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Beneficiary Standard Handbook
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Coordinating Benefits with Other Health Insurance
How TRICARE Calculates Payment with OHI
Third-Party Liability |
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Coordinating Benefits with Other Health Insurance |
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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’ll 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 using a non-network provider, TRICARE may also deny your claim.
Keep Humana Military and health care providers informed about your OHI so that they can coordinate your benefits and help ensure that there is no delay (or denial) in the payment of your claims.
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How TRICARE Calculates Payment with OHI |
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TRICARE regulations require coordination of benefits with OHI coverage. Due to these regulations, TRICARE does not always pay the OHI copayment or the balance remaining after the OHI pays. However, your liability is usually eliminated. Payment calculations differ by provider status as detailed below. |
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TRICARE Network Individual/Group Providers and Most Inpatient Facilities |
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If your OHI pays more than the TRICARE allowed amount, then no payment is authorized, the charge is considered paid in full, and the provider may not bill you. Otherwise, TRICARE pays the lesser of:
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- The allowed amount minus the OHI payment
- The amount TRICARE would have paid without OHI
- The beneficiary’s liability (OHI copayment/deductible)
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Non-Network Individual/Group Providers that Accept TRICARE Assignment (Participating) |
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TRICARE pays the lesser of:
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- The billed amount minus the OHI payment
- The amount TRICARE would have paid without OHI
- The beneficiary’s liability (OHI copayment/deductible)
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Individual/Group Providers that Don’t Accept TRICARE Assignment (Nonparticipating) |
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Nonparticipating providers may only bill you up to 15 percent above the TRICARE allowable charge. If your OHI paid more than 115 percent of the TRICARE allowable charge, then no TRICARE payment is authorized, the charge is considered paid in full, and the provider may not bill you. Otherwise, TRICARE pays the lesser of:
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- 115 percent of the allowed amount minus the OHI payment
- The amount TRICARE would have paid without OHI
- The beneficiary’s liability (OHI copay/deductible)
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Staff Model Health Maintenance Organizations (HMO),
Group HMOs, and Other Capitated OHI Plan Providers |
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If you are enrolled in one of these OHI plans, the provider/group either works directly for the HMO or is paid a monthly/annual amount rather than a fee for each service performed. In these plans you may only receive a copayment receipt, and an itemized bill or explanation of benefits (EOB) may not be available.
In these cases, you can submit a DD Form 2642 Patient’s Request for Medical Payment with a copy of the receipt. For processing, the copay is considered the billed amount. Deductibles and cost-shares are applied, and you may only receive partial reimbursement of your HMO copay.
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Pharmacy Claims (Processed by (ESI)) |
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When using OHI, the OHI is the first payer for pharmacy coverage. You may then be eligible for full or partial reimbursement from TRICARE for out-of-pocket costs, including copayments. If you have OHI, you should use a retail pharmacy under your private insurer that is also in the TRICARE retail network to avoid paying the TRICARE non-network deductible. You may not use the mail order pharmacy if you have prescription drug coverage from OHI, unless the medication is not covered under the other plan, or unless you exceed the dollar limit of coverage under the other plan. When you have OHI, the rules of that insurer apply. You should call ESI at 1 (866) DoD-TRRx (1-866-363-8779) for specific instructions about filing pharmacy claims if you have OHI. |
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Third-Party Liability |
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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 appears to have third-party liability 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. The DD Form 2527 is available to download at TRICARE's Claims Web site.
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