Will Tricare cover my second PSA test?
January 9th, 2012 | TriCare Help | Posted by Military Times
I am 66 and have Tricare for Life. Medicare covers only one PSA test a year. I just had a PSA test and it was high. The biopsy showed cancer. They are going to remove the prostate. After 3 months I am going to need another PSA to see if they got it all. Will tricare cover the test?
Federal law requires Tricare to always be last payer to all other coverage. Claims must always be submitted to any other coverage first.
Under Tricare for Life, Medicare has become your primary health insurance. All claims must be filed with Medicare first. Tricare is second payer on all claims.
When a medical service is covered by both Medicare and by Tricare, Tricare will act as your free Medicare supplement and will pay whatever Medicare did not pay.
It is important for you and your providers to understand that, regardless of whether or not Medicare will cover the second test, all claims for the second test still must be submitted to Medicare first. That is true even if Medicare will deny payment on that claim.
If you diagnosis is made a part of your Medicare claim, I feel certain that it will be paid. Regardless of whether Medicare covers the second PSA or not, Tricare will cover it if the claim, including your diagnosis, is submitted properly to Medicare first.
Even if Medicare denies payment, it will still forward the claim to Tricare just as it always does. That’s the way Tricare for Life works.
After I marry Marine husband, can I get Tricare right away?
December 27th, 2011 | TriCare Help | Posted by Military Times
My fiance is on active duty in the Marine Corps. We are getting married in January. I am currently a flight attendant, so I have my own health insurance right now, but I plan to quit in April when I move to Florida to be with him. Once we get married, is there a waiting period for me to be covered under Tricare, or is it automatic after he has enrolled me?
You will become legally entitled to Tricare at the moment you are married. There is no delay.
If you receive medical care while you still have coverage by your present policy, you must file claims with that plan first. After it has completed all processing of the claim and issued an explanation of benefits, you may file a claim with Tricare as second payer. Tricare will pay all, or most, of what the other plan left unpaid — usually your copayment and, if applicable on that claim, your deductible. For instructions, filing address, and to download claim forms, visit the Tricare website or call your Tricare Service Center.
Here’s how you file a claim with Tricare as second payer:
1. Complete a Tricare claim form DD2642.
2. Attach a copy of the same itemized bill that was sent to the other plan.
3. Attach a copy of the other plan’s EOB reporting its processing of each of the charges on that bill.
4. Send the claim to the proper Tricare claims processor for the state where you live.
For you to use Tricare, your husband must contact his Personnel Section to register you in the Defense Enrollment Eligibility Reporting System, better known as DEERS. (Remember the name. You will soon learn that military folks speak in acronyms.)
DEERS maintains a confidential registry of military beneficiaries and the benefits to which each person is entitled by law. Once registered in the confidential DEERS registry, your name will appear on DEERS under your husband’s Social Security number. DEERS will report that you are eligible for Tricare.
When a Tricare claim is processed, the Tricare computer contacts the DEERS computer automatically. It asks whether the person on the claim was eligible for Tricare on the date he or she received the medical service(s) on the claim. If DEERS replies “yes,” the claim will continue processing.
If DEERS replies “no” for any reason, the claim will be denied at that point, and the patient will be sent an explanation of benefits. The Tricare EOB always reports the reason any claim is denied and tells the patient of his/her right to appeal the decision. That reason for denial must be addressed in order for the claim to be paid.
If you receive medical care after you are married but before you are registered in DEERS, save copies of all itemized bills and receipts until your Tricare registration is complete and you have been issued a uniformed service identification card. Then you may file a claim for reimbursement of your costs. Your Tricare coverage will be retroactive to your first minute of eligibility.
How does doctor’s office file a Tricare claim?
December 23rd, 2011 | TriCare Help | Posted by Military Times
If Tricare is secondary to a commercial insurance, will Tricare pay the primary insurance’s copayment? Our medical practice treated the child of a parent who gave Health Alliance insurance as a primary carrier and Tricare “Active Duty Family Member” as the secondary insurance. The parent refused to pay the primary insurance co-pay and stated Tricare will pay the copay when Tricare is billed.
By federal law, Tricare is always last payer to all other health insurance. In most cases, Tricare will pay whatever the patient’s other coverage did not pay for covered services, up to, but not more than, the amount of the Tricare allowance. That will usually include payment of the patient’s share of the other plans benefits — his copayment and, when applicable, his deductible — withheld by the other plan.
Here’s how to file the Tricare claim and to be paid directly by Tricare:
1. Complete and sign a proper claim form, accepting assignment of benefits.
2. Attach a copy of exactly the same bills as were submitted to the other plan.
3. Attach a copy of the other plan’s EOB.
4. Send the claim to the proper Tricare claims processing contractor.
5. The claim must be filed within one year from the date of service.
For mailing instructions or help with the claim, visit Tricare’s website. The site also maintains a section specifically designed for provider information. To become a primary provider for Tricare beneficiaries, you must register with Tricare and become an authorized provider. That requirement is similar to that seen with commercial policies.
