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If you have other health insurance (OHI), do you know how those benefits coordinate with TRICARE? Understanding some basic guidelines can help ensure that your claims are paid correctly and without hassle.
Depending on the type of OHI plan you have, your OHI may be required to pay before TRICARE makes a payment.
Special situations arise if you are entitled to a public program, such as Medicare, Medicaid or the Indian Health Service. TRICARE pays second to Medicare but is primary to Medicaid and the Indian Health Service.
Coordinating Referrals and Authorizations with Your OHI
When you have OHI, it is not necessary for you to obtain referrals or prior authorizations from Humana Military. However, the following are a few exceptions when TRICARE does require you to obtain prior authorization:
- Adjunctive dental
- Home health services
- Hospice care
- Extended Care Health Option (ECHO) benefits
- Stem cell and organ transplants
- Behavioral health services—All nonemergent inpatient admissions for substance abuse or behavioral health; psychotherapy after the initial eight outpatient visits; psychoanalysis; and intensive outpatient treatment programs, partial hospitalization programs and residential treatment center programs
It is critical that you follow the rules of your OHI plan to prevent claims from being denied. If your claim is denied by your primary insurance because you did not follow the rules of the OHI, TRICARE will not make a primary payment and may not make a secondary payment. If the beneficiary is able to obtain a statement from the OHI, indicating the amount it would have paid had requirements been met, then TRICARE can make a secondary payment. Without that statement from the OHI, TRICARE cannot make any payment.
If your primary insurer is a health maintenance organization (HMO), make sure your provider is an authorized provider for both your OHI and TRICARE. Otherwise, you may be required to pay out of pocket for the care.
Coordinating Your Benefits and Claims Payment
When you have OHI, claims must be coordinated with both your primary OHI and TRICARE. Here are a few simple steps for coordination.
Step 1: Your provider should submit claims to your primary insurer first. Most providers will submit the claim for you. The primary insurer pays its benefits in full as the first payer. Once the claim has been processed, the provider will receive an explanation of benefits (EOB) indicating the amount paid by your primary insurer.
Step 2: If TRICARE is the second payer, your provider should send information from the primary insurer’s EOB with the claim to TRICARE for secondary payment. TRICARE will process the claim and pay the amount that remains, up to the TRICARE allowable charge. (The allowable charge may be the amount the provider agrees to accept from TRICARE or from the OHI carrier as payment in full, or it may be the amount established by law as the maximum amount TRICARE is responsible to pay on the particular service.)
If your primary insurance is Medicare, then your claim will be processed and forwarded to TRICARE for secondary payment. If you have OHI in addition to Medicare and TRICARE, then you will need to submit a claim to TRICARE after Medicare and the OHI have paid.
TRICARE serves as primary payer when your OHI benefits have been exhausted or when a service is not covered under your OHI but is covered under TRICARE.
Submitting Health Care Claims Yourself
As stated previously, your OHI and TRICARE claims are usually submitted on your behalf by your provider. Network providers are required to submit claims for TRICARE beneficiaries. However, if your provider does not submit the claims to TRICARE for secondary payment, you will need to send a completed DD 2642 Form (TRICARE Claim Form), all itemized bills and a copy of your OHI EOB statement to PGBA, LLC.
For your convenience, Humana Military has the DD 2642 Form and details about filing claims available online or at www.tricare.mil/claims. It is important to submit all claims to TRICARE because deductibles may be applied to your annual TRICARE catastrophic cap.
Understanding how your OHI coordinates with TRICARE and following these basic guidelines will help to ensure that your claims are paid without delay.
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