Common Terms & Acronyms

Common Terms and Acronyms

Participating Provider

Providers who participate in TRICARE or accept assignment agree to file claims for TRICARE beneficiaries, accept payment directly from TRICARE and accept the TRICARE-allowable charge as payment in full for their services.

Non-network individual providers may participate on a case-by-case basis. Providers must seek applicable copayments, cost-shares and deductibles from the beneficiary. Hospitals that participate in Medicare must, by law, also participate in TRICARE for inpatient care. For outpatient care, they may or may not participate.

 

Peer Review Organization (PRO)

An organization that reviews cases for provider quality and medical necessity.

Per Diem

A reimbursement methodology based on a per day rate.

Personally Identifiable Information (PII)

Information about an individual that identifies, links, relates, is unique to, or describes him or her (for example, Social Security number, age, military rank, civilian grade, marital status, race, salary, telephone numbers, and other demographic, biometric, medical, and financial information).

PGBA, LLC

The company that processes claims and provides claims customer service for Health Net Federal Services, LLC.

Point of Service (POS)

An option that allows a TRICARE Prime beneficiary to obtain medically necessary TRICARE-covered services – inside or outside the network – from a provider other than his or her primary care manager, without first obtaining a referral. Utilizing the POS option results in greater out-of-pocket expenses for the beneficiary. The POS option does not apply to active duty service members. For more information, visit our Point of Service Option page.

Preferred Provider Organization (PPO)

A network of health care providers that provides services to patients at discounted rates or cost-shares. TRICARE Extra is considered to be a preferred provider organization option.

Primary Care Manager (PCM)

A TRICARE civilian network provider or military treatment facility (MTF) provider who provides primary care services to TRICARE beneficiaries. A PCM is either selected by the beneficiary or assigned by an MTF commander or his or her designated appointee, or Health Net Federal Services, LLC. Internal medicine physicians, family practitioners, pediatricians, general practitioners, obstetricians/gynecologists, physician assistants, nurse practitioners, or certified nurse midwives are considered PCMs.

Note: TRICARE Prime Remote and TRICARE Prime Remote for Active Duty Family Member beneficiaries may choose a TRICARE-authorized provider if a network provider is not available.

 

Prime Service Area (PSA)

A grouping of ZIP codes in which TRICARE Prime is available. Per government specifications, a PSA includes all ZIP codes lying within or intersected by the 40-mile radius around designated military treatment facilities (MTFs) or other areas with a high concentration of TRICARE beneficiaries as a result of past Base Realignment and Closure (BRAC) actions.

Prior Authorization

Certain services or procedures require Health Net Federal Services, LLC review and approval prior to being provided. Some services or procedures that require prior authorization include certain behavioral health care, hospitalization, surgical and therapeutic procedures. Synonyms include authorization, preauthorization and pre-certification. For more information on authorizations, visit our Prior Authorizations and Referrals page.

Protected Health Information (PHI)

Information regarding the physical or behavioral health; or condition of an individual, the medical treatment of an individual; or health care payments that identifies an individual or could be used to identify the individual.