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Provider Handbook
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TRICARE and Other Health Insurance
Submitting OHI Claims
TRICARE Prime Point-of-Service Option
Calculating Payments |
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TRICARE and 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, or other programs/plans as identified by the TRICARE Management Activity TMA. TRICARE beneficiaries who have other health insurance OHI are not required to obtain referrals or prior authorizations for covered services, except in the case of the services listed in Figure 8.7, which continue to require prior authorization even when OHI coverage exists.
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OHI: Services Requiring TRICARE Prior Authorization |
Fig. 8.7
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- Adjunctive dental care
- Behavioral health services
- All nonemergent inpatient admissions for substance use disorder or behavioral health
- Partial hospitalization programs and residential treatment center programs
- Psychotherapy after the initial eight outpatient visits
- Psychoanalysis
- Extended Care Health Option (ECHO) services
- Home health services
- Hospice services
- Solid organ and stem cell transplants
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Additionally, if the OHI benefits are exhausted, TRICARE becomes the primary payer and additional referral/prior authorization requirements may apply.
Providers are encouraged to ask the beneficiary about OHI so that benefits can be coordinated. Since OHI status can change at any time, it is important to obtain this information from the beneficiary on a routine basis, including from family members of activated National Guard/Reserve members. If a beneficiary’s OHI status changes, make sure to update patient billing system records to avoid delays in claim payments. If a provider indicates that there is no OHI, but DEERS or the contractor’s files indicate otherwise, a signed or verbal notice from the beneficiary will be required to inactivate the OHI record.
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Submitting OHI Claims |
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The explanation of benefits (EOB) from the primary insurer must accompany your claim submission to PGBA if you are not able to transmit the required information on your electronic claim. Indicate the amount paid by the other insurer and include a copy of the primary insurer’s EOB with TRICARE paper claims. The primary EOB must contain the following:
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- The definition of any “reason codes” utilized by the primary payer to describe how the claim was processed, when applicable
- Information on the action taken by the primary payer for each specific date of service and charges, when applicable
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Claims submitted without the above information will be denied. |
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TRICARE Prime Point-of-Service Option |
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Point-of-service (POS) cost-sharing and deductible amounts do not apply if a TRICARE Prime beneficiary has OHI. However, it is required that the beneficiary have prior authorization for certain covered services (previously listed in Figure 8.7), whether or not the beneficiary has OHI. |
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Calculating Payments |
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Payments from the primary payer and TRICARE as the secondary payer will not collectively exceed the TRICARE allowable charge. Providers may not collect any out-of-pocket costs from the beneficiary after the payment of the claim, unless TRICARE and the OHI combined have failed to pay one of the following:
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- The negotiated rate (if a network provider)
- The TRICARE allowable charge (if a non-network provider accepting assignment)
- 115 percent of the TRICARE allowable charge (if a non-network provider not accepting assignment)
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If the primary insurer 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 EOB shows no patient responsibility. (Reference the TRICARE Reimbursement Manual, Chapter 4.) |
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