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No beneficiary wants to hear that a service or procedure is not covered, but sometimes it is necessary for providers to say so. When that situation arises, you need to explain to the TRICARE beneficiary, both orally and in writing, that the service is not covered.
Getting a Waiver
Beneficiaries may agree to pay for non-covered services or procedures themselves, but you must request that they sign the Non-covered Services Waiver Form.
If you do not obtain this waiver from the beneficiary and TRICARE does not authorize the service, you will be liable for the full cost of the service or procedure. General agreements to pay, such as those that a beneficiary may sign when being admitted to a hospital, are not considered to be evidence that the beneficiary knew the specific service or procedure in question was not allowable.
TRICARE policy considers a beneficiary to be fully informed about his or her responsibility to pay for a non-covered service only if you have obtained a signed waiver form before the service is rendered. The form should document the specific treatment, dates of service and billed amounts.
Keep copies of all signed waiver forms in your files.
Requesting Authorization
If you aren’t sure whether TRICARE will cover a particular procedure or service, you can file an authorization request. Beneficiaries can file this request, as well. If the procedure or service is denied, TRICARE will send a letter to the beneficiary explaining the denial and outlining the appeal procedures.
More information, including a list of non-covered services and benefits, is available in the “Medical Coverage” chapter of the TRICARE Provider Handbook. |
