Health Care Claims

In order for TRICARE to pay any provider, that provider must be an authorized TRICARE provider. As noted in Figure 1.1 in the Getting Care section, if the provider is also participating, the provider will file claims for you. All network providers are both TRICARE-authorized providers and participating TRICARE providers. If you see a TRICARE network provider or a non-network, participating provider, your provider will submit claims on your behalf. If you see a non-network, non-participating provider, you may be required to submit your own health care claims. You will be reimbursed for TRICARE-covered services at the TRICARE-allowable charge, less any copayments, cost-shares, or deductibles. Claims should be submitted to the claims processor in the region where you live.

Note:You should ask any non-network provider if they are participating and authorized by TRICARE. If providers are not participating, you may incur charges up to 15 percent above the TRICARE-allowable charge for covered services. If providers are not authorized by TRICARE, they will not be paid for services rendered. If a provider would like to become a TRICARE-authorized provider, Humana Military can assist them.

Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge. To file a claim, obtain and fill out a Patient’s Request for Medical Payment (DD Form 2642). You can download forms and instructions from Humana Military’s Web site. You also can get forms and instructions at a TRICARE Service Center (TSC) or a military treatment facility (MTF). If you have claims questions, call Humana Military.

When filing a claim, attach a readable copy of the provider’s bill to the claim form, making sure it contains the following:

• Social Security number of the sponsor (the National Guard or Reserve member)
• Beneficiary (patient) name
• Provider’s name and address (If more than one provider’s name is on the bill, circle the name of the person who treated you.)
• Date and place of each service
• Description of each service or supply furnished
• Charge for each service
• Diagnosis (If the diagnosis is not on the bill, be sure to complete block 8a on the form.)

Be sure to complete all 12 blocks of the form correctly and sign it. Note: Providers submit inpatient facility claims.

You may be required to pay up front for services if you see a non-network, TRICARE-authorized provider who chooses not to participate on the claim. In this case, TRICARE will reimburse you directly for the TRICARE-allowable charge minus any applicable deductible and cost-share. Remember that nonparticipating providers can charge you up to 15 percent above the TRICARE-allowable charge for services in addition to your cost-share and/or deductible. TRICARE does not reimburse you for this charge, and you will have to pay the charge out of pocket.

If you receive care while traveling, file TRICARE claims based on where you live, not where you received care.

Send claims to:

TRICARE South Region
Claims Department
P.O. Box 7031
Camden, SC  29020-7031

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