Why does Tricare need my original bill when it’s the second payer?
May 18th, 2012 | TriCare Help | Posted by Military Times
I have other health insurance, and when I file with Tricare as second payer, I always have a problem getting copies of the original bills from my doctor’s office. The other plan’s EOB says what medical services I got and the amounts it paid, so why isn’t that enough for Tricare’s use? Why are copies of the original bills required?
The way services are listed on the other plan’s EOB may not report a detailed description of the medical services you actually received. For example, there may be several different services labeled simply as “office visit” on the other plan’s EOB. Tricare and the other plan likely allow different amounts for each service, so the words “office visit” and the amount allowed by the other plan does not tell Tricare exactly what kind of medical service the patient received.
Tricare must know exactly what services you received in order to determine the amount it would have allowed for each of them if Tricare had been your primary coverage. If, as I suspect, the problem arises between you and the office staff, perhaps explaining it to your doctor will remedy the situation.
My doctor says Tricare for Life gives me substandard version of Medicare
April 6th, 2012 | TriCare Help | Posted by Military Times
My doctor told me that the kind of Medicare I have under Tricare for Life pays him much less than the kind civilians get. He said that is so the combined payments of Medicare plus Tricare come out to total the same amount that the government would pay if I had civilian Medicare only. It that true?
Your doctor is mistaken. When a military retiree applies for Medicare, he or she gets exactly the same Medicare Part A and Part B as any other person. Medicare was created by federal law enacted by Congress. It would take another act of Congress to create a “special” kind of Medicare just for military retirees. That didn’t happen when Congress authorized Tricare for Life in 2001.
Your doctor can set his mind at ease with a quick letter to the Social Security Administration. If he won’t do it, and if his belief is putting your health care in jeopardy, maybe you should offer to write the letter. You will get the same reply that he would.
In the same way, the Tricare Standard that Tricare for Life members get is exactly the same Tricare Standard they were eligible for before they got Medicare. It has some special rules to allow it to function smoothly as second payer to Medicare under Tricare for Life.
Under Tricare for Life, Tricare Standard acts as a free Medicare supplement. In the vast majority of claims, when both Medicare and Tricare cover a medical service, Tricare Standard will pay the remainder of the Medicare-approved amount after Medicare pays its maximum.
I’m diabetic; when I get married, can I get Tricare right away?
January 27th, 2012 | TriCare Help | Posted by Military Times
My fiancé is active-duty military. I am a diabetic and am on the insulin pump, and I have been told that once I get married and go on Tricare, my care will not be what I’m used to. I have seen the same doctor for 17 years, and I heard Tricare won’t let me pick my doctor. I have also been told I may have to give up my insulin pump and go back to shots. Can you confirm or explain any of that? Also, when we get married, my parents will drop me from their insurance. Do I have to wait for an open enrollment date for Tricare, or is there a way that coverage can start right away?
First of all, if medically necessary and appropriate for the diagnosis, symptoms, and history of the particular beneficiary, an insulin pump can be covered by Tricare.
A problem could arise, however, in your choice of providers. Tricare is not an insurance policy; it is a federal health benefits program. Tricare requires that you receive all civilian medical care from Tricare-authorized providers only. Tricare may not pay for any medical services you receive from an unauthorized provider.
In your case, to retain your same providers, it would be necessary for them to be willing to become Tricare-authorized providers. They can learn how to do that here.
There is no open enrollment period for Tricare. You will become legally entitled to Tricare at the moment you are married. To use Tricare, however, your military sponsor (your husband) must contact his personnel office to register you in the Defense Enrollment Eligibility Reporting System and secure for you a uniformed service identification card. Your coverage will be retroactive to the moment of your marriage.
Can fiancee keep seeing same doctors when we get married?
January 11th, 2012 | TriCare Help | Posted by Military Times
I am an active-duty sailor and I am getting married in February. My fiancee has bipolar disorder. She is concerned about being able to keep her same doctors and counselor/therapist when we are married and what hoops we may have to jump through with Tricare to make it work. How can I help her ensure she keeps her current doctors?
Tricare is a federal program, but it has a rule in common with most commercial health insurance companies and policies: In order for Tricare to help pay for medical services, the provider of care must be registered with Tricare and be authorized to be paid by Tricare for covered services rendered to Tricare beneficiaries.
Your bride will become legally entitled to Tricare the moment she is married to you., For her to use Tricare, however, you must register her in DEERS and apply for her military ID card. Your Personnel Section will help you do that.
Tricare has no limits or restrictions on its coverage of pre-existing conditions. Mental health care, including pharmacy services, is a Tricare benefit, subject to existing rules regarding the medical necessity and appropriateness of care for the particular patient’s diagnosis, symptoms, and medical history.
Seamless continuity with your wife’s same providers may be a problem for two reasons:
One is the perennial element of military service in that you are subject to periodic transfer to a new location, perhaps across the world. You have little or no control over that element of military service.
The other is whether your wife’s providers are, or are willing to become, Tricare-authorized providers, as I discussed above. A section of the official website was designed especially to inform providers of care about Tricare and its rules regarding providers. Your wife should make her doctors aware of the web site and its provider section, but the decision of whether to become Tricare authorized providers is voluntary and entirely in their hands.
