TRICARE Prime Handbook

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Claims


Coordinating Benefits with Other Health Insurance

TRICARE is the primary payer for active duty service members. For all other beneficiaries, TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs/plans as identified by the TRICARE Management Activity (TMA).

If you have OHI, you need to follow the OHI’s rules for filing claims and file the claim with them first. If there is an amount your OHI does not cover, you can file the claim with TRICARE for reimbursement. It is important to follow the requirements of your OHI. If your OHI denies a claim for failure to follow their rules, such as obtaining care without authorization or use of a non-network provider, TRICARE may also deny your claim.

Keep Humana Miltary and health care providers informed about your OHI so they can better coordinate your benefits and help ensure that there is no delay (or denial) in the payment of your claims.

Pharmacy Claims and OHI (Processed by ESI)
When you have OHI, your OHI is the first payer for pharmacy coverage, and the rules of that insurer apply. After your OHI has paid, your TRICARE coverage may reimburse you for part or all of your out-of-pocket costs, including copayments. Your best option with OHI is to use a retail pharmacy that is covered by your OHI and is in the TRICARE retail network to avoid using the POS option.

You may not use TRICARE’s mail-order option if you have prescription drug coverage from OHI, unless the medication is not covered under your OHI, or you exceed the dollar limit of coverage under your OHI.

Contact ESI at 1-866-DoD-TRRX (1-866-363-8779) with questions about filing pharmacy claims with OHI.


Third-Party Liability
The Federal Medical Care Recovery Act allows TRICARE to be reimbursed for its costs of treatment if you are injured in an accident that was caused by someone else. The DD Form 2527 Statement of Personal Injury Third Party Liability form will be sent to you if a claim is received that appears to have third-party involvement. Within 35 calendar days, you must complete and sign this form and follow the directions for returning the form to the appropriate claims processor. You can download the DD Form 2527 from the TRICARE Web site or Humana Military's Web site.


Explanation of Benefits

A TRICARE explanation of benefits (EOB) is not a bill. It is an itemized statement that shows what action TRICARE has taken on your claims. An EOB is for your information and files. After reviewing the EOB, you have the right to appeal certain decisions regarding your claims. You can file an appeal in writing within 90 days of the date of the EOB notice. (For more information about appeals, see the Information and Assistance section.) You should keep EOBs with your health insurance records for reference. For a sample of the EOB in your region, along with instructions for reading the EOB, see the following figure numbers in the Appendix section:

  • North Region: Figure 9.1
  • South Region: Figure 9.2
  • West Region: Figure 9.3

Debt Collection Assistance Officers  
Debt Collection Assistance Officers (DCAOs) are located at military treatment facilities (MTFs) and the TRICARE Regional Offices (TROs) to assist you in resolving health care collection-related issues. Contact a DCAO if you have received a negative credit rating or have been sent to a collection agency due to an issue related to TRICARE services.

When you visit a DCAO for assistance, you must bring or submit documentation associated with a
collection action or adverse credit rating, including debt collection letters, EOB statements, and medical/dental bills from providers. The more information you can provide, the faster the cause of the problem will be determined. The DCAO will research your claim, provide you with a written resolution of your collection problem, and inform the collection agency that action is being taken to resolve the issue. DCAOs cannot provide legal advice or repair your credit rating, but they can help you through the debt collection process by providing documentation for the collection or credit-reporting agency to explain the circumstances relating to the debt. To find a DCAO near you, visit the DCAO directory online.

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Last Reviewed: July 11, 2008