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TRICARE Prime Handbook
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Claims
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Health Care Claims
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In most cases, you will not need to file claims for health care services. There may be times, however, when you will need to pay for care and then file the claims yourself to receive payment. You will be reimbursed for TRICARE-covered services at the TRICARE allowable amount, less any copayments, cost-shares, or deductibles.
Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge. To file a claim, obtain and fill out a DD Form 2642 Patient’s Request for Medical Payment. You can download forms and instructions from Humana Military's Web site or from the TRICARE Web site.
You can also visit a local TRICARE Service Center (TSC) or military treatment facility (MTF) to pick up a copy. If you have questions about a claim, call Humana Military at 1-800-444-5445
When filing a claim, attach a readable copy of the provider’s bill to the claim form, making sure it contains the following:
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Sponsor’s Social Security number (SSN) (eligible former spouses should use their SSN)
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Provider’s name and address (If more than one provider’s name is on the bill, circle the name
of the person who treated you.)
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Date and place of each service
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Description of each service or supply furnished
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Charge for each service
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Diagnosis (If the diagnosis is not on the bill, be sure to complete block 8a on the form.)
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Be sure to complete all 12 blocks of the form correctly and sign it. Note: Your provider will submit inpatient facility claims.
Send your claims to the claims processor for the region in which you live. If you receive care while traveling, you must file your TRICARE claims in the region in which you live, not the region in which you received care. Always keep a copy of the paperwork for your records. Figure 4.1 lists regional claims processing information.
Call Humana Military, or browse the Web site, or visit the TRICARE Web site for additional claims processing information. |
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Regional Claims Processing Information Figure 4.1 |
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TRICARE South Region |
TRICARE West Region |
Send claims to:
Health Net Federal Services, Inc.
c/o PGBA, LLC/TRICARE
P.O. Box 870140
Surfside Beach, SC 29587-9740
Check the status of your claim at
www.myTRICARE.com or
www.healthnetfederalservices.com.
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Send claims to:
TRICARE South Region
Claims Department
P.O. Box 7031
Camden, SC 29020-7031
Check the status of your claim at www.myTRICARE.com or at
www.humana-military.com. |
Send claims to:
West Region Claims
P.O. Box 77028
Madison, WI 53797-7028
Check the status of your claim at www.triwest.com. |
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Pharmacy Claims
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If you have other health insurance (OHI), you will need to submit pharmacy claims to Express Scripts, Inc. (ESI) for payment. Pharmacy claims must be filed within one year of the date of service. To file a pharmacy claim, obtain and fill out a DD Form 2642 Patient’s Request for Medical Payment. Prescription claims require the following information for each drug: |
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- Name of the patient
- Name, strength, date filled, days' supply, quanity dispensed, and price of each drug
- National Drug Code, if available
- Prescription number of each drug
- Name and address of the pharmacy
- Name and address of the prescribing physician
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You can download forms and instructions from the TRICARE Web site or from www.tricare.mil/pharmacy/claims.cfm. |
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Mail the claim to:
Express Scripts, Inc.
TRICARE Claims
P.O. Box 66518
St. Louis, MO 63166-6518
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See “Coordinating Benefits with Other Health Insurance” later in this section or call 1-866-DoD-TRRX (1-866-363-8779) with questions about filing a pharmacy claim. Note: Non-active duty beneficiaries who have prescriptions filled at a non-network pharmacy are using the point of service option. Active duty service members may be required to pay for the prescriptions in full and will receive a full reimbursement when the claim is filed. |
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