Do we have to use other health insurance if it’s available?
November 22nd, 2011 | TriCare Help | Posted by Military Times
My husband has Tricare Prime. He is considering a full-time job with full benefits. If health insurance is an optional benefit, does Tricare require that he take it?
No, Tricare does not require or forbid its beneficiaries from enrolling in other health insurance. It is completely up to the beneficiary. However, if he is enrolled in other health insurance, federal law requires that he use (file claims with) that plan first.
After the other health insurance has processed the claim, paid its maximum, and issued an Explanation of Benefits, the beneficiary or the provider may file a Tricare claim for all amounts the other insurance may have left unpaid. Usually, that will be the patient’s copayment and, when applicable, the deductible. That is commonly called the “patient’s share” of the bills.
The Tricare claim must consist of:
- A properly completed Tricare Claim Form DD2642;
- A copy of exactly the same bill(s) that was/were sent to the other health insurance;
- A copy of the other insurance’s EOB reporting its actions on each of the charges on the provider’s bill.
Send the package to the proper Tricare claims processing contractor for your place of residence.
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.
Does Tricare need to know about my primary insurance?
October 7th, 2011 | TriCare Help | Posted by Military Times
Do I need to let Tricare know our primary insurance information with United Health Care, as we are using Tricare as our secondary insurance? Most doctors will be filing the claims, and I wanted to make sure Tricare was aware of our other insurance. Also, I need the address that the claims should be mailed to — we are in the North Region.
It is not necessary for you to advise Tricare of your other health insurance as long as you use it first. There will be a space on its claim form for you to put the name and address of your other plan, which is Tricare.
By federal law, Tricare is always last payer to all other sources of medical payments including other health insurance, medical plans such as a Health Maintenance Organizations, or medical payments from insurance payments or a lawsuit, such as the result of an auto accident, slip-and-fall, dog bite, and the like.
The only time Tricare pays first is if the other coverage is a bona fide, specially written Tricare supplement or a welfare-related plan such as Medicaid (not Medicare).
As you correctly assumed, you must file all claims with your commercial plan first. After it completes processing and issues an Explanation of Benefits, it will probably forward the claim to Tricare as second payer. If it does not, you will have to do it yourself. In that event, please see below.
After the other plan has completed all processing, paid its maximum, and has issued an Explanation of Benefits (or EOB – the processing report a plan issues when all its actions have been completed), the patient or provider may file a Tricare claim. As second payer, Tricare will usually pay most, or all, of what the other plan did not pay. That will usually be your co-payment, and any part of its deductible that has not been satisfied previously.
The Tricare claim must consist of:
- A properly completed Tricare Claim Form DD2642;
- A copy of exactly the same bills as were submitted to the other plan;
- A copy of the other plan’s EOB reporting its actions (payment, denial, crediting to the deductible) on each of the charges submitted to the other plan.
For official information and instructions about filing the claim with Tricare, including the filing addresses for all regions and to download claim forms, visit the Tricare website. If you need additional help, please call your Regional Tricare Service Center.
Getting a divorce and just got huge surgery bill – aren’t I still covered?
September 19th, 2011 | TriCare Help | Posted by Military Times
I’m a Navy wife going through a divorce and I recently had to get my appendix taken out. I thought I was still covered until the divorce was final, but I just got an $11,000 bill for the surgery. When I reached my husband, he said he took me off his Tricare. Can he do that? And what can I do about this bill?
Your husband does not have the legal authority to cancel your Tricare eligibility. Tricare benefits flow directly to the beneficiary; the military sponsor has no control over it. You will be eligible for Tricare until midnight of the day your divorce is final.
Also, Tricare will not allow him any access to information about your Tricare claims or medical care. You are protected by the Privacy Act.
The provider of your medical care should file a Tricare claim for his bill. If he will not do that, you should do it yourself. You can find detailed instructions at www.tricare.mil/claims. Remember that the only thing that matters is that you were covered at the time the service was rendered; after your divorce is final, you still have a year from the date the service was rendered to file claims.
Mom’s soon-to-be ex threatening to take away her Tricare
August 12th, 2011 | TriCare Help | Posted by Military Times
My 62-year old mother is in the process of divorcing her husband, who’s retired from the Navy. She is currently covered under his Tricare. They have been married 14 years, only 18 month of which while he was on active duty, so we realize she will not be eligible for Tricare on her own after the divorce. Divorce proceedings may take months, however, and he is threatening to “make a phone call” now and have her dropped from his plan before the divorce is final. Can he do this?