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.
If doctor orders it, must Tricare cover it?
August 24th, 2011 | TriCare Help | Posted by Military Times
My doctor says I need laser surgery on my eyes, but he does not do that kind of procedure and recommends a different doctor. Mine is a Tricare doctor, so, if he orders it, will it be covered by Tricare?
Several factors must be considered:
- First, is the surgical procedure itself covered by Tricare? For example, the laser procedure to improve visual acuity called Lasik is not covered by Tricare. Conversely, there are other laser-involved procedures, such as some to treat retinal detachment, that may be covered.
- Second, in order to be covered, a medical or surgical service must be medically necessary and appropriate for the particular patient’s diagnosis, symptoms, or history. Before payment, Tricare would need to ascertain those facts in your particular case. A Tricare-authorized physician recommending or ordering a particular medical or surgical service does not, of itself, make the service medically necessary, appropriate, or covered by Tricare. Your Tricare doctor might recommend something that Tricare is not allowed to cover in your particular case.
- Third, although the referring physician may be Tricare-authorized, his referral does not make the specialist a Tricare-authorized provider. Tricare may not pay for the services of any provider who is not registered with Tricare as an authorized provider — regardless of any recommendations or referrals.
I suggest that you contact your Regional Tricare Office for more, and official, information.
Unhappy with care at base hospital; can Tricare help?
August 1st, 2011 | TriCare Help | Posted by Military Times
Q. My wife has issues with sleeplessness, weight gain and possible hormone imbalance issues. She’s been seen at our local base hospital a dozen times by both women’s clinic doctors and family practice doctors. The docs continue to bounce here back and forth with no resolution of the problem and will not send her off base for another opinion or possibly to see a specialist who works with female hormone problems. How can we get a Tricare referral? We’re almost to the point of paying for off base care out of pocket if necessary, but it’s hard to believe Tricare wouldn’t cover this problem.
Tricare is unrelated to military health services. It has no authority to require or even recommend that the military refer a patient to civilian care or specialists.
If you and your wife have a complaint about care she received at the military hospital, go through the chain of command at that hospital first. If unsuccessful, then ask for guidance about the next step for filing a complaint.
You may want to ask for advice from the Tricare Headquarters. That address is Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. TMA does not have an e-mail address or telephone number suitable for public contact.
How can I find a doctor who will take TFL?
May 27th, 2011 | TriCare Help | Posted by Military Times
Q. I am switching my coverage from Tricare to Tricare for Life (I have enrolled in Medicare Parts A and B), but I can’t find a doctor who says he will take Tricare for Life. Where can I find a list of doctors who will accept TFL?
Once your Medicare coverage becomes effective, usually on the first day of the month you turn 65, you must seek all your medical care from Medicare providers, or it won’t be covered. When you call for an initial appointment, tell the provider you are a Medicare beneficiary. The Medicare claim form asks for the name of your secondary health insurance or Medicare supplement. Write “Tricare.” Do not mention TFL because most providers will not know what that is. Under TFL, however, Tricare Standard will act as your free Medicare supplement.
For every medical service on your Medicare claim that is covered by both Medicare and by Tricare, Tricare Standard will pay whatever Medicare did not pay. Thus, when both Medicare and Tricare cover a medical service, their combined payments will pay the Medicare claim and the provider’s bill in full.
If you receive medical care that is covered by Medicare or by Tricare, but not by both, you must pay that plan’s copayment and deductible yourself. Such claims will be fairly rare. The vast majority of your Medicare claims will be for medical services that are covered by both Medicare and by Tricare.
Does my doctor have to accept TFL payments?
February 16th, 2011 | TriCare Help | Posted by Military Times
Q. If a doctor accepts Medicare payments, does he also have to accept Tricare for Life payments?
If you are a Tricare for Life beneficiary, Medicare makes its payment directly to the provider of care. Then, it automatically forwards the claim to Tricare, which is your free Medicare supplement. Tricare processes the claim using Medicare’s EOB for information about what Medicare paid. For every medical service on the Medicare claim that is covered also by Tricare, Tricare pays directly to the provider whatever Medicare did not pay, up to the amount you owe. As that is an automatic action, the Medicare claim and the provider’s bill are paid in full. As the doctor is paid in full by the automatic combined Medicare plus Tricare payments, it is not necessary for him to “accept” Tricare. He still gets paid in full, and you owe nothing.
Your Tricare EOB will prove that the bill was paid in full. Save it as proof if there is ever a question.
When you’ve already paid Medicare’s copay
January 25th, 2011 | TriCare Help | Posted by Military Times
Q. I had cataract surgery in both eyes. I have Tricare for Life, and the eyeglasses are covered under Medicare and Tricare. The eye care provider accepts Medicare and I had to pay the 20 percent copay. What happens when Tricare pays? Does the provider keep both payments? Who returns my copay?
As both Medicare and Tricare cover one set of eyeglasses following intraocular lens implant surgery, Tricare will pay the provider whatever Medicare did not pay. It usually takes a couple of weeks for Tricare to pay the provider what Medicare did not pay.
Contact the eyeglass provider for a refund. Tricare will send both you and the eyeglasses provider an EOB as proof of payment.