Chapter 3 Flashcards
HEALTHCARE ADMIN PROGRAMS
PATIENT ELIGIBILITY FOR HOSPITALIZATION AND NON-FEDERAL CARE:
The following resources provide guidance regarding eligibility verification by presentation of a valid identification (ID) card and utilization of the Defense Enrollment Eligibility Reporting System (DEERS).
DEERS is a computer-based enrollment and eligibility verification system. It was developed to improve distribution and control of military healthcare services including the projection and allocation of costs for healthcare programs and to minimize fraudulent healthcare claims.
Navy Medicine’s eligibility for care instruction, NAVMEDCOMINST 6320.3 series, provides guidance as to who and under what circumstances members can receive medical and dental care at Navy Medical Department facilities
Both DEERS and the ID card are utilized to establish eligibility for care.
Next using the online computer terminal, the HM will perform an electronic DEERS check via CHCS
If a valid ID card is not provided within 30 calendar days, the patient will be billed as a Civilian Humanitarian Non-indigent IAW the Resources Management Handbook, NAVMED P-5020.
In all cases where a patient presents without an ID card and does not appear in the DEERS database, non-emergency care will be denied.
REASONS FOR INELIGIBILITY.: Sponsor not enrolled in DEERS Family member not enrolled in DEERS Ineligible due to passed terminal (end) eligibility date, i.e. child who ages out at 18 years of age Sponsor has separated from active duty Spouse is divorced from sponsor and is not entitled to benefits as a former spouse Family member child is married Secretary of the Navy Designee
UNDER NO CIRCUMSTANCES WILL THE CLERK PERFORMING THE ELIGIBILITY CHECK DENY THE REQUESTED CARE.
Only command-designated supervisory personnel can perform this function.
The nine “DEERS eligibility overrides” are listed below. Unless otherwise stated, all overrides must be supported by a valid ID card.
1.
DD 1172The patient presents an original or copy of the DD 1172 used for DEERS enrollment. There are other specific items required for verification, and current service directives must be checked
2.
All Other Family Members Recently Becoming Eligible for BenefitsNew mothers, babies, recent adoption, and dependent parents.
3.
New Identification CardPatients presenting with a new valid ID card, issued within the previous 120 days, will not be denied care.
5.
Sponsors Entering Active Duty Status for a Period of Greater than 30 DaysA copy of orders ordering a reservist or guardsman to an active duty period of greater than 30 days may be accepted for the first 120 days of the active duty period. After that, follow the procedure in item 1 above
6.
NewbornsNewborns will not be denied care for a period of 60 days. On the 61st day the newborn will shift to TRICARE STANDARD if not enrolled in Prime. Enrollment into Prime CANNOT occur unless the newborn is put on the sponsor’s Page 2 and enrolled in DEERS. Newborns of Dependent Daughters must be approved for Secretary of the Navy Designee or they are not eligible for care
7.
Emergency CareThis is a medical decision and shall be determined by criteria established within the command.
8.
Sponsor’s Duty Station is Outside the 50 United States or has an APO/FPO AddressFamily members whose sponsors are assigned outside the 50 United States or to a duty station with an APO/FPO address will not be denied care as long as the sponsor is enrolled and eligible in DEERS.
DEERS ELIGIBILITY EXCEPTIONS. The following beneficiaries are categorized as “DEERS Eligibility Exceptions.” Although authorized care, they may not be authorized to be enrolled in the DEERS system. These beneficiaries will NOT be denied care based upon a DEERS check.
Secretary of the Navy Designees Secretary of the Navy Designees will be treated as indicated on their letter of designation
Foreign Military PersonnelThese personnel and their family members, assigned through Personnel Exchange Programs or other means, are or may be eligible. Eligible members may also include
o
North Atlantic Treaty Organization (NATO) military personnel and their family members stationed in or passing through the United States
o
Crew and passengers of visiting military aircraft; and
o
Crews of ships of NATO nations that come into port
Other foreign military personnel may be eligible through Public Law or DoD agreements. As such, they will be treated IAW current service directives
Patients in other organizations, such as Red Cross workers, Secret Service agents, Federal Aviation Administration personnel, and some non-retiree veterans are also in this category of possible beneficiaries due to agreements. Ensure current eligibility requirements are met for these personnel prior to treatment
TRICARE is an enhancement of the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
Active duty members and reservists recalled to active duty for a period of more than 30 days are eligible for all services.
Active duty members and reservists recalled to active duty for a period of more than 30 days are eligible for all services.
PATIENT CONTACT REPRESENTATIVE
Patient contact representatives are appointed in writing by the commanding officer and have their picture posted at the front desk or in the reception area visible to all patients.
Patient survey forms should be located at the front desk area. These forms originate at each clinic and ask questions regarding the patient’s visit
Alcohol consumption is a personal decision of each individual; however, personnel should be aware that the minimum allowable age to consume alcohol is 21. The Navy satisfies the decision of each individual by taking an approach of “Responsible Use.”
The Navy’s Policy on drug abuse is “Zero Tolerance.”
The Drug and Alcohol Program Advisor (DAPA) is the command’s primary advisor for all alcohol and drug matters.
Additional responsibilities of the DAPA are outlined in OPNAVINST 5350.4 series, Drug and Alcohol Abuse Prevention and Control
Military prisoners with punitive discharges that have been executed and require hospitalization beyond expiration of their sentences are not eligible for care; they may be hospitalized as civilian humanitarian non-military indigents until disposition is made to some other facility.
