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TRICARE and Other Health Insurance (Article 1) |
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Coordinating Health Coverage for Your TRICARE Patients
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As a TRICARE provider, understanding some general guidelines regarding other health insurance (OHI) and TRICARE can help ensure that you receive correct payments in a timely manner.
OHI is any non-TRICARE health insurance that a beneficiary may receive through an employer or other public or private source. Federal law requires that TRICARE is the secondary payer to OHI, except for Medicaid, TRICARE Supplements, the Indian Health Service and other programs/plans as identified by the TRICARE Management Activity.
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Coordinating Referrals and Authorizations with OHI |
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Humana Military does not require referrals and prior authorizations for TRICARE beneficiaries who have OHI, except for the following covered services:
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- Adjunctive dental care
- 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
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Additionally, if the OHI benefits are exhausted, TRICARE becomes the primary payer, and additional authorization requirements may apply. |
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Updating OHI Status |
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TRICARE beneficiaries are advised to notify their providers if they have OHI; however, it is recommended that you ask your patients if they have OHI so their benefits can be coordinated and the appropriate authorizations can be obtained. |
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Submitting OHI Claims |
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When TRICARE is the secondary insurance, submit the claim to the primary insurance first. When filing claims with TRICARE as the secondary insurance, you can transmit the required information electronically. Humana Military will need to know the amount the primary insurance paid. If the primary insurance is a preferred provider organization (PPO), health maintenance organization (HMO) or other insurance where there is a limited liability for the patient, then you also need to send the OHI-allowed amount.
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To coordinate benefits, supply the following information:
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- Indicate the insured’s name in Box 4 (CMS-1500) or Locator 58 (UB-92)
- Indicate the primary payer in Box 9 (CMS-1500) or Locator 50 (UB-92)
- Mark “Yes” in Box 11D (CMS-1500) or Locator 34 (UB-92)
- Indicate the amount paid by the other carrier in Box 29 (CMS-1500) or Locator 54 (UB-92)
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If a beneficiary is entitled to Medicare part A & B, Medicare pays first and the claims are automatically transferred to Wisconsin Physicians Service (WPS) for TRICARE payment. However, if a Medicare beneficiary has OHI in addition to TRICARE, Medicare will make its payment and forward the claim to the OHI. The beneficiary then must file a paper claim with TRICARE for any remaining out-of-pocket expenses. |
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Calculating Payments |
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Payments from both the primary insurance and TRICARE as the secondary insurance will not collectively exceed the TRICARE allowable charge.
Providers may not collect any out-ofpocket costs from beneficiaries after the payment of the claim unless TRICARE and the OHI combined have failed to pay: the negotiated rate to a network provider; the allowable charge to a participating non-network provider accepting assignment; or 115 percent of the allowable charge to a nonparticipating non-network provider.
If the primary insurance has paid more than what TRICARE would have allowed for the service, then no additional payment will be made. The beneficiary should not be charged the cost-share when the explanation of benefits (EOB) shows no patient responsibility.
For more information about how TRICARE coordinates with OHI, contact Humana Military at 1-800-444-5445.
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