In short, no. Under the law that created Tricare, the benefit flows directly to the beneficiary, not “through” the military sponsor. The sponsor cannot control the beneficiary’s eligibility for Tricare or use of the program. Neither does the sponsor have a legal right to any information about an adult beneficiary’s Tricare claims or medical care without the beneficiary’s written permission. That information is protected by the federal Privacy Act of 1974.
You are correct that your mother’s Tricare eligibility will end when the divorce is final. Tricare will not cover the costs of any medical service she receives after midnight on the day the divorce is final. She and/or her providers, however, may continue to file Tricare claims for medical services received before that time and date. The filing deadline for those claims is one year from the date of the care.
I strongly recommend that you call the DEERS Support Office for official information regarding this matter and confirmation of the information above.The toll-free number is 1-800-538-9552. DEERS can provide official information and guidance about any matter pertaining to Tricare eligibility only. It can’t help with matters concerning Tricare benefits, claims, or payments. Please contact your Regional Tricare Service Center for that information.
Bear in mind that I am not an attorney; while I can tell you what a law or regulation says, I am not qualified to tell you how it applies to a particular person or situation. Only a qualified attorney or official agency can do that.
How does having other insurance affect my Tricare coverage?
July 25th, 2011 | TriCare Help | Posted by Military Times
I am a military spouse, and I work as a nurse, so I have Tricare as well as my employer’s insurance. My employer and the Tricare Outpatient Clinic I visit told me that Tricare would be my secondary insurance, but neither explained what that means. I continued to see my Tricare provider and they referred me to outside doctors when their own staffing was low at the military treatment facility. Triwest is now asking all providers they had previously authorized to pay them back, and sending me notices that I owe for services they authorized with these providers. They claim they did not know I had another insurance when I had previously filled out papers at the Tricare clinic when I started coverage under my employer’s plan. How does having another insurance affects my benefits through Triwest?
When a Tricare beneficiary has other health insurance, federal law requires that Tricare must always be the last payer. That means all claims for civilian medical care must be filed first with the OHI. When the OHI has paid its maximum and has issued the beneficiary an Explanation of Benefits (the report you get from an insurer showing all of its actions in paying your claim), you may file a Tricare claim.
The Tricare claim must consist of (1) a properly completed Tricare Claim Form DD2642; (2) copies of exactly the same itemized medical bills as were sent to the OHI; and, (3) a copy of the OHI’s EOB showing the way it processed (paid or denied) each of the charges on the medical bills. You must send the completed package to the Tricare claims processor for your state or ZIP code.
(You can download official claim forms and look up the filing address here.)
As last payer, Tricare will pay all, or most, of whatever the OHI did not pay for the medical services on the bills.
You didn’t mention if you have Tricare Standard or Tricare Prime. Tricare Standard is free; Tricare Prime costs $230 per year for one person, or a maximum of $460 for a family of two or more people.
Your mention of using a military treatment facility leads me to think you have Tricare Prime. Unlike Tricare Standard, Tricare Prime functions like a Health Maintenance Organization (HMO). You may use only the health care providers that are enrolled in Tricare Prime’s Provider Network unless you are referred to other providers by Tricare Prime. According to your letter, that was the case with your medical care.
As you report, Tricare is requesting that you refund its payments made in error. According to the information in your letter, Tricare paid in error because you failed to report that you had OHI, and did not file first with the OHI as required by law. No, the cops are not going to come knocking on your door.
But, you do have some problems with having to return payments made in error by Tricare. Pursuant to that, you need more help than Tricare Help can give you.
Please write to the Tricare Headquarters about this matter. The address is Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.
With your letter, please explain the problem in detail, include your full name as it appears on your military ID card, your husband’s name and his Social Security number, and a telephone number where you can be reached during the day. Include copies of any correspondence, bills, EOBs, and the like, that pertain to the problem. The more information you can provide, the more efficiently Tricare can serve you.
Where can I get help with EOBs?
April 18th, 2011 | TriCare Help | Posted by Military Times
Q. I sometimes find it hard to understand Tricare’s explanation of benefits forms. Where can I get help?
Each Tricare contractor maintains a website — find yours on the Tricare website — with a link to information for the beneficiary. That link will provide full explanations of EOBs issued by that Tricare Regional Center and will answer any questions you may have about the way your claim was processed.
Many of the problems experienced by Tricare beneficiaries result from not understanding the program’s rules — your rights and your responsibilities, especially in the matter of claims filing. Very often, problems result from simple clerical errors when claims are filed. Other problems can result from failure to provide additional information when requested.
I strongly recommend that beneficiaries spend some time studying the information provided online. The better you understand Tricare, the better it will serve you.