T M A V e r s i o n TABLE OF CONTENTS PART DEFINITIONS
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1 (a) General. 1 (b) Specific definitions. 1 Abortion. 1 Absent treatment. 1 Abuse. 1 Abused dependent. 1 Accidental injury. 2 Active duty. 2 Active duty member. 2 Activities of daily living. 2 Acupuncture. 2 Adequate Medical Documentation, Medical Treatment 2 Records. Adequate Medical Documentation, Mental Health 2 Records. Adjunctive dental care. 3 Admission. 3 Adopted Child. 3 All-Inclusive Per Diem Rate. 3 Allowable charge. 3 Allowable cost. 3 Ambulance. 3 Amount in dispute. 4 Anesthesia services. 4 Appealable issue. 4 Appealing party. 4 Appropriate medical care. 4 Approved teaching programs. 4 Assistant Secretary of Defense (Health Affairs). 4 Attending physician. 4 Augmentative communication device (ACD). 5 Authorized provider. 5 Automobile liability insurance. 5 Backup hospital. 5 Balance billing. 5 Basic program. 5 Final Rule/FR Vol 69, No 196 i
2 Beneficiary. 5 Beneficiary liability. 5 Birthing center. 6 Birthing room. 6 Brace. 6 Capped Rate. 6 Case Management. 6 Case Managers. 6 Case-mix index. 6 Certified nurse-midwife. 6 Certified psychiatric nurse specialist. 6 CHAMPUS DRG-Based Payment System. 6 CHAMPUS fiscal intermediary. 6 CHAMPUS Health Benefits Advisors (HBAs). 6 Chemotherapy. 6 Child. 7 Chiropractor. 7 Christian Science nurse. 7 (ii) Practical Christian Science nurse. 7 Christian Science practitioner. 7 Christian Science sanatorium. 7 Chronic medical condition. 7 Chronic renal disease (CRD). 7 Clinical psychologist. 7 Clinical social worker. 8 Clinically Meaningful Endpoints. 8 Collateral visits. 8 Combined daily charge. 8 Complications of pregnancy. 8 Confinement. 8 Conflict of Interest. 8 Congenital anomaly. 9 Consultation. 9 Consultation appointment. 9 Consulting physician or dentist. 9 IFinal Rule/FR Vol 69, No 196 ii
3 Conviction. 9 Coordination of benefits. 9 Corporate services provider. 9 Cosmetic, reconstructive, or plastic surgery. 9 Cost-share. 10 Custodial care. 10 Days. 10 Deceased member. 10 Deceased reservist. 10 Deceased retiree. 10 Deductible. 10 Deductible certificate. 10 Defense Enrollment Eligibility Reporting System 10 (DEERS). Dental care. 11 Dentist. 11 Dependent. 11 Deserter or desertion status. 11 Diagnosis-Related Groups (DRGs). 11 Diagnostic admission. 11 Director. 11 Director, OCHAMPUS. 11 Director, TRICARE Management Activity. 11 Doctor of Dental Medicine (D.M.D.). 12 Doctor of Medicine (M.D.). 12 Doctor of Osteopathy (D.O.). 12 Domiciliary care. 12 Donor. 12 Double coverage. 12 Double coverage plan. 12 Dual Compensation. 12 Duplicate equipment. 13 Durable equipment. 13 Durable medical equipment. 13 Economic interest. 13 Final Rule/FR Vol 69, No 196 iii
4 Emergency inpatient admission. 13 Entity. 14 Extended Care Health Option (ECHO). 14 External Partnership Agreement. 14 External Resource Sharing Agreement. 14 Extramedical individual providers of care. 14 Extraordinary condition. 14 Extraordinary physical or psychological condition. 14 Former member. 14 Former spouse. 14 Fraud. 14 Freestanding. 15 Full-time course of higher education. 15 General staff nursing service. 15 Good faith payments. 15 Habilitation. 15 Handicap. 15 High-risk pregnancy. 15 Homebound. 15 Home health discipline. 16 Home health market basket index. 16 Hospice care. 16 Hospital, acute care (general and special). 16 Hospital, long-term (tuberculosis, chronic care, or 16 rehabilitation). Hospital, psychiatric. 16 Illegitimate child. 16 Immediate family. 16 Independent laboratory. 16 Infirmaries. 17 Initial determination. 17 In-out surgery. 17 Inpatient. 17 Institution-affiliated. 17 Institution-based. 17 Final Rule/FR Vol 69, No 196 iv
