Why won’t Tricare talk to me about daughter’s claim?
March 7th, 2012 | TriCare Help | Posted by Military Times
My daughter attends college in another state. She is 20 and still covered by my Tricare. She called me recently because she was having trouble with a claim, but when I called Tricare to try to straighten it out, they refused to help me, saying the Privacy Act wouldn’t allow them to talk to me about my own daughter. I tried to explain she was my dependent, even gave them my Social Security number to prove I was who I said I was, but they wouldn’t listen to reason. Who can I talk to at Tricare to make sure other parents don’t go through this?
You may not like this answer, but for purposes of the Privacy Act, your daughter became an adult when she turned 18. She, alone, has the authority to grant someone else access to her Tricare claims and other personal information. That’s easy to arrange, however: She needs to give you a signed and dated written authorization. If she agrees, contact your Tricare Service Center to learn how to proceed.
If it ever becomes necessary to file an appeal of a denied Tricare claim, and if your daughter wants you to deal with the matter on her behalf, she must provide with the appeal a signed and dated statement appointing you as her representative on the appeal.
When your other health insurance is under a different name
October 31st, 2011 | TriCare Help | Posted by Military Times
I work in the airline industry and can enroll in my employer’s insurance. I also have Tricare Standard as my secondary insurance — my husband is deceased. However, the Tricare coverage is under my married name, and everything with my employer is under my maiden name. Will this cause a problem when I try to file a claim with Tricare as my secondary insurance? I need to enroll in my employer’s insurance soon.
Your problem is a simple administrative issue requiring an explanatory letter. How quickly it gets resolved depends on who gets the letter and when.
Write to your Tricare claims processing office — the same place where you submit Tricare claims — and explain the situation. Make three or four extra copies. Send the letter to the claims processor now, and send another copy with the first claim you submit to Tricare as second payer.
If it doesn’t take, you will know in a few weeks after you submit your first claim to Tricare as second payer. If your claim is denied, it isn’t a disaster; you just need to file and appeal.
If Tricare simply writes asking for more information, no appeal is needed. Just reply immediately, explaining everything again, and include a copy of the letter Tricare sent you so they know what you’re talking about.
If Tricare denies the claim, then it’s time to file an appeal. The appeal must be in writing and state the specific matter in dispute: For example, “Tricare denied claim number X because I used two different names on the claims. I have attached an explanatory letter.”
Attach a copy of the explanatory letter with the appeal letter. Include also a copy of Tricare’s explanation of benefits showing the claim denial.
Send the appeal letter, the explanatory letter, and Tricare’s EOB showing the denial to the address of the Tricare office that denied the claim. It’s on the Tricare EOB. Be sure to answer all questions Tricare asks, if any. That should resolve the name problem.
How can TFL refuse to pay for a test doctor ordered?
April 28th, 2011 | TriCare Help | Posted by Military Times
Q. I am a retired Air Force officer and have Medicare parts A and B and Tricare for Life. Recently my wife’s doctor ordered a set of lab tests that included a thyroid function test; neither Medicare nor TFL would pay for this test, leaving us to pay for that out of pocket (all other billed items were covered by one or both). How can Medicare and Tricare deny that tests ordered by a physician are “necessary”? And why was the $100 out-of-pocket payment we had to make not credited against our Individual/Family Deductible amounts?
You have the answer to your first question in your hands. Anytime a Medicare or a Tricare claim is denied, the reason for the denial is always reported on the Explanation of Benefits.
Every time Medicare or Tricare processes a claim, it sends the beneficiary and the participating provider a report of the details of all its actions when it processed the claim. That document is called an Explanation of Benefits, or EOB, for short.
The EOB reports the amount the provider billed, the amount the insurance plan approved or allowed (those terms mean the same thing), the amount the plan paid, and to whom it was paid.
If the claim, or a portion of the claim was denied (nothing was allowed or paid for that medical service), the EOB also contains a statement that tells you exactly the reason for the denial. If you have questions about the claim, including the denial, the EOB has a toll-free number you can call for a full explanation of the reason and, if possible, what you need to do so the claim becomes payable. Additionally, the EOB describes the things you must do to file an appeal. An appeal requires the plan to reconsider the way it processed the claim to ensure that all the rules for payment were considered correctly.
