If Medicare denies my claim, will Tricare pay it?
November 24th, 2009 | TriCare Help | Posted by Military Times
Q. I have a supplement through an insurance company in case I have a claim denied by Medicare. In this case, the company will not honor my claim. Will Tricare pay the claim that Medicare denies? Could I use Tricare as a Medicare supplement?
Effective on October 1, 2001, Congress authorized Tricare beneficiaries who become entitled to Medicare and who are enrolled in Medicare Part A and Part B to use Tricare Standard as second payer to their Medicare coverage. That Tricare plan is called Tricare for Life.
TFL consists of full coverage under Medicare Parts A and B plus full coverage under Tricare Standard. The TFL beneficiary has two, full-coverage, stand-alone health insurance plans. The Tricare portion is free. Medicare is the primary plan. The beneficiary must seek all his medical care from Medicare providers who will file a Medicare claim for the services he provides.
When Medicare completes all its processing of the claim and pays its share to the provider, it will automatically forward the claim to Tricare as second payer. In the vast majority of claims, Tricare will pay whatever Medicare did not pay for every medical service that is covered by both Medicare and Tricare. When both Medicare and Tricare cover a service, Tricare acts as a free Medicare supplement. The Tricare deductible and cost share are waived, and the combined Medicare plus Tricare payments will pay the Medicare claim, and the provider’s bill, in full. The patient will pay nothing. The vast majority of TFL claims will be of that kind.
In response to your question, if Medicare denies payment on a portion of the claim — if it cannot pay for one or more of the services the patient received — the first thing to do is to file an appeal with Medicare. You will find instructions with the documents Medicare sent to you when it reported the charge was denied.
After all the appeal actions have been taken and resolved for or against your claim, Medicare will forward the claim to Tricare as usual, including the charges for the items Medicare did not pay and the report of the appeal actions.
If the particular item that was denied is for a service that is covered by Tricare, Tricare will process the claim for that particular item as the only insurance coverage for that item. In that case, all Tricare claims processing rules will apply including the Tricare deductible and cost share. That is, the claim for the service not covered by Medicare will be processed as if the patient did not have Medicare coverage — as if Tricare is his only health insurance. It will be processed in exactly the same way as your Tricare claims were processed before you became eligible for Medicare.
If the item is not covered by Tricare or Medicare, the patient must pay the entire charge for that item out of his own pocket.
Tags: appeal, claims, Medicare, Tricare Prime
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