DoD R, DoD Health Information Privacy Regulation, January 2003, this serves as notification of the availability of the Military Health System (MHS) Notice of Privacy Practices. As of April 14, 2003, health care plans and providers are required to provide patients with a Notice of Privacy Practices. The notice describes how patient medical and dental information may be used and with whom it may be shared. It also describes patients rights and how to file a complaint if those rights have been violated. Please take a moment to review the MHS Notice of Privacy Practices and share it with your patients. It is important that patients are fully aware of how their health information can be used and disclosed. The notice is available in multiple languages. To obtain a copy: Go to and click on Notice of Privacy Practices in the right-hand navigation bar. Mail a written request to: TRICARE Management Activity, Privacy Office Five Skyline Place, Suite Leesburg Pike Falls Church, VA

10 Healthy People 2010 Needs Your Participation With just three and a half years to go in the federal government s decade-long Healthy People 2010 initiative, your help is needed if the program is to reach its objectives. Progress has been made, yet there is still much more to accomplish. Healthy People 2010 is managed by the Office of Disease Prevention and Health Promotion and U.S. Department of Health and Human Services. Founded on data that enable progress and trends to be tracked, the initiative is the nation s prevention agenda, providing a set of 10-year evidence-based health objectives for improving the health of all Americans by the year Its two overarching goals are to: Increase the quality and years of healthy life Eliminate health disparities Healthy People 2010 serves as a model for state and international disease prevention and health promotion plans, and it covers 28 focus areas with 467 specific objectives. Health care providers play a critical role in achieving more than 60 percent of these objectives helping to improve patient outcomes related to diabetes management, obesity, prostate cancer screening, access to quality care, smoking cessation, immunizations and many other vital areas. Ten Leading Health Indicators serve as a focus for prevention and performance. Among these indicators are behavioral and lifestyle factors, like tobacco use and obesity, which together cause almost half of all premature deaths in America. As a group, the Leading Health Indicators reflect the major health concerns in the United States at the beginning of the 21st century: Physical activity Overweight and obesity Tobacco use Substance abuse Responsible sexual behavior Behavioral health Injury and violence Environmental quality Immunization Access to health care These indicators were selected on the basis of their ability to motivate action, the availability of data to measure progress and their importance as broad public health issues. What Can You Do to Help? Now more than ever, your help is needed in achieving the objectives of Healthy People Communicating the importance of these health care issues to both your staff and your patients is critical. You can support Healthy People 2010 and greatly impact the health and well-being of TRICARE beneficiaries by simply increasing the focus on education, awareness and prevention in your practice: Understand the role that prevention, health promotion and community-based health programs have on the determinants of health. Provide supportive health promotion and health education to help beneficiaries recognize the value of prevention and the importance of their active role in pursuing healthier lifestyles. Encourage beneficiaries to receive preventive health services appropriate for their age and gender. Identify and document culturally influenced patient-risk factors for your specific population. Ensure staff has training in evidence-based methods to help beneficiaries adopt healthy behaviors. Select among the national Healthy People 2010 objectives to build an agenda for community health improvement and monitor the results over time. Monitor well-being initiatives that are established by the community and are based on population need. Utilize national health observances (e.g., Great American Smokeout or American Heart Month) that align with Leading Health Indicators and focus areas that have been identified in your community. Be aware of the Healthy People 2010 resources and refer to them to assist you in developing and implementing programs and interventions for your patients. For more information on Healthy People 2010 or to become a Healthy People 2010 partner, visit or call For resources to assist you in incorporating education, awareness and prevention in your practice, visit Health Net s Healthy People 2010 section under the Resources tab at

11 TRICARE Reserve Select Health Plan Understanding Your Role Certain National Guard/Reserve 1 members may purchase TRICARE Reserve Select coverage for themselves and their eligible family members. What Is the Coverage? Individuals who purchase TRICARE Reserve Select receive the same comprehensive coverage as active duty family members under TRICARE Standard and TRICARE Extra, including access to military hospitals and clinics on a space-available basis only. They may fill prescription medications through military pharmacies, the TRICARE Mail Order Pharmacy (TMOP) program or at TRICARE retail network and non-network pharmacies. For more information about covered services, refer to the TRICARE Reserve Select Handbook on the TRICARE Web site at Members and their covered family members are issued a TRICARE Reserve Select card. Remember that you must collect the appropriate cost-share for visits. What Services under TRICARE Reserve Select Require Prior Authorization? Like other TRICARE coverage, prior authorization is required for certain services under the TRICARE Reserve Select program. See the article, New Prior Authorization Requirements Set for TRICARE Beneficiaries, on page 5 for a complete list of services requiring prior authorization. 1 National Guard/Reserve includes the Army National Guard, the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air National Guard, the Air Force Reserve, and the U.S. Coast Guard Reserve. Where Do I Submit TRICARE Reserve Select Claims? TRICARE Reserve Select beneficiary claims should be submitted to PGBA in the same manner as TRICARE Standard/Extra beneficiary claims. The claims address for submitting TRICARE Reserve Select claims is: Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE P.O. Box Surfside Beach, SC TRICARE network providers should submit claims to Health Net/PGBA the same way they do other TRICARE claims. Where Should I Direct Questions? Health Net administers TRICARE Reserve Select in the TRICARE North Region and provides customer service, including enrollment, premium collection and claims payment. You may contact Health Net through the dedicated TRICARE Reserve Select customer service line at or visit if you have questions or need additional information. You may also visit for more information on coverage offered by TRICARE Reserve Select

12 Health Net Federal Services, Inc. P.O. Box 2890 Rancho Cordova, CA CONTACTS Health Net Customer Service TRICARE PGBA (Electronic claims set up) EDI-CLAIM WPS TFL (Dual-eligible claims) TDD Express Scripts (Pharmacy inquiries) DoD-TRRx DoD-TMOP Provider News is published by TRICARE Management Activity. Please provide feedback at DoD Says: Prescribe Generics! The Department of Defense (DoD) mandatory generic drug program requires that prescriptions be filled with the generic product, if one is available, at the generic copayment. If a generic equivalent does not exist, the brand-name drug is dispensed at the higher formulary copayment. The DoD estimates that the Military Health System s use of generics saves almost $50 million per year. Generic medications work as well as their brand-name counterparts in dosage, strength, performance and use. They must meet the same Food and Drug Administration (FDA) quality and safety standards. If you feel that a brand-name drug (for which a generic equivalent is available) is medically necessary for a beneficiary, it is recommended that you receive authorization from Express Scripts, the TRICARE Retail Pharmacy (TRRx) program administrator, prior to writing the prescription. Otherwise, the beneficiary may be responsible for the entire cost of the medication. Medical necessity waivers are approved if one or more of the following situations exist: The patient must experience, or would be likely to experience, significant adverse effects from the generic medication. The generic medication has resulted in, or is likely to result in, therapeutic failure. The patient has previously responded to the brand-name medication, and changing to the generic medication would incur an unacceptable clinical risk. To obtain a medical necessity waiver, call the TRRx Prior Authorization Line at You will be asked to complete and submit a Prior Authorization Request Form (also available on the Express Scripts Web site Once Express Scripts has approved the request, you will receive a letter of medical necessity, which the beneficiary must present with the prescription at the pharmacy. To learn more about the DoD s generic drug program, medical necessity waivers or TRRx, visit or call DoD-TRRx. 12