As I do not have a copy of the two EOBs, I have no way to know why the claims were denied. But since a test for thyroid function is a covered service under both Medicare and Tricare, the fact that the claims were denied makes me believe there was a error of some kind in the way you got the medical service or in the way the doctor filed the claim.
Was the doctor who ordered the tests a Medicare provider? A medicare provider is one that is enrolled with the Medicare program and us authorized to file Medicare claims for services provided to Medicare beneficiaries. If you have TFL and get care from a non-Medicare provider, neither Medicare nor Tricare may pay the claim.
Unless the EOB states that the amount Medicare or Tricare would have paid was credited to your deductible, the denial of the claim was not related to the deductible. It was denied for some other reason (which is reported on the EOB). The denial of a charge is unrelated to the deductible.
A phone call works instead of an appeal – sometimes
August 16th, 2010 | TriCare Help | Posted by Military Times
Q. You always recommend that beneficiaries file an appeal with Tricare any time a claim is denied. I have used Tricare for more than 10 years and have had payment denied a few times. Every time, I was able to resolve the problem with a phone call to Tricare. I have never filed an appeal, and I believe what you recommend is a waste of time for me and the government.
You’re right, a claim problem often can be resolved with a phone call, and that’s a much more efficient way of resolving an issue — when it is possible. The problem is that it doesn’t always work, and a simple phone call will not protect your rights to your benefits under the claim. That’s a reason for the formal appeals process established by law and regulation.
When there’s a problem with a claim, including a denial of payment for a charge, you have 90 days to file an appeal or otherwise resolve the issue. It sounds like a long time, but it passes quickly.
What may appear on the surface to be something easily resolved can be the result of something much more complicated. In the meantime, while you’re waiting for Tricare to resolve the issue as a result of your phone call, the time for filing an appeal is running out.
It’s also possible for human error to cause the record of your phone call to get lost, or the person with whom you spoke could leave the job, or simply may not be very efficient. The point is, if the 90 days run out without resolution, you could lose your rights to benefits for the claim.
Perhaps we can combine safety and efficiency by first filing an appeal of the denial of the claim to protect your rights. Then you can make the phone call and try to resolve the problem that way.
The right way to deal with a problem with Express Scripts
July 15th, 2010 | TriCare Help | Posted by Military Times
Q. Why is Express Scripts such a frustrating outfit to do business with? They have not responded to two greivance letters. In particular, I do not believe that they have paid out one single dollar for paper-processed claims for reimbursement that I have filed on behalf of my mother. They just recycle the paperwork back to you and they don’t care.
Your communication problems may have to do with the Privacy Act. By federal law, Tricare, Express Scripts, etc. cannot discuss your mother’s claims with a third party (you) without her written consent.
As that is only a guess, however, please send a detailed report of your mother’s problem to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, Co 80011-9043. Both you and your mother should sign the letter. That way, you can be included in the communications loop. If your mother is unable to sign the letter, please include a statement to that effect.
Include copies of all correspondence and other pertinent documents and a telephone number where you can be reached during the day. Be sure to include your mother’s full name, her military sponsor’s full name, and his Social Security number.
The more information you provide, the more effectively you can be helped. As an example, your letter, above, provided no information I could have used to suggest things you might do to resolve the problem. Surely Express Scripts reported its reasons for not paying the claims. Or perhaps, they didn’t, and said they couldn’t discuss the problem with you because of the Privacy Act. I don’t know, of course.
TMA, above, is a federal agency and the worldwide Tricare Headquarters. That office has the authority to order copies of all your mother’s claims documents and analyze them to get to the root of the problem.
If your mother is enrolled in Medicare Part D Pharmacy Plan (which she does not need unless her income is below the federal poverty line), her problem may be related to the coordination of benefits between two pharmacy benefit plans. Such claims must be filed in a certain order and contain certain documents to be processed and paid smoothly.
Without Part D, all your mother’s prescription services can be handled locally by an Express Scripts network pharmacy, or by mail order where she can get a 90-day supply of her medicines at the same price she pays for a 30-day supply purchased locally. Find information about that on Tricare’s website.