5 Institutional provider. 17 Intensive care unit (ICU). 17 Intermittent home health aide and skilled nursing 17 services. Intern. 18 Internal Partnership Agreement. 18 Internal Resource Sharing Agreement. 18 Item, Service, or Supply. 18 Laboratory and pathological services. 18 Legitimized child. 18 Licensed practical nurse (L.P.N.). 18 Licensed vocational nurse (L.V.N.). 19 Long-term hospital care. 19 Low-risk pregnancy. 19 Major life activity. 19 Marriage and family therapist, certified. 19 Maternity care. 19 Medicaid. 19 Medical. 19 Medical emergency. 19 Medical supplies and dressings (consumables). 19 Medically or psychologically necessary. 20 Medically or psychologically necessary 20 preauthorization. Medicare. 20 Member. 20 Mental disorder. 20 Mental health counselor. 20 Mental health therapeutic absence. 20 Missing in action (MIA). 20 Morbid obesity. 21 Most-favored rate. 21 Natural childbirth. 21 Naturopath. 21 NAVCARE clinics. 21 Nonavailability statement. 21 Final Rule/FR Vol 69, No 196 v
6 No-fault insurance. 21 Nonparticipating provider. 21 North Atlantic Treaty Organization (NATO) member. 21 Not-for-profit entity. 22 Occupational therapist. 22 Official formularies. 22 Optometrist (Doctor of Optometry). 22 Oral surgeon (D.D.S. or D.M.D.). 22 Orthopedic shoes. 22 Other allied health professionals. 22 Other special institutional providers. 22 Outpatient. 22 Ownership or control interest. 22 Part-time home health aide and skilled nursing 23 services. Partial hospitalization. 23 Participating provider. 23 Party to a hearing. 23 Party to the initial determination. 23 Pastoral counselor. 24 Pharmaceutical Agent. 24 Pharmacist. 24 Physical medicine services or physiatry services. 24 Physical therapist. 24 Physician. 24 Physician in training. 24 Podiatrist (Doctor of Podiatry or Surgical Chiropody). 24 Preauthorization. 24 Prescription drugs and medicines. 24 Preventive care. 25 Primary caregiver. 25 Primary payer. 25 PRIMUS clinics. 25 Private room. 25 Profound hearing loss (adults). 25 Final Rule/FR Vol 69, No 196 vi
7 Profound hearing loss (children). 25 Program for Persons with Disabilities (PFPWD). 25 Progress notes. 25 Prosthetic or Prosthetic Device (prosthesis). 26 Prosthetic supplies. 26 Provider. 26 Provider exclusion and suspension. 26 Provider termination. 26 Psychiatric emergency. 26 Public facility. 26 Public facility adequacy. 26 Public facility availability. 26 Qualified accreditation organization. 27 Radiation therapy services. 27 Rare Diseases. 27 Referral. 27 Registered nurse. 27 Rehabilitation. 28 Rehabilitative therapy. 28 Reliable evidence. 28 Representative. 28 Reservist. 28 Resident (medical). 28 Residential treatment center (RTC). 28 Respite care. 28 Retiree. 29 Routine eye examinations. 29 Sanction. 29 Secondary payer. 29 Semiprivate room. 29 Serious physical disability. 29 Skilled nursing facility. 29 Skilled nursing services. 29 Spectacles, eyeglasses, and lenses. 29 Speech generating device (SGD). 29 Final Rule/FR Vol 69, No 196 vii
8 Sponsor. 29 Spouse. 29 State. 30 State victims of crime compensation programs. 30 Student status. 30 Supplemental insurance plan. 30 Suppliers of portable X-ray services. 31 Surgery. 31 Surgical assistant. 31 Suspension of claims processing. 31 Teaching physician. 31 Third-party payer. 31 Timely filing. 32 Treatment plan. 32 TRICARE extra plan. 32 TRICARE prime plan. 32 TRICARE program. 32 TRICARE standard plan. 32 Uniform HMO benefit. 32 Uniformed Services. 32 Unlabeled or Off-Label Drugs. 32 Veteran. 32 Waiver of benefit limitations. 33 Well-child care. 33 Widow or widower. 33 Worker's compensation benefits. 33 X-ray services. 33 Final Rule/FR Vol 69, No 196 viii
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