Who pays first?
January 7th, 2010 | TriCare Help | Posted by Military Times
Q. My daughter’s college infirmary says it’s written in their policy that all other insurance must pay first. That means she has to file claims with Tricare first. When she did, Tricare denied her claim and said the school has to pay first. I asked Tricare what to do. Although I’m her Tricare sponsor, they won’t talk to me because she is 19. What can we do?
By law, Tricare — and probably the school’s insurance under some other rule — must have your adult daughter’s written permission to talk with you. But it’s a good time for her to learn to handle her own insurance business, with your help.
First, within 90 days from the denial, your daughter should file a written appeal with Tricare. Instructions are on the Tricare Explanation of Benefits form, or she can call Tricare for help.
Then, she should write to the school’s insurance company about the problem of who must be first payer. Federal law says that Tricare is always last payer to all other coverage. The insurance company should know that already, or they can easily learn it by calling Tricare.
Once the school’s insurance company understands that it is first payer, she or the doctor should file a claim with that carrier. When it completes processing the claim and sends her an EOB, she should file with Tricare for the family deductible and catastrophic cap records, whether or not there is anything left to pay. Here’s how.
1. Complete a Tricare claim form, DD2642. Your daughter must sign it as the adult patient. You can download claim forms and get the claim filing address at www.tricare.mil/claims.
2. Attach a copy of the same itemized bill that was sent to the school’s insurance.
3. Attach a copy of that plan’s EOB showing its processing of those charges.
Make a habit of saving copies of all claim documents, including the appeal. If you do not, I guarantee that there will come a time when you will wish you had.
If my wife is eligible, what kind of ID does she need?
January 6th, 2010 | TriCare Help | Posted by Military Times
Q. I am retired Naval Reserve, enrolled in Medicare Part B and also eligible for Tricare. My wife is not yet eligible for Medicare (she’s only 63) but is it correct that she is eligible for Tricare? And when she sees a provider, does her military ID serve as evidence of Tricare coverage, or does she require a separate form of Tricare identification?
Both you and your wife became legally eligible for Tricare when you became entitled to receive retired pay on your 60th birthday. For your wife to use Tricare, you had to apply on her behalf so she could get a military ID card and be registered in DEERS.
From what you report, it sounds as if she is eligible for Tricare. But to be sure, you should call DEERS, toll-free, at 1-800-538-9552. Make sure her record is up-to-date and she is reported as Tricare-eligible.
If she is, her military ID card is the only proof of insurance she needs. On the back of her card, it refers to civilian medical care. “YES” in that area shows she is eligible for civilian care at government expense (Tricare.)
When your wife gets Medicare at age 65, and is enrolled in Part B, she will get Tricare for Life just as you did, if her DEERS record and ID card are kept up-to-date.
You need to teach her how to stay up-to-date in case you predecease her. Your death would have no effect on her eligibility unless she were to remarry. In that case, she would lose all her eligibility under your sponsorship. It cannot be restored even if her second marriage were to end by death or divorce.
Is survey letter legit?
January 5th, 2010 | TriCare Help | Posted by Military Times
Q. I recently got a letter from Tricare Management Activity, Health Programs Analysis and Evaluation Directorate. The letter itself didn’t show a return address but the return address on the envelope was Office of The Assistant Secretary of Defense (HA), TMA/HPAE, c/o Synovate, P. O. Box 5030, Chicago, IL 60680. They say they will soon send me a survey asking for my thoughts on health services. The letter is signed by Thomas V. Williams, PHD, Director Health Programs, OSD Tricare Management. I’m a little leery; I retired in 1969 and I’ve never received a letter like this. Can you shed any light on this?
I contacted Health Affairs regarding your inquiry. Here is the reply I received:
Yes, this is a legitimate survey that is conducted by a contracted company to do such surveys. These surveys are managed by HPA&E in Fall Church, Va. It is always the individual’s choice as to whether to participate or not. However, feedback (good or bad) regarding the Tricare programs is indeed welcomed, and these surveys are the mechanisms that are used for this feedback, which we use to identify areas that we may be able to improve, or determine that what Tricare provides is meeting the needs of our folks.
So it’s a legitamite letter, and a chance for you to provide some feedback on the service you receive. But, as Health Affairs states, participating is strictly up to you.
Can my parents get coverage?
January 4th, 2010 | TriCare Help | Posted by Military Times
Q. My parents had to move in with my wife and me, which I think makes them my dependents now. I’m active duty and my parents are in their late 60s and early 70s. Is there a way to get them covered by my Tricare?
I can tell you that dependent parents are not eligible for Tricare. You can confirm that by calling the DEERS Support Office, toll-free, at 1-800-538-9552.
But there is a possibility that the commanding officer of your military treatment facility may grant permission for your parents to receive medical care there. Dependent parents’ use of a MTF is not a right under the law — it is a privilege that may be granted by the MTF’s commanding officer, subject to the availability of space, personnel, and the MTF’s technical ability to provide needed care. Even if permission is granted, it can be terminated at any time.
