TRICARE Prime Remote

 
What happens if I receive care in another TRICARE Region?
 
The contractor shall forward claims for ADSMs enrolled in TRICARE Prime Remote in other regions to the contractors for the regions in which the members are enrolled
 
What if the doctor requires an up-front payment?
 
If a non-participating provider requires a TPR enrollee to make an “up front” payment for health care services, in order for the enrollee to be reimbursed, the enrollee must submit a claim to the contractor with proof of payment and an explanation of the circumstances.  If the claim requires Service Point of Contact (SPOC) review the contractor shall pend the claim to the SPOC for determination. If the SPOC authorizes the care, the contractor shall allow the billed amount and reimburse the enrollee for charges on the claim.
 

Supplemental Health Care

What happens if I am admitted to the hospital during a test or procedure?
 
If an emergency civilian hospitalization becomes necessary during the test or procedure referred by the MTF and comes to the attention of the HMHS, it will be reported to the Patient Administration Department of the referring MTF. The MTF will have primary case management responsibility, including authorization of care and patient movement for all civilian hospitalizations.
 
What are my appeal rights?
 
If the care is still denied after completion of a review to verify that no miscoding or other clerical error took place and the MTF will not authorize the care in question, then the notification of the denial shall include the following statement: “If you disagree with this decision, please contact (insert MTF name here).” TRICARE appeal rights shall pertain to outpatient claims for treatment of TRICARE eligible patients.
 
What happens to a claim when I receive care without a referral from the MTF?
 
If an authorization is not on file, then HMHS shall place the claim in a pending file and verify authorization with the MTF to which the ADSM is enrolled. If the MTF retroactively authorizes the care, then HMHS shall enter the authorization and notify the claims processor to process the claim for payment. If the MTF determines that the care was not authorized, HMHS shall notify the claims processor and an Explanation of Benefits (EOB) denying the claim shall be initiated.