Understanding How Other Health Insurance Works

         
Your TRICARE Standard benefit is flexible and easy to use when it comes to making decisions about your family’s health care. However, if you or your family members are also covered by other health insurance (OHI), you should be aware of several guidelines when filing claims.

If you have OHI coverage, in most instances your OHI pays first and TRICARE Standard pays second. If the OHI is Medicaid, the Indian Health Service, a TRICARE supplement or another secondary payer program or plan identified by the TRICARE Management Activity, then TRICARE pays first.

Note: When an active duty sponsor retires, his or her OHI, which had been secondary to TRICARE, now becomes primary to TRICARE. The same applies to a National Guard or Reserve member transitioning out of active duty. To avoid problems in processing claims, always keep Humana Military informed of your OHI status.

To file a TRICARE Standard claim, you or your provider must first file a claim with your OHI plan. After your OHI makes a payment determination, you may file a claim with TRICARE.

Keep your OHI plan’s explanation of benefits (EOB). You must submit a DD Form 2642 Patient’s Request for Medical Payment to TRICARE along with a copy of the EOB and the provider’s bill with itemized charges. Your EOB is a statement sent to you showing how the claim was processed and the amount paid to providers.

If the claim is denied, an explanation of denial will be provided. If your OHI plan denies your claim for not following its rules, such as receiving care without authorization, TRICARE also will deny the claim.

If your OHI offers a pharmacy benefit, the OHI is the first payer and TRICARE is the second payer for claims involving prescription drug coverage. Your TRICARE Standard benefit supplements your OHI pharmacy benefit. You are encouraged to use a retail pharmacy under your private insurer that is also in the TRICARE retail network, because the retail pharmacist can immediately submit electronic claims to TRICARE when you purchase medications. In many instances, you’ll pay less and not have to file a claim when you visit a TRICARE retail network pharmacy.

If your retail pharmacy is unable to electronically process your claim or your OHI requires you to use their mail-order pharmacy services, you may submit paper claims for full or partial reimbursement from TRICARE for your out-of-pocket costs, including copayments.

If you use a non-network pharmacy, you will be required to file a paper claim and pay the TRICARE nonnetwork deductible and applicable copayment before reimbursement is calculated.

Submit pharmacy claims to Express Scripts, Inc. using the DD Form 2642. Visit TRICARE's Prescription Claims web page for forms and instructions.

You may not use the TRICARE Mail Order Pharmacy if you have prescription drug coverage from OHI, unless the medication is not covered under the plan, or unless you exceed the dollar limit of coverage under the plan. You will save time and money by using a TRICARE network pharmacy. If you have questions about pharmacy claims, call 1-866-DoD-TRRX (1-866-363-8779).