Do two things. First, call DEERS to confirm whether your parents can be made eligible for Tricare. That is so you can be absolutely certain whether they have any rights to medical care at government expense as your dependents. Second, make an appointment to speak with your MTF’s executive officer or the officer in charge of patient administration. Present your case, explaining your parent’s financial situation and/or any special needs that might contribute to a successful request. You wrote that they are dependent on you. Explain why that is. Ask whether approval can be granted for them to use any of the MTF’s facilities, including the pharmacy.
If the XO denies permission, ask for permission to speak with the hospital’s commanding officer about the matter. The CO’s decision is governed by law, regulation, and his special knowledge and experience regarding the capacity of his MTF, and the needs of the military personnel and families under his care. It will be final.
The CO is responsible for the health care of the entire military facility. By law, however, active-duty military personnel always come first. In the competition for MTF space, the spouse and children of active duty members and who also are enrolled in Tricare Prime are second. Everybody else is last.
Should I drop FEHBP and use Prime instead?
January 2nd, 2010 | TriCare Help | Posted by Military Times
Q. I work for the federal government and I will be a retired reservist at 60. I would like to enroll in Tricare Prime instead of using the federal benefits plan, which is more expensive. Am I allowed to do that?
On your 60th birthday, you, your wife, and any unmarried children under 21 (under 23 if an unmarried, full-time college student) will become eligible for Tricare.
If you enroll in one of the plans under the Federal Employees Health Benefits Program, Tricare will automatically be second payer to that plan. Usually it will pay all, or most, of the FEHBP plan’s deductibles and copayments. Whether you keep an FEHBP plan is entirely up to you; Tricare doesn’t care.
I recommend against choosing Tricare Prime if you retain the FEHBP coverage. Standard is the best way to go when you have other health insurance. That’s because it is free, and with Standard, it’s much easier to coordinate benefits between the two plans.
If you leave the FEHBP plan, be sure to suspend membership — do not cancel. If you cancel you can never get it back. If you suspend, you can get it back any year during Open Season. Talk with the Office of Personnel Management to make sure you understand thoroughly before you decide.
Prime is not available everywhere. Check with your Tricare Service Center to find out if Prime is available where you live. Prime is your best bet if that will be your only coverage. If it’s not, the best coverage is to retain the FEHBP.
As an alternative, consider a bona fide Tricare Supplement — a specially written plan designed to be a Tricare supplement. Study the fine print carefully before deciding which supplement to buy. What you will get for your money is what is written in the fine print, not in the ads or sales pitches.
But don’t be seduced by a few bucks. Tricare Standard plus an FEHBP plan, even the least expensive one, provides much better coverage than Tricare plus a supplement.
Remember to check with DEERS (call 1-800-538-9552, toll-free) to confirm that you and your family have been made eligible for Tricare on your 60th birthday. Registration is supposed to be automatic, but people make mistakes.
Can I file claims for back copays?
January 1st, 2010 | TriCare Help | Posted by Military Times
Q. My wife and I have our recently obtained our DEERs cards and I found out we have been in the system since I retired from the reserves a couple of years ago. I have never used any of my military retiree benefits. While getting our ID cards recently at the nearest military facility, we visited the Tricare counter. According to the person there, I should be able to make a claim with Tricare for a year’s worth of back copays for doctor’s visits and medications — charges remaining after my my civilian employer’s health plan paid the bills. Are you familiar with this one year look-back?
To file a claim with Tricare as second payer to any other health insurance (OHI) plan, you do in fact have one year. Please do the following:
- Complete a Tricare Claim Form DD2642 for each patient and each provider.
- Attach clear, legible copies of exactly the same itemized bills that were sent to the OHI. An itemized bill lists each medical service you received plus the price for each service. A “balance due” bill without itemization of services cannot be used.
- Attach a copy of the OHI’s Explanation of Benefits reporting its processing of each of the charges on the itemized bill.
- Send the package to the proper Tricare claims processor.
I strongly recommend that you make copies of each of the documents filed with Tricare, including Tricare’s EOB when it processes the charges. Always keep files on each claim you submit.
Tricare claims must be filed within one year of the date of the medical care. If it is a hospital claim, the filing deadline is one year from the date of discharge from the hospital.
Note that a hospital bill is for the services provided by the hospital itself. That is, for room and board, general nursing services, the use of hospital equipment, supplies, employees, and the like. It does not include bills for doctor services you received while in the hospital. The doctors will bill separately.
If a claim for any service is denied, the Tricare EOB will report $0.00 in the column entitled Amount Allowed. The reason for the denial is always reported on the Tricare EOB. That reason is what must be fixed for the claim to be reconsidered for payment.
If the reason for denial makes any mention of eligibility or DEERS, call the DEERS Support Office, toll-free, at 1-800-538-9552 for help.
If the reason for the denial is not something that can be fixed by a quick phone call, I recommend filing an appeal within 90 days of the date of the EOB showing the denial.
An appeal must be in writing, it must state the specific matter in dispute, it must be accompanied by a copy of the Tricare EOB that reports the denial, and it must be signed by the adult patient, or the legal guardian of a minor or incompetent patient. A husband may not sign for the wife or vice versa. The signature thing is all Privacy Act stuff.
If you have questions or need help with filing claims, call your Tricare Service Center. And you are going to need official help from Express Scripts with the pharmacy issues. The toll-free number is 1-877-363-1303.