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A line-of-duty (LOD) condition is determined by the military service and includes any injury, illness, or disease incurred or aggravated while the National Guard or Reserve member is in a duty status, either inactive duty (such as reserve drill) or active duty. This includes the time period when members are traveling directly to or from the place where they perform military duty. National Guard and Reserve members will receive written authorization that specifies the LOD condition and terms of coverage. Note: DEERS will not show the eligibility for LOD care in the system.
LOD coverage is separate from any other TRICARE coverage in effect, such as:
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Services for LOD conditions are generally delivered at an MTF if there is one nearby that has the capability. The MTF may refer the National Guard or Reserve member to civilian TRICARE providers. If there is no MTF nearby to deliver or coordinate the care, the MMSO may coordinate nonemergency care through any TRICARE-authorized civilian provider for service members residing in remote areas.
If Humana Military receives an LOD claim that was not referred by an MTF or pre-approved by the MMSO, Humana Military will forward the claim to the MMSO for approval or denial. The provider of care should submit medical claims directly to Humana Military unless otherwise specified on the LOD written authorization or requested by the National Guard or Reserve member’s Medical Department Representative. Any services you submit for a National Guard or Reserve member with an LOD condition must be directly related to the condition documented on the LOD written authorization.
If a claim is denied by the MMSO for eligibility reasons, the provider’s office should bill the member. The MMSO may approve payment once the appropriate eligibility documentation is submitted.
It is the National Guard or Reserve member’s responsibility to ensure that appropriate eligibility documentation is submitted by the unit to the MMSO and that all follow-up care is authorized by the MMSO.
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When National Guard and Reserve members are called to active duty for more than 30 consecutive days, they become eligible for TRICARE. They are considered ADSMs and may enroll in TRICARE Prime or TPR, according to local policy, once they reach their final duty station.
Family members of these National Guard and Reserve members may also become eligible for TRICARE if the National Guard or Reserve member (sponsor) is called to active duty for more than 30 consecutive days. Family members can access care with TRICARE Prime, TPRADFM, TRICARE Standard, or TRICARE Extra health care program options, as well as dental coverage through the TDP. Sponsors are required to register their family members in DEERS.
Depending on the program option that the family member chooses, providers should follow the program rules, benefits, costs, referral and prior authorization requirements, and billing guidelines for that program option.
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