If surgery is covered, why did the hospital send a bill?
May 1st, 2012 | TriCare Help | Posted by Military Times
My father is retired Air Force and just recently had retinal re-attachment surgery. He has Medicare as well as Tricare for Life, so I don’t understand why he received a bill from the hospital for over $300. Does Tricare not cover the surgery?
Ordinarily there should be no unpaid balance under Tricare for Life; the combination of payments by Medicare (primary coverage) plus those by Tricare should have paid the Medicare claim and all providers’ bills in full.
The balance most likely results from an error in the way the Medicare claim was filed or processed.
Your father will need to research the matter by comparing the itemized bills for the balance with the explanations of benefits from Medicare and Tricare. He can find contact information for help on the Tricare website.
How can I make sure my surgery is covered?
April 18th, 2012 | TriCare Help | Posted by Military Times
I’m married to an active-duty airman. I have an ovarian cyst that must be removed ASAP. Does Tricare cover this kind of surgery?
Tricare does cover medically necessary care, including surgery, for your condition. If you live near a military hospital, make an appointment to be seen by military physicians. If you do not live near a military facility, you must find a civilian physician who is, or who is willing to become, a Tricare-authorized provider, to provide the care you need.
Tricare may provide coverage only if you use a military hospital, or a civilian physician who is authorized by Tricare to attend its beneficiaries.
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.
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.
Will Standard cover my cataract surgery?
February 28th, 2011 | TriCare Help | Posted by Military Times
I am supposed to have cataract surgery in May. My husband is my Tricare sponsor. I am 62 and not eligible for Medicare yet, but I have a supplemental policy. Will Tricare Standard pay for my surgery?
When medically necessary and appropriate for the particular Tricare beneficiary, the costs of surgery to remove and replace the eye’s natural lens is covered by Tricare, as is one pair of spectacles following the surgery if medically necessary in the particular case.
The fact that the procedure is an authorized benefit does not guarantee Tricare’s payment in a given case. That can be determined only after the service is performed and Tricare claims are filed.
Note that Tricare may cover the procedure only when performed by a Tricare-authorized provider. An authorized provider is one that is registered with Tricare and is approved to be paid by Tricare for covered medical services provided to Tricare beneficiaries. Tricare may not pay for any health-related services received from an unauthorized provider.
Is plastic surgery after weight loss covered?
December 22nd, 2010 | TriCare Help | Posted by Military Times
I am full time Guard on Title 10 orders. While I was gone, my wife lost 135 pounds. I am very proud of her and this accomplishment. The problem is, because of all this weight she has lost, she a lot of excess skin, and this makes her very self-conscious. She would like to have plastic surgery to remove this if this possible. Does Tricare offer any coverage for this?
I understand your wife’s problem. The remedy she seeks, unfortunately, is cosmetic surgery performed for psychological reasons, in order to improve her appearance.
By federal regulation, it is not covered by Tricare.
For an official response about this matter, please write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. For Privacy Act purposes, as the adult patient, your wife must sign the inquiry.
Fiancée needs coverage, ASAP
May 20th, 2010 | TriCare Help | Posted by Military Times
Q. My fiancée and I were planning to marry in June, but she has been hospitalized and may need surgery. Pending our marriage and relocation, she just quit her job and has no health insurance. If we were to marry now, how soon would her Tricare take effect? Can we get married in the hospital? Would having a pre-existing condition affect her Tricare eligibility?
Tricare doesn’t care where you are married. Your wife will become eligible for Tricare the moment you are legally married.
You will have to contact your servicing military personnel office, however, to apply for her military benefits before she can file Tricare claims. She must be registered in DEERS.
Tricare has no restrictions governing pre-existing conditions, so the fact that she’s hospitalized when you get married should cause no problems.
I suggest you call Tricare now about enrolling her in Tricare Prime as soon as you are married. Ask the Tricare Prime office how she can be covered under that plan immediately and avoid the Point of Service option because she is presently under medical care. There will be some administrative things to work out with Tricare due to her unusual situation.
Using Tricare and Medicare after eye surgery
May 12th, 2010 | TriCare Help | Posted by Military Times
Q. I have Tricare for Life and I need surgery for cataracts. I know Medicare and Tricare will pay for the surgery, but what about my new glasses? Medicare will pay part of their cost, but will Tricare pay a share, too? My wife also needs new glasses — how much will Tricare pay for her glasses if she is too young for Medicare?
Medicare will help pay for one pair of glasses after cataract surgery and the implantation of an approved artificial lens. Tricare will most likely pay your Medicare deductible, if applicable on the claim, and your Medicare co-payment, as it usually does for other covered services.
It isn’t necessary for your wife to be eligible for Medicare to use the limited Tricare coverage for eyeglasses and contact lenses. Tricare would help pay for one pair of glasses or lenses if she had an intraocular lens replacement, as in your case. Apart from that, Tricare may not pay for glasses or contact lenses except in the case of certain specific, and uncommon, eye conditions. Common refractive errors, such as near- or farsightedness, are not among those conditions.
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.
Will Tricare cover new orthopedic surgeries?
February 11th, 2010 | TriCare Help | Posted by Military Times
Q. I broke my leg a little over a year ago and have had two reconstructive surgeries that have since proven to be a complete waste of time. My leg is still in pieces. This horrible care was provided through my employer’s insurance.
Last month I married a soldier, and I am now trying to be seen at one of the best hospitals around, hoping that Tricare will approve my claim to be referred to a good orthopedic surgeon. I’ve been told that Tricare will most likely deny my claim because I have been previously treated by my employer’s insurance provider. Is that true?
Although no one can guarantee your unrestricted or unlimited access to the surgeon of your choice, I’m certain that your request for a particular provider will be given fair consideration. Tricare has no limits or restrictions on medically necessary and appropriate coverage for pre-existing conditions.
Please keep in mind that our country is at war, and there are a very large number of orthopedic and reconstructive surgeons with extensive experience in the rebuilding of shattered limbs. Many of them are employed at military medical facilities. Your care, however, is not limited to military medical facilities.