Our appeal was denied; what can we do now?
May 28th, 2010 | TriCare Help | Posted by Military Times
Q. In 2008 my wife had radiofrequency ablation to reduce chronic pain from a broken neck. It worked wonders, but Tricare is denying the procedure and saying that it’s not covered. We have already be denied on appeal. This is the only procedure that has helped my wife’s chronic pain. Are there any other avenues that we could pursue via Tricare?
If your wife’s claim was denied and you filed an appeal that upheld the denial, I doubt there is anything more than can be done.
However, you still should — without delay — write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. Explain that you are asking for a further reconsideration of the denial of the claim.
In your letter, you didn’t tell me the reason Tricare gave for not covering the procedure. My guess is that Tricare said it is an experimental or investigation procedure whose safety and effectiveness has not been documented by properly conducted, peer-reviewed studies.
Perhaps the doctor who provided the treatment can submit additional information not submitted previously to document the research that has been done in support of the procedure.
Be sure to include with your letter a copy of the original EOB showing the denial and a copy of the report of the appeal that upheld the original determination. Both you and your wife should sign the letter.
If the denial was upheld on appeal, don’t get your hopes up that it will be reversed by any subsequent letters. But the worst effort is the one that is never made.
Trouble getting surgery hospitalization covered
March 4th, 2010 | TriCare Help | Posted by Military Times
Q. My child needs dental surgery, and the procedure must be performed in a hospital. Tricare won’t cover the hospital portion – why? The dental insurance and Tricare are each saying the other needs to pay.
Your didn’t say how you learned that Tricare will not cover the hospital portion of your child’s dental care. Depending on whom you asked and the reasons you gave about why hospitalization will be needed, it is possible that you were misinformed.
If certain medical criteria are met, hospitalization for certain dental or oral surgery procedures can be covered for certain patients. Those rules are established by the federal regulation that governs Tricare.
If hospitalization is medically necessary and appropriate for the particular surgery your child needs, or if his medical condition is such that hospitalization is required for his safety, it can be covered by Tricare. That is a decision Tricare’s medical advisors will make based on medical information they receive from his physician and/or oral surgeon.
If Tricare has given you an official statement that the hospitalization will not be covered, I suggest you write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. Ask that office to reconsider its decision. A request for reconsideration is an appeal of an official decision. It requires Tricare to review the entire case to ensure that all the rules were followed correctly.
Include the name, address, and phone number of the oral surgeon. He, or your child’s physician, will need to explain exactly what is the surgical procedure to be done and the reason it must be done in a hospital rather than on an outpatient basis in the oral surgeon’s office or clinic. Tricare may want to speak with him about the case.
In your letter, you must state the specific matter that is dispute, and include copies of all correspondence you have had with the Dental Plan and with Tricare. Include the child’s full name, date of birth, your full name, and your Social Security number. Be sure to include a phone number where you can be reached during the day in case Tricare needs more information from you.
If all the business was transacted by telephone, please tell Tricare exactly whom (exactly which offices) you talked with and when. Include names of those you spoke with, if possible.
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.
Covering dental work after an accident
December 1st, 2009 | TriCare Help | Posted by Military Times
Q. A friend fell off a ladder at work and broke off some teeth below the gum line. It took the dentist an hour to dig the roots out. Now Tricare won’t pay for it. I told him it’s because the bill is from a dentist, and Tricare won’t pay dentist bills. Was I right?
You might be right, but I haven’t seen your friend’s Tricare Explanation of Benefits form. An EOB is the statement you get from a health insurance plan that explains how it processed each of the charges on the claim.
If Tricare denied payment for all or part of the claim, the reason for the denial is reported on the Tricare EOB.
I think it may be more likely that your friend’s Tricare claim was denied because it resulted from a work injury. But there’s a way to find out, and perhaps to get payment.
Tell your friend he has 90 days to file an appeal of the denial. The appeal must be in writing and state the specific matter in dispute. It must be signed by the adult patient and include a copy of the EOB that reports the denied charges. He should send it to the address on the EOB.
If he has questions, advise him to call his Tricare Service center. He can get that number by calling the Defense Enrollment Eligibility Reporting System office toll-free at (800) 538-9552.
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.